Active follow-up of patients identified with multidrug-resistant Gram-negative bacteria to discontinue contact precautions and isolation measures.

BACKGROUND: It is essential to refrain from unnecessary isolation measures indicated for patients identified with multidrug-resistant Gram-negative bacteria (MDR-GNB). AIM: To evaluate whether a pro-active follow-up strategy to discontinue isolation measures of patients identified with MDR-GNB (without carbapenemase production) resulted in reduced isolation days during hospitalization, compared to passive follow-up. METHODS: A comparison was made between active and passive follow-up strategies over a two-year period after first MDR-GNB identification. Patients could be declared negative after two consecutive negative screening cultures. Active follow-up patients received a questionnaire for screening cultures within six months of MDR-GNB identification. Of the 2208 patients included, 1424 patients (64.5%) underwent passive follow-up and 784 patients (35.5%) underwent active follow-up. FINDINGS: A significantly higher proportion of active follow-up patients who had sufficient (at least two) screening cultures were declared MDR-GNB negative compared to those with passive follow-up; 66.9% vs 20.6% (P < 0.001) for adult patients and 76.0% vs 17.1% (P < 0.001) for paediatric patients. A comparison between active follow-up patients with sufficient versus those with active follow-up but insufficient cultures revealed a reduction of isolation days for paediatric patients (median 10.6 vs 1.6 days; P = 0.031). Though this difference was not statistically significant for adults (median 5.3 vs 4.2 isolation days), there was a valuable decrease in the number of isolation days for both adult and paediatric patients under active follow-up with sufficient (≥2) cultures, indicating clinical relevance. CONCLUSION: We recommend an active follow-up strategy for patients identified with an MDR-GNB, to prevent further unneeded infection prevention measures.

Investigating young children's physical activity through time and place.

BACKGROUND: Previous research indicates the start of primary school (4-5-year-old) as an essential period for the development of children's physical activity (PA) patterns, as from this point, the age-related decline of PA is most often observed. During this period, young children are exposed to a wider variety of environmental- and social contexts and therefore their PA is influenced by more diverse factors. However, in order to understand children's daily PA patterns and identify relevant opportunities for PA promotion, it is important to further unravel in which (social) contexts throughout the day, PA of young children takes place. METHODS: We included a cross-national sample of 21 primary schools from the Startvaardig study. In total, 248 children provided valid accelerometer and global positioning (GPS) data. Geospatial analyses were conducted to quantify PA in (social) environments based on their school and home. Transport-related PA was evaluated using GPS speed-algorithms. PA was analysed at different environments, time-periods and for week- and weekend days separately. RESULTS: Children accumulated an average of 60 min of moderate-to-vigorous PA (MVPA), both during week- and weekend days. Schools contributed to approximately half of daily MVPA during weekdays. During weekends, environments within 100 m from home were important, as well as locations outside the home-school neighbourhood. Pedestrian trips contributed to almost half of the daily MVPA. CONCLUSIONS: We identified several social contexts relevant for children's daily MVPA. Schools have the potential to significantly contribute to young children's PA patterns and are therefore encouraged to systematically evaluate and implement parts of the school-system that stimulate PA and potentially also learning processes. Pedestrian trips also have substantial contribution to daily MVPA of young children, which highlights the importance of daily active transport in school- and parental routines.

[A focus on patients with the highest healthcare costs]. / Aandacht voor patiënten met de hoogste zorgkosten.

Wammes et al. (2017) showed that many of the patients who are among the 1% with the highest healthcare costs are being treated for multiple conditions. This suggests that high healthcare costs are at least partly due to treatment for multiple conditions, each of which by itself may not be excessively costly. It is the accumulation of costs for multiple conditions that cause patients to become high-cost patients, and this has implications for cost-control policies. It may be more worthwhile to focus on improving efficiency in the treatment of conditions that occur frequently but have low or medium costs than on conditions with high costs but that occur infrequently.

Utilization of health care services by migrants in Europe-a systematic literature review.

Introduction: Our study reviewed the empirical evidence on the utilization of health care services by migrants in Europe, and on differences in health service utilization between migrants and non-migrants across European countries. Sources of data: A systematic literature review was performed, searching the databases Medline, Cinahl and Embase and covering the period from January 2009 to April 2016. The final number of articles included was 39. Areas of agreement: Utilization of accident and emergency services and hospitalizations were higher among migrants compared with non-migrants in most countries for which evidence was available. In contrast, screening and outpatient visits for specialized care were generally used less often by migrants. Areas of controversy: Utilization of general practitioner services among migrants compared with non-migrants presents a diverging picture. Growing points: Compared with previous systematic reviews, the results indicate a clearer picture of the differences in health service utilization between migrants and non-migrants in Europe. Areas timely for developing research: A comprehensive comparison across European countries is impossible because the number of studies is still limited. Further research should also help to identify barriers regarding the utilization of health care services by migrants.

The use of social services by community-dwelling older persons who are at risk of institutionalization: a survey.

The use of community-based social services additionally to regular home help services to support older persons at risk of institutionalization was studied. Structured interviews were held with 292 persons, who specifically pointed out that they prefer to remain independently at home. Bivariate and multivariate logistic regression models were developed to study the association between social service use and personal, health-related and wellbeing characteristics. 195 respondents indicated that they made use of at least one social service (68%). Only three services (individual care, social-cultural activities and restaurant facilities), out of nine, were used regularly. Those who lived in a sheltered environment or were supported by informal caregivers or who visited day care had a significantly higher probability of using these services. More attention should be given to the nature and accessibility of community-based social services in order to have distinctive added value in enabling older persons to age in place.

Arsenic speciation in food and estimation of the dietary intake of inorganic arsenic in a rural village of West Bengal, India.

Arsenic (As) species were quantified by HPLC-HG-AFS in water and vegetables from a rural area of West Bengal (India). Inorganic species predominated in vegetables (including rice) and drinking water; in fact, inorganic arsenic (i-As) represented more than 80% of the total arsenic (t-As) content. To evaluate i-As intake in an arsenic affected rural village, a food survey was carried out on 129 people (69 men and 60 women). The data from the survey showed that the basic diet, of this rural population, was mainly rice and vegetables, representing more than 50% of their total daily food intake. During the periods when nonvegetarian foods (fish and meat) were scarce, the importance of rice increased, and rice alone represented more than 70% of the total daily food intake. The food analysis and the food questionnaires administrated led us to establish a daily intake of i-As of about 170 microg i-As day (-1), which was above the tolerable daily intake of 150 microg i-As day (-1), generally admitted. Our results clearly demonstrated that food is a very important source of i-As and that this source should never be forgotten in populations depending heavily on vegetables (mainly rice) for their diet.

The use of community-based social services by elderly people at risk of institutionalization: an evaluation.

OBJECTIVE: To examine the use of community-based social services by elderly people at risk of institutionalization, who prefer to remain at home. METHODS: A study with a longitudinal design (measurements at two points in time) was conducted. RESULTS: One hundred and thirty-four elderly people (mean age=82 years) were interviewed twice. At baseline, 81 respondents indicated that they made use of at least one social service (60.4%). After 1 year the use of these services did not increase significantly (64.2%, p=0.53). Only two services (socio-cultural activities and restaurant facility) out of five services were used frequently. The respondents reported more autonomy and fewer feelings of loneliness after 1 year. These positive changes cannot be related to an increased use of services. DISCUSSION: Overall, the use of social services remained moderate. This raises questions about the need for these services, the possible barriers and the ability of these social services to contribute to de-institutionalization.

Do free-of-charge public health services impede cost recovery policies in Khartoum state, Sudan?

We carried out a household survey in Khartoum state in 2001 to analyse the characteristics of those who receive free public health services and to ascertain whether there are any impediments to cost recovery policies for health care use. Data were collected through interviews based on an adapted questionnaire. Those who had other income, always or sometimes had dependents and visited the health services twice in the previous 3 months were more likely to receive free public health services. This does not support claims that beneficiaries of these services are the well-off.

Do free-of-charge public health services impede cost recovery policies in Khartoum state, Sudan?

We carried out a household survey in Khartoum state in 2001 to analyse the characteristics of those who receive free public health services and to ascertain whether there are any impediments to cost recovery policies for health care use. Data were collected through interviews based on an adapted questionnaire. Those who had other income, always or sometimes had dependents and visited the health services twice in the previous 3 months were more likely to receive free public health services. This does not support claims that beneficiaries of these services are the well-off

Demand of elderly people for residential care: an exploratory study.

BACKGROUND: Because of the rapid aging population, the demand for residential care exceeds availability. This paper presents the results of a study that focuses on the demand of elderly people for residential care and determinants (elderly people's personal characteristics, needs and resources) that are associated with this demand. Furthermore, the accuracy of the waiting list as a reflection of this demand has been examined. METHODS: 67 elderly people waiting for admission into a home for the elderly, are subjected to semi-structured interviews. The data are analyzed by using multivariate statistics. RESULTS: Elderly people who indicate that they would refuse an offer of admission into a home for the elderly feel healthier (p = 0.02), have greater self-care agency (p = 0.02) and perceive less necessity of admission (p < 0.01), compared to those who would accept such an offer. Especially the inability to manage everyday activities and the lack of a social network are highly associated with the elderly people's demand for residential care. Furthermore, it is evident that waiting lists for homes for the elderly do not accurately reflect the demand for residential care, since 35% of the elderly people on a waiting list did not actually experience an immediate demand for residential care and stated that they would not accept an offer of admission. Quite a lot of respondents just registered out of a sense of precaution; a strategic decision dictated by current shortages in care provision and a vulnerable health status. CONCLUSION: The results contribute to the understanding of waiting lists and the demand for residential care. It became apparent that not everybody who asks for admission into a home for the elderly, really needed it. The importance of elderly people's resources like social networks and the ability to manage everyday activities in relation to the demand for care became clear. These findings are important because they indicate that resources also play a role in predicting elderly people's demand and as a result can guide the development and the (re)design of adequate health care services.

Systematic review of economic evaluations of smoking cessation: standardizing the cost-effectiveness.

OBJECTIVES: This study was performed to render cost-effectiveness studies on smoking cessation therapies, utilized until now, more comparable and more useful for medical decision making. METHODS: The cost-effectiveness ratios reported by the studies were recalculated using a societal perspective and guidelines for economic evaluation. RESULTS: The costs of individual interventions generally increased as a result of the standardization procedure, whereas the effect size decreased. This resulted in increases in the cost-effectiveness ratios for individual studies ranging from 120% to 5600%. CONCLUSIONS: The variation between studies in the percentage increase in cost-effectiveness ratios is huge. This means that not following guidelines when calculating cost-effectiveness ratios can result in large errors. Despite the fact that the standardized cost-effectiveness ratios of smoking interventions were higher than the unstandardized cost-effectiveness ratios, interventions aimed at reducing the prevalence of smoking are cost-effective.

Cost effectiveness of foldable multifocal intraocular lenses compared to foldable monofocal intraocular lenses for cataract surgery.

AIM: To analyse the cost effectiveness of foldable monofocal intraocular lenses (IOLs) compared to foldable multifocal IOLs in cataract surgery alongside a prospective, multicentre randomised clinical trial (RCT). METHODS: Patients underwent cataract surgery with bilateral monofocal (n = 97) or multifocal (n = 93) IOL implantation. Cost data and patient preferences, using the visual analogue scale (VAS), the time trade-off (TTO), and the standard gamble (SG) technique were obtained preoperatively and postoperatively by structured interviews. The incremental costs (multifocal minus monofocal), mean costs per patient, and differences in preferences were computed. RESULTS: Mean costs for glasses per patient in the monofocal group were 41.67 and in the multifocal group 149.58. The difference in costs between the multifocal and monofocal group was -92.09 and was statistically significant (p = 0.008). No significant differences were found in total costs or in effectiveness between the monofocal and multifocal IOL group. CONCLUSION: The cost effectiveness of multifocal IOLs is reduced to a cost minimisation analysis, because of the inability to demonstrate significant differences in effects. The use of multifocal IOLs in cataract surgery resulted in a significant reduction in costs for patient's postoperative spectacles.

Life-long course and molecular characterization of the original Dutch family with epidermolysis bullosa simplex with muscular dystrophy due to a homozygous novel plectin point mutation.

Plectin is one of the largest and most versatile cytolinker proteins known. Cloned and sequenced in 1991, it was later shown to have nonsense mutations in recessive epidermolysis bullosa with muscular dystrophy. A dominant mutation in the gene was found to cause epidermolysis bullosa simplex Ogna without muscular dystrophy. Here we report the DNA sequencing of the plectin gene (PLEC1) in a Dutch family originally described in 1972 as having epidermolysis bullosa with muscular dystrophy. The results revealed homozygosity for a new plectin nonsense mutation at position 13187 and its specific 8q24 marker haplotype profile. Western blotting of cultured fibroblasts and immunofluorescence microscopy of skin biopsy confirm that the plectin protein expression is grossly reduced or absent. A summary of the life-long clinical course of the two affected brothers homozygous for the new E1914X mutation is given.

Effect of structure and form on the ability of plant sterols to inhibit cholesterol absorption in hamsters.

We investigated the effect of three types of plant sterols (4-desmethylsterols, 4,4'-dimethylsterols, and pentacyclic triterpene alcohols) in three forms (free, esterified with FA, or with phenolic acids) on cholesterol absorption. Plant sterol fractions derived from soybean (99% 4-desmethylsterols), rice bran (70% 4,4'-dimethylsterols), or shea nut (89% pentacyclic triterpene alcohols) were fed to male hamsters (n = 20/group) as free sterols or esterified with FA or phenolic acids (cinnamic or ferulic). Cholesterol absorption was measured after 5-8.5 (mean, 7) wk by a dual-isotope technique. Soybean sterol intake significantly reduced cholesterol absorption efficiency (23%) and plasma total cholesterol (11%). Rice bran sterols tended to lower cholesterol absorption efficiency by 7% and plasma total cholesterol by 5%, whereas shea nut sterols had no effect. In hamsters, dietary 4-desmethylsterols were more effective than 4,4'-dimethylsterols in lowering cholesterol absorption and levels of cholesterol in blood. Pentacyclic triterpene alcohols had no effect on the absorption of cholesterol or on its level in blood. Esterification with FA did not impair the ability of 4-desmethylsterols and 4,4'-dimethylsterols to inhibit cholesterol absorption, whereas esterification with phenolic acids reduced this ability. This study supports the use of 4-desmethylsterols, esterified with FA to increase solubility, as the most effective cholesterol-lowering plant sterols in the diet.

Effect of esterified 4-desmethylsterols and -stanols or 4,4'-dimethylsterols on cholesterol and bile acid metabolism in hamsters.

4-Desmethylsterols and -stanols reduce plasma total cholesterol (TC) and LDL cholesterol by inhibition of intestinal cholesterol absorption, while the cholesterol-lowering potential of 4,4'-dimethylsterols is less well defined. The present study aimed to compare the effects of 4-desmethylsterols, -stanols, and 4,4'-dimethylsterols on plasma and hepatic cholesterol, sterol excretion and bile acid metabolism. Male golden Syrian hamsters were fed diets containing 13 g/100 g fat, 008 g/100 g cholesterol and 0 (control), 0.24 or 0.48% (w/w) esterified 4-desmethylsterols (sterols) and esterified hydrogenated 4-desmethylsterols (stanols) from common vegetable oils or esterified 4,4'-dimethylsterols from rice bran oil for 5 weeks. Sterol and stanol esters at the dose of 0.24% were equally effective and significantly (P<0.05) lowered TC by 15%, while 0.24% 4,4-dimethylsterols reduced TC by 10%. Liver total and esterified cholesterol concentrations were significantly (P<0.05) lowered by 40, 22, 43 and 31% in hamsters fed 0.48% sterols, 0.24% stanols, 0.48% stanols or 0.48% dimethylsterols, respectively. Daily faecal bile acid excretion and hepatic cholesterol 7alpha-hydroxylase activity were not altered, indicating that sterols, stanols and dimethylsterols had no effect on the intestinal re-absorption of bile acids or on hepatic bile acid synthesis. Daily excretion of cholesterol was significantly higher in hamsters fed esterified sterols and stanols, but was only slightly increased in those fed dimethylsterols. The results indicate that esterified sterols and stanols were equally effective in lowering plasma TC and LDL cholesterol, while dimethylsterol esters caused a weaker cholesterol-lowering effect. Sterols and stanols achieve their cholesterol-lowering effect by stimulating faecal cholesterol excretion through inhibiting intestinal cholesterol absorption, but do not affect bile acid excretion. Other mechanisms need to be considered to explain the effect on plasma and hepatic cholesterol of dimethylsterols.

Adaptation and scale of reference bias in self-assessments of quality of life.

Adaptation behaviour and different scales of reference can bias self-assessments of well-being by individuals. In this paper, we analyse the impact of these biases on a subjective measure of the quality of health and on the QALY weights derived from this health measure. It is found that the scale of reference of the subjective health measure changes with age. Accounting for adaptation and scale of reference bias lowers most of the QALY weights for health problems and disabilities.

Appraising the financial reform in Bulgarian public health care sector: the Health Insurance Act of 1998.

The public health care services in Bulgaria were deteriorating, especially during the decade of transitional process. The method of health care finance was a major reason for the poor performance of the Bulgarian public health care sector. Bulgarian policy-makers decided that an insurance-based financial mechanism could help to rescue the failing public health care services. This paper explores the social benefits and the feasibility of the insurance-based finance in the Bulgarian public health care sector. The discussion in the paper implies that, in the current conditions of economic recession, the insurance-based health care finance can not be socially beneficial for Bulgaria. Moreover, the insurance implementation seams to be unfeasible due to a lack of sufficient financial resources.

[Little difference in quality of life of dialysis patients in Utrecht and Willemstad]. / Kwaliteit van leven van dialysepatiënten in Utrecht en Willemstad weinig verschillend.

OBJECTIVE: To assess and compare the quality of life of patients treated with haemodialysis and chronic ambulatory peritoneal dialysis (CAPD) in Utrecht and Willemstad, Curaçao. DESIGN: Transverse multicentre study. METHODS: All haemodialysis and CAPD patients in Utrecht and all haemodialysis patients in Curaçao under treatment for over 6 months were studied. The objective tests applied were the 'Nottingham health profile', the 'affect balance scale', the 'index of well-being' and the 'Amsterdam complaint profile'. Possible correlations between individual patient-related and treatment-related factors and biochemical variables were also investigated. RESULTS: The objective and subjective tests revealed only slight differences in quality of life in the three groups. In a few respects, the CAPD patients rated the quality of life slightly better. In the Utrecht group a positive relationship was seen between haematocrit (higher owing to treatment with erythropoietin) and plasma bicarbonate concentration, and the quality of life.

The timing of maternity in the Netherlands.

"In this paper the timing of maternity is estimated by a hazard model. The novel aspect of this paper is that it is shown that wages and total household labor income have a significant effect on the timing of maternity. Both the wage rate of the woman and the wage rate of the husband have a negative effect on the timing of maternity. Total household labor income increases the probability of having a child at an earlier age.... Women working in the labor market delay the timing of maternity compared to non-participating women. Attending school has the same effect. Until the age of 28 the maternity hazard increases with age, after that it decreases." Data are from a longitudinal survey of 4,020 men and women in the Netherlands who were interviewed during the period 1980-1985.