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The clinical significance of infection in bone marrow failure has been demonstrated in the case histories of five patients with panmyelopathy. In these patients the development of infections was associated with a hematologic relapse. With successful treatment of infections a marked improvement of the hematologic status occurred, characterized by at least a decrease in transfusion requirement and sometimes an increase in leucocyte count and the number of platelets. In one case (no. 1) a complete remission occurred. Apparently infection may lead to acute bone marrow failure in patients with panmyelopathy, possibly by increasing the load on a damaged organ which is already working at the maximum of its limited capacity. Adequate treatment and prevention of infections is therefore of major importance for the hematologic status of those patients.

A 76-year-old woman with combined aortic and mitral valve disease presented with anaemia due to a gastric carcinoma. Further staging revealed no evidence for metastatic disease. Approval for surgery for the carcinoma was obtained after a cardiologist and anaesthesiologist were consulted. On the day of surgery, however, the attending anaesthesiologist estimated the operative risk to be unacceptable. The patient reversed her decision and decided not to have the oncological operation, as she felt well at the moment and considered the limited additional survival time not worth the anxiety. The expert opinion of an anaesthesiologist, a cardiologist and an oncologist not primarily involved in this case show that they differ as to the question who is responsible for the decision-making process in patients such as this one. The evidence on estimating operative risk in patients with cardiac valve disease undergoing noncardiac surgery is not unequivocal. Furthermore, there is a shared responsibility when more physicians are involved in the process of decision-making. Agreement on operative risk between physicians is necessary in order to prevent transfer of conflicting information to the patient.

Refusal of food and/or fluids frequently occurs in nursing home patients. If the patient's decision to stop eating and drinking has been taken consciously and with due consideration of the consequences, it is referred to in Dutch as 'versterven'. A mentally competent, 73-year-old male nursing home patient suffering from progressive supranuclear palsy wished, in order to prevent further suffering, to end his life by taking sleeping tablets that he had saved up and by refusing artificial food and liquids. This wish met with a lot of legal and moral objections from the board of directors of the nursing home as well from experts consulted by the nursing home physician. Closer examination afterwards, however, showed that the patient would have been spared a lot of uncertainty if all parties concerned had been better informed as to the legal and moral framework. There are no legal objections as long as the doctors assess the refusal of food and drink with regard to voluntariness, deliberateness and permanence. If we as a society accept that mentally competent patients who are fully aware of the consequences and of possible alternative methods of treatment may take this road, then there would seem to be no moral obstacles either.

This article presents characteristics and co-morbidity of patients with Korsakoff's syndrome after admission to a nursing home. The medical charts were studied of all patients with Korsakoff's syndrome, admitted between 1984 and 1998 to the special ward for Korsakoff patients of a nursing home in the eastern part of the Netherlands. The 'Standard of classification for diseases in nursing homes' ('Standaard van classificatie voor ziekten in de verpleeghuisgeneeskunde') was used to classify co-morbidity. The group included 77 patients. Almost 75% were male. The average age was 53 years on admission. More than 50% of the patients were divorced. After admission, 30% of the group was transferred to a different setting. The estimated average follow-up period was 7.1 year. Patients had 2.9 co-morbid conditions at admission. Diseases due to alcoholism were frequently diagnosed. During the stay skin diseases, psychological disorders and behavioural disorders were frequently noticed. The prevalence of cognitive impairment and alcohol dementia was surprisingly high. Thirteen patients died, most of them of cancer or combined cardiovascular and respiratory diseases. We conclude that patients with Korsakoff's syndrome are an unexplored area in nursing homes. This group of nursing home inhabitants shows its own characteristics and co-morbidity.

A 74-year-old man was admitted to hospital because of jaundice and malaise of several weeks' duration. Five years earlier he had sustained a stroke from which he had recovered almost completely. On physical examination he was overweight and had an enlarged liver. Laboratory values were consistent with cholestasis and hepatitis. An abdominal ultrasound showed multiple nodular abnormalities in the liver consistent with a malignancy. Rapidly developing abnormalities in blood coagulation were thought to be a contraindication to hepatic biopsy. The patient deteriorated and sustained a new stroke. The physicians were convinced that he had cancer and could not be cured. They planned further diagnostic studies, but at the same time made an advance directive for non-resuscitation. Three days after admission the patient was found dead; no consent for an autopsy was obtained. If it is suspected that a patient is suffering from a malignant disease, the malignancy should be demonstrated or excluded as quickly as possible in the least uncomfortable way. Also, the patient and his family should be informed of any restriction on the possibilities of treatment.

This article is a descriptive study of the characteristics of nursing home day-care patients in the Netherlands in 1995 at first admission and at discharge. Data were derived from the National Nursing Home Registration System (SIVIS), in which in 1995 over 85% of Dutch nursing homes participated. Newly admitted day-care patients are characterized by high age (89% older than 65 years), a distribution with (only!) 9% more women than men and a morbidity pattern of chronic somatic (cerebrovascular disease 45%) and psychogeriatric (dementia 80%) disorders. This morbidity pattern was associated with a considerable degree of disability, in particular regarding the activities of daily living and mobility. Most patients (78%) come from their own homes. The average length of stay from admittance to discharge, for both somatic and psychogeriatic day-care patients was nine months. For about 10% of the somatic patients and 40% of the psychogeriatic ones ambulatory day-care resulted in (subsequent) admission to the nursing home itself. In the last decade nursing home day-care capacity has increased rapidly and parallel to this also the number of day-care patients. Remarkably the average level of disability and the average period of treatment of nursing home day-care patients has remained approximately the same in this period.

All representatives of psychogeriatric patients of two Dutch nursing homes (in Nijmegen and Amsterdam) were asked for their opinion about the use of (physical) restraints. Questions referred to characteristics of the respondents and their relatives in the nursing home, information provided by the nursing home, and decision-making. Furthermore respondents' opinion was studied by means of statements on six patient cases for whom respondents could choose the application of any type of restraint or no restraint. 77% (321) of all 416 representatives who were sent a questionnaire responded. The majority (75%) was well informed on the existence of several types of physical restraints, one third of the respondents, however, answered that information provided by the nursing home in this respect was lacking. 55% of the respondents answered that there was only a need for information on physical restraint when a problem concerning their family member actually occurs. Almost 90% of the respondents wanted to play an active role in decision-making or at least be informed before or shortly after application of a restraint. From the answers on the statements a majority of the respondents may be concluded to choose for safety above freedom for their relatives. Belts tied to a chair or bed, but also chairs with tables across, were judged to be the most restraining and influential on the mood of the relatives. The answers regarding the six patient cases show that a majority of the respondents choose any type of restraint. In most cases they choose for less restraining devices and for devices with less or no influence on the mood. About one-third of the representatives of the Amsterdam nursing home answered that their relatives ever had had any application of a restraint, while in the Nijmegen nursing home this prevalence was twice as high. In many aspects Amsterdam respondents were more critical about the application of restraints. This could probably be explained by the difference in policy of restraint application between the two nursing homes.

Little has been reported on serum levels attained using once-daily aminoglycoside regimens and their relation to dosage administered and renal function. Consecutive patients with serious infections were randomized to receive gentamicin 4 mg/kg q 24h i.v. (n = 69), gentamicin 1.33 mg/kg q 8h i.v. (n = 46) or netilmicin 5.5 mg/kg q 24h i.v. (n = 59) (with dose reduction in case of renal dysfunction). In the three groups, median first serum trough levels were 0.4, 1.0 and 0.4 mg/l, respectively, and median first serum peak levels were 9.5, 4.7 and 12.2 mg/l (p < 0.01 once-daily vs. thrice-daily regimens). Dose adjustment because of first trough concentrations of > 2 mg/l and/or peak concentrations of < 6 mg/l was required in 6%, 78% and 12% of patients, respectively. Second trough and peak concentrations were significantly higher in the thrice-daily gentamicin group; serum levels remained constant in the other two groups. The six patients in the once-daily groups who developed elevated trough levels later in therapy were characterized in most cases by a decline in renal function

The objective of this study was to describe the health problems of a group dementia patients on admission and during residence in a Dutch nursing home and to compare these with figures of patients of 75 years and over from general practice. In 890 nursing home patients suffering from dementia prevalence of health problems on admission and the incidence during the residence were classified by means of the ICHPPC-2-defined. The differences between men and women were studied as was the influence of the season on the incidence during the stay. Results were compared with figures of patients of seventy five year and over from the continuous morbidity registration (CMR) from 'Nijmegen'. The most frequently occurring health problems on admission were: varicose veins of legs, acquired deformation of the spine, presbyacusis, hypertension, arthrosis, COPD, cerebrovascular disorders, heart murmur, cataract and chronic ischemic heart disease. During the residence the following health problems were frequently diagnosed: urinary tract infection, side effect of medicine, constipation, pneumonia, pressure sore, feeding problem, contusion, heart failure, cold and conjunctivitis. There were clear differences between men and women. Especially the incidence of intercurrent diseases showed great differences from the patterns in general practice. Prevalence of health problems on admission to the nursing home home agreed mor with figures from general practice. Respiratory tract infections frequently occurred in winter and urinary tract infections, pressure sores and conjunctivitis seemed to occur more in the summer. Nursing home patients with dementia have a lot of chronic and intercurrent health problems. They differ clearly from patients in general practice.(ABSTRACT TRUNCATED AT 250 WORDS)

To investigate the relationship of progression of dementia with patients' characteristics, comorbidity and psychotropic drug use in nursing home patients.Psychogeriatric nursing home 'Joachim en Anna', Nijmegen, the Netherlands.Retrospective analysis of medical charts.In 645 patients, admitted between 1980 and 1989, progression of dementia was expressed by means of a functional status questionnaire developed in the nursing home. Severity of dementia at entry was expressed by a rating scale for elderly patients. Comorbid conditions were classified according to the ICHPPC-2-defined. Psychotropic drug use was expressed as the ratio between days of usage and days of the observation period. Statistical analysis was done by analysis of (co)variance and regression analysis.In univariate as well as in multivariate analysis progression of dementia was related to time spent in the nursing home, severity of dementia at entry and comorbidity and to a lesser degree psychotropic drug use. Patients who stayed for a short time and had a high frequency of concomitant diseases and psychotropic drug use had a faster progression of dementia. Gender, age at entry and type of dementia were of no significance. The factors mentioned, however, accounted for only 20% of the variance.Progression of dementia is a complex process which can only partly be explained by the factors mentioned. Nursing home physicians nevertheless should consider these factors when predicting progression.

To identify factors that have an effect on mortality after admission of nursing home patients with dementia and to investigate changes in mortality and patients' characteristics throughout ten years of patient admittance.Psychogeriatric nursing home 'Joachim en Anna', Nijmegen, the Netherlands.Retrospective analysis of medical charts.In 890 patients, admitted between 1980 and 1989, the diagnosis of dementia was determined by means of the DSM-III-R criteria and the ischaemia scale of Hachinski. Comorbid conditions were classified by the ICHPPC-2-defined. Severity of dementia was expressed by a rating scale for elderly patients. Survival analysis was done by using product-limit estimates and Cox proportional hazards model.The overall 2-year survival rate after admission was 43%, 30% for men and 49% for women. The results of proportional hazards modelling indicated that gender, age at admission, type of dementia, rate of dependency and some comorbid conditions had a statistically significant influence on mortality. Between 1980 and 1989 there were no significant changes in mortality nor in patients' characteristics.Mortality after admission to this psychogeriatric nursing home is determined by multiple factors. Based on these factors the prognosis with respect to survival can be estimated.

To describe the changes in drug intake during institutionalization in a Dutch psychogeriatric nursing home.Psychogeriatric nursing home Joachim en Anna in Nijmegen, the Netherlands.Retrospective analysis of medical charts.In 390 patients drug intake (sixteen drug groups) at admission, after six weeks, at half yearly intervals and on the day of death was recorded in a longitudinal fashion, as were side effects. Increase or decrease in drug intake was tested by means of linear regression analysis.After an initial decrease there was a gradual increase in mean drug intake during institutionalization. Laxatives and to a lesser degree drugs for the respiratory tract and heart were mostly responsible for this increase. In the other groups no change or even decrease was noted. The degree of dependency and the type of dementia had an influence on these changes. At the day of death analgesics, morphinomimetics and bronchodilators were the most frequent drugs. Neuroleptics caused most of the side effects observed.Prescription of laxatives is mostly responsible for the increase in mean drug intake in this Dutch psychogeriatric nursing home.

A retrospective analysis of the medical charts of 117 patients (50 men and 67 women) with multi-infarct dementia took place. All patients admitted to the psychogeriatric nursing home 'Joachim en Anna' in Nijmegen between 1980 and 1989 were studied. The aim of the study was to obtain epidemiological information and to investigate the prevalence of comorbid conditions, prognosis and mortality. The results were compared with patients with Alzheimer's disease. The patients remained in the institute for 1.4 years and the mean total duration of the disease was 5.3 years. About twenty-five percent died in the first three months of admission. Life expectation, counted from time of admission, was 6 years shorter in comparison with Dutch mortality tables. Morbidity frequently seen at admission included circulatory system diseases and cerebrovascular accidents. The risk factor hypertension was seen in a smaller percentage of patients than expected. During the stay the diseases most frequently diagnosed were respiratory and urinary tract infections, adverse effects of drugs, constipation and chronic ulcers of the skin. About twenty percent of the patients were struck by a (recurrent) cerebrovascular accident or a transient ischaemic attack. Most patients died of dehydration or bronchopneumonia. There was, apart from the diagnosis of multi-infarct dementia, no single patient aspect that could predict a poor prognosis. Nursing home patients with multi-infarct dementia are clearly different from patients with Alzheimer's disease. Time spent in the nursing home and duration of disease are shorter. They have more comorbid conditions, especially of a cardiovascular nature, and they have a poor life expectation.

One hundred medical charts of patients of a psychogeriatric nursing home with 'possible' (senile) dementia of the Alzheimer type were reviewed. Eighty-seven patients had died and 13 were alive at the time of analysis. The aim of the study was to obtain epidemiological information and to investigate (co)morbidity and mortality of these patients. All the data of this group of nursing home patients appeared to have a wide range. The process of dementia started at a mean age of about 75 years and patients remained in their homes for more than five years before admission. The average time spent in the nursing home was 3.0 years. These patients had a shorter life expectancy, counted from the time of admission, compared with the Dutch population. At admission a large percentage of patients suffered from circulatory system disease, musculoskeletal and connective tissue disease and/or sensory deprivation. During the stay the most frequent diseases were urinary and respiratory tract infections, constipation and chronic ulcers of the skin. Symptoms specific of Alzheimer's disease also occurred: feeding problems, disorders of gait and neurological symptoms such as paratonia. A large percentage of patients showed adverse effects of drugs or suffered from the consequences of trauma. Patients died of cachexia or bronchopneumonia. It is unclear whether the population studied is representative of the total population of Alzheimer patients.

In a psychogeriatric nursing home with 252 patients, the policy concerned with so called protective measures was investigated. Protective measures, like physical restraints, guard patients, who are mentally incapable, from physical injury. In 69.1% of the patients one or more protective measures were applied. For most of the patients this was a daily application for a period of at least three months. One hundred and ten patients (43.6%) were continuously exposed, during 24 hours a day, to several protective measures. It is concluded that this policy does not satisfy the official Dutch Governmental requirements for the quality of mental health care. Factors that cause the use of protective measures are discussed.

The glomus of the choroid plexus is located within the trigone of the lateral ventricles. The magnetic resonance images of the choroid plexus in 624 patients of all ages were reviewed and graded to determine the variation of the appearance of the glomus of the choroid plexus as seen on T2-weighted spin echo (SE). With the moderately T2-weighted SE sequences the intensity of the choroid plexus signal was equal to, or less than, that from deep cerebral grey matter in 76% of patients and greater than that from deep cerebral grey matter in 23%; in 1% of patients the glomus of the choroid plexus was "cyst-like". In all 100 patients studied with the heavily T2-weighted SE sequence the intensity of the choroid plexus signal was greater than that from the deep cerebral grey matter. The variation in the normal appearance of the glomus of the choroid plexus is consistent with known histologic changes described in the literature. The importance of recognizing the glomus of the choroid plexus and not mistaking it for other normal anatomical structures or diseases is evident.

Increased blood-brain barrier (BBB) permeability, important in the pathogenesis of MS, may be demonstrated as lesion enhancement with high-volume delayed CT (HVDCT). We studied 40 MS patients with history, neurologic examination, HVDCT, and MRI. In addition, 7 of the patients with enhancing CT lesions were followed with serial MRI for up to 3 years and 7 months. In 3 of these patients we repeated the HVDCT. Patients with enhancing lesions on CT were younger, had shorter duration of disease, and had more frequent clinical relapses than did patients without enhancement. More than half (56%) of the enhancing CT lesions were in the deep white matter, 23% were periventricular, and 21% were at the gray/white matter junction. Half the CT enhancing lesions, when followed by serial MRI, showed significant changes in lesion size. Although the majority (59%) of these lesions faded, some remained actively changing (25%) or became confluent with adjacent lesions (16%). In 48% of the MRI examinations that showed activity, some lesions were increasing in size while others were simultaneously decreasing in size. This study confirms that MS is a dynamic process in which recurrent episodes of BBB disruption and inflammation play a major role. Recurrent episodes of inflammation may well be a prelude to the largely irreversible changes of demyelination and gliosis.

In this study the need for long-term diuretic therapy was investigated in nursing home patients. In 24 patients the need for diuretics was reassessed and the therapy was discontinued if possible. In 17 of the 24 patients therapy was discontinued. There was a follow-up of 17 days. Four patients developed congestive heart failure, and one patient died during the observation period after a series of complicating events. In the remaining 12 patients therapy had been discontinued successfully. Their mean body weight rose with 0.5 kg, and there were no significant changes in physical examination, serum creatinine, urea, potassium and hematocrit. It was concluded that it was possible in a substantial part of the population studied to discontinue diuretics, when there was no obvious current indication for this treatment. Careful clinical observation is needed to guarantee early detection of (recidive of) congestive heart-failure or hypertension.