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Introduction: Multimorbidity challenges quality and sustainability of healthcare systems. Care groups were introduced in the Netherlands to promote integration of chronic primary care, but it remains unknown to which degree they facilitate this. This study therefore aims to determine whether Dutch general practices perceive themselves to be capable of delivering integrated chronic care and uncover the role of care groups. Methods: We performed a survey study amongst 39 care groups and 65 healthcare providers within general practices (GPs and nurse practitioners). Results: 43% of healthcare providers within general practices are (very) dissatisfied with capabilities for chronic care to patients and 56% do not feel capable of delivering integrated care. Care groups and providers show alignment in their perception of some of the most important facilitators and barriers such as motivation and lack of time, but other factors are valued differently at both levels. Discussion: Our findings show inability of general practices to deliver integrated chronic care despite a health system that is inherently supportive of care integration and point to a mismatch between barriers and facilitators amongst practices and care groups, resulting in providers partly relying on their motivation in accommodating integrated chronic care. Conclusion: General practices are not sufficiently supported by care groups and national policies in delivering integrated chronic care. The identified mismatch between policy and practice warrants redesign of support from care groups to align policies with identified barriers and facilitators at the provider level. [ABSTRACT FROM AUTHOR]

We provide a detailed analysis of convectively generated cold pools (CPs) over flat midlatitude land, combining ten-year high-frequency time series of measurements at several heights available from the 213-m tower observatory at Cabauw, the Netherlands, with a collocated 2D radar rainfall dataset. This combination of data allows us to relate observations of the CP’s temporal and vertical structure to the properties of each CP’s parent rain cell, which we identify by rain-cell tracking. Using a new detection method, based on the anomalies of both the vertically averaged wind and the temperature, we monitor the arrival and passing of 189 CPs during ten summers (2010–2019). The time series show a clear signature of vortex-like motion along the leading CP edge in the vertical and horizontal wind measurements. The arrival of CP gust fronts is characterized by a steep decrease in both temperature and moisture, with a recovery time of approximately two hours. We see no evidence of moisture rings on the gust front edge, and therefore no indications for thermodynamic convective triggering. From the tower data, we obtain a median CP temperature drop of Tdrop ≈ −2.9 K and a height-averaged horizontal wind anomaly of Δumax ≈4.4 m⋅s−1. Relating the individual CP’s horizontal wind anomalies and temperature drops, we confirm the validity of the theoretical density current relationship, Δumax ∝ T1∕2 drop. We further propose a simple statistical model to relate the CP strength defined by Tdrop to the environmental properties influencing the CP: rain intensity and lower boundary-layer saturation. A multivariate linear regression suggests a 1 K colder CP for a 4 mm⋅hr−1 more intense rain cell (instantaneous area-averaged rain intensity) or for a 2.5 K larger pre-CP dew-point depression. [ABSTRACT FROM AUTHOR]

Background: A frozen section diagnosis of a borderline ovarian tumor with suspicious features of invasive carcinoma ("at least borderline" or synonymous descriptions) presents us with the dilemma of whether or not to perform a full ovarian cancer staging procedure. Quantification of this dilemma may help us with the issue of this clinical decision. The present study assessed and compared both the prevalence of straightforward borderline and "at least borderline" frozen section diagnoses and the proportion of these women with a final histopathological diagnosis of invasive carcinoma, with a special interest in histologic subtypes. Methods: A retrospective cohort study was performed in three hospitals in The Netherlands. All women that underwent ovarian surgery with perioperative frozen section evaluation in one of these hospitals between January 2007 and July 2018 were identified and included in case of a borderline or "at least borderline" frozen section diagnosis and a borderline ovarian tumor or invasive carcinoma as a final diagnosis. Results: A total of 223 women were included, of which 41 women (18.4%) were diagnosed with "at least borderline" at frozen section. Thirteen of forty-one women (31.7%) following "at least borderline" frozen section diagnosis and 14 of 182 women (7.7%) following a straightforward borderline frozen section diagnosis were diagnosed with invasive carcinoma at paraffin section evaluation (p < 0.001). When compared to straightforward borderline frozen section diagnoses, the proportion of women diagnosed with invasive carcinoma increased from 3.1 to 35.7% for serous tumors (p = 0.001), 10.0 to 21.7% for mucinous tumors (p = 0.129) and 50.0 to 75.0% (p = 0.452) in case of other histologic subtypes following an "at least borderline" frozen section diagnosis. Conclusions: Overall, when compared to women with a decisive borderline frozen section diagnosis, women diagnosed with "at least borderline" frozen section diagnoses were found to have a higher chance of carcinoma upon final diagnosis (7.7% vs 31.7%). Especially in the serous subtype, full staging during initial surgery might be considered after preoperative consent to prevent a second surgical procedure or chemotherapy in unstaged women. Further studies are needed to evaluate whether additional sampling in case of an "at least borderline" diagnosis may decrease the risk of surgical over-treatment. [ABSTRACT FROM AUTHOR]

For-profit hospitals' market share has increased in many nations over recent decades. Previous studies suggest that their growth is not attributable to superior performance on access, quality of care, or efficiency. We analyzed other factors that we hypothesized may contribute to the increasing role of for-profit hospitals. We studied the historical development of the for-profit hospital sector across 4 nations with contrasting trends in for-profit hospital market share: the United States, the United Kingdom, Germany, and the Netherlands. We focused on 3 factors that we believed might help explain why the role of for-profits grew in some nations but not in others: (1) the treatment of for-profits by public reimbursement plans, (2) physicians' financial interests, and (3) the effect of the political environment. We conclude that access to subsidies and reimbursement under favorable terms from public health care payors is an important factor in the rise of for-profit hospitals. Arrangements that aligned financial incentives of physicians with the interests of for-profit hospitals were important in stimulating for-profit growth in an earlier era, but they play little role at present. Remarkably, the environment for for-profit ownership seems to have been largely immune to political shifts. [ABSTRACT FROM AUTHOR]

This exploratory, mixed-methods study analyzes characteristics of the emerging for-profit nursing home industry in the Netherlands and identifies the interrelated set of factors (context, trends, and sector conditions) that contribute to its growth. Until recently, the Dutch nursing home sector relied almost exclusively on nonprofit providers. Even though profit distribution in nursing home care is still banned, the for-profit nursing home sector is expanding. The study uses economic theory on nonprofit organizations and mixed-form markets to understand this expansion. We find that changes in the regulatory framework have unlocked the potential of the for-profit nursing home sector, enabling for-profit nursing homes to circumvent the for-profit ban. The expansion of the for-profit sector was mainly driven by the low responsiveness of the nonprofit sector to increased and changed demands. For-profit providers took advantage of this void. Moreover, they exploited "cream-skimming" potential in the market and used the wider care system to reduce their labor costs by relying on external specialist care. Another main driver was the access to financial capital from private investors (e.g., private equity firms). [ABSTRACT FROM AUTHOR]

Background: Independent treatment centres (ITCs) are a growing phenomenon in many healthcare systems. Focus factory theory predicts that ITCs provide high quality healthcare with low prices, through specialisation, high-volume and routine. This study examines if ITC care outperforms general hospital (GH) care within a regulated competition system in the Netherlands, by focusing on differences in healthcare quality and price. Methods: The cross-sectional study combined publicly available quality data, list prices and insurer contracts for 2017. Clinical outcomes of 5 elective surgeries (total hip and knee replacement, anterior cruciate ligament (ACL), cataract and carpal tunnel surgeries) were compared using zero-or-one inflated beta-regressions, corrected for underlying structural factors (ie, volume of care, process and structure indicators, and chain affiliation). Furthermore, price differences between ITCs and GHs were examined using ordinary least squares regressions. Lastly, we analysed quality of care in relation to the number of insurance contracts of the 4 largest Dutch insurance companies using ordered logistic regressions. Results: Quality differences between ITCs and GHs were found to be inconsistent across procedures. No facility type performed better overall. There were no differences exhibited in the list prices between ITCs and GHs. No consistent relationship was found between the underlying factors and quality or price, in different procedures and time. We found no indication for selective contracting based on quality within the ITC sector. Conclusions: This study found no evidence that ITCs outperform GHs on quality or price. This evidence does not support the focus factory theory. The substantial practice variation in quality of care may justify more evidence-based contracting within the market for elective surgery. [ABSTRACT FROM AUTHOR]

The care for patients with epithelial ovarian cancer(EOC) is organised in eight different geographical regions in the Netherlands. This situation allows us to study differences in practice patterns and outcomes between geographical regions for patients with FIGO stage IIIC and IV. We identified all EOC patients who were diagnosed with FIGO stage IIIC or IV between 01.01.2008 and 31.12.2015 from the Netherlands Cancer Registry. Descriptive statistics were used to summarize treatment and treatment sequence(primary cytoreductive surgery(PCS) or neoadjuvant chemotherapy and interval cytoreductive surgery(NACT-ICS)). Moreover, outcome of surgery was compared between geographical regions. Multilevel logistic regression was used to assess whether existing variation is explained by geographical region and case-mix factors. Overall, 6,741 patients were diagnosed with FIGO IIIC or IV disease. There were no differences in the percentage of patients that received any form of treatment between the geographical regions(range 80–86%, P = 0.162). In patients that received cytoreductive surgery and chemotherapy, a significant variation between the geographical regions was observed in the use of PCS and NACT-ICS(PCS: 24–48%, P < 0.001). The percentage of complete cytoreductive surgeries after PCS ranged from 10 to 59%(P < 0.001) and after NACT-ICS from 37 to 70%(P < 0.001). Moreover, geographical region was independently associated with the outcome of surgery, also when adjusted for treatment sequence(P < 0.001). We observed a significant variation in treatment approach for advanced EOC between geographical regions in the Netherlands. Furthermore, the probability to achieve no residual disease differed significantly between regions, regardless of treatment sequence. This may suggest that surgical outcomes can be improved across geographical regions. [ABSTRACT FROM AUTHOR]

A trial embankment 6 m high was built on peat in the Netherlands, and brought to failure. The aim was to test whether innovative sensor technology could detect incipient failure in time. However, the data generated also made it possible to conduct a geotechnical assessment of stability. The paper discusses the relation between the parameters derived from laboratory tests, field measurements and behaviour observed in the field. Problems encountered in the standard triaxial testing of peat samples are discussed, as the samples tend to fail in tension. A trial pit through the failed embankment showed that there were wide tension cracks in the peat layer, indicating that the peat layer failed in tension, at least locally. However, horizontal movement dominates the overall failure mechanism. As an alternative to triaxial testing, direct simple shear (DSS) testing for the assessment of peat parameters is considered. The results of the DSS tests correspond well with field measurements and the back-analysis of the failure. [ABSTRACT FROM AUTHOR]

Abstract: Objective: In some nursing home populations, antibiotic treatment may not reduce mortality following lower respiratory infection (LRI). To better inform treatment decisions, we determined influences on mortality following LRI among antibiotic-treated and non–antibiotic-treated residents in 2 populations. Design: Observational, prospective, cohort studies. Setting: Ninety-seven nursing homes (36 US, 61 Netherlands). Participants: Residents (1044 US, 513 Netherlands) who met a standardized study definition for LRI. Measurements: Demographics, symptoms and physical findings of LRI, functional status, major illness diagnoses, dementia status, treatments, and date of death within 6 months after diagnosis. Methods: We estimated a 2-period (0–14/15–90 days) weighted proportional hazards model of mortality for antibiotic-treated (n = 1280) and non–antibiotic-treated (n = 277) residents; both weights and regressors provide “doubly robust” risk adjustment—for LRI (illness) severity using a prognostic score and for nonrandom receipt of antibiotic treatment using a propensity score. Results: In both the United States and the Netherlands, 14-day mortality was associated with three factors—LRI severity, water intake at diagnosis, and antibiotic use (not directly by severe dementia)—that accounted for 82% or, sequentially, 39%, 42%, and 1% of the cross-national mortality difference. The LRI Severity Score (based only on at-diagnosis eating dependency, pulse rate, decreased alertness, and breathing difficulty, with adequate discrimination [c ≥ 0.74] and calibration, and cross-indexed to commonly used LRI mortality measures) was related to mortality through 90 days, regardless of treatment. With sufficient water intake at diagnosis, 14-day mortality was unrelated to not receiving antibiotic treatment (adjusted hazard ratio [AHR], 1.20; 95% confidence interval, 0.70–2.04); insufficient water intake was related to increased 14-day mortality with antibiotics (AHR, 1.90; 1.38–2.60) or without (AHR, 7.12; 4.83–10.5). After 14 days, relative mortality worsened for antibiotic-treated residents with insufficient water intake. Inadequate water intake was related to increased eating dependence at onset of the LRI (OR, 4.2; 3.0–5.8). Conclusion: LRI severity, water intake, and antibiotic use explain mortality in both studies and reconcile cross-study Dutch/US 14-day mortality differences. LRI severity, derived at 14 days, is related to mortality through 90 days, regardless of treatment, and is key to risk adjustment. With adequate hydration, the survival benefit from antibiotic use is nonsignificant. Conversely, hydration, even without antibiotic treatment, appears central to curative treatment. In LRI guidelines, treatment, and research, the relative benefits of antibiotics and hydration for curative treatment should be addressed. [Copyright &y& Elsevier]

Background: The aim of this study was to evaluate the association between experienced physical violence and health-related quality of life (HRQoL) by comparing self-reported health status for individuals with and without experience of physical violence. Our hypothesis was that individuals exposed to violence would experience worse HRQoL than non-exposed individuals. We tested whether men and women and different age groups experience similar reductions in HRQoL, and the extent to which such differences might be associated with social circumstances and lifestyle conditions. Finally, we explored the HRQoL consequences of exposure to violence in a longer time perspective. Methods: We used data from self-completed questionnaires in two Danish nationally representative, cross-sectional health interview surveys. Exposure to violence was indicated through specific survey questions (Straus' conflict tactics scale) enquiring about different types of violence during the last 12 months. Health status of respondents was elicited by the EQ-5D and SF-36 questionnaires. The health status profiles were converted to health score indexes using the Danish algorithm for EQ-5D and the revised Brazier algorithm for SF-6D. Differences in score indexes between the exposed and non-exposed individuals were explored separately for men and women using ordinary least square regression with four age categories as explanatory variables. Results: In the 2000 and 2005 surveys, respectively, 4.9% and 5.7% of respondents indicated that they had been exposed to physical violence within the last 12 months. Exposure to violence was more prevalent in the younger age groups and more prevalent for men than women. Respondents exposed to violence had lower score indexes on both the EQ-5D and the SF-6D compared with the non-exposed. Respondents who reported exposure to violence in both 2000 and 2005 reported lower HRQoL than individuals who only reported exposure in one of the surveys. Conclusions: The results of this study provide evidence for an association between exposure to physical violence and reduction in health-related quality of life. [ABSTRACT FROM AUTHOR]

Objective To compare early-pregnancy changes in cardiac diastolic function between formerly pre-eclamptic women with (RECUR) and without (NORECUR) recurrent pre-eclampsia. Design Retrospective observational cohort study. Setting Tertiary referral centre. Population Pregnant women with a history of early-onset preeclampsia (n = 34). Methods The peak mitral filling velocity in early diastole (E) and at atrial contraction (A), and the E/A ratio were assessed before and at 12, 16 and 20 weeks of gestation in the next pregnancy. Differences in early-pregnancy alterations between women with (RECUR) and without (NORECUR) recurrent pre-eclampsia were evaluated by use of mixed design analysis of covariance. Main outcome measures Cardiac function and recurrent preeclampsia. Results In ten women (29%) pre-eclampsia recurred. By 12 weeks of gestation the E/A ratio had increased in the RECUR group, but not in the NORECUR group (P < 0.01). Moreover, from 16 weeks of gestation onwards, the RECUR group had a lower cardiac output and higher systemic vascular resistance as compared with the NORECUR group (P < 0.05). Conclusion Our results suggest that formerly pre-eclamptic women destined to develop recurrent pre-eclampsia differ from their counterparts who do not develop recurrent pre-eclampsia by impaired first-trimester adaptation of cardiac diastolic function. [ABSTRACT FROM AUTHOR]

Purpose: Although lower respiratory tract infections are a leading cause of death in frail elderly patients, few studies have compared treatments and outcomes. We assessed the effects of different antibiotic treatment strategies on survival of elderly nursing home residents with lower respiratory tract infections in the United States and the Netherlands, where treatment approaches are quite different.Methods: We combined data from 2 prospective cohort studies of lower respiratory tract infections conducted in 36 nursing homes in the United States and 61 in the Netherlands. We included residents whose infections were treated with antibiotics: 806 in the United States and 415 in the Netherlands. Outcome measures were 1-month and 3-month mortality. We used logistic regression to adjust for differing illness severity.Results: Dutch residents had higher mortality than US residents (28.1% vs 15.1% at 1 month, respectively; P <.001). After adjusting for illness severity with logistic regression, the differences between the Dutch and US populations were not significant (odds ratio 1.34; 95% confidence interval, 0.94-1.90). Predicted mortality was overestimated for more severely ill US residents at 1 month but not at 3 months. No antibiotic regimen was consistently associated with increased or decreased mortality.Conclusion: Despite differences in illness severity and treatment, adjusted mortality did not differ between the 2 countries. Although we cannot exclude a short-term survival benefit from more aggressive treatment in the United States, differences in baseline health appear prognostically more important than the type of antibiotic treatment. [ABSTRACT FROM AUTHOR]

The concept of ecological speciation implies that habitat differences may split a species by strong selection and rapid adaptation even under sympatric conditions. Studies on the polychaete Scoloplos armiger in the Wadden Sea (North Sea) indicate sibling species existing in sympatry: the intertidal ‘Type I’ with holobenthic development out of egg cocoons and the subtidal ‘Type S’ producing pelagic larvae. In the current study, Types I and S are compared in habitat-related traits of reproductive timing and physiological response to hypoxia and sulphide. Spawnings of Type I and Type S recorded over six years overlap in spring and both appear to be triggered by a rise in seawater temperature above 5 °C. Type S exhibits an additional autumn spawning (at seawater temperatures around 10 °C) which was previously unknown and is absent in Type I. The overall abundance of pelagic larvae in the Wadden Sea is higher in spring than in autumn. Tolerance of both sulphide and hypoxia was lower in Type S than in Type I. This correlates with a 5 to 10-fold lower sulphide concentration in the subtidal compared to the intertidal habitat. Physiological tolerance and divergence in developmental mode appear as traits which may have led to reproductive isolation between Type I and Type S. Their role in allopatric and sympatric speciation scenarios in S. armiger is discussed. Since the pelagic dispersal mode has been neglected so far, a reassessment of population dynamics models for S. armiger is suggested. [Copyright &y& Elsevier]

Discusses the challenges faced by Alan McElroy, vice president of manufacturer and supplier of compact disc (CD), EMI based in the Netherlands . Overview on how he previously managed the global responsibility during the verge of the company's closure; Recent demand of CD's; Company's measuring performance guideline. INSET: MEASURING PERFORMANCE.

This paper discusses the use of genealogical data for the study of the historical development of kinship networks in the Netherlands, 1830-1990. There are two main problems in using genealogies: the year of death is missing for a sizeable part of the research population; and the information available on all relevant branches is far from complete. A mixed estimation procedure was used to impute the missing years of death. Overcoming the second problem is more difficult; the only solution was to exclude individuals without children from the analysis. If these and other limitations of genealogies are not ignored and the effects of various types of under-registration are carefully assessed, genealogies can provide valuable information for our understanding of historical kinship patterns. The empirical results, using data on more than 160,000 persons, show that demographic changes in Dutch society during the last 160 years have significantly affected the kinship configuration. [ABSTRACT FROM AUTHOR]

With the integration of Intermitted Renewables Energy (I-RE) electricity production, capacity is shifting from central to decentral. So, the question is if it is also necessary to adjust the current load balancing system from a central to more decentral system. Therefore, an assessment is made on the overall effectiveness and costs of decentralized load balancing, using Flexible Renewable Energy (F-RE) in the shape of biogas, Demand Side Management (DSM), Power Curtailment (PC), and electricity Storage (ST) compared to increased grid capacity (GC). As a case, an average municipality in The Netherlands is supplied by 100% I-RE (wind and solar energy), which is dynamically modeled in the PowerPlan model using multiple scenarios including several combinations of balancing technologies. Results are expressed in yearly production mix, self-consumption, grid strain, Net Load Demand Signal, and added cost. Results indicate that in an optimized scenario, self-consumption of the municipality reaches a level of around 95%, the total hours per year production matches demand to over 90%, and overproduction can be curtailed without substantial losses lowering grid strain. In addition, the combination of balancing technologies also lowers the peak load to 60% of the current peak load in the municipality, thereby freeing up capacity for increased demand (e.g., electric heat pumps, electric cars) or additional I-RE production. The correct combination of F-RE and lowering I-RE production to 60%, ST, and PC are shown to be crucial. However, the direct use of DSM has proven ineffective without a larger flexible demand present in the municipality. In addition, the optimized scenario will require a substantial investment in installations and will increase the energy cost with 75% in the municipality (e.g., from 0.20€ to 0.35€ per kWh) compared to 50% (0.30€ per kWh) for GC. Within this context, solutions are also required on other levels of scale (e.g., on middle or high voltage side or meso and macro level) to ensure security of supply and/or to reduce overall costs. [ABSTRACT FROM AUTHOR]

The government in The Netherlands has appointed municipalities to perform environmental stress tests in order to assess the impact of a warmer (changing) climate on habitat, safety and comfort in sensible environments, such as cities. Based on insights from these stress tests municipalities are requested to perform sustainable actions to mitigate climate change effects adequately. The assessment of heat waves in cities is one of the most challenging tasks for municipalities due to its complexity, uncertainty and unclear implications of adaptive measures.With the improvement in thermal observations from space and with recent developments in data processing methods to derive (near) surface temperatures, it becomes possible to use remote-sensing data series to extend model-based studies of heat effects with comprehensive observations. We show how these observations can improve the understanding and reliance on studies of heat island effects in different climate scenario's. Based on every-day experience we also indicate the most critical parameters and their required level of confidence needed in order to convince municipalities to adopt required measures more rigorously. [ABSTRACT FROM AUTHOR]

Objectives: Appendectomy is often recommended in patients with mucinous borderline ovarian tumours (mBOTs) based on studies suggesting that metastatic disease from a primary appendiceal tumour can mimic mBOT. The present study assessed the incidence of mucinous neoplasms in the appendix associated with the presence of mBOT., Methods: A retrospective cohort study was performed in two university hospitals in the Netherlands between 1990 and 2011. All patients with mBOT and/or a mucinous appendiceal tumour were included., Results: Of 127 patients included, 98 had a primary mBOT and 29 had a primary mucinous appendiceal tumour. In patients with a mBOT, the appendix was either removed at prior surgery (4%), resected as part of the staging procedure showing no pathological abnormalities (13%), described as normal and not resected (58%), or not described and not resected (25%). During a median follow-up period of 5 years (range 2-23), two patients developed a recurrence in which the appendix was not involved. In all patients with a primary mucinous tumour of the appendix, the appendix appeared abnormal at the time of surgery. Eight of these patients (28%) were diagnosed with invasive ovarian metastases. A review of the literature including the cases from this study identified 510 mucinous ovarian tumours with borderline features and 214 associated appendectomies, of which 4 (1.9%) contained a primary appendiceal malignancy., Conclusions: A thorough inspection of the appendix should be performed in patients with a mucinous ovarian tumour with borderline features. An appendectomy should only be performed when the appendix is macroscopically abnormal., (Copyright © 2014 Elsevier Inc. All rights reserved.)