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Baseball pitching requires fast and coordinated motions of the whole body to reach high ball speeds, putting considerable strain on the musculoskeletal system, particularly the shoulder and elbow. To describe musculoskeletal symptoms and the functional status of the shoulder and elbow in male high school baseball pitchers. Descriptive epidemiology study. Dutch baseball talent academies. One hundred twenty-five male high school baseball pitchers aged 12 to 18 years who participated in 1 of the 6 Dutch baseball talent academies and the Dutch National U-18 team were recruited and enrolled. Musculoskeletal symptoms, functional status of the shoulder and elbow were registered for each player every 6 months over 2 consecutive baseball seasons through self-assessment questionnaires, including the Kerlan-Jobe Orthopaedic Clinic (KJOC) and the Western Ontario Shoulder Instability Index (WOSI) questionnaires. Five hundred seventy musculoskeletal (MSS) symptoms in 93 of the 125 players were reported. The average 6-month prevalence for symptoms of the throwing shoulder was 37% (95% CI = 33%–41%), and for the elbow 37% (95% CI = 31%–42%), followed by the lower back with 36% (95% CI = 26%–45%). The baseball pitchers who experienced only shoulder symptoms had an average KJOC score of 80.0 (95% CI = 75.3–84.7) points, whereas those with only elbow symptoms reported a score of 90.2 (95% CI = 89.2–95.3). On the WOSI questionnaire, baseball pitchers scored an average of 421.2 (95% CI = 200.1–642.4) points. In a cohort of Dutch high school baseball pitchers, one-third reported shoulder and elbow symptoms on the throwing side, with reduced functional status and lower back symptoms. Future efforts should focus on developing preventive strategies through early symptom detection, aiming to prevent symptom progression and, ultimately, the development of severe injuries. [ABSTRACT FROM AUTHOR]

This study describes the prevalence, incidence density, severity, and nature of injuries in elite field hockey players over the Dutch 2015-2016 season. Eighty players answered a baseline questionnaire and were subsequently followed up every 2 weeks to report the hours spent on training/competition and experienced injuries, which were registered using the Oslo Sports Trauma Research Centre Questionnaire on Health Problems. Of the 74 players included in the analysis, 52 (70%) reported 112 injuries. Eighty-seven injuries (78%) received medical attention, and 56 (50%) led to training/competition time-loss. Thirty-four injuries (30%) hampered players' availability to train and compete. Most of the injuries (74%) were not caused by any contact. The mean prevalence of injury was 29% (95% confidence interval [CI] 3-55) for all, 9% (95% CI 0-20) for acute, and 14% (95% CI 0-36) for overuse injuries. Players sustained 3.5 (95% CI 2.5-4.5) new acute injuries per 1000 hours of training and 12.3 (95% CI 7.6-17.0) per 1000 hours of competition. The median of the severity score was 28 from 100 (25%-75% interquartile range [IQR] 16-42) for all, 35 (IQR 23-53) for acute, and 21 (IQR 16-31) for overuse injuries. On average, 1 in 4 elite field hockey players experiences an injury within a 2-week period during the season. Although acute injuries are common, overuse injuries pose a comparable problem in elite field hockey. As injuries are a burden on players' health and may hamper performance and availability to train and compete, prevention is of great importance. [ABSTRACT FROM AUTHOR]

The objective of this study was to estimate the incidence and prevalence of injury and illness among elite junior tennis players. A cohort of 73 players (11-14 years) in the 2012-2013 Dutch national high-performance program was followed for 32 weeks; all participants completed the study. The OSTRC Questionnaire on Health Problems was used to record self-reported injuries and illnesses and to record training and match exposure. Main outcome measures were average prevalence of overuse injury and illness and incidence density of acute injury. On average, players practiced 9.1 h/week ( SD 0.6; range 2.3-12.0) and had 2.2 h of match play ( SD 0.6; range 2.3-12.0). During the course of the study, 67 players reported a total of 187 health problems. The average weekly prevalence of all health problems was 21.3% (95% CI: 19.2-22.9), of which 12.1% (95% CI: 10.9-13.3) constituted overuse injuries and 5.8% (95% CI: 4.6-6.9) illnesses. The incidence of acute injuries was 1.2/1000 h of tennis play (95% CI: 0.7-1.7). The high occurrence of overuse injuries among elite junior tennis players suggests that an early focus on preventative measures is warranted, with a particular focus on the monitoring and management of workload. [ABSTRACT FROM AUTHOR]

The purpose of this study was to describe the prevalence, incidence and risk factors for climbing-related injuries of the upper extremities in recreational climbers. A total of 426 recreational climbers were recruited from indoor climbing halls. The baseline questionnaire included questions on potential risk factors for climbing injuries: personal factors, climbing-related factors and upper extremity injuries that had occurred in the previous 12 months. Follow-up questionnaires collected information on new injuries that occurred during the follow-up period. The incidence of climbing-related injuries during one-year follow-up was 42.4% with 13 injuries per 1 000h of climbing. The finger was the most frequently affected injury location (36.0%). The following risk factors were associated with the occurrence of upper extremity injuries: higher age (OR 1.03, 95%CI 1.01;1.05), performing a cooling-down (OR 2.02, 95%CI 1.28;3.18), climbing with campus board (OR 2.48, 95%CI 1.23;5.02), finger strength middle finger (OR 1.12, 95%CI 1.05;1.18) and previous injuries (OR 3.05, 95%CI 2.01 ;4.83). Climbing injuries of the upper body extremities are very common among recreational climbers in indoor halls and several risk factors can be identified that are related to a higher injury risk. [ABSTRACT FROM AUTHOR]

Objectives: To describe the frequency, type, and severity of health problems in long-track speed skating to inform injury prevention strategies., Methods: We prospectively collected weekly health and sport exposure data on 84 highly trained Dutch athletes aged 15-21 years during the 2019/2020 season using the Oslo Sports Trauma Research Centre questionnaire on Health Problems and the trainers' documentation. We categorised health problems into acute or repetitive mechanisms of injury or illness and calculated incidences (per 1000 sports exposure hours), weekly prevalence and burden (days of time loss per 1000 sports exposure hours) related to the affected body region., Results: We registered 283 health problems (187 injuries, 96 illnesses), yielding an average weekly prevalence of health problems of 30.5% (95% CI 28.7% to 32.2%). Incidence rates were 2.0/1000 hours for acute mechanism injuries (95% CI 1.5 to 2.5) and 3.2/1000 hours for illnesses (95% CI 2.6 to 3.9). For acute mechanism injuries the head, shoulder and lumbosacral region had the highest injury burden of 5.6 (95% CI 4.8 to 6.5), 2.9 (95% CI 2.3 to 3.5) and 2.2 (95% CI 1.7 to 2.8) days of time loss/1000 hours, respectively. For repetitive mechanism injuries, the knee, thoracic spine, lower leg and lumbosacral region had the highest injury burden, with 11.0 (95% CI 9.8 to 12.2), 6.8 (95% CI 5.9 to 7.7), 3.9 (95% CI 3.2 to 4.6) and 2.5 (95% CI 1.9 to 3.1) days of time loss/1000 hours, respectively., Conclusion: Our study demonstrated a high prevalence of acute and repetitive mechanism injuries in speed skating. These results can guide future research and priorities for injury prevention., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This process evaluation aimed to gain insight into the implementation of the VolleyVeilig Youth program by Dutch volleyball clubs within the context of an effectiveness trial., Methods: We applied the UK Medical Research Council framework for process evaluations and assessed the context, implementation and mechanisms of impact. Trainers participating in the effectiveness trial were asked to complete a questionnaire at the end of the study. A subsample of the trainers based on the self-reported adherence score was invited to participate in an interview accordingly. We used a thematic analysis to present the data., Results: Thirty-one trainers (100%) completed the questionnaire, and seven agreed to participate in an interview. Although adherence gradually decreased over the volleyball season, most trainers reported partially adhere with the program until the end of the study. The main themes included factors associated with the (1) VolleyVeilig Youth program, (2) trainer, (3) players, and (4) volleyball club., Conclusion: Although (partial) adherence to the VolleyVeilig Youth program was high in this study, implementation strategies must be developed to target the barriers reported by the trainers before the program can be successfully implemented nationwide in the Netherlands., (© 2024 The Authors. Scandinavian Journal of Medicine & Science In Sports published by John Wiley & Sons Ltd.)

Objectives: To evaluate the effectiveness of a trainer-supervised judo-specific injury prevention warm-up programme on overall injury prevalence., Methods: We conducted a two-arm, cluster randomised controlled trial; the Injury Prevention and Performance Optimization Netherlands (IPPON) study. Judo athletes aged≥12 years were randomised by judo school to IPPON intervention or control group who performed their usual warm-up. Primary outcome was overall injury prevalence (%) over the follow-up period (16-26 weeks) measured fortnightly with the Oslo Sports and Trauma Research Centre Questionnaire. A modified intention-to-treat analysis was performed due to COVID-19, with estimates for the primary outcome obtained using generalised linear mixed models. Secondary outcomes included: prevalence of severe injuries, overall incidence, time-loss injuries, exposure, adherence and experiences of trainers and athletes., Results: 269 judo athletes (IPPON: 117, Control: 152) were included. Mean injury prevalence over 16-26 weeks was 23% (95% CI 20% to 26%) in the IPPON and 28% (95% CI 25% to 30%) in the control group. We observed no significant difference of all reported injuries (OR 0.72 in favour of the IPPON group; 95% CI 0.37 to 1.39). Secondary outcomes also demonstrated no significant differences between groups. Specifically, no significant difference of severe injuries was reported (OR 0.80 in favour of the IPPON group; 95% CI 0.36 to 1.78). All trainers and 70% of athletes perceived the IPPON intervention as successful., Conclusion: The IPPON intervention did not significantly reduce the overall and severe injury prevalence. Despite this, we suggest the IPPON intervention be considered as an useful alternative to regular judo warm-up, given the high adherence and the positive clinical experiences of trainers and athletes., Trial Registration Number: NTR7698., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

When talking about decisionmaking for children with a life-threatening condition, the death of children with brain tumors deserves special attention. The last days of the lives of these children can be particularly harsh for bystanders, and raise questions about the suffering of these children themselves. In the Netherlands, these children are part of the group for whom a wide range of end-of-life decisions are discussed, and questions raised. What does the end-of-life for these children look like, and what motivates physicians and parents to make decisions that may affect the life and death of these children? This article highlights the story of the parents of the sisters Roos and Noor. When both their daughters were diagnosed with a hereditary brain tumor, they had to make similar decisions twice. Their story sheds light on the suffering of children in the terminal phase, and how this suffering may motivate parents and physicians to make decisions that influence the end of life of these children's lives.We argue that complete knowledge about suffering in the terminal phase of children with brain tumors is impossible. However, by collecting experiences like those of Roos and Noor, we can move toward an experienced-based understanding and better guide parents and physicians through these hardest of decisions.

Objective: To identify barriers, as perceived by parents, to good care for children with life-threatening conditions., Design: In a nationwide qualitative study, we held in-depth interviews regarding end-of-life care with parents of children (aged 1 to 12 years) who were living with a life-threatening illness or who had died after a medical trajectory (a maximum of 5 years after the death of the child). Sampling was aimed at obtaining maximum variety for a number of factors. The interviews were transcribed and analysed., Setting: The Netherlands., Participants: 64 parents of 44 children., Results: Parents identified six categories of difficulties that create barriers in the care for children with a life-threatening condition. First, parents wished for more empathetic and open communication about the illness and prognosis. Second, organisational barriers create bureaucratic obstacles and a lack of continuity of care. Third, parents wished for more involvement in decision-making. Fourth, parents wished they had more support from the healthcare team on end-of-life decision-making. Fifth, parents experienced a lack of attention for the family during the illness and after the death of their child. Sixth, parents experienced an overemphasis on symptom-treatment and lack of attention for their child as a person., Conclusions: The barriers as perceived by parents focussed almost without exception on non-medical aspects: patient-doctor relationships; communication; decision-making, including end-of-life decision-making; and organisation. The perceived barriers indicate that care for children with a life-threatening condition focusses too much on symptoms and not enough on the human beings behind these symptoms., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

The objective was to evaluate the effectiveness of an exercise-based warm-up programme ("VolleyVeilig") on the one-season occurrence of musculoskeletal injuries among recreational adult volleyball players. A prospective randomised controlled trial was conducted over the 2017-2018 volleyball season. Recreational adult volleyball players were allocated either to an intervention or control group. The Dutch version of the Oslo Sports Trauma Research Centre questionnaire was used to register and monitor acute and overuse injuries. A total of 672 volleyball players were enrolled: 348 in the intervention group (mean age: 30) and 324 in the control group (mean age: 27). The incidence rate of acute injury was 21% lower in the intervention group, namely 8.9 versus 11.3 per 1,000 h in the control group (Cox mixed effects crude model: hazard ratio = 0.82 [95%CI: 0.69-0.98]; Cox mixed effects adjusted model: 0.85 [95%CI: 0.71-1.02]). No significant difference in mean prevalence of overuse injury was found between the intervention (4.8%) and control (4.2%) groups. The severity of injuries was not significantly different between groups, while injury burden was slightly lower in the intervention group. The exercise-based warm-up programme led to a trend in less acute injuries among recreational adult volleyball players.

Objective: The aim of this study was to investigate whether dynamic balance, measured with the anterior component of the Star Excursion Balance Test (SEBT-ANT), is a risk factor for ankle injuries in physical education teacher education (PETE) students., Design and Setting: A prospective monocentre study in first-year PETE students., Participants: A total of 196 subjects, of which 137 men (70%) and 59 women (30%)., Outcome Measures: This study consisted of measures of the SEBT-ANT at baseline (September 2015) and an injury registration procedure during a follow-up period (September 2015-June 2016). The association between the SEBT-ANT score and subsequent ankle injury was analysed with generalised estimating equations analysis at the leg level., Results: Men and women had an average SEBT-ANT score of, respectively, 65.1% and 67.7% of leg length. In 20 (15%) subjects, the first injured body site involved the ankle. Across all participants, a below average SEBT-ANT score was not associated with increased ankle injury odds (OR OR=2.43, 95% CI: 0.94 to 6.29, p=0.07). In men, a below average SEBT-ANT score indicated sevenfold increased odds for ankle injury (OR=7.06, 95% CI: 1.43 to 34.92, p=0.02). In women, this relationship was not significant (OR=0.72, 95% CI: 0.19 to 2.71, p=0.62)., Conclusions: Below average normalised SEBT-ANT scores were associated with sevenfold likelihood for ankle injuries in men. In contrast, no relationship was found for the SEBT-ANT score and ankle injuries in woman. These results may provide directions for the implementation of screening tools, as part of an injury prevention programme, to identify male PETE students with an increased likelihood for ankle injuries., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Because of practice variation and new developments in palliative pediatric care, the Dutch Association of Pediatrics decided to develop the clinical practice guideline (CPG) palliative care for children. With this guideline, the association also wanted to precipitate an attitude shift towards shared decision-making (SDM) and therefore integrated SDM in the CPG Palliative care for children. The aim was to gain insight if integrating SDM in CPGs can potentially encourage pediatricians to practice SDM. Its objectives were to explore pediatricians' attitudes and thoughts regarding (1) recommendations on SDM in CPGs in general and the guideline Palliative care for children specifically; (2) other SDM enhancing strategies or tools linked to CPGs., Methods: Semi-structured face-to-face interviews. Pediatricians (15) were recruited through purposive sampling in three university-based pediatric centers in the Netherlands. The interviews were audio-recorded and transcribed verbatim, coded by at least two authors and analyzed with NVivo., Results: Some pediatricians considered SDM a skill or attitude that cannot be addressed by clinical practice guidelines. According to others, however, clinical practice guidelines could enhance SDM. In case of the guideline Palliative care for children, the recommendations needed to focus more on how to practice SDM, and offer more detailed recommendations, preferring a recommendation stating multiple options. Most interviewed pediatricians felt that patient decisions aids were beneficial to patients, and could ensure that all topics relevant to the patient are covered, even topics the pediatrician might not consider him or herself, or deems less important. Regardless of the perceived benefit, some pediatricians preferred providing the information themselves instead of using a patient decision aid., Conclusions: For clinical practice guidelines to potentially enhance SDM, guideline developers should avoid blanket recommendations in the case of preference sensitive choices, and SDM should not be limited to recommendations on non-treatment decisions. Furthermore, preference sensitive recommendations are preferably linked with patient decision aids.

Background: To assess the effects of the injury prevention programme '11+ Kids' on reducing severe injuries in 7 to 13 year old football (soccer) players., Methods: Football clubs (under-9, under-11 and under-13 age groups) from the Czech Republic, Germany, the Netherlands and Switzerland were cluster-randomised (clubs) into an intervention (INT) and a control group (CON). INT replaced their usual warm-up by '11+ Kids' two times a week. CON followed their regular training regime. Match and training exposure and injury characteristics were recorded and injury incidence rates (IRs) and 95% CIs calculated. For the present analysis, only severe injuries (absence from training/match ≥28 days) were considered. Hazard ratios (HR) were calculated using extended Cox models., Results: The overall IR of severe injuries per 1000 football hours was 0.33 (95% CI 0.25 to 0.43) in CON and 0.15 (95% CI 0.10 to 0.23) in INT. There was a reduction of severe overall (HR 0.42, 95% CI 0.24 to 0.72), match (0.41, 0.17 to 0.95) and training injuries (0.42, 0.21 to 0.86) in INT. The injury types that were prevented the most were: other bone injuries 66%, fractures 49% and sprains and ligament injuries 37%. Severe injuries located at the knee (82%), hip/groin (81%), the foot/toe (80%) and the ankle (65%) were reduced tremendously., Conclusions: '11+ Kids' has a large preventive effect on severe injuries by investing only 15 to 20 min per training session. The present results should motivate coaches to implement effective injury prevention programmes such as the '11+ Kids' in children's football., Trial Registration Number: NCT02222025., Competing Interests: Competing interests: RR, KadF, MB, JC, EV, AJ and OF were responsible for the conception of ‘11+ Kids’. MB, AJ and JD were involved in the conception of ‘The 11’ and ‘The 11+’., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To investigate the prognosis and possible prognostic factors of running-related injuries (RRIs) in novice runners., Design: Prospective cohort study., Methods: Participants of Start to Run, a 6-weeks course for novice runners in The Netherlands, were asked to participate in this study. Before the start of the course a baseline questionnaire, on demographics, physical activity and perceived health, was sent to runners willing to participate. The 26- or 52-weeks follow-up questionnaires assessed information on RRIs and their duration. Only participants that sustained a RRI during follow-up were included in the analyses. An injury duration of 10weeks or shorter was regarded as a relatively good prognosis, while an injury duration of more than 10weeks was defined as a poor prognosis. To determine the associations between baseline characteristics and injury prognosis and between injury location and injury prognosis, multivariable logistic regression analyses were performed., Results: 347 participants (48.8%) sustained an RRI during follow-up. The RRIs had an overall median duration of eight weeks (range: 1-52weeks). Participants with a previous RRI were more likely to have a poor prognosis (OR 2.31; 95%CI 1.12-4.79), while a calf injury showed a trend towards an association with a relatively good prognosis (OR 0.49; 95%CI 0.22-1.11)., Conclusions: The duration of RRIs in novice runners is relatively long, with only calf injuries being associated with a good prognosis. This emphasizes the need of injury prevention measures in novice runners and adequate support during and after an RRI, especially in runners with a previous injury., (Copyright © 2018 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

Background: It is widely acceptable to involve parents in decision-making about the resuscitation of extremely preterm infants (EPIs) in the gray zone. However, there are different views about where the boundaries of the gray zone should lie. Our aim in this study was to compare the resuscitation thresholds for EPIs between neonatologists in the United Kingdom, Sweden, and the Netherlands., Methods: We distributed an online survey to consultant neonatologists and neonatal registrars and fellows that included clinical scenarios in which parents requested resuscitation or nonresuscitation. Respondents were asked about the lowest gestational age and/or the worst prognosis at which they would provide resuscitation and the highest gestational age and/or the best prognosis at which they would withhold resuscitation. In additional scenarios, influence of the condition at birth or consideration of available health care resources was assessed., Results: The survey was completed by 162 neonatologists (30% response rate). There was a significant difference between countries; the gray zone for most UK respondents was 23 + 0/7 to 23 + 6/7 or 24 weeks' gestation, compared with 22 + 0/7 to 22 + 6/7 or 23 weeks' gestation in Sweden and 24 + 0/7 to 25 + 6/7 or 26 weeks' gestation in the Netherlands. Resuscitation thresholds were higher if an infant was born in poor condition. There was wide variation in the prognosis that warranted resuscitation or nonresuscitation. Consideration of resource scarcity did not alter responses., Conclusions: In this survey, we found significant differences in approach to the resuscitation of EPIs, with a spectrum from most proactive (Sweden) to least proactive (Netherlands). Most survey respondents indicated shifts in decision-making that were associated with particular weeks' gestation. Despite the different approaches to decision-making in the 3 countries, there was relatively little difference between countries in neonatologists' prognostic thresholds for resuscitation., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

In 2002, The Netherlands continued its leadership in developing rules and jurisdiction regarding euthanasia and end-of-life decisions by implementing the Euthanasia Act, which allows euthanasia for patients 12 years of age and older. Subsequently, in 2005, the regulation on active ending of life for newborns was issued. However, more and more physicians and parents have stated that the age gap between these two regulations-children between 1 and 12 years old-is undesirable. These children should have the same right to end their suffering as adults and newborn infants. An extended debate on pediatric euthanasia ensued, and currently the debate is ongoing as to whether legislation should be altered in order to allow pediatric euthanasia. An emerging major question regards the active ending of life in the context of palliative care: How does a request for active ending of life relate to the care that is given to children in the palliative phase? Until now, the distinction between palliative care and end-of-life decisions continues to remain unclear, making any discussion about their mutual in- and exclusiveness hazardous at best. In this report, therefore, we aim to provide insight into the relationship between pediatric palliative care and end-of-life decisions, as understood in the Netherlands. We do so by first providing an overview of the (legal) rules and regulations regarding euthanasia and active ending of life, followed by an analysis of the relationship between these two, using the Dutch National Guidelines for Palliative Care for Children. The results of this analysis revealed two major and related features of palliative care and end-of-life decisions for children: (1) palliative care and end-of-life decisions are part of the same process, one that focuses both on quality of living and quality of dying, and (2) although physicians are seen as ultimately responsible for making end-of-life decisions, the involvement of parents and children in this decision is of the utmost importance and should be regarded as such.

Objective: Helmet use in Dutch recreational skiers and snowboarders (DRSS) remains low. This study evaluated the effects of exposure to a nationwide intervention on relevant determinants of helmet use and helmet use in DRSS., Methods: The intervention mapping protocol was used to develop an in-season intervention programme targeted at adult DRSS. A prospective single-cohort study was conducted to evaluate the impact of intervention exposure on determinants of helmet use (ie, knowledge about head injury risk and preventive measures, risk perception, attitudes to head injury risk and helmet use and intention to helmet use) and self-reported helmet use. A random sample of 363 DRSS from an existing panel participated in this study. Data were collected using online questionnaires before and immediately after the 2010/2011 intervention season. In a separate sample of 363 DRSS, intervention reach was assessed after the 2010/2011 season., Results: Overall, no significant associations were found between intervention exposure and the determinants of helmet use. However, subgroup analyses revealed intervention effects on risk perception and knowledge in specific subpopulations. Intervention exposure had a significant, positive effect on helmet use in DRSS (β=0.23; 95% CI 0.017 to 0.44). Subgroup analyses revealed that this effect was found in: (1) skiers, (2) female DRSS, (3) young skiers and (4) intermediate skiers. Overall, intervention reach was 28.1%, with differences found between skiers and snowboarders., Conclusions: Exposure to a nationwide intervention programme was associated with increased self-reported helmet use in DRSS. Differences were found in intervention effectiveness and reach between subpopulations. These differences must be taken into account when developing and evaluating future interventions., 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.)

Voluntary active euthanasia for adults at their explicit request has been legal in Belgium and the Netherlands since 2002. In those countries, acceptance of the practice for adults has been followed by acceptance of the practice for children. Opponents of euthanasia see this as a dangerous slippery slope. Proponents argue that euthanasia is sometimes ethically appropriate for minors and that, with proper safeguards, it should be legally available in appropriate circumstances for patients at any age. In this Ethics Rounds, we asked philosophers from the United States and the Netherlands, and a Dutch pediatrician, to discuss the ethics of legalizing euthanasia for children., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Background: E-health has the potential to facilitate implementation of effective measures to prevent sports injuries., Aim: We evaluated whether an interactive mobile application containing a proven effective exercise programme to prevent recurrent ankle sprains resulted in higher compliance as compared with regular written exercise materials., Methods: 220 athletes participated in this randomised controlled trial with a follow-up of 8 weeks; 110 athletes received a booklet explaining an 8-week neuromuscular training programme; 110 athletes participated in the same programme in an interactive mobile App (Strengthen your ankle). The primary outcome was compliance with the exercise programme. Secondary outcome measure was the incidence density of self-reported recurrent ankle sprains., Results: The mean compliance to the exercise scheme was 73.3% (95% CI 67.7% to 78.1%) in the App group, compared with 76.7% (95% CI 71.9% to 82.3%) in the Booklet group. No significant difference in compliance was found between groups. The incidence densities of self-reported time-loss recurrences were not significantly different between both groups (HR 3.07; 95% CI 0.62 to 15.20)., Summary: This study shows that the method of implementing the exercises by using an App or a Booklet does not lead to different compliance rates., New Findings: The use of a mobile App or a Booklet lead to similar compliance and injury rates in the short term., Trial Registration Number: The Netherlands National Trial Register NTR 4027. The NTR is part of the WHO Primary Registries., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Running is a popular form of physical activity, despite of the high incidence of running-related injuries (RRIs). Because of methodological issues, the etiology of RRIs remains unclear. Therefore, the purposes of the study were to assess the incidence of RRIs and to identify risk factors for RRIs in a large group of novice runners. In total, 1696 runners of a 6-week supervised "Start to Run" program were included in the NLstart2run study. All participants were aged between 18 and 65, completed a baseline questionnaire that covered potential risk factors, and completed at least one running diary. RRIs were registered during the program with a weekly running log. An RRI was defined as a musculo-skeletal complaint of the lower extremity or back attributed to running and hampering running ability for three consecutive training sessions. During the running program, 10.9% of the runners sustained an RRI. The multivariable Cox regression analysis showed that a higher age, higher BMI, previous musculo-skeletal complaints not attributed to sports and no previous running experience were related to RRI. These findings indicate that many novice runners participating in a short-term running program suffer from RRIs. Therefore, the identified risk factors should be considered for screening and prevention purposes., (© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Developments in legal and medical research concerning end-of-life decisions regarding severely suffering neonates in the Netherlands provide good cause for reflection on specific items of this issue. This article deals with the outcomes of the first national survey on end-of-life practice in Dutch Neonatal Intensive Care Units (NICUs) and examines the legal aspects of the use of medication as a part of this practice. The authors particularly reflect on the application of analgesics and sedatives on the one hand and neuromuscular blockers (NMBs) on the other hand. Furthermore, they focus on different elements of medicinal use such as indication, the moment of administering, dosage, effects of combinations of drugs, the relationship to the causation of death and (failures in) documentation.

Objectives: To describe the incidence and severity of injuries resulting from physical education, sports and leisure time physical activity (PA) in 10-12-year-old children., Design: This was a prospective cohort study conducted in primary schools, with 995 children aged 10-12 years old as participants. Individual weekly exposure was estimated from baseline and follow-up questionnaires. Exposure to physical education (PE) classes was equal in all schools. An injury was recorded if it occurred during either PE class, leisure time PA, or sports, and caused the child to at least stop the current activity. Injuries were reported within 1 week of injury onset. The main outcome measure was injury incidence density., Results: During the school year a total of 119 injuries were reported by 104 children, resulting in an overall injury incidence density (ID) of 0.48 per 1000 h of exposure (95% CI 0.38 to 0.57). Injury ID was lowest for leisure time PA, followed by PE and sports, respectively. Of all injuries, 40% required medical treatment and 14% resulted in 1 or more days of absence from regular school activities. In general for girls a higher injury ID was reported than for boys, mainly caused by a twofold higher risk during leisure time PA., Conclusions: Next to specific areas of preventive interest it was found that in this specific age group, girls require special attention as they seem to be at higher injury risk than boys.

Objective: To gain insight into the role of consultation in palliative sedation., Design: Retrospective analysis., Method: All consultation records of the Palliation Team Midden Nederland (PTMN) from 1 November 2005 to 31 October 2006 were analysed. If palliative sedation was mentioned in the record, the following variables were listed: character of the consultation, data of the questioner, patient data, consultation question, indication for palliative sedation, and character of the advice given., Results: Palliative sedation was a topic in 206 of the 659 consultation records investigated (31%). Intractable delirium, pain, exhaustion, dyspnoea and nausea or vomiting were the most important grounds for palliative sedation. In 47 of the 113 consultations (41%) about starting palliative sedation a negative advice was given, and this was nearly always because there were no intractable somatic symptoms. Existential problems played an important role in 14 of these 113 consultations (12%). In 25 consultations (22%) euthanasia versus palliative sedation was considered explicitly. For these cases there was hardly ever an indication for sedation., Conclusion: Palliative sedation was an important reason for consulting the PTMN. The high percentage of negative advice indicates that consultation about palliative sedation has an added value. It gives the questioner the opportunity to check whether all options for treatment have been tried. The question as to whether existential problems are an indication for palliative sedation should be discussed between medical professionals as well as publicly. Palliative sedation rarely is an alternative for euthanasia.

Objective: This study determines the injury rate (%) and the associated direct medical and indirect costs of sports injuries in Flanders., Setting: Epidemiological cohort designs and a human capital method were set up to measure respectively the medical direct and indirect cost of sports injuries., Participants: 72 out of 82 Flemish sports federations participated., Intervention: Insurance statistics from 2003 were used to determine the overall rate of injury and injury localisations. Using these data, the medical direct cost and the impact sports injuries have on indirect costs were estimated. The indirect costs were determined by multiplying the days of absence from work with the daily cost resulting from a loss of production, being 200 euros., Main Outcome: The total direct medical cost extrapolated for the Flemish sports participants was 15,027,423 euros, which amounted to 0.07% to 0.08% of the total budget spent on healthcare. The indirect cost extrapolated for the Flemish sports participants was 111,420,813 euros, which is about 3.4% of the costs arising from absenteeism from work., Results: Of the 14 in-depth analysed sports, the rate of injury was highest in European team handball (8.96%; 95% confidence interval (CI) 8.95-8.96) and lowest in swimming (0.62%; 95% CI 0.62-0.62). The highest direct medical cost was found for anterior cruciate ligament (ACL) injuries (1358 euros per injury) and the lowest for foot injuries (52 euros per injury)., Conclusion: The costs calculated in this study could become critical statistics in medical care debates. Data obtained here will enable a cost-benefit analysis of the impact of preventive measures to be made.

Goals of Work: To analyze cancer patient-related consultations of a telephone helpdesk (TH) for palliative care over a period of 5 years in the region of Utrecht, The Netherlands., Materials and Methods: A descriptive analysis was performed of consultations over a period of 5 years (2001-2006). The discipline and location of requesting professionals, patient characteristics, reasons for calling, symptoms, palliative care problems and needs for support were registered., Main Results: A total of 1,794 consultations were analyzed. There was an increasing number of consultations during the study period. Of the patients, 51% were male and their median age was 65 years (range 0-104). Eighty-four percent were treated at home by their general practitioner. Two thirds of the patients had a life expectancy <4 weeks. Most questions referred to pain (49%), delirium (20%), nausea and vomiting (16%) and dyspnea (12%). The median number of symptoms was 1 (0-6). Of the questions, 54% were related to pharmacological problems, 19% to psychological problems and 21% to the organization of care. Of the requesting professionals, 17% asked for support for themselves. Of the consultations, 14% were related to end-of-life issues: palliative sedation (11%) and euthanasia (3%)., Conclusion: After more than 5 years, the 24-h telephone consultation service fulfills a need for general practitioners dealing with daily dilemmas in palliative care treatment for cancer patients at home during the last period of their life.

The international press has been full of blood chilling accounts concerning a supposedly new practice in the Netherlands of terminating the life of severely defective newborn babies with a protocol. Our aim is to give insight into the medical and legal aspects of this protocol and to describe its contents. The legal developments concerning termination of life in newborns in the Netherlands are being discussed.

Objective: To estimate the overall incidence of acute and overuse volleyball injuries, and to describe factors associated with ankle sprains., Methods: 486 players from the second and third Dutch national volleyball divisions participated in the study and were followed prospectively during a whole season. Three measurements were made during the season (baseline, follow up 1, and follow up 2), where all players completed a questionnaire on demographic variables (only at baseline), sports participation, use of preventive measures, and previous injuries. Volleyball exposure during training and matches was recorded for each individual player by the coach on a weekly exposure form. In case of injury the coach provided the injured player with an injury registration form, which had to be completed within one week after the onset of injury., Results: 100 injuries were reported, resulting in an overall injury incidence of 2.6 injuries/1000 hours. The incidence of acute injuries was 2.0/1000 hours. Ankle sprains (n = 41) accounted for most of the acute injuries, and 31 (75%) of all players with an ankle sprain reported a previous ankle sprain. Twenty five overuse injuries were reported. The overall incidence of overuse injuries was 0.6/1000 hours; the back and the shoulder were the most common sites., Conclusions: Ankle sprain is the most common injury in volleyball, accounting for 41% of all volleyball related injuries. Previous injury seems to be an important risk factor for an ankle sprain. Injury prevention programmes should focus on ankle sprains and concentrate on players with previous ankle sprains.

In the Amsterdam Growth and Health Longitudinal Study (AGAHLS), a group of apparently healthy males and females (n = 200) were interviewed about their physical activities on eight separate occasions over a period of 20 years between 13 and 33 years of age (multi-measured group: MM). Information about their health was given based on their personally measured lifestyle (activity, diet, smoking) and biological risk characteristics for chronic diseases (medical check-ups). A comparable group of boys and girls (n = 200) was only measured on two occasions (bi-measured group: BM): at 13 and 33 years. Physical activity was estimated with a structured interview. Total physical activity and sports activity were estimated in three intensity levels (light, moderate, and heavy). It was hypothesized that the eight repeated medical check-ups with health information in the MM group would result in a healthier lifestyle with respect to the determinants and levels of habitual physical activity compared to the BM group. Contrary to the hypothesis, males and females in the BM group showed a significantly higher increase or a lower decrease in physical activities compared to the MM group. This negative effect on the physical activity pattern at 33 years in the MM group may have been caused by more underreporting of physical activities than in the BM group. In conclusion, there does not appear to be a significant effect of long-term (multi-measured) health information with medical check-ups during adolescence and young adulthood on level of physical activity in males and females at 33 years of age., (Copyright 2002 Wiley-Liss, Inc.)

In 2 patients, a woman aged 38 years and a man aged 48 years, in the terminal phase of life due to metastasized+ malignancy, palliative care failed. They suffered seriously from pain, delirium, restlessness, nausea, and fear. Deep sedation was given to induce almost continuous sleep without the intention of causing death. After one and five quiet days respectively the patients died. Deep sedation is an option when palliative care fails to diminish serious suffering. Midazolam, given by continuous subcutaneous infusion is the drug of choice.