Search

Addressing equity in healthcare is fundamental for delivering safe care to vulnerable patients, especially during COVID-19. This paper aims to identify barriers and enabling factors for general practitioners (GPs) in delivering safe and equitable care during the COVID-19 pandemic. Semi-structured interviews took place during May–July 2020 among 18 Flemish and 16 Dutch GPs. Thematic analysis of the interviews demonstrated that while GPs acknowledged a smooth information flow by governments and professional organizations on care guidelines, the fast-changing information challenged them to stay up to date. Media communication facilitated information dissemination but also fueled misinformation and miscommunication, creating unrealistic patient expectations. Certain guidelines and patient reluctance delayed necessary care. A shortage of personal protective equipment made GPs concerned about patient safety during face-to-face contacts. Teleconsultations became a popular alternative, but posed increased patient safety risks. GPs struggled to identify and reach vulnerable patients. Equitable care was hindered by time constraints; thus, having the appropriate materials facilitated such care. An interprofessional collaboration involving paramedical, social, and city services benefited patient safety and equity in healthcare. However, limitations in this collaboration pressured GPs. The unprecedented and resource-constrained environment challenged GPs' capacity to provide the healthcare quality they aspired to deliver. A well-structured collaborative network involving all stakeholders could benefit safe and equitable care in future pandemics. [ABSTRACT FROM AUTHOR]

Introduction: Supporting care receivers in Activities of Daily Living (ADL), irrespective of diagnosis, setting, or cultural background, lies at the heart of fundamental nursing care. The pursuit of quality ADL care becomes increasingly challenging with the changing complexity of care needs. ADL care delivery is often undervalued and is considered a low‐status task despite its crucial importance to care receivers. This study aims to synthesize challenges in ADL care irrespective of the care setting. Methods: In the mixed qualitative methods study, we used expert panel consultations, world café sessions, and a rapid literature review. For data analysis, we simultaneously analyzed the three data sets using inductive and deductive inquiry. Results: We identified four challenges and their corresponding subthemes. They are (1) Undervalued common‐sense work versus complex, high‐skilled care provision; (2) Limitations in professional reflective clinical decision‐making; (3) Missed opportunities for shared ADL decisions; and (4) Meeting ADL care needs in a high‐throughput system. Conclusion: These challenges reveal the complexity of ADL care and how its paradoxical narrative relates to the conditions in which nursing professionals struggle to create opportunities, for reflective clinical reasoning and shared ADL decisions, by facing organizational and environmental barriers. Clinical Relevance: This study is relevant to nursing professionals, care organizations, policymakers, and researchers aiming to improve ADL care and provide insights into challenges in ADL care. This study forms the starting point for a changing narrative on ADL nursing care and subsequent quality improvements in the form of, for example, guidelines for nursing professionals. [ABSTRACT FROM AUTHOR]

Background: To improve transmural palliative care for older adults acutely admitted to hospital, the PalliSupport intervention, comprising an educational programme and transmural palliative care pathway, was developed. This care pathway involves timely identification of palliative care needs, advance care planning, multidisciplinary team meetings, warm handover, and follow-up home visits. With this study, we evaluate changes in patient-related outcomes and transmural collaboration after implementation of the care pathway. Methods: We conducted a before-after study, in which we compared 1) unplanned hospital admission and death at place of preference and 2) transmural collaboration before implementation, up to six months, and six to 18 months after implementation. Data from palliative care team consultations were collected between February 2017 and February 2020 in a teaching hospital in the Netherlands. Results: The palliative care team held 711 first-time consultations. The number of consultation, as well as the number of consultations for patients with non-malignant diseases, and consultations for advance care planning increased after implementation. The implementation of the pathway had no statistically significant effect on unplanned hospitalization but associated positively with death at place of preference more than six months after implementation (during/shortly after adjusted OR: 2.12; 95% CI: 0.84–5.35; p-value: 0.11, long term after adjusted OR: 3.14; 95% CI: 1.49–6.62; p-value: 0.003). Effects on transmural collaboration showed that there were more warm handovers during/shortly after implementation, but not on long term. Primary care professionals attended multidisciplinary team meetings more often during and shortly after implementation, but did not more than six months after implementation. Conclusions: The pathway did not affect unplanned hospital admissions, but more patients died at their place of preference after implementation. Implementation of the pathway increased attention to- and awareness for in-hospital palliative care, but did not improve transmural collaboration on long-term. For some patients, the hospital admissions might helped in facilitating death at place of preference. [ABSTRACT FROM AUTHOR]

Introduction: Communication is key in efficient disaster management. However, in many major incidents, prehospital communication failure led to insufficient upscaling, safety concerns for the emergency responders, logistical problems and inefficient disaster management. Methods: A review of medical reports and news articles of mass-casualty terrorist attacks was performed using PubMed-archived and (non-)governmental reports. The terrorist attacks in Tokyo 1995, Oklahoma 1995, Omagh 1998, New York 2001, Myyr-manni 2002, Istanbul 2003, Madrid 2004, London 2005, Oslo/Utøya 2011, Boston 2013, Paris 2015, Berlin 2016, Brussels 2016, Wuerzburg 2016, Manchester 2017, London 2017 were included. Results: In all mass-casualty terrorist attacks, communication failure was reported. Some failures had significant impact on casualty numbers. Outdated communication equipment, overwhelmed communication services, failure due to damaged infrastructure by the terrorist attack itself, and lack of training were the major issues. Communication failures were most commonly observed in both attacks between 1995–2009 and 2011–2017. Discussion: Communication failure was reported in all mass-casualty terrorist incidents. In several cases, communication between the different responding actors was poor or non-existing. Malfunctioning of (outdated) telecommunication services, inadequate training in the use of communication devices, unfortunate damage of telecommunication network infrastructure were also worrisome. Conclusion: Despite reports of lessons learned in previous EMS responses, communication failures were still reported in most recent terrorist attacks. Governments should provide sufficient resources to equip hospitals, emergency departments, and ambulance services with (back-up) communication systems and invest in training. A European registration system is warranted. We provide proposals for improvement. [ABSTRACT FROM AUTHOR]

Background: Multiple studies have focused on medical and pharmacological treatments and outcome predictors of patients with status epilepticus (SE). However, a sufficient understanding of recurrent episodes of SE is lacking. Therefore, we reviewed recurrent SE episodes to investigate their clinical characteristics and outcomes in patients with relapses. Methods: In this retrospective, multicenter study, we reviewed recurrent SE patient data covering 2011 to 2017 from the university hospitals of Frankfurt and Marburg, Germany. Clinical characteristics and outcome variables were compared among the first and subsequent SE episodes using a standardized form for data collection. Results: We identified 120 recurrent SE episodes in 80 patients (10.2% of all 1177 episodes). The mean age at the first SE episode was 62.2 years (median 66.5; SD 19.3; range 21–91), and 42 of these patients were male (52.5%). A mean of 262.4 days passed between the first and the second episode. Tonic–clonic seizure semiology and a cerebrovascular disease etiology were predominant in initial and recurrent episodes. After subsequent episodes, patients showed increased disability as indicated by the modified Rankin Scale (mRS), and 9 out of 80 patients died during the second episode (11.3%). Increases in refractory and super-refractory SE (RSE and SRSE, respectively) were noted during the second episode, and the occurrence of a non-refractory SE (NRSE) during the first SE episode did not necessarily provide a protective marker for subsequent non-refractory episodes. An increase in the use of intravenous-available anti-seizure medication (ASM) was observed in the treatment of SE patients. Patients were discharged from hospital with a mean of 2.8 ± 1.0 ASMs after the second SE episode and 2.1 ± 1.2 ASMs after the first episode. Levetiracetam was the most common ASM used before admission and on discharge for SE patients. Conclusions: This retrospective, multicenter study used the mRS to demonstrate worsened outcomes of patients at consecutive SE episodes. ASM accumulations after subsequent SE episodes were registered over the study period. The study results underline the necessity for improved clinical follow-ups and outpatient care to reduce the health care burden from recurrent SE episodes. Key points: We report on 120 recurrent status epilepticus episodes in 80 patients between 2011 and 2017 The mortality rate at the second SE episode was 11.3% (9/80 patients) The modified Rankin Scale indicated an increased morbidity after each SE episode A non-refractory SE at first admission could not be identified as a protective marker for severity of following episodes An increased drug-load of anti-seizure medication was observed after each SE episode [ABSTRACT FROM AUTHOR]

Objective Treatment of obesity-related diseases, rather than obesity itself, remains the mainstay of medical care. The current study examined a novel approach that prioritizes weight management in primary care to shift this paradigm. Methods PATHWEIGH is a weight management approach consisting of staff team training, workflow system management, and data capture from tools built into the electronic medical record (EPIC). PATHWEIGH was compared to standard of care (SOC) using two family medicine clinics in the same US healthcare system. Descriptive statistics compared patient-, provider-, and clinic-level factors between the groups among those with at least one weight-prioritized visit (WPV) and one follow-up weight over 14 months. Results Groups were similar in terms of total patient visits (7,353 vs. 7,984) and patients eligible for a WPV (i.e. >18 years + body mass index >25 kg/m2; 3,746 vs. 3,008, PATHWEIGH vs. SOC, respectively). However, more PATHWEIGH clinic patients (15.9% vs. 8.4%; P < 0.001) received at least one WPV. Although no difference was observed for average patient weight loss over 14 months (P = 0.991), the number of WPVs per patient was higher in PATHWEIGH (P < 0.001) and significantly associated with weight loss (P = 0.001), with an average decrease in weight of 0.55 kg per additional visit. Conclusions Results from the current study demonstrate early success in changing the paradigm from treating weight-related comorbidities to treating weight in primary care. [ABSTRACT FROM AUTHOR]

Background: The international collaboration study PRICOV-19 –Primary Health Care in times of COVID-19 aims to assess the impact of the COVID-19 pandemic on the organisation of primary health care. The German part focuses on the subjective perceptions of general practitioners on primary health care and the impact of political measures during the second wave of the COVID-19 pandemic. Within this survey, the "open text field" of the questionnaire was utilised remarkably frequently and extensively by the respondents. It became clear that the content that was named needed to be analysed in an exploratory manner. Accordingly, this paper addresses the following question: What preoccupies general practitioners in Germany during COVID-19 that we have not yet asked them enough? Methods: The data collection took place throughout Germany from 01.02.2021 to 28.02.2021with a quantitative online questionnaire consisting of 53 items arranged across six topics as well as an "open text field" for further comments. The questionnaire's open text field was analysed following the premises of the qualitative content analysis. Results: The topics discussed by the respondents were: insufficient support from health policies, not being prioritised and involved in the vaccination strategy, feeling insufficient prepared, that infrastructural changes and financial concerns threatened the practice, and perceiving the own role as important, as well as that health policies affected the wellbeing of the respondents. One of the main points was the way general practitioners were not sufficiently acknowledged for their contribution to ensuring high-quality care during the pandemic. Discussion: German general practitioners perceived their work and role as highly relevant during the COVID-19 pandemic. In controversy with their perception, they described political conditions in which they were the ones who contributed significantly to the fight against the pandemic but were not given enough recognition. [ABSTRACT FROM AUTHOR]

Physician-assisted death (PAD) for patients suffering from mental illness is legally permitted in the Netherlands. Although patients' relatives are not entrusted with a legal role, former research revealed that physicians take into account the patient's social context and their well-being, in deciding whether or not to grant the request. However, these studies focussed on relatives' experiences in the context of PAD concerning patients with somatic illness. To date, nothing is known on their experiences in the context of PAD concerning the mentally ill. We studied the experiences of relatives with regard to a PAD request by patients suffering from mental illness. The data for this study were collected through 12 interviews with relatives of patients who have or had a PAD request because of a mental illness. We show that relatives are ambivalent regarding the patient's request for PAD and the following trajectory. Their ambivalence is characterised by their understanding of the wish to die and at the same time hoping that the patient would make another choice. Respondents' experiences regarding the process of the PAD request varied, from positive ('intimate') to negative ('extremely hard'). Some indicated that they wished to be more involved as they believe the road towards PAD should be a joint trajectory. To leave them out during such an important event is not only painful, but also harmful to the relative as it could potentially complicate their grieving process. Professional support during or after the PAD process was wanted by some, but not by all. [ABSTRACT FROM AUTHOR]

To evaluate the cost-effectiveness of bimekizumab, an inhibitor of IL-17F and IL-17A, against biologic and targeted synthetic disease-modifying antirheumatic drugs (DMARD) for psoriatic arthritis (PsA) from the Swedish healthcare system perspective. A Markov model was developed to simulate the clinical pathway of biologic [b] DMARD-naïve or tumor necrosis factor inhibitor experienced [TNFi-exp] PsA patients over a lifetime horizon. Treatment response was incorporated as achievement of the American College of Rheumatology 50% (ACR50) and Psoriasis Area and Severity Index 75% (PASI75) response, and changes in the Health Assessment Questionnaire-Disability Index (HAQ-DI) score. The efficacy of bimekizumab was obtained from the BE OPTIMAL (bDMARD-naïve) and BE COMPLETE (TNFi-experienced) trials while a network meta-analysis (NMA) informed the efficacy of the comparators. Resource use and drug costs were obtained from published studies and databases of drug retail prices in Sweden. A willingness-to-pay threshold of €50,000 per quality-adjusted life year (QALY) was applied. In bDMARD-naïve patients, bimekizumab achieved greater QALYs (14.08) than with all comparators except infliximab (14.22), dominated guselkumab every 4 and 8 weeks, ixekizumab, secukinumab 300 mg, ustekinumab 45 mg and 90 mg, and was cost-effective against risankizumab, tofacitinib, upadacitinib and TNFis, except adalimumab biosimilar. In TNFi-experienced patients, bimekizumab led to greater QALYs (13.56) than all comparators except certolizumab pegol (13.84), and dominated ixekizumab and secukinumab 300 mg while being cost-effective against all other IL-17A-, IL-23- and JAK inhibitors. An NMA informed the comparative effectiveness estimates. Given gaps in evidence of disease management and indirect costs specific to HAQ-DI scores, and sequential clinical trial evidence in PsA, non-PsA cost data from similar joint conditions were used, and one line of active treatment followed by best supportive care was assumed. Bimekizumab was cost-effective against most available treatments for PsA in Sweden, irrespective of prior TNFi exposure [ABSTRACT FROM AUTHOR]

Background: To mitigate the potential consequences of the coronavirus disease 2019 (COVID-19) pandemic on public life, the German Federal Government and Ministry of Health enacted a strict lockdown protocol on March 16, 2020. This study aimed to evaluate the impact of the COVID-19 pandemic on physical and mental health status and the supply of medical care and medications for people with epilepsy (PWE) in Germany. Methods: The Epi2020 study was a large, multicenter study focused on different healthcare aspects of adults with epilepsy. In addition to clinical and demographic characteristics, patients were asked to answer a questionnaire on the impact of the first wave of the COVID-19 pandemic between March and May 2020. Furthermore, the population-based number of epilepsy-related admissions in Hessen was evaluated for the January-June periods of 2017–2020 to detect pandemic-related changes. Results: During the first wave of the pandemic, 41.6% of PWE reported a negative impact on their mental health, while only a minority reported worsening of their seizure situation. Mental and physical health were significantly more negatively affected in women than men with epilepsy and in PWE without regular employment. Moreover, difficulties in ensuring the supply of sanitary products (25.8%) and antiseizure medications (ASMs; 19.9%) affected PWE during the first lockdown; no significant difference regarding these impacts between men and women or between people with and without employment was observed. The number of epilepsy-related admissions decreased significantly during the first wave. Conclusions: This analysis provides an overview of the general and medical care of epilepsy patients during the COVID-19 pandemic. PWE in our cohort frequently reported psychosocial distress during the first wave of the pandemic, with significant adverse effects on mental and physical health. Women and people without permanent jobs especially reported distress due to the pandemic. The COVID‐19 pandemic has added to the mental health burden and barriers to accessing medication and medical services, as self-reported by patients and verified in population-based data on hospital admissions. Trial registration: German Clinical Trials Register (DRKS), DRKS00022024. Registered October 2, 2020, http://www.drks.de/DRKS00022024 [ABSTRACT FROM AUTHOR]

Background: Working with eHealth requires health care organizations to make structural changes in the way they work. Organizational structure and process must be adjusted to provide high-quality care. This study is a follow-up study of a systematic literature review on optimally organizing hybrid health care (eHealth and face to face) using the Donabedian Structure-Process-Outcome (SPO) framework to translate the findings into a modus operandi for health care organizations. Objective: This study aimed to develop an SPO-based quality assessment model for organizing hybrid health care using an accompanying self-assessment questionnaire. Health care organizations can use this model and a questionnaire to manage and improve their hybrid health care. Methods: Concept mapping was used to enrich and validate evidence-based knowledge from a literature review using practice-based knowledge from experts. First, brainstorming was conducted. The participants listed all the factors that contributed to the effective organization of hybrid health care and the associated outcomes. Data from the brainstorming phase were combined with data from the literature study, and duplicates were removed. Next, the participants rated the factors on importance and measurability and grouped them into clusters. Finally, using multivariate statistical analysis (multidimensional scaling and hierarchical cluster analysis) and group interpretation, an SPO-based quality management model and an accompanying questionnaire were constructed. Results: All participants (n=39) were familiar with eHealth and were health care professionals, managers, researchers, patients, or eHealth suppliers. The brainstorming and literature review resulted in a list of 314 factors. After removing the duplicates, 78 factors remained. Using multivariate statistical analyses and group interpretations, a quality management model and questionnaire incorporating 8 clusters and 33 factors were developed. The 8 clusters included the following: Vision, strategy, and organization; Quality information technology infrastructure and systems; Quality eHealth application; Providing support to health care professionals; Skills, knowledge, and attitude of health care professionals; Attentiveness to the patient; Patient outcomes; and Learning system. The SPO categories were positioned as overarching themes to emphasize the interrelations between the clusters. Finally, a proposal was made to use the self-assessment questionnaire in practice, allowing measurement of the quality of each factor. Conclusions: The quality of hybrid care is determined by organizational, technological, process, and personal factors. The 33 most important factors were clustered in a quality management model and self-assessment questionnaire called the Hybrid Health Care Quality Assessment. The model visualizes the interrelations between the factors. Using a questionnaire, each factor can be assessed to determine how effectively it is organized and developed over time. Health care organizations can use the Hybrid Health Care Quality Assessment to identify improvement opportunities for solid and sustainable hybrid health care. [ABSTRACT FROM AUTHOR]

Since the life expectancy of people with profound intellectual and multiple disabilities (PIMD) is increasing, siblings may take over care/support roles from their parents. To explore how parents and siblings of persons with PIMD view siblings' role regarding future care/support for their family member, we interviewed eight parents and 13 siblings of seven persons with PIMD and analysed the data thematically. While some parents expected that a future care/support role would burden the sibling unfairly, most siblings anticipated such a role and reported no concerns about this future responsibility. Despite a lack of explicit communication, expectations of parents and siblings regarding future responsibilities corresponded. However, some siblings mentioned the lack of explicit communication made them feel unprepared for the future. Explicit family communication may make siblings feel more prepared for the future and decrease the discrepancy between parents' and siblings' views regarding an expected future burden. [ABSTRACT FROM AUTHOR]

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

Aim: To scrutinize the economic impact of different care levels, such as shared care, in the follow-up of adult congenital heart disease (ACHD) patients. Methods: The BELgian COngenital heart disease Database combining Administrative and Clinical data (BELCODAC) was analyzed. Patients (N = 6579) were categorized into five care levels based on their cardiac follow-up pattern between 2006 and 2010. Medical costs, hospitalizations, and emergency department visits were measured between 2011 and 2015. Results: In patients with moderate lesions, highly specialized cardiac care (HSC; exclusive follow-up by ACHD specialists) and shared care with predominantly specialized cardiac care (SC+) were associated with significantly lower medical costs and resource use compared to shared care with predominantly general cardiac care (SC−) and general cardiac care (GCC). In the patient population with mild lesions, HSC was associated with better economic outcomes than SC− and GCC, but SC+ was not. HSC was associated with fewer hospitalizations (− 33%) and less pharmaceutical costs (− 46.3%) compared to SC+. Patients with mild and moderate lesions in the no cardiac care (NCC) group had better economic outcomes than those in the GCC and SC− groups, but post-hoc analysis revealed that they had a different patient profile than patients under cardiac care. Conclusion: More specialized care levels are associated with better economic outcomes in patients with mild or moderate lesions in cardiac follow-up. Shared care with strong involvement of ACHD specialists might be a management option to consider. Characteristics of patients without cardiac follow-up but good medium-term economic prospects should be further scrutinized. [ABSTRACT FROM AUTHOR]

Background: A key aim of palliative care is to improve the quality of life of patients and their families. To help ensure quality of life for the families of patients with migrant backgrounds, this study sought insights into the dignity of informal caregivers in migrant communities. This could improve understanding of family-centered care for migrant patients. Methods: Twenty semi-structured interviews with informal caregivers of Turkish, Moroccan, or Surinamese background living in the Netherlands were analyzed thematically. Results: The dignity of the patient and that of their informal caregivers were found to be strongly interrelated. Most important for the dignity of caregivers was ensuring good care for their patients and preserving the patients' dignity. Ensuring good care involved advocating for good and dignified care and for satisfaction of a patient's wishes. For many informal caregivers, it also included delivering care to the patient by themselves or together with other family members, despite having to give up part of their own lives. Providing care themselves was part of maintaining a good relationship with the patient; the care was to cater to the patient's preferences and help preserve the patient's dignity, and it could be accompanied by valuable aspects such as times for good conversations. Positive interaction between an informal caregiver and a patient positively influenced the informal caregiver's dignity. Informal caregiver and patient dignity were often compromised simultaneously; when informal caregivers felt healthcare professionals were undermining a patient's dignity, their own dignity suffered. According to informal caregivers, healthcare professionals can help them preserve dignity by taking seriously their advice about the patient, keeping them informed about the prognosis of the disease and of the patient, and dealing respectfully with differences in values at the end of life. Conclusion: The dignity of migrant patients' informal caregivers in the last phase of a patient's life is closely entwined with ensuring good care and dignity for the patient. Healthcare professionals can strengthen the dignity of informal caregivers by supporting their caregiving role. [ABSTRACT FROM AUTHOR]

The purpose of this pilot study was to evaluate the impact of mindfulness education of new graduate nurse residents' awareness and use of mindfulness strategies. This pre–post education design study was approved by the university institutional review board. Mindfulness has been shown to improve focus on patient care and reduce job stress and nurse turnover. Improved awareness and use of mindfulness strategies have the potential to improve patient outcomes and reduce the cost of nurse turnover. [ABSTRACT FROM AUTHOR]

Background: Physicians who receive a request for euthanasia or assisted suicide may experience a conflict of duties: the duty to preserve life on the one hand and the duty to relieve suffering on the other hand. Little is known about experiences of physicians with receiving and granting a request for euthanasia or assisted suicide. This study, therefore, aimed to explore the concerns, feelings and pressure experienced by physicians who receive requests for euthanasia or assisted suicide. Methods: In 2016, a cross-sectional study was conducted. Questionnaires were sent to a random sample of 3000 Dutch physicians. Physicians who had been working in adult patient care in the Netherlands for the last year were included in the sample (n = 2657). Half of the physicians were asked about the most recent case in which they refused a request for euthanasia or assisted suicide, and half about the most recent case in which they granted a request for euthanasia or assisted suicide. Results: Of the 2657 eligible physicians, 1374 (52%) responded. The most reported reason not to participate was lack of time. Of the respondents, 248 answered questions about a refused euthanasia or assisted suicide request and 245 about a granted EAS request. Concerns about specific aspects of the euthanasia and assisted suicide process, such as the emotional burden of preparing and performing euthanasia or assisted suicide were commonly reported by physicians who refused and who granted a request. Pressure to grant a request was mostly experienced by physicians who refused a request, especially if the patient was ≥80 years, had a life-expectancy of ≥6 months and did not have cancer. The large majority of physicians reported contradictory emotions after having performed euthanasia or assisted suicide. Conclusions: Society should be aware of the impact of euthanasia and assisted suicide requests on physicians. The tension physicians experience may decrease their willingness to perform euthanasia and assisted suicide. On the other hand, physicians should not be forced to cross their own moral boundaries or be tempted to perform euthanasia and assisted suicide in cases that may not meet the due care criteria. [ABSTRACT FROM AUTHOR]

Crew-resource management is an approach to work and training that focuses on non-technical skills and strategies to prevent human error in complex procedures. It was initially termed 'cockpit-resource management' and developed for aviation in the 1970s after several severe accidents; it has contributed to a measurable increase in flight safety. In recent years, this approach has been successfully implemented in other high- reliability environments; surgical disciplines have made particular use of crew-resource management strategies and training, with resulting reduced mortality rates. The stepwise implementation of different crew-resource management strategies in stroke care at our tertiary stroke centre has helped to speed up process times significantly, and to improve patient safety and staff satisfaction. Here, we summarise our experience in adapting different crew-resource management tools to acute stroke care, sharing specific tools that have proven valuable in our hands, and we encourage colleagues to implement such strategies in acute stroke care. [ABSTRACT FROM AUTHOR]

Background: Efficient incorporation of e-health in patients with heart failure (HF) may enhance health care efficiency and patient empowerment. We aimed to assess the effect on self-care of (i) the European Society of Cardiology/Heart Failure Association website 'heartfailurematters.org' on top of usual care, and (ii) an e-health adjusted care pathway leaving out 'in person' routine HF nurse consultations in stable HF patients.Methods and Results: In a three-group parallel-randomized trial in stable HF patients from nine Dutch outpatient clinics, we compared two interventions ( heartfailurematters.org website and an e-health adjusted care pathway) to usual care. The primary outcome was self-care measured with the European Heart Failure Self-care Behaviour Scale. Secondary outcomes were health status, mortality, and hospitalizations. In total, 450 patients were included. The mean age was 66.8 ± 11.0 years, 74.2% were male, and 78.8% classified themselves as New York Heart Association I or II at baseline. After 3 months of follow-up, the mean score on the self-care scale was significantly higher in the groups using the website and the adjusted care pathway compared to usual care (73.5 vs. 70.8, 95% confidence interval 0.6-6.2; and 78.2 vs. 70.8, 95% confidence interval 3.8- 9.4, respectively). The effect attenuated, until no differences after 1 year between the groups. Quality of life showed a similar pattern. Other secondary outcomes did not clearly differ between the groups.Conclusions: Both the heartfailurematters.org website and an e-health adjusted care pathway improved self-care in HF patients on the short term, but not on the long term. Continuous updating of e-health facilities could be helpful to sustain effects.Clinical Trial Registration: ClinicalTrials.gov ID NCT01755988. [ABSTRACT FROM AUTHOR]

Background: To assess hospital performance, quality perceptions of various stakeholders are increasingly taken into account. However, because of substantial background differences, various stakeholder groups might have different and even contrasting quality perceptions. Purpose: We test the hypothesis that an overall perception gap exists between employees and patients with respect to perceived hospital quality. We additionally elaborate on how various employee groups differ from each other and from patients. Methodology: We use primary survey data on perceived hospital quality from 9,979 patients and 4,306 employees from 11 German hospitals. With a multilevel regression and variance analysis, we test the impact of respondent type (employee or patient) on quality perception scores and test the interaction with hospital size. We additionally contrast different employee groups and test differences for various quality dimensions. Results and Conclusion: Hospital employees score hospital quality consistently lower than patients and are also more heterogeneous in their assessments. This makes it from a managerial point of view relevant to subdivide employees in more homogeneous subgroups. Hospital size has no clear effect on the perception gap. Doctors compared to patients and other employee groups have substantially different perceptions on hospital quality. Practice Implications: Our findings fuel the practical and ethical debate on the extent that perception gaps could and should be allowed in the context of high-quality and transparent hospital performance. Furthermore, we recommend that the quality perception gap is a substantial part of the overall hospital evaluation for ethical reasons but also to enable managers to better understand the (mis)match between employees' priorities and patients' preferences. However, we do warn practitioners that perceptions are only to a limited extent related to the organizational level (in contrast to the individual level), and only minimal improvements can thus be reached by differentiating from other hospitals. [ABSTRACT FROM AUTHOR]

We study whether migrant health in Europe is associated with the cultural distance between their host country and country of origin. To this end, we run multilevel regression models on data merging self-rated health and social background of ≥3800 migrants from the European Social Survey with an index of cultural distance based on country differences in values, norms and attitudes measured in the World Values Survey. We find that higher levels of cultural distance are associated with worse migrant health. This association is comparable in size with the negative association between health and female (compared with male) gender but less important than the association between health and education level. In addition, this association is less significant among second-generation than first-generation migrants. [ABSTRACT FROM AUTHOR]

The work of volunteers is indispensable for the well functioning of healthcare organizations, and for maintaining the quality of care in times of austerity. As feelings of intrinsic motivation stimulate volunteer well-being and their long-term engagement, we study how team inclusion relates to volunteers’ intrinsic motivation during their activities. We hypothesize that volunteers’ perceptions of inclusion are positively related to intrinsic motivation, via the satisfaction of their basic needs for autonomy, competence, and relatedness. To test our hypothesis, we conducted a daily-diary study, obtaining a final sample of 43 volunteers and 204 completed diaries. Multilevel path analyses showed that team inclusion was positively related to volunteers’ intrinsic motivation during their activities. Subsequent mediation analyses revealed that competence and relatedness need satisfaction mediated this relationship. Thus, when volunteers feel part of the team with which they complete their activities, they experience intrinsic motivation because feeling included stimulates their feelings of being competent and being related to others. [ABSTRACT FROM AUTHOR]

Separate literatures have related volunteering to health gains and income gains. We study the association between volunteering, income and health within one statistical framework. A state-of-the-art mediation analysis is conducted on data concerning the health, volunteering and sociodemographic characteristics of 42926 individuals within 29 European countries. We find that volunteering is positively associated to self-rated health. This association is partially mediated by household income. [ABSTRACT FROM AUTHOR]

Access to healthcare is inequitably distributed across different socioeconomic groups. Several vulnerable groups experience barriers in accessing healthcare, compared to their more wealthier counterparts. In response to this, many countries use resources to strengthen their primary care (PC) system, because in many European countries PC is the first entry-point to the healthcare system and plays a central role in the coordination of patients through the healthcare system. However it is unclear whether this strengthening of PC leads to less inequity in access to the whole healthcare system. This study investigates the association between strength indicators of PC and inequity in unmet need by merging data from the European Union Statistics on Income and Living Conditions database (2013) and the Primary Healthcare Activity Monitor for Europe (2010). The analyses reveal a significant association between the Gini coefficient for income inequality and inequity in unmet need. When the Gini coefficient of a country is one SD higher, the social inequity in unmet need in that particular country will be 4.960 higher. Furthermore, the accessibility and the workforce development of a country’s PC system is inverse associated with the social inequity of unmet need. More specifically, when the access- and workforce development indicator of a country PC system are one standard deviation higher, the inequity in unmet healthcare needs are respectively 2.200 and 4.951 lower. Therefore, policymakers should focus on reducing income inequality to tackle inequity in access, and strengthen PC (by increasing accessibility and better-developing its workforce) as this can influence inequity in unmet need. [ABSTRACT FROM AUTHOR]

Background: End-of-life decisions (EoLD) often concern children with profound intellectual and multiple disabilities (PIMD). Yet, little is known about how parents and physicians discuss and make these decisions.Aims: The objective of this research was to investigate the experiences of the parents and the involved physician during the end-of-life decision-making (EoLDM) process for children with PIMD.Methods: In a retrospective, qualitative study, we conducted semi-structured interviews with the physicians and parents of 14 children with PIMD for whom an EoLD was made within the past two years.Results: A long-lasting relationship appeared to facilitate the EoLDM process, although previous negative healthcare encounters could also lead to distrust. Parents and physicians encountered disagreements during the EoLDM process, but these disagreements could also improve the decision-making process. Most parents, as well as most physicians, considered the parents to be the experts on their child. In making an EoLD, both parents and physicians preferred a shared decision-making approach, although they differed in what they actually meant by this concept.Conclusion: The EoLDM process for children with PIMD can be improved if physicians are more aware of the specific situation and of the roles and expectations of the parents of children with PIMD. [ABSTRACT FROM AUTHOR]

Background: Many people are in need of care in the last phase of life. However, the care they receive is not always appropriate. For instance, people can receive overly aggressive treatment or can have limited access to palliative care. The term appropriate care is often used by policy makers, while it is unclear what care recipients consider as appropriate care. This study aims to identify what care patients and relatives perceive as appropriate and as inappropriate in the last phase of life, for patients suffering from different conditions. Methods: We designed an online survey with open questions. Participants were recruited through organizations for patients, older people and medical professionals. Answers were analysed after data-driven coding. Forty-five patients and 547 relatives described the care they received and described why this care was appropriate or inappropriate. Results: Participants described more cases of appropriate care than inappropriate care. The cases of appropriate care were diverse, but all involved care in (one or more of) five dimensions; supportive care, treatment decisions, location, the role of the patient's wish and communication. Each of these dimensions was frequently described (39-62 %). When care was inappropriate, this mostly involved inappropriate treatment decisions (69 %; especially overtreatment was frequently mentioned), and poor communication (50 %). There was considerable consistency in what was seen as (in)appropriate care across different conditions. However, especially patients suffering from other physical diseases than cancer more often received inappropriate care. Conclusion: From the perspective of patients and relatives, appropriate care in the last phase of life is a broad concept. Caregivers should be aware of the diversity of care needs in the last phase of life. Especially treatment decisions and communication can be improved. [ABSTRACT FROM AUTHOR]

The increasing elderly population and the shift from acute to chronic illness makes it difficult to care for people in hospitals and rest homes. Moreover, elderly people, if given a choice, want to stay at home as long as possible. In this article, the methodologies to develop a cloud-based semantic system, offering valuable information and knowledge-based services, are presented. The information and services are related to the different personal living hemispheres of the patient, namely the daily care-related needs, the social needs and the daily life assistance. Ontologies are used to facilitate the integration, analysis, aggregation and efficient use of all the available data in the cloud. By using an interdisciplinary research approach, where user researchers, (ontology) engineers, researchers and domain stakeholders are at the forefront, a platform can be developed of great added value for the patients that want to grow old in their own home and for their caregivers. [ABSTRACT FROM AUTHOR]

Background Euthanasia and physician-assisted suicide (EAS) in patients with psychiatric disease, dementia or patients who are tired of living (without severe morbidity) is highly controversial. Although such cases can fall under the Dutch Euthanasia Act, Dutch physicians seem reluctant to perform EAS, and it is not clear whether or not physicians reject the possibility of EAS in these cases. Aim To determine whether physicians can conceive of granting requests for EAS in patients with cancer, another physical disease, psychiatric disease, dementia or patients who are tired of living, and to evaluate whether physician characteristics are associated with conceivability. A cross-sectional study (survey) was conducted among 2269 Dutch general practitioners, elderly care physicians and clinical specialists. Results The response rate was 64% (n=1456). Most physicians found it conceivable that they would grant a request for EAS in a patient with cancer or another physical disease (85% and 82%). Less than half of the physicians found this conceivable in patients with psychiatric disease (34%), early-stage dementia (40%), advanced dementia (29–33%) or tired of living (27%). General practitioners were most likely to find it conceivable that they would perform EAS. Conclusions This study shows that a minority of Dutch physicians find it conceivable that they would grant a request for EAS from a patient with psychiatric disease, dementia or a patient who is tired of living. For physicians who find EAS inconceivable in these cases, legal arguments and personal moral objections both probably play a role. [ABSTRACT FROM AUTHOR]

People living with chronic illness often report uncertainty about the future, fear of disease progression, fear of becoming physically disabled, and a reduced life expectancy as important sources of stress. However, little is known about psychological interventions targeting these concerns. The aim of this study is to illustrate an intervention to reduce emotional distress and concerns about the future in a patient with systemic sclerosis (SSc), a rare chronic rheumatic disease with serious consequences for most patients, and to present a preliminary report on its effectiveness using a single-case study design. Because of the complexity of symptoms and complaints due to SSc, the psychological intervention was embedded in an interdisciplinary care program also consisting of physical therapy, occupational therapy, and specialized nurse care. [ABSTRACT FROM AUTHOR]

From 1 February 1993 to 1 February 1994 all new patients, known patients with new problems, and prostitutes attending the Outpatient Department of Sexually Transmitted Diseases (STD) of the University Hospital Rotterdam were asked to participate in unlinked anonymous human immunodeficiency virus (HIV) testing and to answer some questions. Data from the medical records of 300 patients refusing to participate were compared with self-reported data obtained from 2701 people accepting, to verify if the HIV seroprevalence among accepters could be representative for all STD department visitors. Men refusing were more often of foreign origin, had more often had more than one partner during the previous 6 months, more often attended the STD department for the first time, and more often had an STD diagnosed than men accepting. Women refusing were more often of foreign origin, had less often had more than one partner during the previous 6 months, and had more often used drugs intravenously than women accepting. Because most findings associated with refusing are also associated with being infected with HIV, the HIV seroprevalence among refusers is likely to be higher than among accepters. We therefore advise unlinked anonymous HIV testing of all patients visiting an STD department. [ABSTRACT FROM AUTHOR]

Background. Despite stable overall antibiotic use between 2007 and 2011 in The Netherlands, use of nitrofurantoin and trimethoprim increased by 32%. The background of this increased antibiotic use against uropathogens is unknown. Objectives. To determine whether increased use of urinary tract infection antibiotics is caused by changes in patients’ consultation or physicians’ prescribing behaviour and to investigate attitudes and opinions of women with respect to cystitis management and antibiotics. Methods. Consultation and prescribing for International Classification of Primary Care (ICPC) codes U01 (dysuria), U02 (frequency), U05 (other urination problems), U70 (pyelonephritis) and U71 (cystitis) were determined from 2007 to 2010, using routinely collected primary health care data. Separately, behaviour of women with respect to managing cystitis, consultation and opinions towards (delayed) antibiotic treatment were studied using questionnaires in 2012. Results. Consultation for U02 and U71 significantly increased from 93 to 114/1000 patient-years from 2007 to 2010; proportion of episodes in which an antibiotic was prescribed remained constant. Questionnaires revealed that urination problems and pain were dominant complaints of cystitis; pain medication, however, was not adequately used. One-third of women directly consult upon first symptoms, whereas the majority awaits an average of 4 days. Sixty-six per cent of women report to be willing to postpone antibiotic use. Conclusion. Increased use of urinary tract infection antibiotics may be caused by increased consultation for cystitis in primary care. Future research should focus on the outcomes of adequate pain medication, enhanced diagnostic procedures and of delaying antibiotic use in cystitis management. [ABSTRACT FROM PUBLISHER]

Background: Maintaining dignity is an important element of end-of-life care and also of the care given in nursing homes. Factors influencing personal dignity have been studied from both nursing home residents' and staff's perspective. Little is however known about the way nursing home staff perceive and promote the personal dignity of individual residents in daily practice, or about staff's experiences with preserving dignity within the nursing home. The aim of this study is to gain more insight in this. Methods: A qualitative descriptive interview study was designed, in which in-depth interviews were performed with 13 physicians and 15 nurses. They expressed their views on the personal dignity of 30 recently admitted nursing home residents on the general medical wards of four nursing homes in The Netherlands. Interviews were transcribed and analyzed following the principles of thematic analysis. Results: According to both physicians and nurses, physical impairment and being dependent on others threatened the residents' dignity. Whether or not this led to a violation of an individual resident's dignity, depended - in staff's opinion - on the resident's ability to show resilience and to keep his/her individuality. Staff mentioned treating residents with respect and taking care of their privacy as most important elements of dignity-conserving care and strived to treat the residents as they would like to be treated themselves. They could often mention aspects that were important for a particular resident's dignity. But, when asked what they could contribute to a particular resident's dignity, they often mentioned general aspects of dignity-conserving care, which could apply to most nursing home residents. By attempting to give dignity-conserving care, physicians and nurses often experienced conflicting values in daily care and barriers caused by the lack of resources. Conclusions: Tailoring dignity-conserving care to an individual nursing home resident appears hard to bring about in daily practice. Both attention to solve contextual barriers within the nursing home as well as more awareness of staff members for their own values, which they take as a reference point in treating residents, is needed to promote personal dignity in the nursing home setting. [ABSTRACT FROM AUTHOR]

Deinstitutionalisation has not only made the social inclusion of clients a key objective in long-term mental healthcare, it may also affect the role of the care professional. This article investigates whether the social inclusion objective clashes with other long-standing professional values, specifically when clients give gifts to care professionals. In making a typology of gifts, we compare the literature on gift-giving with professional codes for gifts and relate both to the objective of social inclusion of clients. Our typology draws on an analysis of ethnographic fieldwork carried out in 2007/2008 at a Dutch mental healthcare centre. We identify four types of gifts for professionals in long-term mental healthcare, each relating individually to professional codes and the objective of social inclusion of clients. Only the 'personal gift' directly supports social inclusion, by fostering personal relationships between professionals and clients. Acceptance of this type of gift is advocated only for long-term care professionals. We suggest that professional codes need to consider this typology of gifts, and we advocate promoting reflexivity as a means of accounting for professional behaviour in deinstitutionalised care settings. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: The aims of the study were to assess opinions of caregivers, families, and patients about involvement of families in the care of intensive care unit (ICU) patients; to evaluate the prevalence of symptoms of anxiety and depression in family members; and to measure family satisfaction with care. Materials and Methods: Between days 3 and 5, perceptions by families and ICU staff of family involvement in care were collected prospectively at a single center. Family members completed the Hospital Anxiety and Depression Scale (HADS) and a satisfaction scale (Critical Care Family Needs Inventory). Nurses recorded care provided spontaneously by families. Characteristics of patient-relative pairs (n = 101) and ICU staff (n = 45) were collected. Patients described their perceptions of family participation in care during a telephone interview, 206 ± 147 days after hospital discharge. Results: The numbers of patient-relative pairs for whom ICU staff reported favorable perceptions were 101 (100%) of 101 for physicians, 91 (90%) for nurses, and 95 (94%) for nursing assistants. Only 4 (3.9%) of 101 families refused participation in care. Only 14 (13.8%) of 101 families provided care spontaneously. The HADS score showed symptoms of anxiety in 58 (58.5%) of 99 and of depression in 26 (26.2%) of 99 family members. The satisfaction score was high (11.0 ± 1.25). Among patients, 34 (77.2%) of 44 had a favorable perception of family participation in care. Conclusions: Families and ICU staff were very supportive of family participation in care. Most patients were also favorable to care by family members. [Copyright &y& Elsevier]

The article presents a study which evaluates the effects of restrictive and liberal red-cell transfusion strategy that is being applied to children after cardiac surgery. Children who are critically ill were randomized to receive red-cell transfusion strategy. Results show that restrictive transfusion strategy shows no difference in new multiple organ dysfunction syndrome (MODS) compared with the liberal one. It notes that further study should be conducted because the results are not perfect.

Background: In order to address the challenges of an ageing population the Belgian government decided to allocate resources to the creation of geriatric day hospitals (GDHs). Although GDHs are meant to be a strategy to support general practitioners (GPs) caring for the frail elderly, few Belgian GPs seem to refer to a GDH. This study aims to explore the barriers and facilitating factors of GPs' referral to GDHs. Methods: A qualitative study using focus group discussions (FGDs) was conducted. Fifteen FGDs were organized in the different Belgian regions (Flanders, Wallonia, Brussels). Results: Contextual factors such as the unsatisfactory cooperation between hospital and GPs and organizational barriers such as the lack of communication on referral procedures between hospital and primary health care (PHC) were identified. Lack of basic knowledge about the concept or the local organization of GDH seemed to be a problem. Unclear task descriptions, responsibilities and activities of a GDH formed prominent points of discussion in all FGDs. Nevertheless a lot of possible advantages and disadvantages of GDHs for the patient and for the GP were mentioned. Conclusions: In the case of poor referral to GDHs, focusing on improving overall collaboration between primary and secondary health care is essential. This can be achieved by actively delivering adequate information, permanent communication and more involvement of PHC in the organization and functioning of GDHs. The absence of a transparent health care system with delineated role definitions, seems to hinder the integration of new initiatives like GDHs in the care process. Strategies to enhance referral to GDHs should use a comprehensive approach. [ABSTRACT FROM AUTHOR]

Background: During a four-year action research project (2003-2007), a program targeting all type 2 diabetes patients was implemented in a well-defined geographical region in Belgium. The implementation of the program resulted in an increase of the overall Assessment of Chronic Illness Care (ACIC) score from 1.45 in 2003 to 5.5 in 2007. The aim of the follow-up study in 2008 was to assess the effect of the implementation of Chronic Care Model (CCM) elements on the quality of diabetes care in a country where the efforts to adapt primary care to a more chronic care oriented system are still at a starting point. Methods: A quasi-experimental study design involving a control region with comparable geographical and socioeconomic characteristics and health care facilities was used to evaluate the effect of the intervention in the region. In collaboration with the InterMutualistic Agency (IMA) and the laboratories from both regions a research database was set up. Study cohorts in both regions were defined by using administrative data from the Sickness Funds and selected from the research database. A set of nine quality indicators was defined based on current scientific evidence. Data were analysed by an institution experienced in longitudinal data analysis. Results: In total 4,174 type 2 diabetes patients were selected from the research database; 2,425 patients (52.9% women) with a mean age of 67.5 from the intervention region and 1,749 patients (55.7% women) with a mean age of 67.4 from the control region. At the end of the intervention period, improvements were observed in five of the nine defined quality indicators in the intervention region, three of which (HbA1c assessment, statin therapy, cholesterol target) improved significantly more than in the control region. Mean HbA1c improved significantly in the intervention region (7.55 to 7.06%), but this evolution did not differ significantly (p = 0.4207) from the one in the control region (7.44 to 6.90%). The improvement in lipid control was significantly higher (p = 0.0021) in the intervention region (total cholesterol 199.07 to 173 mg/dl) than in the control region (199.44 to 180.60 mg/dl). The systematic assessment of long-term diabetes complications remained insufficient. In 2006 only 26% of the patients had their urine tested for micro-albuminuria and only 36% had consulted an ophthalmologist. Conclusion: Although the overall ACIC score increased from 1.45 to 5.5, the improvement in the quality of diabetes care was moderate. Further improvements are needed in the CCM components delivery system design and clinical information systems. The regional networks, as they are financed now by the National Institute for Health and Disability Insurance (NIHDI), are an opportunity to explore how this can be achieved in consultation with the GPs. But it is clear that, simultaneously, action is needed on the health system level to realize the installation of an accurate quality monitoring system and the necessary preconditions for chronic care delivery in primary care (patient registration, staff support, IT support). Trial Registration: Trial registration number: ClinicalTrials.gov Identifier: NCT00824499 [ABSTRACT FROM AUTHOR]

The aim of our study is to investigate prospectively the quantitative relationship between deep venous thrombosis (DVT) and acute pulmonary embolism (PE). 110 patients clinically suspected of having venous thromboembolic disease underwent combined CT pulmonary angiography (CTPA) and venography of lower limb veins. 44 patients presented with clinical signs of DVT and positive ultrasonography or ascending venography, but no clinical sign of PE (Group 1). 66 patients presented with clinical signs of PE and positive CTPA (Group 2). Clot load in lower limb veins and pulmonary arteries were scored by two independent readers, each using two separate systems for DVT and two for PE. 27 (61%) patients in Group 1 also had PE, and 55 (83%) patients in Group 2 also had DVT. Correlations between PE and DVT scores were weak but statistically significant in Group 2 (rs ranging from 0.470-0.520; p≤0.001), but only some were significant in Group 1 (rs ranging from 0.253-0.318; p-values ranging from 0.035-0.097). In conclusion, although PE occurs in a majority of patients with DVT, and vice versa, the amount/burden of clot load in one condition does not necessarily indicate — or indicates only weakly — the degree of burden in the other condition. [ABSTRACT FROM AUTHOR]

Stroke rehabilitation in Canada continues to function under models and practices that have changed little in the last four decades and struggles to implement new evidence-based or best practices. Ontario, Canada’s largest province, has had a coordinated stroke strategy since 2000. The Ontario Stroke System has developed an extensive infrastructure of research syntheses, consensus panel recommendations, practice guidelines, standards of care, and centralized data collection across the continuum of stroke care. This has produced a solid foundation upon which an evidence-based stroke rehabilitation system can be developed. However, failure to invest in stroke rehabilitation or provide incentives to implement change has resulted in the stroke rehabilitation system and critical outcomes remaining largely unchanged. Improvements in time to admission have been countered by rising admission FIM™ scores such that severe stroke patients often cannot access the stroke rehabilitation system. Many stroke patients are still rehabilitated on general rehabilitation units, therapy intensities remain unacceptably low, and many outpatient programs are being reduced or even closed. Although there are pockets of innovation, the stroke rehabilitation system continues to function more according to traditional ways of practicing. The hope is that with appropriate investments and incentives, Canadians and Ontarians can build upon the existing infrastructure to ensure stroke patients receive optimal rehabilitative care based on best evidence. In the meantime, stroke rehabilitation in Canada remains a work in progress. [ABSTRACT FROM AUTHOR]

In an implementation project in The Netherlands a small investigation was made of the most urgent needs of older home care clients. Two potential client groups for the development of specific care-arrangements were selected: "older persons becoming lonely and inactive", and "partners/caregivers of patients with dementia". The care-arrangement "Attention Care" aims to support lonely persons and the care-arrangement "Monitoring of Behavior" aims to provide surveillance at a distance to support the care giving relative of a dementia patient. For both groups the care arrangements use video telephony to communicate with professional caregivers. This paper presents results obtained during the pilot implementation. At the client level the results are encouraging, for both care arrangements positive responses can be noted. However, the pilots are up to now not followed by a full scale implementation of the care arrangements. In the analysis of the results obtained the process of care innovation is discussed. It is concluded that both the healthcare system as well as the individual care organization lack a real stimulus to change practice. [ABSTRACT FROM AUTHOR]

Abstract: Foot-and-mouth disease (FMD) vaccine potency testing has historically been performed by experimentally infecting vaccinated cattle. A few alternative approaches to the in vivo challenge test based on the correlation between serum titres of primo-vaccinated cattle and protection against infection have been proposed, but none have been accepted by the European Pharmacopoeia (Ph.Eur.) due to the lack of statistical power and the pooling of data over time. The present study addresses these issues and presents data of 150 cattle vaccinated according to Ph.Eur. standards. Four laboratories took part in the serological testing and different serological assays were used, including virus neutralisation assays and ELISA formats. Models correlating specific anti-FMD virus antibody titres to protection were built using logistic regression followed by Receiver Operating Characteristic (ROC) analysis. The best models accurately predicted the in vivo protection status in 80.0% of the cases. Although differences were observed between laboratories and assays used, the majority of antibody pass-levels, determined using ROC analysis, corresponded to at least 75.0% probability of protection. The indirect potency assessment procedure proposed is at least as precise (repeatability=65.8%, reproducibility=60.7%) as the in vivo test, can be standardised and results in a quantitative PD50 value. The validity of the procedure was also demonstrated. [Copyright &y& Elsevier]

Background: Brain death in fulminant hepatic failure (FHF) is a rare occurrence after successful orthotopic liver transplantation (OLT). Reuse of the liver graft may be considered. We report a successful OLT using such an organ in a 62-yr-old man with hematochromatosis-related cirrhosis and hepatocellular carcinoma. Methods: Liver donor was 56-yr-old man with normal liver function tests. First recipient was a 26-yr-old woman with an acetaminophen-induced FHF. Before OLT, she developed progressive coma without obvious cerebral edema on the cerebral CT-scan. The transplantation proceeded as planned and was uneventful. However, patient exhibited bilateral non-reactive mydriasis during postoperative hours and was declared brain dead. Transplanted liver was functioning adequately. Its reuse was discussed with her family and the second recipient. After informed consent, the transplanted liver and heart were harvested. First and second liver cold ischemia times were 10 h and 75 min, respectively. Results: Second recipient recovered uneventful and discharged 23 d after OLT. Liver function is still normal 30 months after OLT without rejection or hepatocellular carcinoma recurrence. Conclusion: Even after OLT, brain death remains possible in FHF. In absence of contraindications, reuse of transplanted liver allows for a rational use of already rare liver grafts. [ABSTRACT FROM AUTHOR]

Background: More and more quantitative information is becoming available about the risks of complications arising from medical treatment. In everyday practice, this raises the question whether each and every risk, however low, should be disclosed to patients. What could be good reasons for doing or not doing so? This will increasingly become a dilemma for practitioners. Objective: To report doctors' views on whether to disclose or withhold information on low risks of complications. Methods: In a qualitative study design, 37 respondents (gastroenterologists and gynaecologists or obstetricians) were included. Focus group interviews were held with 22 respondents and individual in-depth interviews with 15. Results: Doctors have doubts about disclosing or withholding information on complication risk, especially in a risk range of 1 in 200 to 1 in 10 000. Their considerations on whether to disclose or to withhold information depend on a complicated mix of patient and doctor-associated reasons; on medical and personal considerations; and on the kind and purpose of intervention. Discussion: Even though the degree of a risk is important in a doctor's considerations, the severity of the possible complications and patients' wishes and competencies have an important role as well. Respondents said that low risks should always be communicated when there are alternatives for the intervention or when the patient may prevent or mitigate the risk. When the appropriateness of disclosing risks is doubtful, doctors should always tell their patients that no intervention is without risk, give them the opportunity to gather all the information they need or want, and enable them to detect a complication at an early stage. [ABSTRACT FROM AUTHOR]

The authors would like to acknowledge funding from the Ontario Stroke Strategy as well as the organisations that participated from the Toronto West Stroke Network.Background: Communicative access to information and decision making in health care appears limited for people with aphasia in spite of research demonstrating that communicative participation can be enhanced with skilled communication partners and appropriate resources. In order to address this concern, a project was designed to target the “systems” level of health care via a multi‐faceted, team‐based intervention called the Communicate Access Improvement Project (CAIP).Aims: This project aimed to improve communicative access to information and decision making for people with aphasia within three healthcare systems (i.e., acute care, rehabilitation, long‐term care) by increasing teams members' knowledge of and skill in providing communicative supports and by facilitating the implementation of facility‐specific communicative access goals.Methods & Procedures: Three teams representing diverse disciplines participated in the project that included a 2‐day training session for each team, development of institution‐specific communicative access improvement goals and materials, and on‐site follow‐up and support from a project speech‐language pathologist. In order to determine the outcomes of team training and follow‐up, qualitative research methods were employed including observation, focus groups, and open‐ended interviews with team members. Qualitative data were collected before and after the 2‐day skills training and after a 4‐month follow‐up period. Using qualitative thematic analysis the qualitative data were analysed in order to evaluate the training process, to estimate the impact of training on team knowledge, attitude, and practice, and to identify trends, themes, emerging patterns, and primary issues associated with communicative access (Spradley, 1980).Outcomes & Results: After the 2‐day training, all teams demonstrated increased knowledge of methods of supporting communicative access, and improved understanding of access and inclusion for aphasia. After follow‐up, the rehabilitation and long‐term care teams achieved communicative access improvement goals and identified examples of systems changes and increased participation of people with aphasia within their programmes. They also perceived changes in team member values that supported communicative access. The acute care team reported less success in implementing goals for systems change after the 4‐month follow‐up. Barriers to and facilitators of sustainable system change were identified.Conclusions: Targeting systems‐level change appeared to be a useful approach to improving access to healthcare information and decision making for people with aphasia. The project provided insights into factors that facilitated or impeded communicative access in each healthcare setting and provided valuable information for future interventions designed to improve communicative access for people with aphasia. [ABSTRACT FROM AUTHOR]

Aims/hypothesis: The effect of a foot ulcer on health-related quality of life (HRQoL) of patients with diabetes mellitus and their caregivers is unclear, and was therefore evaluated prospectively in this multicentre study. Methods: HRQoL according to the 36-item health-related quality of life questionnaire (SF-36) of 294 patients (ulcer duration ≥4 weeks) and 153 caregivers was analysed at baseline (time-point zero [T0]), once the ulcer was healed or after 20 weeks (time-point 1 [T1]), and 3 months later (time-point 2 [T2]). Patients with severe ischaemia were excluded. Results: The mean age of the patients was 60 years, 72% were male, and time since diagnosis of diabetes was 17 years. Patients reported a low HRQoL on all SF-36 subscales. At T1, HRQoL scores in physical and social functioning were higher in patients with a healed vs a non-healed ulcer (p«0.05). At T2, these differences were larger, with higher scores for physical and social functioning, role physical and the physical summary score (all p«0.05). Within-group analysis revealed that HRQoL improved in different subscales in patients with a healed ulcer and worsened in patients with a persistent ulcer from T0 to T2 (all p«0.05). The caregivers of patients with a persisting ulcer had more emotional difficulties at T2. Conclusions/interpretation: Diabetic patients with a healed foot ulcer had a higher HRQoL than patients with a persisting ulcer. Healing of a foot ulcer resulted in a marked improvement of several SF-36 subscales 3 months after healing (from T0 to T2). HRQoL declined progressively when the ulcer did not heal. A diabetic foot ulcer appeared to be a large emotional burden on the patients' caregivers, as well. [ABSTRACT FROM AUTHOR]

This systematic review, in which 12 original research papers and meta-analyses were included, explored whether patients’ socio-economic status influences doctor–patient communication.Results show that patients from lower social classes receive less positive socio-emotional utterances and a more directive and less participatory consulting style, characterised by significantly less information giving, less directions and less socio-emotional and partnership building utterances from their doctor. Doctors’ communicative style is influenced by the way patients communicate: patients from higher social classes communicate more actively and show more affective expressiveness, eliciting more information from their doctor. Patients from lower social classes are often disadvantaged because of the doctor’s misperception of their desire and need for information and their ability to take part in the care process.A more effective communication could be established by both doctors and patients through doctors’ awareness of the contextual communicative differences and empowering patients to express concerns and preferences. [Copyright &y& Elsevier]