The objective of this thesis is to make a first step towards prevention of the progression of chronic venous disease and the development of a first venous leg ulcer in chronic venous disease patients. The aim is to identify chronic venous disease patients at risk of developing more severe clinical stages, provide insight in the lifestyle related risk factors, and provide an overview of current chronic venous disease care in the Netherlands.
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Background: A venous leg ulcer (VLU) has a significant negative impact on quality of life. Prevention of a VLU is not yet imbedded in clinical practice because risk factors for developing a first VLU are not well known. Objectives: To explore further the progression of chronic venous disease (CVD) into a first VLU from the patient’s perspective. Methods: A qualitative study using semistructured interviews was conducted among male and female patients with a VLU. Patients from primary and secondary care,under and over 50 years of age, and with first and recurrent VLUs were included. The interviews were transcribed and analysed using a narrative approach to a thematic analysis. Transcripts were organized in chronological order and an iterative process was used to code the transcripts. Results: Four key themes and the connections made between them emerged from the 11 narratives on the progression of CVD towards a first VLU: ‘comorbidity’, ‘mobility’, ‘work and lifestyle’ and ‘acknowledgment of CVD’. Comorbidity was linked to reduced mobility and late acknowledgment of CVD. Comorbidity also affected work and lifestyle and vice versa. Work and lifestyle affected mobility and was linked to the acknowledgment of CVD. Conclusions: A reduction in mobility as a result of comorbidity and work and lifestyle occurred before the VLU developed. Patients did not recognize symptoms of CVD and did not acknowledge the chronicity of CVD. Healthcare professionals should be aware of reductions in mobility and the knowledge deficit in patients with CVD.
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Background: Patients with chronic obstructive pulmonary disease (COPD) demonstrate reduced levels of daily physical activity (DPA) compared to healthy controls. This results in a higher risk of hospital admission and shorter survival. Performing regular DPA reduces these risks. Objective: To develop an eHealth intervention that will support patients with COPD to improve or maintain their DPA after pulmonary rehabilitation. Methods: The design process consisted of literature research and the iterative developing and piloting phases of the Medical Research Council (MRC) model for complex clinical interventions and the involvement of end users. Participants were healthy adults and persons with COPD. Results: The mobile phone interface met all the set requirements. Participants found that the app was stimulating and that reaching their DPA goals was rewarding. The mean (SD) scores on a 7-point scale for usability, ease of use, ease of learning, and contentment were 3.8 (1.8), 5.1 (1.1), 6.0 (1.6), and 4.8 (1.3), respectively. The mean (SD) correlation between the mobile phone and a validated accelerometer was 0.88 (0.12) in the final test. The idea of providing their health care professional with their DPA data caused no privacy issues in the participants. Battery life lasted for an entire day with the final version, and readability and comprehensibility of text and colors were favorable. Conclusions: By employing a user-centered design approach, a mobile phone was found to be an adequate and feasible interface for an eHealth intervention. The mobile phone and app are easy to learn and use by patients with COPD. In the final test, the accuracy of the DPA measurement was good. The final version of the eHealth intervention is presently being tested by our group for efficacy in a randomized controlled trial in COPD patients.
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Abstract Background: Integrated disease management with self-management for Chronic Obstructive Pulmonary Disease (COPD) is effective to improve clinical outcomes. eHealth can improve patients’ involvement to be able to accept and maintain a healthier lifestyle. Eventhough there is mixed evidence of the impact of eHealth on quality of life (QoL) in different settings. Aim: The primary aim of the e-Vita-COPD-study was to investigate the effect of use of eHealth patient platforms on disease specific QoL of COPD patients. Methods: We evaluated the impact of an eHealth platform on disease specific QoL measured with the clinical COPD questionnaire (CCQ), including subscales of symptoms, functional state and mental state. Interrupted time series (ITS) design was used to collect CCQ data at multiple time points. Multilevel linear regression modelling was used to compare trends in CCQ before and after the intervention. Results: Of 742 invited COPD patients, 244 signed informed consent. For the analyses, we only included patients who actually used the eHealth platform (n = 123). The decrease of CCQ-symptoms was 0.20% before the intervention and 0.27% after the intervention; this difference in slopes was statistically significant (P = 0.027). The decrease of CCQ-mental was 0.97% before the intervention and after the intervention there was an increase of 0.017%; this difference was statistically significant (P = 0.01). No significant difference was found in the slopes of CCQ (P = 0.12) and CCQ-function (P = 0.11) before and after the intervention. Conclusion: The e-Vita eHealth platform had a potential beneficial impact on the CCQ-symptoms of COPD patients, but not on functional state. The CCQ-mental state remained stable after the intervention, but this was a deterioration compared to the improving situation before the start of the eHealth platform. Therefore, health care providers should be aware that, although symptoms improve, there might be a slight increase in anxiety and depression after introducing an eHealth intervention to support self-management. Trial registration: Our study is registered in the Dutch Trial Register (national registration of clinical trails, mandatory for publication) with number NTR4098 and can be found at http://www.trialregister.nl/trial/3936.
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Samenvatting Achtergrond: Een integrale behandeling inclusief zelfmanagement bij chronisch obstructieve longziekte (COPD) leidt tot betere klinische resultaten. eHealth kan zorgen voor meer betrokkenheid bij patiënten waardoor ze in staat zijn een gezondere levensstijl aan te nemen en vast te houden. Desondanks is er geen eenduidig bewijs van de impact van eHealth op de kwaliteit van leven (quality of life (QoL)). Doel: Het primaire doel van de e-Vita COPD-studie was om te onderzoeken wat de effecten zijn van het gebruik van eeneHealth-platform voor patiënten op de verschillende domeinen van ziektespecifieke kwaliteit van leven van COPD-patiënten (CCQ). Methoden: We hebben de impact beoordeeld van het gebruik van een eHealth-platform op de klinische COPD-vragenlijst (CCQ). Deze vragenlijst omvatte subschalen van symptomen, functionele en mentale toestand. Een design met onderbroken tijdreeksen (interrupted time series (ITS)) is gebruikt om CCQ-gegevens op verschillende tijdstippen te verzamelen. Er is gebruik gemaakt van multilevel lineaire regressieanalyse om de CCQ-trends vóór en na de interventie te vergelijken. Resultaten: Van de 742 uitgenodigde COPD-patiënten hebben er 244 het document voor ‘informed consent’ ondertekend. In de analyses hebben we uitsluitend patiënten opgenomen die daadwerkelijk gebruik hebben gemaakt van het eHealthplatform (n=123). De afname van CCQ-symptomen was 0,20% vóór de interventie en 0,27% na de interventie; dit was een statistisch significant verschil (P=0,027). De daling van CCQ-mentale toestand was 0,97% vóór de interventie en na de interventie was er sprake van een stijging van 0,017%; dit verschil was statistisch significant (P=0,01). Er werd geen significant verschil vastgesteld in het verloop van CCQ (P=0,12) en CCQ-functionele toestand (P=0,11) vóór en na de interventie. Conclusie: Het e-Vita eHealth-platform had een gunstig effect op de CCQ-symptomen van COPD-patiënten, maar niet op de functionele status. De CCQ-mentale toestand bleef stabiel na de interventie, maar dit was een verslechtering in vergelijking met de verbeterende situatie voorafgaand aan de start van het eHealth-platform. Deze studie laat dus zien dat patiënten na de introductie van het COPD-platform minder symptomen ervaarden, maar dat hun mentale toestand tegelijkertijd licht verslechterde. Zorgprofessionals moeten zich ervan bewust zijn dat, ondanks de verbetering van symptomen, er een lichte toename van angst en depressie kan optreden na invoering van een eHealth-interventie.
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Introduction: Throughout life, a patient with severe haemophilia is confronted with many treatment-related challenges. Insight into self-management and non-adherence could improve the quality of care for these patients. The aim of this study was to provide an overview of the current evidence on self-management and adherence to prophylaxis in haemophilia. Method: Based on series of studies and published literature, aspects of treatment were explored: learning and performing self-infusion, achieving self-management skills in adolescence, adherence issues and coping with haemophilia. Evidence-based and age-group-specific recommendations for haemophilia professionals were formulated. Results: Nearly, all severe haemophilia patients and parents were able to perform self-infusion and the quality level of infusion skills was acceptable. Learning self-infusion was generally initiated before the onset of puberty and full self-management was obtained 10 years later. Adherence was defined using a Delphi consensus procedure and was determined by skipping, dosing and timing of infusions. Adherence levels varied according to age, with highest levels in children (1–12 years) and the lowest among 25–40 years. Adherence to prophylaxis was acceptable (43%), yet 57% of the population struggled with prophylaxis. Qualitative research showed that the position of prophylaxis in life is the main driver of adherence. This position is influenced by acceptance and self-management skills. Regarding coping with haemophilia, the majority of patients used a problem-focused approach. Conclusion: Self-management and adherence to prophylaxis vary during the life span. Acceptance of the disease and self-management skills were important aspects that may require tailored professional support.
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INLEIDING In deze module worden behandeladviezen gegeven voor de Post-COVID-19 ambulante behandeling in de geriatrische revalidatie gericht op somatische-, functionele- en psychische status. Deze module is een onderdeel van het behandeladvies post-COVID-19 (geriatrische) revalidatie-Verenso. Deze module is in een zeer korte tijd tot stand gekomen en heeft de status van groeidocument. Zorgvuldigheid is betracht om zowel de (beperkte) ervaringskennis, als de actuele stand van de wetenschappelijke literatuur hierin te betrekken. Voor dit behandeladvies is gebruik gemaakt van het door GRZPLUS ontwikkeld ambulant revalidatieprogramma CO FIT+. Bij GRZPLUS is een doorontwikkeling gemaakt op basis van de update behandeladvies post-COVID-19 geriatrische revalidatie van Verenso (Verenso, 19-05-2020) welke is gebaseerd op de principes van longrevalidatie zoals vertaald in het Behandelprogramma geriatrische COPD-revalidatie (van Damvan Isselt et al.) en het Behandelprogramma COVID-19 Post IC, van Revalidatiecentrum de Hoogstraat (Brouwers, de Graaf). Dit is aangevuld met behandeladviezen en leidraden vanuit de beroepsverenigingen en kennis uit wetenschappelijk onderzoek (long-revalidatie) en vanuit het REACH netwerk (REhabilitation After Critical illness and Hospital discharge). De komende maanden zullen zowel de nieuwe wetenschappelijke literatuur als de ervaringen uit de praktijk gebruikt worden om de handreiking te verbeteren en zo nodig aan te vullen. Dat zullen wij doen met specialisten ouderengeneeskunde, revalidatieartsen, klinisch-geriaters, paramedici, longartsen, verpleegkundigen, infectie deskundigen, en andere betrokken beroepsgroepen. De revalidatie van ambulante post-COVID-19 patiënten vereist vooral afstemming binnen de multidisciplinaire zorg. De complexiteit en ernst van de problematiek en de interactie van beperkingen op diverse domeinen maakt dat interdisciplinaire behandeling essentieel is.
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Talloze studies tonen aan dat een fysiek actieve leefstijl bloeddruk, cholesterol en gewicht verlaagt, botten en spieren versterkt en het risico van hart- en vaatziekten, darmkanker en diabetes type II vermindert. Bewegen kan dus worden gezien als een medicijn wat voor iedereen toegankelijk is.
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Abstract Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), has challenged healthcare globally. An acute increase in the number of hospitalized patients has neces‑ sitated a rigorous reorganization of hospital care, thereby creating circumstances that previously have been identifed as facilitating prescribing errors (PEs), e.g. a demanding work environment, a high turnover of doctors, and prescrib‑ ing beyond expertise. Hospitalized COVID-19 patients may be at risk of PEs, potentially resulting in patient harm. We determined the prevalence, severity, and risk factors for PEs in post–COVID-19 patients, hospitalized during the frst wave of COVID-19 in the Netherlands, 3months after discharge. Methods: This prospective observational cohort study recruited patients who visited a post-COVID-19 outpatient clinic of an academic hospital in the Netherlands, 3months after COVID-19 hospitalization, between June 1 and October 1 2020. All patients with appointments were eligible for inclusion. The prevalence and severity of PEs were assessed in a multidisciplinary consensus meeting. Odds ratios (ORs) were calculated by univariate and multivariate analysis to identify independent risk factors for PEs. Results: Ninety-eight patients were included, of whom 92% had ≥1 PE and 8% experienced medication-related harm requiring an immediate change in medication therapy to prevent detoriation. Overall, 68% of all identifed PEs were made during or after the COVID-19 related hospitalization. Multivariate analyses identifed ICU admission (OR 6.08, 95% CI 2.16–17.09) and a medical history of COPD / asthma (OR 5.36, 95% CI 1.34–21.5) as independent risk fac‑ tors for PEs. Conclusions: PEs occurred frequently during the SARS-CoV-2 pandemic. Patients admitted to an ICU during COVID19 hospitalization or who had a medical history of COPD / asthma were at risk of PEs. These risk factors can be used to identify high-risk patients and to implement targeted interventions. Awareness of prescribing safely is crucial to prevent harm in this new patient population.
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Development of novel testing strategies to detect adverse human health effects is of interest to replace in vivo-based drug and chemical safety testing. The aim of the present study was to investigate whether physiologically based kinetic (PBK) modeling-facilitated conversion of in vitro toxicity data is an adequate approach to predict in vivo cardiotoxicity in humans. To enable evaluation of predictions made, methadone was selected as the model compound, being a compound for which data on both kinetics and cardiotoxicity in humans are available. A PBK model for methadone in humans was developed and evaluated against available kinetic data presenting an adequate match. Use of the developed PBK model to convert concentration–response curves for the effect of methadone on human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CM) in the so-called multi electrode array (MEA) assay resulted in predictions for in vivo dose–response curves for methadone-induced cardiotoxicity that matched the available in vivo data. The results also revealed differences in protein plasma binding of methadone to be a potential factor underlying variation between individuals with respect to sensitivity towards the cardiotoxic effects of methadone. The present study provides a proof-of-principle of using PBK modeling-based reverse dosimetry of in vitro data for the prediction of cardiotoxicity in humans, providing a novel testing strategy in cardiac safety studies.
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