Prognosis after traumatic brain injury

Dit proefschrift beschrijft een aantal studies op het gebied van prognose na matig ernstig of ernstig traumatisch hersenletsel (THL). In hoofdstuk 1 wordt het klinische probleem van traumatisch hersenletsel besproken. Traumatisch hersenletsel wordt gedefinieerd als elk hersenletsel dat is ontstaan door een oorzaak van buitenaf, zoals een ongeval, een val of een schotwond. THL vormt een belangrijk volksgezondheidsprobleem in de Westerse wereld; het is een van de meest voorkomende doodsoorzaken bij jong volwassenen en het kan het leven en het functioneren van jonge mensen enorm beïnvloeden. De nadruk van dit proefschrift ligt op de ontwikkeling en validatie van prognostische modellen; statistische modellen waarin individuele patiëntkenmerken worden gecombineerd om de kans op een bepaalde uitkomst of ziekte status te kunnen voorspellen. De doelstellingen betroffen: (1) het beschrijven van methodologische ontwikkelingen ten aanzien van eerder ontwikkelde prognostische modellen voor THL patiënten; (2) de ontwikkeling en validatie van nieuwe prognostische modellen die de lange termijn gevolgen voorspellen voor patiënten met matig ernstig of ernstig traumatisch hersenletsel en (3) het voorspellen van de behoefte van een THL patiënt aan behandeling in een gespecialiseerd traumacentrum om zo de triage criteria (al dan niet transporteren naar een gespecialiseerd trauma centrum) te kunnen verbeteren.This thesis describes studies on prognosis after severe or moderate traumatic brain injury (TBI). In Chapter 1, the clinical problem of TBI is discussed. TBI is generally defined as an injury to the brain caused by an external physical force, such as a traffic accident, a fall or a gunshot. TBI is an important public health care problem in the western world. It is one of the most common causes of death in young adults and it can affect people’s lives enormously. The focus of this thesis is on developing and validating prognostic models: statistical models that combine individual patient characteristics to predict the probability of a particular outcome or disease state. The objectives of this thesis were: (1) to study methodological developments in prognostic modeling in TBI; (2) to develop and validate prognostic models that predict long- term outcome for patients with severe or moderate TBI an (3) to predict the need of specialized intensive care to aid a more efficient triage of patients

Timing of elective pre-labour caesarean section: a decision analysis

__Background:__ Since caesarean sections (CSs) before 39+0 weeks gestation are associated with higher rates of neonatal respiratory morbidity, it is recommended to delay elective CSs until 39+0 weeks. However, this bears the risk of earlier spontaneous labour resulting in unplanned CSs, which has workforce and resource implications, specifically in smaller obstetric units. __Aim:__ To assess, in a policy of elective CSs from 39+0 weeks onward, the number of unplanned CSs to prevent one neonate with respiratory complications, as compared to early elective CS. __Materials and Methods:__ We performed a decision analysis comparing early term elective CS at 37+0–6 or 38+0–6 weeks to elective prelabour CS, without strict medical indication, at 39+0–6 weeks, with earlier unplanned CS, in women with uncomplicated singleton pregnancies. We used literature data to calculate the number of unplanned CSs necessary to prevent one neonate with respiratory morbidity. __Results:__ Planning all elective CSs at 39+0–6 weeks required 10.9 unplanned CSs to prevent one neonate with respiratory morbidity, compared to planning all elective CSs at 38+0–6 weeks. Compared to planning all elective CSs at 37+0–6 weeks we needed to perform 3.3 unplanned CSs to prevent one neonate with respiratory morbidity. __Conclusion:__ In a policy of planning all elective pre-labour CSs from 39+0 weeks of gestation onward, between three and 11 unplanned CSs have to be performed to prevent one neonate with respiratory morbidity. Therefore, in our opinion, fear of early term labour and workforce disutility is no argument for scheduling elective CSs <39+0 weeks

Regional differences in severe postpartum hemorrhage: A nationwide comparative study of 1.6 million deliveries

Background: The incidence of severe postpartum hemorrhage (PPH) is increasing. Regional variation may be attributed to variation in provision of care, and as such contribute to this increasing incidence. We assessed reasons for regional variation in severe PPH in the Netherlands. Methods: We used the Netherlands Perinatal Registry and the Dutch Maternal Mortality Committee to study severe PPH incidences (defined as blood loss ≥ 1000 mL) across both regions and neighborhoods of cities among all deliveries between 2000 and 2008. We first calculated crude incidences. We then used logistic multilevel regression analyses, with hospital or midwife practice as second level to explore further reasons for the regional variation. Results: We analyzed 1599867 deliveries in which the incidence of severe PPH was 4.5%. Crude incidences of severe PPH varied with factor three between regions while between neighborhoods variation was even larger. We could not explain regional variation by maternal characteristics (age, parity, ethnicity, socioeconomic status), pregnancy characteristics (singleton, gestational age, birth weight, pre-eclampsia, perinatal death), medical interventions (induction of labor, mode of delivery, perineal laceration, placental removal) and health care setting. Conclusions: In a nationwide study in The Netherlands, we observed wide practice variation in PPH. This variation could not be explained by maternal characteristics, pregnancy characteristics, medical interventions or health care setting. Regional variation is either unavoidable or subsequent to regional variation of a yet unregistered variable

A Practical Guide to Preprints: Accelerating Scholarly Communication

This guide is the translation adapted to the French background of "A Practical Guide to Preprints: Accelerating Scholarly Communication"International audienceThis guide is the translation adapted to the French background of "A Practical Guide to Preprints: Accelerating Scholarly Communication" prepared and distributed by a team of Dutch researchers and librarians). It is intended for researchers who wish to deposit preprints in repositories even before their manuscript is accepted by a publisher and addresses a number of their questions and concerns related to community review, publication in scientific and scholarly journals, evaluation and assessment, and the visibility of their work.The guide also includes explanations and advice on the use, understanding and interpretation of the preprint for members of the public, who may find it useful as well.Ce guide est la traduction adaptée au contexte français de "A Practical Guide to Preprints: Accelerating Scholarly Communication" préparé et diffusé par une équipe de chercheurs et bibliothécaires néerlandais . Il s'adresse aux chercheuses et chercheurs qui désirent déposer des prépublications dans des archives même avant l'acceptation de leur manuscrit auprès d'un éditeur et répond à un certain nombre de leurs questions et préoccupations en lien avec l'appréciation communautaire, la publication dans des revues scientifiques et savantes, l'évaluation et la visibilité de leur travail.L'ouvrage offre également des explications et des conseils pour l'utilisation, la compréhension et l'interprétation de cet objet particulier qu'est le préprint aux membres du public auprès duquel il trouve également une certaine utilité

Nieuwe onderzoeksmogelijkheden door koppeling van perinatale gegevensbronnen

In the Netherlands two different figures about perinatal mortality are published. The Netherlands Perinatal Registry (PRN) calculates mortality rates based on the perinatal registration. Perinatal mortality rates published by Statistics Netherlands (CBS) are based on the municipal population registers and the register of stillbirths. Both data sources have their own advantages and disadvantages. Linking them provides a better estimation of perinatal and infant mortality for all children born ≥ 22 weeks of gestation. This article describes the linking process and shows the advantages of linked PRN-CBS registration data. By linking data on a personal level it will be possible to add data from other (care) records available at the CBS, such as background data from the GBA as for example the country of origin of the mother. This gives opportunities for research, such as following children in time with respect to the use of care and learning problems, which may be related to gestational age, birth weight or problems at birth. Several illustrative examples of the overall calculated infant mortality are presented

Pre-Eclampsia Increases the Risk of Postpartum Haemorrhage: A Nationwide Cohort Study in The Netherlands

Background: Postpartum haemorrhage is a leading cause of maternal morbidity and mortality worldwide. Identifying risk indicators for postpartum haemorrhage is crucial to predict this life threatening condition. Another major contributor to maternal morbidity and mortality is pre-eclampsia. Previous studies show conflicting results in the association between pre-eclampsia and postpartum haemorrhage. The primary objective of this study was to investigate the association between pre-eclampsia and postpartum haemorrhage. Our secondary objective was to identify other risk indicators for postpartum haemorrhage in the Netherlands. Methods: A nationwide cohort was used, containing prospectively collected data of women giving birth after 19 completed weeks of gestation from January 2000 until January 2008 (n = 1 457 576). Data were extracted from the Netherlands Perinatal Registry, covering 96% of all deliveries in the Netherlands. The main outcome measure, postpartum haemorrhage, was defined as blood loss of ≥1000 ml in the 24 hours following delivery. The association between pre-eclampsia and postpartum haemorrhage was investigated with uni- and multivariable logistic regression analyses. Results: Overall prevalence of postpartum haemorrhage was 4.3% and of pre-eclampsia 2.2%. From the 31 560 women with pre-eclampsia 2 347 (7.4%) developed postpartum haemorrhage, compared to 60 517 (4.2%) from the 1 426 016 women without pre-eclampsia (odds ratio 1.81; 95% CI 1.74 to 1.89). Risk of postpartum haemorrhage in women with pre-eclampsia remained increased after adjusting for confounders (adjusted odds ratio 1.53; 95% CI 1.46 to 1.60). Conclusion: Women with pre-eclampsia have a 1.53 fold increased risk for postpartum haemorrhage. Clinicians should be aware of this and use this knowledge in the management of pre-eclampsia and the third stage of labour in order to reach the fifth Millenium Developmental Goal of reducing maternal mortality ratios with 75% by 2015. © 2013 von Schmidt auf Altenstadt et al

De kwaliteit van dermatologische CBO-richtlijnen beoordeeld met het AGREE-instrument

Aim. To determine to what extent recent Dutch guidelines on dermatology meet internationally accepted quality criteria. Method. Eight guidelines on dermatology, published between 2002 and 2005, were assessed with the AGREE Instrument, which consists of 23 items, grouped into six domains: a) scope and purpose; b) stakeholder involvement; c) methodology; d) clarity and presentation; e) applicability; and f) editorial independence. Results. The quality of recent Dutch guidelines on dermatology is acceptable to good on the average. The quality scores were high on the domains 'methodology' and 'clarity and presentation', but quite low on the domain 'applicability'. The guidelines on venous ulcer and melanoma had the highest scores. Conclusion.The Dutch guidelines on dermatology meet the international quality criteria in general, but certain aspects could be improved. In particular, the involvement of more disciplines, the applicability, and the barriers for implementation should get more attention

Neuroprotectie door hypothermie na perinatale asfyxie bij voldragen pasgeborenen

Randomised controlled trials have demonstrated that mild hypothermia reduces mortality and morbidity in full-term neonates who experience perinatal asphyxia. Hypothermia can be applied to the head or entire body, maintaining a temperature of 33-34°C for 72 hours. Treatment should be started within 6 hours after birth. An estimated 180-200 neonates may be eligible for this novel approach to neuroprotection each year in the Netherlands

Changing Dutch approach and trends in short-term outcome of periviable preterms

Item does not contain fulltextBACKGROUND: In 2006, the Dutch guideline for active treatment of extremely preterm neonates advised to lower the gestational age threshold for active intervention from 26 0/7 to 25 0/7 weeks gestation. OBJECTIVE: To evaluate the association between the guideline modification and early neonatal outcome. DESIGN: National cohort study, using prospectively collected data from The Netherlands Perinatal Registry. PATIENTS: The study population consisted of 9713 infants with a gestational age between 24 0/7 and 29 6/7 weeks, born between 2000 and 2011. Three gestational age subgroups were analysed: 24 0/7 to 24 6/7 weeks (n=269), 25 0/7 to 25 6/7 weeks (n=852) and 26 0/7 to 29 6/7 weeks (n=8592). MAIN OUTCOME MEASURES: Neonatal intensive care unit (NICU) admission, live births, neonatal in-hospital mortality, morbidity and favourable outcome (no mortality or morbidity) before (2000-2005; period 1) and after (2007-2011; period 2) introduction of the modified guideline, using chi(2) tests and univariable and multivariable logistic regression analyses. RESULTS: In the second period, the proportion of live births and NICU admissions increased and the proportion of neonatal and in-hospital mortality decreased significantly in all subgroups. Morbidity in surviving infants of 25 weeks increased significantly, although the association between guideline modification and morbidity became non-significant after case-mix adjustment. Overall, favourable outcome did not change significantly after guideline modification in all subgroups when adjusted for variation in case-mix. CONCLUSIONS: Overall, the trend in mortality gradually declined at all gestational ages, starting before 2006. This suggests that the guideline modification was a formalisation of already existing daily practice

Prescriptive birthweight charts can improve the prediction of adverse outcomes in very preterm infants who are small for gestational age

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