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Purpose: To investigate the agreement between an online nurse-assisted eye-screening tool and reference tests in older adults receiving home healthcare and to collect user experiences. Methods: Older adults (65+) receiving home healthcare were included. Home healthcare nurses assisted in administering the eye-screening tool at participants' homes. Approximately 2 weeks later, a researcher administered reference tests at participants' homes. Experiences from participants and home healthcare nurses were collected. Agreement in outcomes (distance and near visual acuity, with the latter being measured using two different optotypes, and macular problems) between the eye-screening tool and reference clinical testing was compared. A difference of less than ±0.15 logMAR was considered acceptable. Results: A total of 40 participants were included. Here, we describe the results for the right eye; results for the left eye were similar. The mean difference between the eye-screening tool and reference tests for distance visual acuity was 0.02 logMAR. The mean difference between the eye-screening tool and reference tests using two different optotypes for near visual acuity was 0.06 and 0.03 logMAR, respectively. The majority of the individual data points were within the ±0.15 logMAR threshold (75%, 51% and 58%, respectively). The agreement between tests for macular problems was 75%. Participants and home healthcare nurses were generally satisfied with the eye-screening tool, although remarks for further improvements were made. Conclusions: The eye-screening tool is promising for nurse-assisted eye screening in older adults receiving home healthcare, with the mostly satisfactory agreement. After implementing the eye-screening tool in practice, cost-effectiveness needs to be investigated.

PURPOSE: To develop and explore underlying dimensions of the Self-Regulation Assessment (SeRA) and psychometric features of potential components. Further, to identify associations between the SeRA and disability-management self-efficacy, type of diagnosis, and type of rehabilitation.MATERIALS AND METHODS: Based on a previously developed model of self-regulation, expert and patient opinions, and cognitive interviews, a list of 22 items on self-regulation (the SeRA) was constructed. The SeRA was included in a cross-sectional survey among a multi-diagnostic group of 563 former rehabilitation patients. Exploratory analyses were conducted.RESULTS: Respondents had a mean age of 56.5 (SD 12.7) years. The largest diagnostic groups were chronic pain disorder and brain injury. Four components were found within the SeRA, labelled as "insight into own health condition," "insight into own capabilities," "apply self-regulation," and "organization of help." Cronbach's alpha was high (total scale: 0.93, subscales: range 0.85-0.89). Only scores on the first subscale showed a ceiling effect. Subscale three showed the highest correlation with a self-efficacy measure. Small differences in SeRA total scores (range 71.6-78.1) were found between different diagnostic groups.CONCLUSION: The SeRA is a new self-regulation measure with four subscales. Further research is needed to establish the validity and reliability of the SeRA. IMPLICATIONS FOR REHABILITATIONThe Self-Regulation Assessment (SeRA) was developed to provide a comprehensive measurement of self-regulation among rehabilitation populations.The SeRA could potentially be used to identify persons with self-regulation problems at the start of rehabilitation treatment and measure outcomes of rehabilitation for self-regulation.The SeRA could potentially be used to help analyse outcomes of rehabilitation practice as well as evaluate interventions on self-regulation.

Introduction: Conflicting evidence exists concerning whether having sarcopenic obesity has additive mortality risk over having only sarcopenia or obesity. We examined the independent and combined associations of obesity and probable sarcopenia with all-cause mortality. Methods: The pooled analysis included three large, harmonized datasets (Health 2000 Survey; Health, Aging and Body Composition Study; Longitudinal Aging Study Amsterdam) with mortality follow-up data on individuals aged 70 years and over at baseline (n = 4,612). Obesity indicators included body mass index and waist circumference, and probable sarcopenia was defined based on grip strength. The mixed effects Cox model was used for statistical analyses, adjusting for age, sex, marital status, education, race, physical activity, alcohol consumption, smoking, and baseline diseases. Results: Risk of death increased for those having probable sarcopenia only (hazard ratio [HR]: 1.61, 95% confidence interval [CI]: 1.39–1.85) or probable sarcopenia with obesity (HR: 1.36, 95% CI: 1.13–1.64) but not for the obese-only group (HR: 0.92, 95% CI: 0.85–1.01), when compared to non-obese non-sarcopenic individuals. The results were similar regardless of adjustments for covariates or different obesity criteria applied. Conclusion: Probable sarcopenia, whether combined with obesity or not, is associated with increased mortality. Obesity did not increase mortality among older adults. Maintaining muscle strength and identifying older adults at risk of sarcopenia is important for the prevention of premature mortality.

Background Current literature reports a gap between development of effective interventions to promote physical activity and the systematic uptake into real-world settings. Factors relating to implementation and scale-up of physical activity interventions have been examined, however the perspectives of multiple stakeholders from different domains are not well researched. The purpose of this study was to examine the perceived factors related to physical activity intervention implementation and scale-up in different domains from different stakeholders on the island of Ireland. Methods Practitioners, researchers, funders and policy makers in Ireland were invited to take part in a semi-structured interview exploring factors related to the implementation and scale-up of eleven different physical activity interventions. A thematic analysis was conducted to identify factors related to the implementation and scale-up of the included interventions. The data collection and analysis were guided by the Consolidated Framework for Implementation Research. Results Thirty-eight participants took part in the interviews which identified factors related to 1) intervention planning and practical considerations; 2) organisational structures, staffing and resources related to delivery; 3) reflection, evaluation and updating of the intervention; and 4) practical consideration related to scale-up. Furthermore, participants referred to the ongoing commitment, engagement, and support needed throughout the implementation process. Conclusions Future research and practice needs to consider how different factors are experienced at different implementation stages and by the different stakeholder groups involved. The findings highlight multiple inter-related factors that influence the implementation and scale-up of physical activity interventions, but also identifies many strategies that can be utilised to aid future successes.

Background Providing individualized care based on the context and preferences of the patient is important. Knowledge on both prognostic risk stratification and blended eHealth care in musculoskeletal conditions is increasing and seems promising. Stratification can be used to match patients to the most optimal content and intensity of treatment as well as mode of treatment delivery (i.e. face-to-face or blended with eHealth). However, research on the integration of stratified and blended eHealth care with corresponding matched treatment options for patients with neck and/or shoulder complaints is lacking. Methods This study was a mixed methods study comprising the development of matched treatment options, followed by an evaluation of the feasibility of the developed Stratified Blended Physiotherapy approach. In the first phase, three focus groups with physiotherapists and physiotherapy experts were conducted. The second phase investigated the feasibility (i.e. satisfaction, usability and experiences) of the Stratified Blended Physiotherapy approach for both physiotherapists and patients in a multicenter single-arm convergent parallel mixed methods feasibility study. Results In the first phase, matched treatment options were developed for six patient subgroups. Recommendations for content and intensity of physiotherapy were matched to the patient’s risk of persistent disabling pain (using the Keele STarT MSK Tool: low/medium/high risk). In addition, selection of mode of treatment delivery was matched to the patient’s suitability for blended care (using the Dutch Blended Physiotherapy Checklist: yes/no). A paper-based workbook and e-Exercise app modules were developed as two different mode of treatment delivery options, to support physiotherapists. Feasibility was evaluated in the second phase. Physiotherapists and patients were mildly satisfied with the new approach. Usability of the physiotherapist dashboard to set up the e-Exercise app was considered ‘OK’ by physiotherapists. Patients considered the e-Exercise app to be of ‘best imaginable’ usability. The paper-based workbook was not used. Conclusion Results of the focus groups led to the development of matched treatment options. Results of the feasibility study showed experiences with integrating stratified and blended eHealth care and have informed amendments to the Stratified Blended Physiotherapy approach for patients with neck and/or shoulder complaints ready to use within a future cluster randomized trial.

Background Major depression is a highly prevalent disorder causing severe personal distress, and high societal costs. Patients with depression often have comorbid insomnia disorder (ID) leading to even worse personal distress and worse treatment outcomes. Recent results from a non-randomised pilot study with internet-delivered Cognitive Behavioural Therapy (CBTi) for Insomnia (I-Sleep) added to regular depression care were promising regarding feasibility and initial effects on insomnia complaints and depression. However, no randomised controlled trial (RCT) has been performed yet to access the (cost-) effectiveness of I-Sleep for depression. Therefore, this protocol article presents the design of an RCT aimed to assess the (cost-) effectiveness of I-Sleep in addition to usual care for depression compared to usual care alone in depressed patients with a comorbid Insomnia Disorder (ID) treated at outpatient clinics for mood disorders. Methods /design This is a multi-centre RCT with measurements at baseline and at 3, 6, 9, and 12 months of follow-up. Patients with depression and an ID are randomised to either I-Sleep treatment followed by regular depression care or to regular depression care alone. Our aim is to recruit one hundred and seventy-five patients from multiple outpatient clinics for mood disorders. The primary outcome is the change in depressive symptoms over 12 months of follow-up measured with the Patient Health Questionnaire (PHQ-9). Secondary outcomes are recovery from depression (PHQ-9), insomnia severity (Insomnia Severity Index, ISI), daily functioning (Work and Social Adjustment Scale, WSAS), general quality of life (EuroQol 5-level version, EQ-5D-5L), and societal costs (Adapted versions of the iMTA Productivity Cost Questionnaire, iPCQ and iMTA Medical Cost Questionnaire, iMCQ). Discussion We hypothesize that the addition of I-Sleep to usual care will result in a significant improvement in depression treatment outcomes and quality of life as well as a decrease in healthcare and societal costs compared to usual care alone. This study is the first pragmatic RCT evaluating the effectiveness and cost-effectiveness of adding CBTi to usual care for depression. Trial registration Netherlands Trial Register (NL8955). Registered on October 6th2020. https://trialsearch.who.int/Trial2.aspx?TrialID=NL8955

Background The consequences of restrictive measures during the COVID-19 outbreak have potentially been enormous, especially for those in a vulnerable position in the labour market. This study aims to describe the impact of the COVID-19 crisis on work status, working conditions and health among people with (partial) work disabilities—with and in search of work—during the COVID-19 pandemic in the Netherlands. Methods A mixed methods design was used, combining a cross-sectional online survey and ten semi-structured interviews with people with a (partial) work disability. The quantitative data included responses to job-related questions, self-reported health, and demographics. The qualitative data consisted of participants’ perceptions about work, vocational rehabilitation, and health. We used descriptive statistics to summarize the responses, conducted logistic and linear regression and integrated our qualitative findings with the quantitative findings, aiming at complementarity. Results Five hundred and eighty-four participants (response rate 30.2%) completed the online survey. The majority of participants experienced no change in work status: 39 percent remained employed, 45 percent remained unemployed, six percent of respondents lost their job, and ten percent became employed during the COVID-19 crisis. In general, the results showed a deterioration in self-rated health during the COVID-19 outbreak, both for participants at work and in search of work. Participants who lost their job during the COVID-19 crisis reported the highest deterioration in self-rated health. Interview findings revealed that loneliness and social isolation were persistent during the COVID-19 crisis, especially among those in search of work. Additionally, employed participants identified a safe work environment and the possibility to work at the office as important factors for overall health. Conclusions The vast majority of study participants (84.2%) experienced no change in work status during the COVID-19 crisis. Nonetheless, people at work and in search of work encountered barriers to maintaining or (re)gaining employment. People with a (partial) work disability who lost their job during the crisis appeared to be most affected in terms of health. Employment and health protections could be strengthened for persons with (partial) work disabilities in order to build resilience in times of crisis.

The original version of this Article omitted from the author list the 212th author Patrizia Mecocci, who is from the Institute of Gerontology and Geriatrics, Department of Medicine, University of Perugia, Perugia, Italy. Consequently, the “Sample Contribution” section of Author Contributions was updated to add “P.M” between “P.D.” and “R.C.”. Additionally, the original version of this Article contained the incorrect affiliation for author Patrick Gavin Kehoe, which incorrectly read “German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany”. The correct version replaces this affiliation with “Bristol Medical School (THS), University of Bristol, Southmead Hospital, Bristol, UK”. This has been corrected in both the PDF and HTML versions of the Article.

This study set out to evaluate the association between job demands at baseline and physical performance over a six-year period across three cohorts of older Dutch workers examined 10 years apart. Data were drawn from three cohorts (1992–1999, 2002–2009 and 2012–2019) of the Longitudinal Aging Study Amsterdam. Individuals aged 55–65 years from each cohort who worked for pay were included (n = 274, n = 416, n = 618, respectively). Physical performance was measured using gait speed and chair stand performance. A population-based job exposure matrix was used to indicate levels of exposure probability of physical (use of force and repetitive movements) and psychosocial (cognitive demands and time pressure) job demands. We found that psychosocial job demands increased and physical demands decreased across the three cohorts. No between cohort differences were found for how job demands affected changes in physical performance over follow-up. For men, faster decline in gait speed was observed when comparing higher and lower use of force at baseline (β −0.012, 95% CI −0.021, −0.004). Greater use of force and repetitive movements were associated with faster decline in chair stand performance (β −0.012, 95% CI −0.020, −0.004 and β −0.009, 95% CI −0.017, −0.001, respectively). In women, no association of job demands on change in physical performance was observed. The study concluded that higher physical job demands were associated with stronger decline in physical performance across six years for men in all cohorts, while no associations were found among women. peerReviewed

Objective: To evaluate differences regarding the number of treatment sessions, costs, and outcomes (including relapses) between a regular payment-per-session system and the recently introduced product payment system in The Netherlands. Design: Prospective cohort study. Setting: Dutch physical therapy practices in primary care over a 2-year period. Participants: 16,103 patients with low back pain (LBP). Intervention: The new product payment system is compared with the regular payment-per-session system. Main Outcome Measures: Pain, disability, recovery, number of physical therapy sessions, therapy duration, costs (per episode), and LBP relapse. Results: At baseline, we found greater pain and disability scores associated with an increased risk profile in both payment systems. With regard to the payment systems, we found greater costs (€283.8 vs €210.8) and a greater percentage of relapse (4.5% vs 2.8%) for the product payment system compared with the payment-per-session system. Comparing the 2 payment systems within each risk strata, we found no significant differences, except for a decrease in pain in the medium-risk stratum. Concerning the therapy characteristics, we found that in the payment-per-session group, the therapy took 6 days longer for low-risk patients (median 27 vs 21 days) and 7 days shorter for high-risk patients (median 42 vs 49 days) compared with the product payment group. Moreover, the mean number of sessions in the payment-per-session group was greater for low-risk patients (5.4 vs 4.8 sessions) and lower for high-risk patients (7.7 vs 8.1 sessions) compared with the payment-per-session group. Finally, the costs were significantly greater in all strata of the product payment group compared with the payment-per-session group. Conclusions: The 2 payment systems are largely comparable regarding patient outcomes, therapy duration, and treatment sessions. Both the average cost per patient per LBP episode and the number of relapses in the product payment system are statistically significantly greater than in the payment-per-session system.

Background Reducing health inequalities is a challenge for policymakers and civil society. A multisectoral and multilevel approach is most promising to reduce those inequalities. Previous research showed what key elements of Zwolle Healthy City, an integrated community-based approach aimed at reducing socioeconomic health inequalities, are. To fully understand approaches that are complex and context dependent, questions as ‘how does the intervention work’ and ‘in what context does it work’ are just as important as ‘what works’. The current study aimed to identify mechanisms and contextual factors associated with the key elements of Zwolle Healthy City, using a realist evaluation perspective. Methods Transcripts of semi-structured interviews with a wide range of local professionals were used (n = 29). Following realist evaluation logic in the analysis of this primary data, context-mechanism-outcome configurations were identified and thereafter discussed with experts (n = 5). Results How mechanisms (M) in certain contexts (C) were of influence on the key elements (O) of the Zwolle Healthy City approach are described. For example, how, in the context of the responsible aldermen embracing the approach (C), regular meetings with the aldermen (M) increased support for the approach among involved professionals (O). Or, how, in the context of available financial resources (C), assigning a program manager (M) contributed positively to coordination and communication (O). All 36 context-mechanism-outcome configurations can be found in the repository. Conclusion This study showed what mechanisms and contextual factors are associated with the key elements of Zwolle Healthy City. By applying realist evaluation logic in the analysis of primary qualitative data we were able to disentangle the complexity of processes of this whole system approach and show this complexity in a structured manner. Also, by describing the context in which the Zwolle Healthy City approach is implemented, we contribute to the transferability of this approach across different contexts.

Background Malnutrition (i.e., protein-energy malnutrition) in older adults has severe negative clinical consequences, emphasizing the need for effective treatments. Many, often small, randomized controlled trials (RCTs) testing the effectiveness of nutritional interventions for the treatment of malnutrition showed mixed results and a need for meta-analyses and data pooling has been expressed. However, evidence synthesis is hampered by the wide variety of outcomes and their method of assessment in previous RCTs. This paper describes the protocol for developing a Core Outcome Set (COS) for nutritional intervention studies in older adults with malnutrition and those at risk. Methods The project consists of five phases. The first phase consists of a scoping review to identify frequently used outcomes in published RCTs and select additional patient-reported outcomes. The second phase includes a modified Delphi Survey involving experienced researchers and health care professionals working in the field of malnutrition in older adults, followed by the third phase consisting of a consensus meeting to discuss and agree what critical outcomes need to be included in the COS. The fourth phase will determine how each COS outcome should be measured based on a systematic literature review and a second consensus meeting. This will be followed by a dissemination and implementation phase. Patient and Public Involvement (PPI) representatives will contribute to study design, oversight, consensus, and dissemination. Conclusions The result of this project is a COS that should be included in any RCT evaluating the effect of nutritional interventions in older adults with malnutrition and those at risk. This COS will facilitate comparison of RCT results, will increase efficient use of research resources and will reduce bias due to measurement of the outcome and publication bias. Ultimately, the COS will support clinical decision making by identifying the most effective approaches for treating and preventing malnutrition in older adults.

This paper investigated facilitators and barriers to implementing the European Football Fans in Training program (EuroFIT) in professional sports clubs in England, the Netherlands, Norway, and Portugal. We analyzed qualitative data collected at clubs that delivered EuroFIT, based on semi-structured interviews with coordinating staff (n = 15), coaches (n = 16), and focus group interviews with participants (n = 108), as well as data from clubs that considered delivering EuroFIT in the future, based on interviews with staff (n = 7) and stakeholders (n = 8). Facilitators for implementation related to the content and structure of the program, its evidence-base, and the context for delivery in the football stadia. Financial and human resources were both facilitators and barriers. Further barriers were mostly practical, relating to human resources and infrastructure. Major differences between countries related to experience and commitment to running community projects, and differences in infrastructure, financing, and human resources. Professional football clubs’ ability to support health promotion efforts depended on their ethos and the financial and human resources available to them. Overall, the EuroFIT program was well received by clubs, coaches, participants, and stakeholders, which was reflected by the many facilitators supporting sustained implementation. For sustainable implementation, it is crucial that clubs and their stakeholders engage fully with the EuroFIT program and understand that for an adequate program delivery their views (ethos) and ways of working influence the implementation and thereby the effectiveness of EuroFIT. An important prerequisite for future roll out of EuroFIT would be a strong EuroFIT delivery partner organization to ensure financial and human resources while overseeing and guiding the quality of delivery in clubs. Factors influencing the implementation of the EuroFIT lifestyle change program in professional football clubs in Europe: a qualitative study in four European countries

Background: Insomnia is the transdiagnostically shared most common complaint in disorders of anxiety, stress and emotion regulation. Current cognitive behavioral therapies (CBT) for these disorders do not address sleep, while good sleep is essential for regulating emotions and learning new cognitions and behaviours: the core fundaments of CBT. This transdiagnostic randomized control trial (RCT) evaluates whether guided internet-delivered cognitive behavioral therapy for insomnia (iCBT-I) (1) improves sleep, (2) affects the progression of emotional distress and (3) enhances the effectiveness of regular treatment of people with clinically relevant symptoms of emotional disorders across all mental health care (MHC) echelons. Methods: We aim for 576 completers with clinically relevant symptoms of insomnia as well as at least one of the dimensions of generalized anxiety disorder (GAD), social anxiety disorder (SAD), panic disorder (PD), posttraumatic stress disorder (PTSD) or borderline personality disorder (BPD). Participants are either pre-clinical, unattended, or referred to general- or specialized MHC. Using covariate-adaptive randomization, participants will be assigned to a 5 to 8-week iCBT-I (i-Sleep) or a control condition (sleep diary only) and assessed at baseline, and after two and eight months. The primary outcome is insomnia severity. Secondary outcomes address sleep, severity of mental health symptoms, daytime functioning, mental health protective lifestyles, well-being, and process evaluation measures. Analyses use linear mixed-effect regression models. Discussion: This study can reveal for whom, and at which stage of disease progression, better nights could mean substantially better days. Trial registration: International Clinical Trial Registry Platform (NL9776). Registered on 2021-10-07.

Telemonitoring disease activity with electronic patient-reported outcomes (ePROs) may reduce the workload of rheumatic care by decreasing outpatient clinic visits. However, low adherence to reporting ePROs is frequently observed. Our objective was to identify facilitators and barriers to weekly monitoring of disease activity with ePROs. Patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), or ankylosing spondylitis (AS) who recently participated in one of the two telemonitoring studies with ePROs completed in a smartphone app, were invited to participate in focus group discussions (FGD). Thematic analysis was used to identify themes that play a role in the decision to continue or stop reporting weekly ePROs. A total of 22 patients participated in three FGDs. Five themes were identified that were of importance to adhere to telemonitoring: (1) questionnaire frequency, (2) discussing results of completed ePROs, (3) physical consultations, (4) patient insight into disease activity and (5) user experience of the app. All themes contained both barrier and facilitator elements. The results suggest that to improve adherence to telemonitoring of disease activity with ePROs, the perceived benefits of completing ePROs should be maximized. This can be done by providing patients the ability to skip (unneeded) physical consultations in case of low disease activity, and training clinicians to always discuss the completed ePROs. In addition, it is essential to reduce the effort to report ePROs, by tailoring the frequency of ePROs based on the patients’ disease activity or preference, aiming for optimal app functionality as well as by sending notifications when new ePROs are available.

OBJECTIVES: The aim of this study was to evaluate employee return-to-work (RTW) rates and examine predictors of absence duration after COVID-19. RTW rates were referenced against RTW rates after absence due to flu-like symptoms and assessed over the course of the pandemic. METHODS: Routinely collected data from a nationally operating Dutch occupational health service was used. The data were retrieved from employees who reported sick due to COVID-19 (N=30 396) or flu-like symptoms (N=15 862). Data consisted of responses to a triage survey combined with longitudinal register-based information on sickness absence. RTW rates after COVID-19 were evaluated through Kaplan-Meier estimates and compared to RTW rates for flu-like symptoms, and between three periods with different dominant virus variants. Predictors for absence duration were examined through Cox proportional hazards models. RESULTS: RTW after COVID-19 was found to be notably later than after flu-like symptoms (median RTW=10 versus 6 days, respectively). On average, 5.5% of employees who contracted COVID-19 were absent for over 12 weeks. Time-to-RTW shortened as different virus variants became dominant over time. The main predictors contributing to later RTW were older age, female sex, belonging to a risk group, and the symptoms shortness of breath and fatigue. CONCLUSIONS: Estimates of the RTW rate after COVID-19 and identification of predictors may aid healthcare professionals in gaining insight into variations in the disease course and rehabilitation process. The present findings can help employers and policy-makers grasp the impact of COVID-19 on the workplace.

Purpose Cognitive symptoms affect cancer survivors’ functioning at work. To date, cognitive symptoms trajectories in working cancer survivors and the factors associated with these trajectories have not been examined. Methods Data from a heterogeneous group of working cancer survivors (n = 379) of the longitudinal “Work-Life-after-Cancer” study, linked with Netherlands Cancer Registry data, were used. The Cognitive Symptom Checklist-Work was administered at baseline (within the first 3 months after return to work), 6-, 12-, and 18-month follow-up to measure self-perceived memory and executive function symptoms. Data were analyzed using group-based trajectory modeling. Results Four trajectories of memory and executive function symptoms were identified. All memory symptoms trajectories were stable and labeled as “stable-high” (15.3% of the sample), “stable-moderately high” (39.6%), “stable-moderately low” (32.0%), and “stable-low” (13.0%). Executive function symptoms trajectories changed over time and were labeled as “increasing-high” (10.1%), “stable-moderately high” (32.0%), “decreasing-moderately low” (35.5%), and “stable-low” (22.4%). Higher symptoms trajectories were associated with older age, longer time from diagnosis to return to work, more quantitative work demands, and higher levels of depressive symptoms at baseline. Conclusions In cancer survivors who returned to work, four cognitive symptoms trajectory subgroups were identified, representing different but relatively stable severity levels of cognitive symptoms. Implications for Cancer Survivors To identify cancer survivors with higher symptoms trajectories, health care providers should assess cognitive symptoms at baseline after return to work. In case of cognitive symptoms, it is important to also screen for psychological factors to provide appropriate guidance.

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Background: Low back pain (LBP) is the leading cause of disability worldwide and has an excessive societal burden. Accumulating evidence has shown that some medical approaches such as imaging in absence of clear indications, medication and some invasive treatments may contribute to the problem rather than alleviating it. Objectives: To determine the extent of de-implementation of non-evidence-based hospital treatments for LBP care in the Netherlands in the last three decades. Methods: Using a register-based population-level observational study with Dutch hospital data, providing a nearly complete coverage of hospital admissions in the Netherlands in 1991–2018, we assessed five frequently applied non-evidence-based hospital treatments for LBP. Time trends in treatment use (absolute and per 100,000 inhabitants) were plotted and analysed using Poisson regression. Results: The use of bed rest for non-specific LBP and hernia nuclei pulposi, and discectomy for spinal stenosis decreased 91%, 81% and 86% since the availability of evidence/guidelines, respectively. De-implementation, beyond 84%, was reached after 18 and 17 years for bed rest for non-specific LBP and discectomy respectively, while it was not reached after 28 years for bed rest for hernia nuclei pulposi. For spinal fusion and invasive pain treatment, there was an initial increase followed by a reduction. Overall, these treatments reduced by 85% and 75%, respectively. Conclusions: In the Netherlands, de-implementation of five non-recommended hospital LBP treatments, if at all, took several decades. Although de-implementation was substantial, slow de-implementation has likely resulted in considerable waste of resources and avoidable harm to many patients in Dutch hospitals. Significance: Medically intensive approaches to low-back pain care contribute to the high societal burden of this disease. There have been calls to avoid such care. Using Dutch hospital data, we showed that de-implementation of five non-recommended hospital low-back pain treatments, if at all, took several decades (i.e. ≥17 years) after availability of evidence and guidelines. Slow de-implementation has likely resulted in considerable waste of resources and avoidable harm to hospital patients; better ways for de-implementation of non-evidence-based care are needed.

Background: We aimed to evaluate the validity and reliability of the Persian version of the WOrk-Related Questionnaire for UPper extremity disorders (WORQ-UP) questionnaire in a working population with upper extremity musculoskeletal disorders. Methods: We enrolled 181 patients with upper extremity conditions to complete the Persian WORQ-UP. A total of 35 patients returned after 1 week to complete the questionnaire again. To test the construct validity, patients responded to the Persian Quick Disabilities of the Arm, Shoulder and Hand questionnaire (Quick-DASH) at the first visit. The correlation between Quick-DASH and the WORQ-UP was assessed using Spearman correlation coefficient. Internal consistency (IC) was tested using Cronbach’s alpha, and test–retest reliability was measured using the intraclass correlation coefficient (ICC). Results: Spearman correlation coefficient was 0.630 (p < 0.001), indicating a strong correlation between Quick-DASH and WORQ-UP. Cronbach’s alpha was 0.970, which is considered excellent. ICC for the total score of the Persian WORQ-UP was 0.852 (0.691–0.927), indicating good to excellent reliability. Conclusions: Our study demonstrated that the Persian version of the WORQ-UP questionnaire has excellent reliability and IC. Construct validity showed a moderate to strong correlation between WORQ-UP and Quick-DASH, which provides a platform for the workers’ population to assess the extent of disability and follow the progress along the treatment course. Level of Evidence: Level IV (Diagnostic)

Contains fulltext : 290880.pdf (Publisher’s version ) (Open Access) Objective: Workers with a lower socioeconomic position (SEP) often face problems on multiple life domains. This study evaluated an intervention to identify and solve problems on multiple life domains, called 'Grip on Health'. Methods: A mixed methods process evaluation was performed among occupational health professionals (OHPs) and lower SEP workers with problems on multiple life domains. Results: Thirteen OHPs delivered the intervention to 27 workers. For seven workers the supervisor was involved, and for two, stakeholders from outside the workplace. Agreements between OHPs with employers often affected implementation. OHPs were essential to help workers identify and solve problems. The intervention increased workers’ health awareness and self-control, and led to small and practical solutions. Conclusions: Grip on Health can support lower SEP workers with solving problems on multiple life domains. However, contextual factors make implementation difficult. 9 p.

INTRODUCTION: Measurement instruments are important in clinical practice and research for assessing physical function in critically ill patients in the intensive care unit (ICU).OBJECTIVE: To investigate inter-rater reliability and responsiveness of the Danish version of the CPAx (CPAx-D).METHOD: Critically ill patients from three Danish ICUs were included. Patients were assessed with CPAx-D by two blinded testers during a regular physiotherapy session. Follow-up tests were performed in patients who stayed in the ICU for more than 24 hours, were not transferred to another hospital or received palliative care. Floor and ceiling effects were examined in all assessments.Results For the reliability analysis 66 patients were included.Results Showed no significant difference between raters. For the total score, intra class correlation coefficient (ICC) was 0.996 (95% CI: 0.993; 0.997), standard error of measurement was 0.72 point and minimal detectable change 2.0 points. Bland-Altman plot revealed no heteroscedacity. The responsiveness results of 24 patients showed that the effect size was 1.2 and the standardized response mean 1.1, which was in accordance with the hypothesis. No ceiling or floor effect was revealed.CONCLUSION: The CPAx-D showed excellent inter-rater reliability and responsiveness.

Participatory action research (PAR) is a form of community-driven qualitative research which aims to collaboratively take action to improve participants’ lives. This is generally achieved through cognitive, reflexive learning cycles, whereby people ultimately enhance their wellbeing. This approach builds on two assumptions: (1) participants are able to reflect on and prioritize difficulties they face; (2) collective impetus and action are progressively achieved, ultimately leading to increased wellbeing. This article complicates these assumptions by analyzing a two-year PAR project with mothers of disabled children from a South African urban settlement. Participant observation notes, interviews, and a group discussion served as primary data. We found that mothers’ severe psychological stress and the strong intersectionality of their daily challenges hampered participation. Consequently, mothers considered the project ‘inactionable’. Yet, many women quickly started expressing important individual and collective wellbeing transformations. To understand these ‘unlikely’ transformations, a feminist relational account, in particular, that of relational wellbeing, proves essential. We reflect on the consequences of these findings for the dominant PAR methodology and operationalization, and propose to sensitize future PAR with marginalized women by employing relational wellbeing as an overarching ontological awareness.

ObjectivesIn patients with an ovarian mass, a risk of malignancy assessment is used to decide whether referral to an oncology hospital is indicated. Risk assessment strategies do not perform optimally, resulting in either referral of patients with a benign mass or patients with a malignant mass not being referred. This process may affect the psychological well-being of patients. We evaluated cancer-specific distress during work-up for an ovarian mass, and patients’ perceptions during work-up, referral, and treatment.MethodsPatients with an ovarian mass scheduled for surgery were enrolled. Using questionnaires we measured (1) cancer-specific distress using the cancer worry scale, (2) patients’ preferences regarding referral (evaluated pre-operatively), and (3) patients’ experiences with work-up and treatment (evaluated post-operatively). A cancer worry scale score of ≥14 was considered as clinically significant cancer-specific distress.ResultsA total of 417 patients were included, of whom 220 (53%) were treated at a general hospital and 197 (47%) at an oncology hospital. Overall, 57% had a cancer worry scale score of ≥14 and this was higher in referred patients (69%) than in patients treated at a general hospital (43%). 53% of the patients stated that the cancer risk should not be higher than 25% to undergo surgery at a general hospital. 96% of all patients were satisfied with the overall work-up and treatment. No difference in satisfaction was observed between patients correctly (not) referred and patients incorrectly (not) referred.ConclusionsRelatively many patients with an ovarian mass experienced high cancer-specific distress during work-up. Nevertheless, patients were satisfied with the treatment, regardless of the final diagnosis and the location of treatment. Moreover, patients preferred to be referred even if there was only a relatively low probability of having ovarian cancer. Patients’ preferences should be taken into account when deciding on optimal cut-offs for risk assessment strategies.

Purpose: Optimizing return to work after knee arthroplasty is becoming more important because of the growing incidence of KA among workers and poor return to work outcomes. The purpose of this study is to investigate the feasibility of Back At work After Surgery (BAAS): an integrated clinical pathway for return to work after knee arthroplasty. Method: Working patients who received unicompartmental knee arthroplasty (UKA) or total knee arthroplasty (TKA) between January 2021 and November 2021, younger than 65 years and motivated to return to work were eligible to participate. Feasibility was investigated on five domains: reach, dose delivered, dose received, fidelity and patients’ attitudes. These outcomes were obtained by a patient-reported questionnaire and an interview with the occupational case manager and medical case manager.Results: Of the eligible 29 patients, eleven were willing to participate (response rate 38%; due to travel distance to and from the hospital). The dose delivered was between 91 and 100%, except information given about return to work from the orthopedic surgeon which was 18%. The dose received was 100%. For fidelity, case managers reported nine shortcomings for which five solutions were mentioned. In terms of patients’ attitude, all patients were satisfied and one patient mentioned an improvement. Conclusions: In terms of reach, participation was low: only 29%. The BAAS clinical pathway seems feasible based on dose delivered, dose received, fidelity and patient attitudes. The next step is to assess the effectiveness of the BAAS clinical pathway for return to work.

Systematic reviews are necessary to synthesize available evidence and inform clinical practice and health policy decisions. There has been an explosion of evidence available in many fields; this makes it challenging to keep evidence syntheses up to date and useful. Comparative effectiveness systematic reviews are informative; however, producing these often-large reviews bring intense time and resource demands. This commentary describes the implementation of a systematic review using a collaborative model of evidence synthesis. We are implementing the collaborative review model to update a large Cochrane review investigating the efficacy and comparative effectiveness of the design, delivery, and type of exercise treatment for people with chronic low-back pain. Three key benefits of the collaborative review model for evidence synthesis are (1) team coordination and collaboration, (2) quality control measures, and (3) advanced comparative and other analyses. This new collaborative review model is developed and implemented to produce and share high-quality, comparative evidence more efficiently while building capacity and community within a research field.

Objective: In patients with rheumatoid arthritis (RA) with cardiovascular disease risk, it is unknown whether exercises are safe, improve cardiorespiratory fitness and reduce disease-related symptoms and cardiovascular-disease (CVD) risk factors. We aimed to investigate in RA patients with CVD risk: (1) safety of medium to high-intensity aerobic exercises, (2) potential changes of cardiorespiratory fitness and (3) disease activity and CVD risk factors in response to the exercises. Methods: Single-arm pilot-exercise intervention study including 26 consecutive patients (21 women) with > 4% 10-year risk of CVD mortality according to the Dutch Systematic Coronary Risk Evaluation. Aerobic exercises consisted of two supervised-sessions and five home-sessions per week for 12 weeks. Patients were required to exercise at intensities between 65 and 85% of their maximum heart rate. To assess safety, we recorded exercise related adverse events. Before and after the exercises, cardiorespiratory fitness was assessed with a graded maximal oxygen-uptake exercise test, while disease activity was evaluated via the Disease Activity Score-28 (DAS28) using the erythrocyte segmentation rate (ESR). Resting blood pressure, ESR and total cholesterol were assessed as CVD risk factors. Results: Twenty out of 26 patients performed the 12-week exercises without any adverse events. According to patients, withdrawals were unrelated to the exercises. Exercises increased cardiorespiratory fitness (pre: 15.91 vs. post: 18.15 ml.kg−1 min−1, p = 0.003) and decreased DAS28 (pre: 2.86 vs. post: 2.47, p = 0.04). No changes were detected in CVD risk factors. Conclusion: A 12-week exercise intervention seems to be safe and improves cardiorespiratory fitness and disease activity in patients with RA with a high risk for cardiovascular diseases.Key Points1. Rheumatoid arthritis patients with high cardiovascular disease risk were able to perform a maximum exercise test and a 12-week aerobic-based medium-to-high intensity exercise intervention.2. The exercise intervention improved cardiorespiratory fitness and disease activity in rheumatoid arthritis patients with high cardiovascular disease risk.3. Cardiorespiratory fitness levels were still low post-exercise intervention (i.e. 18.15 ml.kg−1min−1 compared to the 20.9 ml.kg−1min−1 baseline mean of the RA patients without CVD risk).

Purpose: To address the feasibility, reliability and internal validity of natural language processing (NLP) for automated functional assessment of hospitalised COVID-19 patients in key International Classification of Functioning, Disability and Health (ICF) categories and levels from unstructured text in electronic health records (EHR) from a large teaching hospital. Materials and methods: Eight human annotators assigned four ICF categories to relevant sentences: Emotional functions, Exercise tolerance, Walking and Moving, Work and Employment and their ICF levels (Functional Ambulation Categories for Walking and Moving, metabolic equivalents for Exercise tolerance). A linguistic neural network-based model was trained on 80% of the annotated sentences; inter-annotator agreement (IAA, Cohen’s kappa), a weighted score of precision and recall (F1) and RMSE for level detection were assessed for the remaining 20%. Results: In total 4112 sentences of non-COVID-19 and 1061 of COVID-19 patients were annotated. Average IAA was 0.81; F1 scores were 0.7 for Walking and Moving and Emotional functions; RMSE for Walking and Moving (5- level scale) was 1.17 for COVID-19 patients. Conclusion: Using a limited amount of annotated EHR sentences, a proof-of-concept was obtained for automated functional assessment of COVID-19 patients in ICF categories and levels. This allows for instantaneous assessment of the functional consequences of new diseases like COVID-19 for large numbers of patients.Key messages Hospitalised Covid-19 survivors may persistently suffer from low physical and mental functioning and a reduction in overall quality of life requiring appropriate and personalised rehabilitation strategies. For this, assessment of functioning within multiple domains and categories of the International Classification of Function is required, which is cumbersome using structured data. We show a proof-of-concept using Natural Language Processing techniques to automatically derive the aforementioned information from free-text notes within the Electronic Health Record of a large academic teaching hospital.

Background Chiropractors commonly provide care to people with low-back pain (LBP). The aim of this survey was to determine the opinions and beliefs of chiropractors regarding the support and management of LBP. We also investigated whether their management is in accordance with the three most commonly recommended approaches to LBP based upon international guidelines (i.e. advice regarding return-to-work, limit bedrest, and stay active). Methods A web-based survey was sent out in 2013 to collect data from registered Dutch and Belgian chiropractors. In addition to providing a description of their sociodemographic and practice characteristics, chiropractors were asked to complete six patient vignettes representing people with LBP who typically present to a chiropractor. The respondents indicated which intervention(s) they would recommend or undertake. Based upon these vignettes, we were able to determine whether their management approach adhered to clinical guidelines. Generalized mixed models were used to explore guidelines adherence and their relationship to chiropractors’ characteristics. Results In total, 60% (n = 203/340) of the chiropractors who were invited, chose to participate. Chiropractors reported applying a chiropractic adjustment in 90% of all vignettes, while the advice to exercise varied from one-third in the chronic cases to approximately half of those with acute LBP. More than 75% of the chiropractors would initially treat LBP 1–2 times a week. More than 90% of the chiropractors advised against bedrest. Overall, self-reported adherence to clinical guidelines for all six vignettes was [64.5% (CI 58.7–70.0)]. Adherence in the chronic vignettes [73.4% (CI 66.7–79.2)] was better than in the acute vignettes [55.9% (CI 50.5–61.1)]. Importantly, regarding recommended approaches to LBP, chiropractors more consistently followed guidelines regarding advice to limit bedrest [98.5% (CI 97.3–99.1)] than advice to stay active [77.5% (CI 72.3–81.9)] or return-to-work [59.4% (CI 55.2–63.4)]. Finally, Dutch chiropractors were more likely to adhere to the guidelines than Belgian chiropractors. Conclusions Chiropractic adjustments were the most common self-reported treatment modalities supplemented by exercise in the management of LBP patients. Two-thirds of the chiropractors reported adhering to the guidelines regarding management and advice for LBP patients. Practitioners should improve guideline adherence, particularly for acute LBP cases, and when advising on return-to-work.

Purpose: Being able to work improves the quality of life of patients with cancer. Much is known about the return to work process of cancer survivors. Yet, studies focusing on the experiences of patients with advanced cancer who want to return to work or stay employed are scarce. Therefore, we aimed to explore the perceptions of patients with advanced cancer regarding work resumption and work retention and the barriers and facilitators they may experience. Methods: Semi-structured interviews were conducted. Patients were included if they: (1) were diagnosed with advanced cancer, (2) worked in paid employment at time of diagnosis, and (3) were currently back in paid employment or had the intention to return to paid employment. Participants were recruited through clinicians and patient organizations. Interviews were transcribed and thematically analysed using ATLAS.ti. Results: Fifteen patients (87% female, mean age 52 (SD 4; range 41–64)) were individually interviewed. Four main themes emerged from the data: (1) holding on to normalcy, (2) high understanding and divergent expectations, (3) social discomfort calls for patient-initiated alignment, and (4) laws and regulations require patient empowerment. Conclusion: Paid employment can contribute to the quality of life of patients with advanced cancer. The findings of this study might correct erroneous preconceptions about the work ability and work intention of patients with advanced cancer. Tools already developed for employers to support reintegration of patients with cancer should be further explored and translated to patients with advanced cancer.

BackgroundDietary interventions did not prevent depression onset nor reduced depressive symptoms in a large multi-center randomized controlled depression prevention study (MooDFOOD) involving overweight adults with subsyndromal depressive symptoms. We conducted follow-up analyses to investigate whether dietary interventions differ in their effects on depressive symptom profiles (mood/cognition; somatic; atypical, energy-related).MethodsBaseline, 3-, 6-, and 12-month follow-up data from MooDFOOD were used (n = 933). Participants received (1) placebo supplements, (2) food-related behavioral activation (F-BA) therapy with placebo supplements, (3) multi-nutrient supplements (omega-3 fatty acids and a multi-vitamin), or (4) F-BA therapy with multi-nutrient supplements. Depressive symptom profiles were based on the Inventory of Depressive Symptomatology.ResultsF-BA therapy was significantly associated with decreased severity of the somatic (B = −0.03, p = 0.014, d = −0.10) and energy-related (B = −0.08, p = 0.001, d = −0.13), but not with the mood/cognition symptom profile, whereas multi-nutrient supplementation was significantly associated with increased severity of the mood/cognition (B = 0.05, p = 0.022, d = 0.09) and the energy-related (B = 0.07, p = 0.002, d = 0.12) but not with the somatic symptom profile.ConclusionsDifferentiating depressive symptom profiles indicated that food-related behavioral interventions are most beneficial to alleviate somatic symptoms and symptoms of the atypical, energy-related profile linked to an immuno-metabolic form of depression, although effect sizes were small. Multi-nutrient supplements are not indicated to reduce depressive symptom profiles. These findings show that attention to clinical heterogeneity in depression is of importance when studying dietary interventions.

OBJECTIVE: We developed a smartphone application for patients with rheumatoid arthritis (RA) that allows them to self-monitor their disease activity in between clinic visits by answering a weekly Routine Assessment of Patient Index Data 3. This study was undertaken to assess the safety (noninferiority in the Disease Activity Score in 28 joints using the erythrocyte sedimentation rate [DAS28-ESR]) and efficacy (reduction in number of visits) of patient-initiated care assisted using a smartphone app, compared to usual care.METHODS: A 12-month, randomized, noninferiority clinical trial was conducted in RA patients with low disease activity and without treatment changes in the past 6 months. Patients were randomized 1:1 to either app-supported patient-initiated care with a scheduled follow-up consultation after a year (app intervention group) or usual care. The coprimary outcome measures were noninferiority in terms of change in DAS28-ESR score after 12 months and the ratio of the mean number of consultations with rheumatologists between the groups. The noninferiority limit was 0.5 difference in DAS28-ESR between the groups.RESULTS: Of the 103 randomized patients, 102 completed the study. After a year, noninferiority in terms of the DAS28-ESR score was established, as the 95% confidence interval (95% CI) of the mean ΔDAS28-ESR between the groups was within the noninferiority limit: -0.04 in favor of the app intervention group (95% CI -0.39, 0.30). The number of rheumatologist consultations was significantly lower in the app intervention group compared to the usual care group (mean ± SD 1.7 ± 1.8 versus 2.8 ± 1.4; visit ratio 0.62 [95% CI 0.47, 0.81]).CONCLUSION: Patient-initiated care supported by smartphone self-monitoring was noninferior to usual care in terms of the ΔDAS28-ESR and led to a 38% reduction in rheumatologist consultations in RA patients with stable low disease activity.

STUDY OBJECTIVE: To compare the prognostic accuracy of clinical judgment for frailty in older patients at the emergency department with a validated screening instrument and patient-perceived frailty.METHODS: A prospective cohort study in patients 70 years of age and older in 2 Dutch EDs with a follow-up of 3 months. A dichotomous question was asked to the physician and patient: "Do you consider the patient / yourself to be frail?" The Identification of Seniors At Risk-Hospitalized Patients (ISAR-HP) was used as a validated screening instrument. The primary composite outcome consisted of either functional decline, institutionalization, or mortality.RESULTS: A total of 736 patients were included. The physician identified 59% as frail, compared with 49% by ISAR-HP and 43% by patients themselves. The level of agreement was fair (Fleiss Kappa, 0.31). After 3 months, 31% of the patients experienced at least 1 adverse health outcome. The sensitivity was 79% for the physician, 72% for ISAR-HP, 61% for the patient, and 48% for all 3 combined. The specificity was 50% for the physician, 63% for ISAR-HP, 66% for the patient, and 85% for all 3 positive. The highest positive likelihood ratio was 3.03 (physician, ISAR-HP, patient combined), and the lowest negative likelihood ratio was 0.42 (physician). The areas under the receiver operating curves were all poor: 0.68 at best for ISAR-HP.CONCLUSION: Clinical judgment for frailty showed fair agreement with a validated screening instrument and patient-perceived frailty. All 3 instruments have poor prognostic accuracy, which does not improve when combined. These findings illustrate the limited prognostic value of clinical judgment as a frailty screener in older patients at the ED.

Purpose Perceived discomfort could indicate an early sign of pain, for example, as a result of a biomechanical load on the musculoskeletal system. Assessing discomfort can, therefore, help to identify workers at increased risk of musculoskeletal disorders for targeted intervention development. We aimed: (1) to identify the optimal cut-off value of neck and low back discomfort among office workers and (2) to evaluate its predictive validity with future neck and low back pain, respectively. Methods At baseline healthy participants (n = 100) completed questionnaires, including the Borg CR-10 discomfort scale (on a 0–10 scale), and were followed for six months, during which musculoskeletal pain was assessed monthly. Logistic regression analyses were performed to assess the associations of baseline discomfort with the onset of future neck or low back pain. Sensitivity, specificity, and the area under the receiver operating characteristics curve were estimated to identify the optimal discomfort cut-off value predicting future pain. Results Borg CR-10 scores ≥ 3.5 for perceived neck and low back discomfort had acceptable sensitivity and specificity to predict future neck and low back pain, respectively. Perceived discomfort at baseline as a dichotomous measure (using the ≥ 3.5 cut-off) was a statistically significant predictor of future neck pain (OR = 10.33) and low back pain (OR = 11.81). Conclusion We identified the optimal cut-off value of the Borg CR-10 discomfort scale to identify office workers at increased risk of developing neck and low back pain. These findings might benefit ergonomists, primary health care providers, and occupational health researchers in developing targeted interventions.

OBJECTIVES: Tinnitus is highly prevalent, but only a few risk factors for developing tinnitus are known and little is known about factors associated with the degree of annoyance of new-onset tinnitus. Longitudinal analysis can reveal risk factors associated with the development of tinnitus and might lead to targeted prevention. The aim of this study is twofold. (1) To identify risk factors that are longitudinally associated with the odds of developing tinnitus 5 years later. (2) To identify factors that are cross-sectionally associated with tinnitus annoyance in adults with new-onset tinnitus. METHODS: Baseline, 5-year, and 10-year follow-up data of participants in the Netherlands Longitudinal Study on Hearing (NL-SH) were used. The NL-SH is a web-based prospective cohort study, which started in 2006 and includes both normal hearing and hearing-impaired adults aged 18 to 70 years at baseline. The NL-SH uses an online digit-triplet speech-in-noise test to asses speech recognition ability in noise, and online questionnaires on various aspects of life. At follow-up, participants are asked (1) if they suffer from tinnitus and (2) to rate tinnitus annoyance on a 0 to 100 numeric rating scale. We investigated whether demographic (age, sex, living arrangement, educational level), lifestyle (history of tobacco smoking, alcohol use), health (asthma, severe heart disease, hypertension, history of stroke, osteoarthritis, rheumatoid arthritis, epilepsy, multiple sclerosis, and migraine), hearing (speech recognition ability in noise, hyperacusis, and occupational noise exposure), and psychological variables (distress, somatization, depression, and anxiety) were potential risk factors for new-onset tinnitus, or associated with annoyance caused by new-onset tinnitus. Generalized estimating equations were used to longitudinally analyze the association between potential risk factors and new-onset tinnitus measured 5 years later. A multivariable association model was constructed using a forward selection procedure with p < 0.05 for model entry. Linear regression analysis was used to cross-sectionally analyze the association between potential factors and tinnitus annoyance in new-onset tinnitus. For this purpose, a multivariable association model was constructed using a forward selection procedure with p

Background The prevalence of inflicted femur fractures in young children varies (1.5–35.2%), but these data are based on small retrospective studies with high heterogeneity. Age and mobility of the child seem to be indicators of inflicted trauma. Objective This study describes other factors associated with inflicted and neglectful trauma that can be used to distinguish inflicted and neglectful from accidental femur fractures. Materials and methods This retrospective study included children (0–6 years) who presented with an isolated femur fracture at 1 of the 11 level I trauma centers in the Netherlands between January 2010 and January 2016. Outcomes were classified based on the conclusions of the Child Abuse and Neglect teams or the court. Cases in which conclusions were unavailable and there was no clear accidental cause were reviewed by an expert panel. Results The study included 328 children; 295 (89.9%) cases were classified as accidental trauma. Inflicted trauma was found in 14 (4.3%), while 19 (5.8%) were cases of neglect. Indicators of inflicted trauma were age 0–5 months (29%, positive likelihood ratio [LR +] 8.35), 6–12 months (18%, LR + 5.98) and 18–23 months (14%, LR + 3.74). Indicators of neglect were age 6–11 months (18%, LR + 4.41) and age 18–23 months (8%, LR + 1.65). There was no difference in fracture morphology among groups. Conclusion It is unlikely that an isolated femur fracture in ambulatory children age > 24 months is caused by inflicted trauma/neglect. Caution is advised in children younger than 24 months because that age is the main factor associated with inflicted trauma/neglect and inflicted femur fractures.

RESEARCH QUESTION: What is the effect of myomectomy in women with uterine fibroids on time to live birth and other reproductive outcomes?DESIGN: This was a monocentric retrospective cohort study of 311 women with fibroids, of whom 165 eventually received myomectomy and 146 remained on expectant management. To assess the primary outcome time to live birth, a Cox proportional hazards model with a time-varying covariate for myomectomy was used. In the sensitivity analyses, this was combined with an approach to account for confounders via a cloning/censoring/weighting that aimed to emulate a randomized controlled trial.RESULTS: Notable differences in baseline characteristics between the myomectomy and expectant management group were fibroid size (fibroid >7 cm: myomectomy 48%; expectant management 15%) and whether the patient had fibroid-related complaints (myomectomy 85%, expectant management 67%). The adjusted hazard ratio for the effect of myomectomy compared with expectant management on live birth was 1.26 (95% CI 0.87-1.81). Sensitivity analyses yielded similar results, but secondary outcomes showed that women remaining on expectant management had more often received assisted reproductive technology (63%) compared with those who eventually received myomectomy (38%).CONCLUSIONS: The study did not find a significant difference in time to live birth after myomectomy compared with expectant management in women with fibroids and a wish to conceive, despite more, larger and more symptomatic fibroids in the myomectomy group. The results after myomectomy encourage the execution of a randomized controlled trial in women with large (symptomatic) fibroids not or minimally distorting the intrauterine cavity, and infertility or a desire to conceive.

Objectives: The objective of this study was to estimate the minimal important change (MIC) and responsiveness of core patient reported outcome measures for chronic low back pain (LBP) and Modic changes. Study Design and Setting: In the Antibiotics in Modic changes (AIM) trial we measured disability (RMDQ, ODI), LBP intensity (NRS) and health-related quality of life (EQ5D) electronically at baseline, three- and 12-month follow-up. MICs were estimated using Receiver Operating Curve (ROC) curve and Predictive modeling analyses against the global perceived effect. Credibility of the estimates was assessed by a standardized set of criteria. Responsiveness was assessed by a construct and criterion approach according to COSMIN guidelines. Results: The MIC estimates of RMDQ, ODI and NRS scores varied between a 15–40% reduction, depending on including “slightly improved” in the definition of MIC or not. The MIC estimates for EQ5D were lower. The credibility of the estimates was moderate. For responsiveness, five out of six hypotheses were confirmed and AUC was >0.7 for all PROMs. Conclusion: When evaluated in a clinical trial of patients with chronic LBP and Modic changes, MIC thresholds for all PROMs were on the lower spectrum of previous estimates, varying depending on the definition of MIC. Responsiveness was sufficient. publishedVersion

Interventions to support mentalizing abilities are relevant for all people to enhance social skills and well-being. For people with mild to borderline intellectual disabilities, learning mentalizing skills may be challenging, however, because of the abstract and complex nature of the construct. The application of serious games has the potential to teach and train in these skills and engage this target group in treatment. This study investigates the key elements of a design model for a serious game aimed at learning abstract skills, taking into account the needs and wishes of adults with mild to borderline intellectual disabilities. We first searched the literature for guidelines covering effective interventions and for game design elements with the potential to train in abstract skills and motivate this specific group. We then included co-researchers with mild to borderline intellectual disabilities in guiding the development of the serious game ‘You & I’. Here we describe application of the recommendations from the literature to the development of the game and the co-creation process. This process resulted in key elements described in a design model that provides more structured knowledge for future studies of teaching abstract skills using a serious game in this population.

Background Low back pain (LBP) is a world leading cause of disability and has substantial impact on individuals and society as a whole. The largest part of the societal burden of LBP is caused by indirect costs, including sick leave. Aims We aimed to describe occupational recovery and associated costs for workers consulting an occupational physician (OP) with LBP, and to determine to what extent this differs by diagnoses: non-specific favourable LBP, non-specific unfavourable LBP, lumbosacral radicular syndrome (LRS) and specific LBP. Methods We analysed longitudinal dynamic cohort data from an occupational health service, representing ~1.2 million workers from various companies and sectors throughout the Netherlands. The OP registered data on sick leave and LBP diagnoses. A survival analysis was performed on sick leave duration to determine recovery and a linear regression analysis on cost per episode, adjusting for sex, age and working hours. Results We analysed 5951 LBP episodes from 5472 workers who consulted an OP, with a median and mean duration sick leave of 95 and 151 days, respectively. The probability of not recovering was 82% at 30 days and 10% at 1 year. The mean cost per episode was €15 350. Specific LBP (€22 999; beta (95% confidence interval [CI]): 16 278 (13 325–19 165)) and LRS (€20 111; beta (95% CI): 13 589 (12 527–14 659)) had the longest and most costly episodes, compared to non-specific favourable LBP (€6745; reference group). Conclusions With LRS and non-specific unfavourable LBP accounting for over 83% of LBP-associated sick leave costs, the work-directed care of workers with these two diagnoses deserves increased attention.

To investigate the effectiveness of a 3-year worksite lifestyle intervention on cardiovascular metrics and to study whether outcomes are influenced by baseline subclinical atherosclerosis (SA) by non-invasive imaging. A randomized controlled trial was performed to compare a lifestyle intervention with standard of care in asymptomatic middle-aged subjects, stratified by SA. The intervention consisted of nine motivational interviews during the first year, followed by three further sessions between Years 1 and 3. The primary outcome was the change in a pre-specified adaptation of the Fuster-BEWAT score (Blood pressure, Exercise, Weight, Alimentation, and Tobacco) between baseline and follow-up Years 1-3. A total of 1020 participants (mean age 50 ± 4 years) were enrolled, of whom 510 were randomly assigned to the intervention and 510 to the control group. The baseline adapted Fuster-BEWAT score was 16.2 ± 3.7 points in the intervention group and 16.5 ± 3.5 points in the control group. At Year 1, the score improved significantly in intervention participants compared with controls [estimate 0.83 (95% CI 0.52-1.15) points]. However, intervention effectiveness decreased to non-significant levels at Year 3 [0.24 (95% CI -0.10 to 0.59) points]. Over the 3-year period, the intervention was effective in participants having low baseline SA [0.61 (95% CI 0.30-0.93) points] but not in those with high baseline SA [0.19 (95% CI -0.26 to 0.64) points]. In middle-aged asymptomatic adults, a lifestyle intervention was associated with a significant improvement in cardiovascular health and behavioural metrics. The effect attenuated after 1 year as the intensity of the intervention was reduced. ClinicalTrials.gov (NCT02561065). TANSNIP-PESA is funded by Fundación Centro Nacional de Investigaciones Cardiovasculares (CNIC) Carlos III through an Investigator-initiated Study grant to Icahn School of Medicine from AstraZeneca. The PESA study is cofunded by the CNIC and Banco Santander. The study also received funding from the Instituto de Salud Carlos III (PI15/02019) and the European Regional Development Fund (ERDF) ‘A way to make Europe’. The CNIC is supported by the Instituto de Salud Carlos III (ISCIII), the Ministerio de Ciencia e Innovación (MCIN), and the Pro CNIC Foundation and is a Severo Ochoa Center of Excellence (grant CEX2020-001041-S funded by MICIN/AEI/10.13039/501100011033. The study funders were not involved in the study design; the collection, analysis, or interpretation of data; the writing of the report; or the decision to submit the paper for publication. Sí

Health informatics (also referred to as medical informatics or biomedical informatics) is an interdisciplinary field that deals with health-related data in healthcare and with the technologies that are used to support healthcare services. While the goal of some health informatics systems is to automate processes, the more common goal is to help clinicians, patients, policymakers, and others to manage health information, and to communicate that information efficiently and effectively to end users. Thus, there is considerable overlap between the fields of health informatics and health communication, and this intriguing intersection between the two fields opens many opportunities for innovation. Health communication is often visible in health informatics in the area of patient communication. Examples of this include patient self-management tools that support behavior change. Correspondingly, health informatics is often visible in health communication in the use of computational methods and “big data” to build on communication theory. Future research in health communication will likely involve more and more intensive use of information technology. This can bring exciting new possibilities for both interventions and analytical techniques, yet researchers should ensure that information technology interventions respect participants' privacy and guarantee their safety. Investigating the effect of information technology on communications between healthcare professionals and with patients also offers interesting opportunities for collaborative research.

Background Employment is important for the quality of life and financial security of patients of working age receiving kidney replacement therapy (KRT). We aimed to examine self-reported work status and general, physical and mental work ability and to determine associations between demographic, disease-related, work-related and macroeconomic factors and employment. Methods Europeans from 37 countries, ages 19–65 years, treated with dialysis or kidney transplantation, filled out the web-based or paper-based cross-sectional EDITH kidney patient survey between November 2017 and January 2019. We performed descriptive analyses and multivariable generalized logistic mixed models. Results Of the 3544 patients, 36.5% were employed and working [25.8% of dialysis patients, 53.9% of kidney transplant recipients (KTRs)]. The mean general work ability was 5.5 out of 10 (dialysis: 4.8, KTRs: 6.5). Non-working patients (all: 4.1, dialysis: 3.9, KTRs: 4.7) scored lower than working patients (all: 7.7, dialysis 7.3, KTRs: 8.0). Working dialysis patients scored lower on physical and mental work ability (7.1 and 8.1) than working KTRs (8.0 and 8.4; P Conclusions Low employment rates and impaired work ability were prevalent among European patients receiving KRT. Demographic, disease-related, work-related and macro-economic factors were associated with employment.

Purpose The aim of this study is to investigate whether total knee arthroplasty (TKA) patients who consulted an occupational medicine specialist (OMS) within 3 months after surgery, return to work (RTW) earlier than patients who did not consult an OMS. Methods A multi-center prospective cohort study was performed among working TKA patients, aged 18 to 65 years and intending to RTW. Time to RTW was analyzed using Kaplan Meier and Mann Whitney U (MWU), and multiple linear regression analysis was used to adjust for effect modification and confounding. Results One hundred and eighty-two (182) patients were included with a median age of 59 years [IQR 54–62], including 95 women (52%). Patients who consulted an OMS were less often self-employed but did not differ on other patient and work-related characteristics. TKA patients who consulted an OMS returned to work later than those who did not (median 78 versus 62 days, MWU p Conclusions Consulting an OMS within 3 months after surgery did not result in a decrease in time to RTW in TKA patients. TKA patients with high expectations did RTW earlier without consulting an OMS. Intervention studies on how OMSs can positively influence a timely RTW, incorporating patients’ preoperative expectations, are needed.