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People with intellectual disabilities often show challenging behaviour, which can manifest itself in self-harm or aggression towards others. Real-time monitoring of stress in clients with challenging behaviour can help caregivers to promptly deploy interventions to prevent escalations, ultimately to improve the quality of life of client and caregiver. This study aimed to assess the impact of real-time stress monitoring with HUME, and the subsequent interventions deployed by the care team, on stress levels and quality of life. Real-time stress monitoring was used in 41 clients with intellectual disabilities in a long-term care setting over a period of six months. Stress levels were determined at the start and during the deployment of the stress monitoring system. The quality of life of the client and caregiver was measured with the Outcome Rating Scale at the start and at three months of use. The results showed that the HUME-based interventions resulted in a stress reduction. The perceived quality of life was higher after three months for both the clients and caregivers. Furthermore, interventions to provide proximity were found to be most effective in reducing stress and increasing the client's quality of life. The study demonstrates that real-time stress monitoring with the HUME and the following interventions were effective. There was less stress in clients with an intellectual disability and an increase in the perceived quality of life. Future larger and randomized controlled studies are needed to confirm these findings. Assistive technology such as real-time stress monitoring enables caregivers to timely intervene and contributes to the reduction of challenging behaviour. Real-time stress monitoring contributes to the quality of life of clients and caregivers in healthcare. There is a reduction in the levels of stress of people with an intellectual disability by using stress-monitoring technology. [ABSTRACT FROM AUTHOR]

Objective: To assess the added value of caregiver-mediated exercises combined with telerehabilitation in addition to usual care compared to usual care alone on the self-reported mobility outcome after subacute stroke. Design: Multicentre, observer-blinded, parallel randomised controlled trial. An off-site researcher allocated treatments using minimisation. Setting: Four rehabilitation centres in the Netherlands. Participants: Forty-one patient–caregiver dyads within 3 months poststroke. Intervention: Eight-week blended care program with caregiver-mediated mobility exercises for 2.5 h per week supported by telerehabilitation and four face-to-face sessions in addition to usual care. Main measures: Self-reported mobility domain of the Stroke Impact Scale postintervention. Secondary outcomes were functional outcome, dyads' psychosocial wellbeing, care transition to the community postintervention and after 6 months. Results: Forty-one dyads (21 intervention, 20 control) were randomised, and 37 (N = 18; N = 19) were analysed following intention-to-treat. The Stroke Impact Scale mobility was not significantly different between groups postintervention (B 0.8, 95% CI –6.8–8.5, p = 0.826). The secondary outcomes, namely, (a) caregivers' quality of life postintervention (p = 0.013), (b) caregivers' symptoms of depression postintervention (p = 0.025), and (c) independence in leisurely activities at 6 months (p = 0.024), showed significant benefits in favour of caregiver-mediated exercises with telerehabilitation. A significant difference favouring controls was found in self-reported muscle strength at 6 months (p = 0.002). Conclusions: Caregiver-mediated exercises combined with telerehabilitation yielded no differential effect on our primary outcome self-reported mobility. Although the trial is underpowered, current findings are in line with previous trials. Future studies should further explore beneficial effects of caregiver involvement in stroke rehabilitation targeting psychosocial wellbeing. [ABSTRACT FROM AUTHOR]

BACKGROUND: Individuals with advanced multiple sclerosis (MS) have complex care requirements and are more likely to use long-term facilities. This study determined the associations between mood and social care--related quality of life (SCRQOL), and health-related quality of life (HRQOL) and examined the association between HRQOL and SCRQOL. METHODS: Baseline data from a cohort study were used. Patients completed questionnaires, including the Hospital Anxiety and Depression Scale (HADS), Adult Social Care Outcomes Toolkit (ASCOT), and EuroQOL 5D-5L (EQ-5D-5L) and EQ-Visual Analogue Scale (EQ-VAS). Linear regression analyses were employed to assess the relationships between mood and both outcomes of QOL while controlling for relevant confounding factors (βs; 95% CI). The cross-sectional association between SCRQOL and HRQOL was examined using Pearson correlation coefficients (r). RESULTS: A total of 75 patients, with a mean age of 56.1 years and a disease duration of 17.3 years, were enrolled from a long-term care facility in the Netherlands. Results showed that after controlling for confounders, HADS is an independent determinant of ASCOT (βs = -.368; 95% CI, -.581 to -.154) and EQ-5D-5L (βs = -.297; 95% CI, -.507 to -.087). Also, there are significant but weak correlations between ASCOT and EQ-5D-5L (r = 0.242; 95% CI, .015-.468), between ASCOT and EQ-VAS (r = 0.230; 95% CI, .003-.457) and between EQ-5D-5L and EQ-VAS (r = 0.227; 95% CI, .000-.454). CONCLUSIONS: Mood, especially the depression component, is an important determinant of both HRQOL and SCRQOL in advanced MS. Focusing on mood in health care and social care may contribute to the improvement of QOL in a broader sense. [ABSTRACT FROM AUTHOR]

Introduction: Providing oral care is an essential part of basic nursing care but receives little priority in daily practice, with a risk of adverse events. Also, nurses report many barriers to adequate provision of oral care, such as time restraints, insufficient materials, fear of causing pain, lack of knowledge and a negative attitude towards providing oral care. Methods: We performed a cluster‐randomized, stepped‐wedge study to explore the effect of the the implementation of a new nursing evidence‐based oral care protocol on nurses' knowledge, attitude and protocol adherence. The study population included both nursing students, graduated nurses and patients in selected wards. The implementation strategy included oral and written information, instruction videos and reminders. Nurses' knowledge and attitude towards oral care were assessed at baseline and after the implementation of the protocol with a validated 47‐item questionnaire with a score range of 0–100. Secondarily, nurses' protocol adherence to teeth brushing, measured in Activities of Daily Living (ADL) dependent patients, was evaluated. The Standards for Reporting Implementation Studies (StaRI) Statement was used. Results: At baseline, the questionnaire was completed by 226 nurses; after implementation by 283. Knowledge had significantly improved from 68.8 to 72.3. Nurses' attitude improved not significantly. Protocol adherence was assessed in 73 ADL‐dependent patients at baseline, in 51 after implementation. Adherence to teeth brushing significantly decreased in patients with permanent teeth. Also, adherence to both teeth brushing and usage of soap decreased in patients with (partial) dentures. Conclusion: Nurses' knowledge and attitude of oral care increased somewhat after the implementation of a new nursing evidence‐based protocol. After implementation, there was an unexplained decreased adherence to oral care in ADL‐dependent patients. [ABSTRACT FROM AUTHOR]

Compounds originating from animal husbandry can pollute surface water through the application of manure to soil. Typically, grab sampling is employed to detect these residues, which only provides information on the concentration at the time of sampling. To better understand the emission patterns of these compounds, we utilized passive samplers in surface water to collect data at eight locations in a Dutch agricultural region, during different time intervals. As a passive sampler, we chose the integrative-based Speedisk® hydrophilic DVB. In total, we targeted 46 compounds, among which 25 antibiotics, three hormones, nine antiparasitics, and nine disinfectants. From these 46 compounds, 22 compounds accumulated in passive samplers in amounts above the limit of quantification in at least one sampling location. Over the 12-week deployment period, a time integrative uptake pattern was identified in 53% of the examined cases, with the remaining 47% not displaying this behavior. The occurrences without this behavior were primarily associated with specific location, particularly the most upstream location, or specific compounds. Our findings suggest that the proposed use of passive samplers, when compared in this limited context to traditional grab sampling, may provide enhanced efficiency and potentially enable the detection of a wider array of compounds. In fact, a number of compounds originating from animal husbandry activities were quantified for the first time in Dutch surface waters, such as flubendazole, florfenicol, and tilmicosine. The set-up of the sampling campaign also allowed to distinguish between different pollution levels during sampling intervals on the same location. This aspect gains particular significance when considering the utilization of different compounds on various occasions, hence, it has the potential to strengthen ongoing monitoring and mitigation efforts. [ABSTRACT FROM AUTHOR]

Aims: To explore potential areas of low‐value home‐based nursing care practices, their prevalence and related influencing factors of nurses and nursing assistants working in home‐based nursing care. Design: A quantitative, cross‐sectional design. Methods: An online survey with questions containing scaled frequencies on five‐point Likert scales and open questions on possible related influencing factors of low‐value nursing care. The data collection took place from February to April 2022. Descriptive statistics and linear regression were used to summarize and analyse the results. Results: A nationwide sample of 776 certified nursing assistants, registered nurses and nurse practitioners responded to the survey. The top five most delivered low‐value care practices reported were: (1) 'washing the client with water and soap by default', (2) 'application of zinc cream, powders or pastes when treating intertrigo', (3) 'washing the client from head to toe daily', (4) 're‐use of a urinary catheter bag after removal/disconnection' and (5) 'bladder irrigation to prevent clogging of urinary tract catheter'. The top five related influencing factors reported were: (1) 'a (general) practitioner advices/prescribes it', (2) 'written in the client's care plan', (3) 'client asks for it', (4) 'wanting to offer the client something' and (5) 'it is always done like this in the team'. Higher educational levels and an age above 40 years were associated with a lower provision of low‐value care. Conclusion: According to registered nurses and certified nursing assistants, a number of low‐value nursing practices occurred frequently in home‐based nursing care and they experienced multiple factors that influence the provision of low‐value care such as (lack of) clinical autonomy and handling clients' requests, preferences and demands. The results can be used to serve as a starting point for a multifaceted de‐implementation strategy. Reporting Method: STROBE checklist for cross‐sectional studies. Patient or Public Contribution: No Patient or Public Contribution. Implications for the Profession and/or Patient Care: Nursing care is increasingly shifting towards the home environment.Not all nursing care that is provided is effective or efficient and this type of care can therefore be considered of low‐value.Reducing low‐value care and increasing appropriate care will free up time, improve quality of care, work satisfaction, patient safety and contribute to a more sustainable healthcare system. [ABSTRACT FROM AUTHOR]

As interest in universal basic income (UBI) policy has peaked in recent years, the study of public support for such a policy is rapidly developing. While recent studies recognise the multidimensionality of the UBI proposal, we still know little about to what extent support for UBI is unambiguously supported or rejected. We show that the public holds distinct but related opinions towards three dimensions of UBI: universalism, redistribution and unconditionality. The higher and lower educated are equally ambivalent towards the policy, suggesting a lack of political entrenchment towards UBI in Dutch society. Post hoc comparisons show that key demographics and constituencies support some dimensions while rejecting others, enabling both compromise and division on the issue. Despite these distinct controversies, however, the strong correlation between attitudinal dimensions suggests that survey experiments tend to overstate the degree of multidimensionality by ignoring the strong commonalities in support for policy aspects. [ABSTRACT FROM AUTHOR]

Background: Nowadays, large benign lateral spreading lesions (LSLs) and sessile polyps in the colorectum are mostly resected by endoscopic mucosal resection (EMR). A major drawback of EMR is the polyp recurrence rate of up to 20%. Snare tip soft coagulation (STSC) is considered an effective technique to reduce recurrence rates. However, clinical trials on STSC have mainly been conducted in expert referral centers. In these studies, polyp recurrence was assessed optically, and additional adjunctive techniques were excluded. In the current trial, we will evaluate the efficacy and safety of STSC in daily practice, by allowing adjunctive techniques during EMR and the use of both optical and histological polyp recurrence to assess recurrences during follow-up. Methods: The RESPECT study is a multicenter, parallel-group, international single blinded randomized controlled superiority trial performed in the Netherlands and Germany. A total of 306 patients undergoing piecemeal EMR for LSLs or sessile colorectal polyps sized 20–60 mm will be randomized during the procedure after endoscopic complete polyp resection to the intervention or control group. Post-EMR defects allocated to the intervention group will be treated with thermal ablation with STSC of the entire resection margin. Primary outcome will be polyp recurrence by optical and histological confirmation at the first surveillance colonoscopy after 6 months. Secondary outcomes include technical success and complication rates. Discussion: The RESPECT study will evaluate if STSC is effective in reducing recurrence rates after piecemeal EMR of large colorectal lesions in daily clinical practice performed by expert and non-expert endoscopists. Moreover, endoscopists will be allowed to use adjunctive techniques to remove remaining adenomatous tissue during the procedure. Finally, adenomatous polyp recurrence during follow-up will be defined by histologic identification. Trial registration: ClinicalTrials.gov NCT05121805. Registered on 16 November 2021. Start recruitment: 17 March 2022. Planned completion of recruitment: 31 April 2025. [ABSTRACT FROM AUTHOR]

Background: To improve patients' privacy, comfort and infection control, newly built hospitals increasingly offer 100% single-occupancy patient rooms. Our study examines how nurses perceived the transition from a hospital with multi-bedded patient rooms to one with solely single-occupancy patient rooms designed according to principles of a healing environment. Methods: In a single-centre, before-after survey study, nurses completed a questionnaire of 21 items in three domains: perceived patient safety and monitoring, nurses' working conditions and patient environment. Before-measurements (n = 217) were compared with two after-measurements in the new hospital, respectively after one (n = 483) and two years (n = 191). Results: Nurses considered the single rooms in the new hospital worse for visibility and monitoring but this had improved somewhat after two years. In either setting, the majority perceived working conditions (walking distances and designated rest area) as unfavourable. The patient environment in the new hospital was generally perceived as much better than in the former hospital. Conclusion: The transition to solely single-occupancy patient rooms was largely considered positive by nurses in terms of patient environment. However, monitoring of patients and working conditions remain a concern. When designing new hospitals, attention should be paid to optimal working conditions for nurses. To improve monitoring of patients, we recommend the use of remote-sensoring. [ABSTRACT FROM AUTHOR]

Introduction and aims: Present-day home care needs to be more efficiently organized in view of the aging of the population and the current nursing shortages. Ensuring safe medication use is part of the challenge. The number of required visits could be reduced if automated home medication dispensers (AHMD) are adequately implemented. However, the barriers and facilitators for implementation are unknown. This project explored determinants (barriers, facilitators, or both) for implementing AHMD in home care, from Dutch home care nurses' perspective. Methods: Semi-structured interviews were conducted with 15 home care nurses. Determinants were identified through thematic content analysis. The first four transcripts were coded inductively. Then, a code tree was developed based on the Tailored Implementation for Chronic Diseases checklist, consisting of seven domains. Each code/determinant was then labelled as a barrier, facilitator, or both. Results: The most relevant domains were innovation factors, individual health professional factors, and patient factors. The most frequently mentioned barrier was the required unplanned visits when patients did not withdraw medication within the scheduled time limit (alarm). According to our respondents, carefully assessing patients' eligibility (e.g., learnability) and properly instructing and guiding them will help prevent these alarms from occurring. Next to these determinants, motivating patients to start using an AHMD and professionals having sufficient knowledge and confidence were the most frequently mentioned facilitators. Conclusion: This project provided an overview of 78 determinants from nurses' perspective for implementation of AHMD in home care. This can form the basis for developing strategies for implementing AHMD in home care. Further research is recommended to investigate the perceived determinants from the patients', relatives', and informal caregivers' perspectives, and to prioritize the determinants from all perspectives. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to evaluate the reasons for emergent cardiac surgery (ECS) after transcatheter aortic valve implantation (TAVI) and assess outcomes of these patients. Methods: All patients undergoing ECS following a complicated TAVI procedure at a high-volume TAVI centre in the Netherlands from 1 January 2008 to 1 April 2022 were included. Baseline and procedural characteristics and outcome data (procedural, 30-day and 1‑year mortality, in-hospital stroke, 30-day pacemaker implantation, 30-day vascular complications, 30-day deep sternal wound infections and 30-day re-exploration) were collected from patient files and analysed using descriptive statistics. Results: During the study period, 16 of 1594 patients (1.0%) undergoing TAVI required ECS. The main reason for ECS was valve embolisation (n = 9; 56.3%), followed by perforation of the left/right ventricle with guide wire/pacemaker lead (n = 3; 18.8%) and annular rupture (n = 3; 18.8%). Procedural, 30-day and 1‑year mortality was 0%, 18.8% (n = 3) and 31.3% (n = 5), respectively. In-hospital stroke occurred in 1 patient (6.3%), a pacemaker was implanted at 30 days in 2 patients (12.5%), and major vascular complications did not occur. Conclusion: ECS following complicated TAVI was performed in only a small number of cases. It had a high but acceptable perioperative and 30-day mortality, taking into account the otherwise lethal consequences. In case of valve embolisation, no periprocedural or 30-day mortality was observed for surgical aortic valve replacement (even in a redo setting), which supported the necessity to perform TAVI in centres with cardiac surgical backup on site. [ABSTRACT FROM AUTHOR]

The objective of this study was to better understand human variation by comparing cone‐beam computed tomography‐based cranial measurements between both sexes of individuals from two distinct populations: Brazilian and Dutch. Cone‐beam computed tomography volumes of 311 patients between 20 and 60 years from Brazil and The Netherlands were selected. Two radiologists performed 16 linear measurements in the maxillary sinuses and mandibular canal. Kruskall–Wallis test compared measurements of the two cranial structures between male and female for the two populations and four age ranges (20–30, 31–40, 41–50, 51–60). Mann–Whitney test compared individual measurements obtained from the cranial structures between male and female for each population, and between both populations for both sexes. Intra‐ and inter‐observer reliability was assessed by intraclass correlation test (α = 0.05). No significant differences were found in the linear measurements among the experimental groups including sex, population and age group for both cranial structures (p > 0.05). Most of the cranial linear measurements were significantly higher for male than those for female irrespective of the population (p ≤ 0.05). When the populations were compared regardless of sex, Brazilians presented four significantly higher measurements, and Dutch presented seven significantly higher measurements (p ≤ 0.05). The assessed cranial structures did not differ between Brazilian and Dutch populations for both sexes and four age ranges. Multiple linear measurements differed between both populations with a predominance of larger dimensions for the Dutch population. [ABSTRACT FROM AUTHOR]

Background: Early mobilisation of critically ill adults has been proven effective and is safe and feasible for critically ill children. However, barriers and perceived benefits of paediatric intensive care unit (PICU) staff involvement in mobilising critically ill children are largely unknown. Aim: To explore the barriers and perceived benefits regarding early mobilisation of critically ill children as perceived by PICU staff. Study design: A cross‐sectional survey study among staff from seven PICUs in the Netherlands has been carried out. Results: Two hundred and fifteen of the 641 health care professionals (33.5%) who were invited to complete a questionnaire responded, of whom 159 (75%) were nurses, 40 (19%) physicians, and 14 (6%) physical therapists. Respondents considered early mobilisation potentially beneficial to shorten the duration of mechanical ventilation (86%), improve wake/sleep rhythm (86%) and shorten the length of stay in the PICU (85%). However, staff were reluctant to mobilise patients on extracorporeal membrane oxygenation (ECMO) (63%), and patients with traumatic brain injury (49%). Perceived barriers to early mobilisation were hemodynamic instability (78%), risk of dislocation of lines/tubes (74%), and level of sedation (62%). In total, 40.3% of PICU nurses stated that physical therapists provided enough support in their PICU, but 84.6% of the physical therapists believed support was sufficient. Conclusion: Participating PICU staff considered early mobilisation as potentially beneficial in improving patient outcomes, although barriers were noted in certain patient groups. Relevance to clinical practice: We identified barriers to early mobilisation which should be addressed in implementation research projects in order to make early mobilisation in critically ill children work. [ABSTRACT FROM AUTHOR]

Aims Patients with suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) are routinely transferred to the emergency department (ED). A clinical risk score with point-of-care (POC) troponin measurement might enable ambulance paramedics to identify low-risk patients in whom ED evaluation is unnecessary. The aim was to assess safety and healthcare costs of a pre-hospital rule-out strategy using a POC troponin measurement in low-risk suspected NSTE-ACS patients. Methods and results This investigator-initiated, randomized clinical trial was conducted in five ambulance regions in the Netherlands. Suspected NSTE-ACS patients with HEAR (History, ECG, Age, Risk factors) score ≤3 were randomized to pre-hospital rule-out with POC troponin measurement or direct transfer to the ED. The sample size calculation was based on the primary outcome of 30-day healthcare costs. Secondary outcome was safety, defined as 30-day major adverse cardiac events (MACE), consisting of ACS, unplanned revascularization or all-cause death. : A total of 863 participants were randomized. Healthcare costs were significantly lower in the pre-hospital strategy (€1349 ± €2051 vs. €1960 ± €1808) with a mean difference of €611 [95% confidence interval (CI): 353–869; P < 0.001]. In the total population, MACE were comparable between groups [3.9% (17/434) in pre-hospital strategy vs. 3.7% (16/429) in ED strategy; P = 0.89]. In the ruled-out ACS population, MACE were very low [0.5% (2/419) vs. 1.0% (4/417)], with a risk difference of −0.5% (95% CI −1.6%–0.7%; P = 0.41) in favour of the pre-hospital strategy. Conclusion Pre-hospital rule-out of ACS with a POC troponin measurement in low-risk patients significantly reduces healthcare costs while incidence of MACE was low in both strategies. Trial registration Clinicaltrials.gov identifier NCT05466591 and International Clinical Trials Registry Platform id NTR 7346. [ABSTRACT FROM AUTHOR]

Background: Bariatric surgery has a proven beneficial effect on asthma symptoms and lung function in patients with class III obesity and asthma. The effects of bariatric surgery on asthma control and small airway function persist for at least 12 months after bariatric surgery. However, long-term follow-up data are lacking. Objectives: To evaluate the very-long term effects of bariatric surgery on asthma symptoms and lung function. Methods: In a prospective, longitudinal follow-up study, we planned an 8-year follow-up visit for patients previously included in the OBAS 1.0 trial, which evaluated the effects of bariatric surgery on asthma control and lung function in patients with asthma and class III obesity in The Netherlands. Results: Fifteen of 78 patients from the OBAS trial completed the 8-year follow-up visit. Nine patients underwent bariatric surgery, and six patients did not. After 8 years of follow-up, asthma control (Asthma Control Questionnaire [ACQ] score at 12 months of 0,4 versus an ACQ score of 0.7 at 8 years of follow-up; p = 0.075) and small airway function (R5-R20 (frequency-dependent resistance at 5Hz-20Hz); score at 12 months of 0,25 versus an ACQ score of 0.07 at 8 years of follow-up; p = 0.345) remained clinically stable compared with 12 months of follow-up. Patients who underwent bariatric surgery had a statistically significant weight regain between 12 months of follow-up and 8 years of follow-up (median [interquartile range] body mass index 30.2 kg/m² [23.9‐43.4 kg/m²] versus 32.3 kg/m² [24.0‐36.4 kg/m²]; p = 0.025). However, the impact of weight regain on asthma control, and asthma quality of life was clinically insignificant (ACQ, β (regression coefficient) = 0.04; 95% Confidence Interval [0.02; 0.06]; p < 0.001; and AQLQ; β = ‐0.04 CI [‐0.07; ‐0.009]; p = 0.013). Conclusion: These results emphasize the importance of bariatric surgery in treating obesity-related asthma. English - EN [ABSTRACT FROM AUTHOR]

Background: The causal pathway between complications after pancreatic cancer resection and impaired long-term survival remains unknown. The aim of this study was to investigate the impact of complications after pancreatic cancer resection on disease-free interval and overall survival, with adjuvant chemotherapy as a mediator. Methods: This observational study included all patients undergoing pancreatic cancer resection in the Netherlands (2014–2017). Clinical data were extracted from the prospective Dutch Pancreatic Cancer Audit. Recurrence and survival data were collected additionally. In causal mediation analysis, direct and indirect effect estimates via adjuvant chemotherapy were calculated. Results: In total, 1071 patients were included. Major complications (hazards ratio 1.22 (95 per cent c.i. 1.04 to 1.43); P = 0.015 and hazards ratio 1.25 (95 per cent c.i. 1.08 to 1.46); P = 0.003) and organ failure (hazards ratio 1.86 (95 per cent c.i. 1.32 to 2.62); P < 0.001 and hazards ratio 1.89 (95 per cent c.i. 1.36 to 2.63); P < 0.001) were associated with shorter disease-free interval and overall survival respectively. The effects of major complications and organ failure on disease-free interval (−1.71 (95 per cent c.i. −2.27 to −1.05) and −3.05 (95 per cent c.i. −4.03 to −1.80) respectively) and overall survival (−1.92 (95 per cent c.i. −2.60 to −1.16) and −3.49 (95 per cent c.i. −4.84 to −2.03) respectively) were mediated by adjuvant chemotherapy. Additionally, organ failure directly affected disease-free interval (−5.38 (95 per cent c.i. −9.27 to −1.94)) and overall survival (−6.32 (95 per cent c.i. −10.43 to −1.99)). In subgroup analyses, the association was found in patients undergoing pancreaticoduodenectomy, but not in patients undergoing distal pancreatectomy. Conclusion: Major complications, including organ failure, negatively impact survival in patients after pancreatic cancer resection, largely mediated by adjuvant chemotherapy. Prevention or adequate treatment of complications and use of neoadjuvant treatment may improve oncological outcomes. This nationwide observational cohort study included 1052 patients and showed that major complications, including organ failure, have a negative impact on disease-free interval and overall survival after resection of pancreatic cancer. This effect was largely mediated by the use of adjuvant chemotherapy. [ABSTRACT FROM AUTHOR]

Aims/Hypothesis: Optimal diabetes care and risk factor management are important to delay micro‐ and macrovascular complications in individuals with type 1 diabetes (T1D). Ongoing improvement of management strategies requires the evaluation of target achievement and identification of risk factors in individuals who do (or do not) achieve these targets. Methods: Cross‐sectional data were collected from adults with T1D visiting six diabetes centers in the Netherlands in 2018. Targets were defined as glycated hemoglobin (HbA1c) <53 mmol/mol, low‐density lipoprotein‐cholesterol (LDL‐c) <2.6 mmoL/L (no cardiovascular disease [CVD] present) or <1.8 mmoL/L (CVD present), or blood pressure (BP) <140/90 mm Hg. Target achievement was compared for individuals with and without CVD. Results: Data from 1737 individuals were included. Mean HbA1c was 63 mmol/mol (7.9%), LDL‐c was 2.67 mmoL/L, and BP 131/76 mm Hg. In individuals with CVD, 24%, 33%, and 46% achieved HbA1c, LDL‐c, and BP targets respectively. In individuals without CVD these percentages were 29%, 54%, and 77%, respectively. Individuals with CVD did not have any significant risk factors for HbA1c, LDL‐c, and BP target achievement. In comparison, individuals without CVD were more likely to achieve glycemic targets if they were men and insulin pump users. Smoking, microvascular complications, and the prescription of lipid‐lowering and antihypertensive medication were negatively associated with glycemic target achievement. No characteristics were associated with LDL‐c target achievement. Microvascular complications and antihypertensive medication prescription were negatively associated with BP target attainment. Conclusion: Opportunities for improvement of diabetes management exist for the achievement of glycemic, lipid, and BP targets but may differ between individuals with and without CVD. [ABSTRACT FROM AUTHOR]

SARS-CoV-2 prevention and control measures did not only impact SARS-CoV-2 circulation, but also the timing and prevalence of other seasonal respiratory viruses. Especially in children, information on exposure and infections to seasonal coronaviruses as well as SARS-CoV-2 in the first year of the pandemic is largely lacking. Therefore, we set up a one-year serological survey in a large tertiary hospital in the Netherlands. We show that seasonal coronavirus seroprevalence significantly decreased in 2021 in children less than one year, most likely due to COVID-19 control measures. The SARS-CoV-2 seroprevalence in children and adolescents increased from 0.4% to 11.3%, the highest in adolescents. This implies higher exposure rates in adolescents as compared to the general population (>18 years old). It is clear that there have been significant changes in the circulation and subsequent immunity against most respiratory pathogens as a result of the mitigation measures. The implications on shorter as well as longer term are still largely unknown, but the impact of the SARS-CoV-2 pandemic and subsequent control measures will continue to affect the dynamics of other pathogens. [ABSTRACT FROM AUTHOR]

Background: The prognostic implication of delirium subtypes in critically ill medical and surgical patients is scarcely investigated. The objective was to determine how delirium subtypes are associated with hospital mortality and other clinical outcomes. Methods: We performed a secondary analysis on data from a prospective multicenter study aimed at implementation of delirium-oriented measures, conducted between 2012 and 2015 in The Netherlands. We included adults (≥ 18 years) admitted to the medical or surgical intensive care unit (ICU). Exclusion criteria were neurological admission diagnosis, persistent coma or ICU readmissions. Delirium was assessed using the Confusion Assessment Method-ICU or Intensive Care Delirium Screening Checklist, and delirium subtypes (hypoactive, hyperactive, or mixed) were classified using the Richmond Agitation–Sedation Scale. The main outcome was hospital mortality. Secondary outcomes were ICU mortality, ICU length of stay, coma, mechanical ventilation, and use of antipsychotics, sedatives, benzodiazepines and opioids. Results: Delirium occurred in 381 (24.4%) of 1564 patients (52.5% hypoactive, 39.1% mixed, 7.3% hyperactive). After case-mix adjustment, patients with mixed delirium had higher hospital mortality than non-delirious patients (OR 3.09, 95%CI 1.79–5.33, p = 0.001), whereas hypoactive patients did not (OR 1.34, 95%CI 0.71–2.55, p = 0.37). Similar results were found for ICU mortality. Compared to non-delirious patients, both subtypes had longer ICU stay, more coma, increased mechanical ventilation frequency and duration, and received more antipsychotics, sedatives, benzodiazepines and opioids. Except for coma and benzodiazepine use, the most unfavourable outcomes were observed in patients with mixed delirium. Conclusions: Patients with mixed delirium had the most unfavourable outcomes, including higher mortality, compared with no delirium. These differences argue for distinguishing delirium subtypes in clinical practice and future research. Trial registration ClinicalTrials.gov NCT01952899. [ABSTRACT FROM AUTHOR]

Purpose Stress-related illnesses are prevalent in Western society, causing sick leave and putting a heavy economic burden on employers and society. For Dutch employers it is particularly relevant to have insight into the costs of absenteeism due to stress-related illness, as they are legally obligated to continue payment of wages. Therefore, this study assessed the duration and costs of an episode of sick leave due to stress-related illness for Dutch employers. Methods Data on sick leave due to various stress-related illnesses were obtained from a nationwide occupational health service database. Stress-related illnesses included tension complaints, burn-out, overexertion, and other reactions to stress. The duration per sick leave episode was estimated in working days, after which the average cost per sick leave period was estimated using age- and gender-specific price weights. Results During the study period, 16,676 employees took 17,338 episodes of sick leave due to stress-related illness. On average, one episode of sick leave lasted 101 working days, for which the costs for the employer were on average €19,151 per worker. Women were responsible for most episodes of sick leave and were on average 37 days more absent per episode compared to men. Moreover, of all kinds of stress-related illnesses, burn-out had the longest duration of sick leave with 313 calendar days and 163 working days, resulting in an average cost of €30,770. Conclusions Sick leave due to stress-related illness places a heavy burden on employers and thus society. Further research should be conducted on how to reduce this burden. [ABSTRACT FROM AUTHOR]

In the Netherlands, 69 of the 126 (55%) mink farms in total became infected with SARS‐CoV‐2 in 2020. Despite strict biosecurity measures and extensive epidemiological investigations, the main transmission route remained unclear. A better understanding of SARS‐CoV‐2 transmission between mink farms is of relevance for countries where mink farming is still common practice and can be used as a case study to improve future emerging disease preparedness. We assessed whether SARS‐CoV‐2 spilled over from mink to free‐ranging animals, and whether free‐ranging animals may have played a role in farm‐to‐farm transmission in the Netherlands. The study encompassed farm visits, farm questionnaires, expert workshops and SARS‐CoV‐2 RNA and antibody testing of samples from target animal species (bats, birds and free‐ranging carnivores). In this study, we show that the open housing system of mink allowed access to birds, bats and most free‐ranging carnivores, and that direct and indirect contact with mink was likely after entry, especially for free‐ranging carnivores and birds. This allowed SARS‐CoV‐2 exposure to animals entering the mink farm, and subsequent infection or mechanical carriage by the target animal species. Moreover, mink can escape farms in some cases, and two SARS‐CoV‐2‐positive mink were found outside farm premises. No other SARS‐CoV‐2‐RNA‐positive free‐ranging animals were detected, suggesting there was no abundant circulation in the species tested during the study period. To investigate previous SARS‐CoV‐2 infections, SARS‐CoV‐2 antibody detection using lung extracts of carcasses was set up and validated. One tested beech marten did have SARS‐CoV‐2 antibodies, but the closest SARS‐CoV‐2‐infected mink farm was outside of its home range, making infection at a mink farm unlikely. Knowing that virus exchange between different species and the formation of animal reservoirs affects SARS‐CoV‐2 evolution, continued vigilance and monitoring of mink farms and surrounding wildlife remains vital. [ABSTRACT FROM AUTHOR]

Introduction: Fasting plasma ketone bodies (KB) are elevated in individuals with type 2 diabetes (T2D) and could affect glycemic control and disease progression. Prolonged KB exposure may result in adaptive beneficial responses, counteracting glycemic dysregulation. In the current proof-of-concept study in adults with T2D, we hypothesized that fasting plasma KB are cross-sectionally associated with poorer glycemic control but prospectively with better glycemic control. Materials and Methods: Fasting plasma KB were measured via nuclear magnetic resonance spectroscopy in patients with T2D treated in primary care (Zodiac cohort; The Netherlands). We analyzed the associations between KB and HbA1c at baseline using linear regression analyses and HbA1c changes over time using linear mixed models. We adjusted for potential confounders, including risk factors for poor glycemic control. Individuals with T2D participating in the general population-based PREVEND study were used as a replication cohort. Results: We included 271 individuals with T2D with a total of 859 HbA1c measurements during a follow-up period of 3.0 (2.0–3.2) years. At baseline, the total amount of fasting plasma KB was independently and positively associated with HbA1c levels (regression coefficient in the fully adjusted analysis = 0.31; 95% CI 0.06–0.57, per doubling of KB; p = 0.02). In contrast, in the longitudinal analyses, fasting plasma KB were associated with a yearly HbA1c (%) decrease of −0.10 (95% CI −0.19 to −0.00 per doubling baseline KB; p = 0.05). Results were replicated in 387 individuals with T2D from a general population cohort with a total of 1115 glucose measurements during a follow-up period of 7.5 (7.2–8.0) years. A yearly decrease in fasting plasma glucose (mmol/L) of 0.09 was found per doubling of baseline KB. Conclusions: This study is the first to suggest a paradoxical role of circulating KB on glycemic control in T2D: elevated KB are associated with cross-sectionally poorer glycemic control but longitudinally with better long-term glycemic control. [ABSTRACT FROM AUTHOR]

Malaysia Airlines flight 17 crashed on 17 July 2014 while flying over an area of armed conflict in eastern Ukraine. The first forensic trace evidence was collected after the human remains were transferred to a safe location in the Netherlands for identification and repatriation. Disaster victim identification processes were therefore undertaken in concert with the forensic investigation. Prior to these processes, X-ray and computed tomography scanners were used to reveal foreign objects in the human remains, and a large number of these fragments were recovered after the forensic triage. A distinct group of metal fragments was identified as being potential remnants of high-energy foreign objects. Forensic analysis revealed that they were explosively deformed unalloyed steel fragments, some of which had shapes consistent with pre-formed metal fragments found in a 9N314M warhead used in Buk SA-11 missiles. Furthermore, thin film deposits of cockpit glass and aluminium were identified on the most heavily deformed side of some of the explosively deformed metal fragments, suggesting they came from outside the airplane. These findings supported early suspicions that Malaysia Airlines flight 17 was struck by a Buk SA-11 missile. A multidisciplinary approach for combined identification and forensic investigation of human remains after a mass fatality incident. The combined use of complementary X-ray techniques for detection and provisional characterization of foreign objects in human remains. The use of sensitive and highly discriminative state of the art techniques for analysing foreign objects recovered from human remains. [ABSTRACT FROM AUTHOR]

Objectives: Over 2500 percutaneous transhepatic cholangiography and biliary drainage (PTCD) procedures are yearly performed in the Netherlands. Most interventions are performed for treatment of biliary obstruction following unsuccessful endoscopic biliary cannulation. Our aim was to evaluate complication rates and risk factors for complications in PTCD patients after failed ERCP. Methods: We performed an observational study collecting data from a cohort that was subjected to PTCD during a 5-year period in one academic and four teaching hospitals. Primary objective was the development of infectious (sepsis, cholangitis, abscess, or cholecystitis) and non-infectious complications (bile leakage, severe hemorrhage, etc.) and mortality within 30 days of the procedure. Subsequently, risk factors for complications and mortality were analyzed with a multilevel logistic regression analysis. Results: A total of 331 patients underwent PTCD of whom 205 (61.9%) developed PTCD-related complications. Of the 224 patients without a pre-existent infection, 91 (40.6%) developed infectious complications, i.e., cholangitis in 26.3%, sepsis in 24.6%, abscess formation in 2.7%, and cholecystitis in 1.3%. Non-infectious complications developed in 114 of 331 patients (34.4%). 30-day mortality was 17.2% (N = 57). Risk factors for infectious complications included internal drainage and drain obstruction, while multiple re-interventions were a risk factor for non-infectious complications. Conclusion: Both infectious and non-infectious complications are frequent after PTCD, most often due to biliary drain obstruction. [ABSTRACT FROM AUTHOR]

Jaundice caused by hyperbilirubinaemia is a common phenomenon during the neonatal period. Population-based studies evaluating assessment, management, and incidence of jaundice and need for phototherapy among otherwise healthy neonates are scarce. We prospectively explored these aspects in a primary care setting via assessing care as usual during the control phase of a stepped wedge cluster randomised controlled trial. We conducted a prospective cohort study embedded in the Screening and TreAtment to Reduce Severe Hyperbilirubinaemia in Infants in Primary care (STARSHIP) Trial. Healthy neonates were included in seven primary care birth centres (PCBCs) in the Netherlands between July 2018 and March 2020. Neonates were eligible for inclusion if their gestational age was ≥ 35 weeks, they were admitted in a PCBC for at least 2 days during the first week of life, and if they did not previously receive phototherapy. Outcomes were the findings of visual assessment to detect jaundice, jaundice incidence and management, and the need for phototherapy treatment in the primary care setting. 860 neonates were included of whom 608 (71.9%) were visibly jaundiced at some point during admission in the PCBC, with 20 being 'very yellow'. Of the latter, four (20%) did not receive total serum bilirubin (TSB) quantification. TSB levels were not associated with the degree of visible jaundice (p = 0.416). Thirty-one neonates (3.6%) received phototherapy and none received an exchange transfusion. Five neonates did not receive phototherapy despite having a TSB level above phototherapy threshold. Jaundice is common in otherwise healthy neonates cared for in primary care. TSB quantification was not always performed in very jaundiced neonates, and not all neonates received phototherapy when indicated. Quality improvement initiatives are required, including alternative approaches to identifying potentially severe hyperbilirubinaemia. Trial registration: NL6997 (Dutch Trial Register; Old NTR ID 7187), registered 3 May 2018. [ABSTRACT FROM AUTHOR]

Background: The evidence for rehabilitation interventions poststroke lack sufficient robustness. However, variation in treatment effects across countries have been given little attention. Objective: To compare two identically protocolized trials conducted in different western countries in order to identify factors that may have caused variation in secondary trial outcomes. Methods: Comparative study based on individual patient data (N = 129) from two randomized controlled trials, conducted in hospitals and rehabilitation facilities in the Netherlands (N = 66) and Australia (N = 63). Patients with stroke and their caregivers were randomly allocated to an 8-week caregiver-mediated exercises intervention (N = 63; 31 Australian and 32 Dutch) or to a control group (N = 66; 32 Australian and 34 Dutch). Patient characteristics, compliance, usual care and process measures were compared across countries. We examined if study setting significantly moderated the trial outcomes: Hospital Anxiety and Depression Scale, Fatigue Severity Scale and General Self-Efficacy Scale, measured at 8- and 12 weeks follow-up. In addition, we explored if factors that were significantly different across countries caused variation in these trial outcomes. Results: Most patients suffered an ischemic stroke, were in the subacute phase and participated with their partner. Dutch patients were younger (P = 0.005) and had a lower functional status (P = 0.001). Australian patients were recruited earlier poststroke (P<0.001), spent less time in exercise therapy (P<0.001) and had a shorter length of stay (P<0.001). The level of contamination was higher (P = 0.040) among Dutch controls. No effect modification was observed and trial outcomes did not change after controlling for cross-country differences. Conclusions: The present study highlighted important clinical differences across countries whilst using an identical study protocol. The observed differences could result in a different potential for recovery and variation in treatment effects across trials. We argue that we can proceed faster to evaluating interventions within international pragmatic trials. [ABSTRACT FROM AUTHOR]

Background: Nonsteroidal anti-inflammatory drugs (NSAIDs), pancreatic duct stenting, and intensive intravenous hydration have been proven to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Trial participation and guideline changes demanded an assessment of the clinical practice of post-ERCP pancreatitis prophylaxis. Aims: The surveys aim to identify points of improvement to inform and educate ERCPists about current evidence-based practice. Methods: Two anonymous surveys were conducted among Dutch gastroenterologists in 2013 (n = 408) and 2020 (n = 575) for longitudinal views and attitudes pertaining to post-ERCP pancreatitis prophylaxis and recognition of post-ERCP pancreatitis risk factors. Results: In 2013 and 2020, respectively, 121 and 109 ERCPists responded. In the 2013 survey, 98% of them utilized NSAID prophylaxis and 62% pancreatic duct stent prophylaxis in specific cases. In the 2020 survey, the use of NSAIDs (100%), pancreatic duct stents (78%), and intensive intravenous hydration (33%) increased among ERCPists. NSAID prophylaxis was the preferred prophylactic measure for all risk factors in the 2020 survey, except for ampullectomy, pancreatic duct contrast injection, and pancreatic duct cannulation, for which NSAID prophylaxis and pancreatic duct stent combined was equally favored or preferred. Conclusion: Rectal NSAIDs are the most applied post-ERCP pancreatitis prophylaxis in the Netherlands, followed by pancreatic duct stents and intensive intravenous hydration. Additionally, there is reason to believe that recent guideline updates and active research participation have led to increased prophylaxis implementation. [ABSTRACT FROM AUTHOR]

Background: Vancomycin-resistant enterococci (VRE) are successful nosocomial pathogens able to cause hospital outbreaks. In the Netherlands, core-genome MLST (cgMLST) based on short-read sequencing is often used for molecular typing. Long-read sequencing is more rapid and provides useful information about the genome's structural composition but lacks the precision required for SNP-based typing and cgMLST. Here we compared prophages among 50 complete E. faecium genomes belonging to different lineages to explore whether a phage signature would be usable for typing and identifying an outbreak caused by VRE. As a proof of principle, we investigated if long-read sequencing data would allow for identifying phage signatures and thereby outbreak-related isolates. Results: Analysis of complete genome sequences of publicly available isolates showed variation in phage content among different lineages defined by MLST. We identified phage present in multiple STs as well as phages uniquely detected within a single lineage. Next, in silico phage typing was applied to twelve MinION sequenced isolates belonging to two different genetic backgrounds, namely ST117/CT24 and ST80/CT16. Genomic comparisons of the long-read-based assemblies allowed us to correctly identify isolates of the same complex type based on global genome architecture and specific phage signature similarity. Conclusions: For rapid identification of related VRE isolates, phage content analysis in long-read sequencing data is possible. This allows software development for real-time typing analysis of long-read sequencing data, which will generate results within several hours. Future studies are required to assess the discriminatory power of this method in the investigation of ongoing outbreaks over a longer time period. [ABSTRACT FROM AUTHOR]

Background: First studies indicate that up to 6 months after hospital discharge, coronavirus disease 2019 (COVID-19) causes severe physical, cognitive, and psychological impairments, which may affect participation and health-related quality of life (HRQoL). After hospitalization for COVID-19, a number of patients are referred to medical rehabilitation centers or skilled nursing facilities for further treatment, while others go home with or without aftercare. The aftercare paths include 1] community-based rehabilitation; 2] in- and outpatient medical rehabilitation; 3] inpatient rehabilitation in skilled nursing facilities; and 4] sheltered care (inpatient). These aftercare paths and the trajectories of recovery after COVID-19 urgently need long-term in-depth evaluation to optimize and personalize treatment. CO-FLOW aims, by following the outcomes and aftercare paths of all COVID-19 patients after hospital discharge, to systematically study over a 2-year period: 1] trajectories of physical, cognitive, and psychological recovery; 2] patient flows, healthcare utilization, patient satisfaction with aftercare, and barriers/facilitators regarding aftercare as experienced by healthcare professionals; 3] effects of physical, cognitive, and psychological outcomes on participation and HRQoL; and 4] predictors for long-term recovery, health care utilization, and patient satisfaction with aftercare.Methods: CO-FLOW is a multicenter prospective cohort study in the mid-west of the Netherlands with a 2-year follow-up period. Measurements comprise non-invasive clinical tests and patient reported outcome measures from a combined rehabilitation, pulmonary, and intensive care perspective. Measurements are performed at 3, 6, 12, and 24 months after hospital discharge and, if applicable, at rehabilitation discharge. CO-FLOW aims to include at least 500 patients who survived hospitalization for COVID-19, aged ≥18 years.Discussion: CO-FLOW will provide in-depth knowledge on the long-term sequelae of COVID-19 and the quality of current aftercare paths for patients who survived hospitalization. This knowledge is a prerequisite to facilitate the right care in the right place for COVID-19 and comparable future infectious diseases.Trial Registration: The Netherlands Trial Register (NTR), https://www.trialregister.nl . Registered: 12-06-2020, CO-FLOW trialregister no. NL8710. [ABSTRACT FROM AUTHOR]

Background: Very few studies assessed the association between Intensive Care Unit (ICU) triage decisions and mortality. The aim of this study was to assess whether an association could be found between 30-day mortality, and ICU admission consultation conditions and triage decisions. Methods: We conducted a retrospective cohort study in two large referral university hospitals in the Netherlands. We identified all adult cancer patients for whom ICU admission was requested from 2016 to 2019. Via a multivariable logistic regression analysis, we assessed the association between 30-day mortality, and ICU admission consultation conditions and triage decisions. Results: Of the 780 cancer patients for whom ICU admission was requested, 332 patients (42.6%) were considered 'too well to benefit' from ICU admission, 382 (49%) patients were immediately admitted to the ICU and 66 patients (8.4%) were considered 'too sick to benefit' according to the consulting intensivist(s). The 30-day mortality in these subgroups was 30.1%, 36.9% and 81.8%, respectively. In the patient group considered 'too well to benefit', 258 patients were never admitted to the ICU and 74 patients (9.5% of the overall study population, 22.3% of the patients 'too well to benefit') were admitted to the ICU after a second ICU admission request (delayed ICU admission). Thirty-day mortality in these groups was 25.6% and 45.9%. After adjustment for confounders, ICU consultations during off-hours (OR 1.61, 95% CI 1.09–2.38, p-value 0.02) and delayed ICU admission (OR 1.83, 95% CI 1.00–3.33, p-value 0.048 compared to "ICU admission") were independently associated with 30-day mortality. Conclusion: The ICU denial rate in our study was high (51%). Sixty percent of the ICU triage decisions in cancer patients were made during off-hours, and 22.3% of the patients initially considered "too well to benefit" from ICU admission were subsequently admitted to the ICU. Both decisions during off-hours and a delayed ICU admission were associated with an increased risk of death at 30 days. Our study suggests that in cancer patients, ICU triage decisions should be discussed during on-hours, and ICU admission policy should be broadened, with a lower admission threshold for critically ill cancer patients. [ABSTRACT FROM AUTHOR]

The aim of this study was to investigate trends in frailty and its relationship with mortality among older adults aged 64–84 years across a period of 21 years. We used data from 1995 to 2016 from the Longitudinal Aging Study Amsterdam. A total of 7,742 observations of 2,874 respondents in the same age range (64–84 years) across 6 measurement waves were included. Frailty was measured with a 32-item frailty index, with a cutpoint of ≥0.25 to indicate frailty. The outcome measure was 4-year mortality. Generalized estimating equation analyses showed that among older adults aged 64–84 years the 4-year mortality rate declined between 1995 and 2016, while the prevalence of frailty increased. Across all measurement waves, frailty was associated with 4-year mortality (odds ratio = 2.79, 95% confidence interval: 2.39, 3.26). There was no statistically significant interaction effect between frailty and time on 4-year mortality, indicating a stable association between frailty and mortality. In more recent generations of older adults, frailty prevalence rates were higher, while excess mortality rates of frailty remained the same. This is important information for health policy-makers and clinical practitioners, showing that continued efforts are needed to reduce frailty and its negative health consequences. [ABSTRACT FROM AUTHOR]

Introduction: Given clinicians' frequent concerns about unfavourable outcomes, Intensive Care Unit (ICU) triage decisions in acutely ill cancer patients can be difficult, as clinicians may have doubts about the appropriateness of an ICU admission. To aid to this decision making, we studied the survival and performance status of cancer patients 2 years following an unplanned ICU admission. Materials and methods: This was a retrospective cohort study in a large tertiary referral university hospital in the Netherlands. We categorized all adult patients with an unplanned ICU admission in 2017 into two groups: patients with or without an active malignancy. Descriptive statistics, Pearson's Chi-square tests and the Mann-Whitney U tests were used to evaluate the primary objective 2-year mortality and performance status. A good performance status was defined as ECOG performance status 0 (fully active) or 1 (restricted in physically strenuous activity but ambulatory and able to carry out light work). A multivariable binary logistic regression analysis was used to identify factors associated with 2-year mortality within cancer patients. Results: Of the 1046 unplanned ICU admissions, 125 (12%) patients had cancer. The 2-year mortality in patients with cancer was significantly higher than in patients without cancer (72% and 42.5%, P <0.001). The median performance status at 2 years in cancer patients was 1 (IQR 0–2). Only an ECOG performance status of 2 (OR 8.94; 95% CI 1.21–65.89) was independently associated with 2-year mortality. Conclusions: In our study, the majority of the survivors have a good performance status 2 years after ICU admission. However, at that point, three-quarter of these cancer patients had died, and mortality in cancer patients was significantly higher than in patients without cancer. ICU admission decisions in acutely ill cancer patients should be based on performance status, severity of illness and long-term prognosis, and this should be communicated in the shared decision making. An ICU admission decision should not solely be based on the presence of a malignancy. [ABSTRACT FROM AUTHOR]

Background: For metabolic laparoscopic surgery, higher pressures up to 20 mmHg are often used to create a surgical field of sufficient quality. This randomized pilot study aimed to determine the feasibility, safety and tolerability of low intraabdominal pressure (IAP) and deep neuromuscular blockade (NMB) to reduce postoperative pain.Methods: In a teaching hospital in the Netherlands, 62 patients eligible for a laparoscopic Roux-en-Y gastric bypass (LRYGB) were randomized into one of four groups in a 2 × 2 factorial design: deep/moderate NMB and standard (20 mmHg)/low IAP (12 mmHg). Patient and surgical team were blinded. Primary outcome measure was the surgical field quality, scored on the Leiden-Surgical Rating Scale (L-SRS). Secondary outcome measures were (serious) adverse events, duration of surgery and postoperative pain.Results: 62 patients were included. L-SRS was good or perfect in all patients that were operated under standard IAP with deep or moderate NMB. In 40% of patients with low IAP and deep NMB, an increase in IAP was needed to improve surgical overview. In patients with low IAP and moderate NMB, IAP was increased to improve surgical overview in 40%, and in 75% of these cases a deep NMB was requested to further improve the surgical overview. Median duration of surgery was 38 min (IQR34-40 min) in the group with standard IAP and moderate NMB and 52 min (IQR46-55 min) in the group with low IAP and deep NMB.Conclusions: The combination of moderate NMB and low IAP can create insufficient surgical overview. Larger trials are needed to corroborate the findings of this study.Trial Registration: Dutch Trial Register: Trial NL7050, registered 28 May 2018. https://www.trialregister.nl/trial/7050 . [ABSTRACT FROM AUTHOR]

Objective: To compare the effectiveness of progressive tendon-loading exercises (PTLE) with eccentric exercise therapy (EET) in patients with patellar tendinopathy (PT).Methods: In a stratified, investigator-blinded, block-randomised trial, 76 patients with clinically diagnosed and ultrasound-confirmed PT were randomly assigned in a 1:1 ratio to receive either PTLE or EET. The primary end point was clinical outcome after 24 weeks following an intention-to-treat analysis, as assessed with the validated Victorian Institute of Sports Assessment for patellar tendons (VISA-P) questionnaire measuring pain, function and ability to play sports. Secondary outcomes included the return to sports rate, subjective patient satisfaction and exercise adherence.Results: Patients were randomised between January 2017 and July 2019. The intention-to-treat population (mean age, 24 years, SD 4); 58 (76%) male) consisted of patients with mostly chronic PT (median symptom duration 2 years). Most patients (82%) underwent prior treatment for PT but failed to recover fully. 38 patients were randomised to the PTLE group and 38 patients to the EET group. The improvement in VISA-P score was significantly better for PTLE than for EET after 24 weeks (28 vs 18 points, adjusted mean between-group difference, 9 (95% CI 1 to 16); p=0.023). There was a trend towards a higher return to sports rate in the PTLE group (43% vs 27%, p=0.13). No significant between-group difference was found for subjective patient satisfaction (81% vs 83%, p=0.54) and exercise adherence between the PTLE group and EET group after 24 weeks (40% vs 49%, p=0.33).Conclusions: In patients with PT, PTLE resulted in a significantly better clinical outcome after 24 weeks than EET. PTLE are superior to EET and are therefore recommended as initial conservative treatment for PT. [ABSTRACT FROM AUTHOR]

Background: Treatment limitation decisions (TLDs) on the ICU can be challenging, especially in patients with a malignancy. Up-to-date literature regarding TLDs in critically ill patients with a malignancy admitted to the ICU is scarce. The aim was to compare the incidence of written TLDs between patients with an active malignancy, patients with a malignancy in their medical history (complete remission, CR) and patients without a malignancy admitted unplanned to the ICU. Methods: We conducted a retrospective cohort study in a large university hospital in the Netherlands. We identified all unplanned admissions to the ICU in 2017 and categorized the patients in 3 groups: patients with an active malignancy (study population), with CR and without a malignancy. A TLD was defined as a written instruction not to perform life-saving treatments, such as CPR in case of cardiac arrest. A multivariate binary logistic regression analysis was used to identify whether having a malignancy was associated with TLDs. Results: Of the 1046 unplanned admissions, 125 patients (12%) had an active malignancy and 76 (7.3%) patients had CR. The incidence of written TLDs in these subgroups were 37 (29.6%) and 20 (26.3%). Age (OR 1.03; 95% CI 1.01 -1.04), SOFA score at ICU admission (OR 1.11; 95% CI 1.05 -1.18) and having an active malignancy (OR 1.75; 95% CI 1.04-2.96) compared to no malignancy were independently associated with written TLDs. SOFA scores on the day of the TLD were not significantly different in patients with and without a malignancy. Conclusions: This study shows that the presence of an underlying malignancy is independently associated with written TLDs during ICU stay. Patients with CR were not at risk of more written TLDs. Whether this higher incidence of TLDs in patients with a malignancy is justified, is at least questionable and should be evaluated in future research. [ABSTRACT FROM AUTHOR]

An emerging and innovative way of organizing projects in health technology and innovation is the so-called "living lab". Because of their characteristics, living labs may provide a solution to a very old problem: how to facilitate the meaningful participation of stakeholders in science and technology? In this article, I (we use a first-person perspective in the paper) aim to contribute to the literature by providing an account of my experiences as a participation researcher with stakeholder participation in a living lab in the Netherlands. I participated in a yearlong project on ensuring freedom for residents in a closed psychogeriatric ward. Using three key moments from that experience, I illustrate why participation was the intention, but was harder to achieve in practice. Participation processes and living labs are situated in specific social and physical contexts. I discuss the "situatedness" of living labs and propose to reconceptualize them as "situated practices": the value of a living lab lies in the processes of work it conducts on specific innovations situated in its local context. A key conclusion is that providing narrative descriptions of living lab projects, with attention to situatedness and stakeholder participation, can provide invaluable examples, insights, and inspirations for other researchers in the field. [ABSTRACT FROM AUTHOR]

Objective: Sit-stand workstations have been shown to be effective in reducing sitting time in office workers. The aim of this study was to explore reasons for use and non-use of sit-stand workstations and strategies to decrease sitting and increase physical activity in the workplace from perspectives of users and non-users, as well as from managers and ergo-coaches. Methods: Six group interviews with employees who have had access to sit-stand workstations for several years were conducted in a large semi-governmental organisation in the Netherlands. Verbatim transcripts were analysed using thematic analysis. Open coding was conducted by three researchers and codes and themes were discussed within the research team. Results: Thematic analysis resulted in two major themes: 1) Reasons for use and non-use and 2) Strategies to increase standing and physical activity in the workplace. Shared and distinct reasons for use and non-use were identified between users and non-users of the sit-stand workstations. The most important reasons for use indicated by users were that they had experiencing immediate benefits, including staying alert and increasing focus; these benefits were not acknowledged by non-users. Non-users indicated that sitting was comfortable for them and that they were therefore not motivated to use the standing option. Strategies to increase the use of the standing option included an introductory phase to become familiar with working while standing and to experience the immediate benefits that come from using the standing option. Furthermore, providing reminders to use the standing option was suggested as a strategy to increase and sustain the use of sit-stand workstations. Increased use may lead to a change in the sitting culture within the organisation, as more employees would adopt active movement behaviours. Conclusion: Immediate benefits of the use of the standing option–only mentioned by the users–was the most distinct reason to use sit-stand workstations. Future research should explore how to motivate potential users to adhere to an introductory phase in order to experience these immediate benefits, whether it is linked to the use of sit-stand workstations or other interventions to reduce sitting time. [ABSTRACT FROM AUTHOR]

Aims and objectives: To identify that workarounds (defined as "informal temporary practices for handling exceptions to normal procedures or workflow") by nurses using information technology potentially compromise medication safety. Therefore, we aimed to identify potential risk factors associated with workarounds performed by nurses in Barcode‐assisted Medication Administration in hospitals. Background: Medication errors occur during the prescribing, distribution and administration of medication. Errors could harm patients and be a tragedy for both nurses and medical doctors involved. Interventions to prevent errors have been developed, including those based on information technology. To cope with shortcomings in information technology‐based interventions as Barcode‐assisted Medication Administration, nurses perform workarounds. Identification of workarounds in information technology is essential to implement better‐designed software and processes which fit the nurse workflow. Design: We used the data from our previous prospective observational study, performed in four general hospitals in the Netherlands using Barcode techniques, to administer medication to inpatients. Methods: Data were collected from 2014–2016. The disguised observation was used to gather information on potential risk factors and workarounds. The outcome was a medication administration with one or more workarounds. Logistic mixed models were used to determine the association between potential risk factors and workarounds. The STROBE checklist was used for reporting our data. Results: We included 5,793 medication administrations among 1,230 patients given by 272 nurses. In 3,633 (62.7%) of the administrations, one or more workarounds were observed. In the multivariate analysis, factors significantly associated with workarounds were the medication round at 02 p.m.–06 p.m. (adjusted odds ratio [OR]: 1.60, 95% CI: 1.05–2.45) and 06 p.m.–10 p.m. (adjusted OR: 3.60, 95% CI: 2.11–6.14) versus the morning shift 06 a.m.–10 a.m., the workdays Monday (adjusted OR: 2.59, 95% CI: 1.51–4.44), Wednesday (adjusted OR: 1.92, 95% CI: 1.2–3.07) and Saturday (adjusted OR: 2.24, 95% CI: 1.31–3.84) versus Sunday, the route of medication, nonoral (adjusted OR: 1.28, 95% CI: 1.05–1.57) versus the oral route of drug administration, the Anatomic Therapeutic Chemical classification‐coded medication "other" (consisting of the irregularly used Anatomic Therapeutic Chemical classes [D, G, H, L, P, V, Y, Z]) (adjusted OR: 1.49, 95% CI: 1.05–2.11) versus Anatomic Therapeutic Chemical class A (alimentary tract and metabolism), and the patient–nurse ratio ≥6–1 (adjusted OR: 5.61, 95% CI: 2.9–10.83) versus ≤5–1. Conclusions: We identified several potential risk factors associated with workarounds performed by nurses that could be used to target future improvement efforts in Barcode‐assisted Medication Administration. Relevance to clinical practice: Nurses administering medication in hospitals using Barcode‐assisted Medication Administration frequently perform workarounds, which may compromise medication safety. In particular, nurse workload and the patient–nurse ratio could be the focus for improvement measures as these are the most clearly modifiable factors identified in this study. [ABSTRACT FROM AUTHOR]

Cultural impacts in planning increasingly receive attention from both academics and practitioners around Europe. However, comparative planning cultures studies face the challenges of lacking systematic comparison and empirical evidence, especially at the micro level of planning actors' behaviour in interaction. This article aims to fill these gaps by (1) operationalizing the concept of planning culture; and (2) measuring and comparing it. We base our operationalization on the culturized planning model (Knieling, J., & Othengrafen, F. (Eds.). (2009). Planning cultures in Europe: Decoding cultural phenomena in urban and regional planning. Farnham: Ashgate). We complement its explanatory power by building a link between planning culture and planning outcome through attitudes of planning actors. This article focuses on three attitudes: risk, trust and co-operation. To measure and compare these attitudes, we adopt three experimental economic games and conduct an experiment with public and private planning practitioners in three European countries: Belgium, the Netherlands and Norway. Both cross-country and public-private differences in these attitudes are tested in the experiment. Our experimental findings suggest that Dutch planning actors value risk aversion and trust; Norwegian planning actors value cooperation; while (French-speaking) Belgian planning actors do not value these variables that much. [ABSTRACT FROM AUTHOR]

This study examines dropout incidence, moment of dropout, and switching behavior in organized exercise programs for seniors in the Netherlands, as determined in a prospective cohort study (with baseline measurements at the start of the exercise program and follow-up after 6 months; N = 1,725, response rate 73%). Participants were community-living individuals 50+ who participated in different forms of organized exercise programs. The average dropout incidence was 0.15 per 6 months, which is lower than that for the general population. The dropout incidence and the timing of dropout differed substantially between the exercise programs. In total, 31% of people who dropped out of one type of exercise program switched to another type of exercise. The type of program and exercise had a strong effect on differences in this switching behavior. It is recommended that switching behavior be monitored in future studies. [ABSTRACT FROM AUTHOR]

There has been a growing research interest in measuring the impact of planning and land-use regulations on housing market outcomes, but parallel development of the evidence base for the business sector has yet to occur. This article examines the impact of planning intervention on the amount of building investment taking place at sites allocated for industrial and business development. Measures that capture different dimensions of planning intervention are incorporated into models of industrial building investment. The models are estimated using a novel micro dataset on permit activity that covers a sample of industrial and business sites in the Netherlands. The results provide evidence of some of the expected negative effects of the regulatory role of planning intervention, but also show that proactive, targeted planning policies exert a significant and positive influence on investment activity. Specifically, policy-induced improvements to the physical environment will stimulate both new construction and refurbishment activity. [ABSTRACT FROM AUTHOR]

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Background: In high-income countries delivery usually takes place in a short-stay hospital setting and includes limited specific care after discharge. Perinatal system performance is therefore predominantly expressed in direct terms of delivery outcomes such as preterm birth (PTB), small for gestational age (SGA) or, in case of the mother, perineal rupture and haemorrhage. Additional postnatal complications may emerge, but their incidence is largely unknown. The Dutch obstetric system includes an 8–10 day episode of professional postnatal home maternity care. Our aim was to establish, under routine conditions, the incidence of a comprehensive set of 67 predefined complications and their predictors. A second aim was to address interaction between maternal and child complications. Methods: The study design was a prospective cohort study of all clients of one large maternity care organization receiving home maternity care in November 2014. We combined maternal background and intrapartum and postnatal characteristics with complication data, routinely recorded by home maternity care assistants. Complication prevalence rates per postnatal day were calculated. Univariate and multivariable logistic regression were used to predict the presence of postnatal complications. Results: Complications occurred throughout the entire episode of home maternity care and prevalence was high, with 55% of all mother-baby pairs experiencing at least one complication (e.g. cracked nipples, >10% weight loss of the baby) and 5% at least one major complication (e.g. mastitis, cyanosis of the baby). Predictive ability of maternal background and intrapartum and postnatal variables on presence of complications was moderate (max. 62.9%), even when a cumulative risk score was used. Conclusions: The prevalence rates of maternal and neonatal postnatal complications with care as usual in high-income countries was higher than expected. Professional postnatal follow-up is to be considered in order to timely detect and manage emerging complications with minimal delay. Opportunities for risk-guided care should be investigated further. The pattern of complications in low-income countries remains to be established. [ABSTRACT FROM AUTHOR]

This paper looks at the consequences of the recent property market boom-bust cycle from the planners’ perspective. It takes the case of Dutch local governments and, in particular, the instrument of public land development. The analysis focusses on the question whether the economic downturn has given rise to a reconsideration of the intertwinement of public and private roles inherent to public land development. The paper sheds light on the formal changes in land management strategies in the recent years and asks whether these formal institutional changes result in less controversial land management, in terms of efficiency, effectiveness, fairness and democratic legitimation. It concludes that, although at first sight the findings suggest a paradigm shift in Dutch land management strategies, municipalities have not sorted out robust new alternatives. Public land development creates serious path dependencies and current changes in the regulatory space of land management are mostly pragmatic and show lots of traces of the old model. If local authorities keep pursuing their active, entrepreneurial, involvement in the land market in an ad-hoc manner, they face challenges regarding how to keep control over the discretionary power. It raises serious new dilemmas on transparency and predictability of municipal behaviour. There is a risk of ending up in a patchwork situation where different regulatory aspects are changed inconsistently. [ABSTRACT FROM AUTHOR]

Inspired by the real life problem of a radiology department in a Dutch hospital, we study the problem of scheduling appointments, taking into account unscheduled arrivals and reprioritization. The radiology department offers CT diagnostics to both scheduled and unscheduled patients. Of these unscheduled patients, some must be seen immediately, while others may wait for some time. Herein a trade-off is sought between acceptable waiting times for appointment patients and unscheduled patients’ lateness. In this paper we use a discrete event simulation model to determine the performance of a given appointment schedule in terms of waiting time and lateness. Also we propose a constructive and local search heuristic that embeds this model and optimizes the schedule. For smaller instances, we verify the simulation model as well as compare our search heuristics’ performance with optimal schedules obtained using a Markov reward process. In addition we present computational results from the case study in the Dutch hospital. These results show that a considerable decrease of waiting time is possible for scheduled patients, while still treating unscheduled patients on time. [ABSTRACT FROM AUTHOR]

Cities in the Netherlands have long relied on active land policy for urban development. More recently, municipalities have started to explore new types of land policies, as they became aware of the financial risks of this policy. As an alternative to their active involvement in land development, new legislation for urban land readjustment (ULR) has been proposed. This policy supports a land assembly strategy, in which the owners swap land positions, and share (infrastructure) development costs and gains. This paper explores the motivations in the Netherlands for introducing this new land policy tool. Additionally, based on two case studies, we discuss how public and private stakeholders might respond to the introduction of ULR. We conclude that it is unlikely that the introduction of ULR legislation itself will bring forward a paradigm shift in Dutch land policy. Nevertheless, the ULR legislation may add to a redistribution of land development-related risks between the public and the private sector. [ABSTRACT FROM AUTHOR]

Background: Sitting too much has been associated with negative health outcomes. 'The End of Sitting' is a newly developed office landscape that moves away from the traditional chair-desk setup. The landscape aims to reduce sitting time by offering a variety of (supported) standing positions. The aim of this study was to determine the usage of the landscape after being placed in the main entrance hall of the VU University in Amsterdam.Methods: We observed the number of spontaneous visitors as well as the duration of visits, changes to another location within the landscape, and adopted postures. Using questionnaires reasons (not) to visit the landscape, perceived affordances of the landscape and associations with long-term use were determined.Results: Observed numbers of visitors were relatively low and duration of visits were short, which seemed to indicate visitors were trying out the landscape. The majority of visitors were in an upright position, reflecting the designers' intentions. Visitors indicated that long-term use would be pleasant to them.Conclusion: 'The End of Sitting' landscape received positive reactions but number of visits were limited in the few months that it was placed in the university main entrance hall. The landscape might be better suited for designated working or study spaces, for which it was originally intended. It might also be worth to explore the landscapes suitability for short stay environments, such as waiting rooms. [ABSTRACT FROM AUTHOR]

Aims and objectives To evaluate the impact of supportive interventions perceived by both the intensive care unit patients' relatives and the healthcare providers, such as deferred intake interviews for providing information and discussing the emotional impacts, encouragement to keep a diary, and the introduction of weekly psychosocial rounds, on the perceptions of relatives of patients in the intensive care unit. Background Patient- and family-centred care is gaining interest, with a shift from provider-centric norms to care arranged around patients' and relatives individual beliefs and needs. This is expected to have a positive influence on the quality of care. Communication is one of the most important factors impacting the perceived quality of care in the intensive care unit from the perspective of patients' relatives. New interventions have been introduced to help the patients' relatives to meet their communication needs. Design A time-trend quantitative design. Methods Two convenience samples of relatives were included (in 2012 and 2013) in four different intensive care units from a large university medical centre in the Netherlands. Results Survey data from 211 relatives (75% net response rate in 2012) and 123 relatives (66% net response rate in 2013) were used for the analysis. The second measurement showed significant improvements regarding informational aspects of care, clarification of roles in participatory caretaking and shared decision-making. Conclusion The results suggest that the additional support offered to patients' relatives increased perceived quality of care, particularly with respect to informational needs. However, patient- and family-centred care still requires a change in the mindset of healthcare professionals. This new point of view should overcome perceived barriers and foster a culture of partnership with patients' relatives in the intensive care unit. Relevance to clinical practice Training in providing psychosocial support for the needs of relatives leads to a stronger perception of patient-centredness. [ABSTRACT FROM AUTHOR]

Background: The concept of responsiveness was introduced by the World Health Organization (WHO) to address non-clinical aspects of service quality in an internationally comparable way. Responsiveness is defined as aspects of the way individuals are treated and the environment in which they are treated during health system interactions. The aim of this study is to assess responsiveness outcomes, their importance and factors influencing responsiveness outcomes during the antenatal and delivery phases of perinatal care.Method: The Responsiveness in Perinatal and Obstetric Health Care Questionnaire was developed in 2009/10 based on the eight-domain WHO concept and the World Health Survey questionnaire. After ethical approval, a total of 171 women, who were 2 weeks postpartum, were recruited from three primary care midwifery practices in Rotterdam, the Netherlands, using face-to-face interviews. We dichotomized the original five ordinal response categories for responsiveness attainment as 'poor' and good responsiveness and analyzed the ranking of the domain performance and importance according to frequency scores. We used a series of independent variables related to health services and users' personal background characteristics in multiple logistic regression analyses to explain responsiveness.Results: Poor responsiveness outcomes ranged from 5.9% to 31.7% for the antenatal phase and from 9.7% to 27.1% for the delivery phase. Overall for both phases, 'respect for persons' (Autonomy, Dignity, Communication and Confidentiality) domains performed better and were judged to be more important than 'client orientation' domains (Choice and Continuity, Prompt Attention, Quality of Basic Amenities, Social Consideration). On the whole, responsiveness was explained more by health-care and health related issues than personal characteristics.Conclusion: To improve responsiveness outcomes caregivers should focus on domains in the category 'client orientation'. [ABSTRACT FROM AUTHOR]