Review: Targeted nutrition in gestating sows: opportunities to enhance sow performance and piglet vitality

Birth weight is a key factor for piglet survival, and therefore, there is ongoing interest in how nutrition during gestation can influence birth weight. Interestingly, sows are generally fed one single diet throughout gestation. This paper reviews past attempts to increase foetal growth to term and discusses opportunities to target nutritional manipulations at specific windows of gestation where key developmental events occur. Birth weight limits chances to survive mainly in piglets with birth weight below 1 kg. These piglets represent around 16% of the population. Given the normal distribution of birth weight, the mean birth weight needs to be increased by at least 50-100 g to have a meaningful impact on this proportion of the population and on perinatal survival. Based on existing variation in reported mean birth weight across a number of studies, it is argued that it is unrealistic to expect an increase in mean birth weight of more than 100 g. Attempts in the past to increase birth weight have focussed on the last trimester of gestation, when foetal growth is accelerated. Increase in feed allowance or nutritional concepts that target placenta vascularisation have not been successful. It is argued that nutritional manipulations should rather focus on the middle of gestation, since in that period, placenta growth occurs and since placenta size limits the foetal size. Alternatively, nutritional manipulations can target placentation during the embryonic phase.

Effect of low colostrum intake on gastrointestinal development and uterine and cervical morphometrical architecture in the neonatal gilt

To assess the importance of natural variation in colostrum intake on piglet gastrointestinal and reproductive development, two equally sized female piglets from each of 27 litters were selected, one with low (average 226 g) and one with high (average 401 g) colostrum intake. At weaning (23 d of age), piglets were euthanised to perform macromorphological measurements on ileum, colon, cervix and uterus tissues, and to obtain tissue samples from the cervix and uterus for histology. Sections of uterine and cervical preparations were analysed using digital image analysis. Despite being selected for the same birth weight (average 1.1 kg, standard deviation 0.18 kg), piglets with low colostrum intake weighed 5.91 ± 0.17 kg and piglets with high colostrum intake weighed 6.96 ± 0.19 kg at weaning (P < 0.05). Most of the micro- and macroscopic measures such as length and weight of ileum and colon, cervix and uterus, luminal size of cervix and uterus, number of cervical crypts and uterine glands, were greater in gilts with high colostrum intake. The histological architecture of the uterus and cervix in gilts with high colostrum intake showed more complexity, reflecting more advanced development in these piglets. In conclusion, these data demonstrate that independent of birth weight, natural variation in colostrum intake is related to the overall development of neonatal piglets, affecting body growth, as well as growth and development of the gut and reproductive tract.

Symptom monitoring in cancer and fully automated advice on supportive care: Patients' perspectives on self-management strategies and the eHealth self-management application Oncokompas

Objective

The web‐based application Oncokompas was developed to support cancer patients to self‐manage their symptoms. This qualitative study was conducted to obtain insight in patients' self‐management strategies to cope with cancer and their experiences with Oncokompas as a fully automated behavioural intervention technology.

Methods

Data were collected from semi‐structured interviews with 22 participants (10 head and neck cancer survivors and 12 incurably ill patients). Interview questions were about self‐management strategies and experiences with Oncokompas. Interviews were audio‐recorded, transcribed verbatim and analysed using thematic analysis.

Results

Participants applied several self‐management strategies, among which trying to stay in control and make the best of their situation. They described Oncokompas' added value: being able to monitor symptoms and having access to a personal online library. Main reasons for not using Oncokompas were concentration problems, lack of time or having technical issues. Recommendations were made for further development of Oncokompas, relating to its content, technical and functional aspects.

Conclusions

Survivors and incurably ill patients use various self‐management strategies to cope with cancer. The objectives of self‐management interventions as Oncokompas correspond well with these strategies: taking a certain responsibility for your well‐being and being in charge of your life as long as possible by obtaining automated information (24/7) on symptoms and tailored supportive care options.

Tailored implementation of internet-based cognitive behavioural therapy in the multinational context of the ImpleMentAll project: a study protocol for a stepped wedge cluster randomized trial

BACKGROUND

Internet-based Cognitive Behavioural Therapy (iCBT) is found effective in treating common mental disorders. However, the use of these interventions in routine care is limited. The international ImpleMentAll study is funded by the European Union's Horizon 2020 programme. It is concerned with studying and improving methods for implementing evidence-based iCBT services for common mental disorders in routine mental health care. A digitally accessible implementation toolkit (ItFits-toolkit) will be introduced to mental health care organizations with the aim to facilitate the ongoing implementation of iCBT services within local contexts. This study investigates the effectiveness of the ItFits-toolkit by comparing it to implementation-as-usual activities.

METHODS

A stepped wedge cluster randomized controlled trial (SWT) design will be applied. Over a trial period of 30 months, the ItFits-toolkit will be introduced sequentially in twelve routine mental health care organizations in primary and specialist care across nine countries in Europe and Australia. Repeated measures are applied to assess change over time in the outcome variables. The effectiveness of the ItFits-toolkit will be assessed in terms of the degree of normalization of the use of the iCBT services. Several exploratory outcomes including uptake of the iCBT services will be measured to feed the interpretation of the primary outcome. Data will be collected via a centralized data collection system and analysed using generalized linear mixed modelling. A qualitative process evaluation of routine implementation activities and the use of the ItFits-toolkit will be conducted within this study.

DISCUSSION

The ImpleMentAll study is a large-scale international research project designed to study the effectiveness of tailored implementation. Using a SWT design that allows to examine change over time, this study will investigate the effect of tailored implementation on the normalization of the use of iCBT services and their uptake. It will provide a better understanding of the process and methods of tailoring implementation strategies. If found effective, the ItFits-toolkit will be made accessible for mental health care service providers, to help them overcome their context-specific implementation challenges.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03652883 . Retrospectively registered on 29 August 2018.

Implementation of a shared care guideline for back pain: effect on unnecessary referrals

Objective

To determine the effect of the implementation of a shared care guideline for the lumbosacral radicular syndrome (LRS) on unnecessary early referrals and the duration of the total diagnostic procedure.

Design

Introduction of shared care guideline in November 2005. Pre-test in 2005 (April to October), a first post-test in 2006 (April to October) and a second post-test in 2007 (April to October).

Setting and Intervention

The introduction of a shared care guideline derived from national guidelines for GPs and several medical/paramedical specialists in two Dutch regions. Three hundred and sixty GPs, 550 physiotherapists and two hospitals (9 neurologists and 18 radiologists) were involved. The essential component of the guideline was a trade-off: if the GP complied with the conservative management approach in the first 6 weeks, the hospital guaranteed a priority appointment with the neurologist after 6 weeks, if still required.

Main Outcome Measures

The neurologists in both hospitals registered whether a patient had been unnecessarily referred during the first 6 weeks. The duration of the total diagnostic procedure was defined as the number of days between referral by the GP and the consultation when the neurologist made the final diagnosis.

Results

The percentage of patients being unnecessarily referred within 6 weeks fell significantly from 15% in 2005 to 9% in 2006 and 8% in 2007. The duration of the total diagnostic procedure also fell significantly in both the long and short terms.

Conclusions

The introduction of a shared care guideline for all care providers in a region reduces the number of unnecessary early referrals for patients with LRS.

Guidelines on anaemia: effect on primary-care midwives in The Netherlands

OBJECTIVE

To assess the adherence and perceived barriers for implementation of a clinical-practice guideline on anaemia, which was the first national guideline for primary-care midwifery in The Netherlands.

DESIGN

Cross-sectional survey study.

SETTING

Primary-care midwifery in The Netherlands.

PARTICIPANTS

160 midwives (60% response rate).

MEASUREMENTS

Questionnaire on the knowledge of, and attitudes and self-reported adherence to, 14 key recommendations in the guideline; attitudes to guidelines in general; and perceived barriers to implementation.

FINDINGS

The number of midwives agreeing with and adhering to specific recommendations varied between 29 and 90%. Most midwives had a positive attitude to the guidelines. The most relevant general barriers were related to the behaviour of general practitioners and obstetricians (32% of the midwives reported this). Larger numbers of midwives mentioned barriers to specific aspects of the guideline, particularly alternative iron supplementation or dietary supplements (59%), and not prescribing iron supplementation if haemoglobin was low but mean corpuscular volume was normal (49%).

KEY CONCLUSIONS

The guideline on anaemia was well received by primary-care midwives in The Netherlands, but implementation of specific recommendations needs further attention.

IMPLICATIONS FOR PRACTICE

The study provides evidence for the national organisation of midwives to continue with the development and implementation of clinical guidelines.

Determinants of innovation within health care organizations: literature review and Delphi study

PURPOSE

When introducing innovations to health care, it is important to gain insight into determinants that may facilitate or impede the introduction, in order to design an appropriate strategy for introducing the innovation. To obtain an overview of determinants of innovations in health care organizations, we carried out a literature review and a Delphi study. The Delphi study was intended to achieve consensus among a group of implementation experts on determinants identified from the literature review.

DATA SOURCES

We searched 11 databases for articles published between 1990 and 2000. The keywords varied according to the specific database. We also searched for free text. Forty-four implementation experts (implementation researchers, programme managers, and implementation consultants/advisors) participated in the Delphi study.

STUDY SELECTION

The following studies were selected: (i) studies describing innovation processes, and determinants thereof, in health care organizations; (ii) studies where the aim of the innovations was to change the behaviour of health professionals; (iii) studies where the health care organizations provided direct patient care; and (iv) studies where only empirical studies were included.

DATA EXTRACTION

Two researchers independently selected the abstracts and analysed the articles. The determinants were divided into four categories: characteristics of the environment, characteristics of the organization, characteristics of the user (health professional), and characteristics of the innovation. When analysing the determinants, a distinction was made between systematically designed and non-systematically designed studies. In a systematic study, a determinant analysis was performed and the innovation strategy was adapted to these determinants. Furthermore, the determinants were associated with the degree of implementation, and both users and non-users of the innovation were asked about possible determinants. In the Delphi study, consensus was defined as agreement among 75% of the experts on both the influence of a determinant and the direction towards which that influence tended (i.e. facilitating, impeding, or neutral).

RESULTS

From the initial 2239 abstracts, 57 studies were retrieved and 49 determinants were identified that affected (impeded or facilitated) the innovation process. The experts identified one other determinant. Seventeen studies had a more-or-less systematic design; the others did not. After three rounds, consensus was reached on the influence of 49 out of 50 determinants.

CONCLUSION

The results of the literature review matched those found in the Delphi study, and 50 potentially relevant determinants of innovation processes were identified. Many of the innovation studies had several methodological flaws, such as not adjusting innovation strategies to relevant determinants of the innovation process, or that data on determinants were gathered only from non-users. Furthermore, the degree of implementation was evaluated in several ways, which made comparison difficult.

The effect of small peer group continuous quality improvement on the clinical practice of midwives in The Netherlands

OBJECTIVE

To study the effects of small group continuous quality improvement (CQI) on the clinical practice of midwives in the Netherlands.

DESIGN

Randomised pre-/post-test (balanced block).

INTERVENTION

The CQI groups were assigned to either the set of peer review topics including 'perineal repair' and 'artificial rupture of the membranes (ARM)', or to the set of topics including 'airway aspiration' and 'measuring blood pressure'. The two research groups acted as each other's control group.

SETTING

The Netherlands.

PARTICIPANTS

Two hundred and fifty-five individual midwives practising in primary and secondary care who made up 28 peer groups. MEASUREMENT AND KEY FINDINGS: Questionnaires were used to collect data on clinical practice prior to the start of the intervention and one year later. Pre- and post-test data were received from 156 respondents. The intervention had a positive effect on adherence to the recommendations with respect to airway aspiration of the baby and measuring blood pressure. For ARM, no difference was found between pre- and post-test adherence to recommendations in the intervention group, while in the control group, the percentage of midwives that adhered to the recommendations decreased in the period between pre- and post-test. No significant effect was found for perineal repair.

IMPLICATIONS FOR PRACTICE

Small group CQI had a positive effect on changing clinical practice when the learning of new skills (e.g. learning a new suturing technique) was not necessary. Additional interventions are needed when implementing guidelines that recommend the learning of new skills.

Do patients matter? Contribution of patient and care provider characteristics to the adherence of general practitioners and midwives to the Dutch national guidelines on imminent miscarriage

OBJECTIVE

To assess the relative contribution of patient and care provider characteristics to the adherence of general practitioners (GPs) and midwives to two specific recommendations in the Dutch national guidelines on imminent miscarriage. The study focused on performing physical examinations at the first contact and making a follow up appointment after 10 days because these are essential recommendations and there was much variation in adherence between different groups of providers.

DESIGN

Prospective recording by GPs and midwives of care provided for patients with symptoms of imminent miscarriage.

SETTING

General practices and midwifery practices in the Netherlands.

SUBJECTS

73 GPs and 38 midwives who agreed to adhere to the guidelines; 391 patients were recorded during a period of 12 months.

MAIN MEASURES

Adherence to physical examinations and making a follow up appointment were measured as part of a larger prospective recording study on adherence to the guidelines on imminent miscarriage. Patient and care provider characteristics were obtained from case recordings and interviews, respectively. Multilevel analysis was performed to assess the contribution of several care provider and patient characteristics to adherence to two selected recommendations: the number of recommended physical examinations at the first contact and the number of days before a follow up appointment took place.

RESULTS

In the multilevel model explaining variance in adherence to physical examinations, the care provider's acceptance of the recommendations was the most important factor. Severity of symptoms and referral to an obstetrician were significant factors at the patient level. In the model for follow up appointments the characteristics of the care provider were less important. Referral to an obstetrician and probability diagnosis were significant factors at the patient level.

CONCLUSIONS

The study showed that characteristics of both the patient and care provider contribute to the variability in adherence. Furthermore, the contribution of the characteristics differed per recommendation. It is therefore advised that the contribution of both patient and care provider characteristics per recommendation should be carefully examined. If implementation is to be successful, strategies should be developed to address these specific contributions.

Does the care given by general practitioners and midwives to patients with (imminent) miscarriage meet the wishes and expectations of the patients?

OBJECTIVE

In 1989 a Dutch national guideline on (imminent) miscarriage was developed for use in general practice. A prospective recording study was carried out to determine how the patients evaluated the care they received from general practitioners (GPs) and midwives who agreed to adhere to this (imminent) miscarriage guideline and to determine the aspects that influence this evaluation.

SETTING

GP practices and midwifery practices in The Netherlands.

DESIGN

Prospective recording of appointments during 4 consecutive weeks in a diary by patients who contacted their GP or midwife with symptoms of (imminent) miscarriage.

STUDY PARTICIPANTS

Over a period of 12 months, 75 GPs and 43 midwives recorded all patients (n = 407) showing symptoms of (imminent) miscarriage. In total 265 patients had completed at least the first contact in the diary; 200 patients actually recorded all contacts.

RESULTS

Most patients gave their GP or midwife a high evaluation score (8.2 or 8.7 respectively). Yet, 20% thought that the care could be improved if the GP or midwife gave more information, was more empathetic and carried out an ultrasound scan. In determining the aspects that have most influence on the patients' evaluation, empathy and support came first, followed by involvement of the patient in decision making, putting her at ease, and the total duration of the contacts. Although patients who wanted a referral gave a lower score, this seems to be of less importance than the above mentioned aspects. Expecting and getting an ultrasound scan did not influence the patient's evaluation.

The quality of the discharge planning process: the effect of a liaison nurse

A project employing a liaison nurse has been started in the Dutch Zaandam region. The liaison project will focus on the experience of problems in preparing for hospital discharge and on continuity between hospital and home care. This article discusses the effect of the liaison nurse on the quality of the discharge planning process. The investigation included a pre-test and a main test for which data were collected using questionnaires. These were sent to patients who had received after-care on being discharged from hospital. To measure the quality of the discharge process and after-care continuity, use was made of explicit quality criteria, targeting discharge planning. The results show that discharge planning in hospitals has improved. No significant improvement was detected with respect to continuity of care. It may be concluded that the discharge process requires more attention. The quality criteria used here could function as points of departure.

Adherence by midwives to the Dutch national guidelines on threatened miscarriage in general practice: a prospective study

OBJECTIVE

To determine the feasibility for midwives to adhere to Dutch national guidelines on threatened miscarriage in general practice.

DESIGN

Prospective recording of appointments by midwives who agreed to adhere to the guidelines on threatened miscarriage. Interviews with the midwives after they had recorded appointments for one year.

SETTING

Midwifery practices in The Netherlands.

SUBJECTS

56 midwives who agreed to adhere to the guidelines; 43 midwives actually made records from 156 clients during a period of 12 months.

MAIN OUTCOME MEASURES

Adherence to each recommendation and reasons for non-adherence.

RESULTS

The recommendation that a physical examination should take place on the first and also on the follow up appointment was not always adhered to. Reasons for non-adherence were the midwives' criticism of this recommendation, their lack of knowledge or skills, and the specific client situation. Adherence to a follow up appointment after 10 days, a counselling consultation after six weeks, and not performing an ultrasound scan was low. Reasons for non-adherence were mainly based on the midwives' criticism of these recommendations and reluctance on the part of the client. Furthermore, many midwives did not give information and instructions to the client. It is noteworthy that in 13% of the cases the midwife's policy was overridden by the obstetrician taking control of the situation after the midwife had requested an ultrasound scan.

CONCLUSIONS

Those recommendations in the guidelines on threatened miscarriage that are most often not adhered to should be reviewed. To reduce conflicts about ultrasound scans and referrals, agreement on the policy on threatened miscarriage should be mutually established between midwives and obstetricians.

Care for the imminent miscarriage by midwives and GPs

A postal questionnaire was sent to a random sample of 495 Dutch general practitioners (GPs) and 278 midwives to evaluate the use of the 'imminent miscarriage' standard used by the Dutch College of General Practitioners. The response rates were 63 and 87% respectively. The first questions asked related to the respondents' routine management of an imminent miscarriage. The second part of the questionnaire addressed the respondents' attitude to the 17 most important guidelines in the standard. Finally, the respondents were invited to describe problems arising in adhering to the standard. Midwives and GPs differed in their management of an imminent miscarriage. Midwives used more 'technology' such as ultrasound scans or a doptone to trace complications or see if the fetus was still viable, whereas the GPs more often carried out vaginal and speculum examinations. Midwives also paid more attention to care following a miscarriage. The guidelines that many respondents did not adhere to involved the period of 10 days for the follow-up appointment and counselling after 6 weeks. Guidelines restricting ultrasound scans and the decision only to refer the patients to an obstetrician after three consecutive miscarriages were also not accepted by all respondents. Respondents mentioned several practical problems or obstacles in adhering to the standard, including women's requests for ultrasound scans or referrals and also the attitude of obstetricians who sometimes simply assumed control. The results will serve as a starting point for updating the standard.