De ammoniakemissie van de Nederlandse melkveehouderij bij een management gelijk aan dat van deelnemers aan "Koeien & Kansen"

De voor 2010 verwachte emissie van ammoniak vanuit de melkveehouderij wordt van 50 kton tot 40 kton teruggebracht als alle melkveehouders hun bedrijfsvoering verbeteren tot het huidige niveau van de 16 voorlopers in het project Koeien & Kansen. Beperking van de emissie is nodig voor het halen van de NEC-doelstellingen die de EU Nederland heeft opgelegd. De belangrijkste bijdrage aan die verbetering wordt geleverd door het beperken van eiwitovermaat in het rantsoen van het melkvee, waardoor de stikstofexcretie van de dieren lager wordt. Ook het beperken van het aantal stuks vee, door een hogere melkproductie per koe en niet meer jongvee aan te houden dan strikt nodig is om koeien te vervangen, werkt sterk door in de ammoniakverliezen. De stal blijft de belangrijkste ammoniakbron. Uit welzijnsoverwegingen neemt de ventilatie uit rundveestallen toe wat de ammoniakvervluchtiging bevordert. Aanbevolen wordt veehouders te helpen hun vakmanschap te verbeteren en de waardering voor goed vakmanschap tot uiting te laten komen in de wetgeving. Trefwoorden: ammoniak, melkveehouderij, milieu, Koeien & Kansen, NEC-richtlij

Evidence and guidelines in otorhinolaryngology: the merits of evidence-based case reports

Evidence-based medicine refers to the conscientious, explicit and judicious use of the current best evidence to support decision making at point of care. To facilitate the transition of evidence into daily practice several evidence-based otorhinolaryngology guidelines have been developed. In this thesis we first describe a survey among Dutch otorhinolaryngologists to study their current awareness, knowledge, and opinion of these evidence based guidelines since clinical uptake of guidelines is of high importance. Our results show that Dutch otorhinolaryngologists are familiar with the available guidelines and a majority uses them in daily practice. Most choose treatment consistent with the guideline. The lack of strict recommendations in guidelines can be difficult to use directive, but it also gives room for flexibility and preferences of doctors and patients when selecting treatment. Since guidelines have such a prominent role in clinical practice, it is important that recommendations in these guidelines are formulated in the same systematic and transparent way, based on the best available evidence. If different guidelines are substantiated from similar scientific studies, they will generate similar conclusions and corresponding recommendations. However, in a comparative study between English (SIGN) Dutch (CBO) and American (ICSI) guidelines for the diagnosis and treatment of patients with obstructive sleep apnea syndrome (OSAS), we come to the conclusion that these guidelines focus on different aspects of the management of OSAHS. Furthermore, for similar clinical questions these 3 guidelines showed conflicting conclusions (11%-18%), differences in attached levels of evidence (32%-63%), and remarkable discrepancies in cited studies. A plausible explanation for these differences is the citation preference for papers from members of the guideline work group and from own country. Despite different publication dates, more recent guidelines fail to cite earlier published guidelines. Despite the generally accepted approach regarding the development of Evidence Based guidelines, remarkable differences exist between guidelines from different countries on the same clinical subject. At last, we emphasize the potential additive value of Evidence Based Case Reports (EBCR’s) to earlier reported limitations of the current evidence based guideline development. An EBCR starts with a knowledge gap identified in daily practice regarding diagnosis, prognosis, or interventions. An explicit and transparent approach is followed, and practical best evidence summaries are provided that are applicable to specific patient management issues. EBCR’s may play a role in guideline development since evidence is transparently separated from judgement. EBCR’s can be used to assist guideline panel consensus sessions. An apparent definition of knowledge gaps and a formal system for rating the evidence can be used. Subsequently, recommendations can be progressively formed by the guideline panel using a considered judgement approach during a group decision making process, instead of being based on so-called “expert discussion”. Furthermore, EBCR’s can also be used in the formation or adjustment of local diagnostic and treatment protocols, and assist in developing interactive media, to further improve evidence and guidelines in otorhinolaryngolog

De ammoniakemissie van de Nederlandse melkveehouderij bij een management gelijk aan dat van deelnemers aan "Koeien & Kansen"

De voor 2010 verwachte emissie van ammoniak vanuit de melkveehouderij wordt van 50 kton tot 40 kton teruggebracht als alle melkveehouders hun bedrijfsvoering verbeteren tot het huidige niveau van de 16 voorlopers in het project Koeien & Kansen. Beperking van de emissie is nodig voor het halen van de NEC-doelstellingen die de EU Nederland heeft opgelegd. De belangrijkste bijdrage aan die verbetering wordt geleverd door het beperken van eiwitovermaat in het rantsoen van het melkvee, waardoor de stikstofexcretie van de dieren lager wordt. Ook het beperken van het aantal stuks vee, door een hogere melkproductie per koe en niet meer jongvee aan te houden dan strikt nodig is om koeien te vervangen, werkt sterk door in de ammoniakverliezen. De stal blijft de belangrijkste ammoniakbron. Uit welzijnsoverwegingen neemt de ventilatie uit rundveestallen toe wat de ammoniakvervluchtiging bevordert. Aanbevolen wordt veehouders te helpen hun vakmanschap te verbeteren en de waardering voor goed vakmanschap tot uiting te laten komen in de wetgeving. Trefwoorden: ammoniak, melkveehouderij, milieu, Koeien & Kansen, NEC-richtlij

Publications on clinical research in otolaryngology–a systematic analysis of leading journals in 2010

Background: We wanted to asses and characterize the volume of Otolaryngology publications on clinical research, published in major journals. Methods and Material: To assess volume and study type of clinical research in Otolaryngology we performed a literature search in high impact factor journals. We included 10 high impact factor Otolaryngology journals and 20 high impact factor medical journals outside this field (2011). We extracted original publications and systematic reviews from 2010. Publications were classified according to their research question, that is therapy, diagnosis, prognosis or etiology. Results: From Otolaryngology journals (impact factor 1.8 to 2.8) we identified 694 (46%) publications on original observations and 27 (2%) systematic reviews. From selected medical journals (impact factor 6.0 to 101.8) 122 (2%) publications related to Otolaryngology, 102 (83%) were on original observations and 2 (0.04%) systematic reviews. The most common category was therapy (40%). Conclusion: Half of publications in Otolaryngology concerns clinical research, which is higher than other specialties. In medical journals outside the field of Otolaryngology, a small proportion (2%) of publications is related to Otolaryngology. Striking is that systematic reviews, which are considered high level evidence, make up for only 2% of publications. We must ensure an increase of clinical research for optimizing medical practice

Healthcare utilisation, follow-up of guidelines and practice variation on rhinosinusitis in adults: A healthcare reimbursement claims study in The Netherlands

Objectives: To provide insight into healthcare utilisation of rhinosinusitis, compare data with clinical practice guideline recommendations and assess practice variation. Design: Anonymised data from claims reimbursement registries of healthcare insurers were analysed, from 1 January 2016 until 31 December 2016. Setting: Secondary and tertiary care in the Netherlands. Participants: Patients ≥18 years with diagnostic code “sinusitis.”. Main outcome measures: Healthcare utilisation (prevalence, co-morbidity, diagnostic testing, surgery), costs, comparison with guideline recommendation, practice variation. Results: We identified 56 825 patients, prevalence was 0.4%. Costs were € 45 979 554—that is 0.2% of total hospital-related care costs (€21 831.3 × 106). Most patients were <75 years, with a slight female preponderance. 29% had comorbidities (usually COPD/asthma). 9% underwent skin prick testing, 61% nasal endoscopy, 2% X-ray and 51% CT. Surgery rate was 16%, mostly in daycare. Nearly, all surgical procedures were performed endonasally and concerned the maxillary and/or ethmoid sinus. Seven recommendations (25%) could be (partially) compared to the distribution of claims data. Except for endoscopy, healthcare utilisation patterns were in line with guideline recommendations. We compared results for three geographical regions and found generally corresponding rates of diagnostic testing and surgery. Conclusion: Prevalence was lower than reported previously. Within the boundaries of guideline recommendations, we encountered acceptable variation in healthcare utilisation in Dutch hospitals. Health reimbursement claims data can provide insight into healthcare utilisation, but they do not allow evaluation of the quality and outcomes of care, and therefore, results should be interpreted with caution

Otolaryngologists adhere to evidence-based guidelines for chronic rhinosinusitis

PurposeTo assess awareness of, opinion about and adherence to evidence-based guidelines on chronic rhinosinusitis among Dutch Otolaryngologists.MethodsWe assessed implementation of two guidelines, one Dutch and one European, that are both intended for diagnosis and treatment of patients with chronic rhinosinusitis. We invited 485 Otolaryngologists to fill out a questionnaire and report on their opinion on and adherence to the guidelines. The adherence was further tested by 4 clinical case scenarios, derived from guideline recommendations.Results166 (34%) completed the questionnaire. 99% of the respondents was aware of one or both guidelines. Most respondents (90%) consider the guidelines as directing or supportive for their clinical practice based on the clinical case scenarios, between 62 and 99% of the respondents act according to guidelines. Concerning diagnosis, CT-imaging is performed more and allergy testing less than recommended. Where multiple treatment options are recommended, the responses are more heterogeneous as a result of this. Nonetheless, high recommended treatment was chosen more often. Otolaryngologists were reluctant in surgical treatment as a first option, which is according to the guidelines.ConclusionsOverall, both the EPOS and CBO guideline are well known among Dutch Otolaryngologists and 90% indicates that the guideline is important in their daily practice. Adherence to the guidelines is sufficient to high. If multiple treatment or diagnostic options are recommended this leads to a more heterogeneous response pattern. Recommendations with a high grade of recommendation were followed up most often.Otorhinolaryngolog

A comparison of international clinical practice guidelines on adult chronic rhinosinusitis shows considerable variability of recommendations for diagnosis and treatment

Objectives: To compare international clinical practice guidelines on adult chronic rhinosinusitis (CRS). Design: Extensive literature search in Embase, PubMed and the internet (Google, websites of well-known guideline organizations) on November 21st 2018. Main outcome measures: Guidelines’ quality was measured by the AGREE II instrument. A summary and comparison of recommendations on diagnosis and treatment with harmonized levels of evidence (LoE) and grade of recommendations (GoR) is given. Results: We selected ten guidelines on CRS. Five guidelines were of sufficient to high quality according to AGREE II, the remaining guidelines predominantly did not meet AGREE II criteria. We harmonized all guideline recommendations so we could compare them, although three guidelines did not provide a LoE. Five guidelines provided recommendations on diagnosis, all of them recommended performing nasal endoscopy, CT scan and allergy testing (with varying GoRs). All ten guidelines provided recommendations on therapy, one treatment, i.e., the use of intranasal steroids, was recommended by all guidelines (with varying GoRs). Recommendations for surgical treatment of CRS were provided by five guidelines. Conclusion: We performed an extensive search and included ten (inter)national guidelines on CRS for adults. According to AGREE II, five were of good or sufficient quality. Overall, there was much variation between guidelines in recommended diagnostic test or treatment, direction of evidence and GoR. We found consensus for nasal endoscopy, CT scan, allergy testing and intranasal steroids. We argue for standardization of guideline development, to increase their quality and improve comparability

No evidence for distinguishing bacterial from viral acute rhinosinusitis using fever and facial/dental pain: a systematic review of the evidence base

Objective To assess the diagnostic value of fever and facial and dental pain in adults suspected of acute bacterial rhinosinusitis. Data Sources PubMed, EMBASE, and the Cochrane Library. Review Methods A comprehensive systematic search was performed on March 18, 2013. We included articles reporting studies on the diagnostic value of fever or facial and dental pain in patients suspected of acute bacterial rhinosinusitis. For included articles, the reported study design was assessed for directness of evidence and risk of bias. Prevalences, positive predictive values, and negative predictive values were extracted. Results Of 3171 unique records, we included 1 study with a high directness of evidence and a moderate risk of bias. The prior probability of bacterial rhinosinusitis was 0.29 (95% confidence interval: 0.24 to 0.35). We could not extract posterior probabilities with accompanying positive and negative predictive values. The study reported an odds ratio from univariate analysis for fever of 1.02 (0.52 to 2.00) and 1.65 (0.83 to 3.28) for facial and dental pain. In subsequent multivariate analysis, the odds ratio of facial and dental pain was 1.86 (1.06 to 3.29). Conclusion and Recommendation There is 1 study with moderate risk of bias, reporting data in such a manner that we could not assess the value of fever and facial and dental pain in adults suspected of an acute bacterial rhinosinusitis. Therefore, these symptoms should not be used in clinical practice to distinguish between a bacterial and viral source of acute rhinosinusitis or for decision making about prescribing antibiotic treatment