Inzicht in de houding van Voedselbankklanten ten opzichte van medische zorg

SamenvattingSinds 2020 voert Provincie Groningen een nieuw armoedebeleid waarbij de nadruk vooral op preventie van armoede ligt. Voedselbank Groningen Stad levert een bijdrage door een Tienpuntenplan op te stellen om mogelijkheden uit te lichten ter voorkoming van armoedeproblemen in Groningen. Eén van de beschreven mogelijkheden gaat over nalatig gebruik van gezondheidszorg onder klanten van Voedselbank Groningen Stad.Om deze hypothese te onderzoeken is de onderzoeksvraag ‘Wat is de houding van klanten van Voedselbank Groningen Stad ten aanzien van medische zorg?’ opgesteld. Aan de hand van literatuurstudie en descriptieve analyse van 49 interviews met klanten van Voedselbank Groningen Stad is de invloed van financiële krapte op de (lichamelijke en mentale) gezondheid, zorggebruik en de houding van de bezoekers van Voedselbank Groningen Stad ten opzichte van medische zorg in kaart gebracht.De onderzoeksresultaten wijzen uit dat klanten van Voedselbank Groningen Stad gebruikmaken van gezondheidszorg en over het algemeen de medische zorg bereikbaar vinden, maar ook regelmatig zorgmijdend gedrag vertonen. De drempels voor het zoeken en gebruik maken van medische hulp zijn met name te vinden in de kosten van medische zorg enerzijds en anderzijds, in bestaande twijfels over de betrouwbaarheid van medische zorg. Zorgmijding door kosten kan vooral worden verklaard door betaalbaarheid; respondenten verwachten dat zorggebruik samengaat met kosten voor specialistenbezoek, behandeling of medicatie. Zorgmijding door wantrouwen kan daarentegen mogelijk worden verklaard door de mate van health literacy (gezondheidsvaardigheden), waardoor de respondenten de (huis)arts moeilijker kunnen begrijpen en het lastig vinden om het zorgsysteem te doorgronden.Zowel respondenten als literatuur gaven suggesties voor implicaties om de ervaren drempels op te heffen. Om de betaalbaarheid van gezondheidszorg te vergroten zou een inkomensafhankelijk eigen risico een optie zijn. Ook kan er gedacht worden aan het vergoeden vanuit tandartskosten vanuit het basispakket. Om het vertrouwen in de gezondheidszorg toe te laten nemen bij individuen met minder health literacy zouden (huis)artsen meer aandacht kunnen vestigen op differentiatie tussen verschillende groepen in de samenleving; bijvoorbeeld door minder vaktaal te gebruiken

Comprehensive Gene-Expression Survey Identifies Wif1 as a Modulator of Cardiomyocyte Differentiation

During chicken cardiac development the proepicardium (PE) forms the epicardium (Epi), which contributes to several non-myocardial lineages within the heart. In contrast to Epi-explant cultures, PE explants can differentiate into a cardiomyocyte phenotype. By temporal microarray expression profiles of PE-explant cultures and maturing Epi cells, we identified genes specifically associated with differentiation towards either of these lineages and genes that are associated with the Epi-lineage restriction. We found a central role for Wnt signaling in the determination of the different cell lineages. Immunofluorescent staining after recombinant-protein incubation in PE-explant cultures indicated that the early upregulated Wnt inhibitory factor-1 (Wif1), stimulates cardiomyocyte differentiation in a similar manner as Wnt stimulation. Concordingly, in the mouse pluripotent embryogenic carcinoma cell line p19cl6, early and late Wif1 exposure enhances and attenuates differentiation, respectively. In ovo exposure of the HH12 chicken embryonic heart to Wif1 increases the Tbx18-positive cardiac progenitor pool. These data indicate that Wif1 enhances cardiomyogenesis

Occurrence and timing of withdrawal of life-sustaining measures in traumatic brain injury patients: a CENTER-TBI study

Funder: National Institute for Health Research (UK)Abstract: Background: In patients with severe brain injury, withdrawal of life-sustaining measures (WLSM) is common in intensive care units (ICU). WLSM constitutes a dilemma: instituting WLSM too early could result in death despite the possibility of an acceptable functional outcome, whereas delaying WLSM could unnecessarily burden patients, families, clinicians, and hospital resources. We aimed to describe the occurrence and timing of WLSM, and factors associated with timing of WLSM in European ICUs in patients with traumatic brain injury (TBI). Methods: The CENTER-TBI Study is a prospective multi-center cohort study. For the current study, patients with traumatic brain injury (TBI) admitted to the ICU and aged 16 or older were included. Occurrence and timing of WLSM were documented. For the analyses, we dichotomized timing of WLSM in early (< 72 h after injury) versus later (≥ 72 h after injury) based on recent guideline recommendations. We assessed factors associated with initiating WLSM early versus later, including geographic region, center, patient, injury, and treatment characteristics with univariable and multivariable (mixed effects) logistic regression. Results: A total of 2022 patients aged 16 or older were admitted to the ICU. ICU mortality was 13% (n = 267). Of these, 229 (86%) patients died after WLSM, and were included in the analyses. The occurrence of WLSM varied between regions ranging from 0% in Eastern Europe to 96% in Northern Europe. In 51% of the patients, WLSM was early. Patients in the early WLSM group had a lower maximum therapy intensity level (TIL) score than patients in the later WLSM group (median of 5 versus 10) The strongest independent variables associated with early WLSM were one unreactive pupil (odds ratio (OR) 4.0, 95% confidence interval (CI) 1.3–12.4) or two unreactive pupils (OR 5.8, CI 2.6–13.1) compared to two reactive pupils, and an Injury Severity Score (ISS) if over 41 (OR per point above 41 = 1.1, CI 1.0–1.1). Timing of WLSM was not significantly associated with region or center. Conclusion: WLSM occurs early in half of the patients, mostly in patients with severe TBI affecting brainstem reflexes who were severely injured. We found no regional or center influences in timing of WLSM. Whether WLSM is always appropriate or may contribute to a self-fulfilling prophecy requires further research and argues for reluctance to institute WLSM early in case of any doubt on prognosis

How do 66 European institutional review boards approve one protocol for an international prospective observational study on traumatic brain injury? Experiences from the CENTER-TBI study

Abstract: Background: The European Union (EU) aims to optimize patient protection and efficiency of health-care research by harmonizing procedures across Member States. Nonetheless, further improvements are required to increase multicenter research efficiency. We investigated IRB procedures in a large prospective European multicenter study on traumatic brain injury (TBI), aiming to inform and stimulate initiatives to improve efficiency. Methods: We reviewed relevant documents regarding IRB submission and IRB approval from European neurotrauma centers participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI). Documents included detailed information on IRB procedures and the duration from IRB submission until approval(s). They were translated and analyzed to determine the level of harmonization of IRB procedures within Europe. Results: From 18 countries, 66 centers provided the requested documents. The primary IRB review was conducted centrally (N = 11, 61%) or locally (N = 7, 39%) and primary IRB approval was obtained after one (N = 8, 44%), two (N = 6, 33%) or three (N = 4, 23%) review rounds with a median duration of respectively 50 and 98 days until primary IRB approval. Additional IRB approval was required in 55% of countries and could increase duration to 535 days. Total duration from submission until required IRB approval was obtained was 114 days (IQR 75–224) and appeared to be shorter after submission to local IRBs compared to central IRBs (50 vs. 138 days, p = 0.0074). Conclusion: We found variation in IRB procedures between and within European countries. There were differences in submission and approval requirements, number of review rounds and total duration. Research collaborations could benefit from the implementation of more uniform legislation and regulation while acknowledging local cultural habits and moral values between countries

Primary versus early secondary referral to a specialized neurotrauma center in patients with moderate/severe traumatic brain injury: a CENTER TBI study

Funder: ZNS - Hannelore Kohl Stiftung; doi: http://dx.doi.org/10.13039/501100007731Funder: Integra LifeSciences CorporationFunder: OneMindAbstract: Background: Prehospital care for patients with traumatic brain injury (TBI) varies with some emergency medical systems recommending direct transport of patients with moderate to severe TBI to hospitals with specialist neurotrauma care (SNCs). The aim of this study is to assess variation in levels of early secondary referral within European SNCs and to compare the outcomes of directly admitted and secondarily transferred patients. Methods: Patients with moderate and severe TBI (Glasgow Coma Scale < 13) from the prospective European CENTER-TBI study were included in this study. All participating hospitals were specialist neuroscience centers. First, adjusted between-country differences were analysed using random effects logistic regression where early secondary referral was the dependent variable, and a random intercept for country was included. Second, the adjusted effect of early secondary referral on survival to hospital discharge and functional outcome [6 months Glasgow Outcome Scale Extended (GOSE)] was estimated using logistic and ordinal mixed effects models, respectively. Results: A total of 1347 moderate/severe TBI patients from 53 SNCs in 18 European countries were included. Of these 1347 patients, 195 (14.5%) were admitted after early secondary referral. Secondarily referred moderate/severe TBI patients presented more often with a CT abnormality: mass lesion (52% vs. 34%), midline shift (54% vs. 36%) and acute subdural hematoma (77% vs. 65%). After adjusting for case-mix, there was a large European variation in early secondary referral, with a median OR of 1.69 between countries. Early secondary referral was not associated with functional outcome (adjusted OR 1.07, 95% CI 0.78–1.69), nor with survival at discharge (1.05, 0.58–1.90). Conclusions: Across Europe, substantial practice variation exists in the proportion of secondarily referred TBI patients at SNCs that is not explained by case mix. Within SNCs early secondary referral does not seem to impact functional outcome and survival after stabilisation in a non-specialised hospital. Future research should identify which patients with TBI truly benefit from direct transportation

Understanding the context of network traffic alerts

For the protection of critical infrastructures against complex virus attacks, automated network traffic analysis and deep packet inspection are unavoidable. However, even with the use of network intrusion detection systems, the number of alerts is still too large to analyze manually. In addition, the discovery of domain-specific multi stage viruses (e.g., Advanced Persistent Threats) are typically not captured by a single alert. The result is that security experts are overloaded with low-level technical alerts where they must look for the presence of an APT. In this paper we propose an alert-oriented visual analytics approach for the exploration of network traffic content in multiple contexts. In our approach CoNTA (Contextual analysis of Network Traffic Alerts), experts are supported to discover threats in large alert collections through interactive exploration using selections and attributes of interest. Tight integration between machine learning and visualization enables experts to quickly drill down into the alert collection and report false alerts back to the intrusion detection system. Finally, we show the effectiveness of the approach by applying it on real world and artificial data sets