From protocol to personalised care: improving and tailoring diabetes management in general practice

To improve primary diabetes care in the Netherlands, in 2007 a ‘care group’ system is initiated. We first studied the association between adherence to a structured diabetes protocol and patient outcomes. We then investigated what practices actually require when seeking to adjust care to patient needs. With that aim in mind, we explored the effect of dispensing with protocol and the key conditions for successful implementation of self-management interventions. Finally, we measured patient outcomes with regard to treatment satisfaction, quality of life and monitoring.A structured care protocol has added value for people with diabetes; the proportion of people having recommended monitoring increases sharply. Practices likely undergo an intensive learning process when they join a care group and appear to reach the same as experienced practice within a year. When comparing the HbA1 levels of people with recommended and incomplete monitoring, we found that the HbA1c levels in people with recommended monitoring are significantly circa 2 mmol/mol lower compared to incomplete monitoring. In other words, recommended monitoring is far more than merely an administrative procedure; it actually reflects better real-world HbA1c levels. Differences in HbA1c level between people with recommended versus incomplete monitoring were greater in vulnerable populations, to the extent of approximately 3 mmol/mol, whereas a circa 1 mmol/mol difference was found in the intermediate category. In other words, within a care group setting people in the deprived category derive the most benefit from recommended monitoring.Protocol-free care provided room for reflection concerning ‘tailored care’; varying self-management interventions were chosen Our study revealed three key conditions for successful implementation of self-management interventions. Considering that patient satisfaction and monitoring decreased, this thesis ends with a roadmap consisting of several recommendations to improve and tailor diabetes care in general practice.Sanof

The provision of education and training for healthcare professionals through the medium of the internet

This paper describes a new initiative to provide Internet based courses to student and professional occupational therapists in four centres in the UK, Belgium the Netherlands and Sweden. The basis of this collaborative Occupational Therapy Internet School (OTIS) is the concept of the “Virtual College”. This comprises the design and implementation of a sophisticated Internet-based system through which courses can be managed, prepared and delivered online in an effective fashion, and where students can communicate both with the staff and their peers. The aim is to support and facilitate the whole range of educational activities within a remote electronic environment. A major feature of the course organisation is the adoption of a problem-based approach in which students will collaborate internationally to propose effective intervention in given case study scenarios. The paper outlines the rationale for OTIS, the content and structure of the courseware, the technical specification of the system and evaluation criteria. In addition to the more conventional web-based learning facilities generally offered, a number of agent-based approaches are being adopted to assist in the management of the course by ensuring the proper delivery of course materials and to assist the functioning of project groups. </p

Reliability and Validity of the Dutch Translation of the Filial Maturity Measure in Informal Caregivers

This study explored the reliability and validity of a Dutch translation of the 10-item Filial Maturity Measure (FMM) in a sample of Dutch informal caregivers. The FMM was translated with a forward–backward method and completed by 93 informal caregivers (62 % response rate) with a need dependent parent. Dimensionality of the Dutch FMM was examined by principal component and internal consistency analyses. Criterion validity was examined by assessing correlations with filial love, filial autonomy and level of closeness between parent and child. Construct validity was tested by examining associations with the traits openness and agreeableness. In addition, the relationship with state and trait affectivity was explored. After removal of the item “I worry about turning out like my parent”, the original dimensional structure, internal consistency, criterion and construct validity were confirmed. Additional exploration of the relation between the FMM subscales and trait and state affectivity scales demonstrated that filial maturity is at most weakly associated with trait affectivity. Both FMM scales showed a positive partial correlation with negative state affectivity. The Dutch FMM appears to be a reliable and valid instrument for measuring filial maturity of informal caregivers who provide care to their need dependent parent. The (non-)functioning of one item pointed to the necessity to validate the FMM, but also questionnaires in general in different population

Complex diffuse radio emission in the merging PLANCK ESZ cluster Abell 3411

We present VLA radio and Chandra X-ray observations of the merging galaxy cluster Abell 3411. For the cluster, we find an overall temperature of 6.4 keV and an X-ray luminosity of 2.8 x 10^{44} erg s^{-1} between 0.5 and 2.0 keV. The Chandra observation reveals the cluster to be undergoing a merger event. The VLA observations show the presence of large-scale diffuse emission in the central region of the cluster, which we classify as a 0.9 Mpc size radio halo. In addition, a complex region of diffuse, polarized emission is found in the southeastern outskirts of the cluster, along the projected merger axis of the system. We classify this region of diffuse emission as a radio relic. The total extent of this radio relic is 1.9 Mpc. For the combined emission in the cluster region, we find a radio spectral index of -1.0 \pm 0.1 between 74 MHz and 1.4 GHz. The morphology of the radio relic is peculiar, as the relic is broken up into five fragments. This suggests that the shock responsible for the relic has been broken up due to interaction with a large-scale galaxy filament connected to the cluster or other substructures in the ICM. Alternatively, the complex morphology reflects the presence of electrons in fossil radio bubbles that are re-accelerated by a shock.Comment: Accepted for publication in ApJ, 8 pages, 5 figure

The evaluation of an integrated network approach of preventive care for children with overweight and obesity:Study protocol for an implementation and effectiveness study

Background: Children with overweight often do not receive appropriate integrated care. An innovative integrated network approach of preventive care for overweight children aged 4-12 years old has been developed and implemented in four neighbourhoods of 's-Hertogenbosch, The Netherlands. This new approach focusses on self-management of the family and is based on the principles of stepped and matched care. Youth health care (YHC) nurses support the families in their new role as central care providers. The aim of this study is to evaluate the implementation and effectiveness of this network approach. Methods: The implementation of the new approach (reach, functioning of the central care provider, network functioning and patient satisfaction) is assessed by interviews and checklists with professionals and parents of 4-12 year old overweight or obese children. To evaluate effectiveness, we aim to compare 120 overweight or obese children in 's-Hertogenbosch with 60 overweight or obese children outside 's-Hertogenbosch during one year of YHC involvement. Quality of life, psychosocial problems of the child and parental empowerment are the main outcomes of the effectiveness study. Outcomes are measured with digital questionnaires at inclusion, at three months and one year after inclusion. BMI measurements and referrals are distracted from medical files. Discussion: Integrated care for overweight and obese children is high on the agenda of many municipalities in The Netherlands. The new approach is expected to have beneficial effects for overweight children, their parents and professionals. With the results of this study, we can optimize the support for overweight and obese children and their parents. The first results are expected to be available in 2019

Serious adverse events and deaths in PCSK9 inhibitor trials reported on ClinicalTrials.gov:a systematic review

Background: Previous reviews of PCSK9 inhibitor trials are limited by a focus on composite cardiovascular outcomes. ClinicalTrials.gov provides trial results for individual clinical outcomes. Aim of this systematic review was to assess the effect of PCSK9 inhibitors on the risk of myocardial infarction, stroke/TIA, heart failure, diabetes mellitus, neurocognitive events, all-cause serious adverse events (SAE), and all-cause deaths as registered on ClinicalTrials.gov. Methods: PubMed, regulatory reports, ClinicalTrials.gov, and company websites were used to search studies. Randomized trials comparing PCSK9 inhibitor with placebo in participants with hypercholesterolemia were eligible. Study characteristics, risk of bias, and numbers of participants with the outcomes of interest were collected. Results: We identified 33 lipid-lowering and 4 clinical outcomes trials with results on ClinicalTrials.gov (n = 16,958 and n = 73,836, respectively). Risk of bias was generally high. PCSK9 inhibitors did not affect the risk of any of the investigated outcomes in either type of trial. However, in clinical outcomes studies, alirocumab decreased the risk of all-cause SAE (OR 0.92; 95% CI 0.86–0.98), and evolocumab probably increased the risk of mortality (OR 1.12; 95% CI 1.00–1.25). Conclusions: Our meta-analysis of clinical events registered on ClinicalTrials.gov did not show that PCSK9 inhibitors improve cardiovascular health. Evolocumab increased the risk of all-cause mortality

Actualisatie excretiecijfers landbouwhuisdieren voor forfaits regeling Meststoffenwet

LNV heeft de Commissie van Deskundigen Meststoffenwet (CDM) gevraagd voor de diercategorieën uit de meststoffenwet de excretiecijfers te valideren en zo nodig te actualiseren. De hiervoor in het leven geroepen werkgroep heeft de forfaits uit de meststoffenwet kritisch vergeleken met de excretiecijfers uit recente rapporten (o.a. CBS) en met de gemiddelde excretiecijfers zoals die met de nu beschikbare informatie worden berekend. De door de CDM verwachte gemiddelde excretie van N en P door melkkoeien in de periode 2006-2009 is hoger dan de in de praktijk gerealiseerde gemiddelde excretie, voornamelijk doordat bij de vaststelling van de verwachte excretie met een geringer aandeel snijmaïs in het rantsoen rekening is gehouden dan in de praktijk nu wordt gerealiseer

Radio continuum observations of new radio halos and relics from the NVSS and WENSS surveys

Radio halos and relics are diffuse radio sources found in galaxy clusters showing significant substructure at X-ray wavelengths. These sources provide important information about non-thermal processes taking place in the ICM. Until now only a few dozen relics and halos are known, while models predict that a much larger number of these sources exist. In this paper we present the results of an extensive observing campaign to search for new diffuse radio sources in galaxy clusters. We discovered 6 new radio relics, including a probable double relic system, and 2 radio halos. In addition, we confirm the presence of diffuse radio emission in four galaxy clusters. By constructing a sample of 35 radio relics we find that relics are mostly found along the major axis of the X-ray emission from the ICM, while their orientation is perpendicular to this axis. This is consistent with the scenario that relics trace merger shock waves. The major and minor axis ratio distribution of the ICM for clusters with relics is also broader than that of the NORAS-REFLEX sample. We compared the X-ray luminosity and redshift distributions of clusters with relics to an X-ray selected sample from the NORAS and REFLEX surveys. We find tentative evidence for an increase of the cluster's relic fraction with X-ray luminosity and redshift. [abridged]Comment: 20 pages, 26 figures, accepted for publication in A\&A on July 14, 201

Pressure-Corrected Carotid Stiffness and Young's Modulus: Evaluation in an Outpatient Clinic Setting

Background: Conventional measures for assessing arterial stiffness are inherently pressure dependent. Whereas statistical pressure adjustment is feasible in (larger) populations, it is unsuited for the evaluation of an individual patient. Moreover, statistical "correction"for blood pressure may actually correct for: (i) the acute dependence of arterial stiffness on blood pressure at the time of measurement; and/or (ii) the remodeling effect that blood pressure (hypertension) may have on arterial stiffness, but it cannot distinguish between these processes. METHODS: We derived - assuming a single-exponential pressure-diameter relationship - 3 theoretically pressure-independent carotid stiffness measures suited for individual patient evaluation: (i) stiffness index β0, (ii) pressure-corrected carotid pulse wave velocity (cPWVcorr), and (iii) pressure-corrected Young's modulus (Ecorr). Using linear regression analysis, we evaluated in a sample of the CATOD study cohort changes in mean arterial pressure (ΔMAP) and comparatively the changes in the novel (Δβ0, ΔcPWVcorr, and ΔEcorr) as well as conventional (ΔcPWV and ΔE) stiffness measures after a 2.9 ± 1.0-year follow-up. RESULTS: We found no association between ΔMAP and Δβ0, ΔcPWVcorr, or ΔEcorr. In contrast, we did find a significant association between ΔMAP and conventional measures ΔcPWV and ΔE. Additional adjustments for biomechanical confounders and traditional risk factors did neither materially change these associations nor the lack thereof. Conclusions: Our newly proposed pressure-independent carotid stiffness measures avoid the need for statistical correction. Hence, these measures (β0, cPWVcorr, and Ecorr) can be used in a clinical setting for (i) patient-specific risk assessment and (ii) investigation of potential remodeling effects of (changes in) blood pressure on intrinsic arterial stiffness