Systematic care for caregivers of people with dementia in the ambulatory mental health service: designing a multicentre, cluster, randomized, controlled trial

Contains fulltext : 81435.pdf (publisher's version ) (Open Access)BACKGROUND: Care for people with dementia and their informal caregivers is a challenging aim in healthcare. There is an urgent need for cost-effective support programs that prevent informal caregivers of people with dementia from becoming overburdened, which might result in a delay or decrease of patient institutionalization. For this reason, we have developed the Systematic Care Program for Dementia (SCPD). The SCPD consists of an assessment of caregiver's sense of competence and suggestions on how to deal with competence deficiencies. The efficiency of the SCPD will be evaluated in our study. METHODS AND DESIGN: In our ongoing, cluster, randomized, single-blind, controlled trial, the participants in six mental health services in four regions of the Netherlands have been randomized per service. Professionals of the ambulatory mental health services (psychologists and social psychiatric nurses) have been randomly allocated to either the intervention group or the control group. The study population consists of community-dwelling people with dementia and their informal caregivers (patient-caregiver dyads) coming into the health service. The dyads have been clustered to the professionals. The primary outcome measure is the patient's admission to a nursing home or home for the elderly at 12 months of follow-up. This measure is the most important variable for estimating cost differences between the intervention group and the control group. The secondary outcome measure is the quality of the patient's and caregiver's lives. DISCUSSION: A novelty in the SCPD is the pro-active and systematic approach. The focus on the caregiver's sense of competence is relevant to economical healthcare, since this sense of competence is an important determinant of delay of institutionalization of people with dementia. The SCPD might be able to facilitate this with a relatively small cost investment for caregivers' support, which could result in a major decrease in costs in the management of dementia. Implementation on a national level will be started if the SCPD proves to be efficient. TRIAL REGISTRATION: NCT00147693

Polymorphisms in immunoregulatory genes and the risk of histologic chorioamnionitis in Caucasoid women: a case control study

BACKGROUND: Chorioamnionitis is a common underlying cause of preterm birth (PTB). It is hypothesised that polymorphisms in immunoregulatory genes influence the host response to infection and subsequent preterm birth. The relationship between histologic chorioamnionitis and 22 single nucleotide polymorphisms in 11 immunoregulatory genes was examined in a case-control study. METHODS: Placentas of 181 Caucasoid women with spontaneous PTB prior to 35 weeks were examined for histologic chorioamnionitis. Polymorphisms in genes IL1A, IL1B, IL1RN, IL1R1, tumour necrosis factor (TNF), IL4, IL6, IL10, transforming growth factor beta-1 (TGFB1), Fas (TNFRSF6), and mannose-binding lectin (MBL2) were genotyped by polymerase chain reaction and sequence specific primers. Multivariable logistic regression including demographic and genetic variables and Kaplan-Meier survival analyses of genotype frequencies and pregnancy outcome were performed. RESULTS: Sixty-nine (34%) women had histologic evidence of acute chorioamnionitis. Carriage of the IL10-1082A/-819T/592A (ATA) haplotype [Multivariable Odds ratio (MOR) 1.9, P = 0.05] and MBL2 codon 54Asp allele (MOR 2.0, P = 0.04), were positively associated with chorioamnionitis, while the TNFRSF6-1377A/-670G (AG) haplotype (MOR 0.4, P = 0.03) and homozygosity for TGFB1-800G/509T (GT) haplotype (MOR 0.2, P = 0.04) were negatively associated. CONCLUSION: These findings demonstrate that polymorphisms in immunoregulatory genes IL10, MBL2, TNFRSF6 and TGFB1 may influence susceptibility to chorioamnionitis

Systematic Identification of Spontaneous Preterm Birth-Associated RNA Transcripts in Maternal Plasma

<div><h3>Background</h3><p>Spontaneous preterm birth (SPB, before 37 gestational weeks) is a major cause of perinatal mortality and morbidity, but its pathogenesis remains unclear. Studies on SPB have been hampered by the limited availability of markers for SPB in predelivery clinical samples that can be easily compared with gestational age-matched normal controls. We hypothesize that SPB involves aberrant placental RNA expression, and that such RNA transcripts can be detected in predelivery maternal plasma samples, which can be compared with gestational age-matched controls.</p> <h3>Principal Findings</h3><p>Using gene expression microarray to profile essentially all human genes, we observed that 426 probe signals were changed by >2.9-fold in the SPB placentas, compared with the spontaneous term birth (STB) placentas. Among the genes represented by those probes, we observed an over-representation of functions in RNA stabilization, extracellular matrix binding, and acute inflammatory response. Using RT-quantitative PCR, we observed differences in the RNA concentrations of certain genes only between the SPB and STB placentas, but not between the STB and term elective cesarean delivery placentas. Notably, 36 RNA transcripts were observed at placental microarray signals higher than a threshold, which indicated the possibility of their detection in maternal plasma. Among them, the <em>IL1RL1</em> mRNA was tested in plasma samples taken from 37 women. It was detected in 6 of 10 (60%) plasma samples collected during the presentation of preterm labor (≤32.9 weeks) in women eventually giving SPB, but was detected in only 1 of 27 (4%) samples collected during matched gestational weeks from women with no preterm labor (Fisher exact test, p = 0.00056).</p> <h3>Conclusion</h3><p>We have identified 36 SPB-associated RNA transcripts, which are possibly detectable in maternal plasma. We have illustrated that the <em>IL1RL1</em> mRNA was more frequently detected in predelivery maternal plasma samples collected from women resulting in SPB than the gestational-age matched controls.</p> </div

How do patient reported outcome measures (PROMs) support clinician-patient communication and patient care? A realist synthesis

Background: In this paper, we report the findings of a realist synthesis that aimed to understand how and in what circumstances patient reported outcome measures (PROMs) support patient-clinician communication and subsequent care processes and outcomes in clinical care. We tested two overarching programme theories: (1) PROMs completion prompts a process of self-reflection and supports patients to raise issues with clinicians and (2) PROMs scores raise clinicians’ awareness of patients’ problems and prompts discussion and action. We examined how the structure of the PROM and care context shaped the ways in which PROMs support clinician-patient communication and subsequent care processes. Results: PROMs completion prompts patients to reflect on their health and gives them permission to raise issues with clinicians. However, clinicians found standardised PROMs completion during patient assessments sometimes constrained rather than supported communication. In response, clinicians adapted their use of PROMs to render them compatible with the ongoing management of patient relationships. Individualised PROMs supported dialogue by enabling the patient to tell their story. In oncology, PROMs completion outside of the consultation enabled clinicians to identify problematic symptoms when the PROM acted as a substitute rather than addition to the clinical encounter and when the PROM focused on symptoms and side effects, rather than health related quality of life (HRQoL). Patients did not always feel it was appropriate to discuss emotional, functional or HRQoL issues with doctors and doctors did not perceive this was within their remit. Conclusions: This paper makes two important contributions to the literature. First, our findings show that PROMs completion is not a neutral act of information retrieval but can change how patients think about their condition. Second, our findings reveal that the ways in which clinicians use PROMs is shaped by their relationships with patients and professional roles and boundaries. Future research should examine how PROMs completion and feedback shapes and is influenced by the process of building relationships with patients, rather than just their impact on information exchange and decision making

A geological investigation of a tertiary intrusive centre in the Vididalur-Vatnsdalur area, Northern Iceland

This thesis is an account of an investigation into the structure, petrology and mineralogy of a small Tertiary intrusive centre in the Vididalur-Vatnsdalur area near the north coast of Iceland. The area concerned lies in the Tertiary area west of the neovolcanic zone. In upper Tertiary times the extrusion of flood basalts in the area studied was locally interrupted by the building of a central volcano characterized by distinctive basalts, andesites and pyroclastics, some of which interfingered with contemporaneously extruded flood basalts. The first episode of this central volcanic activity, of which only the top is seen in the area studied, was subsequently buried by the transgressing flood basalts, and slow downsagging occurred in parts of the area along the prevailing north to north-northeast fracture system. A second central volcanic episode produced basalt, andesite and rhyolite extrusions and some pyroclastics in the northeastern part of the area following the flood transgression. Injection of thin basic dykes proceeded parallel to the two phases of central activity and continued during a final episode in which thin pale grey basalts similar to the Lower Pleistocene to Recent flows elsewhere in Iceland were extruded on to the irregular central volcano land surface. Two phases of intrusive activity proceeded parallel to the extrusive activity, the older More deeply eroded First Phase products being emplaced in the time interval during which the older flood basalts buried the newly extruded earlier central volcano lavas. A consecutive Second Phase of intrusive activity proceeded simultaneously with the second central volcanic episode and its less deeply eroded products show many similarities to the contemporaneous extrusions. These First and Second Phase intrusions are probably the upper apophyses of larger bodies concealed at depth. The intrusions which form the main part of the study are concentrated about an intrusive/extrusive centre in northern Vididalsfjall, and consist of coarse- and fine-grained basic to acid series, ranging in the First Phase from olivineeucrites (bytownite cumulates) through gabbros (labradorite cumulates), hybrid diorite and intermediate-acid hybrid types to acid granophyres. The First Phase was initiated by the intrusion of the eucrites and a dense swarm of tholeiitic cone-sheets centred on a focus about 5 km below northern Vididalsfjall. Commingling of the simultaneously available diorite and granophyre magma later in the First Phase resulted in the formation of small volumes of acid-intermediate hybrid rocks. The Second Phase intrusive activity is expressed as small high-level intrusions and began with a new supply of olivinetholeiite magmas which was injected along cone-fractures to form a late set of high-level cone-sheets centred on a focus about 2 km below northern Vididalsfjall. Cogenetic bytownite cumulates were emplaced as small high-level intrusions, but coarse-grained rocks and acid rocks of Second Phase age are rare in the area studied. iii. A broad aureole of hydrothermally altered rocks surrounds northern Vididalsfjall and smaller alteration zones surround other smaller regions cut by vents and intrusions; these altered and injected zones are taken to represent the eruptive channels at the core of the Vididalur-Vatnsdalur volcano. The intrusive rocks are all plagioclase-pyroxene-ore assemblages with or without olivine, alkali feldspar and quartz, and the First Phase types show a gradation from basic rocks bearing calcic plagioclase and magnesian augite to acid rocks containing sodic plagioclase anorthoclase and ferrian augite. The Second Phase rocks show broad petrographic similarity to those of the First Phase but coarse-grained intermediate and acid types are not found, and the basic rocks are richer in olivine than corresponding First Phase types. All the rocks examined show textural and mineralogical evidence of a high degree of fractionation and rapid final cooling at high crustal levels; the plagioclase of phenocryst rims and groundmasses is in a high-temperature structural state, the calcium-rich pyroxenes have immature exsolution textures, the olivines are strongly zoned and interstitial glassy or salic material is abundant. Many of the acid minor intrusions contain tridynlite paramorphed by quartz. Chemical analyses of 14 Vididalur-Vatnsdalur rocks show that they are low in alumina, combined alkalis and magnesia, and are relatively rich in iron, and titania, as are other Tertiary Icelandic tholeiites, with soda present in greater quantity than potash. The analyses of these basic intermediate and acid rocks fit on the iron-enriched trend for tholeiites (Nockolds a.nd AlIen, 1956) which suggests that the First and Second Phase sequences may have originated by -contiriuous fractionation of basic tholeiitic uuterinl. However there is little direct evidence of a tholeiite fractionation origin for the First Phase granitic acid rocks, and the presence of a few small veins of remelted acid material at some localities casts doubt on a fractionation origin for these granophyres and granites of the Vididalur-Vatnsdalur area