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Introduction: Approximately two-thirds of the patients admitted to the hospital with an ischemic stroke are discharged directly home. Discontinuity of care may result in avoidable patient harm, re-admissions and even death. We hypothesized that the transfer of information is most essential in this patient group since any future care for these patients relies solely on the information that is available to the care provider responsible at that time.Aim: The objective of this study was to evaluate the continuity of transmural care in ischemic stroke patients by assessing 1) the transfer of clinical information through discharge letters to general practitioners (GPs), 2) subsequent documentation of this information and early follow-up by GPs and 3) the documentation of medication-related information in discharge letters, at GPs and community pharmacies (CPs).Methods: This prospective cohort study was conducted from September 2019 through March 2020 in OLVG, Amsterdam, the Netherlands, in patients with a first stroke discharged directly home. Outcome measures were derived from national guidelines and regional agreements. Results were analyzed using descriptive analysis.Results: A total of 33 patients were included. Discharge letters (n = 33) and outpatient clinic letters (n = 24) to GPs contained most of the essential items, but 16% (n = 9) of the letters were sent in time. GPs (n = 31) infrequently adhered to guidelines since 10% (n = 3) of the diagnoses were registered using the correct code and 55% (n = 17) of the patients received follow-up shortly after discharge. Medication overviews were inaccurately communicated to GPs since 62% (n = 150) of all prescriptions (n = 243) were correctly noted in the discharge letter. Further loss of information was seen as only 39% (n = 95) of all prescriptions were documented correctly in GP overviews. We found that 59% (n = 144) of the prescriptions were documented correctly in CP overviews.Conclusion: In this study, we found that discontinuity of care occurred to a varying extent throughout transmural care in patients with a first stroke who were discharged home. [ABSTRACT FROM AUTHOR]

Objective: In the Netherlands the incidence of cervical cancer is higher among ethnic minority populations compared with the general Dutch population. We investigated the prevalence of, and risk factors associated with, vaginal high-risk human papillomavirus (hrHPV) infection in women of six different ethnicities living in Amsterdam.Methods: For this cross-sectional study we selected women aged 18-34 years old of six ethnicities from the large-scale multiethnic HEalthy LIfe in an Urban Setting study. Self-collected vaginal swabs were tested for HPV DNA and genotyped using a highly sensitive PCR and reverse line blot assay (short PCR fragment (SPF)10-PCR DNA enzyme immunoassay/LiPA25-system version-1, delft diagnostic laboratory (DDL)). Participants completed a questionnaire regarding demographics and sexual behaviour. Logistic regression using generalised estimating equations was used to assess risk factors of hrHPV, and to investigate whether prevalence of hrHPV differed among ethnicities.Results: The study population consisted of 592 women with a median age of 27 (IQR: 23-31) years. Dutch and African Surinamese women reported the highest sexual risk behaviour. HrHPV prevalence was highest in the Dutch (40%) followed by the African Surinamese (32%), Turkish (29%), Ghanaian (26%), Moroccan (26%) and South-Asian Surinamese (18%). When correcting for sexual risk behaviour, the odds to be hrHPV-positive were similar for all non-Dutch groups when compared with that of the Dutch group.Conclusions: We found an overall higher hrHPV prevalence and higher sexual risk behaviour in the native Dutch population. Further research is needed to unravel the complex problem concerning cervical cancer disparities, such as differences in participation in the cervical cancer screening programme, or differences in clearance and persistence of hrHPV. [ABSTRACT FROM AUTHOR]

Background/objectives:Preterm infants are at risk of iron deficiency (ID). In the Netherlands, preterm infants born after 32 weeks of gestational age (GA) do not receive iron supplementation on a routine basis. We hypothesized that dietary iron intake in these infants might not be sufficient to meet the high iron requirements during the first 6 months of life.Subjects/methods:In a prospective cohort study, we analyzed the prevalence and risk factors of ID in 143 infants born between 32+0 and 36+6 weeks GA who did not receive iron supplementation.Results:ID at the age of 4 and 6 months was present in 27 (18.9%) and 7 (4.9%) infants. Results of a multivariable logistic regression analysis showed that ID was associated with lower birth weight, a shorter duration of formula feeding, more weight gain in the first 6 months of life and lower ferritin concentrations at the age of 1 week.Conclusions:Preterm infants born after 32 weeks GA have an increased risk of ID compared with those born at term, supporting the need of iron supplementation. Our results suggests that measurement of ferritin at the age of 1 week might be useful to identify those infants at particular risk and could be used in populations without general supplementation programs. However, the efficacy and safety of individualized iron supplementation, based on ferritin concentrations at the age of 1 week, together with other predictors of ID, needs to be further investigated, preferably in a randomized controlled trial. [ABSTRACT FROM AUTHOR]

Objective The objective of this study was to compare outcomes of induced labour with intravenous oxytocin with a start in the evening versus in the morning. Design Randomised controlled trial. Setting Labour wards of three hospitals in Amsterdam, the Netherlands. Participants Women with an indication for induction of labour with intravenous oxytocin. Methods Included women were randomized to either the evening group with a start of induction of labour at 21:00 hours, or the morning group with a start at 07:00 hours. Main outcome measures Primary outcome was duration of labour. Secondary outcomes were instrumental delivery rate, adverse neonatal outcome defined as an Apgar score below 7 after 5 minutes, number and indications of paediatric consults and neonatal admissions, duration of second stage, number of intrapartum infections and necessity of pain relief. Results We randomised 371 women. Mean duration of labour was not significantly different (primiparae: morning 12 hours and 8 minutes versus evening 11 hours and 22 minutes, P value 0.29; multiparae: morning 7 hours and 34 minutes versus evening 7 hours and 46 minutes, P value 0.70). There were no significant differences in instrumental deliveries rates, number of infections or patient satisfaction. Unexpectedly, neonatal outcome was better in women induced in the evening. Conclusion Induction of labour with intravenous oxytocin in the evening is equally effective as induction in the morning. [ABSTRACT FROM AUTHOR]

Objective The aim of this study was to describe the variation of normal maternal temperature during labour. Design A prospective cohort study. Setting Two hospitals in Amsterdam, the Netherlands. Population All women with a live singleton pregnancy and a gestational age of 36 weeks or more admitted to the delivery ward from June 2000 to January 2002. Methods Maternal temperature was measured rectally every 2–3 hours from admission until the beginning of second stage, and 1-hour postpartum. Normal labour ( n = 843) was defined as gestational age ≥37 weeks, spontaneous onset of labour, rupture of membranes <18 hours before birth, normal progress of labour without the need for augmentation or epidural analgesia and spontaneous vaginal delivery of a healthy infant. The remaining group was classified as abnormal ( n = 2209). Main outcome measures Rectal measured temperature in degrees Celsius. Results The mean temperature during labour in the complete study population increased from 37.1°C at the beginning of labour to 37.4°C after 22 hours. Temperature in the abnormal labour group was equal to the normal labour group during the first 3 hours of labour ( P > 0.05) but increased thereafter. Conclusions At the beginning of labour, temperature was 37.1°C. Temperature increased slowly during labour and was 37.4°C (2SD 1.2) after 22 hours. The upper 2SD limit for normal temperature did not follow a circadian pattern and time of day is not relevant for the classification of normal versus elevated temperature. [ABSTRACT FROM AUTHOR]

Following introduction of the lung allocation score (LAS) in 2011, Eurotransplant member centers can apply for an exceptional LAS (eLAS) if the calculated LAS insufficiently reflects the perceived transplant benefit for a patient, specifically in case of primary pulmonary hypertension group 1 and 4; combined lung+non‐renal transplantation; rare diseases; or extracorporeal support. Each eLAS proposal is evaluated by a LAS Review Board, consisting of ≥3 lung transplant experts, which subsequently declines or approves the eLAS request in consensus of ≥3 votes. In case of a lower than accepted score, predefined business rules to assign LAS percentiles are used. A retrospective analysis of all eLAS requests in Eurotransplant from December 2011 until September 2019. Overall, 5183 lung transplants (deceased donors) were performed and 420 eLAS requests were made (Germany 52%, Netherlands 18%, Austria 18%, Belgium 13%), of which 116 (28%) were approved. Most eLAS requests concerned group B/Pulmonary vascular disease (44%), followed by group C/Cystic fibrosis or immunodeficiency disorder (28%), then group D/Restrictive lung disease (15%) and finally group A/Obstructive lung disease (11%); whereas 10 patients (2%) were not classified. The proportion of accepted eLAS requests significantly differed between countries (Germany 25%, Netherlands 37%, Austria 20%, Belgium 36%) (p=0.042). eLAS requests decreased in the Netherlands following its LAS introduction in 2014 (2011-2014 mean 13/yr vs. 2015-2019 mean 4.6/yr; p=0.060). However, since 2015 an overall annual increasing number of eLAS requests is seen, with doubling of the eLAS requests in 2018 vs. 2015, but no difference in acceptance rate (2015-2018: 22.4%) (Figure). Acceptance rates were 38% for Group B, 21% for Group C, 20% for Group D and 11% for Group A. The observed variations require further investigation to optimize lung allocation for specific patient populations in Eurotransplant. [ABSTRACT FROM AUTHOR]

In the Netherlands comparable levels of sports-participation between persons with haemophilia and healthy controls have been reported. This raises the question if children with haemophilia under the currently available prophylaxis do reach comparable levels of physical fitness and health-related quality of life (HRQoL) as their healthy peers. The aim of this study was to investigate the level of physical fitness, functional ability and quality of life and to determine the feasibility to safely test the exercise capacity of boys with severe haemophilia A. Thirteen subjects participated in this study. Physical fitness was determined using the measurement of maximal oxygen uptake (VO2peak) attained during a graded maximal exercise test to volitional exhaustion. Joint health, physical activity levels and health-related quality of life (Haemo-Qol) were also measured. Mean VO2peak was 1.86 ± 0.77 L min−1 ( Z-score: −0.39 ± 1.61) which was not significantly different from reference values. Relative VO2peak was 47.42 ± 8.29 mL min−1 kg−1 ( Z-score: −0.52 ±1.43), which did not differ significantly from reference values either. One boy suffered a joint bleeding one day after the test. Haemo-Qol scores in parents and children ranged from 3.2% to 36.7% (100% reflects poor outcome). Relationship between the child or parent reports of Haemo-QoL and both absolute and relative VO2peak ranged from R = 0.00 and R = 0.4. Exercise testing in children with severe haemophilia A was a safe procedure. Patients with severe haemophilia A with good joint health and no limitations of activities have comparable physical fitness and physical active lifestyle with healthy peers and good HRQoL. [ABSTRACT FROM AUTHOR]

Improving population health and reducing inequalities through better integrated health and social care services is high up on the agenda of policymakers internationally. In recent years, regional cross-domain partnerships have emerged in several countries, which aim to achieve better population health, quality of care and a reduction in the per capita costs. These cross-domain partnerships aim to have a strong data foundation and are committed to continuous learning in which data plays an essential role. This paper describes our approach towards the development of the regional integrative population-based data infrastructure Extramural LUMC (Leiden University Medical Center) Academic Network (ELAN), in which we linked routinely collected medical, social and public health data at the patient level from the greater The Hague and Leiden area. Furthermore, we discuss the methodological issues of routine care data and the lessons learned about privacy, legislation and reciprocities. The initiative presented in this paper is relevant for international researchers and policy-makers because a unique data infrastructure has been set up that contains data across different domains, providing insights into societal issues and scientific questions that are important for data driven population health management approaches., Competing Interests: Declaration of Competing Interest All authors declare that they have no conflict of interest., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objective: After stratifying for age, sex and multimorbidity at baseline, our aim is to analyse time trends in incident multimorbidity and polypharmacy in the 15-year clinical trajectories of individual patients in a family medicine setting., Methods: This study was carried out using data from the Registration Network Family Medicine in the South of the Netherlands. The clinical trajectories of 10037 subjects during the 15-year period (2000-2014) were analyzed in a repeated measurement of using a generalized estimating equations model as well as a multilevel random intercept model with repeated measurements to determine patterns of incident multimorbidity and polypharmacy. Hierarchical age-period-cohort models were used to generate age and cohort trajectories for comparison with prevalence trends in multimorbidity literature., Results: Multimorbidity was more common in females than in males throughout the duration of the 15-year trajectory (females: 39.6%; males: 33.5%). With respective ratios of 11.7 and 5.9 between the end and the beginning of the 15-year period, the youngest female and male groups showed a substantial increase in multimorbidity prevalence. Ratios in the oldest female and male groups were 2.2 and 1.9 respectively. Females had higher levels of multimorbidity than males in the 0-24-year and 25-44-year age groups, but the levels converged to a prevalence of 92.2% in the oldest male and 90.7% in the oldest female group. Similar, albeit, moderate differences were found in polypharmacy patterns., Conclusions: We sought to specify the progression of multimorbidity from an early age. As a result, our study adds to the multimorbidity literature by specifying changes in chronic disease accumulation with relation to polypharmacy, and by tracking differences in patient trajectories according to age and sex. Multimorbidity and polypharmacy are common and their prevalence is accelerating, with a relatively rapid increase in younger groups. From the point of view of family medicine, this underlines the need for a longitudinal approach and a life course perspective in patient care., Competing Interests: The authors have declared that no competing interests exist.

Background: After stroke, many patients experience cognitive and/or emotional problems. While national guidelines recommend screening for these problems, actual screening rates might be limited., Objective: This study aimed to examine the clinical practice at neurology departments regarding screening, information provision and follow-up care for cognitive and emotional problems after transient ischaemic attack (TIA) and ischaemic stroke., Methods: A nationwide, cross-sectional, online survey was conducted between October 2018 and October 2019 among neurologists in all hospitals in the Netherlands., Results: Neurologists in 78 hospitals were invited to join the survey, and 52 (67%) of them completed it. Thirty-one (59%) neurologists reported that screening for cognitive problems after TIA and ischaemic stroke was mostly or always performed. When cognitive screening was performed, 42 (84%) used validated screening instruments. Twenty-nine (56%) of the respondents reported that screening for emotional problems was mostly or always performed. When emotional screening was performed, 31 (63%) reported using validated screening instruments. Timing of screening and information provision was highly variable, and the majority reported that there was no protocol for follow-up care when cognitive or emotional problems were found., Conclusions: This study demonstrates that clinical practice at neurology departments is highly variable regarding screening, information provision and follow-up care for cognitive and emotional problems in patients after TIA or ischaemic stroke. Approximately half of the participating neurologists reported that screening was performed only sometimes or never for cognitive and emotional problems after TIA and ischaemic stroke., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Many individuals with type 2 diabetes mellitus (T2DM) experience "psychological insulin resistance". Consequently, it could be expected that insulin therapy may have negative effects on psychological outcomes and well-being. Therefore, this study compared health status and psychosocial functioning of individuals with T2DM using only oral antihyperglycemic agents (OHA) and on insulin therapy (with or without OHA)., Materials and Methods: In this cross-sectional study, we used baseline data of a cluster randomized controlled trial conducted in 55 Dutch general practices in 2005. Health status was measured with the Short Form (SF)-36 (scale 0-100) and psychosocial functioning with the Diabetes Health Profile (DHP, scale 0-100). To handle missing data, we performed multiple imputation. We used linear mixed models with random intercepts per general practice to correct for clustering at practice level and to control for confounding., Results: In total, 2,794 participants were included in the analysis, their mean age was 65.8 years and 50.8% were women. Insulin-users (n = 212) had a longer duration of T2DM (11.0 versus 5.6 years) and more complications. After correcting for confounders and multiple comparisons, insulin-users reported significantly worse outcomes on vitality (SF-36, adjusted difference -5.7, p=0.033), general health (SF-36, adjusted difference -4.8, p=0.043), barriers to activity (DHP, adjusted difference -7.2, p<0.001), and psychological distress (DHP, adjusted difference -3.7, p=0.004), all on a 0-100 scale., Discussion: While previous studies showed similar or better health status in people with type 2 diabetes receiving insulin therapy, we found that vitality, general health and barriers to activity were worse in those on insulin therapy. Although the causality of this association cannot be established, our findings add to the discussion on the effects of insulin treatment on patient-reported outcomes in daily practice., Competing Interests: AMB reports an unrestricted grant from Sanofi-Aventis for a study in type 2 diabetes patients on insulin therapy (support of self-management by mHealth), outside the submitted work. GR received an unrestricted research grant from Sanofi Aventis and fees from Novo Nordisk for consultancy and lecturing, outside the submitted work. FC received a fee from Novo Nordisk for a lecture (2016), not related to the submitted work. MA reports an unrestricted grant from Sanofi Aventis for conducting studies (till 2010) regarding insulin therapy in type 2 diabetes patients. RV reports an unrestricted grant from Sanofi-Aventis for a study in type 2 diabetes patients on insulin therapy (support of self-management by mHealth) outside the submitted work., (Copyright © 2021 Boels, Rutten, Cleveringa, van Avendonk and Vos.)

Background and Purpose: There are concerns that the coronavirus disease 2019 (COVID-19) outbreak negatively affects the quality of care for acute cardiovascular conditions. We assessed the impact of the COVID-19 outbreak on trends in hospital admissions and workflow parameters of acute stroke care in Amsterdam, The Netherlands., Methods: We used data from the three hospitals that provide acute stroke care for the Amsterdam region. We compared two 7-week periods: one during the peak of the COVID-19 outbreak (March 16th-May 3th 2020) and one prior to the outbreak (October 21st-December 8th 2019). We included consecutive patients who presented to the emergency departments with a suspected stroke and assessed the change in number of patients as an incidence-rate ratio (IRR) using a Poisson regression analysis. Other outcomes were the IRR for stroke subtypes, change in use of reperfusion therapy, treatment times, and in-hospital complications., Results: During the COVID-19 period, 309 patients presented with a suspected stroke compared to 407 patients in the pre-COVID-19 period (IRR 0.76 95%CI 0.65-0.88). The proportion of men was higher during the COVID-19 period (59% vs. 47%, p < 0.001). There was no change in the proportion of stroke patients treated with intravenous thrombolysis (28% vs. 30%, p = 0.58) or endovascular thrombectomy (11% vs 12%, p = 0.82) or associated treatment times. Seven patients (all ischemic strokes) were diagnosed with COVID-19., Conclusion: We observed a 24% decrease in suspected stroke presentations during the COVID-19 outbreak, but no evidence for a decrease in quality of acute stroke care.

Background: Ischemic stroke patients with a good outcome in terms of motor functioning and communication are likely to be discharged home without further rehabilitation. A significant number of these patients experience cognitive and emotional problems resulting in lower quality of life and decreased participation in society. This paper presents the protocol of a study examining the clinical effectiveness, cost-effectiveness and implementation of an intervention focused on screening and patient-tailored care for cognitive and emotional problems as compared to usual care in patients discharged home after ischemic stroke., Methods / Design: A multicenter, patient-blinded, cluster randomized controlled trial will be performed. Centers will be randomized (1:1) to the intervention group or the usual care group. Patients (> 18 years old) with a neurological confirmed diagnosis of ischemic stroke who can be discharged home without follow-up treatment at an outpatient rehabilitation clinic will be included. In the intervention group, patients will receive a short, individualized, semi-structured consultation by specialized nurses in addition to usual care. This consultation includes 1) screening for cognitive and emotional problems, 2) screening for restrictions in participation, 3) promotion of self-management strategies and 4) a decision tool for referral to rehabilitation services. The intervention will be performed approximately 6 weeks after the stroke at the neurology outpatient clinics and will take approximately 60 min. The control group will receive care as usual. Both groups will be followed-up at 6 weeks, 3 months and 12 months after stroke. The primary outcome will be the level of participation measured with the Restriction subscale of the Utrecht Scale for Evaluation of Rehabilitation on the level of Participation (USER-Participation-R) at 12 months. A cost-effectiveness analysis and process evaluation will be performed alongside., Discussion: This trial is the first to evaluate clinical effectiveness, cost-effectiveness and implementation of screening and patient-tailored care for cognitive and emotional problems compared to care as usual in patients discharged home after ischemic stroke. Potentially, this will improve the outcomes for patients with frequently occurring cognitive and emotional problems after stroke., Trial Registration: Netherlands Trial Register: NL7295 , registered 25 September 2018.

Introduction: Platelet-rich plasma (PRP) is a potentially efficacious treatment for ankle osteoarthritis (OA), but its use has not been examined in high-quality studies. Systematic reviews show that PRP injections significantly decrease pain and improve function in patients with knee OA. Ankle OA is more common than hip or knee OA in the young active population; with a prevalence of 3.4%.PRP injections in ankle OA are shown to be safe and improve quality of life over time, but no randomised controlled trial has been conducted. Our randomised controlled trial will evaluate the efficacy of PRP injections for symptom reduction and functional improvement, compared with placebo, in the treatment of ankle (talocrural) OA., Methods and Analysis: We will conduct the Platelet-Rich plasma Injection Management for Ankle OA study: a multicentre, randomised, placebo-controlled trial. One hundred patients suffering from ankle OA will be randomised into two treatment groups: PRP injection or placebo (saline) injection. Both groups will receive two injections of PRP or placebo at an interval of 6 weeks. Primary outcome is the American Orthopaedic Foot and Ankle Society score at 26 weeks. Secondary outcomes determined at several follow-up moments up to 5 years, include Ankle Osteoarthritis Score, Foot and Ankle Outcome Score, pain subscale of (0-40), Visual Analogue Scale score (0-100), Ankle Activity Score (0-10), subjective patient satisfaction Short Form Health Survey-36, Global Attainment Scaling and the EuroQol-5 dimensions-3 levels utility score. A cost-effectiveness analysis will be performed at 1 year., Ethics and Dissemination: The study is approved by the Medical Ethics Review Committee Amsterdam Medical Center, the Netherlands (ABR 2018-042, approved 23 July 2018) and registered in the Netherlands trial register (NTR7261). Results and new knowledge will be disseminated through the Dutch Arthritis Association (ReumaNederland), Dutch patient federation, conferences and published in a scientific peer-reviewed journal., Trial Registration Number: NTR7261., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Background: The shift in healthcare to extramural leads to more patients with complex health problems receiving nursing care at home. However, the interest of baccalaureate nursing students for community nursing is moderate, which contributes to widespread labour-market shortages. This study investigates the effect of a more 'community-care-oriented' curriculum on nursing students' perceptions of community care., Methods: A quasi-experimental quantitative survey study with a historic control group (n = 477; study cohorts graduating in 2015, 2016, and 2017; response rate 90%) and an intervention group (n = 170; graduating in 2018; response rate 93%) was performed in nursing students of a University of Applied Sciences in a large city in the Netherlands. The intervention group underwent a new curriculum containing extended elements of community care. The primary outcome was assessed with the Scale on Community Care Perceptions (SCOPE). The control and intervention group were compared on demographics, placement preferences and perceptions with a chi-square or T-test. Multiple regression was used to investigate the effect of the curriculum-redesign on nursing students' perceptions of community care., Results: The comparison between the control and intervention group on students' perceptions of community care shows no significant differences (mean 6.18 vs 6.21 [range 1-10], respectively), nor does the curriculum-redesign have a positive effect on students' perceptions F (1,635) = .021, p = .884, R 2  = < .001. The comparison on placement preferences also shows no significant differences and confirms the hospital's popularity (72.7% vs 76.5%, respectively) while community care is less often preferred (9.2% vs 8.2%, respectively). The demographics 'working in community care' and 'belonging to a church/religious group' appear to be significant predictors of more positive perceptions of community care., Conclusions: Graduating students who experienced a more 'community-care-oriented' curriculum did not more often prefer community care placement, nor did their perceptions of community care change. Apparently, four years of education and placement experiences have only little impact and students' perceptions are relatively static. It would be worth a try to conduct a large-scale approach in combination with a carefully thought out strategy, based on and tying in with the language and culture of younger people.

Objectives: Prophylactic surgery for prevention of acute type A aortic dissection (ATAAD) is reserved for patients with an ascending aortic aneurysm ≥55 mm. Identification of additional risk predictors is warranted since over 70% of patients presenting with ATAAD have a non-dilated aorta or an aneurysm that would not have met the diameter criterion for preventative surgery. Aim of the study was to evaluate ascending aortic elongation as a risk factor for ATAAD and to compare aortic lengths between ATAAD patients and healthy controls., Methods: Aortic lengths and diameters of ATAAD patients were measured on three-dimensional modelled computed tomography and adjusted to predissection dimensions in this cross-sectional single-centre study. Logistic regression was used to evaluate the relation between ATAAD and aortic dimensions. Lengths of different aortic segments were compared with a healthy control group using propensity score matching., Results: Two-hundred and fifty patients were included in the study (ATAAD, n=40; controls, n=210). Ascending aortic length and diameter proved to be independent predictors for ATAAD (OR=5.3, CI 2.5 to 11.4, p<0.001 and OR=8.6, CI 2.4 to 31.0, p=0.001). Eighty patients were matched based on propensity scores (ATAAD n=40, controls n=40). The ascending aorta was longer and more dilated in ATAAD patients compared with healthy controls (78.6±8.8 mm vs 68.9±7.2 mm, p<0.001, 34.4 mm ±3.2. vs 39.4 mm ±5.7, p<0.001, respectively). No differences were found in lengths of the aortic arch and descending aorta., Conclusions: Ascending aortic length could serve as an independent predictor for ATAAD. Future studies addressing indications for prophylactic surgery should also investigate aortic length., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objectives: Differentiation between normal and abnormal features of vascular ageing is crucial, as the latter is associated with adverse outcomes. The normal aortic ageing process is accompanied by gradual luminal dilatation and reduction of vessel compliance. However, the influence of age on longitudinal aortic dimensions and geometry has not been well studied. This study aims to describe the normal evolution of aortic length and shape throughout life., Methods: A total of 210 consecutive patients were prospectively enrolled in this cross-sectional single-centre study. All subjects underwent CT on a third-generation dual-source CT scanner. Morphometric measurements, including measurements of segmental length and tortuosity, were performed on three-dimensional models of the thoracic aorta., Results: The length of the thoracic aorta was significantly related to age (r=0.54) and increased by 59 mm (males) or 66 mm (females) between the ages of 20 and 80 years. Elongation was most pronounced in the proximal descending aorta, which showed an almost 2.5-fold length increase during life. The lengthening of the thoracic aorta was accompanied by a marked change of its geometry: whereas the aortic apex was located between the branch vessels in younger patients, it shifted to a more distalward position in the elderly., Conclusions: The normal ageing process is accompanied by gradual aortic elongation and a notable change of aortic geometry. Part II of this two-part article investigates the hypothesis that excessive elongation could play a role in the occurrence of acute aortic dissection., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

The aim of this study was to develop a valid instrument to measure student nurses' perceptions of community care (SCOPE). DeVellis' staged model for instrument development and validation was used. Scale construction of SCOPE was based on existing literature. Evaluation of its psychometric properties included exploratory factor analysis and reliability analysis. After pilot-testing, 1062 bachelor nursing students from six institutions in the Netherlands (response rate 81%) took part in the study. SCOPE is a 35-item scale containing: background variables, 11 measuring the affective component, 5 measuring community care perception as a placement, 17 as a future profession, and 2 on the reasons underlying student preference. Principal axis factoring yielded two factors in the affective component scale reflecting 'enjoyment' and 'utility', two in the placement scale reflecting 'learning possibilities' and 'personal satisfaction', and four in the profession scale: 'professional development', 'collaboration', 'caregiving', and 'complexity and workload'. Cronbach's α of the complete scale was 0.892 and of the subscales 0.862, 0.696, and 0.810 respectively. SCOPE is a psychometrically sound instrument for measuring students' perceptions of community care. By determining these perceptions, it becomes possible to positively influence them with targeted curriculum redesign, eventually contributing to decreasing the workforce shortage in community nursing., (Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The objective of this prospective cohort study was to assess whether the 45-minute prehospital limit for ambulance transfer is met in case of postpartum hemorrhage (PPH) after midwifery-supervised home birth in The Netherlands and evaluate the process of ambulance transfer, maternal condition during transfer, and outcomes in relation to whether this limit was met., Methods: Using ambulance report forms and medical charts, ambulance intervals, urgency coding, clinical condition (using the lowest Revised Trauma Score, [RTS]), and maternal outcomes were collected. From April 2008 to April 2010, midwives reported 72 cases of PPH. Associations between duration of the ambulance transfer, maternal condition during ambulance transfer and outcomes were analyzed. The main outcome measures were duration of ambulance transfer, RTS, blood loss, surgical procedures, and blood transfusions., Results: Seventy-two cases were reported, 18 (25%) were excluded: 54 cases were analyzed. In 63 percent, the 45-minute prehospital limit was met, 75.9 percent received a RTS of 12, indicating optimal Glasgow Coma Scale, systolic blood pressure, and respiratory frequency. In 24.1 percent a decrease in systolic blood pressure was found (RTS 10 or 11). We found no difference in outcomes between women with different RTS or in whom the 45-minute prehospital limit was or was not met., Conclusions: We found no relation between the duration of ambulance transfer and maternal condition or outcomes. All women fully recovered. The low-risk profile of women in primary care, well-organized midwifery, and ambulance care in The Netherlands are likely to contribute to these findings., (© 2015 Wiley Periodicals, Inc.)

Background: Physicians are frequently confronted with complex health situations of patients, but knowledge of intensive forms of multimorbidity and their development during life is lacking. This study explores patterns and trajectories of chronic health problems of patients with multimorbidity particularly those with more than ten conditions and type and variety of organ systems involved in these patterns during life., Method: Life time prevalence patterns of chronic health problems were determined in patients with illness trajectories accumulating more than ten chronic health problems during life as registered by general practitioners in the South of the Netherlands in the Registration Network Family Practices (RNH)., Results: Overall 4,560 subjects (5%) were registered with more than ten chronic health problems during their life (MM11+), accounting for 61,653 (20%) of the 302,808 registered health problems in the population (N = 87,837 subjects). More than 30% accumulates 4 or more chronic health conditions (MM4-5: 4-5 conditions (N = 14,199; 16.2%); MM6-10: 6-10 conditions (N = 14,365; 16.4%). Gastro-intestinal, cardiovascular, locomotor, respiratory and metabolic conditions occur more frequently in the MM11+ patients than in the other patients, while the nature and variety of body systems involved in lifetime accumulation of chronic health problem clusters is both generic and specific. Regarding chronic conditions afflicting multiple sites throughout the body, the number of neoplasms seems low (N = 3,592; 5.8%), but 2,461 (49%) of the 4,560 subjects have registered at least one neoplasm condition during life. A similar pattern is noted for inflammation (N = 3,537, 78%), infection (N = 2,451, 54%) and injury (N = 3,401, 75%)., Conclusion: There are many challenges facing multimorbidity research, including the implementation of a longitudinal, life-time approach from a family practice perspective. The present study, although exploratory by nature, shows that both general and specific mechanisms characterize the development of multimorbidity trajectories. A small proportion of patients has a high number of chronic health problems (MM11+) and keeps adding health problems during life. However, GP's need to realise that more than one third of their patients accumulate four or more chronic health problems (MM4-5 and MM6-10) during life.

Background: Treatment rates with intravenous tissue plasminogen activator vary by region, which can be partially explained by organizational models of stroke care. A recent study demonstrated that prehospital factors determine a higher thrombolysis rate in a centralized vs. decentralized model in the north of the Netherlands., Aim: To investigate prehospital factors that may explain variation in thrombolytic therapy between a centralized and a decentralized model., Methods: A consecutive case observational study was conducted in the north of the Netherlands comparing patients arriving within 4·5 h in a centralized vs. decentralized stroke care model. Factors investigated were transportation mode, prehospital diagnostic accuracy, and preferential referral of thrombolysis candidates. Potential confounders were adjusted using logistic regression analysis., Results: A total of 172 and 299 arriving within 4·5 h were enrolled in centralized and decentralized settings, respectively. The rate of transportation by emergency medical services was greater in the centralized model (adjusted odds ratio 3·11; 95% confidence interval, 1·59-6·06). Also, more misdiagnoses of stroke occurred in the central model (P = 0·05). In postal code areas with and without potential preferential referral of thrombolysis candidates due to overlapping catchment areas, the odds of hospital arrival within 4·5 h in the central vs. decentral model were 2·15 (95% confidence interval, 1·39-3·32) and 1·44 (95% confidence interval, 1·04-2·00), respectively., Conclusions: These results suggest that the larger proportion of patients arriving within 4·5 h in the centralized model might be related to a lower threshold to use emergency services to transport stroke patients and partly to preferential referral of thrombolysis candidates., (© 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization.)

Objective: To compare the similarities among the multimorbidity patterns identified in primary care patients from two European regions (Spain and the Netherlands) with similar organisational features of their primary care systems, using validated methodologies., Methodology: This observational, retrospective, multicentre study analysed information from primary care electronic medical records. Multimorbidity patterns were assessed using exploratory factor analysis of the diagnostic information of patients over 14 years of age. The analysis was stratified by age groups and sex., Results: The analysis of Dutch data revealed a higher prevalence of multimorbidity which corresponds with the clustering of a higher number of diseases in each of the patterns. Relevant clinical similarities were found between both countries for three multimorbidity patterns that were previously identified in the original Spanish study: cardiometabolic, mechanical and psychiatric-substance abuse. In addition, the clinical evolution towards complexity of the cardiometabolic pattern with advancing age--already demonstrated in the original study--was corroborated in the Dutch context. A clear association between mechanical and psychosocial disorders was unique to the Dutch population, as well as the recurrent presentation of the psychiatric-substance abuse pattern in all age and sex groups., Conclusions: The similarities found for the cardiometabolic, mechanical and psychiatric-substance abuse patterns in primary care patients from two different European countries could offer initial clues for the elaboration of clinical practice guidelines, if further evidenced in other contexts. This study also endorses the use of primary care electronic medical records for the epidemiologic characterization of multimorbidity.

Objectives: Iron deficiency (ID) and iron deficiency anemia (IDA), during the first years of life, are associated with delayed motor and neurological development. Many studies evaluated iron status without an assessment of an acute-phase protein to identify infection. Because most indicators of iron status are influenced by infection, these data may underestimate the ID prevalence. A food consumption survey in the Netherlands showed that the mean iron intake of children ages 2 to 3 years was below the advised adequate intake of 7 mg/day. The aim of the study was to investigate iron status in a well-defined, healthy population of young children in the southwestern region of the Netherlands and to identify risk factors for ID., Methods: We conducted a multicenter, observational study in healthy children ages 0.5 to 3 years. We defined ID as ferritin <12 μg/L and IDA when, in addition, hemoglobin was <110 g/L. Children with elevated C-reactive protein levels (>5 mg/L) or underlying causes for anemia were excluded. Parents filled in a questionnaire to identify risk factors for ID., Results: We included 400 children in the study. ID and IDA were detected in 18.8% and 8.5% of the children, respectively. The present use of formula and the visit of preschool/day care were associated with a lower prevalence of ID, and a high intake of cow's milk was associated with a higher prevalence of ID, after adjustment for age., Conclusions: ID is present in 18.8% of healthy children ages 0.5 to 3 years and living in the southwestern region of the Netherlands. The present visit of preschool/day care and the use of formula are associated with a reduced risk of ID, whereas a high intake of cow's milk is associated with an increased risk of ID.

Background: For patients with ST-elevation myocardial infarction (STEMI), guidelines recommend prehospital triage and direct referral to a percutaneous coronary intervention (PCI)-capable centre in order to minimize ischemic time. However, few have studied failed prehospital diagnosis. We assessed the incidence, predictors, and clinical impact of interhospital transfer for primary PCI after initial referral to a non-PCI-capable centre due to a failed prehospital STEMI diagnosis., Methods: We studied 846 consecutive STEMI patients undergoing primary PCI between January 2008 and January 2010., Results: We found that 609 patients (72%) were directly admitted through prehospital triage and 127 patients (15%) required interhospital transfer after failed prehospital diagnosis. Median first medical contact to treatment time was 88 min in the prehospital diagnosis group and 155 min in the interhospital transfer group (p<0.001). In the interhospital transfer group, the first available electrocardiogram was diagnostic for STEMI in 77% of cases. Predictors of interhospital transfer were female gender, diabetes, prior myocardial infarction, and greater event location to PCI-capable centre distance. Interhospital transfer independently accounted for a 47% increase in ischemic time (95% CI 33 to 63%; p<0.001). One-year mortality was higher in the interhospital transfer group (10 vs. 5.3%; p=0.030)., Conclusions: Despite an often-diagnostic electrocardiogram, interhospital transfer after failed prehospital diagnosis occurred in 15% of STEMI patients undergoing primary PCI. Interhospital transfer was a major predictor of ischemic time and 1-year mortality was significantly higher. Continuing efforts to optimize prehospital triage are warranted, especially among patients at higher risk of failed prehospital diagnosis.

Objective: The objective of this study was to describe postoperative undernutrition in terms of postoperative losses of appendicular skeletal muscle mass (ASMM) with respect to complications, quality of life, readmission, and 1-y mortality after cardiac surgery., Methods: Patients undergoing cardiac surgery were prospectively followed. ASMM was measured 2 wk before and 2 mo after surgery using dual-energy X-ray absorptiometry. ASMM consists of arm skeletal muscle mass (SMM) and leg SMM. The association between ≥5% of ASMM decrease and postoperative outcome was analyzed using the chi-square test. A similar approach was used to analyze arm SMM and leg SMM decreases separately., Results: Twenty-nine patients were included (23 male, 34.5% ≥65 y old). Postoperatively, seven patients (24.1%) lost ≥5% ASMM. When analyzed separately, a ≥5% decrease in leg SMM was associated with a decrease in experienced vitality (odds ratio 13.0, 95% confidence interval 1.32-128.11, P = 0.03). In contrast, a ≥5% loss of arm SMM was associated with fewer in-hospital complications (odds ratio 0.20, 95% confidence interval 0.04-0.98, P = 0.04). These patients were characterized by a higher preoperative fat-free mass index (kilograms per meter squared; P = 0.01)., Conclusions: The results suggest that a preoperatively higher fat-free mass index indicates better ability to cope with operative stress, resulting in fewer complications. In addition, postoperative loss of muscle mass was associated with decreased vitality. We advocate further research investigating the effect of preoperative and postoperative nutritional intervention combined with physical exercise programs to increase lean body mass and thereby improve postoperative recovery after cardiac surgery., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Introduction: Faster emergency response times are generally considered to have a positive effect on life expectancy of patients with a life-threatening event, leading many communities to determine response time intervals. However, worldwide, increasing urbanization and traffic congestion threatens ambulance response times. An emergency motorcycle response vehicle (MRV) can overcome these hurdles more easily than a larger ambulance. It also offers dispatch flexibility in responding to calls estimated to have a low likelihood of a patient who needs transport. The first aim of this study was to determine whether an MRV can shorten response times and impact on resuscitation outcomes in a heavily urbanized and densely populated region in the Netherlands. The second aim was to evaluate differences in dispatch and transport between MRV and ambulance., Methods: This was a nonrandomized, prospective cohort study comparing an MRV unit with regular ambulances in a Dutch city of 265 000 people. Included were all 'urgent patient' cases within operating time of the MRV between January 2003 and August 2003., Results: A total of 1664 patients was evaluated, including 468 motorcycle and 1196 ambulance responses. Use of MRVs led to a decrease in response time of 54 s (P≤0.01). We could not show a decrease in mortality risk in cases of resuscitation [relative risk (RR): 2.50, confidence interval (CI): 0.17-36.21]. There was a slightly improved 1-year survival in other life-threatening cases (RR: 1.13, CI: 1.03-1.24). However, this is most likely because of differences in dispatch decisions (the MRV is sent to 'lighter' cases) and not because of faster assistance. The MRV paramedic was more likely to treat and release the patient (RR: 2.21, CI: 1.80-2.73) or refer them to a general practitioner (RR: 2.11, CI: 1.73-2.58) and much less likely to refer them to the hospital emergency department (41.2 vs. 72.6%). Referrals to the hospital by the MRV were mostly by the patient's own means of transportation (RR: 13.14, CI: 5.89-29.32) rather than by ambulance., Conclusion: Using motorcycles in a Dutch setting lead to better emergency medical service response times. The MRV serves a different population. Resulting in a higher treat and release rate and less transportation to hospital.

Objective: Several studies have shown low fat-free mass index to be a stronger predictor for mortality than low body mass index. The main aim of this study was to assess the still unknown association between preoperative low fat-free mass index and adverse cardiac surgical outcomes., Methods: In a prospective observational study, fat-free mass index was determined by bioelectric impedance spectroscopy on hospital admission. Associations between low fat-free mass index and postoperative infections and mortality, as well as prolonged intensive care unit and hospital stays, were analyzed with logistic and Cox regression techniques., Results: Between February 2008 and December 2009, 325 adult patients admitted for elective heart surgery were included. Analyses showed that low fat-free mass index, present in 8.3% of patients, was independently associated with occurrence of infections after cardiac surgery (18.5% vs 4.7%; adjusted odds ratio, 6.9; 95% confidence interval, 1.8-27.7; P = .01). Low fat-free mass index also tended to be associated with higher risk of longer postoperative intensive care unit stay (adjusted hazard ratio, 0.7; 95% confidence interval, 0.4-1.1; P = .09). When classifying patients as undernourished by traditional methods (body mass index ≤21.0 kg/m(2) or ≥10% weight loss in preceding 6 months), half of patients with low fat-free mass index were misclassified as well nourished., Conclusions: Low fat-free mass index is associated with increased occurrence of adverse outcomes after cardiac surgery. We advocate fat-free mass index as the leading parameter in classifying and treating undernourished cardiac surgical patients, which might improve recovery rates after cardiac surgery., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Achilles tendon disorders, like Achilles tendinopathy, are very common among athletes. In the general population, however, knowledge about the incidence of Achilles tendinopathy is lacking. Design Cross-sectional study., Methods: In a cohort of 57.725 persons registered in primary care, the number of patients visiting the general practitioner (GP) with diagnosis of mid-portion Achilles tendon problems was counted using computerised registration networks of GPs in 2009. Subsequently, the authors assessed associations of these rates with demographic characteristics., Results: The incidence rate of Achilles tendinopathy is 1.85 per 1,000 Dutch GP registered patients. In the adult population (21-60 years), the incidence rate is 2.35 per 1,000. In 35% of the cases, a relationship with sports activity was recorded., Conclusion: This is the first report on incidence rates of mid-portion Achilles tendinopathy in general practice. With an incidence of 1.85 per 1,000 registered persons, Achilles tendinopathy is frequently seen by GPs. The actual incidence might even be higher due to study limitations. More research on the frequency of this injury is required.

Aim: To identify which patient groups can be safely discharged early after high dose chemotherapy., Background: Until recently, the standard of care for patients with haematological malignancies who have been treated with high dose chemotherapy has been to hospitalise them until neutrophil recovery and clinical improvement. Over the past years, a more liberal approach has resulted in a tendency to discharge patients earlier. However, currently it is unclear which clinical variables are important and which patient groups are most suitable to be discharged early., Design: Prospective cohort study., Methods: The study group of 55 patients underwent 82 admission periods for a total of 2269 patient days, which could be classified into four categories: induction treatment, consolidation treatment and autologous or allogeneic stem cell transplantation. Different clinical variables potentially interfering with early discharge were subsequently analysed for their association with each treatment group., Results: The median duration of admission was 27 days. The incidence of fever (82.9%) and use of intravenous antibiotics (79.3%) was high in all treatment groups. The only statistically significant differences between groups were found for performance status and mucositis. In the patient group undergoing consolidation chemotherapy for acute myeloid leukaemia, the performance status was better and mucositis was less severe. The decline in performance status and the severity of mucositis were as expected most obvious 10-14 days after the start of chemotherapy., Conclusion: Patients undergoing consolidation chemotherapy appear to be the most suitable candidates for early discharge, especially in the first-week postchemotherapy treatment. Early discharge can also be considered in patients with a good performance status in the autologous stem cell transplantation group, directly after transplantation., Relevance to Clinical Practice: An important factor in developing an early discharge programme is a good infrastructure, both at home and in the hospital., (© 2010 Blackwell Publishing Ltd.)

Drawing from Science and Technology Studies we investigate the consequences for social differentiation of physicians' practices in Dutch illness certification. Using participant observation methods, we followed six 'Arbodienst' physicians for two weeks each. Our analysis explores whether and how the work of Dutch physicians contributes to the appearance of a category of 'problematic migrant patients'. We present how physicians, in using instruments to distinguish plausible from implausible claims for sick leave, impose order upon reality. In particular situations this ordering involves a distinction between Dutch and migrant clients. Here ethnicity appears in physicians' practice as a separate instrument to constitute order, which in the case of migrants overrules the productive instruments that are used for 'Dutch' clients. By interpreting clients' behaviour in cultural terms and making them into strangers, physicians lose their ability to fine-tune their coaching activities to the needs of these clients. As a result migrants remain work incapacitated for a longer period, which leads to a higher risk of their ending up in the disability pension program. As a consequence migrants become visible as a problematic group in the data on work incapacity and disability. The practice to categorise migrant clients with separate instruments thus results in a 'hard' category of problematic migrant clients and leads to social differentiation., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Background and Aim: With the increasing interest in lifestyle, health and consequences of unhealthy lifestyles for the healthcare system, a new kind of solidarity is gaining importance: lifestyle solidarity. While it might not seem fair to let other people pay for the costs arising from an unhealthy lifestyle, it does not seem fair either to punish people for their lifestyle. However, it is not clear how solidarity is assessed by people, when considering disease risks or lifestyle risks. The aim of this study was to investigate the degree of solidarity with lifestyle as well as with other factors that are related to health outcomes-for example, old age-and the relation between this degree of solidarity and various characteristics., Methods: This cross-sectional study is part of the Dutch longitudinal SMILE study. Data on the degree of solidarity with different lifestyles and old age, and the relation between the degree of solidarity and various demographic and other variables were obtained in a questionnaire survey., Results: Solidarity with smokers and overweight people was moderate, as was solidarity with older people. Respondents were ambivalent about athletes. Respondents who were younger, male and highly educated, and those with a healthy lifestyle, a small social network, high quality of life and an internal locus of control, showed low solidarity., Conclusions: Solidarity with an unhealthy lifestyle and old age is moderate and the degree of solidarity varies among the different subgroups.

This article deals with the issue of public trust in decisions made by individual physicians, concerning older people, as perceived by various key professionals. While trust is a basic element in our health care service, it is at the same time a difficult phenomenon to conceptualize. This article tries to contribute to a better understanding of what trust in medical practice entails and what are the necessary conditions for a society to put trust in the medical profession. The focus is on care for older people under the condition of scarcity in health care resources. Our study has a qualitative design consisting of semi-structured in-depth interviews with 24 key professionals focusing on decision-makers and those in line of professionally organizing or influencing the decision-making process. We found roughly three categories of trust: distrust; trust; and qualified trust. In each category we found different reasons to give or withhold trust and different views on how far the discretionary power of doctors should go. We recommend promoting trust by addressing the criteria or limits brought forward in the qualified trust category. The preconditions as identified in the qualified trust section provide the boundaries and marking points between which physicians have to move regarding the care for older people. The qualifications provide us insight in where and how to invest in trust under these and under different circumstances. An important conclusion is that trust is never finished: trust needs to be gained and negotiated in a continuous process of action and interaction.

Introduction: Our objectives were to determine the incidence of missed injuries and inappropriately managed cases in patients with minor injuries and illnesses and to evaluate diagnostic accuracy of the emergency nurse practitioners (ENPs) compared with junior doctors/senior house officers (SHOs)., Methods: In a descriptive cohort study, 741 patients treated by ENPs were compared with a random sample of 741 patients treated by junior doctors/SHOs. Groups were compared regarding incidence and severity of missed injuries and inappropriately managed cases, waiting times, and length of stay., Results: Within the total group, 29 of the 1,482 patients (1.9%) had a missed injury or were inappropriately managed. No statistically significant difference was found between the ENP and physician groups in terms of missed injuries or inappropriate management, with 9 errors (1.2%) by junior doctors/SHOs and 20 errors (2.7%) by ENPs. The most common reason for missed injuries was misinterpretation of radiographs (13 of 17 missed injuries). There was no significant difference in waiting time for treatment by junior doctors/SHOs versus ENPs (20 minutes vs 19 minutes). The mean length of stay was significantly longer for junior doctors/SHOs (65 minutes for ENPs and 85 minutes for junior doctors/SHOs; P < .001; 95% confidence interval, 72.32-77.41)., Discussion: ENPs showed high diagnostic accuracy, with 97.3% of the patients being correctly diagnosed and managed. No significant differences between nurse practitioners and physicians related to missed injuries and inappropriate management were detected., (2010 Emergency Nurses Association. Published by Mosby, Inc. All rights reserved.)

Objectives: to investigate the prevalence of anaemia in pregnancy according to the cut-off points used in the national clinical guideline 'Anaemia in Primary Care Midwifery Practice', and to investigate a possible difference in prevalence between pregnant women of Northern European descent compared with women of non-Northern European descent. The study also investigated whether any difference in prevalence resulted in a higher risk of a transferred home delivery, thus reducing the chance for women to choose the place of birth., Design: retrospective cohort study., Setting: primary care midwifery practices in a highly urbanised area in Amsterdam, the Netherlands., Participants: all patients in three midwifery practices over 1 year were selected provided that they met the inclusion and exclusion criteria. The practices were selected on the basis of urbanisation, resulting in an adequate ethnic population which was comparable with the ethnic mix in other similarly urbanised areas in the Netherlands. This resulted in a study population of 828 pregnant women of Northern European and non-Northern European descent with low-risk singleton pregnancies during 2003., Analysis: mean haemoglobin level and anaemia rate were computed for the total study population as well as separate ethnic groups. Differences between groups were determined using chi(2) tests, and effect sizes were expressed in relative risks including 95% confidence intervals (CI)., Findings: the prevalence of anaemia in pregnancy was 3.4% (n = 28) at booking (first visit) and 2.7% (n = 22) at approximately 30 weeks of gestation. The relative risk of anaemia at booking was 5.9 (95% CI 2.1-16.7) for pregnant women of non-Northern European descent compared with those of Northern European descent. The relative risk of anaemia at approximately 30 weeks of gestation was 22 (95% CI 3-162) for pregnant women of non-Northern European descent compared with those of Northern European descent. The incidence of transferred home delivery was 3.1% in the study population. The relative risk for transferred home delivery was 24.1 (95% CI 3.3-176.7) for pregnant women of non-Northern European descent compared with those of Northern European descent., Key Conclusions and Implications for Practice: pregnant women of non-Northern European descent are a specific group in terms of anaemia and are at high risk of a low haemoglobin level for all cut-off values; they have a higher chance of becoming anaemic in pregnancy than women of Northern European descent. As a result, they have a higher risk of a transferred home delivery, taking away their opportunity to choose the place of birth. Haemoglobinopathies did not explain the higher risk of anaemia in pregnant women of non-Northern European descent. Being of non-Northern European descent should be added as a risk factor for anaemia in pregnancy until more is known about the background of this risk factor.

Objective: Smoking cessation is an important factor in reducing cardiovascular mortality, but considerable effort is needed to successfully persuade patients to quit smoking. We studied the efficiency of the Minimal Intervention Strategy (C-MIS) in addition to nicotine replacement therapy (NRT) for smoking cessation in cardiovascular outpatients in relation to the outcome of mortality., Design: Prospective cohort data studying the C-MIS in three outpatient clinics: cardiology, vascular surgery and vascular medicine., Methods: Two thousand, two hundred and seventy-five consecutive patients attending the clinics for first or routine follow-up visits were screened for atherosclerosis and smoking. The efficiency of the C-MIS was expressed as the number of smokers needed to screen and needed to treat in relation to the number of deaths prevented over a 5-year period. Mortality estimates were derived from the literature., Results: One thousand, four hundred and thirty-one patients were screened at first-time follow-up visits and 1294 at routine follow-up visits. With a rate of effectiveness of 4.3% for the C-MIS, the number needed to treat was 240 (min-max: 64-infinity) to prevent one death. The corresponding number needed to screen was 687 (min-max: 141-infinity) in the cardiology clinic, 574 (min-max: 134-infinity) in the vascular surgery clinic and 444 (min-max: 90-infinity) in the vascular medicine clinic. Within 5 years, 10 (min-max: 0-58) deaths could be prevented in all three clinics together. With the effectiveness of the C-MIS for first-time and routine follow-up attendees, only six (min-max: 0-36) and zero (min-max: 0-25) deaths could be prevented, respectively., Conclusion: In terms of the efficiency of the C-MIS in addition to nicotine replacement therapy, there is some benefit for first-time attendees and no benefit for routine follow-up attendees in preventing death.

Objective: This study assessed the relative importance of clinical and transport-related factors in physicians' decision-making regarding the interhospital transport of critically ill patients., Methods: The medical heads of all 95 ICUs in The Netherlands were surveyed with a questionnaire using 16 case vignettes to evaluate preferences for transportability; 78 physicians (82%) participated. The vignettes varied in eight factors with regard to severity of illness and transport conditions. Their relative weights were calculated for each level of the factors by conjoint analysis and expressed in beta. The reference value (beta = 0) was defined as the optimal conditions for critical care transport; a negative beta indicated preference against transportability., Results: The type of escorting personnel (paramedic only: beta = -3.1) and transport facilities (standard ambulance beta = -1.21) had the greatest negative effect on preference for transportability. Determinants reflecting severity of illness were of relative minor importance (dose of noradrenaline beta = -0.6, arterial oxygenation beta = -0.8, level of peep beta = -0.6). Age, cardiac arrhythmia, and the indication for transport had no significant effect., Conclusions: Escorting personnel and transport facilities in interhospital transport were considered as most important by intensive care physicians in determining transportability. When these factors are optimal, even severely critically ill patients are considered able to undergo transport. Further clinical research should tailor transport conditions to optimize the use of expensive resources in those inevitable road trips.

Aim: To assess whether the use of a night splint is of added benefit on functional outcome in treating chronic midportion Achilles tendinopathy., Methods: This was a single-blind, prospective, single centre, randomised controlled trial set in the Sports Medical Department, The Hague Medical Centre, The Netherlands. Inclusion criteria were: age 18-70 years, active participation in sports, and tendon pain localised at 2-7 cm from distal insertion. Exclusion criteria were: insertional disorders, partial or complete ruptures, or systemic illness. 70 tendons were included and randomised into one of two treatment groups: eccentric exercises with a night splint (night splint group, n = 36) or eccentric exercises only (eccentric group, n = 34)., Interventions: Both groups completed a 12-week heavy-load eccentric training programme. One group received a night splint in addition to eccentric exercises. At baseline and follow-up at 12 weeks, patient satisfaction, Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A) score and reported compliance were recorded by a single-blind trained researcher who was blinded to the treatment., Results: After 12 weeks, patient satisfaction in the eccentric group was 63% compared with 48% in the night splint group. The VISA-A score significantly improved in both groups; in the eccentric group from 50.1 to 68.8 (p = 0.001) and in the night splint group from 49.4 to 67.0 (p<0.001). There was no significant difference between the two groups in VISA-A score (p = 0.815) and patient satisfaction (p = 0.261)., Conclusion: A night splint is not beneficial in addition to eccentric exercises in the treatment of chronic midportion Achilles tendinopathy.

Objective: In this study among patients with cancer in the palliative phase, we analysed whether assessing the symptom, which is causing the most trouble in the patient's every day life ('most troublesome' symptom) had added value apart from the presence and severity of symptoms, which are most commonly assessed in clinical practice., Methods: Patients with cancer (lung, gastro-intestinal, breast cancer) in the palliative phase from two non-academic hospitals were included in the study. Using the Symptom Monitor tool, 10 physical symptoms were assessed with regard to presence and severity. The Symptom Monitor has an extra added item indicating as the 'most troublesome' symptom. This item was monitored to determine whether it had added value apart from the presence of symptoms and 'most severe' symptom. The severity score on the indicated 'most troublesome' symptom was subtracted from the severity score of the 'most severe' symptom. The generated delta score of 0 indicated no added value, whereas a score of one or more indicated that the 'most troublesome' symptom would have been missed if not specifically asked for by the physician, because its severity was lower that the 'most severe' symptom., Results: One hundred and forty-six patients reported 590 symptoms to be present. In total, 227 symptoms were reported as 'most severe' symptom (n = 138 patients). Among these, fatigue (n = 52) and pain (n = 24) were reported most frequently as 'most severe' symptom. In total, 134 patients indicated a symptom as 'most troublesome'. Fatigue (n = 33; 25%) and pain (n = 22; 16%) were also indicated by most of these patients as the 'most troublesome' symptom. One hundred and fifty-two comparisons could be made between the 'most severe' and the 'most troublesome' symptom. In 102 (67%) of the comparisons assessing the 'most troublesome' symptom had no added value: the score for 'most severe' symptom did not differ from the score for the 'most troublesome' symptom revealing a delta score of 0. In 23 times (15%) of the 152 comparisons made, the delta score was 1 and in 27 (18%) of the comparisons the delta score was 2 or more indicating that assessing the 'most troublesome' symptom substantially had added value., Conclusion: In patients in the palliative phase of their disease, extra attention for the 'most troublesome' symptom is needed. In our study, in almost 1/3 of the cases, this symptom would have been missed the physicians attention if not specifically asked for., Practice Implications: We recommend not only to assess the presence and severity of symptoms, but furthermore to assess the patient's 'most troublesome' symptom in addition.

Objective: To describe the triage of patients operated for non-ruptured and ruptured abdominal aortic aneurysms (AAAs) before the endovascular era., Design: Retrospective single-centre cohort study., Methods: All patients treated for an acute AAA between 1998 and 2001 and admitted to our hospital were evaluated in the emergency department for urgent AAA surgery. All time intervals, from the telephone call from the patient to the ambulance department, to the arrival of the patient in the operating theatre, were analysed. Intraoperative, hospital and 1-year survival were determined., Results: 160 patients with an acute AAA were transported to our hospital. Mean (SD) age was 71 (8) years, and 138 (86%) were men. 34 (21%) of these patients had symptomatic, non-ruptured AAA (sAAA) and 126 patients had ruptured AAA (rAAA). All patients with sAAA and 98% of patients with rAAA were operated upon. For the patients with rAAA, median time from telephone call to arrival at the hospital was 43 min (interquartile range 33-53 min) and median time from arrival at the hospital to arrival at the operating room was 25 min (interquartile range 11-50 min). Intraoperative mortality was 0% for sAAA and 11% for rAAA (p = 0.042), and hospital mortality was 12% and 33%, respectively (p = 0.014)., Conclusions: A multidisciplinary unified strategy resulted in a rapid throughput of patients with acute AAA. Rapid transport, diagnosis and surgery resulted in favourable hospital mortality. Despite the fact that nearly all the patients were operated upon, survival was favourable compared with published data.

Introduction: The quality of first-responder performance at the end of automated external defibrillator (AED) training may not predict the performance adequately during a real resuscitation attempt., Methods: Between January and December 2000, we evaluated 67 resuscitation attempts in Amsterdam and surroundings, where police officers used an AED. We compared their performance with their assessment at the end of their ERC AED training course. One of the main goals of training was to deliver a shock within 90 s after switching the power on in the AED., Results: We analysed 127 police officers working in 67 police-teams. The police officers had a mean age of 35 years (range 23-54 years), 73% was male. The interval between AED training and the first resuscitation attempt was a median of 4 months (range 1-13). 78% percent of the 67 teams consisted of two police officers who both were qualified as "competent" after the initial training. Successful completion of the course correlated well with good performance during a resuscitation attempt (p = 0.009). When measured switching the power on in the AED, 92% of the victims received a shock within 90 s., Conclusions: Successful training correlates well with successful performance in the field. Competence of a team may be better than competence of two separate individuals.

Purpose: To evaluate the functional outcome of intensive care patients with critical illness polyneuropathy (CIP), 6 and 12 months after the onset., Design: A prospective observational cohort study and a cross-sectional study., Setting: University hospital in the Netherlands., Patients: Eight consecutive intensive care patients with CIP for the prospective study and eight patients diagnosed with CIP in the past 6 months for the cross-sectional study., Main Outcome Measures: Functional outcome regarding body functions and structure, activities, participation and perceived quality of life., Results: Nine patients (56%) died within one year. Functional outcome, participation and subjective health status in survivors varied widely at 6 and 12 months. After 12 months, physical functioning was improved in all patients. However activities related to mobility outdoors, autonomy, participation and quality of life were restricted in most patients., Conclusions: The majority of survivors have persistent functional disabilities in activities, reduced quality of life and restrictions in autonomy and participation one year after the onset of CIP. Prolonged rehabilitation treatment is necessary for an increasing number of intensive care patients who develop CIP, in order to reduce handicaps and achieve optimal autonomy and social participation.

Unlabelled: A short and effective training programme is an essential prerequisite for the use of automated external defibrillators (AED) by EMS providers and first responders. We evaluated a 3-h AED course based on the ERC requirements., Methods: As part of a study evaluating the effectiveness of AEDs used by first responders (ARREST 4), we trained all police officers in the region of Amsterdam, the Netherlands. By means of a Basic Life Support (BLS) assessment at the beginning of the course and at the end, we evaluated whether BLS can be improved in a 3-h AED course. Through a combined BLS and AED assessment at the end of the course, we evaluated whether AED skills can be acquired sufficiently. BLS skills were measured with the Laerdal SkillMeter in evaluation mode. AED skills were assessed using 13 criteria. By means of logistic regression, we analysed the influence of student characteristics, such as age, gender, previous training, resuscitation experience and motivation for BLS and AED on BLS and AED skills acquisition., Results: Between September 1999 and June 2000, 823 police officers were trained (76% male, mean age 36 (S.D. 9) years). BLS improved significantly (P < 0.001) in all criteria, except for hypoventilation (P < 0.001). After training, 89% of the students were able to use an AED safely and effectively. Self-confidence and motivation improved from 12 and 73% to 99 and 94% over the course (P < 0.001). Independent student characteristics influencing the success of the AED course were: previous BLS training, motivation before the course for an AED, and resuscitation experience that dated back for more than 12 months., Conclusion: The majority of police officers can be trained to use an AED safely and effectively within a 3-h AED course. During this course, they also improve on their BLS skills. Successful completion of the course depends in part on the student characteristics.

Objective: To assess the factors that may influence a patient's consent to participate in a clinical trial., Design: Systematic literature survey., Method: Studies on the characteristics of patients, trials, the physicians requesting informed consent and the informed consent procedures were looked for in Medline, Embase, and Cinahl. Articles published in English, German, Dutch or French in the period 1980-2002 and originating in Europe, the United States, Canada, New Zealand or Australia were included. Studies on non-adults, healthy experimental subjects or less than 30 patients were excluded., Results: Thirty suitable studies were retrieved. Factors that may affect the granting of consent to participate in a clinical trial included: uncertainty of the patient, randomisation and the use of a placebo, the relationship between the person asking for informed consent and the patient, and the dissemination of information during the informed consent procedure. Since these factors are often interrelated, no single factor could be identified as decisive for participation in a clinical trial; they can influence the decision of the patient to participate in a trial in either a positive or a negative direction., Conclusion: Optimalization of the information concerning informed consent, the way the information is provided and the attitude of the person requesting informed consent are important and sometimes decisive factors that may determine the participation process.

Background: There is controversy about performing either a planned relaparotomy (PR) or relaparotomy on demand (ROD) in patients with secondary peritonitis. Subjective factors influencing surgeons in decision making for either surgical treatment strategy have never been studied., Methods: All 858 surgeons of the Association of Surgeons of The Netherlands were sent a survey with 16 case vignettes simulating peritonitis patients and evaluating the preference for PR or ROD., Results: Sixty-two percent of surgeons responded to the survey. Of the returned surveys, 407 were eligible for evaluation. The responding surgeons had a slight overall preference for the ROD strategy, as shown by the mean overall preference score of 5.2 (range 3.54-6.52, with a maximal score of 7). Gastrointestinal surgeons and surgeons working in regional and smaller hospitals were significantly more in favour of a ROD strategy than their counterparts. Factors significantly influencing the preference towards PR were ischaemia as aetiology and performing a primary anastomosis; as for ROD, it was small bowel as focus, local extent of contamination and the question whether abdominal closure was possible. However, there was a considerable variability in treatment decisions by surgeons., Conclusion: The majority of responding surgeons would make a choice for a particular treatment strategy based on peritonitis and surgical treatment characteristics. There was a slight overall preference towards the ROD strategy despite the considerable variability per case vignette., (Copyright 2004 S. Karger AG, Basel.)

Objective: To test the hypothesis that the use of an automated external defibrillator by police and fire fighters results in higher discharge rates for out of hospital cardiac arrest., Design: Controlled clinical trial with initial random allocation of automated external defibrillators to first responders in four of the eight participating regions; each region switched from control to experimental, and vice versa, every four months., Setting: Amsterdam and surroundings, the Netherlands., Participants: Patients with witnessed out of hospital cardiac arrests, identified by the emergency medical system between January 2000 and January 2002., Main Outcomes Measures: Survival to hospital discharge; return of spontaneous circulation; admission to hospital., Results: 243 patients (65% in ventricular fibrillation) were included in the experimental area and 226 patients (67% in ventricular fibrillation) in the control area. The median time interval between collapse and first shock was 668 seconds in the experimental area and 769 seconds in the control area (P < 0.001). 44 (18%) patients in the experimental area versus 33 (15%) patients in the control area were discharged (odds ratio 1.3 (95% confidence interval 0.8 to 2.2), P = 0.33), 139 (57%) experimental versus 108 (48%) control patients had return of spontaneous circulation (1.5 (1.0 to 2.2), P = 0.05), and 103 (42%) experimental versus 74 (33%) control patients were admitted (1.5 (1.1 to 1.6), P = 0.02). The median delay from receipt of call to dispatch of the ambulance was 120 seconds, and the delay to dispatch of the first responder was 180 seconds., Conclusions: Use of automated external defibrillators by first responders did not significantly increase survival to discharge from hospital, although it did improve return of spontaneous circulation and admission to hospital. Improved dispatch procedures should increase the success of programmes of first responders using external defibrillators.

Objectives: To identify core issues that contribute to the gap between pre-marketing clinical research and practice as seen from the perspective of medical practice, as well as possible changes and potential barriers for dosing this gap., Methods: Interviews with 47 physicians and pharmacists who were liaised to drug regulation through their role in the pre- and post-marketing shaping of new cardiovascular drugs. Data were analyzed using methods of grounded theory and analytical evaluations., Results: Six core issues were identified that referred to the standards in drug regulation, the organization of the regulatory system, and conflicting interests. Pre-marketing trials should focus more on populations and research questions relevant to medical practice. In particular, variability in drug responses between subgroups of patients and demonstration of effectiveness should become major principles in drug regulation. An interactive post-marketing process in which public interests are represented was considered necessary to further guide research and development according to the needs in daily practice. Strategies for change could be applied within the present system of drug regulation, or affect its basic principles. Regulatory authorities were primarily identified to initiate changes, but many other parties should be involved. Barriers for change were identified regarding differences in interests between parties, organizational matters, and with respect to broader healthcare policies., Conclusions: Based on the respondents' opinions, there is a need to focus regulatory standards more on the needs in medical practice. Therefore, regulatory authorities should further develop their influence in the pre- and post-marketing drug development process, together with other parties involved, in order to bridge the gap between clinical research and medical practice.