OBJECTIVEThe aim of this study was to determine whether written and video instructions improved the recall of how to use analgesics correctly in parents of children discharged following assessment in ...the emergency department (ED).
METHODSThis was a prospective pre- and post-implementation study set in the EDs of a tertiary teaching hospital and an urban general hospital in the Netherlands. The participants were parents/carers of children under 12-years-old who had been assessed in and subsequently discharged from the ED. The pre-implementation phase involved 165 participants; the post-phase involved 174 participants. In the post-implementation phase, written instructions about correct analgesic use in children and a link to an online video were provided at discharge. Endpoints were measured using a questionnaire designed to ascertain participants’ recall of how to use analgesics correctly and their patterns of use, completed 3–5 days following discharge of their child from the ED. Additionally, participants were asked about re-attending healthcare services and their satisfaction with and preferences for information about analgesic use.
RESULTSRecall of the correct use of analgesics was significantly higher in participants in the post-implementation phase compared to the pre-implementation phase difference 29%; 95% confidence interval (CI) 19–39%. In the post-implementation phase, participants represented to healthcare services less frequently (difference –6%; 95% CI –13–0%). Patterns of use of analgesics varied between the pre- and post-phases, with significantly more participants giving analgesics at home (difference 11%; 95% CI 1–20%). Participants in the post-implementation phase were significantly more (highly) satisfied about the analgesic advice they received compared to parents in the pre-implementation phase (difference –13; 95% CI –23% to –3%). Verbal (93%) or written instructions (83%) were the most popular choices for discharge instructions.
CONCLUSIONIn our study, we observed that the recall of the correct use of analgesics was increased in participants who had been given written instructions at discharge.
Objective:
To compare healthcare and productivity costs between patients with mild traumatic brain injury (mTBI) who received verbal discharge instructions only and patients who received an ...additional flyer with or without video instructions.
Setting:
Emergency departments (EDs) of 6 hospitals in the Netherlands.
Participants:
In total, 1155 adult patients with mTBI (384 with verbal instructions; 771 with additional flyer with or without video instructions) were included.
Design:
Cost study with comparison between usual care and intervention.
Methods:
Medical and productivity costs up to 3 months after presentation at the ED were compared between mTBI patients with usual care and mTBI patients who received the intervention.
Results:
Mean medical costs per mTBI patient were slightly higher for the verbal instructions–only cohort (€337 vs €315), whereas mean productivity costs were significantly higher for the flyer/video cohort (€1625 vs €899). Higher productivity costs were associated with higher working age, injury severity, and postconcussion symptoms.
Conclusion:
This study showed that the implementation of flyer (and video) discharge instructions for patients with mTBI who present at the ED increased reports of postconcussion symptoms and reduced medical costs, whereas productivity costs were found to be higher for the working population in the first 3 months after the sustained head injury.
Hypnotherapy for irritable bowel syndrome (IBS) has been used primarily in patients with refractory symptoms in specialised departments and delivered on an individual basis. We aimed to test the ...hypothesis that hypnotherapy would be more effective than educational supportive therapy, and that group hypnotherapy would be non-inferior to individual hypnotherapy for patients with IBS referred from primary and secondary care.
We did a multicentre randomised controlled trial (IMAGINE) in 11 hospitals in the Netherlands. Patients with IBS, aged 18-65 years, who were referred from primary or secondary care were randomly allocated (3:3:1) in blocks of six using a computer-based random number table procedure by staff not involved in the treatment to receive six sessions of individual or group hypnotherapy or group educational supportive therapy (control group). The primary outcome was adequate relief of IBS symptoms, with responders defined as patients who reported adequate relief when asked once weekly on three or four occasions in 4 consecutive weeks. We compared hypnotherapy (both groups) with control in the intention-to-treat population (excluding individuals subsequently found to be ineligible for enrolment), and assessed non-inferiority of group hypnotherapy versus individual hypnotherapy in the per-protocol population (with a non-inferiority margin of 15%) at 3 months and 12 months. This trial is registered with ISRCTN, number ISRCTN22888906, and is completed.
Between May 31, 2011, and April 6, 2016, 494 patients referred for psychological treatment for IBS were assessed for eligibility, of whom 354 were randomly allocated to the three groups: 150 to individual hypnotherapy, 150 to group hypnotherapy, and 54 to educational supportive therapy. After exclusion of individuals subsequently found to be ineligible for enrolment, 142 patients in the individual hypnotherapy group, 146 in the group hypnotherapy group, and 54 in the control group were included in the intention-to-treat population. Of these, 22 (15%) patients in the individual hypnotherapy group, 22 (15%) in the group hypnotherapy group, and 11 (20%) in the control group dropped out before or during therapy. In the intention-to-treat analysis, the adequate response rate was 40·8% (95% CI 31·7-50·5) in the individual hypnotherapy group, 33·2% (24·3-43·5) in the group hypnotherapy group, and 16·7% (7·6-32·6) in the control group at 3 months. At 12 months, 40·8% (31·3-51·1) of patients in the individual hypnotherapy group, 49·5% (38·8-60·0) of patients in the group hypnotherapy group, and 22.6% (11·5-39·5) of patients in the control group reported adequate relief. Hypnotherapy was more effective than control at 3 months (odds ratio 2·9, 95% CI 1·2-7·4, p=0·0240) and 12 months (2·8, 1·2-6·7, p=0·0185). In the per-protocol analysis, 49·9% (39·2-60·6) in the individual hypnotherapy group and 42·7% (32·3-53·8) in the group hypnotherapy group had adequate relief at 3 months, and 55·5% (43·4-67·1) of individual and 51·7% (40·2-63·0) of group hypnotherapy patients reported adequate relief at 12 months. Group hypnotherapy was therefore non-inferior to individual hypnotherapy. Eight unexpected serious adverse reactions (six in the individual hypnotherapy group and two in the group hypnotherapy group) were reported, most of which were cancer or inflammatory bowel disease, and were judged by the medical ethics committee as not being related to the therapy.
Hypnotherapy should be considered as a possible treatment for patients with IBS in primary and secondary care. Furthermore, group therapy could allow many more patients to be treated for the same cost.
None.
In the Netherlands a substantial proportion of newly diagnosed human immunodeficiency virus (HIV) patients present late for care and an estimated 12-34% of people living with HIV are undiagnosed. ...Linkage to care of these patients is important to decrease HIV transmission and to improve individual patient outcomes. We investigated if non-targeted HIV testing in emergency departments is a useful and cost-effective way to identify these patients.
In a cross-sectional multicentre study, eligible adult patients who underwent phlebotomy were given an active choice to be additionally tested for HIV. In a subset of patients, risk factors for HIV infection were asked for. A cost-effectiveness analysis was conducted.
Of 7577 eligible patients, 3223 patients were tested, and two new HIV infections were diagnosed (0.06%). Both patients had risk factors for HIV infection. Non-targeted HIV testing in the emergency department was not considered cost-effective, with a cost per quality adjusted life years gained of € 77,050, more than triple the Dutch cost-effectiveness threshold of € 20,000.
Non-targeted HIV testing in emergency departments in the Netherlands had a low yield of newly diagnosed HIV infections and was not cost-effective. Our data suggest that targeted HIV testing may offer an alternative approach to decrease the number of undiagnosed people living with HIV.
•Land use related to Dutch consumption was calculated in detail for the years 1990, 1995, 2000, 2005, 2010 and 2013.•Land use decreased during the 1990–2013 period due to increasing agricultural ...yields, despite growth in GDP and population.•Yields from import regions were used and global average yields; total land use amounted to 0.51 ha per capita using regional yields.•Most land use takes place abroad, mainly in the EU.•Wood, paper and animal products are the most important products.
Effects of Dutch consumption reach far beyond the country borders. The international consequences of consumption are related to imports of many commodities for consumptive needs. The goal of this study was to show the amount and distribution of land needed for Dutch national consumption, inside and outside the national borders. While this question has been investigated in general terms, the present study is motivated by the need to provide more accurate and precise product-level results that can be used in a practical way, for example to guide circular economy policy goals.
A model was developed to determine land use of 40 commodities, combining use- /supply-based consumption data with agricultural/forestry yields in the main regions of origin, plus land used for housing, recreation etc. The model thus calculates a land footprint that reflects actual occupied hectares. The model comprises the time series from 1990 to 2013.
The land used for the consumptive needs of Dutch people amounts to 8.6 million hectares in 2013, corresponding to 0.51 ha per capita. This is over two and a half times the land area of the Netherlands itself. Land use is primarily related to forestry and agriculture, with paper and meat as important land requiring products. During the 1990–2013 period total land use has decreased by 10%, despite a population increase of 13% and an increase in GDP by 54%. The main causes for this decrease are increased agricultural yields and a decrease in paper and wood consumption after 2010. For the years 1990 and 2013 a comparison was made between land use with actual region-specific yields and global average yields. This exercise showed that, for the year 2013, land use calculated using global average yields was almost twice as much as that calculated using regional yields. This means our commodities originate from regions with relatively productive lands. For the year 1990 the difference was even larger, indicating a converging trend in global yields. In 2013 most land for Dutch consumption was occupied within the EU (53%, of which 20% in the Netherlands) and South America (18%).
Many patients do not reach haematopoietic stem cell transplantation. Shortage of unrelated donors (UDs) is still seen as the main cause. However, with a worldwide UD pool containing more than 8 ...million donors, it is possible that other impediments are becoming more important. We analysed 549 UD searches for Dutch patients, performed between 1987 and 2000, in order to find the reasons for failure or success to reach transplantation. Between 1996 and 2000, 59% of the patients of Northwest European origin received a graft from an UD with a median time span of 4.4 months from the start of the search. In all, 11% of the patients lacked a compatible donor, while 30% became medically unfit for transplantation. This is in contrast to the patients of non-Northwest European origin for whom UD shortage is still the most important impediment; only 32% were transplanted while 50% lacked a compatible donor. We conclude that the shortage of donors is no longer the biggest constraint in unrelated stem cell transplantation for patients of Northwest European origin. It may be more effective to optimize the chance on transplantation by making the search process more efficient.
The effect of intra-arterial treatment (IAT) for acute ischemic stroke is highly time-dependent. We investigated the delay of IAT and factors associated with such delay.
MR CLEAN was a randomized ...trial of IAT plus usual care versus usual care alone (n=500). With multivariable linear regression, we analyzed the effect of intravenous treatment, general anesthesia, off-hours and inter-hospital transfer on time to admission to the emergency department (ED) of the intervention center and time to treatment. Furthermore, we assessed compliance with a target of 75 min for time from ED to treatment, and calculated the potential absolute increase in the number of patients with a good outcome (modified Rankin Scale score ≤2) if this target had been achieved in all treated patients.
Inter-hospital transfer prolonged time to ED by 140 min (95% CI 129 to 150) but reduced time from ED to treatment by 77 min (95% CI 64 to 91). Time from ED to treatment was increased by 19 min by general anesthesia (95% CI 5 to 33) and total time was increased by 23 min during off-hours (95% CI 6 to 40). The in-hospital target was achieved in 11.5% (22/192) of patients. Full compliance with the target time of 75 min from ED to treatment would have increased the proportion of patients with a good outcome by 7.6% (95% CI 6.7% to 8.5%).
Inter-hospital transfer is an important cause of delay in the delivery of IAT and every effort should be made to avoid transfers and reduce transfer-related delay. Furthermore, in-hospital workflow should be optimized to improve functional outcome after IAT.
Pig islets constitute a possible resolution to the shortage of human islets for transplantation. After intraportal infusion of porcine islets in primates, many islets are lost through what has been ...termed the instant blood-mediated inflammatory reaction (IBMIR). We report on our experience with IBMIR.
Ten monkeys underwent intraportal porcine islet transplantation. Immunosuppressive therapy was with conventional agents (n=3) or based on costimulation blockade (n=7). Treatment specific for IBMIR was administered in eight monkeys; two additional monkeys received no such therapy (group 1). Cobra venom factor completely inhibited complement activity in four (group 2) and dextran sulfate provided anticoagulation in four (group 3). Islet graft function was monitored by following blood glucose, insulin requirement, and porcine C-peptide values.
In monkeys that received neither cobra venom factor nor dextran sulfate (group 1), there was rapid destruction of islets indicated by severe hypoglycemia and the need for dextrose infusion; C-peptide levels were initially low and further reduction occurred within the first five days. In both groups 2 and 3, there was significantly less destruction of islets and some reversal of diabetes. However, when 40,000 IEQ/kg were infused, normoglycemia was lost within five days, but when 80,000 IEQ/kg were infused in one case, normoglycemia was more persistent. We observed that even when C-peptide levels were in the normal range for healthy nondiabetic pigs, these were not sufficient to maintain normoglycemia in the monkeys.
Although pretransplantation complement depletion or anticoagulation reduces porcine islet xenograft loss significantly, neither alone is sufficient to prevent IBMIR.
OBJECTIVETo investigate the demographic and service characteristics, motive for consultation, and disposition of adult frequent users (FUs) of the largest academic hospital in the Netherlands over a ...5-year period.
PATIENTS AND METHODSThis retrospective study included all patients aged 18 years and older visiting the emergency department (ED) during a 5-year period (2009–2013). Frequent ED use was defined as having four or more visits to the ED during a year. Patient and service characteristics, motive for consultation, and disposition were explored.
RESULTSFrequent ED users represented 2% of all patients who visited the ED during 2009–2013 (8% of all ED consultations). On average, each FU visited the ED five times per year. Compared with nonfrequent users (NFUs), FUs were significantly less often self-referred, less frequently transported to the hospital by ambulance, received a lower urgency code upon arrival to the ED, and more often admitted to hospital than NFUs. Complaints related to the digestive system (19%), general complaints such as fever (18%), respiratory (10%), or cardiovascular problems (10%) were the main motive for consultations of the frequent ED users. Two percent of the FUs were serial FUs (FUs during 3 or more consecutive years).
CONCLUSIONFrequent use of the ED has been depicted as inappropriate use of these services. However, our study shows that FUs consist of a relatively small number of patients and that FUs suffer from chronic, and often, severe somatic illnesses that require specialized medical care.
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