Gelre Hospitals

With great interest, we read the letter to the editor of Dr Bulent Mamikoglu in response to our paper “The Differences in Caloric Test and vHIT Results Between Menière’s Disease and Vestibular Migraine: A Systematic Review and Meta-Analysis.” The author of this letter seems to conclude that VM is a disorder of central network modulation that is susceptible to peripheral perturbations, including pressure-coupled perilymph changes and otolith dysregulation, in subsets of patients. This model aligns with (1) CSF–perilymph literature, (2) pressure-linked oval-window mechanics, (3) BPPV comorbidity, and (4) IIH-spectrum associations. The assertion that disorders unrelated to vestibular migraine (VM) or migraine in general provide evidence for vestibular migraine being a peripheral disorder is not supported by current clinical or pathophysiological data. Multiple lines of evidence indicate that vestibular migraine is primarily a disorder of central origin, involving sensitization and altered processing within central vestibular pathways. Functional neuroimaging studies have suggested abnormal connectivity and activity in brain regions responsible for multisensory vestibular integration and sensorimotor control in patients with vestibular migraine, supporting a central mechanism rather than a peripheral vestibulopathy.1,2 Clinical studies have shown that vestibular migraine patients exhibit abnormal sensitivity to vestibular stimuli that implicates central canal-otolith integration, rather than isolated peripheral vestibular dysfunction.3 The overlap between migraine circuits and central vestibular pathways further reinforces the central origin, with the trigeminovascular system and brainstem nuclei playing key roles in symptom generation.4 Regarding the definition of vestibular migraine, there is substantial heterogeneity in clinical presentations. The diagnostic criteria jointly proposed by the Bárány Society and the International Headache Society require a history of migraine and vestibular symptoms that are temporally associated with migraine features; however, they do not, for example, distinguish between separate vestibular episodes in patients with a history of migraine and vestibular complaints occurring during the migraine aura or headache phase.5 Recent cluster analyses and large cohort studies have identified multiple subgroups within vestibular migraine, with variable symptom profiles, attack durations, and associated features, indicating that the current diagnostic entity likely encompasses a heterogeneous group of patients with different underlying mechanisms.6,7 This heterogeneity complicates both diagnosis and management, and underscores the need for further research to refine the classification and understanding of vestibular migraine. In summary, disorders unrelated to vestibular migraine do not provide evidence for a peripheral origin of vestibular migraine, and the current definition likely includes a diverse patient population with both central and peripheral features, but with predominant central pathophysiology.

The population-related incidence of pediatric battery ingestion is 1.18 episodes per 100,000 children per year in the Netherlands with 17% complications. Battery swallowing in young children is a life-threatening emergency-urgent action and increased awareness among politicians, industry and healthcare professionals are essential to prevent serious harm. • Battery ingestion can lead to severe complications and mortality. • Young children are prone to accidental button battery ingestion due to oral exploration. • Esophageal impaction and related complications are more common in children compared to adults due to small anatomy. • The incidence rate of pediatric battery ingestion is rarely described worldwide. In the Netherlands, the incidence is 1.18 per 100,000 children per year. • Unfortunately, complications are relatively often after ingestion (17%).

Generalists in palliative care and professionals with specialized expertise, including palliative care nurses, achieve high-quality palliative care. To strengthen their role, it is essential to understand the tasks palliative care nurses perform and their position within the organizations. We aim to accomplish this understanding and explore facilitators and barriers to taking on the role as specialized nurses from both the nurses’ and managers’ perspectives. A sequential mixed-method design combined an online survey, followed up by five focus groups. Analysis involved descriptive statistics and thematic coding. A total of 234 palliative care nurses across various care settings answered the survey. They primarily provided physical care (88%), with less focus on psychological (72%), social (68%), and spiritual (68%) domains, and were consulted for fewer than half of their activities. Having no job descriptions often occurred (from 78% in home care and nursing homes to 44% in hospitals). Hospital nurses were more involved in advisory teams (56%) than those in other settings (26% − 28%). Nurses showed leadership by promoting generalists’ expertise, connecting partners, serving as role models, and advocating for palliative care. Focus groups with twelve nurses and nine managers identified facilitators and barriers that palliative care nurses and their managers encounter in embedding their roles and positions. These covered: (1) distinction between generalist and specialist palliative care, (2) collaboration, (3) job descriptions, (4) leadership, (5) visibility, (6) funding and reimbursement. Palliative care nurses fulfill an essential role but experience ambiguity about their role and position. They and their managers emphasized the importance of leadership and advocating for palliative care in their organizations. Visibility, funding, reimbursement, and collaboration are facilitators and barriers to their role and position. There are notable areas for improvement, including joining a palliative care advisory team, having a job description, and finding ways to demonstrate cost-effectiveness.

Many patients with COPD use inhaled corticosteroids (ICS) without proper indication. We developed a multifaceted tailor-made de-implementation strategy—including a toolbox, communication plan, and training—to reduce inappropriate ICS use in general practice. We evaluated its effectiveness (i.e. decline in percentage of patients with COPD that use ICS) and other outcomes during a 15-month study in Drenthe, the Netherlands. Less patients (−4.7%,95%CI: 2.6–6.7%) used ICS at the end of follow-up and the percentage of ICS-users declined by 8.2% (95%CI: 2.9–13.4%) across the 14 practices that fully participated in the project. ICS user percentages declined significantly moreover time in the fully participation group than in the control group (beta-regression, β = −0.041,SE = 0.011, p < 0.01). While these findings are promising, further research is needed to assess additional penetration and sustainability of the strategy in the region and to explore the applicability of comparable regional ICS de-implementation plans.

BackgroundHalf of the population succumbs to syncope in their lifetime, entailing up to three percent of ED presentations and accumulating to over 11 thousand euros per patient in healthcare costs. Syncope has a broad differential diagnosis making management a multidisciplinary effort, causing a non-standardized approach across healthcare providers and disciplines. ESC guidelines on syncope recommend to apply the ESC diagnostic syncope algorithm to identify and discharge syncope patients with low and intermediate risk of severe underlying illness (~70 percent of patients). Although the safety regarding false low/intermediate risk diagnoses has been verified in the Synergy trial, the optimal time window when to discharge these patients is not defined in the guidelines. In current medical practice low and intermediate risk syncope patients are either immediately discharged or admitted for 24 hour in-hospital rhythm monitoring (43% of low risk patients). To our knowledge, there is not sufficient scientific basis for superiority of either. This results in unstandardized and possibly unnecessary admission of patients. The current study (RISC) aims to resolve this knowledge gap.Study Design The RISC trial is an investigator-initiated multicenter prospective randomized controlled trial, comparing immediate discharge to discharge after 24 hour in-hospital rhythm monitoring (telemetry). All patients with low and intermediate risk syncope, as defined by the guideline-based syncope algorithm, are included. A total of 640 patients are randomized to either immediate discharge or discharge after 24 hour in-hospital rhythm monitoring (1:1). A power analysis has been performed to ensure enough power to claim noninferiority of immediate discharge with respect to the (non-)fatal endpoints. For the comparison of (non-)fatal endpoints in both arms we will apply 24 hour ambulant rhythm monitoring in all patients. The ambulant rhythm monitoring is solely for the study purpose, it will not be available for clinicians at the time of monitoring and will therefore have no impact on treatment during the trial. Endpoints will entail arrhythmic disorders, syncope recurrence and (cardiovascular)death.PurposeThe aim of this study is to prove non-inferiority of immediate discharge in low and intermediate risk syncope patients compared to admission with telemetry for 24 hours, resulting in lower healthcare costs.ConclusionThe RISC trial is a multicenter randomized controlled trial that aims to gain scientific evidence for immediate discharge compared to discharge after 24 hour in-hospital rhythm monitoring in syncope patients with a calculated low or intermediate risk of severe underlying illness. Primary endpoints will entail arrhythmias, syncope and fatalities. This trial is registered at ClinicalTrials.gov with trial ID NCT06472375).RISC Trial Flowchart

Nocturnal in-center hemodialysis (HD) offers a higher dialysis dose and longer ultrafiltration time than regular HD, which potentially benefits at least a selection of patients. Currently, only a minority of HD patients have access to in-center nocturnal HD. Many practical and logistical problems must be overcome by an HD center before the treatment can become operational. For assessing the detailed organization of in-center nocturnal HD in the Netherlands, an observational cross-sectional study was performed using Nefrodata (Dutch Registry of dialysis patients) and structured questionnaires for center managers and nephrologists. Descriptive analyses were performed, followed by an analysis of best practices. Out of 55 Dutch dialysis centers, 27 offer in-center nocturnal HD, treating 255 out of 5200 patients treated with intermittent HD. Of these 27 centers, 4 stopped providing in-center nocturnal HD, mostly due to organizational problems. Our survey showed that some aspects of treatment were similar in the various centers, such as duration of sessions (7-8 h), patient education at the pre-dialysis outpatient department, treatment prescription, and blood pressure monitoring. In contrast, patient selection varied between centers, for example, regarding functional vascular access: non-tunneled catheters were not allowed during in-center nocturnal HD in some centers. Also, hemodynamic instability observed during daytime treatment was, by some centers, considered a problem for starting in-center nocturnal HD. Furthermore, large differences regarding the organization of nursing staff exist. Importantly, all nephrologists agree that in-center nocturnal HD is a useful part of the treatment repertoire offered in their centers. Practical guidance to organize a successful and safe in-center nocturnal HD program is provided. Patients' safety should be guaranteed without affecting the patient's night's sleep. In-center nocturnal HD offers patients the most optimal metabolic control, excellent intradialytic hemodynamic stability, and volume control with more free time during the day.

Artificial intelligence (AI) could reduce lung cancer screening computer tomography (CT)-reading workload if used as a first-reader, ruling-out negative CT-scans at baseline. Evidence is lacking to support AI performance when compared to gold-standard lung cancer outcomes. This study validated the performance of a commercially available AI software in the UK lung cancer screening (UKLS) trial dataset, with comparison to human reads and histological lung cancer outcomes, and estimated CT-reading workload reduction. 1252 UKLS-baseline-CT-scans were evaluated independently by AI and human readers. AI performance was evaluated on two-levels. Firstly, AI classification and individual reads were compared to a EU reference standard (based on NELSON2.0-European Position Statement) determined by a European expert panel blinded from individual results. A positive misclassification was defined as a nodule positive read ≥ 100mm3 and no/<100mm3 nodules in the expert read; A negative misclassification was defined as a nodule negative read, whereas an indeterminate or positive finding in the expert read. Secondly, AI nodule classification was compared to gold-standard histological lung cancer outcomes. CT-reading workload reduction was calculated from AI negative CT-scans when AI was used as first-reader. Expert panel reference standard reported 815 (65 %) negative and 437 (35 %) indeterminate/positive CT-scans in the dataset of 1252 UKLS-participants. Compared to the reference standard, AI resulted in less misclassification than human reads, NPV 92·0 %(90·2 %-95·3 %). On comparison to gold-standard, AI detected all 31 baseline-round lung cancers, but classified one as negative due to the 100mm3 threshold, NPV 99·8 %(99·0 %-99·9 %). Estimated maximum CT-reading workload reduction was 79 %. Implementing AI as first-reader to rule-out negative CT-scans, shows considerable potential to reduce CT-reading workload and does not lead to missed lung cancers.

Figure 1 High-level process map.This process map demonstrates the complexities and the events/stages required in order to ensure medications are prescribed Abstract 141 Figure 2 Fishbone diagram.This diagram demonstrates the multifactorial nature of the problem with the different systems, people, processes, environments, equipment, management and materials involved

This article contextualises the 2023 European Society of Cardiology (ESC) guidelines for the management of cardiomyopathies for clinical practice in the Netherlands. The guideline addendum provides additional recommendations for situations where the ESC guidelines may not fully align with Dutch clinical practice. By endorsing the ESC guidelines through this addendum, the Netherlands Society of Cardiology (Nederlandse Vereniging Voor Cardiologie) supports its members in adhering to evidence-based management strategies for cardiomyopathies. As Dutch cardiologists generally adopt the ESC guidelines quickly, this contextualisation is essential for effective application thereof within the Dutch healthcare setting.