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The article discusses the regulation pertaining to high-technological surrogacy in Netherlands. It states that the government has adopted a very strict condition on maternity for another, however, it has no special framework geared towards transferring parental rights and duties from the surrogate mother to the commissioning parents. However, it mentions the debate in the Parliament regarding the desirability of surrogacy due to the number of infant buying cases and scams in the country.

The use of telemedicine (telephone and video consultations) has increased over the past decades and has grown substantially during the COVID-19 pandemic. Multimorbidity, visual - and hearing impairment, cognitive impairment and lack of technical skills might complicate the use of telemedicine in frail elderly patients. Limited research on this topic is has been performed. The aim of this article is to investigate which elements of care could be performed by telemedicine and what patient characteristics are useful in selecting patients for telemedicine. To get more information about the use of telemedicine in frail elderly patients, an online survey was conducted amongst caregivers working in geriatric outpatient care departments in the Netherlands. 67 caregivers completed the survey. The results indicate there is limited experience in video consultations in this population. The experience so far is mainly positive. Caregivers indicate the following elements of care could be performed by telemedicine: follow-up consultations, taking an (hetero)anamnesis, medication review, conversations with multiple contacts or caregivers and informing about test results. Our advice is to decide in dialogue with patient and caregiver, which form of consultation is feasible, desirable and appropriate for every individual process and consultation.

Background: Postoperative delirium (POD) is a frequently observed complication after transcatheter aortic valve replacement (TAVR). The effects of intraoperative hypotension (IOH) on POD occurrence are currently unclear., Methods: A retrospective observational cohort study of patients who underwent TAVR was conducted. We predefined IOH as area under the threshold (AUT) of five mean arterial blood pressures (MBP), varying from <100 to <60 mmHg. The AUT consisted of the combination of duration and depth under the MBP thresholds, expressed in mmHg*min. All MBP AUTs were computed based on the complete procedure, independent of procedural phase or duration., Results: This cohort included 675 patients who underwent TAVR under general anesthesia (n = 128, 19%) or procedural sedation (n = 547, 81%). Delirium occurred mostly during the first 2 days after TAVR, and was observed in n = 93 (14%) cases. Furthermore, 674, 672, 663, 630, and 518 patients had at least 1 min intraoperative MBP <100, <90, <80, <70, and <60 mmHg, respectively. Patients who developed POD had higher AUT based on all five MBP thresholds during TAVR. The penalized adjusted odds ratio varied between 1.08 (99% confidence interval [CI] 0.74-1.56) for the AUT based on MBP < 100 mmHg and OR 1.06 (99% CI 0.88-1.28) for the AUT based on MBP < 60 mmHg., Conclusions: Intraoperative hypotension is frequently observed during TAVR, but not independently associated with POD after TAVR. Other potential factors than intraoperative hypotension may explain the occurrence of delirium after TAVR., (© 2021 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Objective: In recent years, transcatheter aortic valve implantation (TAVI) has become the treatment of choice for patients with symptomatic aortic valve stenosis considered to be at increased or high surgical risk. The aim of this study was to identify predictors of postoperative adverse events in older adults undergoing TAVI., Methods: A prospective observational cohort study of patients who were referred to a geriatric outpatient clinic for a geriatric assessment prior to TAVI was conducted. The outcomes were mortality and hospital readmission within 3 months of TAVI and the occurrence of major postoperative complications during hospitalisation according to the Clavien-Dindo classification. These three outcomes were also combined to a composite outcome. Univariate and multivariate logistic regression analyses were performed to identify predictors of the outcomes and composite outcome of adverse events., Results: This cohort included 490 patients who underwent TAVI (mean age 80.7±6.2 years, 47.3% male). Within 3 months of TAVI, 19 (3.9%) patients died and 46 (9.4%) patients experienced a hospital readmission. A total of 177 (36.1%) patients experienced one or more major complications according to the Clavien-Dindo classification during hospitalisation and 193 patients (39.4%) experienced the composite outcome of adverse events. In multivariate analyses, cognitive impairment was identified as an independent predictor of major postoperative complications (OR 2.16; 95% CI 1.14 to 4.19) and the composite outcome of adverse events (OR 2.40; 95% CI 1.21 to 4.79). No association was found between the other variables and the separate outcomes and composite outcome., Conclusion: Cognitive impairment is associated with postoperative adverse events in older patients undergoing TAVI. Therefore, it is important to screen for cognitive impairment prior to TAVI and it is recommended to include this in current TAVI guidelines., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This study aims to assess age-related treatment patterns and primary reasons for adjusted treatment in patients with colorectal cancer., Methods: Patients with colorectal cancer stage II or III diagnosed between 2015 and 2018 in the Netherlands were eligible for this study. Data were provided by the Netherlands Cancer Registry and included socio-demographics, clinical characteristics, treatment patterns and primary reasons for adjusted treatment. Treatment patterns and reasons for adjusted treatment were analysed according to age groups., Results: Of all 29,620 patients, 30% were aged <65 years (n = 8994), 34% between 65 and 75 years (n = 10,173), 27% between 75 and 85 years (n = 8102) and 8% were ≥85 years (n = 2349). Irrespective of cancer location or stage, older patients received less frequently a combination of surgery and (neo)adjuvant therapy compared to younger patients (decreasing from 55% to 1% in colon cancer patients, and from 71% to 23% in rectal cancer patients aged <65 years and ≥85 years respectively). Omission of surgical treatment increased with age in both patients with colon cancer (ranging from 1% in patients aged <65 years to 16% in those ≥85 years) and rectal cancer (ranging from 12% in patients aged <65 years to 56% in those ≥85 years). The most common reasons for adjusted treatment were patient preference (27%) and functional status (20%), both reasons increased with advancing age., Conclusions: Guideline non-adherence increased with advancing age and omission of standard treatment was mainly based on patient preference and functional status. These findings provides insight in the treatment decision-making process in patients with colorectal cancer. Future research is necessary to further assess patient's role in the treatment decision-making process., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

This study evaluated the 2-year persistence with teriparatide in the Netherlands. Analyses showed that the risk of non-persistence was 28% lower in patients who were followed according to an additional educational and motivational support program., Introduction: Until recently, teriparatide (TPTD) was a third-line treatment option for severe osteoporosis in the Netherlands, which could only be prescribed by medical specialists based on a specific medical statement. We aimed to determine whether an educational and motivational support program (EMSP) increased 2-year treatment persistence with TPTD in patients with severe osteoporosis., Methods: We evaluated persistence in 1573 Dutch patients treated with TPTD from January 2013 until January 2018. From January 2013 onwards, all patients received a basic support program (BSP) consisting of an educational home visit to initiate TPTD treatment and phone calls (at 1, 2.5 and 8 weeks). Since May 2015, all patients received the EMSP consisting of the BSP extended with evaluation of medication adherence during phone calls, an additional phone call (at 12 months), and motivational letters at 9 and 14 months., Results: The EMSP showed a statistically significantly higher 2-year persistence (78%) with TPTD as compared with the BSP (72%). Reasons for treatment discontinuation were comparable between groups, except for the proportion of patients who had stopped TPTD administration due to side effects, which was significantly lower in the EMSP group (8% vs. 15% in BSP, p < 0.001). Overall, the risk of non-persistence was 28% lower in the EMSP compared with the BSP group (HR: 0.72; 95% CI: 0.55-0.93)., Conclusion: The introduction of the EMSP has demonstrated to improve the persistence with TPTD, resulting in 78% of the patients being persistent with TPTD during the 2-year treatment period.

Objective: Delirium is an impactful, frequently occurring complication in older hospital patients. Consequently, risk stratification of delirium was included in a set of mandatory safety measures in general hospitals in the Netherlands. This risk stratification contains three consensus-based questions that have not been validated. Therefore, we evaluated their predictive performance and examined whether other routinely collected patient data can improve the prediction of delirium., Method: Using data from a continuous data registry from a general hospital, the prediction of the three questions was compared with the occurrence of delirium in 3786 older patients. Regression models were fitted that included other patient-related delirium risk factors. The performance was expressed by discrimination and calibration., Results: Delirium occurrence was 16.8%. The three questions, a regression model with the three questions, a full model and a reduced model - including the three questions, age, use of glasses, number of medications and Katz-ADL - showed sensitivities of 0.88, 0.88, 0.92 and 0.91 and specificities of 0.52, 0.52, 0.53 and 0.54, when treated as dichotomous models respectively. The three risk models had C-statistics of 0.81, 0.86 and 0.86, with excellent p-values of the U-statistics., Conclusion: The three risk-stratification questions show promising results but substantial overprediction (49% predicting positive). Further validation should be done outside the Netherlands, given the potential bias as a result of clinical activities following the risk stratification. The reduced model shows excellent calibration performance, indicating good prediction in each individual patient. In clinical practice, this advantage adds to clinical reasoning., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Although it is recognised that the dialysis population is ageing rapidly, geriatric complications such as falls are poorly appreciated, despite the many risk factors for falls in this population. The objective of this study was to determine the incidence, complications and risk factors for falls in an elderly dialysis population., Methods: A one-year observational study of chronic dialysis patients aged ≥ 70 years. At baseline, patient characteristics were noted and during follow-up the vital parameters and laboratory values were recorded. Patients were questioned weekly about falls, fall circumstances and consequences by trained nurses., Results: 49 patients were included with a median age of 79.3 years (70-89 years). During follow-up 40 fall accidents occurred in 27 (55%) patients. Falls resulted in fractures in 15% of cases and in hospital admissions in 15%. In haemodialysis (HD) patients, the mean systolic blood pressure (SBP) before HD was lower in fallers compared with non-fallers (130 vs. 143 mmHg). Several patients in the lower blood pressure category received antihypertensive medication. For every 5 mmHg lower SBP (before HD) the fall risk increased by 30% (hazard ratio (HR) 1.30, 95% CI 1.03-1.65, p = 0.03). Furthermore, fall risk increased by 22% for every 10 pmol/l rise of parathyroid hormone (HR 1.22, 95% CI 1.06-1.39, p = 0.004)., Conclusions: Elderly dialysis patients have a high incidence of falls accompanied by a high fracture rate. Given the high complication rate, elderly patients at risk of falling should be identified and managed. Reduction of blood pressure-lowering medication might be a treatment strategy to reduce falls.

We previously showed that 40 % of clinically stable patients hospitalised for community-acquired pneumonia (CAP) are not switched to oral therapy in a timely fashion because of physicians' barriers. We aimed to decrease this proportion by implementing a novel protocol. In a multi-centre controlled before-and-after study, we evaluated the effect of an implementation strategy tailored to previously identified barriers to an early switch. In three Dutch hospitals, a protocol dictating a timely switch strategy was implemented using educational sessions, pocket reminders and active involvement of nursing staff. Primary outcomes were the proportion of patients switched timely and the duration of intravenous antibiotic therapy. Length of hospital stay (LOS), patient outcome, education effects 6 months after implementation and implementation costs were secondary outcomes. Statistical analysis was performed using mixed-effects models. Prior to implementation, 146 patients were included and, after implementation, 213 patients were included. The case mix was comparable. The implementation did not change the proportion of patients switched on time (66 %). The median duration of intravenous antibiotic administration decreased from 4 days [interquartile range (IQR) 2-5] to 3 days (IQR 2-4), a decrease of 21 % [95 % confidence interval (CI) 11 %; 30 %) in the multi-variable analysis. LOS and patient outcome were comparable before and after implementation. Forty-three percent (56/129) of physicians attended the educational sessions. After 6 months, 24 % (10/42) of the interviewed attendees remembered the protocol's main message. Cumulative implementation costs were 5,798 (20/reduced intravenous treatment day). An implementation strategy tailored to previously identified barriers reduced the duration of intravenous antibiotic administration in hospitalised CAP patients by 1 day, at minimal cost.

Background: Classroom ventilation rates often do not meet building standards, although it is considered to be important to improve indoor air quality. Poor indoor air quality is thought to influence both children's health and performance. Poor ventilation in The Netherlands most often occurs in the heating season. To improve classroom ventilation a tailor made mechanical ventilation device was developed to improve outdoor air supply. This paper studies the effect of this intervention., Methods: The FRESH study (Forced-ventilation Related Environmental School Health) was designed to investigate the effect of a CO2 controlled mechanical ventilation intervention on classroom CO2 levels using a longitudinal cross-over design. Target CO2 concentrations were 800 and 1200 parts per million (ppm), respectively. The study included 18 classrooms from 17 schools from the north-eastern part of The Netherlands, 12 experimental classrooms and 6 control classrooms. Data on indoor levels of CO2, temperature and relative humidity were collected during three consecutive weeks per school during the heating seasons of 2010-2012. Associations between the intervention and weekly average indoor CO2 levels, classroom temperature and relative humidity were assessed by means of mixed models with random school-effects., Results: At baseline, mean CO2 concentration for all schools was 1335 ppm (range: 763-2000 ppm). The intervention was able to significantly decrease CO2 levels in the intervention classrooms (F (2,10) = 17.59, p < 0.001), with a mean decrease of 491 ppm. With the target set at 800 ppm, mean CO2 was 841 ppm (range: 743-925 ppm); with the target set at 1200 ppm, mean CO2 was 975 ppm (range: 887-1077 ppm)., Conclusions: Although the device was not capable of precisely achieving the two predefined levels of CO2, our study showed that classroom CO2 levels can be reduced by intervening on classroom ventilation using a CO2 controlled mechanical ventilation system.

Background: Centralization of pancreatic surgery in high-volume hospitals is under debate in many countries. In the western part of the Netherlands, the professional network of surgical oncologists agreed to centralize all pancreatic surgery from 2006 in two high-volume hospitals. Our aim is to evaluate whether centralization of pancreatic surgery has improved clinical outcomes and has changed referral patterns., Materials and Methods: Data of the Comprehensive Cancer Centre West (CCCW) of all 249 patients who had a resection for suspected pancreatic cancer between 1996 and 2008 in the western part of the Netherlands were analyzed. Multivariable modeling was used to evaluate survival for 3 time periods; 1996-2000, 2001-2005 (introduction of quality standards), and 2006-2008 (after centralization). In addition, the differences in referral pattern were analyzed., Results: From 2006, all pancreatic surgery was centralized in 2 hospitals. The 2-year survival rate increased after centralization from 39% to 55% (P =.09) for all patients who had a pancreatic resection for pancreatic cancer. After adjustment for age, tumor location, stage, histology, and adjuvant treatment, the latter period was significantly associated with improved survival (hazard ratio [HR] 0.50; 95% confidence interval [95% CI] 0.34-0.73)., Conclusions: Centralization of pancreatic surgery was successful and has resulted in improved clinical outcomes in the western part of the Netherlands, demonstrating the effectiveness of centralization.

Recently, two articles are published about the effectiveness of a multifactorial fall prevention programme performed by two falls clinics in the Netherlands. Both studies have shown negative results. The question is if those two studies are representative for the real situation in most falls clinics in the Netherlands. Two important differences are the selection of the patients and the completion of the fall prevention program. It is important to select the patients with the highest fall risk (> or = 2 falls/year and/or > or = 4 fall risk factors) and to provide an active and direct management of the identified fall risk factors to improve the effectiveness of falls clinics.

The aim of this single-center retrospective cohort study was to evaluate the effect of a multidisciplinary falls-assessment, consisting of identification and possible modification of risk factors for falls, on the frequency of falls among elderly individuals attending the geriatric outpatient department of the University Medical Center (UMC) Utrecht, the Netherlands. The characteristics of 70 elderly people who visited the outpatient department because of a fall in the period from May 2005 till February 2007 were evaluated. The effectiveness of the falls-assessment was evaluated by telephone interview of those individuals who had attended the falls-assessment. Fifty-three patients (mean age=79.8 years) were interviewed after a mean+/-S.D. of 1.47+/-0.41 years (ranging 0.72-2.34 years) subsequent to the falls-assessment. Falls-assessment led to significantly fewer falls, from 3.78+/-4.66 at the time of the assessment at baseline to 1.10+/-1.86 at the time of the interview (p=0.000041). Fear of falling was also significantly diminished. In conclusion, falls-assessment leads to fewer falls and less fear of falling among elderly individuals.

Unlabelled: The prevalence and incidence of systemic sclerosis (SSc) in The Netherlands is unknown. The same holds true for its leading causes of death: pulmonary fibrosis and pulmonary arterial hypertension (PAH), for which effective treatment options have recently become available., Objective: To establish the prevalence and incidence of SSc and its pulmonary complications., Methods: Detailed information on patients in the POEMAS registry, "Pulmonary Hypertension Screening, a Multidisciplinary Approach in Scleroderma", consisting of 819 patients, was combined with a nationwide questionnaire., Results: By combining the two sources the prevalence of SSc was found to be 8.9 per 100 000 adults. The incidence was 0.77 patients per 100 000 per year. PAH was diagnosed in 9.9% of SSc patients. The prevalence of interstitial lung disease in SSc varied from 19% to 47% depending on the definition used., Conclusion: This study clarifies the epidemiology of SSc in The Netherlands and confirms the frequent occurrence of pulmonary complications, based on 654 cases. This can and will be studied further in the ongoing POEMAS study.

In recent years much attention has been paid to the equal treatment of same-sex couples in the Netherlands. This led to the introduction of registered partnerships in 1998 and culminated in the opening of marriage to same-sex couples on 1 April 2001. But what of the children being raised or growing up in these registered partnerships and marriages? How much attention has been paid to their rights to equal treatment? Since 1998 the Dutch government has taken a number of measures to give more legal protection to same-sex families and their children. However, the regulations introduced for this purpose turn out to be rather incoherent and do not yet guarantee full equality, in particular for the children concerned. This article discusses the problems that may occur in practice and suggests possible solutions in the context of a specific case that recently came before the Dutch courts which concerned a lesbian couple who had met a man willing to donate his sperm, on the condition that he could be involved in the child's life in the background and be known as the child's father. The dispute centred on the question of which two of these three adults were entitled to become the legal parents of the child.