Safe implementation of robotic right colectomy with intracorporeal anastomosis.

The robotic platform can overcome technical difficulties associated with laparoscopic colon surgery. Transitioning from laparoscopic right colectomy with extracorporeal anastomosis (ECA) to robotic right colectomy with intracorporeal anastomosis (ICA) is associated with a learning phase. This study aimed at determining the length of this learning phase and its associated morbidity. We retrospectively analyzed all laparoscopic right colectomies with ECA (n = 38) and robotic right colectomies with ICA (n = 67) for (pre)malignant lesions performed by a single surgeon between January 2014 and December 2020. CUSUM-plot analysis of total procedure time was used for learning curve determination of robotic colectomies. Non-parametric tests were used for statistical analysis. Compared to laparoscopy, the learning phase robotic right colectomies (n = 35) had longer procedure times (p < 0.001) but no differences in anastomotic leakage rate, length of stay or 30-day morbidity. Conversion rate was reduced from 16 to 3 percent in the robotic group. This study provides evidence that robotic right colectomy with ICA can be safely implemented without increasing morbidity.

Technology implementation in care practices for community-dwelling older adults with mild cognitive decline: Perspectives of professional caregivers in Quebec and Brussels.

Objective: As worldwide population aging is accelerating, innovative technologies are being developed to support independent living among community-dwelling older adults with mild cognitive decline. However, the successful implementation of these interventions is often challenging. Until now, literature on implementation issues related to the specific context of older adults with mild cognitive decline is lacking and the few studies available do not focus specifically on the perspective of professional caregivers. Yet the perspective of these caregivers is important as they can be considered a key facilitator for technology implementation among this population. Therefore, this study was the first to examine technology implementation among community-dwelling older adults with mild cognitive decline from the broader perspective of professional caregivers. Methods: In this qualitative study, two focus groups consisting of a heterogeneous pool of professional caregivers were conducted: one in Quebec (Canada, n = 6) and one in Brussels (Belgium, n = 8). Braun and Clarke' method for thematic analysis, guided by a qualitative descriptive approach was applied to inductively identify themes from the data. Results: We identified factors influencing technology implementation in older adults with mild cognitive decline on three levels: an individual level (e.g., characteristics of older adults with mild cognitive decline and professional caregivers' attitude), an organizational level (e.g., lack of training among professional caregivers) and a level referring to the broader context (e.g., ethical considerations). Conclusions: This study contributes to the research gap in knowledge on the needs of professional caregivers to facilitate technology implementation among the population of older adults with cognitive decline. Future directions for research, practice, and policy are given, more specifically to improve knowledge among caregivers and on the development of decision support to retrieve safe and effective technologies that suit patient-centered care.

Discrepancies between ePrescriptions and dispensing in Belgium, 6 years after the launch of the electronic prescribing - a mixed-method study.

OBJECTIVES: The number of electronic prescriptions (ePrescriptions) grows steadily in Belgium as in other European countries. In the future, Belgium wants to dematerialize the ePrescription flow, removing all paper trails. A quality check of the digital content and implementation of national ePrescription guidelines in the field was conducted, comparing the content at both prescription and pharmacy side. METHODS: An explanatory mixed-methods design was applied. In a first phase, potential problems (warning flags) were identified by consulting stakeholders. Secondly, the warning flags were validated to problems (errors) in a random set of ePrescriptions collected in April 2019. In a third phase, explanatory interviews were held with various stakeholders in order to find explanations and to identify the initiators of these errors. RESULTS: In the first phase, 15 warning flags were identified to evaluate the quality of an ePrescription. In the second phase, a random selection of 11,798 ePrescriptions was validated. The most prevalent errors found, were the digital construction of the messages (18.88%), combined with lots of necessarily deemed substitutions by the pharmacist (3.39%) not following what was prescribed originally. In the third phase, stakeholders indicated that software of the prescriber and the use of inconsistent databases between prescriber and pharmacy can often be seen as the cause and initiator of these problems. CONCLUSIONS: Use of authentic medication databases and well-designed software systems have the potential to solve ePrescription problems. Focus should go to prevention instead of detection.

How is your proctology patient really doing? Outcome measurement in proctology: development, design and validation study of the Proctoprom.

BACKGROUND: The aim of the present study was to develop and evaluate the reliability and validity of proctology patient-reported outcome measurements (PROM): Proctoprom. METHODS: Development of the Proctoprom was based on interview rounds with experts (n = 4) and patients (n = 19) in open informal interview rounds regarding content and form. Once consensus was achieved on five items, data were collected between July 2014 and August 2016 from 991 patients recruited consecutively in a specialized proctology center. Reliability, construct validity and responsiveness of the PROM were determined through exploratory factor analysis, test-retest analysis and anchor-based hypothesis testing. We also estimated discriminant validity, standard error of measurement (SEM), minimal detectable change (MDC95%) and minimal clinically important difference (MCID). RESULTS: The five items loaded on one factor that reflected good internal consistency (Cronbach's α 0.81). Test-retest analysis showed good reliability with intraclass correlation of 0.81. Construct validity measurement resulted in AUCs of 0.85 and 0.90. Responsiveness measurement resulted in AUCs of > 0.76 for both hypotheses. SEM was estimated at 3.0 points and MDC at 4.8 points. We estimated an MCID of 10 points. CONCLUSIONS: Proctoprom is a valid and reliable tool that is responsive to change and that meets consensus-based standards for the selection of health measurement instruments. It can be used to evaluate disease burden and effect of treatment in all adult proctology patients regardless of their proctologic diagnosis.

Obstetric and neonatal outcome of ART in patients with polycystic ovary syndrome: IVM of oocytes versus controlled ovarian stimulation.

STUDY QUESTION: Does IVM of immature oocytes retrieved from small antral follicles in women with polycystic ovary syndrome (PCOS) have an impact on obstetric and neonatal outcomes compared to controlled ovarian stimulation (COS)? SUMMARY ANSWER: Obstetric and neonatal outcomes after IVM appear to be similar to those after COS. WHAT IS KNOW ALREADY: Women with PCOS have an increased risk of adverse pregnancy outcomes and congenital malformations in their offspring. For patients with PCOS who require IVF, IVM of germinal vesicle (GV)-stage oocytes retrieved from antral follicles has been adopted as a mild approach ART, with improved pregnancy rates over the last two decades. Although reports of obstetrical and neonatal outcomes after IVM have been reassuring, the limited sample sizes in previous studies preclude firm conclusions, and further study is warranted. STUDY DESIGN, SIZE, DURATION: This is a retrospective observational study analysing obstetric and neonatal data from 1036 clinical pregnancies in unique patients with PCOS who conceived following a cycle of IVM or COS between January 2010 and December 2016 in a tertiary reproductive centre. In total, 393 singleton pregnancies with a gestational age beyond 20 weeks were included. A phenotypic approach was used for the diagnosis of PCOS. Pregnancies following oocyte donation, standard IVF (as opposed to ICSI) or preimplantation genetic testing and pregnancies requiring testicular biopsy in the male partners were excluded. PARTICIPANTS/MATERIALS,SETTING, METHODS: Pregnancy outcomes were analysed in women with PCOS phenotype A, C or D, as defined by different combinations of the Rotterdam criteria. Data from 164 pregnancies beyond 20 weeks after IVM were compared with those from 229 pregnancies after COS. Pregnancies in the IVM group were obtained after minimal ovarian stimulation and IVF with ICSI of transvaginally collected GV oocytes that had reached the metaphase II stage in vitro after 28 to 40 h of culture. No hCG trigger was administered before oocyte retrieval. Outcome measures were analysed or reported in singleton pregnancies only and included adverse obstetric events and neonatal health parameters, in particular birthweight, prematurity, small-for-gestational age, large-for-gestational age, perinatal death and major/minor malformation rates. The incidence of hypertensive disorders of pregnancy (HDP) and birthweight was analysed by multiple linear and logistic regression, adjusted for relevant treatment variables and maternal characteristics. MAIN RESULTS AND THE ROLE OF CHANCE: The IVM and the COS groups differed significantly (P < 0.001) for maternal circulating AMH levels and PCOS phenotype distribution, with more of the PCOS phenotype A in the IVM group. Pregnant women in the IVM group were younger than pregnant women in the COS group (P = 0.05). With regard to obstetric complications in singleton pregnancies, in the unadjusted analysis, mothers of infants in the IVM group more often had HDP (29/164 (17.9%) vs 22/229 (9.6%), P = 0.02) compared with mothers in the COS group. Singletons born after IVM and COS had a similar birthweight standard deviation score (SDS) (0.51 ± 0.94 after IVM vs 0.33 ± 1.05 after COS, P = 0.19). Preterm birth rate (32-36.9 weeks) and early preterm birth rate (<32 weeks) were also similar in both groups. The total malformation rate was 4.1% in singletons after IVM and 2.4% in singletons after COS. Multivariate linear regression analysis accounting for relevant confounders demonstrated that parity was the only independent predictive factor (P = 0.04) for birthweight SDS. Multivariate logistic regression analysis showed that BMI, parity and type of ART (IVM as opposed to COS) were significantly correlated with the incidence of HDP. Only patients with the PCOS phenotype A showed a tendency towards a higher risk of HDP in those who underwent IVM compared to those who had COS. LIMITATIONS, REASONS FOR CAUTION: The study is limited by its retrospective nature and loss to follow-up of a subset of children with no information regarding congenital malformations. Furthermore, the paediatricians who assessed the children after birth were not blinded for the type of ART procedure. WIDER IMPLICATIONS OF THE FINDINGS: This study provides further evidence that, compared to COS, IVM of oocytes derived from small antral follicles does not adversely affect the neonatal health of the offspring of patients with PCOS. The observed increased risk of HDP in patients with PCOS phenotype A following IVM treatment warrants further scrutiny. STUDY FUNDING/COMPETING INTEREST(S): Translational IVM research at Universitair Ziekenhuis Brussel (UZ Brussel) and Vrije Universiteit Brussel (VUB) has been supported by grants from the Institute for the Promotion of Innovation by Science and Technology in Flanders (Agentschap voor Innovatie door Wetenschap en Technologie-IWT, project 110680), the Fund for Research Flanders (Fonds Wetenschappelijk Onderzoek-Vlaanderen-FWO, project G.0343.13) and the Belgian Foundation Against Cancer (HOPE project, Dossier C69). Clinical IVM research was supported by research grants from Cook Medical and Besins Healthcare. M.D.V. reports honoraria for lectures from Cook Medical and Besins Healthcare outside the submitted work. S.S.R. reports honoraria for lectures by MSD and Besins and research grants by MSD, Ferring and Merck Serono outside of the submitted work. C.B. reports personal fees from Merck-Serono, Ferring, IBSA, Finox, MSD and Abbott outside the submitted work. H.T. reports grants from Merck, MSD, Goodlife, Cook, Roche, Besins, Ferring, Mithra (now Allergan) and the Research Fund of Flanders (FWO) and consultancy fees from Finox, Abbott, Obseva and Ovascience outside the submitted work. The other authors have nothing to disclose.

Risk determinants for the development of typical haemolytic uremic syndrome in Belgium and proposition of a new virulence typing algorithm for Shiga toxin-producing Escherichia coli.

In Belgium, it is mandatory to report Shiga toxin-producing Escherichia coli (STEC) infections to the health inspection authorities. To facilitate the decision making regarding infection control measures, information about the risk factors for the development of the haemolytic uremic syndrome (HUS) can be helpful. We performed statistical analyses on a dataset of 411 Belgian STEC strains. Demographic and clinical patient characteristics as well as phenotypical and genotypical STEC strain characteristics were taken into account. Multivariate logistic regression models indicated that age categories ⩽5, 6-12 and ⩾75; the stx2 gene; and the eae gene were significant HUS development risk determinants. The stx2a subtype had the highest risk (OR 29.6, 95% CI 7.0-125.1), while all stx1 subtypes encompassed a significant lower risk (OR 0.3, 95% CI 0.1-0.5). Presence of the stx1 gene without stx2 encompassed a lower risk than the combined presence of stx1 and stx2, or stx2 solely. Based on these results, we propose a new virulence typing algorithm that will enable the National Reference Centre to provide the physicians and health inspection authorities with a risk classification for the development of HUS. We believe this will contribute to a more efficient STEC infection control management in Belgium.

Three-dimensional kinematics of the cervical spine using an electromagnetic tracking device. Differences between healthy subjects and subjects with non-specific neck pain and the effect of age.

BACKGROUND: A cross-sectional observational study of three-dimensional cervical kinematics in 35 non-specific neck pain patients and 100 asymptomatic controls. To compare qualitative and quantitative aspects of cervical kinematics between healthy subjects and subjects with non-specific neck pain and to determine the effect of age on cervical kinematics in healthy subjects. METHODS: Three-dimensional kinematics of active lateral bending and flexion-extension of 35 patients and 100 controls were registered by means of an electromagnetic tracking system. The means of several kinematic parameters were compared using t-tests. In addition, we assessed the age-dependency of the three-dimensional kinematic parameters by stratifying the 100 control subjects in 6 age categories. FINDINGS: Comparison of the patient group with the control group reveals no statistically significant differences in qualitative and quantitative parameters. Analysis of the effect of age showed that the range of motion decreases significantly (p < 0.01) with increasing age. In lateral bending, the ratio between axial rotation and lateral bending increases significantly (p < 0.01) among older subjects. Differences in acceleration, jerk and polynomial fit are seen between the age categories, but are not significant. INTERPRETATION: This study demonstrates no significant differences in kinematic parameters between healthy subjects and subjects with non-specific neck pain. Healthy subjects in higher age categories demonstrate higher ratios of coupled movements and lower ranges of motion. Future research should focus on classifying patients with non-specific neck pain in order to gain a better insight on possible subgroup specific differences in kinematics. More studies on this subject are warranted. LEVEL OF EVIDENCE: 4.

Effectiveness of airway clearance techniques in children hospitalized with acute bronchiolitis.

OBJECTIVE: To evaluate the effectiveness of two airway clearance techniques (ACT's) in children <24 months hospitalized with mild to moderate bronchiolitis. DESIGN: One hundred and three children were randomly allocated to receive one 20-min session daily, either assisted autogenic drainage (AAD), intrapulmonary percussive ventilation (IPV), or bouncing (B) (control group), ninety-three finished the study. OUTCOME MEASURES: Mean time to recovery in days was our primary outcome measure. The impact of the treatment and the daily improvement was also assessed by a validated clinical and respiratory severity score (WANG score), heart rate (HR), and oxygen saturation (SaO2 ). RESULTS: Mean time to recovery was 4.5 ± 1.9 days for the control group, 3.6 ± 1.4 days, P < 0.05 for the AAD group and 3.5 ± 1.3 days, P = 0.03 for the IPV group. Wang scores improved significantly for both physiotherapy techniques compared to the control group. CONCLUSION: Both ACT's reduced significantly the length of hospital stay compared to no physiotherapy. Pediatr Pulmonol. 2017;52:225-231. © 2016 Wiley Periodicals, Inc.

Influence of intrapulmonary percussive ventilation in upright position on gastro-oesophageal reflux in infants.

OBJECTIVES: To determine the influence of physiotherapy using intrapulmonary percussive ventilation on gastro-oesophageal reflux (GOR) in infants <1 year. METHODS: In this controlled trial with intra-subject design, children were studied using multichannel intraluminal impedance pH (pH-MII) monitoring over 24 hr, during which they received one 20-min session of intrapulmonary percussive ventilation in upright position (IPVR ), 2 hr after their latest feeding. Two hours after each feeding, the number of reflux episodes (RE) over a 20-min period was registered for each infant and a mean per 20 min was calculated in order to obtain a baseline value. The number of RE during IPVR intervention was compared to baseline. RESULTS: Fifty infants with a median age of 133 days were recruited of whom 21 were diagnosed with pathological GOR. During IPVR , the incidence of RE in the entire group was significantly lower compared to baseline; median (inter-quartile range [IQR]) 0 (0-1) versus 0.71 (0-1.33) RE, respectively, P = 0.003. The subgroup with abnormal GOR showed also a significant decrease of RE during IPVR ; median (IQR) 0 (0-1) versus 1.17 (0.55-2.16) RE, respectively, P = 0.03. No difference was detected in the group with normal reflux; median (IQR) 0.6 (0-1) compared to 0 (0-1) RE, respectively, P = 0.34. CONCLUSION: IPVR does not induce, nor aggravate GOR in infants without and with pathological GOR, respectively, but on the contrary decreases the number of RE in patients with pathological reflux. Pediatr Pulmonol. 2016;51:1065-1071. © 2016 Wiley Periodicals, Inc.

A semi-blinded study comparing 2 methods of measuring nasal potential difference: Subcutaneous needle versus dermal abrasion.

BACKGROUND: According to European and US protocols, two nasal potential difference (NPD) measurement methods are considered acceptable, although they have not been formally compared: subcutaneous agar-filled needle with calomel (Ndl) and dermal abrasion with conducting cream and Ag/AgCl electrodes (Abr). We compared both in CF and healthy volunteers (HV), assessing their discriminative value and subject's preference. METHODS: Twelve classic CF and 17 HV underwent both NPD methods, performed by one operator in random order. A written questionnaire, assessing preference, was completed after each test. Tracings were coded, scored in a semi-blinded fashion and categorised as CF/non-CF. RESULTS: 110 tracings (56 Ndl/54 Abr) were collected: 42/110 scored CF and 68/110 non-CF, showing a good correlation. No significant preference for either method was reported. CONCLUSION: Both NPD methods are similar in terms of discriminative value and subject's preference, comparing classical CF and HV. For diagnosing CF, the operator's preferred NPD-method may be used.

Predictors of late initiation for prenatal care in a metropolitan region in Belgium. A cohort study.

OBJECTIVES: Timely initiation of prenatal care (PNC) in the first pregnancy trimester allows prevention, identification and treatment of risk factors. However, not all women initiate PNC timely, especially women in a deprived situation. The aim of this study was to measure the prevalence of late initiation, defined as initiation after 14 weeks of gestational age. Secondly the authors wanted to identify predictors for late PNC onset. STUDY DESIGN: Observational cohort study. METHODS: Pregnant women (n = 1750) were recruited in all four hospitals in Ghent (Belgium), a metropolitan region. A socio-economic deprivation ranking was measured by using a General Deprivation Index (GDI), which consists of six criteria to assess a socio-economic situation as deprived. A univariate analysis and a forward conditional multivariate logistic regression model were used analysing the association between deprivation and the likelihood to initiate PNC late. RESULTS: 1115 women were included of whom 6.1% (n = 68) initiated PNC late. A foreign maternal country of birth (OR 2.10; 95% CI 1.15-3.83) and a total GDI ≥3 (OR 4.40; 95% CI 2.36-8.21) were good predictors for late initiation. More specifically, the GDI criteria education (OR 4.02; 95% CI 2.00-8.08) and unemployment (OR 2.40; 95% CI 1.17-4.90) were significantly associated with higher likelihood for late initiation. CONCLUSIONS: A small group of women initiates PNC late. Vulnerable groups, at risk for late initiation can be identified through assessing their deprivation status. Priority for additional support should be given to women with low educational attainment or women in uncertain employment situations.

The attitude of Flemish paediatricians regarding informed consent of adolescents.

BACKGROUND: Since 2002 the Belgian law requires an informed consent of the patient before each medical intervention. This provision applies also for adolescent patients on condition that the physician considers the young patient as competent to autonomously participate in the decision making process. AIM: The purpose of this study is to evaluate to what extent Belgian paediatricians from the Flemish part of the country have implemented the legal requirements for informed consent of adolescent patients, in particular when they consult alone. METHODS: In the frame of a larger study regarding the relation between paediatricians and their patients, a questionnaire was sent via regular mail to 570 Flemish paediatricians, evaluating how and how often they obtain an informed consent of the adolescent when consulting a physician unaccompanied. RESULTS: In only 1% of all consultations an adolescent consulted the physician alone and agreed to a medical intervention on his/her own. The information given by the paediatrician did not differ if the adolescent consulted alone or was accompanied by (one of) his/her parents for the following items: purpose and type of treatment (100% vs 100%), duration of treatment (92% vs 94%) and aftercare (89% vs 93%). However, the information differed with regard to alternatives to the treatment (65% vs 76%), degree of urgency (89% vs 95% ), treatment related risks (82% vs 90%) and cost (21% vs 45%). 18.6% of the paediatricians consider age as the single criterion to evaluate the competence of the adolescent to provide an informed consent; other criteria that are considered: experience (92%), insight into and factual understanding of the clinical picture (84%). To fulfil the tasks of providing information and asking for consent, paediatricians rarely had recourse to prior established protocols (14%), they preferred to rely on proper experience and expertise (81%). Fifty percent appealed to the opinion of other health care providers. CONCLUSIONS: Although the Belgian law stipulates regulations that should be complied with by the physician during the decision making process about any medical intervention on adolescents, this legislation has rarely been put into practice, as the adolescents used their right to autonomously consent in barely 1% of all paediatric consultations. For the majority of the respondents other criteria than age were taken into account to consider an adolescent as able to provide informed consent.

Comparative study between mobile infrared optoelectronic volumetry with a Perometer and two commonly used methods for the evaluation of arm volume in patients with breast cancer related lymphedema of the arm.

There is no consensus on the definition of Breast Cancer Related Lymphedema of the arm (BCRL) because there are no agreed standards in measurement methods and diagnostic criteria. The main objective of this study is to compare mobile infrared optoelectronic volumetry with a Perometer with two commonly used methods for the evaluation of arm volume in patients with different degrees of BCRL. Bilateral arm volumes of eighty participants, with and without clinical BCRL, were calculated with a mobile Perometer, by water displacement, and with circumferential measurements, integrated in the frustrum, single frustrum, and disc model method. The ICC of the Perometer was between 0.997 and 0.999. The frustrum and disc model method produced the largest volume measurements and water displacement the smallest, while Perometer measures were in between. On average, volume of the dominant arm was found to be 2.2% higher than the non-dominant arm in the healthy control group, cautioning for intra- patient differences between both arms when comparing ipsilateral to contralateral arm for the diagnosis of BCRL with a threshold value. Future research would likely benefit from the use of the Perometer compared to the other arm volume evaluation tools for BCRL, and further, the single frustrum method should not be used for volume estimations of edematous arms.

MedSkills: a learning environment for evidence-based medical skills.

OBJECTIVES: EBP (evidence-based practice) is becoming the standard paradigm in modern healthcare. Therefore different healthcare providers have the need for easily accessible evidence-based information. The Internet creates new opportunities to fill the gaps in education that are experienced by healthcare workers. Contributing to solutions and filling in the needs in the above-mentioned scope, the University of Brussels initiated a European project called MedSkills in 2004. METHODS: MedSkills' main goal was to create a copyright-free reference work containing valuable evidence-based information on medical skills for all levels of healthcare professionals (paramedics, nurses and physicians, teachers of medical skills and students). RESULTS: We succeeded in designing and creating a framework to suit the requirements of different users, in 'cellular', 'organ', 'body' and 'best treatment' content maps. A wiki tool was installed to allow the project to be built and in order to maintain itself. CONCLUSIONS: This multi-professional and international initiative, unique in its kind aims at contributing to a gold standard for European healthcare, via the creation of a freely available, consistent and updatable evidence-based teaching environment.