The effect of a locally tailored intervention on the uptake of preconception care in the Netherlands: a stepped-wedge cluster randomized trial (APROPOS-II study).

BACKGROUND: The preconception period provides a window of opportunity for interventions aiming to reduce unhealthy lifestyle behaviours and their negative effect on pregnancy outcomes. This study aimed to assess the effectiveness of a locally tailored preconception care (PCC) intervention in a hybrid-II effectiveness implementation design. METHODS: A stepped-wedge cluster randomized controlled trial was performed in four Dutch municipalities. The intervention contained a social marketing strategy aiming to improve the uptake (prospective parents) and the provision (healthcare providers) of PCC. Prospective parents participated by administering a questionnaire in early pregnancy recalling their preconceptional behaviours. Experiences of healthcare providers were also evaluated through questionnaires. The composite primary outcome was adherence to at least three out of four preconceptional lifestyle recommendations (early initiation of folic acid supplements, healthy nutrition, no smoking or alcohol use). Secondary outcomes were preconceptional lifestyle behaviour change, (online) reach of the intervention and improved knowledge among healthcare providers. RESULTS: A total of 850 women and 154 men participated in the control phase and 213 women and 39 men in the intervention phase. The composite primary outcome significantly improved among women participating in the municipality where the reach of the intervention was highest (Relative Risk (RR) 1.57 (95% Confidence Interval (CI) 1.11-2.22). Among women, vegetable intake had significantly improved in the intervention phase (RR 1.82 (95%CI 1.14-2.91)). The aimed online reach- and engagement rate of the intervention was achieved most of the time. Also, after the intervention, more healthcare providers were aware of PCC-risk factors (54.5% vs. 47.7%; p = 0.040) and more healthcare providers considered it easier to start a conversation about PCC (75.0% vs. 47.9%; p = 0.030). CONCLUSION: The intervention showed some tentative positive effects on lifestyle behaviours among prospective parents. Primarily on vegetable intake and the knowledge and competence of healthcare providers. The results of this study contribute to the evidence regarding successfully implementing PCC-interventions to optimize the health of prospective parents and future generations. TRIAL REGISTRATION: Dutch Trial Register: NL7784 (Registered 06/06/2019).

Parental perspectives on the awareness and delivery of preconception care.

BACKGROUND: The attention for Preconception Care (PCC) has grown substantially in recent years, yet the implementation of PCC appears challenging as uptake rates remain low. The objective of this study was to assess parental perspectives on how PCC should be provided. METHODS: Recruitment of participants took place among couples who received antenatal care at a Dutch community midwifery practice. Between June and September 2014, five focus group sessions were held with 29 women and one focus group session with 5 men. Thematic analysis was conducted using NVivo 10 software. RESULTS: Participants were generally unfamiliar with the concept of PCC. It was proposed to raise awareness by means of a promotional campaign, stipulating that PCC is suited for every couple with a (future) child wish. Suggestions were made to display marketing materials in both formal and informal (local community) settings. Addressing existing social networks and raising social dialogue was expected to be most efficient. It was recommended to make PCC more accessible by offering multiple forms and to involve male partners. Opportunistic offering PCC by healthcare providers was considered more acceptable when the subject was deliberately raised, for example while discussing contraceptives, lifestyle risks or drug prescriptions. GP's or midwifes were regarded the most suitable PCC providers, however provider characteristics such as experience, empathy and communication skills were considered more important. CONCLUSIONS: This study showed that from the parental perspective it is recommended to address every couple with a (future) child wish by means of enlarging the awareness and accessibility of PCC. In order to enlarge the awareness, it is recommended to address social networks, to raise the social dialogue and to conduct promotional campaigns regarding PCC. In order to improve the accessibility of PCC, it was suggested to simultaneously offer multiple forms: group sessions, individual consultations, walk-in-hours and online sessions, and to involve male partners.

Healthcare providers' views on the delivery of preconception care in a local community setting in the Netherlands.

BACKGROUND: The attention for preconception care (PCC) has grown substantially in recent years, yet PCC is far from routine in daily practice. One of the major challenges for the implementation of PCC is to identify how it can best be organized and provided within the primary care setting. The aim of this study was to identify bottlenecks and solutions for the delivery of PCC from a healthcare providers' perspective in a local community setting in the Netherlands. METHODS: Health professionals within the region of Zeist, the Netherlands, were invited for a meeting on the local implementation of PCC. Five parallel group sessions were held with 30 participants from different disciplines. The sessions were moderated based on the Nominal Group Technique, in which bottlenecks (step 1) and solutions (step 2) for the delivery of PCC were gathered, categorized and prioritized by the participants. RESULTS: Participants expressed that the provision of PCC is challenging due to lack of awareness, the absence of a costing structure and unclear allocation of responsibilities. The most pragmatic approach considered was to make interdisciplinary arrangements within the local primary care setting. Participants recommended to 1) settle a costing structure by means of third party reimbursement, 2) improve collaboration by means of a local cooperation network and an adequate referral system, 3) invest in education, tools and logistics and 4) increase uptake rates by the routine opportunistic offer of PCC and promotional campaigns. CONCLUSIONS: From a provider's perspective a tailored approach is advocated in which interdisciplinary arrangements for collaboration and referral are set up within the local primary care setting.

[Use of the film Keep on the open road in palliative care education of undergraduate medical students : Proof-of-concept study]. / Verwendung des Kinofilms Halt auf freier Strecke in der palliativmedizinischen Pflichtlehre von Medizinstudenten. "Proof-of-concept"-Studie.

OBJECTIVE: Recently palliative care has become an integral and compulsory part of undergraduate medical training in Germany. From 2014 onwards every German medical faculty must have developed and implemented undergraduate teaching in this cross-disciplinary medical field and to conduct examinations. At Witten/Herdecke University (Germany) this new cross-sectional course in palliative care was taught for the first time in 2011. The film "Keep on the open road" was incorporated and the use of this film as part of compulsory palliative care education was evaluated from the student perspective. METHOD: In two teaching units (1.5 h each) the film was watched with the students and discussed in the context of the palliative care setting with a special focus on psychosocial aspects. A semi-quantitative evaluation was performed after the debriefing. RESULTS: A total of 23 students participated in the course, 87 % (n = 20) evaluated the use of the film as unrestricted useful and 14 indicated a benefit from the film in terms of their medical attitude. Most of the students (n = 19, 83%) did not consider bed-side teaching to be more useful than the film unit. The free text answers underlined that primarily the multidisciplinary aspects of a palliative treatment situation and the meaning of a social environment were highlighted by the film. CONCLUSIONS: According to the evaluation of the students and the judgement of the participating teachers the use of the film is a suitable method to clarify complex medical, social and psychological aspects in palliative care. Especially at faculties with much larger numbers of students the film unit is thought to be a helpful method to teach psychosocial aspects and to promote development of attitude in palliative care. In future semesters further experience with the unit and the use of films in palliative care teaching will be collected.

[Quality management in acute pain therapy: results from a survey of certified hospitals]. / Qualitätsmanagement in der Akutschmerztherapie : Ergebnisse einer Befragung TÜV-zertifizierter Kliniken.

AIM: Systems for and methods of quality management are increasingly being implemented in public health services. The aim of our study was to analyze the current state of the integrated quality management concept "quality management acute pain therapy" of the TÜV Rheinland® (TÜV) after a 5-year project period. MATERIAL AND METHODS: General characteristics of the participating hospitals, number of departments certified by the TÜV and implementation of structures and processes according to the TÜV guidelines were evaluated by a mail questionnaire. Furthermore, positive and negative aspects concerning the effects of certification were evaluated by the hospitals' representatives of certification. RESULTS: A total of 36 questionnaires were returned. Since 2006 the number of certified hospitals (2011: n = 48) and surgical departments (2011: n = 202) has increased continuously. The number of certified medical departments is low (2011: n = 39); however, in the last 3 years, it has increased by about 200-300% annually. Standard operative procedures for pain therapy and measurement of pain intensity at regular intervals were implemented in all certified clinics (100%). Although 41% take part in the benchmarking project QUIPS (Quality Improvement in Postoperative Pain Therapy), 24% do not systematically check the quality of the outcome of pain management. Acceptance of the new pain therapy concepts among nursing staff was rated positively (ratio positive:negative 16:1); however, acceptance among physicians was rated negatively (1:15). CONCLUSION: Certification by the TÜV leads to sustainable implementation of quality management principles. Future efforts should focus on better integration of physicians in acute pain therapy and the development of an integrated tool to measure patients' outcome.

Improved MR imaging detection of cerebral microbleeds more accurately identifies persons with vasculopathy.

BACKGROUND AND PURPOSE: The clinical relevance of improved detection of cerebral microbleeds by using advanced-versus-conventional MR imaging techniques remains uncertain. As part of the population-based Rotterdam Scan Study, we compared whether participants whose microbleeds were only demonstrated on a high-resolution MR imaging sequence differed with respect to risk profile and risk of new microbleeds from participants whose microbleeds were also depicted on a conventional MR imaging sequence. MATERIALS AND METHODS: Two hundred participants (mean age, 79.2 years) underwent both conventional 2D T2*-weighted MR imaging and high-resolution 3D T2*-weighted MR imaging at 1.5T. Vascular risk factors, APOE allele status, and markers of small vessel disease and risk of incident microbleeds were compared for microbleed status by using logistic regression models adjusted for age and sex. RESULTS: There were no significant associations between any of the factors and microbleed presence in participants whose microbleeds were only demonstrated on a high-resolution MR imaging sequence. However, the estimates in these participants were more similar to those in participants whose microbleeds were also depicted on a conventional MR imaging sequence than to those in participants without microbleeds. Moreover, significantly more participants whose microbleeds were only demonstrated on high-resolution MR imaging developed new CMBs during follow-up compared with participants without CMBs (25.0% versus 5.9%; OR, 5.98; 95% CI, 1.35-26.49). CONCLUSIONS: Improved detection of microbleeds may contribute to more accurate identification of persons with underlying small-vessel pathology in the general elderly population. Further studies are needed to replicate these findings and firmly establish the role of improved detection of CMBs in the identification of persons with vasculopathy.

Cerebral microbleeds are associated with worse cognitive function: the Rotterdam Scan Study.

OBJECTIVE: Cerebral microbleeds are frequently found in the general elderly population and may reflect underlying vascular disease, but their role in cognitive function is unknown. METHODS: We investigated the association between cerebral microbleeds and performance in multiple cognitive domains in 3,979 persons without dementia (mean age, 60.3 years). Mini-Mental State Examination (MMSE) score and neuropsychological tests were used to assess global cognition and the following cognitive domains: memory, information processing speed, executive function, and motor speed. We used number of microbleeds as continuous variable, and additionally distinguished between persons with no microbleeds, 1 microbleed, 2-4 microbleeds, and ≥5 microbleeds. The association of microbleeds with different cognitive domains was estimated using linear regression models. Additional adjustments were made for vascular risk factors, brain atrophy, and other imaging markers of cerebral small vessel disease. We stratified analyses by location of microbleeds. RESULTS: A higher number of microbleeds was associated with lower MMSE score and worse performance on tests of information processing speed and motor speed. When analyzed per category, presence of 5 or more microbleeds was associated with worse performance in all cognitive domains, except memory. These associations were most robust in participants with strictly lobar microbleeds, whereas after additional adjustments associations disappeared for deep or infratentorial microbleeds. CONCLUSIONS: Presence of numerous microbleeds, especially in a strictly lobar location, is associated with worse performance on tests measuring cognitive function, even after adjustments for vascular risk factors and other imaging markers of small vessel disease. These results suggest an independent role for microbleed-associated vasculopathy in cognitive impairment.

[Analgesic therapy of calciphylaxis with levomethadone : a case study]. / Analgetische therapie mit levomethadon bei kalziphylaxie : eine kasuistik.

Calciphylaxis, or calcific uremic arteriopathy, is a rare complication of end-stage renal impairment. It is characterized by calcification of arterioles and development of intensely painful subcutaneous ischemic ulcerations. While symptomatic management is the mainstay of treatment, particular emphasis is placed on adequate analgesia. Conventional analgesic concepts have mostly proved to be insufficient which increases the extreme suffering of patients. This case report describes the successful analgesic treatment of calciphylaxis with levomethadone.

[Fulminant pulmonary artery embolism in the early postoperative phase. Use of transesophageal echocardiography in acute diagnostics]. / Fulminante Lungenarterienembolie in der frühen postoperativen Phase. Einsatz der transösophagealen Echokardiographie in der Akutdiagnostik.

Acute pulmonary embolism is a serious perioperative complication with a high mortality. A case of early onset pulmonary embolism with acute right heart failure and resuscitation after spinal surgery is reported. The diagnosis was rapidly and reliably confirmed by transesophageal echocardiography (TEE) and a right atrial thrombus was detected. Persistent life-threatening hemodynamic instability required thrombolysis with 100 mg recombinant tissue-type plasminogen activator (rt-PA). The patient survived this critical situation but sustained permanent paraparesis.

[Perioperative beta-receptor blockade. For and against]. / Perioperative beta-Rezeptoren-Blockade. Für und Wider.

Results from recent studies have questioned the application of beta-receptor blockers for reduction of morbidity and mortality during the perioperative period. This holds true especially for patients with no or only low cardiac risk. Although beta-receptor blockade was a form of standard therapy at the end of the 1990s, data today show no clear evidence for such a therapy not even in patients at risk for cardiac events. At least in patients with low risk the initiation of beta-receptor blockade during the perioperative period might lead to side-effects, thereby increasing morbidity and mortality.

Coxiella burnetii isolates cause genogroup-specific virulence in mouse and guinea pig models of acute Q fever.

Q fever is a zoonotic disease of worldwide significance caused by the obligate intracellular bacterium Coxiella burnetii. Humans with Q fever may experience an acute flu-like illness and pneumonia and/or chronic hepatitis or endocarditis. Various markers demonstrate significant phylogenetic separation between and clustering among isolates from acute and chronic human disease. The clinical and pathological responses to infection with phase I C. burnetii isolates from the following four genomic groups were evaluated in immunocompetent and immunocompromised mice and in guinea pig infection models: group I (Nine Mile, African, and Ohio), group IV (Priscilla and P), group V (G and S), and group VI (Dugway). Isolates from all of the groups produced disease in the SCID mouse model, and genogroup-consistent trends were noted in cytokine production in response to infection in the immunocompetent-mouse model. Guinea pigs developed severe acute disease when aerosol challenged with group I isolates, mild to moderate acute disease in response to group V isolates, and no acute disease when infected with group IV and VI isolates. C. burnetii isolates have a range of disease potentials; isolates within the same genomic group cause similar pathological responses, and there is a clear distinction in strain virulence between these genomic groups.