[Value-based healthcare in mental health care: a practical example]. / Waardegedreven zorg in de ggz: een praktijkvoorbeeld.

BACKGROUND: To promote quality improvement in Dutch mental health care, it is imperative to line up methods of quality improvement with daily care practice. In value-based healthcare the joint vision of medical professionals and patients is leading in the design and execution of care improvements. AIM: To demonstrate the value of value-based care. METHOD: Description of a practical example of the application of value based healthcare in mental healthcare, including a practical example of value-based improvement of patient care. RESULTS: A multidisciplinary improvement team was formed, consisting of patients and employees who were involved in the depression care pathway. The team determined important outcomes of care from the patient’s perspective, and successfully executed several improvement initiatives. CONCLUSION: The bottom-up approach of value-based healthcare is in line with day-to-day care practice and provides opportunities for effectively improving the quality of mental health care.

Phylogenetic and kinematic constraints on avian flight signals.

Many birds vocalize in flight. Because wingbeat and respiratory cycles are often linked in flying vertebrates, birds in these cases must satisfy the respiratory demands of vocal production within the physiological limits imposed by flight. Using acoustic triangulation and high-speed video, we found that avian vocal production in flight exhibits a largely phasic and kinematic relationship with the power stroke. However, the sample of species showed considerable flexibility, especially those from lineages known for vocal plasticity (songbirds, parrots and hummingbirds), prompting a broader phylogenetic analysis. We thus collected data from 150 species across 12 avian orders and examined the links between wingbeat period, flight call duration and body mass. Overall, shorter wingbeat periods, controlling for ancestry and body mass, were correlated with shorter flight call durations. However, species from vocal learner lineages produced flight signals that, on average, exceeded multiple phases of their wingbeat cycle, while vocal non-learners had signal periods that were, on average, closer to the duration of their power stroke. These results raise an interesting question: is partial emancipation from respiratory constraints a necessary step in the evolution of vocal learning or an epiphenomenon? Our current study cannot provide the answer, but it does suggest several avenues for future research.

Systemic inflammation in acute intermittent porphyria: a case-control study.

This study aimed to examine whether acute intermittent porphyria (AIP) is associated with systemic inflammation and whether the inflammation correlates with disease activity. A case-control study with 50 AIP cases and age-, sex- and place of residence-matched controls was performed. Plasma cytokines, insulin and C-peptide were analysed after an overnight fast using multiplex assay. Long pentraxin-3 (PTX3) and complement activation products (C3bc and TCC) were analysed using enzyme-linked immunosorbent assay (ELISA). Urine porphobilinogen ratio (U-PBG, µmol/mmol creatinine), haematological and biochemical tests were performed using routine methods. Questionnaires were used to register AIP symptoms, medication and other diseases. All 27 cytokines, chemokines and growth factors investigated were increased significantly in symptomatic AIP cases compared with controls (P < 0·0004). Hierarchical cluster analyses revealed a cluster with high visfatin levels and several highly expressed cytokines including interleukin (IL)-17, suggesting a T helper type 17 (Th17) inflammatory response in a group of AIP cases. C3bc (P = 0·002) and serum immunoglobulin (Ig)G levels (P = 0·03) were increased significantly in cases with AIP. The U-PBG ratio correlated positively with PTX3 (r = 0·38, P = 0·006), and with terminal complement complex (TCC) levels (r = 0·33, P = 0·02). PTX3 was a significant predictor of the biochemical disease activity marker U-PBG in AIP cases after adjustment for potential confounders in multiple linear regression analyses (P = 0·032). Prealbumin, C-peptide, insulin and kidney function were all decreased in the symptomatic AIP cases, but not in the asymptomatic cases. These results indicate that AIP is associated with systemic inflammation. Decreased C-peptide levels in symptomatic AIP cases indicate that reduced insulin release is associated with enhanced disease activity and reduced kidney function.

Mortality risk prediction in cardiac surgery: comparing a novel model with the EuroSCORE.

BACKGROUND: Several models for prediction of early mortality after open-heart surgery have been developed. Our objectives were to develop a local mortality risk prediction model, compare it with the European System for Cardiac Operative Risk Evaluation (EuroSCORE), and investigate whether the addition of intra-operative variables could enhance the accuracy of risk prediction. METHODS: All 5029 patients undergoing open-heart surgery in 2000-2007 were included in the study. Logistic regression with bootstrap methods was used to develop a pre-operative risk prediction model for in-hospital mortality. Next, several intra-operative variables were added to the pre-operative model. Calibration and discrimination were assessed, and the model was internally validated for prediction in future datasets. We thereafter compared the pre-operative model with the additive and logistic EuroSCOREs. RESULTS: Our pre-operative model included eight risk factors that are routinely registered in our department: age, gender, degree of urgency, operation type, previous cardiac surgery, and renal, cardiac, and pulmonary dysfunction. The model estimated mortality accurately throughout the dataset except in the 1% of patients at extremely high risk, in which mortality was somewhat overestimated. The estimated shrinkage factor was 0.930. The areas under the receiver operating characteristic curve for our pre-operative model and the logistic EuroSCORE were 0.857(0.823-0.891) and 0.821(0.785-0.857) (P=0.02). There was no significant difference in performance between the pre-operative and the intra-operative model (P>0.10). CONCLUSION: Our pre-operative model was simple and easy to use, and showed good predictive ability in our population. Internal validation indicated that it would accurately predict mortality in a future dataset.

The advantage of using a synoptic pathology report format for cutaneous melanoma.

AIMS: Although the synoptic format is being increasingly used for primary cutaneous melanoma pathology reporting, no study assessing its value has yet been reported in the literature. The aim was to determine whether the use of synoptic reports increases the frequency with which pathological features that may influence prognosis and guide management are documented. METHODS AND RESULTS: Melanoma pathology reports (n = 1692) were evaluated; 904 were in a synoptic format [671 Sydney Melanoma Unit (SMU) reports and 233 non-SMU reports] and 788 were non-synoptic (184 SMU reports and 604 non-SMU reports). Reports (n = 1354) from 677 patients who had both a SMU report and a non-SMU report were compared. Almost all features were reported more frequently in synoptic than in non-synoptic reports (P < 0.001). No significant differences were found in the frequency of reporting the main pathological features between SMU and non-SMU synoptic reports. Synoptic reports were more frequently used by SMU (78%) than by non-SMU pathologists (28%). CONCLUSIONS: This is the first study to provide objective evidence that synoptic pathology reports for melanoma are more complete than non-synoptic reports (regardless of whether the reports are generated within or outside a specialist melanoma centre). All synoptic reports should include the facility for free text, be tailored to individual institutional requirements and be updated regularly to be of maximal value.