[Analysis of mental health care utilization data in comparison with medical-specialist and general practitioner health care consumption data]

Quantification of population-level socioeconomic-demographic factors impacting onset and course of health care consumption can help health care commissioning and public health planning.<br/> AIM: To analyse associations between mental health care, medical-specialist care and general practitioner (GP) care with regional socioeconomic-demographic factors. Two cost parameters were examined: (i) absolute costs; and (ii) relative costs, defined as the proportion of PC3-level costs attributable to outliers (defined as costs above the 80th percentile - as a proxy for care intensity).<br/> METHOD: Analysis of Vektis data over the period 2014-2017 in the age range of 18-65 years.<br/> RESULTS: Mental health care cost variation was for 28% reducible to (younger) age, urbanicity, PC3-level ethnic density and PC3-level socioeconomic-demographic factors. Variation in medical-specialist care and GP care costs were reducible principally to (older) age. Costs attributable to outliers ranged from 34% for GP care to 55% for mental health care. Socioeconomic-demographic factors explained a substantial part of the variation in the PC3-level proportion of outlier costs for mental health care (31%), medical-specialist care (43%) and GP-care (33%).<br/> CONCLUSION: Analysis of the degree and pattern of socioeconomic-demographic factors impacting mental health care can inform both public mental health planning and mental health care commissioning. Tijdschrift voor psychiatrie 63(2021)1, 39-47.

Editor's Choice - Nationwide Analysis of Patients Undergoing Iliac Artery Aneurysm Repair in the Netherlands

OBJECTIVE

The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR).

METHODS

This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests.

RESULTS

The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively).

CONCLUSION

In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair.

Usually Available Clinical and Laboratory Data Are Insufficient for a Valid Medication Review: A Crossover Study

OBJECTIVES

To establish the quality of medication reviews performed by nursing home physicians, general practitioners and pharmacists.

DESIGN AND SETTING

15 Pharmacists, 13 general practitioners and 18 nursing home physicians performed a medication review for three cases (A, B and C), at three evaluation moments. First, they received the medication list. Secondly, they also received laboratory results and reason for admission and finally, we added medical history. Remarks were divided into 6 categories, i.e. indication without medication, medication without indication, contraindications/ interactions, dosage problems, double medication and wrong medication. Remarks were compared to the remarks made by our expert panel and scored according to our grading model as appropriate (0 to +3) or missed or potentially harmful (-1). For each medication error category, the percentage of participants who made this error was computed.

RESULTS

After the first evaluation moment, the overall estimated mean percentage score was -1.7% for case A, 3.9% for case B, and 8.7% for case C. After the second review, this score was 15.0% for case A, 19.8% for case B, and 22.2% for case C. This further increased to 30.0% for case A, 36.7% for case B and 44% for case C at the final evaluation. The absence of medication where there was an indication (indication without medication) was frequently missed and did not improve after adding the extra information regarding laboratory results, reason for admission and finally medical history.

CONCLUSION

Increasing clinical information helps physicians and pharmacists to improve their medication reviews, however, additional information was still related with a high margin of error. Detection of certain errors becomes easier with additional information, whereas other errors remain undetected. To achieve a high standard of medication review, we have to change the way medication reviews should be performed.

Risk modelling of outcome after general and trauma surgery (the IRIS score)

Background

A practical, easy to use model was developed to stratify risk groups in surgical patients: the Identification of Risk In Surgical patients (IRIS) score.

Methods

Over 15 years an extensive database was constructed in a general surgery unit, containing all patients who underwent general or trauma surgery. A logistic regression model was developed to predict mortality. This model was simplified to the IRIS score to enhance practicality. Receiver operating characteristic (ROC) curve analysis was performed.

Results

The database contained a consecutive series of 33 224 patients undergoing surgery. Logistic regression analysis gave the following formula for the probability of mortality: P (mortality) = A/(1 + A), where A = exp (−4·58 + (0·26× acute admission) + (0·63× acute operation) + (0·044× age) + (0·34× severity of surgery)). The area under the ROC curve (AUC) was 0·92. The IRIS score also included age (divided into quartiles, 0–3 points), acute admission, acute operation and grade of surgery. The AUC predicting postoperative mortality was 0·90.

Conclusion

The IRIS score accurately predicted mortality after general or trauma surgery.

Characterisation and foaming properties of hydrolysates derived from rapeseed isolate

Two hydrolysis methods used to obtain rapeseed isolate derivates were compared: chemical hydrolysis performed under alkaline conditions and pepsic proteolysis performed under acidic conditions. The mean molecular weights obtained for the hydrolysates varied from 26 to 2.5 kDa, depending on the level of hydrolysis. Further characterisation showed that, at the same level of hydrolysis, the chemical hydrolysates differed by their charges and hydrophobicity from those derived from enzymatic digestion. Analysis of the foaming properties showed, for both cases, that a limited degree of hydrolysis, around 3%, was sufficient to optimise the foaming properties of the isolate despite the different physicochemical properties of the peptides generated. The study of foaming properties at basic, neutral and acidic pHs showed that the hydrolysate solutions yielded dense foams which drained slowly and which maintained a very stable volume under the three pH conditions tested.

Ventricular fibrillation caused by electrocoagulation during laparoscopic surgery

A 35-year-old man with morbid obesity was admitted to our hospital to undergo gastric banding gastroplasty by the laparoscopic approach. Aside from his morbid adiposity, with a body mass index (BMI) of 49.9 kg/m2, the patient was healthy. During the procedure, he developed ventricular fibrillation (VF) while a diathermic knife was being used. After defibrillation, his heart rate returned to normal. The postoperative clinical course was uneventful, and there was no evidence of permanent heart failure. Although the VF could have been caused by patient- or material-related variables, it was most likely the result of unwanted electrical effects. Specifically, the occurrence of an arc between the patient's tissue and the tip of the electrode during cutting in the coagulation mode can lead to low-frequency current. The modified low-frequency current may produce arrhythmias. Thus, the use of the coagulation mode to cut tissue in the cardiac region during laparoscopic procedures could increase the risk for arrhythmias. An understanding of the physical principles of electrosurgery, as well as familiarity with the equipment and its various functions, is essential for the patient's safety. In addition, cardioversion equipment should be readily available on every surgical unit.

[New structures in geriatric care: the geriatric home consultation by a nurse practitioner]

The growing number of elderly and chronically ill people causes an increasing demand for care. New patterns in care for geriatric patients are required, to guarantee geriatric care in the future. In the Transmural Model for Geriatric Care, the geriatric nurse practitioner participates in geriatric home consultation. The geriatric nurse practitioner makes the home visits of the geriatrician. First experiences with home consultation by geriatric nurse practitioner are positive. The input of the geriatric nurse practitioner in home consultation has two goals: care substitution and improvement of quality of care. Substitution of care enlarges the possibilities of the geriatrician, which are limited now, because of the enormous demand for geriatric care. The specific tasks of the geriatric nurse practitioner are functional assessment and care coordination.

Cloning and partial characterization of endopolygalacturonase genes from Botrytis cinerea

Botrytis cinerea is a plant-pathogenic fungus infecting over 200 different plant species. We use a molecular genetic approach to study the process of pectin degradation by the fungus. Recently, we described the cloning and characterization of an endopolygalacturonase (endoPG) gene from B. cinerea (Bcpg1) which is required for full virulence. Here we describe the cloning and characterization of five additional endoPG-encoding genes from B. cinerea SAS56. The identity at the amino acid level between the six endoPGs of B. cinerea varied from 34 to 73%. Phylogenetic analysis, by using a group of 35 related fungal endoPGs and as an outgroup one plant PG, resulted in the identification of five monophyletic groups of closely related proteins. The endoPG proteins from B. cinerea SAS56 could be assigned to three different monophyletic groups. DNA blot analysis revealed the presence of the complete endoPG gene family in other strains of B. cinerea, as well as in other Botrytis species. Differential gene expression of the gene family members was found in mycelium grown in liquid culture with either glucose or polygalacturonic acid as the carbon source.

The endopolygalacturonase gene Bcpg1 is required for full virulence of Botrytis cinerea

Botrytis cinerea, a fungus that causes diseases in over 200 plant species, secretes a number of endopolygalacturonases that have been suggested to be involved in pathogenesis. However, so far the corresponding genes have not been isolated from this fungus. We cloned Bcpg1, encoding endopolygalacturonase, with the pgaII gene from Aspergillus niger as a heterologous probe. The Bcpg1 gene is expressed to similar levels in liquid cultures of B. cinerea containing either 1% polygalacturonic acid or 1% sucrose, and is expressed during infection of tomato leaves. The Bcpg1 gene was eliminated by partial gene replacement, and the resulting mutants were tested for virulence on tomato leaves and fruits, as well as on apple fruits. Although the mutants were still pathogenic and displayed similar primary infections when compared with control strains, a significant decrease in secondary infection, i.e., growth of the lesion beyond the inoculation spot, was observed on all three host tissues. These results indicate that the Bcpg1 gene is required for full virulence.

Carney's triad

The purpose of this study is to provide an overview of cases of Carney's triad and to discuss the clinical implications of this diagnosis. A search was made of the English-language literature for original articles, reviews and abstracts addressing Carney's triad. A new patient was described and added to the number of known patients. In literature 40 patients were found with a complete or incomplete triad. There exists no agreement on the pathology and possible common origin of these tumours. Directions are given for diagnostics and therapy. The diagnosis of Carney's triad has specific clinical implications that make a good knowledge of this syndrome mandatory.

Detection of wild-type Aujeszky's disease virus by polymerase chain reaction in sheep vaccinated with a modified live vaccine strain

An outbreak of Aujeszky's disease occurred in a flock of sheep which had been housed together with pigs. After the death of five sheep with clinical signs of Aujeszky's disease, the remaining sheep were vaccinated with the Bartha vaccine strain, and the pigs were vaccinated with the 783 vaccine strain of Aujeszky's disease virus. Despite vaccination, however, more sheep died. Brain tissues from four sheep were collected for virus isolation and for immunohistological examinations. Only vaccine virus (gE-negative) was detected in the tissue. After DNA restriction enzyme analysis of the isolated virus, DNA of one or both of the vaccine strains was detected in all sheep. In one sheep field virus DNA was also detected. However, when the polymerase chain reaction was performed on samples prepared from paraffin-embedded tissues, DNA of field virus (gE-positive) was detected in all four sheep. It was probable that the sheep had not yet mounted a sufficient immune response to the vaccine virus, or were already infected with field virus at the time of vaccination. We concluded that the sheep died from field virus infection and not from vaccine virus infection and that only the polymerase chain reaction made it possible to specifically detect even very small amounts of field virus DNA among vaccine virus DNA in all investigated sheep.

Glycoprotein D-negative pseudorabies virus can spread transneuronally via direct neuron-to-neuron transmission in its natural host, the pig, but not after additional inactivation of gE or gI

Envelope glycoprotein D (gD) is essential for entry of pseudorabies virus (PRV) into cells but is not required for the subsequent steps in virus replication. Phenotypically complemented gD mutants can infect cells and can spread, both in vitro and in mice, by direct cell-to-cell transmission. Progeny virions released by infected cells are noninfectious because they lack gD. The aim of this study was to determine the role of gD in the neuropathogenicity of PRV in its natural host, the pig. We investigated whether gD-negative PRV can spread transneuronally via synaptically linked neurons of the olfactory and trigeminal routes. High doses of a phenotypically complemented gD mutant and gD mutants that are unable to express either gI or gI plus gE were inoculated intranasally in 3- to 5-week-old pigs. Compared with the wild-type virus, the virulence of the gD mutant was reduced. However, pigs inoculated with the gD mutant still developed fever and respiratory signs. Additional inactivation of either gI or gI plus gE further decreased virulence for pigs. Immunohistochemical examination of infected pigs showed that a PRV gD mutant could replicate and spread transneuronally into the central nervous system (CNS). Compared with the wild-type virus, the gD mutant had infected fewer neurons of the CNS on day 2. Nevertheless, on day 3, the gD-negative PRV had infected more neurons and viral antigens were present in second- and third-order neurons in the olfactory bulb, brain stem, and medulla oblongata. In contrast, gD mutants which are unable to express either gI or gI plus gE infected a limited number of first-order neurons in the olfactory epithelium and in the trigeminal ganglion and did not spread transneuronally or infect the CNS. Thus, transsynaptic spread of PRV in pigs can occur independently of gD. Possible mechanisms of transsynaptic transport of PRV are discussed.

Distinct transcriptional regulation of a gene coding for a mitochondrial protein in the yeasts Saccharomyces cerevisiae and Kluyveromyces lactis despite similar promoter structures

In Saccharomyces cerevisiae transcription of QCR8, encoding subunit VIII of the mitochondrial ubiquinol cytochrome c oxidoreductase, is subject to glucose repression, whereas in the distantly related yeast Kluyveromyces lactis it is not. The homologous promoter regions lack overall DNA-sequence identity, but do share binding sites for the transcription factors Abf1p, Cpf1p and Hap2/3/4p. For S. cerevisiae it has been established that these factors are involved in growth and carbon source control of nuclear genes encoding mitochondrial proteins. Here we present experimental evidence that K. lactis counterparts of Abf1p and Cpf1p bind independently to the KIQCR8 promoter. The presence of the KIHap2/3/4p binding site enhances binding of KIAbf1p, strongly suggesting that the KIHap2/3/4p complex stabilizes binding of KIAbf1p. In reciprocal exchanges of the QCR8 genes between S. cerevisiae and K. lactis, overall regulation of transcription was found to be species specific. In contrast to S. cerevisiae, additional elements and factors in K. lactis, distinct from Abf1p, Cpf1p and Hap2/3/4p, are able to activate transcription of the QCR8 gene during both fermentative and non-fermentative growth, as well as to induce transcription during growth on non-fermentable carbon sources. In both yeasts, Abf1p is involved in transcriptional activation under both fermentative and non-fermentative growth conditions. Hap2/3/4p plays a minor activational role during fermentative growth, but is mainly responsible for transcriptional induction under non-fermentative growth conditions. Under these latter conditions Abf1p and Hap2/3/4p activate transcription synergistically.

Carbon catabolite regulation of transcription of nuclear genes coding for mitochondrial proteins in the yeast Kluyveromyces lactis

Promoter regions of the KlQCR7, KlQCR8 and KlCYC1 genes, coding for subunits of the bc1-complex and cytochrome c respectively, in the short-term Crabtree-negative yeast Kluyveromyces lactis differ markedly in sequence from their Saccharomyces cerevisiae counterparts. They have, however, conserved very similar configurations of binding-site motifs for various transcription factors known to be involved in global and carbon-source regulation in S. cerevisiae. To investigate the carbon source-dependent expression of these genes in K. lactis, we have carried out medium-shift experiments and determined transcript levels during the shifts. In sharp contrast to the situation in S. cerevisiae, the level of expression in K. lactis is not affected when glucose is added to a non-fermentable carbon-source medium. However, the genes are not constitutively expressed, but become significantly induced when the cells are shifted from glucose to a non-fermentable carbon source. Finally, induction of transcriptional activation does not occur in media containing both glucose and non-fermentable carbon sources.

Posterior sagittal anorectoplasty: functional results of primary and secondary operations in comparison to the pull-through method in anorectal malformations

BACKGROUND

Control of defaecation after surgical correction of high and intermediate types of congenital anorectal malformations is difficult. The posterior sagittal approach with careful reconstruction of the external sphincter is postulated to give a better outcome than the pull-through operation. The functional results of these procedures performed in one centre were evaluated in order to identify prognostic factors.

MATERIAL AND METHODS

Between 1979 and 1992 66 patients with high or intermediate congenital anorectal anomalies were treated in our centre. In 16 patients a pull-through operation (Kĩesewetter-Rehbein) was performed. After 1984, the posterior sagittal anorectoplasty (PSARP) (Peña and deVries) was used in 35 patients as the primary operation. In 22 patients a PSARP operation was done as a secondary procedure, in one third of these patients after a previous pull-through operation in our centre. The functional results were analysed in retrospect.

RESULTS

Sixty operations in 53 patients could be evaluated. The overall continence rate was 34%. After the pull-through operation six out of 15 patients (40%) were continent, after a primary PSARP 10 out of 25 (40%) and after a secondary PSARP operation five out of 20 patients (25%). Patients with a sacral defect were continent only in 16% as compared to 44% of the patients with a normal sacrum. Sex was also relevant: 67% of the girls were continent, compared to 30% of the boys. Ten out of 11 girls (90%) with a normal sacrum became continent.

CONCLUSION

The PSARP for high and intermediate anorectal malformations does not give better functional results than the pull-through operation. The prognosis is determined by other factors than the type of operation, notably sex and the presence or absence of sacral defects.

Isolation and characterisation of the linked genes APA2 and QCR7, coding for Ap4A phosphorylase II and the 14 kDa subunit VII of the mitochondrial bc1-complex in the yeast Kluyveromyces lactis

We report the isolation and characterization of the KlQCR7 gene encoding subunit VII of the mitochondrial bc1 complex of the yeast Kluyveromyces lactis. The coding region is 69.3% identical to its counterpart in Saccharomyces cerevisiae (ScQCR7). Like the KlQCR8 gene (Mulder et al., accompanying paper) expression of the KlQCR7 gene during growth on glucose is high and can be further induced when cells are grown on non-fermentable carbon sources. The chromosomal linkage of the APA2 and QCR7 genes is conserved between S. cerevisiae and K. lactis. The intergenic regions containing the QCR7 promoters of the two yeasts, differ significantly in length and lack overall DNA sequence similarity, but they do share a binding site for the transcription factor complex HAP2/3/4. The KlQCR7 promoter contains, in addition, a CPF1 consensus binding site which is absent from ScQCR7. Deletion of a 35 bp region containing these two sites severely lowers the mRNA expression during growth on both glucose and ethanol/glycerol, but growth rate on both carbon sources is only mildly affected. Interestingly, in respect to the KlQCR7 gene, KlCPF1 seems to act as an important transcriptional activator, thus contrasting the proposed repressor function of ScCPF1 for the ScQCR8 gene of S. cerevisiae.

Isolation and characterisation of the linked genes, FPS1 and QCR8, coding for farnesyl-diphosphate synthase and the 11 kDa subunit VIII of the mitochondrial bc1-complex in the yeast Kluyveromyces lactis

The KlQCR8 gene of the yeast Kluyveromyces lactis encoding subunit VIII of the mitochondrial bc1 complex is 70.2% identical to its counterpart in Saccharomyces cerevisiae (ScQCR8). As in S. cerevisiae, chromosomal linkage between the K. lactis QCR8 and FPS1 genes is conserved, the two genes being separated by only 292 bp. Disruption of the KlQCR8 gene results in a respiratory-deficient phenotype. Compared with S. cerevisiae, expression of the KlQCR8 gene in glucose-grown cells is relatively high, yet is significantly induced when the cells are grown on non-fermentable carbon sources. The QCR8 promoters regions of the two yeasts lack overall DNA sequence similarity, but share DNA-binding sites for the transcription factors ABF1, CPF1 and HAP2/3/4. Deletion from the KlQCR8 promoter of a 93 bp region containing these sites significantly lowers mRNA levels during growth on either glucose or ethanol/glycerol, with a consequent reduction of growth rate on ethanol/glycerol.

Sequence of the HAP3 transcription factor of Kluyveromyces lactis predicts the presence of a novel 4-cysteine zinc-finger motif

The Kluyveromyces lactis homologue of the Saccharomyces cerevisiae HAP3 gene was isolated by functional complementation of the respiratory-deficient phenotype of the S. cerevisiae hap3::HIS4 strain SHY40. The KlHAP3 gene encodes a protein of 205 amino acids, of which the central B-domain of 90 residues is highly homologous to HAP3 counterparts of S. cerevisiae and higher eukaryotes. The protein contains a novel 4-cysteine zinc-finger motif and we propose by analogy that all other homologous HAP3 proteins contain the same motif, with the position containing the third cysteine being occupied by a serine residue. In contrast to the situation in S. cerevisiae, disruption of the KlHAP3 gene in K. lactis does not result in a respiratory-deficient phenotype and the growth of the null strain is indistinguishable from wild type. There is also no effect on the expression of the carbon source-regulated KlCYC1 gene, suggesting either a different role for the HAP2/3/4 complex, or the existence of a different mechanism of carbon source regulation. Sequence verification of the S. cerevisiae HAP3 locus reveals that, just as in K. lactis, a long open reading frame (ORF) is present upstream of the HAP3 gene. These highly homologous ORFs are predicted to have at least eight membrane-spanning fragments, but do not show significant homology to any known sequence present in databases. The ScORFX gene is transcribed in the opposite direction to ScHAP3, but, in contrast to an earlier report by Hahn et al. (1988), the transcripts of the two genes do not overlap. The model proposed by these authors, in which the ScHAP3 gene is regulated by an anti-sense non-coding mRNA, is therefore not correct.

Centromere promoter factors (CPF1) of the yeasts Saccharomyces cerevisiae and Kluyveromyces lactis are functionally exchangeable, despite low overall homology

The KlCPF1 gene, coding for the centromere and promoter factor CPF1 from Kluyveromyces lactis, has been cloned by functional complementation of the methionine auxotrophic phenotype of a Saccharomyces cerevisiae mutant lacking ScCPF1. The amino-acid sequences of both CPF1 proteins show a relatively-low overall identity (31%), but a highly-homologous C-terminal domain (86%). This region constitutes the DNA-binding domain with basic-helix-loop-helix and leucine-zipper motifs, features common to the myc-related transcription factor family. The N-terminal two-thirds of the CPF1 proteins show no significant similarity, although the presence of acidic regions is a shared feature. In KlCPF1, the acidic region is a prominent stretch of approximately 40 consecutive aspartate and glutamate residues, suggesting that this part might be involved in transcriptional activation. In-vitro mobility-shift experiments were used to establish that both CPF1 proteins bind to the consensus binding site RTCACRTG (CDEI element). In contrast to S. cerevisiae, CPF1 gene-disruption is lethal in K. lactis. The homologous CPF1 genes were transformed to both S. cerevisiae and K. lactis cpf1-null strains. Indistinguishable phenotypes were observed, indicating that, not withstanding the long nonconserved N-terminal region, the proteins are sufficiently homologous to overcome the phenotypes associated with cpf1 gene-disruption.

"Split" pancreaticojejunostomy in the surgical treatment of chronic pancreatitis

"Split" pancreaticojejunostomy is a procedure consisting of vertical transection of the pancreas and anastomosis of both sides of the cut pancreatic duct with an interposed, Roux-en-Y jejunal loop. In this paper we report the long term results of this procedure in the treatment of eight patients with chronic pancreatitis (CP).

[A mixed form of mucocele of the colon]

The term mucocele is applied to an accumulation of mucus within a lumen lined with mucus-secreting epithelium as well as to the structure resulting from leakage of mucus into surrounding connective tissue. The case report is presented of a patient with a bizarre, mixed type of mucocele after perforation of a hemicolon retained 26 years previously, a clinical picture which could not be traced in the literature.