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Blood cultures are essential diagnostic tools to identify pathogens in systemic infections. However, logistics of blood culture performance is often suboptimal. This study analyses the pre-analytic phase of blood culture processing through different types of risk assessments.We performed direct observations to gain in-depth knowledge of the root causes of suboptimal blood culture performance. These findings were summarised in a Bow-Tie chart. We then utilised a healthcare failure mode and effect analysis to prioritise failures per step in the process and to organise improvement activities. Finally, improvement actions were planned.Not obtaining a second set of blood cultures in the logistics of blood culture performance had the highest priority for action. Several failure modes, including human and system factors, were identified. Improvement actions included training and clinical lessons for nurses in the emergency department, updating hospital search engines to ease identification of relevant protocols, and an evaluation of the workload at the emergency department. Failure modes caused by human factors appear easy to address, however changing human behaviour is challenging.The analysis provided useful insight into the different steps in the logistics of blood culture performance and facilitated the organisation of actions focused on addressing the most urgent root causes.

Purpose Oncological patients are susceptible to various severe viral infections, including influenza. Vaccinating oncological patients and their household contacts (“cocoon vaccination”) may protect these patients from contracting influenza. To understand the potential of cocoon vaccination in oncological patients, this study assesses the influenza vaccination status of oncological patients and their household contacts and their considerations regarding the vaccination. Methods In this retrospective study, oncological patients with a solid tumor were asked to fill in a questionnaire about their own and their household contacts’ influenza vaccination status in the influenza season of 2018–2019. Results Ninety-eight patients were included (response rate 88%). The influenza vaccination rates of oncological patients and their first household contacts were 43.9% and 44.9%, respectively. The majority of vaccinated patients and vaccinated first household contacts had been advised by their general practitioner to get the vaccination. A minority of the first household contacts reported getting vaccinated specifically because of the patient’s vulnerability. Unvaccinated patients and unvaccinated household contacts mainly believed the vaccination was unnecessary or were afraid of side effects. None of the included patients had been hospitalized with influenza. Conclusion The oncological patients’ and first household contacts’ vaccination rates in this study were lower than the vaccination rates of the general Dutch population of over 60 years old, possibly due to a lack of knowledge and misconceptions about the vaccination. Further research is required to establish whether cocoon vaccination can contribute to protecting oncological patients from contracting an influenza infection.

Diabetes & Metabolism - In Press.Proof corrected by the author Available online since jeudi 30 juin 2016

To determine the effect of qSOFA and SOFA compared with the MEWS and SIRS criteria on the classification of emergency department (ED) patients with an infection as having sepsis.A retrospective single-centre study was performed in a random sample of 600 medical patients who visited the ED of the Academic Medical Centre Amsterdam between 1 November 2015 and 1 November 2016. Data for the different sepsis scores, as well as general data and demographics were retrieved. Descriptive analytics and sensitivity/specificity analysis were used to evaluate the performance of the different sepsis tools.Of 577 evaluable medical patients, 198 patients (34.3%) had a probable infection. The SIRS sepsis criteria, severe sepsis criteria, MEWS ≥ 5 and qSOFA criteria classified 141/198 (71.2%), 55/198 (27.8%), 58/198 (29.3%) and 17/198 patients (8.6%) respectively, as septic. The in-hospital mortality of patients classified as septic by the SIRS and qSOFA score was 6.4% and 29.4%. The qSOFA and SIRS score of ≥ 2 had a specificity of 93.7% (95% CI: 91.3-95.6) and 56.9% (52.7-61.1) in predicting in-hospital mortality.No major differences in gender, age, comorbidity and site of infection between patients with sepsis or severe sepsis classified by the SIRS, qSOFA criteria or MEWS of ≥ 5 were found. The qSOFA criteria classifies a smaller group of patients as septic compared with the SIRS or MEWS. Due to this strict selection, the qSOFA score seems unsuitable as a bedside tool in the work-up and treatment of sepsis at the ED.

Aim One of the main causes of adverse events in the healthcare chain is communication failure. Information loss from handovers could lead to a prolonged stay in the Emergency Department (ED) and reduced patient safety. Objectives in this study were to evaluate the accurate use of the SBARR and to evaluate the influence of the (appropriate) use of the SBARR on the agreement between the probable diagnosis after handover and the final diagnosis and time of stay at the ED. Method Data on handovers were collected through observations in 4 hospitals in Amsterdam, from February until May 2017. Subsequently multiple interventions to improve the use of SBARR were implemented (education, newsletters, e-learning, posters and notebooks). This was followed by a second observation period from September until November 2017. Results A total of 990 handovers was observed. 45 Handovers were excluded because these were transfers patients from other hospitals or patients refused to participate. Of the remaining 945 handovers, 14 (1,5%) used only one element of the SBARR and 242 (25,6%) of handovers used 2 elements. In over half of cases (567, 60%) 3 elements were used. In 107 handovers (11,3%) 4 elements where used and in 15 handovers (1,6%) all 5 elements where used. For the appropriate use of the SBARR, there were 7 handovers which didn’t start with the S, 267 (28,3%) which only consisted of the S, 451 (47,7) with the SB order, 197 (20,8%) SBA, 17 handovers (1,8% SBAR and 6 handovers (0,6%) SBARR. Other analyses are currently in progress. Conclusion The use of the SBARR in these observations was suboptimal. With further analysis, we want to study if this also has a important effect on patient oriented outcomes, like length of stay in the emergency department. Conflict of interest None Funding This project is funded by ZonMw (The Netherlands Organisation for Health Research and Development).

Brown adipose tissue (BAT) is able to convert calories into heat rather than storing them. Therefore, activated BAT could be a potential target in the battle against obesity and type 2 diabetes. This review focuses on the role of the autonomic nervous system in the activation of human BAT. Although the number of studies focusing on BAT in humans is limited, involvement of the sympathetic nervous system (SNS) in BAT activation is evident. Metabolic BAT activity can be visualized with (18)F-fluorodeoxyglucose, whereas sympathetic activation of BAT can be visualized with nuclear-medicine techniques using different radiopharmaceuticals. Also, interruption of the sympathetic nerves leading to BAT activation diminishes sympathetic stimulation, resulting in reduced metabolic BAT activity. Furthermore, both β- and α-adrenoceptors might be important in the stimulation process of BAT, as pretreatment with propranolol or α-adrenoceptor blockade also diminishes BAT activity. In contrast, high catecholamine levels are known to activate and recruit BAT. There are several interventional studies in which BAT was successfully inhibited, whereas only one interventional study aiming to activate BAT resulted in the intended outcome. Most studies have focused on the SNS for activating BAT, although the parasympathetic nervous system might also be a target of interest. To better define the possible role of BAT in strategies to combat the obesity epidemic, it seems likely that future studies focusing on both histology and imaging are essential for identifying the factors and receptors critical for activation of human BAT.

BACKGROUND: Emergency medical services (EMS) personnel have already made substantial contributions to improving care for patients with time-dependent illnesses, such as trauma and myocardial infarction. Patients with sepsis could also benefit from timely prehospital care.METHODS: After training EMS personnel in recognising sepsis, we did a randomised controlled open-label trial in ten large regional ambulance services serving 34 secondary and tertiary care hospitals in the Netherlands. We compared the effects of early administration of antibiotics in the ambulance with usual care. Eligible patients were randomly assigned (1:1) using block-randomisation with blocks of size 4 to the intervention (open-label intravenous ceftriaxone 2000 mg in addition to usual care) or usual care (fluid resuscitation and supplementary oxygen). Randomisation was stratified per region. The primary outcome was all-cause mortality at 28 days and analysis was by intention to treat. To assess the effect of training, we determined the average time to antibiotics (TTA) in the emergency department and recognition of sepsis by EMS personnel before and after training. The trial is registered at ClinicalTrials.gov, number NCT01988428.FINDINGS: 2698 patients were enrolled between June 30, 2014, and June 26, 2016. 2672 patients were included in the intention-to-treat analysis: 1535 in the intervention group and 1137 in the usual care group. The intervention group received antibiotics a median of 26 min (IQR 19-34) before arriving at the emergency department. In the usual care group, median TTA after arriving at the emergency department was 70 min (IQR 36-128), compared with 93 min (IQR 39-140) before EMS personnel training (p=0·142). At day 28, 120 (8%) patients had died in the intervention group and 93 (8%) had died in the usual care group (relative risk 0·95, 95% CI 0·74-1·24). 102 (7%) patients in the intervention group and 119 (10%) in the usual care group were re-admitted to hospital within 28 days (p=0·0004). Seven mild allergic reactions occurred, none of which could be attributed to ceftriaxone.INTERPRETATION: In patients with varying severity of sepsis, EMS personnel training improved early recognition and care in the whole acute care chain. However, giving antibiotics in the ambulance did not lead to improved survival, regardless of illness severity.FUNDING: The NutsOhra Foundation, Netherlands Society of Internal Medicine (NIV).

Bariatric surgery is performed in patients with a body mass index (BMI)40kg/m2, or BMI35 kg/m2 with obesity-related comorbidities. The Roux-en-Y gastric bypass and sleeve gastrectomy are the most frequently used procedures.- On average, patients have lost 25-27% of their original weight 10 years after surgery.- Obesity-related comorbidities improve dramatically in many patients following surgery. The effect is most noticeable in patients with diabetes mellitus type 2 and obstructive sleep apnoea syndrome. - The prevalence of 30-day complications is5%. Mortality is0.2% in centres with a lot of experience. - Commonly occurring long-term complications of bariatric surgery include deficiencies, particularly of iron and vitamin B12, along with gallstone disease and sagging skin. - Specific complications can arise following Roux-en-Y gastric bypass, such as internal herniation and hypoglycaemia, and these are often not recognised.

Individual indicators of socio-economic status have been associated with glycaemic control in people with Type 2 diabetes, but little is known about the association between partner's socio-economic status and HbAWe included people with Type 2 diabetes with a partner who were treated in primary, secondary and tertiary care in the Diabetes Pearl cohort. Occupational level was classified according to International Standard Classification of Occupations (ISCO)-08 skill levels. Linear regression analyses were performed stratified for sex, and corrected for age, recruitment centre and diabetes medication.In total, 3257 participants (59.8% men, mean 62.2±9.4 years) were included. For men, having a partner with an intermediate level of occupation was associated with lower HbAPartner's occupational status provided additional information on the association between socio-economic status and HbA