Iedereen verantwoordelijk

Goede palliatieve zorg gaat iedereen aan: wij worden immers allemaal op enig moment met de dood geconfronteerd, zowel persoonlijk als binnen onze familie- en kennissenkring. En als zorgverleners dragen de meeste van ons zorg voor patiënten die lijden aan ziektes waaraan ze uiteindelijk zullen overlijden. Het is dan ook opmerkelijk, dat zorgverleners zelf, beleidsmakers en onderzoekers nog maar kort specifieke aandacht aan palliatieve zorg geven. Een groot deel van de dagelijkse zorg die wij bieden aan patiënten met een korte levensverwachting, of zelfs patiënten die stervende zijn, is niet gebaseerd op wetenschappelijke kennis van voldoende niveau. Waar praten we over? In Nederland overleden in 2006 136.000 mensen. Vierenvijftig procent van het totaal, te weten 73.000 mensen, overleed ten gevolg van een chronische ziekte. Bij hen werd het overlijden dus voorafgegaan door een ziekteperiode en komt palliatieve zorg nadrukkelijk aan de orde. Kanker is meest voorkomende ziekte die leidt tot een niet-acuut overlijden, maar 45% van de mensen overlijdt t.g.v. andere aandoeningen zoals hart- en vaatziekte, dementie en chronisch longlijden. In Nederland overlijdt ongeveer een derde van de mensen met een chronische ziekte thuis, een ander derde in een verpleeg- of verzorgingshuis, 27% in het ziekenhuis en een klein deel van de patiënten in andere instellingen, waar onder de speciale hospice voorzieningen

Micromechanical testing of single collagen type I fibrils

In this thesis the following subjects will be covered. In chapter 2 the current understanding of the structure and corresponding mechanical properties of collagen and its substructures will be\ud reviewed. In chapter 3 the methodology to enable fixation and subsequent tensile testing of collagen fibrils is described. The mechanical behaviour of native collagen fibrils at ambient conditions and in aqueous media using the method described in chapter 3, is discussed in chapter 4. In chapter 5 the influence of cross-linking reagents, such as glutaraldehyde and a carbodiimide-based reagent, on the mechanical properties of collagen fibrils is evaluated. The\ud obtained information on the structure and mechanical properties of collagen fibrils is further discussed in chapter 6, and an attempt is made to explain the differences in mechanical behaviour of non-treated and cross-linked fibrils at the molecular level. In chapter 7 the most important conclusions of this study are summarized and an outlook is given on new research projects based on the developed methodology

Sharing corporate tax knowledge with external advisers

Tax knowledge is critical for companies to comply with tax laws and engage in tax planning and avoidance. Firms rely on external advisers in handling tax issues, however, sharing corporate tax knowledge with external advisers entails both opportunities and risks. We identify four relational factors that are associated with the decision of corporate taxpayers to share knowledge with external tax advisers. Survey data from 221 corporate taxpayers reveals a novel distinction between operational and strategic knowledge sharing. The operational dimension has a functional nature, whereas the strategic dimension has a more intentional character. Accessibility to, and a positive experience with, external advisers enables operational knowledge sharing. When firms perceive specific tax benefits in relation to sharing knowledge, they are more inclined to engage in operational knowledge sharing with external advisers but less prone to strategic knowledge sharing. Instead, strategic knowledge sharing is enhanced when firms have access to, and value the knowledge of their advisers, although this latter factor plays no significant role in explaining operational knowledge sharing. A positive experience with advisers also associates with strategic knowledge sharing. We link our results to other research and discuss implications for regulators considering, or requiring, firm disclosures of corporate tax strategy

Een praktisch voorbeeld van slachtkuikenbegeleiding

De specialisatie in de pluimveehouderij is dusdanig dat het geven van algemene voorlichting niet meer voldoende is. Specialisatie in de voorlichting is niet meer weg te denken

Prevalence, Impact, and Treatment of Death Rattle

Context: Death rattle, or respiratory tract secretion in the dying patient, is a common and potentially distressing symptom in dying patients. Health care professionals often struggle with this symptom because of the uncertainty about management. Objectives: To give an overview of the current evidence on the prevalence of death rattle in dying patients, its impact on patients, relatives, and professional caregivers, and the effectiveness of interventions. Methods: We systematically searched the databases PubMed, EMBASE, CINAHL, PsychINFO, and Web of Science. English-language articles containing original data on the prevalence or impact of death rattle or on the effects of interventions were included. Results: We identified 39 articles, of which 29 reported on the prevalence of death rattle, eight on its impact, and 11 on the effectiveness of interventions. There is a wide variation in reported prevalence rates (12%-92%; weighted mean, 35%). Death rattle leads to distress in both relatives and professional caregivers, but its impact on patients is unclear. Different medication regimens have been studied, that is, scopolamine, glycopyrronium, hyoscine butylbromide, atropine, and/or octreotide. Only one study used a placebo group. There is no evidence that the use of any antimuscarinic drug is superior to no treatment. Conclusion: Death rattle is a rather common symptom in dying patients, but it is doubtful if patients suffer from this symptom. Current literature does not support the standard use of antimuscarinic drugs in the treatment of death rattle

Hepatic encephalopathy: clinical and experimental studies

The pathogenesis of hepatic encephalopathy is still unsolved. Therapy, therefore, is often insufficient. For the development of effective, new therapies insight into the disease-inducing substrates and the mechanisms of its toxic actions in the central nervous system ·are required. For both studies on pathogenesis and therapy of hepatic encephalopathy, methods for the quantitation of its severity are needed. For the measurement of hepatic encephalopathy clinical grading, conventional electroencephalography and psychometric tests are mostly used. The former two methods are characterized by considerable intra- and interobserver error; the last one can only be used in mild encephalopathy. Quantitative EEG analysis has been shown to be useful! in longitudinal studies but its value for the classification of the whole spectrum of severities of encephalopathy had not been investigated. In studies on the pathogenesis of hepatic encephalopathy ammonia was considered as a major toxin from the beginning. However, its importance was rejected by many hepatologists because the correlation between plasma concentrations and encephalopathy is poor. New theories, especially the false neurotransmitter theory and the GABA-benzodiazepine receptor hypothesis, tried to explain cerebral dysfunction directly at the neuronal leveL The GABA-benzodiazepine receptor theory as originally proposed by Schafer and Jones resulted in the use of flumazenil, a benzodiazepine receptor antagonist, in hepatic encephalopathy. Uncontrolled clinical studies seemed to indicate remarkable therapeutic activity and therefore supported the presence of endogenous benzodiazepines. Besides specific toxins little attention has been given to the role of nonspecific metabolic factors, often present in liver failure, in the precipitation of encephalopathy in liver disease. With regard to these considerations the aims of this thesis were: 1. the development of an objective method, spectral analysis, for the measurement of hepatic encephalopathy; 2. to study the effect of flumazenil in hepatic encephalopathy; and 3. to study the role of aspecific factors in the induction of hepatic encephalopathy

Development and feasibility of a web application to monitor patients’ cancer-related pain

Background: In the outpatient setting, pain management is often inadequate in patients with cancer-related pain, because of patient- and professional-related barriers in communication and infrequent contacts. The internet may provide new opportunities for monitoring these patients. Purpose: The purpose of this study was to investigate whether internet monitoring of cancer-related pain in outpatients was feasible. Methods: We developed an internet application that contained a pain diary, eConsult, and patient pain education. In the pain diary, patients scored their pain intensity (0–10 Numeric Rating Scale) and analgesic use daily and their side effects twice a week. Feasibility was defined as the percentage of diaries patients completed during the first 6 weeks. Results: We included 100 outpatients. Sixteen were not evaluable due to cognitive problems (2); withdrawal of participation (2); internet problems (2), or because they were too ill (10). During the first 6 weeks, 60% of 84 evaluable patients completed their diary for at least 65% of the days (median number of diaries, 21; range, 3–42) and asked for a median of five eConsults (range, 0–37). Patients most frequently used an eConsult for questions about pain or side effects, how to use their analgesics and to improve their self-management. Over the 6-week period, current pain intensity decreased from 3.3 (SD = 2) to 2.5 (SD = 1.6, p = 0.005), and worst pain intensity decreased from 5.7 (SD = 2) to 3.8 (SD = 2.0, p < 0.001). Conclusion: Internet monitoring of pain is feasible in most outpatients with cancer-related pain. The frequent use of the pain diary in the majority of patients indicates that those patients felt confident with the regular assessment of pain