Diagnostic value of preoperative measures in selecting post-lingually deafened candidates for cochlear implantation - a different approach.

OBJECTIVES: We examined which preoperative diagnostic measure is most suited to serve as a selection criterion to determine adult cochlear implantation (CI) candidacy. DESIGN: Preoperative diagnostic measures included pure tone audiometry (PTA; 0.5, 1, 2, 4 kHz), speech perception tests (SPT) unaided with headphones and with best-aided hearing aids (in quiet and in noise). Gain in speech perception was used as outcome measure. Performance of preoperative measures was analysed using the area under the curve (AUC) of receiver operating characteristic (ROC) curves. STUDY SAMPLE: This retrospective longitudinal cohort study included 552 post-lingually deafened adults with CI in a tertiary referral centre in the Netherlands. RESULTS: Best-aided SPT in quiet was the most accurate in defining which CI candidates improved their speech perception in quiet postoperatively. For an improvement in speech perception in noise, the best-aided SPT in noise was the most accurate in defining which adult would benefit from CI. PTA measures performed lower compared to the SPT measures. CONCLUSIONS: SPT is better than PTA for selecting CI candidates who will benefit in terms of speech perception. Best-aided SPT in noise was the most accurate for indicating an improvement of speech perception in noise but was only evaluated in high performers with residual hearing. These insights will assist in formulating more effective selection criteria for CI.

Full-array channel discrimination in cochlear implants: validation and clinical application.

OBJECTIVE: We sought to validate our proposed tool for estimating channel discrimination of cochlear implant (CI) users along the full electrode array and to assess associations between place-pitch discrimination and speech perception. DESIGN: In two tests, participants identified one stimulus (probe) as the odd-one-out compared with two reference stimuli. Probe stimuli were evoked using dual electrode stimulation characterised by the current steering coefficient α. The first test measured psychometric functions (PFs) on pre-defined contacts, with just a noticeable difference (JNDα) as the outcome variable. The second test estimated channel discrimination on the full electrode array, yielding a discrimination score of Dα. We measured speech perception as free-field consonant-vowel-consonant phoneme recognition scores. STUDY SAMPLE: We included 25 adults with at least 6 months of CI experience. RESULTS: JNDα and Dα scores measured on the same contact correlated significantly (rs = 0.64, p < 0.001). Mean JNDα and speech perception scores showed significant relationships in quiet and in noise. CONCLUSIONS: Dα correlated strongly with JNDα scores obtained with the PFs. For poor performers, the full-array test may underestimate JNDα. The full-array pitch discrimination test could be a helpful clinical tool, such as for fitting regions of lesser pitch discrimination ability.

Selection Criteria for Cochlear Implantation in the United Kingdom and Flanders: Toward a Less Restrictive Standard.

OBJECTIVES: The impact of the newly introduced cochlear implantation criteria of the United Kingdom and Flanders (Dutch speaking part of Belgium) was examined in the patient population of a tertiary referral center in the Netherlands. We compared the patients who would be included/excluded under the new versus old criteria in relation to the actual improvement in speech understanding after implantation in our center. We also performed a sensitivity analysis to examine the effectiveness of the different preoperative assessment approaches used in the United Kingdom and Flanders. DESIGN: The selection criteria were based on preoperative pure-tone audiometry at 0.5, 1, 2, and 4 kHz and a speech perception test (SPT) with and without best-aided hearing aids. Postoperatively, the same SPT was conducted to assess the benefit in speech understanding. RESULTS: The newly introduced criteria in Flanders and the United Kingdom were less restrictive, resulting in greater percentages of patients implanted with CI (increase of 30%), and sensitivity increase of 31%. The preoperative best-aided SPT, used by both countries, had the highest diagnostic ability to indicate a postoperative improvement of speech understanding. We observed that patient selection was previously dominated by the pure-tone audiometry criteria in both countries, whereas speech understanding became more important in their new criteria. Among patients excluded by the new criteria, seven of eight (the United Kingdom and Flanders) did exhibit improved postoperative speech understanding. CONCLUSIONS: The new selection criteria of the United Kingdom and Flanders led to increased numbers of postlingually deafened adults benefitting from CI. The new British and Flemish criteria depended on the best-aided SPT with the highest diagnostic ability. Notably, the new criteria still led to the rejection of candidates who would be expected to gain considerably in speech understanding after implantation.

[Hearing without ears]. / Horen zonder oren.

An Auditory Brainstem Implant (ABI) is a technique developed for patients with severe hearing loss. The ABI consists of a microphone and speech processor located on the scalp, which is connected to a transmitting and receiving coil and electrode on the brain stem placed in the skull. Eligible for an ABI are adults with cochlea and acoustic nerve damage due to neurofibromatosis type 2, and children with congenital malformation or aplasia, cochlear trauma or cochlear ossification after meningitis. An ABI can provide useful hearing. It has proven to be a safe procedure without serious complications. The entire ABI process is handled by a multidisciplinary team with extensive experience in cerebellopontine angle tumour surgery and cochlear implantation in adults and children. Concentration of this care in a specialized centre is important to maximize the chances of a successful outcome.

Epithelial-to-mesenchymal transition is a prognostic marker for patient outcome in advanced stage HNSCC patients treated with chemoradiotherapy.

BACKGROUND: The prognosis of patients with HPV-negative advanced stage head and neck squamous cell carcinoma (HNSCC) remains poor. No prognostic markers other than TNM staging are routinely used in clinic. Epithelial-to-mesenchymal transition (EMT) has been shown to be a strong prognostic factor in other cancer types. The purpose of this study was to determine the role of EMT in HPV-negative HNSCC outcomes. METHODS: Pretreatment tumor material from patients of two cohorts, totalling 174 cisplatin-based chemoradiotherapy treated HPV-negative HNSCC patients, was RNA-sequenced. Seven different EMT gene expression signatures were used for EMT status classification and generation of HNSCC-specific EMT models using Random Forest machine learning. RESULTS: Mesenchymal classification by all EMT signatures consistently enriched for poor prognosis patients in both cohorts of 98 and 76 patients. Uni- and multivariate analyses show important HR of 1.6-5.8, thereby revealing EMT's role in HNSCC outcome. Discordant classification by these signatures prompted the generation of an HNSCC-specific EMT profile based on the concordantly classified samples in the first cohort (cross-validation AUC > 0.98). The independent validation cohort confirmed the association of mesenchymal classification by the HNSCC-EMT model with poor overall survival (HR = 3.39, p < 0.005) and progression free survival (HR = 3.01, p < 0.005) in multivariate analysis with TNM. Analysis of an additional HNSCC cohort from PET-positive patients with metastatic disease prior to treatment further supports this relationship and reveals a strong link of EMT to the propensity to metastasize. CONCLUSIONS: EMT in HPV-negative HNSCC co-defines patient outcome after chemoradiotherapy. The generated HNSCC-EMT prediction models can function as strong prognostic biomarkers.

Ovarian cancer-derived copy number alterations signatures are prognostic in chemoradiotherapy-treated head and neck squamous cell carcinoma.

DNA copy number alterations (CNAs) are frequent in cancer, and recently developed CNA signatures revealed their value in molecular tumor stratification for patient prognosis and platinum resistance prediction in ovarian cancer. Head and neck squamous cell carcinoma (HNSCC) is also characterized by high CNAs. In this study, we determined CNA in 173 human papilloma virus-negative HNSCC from a Dutch multicenter cohort by low-coverage whole genome sequencing and tested the prognostic value of seven cancer-derived CNA signatures for these cisplatin- and radiotherapy-treated patients. We find that a high CNA signature 1 (s1) score is associated with low values for all other signatures and better patient outcomes in the Dutch cohorts and The Cancer Genome Atlas HNSCC data set. High s5 and s7 scores are associated with increased distant metastasis rates and high s6 scores with poor overall survival. High cumulative cisplatin doses result in improved outcomes in chemoradiotherapy-treated HNSCC patients. Here we find that tumors high in s1 or low in s6 are most responsive to a change in cisplatin dose. High s5 values, however, significantly increase the risk for metastasis in patients with low cumulative cisplatin doses. Together this suggests that the processes causing these CNA signatures affect cisplatin response in HNSCC. In conclusion, CNA signatures derived from a different cancer type were prognostic and associated with cisplatin response in HNSCC, suggesting they represent underlying molecular processes that define patient outcome.

An empirical study of how the Dutch healthcare regulator first formulates the concept of trust and then puts it into practice.

BACKGROUND: Responsive regulation assumes that the parties being regulated are trustworthy and motivated by social responsibility. This assumes that regulation based upon trust will improve the regulated organization more effectively than other regulation models. The purpose of our qualitative study was to unravel the most important elements of trust in the inspectee which can support the inspector's work and to develop a model and a framework of trust that can be used by the inspectors to legitimize their trust in the inspectee. METHODS: We conducted an empirical study on trust regarding the regulation of care services to reveal how trust in the inspectee is conceptualized and assessed. Based on literature and empirical research, we synthesized the concept of trust into six elements, five regarding behavior, and a sixth looking at information about its context. We developed a practical framework for the concept to reduce the conceptual ambiguity, strengthen regulatory assessment, and support appropriate tailoring of the regulatory response. RESULTS: Six elements with respect to trust emerged from the data: showing integrity; transparency; ability to learn; accepting feedback; showing actual change in behavior; context information. These five behavioral elements, plus the context information were merged into a Framework of Trust and designed into an interactive PDF document. CONCLUSIONS: This study has sought to address a gap in the empirical knowledge regarding the assessment of trust in the inspectee. The results aim to inform and clarify the regulatory conceptualization and understanding of trust in the inspectee. Other inspectorates may learn from these results for their own practice and explore whether operational deployment of our Framework of Trust effects their assessment and enforcement strategies.

Drug Sensitivity Prediction Models Reveal a Link between DNA Repair Defects and Poor Prognosis in HNSCC.

Head and neck squamous cell carcinoma (HNSCC) is characterized by the frequent manifestation of DNA crosslink repair defects. We established novel expression-based DNA repair defect markers to determine the clinical impact of such repair defects. Using hypersensitivity to the DNA crosslinking agents, mitomycin C and olaparib, as proxies for functional DNA repair defects in a panel of 25 HNSCC cell lines, we applied machine learning to define gene expression models that predict repair defects. The expression profiles established predicted hypersensitivity to DNA-damaging agents and were associated with mutations in crosslink repair genes, as well as downregulation of DNA damage response and repair genes, in two independent datasets. The prognostic value of the repair defect prediction profiles was assessed in two retrospective cohorts with a total of 180 patients with advanced HPV-negative HNSCC, who were treated with cisplatin-based chemoradiotherapy. DNA repair defects, as predicted by the profiles, were associated with poor outcome in both patient cohorts. The poor prognosis association was particularly strong in normoxic tumor samples and was linked to an increased risk of distant metastasis. In vitro, only crosslink repair-defective HNSCC cell lines are highly migratory and invasive. This phenotype could also be induced in cells by inhibiting rad51 in repair competent and reduced by DNA-PK inhibition. In conclusion, DNA crosslink repair prediction expression profiles reveal a poor prognosis association in HNSCC. SIGNIFICANCE: This study uses innovative machine learning-based approaches to derive models that predict the effect of DNA repair defects on treatment outcome in HNSCC.Graphical Abstract: http://cancerres.aacrjournals.org/content/canres/79/21/5597/F1.large.jpg.

Pediatric Auditory Brainstem Implant Users Compared With Cochlear Implant Users With Additional Disabilities.

OBJECTIVES: To evaluate long-term language development in children with prelingual deafness who received auditory brainstem implants (ABIs) compared with children who received cochlear implants (CIs) at the same hospital. Additional non-auditory disabilities were taken into account. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary referral center. PATIENTS: Ten children with bilateral malformations of the cochlea and/or cochlear nerve who received ABIs, including seven with additional disabilities, and 147 children with CIs as a reference group, including 22 children with additional disabilities. INTERVENTION: ABIs were implanted at 1.3 to 6.2 years of age. Follow-up ranged from 1.1 to 7.7 years. MAIN OUTCOME MEASURES: Receptive and expressive language abilities were assessed using the Infant Toddler Meaningful Auditory Integration Scale (IT-MAIS), the Categories of Auditory Performance (CAP), the Meaningful Use of Speech Scale (MUSS), and the Speech Intelligibility Rate (SIR). RESULTS: Of the 10 children with ABIs, seven had long-term follow-up data. Within 1 year, six of the seven children with ABIs could identify sounds, respond to speech, and use their voice to attract attention. Language skills developed at a slower rate than in children with CIs and reached the same competence level when additional disabilities were absent. These language skills matched, on average, those of children with CIs with additional disabilities. CONCLUSION: For deaf children with bilateral inner ear malformations, ABIs provide satisfactory auditory input. Children with ABIs are able to develop receptive and expressive language skills comparable to those of children with CIs with additional disabilities. Using this knowledge, preoperative parent counselling can be refined.

Genetic Factors Associated with a Poor Outcome in Head and Neck Cancer Patients Receiving Definitive Chemoradiotherapy.

About half of advanced stage head and neck squamous cell carcinoma (HNSCC) patients can be cured by chemoradiotherapy. Patient outcome may be partially determined by the genetic alterations in HNSCC, rendering these alterations promising candidate prognostic factors and/or therapeutic targets. However, their relevance in patient outcome prognosis remains to be assessed in patients that receive standard-of-care chemoradiotherapy. We therefore tested whether frequent genetic alterations were associated with progression free survival (PFS) in advanced stage HNSCC patients who were uniformly treated with definitive platinum-based chemoradiotherapy. To this end, we performed targeted DNA sequencing on frozen pre-treatment tumor biopsy material from 77 patients with advanced stage oro- and hypopharyngeal carcinoma. This provided somatic point mutation and copy number aberration data of 556 genes. The most frequently mutated genes, TP53 (62%), CCND1 (51%), CDKN2A (30%) and PIK3CA (21%), were not associated with PFS. However, co-occurring CCND1 and CDKN2A mutations were associated with short PFS (HR 2.24, p = 0.028) in HPV-negative tumors. Furthermore, tumor mutational burden (sum of somatic point mutations) showed a trend towards decreased PFS (HR 1.9, p = 0.089), and chromosomal instability (CIN) was associated with shorter PFS (HR 2.3, p = 0.023), independent of HPV status. Our results show that tumor mutational burden, CIN markers, and co-occurring CCND1 and CDKN2A mutations are associated with chemoradiotherapy outcomes in advanced stage oro- and hypopharyngeal HNSCC patients, thereby highlighting their prognostic potential. Given their poor prognosis association and link to biological targets, they may also identify patients for novel targeted therapies and immunotherapies.

Biological Determinants of Chemo-Radiotherapy Response in HPV-Negative Head and Neck Cancer: A Multicentric External Validation.

Purpose: Tumor markers that are related to hypoxia, proliferation, DNA damage repair and stem cell-ness, have a prognostic value in advanced stage HNSCC patients when assessed individually. Here we aimed to evaluate and validate this in a multifactorial context and assess interrelation and the combined role of these biological factors in determining chemo-radiotherapy response in HPV-negative advanced HNSCC. Methods: RNA sequencing data of pre-treatment biopsy material from 197 HPV-negative advanced stage HNSCC patients treated with definitive chemoradiotherapy was analyzed. Biological parameter scores were assigned to patient samples using previously generated and described gene expression signatures. Locoregional control rates were used to assess the role of these biological parameters in radiation response and compared to distant metastasis data. Biological factors were ranked according to their clinical impact using bootstrapping methods and multivariate Cox regression analyses that included clinical variables. Multivariate Cox regression analyses comprising all biological variables were used to define their relative role among all factors when combined. Results: Only few biomarker scores correlate with each other, underscoring their independence. The different biological factors do not correlate or cluster, except for the two stem cell markers CD44 and SLC3A2 (r = 0.4, p < 0.001) and acute hypoxia prediction scores which correlated with T-cell infiltration score, CD8+ T cell abundance and proliferation scores (r = 0.52, 0.56, and 0.6, respectively with p < 0.001). Locoregional control association analyses revealed that chronic (Hazard Ratio (HR) = 3.9) and acute hypoxia (HR = 1.9), followed by stem cell-ness (CD44/SLC3A2; HR = 2.2/2.3), were the strongest and most robust determinants of radiation response. Furthermore, multivariable analysis, considering other biological and clinical factors, reveal a significant role for EGFR expression (HR = 2.9, p < 0.05) and T-cell infiltration (CD8+T-cells: HR = 2.2, p < 0.05; CD8+T-cells/Treg: HR = 2.6, p < 0.01) signatures in locoregional control of chemoradiotherapy-treated HNSCC. Conclusion: Tumor acute and chronic hypoxia, stem cell-ness, and CD8+ T-cell parameters are relevant and largely independent biological factors that together contribute to locoregional control. The combined analyses illustrate the additive value of multifactorial analyses and support a role for EGFR expression analysis and immune cell markers in addition to previously validated biomarkers. This external validation underscores the relevance of biological factors in determining chemoradiotherapy outcome in HNSCC.

Schizosaccharomyces pombe contains separate CC- and A-adding tRNA nucleotidyltransferases.

A specific cytidine-cytidine-adenosine (CCA) sequence is required at the 3'-terminus of all functional tRNAs. This sequence is added during tRNA maturation or repair by tRNA nucleotidyltransferase enzymes. While most eukaryotes have a single enzyme responsible for CCA addition, some bacteria have separate CC- and A-adding activities. The fungus, Schizosaccharomyces pombe, has two genes (cca1 and cca2) that are thought, based on predicted amino acid sequences, to encode tRNA nucleotidyltransferases. Here, we show that both genes together are required to complement a Saccharomyces cerevisiae strain bearing a null mutation in the single gene encoding its tRNA nucleotidyltransferase. Using enzyme assays we show further that the purified S. pombe cca1 gene product specifically adds two cytidine residues to a tRNA substrate lacking this sequence while the cca2 gene product specifically adds the terminal adenosine residue thereby completing the CCA sequence. These data indicate that S. pombe represents the first eukaryote known to have separate CC- and A-adding activities for tRNA maturation and repair. In addition, we propose that a novel structural change in a tRNA nucleotidyltransferase is responsible for defining a CC-adding enzyme.

Neuroimaging correlates of language network impairment and reorganization in temporal lobe epilepsy.

Advanced, noninvasive imaging has revolutionized our understanding of language networks in the brain and is reshaping our approach to the presurgical evaluation of patients with epilepsy. Functional magnetic resonance imaging (fMRI) has had the greatest impact, unveiling the complexity of language organization and reorganization in patients with epilepsy both pre- and postoperatively, while volumetric MRI and diffusion tensor imaging have led to a greater appreciation of structural and microstructural correlates of language dysfunction in different epilepsy syndromes. In this article, we review recent literature describing how unimodal and multimodal imaging has advanced our knowledge of language networks and their plasticity in epilepsy, with a focus on the most frequently studied epilepsy syndrome in adults, temporal lobe epilepsy (TLE). We also describe how new analytic techniques (i.e., graph theory) are leading to a refined characterization of abnormal brain connectivity, and how subject-specific imaging profiles combined with clinical data may enhance the prediction of both seizure and language outcomes following surgical interventions.

A cross-sectional study into medical students' perceptions of healthcare regulation and self-reported compliance: a study conducted in the City of Al Ain, United Arab Emirates, 2016.

BACKGROUND: Although healthcare regulation is commonplace, there is limited evidence of its impact. Making sure that healthcare professionals comply with the regulatory requirements is a prerequisite to achieving effective regulation. Therefore, investigating factors that influence compliance may provide better insights into how regulators can be more effective. This study aimed to find out if medical students' perceptions of regulation in the United Arab Emirates are associated with self-reported regulatory compliance. METHODS: In the cross-sectional study, we administered a structured questionnaire to students of medicine with different statements concerning their perceptions of healthcare regulation and self-reported compliance. The statements included statement regarding the legitimacy, fairness and regulatory performance, as well as the risk to getting caught and being punished. The association between perceptions and self-reported compliance was analyzed using multiple regression models. RESULTS: One hundred and six Year 3 and 4 pre-clinical medicine students (56.4% response rate) completed the survey. Almost 40% of the students rated their level of awareness and understanding of regulation as Good or Very Good., despite their lack of direct contact with the regulatory authorities (less than 10% reported monthly or more frequent contact). Self-reported compliance was high with almost 85% of the students either agreeing or strongly agreeing with the four compliance statements (mean score 4.1 out of 5). The findings suggest that positive perceptions of the regulator's performance (ß 0.27; 95% CI 0.13-0.41), fairness of the regulatory processes (ß 0.25; 95% CI 0.11-0.38) and its legitimacy (ß 0.23; 95% CI 0.05-0.41), are stronger associated with compliance than the perceived risks of getting caught and being punished (ß 0.10; 95% CI -0.04 - 0.23). CONCLUSIONS: To improve compliant behavior, healthcare regulators should pay more attention to their own perceived performance, as well as the perceived fairness and legitimacy of their regulatory processes rather than focusing on more traditional methods of deterrence, such as perceived risk of getting caught and being published.

Surveillance cues do not enhance altruistic behavior among anonymous strangers in the field.

The degree of altruistic behavior among strangers is an evolutionary puzzle. A prominent explanation is the evolutionary legacy hypothesis according to which an evolved reciprocity-based psychology affects behavior even when reciprocity is impossible, i.e., altruistic behavior in such instances is maladaptive. Empirical support for this explanation comes from laboratory experiments showing that surveillance cues, e.g., photographs of watching eyes, increase altruistic behavior. A competing interpretation for this evidence, however, is that the cues signal the experimenter's expectations and participants, aware of being monitored, intentionally behave more altruistically to boost their reputation. Here we report the first results from a field experiment on the topic in which participants are unaware they are being monitored and reciprocity is precluded. The experiment investigates the impact of surveillance cues on a textbook example of altruistic behavior-hand hygiene prior to treating a 'patient'. We find no evidence surveillance cues affect hand hygiene, despite using different measures of hand-hygiene quality and cues that have been previously shown to be effective. We argue that surveillance cues may have an effect only when participants have reasons to believe they are actually monitored. Thus they cannot support claims altruistic behavior between strangers is maladaptive.

Evidence-Based Inclusion Criteria for Cochlear Implantation in Patients With Postlingual Deafness.

OBJECTIVES: This study determined the relationship between preoperative phoneme and word scores and the gain in speech perception after cochlear implantation in a large cohort of patients. The authors aimed to define evidence-based selection criteria for cochlear implantations in adults with postlingual deafness. DESIGN: This retrospective study included 364 adults with postlingual deafness who received a cochlear implant between 2000 and 2013 at the Leiden University Medical Center. The gain in speech perception observed postimplantation was compared with preoperative-aided/binaural speech perception scores, measured at 65 dB SPL in quiet. Patients who showed preoperative phoneme scores on monosyllabic words above 50% were also tested for speech perception in the presence of speech-shaped background noise, at a +5 dB signal to noise ratio. RESULTS: Speech perception in quiet improved after implantation in all except 7 patients. Average scores in quiet continued to improve, up to approximately 1 year after implantation. When participants were divided into five groups, based on preoperative speech perception scores, all groups showed gains in speech perception, except for the group with aided preoperative phoneme scores above 80%. However, all patients who were tested preoperatively with the addition of background noise showed improvements in speech perception in noise after the cochlear implantation. CONCLUSIONS: Although the decision to implant should consider individual ear differences and other factors that might apply to a particular case, based on our data, all patients with preoperative scores of either 80% (phonemes correct) or 60% (words correct) and lower in an optimal-aided situation are potential candidates for a cochlear implant, provided that their preoperative speech perception score decreases below 50% (phonemes correct) or 20% (words correct), when background noise is added at a +5 dB signal to noise ratio.

Government supervision on quality of smoking-cessation counselling in midwifery practices: a qualitative exploration.

BACKGROUND: The Dutch Healthcare Inspectorate supervises care providers in order to improve quality of care. Recently the inspectorate assessed and promoted the use of a guideline on smoking-cessation counselling in midwifery practices. The supervision programme consisted of an announcement of the enforcement deadline for the guideline and site visits. The purpose of our qualitative study was to identify factors related to guideline adherence after the supervision programme, and investigate whether the programme had helped improve adherence. METHODS: We conducted semi-structured interviews with inspected and non-inspected midwives. Additionally, we studied documents and observed the inspection process. The sampled midwives all work in primary care midwifery practices providing care to pregnant smokers. The questions included the current provision of smoking-cessation counselling, support to the midwife in counselling, recent changes in provision of counselling, reasons for recent changes, knowledge about the supervision programme, and experiences with supervision by the inspectorate. RESULTS: Our results show that guideline adherence depends on several factors. Awareness and familiarity with the guideline are important, as is outcome expectancy. Additionally, motivation, guideline factors and environment factors were mentioned. Besides these previously documented factors, we found that professional collaboration also determined guideline adherence. Increased collaboration in counselling is associated with greater adherence to the guideline, such as provision of counselling and taking required training. The supervision programme helped improve stop-smoking counselling, by making midwives aware of the counselling and giving them an extrinsic motivation to provide counselling. CONCLUSION: Motivation and environmental aspects were the most important factors related to guideline adherence, and professional environment was added as significant factor. The improved guideline adherence is partly attributable to the supervision programme.

[Effects of government supervision on quality of integrated diabetes care: a cluster randomized controlled trial]. / Effecten van overheidstoezicht op kwaliteit van diabetesketenzorg: een clustergerandomiseerde gecontroleerde trial.

OBJECTIVES: The quality of integrated diabetes care is important for reducing the burden of diabetes. Therefore, we have evaluated the effect of a supervision program on the quality of integrated diabetes care in the Netherlands in the 2011-2012 period. METHODS: In this cluster RCT, the supervision program was assigned to randomly selected care groups providing care to diabetes patients. The supervision program included announcements of inspections, site visits, and sending individualized reports. Indicators of effectiveness were derived from the structures, processes, and outcomes of care. These indicators were collected from patients' files, before and after the supervision program. Hierarchical linear and logistic regression models were used to analyze data from 356 patients of 10 intervention and 8 control care groups. RESULTS: Structures and processes of care did not improve more in the intervention groups than in the control care groups. Moreover, health outcomes did not improve more in the intervention groups than in the control care groups. Although structures of care improved over time in the total population of intervention and control care groups, there were no changes in process of care or health outcomes. CONCLUSIONS: In this cluster RCT, we could not demonstrate improvements in quality of integrated diabetes care resulting from the supervision program. Although structures of care did improve over time, other quality-improvement initiatives are necessary to substantially strengthen integrated care for diabetes patients.

Intelligibility of the Patient's Speech Predicts the Likelihood of Cochlear Implant Success in Prelingually Deaf Adults.

OBJECTIVES: The objective of this study was to determine the validity and clinical applicability of intelligibility of the patient's own speech, measured via a Vowel Identification Test (VOW), as a predictor of speech perception for prelingually deafened adults after 1 year of cochlear implant use. Specifically, the objective was to investigate the probability that a prelingually deaf patient, given a VOW score above (or below) a chosen cutoff point, reaches a postimplant speech perception score above (or below) a critical value. High predictive values for VOW could support preimplant counseling and implant candidacy decisions in individual patients. DESIGN: One hundred and fifty-two adult cochlear implant candidates with prelingual hearing impairment or deafness took part as speakers in a VOW; 149 speakers completed the test successfully. Recordings of the speech stimuli, consisting of nonsense words of the form [h]-V-[t], where V represents one of 15 vowels/diphthongs ([(Equation is included in full-text article.)]), were presented to two normal-hearing listeners. VOW score was expressed as the percentage of vowels identified correctly (averaged over the 2 listeners). Subsequently, the 149 participants enrolled in the cochlear implant selection procedure. Extremely poor speakers were excluded from implantation, as well as patients who did not meet regular selection criteria as developed for postlingually deafened patients. From the 149 participants, 92 were selected for implantation. For the implanted group, speech perception data were collected at 1-year postimplantation. RESULTS: Speech perception score at 1-year postimplantation (available for 77 of the 92 implanted participants) correlated positively with preimplant intelligibility of the patient's speech, as represented by VOW (r = 0.79, p < 0.00001): the more intelligible the patient's speech, the higher the predicted postimplant speech perception score. This correlation is explained by the hypothesis that the two variables have a common driving force, i.e., (in)adequacy of auditory speech input in the earliest years of life. With a 60% cutoff point, VOW can discriminate between individuals with "above-chance" postimplant speech perception and those with "chance level" postimplant speech perception with sensitivity and specificity of 0.84 and 0.86, respectively. The probability that a patient with a VOW score ≥ 60% achieves "above-chance" speech perception after implantation is 0.91. Conversely, the probability that a patient with VOW < 60% reaches "above-chance" speech perception is 0.25. CONCLUSIONS: For prelingually deaf adults, intelligibility of the patient's speech-as represented by VOW-is a valid predictor of postimplant speech perception. A patient with a VOW score above a preset cutoff is much more likely to develop acceptable speech perception after implantation than a patient with a VOW score below that cutoff. The binary classification based on VOW and the associated probabilities of cochlear implant success in terms of speech perception can be used-in addition to existing criteria-to support the clinician in guiding patient expectations and in considering implant candidacy for individual patients.

The disciplined healthcare professional: a qualitative interview study on the impact of the disciplinary process and imposed measures in the Netherlands.

OBJECTIVE: It is known that doctors who receive complaints may have feelings of anger, guilt, shame and depression, both in the short and in the long term. This might lead to functional impairment. Less is known about the impact of the disciplinary process and imposed measures. Previous studies of disciplinary proceedings have mainly focused on identifying characteristics of disciplined doctors and on sentencing policies. Therefore, the aim of this study is to explore what impact the disciplinary process and imposed measures have on healthcare professionals. DESIGN: Semistructured interview study, with purposive sampling and inductive qualitative content analysis. PARTICIPANTS: 16 healthcare professionals (9 medical specialists, 3 general practitioners, 2 physiotherapists and 2 psychologists) that were sanctioned by the disciplinary tribunal. SETTING: The Netherlands. RESULTS: Professionals described feelings of misery and insecurity both during the process as in its aftermath. Furthermore, they reported to fear receiving new complaints and provide care more cautiously after the imposed measure. Factors that may enhance psychological and professional impact are the publication of measures online and in newspapers, media coverage, the feeling of treated as guilty before any verdict has been reached, and the long duration of the process. CONCLUSIONS: This study shows that the disciplinary process and imposed measures can have a profound psychological and professional impact on healthcare professionals. Although a disciplinary measure is meant to have a corrective effect, our results suggest that the impact that is experienced by professionals might hamper optimal rehabilitation afterwards. Therefore, organising emotional support should be considered during the disciplinary process and in the period after the verdict.