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Identified organisational aspects stressed the importance of organisational embedding of improvement of pain management. However, change of clinical practice requires a comprehensive approach focused at all five concepts. We think a shift in attitudes is needed, together with constant surveillance and feedback to emergency care providers. Implementation efforts need to be aimed at the identified barriers and facilitators, tailored to the chain of emergency care and the multi-professional group of emergency care providers.

The aim of this prospective study was to detect subjects in the general population with objective signs of chronic obstructive pulmonary disease (COPD) or asthma at an early stage. This was done by means of a two-stage protocol involving screening and a subsequent 2-yr monitoring of all subjects with positive results of screening. The study was done in 10 general practices located in the eastern part of the Netherlands. A random sample was taken from the general population aged 25 to 70 yr. All known COPD and asthma patients were excluded. A total of 1,749 subjects met the inclusion criteria: 1,155 subjects (66%) agreed to participate in the screening stage of the study. A total of 604 subjects (52.3%) showed symptoms or objective signs of COPD or asthma during the screening and were considered "positive." Of those with positive screening results, 384 subjects (64%) agreed to participate in the second, 2-yr monitoring stage of the study. The costs involved in detection were calculated for three different scenarios, as follows: (1) The detection of subjects with persistently decreased lung function or an increased level of bronchial hyperresponsiveness (BHR) during 6 mo of monitoring; (2) Scenario 1 plus the detection of subjects with a rapid decline in lung function with signs of BHR during 12 mo of monitoring; (3) Scenario 2 plus the detection of subjects with a moderate increase in the decline in lung function or signs of BHR during 24 mo of monitoring. The costs of lung function assessments, organization, transportation, and patient time were included. The costs were converted to United States dollars on the basis of purchasing power (1 United States dollar = 2.08 Netherlands guilders). During the second stage, 252 subjects were detected with objective signs of COPD or asthma at an early stage. Smoking status as a screening criterion was neither sensitive nor specific. Because there was no evidence of biased recruitment or selection during the program, the proportions of subjects found to have objective signs of COPD or asthma at an early stage could be extrapolated to the general population. Of the general population, 7.7% showed persistently reduced lung function or increased BHR. Another 12.5 % of the general population showed a rapid decline in lung function (> 80 ml/yr) in combination with signs of BHR, and a further 19.4% of the general population showed mild objective signs of COPD or asthma. The average costs per detected case varied from US$953 (Scenario 1) to US$469 (Scenario 3). In conclusion, detection of COPD or asthma at an early stage by means of a two-stage protocol was feasible at relatively little expense in comparison with other mass screening programs. Persistently decreased lung function or a rapid decline in lung function (Scenario 2) was observed in approximately 20% of the general adult population.

Adding beclomethasone, 800 micrograms daily, slowed the unfavorable course of asthma or COPD seen with bronchodilator therapy alone. This effect was most evident in asthmatic patients.

Prevalence of pain in trauma was high, and without consistent "objective" reporting of pain it is difficult to evaluate the effectiveness of pain management, despite the adherence to clinical practice guideline or protocol. Paramedics need to elicit and report validated pain measurements.

Conclusions-This meta-analysis in patients with clearly defined moderately severe COPD showed a beneficial course of FEV 1 during two years of treatment with relatively high daily dosages of inhaled corticosteroids.

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BackgroundNot all patients where an ambulance is dispatched are conveyed to an emergency department. Although non-conveyance is a substantial part of ambulance care, there is limited insight in the non-conveyance patient population. Therefore, the study aim was to compare demographics, initial on-scene reasons for care, and vital signs between conveyed and non-conveyed patients attended by an ambulance.MethodsA retrospective study of ambulance runs from 2 EMS regions in the Netherlands in 2016 was performed. For each ambulance run demographics (age, gender and geographical location), initial reasons for care categorised into the ICD-10 classification system, and vital functions or observational scales (according to the national ambulance care protocol) were collected and analyzed.Results54.797 ambulance runs met the inclusion criteria, of which 14.383/54.797 (26.2%) resulted in non-conveyance. There was no significant difference in gender, but the non-conveyance group was significantly younger (48.5 (±26.4) years) compared to the conveyance group (60.7 (±22.2) years) (p = .000). The most common initial reasons for care for the conveyance group could be classified into chapter-9 diseases of the circulatory system, chapter-19 injury, poisoning and certain other consequences of external causes, and chapter-10 diseases of the respiratory system. The most common reasons for care in the non-conveyance group could be classified into the chapter-9 diseases of the circulatory system, chapter-19 injury, poisoning and certain other consequences of external causes, and -chapter-5 mental, behavioral and neurodevelopmental disorders. The total percentage abnormal vital functions/observation scales between the conveyance (69.5%) and non-conveyance group (58.6%) was significantly different (p = .000). 15 out of 17 vital functions/observation scales are significantly different between the conveyance and non-conveyance group.ConclusionsThis study shows that non-conveyed patients are younger, are more likely to be in (highly) rural areas, and more often have initial reasons for care related to mental, behavioral and neurodevelopmental disorders (ICD-10 chapter 5). Although abnormal vital functions/observation scale were more prevalent in the conveyance group, 58.6% of the non-conveyed patients had at least one abnormal vital function/observation scale.