Care complexity, perceptions of complexity and preferences for interprofessional collaboration: an analysis of relationships and social networks in paediatrics.

BACKGROUND: In the context of increasingly intricate healthcare systems, professionals are compelled to collaborate within dynamically changing interprofessional teams. Moreover, they must adapt these collaborative processes to effectively and efficiently manage the evolving complexity of care needs. It remains unclear how professionals determine care complexity and relate this complexity to their preferences for interprofessional collaboration (IPC). This study investigated the relationships between care complexity, professionals' perceived complexity and IPC preferences, and examined the variation in individual and team characteristics of IPC-practices across different levels of complexity in paediatric care. METHODS: In an online questionnaire, 123 healthcare professionals working at an academic tertiary children's hospital scored their perceptions of complexity and preferences for IPC. They also selected family and various professions as members of the interprofessional (IP-) team based on thirteen patient cases. We employed conjoint analysis to systematically model the complexity of case descriptions across the five domains of the International Classification of Functioning, Disability and Health (ICF). Additionally, we applied social network analysis to identify important professions, crucial connectors and influential professions in the IP-team, and to describe the cohesiveness of IP-teams. RESULTS: Modelled case complexity, professionals' perceived complexity and IPC preferences were positively associated. We found large inter-individual variations in the degree of these associations. Social network analysis revealed that the importance and influence of professions was more equally distributed when case complexity increased. Depending on the context and complexity of the case, different professions (e.g. medical doctors, social professionals, extramural professionals) were considered to be more crucial connectors within the IP-team. Furthermore, team cohesion was positively associated with modelled and perceived care complexity. CONCLUSIONS: In conclusion, our study contributes to the existing knowledge by integrating task-specific insights and broadening the use of conjoint and social network analysis in the context of IPC. The findings substantiate the contingency theory that relates characteristics of IPC to care complexity, offering quantified insights into how IP-teams adapt to situational needs. This understanding of relationships and variations within IPC holds crucial implications for designing targeted interventions in both clinical and health profession education contexts. Consequently, it contributes to advancements in healthcare systems.

Opening the black box of team-based learning (TBL): A study of verbal interactions in online application sessions.

CONTEXT: In team-based learning (TBL), an instructional strategy that encourages in-depth team discussion and deep learning, interactions in terms of sharing, co-construction, constructive conflict and procedural interactions are important. Since TBL has also been applied online in recent years, the question is whether these interactions are sufficiently present in an online setting. AIM: Gain insight into the nature and extent of these types of interactions in online TBL application sessions and to what extent these vary between teams and sessions. METHODS: We made audiovisual recordings of 12 TBL teams in two online application sessions during assignments. Transcripts were coded and analyzed using a framework derived. RESULTS: Teams spent more than 85% of their time on all four types of interactions in both sessions. The largest proportion of time was spent on sharing and co-construction. Constructive conflict occurred to a limited extent. We observed variation in proportion of time spent on and the distribution of the four types of interactions between teams and sessions. DISCUSSION: All interactions important for achieving deep learning occurred in online TBL application sessions. However, the effective use of these types of interaction should not be left to chance.

Perception of oral health related quality of life and orofacial aesthetics following restorative treatment of tooth wear: A five-year follow-up.

OBJECTIVES: Non-carious tooth wear often has a multifactorial etiology and may lead to functional or aesthetically related problems. The most common complaints associated with tooth wear are dissatisfaction with dental appearance and a negative impact on the experienced Oral Health Related Quality of Life (OHRQoL). The aim of this study was to investigate the change in OHRQoL and the perception of aesthetics, following restorative treatment of moderate to severe tooth wear patients, with a five-year follow-up. METHODS: An explorative study, based on prospective data, was performed. OHRQoL and the perception of aesthetics were measured with the OHIP-NL and OES-NL. These questionnaires were completed before treatment, one month after treatment, and at 1-, 3- and 5-years post-treatment. Treatment involved full mouth reconstruction with composite resin restorations. The data was analysed as repeated measures by using a linear mixed-effects model. RESULTS: One hundred and twenty-three tooth wear patients that received restorative rehabilitation were included (97 males, 26 females, 37.5 ± 8.8 years-old). Data showed a statistically significant increase in both experienced OHRQoL and orofacial appearance after restorative treatment. The OHIP-scores remained stable over time, while the OES-scores slightly decreased during the years after treatment. Regarding the seven domains of the OHIP, the largest difference in OHIP-score was found in the domain of 'Psychological Discomfort'. The mean overall OHIP-score was 1.8 at baseline and 1.3 at the 5-years recall. The mean OES score increased from 41.8 at baseline to 66.1 at the 5-years follow-up. CONCLUSIONS: Tooth wear patients reported significant improvements in their OHRQoL and their perception of orofacial aesthetics after restorative treatment. This increase remained at least five years post-treatment. CLINICAL SIGNIFICANCE: The clinical impact of restorative treatment for tooth wear patients is considerable. This paper emphasizes the need to include a discussion of the patient related outcome measures when planning care.

The effect of a more community-oriented curriculum on nursing students' intervention choice in community care: A quasi-experimental cohort study.

AIM: The aim of this study is to investigate the effect of a more 'community-oriented' baccalaureate nursing curriculum on students' intervention choice in community care. BACKGROUND: Following a healthcare shift with increased chronic diseases in an ageing patient population receiving care at home, nursing education is revising its curricula with new themes (e.g., self-management) on community care. Although it seems obvious that students incorporate these themes in their nursing care interventions, this is unclear. This study investigates the effect of a redesigned curriculum on students' care intervention choice in community nursing. DESIGN: A quasi-experimental quantitative study. METHODS: This study with an historic control group (n = 328; study cohorts graduating in 2016 and 2017; response rate 83 %) and an intervention group n = 152; graduating in 2018; response rate 80 %) was performed at a University of Applied Sciences in the Netherlands. The intervention group experienced a curriculum-redesign containing five new themes related to community care (e.g., enhancing self-management, collaboration with the patients' social network, shared decision making, using health technology and care allocation). The primary outcome 'intervention choice in community nursing' was assessed with a specially developed vignette instrument 'Assessment of Intervention choice in Community Nursing' (AICN). Through multiple regression analyses we investigated the effect of the curriculum-redesign on students' intervention choice (more 'traditional' interventions versus interventions related to the five new themes). The control and intervention groups were compared on the number of interventions per theme and on the number of students choosing a theme, with a chi-square or T-test. RESULTS: Students who studied under the more community-oriented curriculum chose interventions related to the new themes significantly more often, F(1461) = 14.827, p = <0.001, R2 = .031. However, more traditional interventions are still favourite (although less in the intervention group): 74.5 % of the chosen interventions in the historic control group had no relation with the new curriculum-themes, vs. 71.3 % in the intervention group; p = .055). CONCLUSIONS: Students who experienced a more 'community-oriented' curriculum were more likely, albeit to a limited extent, to choose the new community care themes in their caregiving. Seeing this shift in choices as a step in the right direction, it can be expected that the community care field in the longer term will benefit from these better skilled graduates.

Team-based learning (TBL): Each phase matters! An empirical study to explore the importance of each phase of TBL.

CONTEXT: In Team Based Learning (TBL), it is, based on theory, assumed that knowledge development in each phase contributes to the subsequent phase and to learning performance. However, there is no empirical evidence for this assumption. AIM: In order to find support for the relation between TBL and the underlying theory, we determined to what extent each phase of TBL is associated with the knowledge development in the next phase and with the total learning performance. METHODS: We measured the scientific concepts recalled by 56 second-year undergraduate medical students before TBL, after each of the three phases and after TBL. We used multivariate regression analysis to determine the statistical association between the phases as well as the total learning performance. RESULTS: Results showed that in each phase, students produced new concepts in addition to those previously recalled. Regression models showed statistically significant explained variance ranging from 0.19 to 0.26, between the three phases and the total learning performance. DISCUSSION: Each phase of the TBL is significantly associated with knowledge development in the subsequent phase and with the total learning performance, and therefore matters. This study contributes to the scientific underpinning of TBL and offers leads to more elaborate research and interventions to improve TBL.

Additional preconditioning program for bariatric surgery: Any benefits? A large cohort study.

Postbariatric outcomes may improve by providing an additional preconditioning program (APP) in targeted patients. However, APPs are a demand for health resources while only little and inconsistent evidence consists to support their effectiveness. This cohort study aims to evaluate the effectiveness of APP, by comparing outcomes of patients with and without such APP. We carried out a retrospective single-centre cohort study in a before-after design. Patients signing up for primary gastric bypass or sleeve gastrectomy and eligible for surgery were included if screened as vulnerable patients. Vulnerable patients screened between September 2017 and March 2018 followed an APP and formed the APP-group. Due to a policy change, APPs were no longer performed since September 2018. Vulnerable patients screened between September 2018 and March 2019 thus did not receive an APP (comparator-group). Multidisciplinary follow-up remained unchanged. Endpoints included percentage total weight loss (%TWL), bodyweight, evolution of comorbidities, protein intake, and number of no-shows. The APP-group comprised 231 patients and the comparator-group 153. %TWL differed statistically significantly at 7 (Δ1.5%, p = .01) and 12 months postoperative (Δ2.8%, p < .01) in favour of the comparator-group, as did bodyweight 12 months postoperative (Δ1.8 kg, p < .01). Statistically significant differences were also found in the evolution of comorbidities, protein intake, and the number of no-shows, most in favour for the comparator-group. APP proofed not to be superior to Non-App. It is debatable whether statically significant differences are clinically relevant given their small magnitude. A care pathway without an APP seems at least as effective as a care pathway without.

How nursing students' placement preferences and perceptions of community care develop in a more 'community-oriented' curriculum: a longitudinal cohort study.

BACKGROUND: Extramuralisation in healthcare has influenced medical and nursing curricula internationally with the incorporation of themes related to primary/ community care. Despite this, students do not easily change their career preferences. The hospital is still favourite, leading to labour market shortages in extramural care. This study investigates how baccalaureate nursing students' perceptions of community care and placement preferences develop over time in a more 'community-care-oriented' curriculum, to gain insights on which curriculum elements potentially influence career choices. METHODS: A nursing student cohort of a University of Applied Sciences in the Netherlands (n = 273) underwent a new four-year curriculum containing extended elements of community care. The primary outcome was assessed with the Scale on Community Care Perceptions (SCOPE). Data were collected each year of study. Descriptive statistics were used to investigate students' placement preferences and perceptions, and linear mixed model techniques (LMMs) for measuring how students' perceptions develop over time. Patterns of placement preferences at individual level were visualised. RESULTS: Students' perceptions of community care, as measured with SCOPE, show a slight decrease between year 1 and 4, while items mutually differ substantially. In contrast, the preference of community care for a placement increases from 2.6% in year 1 tot 8.2% in year 4. The hospital is favourite in year 1 (79.8%), and remains most popular. At individual level, students often change placement preferences, although a preference for the hospital is more consistent. The LMMs indicates that, at the four time-points, the estimated marginal means of students' perceptions fluctuate between 6 and 7 (range 1-10). A placement in community care did not positively influence students' perceptions, and an intensive 1 week theoretical programme was only temporarily influential. CONCLUSIONS: Although interest for placement in community care increased substantially, it was not clear which curriculum elements stimulated this, nor did the curriculum positively influence students' perceptions. As most students do not look forward to the high responsibility of the field, other curricula with educational tracks for more mature students/ nurses with a vocational training may be an alternative contribution to solving the labour market problems in community care.

Influencing nursing students' perceptions of community care with curriculum-redesign; a quasi-experimental cohort study.

BACKGROUND: The shift in healthcare to extramural leads to more patients with complex health problems receiving nursing care at home. However, the interest of baccalaureate nursing students for community nursing is moderate, which contributes to widespread labour-market shortages. This study investigates the effect of a more 'community-care-oriented' curriculum on nursing students' perceptions of community care. METHODS: A quasi-experimental quantitative survey study with a historic control group (n = 477; study cohorts graduating in 2015, 2016, and 2017; response rate 90%) and an intervention group (n = 170; graduating in 2018; response rate 93%) was performed in nursing students of a University of Applied Sciences in a large city in the Netherlands. The intervention group underwent a new curriculum containing extended elements of community care. The primary outcome was assessed with the Scale on Community Care Perceptions (SCOPE). The control and intervention group were compared on demographics, placement preferences and perceptions with a chi-square or T-test. Multiple regression was used to investigate the effect of the curriculum-redesign on nursing students' perceptions of community care. RESULTS: The comparison between the control and intervention group on students' perceptions of community care shows no significant differences (mean 6.18 vs 6.21 [range 1-10], respectively), nor does the curriculum-redesign have a positive effect on students' perceptions F (1,635) = .021, p = .884, R2 = < .001. The comparison on placement preferences also shows no significant differences and confirms the hospital's popularity (72.7% vs 76.5%, respectively) while community care is less often preferred (9.2% vs 8.2%, respectively). The demographics 'working in community care' and 'belonging to a church/religious group' appear to be significant predictors of more positive perceptions of community care. CONCLUSIONS: Graduating students who experienced a more 'community-care-oriented' curriculum did not more often prefer community care placement, nor did their perceptions of community care change. Apparently, four years of education and placement experiences have only little impact and students' perceptions are relatively static. It would be worth a try to conduct a large-scale approach in combination with a carefully thought out strategy, based on and tying in with the language and culture of younger people.

The Scale on COmmunity care PErceptions (SCOPE) for nursing students: A development and psychometric validation study.

The aim of this study was to develop a valid instrument to measure student nurses' perceptions of community care (SCOPE). DeVellis' staged model for instrument development and validation was used. Scale construction of SCOPE was based on existing literature. Evaluation of its psychometric properties included exploratory factor analysis and reliability analysis. After pilot-testing, 1062 bachelor nursing students from six institutions in the Netherlands (response rate 81%) took part in the study. SCOPE is a 35-item scale containing: background variables, 11 measuring the affective component, 5 measuring community care perception as a placement, 17 as a future profession, and 2 on the reasons underlying student preference. Principal axis factoring yielded two factors in the affective component scale reflecting 'enjoyment' and 'utility', two in the placement scale reflecting 'learning possibilities' and 'personal satisfaction', and four in the profession scale: 'professional development', 'collaboration', 'caregiving', and 'complexity and workload'. Cronbach's α of the complete scale was 0.892 and of the subscales 0.862, 0.696, and 0.810 respectively. SCOPE is a psychometrically sound instrument for measuring students' perceptions of community care. By determining these perceptions, it becomes possible to positively influence them with targeted curriculum redesign, eventually contributing to decreasing the workforce shortage in community nursing.

Factors underlying perceptions of community care and other healthcare areas in first-year baccalaureate nursing students: A focus group study.

BACKGROUND: Despite the increasing labour market shortage of well-educated community nurses, few baccalaureate nursing students choose for a career in community care. Obtaining knowledge of how students perceive healthcare areas early in their education is important to take meaningful steps in counteracting any existing misconceptions with targeted curriculum redesign. OBJECTIVE: Determination of factors underlying perceptions of healthcare areas in first-year baccalaureate nursing students. DESIGN: A descriptive qualitative study using focus group inquiry. METHODS: This study follows up on a large-sample quantitative multicentre survey study. Fourteen first-year nursing students at a university of applied sciences in the Netherlands participated in focus group discussions in October 2014. Transcripts of the discussions were coded by two independent researchers at three levels - open, axial and selective coding - on the basis of two templates. The codes were sorted into categories and assigned to suitable main codes in the templates. The number of sub-codes per category and code were added together. RESULTS: Eight main themes were formulated, to wit (1) variety and diversity, (2) challenges, (3) improving people's health, (4) collaboration, (5) role models, (6) patient- or environment-based perceptions, (7) self-efficacy and (8) immediate vicinity. Data suggest that first-year students have clear ideas about the characteristics which they consider important in professional practice. Their perceptions do not necessarily reflect the actual situation, as they expect the hospital to possess all desired characteristics while community nursing seems to be undervalued. CONCLUSION: To remedy students' misperceptions, four recommendations are formulated for curriculum redesign strategies deriving from the eight themes. These recommendations are based on collaboration between school and care organisations as well as on themes related to in-depth knowledge within the educational programme. The interventions will potentially help to strengthen the focus on community care, which will foster a more optimistic and realistic career outlook on this field.

Perceptions of community care and placement preferences in first-year nursing students: A multicentre, cross-sectional study.

BACKGROUND: Despite increasing shortages of highly educated community nurses, far too few nursing students choose community care. This means that a strong societal problem is emerging that desperately needs resolution. OBJECTIVES: To acquire a solid understanding of the causes for the low popularity of community care by exploring first-year baccalaureate nursing students' perceptions of community care, their placement preferences, and the assumptions underlying these preferences. DESIGN: A quantitative cross-sectional design. SETTINGS: Six universities of applied sciences in the Netherlands. PARTICIPANTS: Nursing students in the first semester of their 4-year programme (n=1058). METHODS: Data were collected in September-December 2014. The students completed the 'Scale on Community Care Perceptions' (SCOPE), consisting of demographic data and three subscales measuring the affective component of community care perception, perceptions of a placement and a profession in community care, and students' current placement preferences. Descriptive statistics were used. RESULTS: For a practice placement, 71.2% of first-year students prefer the general hospital and 5.4% community care, whereas 23.4% opt for another healthcare area. Students consider opportunities for advancement and enjoyable relationships with patients as most important for choosing a placement. Community care is perceived as a 'low-status-field' with many elderly patients, where students expect to find little variety in caregiving and few opportunities for advancement. Students' perceptions of the field are at odds with things they believe to be important for their placement. CONCLUSION: Due to misconceptions, students perceive community care as offering them few challenges. Strategies to positively influence students' perceptions of community nursing are urgently required to halt the dissonance between students' preference for the hospital and society's need for highly educated community nurses.

Thiamine Levels During Intensive Insulin Therapy in Critically Ill Patients.

INTRODUCTION: Thiamine is an essential cofactor in carbohydrate metabolism, and deficiency can therefore cause various organ dysfunctions. Little is known about the prevalence and possible worsening of thiamine deficiency in critically ill patients. In this study, we investigated the prevalence of thiamine deficiency at admission to the intensive care unit (ICU) and hypothesized that intensive insulin therapy, aimed at regulating glucose levels, increases thiamine utilization and therefore might cause or worsen deficiency in patients with limited thiamine stores. MATERIALS AND METHODS: An observational prospective cohort study was carried out in a medical-surgical ICU in a general teaching hospital in Apeldoorn, the Netherlands. All adults who were treated during that time with intensive insulin therapy were included. Deficiency was defined as a thiamine level <100 nmol/L. No thiamine supplementation was administered except for normal amounts present in standard enteral feeding. RESULTS: A total of 58 patients were available for analysis. Median thiamine level at admission was 111 nmol/L. Deficiency was present in 39.7% of patients and was significantly associated with the presence of gastrointestinal pathology and with recent surgery. Thiamine levels increased a median of 14 nmol/L in 48 hours. Only 3.4% of patients showed a predefined relevant decline in thiamine levels. CONCLUSION: Intensive insulin therapy does not appear to cause or worsen thiamine deficiency. However, based on the high prevalence of deficiency at admission, it might be warranted to supplement thiamine in all patients admitted to the ICU, especially when there is an underlying gastrointestinal disease or recent surgery.

Nursing students' perceptions of community care and other areas of nursing practice - A review of the literature.

OBJECTIVES: To review recent literature on student nurses' perceptions of different areas of nursing practice, in particular community care. Healthcare is changing from care delivery in institutional settings to care to patients in their own homes. Problematic is that nursing students do not see community care as an attractive line of work, and their perceptions of community care do not reflect the realities of the profession. Understanding the factors influencing the perception of the professional field is important to positively influence students' willingness to see community nursing as a future profession. DESIGN: Literature search with accompanying narrative synthesis of primary research. DATA SOURCES: ERIC(®), PsycInfo(®), Pubmed(®), and CINAHL(®) (2004-2014) databases using the search terms: 'nursing student', 'student nurse', 'community care', 'community nurse', 'image', 'attitude', and 'perception'. REVIEW METHODS: After screening 522 retrieved article titles with abstracts, the number of articles was reduced based upon specified inclusion/exclusion criteria leading to inclusion of 34. Evaluation of the references in those articles yielded an additional 5 articles. A narrative synthesis of those articles was created to uncover students' perception of community care, other areas of professional practice, and the factors influencing those perceptions. RESULTS: 39 articles were selected. Results show that many nursing students begin their education with a lay person's conception of the profession, shaped by media representations. Work placements in different settings offer clinical experience that helps students orient themselves towards a future profession. Students prefer hospitals as a place of work, because of the acute nature and technologically advanced level of care offered there. Few students perceive mental health and elderly care as appealing. Perceptions of community care can vary widely, the most prevalent view being that it is unattractive because of its chronic care profile, with little technical skill, untrained workers, and a high workload. However, another view is that it offers challenging and meaningful work because of the variety of caregiving roles and the opportunity to work independently. CONCLUSIONS: Few nursing students choose community nursing as a future profession. They have a limited and often mistaken view of community care, and they underestimate the field's complexity because it is less visible than in the environment of acute care. Providing students with specific curricular content and employing a structured approach to preparation for work placement could help build a more positive perception of community care, leading to more students seeing/choosing community care as a desirable field of work.

Practice variation in treatment of suspected asymptomatic bacteriuria prior to cardiac surgery: are there differences in postoperative outcome? A retrospective cohort study.

OBJECTIVES: It is unclear whether postoperative infections can be prevented by treating asymptomatic bacteriuria, or whether, on the other hand, such treatment will increase the risk of more serious infection by pathogenic bacteria different from the ones causing bacteriuria. This study aimed to support future treatment decisions for preoperative cardiothoracic surgery patients with asymptomatic bacteriuria, by examining current preoperative practice, in relation to postoperative outcome. METHODS: A retrospective cohort study was conducted. All patients who underwent cardiothoracic surgery in 2011-2013 using extracorporeal circulation in St. Antonius Hospital Nieuwegein, and who preoperatively had nitrituria and/or leucocyturia were included. Exclusion criteria were C-reactive protein level higher than 10 mg/l, emergency surgery, critical preoperative state and/or antibiotic treatment because of other infections. Outcomes were postoperative infections and length of stay. Furthermore, we compared culture results of preoperative urine with postoperative infection sites in order to study the hypothesis of haematogenous spread. RESULTS: One thousand and two patients with leucocyturia or nitrituria were eligible, of whom 3.9% had been treated with antibiotics preoperatively (AB+). Of the 96.1% of patients who had not been treated (AB-), 8.3% had an infection postoperatively, compared with 5.1% in the treatment (AB+) group. This was not statistically significant {odds ratio, corrected for EuroSCORE, 0.53 [95% confidence interval (CI) 0.12-2.24, P = 0.39]}. Length of stay, corrected for EuroSCORE, between the treated (AB+) and the non-treated (AB-) group did not differ, with a hazard ratio of 1.05 (95% CI 0.63-1.75, P = 0.85). As regards bacterial culture results, none of patients not treated with antibiotics preoperatively (AB-) seemed to have a postoperative infection due to haematogenous spread of bacteria from the urinary tract present preoperatively. CONCLUSIONS: The risk of haematogenous spread of bacteria seems to be non-existent in this large cohort of non-treated patients, under our local clinical practice. Based on this current, best available evidence, it seems therefore safe not to treat patients with asymptomatic bacteriuria prior to cardiothoracic surgery. This could also imply that it is safe not to perform routine preoperative urine testing.

Incident and error reporting systems in intensive care: a systematic review of the literature.

PURPOSE: We performed a systematic review to assess (i) to what extent incident reporting systems (IRSs) on the adult intensive care unit (ICU) meet the criteria of the WHO Draft Guidelines for Adverse Event Reporting and Learning Systems, (ii) to what extent the IRSs comply with the four aspects of the iterative quality loop and (iii) whether IRSs have led to improvement measures in clinical practice. DATA SOURCES: The authors searched multiple electronic databases from 1966 until 26 June 2014. STUDY SELECTION: Studies were included if they reported incident reporting systems on the adult ICU. DATA EXTRACTION: Data on study design, characteristics of the incident reporting system, implementation, feedback and improvement measures were collected using structured data extraction forms. RESULTS OF DATA SYNTHESIS: A total of 2098 studies were identified and 36 studies reported IRSs on the adult ICU. Studies were divided into: ICU-specific IRSs and general IRSs. Items of the WHO checklist were assessed and categorized into the four phases of the iterative quality loop. CONCLUSION: None of the IRSs completely fulfilled the WHO checklist criteria. With respect to the iterative loop, data input and data collection are well established but not much attention was given to analyzing incidents and to give feedback. This resulted in an administrative report system, rather than the much desired instrument for change of practice and increase of quality as an IRS can only effectively contribute to improve patient safety and quality of care if more attention is given to analyzing incidents and feedback.

Ambulance Transfer in Case of Postpartum Hemorrhage after Birth in Primary Midwifery Care in The Netherlands: A Prospective Cohort Study.

BACKGROUND: The objective of this prospective cohort study was to assess whether the 45-minute prehospital limit for ambulance transfer is met in case of postpartum hemorrhage (PPH) after midwifery-supervised home birth in The Netherlands and evaluate the process of ambulance transfer, maternal condition during transfer, and outcomes in relation to whether this limit was met. METHODS: Using ambulance report forms and medical charts, ambulance intervals, urgency coding, clinical condition (using the lowest Revised Trauma Score, [RTS]), and maternal outcomes were collected. From April 2008 to April 2010, midwives reported 72 cases of PPH. Associations between duration of the ambulance transfer, maternal condition during ambulance transfer and outcomes were analyzed. The main outcome measures were duration of ambulance transfer, RTS, blood loss, surgical procedures, and blood transfusions. RESULTS: Seventy-two cases were reported, 18 (25%) were excluded: 54 cases were analyzed. In 63 percent, the 45-minute prehospital limit was met, 75.9 percent received a RTS of 12, indicating optimal Glasgow Coma Scale, systolic blood pressure, and respiratory frequency. In 24.1 percent a decrease in systolic blood pressure was found (RTS 10 or 11). We found no difference in outcomes between women with different RTS or in whom the 45-minute prehospital limit was or was not met. CONCLUSIONS: We found no relation between the duration of ambulance transfer and maternal condition or outcomes. All women fully recovered. The low-risk profile of women in primary care, well-organized midwifery, and ambulance care in The Netherlands are likely to contribute to these findings.

Microcirculatory perfusion and vascular reactivity are altered in post cardiac arrest patients, irrespective of target temperature management to 33 °C vs 36 °C.

AIM: In previous reports both microcirculatory alterations and impaired vascular reactivity have been described in post cardiac arrest patients treated with mild therapeutic hypothermia. As of now it is unknown whether these alterations are related to the temperature management or to the cardiac arrest itself. Aim of the present study was to investigate the potential difference in microcirculatory alterations and vascular reactivity in comatose patients after out of hospital cardiac arrest treated with target temperature management of 33 °C (TTM33) in comparison to patients treated with 36 °C (TTM36). METHODS: Our study was designed as a predefined substudy of the open label randomized controlled TTM trial in 2 Dutch mixed ICU's. Sublingual microvascular flow index (MFI) was assessed by Side Stream Darkfield imaging and vascular reactivity at the thenar region of the hand by near infrared spectroscopy. Variables, including systemic hemodynamics were recorded at start study (T1), after 12h (T2) and after 24h (T3). RESULTS: 22 patients were included, 13 in TTM33 and 9 in TTM36. At T1 MFI between groups did not differ significantly (1.08 [0.4-1.9] versus 1.67 [0.7-2.4] respectively, p = 0.59). The difference between groups remained insignificant over time. At T1 tissue oxygenation (StO2) was significantly lower in TTM36 in comparison to TTM33: (44.6 ± 15.8 versus 58.9 ± 13.5, p = 0.03). Over time this difference between groups disappeared. However, vascular reactivity, expressed as the descending and ascending slope of StO2 after a standardized ischemic occlusion test was similar between groups. CONCLUSIONS: In this relatively small sample size study microcirculatory blood flow and vascular reactivity did not differ nor change between TTM33 and TTM36.

Generalized joint hypermobility, muscle strength and physical function in healthy adolescents and young adults.

BACKGROUND: Generalized Joint Hypermobility (GJH) is regarded as the main diagnostic criterion for Hypermobility Syndrome and is assumed to be of importance for the development of musculoskeletal complaints and functional decline. However GJH is also highly prevalent amongst healthy individuals whereas its consequences for physical functioning are unclear. Therefore the objective of the study was to determine the association of GJH with physical functioning in healthy adolescents and young adults. METHODS: 328 participants (mean age (sd): 20.2 (1.8), gender (male/female): 134/194) were included. In order to establish the effect of GJH, subjects with symptomatic forms of GJH were excluded, as were subjects with other conditions that could influence physical functioning. Age, gender, BMI, GJH, muscle strength and physical activity level (PAL) in METS were collected. RESULTS: GJH was associated with reduced muscle strength for all muscle groups (p=<.05), controlled for age and BMI. Ranging from -0.7 to -1.0SD in females and -.3 to -1.3SD in males. GJH was found to be significantly associated with higher amounts of METS spent on cycling, ranging from +0.2 to +0.9SD in females (p=.002) and +0.3 to +0.9SD in males (p=.041), where lower amounts of METS spent on sports activities was observed, ranging from -0.4 to -1.2SD in females (p=.002) and -0.2 to -1.9SD in males (p=.004). CONCLUSION: Individuals with GJH have reduced muscle strength and tend to avoid dynamic activities and prefer more stable activities, like cycling. This may indicate that individuals with GJH adapt their behaviour to prevent musculoskeletal complaints and functional decline.

Cardiac surgery-specific screening tool identifies preoperative undernutrition in cardiac surgery.

BACKGROUND: Loss of body tissue resulting in undernutrition can be caused by reduced food intake, altered metabolism, ageing, and physical inactivity. The predominant cause of undernutrition before cardiac operations is unknown. First, we explored the association of reduced food intake and inactivity with undernutrition in patients before elective cardiac operations. Second, we assessed if adding these reversible, cause-based items to the nutritional screening process improved diagnostic accuracy. METHODS: A prospective observational study was performed. Undernutrition was defined by low fat-free mass index (LFFMI) measured by bioelectrical impedance spectroscopy and/or unintended weight loss (UWL). Reduced food intake was defined as the patient having a decreased appetite over the previous month. Patients admitted to hospital preoperatively were assumed to be less physically active than patients awaiting cardiac operations at home. Using these data, we developed a new tool and compared this with an existing cardiac surgery-specific tool (Cardiac Surgery-Specific Malnutrition Universal Screening Tool [CSSM]). RESULTS: A total of 325 patients who underwent open cardiac operations were included. Reduced food intake and inactivity were associated with undernutrition (odds ratio [OR], 4.2; 95% confidence interval [CI], 2.1-8.5 and OR, 2.0; 95% CI, 1.0-4.0). Reduced food intake and inactivity were integrated with body mass index (BMI) and UWL into a new scoring system: the Cardiac Surgery-Specific Undernutrition Screening Tool (CSSUST). Sensitivity in identification of undernourished patients was considerably higher with the CSSUST (90%) than with the CSSM (71%) (receiver operating characteristic [ROC] curve-based area under the curve [AUC], 0.79; 95% CI, 0.73-0.86 and ROC AUC, 0.71; 95% CI, 0.63-0.80). CONCLUSIONS: Results suggest that reduced food intake and inactivity partly explain undernutrition before cardiac operations. Our new cause-based CSSUST, which includes reduced food intake and inactivity, is superior to existing tools in identifying undernutrition in patients undergoing cardiac operations.