The effective coverage of the youth health services

Alle kinderen moeten de kans krijgen in een veilige omgeving op te groeien en zich te ontwikkelen tot gezonde volwassenen. De preventieve zorg van de jeugdgezondheidszorg (JGZ) kan daar een belangrijke bijdrage aan leveren. Dit doet de JGZ door gezondheidsproblemen tijdig te signaleren waardoor kinderen in een vroeg stadium hulp kunnen krijgen. JGZ-organisaties streven naar 100 % bereik van hun doelgroep, alle jeugdigen en hun ouders. Zij doen daar veel voor, met wisselend succes. Een deel van de JGZ-organisaties heeft een bereik van minder dan 95 %. Gebaseerd op de probleemanalyse kan geconcludeerd worden dat de JGZ niet alle jeugdigen in Nederland even goed bereikt. Dat geldt in het bijzonder voor jeugdigen die opgroeien in een probleemgezin. Het literatuuronderzoek naar outreachende zorg heeft onderbouwd dat de outreachende interventies 'Bemoeizorg in de JGZ' en 'Vangnet Jeugd' effectief zijn om deze kinderen te bereiken. Het Centrum Jeugdgezondheid heeft het Standpunt 'Bereik van de jeugdgezondheidszorg' ontwikkeld. Dit standpunt ondersteunt JGZ-organisaties bij hun inspanningen om eind 2011 alle jeugdigen in hun werkgebied in beeld te hebben en minimaal 95 % van de jeugdigen te bereiken. Daarnaast zijn met het standpunt de definities van begrippen zoals 'in beeld', 'bereik', 'in zorg', 'elders zorg' en 'uit zorg' vastgesteld. Dit standpunt omvat: - eenduidige definieringen van begrippen gerelateerd aan het bereiken van jeugdigen door JGZorganisaties; - een beschrijving van de meest optimale werkwijzen waarmee JGZ-organisaties hun bereik kunnen optimaliseren; - duidelijkheid over welke organisatie verantwoordelijk is voor het bereiken van welke jeugdige en welke afspraken met collega JGZ-organisaties gemaakt moeten worden om geen jeugdigen te missen; - aanwijzingen voor het eenduidig registreren van gegevens over het bereik van de doelgroep; - aanbevelingen met betrekking tot samenwerkingsafspraken met ketenpartners in het kader van het bereiken van jeugdigen.All children must have a chance to grow up in a safe environment and to develop into healthy adults. The preventive care of the youth health services (YHSs) can provide an important contribution to making this possible. The YHSs do this by identifying health problems in a timely way so that children can get help at an early stage. The YHS organisations aim at reaching 100% of their target group: all young people and their parents. They make great efforts to achieve this aim, but with varying degrees of success. Some of the YHS organisations reach less than 95%. The conclusion based on problem analysis is that the YHSs do not reach the youths equally well. This is particularly true for youths who grow up in problem families. A review of the outreach care literature has confirmed that the outreach interventions Intervening care in the YHS and A safety net for children and youths are effective in reaching these children and youths. The Centre for Youth Health has developed the report The effective coverage of the youth health services: an 'opinion'. This report supports YHS organisations in their efforts to have all children and youths in their own regions on their radar and to reach at least 95% of them. In addition, the report has assigned definitions of terms such as 'on the radar', 'reach', 'in care', 'care elsewhere', and 'not in care'. This report includes: - Unambiguous definitions of terms related to the YHS organisations reaching the youths; - A description of the optimal work methods with which YHSs can optimise their outreach; - Clarity about which organisation is responsible for reaching which youths and what agreements must be made with cooperating YHS organisations in order not to miss any youths; - Indicators for the unambiguous registration of data about the range of the target group; - Recommendations with regard to agreements for working together with interagency partners within the framework of reaching the youth.VW

Advice Additional contact episode for 12-19 year-olds

Om jongeren goed te kunnen volgen, is meer nodig dan de huidige reguliere contactmomenten met de jeugdgezondheidszorg (JGZ). Het is daarom raadzaam om kinderen van 15-16 jaar de JGZ een keer extra te laten bezoeken. De verwachting is dat voorlichting, een tijdige signalering van en een tijdige inzet van effectieve interventies er aan bijdragen dat gezondheidsproblemen worden voorkomen, of dat de nadelige gevolgen ervan minder groot zijn. Hierdoor treedt op korte en lange termijn (gezondheids)winst op. Dit blijkt uit het advies van het Centrum Jeugdgezondheid van het RIVM. Momenteel vindt op 13-jarige leeftijd het laatste contactmoment plaats. Jeugdgezondheidszorg is er voor kinderen van 0 tot 19 jaar en kan, indien gewenst, buiten de reguliere contactmomenten worden geraadpleegd. Tussen 12 en 19 jaar maken jongeren grote lichamelijke en psychosociale veranderingen door. Ze zijn op zoek naar hun identiteit en rol in de samenleving. Dit roept uiteenlopende vragen bij ze op, bijvoorbeeld over seksualiteit en gezondheid. Daarnaast komt er bij die leeftijdsgroep veel risicovol gedrag voor, zoals overmatig alcoholgebruik, roken of blowen. Jongeren zijn zich vaak niet bewust van de risico's hiervan. In het advies worden verschillende opties beschreven waarop het extra contactmoment kan worden ingevuld. Te denken valt aan een preventief gezondheidsonderzoek door middel van een consult, een beperkt consult waarin wordt bepaald wie meer onderzoek nodig heeft (triage-contactmoment), en een vragenlijst op basis waarvan wordt bepaald wie een vervolgonderzoek nodig heeft. De laatste optie kan ook worden aangevuld met een klassikale voorlichtingsles door de JGZ. Het is niet bekend welke optie het meest efficiknt is en welke het meeste effect heeft.The current number of contact episodes that child and youth health services in The Netherlands are allowed to offer is not sufficient to monitor young people's health and development. At present, the last episode of contact takes place when the child is 13. It is recommended to add a consultation episode at the age of 15-16 years. Such extra contact episode provides an opportunity for health education, early recognition, and timely implementation of effective interventions. This will help prevent health problems to emerge and reduce the negative impact of exiting health problems. It will improve young people's health in the short term, and will also result in long-term health gain. In The Netherlands, child and youth health services are available to all 0-19 year-olds. When necessary or appropriate, the services can also be consulted outside the scheduled contact episodes. Young people between 12 and 19 go through many physical, mental and social changes. In their search for identity and role in society they may encounter many questions around a range of issues including health and sexuality. Risky behaviour such as the high use of alcohol, illicit drugs or tobacco is common in this age group. Young people are not always aware of the negative impact this may have on their health. This report presents a range of options for the implementation of the additional contact episode for 15-16 year-olds, should this indeed be added to the current set of contact episodes offered by the child and youth health sector. These options include a preventative health examination, a targeted triage session to determine needs for further consultation, or a structured questionnaire to identify the need for further referral. This last option could also be offered in conjunction with an in-school health education session. At the moment, no evidence is available as to which of these options would be most effective in terms of health gain.VW

Activiteiten Basistakenpakket Jeugdgezondheidszorg 0-19 jaar per Contactmoment

Het rapport Activiteiten Basistakenpakket Jeugdgezondheidszorg 0-19 jaar per Contactmoment (ABC) geeft een overzicht van wat jeugdgezondheidszorg aanbiedt vanuit het uniform deel van het Basistakenpakket JGZ 0-19 jaar. De activiteiten die plaatsvinden in de reguliere contactmomenten zijn hiermee in kaart gebracht. Het Centrum Jeugdgezondheid bij het Rijksinstituut voor Volksgezondheid en Milieu (RIVM) heeft dit rapport samengesteld in samenwerking met JGZ professionals en relevante koepelorganisaties. De Wet Collectieve Preventie Volksgezondheid (WCPV) verplicht gemeenten jeugdgezondheidszorg aan te bieden. Hierover maken zij afspraken met de JGZ-organisaties: de consultatiebureaus en de GGD'en. Deze taak is uitgewerkt in het besluit jeugdgezondheidszorg. Het aanbod van de jeugdgezondheidszorg is omschreven in het Basistakenpakket Jeugdgezondheidszorg 0 -19 jaar (BTP). Het BTP bestaat uit een uniform en een maatwerk deel. Het uniforme deel wordt aan alle kinderen en jongeren aangeboden. Het maatwerk deel is per gemeente verschillend, omdat iedere gemeente het zorgaanbod afstemt op de zorgbehoefte en de gezondheidssituatie van de jeugd in de eigen gemeente. De jeugdgezondheidszorg (JGZ) biedt preventieve zorg aan alle kinderen in Nederland van 0 tot 19 jaar. De JGZ volgt de lichamelijke, psychische, sociale en cognitieve ontwikkeling van kinderen en geeft informatie aan ouders en kinderen over een gezonde ontwikkeling van het kind op al deze gebieden. Daarnaast signaleert de JGZ vroegtijdig mogelijke gezondheidsproblemen zoals groeistoornissen, overgewicht, motoriek- en taal/spraakstoornissen, problemen met het gehoor en het gezichtsvermogen en ook psychosociale problemen zoals angst, depressie, agressie en contactstoornissen. Waar nodig biedt de jeugdgezondheidszorg adequate ondersteuning of doorverwijzing. Het rapport ABC geeft een overzicht van de preventieve zorg die de JGZ biedtvanuit het uniforme deel van het Basistakenpakket Jeugdgezondheidszorg 0-19 jaar. De aanbevelingen uit dit rapport samengevat: 1/ Voorlichting, advies, instructie en begeleiding opnemen in het uniforme deel van het basistakenpakket jeugdgezondheidszorg; 2/ onderzoeken van de leeftijd waarop een aanbod van preventie van gezondheids- of ontwikkelingsproblemen het meest effectief is; 3/ onderzoeken van de mogelijkheden van flexibilisering binnen het huidige aanbod. Het Rapport ABC kan als basis dienen voor discussie over de toekomst van de Jeugdgezondheidszorg.Abstract not availabl

Torsade de pointes arrhythmias arise at the site of maximal heterogeneity of repolarization in the chronic complete atrioventricular block dog

Aims: The chronic complete atrioventricular block (CAVB) dog is highly sensitive for drug-induced torsade de pointes (TdP) arrhythmias. Focal mechanisms have been suggested as trigger for TdP onset; however, its exact mechanism remains unclear. In this study, detailed mapping of the ventricles was performed to assess intraventricular heterogeneity of repolarization in relation to the initiation of TdP. Methods and results: In 8 CAVB animals, 56 needles, each containing 4 electrodes, were inserted in the ventricles. During right ventricular apex pacing (cycle length: 1000 – 1500 ms), local unipolar electrograms were recorded before and after administration of dofetilide to determine activation and repolarization times (RTs). Maximal RT differences were calculated in the left ventricle (LV) within adjacent electrodes in different orientations (transmural, vertical, and horizontal) and within a square of four needles (cubic dispersion). Dofetilide induced TdP in five out of eight animals. Right ventricle – LV was similar between inducible and non-inducible dogs at baseline (327 + 30 vs. 345 + 17 ms) and after dofetilide administration (525 + 95 vs. 508 + 15 ms). All measurements of intraventricular dispersion were not different at baseline, but this changed for horizontal (206 + 20 vs. 142 + 34 ms) and cubic dispersion (272 + 29 vs. 176 + 48 ms) after dofetilide: significantly higher values in inducible animals. Single ectopic beats and the first TdP beat arose consistently from a subendocardially located electrode terminal with the shortest RT in the region with largest RT differences. Conclusion: Chronic complete atrioventricular block dogs susceptible for TdP demonstrate higher RT differences. Torsade de pointes arises from a region with maximal heterogeneity of repolarization suggesting that a minimal gradient is required in order to initiate TdP

Torsade de pointes arrhythmias arise at the site of maximal heterogeneity of repolarization in the chronic complete atrioventricular block dog

The chronic complete atrioventricular block (CAVB) dog is highly sensitive for drug-induced torsade de pointes (TdP) arrhythmias. Focal mechanisms have been suggested as trigger for TdP onset; however, its exact mechanism remains unclear. In this study, detailed mapping of the ventricles was performed to assess intraventricular heterogeneity of repolarization in relation to the initiation of TdP. In 8 CAVB animals, 56 needles, each containing 4 electrodes, were inserted in the ventricles. During right ventricular apex pacing (cycle length: 1000-1500 ms), local unipolar electrograms were recorded before and after administration of dofetilide to determine activation and repolarization times (RTs). Maximal RT differences were calculated in the left ventricle (LV) within adjacent electrodes in different orientations (transmural, vertical, and horizontal) and within a square of four needles (cubic dispersion). Dofetilide induced TdP in five out of eight animals. Right ventricle-LV was similar between inducible and non-inducible dogs at baseline (327 ± 30 vs. 345 ± 17 ms) and after dofetilide administration (525 ± 95 vs. 508 ± 15 ms). All measurements of intraventricular dispersion were not different at baseline, but this changed for horizontal (206 ± 20 vs. 142 ± 34 ms) and cubic dispersion (272 ± 29 vs. 176 ± 48 ms) after dofetilide: significantly higher values in inducible animals. Single ectopic beats and the first TdP beat arose consistently from a subendocardially located electrode terminal with the shortest RT in the region with largest RT differences. Chronic complete atrioventricular block dogs susceptible for TdP demonstrate higher RT differences. Torsade de pointes arises from a region with maximal heterogeneity of repolarization suggesting that a minimal gradient is required in order to initiate Td

Repeating noninvasive risk stratification improves prediction of outcome in ICD patients.

BACKGROUND: Noninvasive risk stratification aims to detect abnormalities in the pathophysiological mechanisms underlying ventricular arrhythmias. We studied the predictive value of repeating risk stratification in patients with an implantable cardioverter-defibrillator (ICD). METHODS: The EUTrigTreat clinical study was a prospective multicenter trial including ischemic and nonischemic cardiomyopathies and arrhythmogenic heart disease. Left ventricular ejection fraction ≤40% (LVEF), premature ventricular complexes >400/24 hr (PVC), non-negative microvolt T-wave alternans (MTWA), and abnormal heart rate turbulence (HRT) were considered high risk. Tests were repeated within 12 months after inclusion. Adjusted Cox regression analysis was performed for mortality and appropriate ICD shocks. RESULTS: In total, 635 patients had analyzable baseline data with a median follow-up of 4.4 years. Worsening of LVEF was associated with increased mortality (HR 3.59, 95% CI 1.17-11.04), as was consistent abnormal HRT (HR 8.34, 95%CI 1.06-65.54). HRT improvement was associated with improved survival when compared to consistent abnormal HRT (HR 0.10, 95%CI 0.01-0.82). For appropriate ICD shocks, a non-negative MTWA test or high PVC count at any moment was associated with increased arrhythmic risk independent of the evolution of test results (worsening: HR 3.76 (95%CI 1.43-9.88) and HR 2.50 (95%CI 1.15-5.46); improvement: HR 2.80 (95%CI 1.03-7.61) and HR 2.45 (95%CI 1.07-5.62); consistent: HR 2.47 (95%CI 0.95-6.45) and HR 2.40 (95%CI 1.33-4.33), respectively). LVEF improvement was associated with a lower arrhythmic risk (HR 0.34, 95%CI 0.12-0.94). CONCLUSIONS: Repeating LVEF and HRT improved the prediction of mortality, whereas stratification of ventricular arrhythmias may be improved by repeating LVEF measurements, MTWA and ECG Holter monitoring.peerReviewe

Deleterious acute and chronic effects of bradycardic right ventricular apex pacing : consequences for arrhythmic outcome

In the chronic complete atrioventricular (AV) block dog (CAVB) model, both bradycardia and altered ventricular activation due to the uncontrolled idioventricular rhythm contribute to ventricular remodeling and the enhanced susceptibility to Torsade de Pointes (TdP) arrhythmias. We investigated the effect of permanent bradycardic right ventricular apex (RVA) pacing on mechanical and electrical remodeling and TdP. In 23 anesthetized dogs, serial experiments were performed at sinus rhythm (SR), acutely after AV block (AAVB) and 3 weeks of remodeling CAVB at a fixed pacing rate of 60/min. ECG, and left (LV) and right ventricular (RV) monophasic action potentials durations (MAPD) were recorded; activation time (AT) and activation recovery interval (ARI) were determined from ten distinct LV electrograms; interventricular mechanical delay (IVMD) and time-to-peak strain (TTP) of the LV septal and lateral wall (ΔTTP: lateral wall minus septal wall) were obtained echocardiographically. Dofetilide (25 μg/kg/5 min) was infused to study TdP inducibility. In baseline AAVB, in comparison to SR, RVA bradypacing acutely increased QT interval, LV, and RVMAPD. Echocardiographic IVMD and ΔTTP were initially increased, which was partially corrected after 3 weeks of RVA pacing (IVMD: 22 ± 13 vs. 42 ± 11 vs. 31 ± 6 ms; ΔTTP: -2 ± 47 vs. -114 ± 38 vs. -36 ± 22 ms). QT interval (362 ± 23 vs. 373 ± 29 ms), LVMAPD (245 ± 18 vs. 253 ± 22 ms), RVMAPD (226 ± 26 vs. 238 ± 31 ms), and mean LV-ARI (268 ± 5 vs. 267 ± 6 ms) were not significantly changed after 3 weeks of RVA pacing. During AAVB, dofetilide increased mean LV-ARI (381 ± 11 ms) with largest increases in the later activated basal areas (slope AT-ARI: +0.96). In contrast with acute RVA pacing, 3 week pacing increased TdP inducibility (0/13 vs. 11/21) and mean LV-ARI (484 ± 18 ms), while the slope of AT-ARI responded differently on dofetilide (-2.37), with larger APD increases in the early region. The latter was supported at the molecular level: reduced RNA expressions of three repolarization-related ion channel genes in early (KCNQ1, KCNH2, and KCNJ2) versus two in late regions (KNCQ1 and KCNJ2). In conclusion, bradycardic RVA pacing acutely induced LV intra- and interventricular mechanical dyssynchrony, which was partially reversed after 3 weeks of pacing (remodeling). The latter occurred without apparent baseline electrical effects. However, dofetilide clearly unmasked (region-specific) arrhythmic consequences of remodeling

Deleterious acute and chronic effects of bradycardic right ventricular apex pacing : consequences for arrhythmic outcome

In the chronic complete atrioventricular (AV) block dog (CAVB) model, both bradycardia and altered ventricular activation due to the uncontrolled idioventricular rhythm contribute to ventricular remodeling and the enhanced susceptibility to Torsade de Pointes (TdP) arrhythmias. We investigated the effect of permanent bradycardic right ventricular apex (RVA) pacing on mechanical and electrical remodeling and TdP. In 23 anesthetized dogs, serial experiments were performed at sinus rhythm (SR), acutely after AV block (AAVB) and 3 weeks of remodeling CAVB at a fixed pacing rate of 60/min. ECG, and left (LV) and right ventricular (RV) monophasic action potentials durations (MAPD) were recorded; activation time (AT) and activation recovery interval (ARI) were determined from ten distinct LV electrograms; interventricular mechanical delay (IVMD) and time-to-peak strain (TTP) of the LV septal and lateral wall (ΔTTP: lateral wall minus septal wall) were obtained echocardiographically. Dofetilide (25 μg/kg/5 min) was infused to study TdP inducibility. In baseline AAVB, in comparison to SR, RVA bradypacing acutely increased QT interval, LV, and RVMAPD. Echocardiographic IVMD and ΔTTP were initially increased, which was partially corrected after 3 weeks of RVA pacing (IVMD: 22 ± 13 vs. 42 ± 11 vs. 31 ± 6 ms; ΔTTP: -2 ± 47 vs. -114 ± 38 vs. -36 ± 22 ms). QT interval (362 ± 23 vs. 373 ± 29 ms), LVMAPD (245 ± 18 vs. 253 ± 22 ms), RVMAPD (226 ± 26 vs. 238 ± 31 ms), and mean LV-ARI (268 ± 5 vs. 267 ± 6 ms) were not significantly changed after 3 weeks of RVA pacing. During AAVB, dofetilide increased mean LV-ARI (381 ± 11 ms) with largest increases in the later activated basal areas (slope AT-ARI: +0.96). In contrast with acute RVA pacing, 3 week pacing increased TdP inducibility (0/13 vs. 11/21) and mean LV-ARI (484 ± 18 ms), while the slope of AT-ARI responded differently on dofetilide (-2.37), with larger APD increases in the early region. The latter was supported at the molecular level: reduced RNA expressions of three repolarization-related ion channel genes in early (KCNQ1, KCNH2, and KCNJ2) versus two in late regions (KNCQ1 and KCNJ2). In conclusion, bradycardic RVA pacing acutely induced LV intra- and interventricular mechanical dyssynchrony, which was partially reversed after 3 weeks of pacing (remodeling). The latter occurred without apparent baseline electrical effects. However, dofetilide clearly unmasked (region-specific) arrhythmic consequences of remodeling