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Objective: To evaluate whether double‐layer uterine closure after a first caesarean section (CS) is superior compared with single‐layer uterine closure in terms of postmenstrual spotting and niche development in the uterine caesarean scar. Design: Multicentre, double‐blind, randomised controlled superiority trial. Setting: Thirty‐two hospitals in the Netherlands. Population: A total of 2292 women aged ≥18 years undergoing a first CS were randomly assigned to each procedure (1:1): 1144 women were assigned to single‐layer uterine closure and 1148 women were assigned to double‐layer uterine closure. Methods: Single‐layer unlocked closure and double‐layer unlocked closure, with the second layer imbricating the first. Main outcome measures: Number of days with postmenstrual spotting during one menstrual cycle 9 months after CS. Secondary outcomes: perioperative and menstrual characteristics; transvaginal ultrasound measurements. Results: A total of 774 (67.7%) women from the single‐layer group and 770 (67.1%) women from the double‐layer group were evaluable for the primary outcome, as a result of drop‐out and amenorrhoea. The mean number of postmenstrual spotting days was 1.33 (bootstrapped 95% CI 1.12–1.54) after single‐layer closure and 1.26 (bootstrapped 95% CI 1.07–1.45) after double‐layer closure (adjusted mean difference −0.07, 95% CI −0.37 to 0.22, P = 0.810). The operative time was 3.9 minutes longer (95% CI 3.0–4.9 minutes, P < 0.001) and niche prevalence was 4.7% higher (95% CI 0.7–8.7%, P = 0.022) after double‐layer closure. Conclusions: The superiority of double‐layer closure compared with single‐layer closure in terms of postmenstrual spotting after a first CS was not shown. Long‐term obstetric follow‐up of our trial is needed to assess whether uterine caesarean closure guidelines should be adapted. Double‐layer uterine closure is not superior for postmenstrual spotting after a first caesarean; single‐layer closure performs slightly better on other outcomes. Double‐layer uterine closure is not superior for postmenstrual spotting after a first caesarean; single‐layer closure performs slightly better on other outcomes. [ABSTRACT FROM AUTHOR]

Objective: Presence of lung metastases in low-risk gestational trophoblastic neoplasia (GTN) is generally considered not to influence prognosis. However, in a recent study in the Netherlands, GTN patients with lung metastases had a higher recurrence rate and more disease-specific deaths compared with patients without metastases. The aim of the present study was to validate these findings in a different country.Design: Historical cohort study.Setting: Charing Cross Hospital, United Kingdom.Population: A total of 1040 low-risk GTN patients treated with methotrexate (MTX) between 2002 and 2016 were identified: 65 with lung metastases (group 1) and 975 without metastases (group 2).Methods: Baseline characteristics, MTX resistance, survival and recurrence rates were recorded and compared between both groups.Main Outcome Measures: MTX resistance, recurrence rate and survival.Results: The occurrence of MTX resistance and median number of MTX courses to achieve remission was significantly higher in patients with lung metastases than patients without metastases (60% versus 38.9%, P = 0.001; and nine versus six courses, P < 0.001). All choriocarcinoma patients (n = 4) with lung metastases developed MTX resistance. The recurrence rate was also higher in group I (9.2% versus 2.7%; P = 0.012). Disease-specific survival was 100% in both groups.Conclusions: The presence of lung metastases at the start of MTX therapy is associated with increased incidence of MTX resistance and recurrence in low-risk GTN without affecting overall survival, which remains 100%. However, individuals with low-risk choriocarcinoma with lung metastases are likely to become resistant to MTX and primary multi-agent chemotherapy should be considered.Tweetable Abstract: The presence of lung metastases appears to increase the risk of recurrence in low-risk GTN, but does not affect overall cure rates and survival. [ABSTRACT FROM AUTHOR]

Background. Vascular depression is regarded as a subtype of depression, especially in, but not entirely restricted to, the elderly, characterized by a specific clinical presentation and an association with (cerebro)vascular risk and disease. It could have major implications for treatment if subjects at risk for such a depression could be easily identified by their clinical presentation in general practice.Method. We studied the symptom profile of depression in subjects with and without vascular risk factors in two large Dutch community-based studies, the Rotterdam Study and the Amsterdam Study of the Elderly (AMSTEL).Results. We could not confirm the specific symptom profile in depressed subjects with vascular risk factors in either of the two cohorts. Depressed subjects with vascular risk factors showed more loss of energy and more physical disability than those without vascular risk factors. However, presumed specific symptoms of vascular depression, namely psychomotor retardation and anhedonia, were not significantly associated with any of the vascular risk indicators. Loss of energy was significantly associated with myocardial infarction and peripheral arterial disease.Conclusions. In these two large community-based studies we identified some differences between vascular and non-vascular depressed subjects but found no evidence for a specific symptom profile of vascular depression as previously defined. [ABSTRACT FROM AUTHOR]

Background: Appropriate use of antibiotics is a major issue in today's medicine. The increasing worldwide bacterial resistance to antimicrobial agents is forcing us to prescribe antibiotics more rationally. It is known that overuse of antibiotics for upper respiratory tract infections exists. Little is known about the reasons for actual prescribing of antibiotics. In order to be able to implement strategies to restrict inappropriate antibiotic prescriptions, insight into the reasons for the actual prescribing could be important.Objective: We aimed to explore the reasons, other than those stated in the guidelines of the Dutch College of GPs, for prescribing antibiotics for acute otitis media.Method: Seventy antibiotic prescriptions for acute otitis media, prescribed by 22 Dutch GPs, were evaluated to see whether they followed the guidelines on acute otitis media of the Dutch College of General Practitioners. Non-guideline-based antibiotic prescriptions were discussed in stimulated recall interviews with the prescribing GPs regarding their prescribing behaviour of antibiotics for acute otitis media.Results: In total, 77% of the antibiotic prescriptions did not follow the guidelines of the Dutch College of General Practitioners. Medical reasons for prescribing antibiotics were mentioned most often for non-guideline-based antibiotic prescriptions; however, in a substantial number of cases doctors gave non-medical reasons as well.Conclusions: Appropriate use of antibiotics might not be reached by focusing only on the efficacy of these drugs. The impact of doctors' awareness of their non-medical motives for prescribing antibiotics on more rational antibiotic prescribing should be investigated further. [ABSTRACT FROM AUTHOR]

Background: Foot problems in people with rheumatoid arthritis (RA) are highly prevalent and have a substantial impact on quality of life. Healthcare professionals from various professions can be involved in the management of these foot problems. There is currently no consensus on optimal management. Therefore, the aim of the present study was to develop multidisciplinary recommendations for the management of foot problems in people with RA in the Netherlands. Methods: The recommendations were based on research evidence and consensus among experts, following published strategies for the development of practice recommendations. The expert group was composed of 2 patients and 22 experienced professionals (rheumatologists, rehabilitation physicians, orthopaedic surgeons, specialized nurses, podiatrists, orthopaedic shoe technicians, pedicurists, and researchers) in the Netherlands. For each developed recommendation i) the level of evidence was determined, and ii) the level of agreement (among the expert group) was set by an anonymous voting procedure using a numeric rating scale. The mean and range of the level of agreement for each recommendation was calculated. A recommendation was approved when ≥70% of the expert group voted an NRS-agreement ≥7. Results: In total, 41 recommendations were developed. Two recommendations concerned a framework for diagnosis and treatment. Thirty-nine recommendations on foot care were developed: seven on diagnosis (including check-ups of feet and shoes and diagnostic imaging), 27 on treatment (including corticosteroid injections, foot surgery, therapeutic shoes, foot orthoses, exercise therapy, toe-orthoses and toenail-braces, treatment of toenails and skin), four on communication, and one on organisation of RA-related footcare. All recommendations were approved by the expert group. The percentage score of NRS-agreement ≥7 ranged from 80 to 100%. Conclusions: These are the first published multidisciplinary recommendations specific to the management of foot problems in people with RA. Multidisciplinary recommendations can provide guidance in timely referrals and access to adequate footcare. More research is needed to strengthen the evidence on diagnosis and treatment of RA-related foot problems. These national recommendations may be a first step towards developing international multidisciplinary recommendations for the management of foot problems in RA. [ABSTRACT FROM AUTHOR]

Background: Severe flares (ALT ≥ 10×ULN) are a well-recognised adverse outcome after nucleos(t)ide analogue (NA) cessation and may lead to liver failure. Thus, identification of patients at risk for these flares is of major importance., Methods: Data were used from two prospective studies on NA cessation conducted in the Netherlands and Canada. Patients were eligible based on EASL criteria. HBcrAg and anti-HBc levels were measured at end of treatment (EOT) and week 6 (FUW6). Logistic regression was used to study the association with severe flares., Results: Seventy-eight patients were analysed with a mean age of 49 years, 16 (21%) Caucasian and a majority (65%) were treated with Tenofovir. Overall, 22 patients (28%) developed a severe flare, and 29 (37%) patients were retreated. At EOT, higher HBcrAg levels (aOR: 1.97, p = 0.05; ≥ 4log: 47% severe flare vs. < 3log: 19%, p = 0.036), lower anti-HBc (aOR: 0.29, p = 0.036; < 2log: 50% vs. ≥ 3log: 11%, p = 0.029) and higher HBcrAg/anti-HBc-ratio (aOR: 3.17, p = 0.015; ≥ 2: 58% vs. < 1.5: 14%, p < 0.001) were associated with an increased risk of severe flares, adjusted for HBsAg. At FUW6, higher HBcrAg (aOR: 2.91, p = 0.035; ≥ 5log: 83%, < 3log: 4%, p < 0.001), lower anti-HBc (aOR: 0.46, p = 0.29; < 2log: 50% vs. ≥ 3log: 0%, p = 0.003) and higher HBcrAg/anti-HBc-ratio (aOR: 2.19, p = 0.048; ≥ 1.75: 52% vs. < 1.75: 8%, p < 0.001) were associated with an increased risk of severe flares, adjusted for HBV DNA and ALT., Conclusion: Higher HBcrAg, lower anti-HBc and higher HBcrAg/anti-HBc ratio at EOT and during the first weeks of post-treatment follow-up are associated with an increased risk of hepatic flares after NA withdrawal and could therefore potentially be used to select patients eligible for therapy cessation and to identify patients requiring retreatment., Trial Registration: This study was a post hoc and follow-up study of two previously registered clinical trials (NCT01911156 & NTR7001). No new patients were prospectively included., (© 2024 The Author(s). Alimentary Pharmacology & Therapeutics published by John Wiley & Sons Ltd.)

Objectives: To investigate the incidence, type and location of growth-related sports injuries (GRSI) in youth professional football in the Netherlands. Secondary, to gain more knowledge on the injury severity and burden of GRSI., Methods: In this prospective, longitudinal cohort study, 813 players aged 10-18 are included. Data collection is performed by instructing the medical staff of six professional football club academies to register GRSI by means of standardized forms. Training and match exposure are registered individually on a weekly basis. Injury incidence was calculated as number of GRSI per 1000 hours, injury severity as the median number of days lost in categories and injury burden as the number of days lost per 1000 hours., Results: A total of 62 GRSI were documented in the football season 2021-2022. The total incidence of GRSI was 0.62/1000 hours football exposure. Morbus Osgood Schlatter and Morbus Sever were most common types of GRSI, both with incidence rates of 0.22/1000 hours exposure. About 58.3% of the documented GRSI were classified as major (>28 days lost). Within this group, the mean severity was 55 days time-loss to football., Conclusions: GRSI are relatively common in youth professional football. The most common types are Morbus Sever and Morbus Osgood Schlatter. Morbus Osgood Schlatter has the highest injury severity and burden compared to other types of GRSI.

Background: Some of those infected with SARS-CoV-2 suffer from post-COVID syndrome (PCS). However, an uniform definition of PCS is lacking, causing uncertainty about the prevalence and nature of this syndrome. We aimed to improve understanding of PCS by operationalizing different classifications and to explore clinical subtypes., Methods: We used data from Nivel Primary Care database from 2019-2020 which consists of electronic health records (EHR) from general practices (GPs) combined with sociodemographic data for n = 10,313 individuals infected with the SARS-CoV-2. In addition, data from n = 276 individuals who had been infected with the SARS-CoV-2 in 2021, collected via a longitudinal survey, was used. In the GP-EHR data, we operationalized two classifications of PCS (based on symptoms and diagnosis recorded in GP-EHR data and healthcare utilization 3-12 months after acute infection) to calculate frequency and characteristics and compared this to the survey results. In a subgroup of the EHR data we conducted community detection analyses to explore clinical subtypes of PCS., Results: The frequency of PCS was 15% with on average 4.6 symptoms for which the GP was consulted using the narrow definition and 32% with on average 6.8 symptoms for the broad definition. Across all methods and classifications, the mean age of individuals with PCS was around 53 years and they were more often female. There were small sex differences in the type of symptoms and overall symptoms were persistent for 6 months. The community detection analysis revealed three possible clinical subtypes., Discussion: We showed that frequency rates of PCS differ between methods and data sources, but characteristics of the affected individuals are relatively stable. Overall, PCS is a heterogeneous syndrome affecting a substantial group of individuals who need adequate care. Future studies should focus on care trajectories and qualitative measures such as quality of life of individuals living with PCS., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2025 Bos et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Purpose: Little is known about the prevalence, impact and change of the symptoms after implant removal due to irritation in multiple rib fractures. This study aims to explore these aspects to improve treatment decision-making., Methods: Data was collected from two hospitals in the Netherlands and Switzerland. The study included only adults with operatively treated multiple rib fractures, regardless of whether the fractures were flail or non-flail. The primary outcome was the incidence of implant removal due to irritation. Secondary outcomes included implant irritation not leading to removal, other postoperative complications, and remission rates after implant removal. These outcomes were assessed during a follow-up phone call using a standardized questionnaire., Results: Hundred-twenty patients were identified, with 83 (69.2%) completing the final follow-up after a median of 49 months (IQR 40-59). Twenty-five (30.1%) patients experienced implant irritation, of whom four (4.8%) got their implant removed. Two (2.4%) reported significant improvement, one (1.2%) moderate, and one (1.2%) no improvement of symptoms., Conclusion: Implant irritation in patients with multiple rib fractures is a common problem, even years after surgery, without guaranteed symptom improvement post-removal. These results provide an additional argument to be more selective in offering rib fixation to patients with multiple rib fractures in the first place., Competing Interests: Declarations. Ethical approval: The local Medical Research Ethics Committee at UMC Utrecht approved a waiver of consent (with reference number WAG/ mb/17/024787 and METC protocol number 17–544/C). The study followed the principles outlined in the Declaration of Helsinki. Patients were provided with comprehensive information about the study’s objectives and procedures, and their informed consent, in accordance with the General Data Protection Regulation, was obtained prior to participation. Competing interests: The authors declare no competing interests. Conflict of interest: The authors have no other conflicts of interest to declare., (© 2025. The Author(s).)

Background: A major lower limb amputation (LLA) for dysvascular disease carries the risk of disturbed wound healing necessitating reamputation at a higher level. A reamputation causes a delay in prosthetic fitting and recovery of walking ability. The combination of a prolonged open wound and inability to walk can worsen the physical and psychological situation. Prevention of reamputation seems therefore important. This study aims to identify risk factors for reamputation, and to evaluate a possible altered mortality rate after a dysvascular major LLA. These issues are crucial for shared decision-making prior to surgery., Methods: Retrospective study investigating a Dutch regional cohort of patients with a dysvascular below-knee, through-knee, or above-knee LLA., Results: Five hundred sixteen dysvascular major LLAs were included (2014-2018). One hundred reamputations were performed within 1 year after initial amputation (19.4%). Risk factors for ipsilateral reamputation were diabetes mellitus, lipid-lowering drugs usage, and lower level of amputation (P ≤ 0.01, 0.037, and < 0.01, respectively). The 30-day mortality rates were 1% and 12% for the reamputation group and the nonreamputation group, respectively (P ≤ 0.01). The 1-year mortality rates were 23% and 27% for the reamputation group and the nonreamputation group, respectively (P = 0.423)., Conclusions: Ipsilateral reamputation within 1 year after initial amputation is common. Several risk factors for reamputation were identified. The 30-day and 1-year mortality rate is high, but not significantly different after 1 year. A clinical decision tool for dysvascular patients needs to be developed to improve shared decision-making, reduce reamputation rates, and improve survival., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: Patient-reported outcomes are important as obesity is a chronic disease with a substantial impact. A multidisciplinary task force selected six scales (48 questions) from the validated BODY-Q questionnaire. This subset was gradually introduced and evaluated in a mandatory nationwide registry. The focus was to assess the scale's module results and its feasibility in a quality registry., Materials and Methods: All Dutch patients undergoing bariatric surgery between 2019 and 2022 were selected. Completed questionnaires of RAND-36, EQ-5D-5L, and BODY-Q were reviewed with baseline and 1-year results. Uni- and multivariable regression analyses were performed to assess the relationship between baseline characteristics and quality of life scores over time., Results: A total of 10,972 patients completed at least one BODY-Q scale. The lowest score was on the body image scale preoperatively (28.2, SD 20.9) and the highest on the social scale postoperatively (76.2, SD 18.8). A representative group of 510 patients with repeated measurements showed the most improvement on the body image scale (+ 32.2) followed by physical function (+ 26.3). Multivariable linear regression analysis showed a significant influence, primarily for gender, age, and BMI on BODY-Q scores. Score improvement for BODY-Q was mainly driven by weight loss, while EQ-5D-5L and RAND-36 showed no clear pattern. Comparing the three questionnaires showed significant correlations for physical and social function only., Conclusion: The BODY-Q obesity module demonstrates potential as a relevant PROM for inclusion in a quality registry. BODY-Q scores provide a foundation for future research, with notable improvements in quality of life observed, particularly in the body image and physical function scales., Competing Interests: Declarations. Conflict of Interest: Dr. Nienhuijs is part of clinical immersion for bariatric surgery training for Medtronic. The BODY-Q is owned by Memorial, Sloan Kettering Cancer Center, Mass General Brigham, and McMaster University. Drs. Pusic and Klassen are co-developers and receive royalty for use in for-profit studies. Anne Klassen provides research consulting services to the pharmaceutical industry through EVENTUM Research. Dr. Liem is an educational consultant for Medtronic, gives medical expert training for Olympus, and is part of clinical immersion for bariatric surgery at the Johnson and Johnson Institute. Drs. Schouten, Hoogbergen, van Rossum, de Vries, Monpellier, and Ms. Cnossen and Gernette have no conflict of interest., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: To improve lifestyle guidance within cardiac rehabilitation (CR), a comprehensive understanding of the motivation and lifestyle-supporting needs of patients with cardiovascular disease (CVD) is required., Objectives: This study's purpose is to evaluate patients' lifestyle and their motivation, self-efficacy and social support for change when starting CR., Methods: 1782 CVD patients (69 % male, mean age 62 years) from 7 Dutch outpatient CR centers participated between 2020 and 2022. Modifiable risk factors were assessed with a survey and interviews by healthcare professionals during CR intake., Results: Most patients exhibited an elevated risk in 3-4 domains. Elevated risks were most prominent in domains of (1) waist circumference and BMI (2) physical exercise (3) healthy foods intake and (4) sleep duration. Most patients chose to focus on increasing physical exercise, but about 20 % also wanted to focus on a healthy diet and/or decrease stress levels. Generally, motivation, self-efficacy and social support to reach new lifestyle goals were high. However, patients with an unfavorable risk profile had lower motivation and self-efficacy to work on lifestyle changes, while patients with lower social support had a higher chance to quit the program prematurely., Conclusions: Our results underscore the need to begin CR with a comprehensive lifestyle assessment and highlight the importance of offering lifestyle interventions tailored to patients' specific modifiable risk factors and lifestyle-supporting needs, targeting multiple lifestyle domains. Expanding the current scope of CR programs to address diverse patient needs and strengthening support may enhance motivation and adherence and lead to significant long-term benefits for cardiovascular health., Clinical Trial Registration Number: Netherlands Trial Register; registration number NL8443., Competing Interests: Declaration of competing interest Roderik Kraaijenhagen is the CEO of the participating cardiac rehabilitation centers. All other authors declare no conflict of interest., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Highly pathogenic avian influenza (HPAI) epizootics have caused repeated mass mortality events among wild birds. The effect of the infection is potentially detrimental for a variety of bird species, including the Peregrine Falcon ( Falco peregrinus ). The numbers of wintering and breeding Peregrine Falcons in the Netherlands have recently declined. We investigated the changes in population trends in relation to HPAI H5 virus outbreaks. For this purpose, we analyzed variations in annual numbers of wintering and breeding birds, the virology of reported dead birds, and the presence of the HPAI H5 virus in unhatched eggs. We showed that significant mortalities of Peregrine Falcons had occurred in 2016-2017 and 2020-2023, years of major HPAI H5 virus outbreaks. In particular, the highest rates of bird mortality and HPAI virus infection were reported in 2023. In this year, over 80% (28/32) of the tested birds were positive for HPAI H5 virus. No HPAI H5 virus was present in the eggs. Based on these findings, we concluded that HPAI represents a serious threat to the Peregrine Falcon population in the Netherlands, and, in combination with anthropogenic factors, may contribute to the decline of this species. Targeted HPAI surveillance and disease mitigation measures are necessary for the conservation of this species.

Background: At the beginning of the COVID-19 pandemic in 2020, little was known about the spread of COVID-19 in Dutch nursing homes while older people were particularly at risk of severe symptoms. Therefore, attempts were made to develop a nationwide COVID-19 repository based on routinely recorded data in the electronic health records (EHRs) of nursing home residents. This study aims to describe the facilitators and barriers encountered during the development of the repository and the lessons learned regarding the reuse of EHR data for surveillance and research purposes., Methods: Using inductive content analysis, we reviewed 325 documents written and saved during the development of the COVID-19 repository. This included meeting minutes, e-mails, notes made after phone calls with stakeholders, and documents developed to inform stakeholders. We also assessed the fitness for purpose of the data by evaluating the completeness, plausibility, conformity, and timeliness of the data., Results: Key facilitators found in this study were: 1) inter-organizational collaboration to create support; 2) early and close involvement of EHR software vendors; and 3) coordination and communication between partners. Key barriers that hampered the fitness of EHR data for surveillance were: 1) changes over time in national SARS-CoV-2 testing policy; 2) differences between EHR systems; 3) increased workload in nursing homes and lack of perceived urgency; 4) uncertainty regarding the legal requirements for extracting EHR data; 5) the short notice at which complete and understandable information about the repository had to be developed; and 6) lack of clarity about the differences between various COVID-19 monitors., Conclusions: Despite the urgent need for information on the spread of SARS-CoV-2 among nursing home residents, setting up a repository based on EHR data proved challenging. The facilitators and barriers found in this study affected the extent to which the data could be used. We formulated nine lessons learned for developing future repositories based on EHR data for surveillance and research purposes. These lessons were in three main areas: legal framework, contextual circumstances, and quality of the data. Currently, these lessons are being applied in setting up a new registry in the nursing home sector., Competing Interests: Declarations. Ethics approval and consent to participate: According to Dutch legislation (the Medical Research Involving Human Subjects Act (WMO)), ethics approval and consent to participate for this study were not required, because it did not concern medical scientific research, and did not make participants subject to procedures or required them to follow rules of behavior [55]. The legal basis for extracting data from electronic health records was found in the legal obligation of RIVM to prevent and combat infectious diseases as described in the Dutch Public Health Act [34] and RIVM Act [35]. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Bovine respiratory syncytial virus (BRSV) causes infections of the respiratory tract of cattle and is endemic in the Netherlands. We aimed to update our knowledge on the seroprevalence of BRSV in youngstock on Dutch dairy farms by performing a cross sectional study during the winter of 2021-2022 and a telephone survey with the farmers to map the most important risk factors for the introduction, presence, and circulation of BRSV. Of 671 sampled calves among 135 herds, we found a seropositivity of 75 % at calf level and 77 % on herd level. Risk factors appeared similar to those identified by others including a higher ratio of youngstock versus adult cows and suboptimal colostrum administration. We concluded that the BRSV seroprevalence at animal and herd level is still substantially high, confirming the endemic circulation of this virus on the majority of the Dutch dairy farms. But given that there is also a smaller number of seronegative herds and the available knowledge about biological sound risk factors for BRSV circulation, it could be worth investigating the feasibility of decreasing the seroprevalence of BRSV at herd level in the Netherlands taking into account the lessons learned from the Norwegian control program., Competing Interests: Declaration of Competing Interest The authors declare that there is no conflict of interest regarding the publication of this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: There has been a growing concern about a possible causal relationship between silicone breast implants (SBIs) and health symptoms, referred to as breast implant illness. This study assessed the association between SBIs for cosmetic augmentation and health symptoms., Methods: This retrospective cohort study used the data from the Dutch Breast Implant Registry and Nivel Primary Care Database. A total of 688 women with cosmetic SBIs were age-matched with 1301 women without SBIs. The occurrence of 13 health symptoms presented in general practice was assessed 1 year before implantation until 3 years after implantation. Comparisons were made regarding the number of symptoms and general practice consultations, before and after implantation and between the two groups., Results: Women with SBIs were more likely to experience three or more distinct health symptoms and a combination of multiple symptoms with multiple consultations during follow-up than women without SBIs (adjusted OR 1.44, 95% CI 1.06 to 1.96; adjusted OR 1.44, 95% CI 1.04 to 2.00, respectively). Women with SBIs also had more than twice the likelihood of manifesting these outcomes in the second year after implantation compared to the first year before implantation (OR 2.13, 95% CI 1.27 to 3.57; OR 2.13, 95% CI 1.22 to 3.72, respectively)., Conclusions: Women with cosmetic SBIs had increased odds of developing health symptoms after implantation compared to those before implantation and to women without SBIs. These results suggest an association between health symptoms and cosmetic SBIs that needs further research to explore whether there is causality or residual confounding., Competing Interests: Conflict of interest The authors declared no potential conflicts of interest with respect to the research, authorship and publication of this article., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Passive surveillance can be most effective in the early detection of disease outbreaks given that farmers observe their animals daily. The European Animal Health Law states that unexplained excess mortality should be reported to the veterinary authorities. In the Netherlands, in addition to notifications to the competent authority, Royal GD is commissioned a passive surveillance component that consists of a veterinary helpdesk and postmortem examination for early detection of emerging diseases. The aim of this study was to evaluate this voluntary passive surveillance component through excess mortality in cattle. Weekly on-farm mortality was calculated using the cattle Identification and Registration records. Mortality was assessed on regional level for dairy, veal and other beef cattle using a Generalized Linear Model (GLM) (log-link, negative binomial). We used a cumulative sum of the model residuals to identify periods of excess mortality. The mortality was defined as excessive when above five times the standard error. The analysis was also conducted on herd level, but these models did not converge. We checked for an association between the two passive surveillance components elements and excess mortality. A GLM (log-link, negative binomial) with the number of contacts or submissions per region as the dependent variables and excess mortality per region and year as independent variables was carried out. Overall, the models showed significantly higher use of passive surveillance components in periods of excess mortality compared to non-excess periods. In dairy cattle the odds for contact or submission were between 1.72 (1.59-1.86) and 2.02 (1.82-2.25). For veal calves we found the odds of 2.19 (1.18-4.04) and 2.24 (1.78-2.83) relative to periods without excess mortality. Beef cattle operations, other than veal, showed only an increased odds for postmortem submissions in calves of 3.71 (2.74-5.01), submissions for cattle and contact in general was not increased for this farm type. In conclusion, the voluntary passive surveillance component in the Netherlands is used more often in periods of excess mortality in cattle. The chance of getting a timely response is highest for dairy farms. For veal calf operations the chance of receiving a timely response is more likely for postmortem submissions. A comparison with passive surveillance for excess mortality in other countries was not possible because no literature could be found. However, the method of this study can be used by other countries to evaluate their passive surveillance. This would make comparison of the performance of passive surveillance in different countries possible., Competing Interests: Declaration of Competing Interest G.S. is parttime employed at Royal GD; the other authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Objectives: In absence of national legislation, local governments may stimulate outdoor sports clubs to become smoke-free. However, it is unknown whether and to what extent such efforts are effective in encouraging sports clubs to adopt a smoke-free policy (SFP). The aim of this study was to assess the association between tobacco control policies of municipalities and the prevalence of SFPs among outdoor sports clubs., Study Design: Retrospective, cross-sectional., Methods: Information on Dutch sports clubs (N = 3068) was linked to information on tobacco control policies of municipalities (i.e., "smoking prevention policies", "smoke-free environment policies", and "smoke-free sports policies") (N = 218). Multilevel logistic regression models examined the association between municipal tobacco control policies and the prevalence of SFPs among outdoor sports clubs, while controlling for sports clubs' characteristics., Results: We found a positive, dose-response association between tobacco control policies of municipalities and the prevalence of SFPs among outdoor sports clubs. The odds of having an SFP in place was significantly higher for sports clubs in municipalities with moderate "smoking prevention policies" (OR = 1.85, 95%CI = 1.18-2.89), strong "smoke-free environment policies" (OR = 1.95, 95%CI = 1.19-3.20), and strong "smoke-free sports policies" (OR = 1.66, 95%CI = 1.02-2.24) compared to sports clubs in municipalities with no/weak policies., Conclusions: The results suggest that local tobacco control policies can increase the prevalence of SFPs among outdoor sports clubs. In order to create maximum effect, local policies need to be comprehensive and widely implemented., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Antimicrobial use (AMU) is the main driver of antimicrobial resistance (AMR). In the Netherlands, the veal calf sector was among the largest consumers of antimicrobials in Defined Daily Doses Animal (DDDA) for the year of 2022. As preventive use in Dutch livestock farms is forbidden since 2011, most AMU is due to the herd health status which is affected by the farm environment in which the conditions for diseases to spread are created. The aim of this study was to determine which disease etiologies for group treatments are associated with AMU in rosé starter veal calves, and which modifiable technical risk factors on farm are associated with those diseases and with total AMU. Cross-sectional data were collected from 36 Dutch rosé starter veal calf farms in the Netherlands in 2021 using a digital survey. Linear regression analysis showed that the main indications for AMU were respiratory infections, for which mainly tetracyclines and macrolides were used. Partial least squares regression analysis (PLS) revealed 13 on-farm practices associated with the number of group treatments for respiratory diseases and 19 with total AMU. Overlapping variables in both PLS models were related to regrouping of calves, micro-climate conditions, water access and weaning strategies. Overall, these features focused on improving animal welfare and nutrition during production and enhancing a farm's internal and external biosecurity. This study identified opportunities for reducing AMU in rosé starter veal calf farms, which thereby could contribute to limiting AMR emergence and spread., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Lay Abstract: Even though there are about 10 million Chinese autistic individuals, we know little about autistic adults in China. This study examined how well young autistic adults in China integrate into their communities (such as having a job, living independently and having friends) and how satisfied they are with their lives as reported by their caregivers. We compared them to autistic adults with similar characteristics (such as high support needs) from the Netherlands. We included 99 autistic adults in China and 109 in the Netherlands (18-30 years). In both countries, autistic adults were reported to have a hard time fitting into their communities. They often had no work, did not live on their own and had few close friends. Also, in both countries, caregivers reported that autistic adults felt low satisfaction with their life. Chinese adults were less satisfied with their life than Dutch adults, as indicated by their caregivers. This could be because of a lack of support for autistic adults in China, higher parental stress in Chinese caregivers, or general cross-country differences in happiness. Only in the Dutch group, younger compared with older adults fitted better into their communities, and adults without additional psychiatric conditions were reported to have higher life satisfaction. Country was a significant predictor of independent living only, with Dutch participants more likely living in care facilities than Chinese participants. In conclusion, our study shows that autistic adults with high support needs generally face similar challenges in both China and the Netherlands., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect of the research, authorship, and/or publication of this article.

Objective: To explain how Dutch novice physical therapists experience their transition from student to physical therapist in private practice., Methods: A qualitative, phenomenological study was performed in The Netherlands to collect personal experiences from novice physical therapists who graduated <1 year ago. Data were collected with semi-structured interviews and analyzed using interpretative phenomenological analysis., Results: The transition experience from student to novice physical therapist is a personal, complex, and context-dependent phenomenon. Sixteen novice physical therapists (of whom 10 were still working in private practice) said their transition was liberating, stressful, insecure, unexpected, chaotic, and challenging. The variety in experiences occurred from the fact that the impact of an experience varies from one individual to the other, depending on their previous (life) experiences, uncertainty tolerance, coping, and personal and professional environment. Four overarching themes emerged: (1) 'Suddenly, I was on my own', (2) 'I was unprepared for the hassle and demands of clinical practice', (3) 'I couldn't make the impact I expected', and (4) 'I had to find a new me'., Conclusions: A novice physical therapist's transition is a context-related phenomenon, unique for each individual and determined by individual experiences and coping strategies. Novice physical therapists described a feeling of 'faking': they had to pretend to know what they were doing [while treating a patient] while in reality, they felt like they did not. For some novice physical therapists, a primary reason to leave the profession.

Veterinary guidelines have been published in the Netherlands to promote antimicrobial stewardship. An evidence-based intervention program using Implementation Mapping and performance indicators was developed to enhance veterinarians' adherence to the veterinary guideline "Streptococcus suis in weaned pigs". The present study evaluates the effect of this eight-month intervention program in a multicenter, pragmatic, stepped-wedge cluster design trial. Of the 49 veterinarians that participated, 33 provided data from 125 S. suis problem farms. A baseline measurement (M0) before the intervention program, and two measurements during (M1) and partly after (M2) the intervention program were conducted. A significant reduction in farm-level antimicrobial use of 25% in M1 and 49% in M2 was achieved compared to M0. For the performance indicators at veterinarian level, a significant reduction (- 36%) was found for antimicrobial prescription in M2, a significant increase occurred in argumentation for 2nd choice antimicrobials (M2) and the usage of bacteriological examination (M1). Two other performance indicators (ratio of 1st to 2nd or 3rd choice antimicrobials and corticosteroids) did not change significantly. These results show how an evidence-based intervention program to foster adherence to an existing veterinary clinical practice guideline achieved a significant reduction in antimicrobial prescriptions by swine veterinarians., Competing Interests: Competing interests: The authors declare no competing interests. Ethics approval and consent to participate: In accordance with directive 2010/63 of the European Parliament, no ethical approval was needed for this study as there is no animal trial included. This study complies with Regulation 2016/679 of the European Parliament on the protection of people regarding the processing of personal data and was started after a Privacy Impact Assessment (PIA) and a Data Management Plan were made and discussed in cooperation with the Data Protection Officer and Information Security Manager of Utrecht University. Informed consent was obtained from all the study participants. Consent for publication: Informed consent was obtained from all the study participants., (© 2024. The Author(s).)

Background: Exposure to pesticides in the living environment can be associated with the prevalence of health symptoms. This study investigates associations between health symptoms among residents in areas with fruit crop fields where pesticides are applied, and psychological perceptions and attitudes about environmental aspects and exposures., Methods: A cross-sectional survey combined with routine primary care electronic health records (EHR) data was conducted in 2017 in rural areas of the Netherlands with high concentration of fruit crops (n = 3,321, aged ≥ 16 years). Individual exposure to pesticides was estimated using geocoded data on fruit crops around the home. Validated instruments were used to assess symptom report and psychological perceptions and attitudes. Annual prevalence of various health symptoms was derived from EHRs. Multilevel regression models were used to analyze associations between health symptoms (outcome), fruit crops, and multiple psychological perceptions and attitudes (confounders)., Results: Living in the vicinity of fruit crop fields was generally not associated with self-reported symptom duration and general practitioner (GP) registered symptoms. For self-reported symptoms, symptom prevalence decreased when crop density within 250 m and 500 m from the home increased. No associations were found at other distances. Furthermore, higher levels of environmental worries, perceived exposure, and perceived sensitivity to pesticides and attribution of symptoms to environmental exposures were generally associated with a higher number of self-reported symptoms, and longer symptom duration. Symptoms reported to GPs were not associated with psychological perceptions and attitudes, except for perceived sensitivity to pesticides., Conclusion: Psychological perceptions and attitudes appear to be related to self-reported symptoms, but not to GP-registered symptoms, independent of the actual levels of exposure as measured by the size of the area of crop fields. Perceptions about environmental factors should be taken into account in environmental health risk assessment research when studying health symptoms., Competing Interests: Declarations Ethics approval and consent to participate The use of Electronic Health Records data from the Nivel Primary Care Database, as used for this study, is permitted by the Dutch law – under certain conditions – without having to ask permission from each individual patient, or without review by a medical ethics committee. Nivel Primary Care Database meets the Dutch regulations on data protection and laws on use of health data for epidemiological research purposes (Dutch Civil Law, Article 7:458). According to this legislation, neither obtaining informed consent from patients nor approval by a medical ethics committee is obligatory for observational studies containing no directly identifiable data.For matching the EHR data and the questionnaire data, a Trusted Third Party ensured anonymity of data at all times. For this purpose, a privacy regulation was established, which included the requirement for general practitioners to inform their patients through posters and brochures in the waiting room about participation in the study. The proposal for the study was submitted to the Privacy Committee of Nivel, which provided positive recommendations. For the linkage between datasets (EHR data - distance to fruit cultivation/buffers), a Trusted Third Party (TTP) was used (IVZ, Houten, https://www.sivz.nl/en/datamanagement). Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Purpose: Global prevalence of tinnitus (15%) is rising, indicating an increase in patients seeking help for this common symptom and potentially affecting the accessibility of care. The aim of this retrospective study is twofold; describing the morbidity trends and healthcare utilization among patients with recorded tinnitus at Dutch general practices (GP), and comparing overall healthcare utilization before and after tinnitus to similar patients without recorded tinnitus., Patients and Methods: Routine electronic health records data from general practices participating in Nivel Primary Care Database were used to describe trends in age- and sex-specific incidence, contact prevalence and healthcare utilization (contacts, prescriptions, and referrals to secondary care) for tinnitus from 2012 to 2021. Patients with tinnitus were matched (on sex, age, general practice) to patients without tinnitus (1:2). Healthcare use one year before and after a first GP contact for tinnitus (period) was analyzed with negative binominal (number of contacts) and logistic regression (prescriptions or referrals)., Results: Between 2012 and 2021, tinnitus incidence increased by 33% (3.3 to 4.4 per 1000 person-years). The largest increase was observed among 20-44-years (2.6 to 3.8 per 1000 person-years). One year after the first GP contact for tinnitus, patients with tinnitus utilized healthcare more frequently than patients without tinnitus. The referral rate increased the most (OR 1.99, 95%CI 1.83-2.16). The year before tinnitus at the GP, patients with tinnitus had more often GP consultations (IRR 1.16, 95%CI 1.12-1.19) and referrals (OR 1.09, 95%CI 1.01-1.18) than patients without tinnitus., Conclusion: Although GPs saw an increased number of patients with tinnitus, absolute numbers of patients remained low. Patients' healthcare use increased after the first tinnitus complaint at the GP, mainly for secondary care. Yet, they already used healthcare services more frequently than similar patients without tinnitus. Insight into possible explanations for these health disparities could contribute to targeted prevention., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Bes et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The rising popularity and use of a bone-anchored prosthesis (BAP) involving an osseointegrated implant for patients with lower-limb amputations experiencing socket-related issues have led to increased interest in the measurement of clinical and functional outcomes. However, the value of BAP treatment characteristics from the patient perspective has not yet been investigated. This study aimed to determine the relative importance of specific BAP characteristics, and the effect of complications in quality-of-life (QoL) points and monetary utility decrement (loss [€]), using a 2-center discrete choice experiment (DCE) conducted in The Netherlands., Methods: A DCE was developed that included the most salient characteristics of BAP treatment based on a review of the literature and qualitative and quantitative methods. The following characteristics were selected: QoL change, short- and long-term complications, osseointegrated implant survival, and out-of-pocket contributions (costs). Patients aged 18 to 99 years who were eligible for, or had already received, an osseointegrated implant were invited to participate, after informed consent, to elicit BAP treatment preferences. A Bayesian mixed logit model was used., Results: Two hundred and forty-seven completed surveys were collected; 64% of the patients were male, 73% had undergone a transfemoral amputation, and 33% had >36 months of experience with a BAP. Patients considered long-term complications and QoL the most important characteristics. Long-term complications were 3.4 times more important than short-term complications. Opting out was undesirable, and patients valued better and beneficial levels (associated with better outcomes) of BAP characteristics positively. Implant removal was the level with the greatest loss among all complications, at 1.15 (95% credible interval [CI], 0.96 to 1.38) QoL points and €16,940 (95% CI, €14,780 to €19,040) loss., Conclusions: To our knowledge, this is the first study to use a DCE to elicit patients' preferences regarding BAP treatment, outcomes, and related complications; we found that patients strongly care about long-term complications. The results suggest that osseointegrated implant teams and policy-makers should consider these areas when proposing treatment protocols. Furthermore, policy and clinical guidelines for BAP treatment could be enhanced by our results with respect to patients' perspectives, management of patients' expectations, and associated losses in QoL points and monetary loss secondary to complications., Level of Evidence: Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Article Processing Charge for open access publication was funded by Erasmus University Rotterdam. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I176 )., (Copyright © 2024 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: Ototoxicity is an adverse effect of childhood cancer treatment with a negative impact on speech-language development and quality of life. This study aimed to retrospectively assess ototoxicity monitoring in a national cohort of pediatric patients with solid tumors, examining the frequency and determinants associated with hearing loss (HL)., Methods: This retrospective cohort study included 305 patients treated between 2015 and 2020 at the Princess Máxima Center. Patients receiving platinum agents, head and neck radiotherapy, and/or ear-nose-throat surgery were analyzed. Electronic patient files provided demographic, clinical, and audiological data. HL was defined as Muenster ≥ 2b or SIOP ≥ 2 grade. Associations between clinical characteristics and HL occurrence were analyzed using logistic regression analysis., Results: Audiological monitoring was performed at baseline (62.6%), during treatment (79.0%), and at the end of treatment (82.1%). Post treatment, 51.2% and 36.5% experienced Muenster and SIOP-defined HL, respectively. Multivariable analyses revealed that age at diagnosis (OR 0.9, 95% CI 0.9-1.0), total cumulative dose cisplatin per 100 mg/m 2 (OR 1.6, 95% CI 1.4-2.0), and vincristine treatment (OR 3.3, 95% CI 1.4-7.8) remained significantly associated with Muenster grade ≥ 2b HL. Age at diagnosis in years (OR 0.9, 95% CI 0.8-1.0), total cumulative dose cisplatin per 100 mg/m 2 (OR 1.5, 95% CI 1.2-1.8), and male sex (OR 2.7, 95% CI 1.4-5.3) were associated with SIOP ≥ 2 HL., Conclusion: This study shows that more than half of the children treated with ototoxic cancer therapies develop HL by the end of treatment. Therefore, audiological monitoring during and after treatment is essential. Improved insight into clinical determinants aids in identifying patients at high risk for HL, who may benefit from prevention strategies that are currently being implemented., (© 2024 The Author(s). Cancer Reports published by Wiley Periodicals LLC.)

Introduction: A nationwide pay-for-performance (P4P) scheme was introduced in the Netherlands between 2018 and 2023 to incentivize appropriate prescribing in general practice. Appropriate prescribing was operationalised as adherence to prescription formularies and measured based on electronic health records (EHR) data. We evaluated this P4P scheme from a learning health systems perspective., Methods: We conducted semi-structured interviews with 15 participants representing stakeholders of the scheme: general practitioners (GPs), health insurers, pharmacists, EHR suppliers and formulary committees. We used a thematic approach for data analysis., Results: Using EHR data showed several benefits, but lack of uniformity of EHR systems hindered consistent measurements. Specific indicators were favoured over general indicators as they allow GPs to have more control over their performance. Most participants emphasized the need for GPs to jointly reflect on their performance. Communication to GPs appeared to be challenging. Partly because of these challenges, impact of the scheme on prescribing behaviour was perceived as limited. However, several unexpected positive effects of the scheme were mentioned, such as better EHR recording habits., Conclusions: This study identified benefits and challenges useful for future P4P schemes in promoting appropriate care with EHR data. Enhancing uniformity in EHR systems is crucial for more consistent quality measurements. Future P4P schemes should focus on high-quality feedback, peer-to-peer learning and establish a single point of communication for healthcare providers., Competing Interests: Declaration of competing interest None of the authors had a conflict of interest., (Copyright © 2024. Published by Elsevier B.V.)

Background: Explantation is the proposed treatment for breast implant illness (BII). Little is known about which medical specialists are visited and what diagnoses are made before explantation is provided as the treatment., Objectives: This study investigated medical specialist care utilization in women with cosmetic breast implants who underwent explantation compared to women who chose breast implant replacement surgery and to women without breast implants., Methods: Retrospective cohort study using data linkage with the Dutch Breast Implant Registry and the Dutch health insurance claims database. Visits to medical specialists were examined over the 3 years before explantation. A total of 832 explantation patients were matched and compared to 1463 breast implant replacement patients and 1664 women without breast implants., Results: Explantation patients were more likely to have visited > 5 different medical specialties compared to both replacement patients (12.3% vs. 5.7%; p < 0.001) and women without breast implants (12.3% vs. 3.7%; p < 0.001). Among explantation patients, women who underwent explantation because of BII were more likely to have visited > 5 different medical specialties compared to women who underwent explantation because of other reasons (25.0% vs. 11.0%; p < 0.001)., Conclusions: Women who underwent explantation of breast implants had higher utilization of medical specialist care in the years before explantation compared to women who underwent breast implant replacement surgery and women without breast implants. Medical specialist care use was especially high among women for whom BII was the registered reason for explantation. These findings suggest further research is needed into the link between BII and the use of medical specialist care., Level of Evidence Iii: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 ., Competing Interests: Declarations. Conflict of interest: The authors declare that they have no conflicts of interest to disclose. Ethical approval Ethical approval for this study was waived by the medical ethics committee of the University Medical Centre Maastricht (2021-2515). Informed consent: For this type of study, informed consent is not required. Obtaining informed consent from patients is not obligatory for observational studies using routinely recorded health data if the database does not contain directly identifiable data (art. 24 GDPR Implementation Act jo art. 9.2 sub j GDPR)., (© 2024. The Author(s).)

Objectives: Research shows that smoking persists in sports clubs with smoke-free policies (SFPs). It is unknown to what extent smoking occurs at such clubs and how much that may differ from clubs without SFPs. This study aimed to determine whether and to what extent smoking differs at Dutch football clubs with and without SFPs., Study Design: This cross-sectional study used a purposive sampling method to compare smoking indicators at 117 Dutch football clubs, with 49 clubs (41.8%) having an SFP., Methods: Using a standardised checklist, three smoking indicators were observed (number of people smoking, smoking facilities, and cigarette butts) and combined in a total smoking score (scale 0-9). Multi-level linear regression analysis was used to analyse the association between club SFP, local tobacco control policies (TCPs), and smoking indicators., Results: Significantly fewer smoking facilities were present at clubs with an SFP (-2.35, 95% confidence interval [CI]: -3.61; -1.09), but no significant associations were found between SFP and the number of people smoking and cigarette butts. The total smoking score was 1.74 points lower for clubs with an SFP (95% CI: -2.53; -0.96) and 1.85 points lower for clubs in municipalities with strong local TCPs (95% CI: -2.98; -0.72). Strong local TCPs were associated with significantly fewer people smoking at clubs (-1.79, 95% CI: -3.41; -0.17)., Conclusions: SFPs at sports clubs succeed in limiting the number of smoking facilities but do not show differences in terms of smoking rates or smoking-related litter when compared to clubs without SFPs. Our results highlight the need for enhancing implementation of comprehensive SFPs, including clear guidelines for compliance and enforcement., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: To prevent cross-contamination between patients, adequate reprocessing is necessary when using flexible endoscopes (FEs) without a working channel. The current reprocessing process using an Endoscope Washer Disinfector (EWD) is time-consuming. Ultraviolet light group C (UV-C) exposition is an alternative and fast disinfection method and has previously been shown to adequately reduce Colony Forming Units (CFUs) on FEs without a working channel. The objective of this study was to examine whether UV-C light is as effective in reducing CFUs on contaminated FEs without a working channel compared to the EWD., Methods: FEs without a working channel were collected in three different Otorhinolaryngology Departments in the Netherlands. After pharyngolaryngoscopy, a manual pre-cleaning with tap water was performed and a culture was collected by rolling the distal 8-10 cm of the FE over an agar plate. Next, the FE was randomly assigned to be disinfected with UV-C light (D60) or the EWD (gold standard). After disinfection, another culture was taken. The primary outcome was microbiological contamination, defined by Colony Forming Units (CFU)., Results: 600 FEs without a working channel were randomized. After clinical use and manual pre-cleaning, 239/300 (79.7%) FEs in the UV-C group and 262/300 (87.3%) FEs in the EWD group were contaminated (i.e., > 0 CFU). FEs without culture confirmed contamination were excluded from further analysis. After UV-C light disinfection, 195/239 (81.6%) FEs showed 0 CFUs, compared to 187/262 (71.4%) FEs disinfected with the EWD (p < 0.01). A multivariate logistics regression analysis showed an increased odds of 0 CFUs when using UV-C light (OR 1.83, 95% CI 1.19-2.79; p < 0.01), conditional on participating hospitals and types of FE., Conclusions: UV-C light disinfection of FEs without a working channel appears more effective in reducing CFUs compared to the EWD and might be a good alternative disinfection method., Trial Registration: Not applicable., (© 2024. The Author(s).)