Guideline compliance for bridging anticoagulation use in vitamin-K antagonist patients; practice variation and factors associated with non-compliance.

BACKGROUND: Bridging anticoagulation is used in vitamin-K antagonist (VKA) patients undergoing invasive procedures and involves complex risk assessment in order to prevent thromboembolic and bleeding outcomes. OBJECTIVES: Our aim was to assess guideline compliance and identify factors associated with bridging and especially, non-compliant bridging. METHODS: A retrospective review of 256 patient records in 13 Dutch hospitals was performed. Demographic, clinical, surgical and care delivery characteristics were collected. Compliance to the American College of Chest Physicians ninth edition guideline (AT9) was assessed. Multilevel regression models were built to explain bridging use and predict non-compliance. RESULTS: Bridging use varied from 15.0 to 83.3% (mean = 41.8%) of patients per hospital, whereas guideline compliance varied from 20.0 to 88.2% (mean = 68.5%) per hospital. Both established thromboembolic risk factors and characteristics outside thromboembolic risk assessment were associated with bridging use. Predictors for overuse were gastrointestinal surgery (OR 14.85, 95% CI 2.69-81.99), vascular surgery (OR 13.01, 95% CI 1.83-92.30), non-elective surgery (OR 8.67, 95% CI 1.67-45.14), lowest 25th percentile socioeconomic status (OR 0.33, 95% CI 0.11-1.02) and use of VKA reversal agents (OR 0.22, 95% CI 0.04-1.16). CONCLUSION: Bridging anticoagulation practice was not compliant with the AT9 in 31.5% of patients. The aggregated AT9 thromboembolic risk was inferior to individual thromboembolic risk factors and other characteristics in explaining bridging use. Therefor the AT9 risk seems less important for the decision making in everyday practice. Additionally, a heterogeneous implementation of the guideline between hospitals was found. Further research and interventions are needed to improve bridging anticoagulation practice in VKA patients.

Implementing paediatric early warning scores systems in the Netherlands: future implications.

BACKGROUND: Paediatric Early Warning Scores (PEWS) are increasingly being used for early identification and management of clinical deterioration in paediatric patients. A PEWS system includes scores, cut-off points and appropriate early intervention. In 2011, The Dutch Ministry of Health advised hospitals to implement a PEWS system in order to improve patient safety in paediatric wards. The objective of this study was to examine the results of implementation of PEWS systems and to gain insight into the attitudes of professionals towards using a PEWS system in Dutch non-university hospitals. METHODS: Quantitative data were gathered at start, midway and at the end of the implementation period through retrospective patient record review (n = 554). Semi-structured interviews with professionals (n = 8) were used to gain insight in the implementation process and experiences. The interviews were transcribed and analysed using an inductive approach. RESULTS: Looking at PEWS systems of the five participating hospitals, different parameters and policies were found. While all hospitals included heart rate and respiratory rate, other variables differed among hospitals. At baseline, none of the hospitals used a PEWS system. After 1 year, PEWS were recorded in 69.2% of the patient records and elevated PEWS resulted in appropriate action in 49.1%. Three themes emerged from the interviews: 1) while the importance of using a PEWS system was acknowledged, professionals voiced some doubts about the effectiveness and validity of their PEWS system 2) registering PEWS required little extra effort and was facilitated by PEWS being integrated into the electronic patient record 3) Without a national PEWS system or guidelines, hospitals found it difficult to identify a suitable PEWS system for their setting. Existing systems were not always considered applicable in a non-university setting. CONCLUSIONS: After 1 year, hospitals showed improvements in the use of their PEWS system, although some were decidedly more successful than others. Doubts among staff about validity, effectiveness and communication with other hospitals during transfer to higher level care hospital might hinder sustainable implementation. For these purposes the development of a national PEWS system is recommended, consisting of a "core set" of PEWS, cut-off points and associated early intervention.

Wheelchair Mobility Confidence Scale for Dutch youth using a manual wheelchair.

Purpose: The objective of this study was to develop a questionnaire to assess confidence in wheelchair mobility in Dutch youth (WheelCon-Mobility Dutch Youth).Methods: (1) A forward-backward translation process was used to translate the original WheelCon-M from English to Dutch. (2) Items related to wheelchair mobility in Dutch youth were selected and adapted based on focus groups with youth, parents and health care professionals to create the WheelCon-Mobility Dutch Youth. (3) The WheelCon-Mobility Dutch Youth and the Utrecht Pediatric Wheelchair Mobility Skills Test 2.0 (UP-WMST 2.0) were administered to 62 participants to evaluate internal consistency and construct validity.Results: Translation and cultural adaptation led to general adaptations in instructions, sentence structure and response scale. At the item level, 24 items were included with (n = 17) and without (n = 7) adaptation, 10 items were deleted and 7 new items were included. The WheelCon-Mobility Dutch Youth had an excellent Cronbach's alpha of 0.924 and a significant correlation (r = 0.44, p < .001) with the UP-WMST 2.0.Conclusions: This study resulted in the adaptation of the WheelCon-M into the WheelCon-Mobility for Dutch youth using a manual wheelchair. Our study suggests there is evidence supporting the internal consistency and construct validity of the WheelCon-Mobility Dutch Youth.Implications for RehabilitationThe WheelCon-Mobility Dutch Youth is a newly developed tool for assessing confidence in wheelchair mobility in Dutch youth using a manual wheelchair.It is important to assess performance and confidence in wheelchair mobility in paediatric rehabilitation.

Validation of the Actical and Actiheart monitor in ambulatory children with spina bifida.

BACKGROUND: Ambulatory children with Spina Bifida (SB) often show a decline in physical activity leading to deconditioning and functional decline. Therefore, assessment and promotion of physical activity is important. Because energy expenditure during activities is higher in these children, the use of existing pediatric equations to predict physical activity energy expenditure (PAEE) may not be valid. AIMS: (1) To evaluate criterion validity of existing predictions converting accelerocounts into PAEE in ambulatory children with SB and (2) to establish new disease-specific equations for PAEE. METHODS: Simultaneous measurements using the Actical, the Actiheart, and indirect calorimetry took place to determine PAEE in 26 ambulatory children with SB. DATA ANALYSIS: Paired T-tests, Intra-class correlations limits of agreement (LoA), and explained variance (R(2)) were used to analyze validity of the prediction equations using true PAEE as criterion. New equations were derived using regression techniques. RESULTS: While T-tests showed no significant differences for some models, the predictions developed in healthy children showed moderate ICC's and large LoA with true PAEE. The best regression models to predict PAEE were: PAEE=174.049+3.861 × HRAR - 60.285 × ambulatory status (R(2) =0.720) and PAEE=220.484+0.67 × Actical counts - 60.717 × ambulatory status (R(2) =0.681). CONCLUSIONS: Existing equations to predict PAEE are not valid for use in children with SB for the individual evaluation of PAEE. The best regression model was based on HRAR in combination with ambulatory status, followed by a new model for the Actical monitor. A benefit of HRAR is that it does not require the use of expensive accelerometry equipment. Further cross-validation of these models is still needed.

Feasibility and preliminary effectiveness of preoperative therapeutic exercise in patients with cancer: a pragmatic study.

The aim of this pilot study is to determine the feasibility and preliminary effectiveness of an individually designed preoperative therapeutic exercise program (PreTEP), in patients recently diagnosed with cancer and awaiting elective surgery. The purpose is to improve their physical fitness levels during this waiting period with the intention of decreasing postoperative morbidity. A preexperimental pilot study was performed at the University Medical Center Utrecht, The Netherlands. Thirty-nine patients diagnosed with cancer, scheduled for elective abdominal/thoracic surgery, were referred to a multidisciplinary preoperative screening. Fifteen patients (38%) participated in PreTEP. Participants were satisfied and motivated during the period of training (on average 5 weeks) in which they attended 84% of the sessions. Cardiorespiratory fitness (A strand-test) and muscle strength (Handheld Dynamometry) increased significantly, from 25 to 33 mL/kg/min, respectively (p<0.01; 95% confidence interval [CI]=-0.011 to -0.004) and from 894 Newton (N) to 961N (p<0.01; 95% CI=-94.53 to -39.0). No adverse events occurred during the training period. PreTEP was shown to be feasible, safe, and well-tolerated and appreciated by participants. Despite the relatively short period of training, physical fitness improved in all participants.

Reproducibility of energy cost of locomotion in ambulatory children with spina bifida.

OBJECTIVES: Many ambulatory children with Spina Bifida (SB) experience functional decline in ambulation despite stable or even improving motor exams. Improving or maintaining low energy cost of locomotion during childhood and throughout the teenage years, could be an important goal for children and adolescents with SB. Purpose of this study was to determine reproducibility of energy expenditure measures during gait in ambulatory children with SB. DESIGN: Reproducibility study. SETTING: Child Development and Exercise Center of the University Children's Hospital in Utrecht, the Netherlands. PARTICIPANTS: Fourteen ambulatory children (6 boys/8 girls) with SB. Mean age was 10.8 years (+ or - 3.4). INTERVENTIONS: Net and gross energy expenditure measures during locomotion were determined during a six-minute walking test. These measures consisted of energy consumption (ECS), expressed in J/kg/min, and energy cost (EC), expressed in J/kg/m. For reliability, the intra-class coefficient (ICC) was determined. For agreement, the smallest detectable difference (SDD) was calculated. RESULTS: ICCs vary from 0.86 to 0.96 for both EC and ECS. The SDD ranges from 18-24% for gross measures, up to over 30% for net values. CONCLUSION: Reproducibility of energy expenditure during ambulation in children with SB should be considered carefully when using these measures in the evaluation of gait. High reliability of energy expenditure measurements makes these measurements appropriate to use as discriminative tools in children with SB, while agreement of only gross EC seems acceptable to use as a evaluative tool in children with SB. Overall, measures of reliability and agreement seem higher in young children when compared to adolescents. Further research is recommended to determine clinically relevant changes in energy expenditure in children with SB.

Limiting factors in peak oxygen uptake and the relationship with functional ambulation in ambulating children with spina bifida.

The objective of this study is to interpret the outcomes of peak oxygen uptake (VO(2peak)) in children with SB and explore the relationship between VO(2peak) and functional ambulation using retrospective cross-sectional study. Twenty-three ambulating children with SB participated at Wilhelmina's Children's Hospital Utrecht, the Netherlands. VO(2peak) was measured during a graded treadmill-test. Eschenbacher's and Maninna's algorithm was used to determine limiting factors in reaching low VO(2peak) values. Energy expenditure during locomotion (both O(2) rate and O(2) cost) and percentage of VO(2peak) and HR(peak) were determined during a 6-min walking test (6MWT). Differences between community and normal ambulators were analyzed. VO(2peak), VO(2peak)/kg, HR(peak), RER(peak) and VE (peak) were significantly lower compared to reference values, with significant differences between normal and community ambulators. Limiting factors according to the algorithm were mostly "muscular and/or deconditioning" (47%) and ventilatory "gasexchange" (35%). Distance walked during 6MWT was 48.5% of predicted distance. Both O(2) rate and O(2) cost were high with significant differences between normal and community ambulators [17.6 vs. 21.9 ml/(kg min) and 0.27 vs 0.43 ml/(kg m)]. Also %HR(peak) and %VO(2peak) were significantly higher in community ambulators when compared to normal ambulators (resp. 97.6 vs. 75% and 90.2 vs. 55.9%). VO(2peak) seems to be mostly limited by deconditioning and/or muscular components and possible ventilatory factors. For both peak values and functional ambulation, community ambulators were significantly more impaired than normal ambulators. High energy expenditure, %VO(2peak) and %HR(peak) reflect high level of strain during ambulation in the community ambulators. Future exercise testing in children with SB should include assessment of ventilatory reserve. Exercise training in ambulatory children should focus on increasing both VO(2peak) and muscular endurance, as well as decreasing energy cost of locomotion.

Phase II study of carboplatin and erlotinib (Tarceva, OSI-774) in patients with recurrent glioblastoma.

Targeting the epidermal growth factor receptor (EGFR) may be effective in a subset of glioblastoma patients. This phase II study assessed the clinical activity of erlotinib plus carboplatin and to determine molecular predictors of response. The primary endpoint was progression free survival (PFS). Patients with recurrent glioblastoma with no more than two prior relapses received carboplatin intravenously on day 1 of every 28-day cycle (target AUC of 6 mg x ml/min). Daily erlotinib at 150 mg/day was dose escalated to 200 mg/day, as tolerated. Clinical and MRI assessments were made every 4 and 8 weeks, respectively. Tumor tissue was evaluated for EGFR, AKT and phosphatase and tensin homolog (PTEN) status. One partial response (PR) was observed out of 43 assessable patients. Twenty patients (47%) had stable disease (SD) for an average of 12 weeks. Median PFS was 9 weeks. The 6-month PFS rate was 14%. Median overall survival (OS) was 30 weeks. This regimen was well tolerated with grade 3/4 toxicities of fatigue, leukopenia, thrombocytopenia and rash requiring dose reductions. A recursive partitioning analysis (RPA) predicted that patients with KPS >or=90 treated with more than 1 prior regimen had the highest OS. No correlation was observed between EGFR, Akt or PTEN expression and either PFS or OS. Carboplatin plus erlotinib is well tolerated but has modest activity in unselected patients. Future trials should be stratified based on optimal molecular or clinical characteristics.

Some aspects of artificial caries lesion formation of human dental enamel in vitro.

Investigations of artificial carious lesion formation of human dental enamel showed great variability in caries susceptibility. Human specimens were demineralized in acid buffers with Ca and phosphate ions, undersaturated with respect to hydroxyapatite. Under nearly all conditions the results varied from no lesion formations to etching. This may be due to properties of the surface layer such as fluoride content and permeability.