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Contains fulltext : 286715.pdf (Publisher’s version ) (Open Access), INTRODUCTION: Different multimodal pain management strategies following total hip arthroplasty(THA) and total knee arthroplasty (TKA) surgery are used in clinical practice. The optimal pain management strategy, however, remains unclear. This study aims to evaluate the differences in perioperative multimodal pain management strategies for THA and TKA in the Netherlands, and studies the associations between patient- and therapy related factors and pain outcomes. METHODS: Data from the Dutch hospitals in the PAIN OUT network were used in this study. Demographic data, pain management strategy including perioperative medication use and anesthetic techniques were recorded and used in a multivariable regression analysis to study the association with maximum pain intensity, the duration of severe pain, pain interference in bed and postoperative nausea. RESULTS: In 343 hip arthroplasty patients and 301 knee arthroplasty patients in seven hospitals, respectively 28 and 35 different combinations of analgesic regimens were used. The number of different drugs prescribed was not related to postoperative pain intensity. Female sex, younger age and spinal anesthesia were associated with higher postoperative maximum pain scores (Numeric Rating Scale (NRS) > 5). Hip surgery and ketamine use were associated with lower postoperative pain scores. The use of non-steroidal anti-inflammatory drugs (NSAIDs) and gabapentinoids, higher age, higher body mass index (BMI) and male gender were associated with less postoperative nausea (NRS < 3). CONCLUSION: In conclusion, our study demonstrated a large diversity of analgesic strategies following total joint arthroplasties in the Netherlands. Although no ideal strategy was identified, the use of NSAIDs, ketamine and dexamethasone were associated with less pain and less side effects.

In drie regio’s onderzocht het College van Rijksadviseurs hoe landbouw ‘landschapsinclusief’ kan zijn. Eén van die regio’s is Salland. Salland – gelegen in Overijssel - kent een grote landschappelijke diversiteit; de IJssel en haar uiterwaarden, oeverwallen, marken, enken, jonge ontginningen, dekzandruggen en de weteringen die door het gebied lopen. De landschappelijke diversiteit staat onder druk door intensivering en schaalvergroting in de landbouw. Het perspectief voor 2050 toont hoe in Salland een nieuwe balans gerealiseerd kan worden tussen landschap, schaalgrootte en agrarisch landgebruik.

Het College van Rijksadviseurs heeft in drie regio’s onderzocht hoe landbouw ‘landschapsinclusief’ kan zijn. Eén van die regio’s is de Krimpenerwaard in het Groene Hart. Het veenweidegebied in de Krimpenerwaard behoort tot een van de meest waardevolle en kenmerkende landschappen van ons land. Opgaven als verduurzamen en de reductie van stikstof, komen in de Krimpenerwaard samen met specifieke gebiedsopgaven zoals het tegengaan van CO2 emissies en bodemdaling in het veen en de zorg voor weidevogels en biodiversiteit. Het toekomstbeeld voor 2050 gaat uit van een landschap met kwaliteiten van vroeger en de technieken van nu.

In drie regio’s onderzocht het College van Rijksadviseurs hoe landbouw ‘landschapsinclusief’ kan zijn. Eén van die regio’s is De Marne. De vruchtbare zeeklei in combinatie met het milde klimaat maken van de Marne een van de beste landbouwgebieden ter wereld. De afgelopen decennia heeft het gebied zich echter steeds meer gespecialiseerd in een beperkt aantal gewassen. De intensieve landbouw van vandaag de dag leidt tot opgaves op het gebied van bodemkwaliteit, gesloten kringlopen, biodiversiteit, waterkwaliteit en waterkwantiteit. De pilot bevat een voorstel voor een mogelijk toekomstperspectief en een aantal concrete stappen en adviezen naar de overheid.

Chronic pain is a common chronic medical condition. Its treatment is difficult and relies upon a multidisciplinary approach. Although pain medication remain one of the cornerstones of chronic pain therapy, the effects of pharmacological therapy are often less than expected. One of the reasons might be that a large proportion of chronic pain patients do not adhere to the prescribed therapy. In this thesis, prevalence and determinants of medication non- adherence in chronic pain patients are reviewed and investigated. Furthermore, the results of two randomized clinical trials investigating the effects of potential adherence improving interventions are presented. Finally, the design of a theory-based intervention with the help of psychological models of behaviour change is described. Medication adherence in chronic pain patients is complex behaviour in a complex medical condition. Health care providers play a crucial role to improve medication adherence by identifying patients at risk and apply adherence improving interventions.

Objective: Evidence exists for the efficacy of collaborative care (CC) for major depressive disorder (MDD), for the efficacy of the consequent use of pain medication against pain, and for the efficacy of duloxetine against both MDD and neuropathic pain. Their relative effectiveness in comorbid MDD and pain has never been established so far. This study explores the effectiveness of CC with pain medication and duloxetine, and CC with pain medication and placebo, compared with duloxetine alone, on depressive and pain symptoms. This study was prematurely terminated because of massive reorganizations and reimbursement changes in mental health care in the Netherlands during the study period and is therefore of exploratory nature. Methods: Three-armed, randomized, multicenter, placebo-controlled trial at three specialized mental health outpatient clinics with patients who screened positive for MDD. Interventions lasted 12 weeks. Pain medication was administered according to an algorithm that avoids opiate prescription as much as possible, where paracetamol, COX inhibitors, and pregabalin are offered as steps before opiates are considered. Patients who did not show up for three or more sessions were registered as non-compliant. Explorative, intention-to-treat and per protocol, multilevel regression analyses were performed. The trial is listed in the trial registration (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1089; NTR number: NTR1089). Results: Sixty patients completed the study. Patients in all treatment groups reported significantly less depressive and pain symptoms after 12 weeks. CC with placebo condition showed the fastest decrease in depressive symptoms compared with the duloxetine alone group (b = -0.78; p = 0.01). Non-compliant patients (n = 31) did not improve over the 12-week period, in contrast to compliant patients (n = 29). Pain outcomes did not differ between the three groups. Conclusion: In MDD and