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Monday, April 30, 2012

The Clinical Value of Intensive Monitoring in Term Asphyxiated Newborns Swarte, R.M.C. 2010-04-22 Doctoral Thesis Pediatrics

Perinatal asphyxia is an important cause of brain injury. It may lead to hypoxic-ischaemic encephalopathy (HIE) which occurs in one to six of every 1000 full term births. The risk of death or severe handicap is 0.5-2.0 out of 1000. Following intrapartum asphyxia cerebral hypoperfusion in combination with hypoxia produces characteristic neuropathological changes and related clinical signs. After the primary insult there is a thirty minutes period of reperfusion characterized by the partial recovery of cell and metabolic processes. This is followed by a latent phase which may last up to six hours. In this phase oxidative metabolism (near) normalizes (shown by MRspectroscopy) but EEG activity is depressed and the blood flow is likely to be reduced. Secondary energy failure and secondary hyperperfusion (‘luxury perfusion’) may occur in the neonatal brain within 6-15 hours after an acute ischaemic insult, marked by the acute onset of seizures (peaking at about 12 hours post insult). Excitotoxins accumulate in the cell and cell death may take 72 hours to completion. The infant’s gestational age and thus the maturational stage of the brain, as well as type, severity and duration of the insult are determinants of the brain injury. During the insult there is redistribution of blood flow to the brain, heart and adrenals. Our current understanding of perinatal asphyxia is based on animal experiments. Different and mixed etiologies lead to a range of post asphyxial patterns, usually subdivided into different patterns; acute, chronic or a combination of these two. With chronic, possibly repetitive insults, lesions are predominantly seen in (sub)cortical structures. This has been named watershed injury for its classical distribution along the borderzones between the major pial arteries, sparing thalamus and basal ganglia. From the literature it appears that watershed injury is observed most frequently in context of term birth asphyxia. In acute and (near) total asphyxia the damage is mostly to the thalami, basal ganglia, hippocampus, cerebellum, brain stem and specific areas of the neocortex like the rolandic, calcarine and insular cortex. 

Compliance to Hand Hygiene Guidelines in Hospital Care: A stepwise behavioural approach Erasmus, V. 2012-04-25 Doctoral Thesis

Healthcare associated infections (HAI) are a threat to the health of people requiring acute or chronic care. Since HAI can often be avoided by taking preventative measures, including proper application of hand hygiene principles, the prevention of these infections has received growing attention over the past decades. However, the application of preventive measures in clinical practice remains problematic and the observed compliance with such measures is often poor. Hand hygiene is one such area where compliance needs to be improved. To be able to develop successful interventions for the improvement of hand hygiene, it is essential to identify the factors influencing hand hygiene behaviour, and to investigate which interventions best target these factors. This thesis reports on a number of studies on the identification of behavioural and environmental correlates of hand hygiene behaviour among healthcare workers, and the translation of these determinants into an intervention. This chapter describes the background, aims and theoretical framework used, and presents an introduction to the individual studies that are part of this thesis.

Understanding Outstanding: quality assurance in colonoscopy Jonge, V. de Nicolaas, J.S. 2012-04-20 Doctoral Thesis

Since a couple of years, quality assurance (QA) stands at the core of the attention in the healthcare sector. Especially after the publication in 2000 of the Institute of Medicine’s report ‘To err is human’ the interest in QA has taken a quantum leap and many quality initiatives have been developed. This report revealed that every year in the United States approximately 98,000 patients died because of medical errors. Following this report, within the healthcare sector the awareness arose that the quality of the service had to improve, with special attention to safety and patient experiences. Since then the healthcare sector has learned some important lessons in QA from other industries such as the airline industry and energy sector, which are generally classified as ultra-safe organizations. Gastrointestinal endoscopy has been one of the medicine specialties which enrolled important quality initiatives. Especially since the introduction of colorectal cancer (CRC) screening programs, many efforts have been undertaken to better understand the concept of high quality endoscopy. CRC screening has been proven to decrease the incidence of CRC, and CRC related mortality. Therefore many institutions and societies recommend to screen asymptomatic individuals by fecal occult blood tests, flexible sigmoidoscopy, or colonoscopy. As these screening programs involve healthy individuals, the cost-effectiveness of such programmatic screening approaches is highly dependent on the quality of the procedure, but also on pre- and post-procedure quality aspects to improve screenee experiences and thereby the uptake of and adherence to screening modalities. In the Netherlands, CRC screening is about to start in 2013 by means of biennial fecal immunochemical testing. To attain the highest effect a comprehensive QA program should be enrolled with major focus on endoscopy as secondary screening method, as is recommended now by the European Union. The other diagnostic and therapeutic services provided by the endoscopy units will benefit simultaneously from such an initiative.