Citizens' perspectives on relocating healthcare.

BACKGROUND: Healthcare systems around the globe are facing challenges. There are increasing demands and costs at the same time as a diminishing health workforce. Without change, healthcare will become unsustainable. The Dutch government is searching for solutions, one of which is relocating healthcare. Relocating healthcare from expensive institutions to sites closer to patients' homes is an important part of this. This relocation is expected to reduce costs and lessen shortages of personnel. However, although citizens have an important stake in this, little is known about how they think about this topic. This research aims at investigating citizens' perspectives on relocating care. METHODS: In December 2021, three open-ended questions were sent to 1,500 members of Nivel's Dutch Healthcare Consumer Panel, 796 respondents responded. In addition, two citizen platforms were organised in March and April 2022. A total of 23 citizens participated. RESULTS: Our results indicated that the following aspects are important for citizens in healthcare delivery: being treated by someone with expertise in the area of their need, familiarity with the healthcare provider and the treatment of less complex care close to home. When certain conditions are met, citizens prefer treatment for less complex care from their general practitioner rather than in a hospital. The most important condition is that the general practitioner has the right expertise regarding their health question. The willingness to relocate care from the general practitioner to other healthcare providers or to self-care is also present. One of the problems, however, is that citizens often do not know to which healthcare provider they should go or what they should do to increase self-care. CONCLUSION: From a citizens' perspective, relocating care is an acceptable solution for keeping healthcare sustainable in the future, provided that certain conditions are met.

General practitioners' perspectives on relocating care: a Dutch interview study.

BACKGROUND: Healthcare systems around the world are facing significant challenges because higher costs and an increase in demand for care has not been matched by a corresponding growth in the health workforce. Without reform, healthcare systems are unsustainable. Relocating care, such as from hospitals to general practices, is expected to make a key contribution to ensuring healthcare remains sustainable. Relocating care has a significant impact upon general practitioners (GPs). Therefore, we investigated which care, according to GPs, could be relocated and under which conditions. METHOD: GPs were recruited through Nivel's GPs network on eHealth and innovation, located in the Netherlands. One exploratory focus group and 12 in-depth interviews were conducted. Interview transcripts were analyzed using the qualitative research principles of thematic analysis. RESULTS: According to the participants, some diagnostic and follow-up care could be relocated from hospitals to GPs once certain prerequisites are fulfilled. An important condition of relocating care from the hospital to the GP is that GPs have sufficient time to take over these tasks. The types of care that can be relocated from the GP to other settings are those questions where the medical knowledge of the GP can offer nothing extra or where problems in navigating the health system cause patients to either turn to, or stay with, their GP. CONCLUSION: Care should first be relocated from the GP to other settings before attempting to organize the relocation of care from the hospital to the GP. When this, and other conditions are met, some diagnostic and follow-up care can be relocated from the hospital to the GP.

Citizens' perspectives on relocating care: a scoping review.

BACKGROUND: Healthcare systems around the world are facing large challenges. There are increasing demands and costs while at the same time a diminishing health workforce. Without reform, healthcare systems are unsustainable. Relocating care, for example, from hospitals to sites closer to patients' homes, is expected to make a key contribution to keeping healthcare sustainable. Given the significant impact of this initiative on citizens, we conducted a scoping review to provide insight into the factors that influence citizens' attitudes towards relocating care. METHOD: A scoping review was conducted. The search was performed in the following databases: Pubmed, Embase, Cinahl, and Scopus. Articles had to include relocating healthcare and citizens' perspectives on this topic and the articles had to be about a European country with a strong primary care system. After applying the inclusion and exclusion criteria, 70 articles remained. RESULTS: Factors positively influencing citizens' attitudes towards relocating care included: convenience, familiarity, accessibility, patients having more control over their disease, and privacy. Factors influencing negative attitudes included: concerns about the quality of care, familiarity, the lack of physical examination, contact with others, convenience, and privacy. Furthermore, in general, most citizens preferred to relocate care in the studies we found, especially from the hospital to care provided at home. CONCLUSION: Several factors influencing the attitude of citizens towards relocating care were found. These factors are very important when determining citizens' preferences for the location of their healthcare. The majority of studies in this review reported that citizens are in favour of relocating care. In general citizens' perspectives on relocating care are very often missing in articles. It was significant that very few studies on relocation from the hospital to the general practitioner were identified.

Long-term cortisol levels in hair of children and adolescents with Prader-Willi Syndrome.

CONTEXT: Prader-Willi syndrome (PWS) is characterized by hypothalamic dysfunction. In children with PWS, stress-induced central adrenal insufficiency (CAI) has been described, however, daily life cortisol production may be normal. Hair cortisol concentration (HCC) is a marker of long-term systemic cortisol production. Cortisol awakening response (CAR) is the increase in cortisol level after awakening. A negative CAR might suggest hypothalamic-pituitary-adrenal (HPA)-axis reactivity problems. Little is known about HCC and CAR in children with PWS. OBJECTIVE: To investigate long-term cortisol levels in hair and CAR in children with PWS. DESIGN: Cross-sectional study. PATIENTS: 41 children with PWS. SETTING: Dutch PWS Reference Center. MAIN OUTCOME MEASURES: HCC and salivary cortisol measured by LCMS. RESULTS: Median (IQR) HCC was 1.90 (1.02-3.30) pg/mg at a median (IQR) age of 14.5 (8.20-19.0) years, with median HCC in age-matched references being 2.63 pg/mg. Five patients (13.2%) had HCC < 2.5th percentile for age and these patients had a repeatedly negative CAR. Median HCC was significantly lower in patients with negative CAR than in patients with normal CAR (1.00 (0.22-1.59) vs. 2.25 (1.47-3.26) pg/mg, p = 0.007). One patient had both HCC < 2.5th percentile and repeatedly low morning salivary cortisol levels and negative CAR, and was diagnosed with adrenal insufficiency by overnight metyrapone test. CONCLUSIONS: HCC were normal in the majority of children with PWS. Our data suggest that children with HCC < 2.5th percentile and (repeatedly) negative CAR might possibly have adrenal insufficiency or delayed HPA-axis responsiveness.

Cognitive functioning in children with Prader-Willi syndrome during 8 years of growth hormone treatment.

OBJECTIVE: Children with Prader-Willi syndrome (PWS) have mild to moderate cognitive impairment. Short-term studies showed positive effects of growth hormone (GH) on cognitive development. This study investigated the effects of 8 years of GH on cognitive development in children with PWS. We also investigated whether starting GH during infancy results in higher cognitive functioning after 8 years of GH. DESIGN: Longitudinal study in 43 children with PWS during 8 years of GH (median age at GH start 8.1 years). Cognitive functioning after 8 years was compared to another group of 22 children with PWS (median age at GH start 1.4 years). METHODS: Cognitive functioning was measured by Wechsler Intelligence Scale for Children. Vocabulary, Similarities and Block Design subtests were expressed as standard deviation scores (SDS) and total IQ (TIQ) calculated. RESULTS: Estimated mean (95%CI) Block Design SDS changed from -2.2 (-2.6; -1.8) at GH start to -1.8 (-2.2; -1.4) after 8 years of GH (P = 0.18), similarly SDS from -1.5 (-2.1; -0.9) to -1.3 (-1.9; -0.7, P = 0.66) and TIQ from 66 (60; 72) to 69 (63; 75, P = 0.57). Vocabulary SDS remained similar, being -1.9 (-2.3; -1.4) at GH start and -1.9 (-2.4; -1.5) after 8 years (P = 0.85). After 8 years of GH Vocabulary, SDS and TIQ were higher in the children who started GH during infancy, compared to those who started GH later in childhood (P < 0.01, P = 0.04, respectively). CONCLUSIONS: Cognitive functioning in children with PWS remains similar during long-term GH and develops at the same pace as healthy peers.

Apparent Life-Threatening Event following Maternal Use of Temazepam during Labour.

Benzodiazepines are one of the most frequently prescribed psychotropic drugs during pregnancy. Despite the fact that these drugs have been in use for a long time, there is still debate about the safety for the developing fetus and neonate. We present a case of a newborn with an apparent life-threatening event shortly after birth following maternal temazepam use during labour and advise to be reserved in prescribing any dose of any kind of benzodiazepine during labour.

Oportunidades perdidas para la prevención de enfermedad cardiovascular en consultorio externo de Clínica Médica del Hospital de Clínicas / Lost opportunities in the prevention of cardiovascular diseases in external doctor's office department of General Medicine of the Hospital de Clínicas

En nuestro país la enfermedad cardiovascular es la primera causa de morbi-mortalidad. Engeneral los centros de atención primaria fallan en diagnosticar los factores de riesgocardiovascular, los cuales se constituyen como oportunidades perdidas. Este estudioretrospectivo descriptivo de corte transverso se realizó para cuantificar los parámetros noconsignados en la historia clínica de los pacientes mayores de 14 años de edad que acudieron aprimera consulta en la 3ra Cátedra de Clínica Médica del Hospital de Clínicas, de marzo de 2005a febrero de 2006. De los 900 pacientes estudiados 64,6% fueron mujeres, con una edad mediade 44±19 años. Los médicos que llenaron las fichas clínicas fueron instructores (25%),residentes de 2º y 3º año (35,2 y 39,8%, respectivamente). Las oportunidades perdidas fuerondel 5% para los antecedentes patológicos personales, 5,4% para la HTA, 10,6% para el hábitode fumar, 13,4% para el consumo de alcohol y 61% para la medición del IMC. Lasoportunidades perdidas en los factores de riesgo cardiovascular variaron entre 5% y 61% lo queconcuerda con otros estudios. Deberíamos enfatizar en dar a conocer los factores de riesgocardiovascular a los pacientes y en la necesidad de una política nacional de prevención deenfermedades cardiovasculares en nuestro país

Prophylactic treatment of migraine in children. Part 2. A systematic review of pharmacological trials.

The aim of this study was to assess the efficacy of pharmacological prophylactic treatments of migraine in children. Databases were searched from inception to June 2004 and references were checked. We selected controlled trials on the effects of pharmacological prophylactic treatments in children with migraine. We assessed trial quality using the Delphi list and extracted data. Analyses were carried out according to type of intervention. A total of 20 trials were included. Headache improvement was significantly higher for flunarizine compared with placebo (relative risk 4.00, 95% confidence interval 1.60, 9.97). There is conflicting evidence for the use of propranolol. Nimodipine, clonidine, L-5HTP, trazodone and papaverine showed no effect when compared with placebo. All medications were well tolerated and adverse events showed no significant differences. Flunarizine may be effective as prophylactic treatment for migraine in children. Because of the small number of studies and the methodological shortcomings, conclusions regarding effectiveness have to be drawn with caution.

Prophylactic treatment of migraine in children. Part 1. A systematic review of non-pharmacological trials.

The aim of this study was to assess the efficacy of non-pharmacological prophylactic treatments of migraine in children. Databases were searched from inception to June 2004 and references were checked. We selected controlled trials reporting the effects of non-pharmacological prophylactic treatments in children with migraine. We assessed trial quality using the Delphi list and extracted data. Analyses were carried out according to type of intervention. A total of 19 trials were included. Relaxation, relaxation + biofeedback, relaxation + biofeedback + cognitive behavioural treatment were more effective compared with waiting list controls. Relaxation + behavioural therapy was more effective than placebo. There is conflicting evidence for the use of oligoantigenic diets. A few non-pharmacological treatments such as relaxation may be effective as prophylactic treatment for migraine in children. Because of the small number of studies and the methodological shortcomings, conclusions on effectiveness have to be drawn with caution.

Pelvic pain during pregnancy is associated with asymmetric laxity of the sacroiliac joints.

OBJECTIVE: The aim of this study was to investigate the association between pregnancy-related pelvic pain (PRPP) and sacroiliac joint (SIJ) laxity. METHODS: A cross-sectional analysis was performed in a group of 163 women, 73 with moderate or severe (PRPP+) and 90 with no or mild (PRPP-) PRPP at 36 weeks of pregnancy. SIJ laxity was measured by means of Doppler imaging of vibrations in threshold units (TU). Pain, clinical signs and disability were assessed with visual analog scale (VAS), posterior pelvic pain provocation (PPPP) test, active straight leg raise (ASLR) test, and Quebec back pain disability scale (QBPDS), respectively. RESULTS: Mean SIJ laxity in the PRPP+ group was not significantly different from the PRPP- group (3.0 versus 3.4 TU). The mean left-right difference, however, was significantly higher in the PRPP+ group (2.2 TU) than in the PRPP- group (0.9 TU). In the PRPP- group, only 4% had asymmetric laxity of the SIJs in contrast to 37% of the PRPP+ group. Between the PRPP+ subjects with asymmetric and symmetric laxity of the SIJs significant differences were found with respect to mean VAS for pain (7.9 versus 7.0), positive PPPP test (59% versus 35%), positive ASLR test (85 versus 41%) and mean QBPDS score (61 versus 50). CONCLUSIONS: Increased SIJ laxity is not associated with PRPP. In fact, pregnant women with moderate or severe pelvic pain have the same laxity in the SIJs as pregnant women with no or mild pain. However, a clear relation between asymmetric laxity of the SIJs and PRPP is found.

Quantification of first tarsometatarsal joint stiffness in hallux valgus patients.

OBJECTIVE: Comparison of the clinical mobility test of the first tarsometatarsal joint with Doppler Imaging of Vibrations measurement of the stiffness of this joint in hallux valgus patients. DESIGN: Clinical testing of first tarsometatarsal joint mobility was related to independent Doppler Imaging of Vibrations measurement of first tarsometatarsal joint stiffness. BACKGROUND: Hypermobility of the first tarsometatarsal joint has consequences for the surgical treatment of hallux valgus deformity. However, the clinical test is subjective. Doppler Imaging of Vibrations could be helpful in quantification of the stiffness of this joint. METHODS: Clinical examination of the mobility of 32 first tarsometatarsal joints in 20 hallux valgus patients was compared with Doppler Imaging of Vibrations stiffness measurements performed by an independent observer. RESULTS: There was a statistically significant relation between the clinical test and the stiffness measurement by Doppler Imaging of Vibrations. CONCLUSION: Doppler Imaging of Vibrations proves to be a method to quantify first tarsometatarsal joint stiffness and could contribute to a rational policy for the surgical treatment of hallux valgus deformity. RELEVANCE: The clinical test to establish hypermobility of the first tarsometatarsal joint is subjective. Doppler Imaging of Vibrations offers objective criteria and quantification of first tarsometatarsal joint stiffness. This provides additional information for the choice of the surgical procedure to correct hallux valgus deformity.

Analysis and decomposition of signals obtained by thigh-fixed uni-axial accelerometry during normal walking.

The use of piezo-resistive uni-axial accelerometer signals in gait analysis is complicated by the fact that the measured signal is composed of different types of acceleration. The aim of the study is to obtain insight into the signal from a tangential accelerometer attached to the thigh during walking. Six subjects walk with three different speeds. Simultaneous measurements are performed with accelerometers, footswitches and an opto-electronic system. The components of the accelerometer signal are calculated from the opto-electronic system. A clear relationship is found between the measured and calculated accelerometer signals (range RMS: 0.76-3.69 m x s(-2), range rms: 0.22-0.61). The most pronounced feature is a high positive acceleration peak (> 10 m x s(-2)) at the end of the cycle. The gravitational acceleration during one cycle is characterised by a sinusoidal shape, whereas the inertial acceleration contains higher-frequency components (up to 20 Hz). During the major part of the gait cycle, the gravitational and inertial acceleration make opposing contributions to the signal As a result, the gravitational acceleration influences the amplitudes of the measured acceleration signal, the shape and peaks of which are mainly determined by the inertial acceleration. Because the gravitational and inertial accelerations differ in frequency components, the application for gait analysis remains feasible.

[Sildenafil (Viagra) for the treatment of erectile disorder]. / Sildenafil (Viagra) voor de behandeling van erectiestoornissen.

Erectile dysfunction is a common but underreported condition. It is to be expected that the number of patients consulting their physician with the complaint of erectile dysfunction will increase considerably with the introduction of sildenafil (Viagra), the first oral drug that enhances penile erection. Sildenafil is an inhibitor of the enzyme phosphodiesterase type 5. It causes erection of the penis by allowing the relaxation of the smooth musculature of the cavernous body to persist. The first clinical results indicate that the treatment with sildenafil is safe and effective in the hands of a sexologically qualified physician. An erection disorder is essentially not more than a symptom which primarily requires causal therapy.

Narrowing of the Hailey-Hailey disease gene region on chromosome 3q and identification of one kindred with a deletion in this region.

Hailey-Hailey disease is a cutaneous abnormality transmitted as an autosomal dominant trait in which impaired interkeratinocyte adhesion produces recurrent blisters in characteristic skin sites. We report here a confirmation of the initial mapping of the mutant gene to chromosome 3q in an additional seven kindreds, narrowing of the candidate region to the sequences flanked by D3S1589 and D3S1541, and the finding in one family of a genomic DNA deletion whose centromeric end is located between these two flanking markers.