Challenges in economic evaluations in obstetric care: a scoping review and expert opinion.

OBJECTIVE: The aim of this study is to identify items of economic evaluation guidelines that are frequently not complied within obstetric economic evaluations and to search for reasons for non-adherence. DESIGN: Scoping review and qualitative study. SETTING: Literature on economic evaluations in obstetric care and interviews with experts. POPULATION OR SAMPLE: The sample included 229 scientific articles and five experts. METHODS: A systematic literature search was performed. All types of literature about economic evaluations in obstetric care were included. The adherence to guidelines was assessed and articles were qualitatively analysed on additional information about reasons for non-adherence. Issues that arose from the scoping review were discussed with experts. MAIN OUTCOME MEASURES: Adherence to guideline items of the included economic evaluations studies. Analytical themes describing reasons for non-adherence, resulting from qualitative analysis of articles and interviews with experts. RESULTS: A total of 184 economic evaluations and 45 other type of articles were included. Guideline items frequently not complied with were time horizon, type of economic evaluation and effect measure. Reasons for non-adherence had to do with paucity of long-term health data and assessing and combining outcomes for mother and child resulting from obstetric interventions. CONCLUSIONS: This study identified items of guidelines that are frequently not complied with and the reasons behind this. The results are a starting point for a broad consensus building on how to deal with these challenges that can result in special guidance for the conduct of economic evaluations in obstetric care. TWEETABLE ABSTRACT: Non-adherence to guidelines in obstetric economic evaluation studies: the difficulties in detail.

[Experiences and wishes of family members regarding their involvement in dealing with a psychiatric patient's request for termination of life. A checklist for physicians]. / Ervaringen en wensen van familieleden bij het omgaan met een verzoek om levensbeëindiging in de psychiatrie. Een checklist voor behandelaars.

BACKGROUND: In the Netherlands, increasing attention is being paid to psychiatric patients with a request for termination of life. One discussion related to this is the role of the family. However, the experiences and wishes of the family regarding their involvement in dealing with a psychiatric patient's request for termination of life, are not yet well documented.
AIM: To investigate the experiences and wishes of families regarding their role in dealing with the psychiatric patient's request for termination of life, and to develop a checklist for physicians to adequately involve the family in the process of dealing with such a request.
METHOD: The experiences and wishes of families regarding their role in dealing with a psychiatric patient's request for termination of life were investigated in a focus group meeting with family members. Based on the results, recommendations were formulated for physicians and their feasibility was tested in a dialogue group of family members and caregivers. Finally, the results were discussed in a focus group of family members to develop a checklist for physicians to involve the family in dealing with a psychiatric patient's request for termination of life.
RESULTS: Family members prefer that physicians: 1. involve the family in the process and understand the impact of the situation on family members; 2. discuss expectations and explore the wishes of the family; 3. make use of the knowledge and expertise of the family in order to understand the patient in the context of his/her life; 4. support the family and provide after care, and jointly evaluate the process. The recommendations were consolidated in a checklist for physicians about involving the family in dealing with a psychiatric patient's request for termination of life.
CONCLUSION: It is expected that application of the recommendations and the checklist will promote adequate involvement of the family in dealing with a psychiatric patient's request for termination of life.

Postnatal screening and care for non-medical risk factors by preventive child healthcare in deprived and non-deprived neighbourhoods.

BACKGROUND: Children born in families with non-medical risk factors, such as deprivation, have higher odds of preterm birth (< 37 weeks of gestation) or being born small for gestational age (birth weight < 10th percentile). In addition, growing up they are at risk for growth and developmental problems. Preventive Child Healthcare (PCHC) monitors growth and development of babies and children. Early identification of children at risk could result in early interventions to prevent growth and developmental problems in later life. Therefore, we aimed to assess current practices in postnatal risk screening and care for non-medical risk factors and the collaboration with other healthcare professionals, in both deprived and non-deprived neighbourhoods in the Netherlands. METHODS: Eight out of ten invited PCHC organisations, from different areas in the Netherlands, consented to participate in this study. A questionnaire was designed and digitally distributed to professionals working at these organisations, where 370 physicians and nurses were employed. Data was collected between June and September 2016. Descriptive statistics, chi square tests and t-tests were applied. RESULTS: Eighty-nine questionnaires were eligible for analyses. Twenty percent of the respondents were working in a deprived neighbourhood and 70.8% of the respondents were employed as nurse. Most of them performed screening for non-medical risk factors in at least 50% of their consultations. PCHC professionals working in deprived neighbourhoods encountered significantly more often families with non-medical risk factors and experienced significantly more communication problems than their colleagues working in non-deprived neighbourhoods. 48.2% of the respondents were satisfied with the current form of postnatal risk screening in their organisation, whereas 41.2% felt a need for a structured postnatal risk assessment. Intensified collaboration is preferred with district-teams, general practitioners and midwifes, concerning clients with non-medical risk factors. CONCLUSION: This study shows that postnatal screening for non-medical risk factors is part of current PCHC practice, regardless the neighbourhood status they are deployed. PCHC professionals consider screening for non-medical risk factors as their responsibility. Consequently, they felt a need for a structured postnatal risk assessment and for an intensified collaboration with other healthcare professionals.

[Postpyloric feeding tubes for surgical intensive care patients. Pilot series to evaluate two methods for bedside placement]. / Postpylorische Ernährungssonden bei operativen Intensivpatienten. Pilotserie zur Bewertung von zwei Methoden zur bettseitigen Anlage.

Bedside placement of postpyloric feeding tubes in surgical intensive care patients: a pilot series to evaluate two methods. Early enteral feeding is thought to be a key factor in maintaining the integrity of the gastrointestinal tract mucosal barrier associated with less bacterial translocation and decreased stimulation of the systemic inflammatory response and subsequent improved outcome in intensive care patients. Thus enteral feeding by nasogastric tubes is the preferred route of nutritional support for most surgical intensive care patients. However, intensive care patients with delayed gastric emptying and poor intestinal motility may not tolerate gastric feeding and may therefore benefit from postpyloric feeding. Postpyloric feeding tube placement may be achieved by endoscopic procedures or different bedside techniques with variable success. In the present study two feeding tubes for bedside postpyloric placement without endoscopic assistance were compared. The time to successful positioning was compared for jejunal feeding tubes from the companies Cook (Tiger 2™) and PortaMedical (Corflo-Tube®). The description for the Tiger 2™ states that because of its design slight residual peristalsis can cause it to migrate from the stomach to the jejunum. The Corflo-Tube® is also positioned at the bedside with the help of a detector and a monitor which maps the movements of the magnetic tip of the mandrin as it is pushed forward. Patients receiving early enteral nutrition through a gastric tube and exhibiting enhanced reflux, in spite of the head of the bed being raised and the administration of prokinetics randomly received either a Tiger 2™ or a Corflo-Tube®. The study included 41 patients from an intensive care ward for surgical patients and 13 out of 20 Tiger 2™-Tubes (65%) and 16 out of 21 Corflo-Tubes® (76%) were successfully positioned (p>0.05). The median time to successful positioning with the Corflo-Tubes® was 0.83 h (range 0.06-2.5 h), which was significantly shorter than the 24 h (range 2-72 h) found with the Tiger 2™ (p<0.001). There was no significant difference between the groups with respect to the period between the insertion of the tubes and the attainment of complete enteral nutrition, corresponding to the calculated individual calorie requirements. These tubes offer a good alternative to more demanding procedures as they are easy to handle and rapidly available. They confer clinical and cost advantages in terms of the early establishment of enteral feeding, no routine X-ray confirmation in the case of the Corflo-Tube® and avoidance of endoscopic guidance for tube placement or parenteral nutrition. In addition they are always justified in the event of a lack of endoscopic positioning.

[Nasojejunal enteral feeding tubes in critically ill patients. Successful placement without technical assistance]. / Nasojejunale Ernährungssonden bei Intensivpatienten. Erfolgreiche Platzierung ohne technische Hilfsmittel.

BACKGROUND: Critically ill patients with early enteral feeding seem to profit from post-pyloric administration. Two feeding tubes were studied that, due to their construction, are able to move into the duodenum without the necessity of technical support. The duration until successful positioning, time until total enteral feeding and possible complications were compared. PATIENTS AND METHOD: Patients with naso-gastric tubes and early enteral feeding, who had an increased reflux despite head of bed elevation and prokinetic drugs, were randomly assigned to either a Tiger tube (Cook) or a Bengmark tube (Pfrimmer Nutricia). RESULTS: A total of 28 patients from the surgical intensive care ward were included. Of the 16 Tiger tubes 14 could be successfully placed but only 2 out of the 12 Bengmark tubes. With Tiger tubes total enteral feeding was established within 6 days (median), with Bengmark tubes within 4 days. CONCLUSION: In comparison to the Bengmark tube the Tiger tube has a higher success rate in terms of positioning in intensive care patients with impaired abdominal motility.

RANTES, eotaxin and eotaxin-2 expression and production in patients with aspirin triad.

BACKGROUND: Polyposis, asthma, aspirin-intolerance and aspirin-triad are mostly accompanied with eosinophilia of mucosal airways. Chemotactic cytokines, the CC-chemokines regulated on activation, normal T-cell expressed (RANTES), eotaxin, and eotaxin-2 activate and attract eosinophilic leukocytes to the site of inflammation. This points to the implication of CC-chemokines in eosinophilia of nasal tissue of these diseases. METHODS: Therefore, nasal polypous tissue specimens of patients suffering from chronic nasal polypous sinusitis (NP), intrinsic asthma (ATA), aspirin-intolerance (AINA), and aspirin-triad (TRIAD) were investigated. The amount of mRNA and protein of CC-chemokines was analyzed using semi-quantitative reverse transcriptase polymerase chain reaction and chemokine-specific enzyme-immuno-assays. The patterns of CC-chemokines were compared. RESULTS: The mRNA-expression as well as protein synthesis of CC-chemokines was quantified in all tissues investigated. The expression of RANTES-mRNA in NP, ATA, AINA, and TRIAD (averaging 148-324% D-glyceraldehyde-3-phosphate dehydrogenase) and protein synthesis (0.13-0.15 ng/mg tissue weight) did not differ significantly. But the protein synthesis of eotaxin- and eotaxin-2-mRNA was significantly (P < 0.05) higher in TRIAD (3.3 pg/mg and 3.4 ng/mg tissue weight) (4 ng/mg tissue weight), than in NP, ATA, or AINA (1.8 pg/mg and 2.1 ng/mg, 2.1 pg/mg and 1.6 ng/mg, or 1.7 pg/mg and 2.2 ng/mg tissue weight, respectively). CONCLUSION: Patients suffering from TRIAD in association with tissue eosinophilia were characterized by elevated eotaxin and eotaxin-2 mRNA-expression as well as protein-synthesis. This pointed to the implication of eotaxins and RANTES in eosinophilia-associated diseases. Further studies will have to prove, whether the analysis of these chemokines might improve the diagnosis of eosinophilia associated polyposis and initiate the development of new therapeutic strategies.

Expression scanning of an array of growth control genes in human tumor cell lines.

Analysis of gene expression on a medium- or large-scale is an increasingly recognized method for functional and clinical investigations based on the now extensive catalog of known or partially sequenced genes. The accessibility of this approach can be enhanced by using readily available technology (macroarrays on Nylon, radioactive detection) and the IMAGE resource to assemble sets of targets. We have set up such a medium-scale, flexible system and validated it by the study of quantitative expression levels for 120 genes in six cell lines, including three mammary carcinoma cell lines. A number of important parameters are identified as necessary for the assembly of a valid set and the obtention of good-quality quantitative data. The extensive data assembled in this survey identified potential targets of carcinogenesis, for example the CRABP2 and GATA3 transcription factor genes. We also demonstrate the feasibility of this procedure for relatively small tumor samples, without recourse to probe amplification methods.

Time-action profile of zinc human insulin (recombinant DNA) in young volunteers as compared with zinc porcine insulin (Monotard).

Zinc human insulin (recombinant DNA) or zinc PPI (Monotard) 20 U was injected subcutaneously to study the time-action profile in six healthy volunteers. During the test period they received a 10-g biscuit containing 3% moisture, 7% protein, 10% fat, 80% carbohydrate, and 30 ml of water every hour. The onset of action with zinc human insulin occurred earlier than with zinc PPI. Also, the intensity of the blood sugar-lowering effect was more pronounced 3 and 4 h after administration of insulin. No other statistically significant differences were detected between the two blood glucose curves. The results show that it is possible to develop a zinc human insulin formulation with a duration of the blood sugar-lowering effect equal to a zinc PPI formulation.

Two patients with recurrent pneumonias in one lung.

Case histories are described of two young patients, both known to have recurrent infections of one pulmonary lobe. Further investigations (especially aortography) disclosed the cause in both to be an intrapulmonary sequestration. Surgical intervention made both patients symptom-free. The aetiology, clinical and investigational findings as well as therapy are discussed. The need for further investigations in patients with recurring infections of one pulmonary lobe is stressed.

Treatment of insulin-induced lipoatrophy.

Twenty children with insulin-induced lipoatrophy were successfully treated by injecting the insulin into the lipoatrophic area. In 10 children insulin therapy was replaced by monocomponent insulins, while the other 10 children were treated with the insulins they previously used. It is concluded that both monocomponent and less purified insulins are suitable for treating the complication of insulin therapy when the insulin is injected into the lipoatrophic area.