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Zuidgeest MGP, Goetz I, Meinecke AK, Boateng D, Irving EA, van Thiel GJM, Welsing PMJ, Oude-Rengerink K, Grobbee DE, Initiative G. The GetReal Trial Tool: Design, Assess and Discuss Clinical Drug Trials in Light of RWE Generation. J Clin Epidemiol 2021; 149:244-253. [PMID: 34929319 DOI: 10.1016/j.jclinepi.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/25/2021] [Accepted: 12/13/2021] [Indexed: 10/19/2022]
Abstract
Methodologies incorporating Real World Elements into clinical trial design (also called pragmatic trials) offer an attractive opportunity to assess the effect of a treatment strategy in routine care and as such guide decision making in practice. Uptake of these methods is slow for several reasons, including uncertainty about acceptability of trial results, lack of experience with the methodology and operational challenges. We developed the 'Get Real Trial Tool', an easy-to-use interface, which allows users to assess the impact of design choices on generalisability to routine clinical practice, while taking into account risk of bias, precision, acceptability and operational feasibility. The tool is grounded in the scientific literature on pragmatic trials combined with knowledge of experts from academia, pharmaceutical companies, HTA bodies, patient organisations, and regulators. The aim is to help researchers optimise trial design and facilitate translation of evidence from pragmatic trials to clinical practice. In this paper we describe the development, structure and application of the GetReal Trial Tool.
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Affiliation(s)
- Mira G P Zuidgeest
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.
| | | | - Anna-Katharina Meinecke
- Partnerships and IEG Office, Integrated Evidence Generation & Business Innovation, Medical Affairs & Pharmacovigilance, Bayer AG
| | - Daniel Boateng
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Elaine A Irving
- Clinical Development, GSK Research & Development Ltd., Stevenage, Hertfordshire, SG1 2NY, UK
| | - Ghislaine J M van Thiel
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Paco M J Welsing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Rheumatology & Clinical immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Katrien Oude-Rengerink
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Diederick E Grobbee
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands; Julius Clinical, Zeist, the Netherlands
| | - GetReal Initiative
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands; Eli Lilly & Co Ltd, Bracknell, UK; Partnerships and IEG Office, Integrated Evidence Generation & Business Innovation, Medical Affairs & Pharmacovigilance, Bayer AG; Clinical Development, GSK Research & Development Ltd., Stevenage, Hertfordshire, SG1 2NY, UK; Department of Rheumatology & Clinical immunology, University Medical Center Utrecht, Utrecht, the Netherlands; Julius Clinical, Zeist, the Netherlands
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Gemzoe K, Crawford R, Caress A, McCorkindale S, Conroy R, Collier S, Doward L, Vekaria RM, Worsley S, Leather DA, Irving E. Patient and healthcare professional experiences of the Salford Lung Studies: qualitative insights for future effectiveness trials. Trials 2020; 21:798. [PMID: 32943093 PMCID: PMC7499906 DOI: 10.1186/s13063-020-04655-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 08/05/2020] [Indexed: 01/09/2023] Open
Abstract
Background Randomized controlled trials (RCTs) conducted in the routine care setting provide the opportunity to better understand the effectiveness of new medicines but can present recruitment difficulties. An improved understanding of the challenges/opportunities for patient and healthcare professional (HCP) engagement in clinical research is needed to enhance participation and trial experience. In this study, we explored patient and HCP drivers for, and experiences of, participation in the Salford Lung Studies (SLS), and their views on future trial participation and the overall value of such trials. Methods This was a qualitative study set in Salford, UK, comprising patient telephone interviews (N = 10) and HCP advisory boards (one with general practitioners [GPs], one with practice managers [PMs]); all individuals had participated in the SLS. Semi-structured telephone interviews were recorded, transcribed and analysed thematically. Advisory board meetings were analysed based on transcriptions of audio recordings and field notes. Results For patients, key positive aspects of the SLS were the ease/convenience of study assessments and excellent relationships with study nurses. GPs and PMs considered the SLS to be well-organized and highlighted the value of research nurse support; they also described minor challenges relating to trial systems, initial financial strain on practices and staff turnover. All participants indicated that they were very likely to participate in future trials, citing a design closely aligned with routine care practice as essential. Several strategies to encourage trial participation were suggested, such as clearly communicating benefits to patients and ensuring flexible study assessments. Conclusions Patients and HCPs had positive experiences of the SLS. The study design, closely aligned with routine care, was considered important to their high likelihood of participating in future trials. The experiences of patients and HCPs in the SLS provide valuable insights that will help inform future best practice in the design and conduct of future real-world effectiveness RCTs in primary care. The detailed first-hand experiences of HCPs will be of significant value to others considering engaging in clinical research and participating in effectiveness RCTs.
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Affiliation(s)
- Kim Gemzoe
- Real World Study Delivery, Value Evidence and Outcomes, GlaxoSmithKline plc., Research & Development Ltd., Stockley Park West, 1-3 Ironbridge Road, Uxbridge, Middlesex, UB11 1BT, UK.
| | | | - Ann Caress
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, HD1 3DH, UK
| | | | | | - Susan Collier
- UK Medical, GlaxoSmithKline plc, Uxbridge, UB11 1BT, UK
| | | | | | - Sally Worsley
- Real World Study Delivery, Value Evidence and Outcomes, GlaxoSmithKline plc., Research & Development Ltd., Stevenage, SG1 2NY, UK
| | - David A Leather
- Global Respiratory Franchise, GlaxoSmithKline plc., Brentford, TW8 9GS, UK
| | - Elaine Irving
- Real World Study Delivery, Value Evidence and Outcomes, GlaxoSmithKline plc., Research & Development Ltd., Stevenage, SG1 2NY, UK
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Hou L, Chen X, Chen B, Liu L, Sun X, Zou Y, Liu H, Guo H, Zhang J, Ma J. Pharmacological therapy and blood pressure control in primary health care sites in China: data from 254,848 hypertensive patients. Clin Epidemiol 2018; 10:1467-1478. [PMID: 30349394 PMCID: PMC6188195 DOI: 10.2147/clep.s172567] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Studies on pharmacological therapy and blood pressure (BP) control in primary health care sites of China are limited. We aimed to investigate drug use and compliance as well as compare BP control between pharmacological therapies for lowering BP in hypertensive population serviced by these sites. Methods This is a 1-year cohort study using electronic health care records from the National Primary Public Health Services of China. For patients with antihypertensive drugs at the first follow-up, we defined compliance with treatment as a continued treatment with the same specified class of agents at next three follow-ups. In those with compliance, BP control was defined as systolic BP <140 mmHg and diastolic BP <90 mmHg in four follow-ups within 1 year. Results Primary health care sites of four areas managed 254,848 hypertensive patients aged ≥35 years. At the first follow-up, 50.2% of the patients took medicines for lowering BP. In those, calcium channel antagonist monotherapy was the most common medicine in urban areas (57.1% vs 15.6% in rural areas, P<0.001); however, the most common one was single-pill combinations including diuretics and non-first-line drugs in rural areas (34.4% vs 10.7% in urban areas, P<0.001). Compliance was 79.9% and 53.2% for single- and multiple-pill combinations in first-line drugs; this rate was 69.5% and 45.0% in regimens combined with non-first-line drugs, respectively. Compared with calcium channel antagonists, diuretics monotherapy increased the overall BP control by 11% (risk ratio, 1.11; 95% confidence interval, 1.08 to 1.13), but it was used in few patients (3.3%); first-line multiple-pill combinations significantly decreased BP control by 20% to 28% in three less urbanized areas, but a similar BP control was achieved in the highly urbanized area. Conclusion Our study indicated that drug use such as diuretics could be strengthened in primary health care sites and combined therapy may be improved particularly in less urbanized areas.
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Affiliation(s)
- Lei Hou
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 100050, China,
| | - Xiaorong Chen
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 100050, China,
| | - Bo Chen
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 100050, China,
| | - Longjian Liu
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA, 19104, USA
| | - Xiaohui Sun
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 100050, China, .,Qingdao Center for Disease Control and Prevention, Qingdao, 266033, China
| | - Yuewei Zou
- Rushan Center for Disease Control and Prevention, Rushan, 264500, China
| | - Hongjian Liu
- Taixing Center for Disease Control and Prevention, Taixing, 225400, China
| | - Hui Guo
- Xiangtan Center for Disease Control and Prevention, Xiangtan, 411100, China
| | - Jian Zhang
- Wuhou Center for Disease Control and Prevention, Wuhou, 610041, China
| | - Jixiang Ma
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 100050, China,
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Series: Pragmatic trials and real world evidence: Paper 1. Introduction. J Clin Epidemiol 2017; 88:7-13. [DOI: 10.1016/j.jclinepi.2016.12.023] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 11/28/2016] [Accepted: 12/12/2016] [Indexed: 11/21/2022]
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Worsley SD, Oude Rengerink K, Irving E, Lejeune S, Mol K, Collier S, Groenwold RHH, Enters-Weijnen C, Egger M, Rhodes T. Series: Pragmatic trials and real world evidence: Paper 2. Setting, sites, and investigator selection. J Clin Epidemiol 2017; 88:14-20. [PMID: 28502811 DOI: 10.1016/j.jclinepi.2017.05.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 08/22/2016] [Accepted: 05/03/2017] [Indexed: 11/16/2022]
Abstract
This second article in the series on pragmatic trials describes the challenges in selection of sites for pragmatic clinical trials and the impact on validity, precision, and generalizability of the results. The selection of sites is an important factor for the successful execution of a pragmatic trial and impacts the extent to which the results are applicable to future patients in clinical practice. The first step is to define usual care and understand the heterogeneity of sites, patient demographics, disease prevalence and country choice. Next, specific site characteristics are important to consider such as interest in the objectives of the trial, the level of research experience, availability of resources, and the expected number of eligible patients. It can be advisable to support the sites with implementing the trial-related activities and minimize the additional burden that the research imposes on routine clinical practice. Health care providers should be involved in an early phase of protocol development to generate engagement and ensure an appropriate selection of sites with patients who are representative of the future drug users.
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Affiliation(s)
- Sally D Worsley
- Real World Evidence, GSK R&D, Gunnels Wood Road, Stevenage, Hertfordshire SG12NY, UK.
| | - Katrien Oude Rengerink
- Julius Center for Health Sciences and Primary Care, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
| | - Elaine Irving
- Real World Evidence, GSK R&D, Gunnels Wood Road, Stevenage, Hertfordshire SG12NY, UK
| | - Stephane Lejeune
- European Organisation for Research and Treatment of Cancer, 83 Avenue Mounier, Brussels 1200, Belgium
| | - Koen Mol
- EMEA Medical Affairs, Janssen Pharmaceutica NV, Turnhoutseweg 30, Beerse 2340, Belgium
| | - Sue Collier
- Respiratory Therapeutic Area, GSK R&D, Stockley Park West, 1-3 Ironbridge Road, Uxbridge, Middlesex UB11 1BT, UK
| | - Rolf H H Groenwold
- Julius Center for Health Sciences and Primary Care, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
| | - Catherine Enters-Weijnen
- Julius Center for Health Sciences and Primary Care, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands; Department of Primary Care Research, Julius Clinical, Zeist 3703 CD, The Netherlands
| | - Matthias Egger
- Institute of Social and Preventive Medicine & Department of Clinical Research, Clinical Trials Unit, University of Bern, Finkenhubelweg 11, Bern CH-3012, Switzerland
| | - Thomas Rhodes
- Center for Observational and Real-world Evidence (CORE) - Pharmacoepidemiology, MSD, 351N. Sumneytown Pike, North Wales, PA 19454, USA
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Zuidgeest MG, Goetz I, Grobbee DE. PRECIS-2 in perspective: what is next for pragmatic trials? J Clin Epidemiol 2017; 84:22-24. [DOI: 10.1016/j.jclinepi.2016.02.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 02/29/2016] [Indexed: 12/17/2022]
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Egan BM, Laken MA, Sutherland SE, Qanungo S, Fleming DO, Cook AG, Hester WH, Jones KW, Jebaily GC, Valainis GT, Way CF, Wright MB, Davis RA. Aldosterone Antagonists or Renin-Guided Therapy for Treatment-Resistant Hypertension: A Comparative Effectiveness Pilot Study in Primary Care. Am J Hypertens 2016; 29:976-83. [PMID: 27076600 DOI: 10.1093/ajh/hpw016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 01/31/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Uncontrolled treatment-resistant hypertension (TRH), i.e., blood pressure (BP, mm Hg) ≥140/≥90mm Hg in and out of office on ≥3 different BP medications at optimal doses, is common and has a poor prognosis. Aldosterone antagonist (AA) and renin-guided therapy (RGT) are effective strategies for improving BP control in TRH but have not been compared. METHODS A comparative effectiveness TRH pilot study of AA vs. RGT was conducted in 4 primary care clinics with 2 each randomized to AA or RGT. The primary outcome was change in clinic BP defined by means of 5 automated office BP values. Eighty-nine patients with apparent TRH were screened and 44 met criteria for true TRH. RESULTS Baseline characteristics of 20 patients in the AA (70% Black, 45% female, mean age: 57.4 years) and 24 patients in RGT (79% Black, 50% female, 57.8 years) arms were similar with baseline BP 162±5/90±3 vs. 153±3/84±3, respectively, P = 0.11/0.20. BP declined to 144±5/86±4 in AA vs. 132±4/75±3 in RGT, P = 0.07/0.01; BP was controlled to JNC7 (Seventh Joint National Committee Report) goal in 25% vs. 62.5%, respectively, P < 0.01. Although BP changes from baseline, the primary outcome, were not different (-17.6±5.1/-4.0±3.0 AA vs. -20.4±3.8/-9.7±2.0 RGT, P = 0.65/0.10.), more BP medications were added with AA than RGT (+0.9±0.1 vs. +0.4±0.1 per patient, P < 0.01). CONCLUSIONS In this TRH pilot study, AA and RGT lowered BP similarly, although fewer additional medications were required with RGT. A larger comparative effectiveness study could establish the utility of these treatment strategies for lowering BP of uncontrolled TRH patients in primary care.
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Affiliation(s)
- Brent M Egan
- Care Coordination Institute, Greenville Health System, Greenville, South Carolina, USA; University of South Carolina School of Medicine-Greenville, Greenville, South Carolina, USA;
| | - Marilyn A Laken
- College of Nursing, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Susan E Sutherland
- Care Coordination Institute, Greenville Health System, Greenville, South Carolina, USA
| | - Suparna Qanungo
- College of Nursing, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Douglas O Fleming
- Care Coordination Institute, Greenville Health System, Greenville, South Carolina, USA; University of South Carolina School of Medicine-Greenville, Greenville, South Carolina, USA
| | - Anne G Cook
- Department of Family Medicine, AnMed Health, Anderson, South Carolina, USA
| | - William H Hester
- Department of Family Medicine, McLeod Regional Medical Center, Florence, South Carolina, USA
| | - Kelly W Jones
- Department of Family Medicine, McLeod Regional Medical Center, Florence, South Carolina, USA
| | - Gerard C Jebaily
- Department of Family Medicine, McLeod Regional Medical Center, Florence, South Carolina, USA
| | | | - Charles F Way
- Family Diagnostic Associates, Holly Hill, South Carolina, USA
| | - Mary Beth Wright
- Department of Family Medicine, AnMed Health, Anderson, South Carolina, USA
| | - Robert A Davis
- Care Coordination Institute, Greenville Health System, Greenville, South Carolina, USA
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Buonaiuto G, De Mori V, Braus A, Balini A, Berzi D, Carpinteri R, Forloni F, Meregalli G, Ronco GL, Bossi AC. PERS&O (PERsistent Sitagliptin treatment & Outcomes): observational retrospective study on cardiovascular risk evolution in patients with type 2 diabetes on persistent sitagliptin treatment. BMJ Open Diabetes Res Care 2016; 4:e000216. [PMID: 27486519 PMCID: PMC4947782 DOI: 10.1136/bmjdrc-2016-000216] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 05/15/2016] [Accepted: 05/31/2016] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES The UK Prospective Diabetes Study (UKPDS) Risk Engine (RE) provides the best risk estimates available for people with type 2 diabetes (T2D), so it was applied to patients on persistent sitagliptin treatment. DESIGN A 'real-world' retrospective, observational, single-center study. SETTING The study was performed in a general hospital in Northern Italy in order: (1) to validate UKPDS RE in a cohort of Italian participants with T2D without prespecified diabetes duration, with/without cardiovascular (CV) disease, treated with sitagliptin; (2) to confirm CV risk gender difference; (3) to evaluate the effect on metabolic control and on CV risk evolution obtained by 'add-on' persistent sitagliptin treatment. PARTICIPANTS Sitagliptin 100 mg once a day was taken by 462 participants with T2D: 170 of them (males: 106; age: 63.6±8.8; T2D duration: 11.58±7.33; females: 64; age: 65.6±7.95; T2D duration 13.5±7.9) were treated for 48 months with the same dosage. INTERVENTIONS An analysis of normality was performed both for continuous, and for groups variables on UKPDS RE percentage values, defining the requirement of a base log10 transformation to normalize risk factor values for analysis validation. RESULTS The evaluation of CV risk evolution by gender (t-test) confirmed the expected statistical difference (p<0.0001). Sitagliptin obtained significant results after 12 months, and at the end of the observation, both on metabolic control (expressed by glycated hemoglobin) and on UKPDS RE. Analysis of variance test revealed a significant effect on CV risk after 12 months (p=0.003), and after 48 months (p=0.04). A bivariate correlation analysis revealed a correlation index (r)=0.2 between the two variables (p<0.05). CONCLUSIONS These 'real-world' data obtained applying UKPDS RE may reflect patients' and clinicians' interest in realizing individual CV risk, and its evolution. Sitagliptin-persistent treatment for a medium-long period obtained an improvement on metabolic control, as well as a reduction on CV risk.
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Affiliation(s)
| | | | | | | | - Denise Berzi
- Endocrine Unit, Diabetes Regional Center, Treviglio, Italy
| | | | - Franco Forloni
- Endocrine Unit, Diabetes Regional Center, Treviglio, Italy
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Carrera PM, Lambooij MS. Implementation of Out-of-Office Blood Pressure Monitoring in the Netherlands: From Clinical Guidelines to Patients' Adoption of Innovation. Medicine (Baltimore) 2015; 94:e1813. [PMID: 26512579 PMCID: PMC4985393 DOI: 10.1097/md.0000000000001813] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Out-of-office blood pressure monitoring is promoted by various clinical guidelines toward properly diagnosing and effectively managing hypertension and engaging the patient in their care process. In the Netherlands, however, the Dutch cardiovascular risk management (CVRM) guidelines do not explicitly prescribe 24-hour ambulatory blood pressure measurement (ABPM) and home BP measurement (HBPM). The aim of this descriptive study was to develop an understanding of patients' and physicians' acceptance and use of out-of-office BP monitoring in the Netherlands given the CVRM recommendations.Three small focus group discussions (FGDs) with patients and 1 FGD with physicians were conducted to explore the mechanisms behind the acceptance and use of out-of-office BP monitoring and reveal real-world challenges that limit the implementation of out-of-office BP monitoring methods. To facilitate the FGDs, an analytical framework based on the technology acceptance model (TAM), the theory of planned behavior and the model of personal computing utilization was developed to guide the FGDs and analysis of the transcriptions of each FGD.ABPM was the out-of-office BP monitoring method prescribed by physicians and used by patients. HBPM was not offered to patients even with patients' feedback of poor tolerance of ABPM. Even as there was little awareness about HBPM among patients, there were a few patients who owned and used sphygmomanometers. Patients professed and seemed to exhibit self-efficacy, whereas physicians had reservations about (all of their) patients' self-efficacy in properly using ABPM. Since negative experience with ABPM impacted patients' acceptance of ABPM, the interaction of factors that determined acceptance and use was found to be dynamic among patients but not for physicians.In reference to the CVRM guidelines, physicians implemented out-of-office BP monitoring but showed a strong preference for ABPM even where there is poor tolerance of the method. We found that physicians' positive attitude to ABPM enabled the use of the method by patients which, in turn, impeded the diffusion of HBPM. For patients, the acceptance process of HBPM can only begin after the physician has adopted the innovation. Physicians are in a position to encourage as well as hinder out-of-office BP monitoring and self-management.
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Affiliation(s)
- Pricivel M Carrera
- From the National Institute for Public Health and the Environment (RIVM), Department Quality of Care and Health Economics, Center for Nutrition, Prevention and Health Services, Bilthoven, The Netherlands
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