Current preconception care practice in the Netherlands - An evaluation study among birth care professionals.

OBJECTIVE: To evaluate the current practice of preconception care in the Netherlands and the perceptions of birth care professionals concerning preconception care. METHODS: We have developed a digital questionnaire and conducted a cross-sectional study by distributing the questionnaire among 102 organisations: 90 primary care midwifery practices and obstetric departments of 12 hospitals in the Southwest region of the Netherlands between December 2020 and March 2021. One birth care professional per organization was asked to complete the questionnaire. Descriptive statistics were used to present the results. FINDINGS: Respondents of eighty-three organisations (81.4 %) filled in the questionnaire, of whom 74 respondents were independent primary care midwives and 9 respondents were obstetricians. Preconception care mostly consisted of an individual consultation in which personalized health and lifestyle advice was given. Among the respondents, 44.4 % reported that the organization had a preconception care protocol. The way in which the consultation was carried out, as well as the health and lifestyle related questions asked, differed between respondents. More than 85 % of the respondents inquire about the following possible risk factors for complications: maternal illnesses, obstetric history, folic acid supplement intake, alcohol intake, smoking, substance abuse, hereditary disease, prescription medication, dietary habits, overweight, and birth defects in the family. The respondents acknowledged that preconception care should be offered to all couples who wish to become pregnant, as opposed to offering preconception care only to those with an increased risk of complications. Still, respondents do not receive many questions regarding the preconception period or requests for preconception care consultations. KEY CONCLUSION: Birth care professionals acknowledge the need for preconception care for all couples. In the Netherlands, preconception care consists mostly of an individual consultation with recommendations for health and lifestyle advice. However, the identification of risk factors varies between birth care professionals and less than half of the respondents indicate that they have a protocol available in their practice. Furthermore, the demand of parents-to-be for preconception care is low. More research, that includes more obstetricians, is necessary to investigate if there is a difference between the care provided by primary care midwives and obstetricians. IMPLICATIONS FOR PRACTICE: To increase the awareness and uptake of preconception care, it would be prudent to emphasize its importance to parents-to-be and professionals, and actively promote the use of widespread, standardized protocols for birth care professionals.

Development of a Blueprint for Integrated Care for Vulnerable Pregnant Women.

PURPOSE: There has been increasing awareness of perinatal health and organisation of maternal and child health care in the Netherlands as a result of poor perinatal outcomes. Vulnerable women have a higher risk of these poor perinatal outcomes and also have a higher chance of receiving less adequate care. Therefore, within a consortium, embracing 100 organisations among professionals, educators, researchers, and policymakers, a joint aim was defined to support maternal and child health care professionals and social care professionals in providing adequate, integrated care for vulnerable pregnant women. DESCRIPTION: Within the consortium, vulnerability is defined as the presence of psychopathology, psychosocial problems, and/or substance use, combined with a lack of individual and/or social resources. Three studies focussing on population characteristics, organisation of care and knowledge, skills, and attitudes of professionals regarding vulnerable pregnant women, were carried out. Outcomes were discussed in three field consultations. ASSESSMENT: The outcomes of the studies, followed by the field consultations, resulted in a blueprint that was subsequently adapted to local operational care pathways in seven obstetric collaborations (organisational structures that consist of obstetricians of a single hospital and collaborating midwifery practices) and their collaborative partners. We conducted 12 interviews to evaluate the adaptation of the blueprint to local operational care pathways and its' embedding into the obstetric collaborations. CONCLUSION: Practice-based research resulted in a blueprint tailored to the needs of maternal and child health care professionals and social care professionals and providing structure and uniformity to integrated care provision for vulnerable pregnant women.

Defining vulnerability in European pregnant women, a Delphi study.

OBJECTIVE: Vulnerability among pregnant women is an important and complex theme in the everyday practice of midwives. Exchanging knowledge and best practices about vulnerability between midwives in Europe can contribute to improving the knowledge and skills of midwives and as a result improve the care for vulnerable pregnant women. We therefore start a consortium with midwives, midwifery teachers, researchers and students from organizations of seven European cities with the aim to exchange knowledge and best practices concerning vulnerable pregnant women between midwives. To be able to effectively exchange knowledge and best practices, our consortium started with this study focuses on establishing a mutual definition of vulnerable pregnant women. Therefore, the aim of this study is to develop a mutual definition of vulnerable pregnant women and to identify aspects related to vulnerability. DESIGN: Delphi study with four rounds: (1) gathering existing knowledge from literature and definitions used by partners of the consortium, (2) and (3) two survey rounds and (4) an in-person consensus meeting. SETTING: Consortium of midwives, midwifery teachers, researchers and students from Antwerp (Belgium), Ghent (Belgium), Turku (Finland), Milan (Italy), Pila (Poland), Lisbon (Portugal) and Rotterdam (The Netherlands) PARTICIPANTS: We included all consortium members in the Delphi study. FINDINGS: Various aspects related to vulnerability and appropriate definitions were identified during the Delphi rounds. Consensus about the aspects related to vulnerability and the definition of vulnerable pregnant women was reached during the final consensus meeting. A vulnerable pregnant woman was defined as a woman who is threatened by physical, psychological, cognitive and/or social risk factors in combination with lack of adequate support and/or adequate coping skills. KEY CONCLUSION: We reached consensus about a mutual definition of vulnerable pregnant women and aspects related to vulnerability within this consortium. The Delphi approach led to interesting discussions and was a valuable method to define the concept of vulnerable pregnant women within our project . IMPLICATIONS FOR PRACTICE: In order to accomplish a project that aimed to improve care for vulnerable pregnant women it was important to first identify the population of vulnerable pregnant women with a mutual definition.

Characteristics of older patients with back pain in general practice: BACE cohort study.

BACKGROUND: Although back pain is common among older people, limited information is available about the characteristics of these patients in primary care. Earlier research suggests that the severity of back symptoms increases with older age. METHODS: Patients aged >55 years visiting a general practitioner with a new episode of back pain were included in the BACE study. Information on patients' characteristics, characteristics of the complaint and physical examination were derived from the baseline measurement. Cross-sectional differences between patients aged >55-74 and ≥75 years were analysed using an unpaired t-test, Mann-Whitney U-test or a chi-square test. RESULTS: A total of 675 back pain patients were included in the BACE study, with a median age of 65 (interquartile range 60-71) years. Patients aged >55-74 years had a mean disability score (measured with the Roland Disability Questionnaire) of 9.4 [standard deviation (SD) 5.8] compared with 12.1 (SD 5.5) in patients aged ≥75 years (p ≤ 0.01). The older group reported more additional musculoskeletal disorders and more often had low bone quality (based on ultrasound measurement of the heel) than patients aged >55-74 years. Average back pain severity over the previous week showed no difference (p = 0.11) between the age groups, but severity of back pain at the moment of filling in the questionnaire was higher (p = 0.03) in the older age group. CONCLUSIONS: In this study, older back pain patients reported more disabilities and co-morbidity. However, the clinical relevance of these differences for the course of the back pain episode in older patients remains a subject for further research.

A phase I trial assessing the safety, tolerability, pharmacokinetic and pharmacodynamic characteristics of single-dose Auron Misheil therapy in healthy male subjects.

BACKGROUND AND OBJECTIVE: Auron Misheil therapy (AMT) is a combination of widely used pharmaceuticals and herbal components that has been used since the 1980s as a supportive therapy, mainly in end-stage cancer patients on a compassionate basis. This phase I study was conducted to assess the safety, tolerability, and pharmacokinetic (PK) and pharmacodynamic (PD) properties of AMT in a controlled trial environment. METHODS: The study was conducted in a single rising dose, double-blind, placebo-controlled design. Three groups of eight healthy male volunteers received one of three doses of AMT (0·011, 0·033 or 0·066 mL AMT/kg body weight intramuscularly; n = 6 per group) or placebo (n = 2 per group). RESULTS AND DISCUSSION: Auron Misheil therapy was shown to be well tolerated, revealing no severe or serious adverse events. There were no unexpected PK or PD results for any of the three components of AMT. CONCLUSIONS: These data provide important PK, PD and safety data for AMT, and support further controlled clinical investigation in patients with different types of cancer as an option for supportive care.

Course of back complaints in older adults: a systematic literature review.

BACKGROUND: Back pain is a common musculoskeletal complaint seen in older people. It is important to get an insight in the course of back complaints and to identify factors associated with a chronic course. AIM: To describe the course of acute and subacute back complaints in older people (≥ 45 years) and to identify prognostic factors for developing chronic back complaints. DESIGN: Systematic review of the literature. METHODS: A database search was conducted in MEDLINE, EMBASE, Cochrane library, CINAHL, PsycINFO and PEDro. Cohort studies or randomized controlled trials reporting on the course of acute or subacute back complaints in older people were included. The percentage of patients that developed chronic back complaints was calculated, if possible. RESULTS: The search yielded 9293 potentially relevant articles. Of these, 5 studies met all inclusion criteria. At 3 months follow-up 37-40% of the patients still had back complaints. At 12 months follow-up, the percentage ranged from 26-45%. Older age was frequently reported as a prognostic factor for developing chronic back complaints of the whole study population. No prognostic factors could be retrieved for patients aged 45 years and older. CONCLUSIONS: At 3 and 12 month follow-up, about 40% of the older people still reported back complaints. However, the heterogeneity of the studies made comparisons difficult. In order to get a clear insight in the course of back complaints in the older adult patients and to indentify prognostic factors for developing chronic back complaints in older people, high quality prospective cohort studies are needed. CLINICAL REHABILITATION IMPACT: More than one-third of the older patients with back pain still experience complaints after 3 and 12 months.

Association between spinal morning stiffness and lumbar disc degeneration: the Rotterdam Study.

OBJECTIVE: To explore the associations between spinal morning stiffness and lumbar disc degeneration (LDD). DESIGN: Data from a cross-sectional general population-based study (Rotterdam Study-I) were used. Intervertebral disc spaces and osteophytes of people aged ≥55 years were scored on lumbar lateral radiographs (L1-2 through L5-S1 was scored). Logistic regression analysis was used to explore associations between spinal morning stiffness and two definitions of LDD (i.e., 'narrowing' and 'osteophytes'). Spinal morning stiffness combined with low back pain and its association with LDD was also analyzed. Similar analyses were performed for knee and hip pain, morning stiffness in the legs, and radiographic knee and hip osteoarthritis (OA) in order to compare these associations with those of LDD. All analyses were adjusted for age, gender, and body mass index (BMI). RESULTS: Lumbar lateral radiographs were scored for 2,819 participants. Both definitions of LDD were associated with spinal morning stiffness: adjusted odds ratio (aOR) 1.3; 95% confidence interval (CI): 1.1-1.6 for 'osteophytes' and aOR 1.8; 95% CI: 1.4-2.2 for 'narrowing'. Both the odds ratios increased when spinal morning stiffness was combined with low back pain: aOR 1.5; 95% CI: 1.1-2.0 for 'osteophytes' and aOR 2.5; 95% CI: 1.9-3.4 for 'narrowing'. When morning stiffness in the legs was combined with knee or hip pain, the associations with radiographic knee or hip OA were: aOR 3.0; 95% CI: 2.1-4.1 for knee OA and aOR 3.1; 95% CI: 1.9-5.0 for hip OA. CONCLUSIONS: Reported spinal morning stiffness is associated with LDD. The associations increased when we combined spinal morning stiffness with low back pain. The magnitude of the association for the definition 'narrowing' is similar to the association between morning stiffness in the legs and knee or hip OA.

Pharmacokinetics of ertapenem in colorectal tissue.

BACKGROUND: There are only limited data on tissue kinetics of ertapenem in colorectal tissue more than 3 h after administration of the drug. The purpose of this study was to assess the pharmacokinetics (PK) of ertapenem in colorectal tissue via population PK modeling. PATIENTS AND METHODS: Patients ≥18 years requiring surgical intervention at the colon and/or rectum were eligible (ClinicalTrials.gov identifier: NCT 00535652). Tissue and blood samples were taken during surgery after a single dose of 1 g ertapenem. Ertapenem concentration was determined by high-performance liquid chromatography/mass spectrometry. Population PK modeling was performed in S-ADAPT. RESULTS: Twenty-three patients were enrolled. The highest tissue concentration was 6.4 ± 2.3 mg/kg, the highest total plasma concentration 51.34 ± 9.4 mg/l, the highest unbound plasma concentration 7.05 ± 1.1 mg/l, and the unbound fraction in plasma was 14-15% for total ertapenem concentrations below approximately 22 mg/l, 19% at 100 mg/l, and 25% at 250 mg/l. The estimated geometric mean terminal half-life was 2.5 h for plasma and tissue. In the Monte Carlo simulation, a single dose of 1,000 mg ertapenem achieved robust (≥90%) probabilities of target attainment up to a minimum inhibitory concentration (MIC) of approximately 2 mg/l for the bacteriostasis target (free time above MIC, fT(>)(MIC) = 20%) and up to 0.25-0.5 mg/l for the near-maximal killing target (40% fT(>)(MIC)). CONCLUSION: Our data indicate an adequate penetration of ertapenem into uninfected colorectal tissue up to 8.5 h (35% of the dosing interval) after administration of 1 g intravenously.

[Spontaneous rupture of a splenic artery]. / Idiopathische spontane Milzarterienruptur.

BACKGROUND: Hemoperitoneum due to spontaneous rupture of a visceral vessel may result from a variety of underlying pathologies. However, its idiopathic form does not show evidence of any predisposition. PATIENT AND METHODS: An abdominal CT scan for acute abdominal pain yielded the unexpected diagnosis of a ruptured splenic artery in a 21-year-old patient. Hemostasis was achieved by endovascular coiling of a segmental splenic artery lacking any evidence of pathological transformation. An extensive intraabdominal hematoma was evacuated in a consecutive laparoscopy which, furthermore, confirmed interventional success. Despite extensive diagnostic efforts, the cause of the bleeding remained undefined. CONCLUSION: Spontaneous hemoperitoneum may occasionally be considered as a cause of acute abdomial pain and is diagnostically challenging. An interdisciplinary approach is desirable to meet the objective of modern organ-preserving therapy in splenic artery rupture.

Determination of Ras-GTP and Ras-GDP in patients with acute myelogenous leukemia (AML), myeloproliferative syndrome (MPS), juvenile myelomonocytic leukemia (JMML), acute lymphocytic leukemia (ALL), and malignant lymphoma: assessment of mutational and indirect activation.

The 21-kD protein Ras of the low-molecular-weight GTP-binding (LMWG) family plays an important role in transduction of extracellular signals. Ras functions as a 'molecular switch' in transduction of signals from the membrane receptors of many growth factors, cytokines, and other second messengers to the cell nucleus. Numerous studies have shown that in multiple malignant tumors and hematopoietic malignancies, faulty signal transduction via the Ras pathway plays a key role in tumorigenesis. In this work, a non-radioactive assay was used to quantify Ras activity in hematologic malignancies. Ras activation was measured in six different cell lines and 24 patient samples, and sequence analysis of N- and K-ras was performed. The 24 patient samples comprised of seven acute myelogenous leukemia (AML) samples, five acute lymphocytic leukemia (ALL) samples, four myeloproliferative disease (MPD) samples, four lymphoma samples, four juvenile myelomonocytic leukemia (JMML) samples, and WBC from a healthy donor. The purpose of this study was to compare Ras activity determined by percentage of Ras-GTP with the mutational status of the Ras gene in the hematopoietic cells of the patients. Mutation analysis revealed ras mutations in two of the seven AML samples, one in codon 12 and one in codon 61; ras mutations were also found in two of the four JMML samples, and in one of the four lymphoma samples (codon 12). We found a mean Ras activation of 23.1% in cell lines with known constitutively activating ras mutations, which was significantly different from cell lines with ras wildtype sequence (Ras activation of 4.8%). Two of the five activating ras mutations in the patient samples correlated with increased Ras activation. In the other three samples, Ras was probably activated through "upstream" or "downstream" mechanisms.

[Current perioperative antibiotic prophylaxis]. / Neues in der perioperativen antibiotischen Prophylaxe.

Perioperative antimicrobial prophylaxis (PAP) leads to a reduction in surgical site infections. The aim of PAP is adequate serum and tissue concentrations of the antimicrobial drug in the field of operation. The antibiotic must be effective against the expected pathogens during the operation, safe, and have the fewest possible side effects. The indication for PAP should take into account the risks of the operative procedure and especially the individual risk factors of the patient. Depending on pharmacokinetics, the antibiotic should be administered within 60 min before incision. After closure of the wound, further applications of the antibiotic drug have no influence on the infection rate of the wound but do increase the side effects (resistance, CDT colitis, allergy). Operation-specific recommendations according to guidelines of the Paul Ehrlich Society are given.

[Fungi in the mediastinum: rare, but relevant]. / Pilze im Mediastinum: Selten aber relevant.

Fungal infections of the mediastinum are rare. There are five forms to be differentiated: (i) hematogenous fungal infection of the mediastinum after fungemia; (ii) postoperative fungal infection after cardiosurgical sternotomy; (iii) as special form of a descending necrotizing fasciitis; (iv) infection of the mediastinum per continuitatem; (v) fungal infection of the posterior mediastinum after esophageal perforation. In the surgical department, University of Schleswig-Holstein, Campus Lübeck, five patients with a fungal mediastinitis were treated during a period of 10 years. Three patients suffered from a descending mediastinitis, one patient from a fungal infection after pseudarthrosis of the sternum (postoperatively after cardiosurgery). The section results of one other patient with pulmonary aspergillosis showed a complete invasion of the mediastinum by Aspergillus fumigatus.

[Fungal infections in patients with necrotizing pancreatitis: risk-factors, incidence, therapy]. / Pilzinfektion bei hämorrhagisch-nekrotisierender Pankreatitis: Risikofaktoren, Inzidenz, Therapie.

Haemorraghic necrotizing pancreatitis may lead to a serious disease with multi-organ failure, which is to be treated with intensive care. Patients suffering from infected necrosis are usually operated (necrosectomy). By doing this, it is possible to get a microbiological analysis. The most common virulent species are Enterobacteriaceae. According to the literature, fungal infections appear in 15-30% of the cases. Since 1996, 73 patients were treated surgically in our department. A number of 50 patients (68,5%) developed a fungal infection during the course of the disease. The mortality rate was 62%.

[Therapy of intraabdominal fungal infections]. / Therapie der intraabdominellen Pilzinfektionen.

Candida albicans is the fourth most germ that can be identified on surgical intensive care unit (SICU). During the course of severe peritonitis recognition of Candida is crucial for physicians but interpretation of Candida-positive microbiologic samples is difficult. The indication for antimycotic therapy requires differentiation between harmless contamination or severe invasive mycosis associated with high mortality. Therefore, we propose a four-stage classification. Stage I is the initial contamination of the abdominal cavity by Candida spp. Stage IIa is characterized by persistence of fungi in patients without risk factors, IIb with risk factors respectively. Stage III means histological evidence of Candida invasion into the peritoneal layer. Stage IV is a generalized infection with fungemia/fungal sepsis. We recommend antimycotic therapy in stage IIb or higher.

Rectal prolapse: which surgical option is appropriate?

Numerous surgical procedures have been suggested to treat rectal prolapse. In elderly and high-risk patients, perineal approaches such as Delorme's procedure and perineal rectosigmoidectomy (Altemeier's procedure) have been preferred, although the incidence of recurrence and the rate of persistent incontinence seem to be high when compared with transabdominal procedures. Functional results of transabdominal procedures, including mesh or suture rectopexy and resection-rectopexy, are thought to be associated with low recurrence rates and improved continence. Transabdominal procedures, however, usually imply rectal mobilization and fixation, colonic resection, or both, and some concern is voiced that morbidity, in terms of infection or leakage, and mortality could be increased. If we focus on surgical outcome, our own experience of laparoscopic resection-rectopexy for rectal prolapse shows that the laparoscopic approach is safe and effective, and functional results with respect to recurrence are favorable. However, the controversy "which operation is appropriate?" cannot be answered definitely, as a clear definition of rectal prolapse, the extent of a standardized diagnostic assessment, and the type of surgical procedure have not been identified in published series. Randomized trials are needed to improve the evidence with which the optimal surgical treatment of rectal prolapse can be defined.

Impact of mycophenolate mofetil versus azathioprine on early recurrence of hepatitis C after liver transplantation.

The aim of this study was to evaluate the impact of mycophenolate mofetil (MMF) on incidence, delay, severity and clinical course of early recurrent hepatitis C after liver transplantation (LT). A total of 21 hepatitis C virus (HCV)-positive patients after LT were prospectively enrolled in this study. All of them received a quadruple induction cyclosporine A (CsA)-based immunosuppression, augmented by MMF (n=12) or by azathioprine (n=9, AZA). MMF tended to delay recurrent disease (50+/-35 versus 35+/-35 weeks, P=0.5) with significantly lower levels of aminotransferases (P<0.05). Furthermore, patients under MMF revealed less severe allograft fibrosis at disease recurrence (stage of fibrosis: 1.5+/-0.5 versus 2.2+/-1.2; P=0.07). But stage of fibrosis significantly increased in the MMF-group (P<0.05) during 6 months of antiviral treatment. Three patients in the MMF-group and none of the controls suffered from severe fibrosing cholestatic recurrent hepatitis C. Initial post-LT administration of MMF tended to delay recurrent hepatitis C and to limit initial HCV-related biochemical and morphological graft dysfunction. But during clinical follow-up, its immunosuppressive capabilities exceeded possible antiviral properties, finally leading to significant progression of graft fibrosis. Thus, concomitant dose reduction of other basic immunosuppressants might be useful in this clinical setting.