The effect of regional transmural agreements on the information transfer of frail older patients.

INTRODUCTION: Frail older patients are at risk for many complications when admitted to the hospital. Multidisciplinary regional transmural agreements (RTA) in which guidelines were set concerning the information transfer of frail older patients might improve outcomes. We aim to investigate the effect of implementation of the RTA on the completeness of the information transfer of frail older patients when admitted to and discharged from the hospital. METHODS: This is a retrospective cohort study in which we collected data from 400 randomly selected hospitalized frail older patients (70+) before the implementation of the RTA, January through March 2021, and after, October through December 2021. The cohort was split up into four groups, which determined what correspondence would be checked (referral letter by General Practitioner (GP) and three groups of 'hospital letters': ED letter upon admittance, clinical discharge letter to the elderly care physician and clinical discharge letter to the GP. We assessed for mention of frailty, a medication list and mention of resuscitation orders. RESULTS: In the period before implementation the mean age of patients was 82.6 years (SD 7.4) and 101 were female (50.5%), after implementation mean age was 82.3 (SD 6.9) and 112 were female (56.0%). Frailty was mentioned in hospital letters in 12.7% before and 15.3% after implementation (p = 0.09). More GP referral letters were present after implementation (32.0% vs. 54.0%, p = 0.03), however frailty was mentioned only in 12.5% before and 7.4% after (p = 0.58). There was a good handover of medication lists from the hospital (89.3% before, 94% after, p = 0.20) and even better from the GP (93.8% before, 100% after, p = 0.19). Resuscitation orders were mentioned in 59.3% of letters from the hospital before implementation and 57.3% after (p = 0.77), which is higher than in the referral letters (18.8% before and 22.2% after (p = 0.91). DISCUSSION: The implementation of RTA improved the number of GP referral letters present; however, it did not lead to other significant improvements in communication between the hospital and the GP's. Frailty and resuscitation orders are still frequently not mentioned in the reports. After a successful reimplementation, the improvements of outcomes could be investigated.

Effect of neuromuscular reversal with neostigmine/glycopyrrolate versus sugammadex on postoperative ileus following colorectal surgery.

BACKGROUND: Postoperative ileus (POI) is a common complication following colorectal surgery and is mediated in part by the cholinergic anti-inflammatory pathway (CAIP). Neostigmine (acetylcholinesterase inhibitor), co-administered with glycopyrrolate, is frequently given for neuromuscular reversal before tracheal extubation and modulates the CAIP. An alternative reversal agent, sugammadex (selective rocuronium or vecuronium binder), acts independently from the CAIP. The aim of our study was to assess the impact of neuromuscular reversal agents used during anaesthesia on gastrointestinal recovery. METHODS: Three hundred thirty-five patients undergoing elective colorectal surgery at the Royal Adelaide Hospital between January 2019 and December 2021 were retrospectively included. The primary outcome was GI-2, a validated composite measure of time to diet tolerance and passage of stool. Demographics, 30-day complications and length of stay were collected. Univariate and multivariate analyses were performed. RESULTS: Two hundred twenty-four (66.9%) patients (129 [57.6%] males and 95 [42.4%] females, median age 64 [19-90] years) received neostigmine/glycopyrrolate and 111 (33.1%) received sugammadex (62 [55.9%] males and 49 [44.1%] females, median age 67 [18-94] years). Sugammadex patients achieved GI-2 sooner after surgery (median 3 (0-10) vs. 3 (0-12) days, p = 0.036), and reduced time to first stool (median 2 (0-10) vs. 3 (0-12) days, p = 0.035). Rates of POI, complications and length of stay were similar. On univariate analysis, POI was associated with smoking history, previous abdominal surgery, colostomy formation, increased opioid use and postoperative hypokalaemia (p < 0.05). POI was associated with increased complications, including anastomotic leak and prolonged hospital stay (p < 0.001). On multivariate analysis, neostigmine, bowel anastomoses and increased postoperative opioid use (p < 0.05) remained predictive of time to GI-2. CONCLUSIONS: Patients who received sugammadex had a reduced time to achieving first stool and GI-2. Neostigmine use, bowel anastomoses and postoperative opioid use were associated with delayed time to achieving GI-2.

[Daily practice of a FACT-team: results of an experience sampling study]. / De dagelijkse praktijk van een FACT-team: resultaten van een experience-samplingstudie.

BACKGROUND: Flexible assertive community treatment (FACT) teams are widespread in the Netherlands. Despite the presence of a model description and model fidelity scale, it is unclear what FACT workers actually do daily. AIM: Examination of the daily activities of FACT workers on weekdays in relation to the intended activities from the theoretical FACT framework. METHOD: Repeated momentary activity assessments were made among all employed staff (n = 54) of four FACT teams from three different organizations using the experience sampling method (ESM) yielding multiple reports on each workday for one week. 936 reports were analyzed with SPSS, providing a picture of the daily activities of FACT workers. RESULTS: Overall, employees spent 30% of their time with clients, 30% in consultation (4% with network partners), 20% on administration and 20% in travel time and personal activities (30-30-20-20). CONCLUSION: The actual time spent by FACT workers with clients does not match the expected production standards. Contact with relatives and network partners lags far behind the desired figures required for modern network-oriented care. The ESM-based results are different from actual methodologies and require careful interpretation. Applying ESM in FACT teams promises to support a quality development dialogue.

[Stigmatization in mental health care. Research among clients and care providers]. / Stigmatisering binnen de ggz; onderzoek onder cliënten en hulpverleners.

BACKGROUND: In addition to impediments to social and social functioning, people with severe mental illness also experience the negative consequences of prejudice and stigmatization. Stigmatization also occurs in mental health care, including addiction care. AIM: To describe the occurrence and manifestations of stigmatization by care providers, from the perspective of clients and care providers. METHOD: Digital surveys among clients of the panel Psychisch Gezien (n = 628) and among care providers (n = 471). RESULTS: More than half (54%) of the panel members had experienced stigmatization by mental health care providers in the past two years. They experienced this mainly through a distant attitude (22%) and the language used by care providers (20%). Two-fifths (40%) of the care providers indicated that stigmatization occured regularly or often in their own team. Both clients and counselors emphasized the importance of normalizing mental health problems, reluctant use of psychiatric labels and recovery-oriented work to reduce stigma. CONCLUSION: Stigmatization by mental health care providers is manifested in many ways, making it a complex and ambiguous problem. Although there is no ‘one size fits all’ solution, normalization of mental problems is an important starting point.

Clinical consequences of consecutive self-expanding transcatheter heart valve iterations.

OBJECTIVE: To compare early clinical outcomes after transcatheter aortic valve implantation (TAVI) with three consecutive generations of self-expanding valves (SEVs). METHODS: Clinical endpoints of consecutive patients who underwent TAVI with CoreValve, Evolut R or Evolut PRO were included in a prospective database. RESULTS: TAVI was performed with CoreValve (n = 116), Evolut R (n = 160) or Evolut PRO (n = 92). Evolut R and Evolut PRO showed a tendency towards lower permanent pacemaker implantation (PPI) rates compared to CoreValve (CoreValve 27% vs Evolut R 16% vs Evolut PRO 18%, p = 0.091). By multivariable regression analysis CoreValve had a significantly higher risk for PPI (odds ratio (OR) 2.79, 95% confidence interval (CI) 1.31-5.94, p = 0.008) compared to Evolut R, while Evolut R and PRO were similar. Severe paravalvular leakage (PVL) occurred only with CoreValve, but no significant difference was observed in moderate PVL (10% vs 8% vs 6%, p = 0.49). CoreValve had a tendency towards a higher risk for more-than-mild PVL as compared with the Evolut platform (R + PRO) (OR 2.46, 95% CI 0.98-6.16, p = 0.055). No significant differences in all-cause mortality (7% vs 4% vs 1%, p = 0.10), stroke (6% vs 3% vs 2%, p = 0.21) or major vascular complications (10% vs 12% vs 4%, p = 0.14) were observed. CONCLUSIONS: TAVI with self-expanding valves was safe, and device iterations may result in a lower need for PPI. More-than-mild PVL seemed to occur less often with repositionable technology.

Impact of STIMUlant and osmotic LAXatives (STIMULAX trial) on gastrointestinal recovery after colorectal surgery: randomized clinical trial.

BACKGROUND: Recovery of gastrointestinal (GI) function is often delayed after colorectal surgery. Enhanced recovery protocols (ERPs) recommend routine laxative use, but evidence of benefit is unclear. This study aimed to investigate whether the addition of multimodal laxatives to an ERP improves return of GI function in patients undergoing colorectal surgery. METHODS: This was a single-centre, parallel, open-label RCT. All adult patients undergoing elective colorectal resection or having stoma formation or reversal at the Royal Adelaide Hospital between August 2018 and May 2020 were recruited into the study. The STIMULAX group received oral Coloxyl® with senna and macrogol, with a sodium phosphate enema in addition for right-sided operations. The control group received standard ERP postoperative care. The primary outcome was GI-2, a validated composite measure defined as the interval from surgery until first passage of stool and tolerance of solid intake for 24 h in the absence of vomiting. Secondary outcomes were the incidence of prolonged postoperative ileus (POI), duration of hospital stay, and postoperative complications. The analysis was performed on an intention-to-treat basis. RESULTS: Of a total of 170 participants, 85 were randomized to each group. Median GI-2 was 1 day shorter in the STIMULAX compared with the control group (median 2 (i.q.r. 1.5-4) versus 3 (2-5.5) days; 95 per cent c.i. -1 to 0 days; P = 0.029). The incidence of prolonged POI was lower in the STIMULAX group (22 versus 38 per cent; relative risk reduction 42 per cent; P = 0.030). There was no difference in duration of hospital day or 30-day postoperative complications (including anastomotic leak) between the STIMULAX and control groups. CONCLUSION: Routine postoperative use of multimodal laxatives after elective colorectal surgery results in earlier recovery of gastrointestinal function and reduces the incidence of prolonged POI. Registration number: ACTRN12618001261202 (www.anzctr.org.au).

Impact of timing of reversal of loop ileostomy on patient outcomes: a retrospective cohort study.

BACKGROUND: Diverting loop ileostomies (DLIs) are ideally reversed 6-12 weeks after the index operation. However, reversal surgery is frequently delayed in a real-world setting, with potential implications on patient's quality of life and postoperative complications. The aim of this study was to investigate the impact of timing of the reversal on patient outcomes at a tertiary referral hospital. METHODS: Consecutive patients who underwent elective reversal of loop ileostomy (RLI) between January 2007 and January 2019 were included. The primary outcomes were incidence of postoperative ileus (POI) and 30-day postoperative complications. RESULTS: Of 251 eligible patients, 158 (63%) were men, the median age was 64 years (range 23-88 years), and the most common index operation was an ultra-low anterior resection in 106 (42%). The median time to reversal for the entire cohort was 7.4 months (range 1-28). RLI was performed within 6 months after the index surgery in 89 patients (35%, early group), 6-12 months in 120 (48%, middle group) and after more than 12 months in 42 (17%, late group) patients. A significantly lower incidence of postoperative ileus (13.5% vs. 25.8% vs. 38.1%, p = 0.006), and 30-day postoperative complications (29.2% vs 41.7% vs. 57.1%, p = 0.011) were seen in the early group compared to the middle and late groups, respectively. There was no difference in the return to theater, length of hospital stay, and readmission rate between groups. CONCLUSION: Delayed RLI is associated with increased risk of postoperative complications.

[Assertive Treatment as a regular function within mental health]. / Van bemoeizorg naar assertieve behandeling als regulier aanbod vanuit de ggz.

BACKGROUND: The setting for providing assertive treatment (AT) has changed during the last 30 years in The Netherlands from assertive community treatment (ACT) and flexible assertive community treatment (FACT) to municipalities. The provision of AT varies between municipalities. AIM: Describing the concept of AT, the nature and size of the target group, and the reasons why people with severe mental illness (SMI) do not seek treatment and the place of AT in mental health care. METHOD: We used literature en available quantitative data. RESULTS: AT regularly provided by mental health care is required in patients with SMI and social problems who do not seek treatment. When mental health care and social care collaborate on the level of the patient, treatment and handling of social problems can strengthen each other. This collaboration prevents discontinuity of care and breaking a trusting relationship because patients do not need to be transferred from social service to mental health care or vice versa. AT is on the continuum of voluntarily to compulsory care.AT provided by mental health care (usually provided by FACT-teams) is indicated for SMI patients with social problems and who do not seek treatment. The size of the target group is around 5000 - 20.000 patients in The Netherlands. Reasons not to seek help for people with SMI include within person factor, mental health related factors, or factors related to the interaction of SMI patients and mental health. We advocate for AT to become a regular part of mental health care, and for mental health care and social domain professionals to collaborate on case level. Acting this way, mental health treatment and addressing social problems can reinforce each other and discontinuity of care and breaking a trusting relationship can be prevented. AT is on the continuum of voluntary to involuntary treatment. That is why we suggest AT to be a better term than assertive outreach. CONCLUSION: It is a given fact that not all patients with SMI and social problems seek treatment. By making AT a regular part of mental health services, we prevent discontinuity of care and we fill the gap between voluntarily and compulsory care.

[Mental health in Eastern Lille: a future of network-psychiatry?] / De ggz in Oost-Lille: inspiratie voor de praktijk van netwerkzorg in de ggz.

BACKGROUND: For some time now, East Lille has been working with a relatively modern mental health care system that remarkably resembles Dutch health care with the same values and norms that we want to implement in the Netherlands as well.
AIM: Gaining inspiration to further investigate regional cooperation and 'network care' in Dutch psychiatry.
METHOD: A delegation from the board of f-act-Netherlands and ccaf paid a working visit to Lille.
RESULTS: The basis of the East Lille working method is a charter of shared values developed with all parties, clients, relatives, employees and external professionals, which is signed by every professional. In case of doubt, a change of context or the introduction of new working methods, these values are used first. CONCLUSIONS High quality mental health care develops in dialogue, in which working methods, service delivery models and interventions are linked to each other by means of network care. Through reflection, moral deliberation and appreciative auditing, care is progressively improved. These procedures guarantee a modern process of quality improvement.

[Flexible assertive community treatment (FACT) as part of a community (health) network]. / FACT als onderdeel van wijkgerichte zorg in het (zorg)netwerk.

BACKGROUND: Community-based care for people with severe mental illness increasingly requires far-reaching cooperation between different domains. This cooperation must always be unique and local, and at the same time provide an answer to generic and nationally set goals.
AIM: Offering new insights on collaboration within and between domains.
METHOD: Reflection on developments in the social domain and specialist mental healthcare using relevant literature and recent (inter)national experiences.
RESULTS: It seems possible to provide better integral care by allowing FACT-teams to network together with Social Support partners (e.g. by sharing financial and/or human resources). In this process, networks of care for people with serious mental illness (SMI), develop over various phases and realize new partnerships. The model fidelity scale for FACT-teams was adjusted to facilitate that process. CONCLUSIONS The new FACT model fidelity scale is ready to allow FACT-teams to explore flexible local solutions for partnerships to realize the much-needed multi-domain integrated community care for people with SMI.

[Positive effects of psychoeducation on mental disorders in the Netherlands]. / Positieve effecten van voorlichting over psychiatrische aandoeningen in de algemene bevolking.

BACKGROUND: Mental Health First Aid (mhfa) is a psychoeducation program designed to recognize mental health problems in others, to approach and support them and to refer them to appropriate help.
AIM: To discuss the possible contribution that mhfa can make to the early detection, intervention and destigmatization of mental health problems in the Netherlands.
METHOD: Description of the characteristics, effectiveness and knowledge gaps of mhfa in the Dutch context based on literature and practice.
RESULTS: Positive experiences abroad suggest that mhfa can also contribute to early detection, intervention and destigmatization of mental disorders in the Netherlands. Optimization of the program on the local context is important here.
CONCLUSION: Dutch evaluation- and effect studies are needed to determine whether the positive effects from international research also apply in the Netherlands, whether adults and young people receive early and adequate help thanks to mhfa, and how the stigma surrounding mental disorders can be further reduced.

Assessment of osteoarthritic features in the thumb base with the newly developed OMERACT magnetic resonance imaging scoring system is a valid addition to standard radiography.

OBJECTIVE: To investigate the construct validity of the new thumb base OA magnetic resonance imaging (MRI) scoring system (TOMS) by comparing TOMS scores with radiographic scores in patients with primary hand OA. DESIGN: In 200 patients (83.5% women, mean (SD) age 61.0 (8.4) years), postero-anterior radiographs and MR scans (1.5 T) of the right first carpometacarpal (CMC-1) and scaphotrapeziotrapezoid (STT) joints, were scored using the OARSI atlas and TOMS, respectively. The distributions of the TOMS scores (specified in results section) were stratified for the OARSI scores of corresponding radiographic features and investigated using boxplots and non-parametric tests. Furthermore, Spearman's rank or Phi correlation coefficients (ρ/φ) were calculated. RESULTS: For all features, especially for erosions and osteophytes, the prevalence found with MRI was higher than with radiography. TOMS osteophyte and cartilage loss scores differed statistically significant between corresponding OARSI scores in CMC-1 (0 vs 1; 1 vs 2). TOMS scores were positively correlated with radiographic scores in CMC-1 for osteophytes (coefficient [95% confidence interval], ρ = 0.75 [0.69; 0.81]), cartilage loss/joint space narrowing (ρ = 0.70 [0.62; 0.76]), subchondral bone defects (SBDs)/erosion-cyst (ρ = 0.41 [0.29; 0.52]), bone marrow lesions (BMLs)/subchondral sclerosis (ρ = 0.65 [0.56; 0.73]) and subluxation (φ = 0.65 [0.57; 0.73]); and in STT for osteophytes (ρ = 0.30 [0.17; 0.42]) and cartilage loss/joint space narrowing (ρ = 0.53 [0.42; 0.62]). CONCLUSIONS: In patients with hand OA, TOMS scores positively correlated with radiographic scores, indicating good construct validity. However, the prevalence of features on MR images was higher compared to radiographs, suggesting that TOMS might be more sensitive than radiography. The clinical meaning of these extra MR detected cases is currently still unknown.

Flexible assertive community treatment for individuals with a mild intellectual disability or borderline intellectual functioning: results of a longitudinal study in the Netherlands.

BACKGROUND: Assertive community treatment (ACT) and Flexible assertive community treatment (FACT) are organisation models for intensive assertive outreach that were originally developed for individuals with severe mental illness. The models are increasingly applied to people with mild intellectual disability (MID) or borderline intellectual functioning (BIF) and challenging behaviour or mental illness. Research on these types of care for this population is limited. To gain experience in FACT MID/BIF in the Netherlands and to obtain insight in its outcomes, four organisations specialised in the treatment of individuals with MID/BIF and challenging behaviour participated in a 6-year implementation and research project. METHODS: A longitudinal study was set up to investigate outcomes over time. Outcome measures concerned admissions to (mental) health care, social and psychological functioning, (risk of) challenging and criminal behaviour, social participation and client satisfaction. Data were analysed using descriptive statistics and linear mixed models. RESULTS: Over time, clients showed improvement in their social and psychiatric functioning and living circumstances. The number of admissions to (mental) health care diminished as well as the number of contacts with police and justice, the level of social disturbance and the risk factors for challenging and criminal behaviour. Problems related to finances, work and substance abuse remained unchanged. CONCLUSIONS: The results are encouraging and give rise to continued development of and broader research on FACT MID/BIF.

[Development of the renewed Flexible ACT scale: F-ACT fidelity 2017]. / De ontwikkeling van de vernieuwde Flexible ACT-schaal: F-ACT-s 2017.

BACKGROUND: An important model for the organisation of care for people with severe mental illness is flexible assertive community treatment (F-ACT). F-ACT combines case management with assertive crisis intervention. Quality control was implemented in 2008 using a model fidelity scale. Research has shown that the norms used for the F-ACT fidelity scale no longer correspond with current norms concerning restorative and evidence-based care, as established in treatment guidelines.
AIM: To develop a new model fidelity scale for F-ACT teams.
METHOD: Using knowledge of experts, relevant articles and feedback from professionals, researchers, interest groups and family members, a new model fidelity scale was developed: the F-ACTs 2017. The revised scale was tested by trained auditors in 21 F-ACT teams and adjusted in two pilot rounds.
RESULTS: In 2017 the final version was presented to the stakeholders and was approved by the board of auditors; the final version is currently in use. CONCLUSIONS With the availability of F-ACTs 2017, the (research) field has state-of-the-art instrument to monitor the quality of care of persons with severe mental illness. It uses field standards to evaluate the degree of model fidelity of teams that focus on patients with severe mental illness in a rapidly changing context.

Multicentre randomized clinical trial of the effect of chewing gum after abdominal surgery.

BACKGROUND: Postoperative ileus is a common complication of abdominal surgery, leading to patient discomfort, morbidity and prolonged postoperative length of hospital stay (LOS). Previous studies suggested that chewing gum stimulates bowel function after abdominal surgery, but were underpowered to evaluate its effect on LOS and did not include enhanced recovery after surgery (ERAS)-based perioperative care. This study evaluated whether chewing gum after elective abdominal surgery reduces LOS and time to bowel recovery in the setting of ERAS-based perioperative care. METHODS: A multicentre RCT was performed of patients over 18 years of age undergoing abdominal surgery in 12 hospitals. Standard postoperative care (control group) was compared with chewing gum three times a day for 30 min in addition to standard postoperative care. Randomization was computer-generated; allocation was concealed. The primary outcome was postoperative LOS. Secondary outcomes were time to bowel recovery and 30-day complications. RESULTS: Between 2011 to 2015, 1000 patients were assigned to chewing gum and 1000 to the control arm. Median LOS did not differ: 7 days in both arms (P = 0·364). Neither was any difference found in time to flatus (24 h in control group versus 23 h with chewing gum; P = 0·873) or time to defaecation (60 versus 52 h respectively; P = 0·562). The rate of 30-day complications was not significantly different either. CONCLUSION: The addition of chewing gum to an ERAS postoperative care pathway after elective abdominal surgery does not reduce the LOS, time to bowel recovery or the rate of postoperative complications. Registration number: NTR2594 (Netherlands Trial Register).

[Model fidelity of flexible assertive community treatment (F-ACT) teams: five years of audit results]. / Modelgetrouwheid van flexible assertive community treatment(F-ACT)-teams: resultaten van vijf jaar auditeren.

BACKGROUND: The Flexible act (f-act) has been introduced in the Netherlands since 2004, alongside the Assertive Community Treatment (act) model. An estimate of 400 (f-)act teams concurrently provide care to approximately 70.000 people with serious mental illness. The ccaf has been assessing the model fidelity of act and f-act teams since 2009 to promote the quality and transparency of healthcare for clients with serious mental illness. OBJECTIVE To describe the state of implementation of f-act and associated trends in the Netherlands.
METHOD: Analysis of the ccaf database, which holds the data of audits conducted between 2009 and 2014.
RESULTS: The audits conducted by ccaf between 2009 and 2014 indicated an adequate implementation of f-act. The team foundations were well organized, featuring a multidisciplinary team structure, management of medication, practical support and investment in healthcare continuity, including during an admission. However, the results regarding participation and recovery were unsatisfactory. Furthermore, the results depicted a decline in the scores concerning a number of areas, including outreach and support of participation and recovery. CONCLUSIONS Although the data indicates an on average satisfactory implementation of f-act in the Netherlands, there are signs that the implementation of f-act is under pressure with relatively fewer home visits, a rising caseload and a reduced investment in recovery and participation. The findings are in accordance with the signs and arguments to adjust the emphasis on reducing hospital admissions, prioritizing the consolidation of outpatient care instead.

Value and potential limitations of vertebral fracture assessment (VFA) compared to conventional spine radiography: experience from a fracture liaison service (FLS) and a meta-analysis.

We evaluated the value of VFA in the identification of vertebral fractures using a retrospective study and a meta-analysis. Performance of VFA was adequate in the meta-analysis although this was not demonstrated in our centre. We recommend checking the performance of VFA tools before exclusively relying on this tool. INTRODUCTION: Vertebral fractures are traditionally diagnosed using conventional radiographs of the spine. Vertebral fracture assessment (VFA) has been advocated as an alternative tool in the diagnosis of these fractures. METHODS: We conducted a retrospective study as well as a systematic review and a meta-analysis to evaluate the performance of VFA compared to conventional spinal radiography in patients who had sustained a fracture and thus at risk for osteoporosis. A risk of bias analysis was also performed. RESULTS: The diagnostic study included 542 patients (25% male) with fractures. The sensitivity of low-radiation VFA to detect a patient with a vertebral fracture ≥ Genant grade 2 was 0.77 and its specificity 0.80. Two hundred ninety-seven (55%) patients had ≥1 and 135(25%) ≥3 unevaluable vertebrae. The systematic review identified 16 studies including a total of 3238 subjects (19% male) with a mean age range of 45 to 74 years. Seven studies had a low risk of bias and 9 had an intermediate risk, mainly due to not consecutively including patients. The pooled sensitivity of VFA to detect a patient with a vertebral fracture ≥Genant grade 2 was 0.84 (95% CI, 0.72-0.92) and specificity 0.90 (95% CI, 0.84-0.94). CONCLUSIONS: Our findings from the meta-analysis suggest an adequate performance of VFA for the detection of vertebral fractures. However, we could not demonstrate these findings in our center, especially the specificity. Our data advocate caution with exclusively relying on VFA in the assessment of vertebral fractures without identifying performance and potential limitations of the technique.

[Forensic (flexible) assertive community treatment: client characteristics and treatment outcomes]. / Forensische (flexibele) assertive community treatment ((F)ACT): cliëntkenmerken en behandelresultaten.

BACKGROUND: (Flexible) Assertive community treatment ((f)act) is applied increasingly to forensic psychiatric clients. However, evidence about the effectiveness of forensic (f)act is scanty. AIM: To investigate to what extent (subgroups of) clients receiving care from forensic (f)act teams show, after a year, changes in their social and psychological functioning and are subjected to fewer justicial outcome measures. METHOD: Between 2009 and 2011, eight forensic (f)act teams collected, at two measurement moments separated by an average of 12 months, data relating to client characteristics and outcomes of care. The study involved 202 clients. RESULTS: After a year clients showed significant improvements in psychological and social functioning, and had fewer confrontations with the police and the law. They were detained less often and for shorter periods and were considered to be less likely to reoffend. The number of admissions to mental health care and to addiction and forensic care remained constant. CONCLUSION: Clients with a psychiatric disorder and likely to display criminal behaviour showed improvement while being treated by forensic (f)act teams. Further research is needed to prove whether forensic (f)act treatment will have the desired effects in the longer term and will enjoy the status of being regarded as evidence based practice.

Radiographic progression of knee osteoarthritis is associated with MRI abnormalities in both the patellofemoral and tibiofemoral joint.

OBJECTIVE: To investigate patterns of MRI abnormalities in the patellofemoral (PFJ) and tibiofemoral joint (TFJ) and their association with radiographic progression, using hypothesis free analyses. DESIGN: 205 patients from the GARP study with symptomatic OA at multiple sites (mean age 60 years, 80% woman, median BMI 26 kg/m(2)), underwent knee MRI at baseline. Cartilage damage, osteophytes, cysts, bone marrow lesions (BMLs) and effusion/synovitis were scored according to a validated scoring method. Baseline and 6-year TFJ and PFJ radiographs were scored (0-3) for JSN and osteophytes according to OARSI and Burnett atlases, respectively; progression was defined as ≥1 point increase. Baseline patterns of MRI abnormalities derived from principal component analysis (PCA) were associated with progression using adjusted generalized estimating equations (GEE). RESULTS: PCA resulted in extraction of six components, explaining 69% of variance. In 29% and 29% of 133 patients with follow-up the TFJ progressed, whereas in 15% and 9% the PFJ progressed for osteophytes and JSN, respectively. Component 1 (cartilage damage of the PFJ and osteophytes of both joints) was statistically significant associated with TFJ JSN progression and PFJ osteophyte progression. Component 2 (all lateral PFJ abnormalities except osteophytes) was associated with JSN/osteophyte progression in the PFJ alone, whereas component 3 (all medial TFJ abnormalities except osteophytes) was associated with JSN and osteophyte progression in both PFJ and TFJ. CONCLUSION: Baseline structural damage and bone turnover activity, as reflected by BMLs, seem to be involved in knee OA progression. Moreover, progression in PFJ and TFJ seems to be related.

Evolution of synovitis in osteoarthritic knees and its association with clinical features.

OBJECTIVE: To investigate the course of synovitis on contrast-enhanced magnetic resonance images (CE-MRI) in osteoarthritic knees over 2 years, and its association with pain and cartilage deterioration. DESIGN: Consecutive patients (n = 39, mean age 61 years, 79% woman, median (range) body mass index (BMI) 29 (24-48) kg/mm2) with clinical osteoarthritis (OA) were included. Baseline and follow-up CE-MRI (3 T) were scored paired in chronological order for synovitis (semi-quantitatively at 11 sites (range 0-22)), cartilage deterioration and bone marrow lesions (BMLs) (semi-quantitatively according to Knee Osteoarthritis Scoring System (KOSS)). Changes in sum scores were calculated. Cartilage deterioration was defined as change of ≥2 above the smallest detectable change (SDC). Pain was assessed by standardized questionnaires. Analysis of covariance (ANCOVA) and linear regression models were used to investigate association between synovitis change and cartilage deterioration and between synovitis change or cartilage deterioration and change in pain. RESULTS: The total synovitis score did not change over 2 years (mean change 0.2 (standard deviation (SD) 3.2)), although changes in individual patients were observed. Cartilage deterioration was observed in 51% of patients. Synovitis change score was lower in patients without compared to patients with cartilage deterioration, taking BML change in account (mean difference -2.1 (-4.1 to -0.1)). Change in synovitis was not associated with change in pain, whereas cartilage deterioration was associated with change in Intermittent and Constant OsteoArthritis Pain (ICOAP) constant pain in adjusted models (unstandardised coefficient (B) (95% confidence interval (CI)) 2.8 (0.4-5.3)). CONCLUSIONS: In individual patients synovitis fluctuates during disease course. Synovitis change was not associated with change in pain. Increase in synovitis is associated with cartilage deterioration, suggesting a role for synovitis as a target for disease-modifying treatment.