Southwest Netherlands Research Articles

Missing patient registrations in the Dutch National Trauma Registry of Southwest Netherlands: Prevalence and epidemiology

IntroductionHealth care patient records have been digitalised the past twenty years, and registries have been automated. Missing registrations are common, and can result in selection bias. ObjectiveTo assess the prevalence and characteristics of missed registrations in a Dutch regional trauma registry. MethodsAn automatically generated trauma registry export was done for ten out of eleven hospitals in trauma region Southwest Netherlands, between June 1 and August 31, 2020. Second, lists were checked for being falsely flagged as ‘non-trauma’. Finally, a list was generated with trauma tick box flagged as ‘trauma’ but were not automatically in the export due to administrative errors. Automated and missed registration datasets were compared on patient characteristics and logistic regression models were run with random intercepts and missed registration as outcome variable on the complete dataset. ResultsA total of 2,230 automated registrations and 175 (7.3 %) missed registrations were included for the Dutch National Trauma Registry, ranging from 1 to 14 % between participating hospitals. Patients of the missed registration dataset had characteristics of a higher level of care, compared with patients of automated registrations. Level of trauma care (level II OR 0.464 95 % CI 0.328–0.666, p < 0.001; level III OR 0.179 95 % CI 0.092–0.325, p < 0.001), major trauma (OR 2.928 95 % CI 1.792–4.65, p < 0.001), ICU admission (OR 2.337 95 % CI 1.792–4.650, p < 0.001), and surgery (OR 1.871 95 % CI 1.371–2.570, p < 0.001) were potential predictors for missed registrations in multivariate logistic regression analysis. ConclusionMissed registrations occur frequently and the rate of missed registrations differs greatly between hospitals. Automated and missed registration datasets display differences related to patients requiring more intensive care, which held for the major trauma subset. Checking for missed registrations is time consuming, automated registration lists need a human touch for validation and to be complete.

Factors influencing submerged macrophyte presence in fresh and brackish eutrophic waters and their impact on carbon emissions

In agricultural landscapes of North-Western Europe, the majority of water bodies do not meet the targets set by the European Water Framework Directive due to a lack of submerged macrophytes and associated biodiversity. These eutrophic waters can also be a substantial source of methane (CH4) and carbon dioxide (CO2) to the atmosphere. Here we present a two-year field experiment on the island of Goeree-Overflakkee (southwest Netherlands), conducted in six drainage ditches varying in salinity, where we monitored four permanent plots per ditch and varied the presence of both fish and macrophytes. We aimed to: 1) investigate factors limiting submerged macrophyte growth, focussing on exclusion of grazing pressure and bioturbation by fish; and 2) quantify the CO2 and CH4 emission under these conditions. Even in highly eutrophic, semi turbid ditches with fluctuating salinity levels and sulphide presence in the root zone, submerged macrophytes established successfully after introduction when the influence of grazing and bioturbation by fish was excluded. In the exclosures, diffusive CH4 and CO2 emissions, but not ebullitive CH4 emissions were significantly reduced. The spontaneous development of submerged macrophytes in the exclosures without macrophyte introduction underlined the effect of grazing and bioturbation by fish and suggest that abiotic conditions did not hamper submerged macrophyte development. Our results provide important insights into the influential factors for submerged macrophyte development and potential for future management practices. Large-scale fish removal may stimulate submerged macrophyte growth and reduce methane emissions, albeit that the macrophyte diversity will likely stay low in our study region due to fluctuating salinity and eutrophic conditions.

Piloting a complex intervention to promote a tobacco and alcohol-free pregnancy: the Smoke and Alcohol Free with EHealth and Rewards (SAFER) pregnancy study

BackgroundTobacco smoking and alcohol consumption before and during pregnancy increase the risk of adverse health outcomes for mother and child. Interventions to address smoking and drinking before and during pregnancy have the potential to reduce early-life health inequalities. In the Smoke and Alcohol Free with EHealth and Rewards (SAFER) pilot study we aimed to evaluate the acceptability, feasibility and effectiveness of a complex intervention supporting women in smoking and alcohol cessation before and during pregnancy.MethodsFrom February 2019 till March 2021, we piloted the SAFER pregnancy intervention among pregnant women and women planning pregnancy in South-West Netherlands in an uncontrolled before-after study. Participants were supported in smoking and alcohol cessation via up to six group sessions and an online platform. In addition, biochemically validated cessation was rewarded with incentives (i.e. shopping vouchers) amounting up to 185 euros. We aimed to include 66 women. The primary outcome was smoking and/or alcohol cessation at 34–38 weeks of gestation (if pregnant) or after six group sessions (if not pregnant). Quantitative data were analysed using descriptive statistics. Focus group interviews among those involved in the study were conducted at the end of the study to explore their experiences. Qualitative data was analysed using thematic analysis.ResultsThirty-nine women who smoked were included; no women who consumed alcohol were referred to the study. Unemployment (51%), financial problems (36%) and a smoking partner (72%) were common. Thirteen women (33%) dropped out, often due to other problems impeding smoking cessation or ‘being too busy’ to participate in the group sessions. Eleven women (28%) had quit smoking at the study’s endpoint. The personal and positive approach was highly valued and biochemical validation was felt to be helpful.ConclusionThe SAFER pregnancy intervention seems appropriate for women in need of extra support for smoking cessation before and during pregnancy. Its impact on alcohol cessation could not be studied due to recruitment issues. Recruitment and prevention of early dropout need attention in further development of this intervention.Trial registrationNetherlands Trial Register: NL7493. Date registered: 04/02/2019.

Identifying Marine Sources of Beached Plastics Through a Bayesian Framework: Application to Southwest Netherlands.

Beaches are thought to be a large reservoir for marine plastics. To protect vulnerable beaches, it is advantageous to have information on the sources of this plastic. Here, we develop a universally applicable Bayesian framework to map sources of plastic arriving on a specific beach. In this framework, we combine Lagrangian backtracking simulations of drifting particles with estimates of plastic input from coastlines, rivers and fisheries. The advantage over traditional Lagrangian simulations is that the Bayesian framework can consider information on known sources, and thus facilitates spatiotemporal source attribution for plastic arriving at the specified beach. We show that the main sources for our target beach in southwest Netherlands are the east coast of the UK, the Dutch coast, the English Channel (fisheries) and the Thames, Seine, Rhine and Trieux (rivers). We also show that floating time is a major uncertainty in source attribution using backtracking.

Health-related quality of life and return to work 1 year after major trauma from a network perspective

IntroductionMajor trauma often results in long-term disabilities. The aim of this study was to assess health-related quality of life, cognition, and return to work 1 year after major trauma from a trauma network perspective.MethodsAll major trauma patients in 2016 (Injury Severity Score > 15, n = 536) were selected from trauma region Southwest Netherlands. Eligible patients (n = 365) were sent questionnaires with the EQ-5D-5L and questions on cognition, level of education, comorbidities, and resumption of paid work 1 year after trauma.ResultsA 50% (n = 182) response rate was obtained. EQ-US and EQ-VAS scored a median (IQR) of 0.81 (0.62–0.89) and 70 (60–80), respectively. Limitations were prevalent in all health dimensions of the EQ-5D-5L; 90 (50%) responders reported problems with mobility, 36 (20%) responders reported problems with self-care, 108 (61%) responders reported problems during daily activities, 129 (73%) responders reported pain or discomfort, 70 (39%) responders reported problems with anxiety or depression, and 102 (61%) of the patients reported problems with cognition. Return to work rate was 68% (37% full, 31% partial). A median (IQR) EQ-US of 0.89 (0.82–1.00) and EQ-VAS of 80 (70–90) were scored for fully working responders; 0.77 (0.66–0.85, p < 0.001) and 70 (62–80, p = 0.001) for partial working respondents; and 0.49 (0.23–0.69, p < 0.001) and 55 (40–72, p < 0.001) for unemployed respondents.ConclusionThe majority experience problems in all health domains of the EQ-5D-5L and cognition. Return to work status was associated with all health domains of the EQ-5D-5L and cognition.

Development and implementation of a transmural palliative care consultation service: a multiple case study in the Netherlands

BackgroundIn the Netherlands, healthcare professionals attending patients in the last phase of life, can consult an expert palliative care team (PCT) in case of complex problems. There are two types of PCTs: regional PCTs, which are mainly consulted by general practitioners, and hospital PCTs, which are mainly consulted by healthcare professionals in the hospital. Integration of these PCTs is expected to facilitate continuity of care for patients receiving care in different settings. We studied facilitators and barriers in the process of developing and implementing an integrated transmural palliative care consultation service.MethodsA multiple case study was performed in four palliative care networks in the southwest Netherlands. We aimed to develop an integrated transmural palliative care consultation service. Researchers were closely observing the process and participated in project team meetings. A within-case analysis was conducted for each network, using the Consolidated Framework for Implementation Research (CFIR). Subsequently, all findings were pooled.ResultsIn each network, project team members thought that the core goal of a transmural consultation service is improvement of continuity of palliative care for patients throughout their illness trajectory. It was nevertheless a challenge for hospital and non-hospital healthcare professionals to arrive at a shared view on goals, activities and working procedures of the transmural consultation service. All project teams experienced the lack of evidence-based guidance on how to organise the service as a barrier. The role of the management of the involved care organisations was sometimes perceived as unsupportive, and different financial reimbursement systems for hospital and out-of-hospital care made implementation of a transmural consultation service complex. Three networks managed to develop and implement a transmural service at some level, one network did not manage to do so.ConclusionsHealthcare professionals are motivated to collaborate in a transmural palliative care consultation service, because they believe it can contribute to high-quality palliative care. However, they need more shared views on goals and activities of a transmural consultation service, more guidance on organisational issues and appropriate financing. Further research is needed to provide evidence on benefits and costs of different models of integrated transmural palliative care consultation services.

Injuries, treatment, and impairment caused by different types of fireworks; results of a 10\u2009year multicenter retrospective cohort study

ObjectivesThe primary aim of this study was to evaluate the number of patients reported to a hospital with injuries from consumer fireworks in the months December–January in the past 10 years, and to describe the association between the type of fireworks, injury pattern, treatment, and permanent impairment.MethodsA multicenter, retrospective, observational case series. Patients were selected from two hospitals in the Southwest Netherlands: a level 1 trauma center and a specialized burn center. All patients with any fireworks-related injuries treated between December 1 and January 31, during 2007 (December) to 2017 (January), were eligible for participation. The primary outcome was the number of patients with any type of injury caused by fireworks. The secondary outcome measures were patient and injury characteristics, treatment details, and whole person impairment (WPI). The percentage WPI expresses a patient’s degree of permanent impairments as a result of fireworks-related injuries.ResultsOf the 297 eligible patients, 272 patients were included. From 2007 to 2017, between 21 and 40 patients were treated, and no clear increase or decrease was observed in the number of patients and in the number of patients per type of fireworks. Explosive fireworks mainly caused upper extremity (N = 65; 68%) injuries, while rockets (N = 24; 41%) and aerials (N = 7; 41%) mainly affected the head/neck. Decorative fireworks predominantly resulted in burns (N = 82; 68%), and explosive fireworks in soft tissue lacerations (N = 24; 25%), fractures (N = 16; 17%), and amputations (N = 14; 15%). Patients injured by explosive and homemade fireworks were most often admitted to a hospital (respectively N = 24; 36% and N = 12; 80%), and resulted in the highest proportion undergoing surgical procedures (respectively N = 22; 33% and N = 7; 47%). WPI found in this study was between 0 to 95%, with a median of 0%. In 34 (14%) patients, the injuries resulted in a WPI of ≥1%, mostly as a result of explosive fireworks (N = 18; 53%).ConclusionThis study found no increase or decrease in the number of patients treated in two specialized hospitals. Explosive and homemade fireworks could be considered as most dangerous, as they result into the most hospital admissions, surgical procedures, and into the most injuries with permanent impairment as a result.

Comparison of eight prehospital stroke scales to detect intracranial large-vessel occlusion in suspected stroke (PRESTO): a prospective observational study

Due to the time-sensitive effect of endovascular treatment, rapid prehospital identification of large-vessel occlusion in individuals with suspected stroke is essential to optimise outcome. Interhospital transfers are an important cause of delay of endovascular treatment. Prehospital stroke scales have been proposed to select patients with large-vessel occlusion for direct transport to an endovascular-capable intervention centre. We aimed to prospectively validate eight prehospital stroke scales in the field. We did a multicentre, prospective, observational cohort study of adults with suspected stroke (aged ≥18 years) who were transported by ambulance to one of eight hospitals in southwest Netherlands. Suspected stroke was defined by a positive Face-Arm-Speech-Time (FAST) test. We included individuals with blood glucose of at least 2·5 mmol/L. People who presented more than 6 h after symptom onset were excluded from the analysis. After structured training, paramedics used a mobile app to assess items from eight prehospital stroke scales: Rapid Arterial oCclusion Evaluation (RACE), Los Angeles Motor Scale (LAMS), Cincinnati Stroke Triage Assessment Tool (C-STAT), Gaze-Face-Arm-Speech-Time (G-FAST), Prehospital Acute Stroke Severity (PASS), Cincinnati Prehospital Stroke Scale (CPSS), Conveniently-Grasped Field Assessment Stroke Triage (CG-FAST), and the FAST-PLUS (Face-Arm-Speech-Time plus severe arm or leg motor deficit) test. The primary outcome was the clinical diagnosis of ischaemic stroke with a proximal intracranial large-vessel occlusion in the anterior circulation (aLVO) on CT angiography. Baseline neuroimaging was centrally assessed by neuroradiologists to validate the true occlusion status. Prehospital stroke scale performance was expressed as the area under the receiver operating characteristic curve (AUC) and was compared with National Institutes of Health Stroke Scale (NIHSS) scores assessed by clinicians at the emergency department. This study was registered at the Netherlands Trial Register, NL7387. Between Aug 13, 2018, and Sept 2, 2019, 1039 people (median age 72 years [IQR 61-81]) with suspected stroke were identified by paramedics, of whom 120 (12%) were diagnosed with aLVO. Of all prehospital stroke scales, the AUC for RACE was highest (0·83, 95% CI 0·79-0·86), followed by the AUC for G-FAST (0·80, 0·76-0·84), CG-FAST (0·80, 0·76-0·84), LAMS (0·79, 0·75-0·83), CPSS (0·79, 0·75-0·83), PASS (0·76, 0·72-0·80), C-STAT (0·75, 0·71-0·80), and FAST-PLUS (0·72, 0·67-0·76). The NIHSS as assessed by a clinician in the emergency department did somewhat better than the prehospital stroke scales with an AUC of 0·86 (95% CI 0·83-0·89). Prehospital stroke scales detect aLVO with acceptable-to-good accuracy. RACE, G-FAST, and CG-FAST are the best performing prehospital stroke scales out of the eight scales tested and approach the performance of the clinician-assessed NIHSS. Further studies are needed to investigate whether use of these scales in regional transportation strategies can optimise outcomes of patients with ischaemic stroke. BeterKeten Collaboration and Theia Foundation (Zilveren Kruis).

Prehospital Triage of Patients with Suspected Stroke (PRESTO): A Prospective In-Field Validation of Eight Prehospital Stroke Scales to Detect Intracranial Large Vessel Occlusion

Background: Due to the time-sensitive effect of endovascular treatment (EVT), rapid prehospital identification of large vessel occlusion (LVO) in suspected stroke patients is essential to optimize outcome. Inter-hospital transfers are an important cause of delay of EVT. Prehospital stroke scales have been proposed to select patients with LVO for direct transport to an endovascular-capable intervention centre. We aimed to prospectively validate eight prehospital stroke scales in the field. Methods: In a multi-centre prospective observational cohort study, we included suspected stroke patients transported by ambulance in the Southwest Netherlands. Paramedics assessed items from eight prehospital stroke scales: Rapid Arterial oCclusion Evaluation (RACE), Los Angeles Motor Scale (LAMS), Cincinnati Stroke Triage Assessment Tool (C-STAT), Gaze-Face-Arm-Speech-Time (G-FAST), Prehospital Acute Stroke Severity (PASS), Cincinnati Prehospital Stroke Scale (CPSS), Conveniently-Grasped Field Assessment Stroke Triage (CG-FAST), and the FAST PLUS Test. Patients that presented beyond six hours from symptom onset were excluded. Primary outcome was the clinical diagnosis of ischaemic stroke with a proximal intracranial LVO in the anterior circulation (aLVO) on CT-angiography. Prehospital stroke scale performance was expressed as the area under the receiver operating characteristic curve (AUC) and was compared with National Institute of Health Stroke Scale (NIHSS) scores assessed by physicians at the emergency department. Findings: We included 1039 patients, of which 121 patients (12%) were diagnosed with aLVO. AUCs for the prehospital stroke scales ranged from 0·69 (FAST PLUS) to 0·82 (RACE). The performance of RACE was not significantly different from G-FAST (AUC=0·80, p=0·14) and CG-FAST (AUC=0·80, p=0·09), but was significantly different from the other scales (p-values<0·05). The NIHSS performed somewhat better (AUC 0·86, p-values<0·05). Interpretation: Prehospital stroke scales detect aLVO with good accuracy and approach the performance of the physician-assessed NIHSS. RACE is the best performing prehospital stroke scale, but does not differ significantly from G-FAST and CG-FAST. Trial Registration: This study was registered at the Netherlands Trial Register (www.trialregister.nl), NL7387 Funding: BeterKeten collaboration and Theia Foundation (Zilveren Kruis) Declaration of Interests: Diederik Dippel and Aad van der Lugt report funding from the Dutch Heart Foundation, Brain Foundation Netherlands, The Netherlands Organisation for Health Research and Development, Health Holland Top Sector Life Sciences & Health, and unrestricted grants from Penumbra Inc., Stryker, Stryker European Operations BV, Medtronic, Thrombolytic Science, LLC and Cerenovus for research, all paid to institution. Pieter Jan van Doormaal reports funding from Stryker, paid to institution and an unrestricted fee from Bayer. All other authors declare no conflict of interest. Ethics Approval Statement: This study was conducted in accordance with the Dutch Agreement on Medical Treatment Act and the European General Data Protection Regulation. The Institutional Review Board of the Erasmus MC University Medical Centre has reviewed the study protocol and confirmed that the Dutch Medical Research Involving Human Subjects Act is not applicable. Because our study met the exceptions of informed consent regulations, the need for informed consent was waived. Patients or their relatives were informed about the study and could withdraw from the study through an opt-out system.

The Process of Developing and Implementing a Simplified Guideline for Hand Hygiene in the Operating Room

Background: Most studies on improving hand hygiene compliance (HHC) focus on clinical wards. The 5 Moments of Hand Hygiene, as stated by the WHO, are less easy to identify in an outpatient setting or procedure rooms. Therefore, observing compliance of these moments in an outpatient clinic or among healthcare workers (HCWs) in the operating room (OR), is far more difficult. Nonetheless, proper hand hygiene in the OR is of utmost importance to prevent postoperative wound infection. Objective: We developed and implement a scoring instrument with simplified moments of hand hygiene for nonsterile HCWs in the OR. Methods: All 13 hospitals of the Antibiotic Resistance Network Southwest Netherlands were asked to submit their guidelines on hand hygiene in the OR. These guidelines were, after discussion, combined into 1 guideline, describing different hand hygiene areas for different groups of nonsterile HCWs in the OR. After asking for feedback and incorporating these adjustments, the guideline was converted into a policy document. Based on this document, a paper scoring instrument was developed to observe HHC in the OR in a uniform way across all hospitals. The Erasmus University Medical Center Rotterdam, the Netherlands (Erasmus MC) acted as a pilot hospital where the implementation of the scoring instrument was studied. Results: The policy document has been approved by the infection committees of all 13 hospitals. The preliminary data of the pilot in the Erasmus MC, although still ongoing, are as follows. Hand hygiene in the OR was observed at 4 different time points. The anesthetist was observed once during 4 procedures in 3 different ORs. At the other 3 time points, the OR assistants (ie, OR nurses and circulating nurses) were observed during 4 procedures in 4 different ORs. Hand hygiene moments were easy to identify; the paper scoring instrument could be used to record observations of HHC in the OR. Conclusions: The guideline with the simplified moments of hand hygiene for nonsterile HCWs in the OR has been successfully implemented. The pilot test in the Erasmus MC already showed that, after defining the hand hygiene moments in the OR, the HHC in the OR is easier to observe and record using the scoring instrument. Moreover, the instrument has provided clarity for HCWs regarding the moments ate which they should disinfect their hands.Funding: NoneDisclosures: None

Epidemiology, treatment, costs, and long-term outcomes of patients with fireworks-related injuries (ROCKET); a multicenter prospective observational case series.

ObjectivePeople in the Netherlands are legally allowed to celebrate New Year’s Eve with consumer fireworks. The aim of this study was to provide detailed information about the patient and injury characteristics, medical and societal costs, and clinical and functional outcome in patients with injuries resulting from this tradition.MethodsA multicenter, prospective, observational case series performed in the Southwest Netherlands trauma region, which reflects 15% of the country and includes a level I trauma center, a specialized burn center, a specialized eye hospital, and 13 general hospitals. All patients with any injury caused by consumer fireworks, treated at a Dutch hospital between December 1, 2017 and January 31, 2018, were eligible for inclusion. Exclusion criteria were unknown contact information or insufficient understanding of Dutch or English language. The primary outcome measure was injury characteristics. Secondary outcome measures included treatment, direct medical and indirect societal costs, and clinical and functional outcome until one year after trauma.Results54 out of 63 eligible patients agreed to participate in this study. The majority were males (N = 50; 93%), 50% were children below 16 years of age, and 46% were bystanders. Injuries were mainly located to the upper extremity or eyes, and were mostly burns (N = 38; 48%) of partial thickness (N = 32; 84%). Fifteen (28%) patients were admitted and 11 (20%) patients needed surgical treatment. The mean total costs per patient were €6,320 (95% CI €3,400 to €9,245). The most important cost category was hospital admission. Only few patients reported complaints in patient-reported quality of life and functional outcome after 12 months follow-up.ConclusionThis study found that young males are most vulnerable for fireworks injuries and that most injuries consist of burns, located to the arm and hand, and eye injuries. On the long-term only few patients experienced reduced quality of life and functional limitations.

Preferred and actual mode of delivery in relation to fear of childbirth

Purpose This prospective cohort study aimed to investigate the interrelation between preferred/actual mode of delivery and pre- and postpartum fear of childbirth (FOC). Material and methods Participants from 13 midwifery practices and four hospitals in Southwest Netherlands filled out questionnaires at 30 weeks’ gestation (n = 561) and two months postpartum (n = 463), including questions on preferred mode of delivery, the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) and Hospital Anxiety Depression Scale (HADS). Results were related to obstetric data. Results Both severe FOC (OR 7.0, p < .001) and previous Cesarean section (CS) (OR 16.6, p < .001) predicted preference for CS. Severe prepartum FOC also predicted actual CS. Preferring a vaginal delivery (VD) and actually having a CS predicted higher postpartum W-DEQ scores (partial r = 0.107, p < .05). Other significant predictors for high postpartum W-DEQ scores were high prepartum W-DEQ (partial r = 0.357) and HADS anxiety scores (partial r = 0.143) and the newborn in need of medical assistance (partial r = −0.169). Conclusions Women preferring a VD but ending up with a CS are at risk for severe FOC postpartum, while the same risk was not demonstrated for women who preferred a CS but had a VD. Prepartum FOC is strongly associated with postpartum FOC, regardless of congruence between preferred and actual mode of delivery.

Epidemiology of injuries, treatment (costs) and outcome in burn patients admitted to a hospital with or without dedicated burn centre (Burn-Pro): protocol for a multicentre prospective observational study

IntroductionThe Emergency Management of Severe Burns (EMSB) referral criteria have been implemented for optimal triaging of burn patients. Admission to a burn centre is indicated for patients with severe burns...

Differences in Rate of Complete Excision of Basal Cell Carcinoma by Dermatologists, Plastic Surgeons and General Practitioners: A Large Cross-Sectional Study

Background: Due to the increasing incidence of basal cell carcinoma (BCC) and rising health care costs, health care insurance companies seek ways to shift skin surgery for BCC from secondary to primary care. Objectives: To study the differences in complete excision of BCC by general practitioners (GPs), dermatologists, and plastic surgeons. Methods: A retrospective cross-sectional study of pathology records of 2,986 standard excisions of primary BCCs performed by a GP, dermatologist, or plastic surgeon in the area of Southwest Netherlands between 2008 and 2014. To compare the risk of an incomplete BCC excision between the specialties, the odds ratio (OR) was used adjusted for patient age, sex, tumor site, size, and histological subtype. Results: BCCs were completely excised by GPs in 70%, which was lower than the 93% by dermatologists and 83% by plastic surgeons (p < 0.001). Compared to the dermatologist, BCCs which were excised by a GP were 6 times higher at risk of an incomplete excision (adjusted OR 6, 95% CI 5–8) and 2 times higher at risk when excised by a plastic surgeon (adjusted OR 2, 95% CI 2–3). Conclusion: BCCs were more often completely excised by dermatologists than by GPs and plastic surgeons. Dermatologists probably perform better because of their extensive training and high experience in BCC care. To minimize incomplete BCC excision, GPs should receive specific training before the shift of BCC care from secondary to primary care is justifiable.

Patterns of injury and outcomes in the elderly patient with rib fractures: a multicenter observational study

BackgroundHigh rates of pneumonia and death have been reported among elderly patients with rib fractures. This study aims to identify patterns of injury and risk factors for pneumonia and death in elderly patients with rib fractures.MethodsA retrospective multicenter observational study was performed using data registered in the national trauma registry between 2008 and 2015 in the South West Netherlands Trauma region. Data regarding demographics, mechanism of injury, pulmonary and cardiovascular history, pattern of extra-thoracic and intrathoracic injuries, ICU admission, length of stay, and morbidity and mortality following admission were collected.ResultsEight hundred eighty-four patients were included. Median age was 76 years (P25–P75 70–83). 235 patients (26.6%) were 81 years or older. Moderate or worse extra-thoracic injuries were present in 456 patients (51.6%), of whom 146 (16.6%) had severe head injuries and 45 (5.1%) severe spinal injuries. Median ISS was 9 (P25–P75 5–18). The rate of pneumonia was 10% (n = 84). Ten percent of patients (n = 88) died. Risk factors for in-hospital mortality included age (OR 3.4; p = 0.003), presence of COPD (OR 1.3; p = 0.01), presence of cardiac disease (OR 2.6; p = 0.003), severe or worse head (OR 3.5; p < 0.001), abdominal (OR 6.8; p = 0.004) and spinal injury (OR 4.6; p = 0.011) by AIS, number of rib fractures (OR 2.6; p = 0.03), and need for chest tube drainage (OR 2.1; p = 0.021).ConclusionsPneumonia and death occur in about 10% of elderly patients with rib fractures. Apart from the severity of thoracic injuries, the presence and severity of extra-thoracic injuries and cardiopulmonary comorbidities are associated with poor outcome.

Conditional effects of tides and waves on short‐term marsh sedimentation dynamics

AbstractSalt marshes are in danger of degradation due to human impact and climate change. A thorough understanding of mechanisms controlling sedimentation and erosion in salt marshes is essential for their conservation and restoration. To understand short‐term dynamics of sediment availability and deposition around marsh edges, two contrasting marshes, Rattekaai and Sint Annaland, were studied in the Oosterschelde (southwest Netherlands). Suspended sediment concentration (SSC) was measured by siphon samplers along four transects perpendicular to the marsh edge in each marsh, during nine flood tides between March and December 2013. Each transect was comprised of four sampling sites (−10 m and −1 m on the mudflat and +1 m and +10 m on the marsh plateau, relative to the marsh edge). Sediment deposition was measured along the transects on the marsh, at +1 m and +10 m from the marsh edge, over seven c. 14‐day intervals during the same 10‐month period. Two types of sediment traps were used, one measuring gross sediment deposition (TTD – tube trap deposition) and one measuring net sediment deposition (FTD – filter trap deposition). Wave loggers were deployed 10 m away from the marsh edge on the mudflat at each marsh. The results showed that both SSC and sediment deposition varied greatly through space, both between the two marshes and within each marsh along the marsh edge. The SSC and gross sediment deposition were much higher at Rattekaai than at Sint Annaland. SSC was significantly correlated with wind speed during sampling. Sediment deposition rates (TTD and FTD) and retention ratio (FTD/TTD) were significantly correlated with cumulative wave energy during the measurement period. A conceptual model of local sediment dynamics is proposed to explain the sediment dynamics around the marsh edge. This study highlights the importance of incorporating local sediment dynamics when evaluating marsh vulnerability and stability. Copyright © 2018 John Wiley &amp; Sons, Ltd.

Henk Schat.

Henk Schat.

Effect of short-term hypoxia on the feeding activity of abundant nematode genera from an intertidal mudflat

The effect of short-term hypoxia (6 days) on the feeding activity of abundant nematode genera was investigated by means of a tracer experiment. Nematodes were sampled from the Paulina intertidal flat in the Westerschelde estuary (south-west Netherlands) and incubated with 13C pre-labelled diatoms at the sediment-water interface in oxic and hypoxic treatments. In general, specific uptake and uptake of carbon per unit of nematode carbon were low in all studied genera, which indicated that the added diatoms represented a limited food source for the investigated nematode genera. Results from such a low uptake are difficult to interpret; however, there was no significant decrease in feeding activity of all dominant nematodes in the hypoxic treatments. The low carbon uptake might be related to low access of nematodes and their low feeding preference to the added diatoms in the experimental cores.

Vulnerable pregnant women in antenatal practice: Caregiver's perception of workload, associated burden and agreement with objective caseload, and the influence of a structured organisation of antenatal risk management

Introductionpregnancy care for vulnerable women is often perceived as a burden by caregivers as vulnerable clients require complex case management, additional time, and more often show adverse perinatal outcomes. Vulnerable clients bring about additional work strain for the caregiver, especially when the workload is high. We define client vulnerability as coexistence of psychopathology, psychosocial problems or substance use, together with features of deprivation. We investigated, as part of a national programme, whether the subjective caregiver's perception of workload and the objective registry-based caseload of vulnerable clients are in agreement, and whether a structured organisation of antenatal risk management reduces the burden associated with the perceived workload, in particular if the objective caseload is high. Methodswe combined three data sources: (1) at the unit level (i.e. midwifery practice, obstetric unit) interview data from caregivers, from which we derived a) the (subjective) caregiver's perception of workload, b) the associated burden and c) organisational structure of antenatal risk management, (2) at the unit level perinatal registry data, from which we derived a) unit characteristics and b) (objective) unit specific caseload, and (3) at the individual client level survey data collected during the first antenatal visit, from which the prevalence of vulnerable clients was derived. The study area was the South-West Netherlands (2.5 million inhabitants), containing areas with varying degrees of urbanisation and deprivation. Findingssixteen units had complete data on all measures. Generally, subjective workload and objective caseload were only weakly related, the relation being modified by the organisation of antenatal risk management. If the organisational structure of antenatal risk management was low, the experienced burden was high, even if the objective caseload was low. Highly structured antenatal risk management was associated with a medium to low burden. Discussionour observational study suggests that even a high caseload can be dealt with by structured antenatal risk management. A change from the current individual case-finding policies towards a more universal screen-like approach may thus benefit both the client and the caregiver.

Evaluation of Socio-Economic Factors that Determine Adoption of Climate Compatible Freshwater Supply Measures at Farm Level: a Case Study in the Southwest Netherlands

The availability of freshwater resources in soil and groundwater bodies in the southwestern part of The Netherlands is expected to decrease during the agricultural growing season because of an expected increase of freshwater demands and a changing climate. This expected shortage of fresh water might negatively affect agricultural production. To cope with this problem, three pilots were initiated aimed at increasing freshwater supply at farm-level. The objective of this paper is to evaluate the socio-economic factors that determine the wider use of the measures investigated in these pilots. Therefore, the results of a feasibility study and a survey about drought risks were compared. The survey indicates that respondents do not make distinction between a dry and extremely dry year in their estimation of the return period. The results of a feasibility study illustrate that confidence and the level of common understanding regarding the reliability of these innovative measures has increased amongst project participants since 2012. The survey respondents were less optimistic about the wider implementation of the investigated technologies. A reliable freshwater supply and supportive legislation are the most decisive socio-economic factors for a future investment in additional freshwater supply for farmers in this region. Both studies illustrate that the impact of additional freshwater supply on farm economics strongly depends on farm type and crop cultivation plan. These insights may support the wider use of these innovations and may help to improve agro-hydrological models.