Treatment Variation of Sequential versus Concurrent Chemoradiotherapy in Stage III Non-Small Cell Lung Cancer Patients in the Netherlands and Belgium.

AIMS: Concurrent chemoradiotherapy (CCRT) is considered the standard treatment regimen in non-surgical locally advanced non-small cell lung cancer (NSCLC) patients and sequential chemoradiotherapy (SCRT) is recommended in patients who are unfit to receive CCRT or when the treatment volume is considered too large. In this study, we investigated the proportion of CCRT/SCRT in the Netherlands and Belgium. Furthermore, patient and disease characteristics associated with SCRT were assessed. MATERIALS AND METHODS: An observational study was carried out with data from three independent national registries: the Belgian Cancer Registry (BCR), the Netherlands Cancer Registry (NCR) and the Dutch Lung Cancer Audit-Radiotherapy (DLCA-R). Differences in patient and disease characteristics between CCRT and SCRT were tested with unpaired t-tests (for continuous variables) and with chi-square tests (for categorical variables). A prognostic model was constructed to determine patient and disease parameters predictive for the choice of SCRT. RESULTS: This study included 350 patients from the BCR, 780 patients from the NCR and 428 patients from the DLCA-R. More than half of the stage III NSCLC patients in the Netherlands (55%) and in Belgium more than a third (35%) were treated with CCRT. In both the Dutch and Belgian population, higher age and more advanced N-stage were significantly associated with SCRT. Performance score, pulmonary function, comorbidities and tumour volume were not associated with SCRT. CONCLUSION: In this observational population-based study, a large treatment variation in non-surgical stage III NSCLC patients was observed between and within the Netherlands and Belgium. Higher age and N-stage were significantly associated with the choice for SCRT.

The Dutch surgical colorectal audit.

INTRODUCTION: In 2009, the nationwide Dutch Surgical Colorectal Audit (DSCA) was initiated by the Association of Surgeons of the Netherlands (ASN) to monitor, evaluate and improve colorectal cancer care. The DSCA is currently widely used as a blueprint for the initiation of other audits, coordinated by the Dutch Institute for Clinical Auditing (DICA). This article illustrates key elements of the DSCA and results of three years of auditing. METHODS: Key elements include: a leading role of the professional association with integration of the audit in the national quality assurance policy; web-based registration by medical specialists; weekly updated online feedback to participants; annual external data verification with other data sources; improvement projects. RESULTS: In two years, all Dutch hospitals participated in the audit. Case-ascertainment was 92% in 2010 and 95% in 2011. External data verification by comparison with the Netherlands Cancer Registry (NCR) showed high concordance of data items. Within three years, guideline compliance for diagnostics, preoperative multidisciplinary meetings and standardised reporting increased; complication-, re-intervention and postoperative mortality rates decreased significantly. DISCUSSION: The success of the DSCA is the result of effective surgical collaboration. The leading role of the ASN in conducting the audit resulted in full participation of all colorectal surgeons in the Netherlands. By integrating the audit into the ASNs' quality assurance policy, it could be used to set national quality standards. Future challenges include reduction of administrative burden; expansion to a multidisciplinary registration; and addition of financial information and patient reported outcomes to the audit data.

Failure-to-rescue after colorectal cancer surgery and the association with three structural hospital factors.

BACKGROUND: This study was designed to evaluate the association between structural hospital characteristics and failure-to-rescue (FTR) after colorectal cancer surgery. A growing body of evidence suggests a large hospital variation concerning mortality rates in patients with a severe complication (FTR) in colorectal cancer surgery. Which structural hospital factors are associated with better FTR rates remains largely unclear. METHODS: All patients undergoing colorectal cancer surgery from 2009 through 2011 in 92 Dutch hospitals were analysed. Univariate and multivariate logistic regression models, including casemix, hospital volume, teaching status, and different levels of intensive care unit (ICU) facilities, were used to analyse risk-adjusted FTR rates. RESULTS: A total of 25,591 patients from 92 hospitals were included. The FTR rate ranged between 0 and 39 %. In univariate analysis, high hospital volume (>200 vs. ≤200 patients/year), teaching status (academic vs. teaching vs. nonteaching hospitals) and high level of ICU facilities (highest level 3 vs. lowest level 1) were associated with lower FTR rates. Only the higher levels of ICU facilities (2 or 3 compared with level 1) were independently associated with lower failure-to-rescue rates (odds ratio 0.72; 95 % confidence interval 0.65-0.88) in multivariate analysis. DISCUSSION: Hospital type and annual hospital volume were not independently associated with FTR rates in colorectal cancer surgery. Instead, the lowest level of ICU facilities was independently associated with higher rates. This suggests that a more advanced ICU may be an important factor that contributes to better failure-to-rescue rates, although individual hospitals perform well with lower ICU levels.

Anastomotic leakage as an outcome measure for quality of colorectal cancer surgery.

INTRODUCTION: When comparing mortality rates between hospitals to explore hospital performance, there is an important role for adjustment for differences in case-mix. Identifying outcome measures that are less influenced by differences in case-mix may be valuable. The main goal of this study was to explore whether hospital differences in anastomotic leakage (AL) and postoperative mortality are due to differences in case-mix or to differences in treatment factors. METHODS: Data of the Dutch Surgical Colorectal Audit were used. Case-mix factors and treatment-related factors were identified from the literature and their association with AL and mortality were analysed with logistic regression. Hospital differences in observed AL and mortality rates, and adjusted rates based on the logistic regression models were shown. The reduction in hospital variance after adjustment was analysed with Levene's test for equality of variances. RESULTS: 17 of 22 case-mix factors and 4 of 11 treatment factors related to AL derived from the literature were available in the database. Variation in observed AL rates between hospitals was large with a maximum rate of 17%. This variation could not be attributed to differences in case-mix but more to differences in treatment factors. Hospital variation in observed mortality rates was significantly reduced after adjustment for differences in case-mix. CONCLUSIONS: Hospital variation in AL is relatively independent of differences in case-mix. In contrast to 'postoperative mortality' the observed AL rates of hospitals evaluated in our study were only slightly affected after adjustment for case-mix factors. Therefore, AL rates may be suitable as an outcome indicator for measurement of surgical quality of care.

Perforating veins: an anatomical approach to arteriovenous fistula performance in the forearm.

OBJECTIVES: Arteriovenous fistulae (AVFs) play a key role for people who rely on chronic haemodialysis. Stenosis in the venous outflow of the AVF will cause an alternative route of the subcutaneous blood flow via the deeper venous pathways by means of side branches and the perforating veins (PVs). The purpose for the present study was to define the number and anatomical localisation of the perforating veins in the forearm. METHODS: Twenty forearms were dissected to study the venous anatomy. The localisation, size and connections of the perforators were recorded and stored digitally. RESULTS: In total, 189 PVs were defined (mean, 9.5 per arm; range, 6-19), with 60 (32%) PVs connected to the cephalic vein, 97 (51%) connections to the basilic vein and 32 (17%) PVs to the median vein of the forearm. Most PVs originate from the basilic vein and connect with the ulnar venae comitans. The cephalic vein connects equally to the radial venae comitans, interossea veins and the muscles. CONCLUSION: The cephalic vein has the fewest PVs and almost a third of them connect to the muscles. This is probably important for the maturation of the AVF, the superficial flow volume and the accessibility for puncture.

[Prediction of dental behavior problems in preschool children]. / Voorspellende factoren voor onbehandelbaar gedrag bij peuters tijdens een tandheelkundige behandeling.

Aim of this study was to investigate behavioural and emotional problems in preschool children in relation with behaviour problems during a highly stress provoking dental treatment. Eighty one healthy children between 2 and 4 years referred to the clinic of Special Dental Care (SBT) in Amsterdam were selected, based on dental need (extraction of one or more primary incisors). Each child was sedated with oral midazolam. Their behaviour was rated by registering the degree of acceptance during four consecutive time periods of the dental treatment. Prior to the treatment parents were asked to fill in a questionnaire. No significant correlations between temperament and behaviour were found with the total CBCL profile or its subscales. This confirms the results of earlier studies that the relationship of temperament, dental anxiety and behaviour problems is a complex matter and not yet fully understood. It is also indicated that within the entire treatment a child's behaviour is closely related to its behaviour in the preceded treatment step.

Childhood dental fear in relation to parental child-rearing attitudes.

The aim of this study was to assess the relation between parental self-reported child-rearing attitudes and dental fear in children. The parents of 51 children with high dental fear and of 56 children with low dental fear, of different age groups, completed the Amsterdam version of the Parental Attitude Research Instrument. In addition, parents were asked to rate their own dental fear. Multivariate analysis of variance (child fear x parental fear x child age) showed a significant main effect only of child dental fear on parental self-complaints (p = .03). For parental dental fear, main effects were found on overprotection and on promotion of autonomy (p < or = .01). No age effects were found. Also, no relation between children's dental fear and parental dental fear was found. Based on the present findings, it was concluded that parents may play a more secondary, mediating role in the etiological process of dental fear in children.

The etiology of childhood dental fear: the role of dental and conditioning experiences.

This study was aimed to examine the relative importance of invasive treatment experiences in the acquisition of dental fear in children. For this purpose, the complete dental history of 401 children (5-10 years) was studied. The level of dental fear in these children was assessed using the Dental Subscale of the Children's Fear Survey Schedule (CFSS-DS). Differences in treatment variables between fearful and low fearful children were analyzed, and regression analysis was performed to determine significant predictors of dental fear. A significant but weak relation with the number of extractions was found, while no relation with the number of fillings was found. The results have indicated that within the (direct) conditioning pathway, objective dental experiences seem to play a minor role in children's fear acquisition, and it was suggested that subjective dental experiences may play a more decisive role. In addition, clinical support for the latent inhibition theory was provided.

On the structure of childhood dental fear, using the Dental Subscale of the Children's Fear Survey Schedule.

AIM: The aim of the present study was to assess the structure of childhood dental fear, using the Dutch parent's version of the Dental Subscale of the Children's Fear Survey Schedule (CFSS-DS) and to report on its validity. MATERIALS AND METHODS: Factor analysis (principal components, varimax rotation) was performed using the scores of a group of high fearful children (n=322). Results were compared with those from a previous study among low fearful children, also using the parent's version of the CFSS-DS. In addition, mean item scores between the samples were compared to examine specific differences. RESULTS: Factor analysis resulted in a stronger factor pattern than that found in previous research. Four factors accounting for 60% of the variance were found: 1) fear of general, less invasive aspects of dental treatment; 2) fear of medical aspects; 3) fear of drilling; 4) fear of strangers. CONCLUSION: It was concluded that with increasing fear levels, underlying factors of dental fear can be distinguished more clearly. The CFSS-DS was indicated to be a reliable and valid measure of dental fear.

[Dental fear in children: dental experiences during childhood]. / Angst bij kinderen. Tandheelkundige ervaringen in de kindertijd.

This study aimed to examine the relative importance of invasive treatment experiences in the acquisition of dental fear in children. For this purpose, the complete dental history of 401 children (5-10 years) from 2 dental practices was studied. The level of dental fear in these children was assessed using the Dental Subscale of the Children's Fear Survey Schedule (CFSS-DS). Differences in treatment variables between high fearful and low fearful children were analysed, and regression analysis was performed to determine significant predictors of dental fear. A significant though weak relation of dental fear with the number of experienced extractions was found, while no relation with the number of experienced fillings was found. The results indicate that within the (direct) conditioning pathway, objective dental procedures seem to play a minor role in children's fear acquisition. Clinical support for the 'latent inhibition' theory was provided: a history of neutral or positive dental visits seems to serve as a defence against the development of dental fear in children.

Parental beliefs on the origins of child dental fear in The Netherlands.

The aim of this study was to assess parental beliefs on the causes and prevention of child dental fear in the Netherlands. The parents of 123 children (67 high fearful and 56 low fearful children) were interviewed about the causes of their children's dental fears, and about factors contributing to the prevention of this fear. Parents attributed their child's dental fear to the following factors: invasive dental experiences (37 percent), medical problems (19 percent), child's temperament (16 percent), negative dentist behavior (13 percent) and social influences (5 percent). In the prevention of child dental fear, an empathetic dentist (34 percent) and parental guidance (30 percent) were mentioned most frequently. In conclusion, conditioning factors were reported to be highly important in the development of child dental fear. Some of the parents, however, indicated temperamental factors to have played a role, suggesting that subgroups of dentally fearful children exist. These temperamental or psychological factors seem also to contribute substantially to the development of dental fear. Possible differences in parental attributional style are discussed.

Behavioural and emotional problems in children referred to a centre for special dental care.

This study was conducted among 203 children (103 boys) referred to a centre for special dental care because of a high level of dental fear. It was undertaken to explore to what extent behavioural and emotional problems co-exist in these children compared with children of a Dutch norm group. The children's parents filled out the parental version of the Child Behaviour Checklist (CBCL), before their first appointment at the centre. The behavioural and emotional problems of the children were assessed by this CBCL, and the mean scores of the children in the study were compared with the mean scores of the norm group. The mean scores on all scales, except on the subscale 'sex problems', of the children with a high level of dental fear proved to be significantly higher than the mean scores of the norm group (P< or =0.001). The results indicated that children referred to a special dental care centre not only suffer from high dental fear but also have problems in several other behavioural and emotional areas. These problems appear to be heterogeneous; they were found in several specific problem areas, both external and internal.

Dentists' behavior in response to child dental fear.

Dental fear is a multifactorial problem frequently encountered during dental treatment of children. Studies have indicated that, among others, the behavior of the dentist may play a part in the development of this dental fear. The present study was undertaken to examine the behavioral aspects of the dentist-patient relationship, and specific dentists' behavior that can reduce dental fear. The behavior of forty children referred to a center for special dental care and of two dentists was assessed during treatment. T-test results showed that the children's level of fear decreased after treatment (mean 3.2 vs. 2.1, t = -5.6, p = .000). In addition, it was found that the dentists behaved more directly and authoritatively during the treatment of highly fearful children than during the treatment of relatively less fearful children (p < or = .034). It seems that this direct approach had a positive, long-term effect on these children's fearful behavior during treatment.

The Dental Subscale of the Children's Fear Survey Schedule: a factor analytic study in The Netherlands.

The Dental Subscale of the Children's Fear Survey Schedule (CFSS-DS) is a well-known instrument for assessing dental fear in children. Previous studies have shown that the scale has acceptable reliability and validity. Factor analysis using scores of a group of Finnish schoolchildren resulted in three factors. No other data on the factor structure have been published. In order to report on the factor structure of the Dutch parental version of the CFSS-DS, the present study was undertaken. Factor analysis using scores from a group of Dutch children (n= 150) demonstrated a factor pattern fairly similar to the results found in the Finnish study. Three factors were found: 1) fear of highly invasive dental procedures, 2) fear of less invasive aspects of treatment and 3) fear of medical aspects. Considering that almost all items load substantially (> or =0.20) on more than one factor, it seems that one primary underlying dimension exists: fear of invasive treatment aspects. The CFSS-DS is proposed as a reliable, one-dimensional measure of dental fear.

Correlates of disablement in polyarticular juvenile chronic arthritis--a cross-sectional study.

To assess the impact of disease on the functional outcome of patients with polyarticular juvenile chronic arthritis (JCA), the relationship between impairments and functional limitations was studied. Therefore, variables from the impairment domain were correlated with variables of the functional limitation domain and outcome variables were analysed for differences as a result of inflammatory disease, rheumatoid factor (RF), disease duration and age at onset. Twenty-three patients with polyarticular JCA were subjected to auxologic evaluation, a laboratory check, radiographic evaluation, joint count on tenderness and swelling, joint mobility/deformity examination, functional assessment of skills, health assessment and psychosocial evaluation. Inflammatory disease parameters, like CRP, ESR, thrombocytosis and leucocytosis, were increased in 6/23 patients. The parameters of the impairment domain, like joint tenderness and swelling, showed mild outcome, while parameters of the functional limitation domain showed more severe outcome. Generally, perceived competence was found to be normal. A clinically relevant number of patients (10/13) showed low scores on the activity factor of the Child Behaviour Check List (CBCL). A significant relationship was found between inflammatory disease variables and functional limitation outcome. RF seropositivity was not a good outcome predictor. Disease duration and age of onset showed no significant difference in the outcome of the domains. Significant correlation was found between the parental report of the Childhood Health Assessment Questionnaire (CHAQ) and all impairment parameters. Joint swelling showed a significant relationship with CHAQ and Juvenile Arthritis Functional Assessment Report (JAFAR). Disability outcome did not correlate with functional limitation. In general, children with polyarticular JCA function rather well when using a multidomain evaluation approach. Compensatory and adaptational mechanisms might contribute to the poor correlation between impairment and functional limitation parameters. Laboratory evaluation of inflammatory disease, a joint count of swollen joints and parent's report of the child's health status related best in our study.

Substance P and ciliary beat of human upper respiratory cilia in vitro.

On stimulation of trigeminal nerve endings, neuropeptides are released into the nasal mucosa. Among these neuropeptides is substance P(SP). In this study, we determined the effect in vitro of SP, as well as SP together with thiorphan, a blocker of the SP-degrading enzyme neutral endopeptidase, on the ciliary beat frequency (CBF) of the human upper respiratory tract. Ciliated epithelium of human adenoid tissue was used in the experiments. The CBF was measured by means of a computer-assisted photoelectric method. Substance P(10(-8) to 10(-5) mol/L, n = 7) showed a small but statistically significant dose-dependent decrease in CBF. On perfusion with SP (10(-8)) to 10(-5) mol/L, n = 8) in combination with thiorphan, no statistically significant effect was found. We conclude that SP does not have a direct effect on ciliary activity to such an extent that it will affect mucociliary transport in vivo.

Effects of prostaglandins D2 and E2 on ciliary beat frequency of human upper respiratory cilia in vitro.

Diminished mucociliary transport can occur in a type-I (Ig-E mediated) allergic reaction. We determined the effects of the allergy mediators prostaglandin D2 (PGD2) and prostaglandin E2 (PGE2) on the ciliary beat frequency (CBF) of human upper respiratory cilia in vitro. Human adenoid tissue was used as the source for ciliated epithelium. CBF was measured by a computerized photo-electric method. PGD2 (10(-8)-10(-5) M, n = 7) showed no statistically significant effect on CBF. PGE2 (10(-9)-10(-6) M, n = 10) caused a significant dose-dependent stimulation, with a maximum of 37% (ANOVA, p < 0.001). Thus prostaglandins D2 and E2 do not exert a direct negative influence on ciliary activity, which could account for a decrease in mucociliary transport. The stimulating effect of PGE2 may be relevant in promoting mucociliary clearance in vivo.

Histamine and leukotriene C4 effects on in vitro ciliary beat frequency of human upper respiratory cilia.

Decreased mucociliary transport can occur in patients with type I (IgE-mediated) allergic rhinitis or allergic asthma. This study investigated if the allergic mediators histamine and leukotriene C4 (LTC4) could interfere with ciliary beat frequency (CBF) of in vitro human upper respiratory cilia and eventually result in decreased mucociliary transport. Ciliated epithelium of human adenoid tissue was used in the experiments and CBF was determined using a computer-assisted photoelectric method. Histamine in concentrations of 10(-6) - 10(-3) M (n = 12) and LTC4 as 10(-9) - 10(-6) M solutions (n = 10) showed no statistically significant dose-dependent effect on CBF in vitro.

Platelet freezing for serological purposes with and without a cryopreservative.

We compared the reactivity of fresh platelets with platelets frozen in dimethylsulfoxide (DMSO) or without a cryopreservative by testing agglutinating and non-agglutinating platelet-specific alloantibodies in titration. Frozen platelets, irrespective of the method of preservation, showed no loss of antigenicity as compared with fresh platelets. The yield of platelets frozen without a cryopreservative proved to be higher (80%) than platelets frozen in the presence of DMSO (50%). Platelets sensitized with autoantibodies from patients with autoimmune thrombocytopenia could also be stored by simple freezing in platelet-rich plasma and used for (re)testing.