Explore the vast range of titles available.

\"Innovation in the Public Sector addresses issues relevant to an understanding of the innovation journeys on which public organizations have embarked. If public innovation is defined as a necessary condition for establishing meaningful interactions between the government and society, what are the relevant issues that may explain successful processes and forms of public innovation?\"-- Provided by publisher.

The public sector may be considered as a highly fragmented and at the same time enormously interconnected system. Resources are dispersed among a huge variety of actors and entities and these affect each other in many unexpected ways. This book analyses the apparently paradoxical occurrence of simultaneous fragmentation and interconnectivity within the public domain and reflects on its consequences for public governance and management. It discusses and assesses strategies to create connective capacities from different policy domains and countries and offers new insights in the complexity of public governance. About the Editors: Menno Fenger is associate professor in public administration at Erasmus University Rotterdam. He has published widely on issues of public governance and implementation, specifically in the area of social policies. Victor Bekkers is professor of public administration at Erasmus University Rotterdam and academic director of the Center for Public Innovation. He specializes in the impact of information and communication technology, including social media, on public governance. He is the author of numerous books and articles on this topic.

The modernization of public administration is a recurring theme on the political and public agenda in many countries. Modernization presupposes innovation. However, is an innovative public administration a contradiction in terminis? If we look at the practice of public administration, and evaluate - from an evolutionary perspective - how public administration has transformed itself during the last 40 years, we actually see a variety of radical and incremental changes. Hence, innovation does take place. This book clearly demonstrates how public administration organizations try to adapt to changing circumstances in their environment in order to secure their legitimacy. At the same time we see that public administration tries to respond and anticipate to new technological developments as well as to make use of them. In many countries e-government has become the symbol of the way in which ICT has penetrated in the nerves of ministries, local and regional government and all kinds of agencies. In this publication, a number of case studies have been presented in which different kind of ICT-driven innovations have been described and analyzed.

Human papillomavirus (HPV) testing on self-collected samples is a potential alternative to HPV testing on clinician-collected samples, but non-inferiority of its clinical accuracy remains to be assessed in the regular screening population. The IMPROVE study was done to evaluate the clinical accuracy of primary HPV testing on self-collected samples within an organised screening setting. In this randomised, non-inferiority trial, women aged 29–61 years were invited to participate in the study as part of their regular screening invitation in the Netherlands. Women who provided informed consent were randomly allocated (1:1, with a block size of ten stratified by age) to one of two groups: a self-sampling group, in which women were requested to collect their own cervicovaginal sample using an Evalyn Brush (Rovers Medical Devices BV, Oss, Netherlands); or a clinician-based sampling group, in which samples were collected by a general practitioner with a Cervex-Brush (Rovers Medical Devices BV). All samples were tested for HPV using the clinically validated GP5+/6+ PCR enzyme immunoassay (Labo Biomedical Products BV, Rijswijk, Netherlands). HPV-positive women in both groups were retested with the other collection method and triaged by cytology and repeat cytology in accordance with current Dutch screening guidelines. Primary endpoints were detection of cervical intraepithelial neoplasia (CIN) of grade 2 or worse (CIN2+) and grade 3 or worse (CIN3+). Non-inferiority of HPV testing on self-collected versus clinician-collected samples was evaluated against a margin of 90% for the relative sensitivity and 98% for the relative specificity. This study is registered at the Dutch Trial register (NTR5078) and has been completed. Of the 187 473 women invited to participate, 8212 were randomly allocated to the self-sampling group and 8198 to the clinician-based sampling group. After exclusion of women who met the exclusion criteria or who did not return their sample, 7643 women were included in the self-sampling group and 6282 in the clinician-based sampling group. 569 (7·4%) self-collected samples and 451 (7·2%) clinician-collected samples tested positive for HPV (relative risk 1·04 [95% CI 0·92–1·17]). Median follow-up duration for HPV-positive women was 20 months (IQR 17–22). The CIN2+ sensitivity and specificity of HPV testing did not differ between self-sampling and clinician-based sampling (relative sensitivity 0·96 [0·90–1·03]; relative specificity 1·00 [0·99–1·01]). For the CIN3+ endpoint, relative sensitivity was 0·99 (0·91–1·08) and relative specificity was 1·00 (0·99–1·01). HPV testing done with a clinically validated PCR-based assay had similar accuracy on self-collected and clinician-collected samples in terms of the detection of CIN2+ or CIN3+ lesions. These findings suggest that HPV self-sampling could be used as a primary screening method in routine screening. Ministry of Health, Welfare, and Sport (Netherlands), and the European Commission.

Background: Primary high-risk human papillomavirus (hrHPV) testing in cervical cancer screening shows relatively low specificity, which makes triage testing necessary. In this study, DNA methylation analysis was compared with cytology for triage testing in hrHPV-positive women. Moreover, feasibility of DNA methylation analysis directly on brush-based self-sampled specimens was assessed. Methods: Non-responding women from population-based screening were invited to self-collect a cervico-vaginal specimen for hrHPV testing; hrHPV-positive women were referred to a physician for triage liquid-based cytology. DNA methylation analysis was performed on 128 hrHPV-positive physician-collected triage samples and 50 matched brush self-samples with QMSP for C13ORF18 , EPB41L3 , JAM3 and TERT. Results: In physician-taken triage material, DNA methylation analysis of JAM3 showed the highest combined specificity (88%) and sensitivity (82%) for detection of CIN3+, whereas cytology showed a specificity of 48% and a sensitivity of 91%. Out of 39 women with abnormal cytology and normal histology (false-positive by cytology), 87% were negative for JAM3 and 90% for C13ORF18 methylation. Agreement between DNA methylation analysis performed directly on the matched self-sampled material and physician-taken samples was 88% for JAM3 ( κ =0.75, P <0.001) and 90% for C13ORF18 ( κ =0.77; P <0.001). Conclusions: DNA methylation analysis as a triage test in hrHPV-positive women is an attractive alternative to cytology. Furthermore, DNA methylation is feasible directly on brush-based self-samplers and showed good correlation with matched physician-taken samples. Direct molecular triage on self-collected specimens could optimise the screening program, especially for non-responders, as this would eliminate the need for an additional physician-taken scraping for triage testing.

Cytology is a widely used method of triaging women who test positive for human papillomavirus (HPV). However, self-sampled specimens, which can substantially increase participation in screening programmes, are not suitable for accurate cytological assessment. We investigated whether direct DNA methylation-based molecular triage on self-sampled cervicovaginal specimens was non-inferior to cytology triage on additional physician-collected cervical samples in the detection of cervical intraepithelial neoplasia grade 2 (CIN2) or worse in women who did not attend cervical screening programmes. In this randomised controlled non-inferiority trial, we invited women (aged 33–63 years) registered as non-attendees of cervical screening in the Netherlands in 2007 to submit a self-collected cervicovaginal sample for HPV testing. Using a computer-generated sequence, we randomly allocated women who tested positive for high-risk hrHPV on a self-sample to either triage by cytology on an additional physician-taken smear or direct triage on the self-sample by methylation analysis of MAL and miR-124-2 genes (1:1; stratified by age and region, with block sizes by age group). Triage-positive women in either group were referred for colposcopy. The primary endpoint was detection of CIN2 or worse, analysed by intention to treat. The non-inferiority margin was 0·80. This study is registered in the Primary Trial Register of the Netherlands, number NTR6026. We invited 46 001 women to participate, 12 819 of whom returned self-sampled material; 1038 samples tested positive for high-risk HPV. Between Nov 1, 2010, and Dec 31, 2011, after exclusion of women who were ineligible, we enrolled and randomly allocated 515 women to methylation triage and 509 to cytology triage. The detection of CIN2 or worse with methylation triage was non-inferior to that with cytology triage (90 [17%] of 515 women vs 75 [15%] of 509 women; relative risk 1·19, 95% CI 0·90–1·57). Referral for colposcopy was more common in the molecular group (284 [55%] women) than in the cytology group (149 [29%] women; p<0·0001). Mean time to CIN2 or worse diagnosis was shorter in the molecular triage group (96 days, range 44–101) than in the cytology triage group (158 days, 71–222; p=0·00084). DNA methylation analysis of MAL and miR-124-2 genes on HPV-test-positive self-samples is non-inferior to cytology triage in the detection of CIN2 or worse, opening the way to full molecular screening. Midden-West and Oost Screening Organisations and Stichting Achmea Gezondheidszorg.

Background Older age of women is strongly associated with reduced fertility and early pregnancy complications. These associations might also be present across the full range of reproductive age of both women and men. We assessed the associations of age of women and men with time to pregnancy and miscarriage risk. Methods This population-based prospective cohort study was conducted in Rotterdam, the Netherlands. A total of 3604 women and their partners were included from the preconception period onwards with follow-up until birth. For this study, participants were followed until conception or 22 weeks of pregnancy for the time to pregnancy and miscarriage analyses, respectively. Outcomes included fecundability, defined as the per-month probability of conceiving; infertility, defined as a time to pregnancy or duration of pursuing pregnancy of more than 12 months or use of assisted reproductive technology; and miscarriage, defined as pregnancy loss before 22 weeks of gestation. Results In total, 18.1% of the population was infertile and 12.7% of all recognized pregnancies led to a miscarriage. As compared to women aged 30.0–34.9 years, those aged < 25.0, 25.0–29.9, and ≥ 40.0 years had increased odds of infertility (odds ratio (OR) 2.14 (95% confidence interval (CI), 1.60–2.87); OR 1.27 (95% CI, 1.05–1.53); and OR 2.00 (95% CI, 1.05–3.80), respectively). Women aged 35.0–39.9 years had no increased odds of infertility. Similar results were observed for fecundability. As compared to women aged 30.0–34.9 years at conception, those aged 35.0–39.9 and ≥ 40.0 years had strongly increased odds of miscarriage (OR 2.03 (95% CI, 1.51–2.72) and 4.24 (95% CI, 2.45–7.36), respectively). As compared to men aged 30.0–34.9 years, those aged < 25.0 years had lower fecundability (fecundability ratio (FR) 0.71 (95% CI, 0.58–0.87)). As compared to men aged 30.0–34.9 years, those aged ≥ 40.0 years had the highest odds of miscarriage (OR, 2.09 (95% CI, 1.39–3.14)). Conclusions Age among both women and their partners is a strong risk factor for adverse fertility and early pregnancy outcomes. Strategies optimizing age at which couples start family planning, focusing on both women and men, will have a great individual and public health impact.

ObjectivesImaging is increasingly used to assess lymph node involvement in clinically early-stage cervical cancer. This retrospective study aimed to evaluate the diagnostic accuracy of MRI, CT, and [18F]FDG-PET-CT.MethodsWomen with International Federation of Gynaecology and Obstetrics (FIGO) 2009 stage IA2-IIA cervical cancer and pretreatment imaging between 2009 and 2017 were selected from the Netherlands Cancer Registry. Patient-based and region-based (i.e. pelvic and common iliac) nodal status was extracted from radiology reports. Pathology results were considered the reference standard for calculating accuracy indices. Multiple imputation was used for missing pathology to limit verification bias risk.ResultsNodal assessment was performed in 1676 patients with MRI, 926 with CT, and 379 with [18F]FDG-PET-CT, with suspicious nodes detected in 17%, 16%, and 48%, respectively. [18F]FDG-PET-CT was used to confirm MRI/CT results in 95% of patients. Pathology results were imputed for 30% of patients. [18F]FDG-PET-CT outperformed MRI and CT in detecting patient-based nodal metastases with sensitivities of 80%, 48%, and 40%, and AUCs of 0.814, 0.706, and 0.667, respectively, but not in specificity: 79%, 92%, and 92%. Region-based analyses showed similar indices in the pelvic region, but worse performance in the common iliac region with AUCs of 0.575, 0.554, and 0.517, respectively.Conclusions[18F]FDG-PET-CT outperformed MRI and CT in detecting nodal metastases, which may be related to its use as a verification modality. However, MRI and CT had the highest specificity. As MRI is generally performed routinely to assess local and regional spread of cervical cancer, [18F]FDG-PET-CT can be used to confirm suspicious nodes.Critical relevance statementAccurate assessment of the nodal status in clinically early-stage cervical cancer is essential for tumour staging, treatment decision making and prognosis.Key points• The accuracy of MRI, CT or [18F]FDG-PET-CT for nodal staging in early cervical cancer is a subject of discussion.• Overall, [18F]FDG-PET-CT outperformed MRI, followed by CT, when used as a verification modality.• Staging with MRI and the addition of [18F]FDG-PET-CT to verify high-risk cases seems to be a good approach.

The efficacy of an implantable cardioverter-defibrillator (ICD) in patients with a non-ischaemic cardiomyopathy for primary prevention of sudden cardiac death is increasingly debated. We developed a multimodal deep learning model for arrhythmic risk prediction that integrated late gadolinium enhanced (LGE) cardiac magnetic resonance imaging (MRI), electrocardiography (ECG) and clinical data. Short-axis LGE-MRI scans and 12-lead ECGs were retrospectively collected from a cohort of 289 patients prior to ICD implantation, across two tertiary hospitals. A residual variational autoencoder was developed to extract physiological features from LGE-MRI and ECG, and used as inputs for a machine learning model (DEEP RISK) to predict malignant ventricular arrhythmia onset. In the validation cohort, the multimodal DEEP RISK model predicted malignant ventricular arrhythmias with an area under the receiver operating characteristic curve (AUROC) of 0.84 (95% confidence interval (CI) 0.71–0.96), a sensitivity of 0.98 (95% CI 0.75–1.00) and a specificity of 0.73 (95% CI 0.58–0.97). The models trained on individual modalities exhibited lower AUROC values compared to DEEP RISK [MRI branch: 0.80 (95% CI 0.65–0.94), ECG branch: 0.54 (95% CI 0.26–0.82), Clinical branch: 0.64 (95% CI 0.39–0.87)]. These results suggest that a multimodal model achieves high prognostic accuracy in predicting ventricular arrhythmias in a cohort of patients with non-ischaemic systolic heart failure, using data collected prior to ICD implantation.