Nationwide Evaluation of Congenital Hypothyroidism Screening during Neonatal Extracorporeal Membrane Oxygenation

Background: Thyroid hormone concentrations may deviate from normal values during critical illness. This condition is known as nonthyroidal illness syndrome (NTIS), and it can influence the results of screening for congenital hypothyroidism (CH) during neonatal extracorporeal membrane oxygenation (ECMO). Objectives: To determine the incidence of aberrant CH screening results in ECMO-treated neonates, to identify possible determinants, and to follow up patients with abnormal thyroid hormone concentrations. Methods: In this retrospective cohort study, we included 168 ECMO-treated neonates admitted from 2004 to 2014 and screened by protocol and divided them into the following 3 groups: group 1 (screened during ECMO, n = 107), group 2 (screened shortly before ECMO, n = 26), and group 3 (screened shortly after ECMO, n = 35). Results: CH screening results were aberrant in 67.3% (72/107) of the neonates screened during ECMO, in 73.1% (19/26) of the neonates screened before ECMO, and in 31.4% (11/35) of the neonates screened after ECMO (p < 0.001). Of the neonates with an aberrant screening result, all but 2 (i.e. 98%) had a low thyroxine concentration with a normal thyrotropin concentration at screening, as is seen in NTIS. None was diagnosed with CH. Mortality did not significantly differ between neonates with an aberrant screening result (32.4%) and neonates with a normal screening result (22.7%; p = 0.18). Screening before ECMO (OR 5.92; 95% CI 1.93-18.20), screening during ECMO (OR 4.49; 95% CI 1.98-10.19), and a higher Pediatric Logistic Organ Dysfunction-2 score (OR 1.31; 95% CI 1.04-1.66) were associated with an aberrant screening result. Conclusions: Aberrant CH screening results were found in most ECMO-treated neonates screened before or during ECMO, which is likely due to NTIS. Follow-up of thyroid hormone concentrations is best started after recovery from critical illness. Our results suggest that thyroxine therapy is not required during ECMO

Predictive resource planning: coupling construction needs with demolition waste forecasts

Current systems of construction and demolition waste (CDW) recycling function insufficiently to meet the European ambitions of resource efficiency (Dahlbo et al., 2015). Knowledge about when, where and what will become available from CDW could stimulate the development of new recycling and production processes based on secondary materials, thereby reducing environmental and societal impact related to primary materials. Various methods exist to quantify CDW streams (see Wu et al., 2014), but the application of CDW forecasting methods is not yet common practice in waste and resource management. Lifetime Analysis (LA) seems to be a useful approach, comprising a practical bottom-up analysis of building materials and their expected replacements. Especially for countries with a high expected need for future construction activities and high material demand, LA is a potentially useful though scarcely tested method to forecast secondary material supply. Examples of these countries can be the rapidly emerging and developing countries, but can also be densely built and developed countries like The Netherlands, where current construction and demolition rates reflect a replacement of existing dwellings in cycles of 200 years, while buildings are designed and expected to function for only about 50 years (Mulder et al., 2015). Our study aimed to provide insight in the benefits and drawbacks of LA in resource planning, addressing three main questions: (1) How can future CDW streams be modelled realistically? (2) Can this model deliver useful insights into the supply of (secondary) materials? (3) Can the forecasted supply of materials be coupled with the expected demand for (secondary) construction materials? The combination of CDW forecasting and resource management was evaluated by means of a regional case study in the architecturally diverse and strategically important Metropole Region of Amsterdam (MRA). In the case study, the material flows of the main components (e.g. foundation, walls, windows) of the most common dwelling type (the terrace house) were inventoried, taking into account several architectural styles. The expected replacement times of these materials were modelled over a period of 50 years, based on economic trends and technical characteristics. This resulted in a forecast of diverse waste streams becoming available at different moments in the next decades. Results showed a distinction between bulk streams (amongst others: calcium silicate bricks) and smaller streams (amongst others: glass), and the temporal variations in expected supply of these materials. Combined with construction forecasts, several demolition scenarios were developed which explored the potential match between supply and demand. For example, the largest waste stream from CDW was stony material which is currently used as foundation materials in infrastructure, but this market is expected to be saturated in the coming decades and therefore other applications for this waste material have to be explored. The kind of modelling as applied in this study can be translated to other urban cases, but the results of this study should be considered with care with respect to the scope of materials included, the exact years of demolition and the location dependent characteristics. The list of analysed materials in this study was limited due to time constraints, though sufficient materials are inventoried to illustrate the potential of this type of modelling. The exact year of demolition as used in the scenarios is a variable parameter which can be altered to find matches between supply and demand. It is recommended to expand the study area to other regions and countries, which enable tailored policy and business development and validation of results. References: Dahlbo, H., Bachér, J., Lähtinen, K., Jouttijärvi, T., Suoheimo, P., Mattila, T., Sironen, S., Myllymaa, T., & Saramäki, K. (2015). Construction and demolition waste management - a holistic evaluation of environmental performance. Journal of Cleaner Production 107, pp333-341. Wu, S. Yu, A.T.W., Shen, L., & Liu, G. (2014). Quantifying construction and demolition waste: An analytical review. Waste Management 34 (9), pp1683–1692. Mulder, G., Koops, O., Kamphuis, V., Willems, M. Vos-Effting, S. de, Donkervoort, R., & Dijkmans, T. (2015). Vervangende Nieuwbouw. TNO Report R10515. TNO: Delft

Variation Between Hospitals in Outcomes and Costs of IBD Care:Results From the IBD Value Study

Background: Data on variation in outcomes and costs of the treatment of inflammatory bowel disease (IBD) can be used to identify areas for cost and quality improvement. It can also help healthcare providers learn from each other and strive for equity in care. We aimed to assess the variation in outcomes and costs of IBD care between hospitals.Methods: We conducted a 12-month cohort study in 8 hospitals in the Netherlands. Patients with IBD who were treated with biologics and new small molecules were included. The percentage of variation in outcomes (following the International Consortium for Health Outcomes Measurement standard set) and costs attributable to the treating hospital were analyzed with intraclass correlation coefficients (ICCs) from case mix-adjusted (generalized) linear mixed models.Results: We included 1010 patients (median age 45 years, 55% female). Clinicians reported high remission rates (83%), while patient-reported rates were lower (40%). During the 12-month follow-up, 5.2% of patients used prednisolone for more than 3 months. Hospital costs (outpatient, inpatient, and medication costs) were substantial (median: €8323 per 6 months), mainly attributed to advanced therapies (€6611). Most of the variation in outcomes and costs among patients could not be attributed to the treating hospitals, with ICCs typically between 0% and 2%. Instead, patient-level characteristics, often with ICCs above 50%, accounted for these variations.Conclusions: Variation in outcomes and costs cannot be used to differentiate between hospitals for quality of care. Future quality improvement initiatives should look at differences in structure and process measures of care and implement patient-level interventions to improve quality of IBD care. Trial Registration Number: NL8276.</p

Recognition and localization of relevant human behavior in videos, SPIE,

ABSTRACT Ground surveillance is normally performed by human assets, since it requires visual intelligence. However, especially for military operations, this can be dangerous and is very resource intensive. Therefore, unmanned autonomous visualintelligence systems are desired. In this paper, we present an improved system that can recognize actions of a human and interactions between multiple humans. Central to the new system is our agent-based architecture. The system is trained on thousands of videos and evaluated on realistic persistent surveillance data in the DARPA Mind&apos;s Eye program, with hours of videos of challenging scenes. The results show that our system is able to track the people, detect and localize events, and discriminate between different behaviors, and it performs 3.4 times better than our previous system

Introduction of a nationwide first-trimester anomaly scan in the Dutch national screening program

Background: A significant proportion of major fetal structural anomalies can be detected in the first trimester by ultrasound examination. However, the test performance of the first-trimester anomaly scan performed in a low-risk population as part of a nationwide prenatal screening program is unknown. Potential benefits of the first-trimester anomaly scan include early detection of fetal anomalies, providing parents with more time for reproductive decision-making. Objective: To investigate the uptake, test performance, and time to a final prenatal diagnosis after referral. Study Design: A nationwide implementation study was conducted in the Netherlands (November 2021−November 2022). The FTAS was performed between 12+3 and 14+3 weeks of gestation by certified sonographers using a standard protocol. Women were referred to a tertiary care center if anomalies were suspected. Uptake, test performance, and time to a final prenatal diagnosis (days between referral and date of final diagnosis/prognosis for reproductive decision-making) were determined. Test performance was calculated for first-trimester major congenital anomalies, such as anencephaly and holoprosencephaly and all diagnosed anomalies &lt;24 weeks of gestation. Results: The first-trimester anomaly scan uptake was 74.9% (129,704/173,129). In 1.0% (1313/129,704), an anomaly was suspected, of which 54.9% (n=721) had abnormal findings on the detailed first-trimester diagnostic scan and 44.6% (n=586) showed normal results. In 0.5% (n=6), intrauterine fetal death occurred. In the total group of 721 cases with abnormal findings, 332 structural anomalies, 117 genetic anomalies, 82 other findings (abnormal fetal biometry, sonomarkers, placental/umbilical cord anomaly, an-/oligohydramnios), and 189 cases with transient findings (defined as ultrasound findings which resolved &lt;24 weeks of gestation) were found, with 1 case having an unknown outcome. 0.9% (n=1164) of all cases with a normal first-trimester anomaly scan were diagnosed with a fetal anomaly in the second trimester. Test performance included a sensitivity of 84.6% (126/149) for first-trimester major congenital anomalies and 31.6% (537/1701) for all types of anomalies. Specificity for all anomalies was 99.2% (98,055/98,830); positive predictive value 40.9% (537/1312); negative predictive value 98.8% (98,055/99,219); positive likelihood ratio 40.3; negative likelihood ratio 0.7; false positive rate 0.8% (775/98,830), and false negative rate 68.4% (1164/1701). The median time to diagnosis for structural anomalies was 20 days (6–43 days; median gestational age 16+3), for genetic anomalies 17 days (8.5–27.5 days; median gestational age 15+6 weeks), and for first-trimester major congenital anomalies 9 days (5–22 days; median gestational age 14+6 weeks). Conclusion: The performance of a newly introduced nationwide first-trimester anomaly scan in a low-risk population showed a high sensitivity for first-trimester major congenital anomalies and a lower sensitivity for all anomalies combined. The program was accompanied by a referral rate of 1.0%, of which 59.1% involved cases where anomalies were either not confirmed or resolved before 24 weeks gestation. Timing of diagnosis was around 16 weeks of gestation for referred cases. To evaluate the balance between benefits and potential harm of the first-trimester anomaly scan within a nationwide prenatal screening program, it is essential to assess the effectiveness of the program over time and to consider the perspectives of both women and their partners, as well as healthcare professionals.</p

Blood integrin- and cytokine-producing T cells are associated with stage and genetic risk score in age-related macular degeneration

Age-related macular degeneration (AMD) remains a leading cause of vision loss in the geriatric population. There are age-related changes in peripheral blood leukocyte composition, but their significance for AMD remains unclear. We aimed to determine changes in immune cell populations in the blood of AMD patients. A standardized 31-parameter flow cytometry analysis was conducted on peripheral blood mononuclear cells from 59 patients with early and advanced AMD and 39 controls without AMD, all older than 65 years. Fundus photography and optical coherence tomography were used to classify disease stages and a custom genotype array was used to compute an AMD genetic risk score based on 52 AMD disease risk variants (GRS-52). A generalized linear regression model corrected for age, sex, and smoking status revealed that AMD patients showed decreased frequencies of CD4+ T helper cell population expressing Integrin Alpha E (CD103) (Padj = 0.019). We further noted that early AMD was characterized by increased interleukin-4 (IL-4)-producing CD4+ T helper cells (Padj = 0.013; <0.001), as well as IL-4-producing cytotoxic CD8+ T cells (Padj = 0.016; <0.001). Reclassification of samples based on the GRS-52 revealed that IL-17-producing T cells decreased incrementally across GRS-52 categories. In AMD, alterations in peripheral blood leukocyte populations are associated with genetic risk score and disease stage and include specifically IL-4 and IL-17A cytokine-producing and CD103 integrin-expressing T cell populations

Safety and effectiveness of the early-onset sepsis calculator to reduce antibiotic exposure in at-risk newborns:a cluster-randomised controlled trial

Background: Newborns are at risk for early-onset sepsis (EOS), occurring 0.2–2.0 per 1000 live births, and for antibiotic overtreatment: approximately 5–15% receive antibiotics for suspected EOS under conventional guidelines with categorical risk factor assessment. Use of the multivariate neonatal EOS calculator prediction tool can reduce overtreatment, but no trials have been conducted to compare its safety to these categorical guidelines. Methods: Between April 12th, 2022, and March 19th, 2024, we conducted an open-label, two-armed, cluster-randomised controlled trial among newborns born at ≥34 weeks’ gestational age with ≥1 EOS risk factor, comparing 10 hospitals randomised 1:1 to EOS calculator use versus categorical guideline use (ClinicalTrials.gov number: NCT05274776). The EOS calculator was slightly adapted for Dutch use. The co-primary non-inferiority outcome assessed safety using four predefined harm criteria (respiratory support, circulatory support, referral to intensive care unit, and culture-confirmed EOS). Non-inferiority was established if the upper limit of the 95% confidence interval (CI) for the relative risk did not exceed 1.5. The co-primary superiority outcome assessed the reduction of participants starting antibiotic therapy for suspected EOS within 24 h postpartum. Secondary endpoints were the duration of antibiotic therapy and the initiation of antibiotic therapy between 24 and 72 h after birth. Intention-to-treat and per-protocol analyses were performed. Findings:1830 newborns (183 per cluster) were included. At least one harm criterion was present in 64 (7.0%) of 915 in the EOS calculator arm and 134 (14.6%) of 915 in the categorical guideline arm (relative risk 0.48; 95% Cl 0.36–0.63). Antibiotics for suspected EOS were started in 66 (7.2%) of 915 in the EOS calculator arm, compared with 243 (26.6%) of 915 in the categorical guideline arm (absolute risk reduction: 19.0%, 95% CI 11.3–26.7). Median duration of antibiotics was longer in the EOS calculator arm (5.5 days, IQR 1.8–6.6) than in the categorical guideline arm (2.1 days, IQR 1.6–6.3) (P 0.0019). We found no difference in the proportion of newborns started on antibiotic therapy for suspected EOS between 24 and 72 h after birth. Adverse event rates were similar between arms. Readmission for suspected early-onset sepsis occurred three times in the EOS calculator and two times in the categorical guideline arm. Any cultures obtained at readmission remained negative, and any symptoms resolved completely.Interpretation: These trial data support safety and effectiveness of the EOS calculator for harm criteria and for the proportion of participants that started antibiotic therapy. Funding: This study was supported by SPIN, the General Paediatrics Research Network of the Dutch Association for Paediatrics, supported by het Cultuurfonds.</p

Validity of Early Outcomes as Indicators for Comparing Hospitals on Quality of Stroke Care

BACKGROUND: Insight into outcome variation between hospitals could help to improve quality of care. We aimed to assess the validity of early outcomes as quality indicators for acute ischemic stroke care for patients treated with endovascular therapy (EVT). METHODS AND RESULTS: We used data from the MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry, a large multicenter prospective cohort study including 3279 patients with acute ischemic stroke undergoing EVT. Random effect linear and proportional odds regression were used to analyze the effect of case mix on between-hospital differences in 2 early outcomes: the National Institutes of Health Stroke Scale (NIHSS) score at 24 to 48 hours and the expanded thrombolysis in cerebral infarction score. Between-hospital variation in outcomes was assessed using the variance of random hospital effects (tau2). In addition, we estimated the correlation between hospitals’ EVT-patient volume and (case-mix– adjusted) outcomes. Both early outcomes and case-mix characteristics varied significantly across hospitals. Between-hospital variation in the expanded thrombolysis in cerebral infarction score was not influenced by case-mix adjustment (tau2=0.17 in both models). In contrast, for the NIHSS score at 24 to 48 hours, case-mix adjustment led to a decrease in variation between hospitals (tau2 decreases from 0.19 to 0.17). Hospitals’ EVT-patient volume was strongly correlated with higher expanded thrombolysis in cerebral infarction scores (r=0.48) and weakly with lower NIHSS score at 24 to 48 hours (r=0.15). CONCLUSIONS: Between-hospital variation in NIHSS score at 24 to 48 hours is significantly influenced by case-mix but not by patient volume. In contrast, between-hospital variation in expanded thrombolysis in cerebral infarction score is strongly influenced by EVT-patient volume but not by case-mix. Both outcomes may be suitable for comparing hospitals on quality of care, provided that adequate adjustment for case-mix is applied for NIHSS score