MUD JEANS. A Circular Economy Business Model Case

This report presents the case study corresponding to the retail company MUD Jeans, which has been selected by the R2π project given its importance in the world fashion market. The adoption of a circular model by fashion companies is extremely important, given the huge social, economic, and environmental impact of this industry. This report presents the analysis of the MUD Jeans business model. The objective of the report is to offer a holistic view of how the MUD Jeans circular business model creates, delivers, and captures value. We obtained this holistic view through analysis and synthesis of the business context in which MUD Jeans operates and their business model, followed by an assessment of the circularity of their business model. MUD Jeans is a company with a truly circular ambition: a world without waste. They have a clear and specific vision about circular value creation and are acting on it. Their business model is a circular business model designed from scratch and implements a variety of circular business model patterns. They implement the Circular Sourcing pattern using both recycled jeans (40%) and bio-organic cotton (60%). They implement the Recondition pattern by turning worn and leased jeans into vintage jeans. They implement the Performance pattern by offering a long-lasting and stylish product making people look good while contributing to a sustainable lifestyle. Customers of MUD Jeans are conscious men and women. Initially their customers were confined to a small niche, vegans. Currently, more and more people are wearing their jeans, either by buying (75%) or leasing them (25%). Customers get free repairs if required. Besides that, MUD Jeans offers customer service like any other fashion company. Many customers like their fashionable and modern jeans so much that they actively share why and what they buy or lease from MUD Jeans. This active community leads to word of mouth that grows the customer base as well as sharing the story about their vision and mission. In everything they do, there is the drive to further decouple growth from social and environmental impact. MUD Jeans received several awards for their innovative approach in the fashion industry. At the core of how they organize value creation is their circular design approach, which is implemented and executed with a number of strong partners, who share a similar vision about changing the fashion industry. The report contains an in-depth analysis and assessment of the MUD Jeans business model in order to better understand the design and dynamics of their circular value creation. We also provide a detailed look at the business context in which MUD Jeans operates. Important contextual factors are the explosion of production and the associated negative effects, consumer awareness of the negative effects of fast fashion, and the growing need of personalized and customized products and experiences. The business model is presented visually using the Business Model Canvas, both the big picture and at a more detailed level. The MUD Jeans business model is consistently designed and implemented, with clearly defined strategic choices underpinning their model. They have a very strong value network with partners that share a similar vision and help each other succeed in bringing circular fashion to the market. We also include an assessment of the strengths and weaknesses of the building blocks of the business model as well as an assessment of the opportunities and threats for the business as a whole. Three options for future business models are also identified: 1) a shift towards a new customer segment, 2) a shift in the value proposition, and 3) shift in using new materials. MUD Jeans has traction in the market and is a serious circular company now. They are on a growth trajectory both in terms of increasing customers and revenues as well as decreasing socio-environmental impacts. Their loyal and active customers and strong partnerships work as an enabler in this. The media these days is also paying close attention to these new ways of creating, delivering, and capturing value. There are still some barriers to overcome. Circular business models are treated in the same way as traditional business models with respect to taxes. Another barrier is the financial evaluation of leased jeans, without much recognition of the value of materials that is retained for the long term. It is also difficult for MUD Jeans to find the right investor to double down on growth. The report concludes with guidelines for entrepreneurs to make better strategic choices as well as recommendations for policy makers to accelerate circular value creation.This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No. 73037

Comparison of capillary and venous blood sampling for routine coagulation assays

Objectives: Capillary blood samples are generally assumed as unsuitable for coagulation testing since it is recognized that contamination with tissue factor and dilution with tissue fluid affects the coagulation assay. However, limited data is available about coagulations assays in which capillary blood sampling is compared to the standard venous blood withdrawal method. The aim of this study was to perform a method comparison between capillary and venous blood sampling for routine coagulation assays. Methods: Both venous and capillary (finger stick) blood samples were collected from 188 healthy volunteers and patients. In citrate plasma, International Normalized Ratio (INR), prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), fibrinogen, and D-dimer were measured according to routine protocols using the ACL-TOP 750 LAS (Werfen) coagulation analyzer. Regression analysis was performed and the mean relative difference between capillary and venous sampling was reflected to the total allowable error (TEa). Results: Strong correlations and acceptable variations, using the TEa as decision limit, were found for INR, PT, TT, fibrinogen, and D-dimer between capillary and venous sampling. However, capillary sampling resulted in significant shorter APTT values when using the standard APTT-SP Liquid reagent with a mean bias of −10.4% [95% CI −12.4 to −8.4]. Conclusion: Based on these results, capillary blood sampling proved to be an alternative blood withdrawal method for routine coagulation assays, with the exception of APTT, if a venipuncture is unavailable or undesired

Evaluation and management of leukolysis-mediated pseudohyperkalemia in paediatric leukemic samples

Leukolysis-related pseudohyperkalemia due to preanalytical procedures may lead to erroneous (or absence of) treatment based on an invalid lab test result. We aimed to obtain a leukocyte threshold above which leukolysis-related pseudohyperkalemia becomes clinical relevant. Secondly, temporal dynamics of treatment-induced leukocyte decrease were studied to allow tailored implementation of laboratory information system (LIS) decision rules based on the leukocyte threshold to avoid leukolysis-related pseudohyperkalemia. Potassium results of AU5811 routine chemistry (Beckman Coulter, Brea, California, USA) and iStat point of care (POC) (Abbott Diagnostics, Chicago, Illinois, USA) analysers were compared, the latter method being insensitive to leukolysis caused by pre-analytical procedures. Potassium results were combined with leukocyte counts obtained using a Cell-Dyn Sapphire haematology analyser (Abbott Diagnostics, Santa Clara, California, USA), resulting in 132 unique data triplets. Regression analysis was performed to establish a leukocyte threshold. The Reference Change Value (√2 x Z x √(CVa2 + CVi2)) was used to calculate maximum allowable difference between routine analyser and POC potassium results (deltamax + 0.58 mmol/L). Temporal analysis on the treatment-induced leukocyte decrease was performed by plotting leukocyte counts in time for all patients above the threshold leukocyte count (N = 41). Established leukocyte threshold was 63 x109/L. Temporal analysis showed leukocyte counts below the threshold within 8 days of treatment for all patients. Based on performed analyses we were able to implement LIS decision rules to reduce pseudohyperkalemia due to preanalytical procedures. This implementation can contribute to a reduction in erroneous (or absence of) treatments in the clinic

Stability and comparison of complete blood count parameters between capillary and venous blood samples

Introduction: This study assessed the comparability of complete blood count (CBC) parameters between capillary and venous samples, and extended previous research by examining the influence of different storage temperatures on CBC stability up to 7 days after sample collection. Methods: Venous and capillary blood samples were collected from 93 adult patients. Hemoglobin (Hb), hematocrit (Ht), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), mean platelet volume (MPV), leukocytes, lymphocytes, basophils, eosinophils, erythrocytes, red cell distribution width (RDW), immature granulocytes (IG), immature reticulocyte fraction (IRF), monocytes, neutrophils, platelets, and reticulocytes were measured. Deming regression and mean relative differences between venous and capillary measurements were contrasted with desirable total allowable error (TEa). Stability was assessed in 20–27 venous blood samples stored at 4, 21–22, or 30°C, and analyzed at 0, 24, 48, 72, 96, 120, 144, and 168 h. Mean relative change with respect to baseline measurements was compared to the desirable TEa to determine acceptable stability. Results: Deming regression demonstrated strong linear correlations and acceptable variation between venous and capillary measurements. Erythrocytes, Hb, Ht, MCH, MCV, RDW, reticulocytes, and platelets showed acceptable stability for at least 96 h at 4°C. Mean relative change exceeded desirable TEa after 24 h at 30°C for all parameters, except erythrocytes, Hb, leukocytes, and MCH. Conclusion: Clinical laboratory specialists and clinicians should be aware of potential differences between venous and capillary measurements, and the influence of storage conditions. Clinical validity of delayed CBC analysis depends on the clinical situation and required precision of the result

Analysis of C-reactive protein from finger stick dried blood spot to predict high risk of cardiovascular disease

C-reactive protein (CRP) is an acute-phase protein involved in inflammation. Furthermore, CRP is an important biomarker used in diagnostics to predict risk of cardiovascular disease (CVD) in addition to monitoring bacterial and viral infections. To measure plasma CRP, venipuncture is still necessitated and has to be performed by trained phlebotomists. As a solution, dried blood spots (DBS) are used for minimally invasive at-home sampling of blood and can be send to diagnostic laboratories by regular mail. In this study, we included 53 patients that presented to the outpatient clinic of the University Medical Center Utrecht. Capillary finger stick was used to spot blood on a filter paper card and allowed to dry. After extraction of DBS, CRP was analyzed on an automated high-throughput chemistry analyzer. Additional validation steps regarding stability, effect of hematocrit, precision, and limits of blank and quantitation were conducted according to corresponding Clinical and Laboratory Standards Institute standards. An excellent regression analysis of R2 (95% confidence interval) = 0.986 (0.982–0.989) was found. This enabled correct classification for high CVD risk of all 25 cases with sensitivity (95% CI) of 1.00 (1.00–1.00) and specificity (95% CI) of 0.96 (0.89–1.03) and correct diagnosis of inflammation of 12/13 cases with sensitivity (95% CI) of 0.92 (0.77–1.07) and specificity (95% CI) of 1.00 (1.00–1.00). Furthermore, CRP was found to be stable for 31 days and observed hematocrit variation amongst patients was clinically acceptable. CRP from DBS can be accurately measured on an automated high-throughput chemistry analyzer and used to diagnose inflammation and classify high CVD risk. This method enables individuals to engage in at-home sampling of blood on DBS for (tele)diagnostics, screening programs, patient follow-up, and medication management

Improving acute kidney injury alerts in tertiary care by linking primary care data: An observational cohort using routine care data

OBJECTIVE: Acute kidney injury (AKI) is easily missed and underdiagnosed in routine clinical care. Timely AKI management is important to decrease morbidity and mortality risks. We recently implemented an AKI e-alert at the University Medical Center Utrecht, comparing plasma creatinine concentrations with historical creatinine baselines, thereby identifying patients with AKI. This alert is limited to data from tertiary care, and primary care data can increase diagnostic accuracy for AKI. We assessed the added value of linking primary care data to tertiary care data, in terms of timely diagnosis or excluding AKI. METHODS: With plasma creatinine tests for 84,984 emergency department (ED) visits, we applied the Kidney Disease Improving Global Outcome guidelines in both tertiary care-only data and linked data and compared AKI cases. RESULTS: Using linked data, the presence of AKI could be evaluated in an additional 7886 ED visits. Sex- and age-stratified analyses identified the largest added value for women (an increase of 4095 possible diagnoses) and patients ≥60 years (an increase of 5190 possible diagnoses). We observed 398 additional visits where AKI was diagnosed, as well as 185 cases where AKI could be excluded. We observed no overall decrease in time between baseline and AKI diagnosis (28.4 days vs. 28.0 days). For cases where AKI was diagnosed in both data sets, we observed a decrease of 2.8 days after linkage, indicating a timelier diagnosis of AKI. CONCLUSIONS: Combining primary and tertiary care data improves AKI diagnostic accuracy in routine clinical care and enables timelier AKI diagnosis

Ambiguous definitions for baseline serum creatinine affect acute kidney diagnosis at the emergency department

Background: Acute kidney injury (AKI) incidence is increasing, however AKI is often missed at the emergency department (ED). AKI diagnosis depends on changes in kidney function by comparing a serum creatinine (SCr) measurement to a baseline value. However, it remains unclear to what extent different baseline values may affect AKI diagnosis at ED. Methods: Routine care data from ED visits between 2012 and 2019 were extracted from the Utrecht Patient Oriented Database. We evaluated baseline definitions with criteria from the RIFLE, AKIN and KDIGO guidelines. We evaluated four baseline SCr definitions (lowest, most recent, mean, median), as well as five different time windows (up to 365 days prior to ED visit) to select a baseline and compared this to the first measured SCr at ED. As an outcome, we assessed AKI prevalence at ED. Results: We included 47,373 ED visits with both SCr-ED and SCr-BL available. Of these, 46,100 visits had a SCr-BL from the − 365/− 7 days time window. Apart from the lowest value, AKI prevalence remained similar for the other definitions when varying the time window. The lowest value with the − 365/− 7 time window resulted in the highest prevalence (21.4%). Importantly, applying the guidelines with all criteria resulted in major differences in prevalence ranging from 5.9 to 24.0%. Conclusions: AKI prevalence varies with the use of different baseline definitions in ED patients. Clinicians, as well as researchers and developers of automatic diagnostic tools should take these considerations into account when aiming to diagnose AKI in clinical and research settings

GFR estimation is complicated by a high incidence of non-steady-state serum creatinine concentrations at the emergency department

Background Acquiring a reliable estimate of glomerular filtration rate (eGFR) at the emergency department (ED) is important for clinical management and for dosing renally excreted drugs. However, renal function formulas such as CKD-EPI can give biased results when serum creatinine (SCr) is not in steady-state because the assumption that urinary creatinine excretion is constant is then invalid. We assessed the extent of this by analysing variability in SCr in patients who visited the ED of a tertiary care centre. Methods Data from ED visits at the University Medical Centre Utrecht, the Netherlands between 2012 and 2019 were extracted from the Utrecht Patient Oriented Database. Three measurement time points were defined for each visit: last SCr measurement before visit as baseline (SCr-BL), first measurement during visit (SCr-ED) and a subsequent measurement between 6 and 24 hours during admission (SCr-H1). Non-steady-state SCr was defined as exceeding the Reference Change Value (RCV), with 15% decrease or 18% increase between successive SCr measurements. Exceeding the RCV was deemed as a significant change. Results Of visits where SCr-BL and SCr-ED were measured (N = 47,540), 28.0% showed significant change in SCr. Of 17,928 visits admitted to the hospital with a SCr-H1 after SCr-ED, 27,7% showed significant change. More than half (55%) of the patients with SCr values available at all three timepoints (11,054) showed at least one significant change in SCr over time. Conclusion One third of ED visits preceded and/or followed by creatinine measurement show non-stable serum creatinine concentration. At the ED automatically calculated eGFR should therefore be interpreted with great caution when assessing kidney function

Design, validation and implementation of an automated e-alert for acute kidney injury: 6-month pilot study shows increased awareness

BACKGROUND: Acute kidney injury (AKI) is defined as a sudden episode of kidney failure but is known to be under-recognized by healthcare professionals. The Kidney Disease Improving Global Outcome (KDIGO) guidelines have formulated criteria to facilitate AKI diagnosis by comparing changes in plasma creatinine measurements (PCr). To improve AKI awareness, we implemented these criteria as an electronic alert (e-alert), in our electronic health record (EHR) system. METHODS: For every new PCr measurement measured in the University Medical Center Utrecht that triggered the e-alert, we provided the physician with actionable insights in the form of a memo, to improve or stabilize kidney function. Since e-alerts qualify for software as a medical device (SaMD), we designed, implemented and validated the e-alert according to the European Union In Vitro Diagnostic Regulation (IVDR). RESULTS: We evaluated the impact of the e-alert using pilot data six months before and after implementation. 2,053 e-alerts of 866 patients were triggered in the before implementation, and 1,970 e-alerts of 853 patients were triggered after implementation. We found improvements in AKI awareness as measured by (1) 2 days PCr follow up (56.6-65.8%, p-value: 0.003), and (2) stop of nephrotoxic medication within 7 days of the e-alert (59.2-63.2%, p-value: 0.002). CONCLUSION: Here, we describe the design and implementation of the e-alert in line with the IVDR, leveraging a multi-disciplinary team consisting of physicians, clinical chemists, data managers and data scientists, and share our firsts results that indicate an improved awareness among treating physicians

Non-technical Skills in Healthcare

AbstractNon-technical Skills (NTS) are a set of generic cognitive and social skills, exhibited by individuals and teams, that support technical skills when performing complex tasks. Typical NTS training topics include performance shaping factors, planning and preparation for complex tasks, situation awareness, perception of risk, decision-making, communication, teamwork and leadership. This chapter provides a framework for understanding these skills in theory and practice, how they interact, and how they have been applied in healthcare, as well as avenues for future research