A framework for the systematic implementation of Green-Lean and sustainability in SMEs

Evidence suggests that smaller organisations find the implementation of combined operations- and environmental Sustainability improvement initiatives such as Green-Lean and Sustainability (GLS) challenging. This paper, therefore, develops a framework for the systematic implementation of Green-Lean and Sustainability in small and medium-sized enterprises (SMEs) to achieve long-term improvement of environmental, social and economic processes and performance. A literature assessment of theories, frameworks, and concepts was employed in the study to better comprehend the difficulties confronting the modern business world. In addition, the research employed expert perspectives from the lean, green-lean, and sustainability fields to propose, develop, test, and validate a framework for addressing business concerns. The research uncovers considerable implementation problems, such as employee motivation and integration, responsibilities, and measurements. It also underlines the success factors for the implementation process, such as management, firm- goals and strategy, reviews and audits, vision, and guidance by lean, green and sustainability frameworks. The novelty in this research lies in the approach where Green-Lean and Sustainability are combined and applied in an SME context. The presented framework offers the potential to be implemented in SMEs that operate in different sectors and contexts and are affected by different environmental and social considerations

Commencement of flash glucose monitoring is associated with a decreased rate of depressive disorders among persons with diabetes (FLARE-NL7)

INTRODUCTION: Depressive disorders are more common among persons with diabetes, as compared with persons without diabetes. The burden of glucose management is known to associate with depressive symptoms. This study aims to assess the effects of commencement of FreeStyle Libre flash glucose monitoring (FSL-FGM) on the mental health status of persons with diabetes. RESEARCH DESIGN AND METHODS: Post-hoc analysis of data from a 1-year prospective nationwide FSL-FGM registry. Participants who used FSL-FGM for 12 months and completed the 12-Item Short Form Health Survey version 2 (SF-12v2) questionnaires at baseline, 6 and 12 months were included. An SF-12v2 Mental Component Score (MCS) of ≤45 was used as a cut-off to discriminate between persons with and without a depressive disorder. RESULTS: A total of 674 patients were included with a mean age of 48.2 (±15.8) years, 51.2% men, 78.2% type 1 diabetes and baseline HbA1c 62.8 (±13.4) mmol/mol (7.9±1.2%). At baseline, 235 (34.9%) persons had an SF-12 MCS ≤45 while after 6 and 12 months these numbers decreased: 202 (30.0%, p<0.01) and 173 (25.7%, p<0.01). Overall, MCS improved from 48.5 at baseline to 50.7 after 6 months and 51.3 after 12 months. In multivariable regression analysis, age and MCS at baseline were associated with improvement of MCS after 12 months of FSL-FGM use. CONCLUSIONS: This analysis suggests that use of FSL-FGM is associated with a decreased rate of depressive disorders among persons with diabetes. Future studies are needed to corroborate these findings

Maternal mortality due to cardiovascular disease in the Netherlands:a 21-year experience

Objective Cardiovascular disorders are the leading cause of indirect maternal mortality in Europe. The aim of this study is to present an extensive overview concerning the specific cardiovascular causes of maternal death and to identify avoidable contributing care factors related to these deaths. Methods We assessed all cases of maternal death due to cardiovascular disorders collected by a systematic national confidential enquiry of maternal deaths published by the Dutch Maternal Mortality and Morbidity Committee on behalf of the Netherlands Society of Obstetrics and Gynaecology over a 21-year period (1993-2013) in the Netherlands. Results There were 96 maternal cardiovascular deaths (maternal mortality rate due to cardiovascular diseases 2.4/100,000 liveborn children). Causes were aortic dissection (n & x202f;= 20, 21%), ischaemic heart disease (n & x202f;= 17, 18%), cardiomyopathies (including peripartum cardiomyopathy and myocarditis, n & x202f;= 20, 21%) and (unexplained) sudden death (n & x202f;= 27, 28%). Fifty-five percent of the deaths occurred postpartum (n & x202f;= 55, 55%). Care factors that may have contributed to the adverse outcome were identified in 27 cases (28%). These factors were patient-related in 40% (pregnancy against medical advice, underestimation of symptoms) and healthcare-provider-related in 60% (symptoms not recognised, delay in diagnosis, delay in referral). Conclusion The maternal cardiovascular mortality ratio is low in the Netherlands and the main causes of maternal cardiovascular mortality are in line with other European reports. In a minority of cases, care factors that were possibly preventable were identified. Women with cardiovascular disease should be properly counselled about the risks of pregnancy and the symptoms of complications. Education of care providers regarding the incidence, presentation and diagnosis of cardiovascular disease during pregnancy is recommended

Developing and testing a robotic MRI/CT fusion biopsy technique using a purpose-built interventional phantom.

BACKGROUND: Magnetic resonance imaging (MRI) can be used to target tumour components in biopsy procedures, while the ability to precisely correlate histology and MRI signal is crucial for imaging biomarker validation. Robotic MRI/computed tomography (CT) fusion biopsy offers the potential for this without in-gantry biopsy, although requires development. METHODS: Test-retest T1 and T2 relaxation times, attenuation (Hounsfield units, HU), and biopsy core quality were prospectively assessed (January-December 2021) in a range of gelatin, agar, and mixed gelatin/agar solutions of differing concentrations on days 1 and 8 after manufacture. Suitable materials were chosen, and four biopsy phantoms were constructed with twelve spherical 1-3-cm diameter targets visible on MRI, but not on CT. A technical pipeline was developed, and intraoperator and interoperator reliability was tested in four operators performing a total of 96 biopsies. Statistical analysis included T1, T2, and HU repeatability using Bland-Altman analysis, Dice similarity coefficient (DSC), and intraoperator and interoperator reliability. RESULTS: T1, T2, and HU repeatability had 95% limits-of-agreement of 8.3%, 3.4%, and 17.9%, respectively. The phantom was highly reproducible, with DSC of 0.93 versus 0.92 for scanning the same or two different phantoms, respectively. Hit rate was 100% (96/96 targets), and all operators performed robotic biopsies using a single volumetric acquisition. The fastest procedure time was 32 min for all 12 targets. CONCLUSIONS: A reproducible biopsy phantom was developed, validated, and used to test robotic MRI/CT-fusion biopsy. The technique was highly accurate, reliable, and achievable in clinically acceptable timescales meaning it is suitable for clinical application

Determinants of HbA1c reduction with FreeStyle Libre flash glucose monitoring (FLARE-NL 5)

Aims: To identify factors predicting HbA1c reduction in patients with diabetes mellitus (DM) using FreeStyle Libre Flash Glucose Monitoring (FSL-FGM). Methods: Data from a 12-month prospective nation-wide FSL registry were used and analysed with multivariable regression. For the present study we included patients with hypoglycaemia unawareness or unexpected hypoglycaemias (n = 566) and persons who did not reach acceptable glycaemic control (HbA1c > 70 mmol/mol (8.5%)) (n = 294). People with other indications for use, such as sensation loss of the fingers or individuals already using FSL-FGM or rtCGM, were excluded (37%). Results: Eight hundred and sixty persons (55% male with a mean age of 46.7 (+/- 16.4) years) were included. Baseline HbA1c was 65.1 (+/- 14.5) mmol/mol (8.1 +/- 1.3%), 75% of the patients had type 1 DM and 37% had microvascular complications. Data concerning HbA1c was present for 482 (56.0%) at 6 months and 423 (49.2%) persons at 12 months. A significant reduction in HbA1c (>= 5 mmol/mol (0.5%)) was present in 187 (22%) persons. For these persons, median HbA1c reduction was -9.0 [-13.0, -4.0] mmol/mol (-0.82 [-1.19, -0.37]%) at 6 months and -9.0 [-15.0, -7.0] mmol/mol (-0.82 [-1.37, -0.64]%) at 12 months. In multi-variable regression analysis with age, gender and SF-12 physical and mental component scores as covariates, only baseline HbA1c was significant: -0.319 (SE 0.025; p <0.001; R-2 = 0.240 for the model). In exploratory analysis among subgroups with different indications for FSL-FGM use (hypoglycaemia unawareness or persistently high HbA1c) and persons with a significant HbA1c decrease over the study period, baseline HbA1c remained the only significant predictor. Conclusions: Among the variables we analysed in the present study, only high HbA1c at baseline predicts significant HbA1c reduction during FSL-CGM use

Two-year use of flash glucose monitoring is associated with sustained improvement of glycemic control and quality of life (FLARE-NL-6)

INTRODUCTION: The FreeStyle Libre (FSL) is a flash glucose monitoring (FGM) system. The Flash Monitor Register in the Netherlands (FLARE-NL-4) study previously demonstrated the positive effects of FSL-FGM use during 1 year on glycemic control, quality of life and disease burden among persons with diabetes mellitus (DM). The present follow-up study assesses the effects of FSL-FGM after 2 years. RESEARCH DESIGN AND METHODS: Patients included in the FLARE-NL-4 study who continued FSL-FGM during the 1-year study period were invited to participate (n=687). Data were collected using questionnaires (the 12-Item Short Form Health Survey version 2 (SF-12(v2)) and the EuroQol 5-Dimension 3-Level (EQ-5D-3L) for quality of life), including self-reported hemoglobin A1c (HbA1c). RESULTS: A total of 342 patients agreed to participate: mean age 48.0 (±15.6) years, 52% men and 79.5% with type 1 DM. HbA1c decreased from 60.7 (95% CI 59.1 to 62.3) mmol/mol before use of FSL-FGM to 57.3 (95% CI 55.8 to 58.8) mmol/mol after 1 year and 57.8 (95% CI 56.0 to 59.5) mmol/mol after 2 years. At the end of the 2-year follow-up period, 260 (76%) persons were still using the FSL-FGM and 82 (24%) had stopped. The main reason for stopping FSL-FGM was financial constraints (55%). Concerning the whole 2-year period, there was a significant decrease in HbA1c among persons who continued use of FSL-FGM (−3.5 mmol/mol, 95% CI −6.4 to –0.7), while HbA1c was unaltered compared with baseline among persons who stopped FSL-FGM (−2.4 mmol/mol, 95% CI −7.5 to 2.7): difference between groups 2.2 (95% CI −1.3 to 5.8) mmol/mol. After 2 years, persons who continued use of FSL-FGM had higher SF-12 mental component score and higher EQ-5D Dutch tariff score and felt less often anxious or depressed compared with persons who discontinued FSL-FGM. CONCLUSIONS: Although the considerable number of non-responders limits generalizability, this study suggests that persons who continue to use FSL-FGM for 2 years may experience sustained improvement in glycemic control and quality of life