Year-by-Year Blood Pressure Variability From Midlife to Death and Lifetime Dementia Risk

Importance

High visit-to-visit blood pressure variability (BPV) in late life may reflect increased dementia risk better than mean systolic blood pressure (SBP). Evidence from midlife to late life could be crucial to understanding this association.

Objective

To determine whether visit-to-visit BPV at different ages was differentially associated with lifetime incident dementia risk in community-dwelling individuals.

Design, Setting, and Participants

This cohort study analyzed data from the Adult Changes in Thought (ACT) study, an ongoing population-based prospective cohort study in the US. Participants were 65 years or older at enrollment, community-dwelling, and without dementia. The study focused on a subset of deceased participants with brain autopsy data and whose midlife to late-life blood pressure data were obtained from Kaiser Permanente Washington medical archives and collected as part of the postmortem brain donation program. In the ACT study, participants underwent biennial medical assessments, including cognitive screening. Data were collected from 1994 (ACT study enrollment) through November 2019 (data set freeze). Data analysis was performed between March 2020 and September 2023.

Exposures

Visit-by-visit BPV at ages 60, 70, 80, and 90 years, calculated using the coefficient of variation of year-by-year SBP measurements over the preceding 10 years.

Main Outcomes and Measures

All-cause dementia, which was adjudicated by a multidisciplinary outcome adjudication committee.

Results

A total of 820 participants (mean [SD] age at enrollment, 77.0 [6.7] years) were analyzed and included 476 females (58.0%). A mean (SD) of 28.4 (8.4) yearly SBP measurements were available over 31.5 (9.0) years. The mean (SD) follow-up time was 32.2 (9.1) years in 27 885 person-years from midlife to death. Of the participants, 372 (45.4%) developed dementia. The number of participants who were alive without dementia and had available data for analysis ranged from 280 of those aged 90 years to 702 of those aged 70 years. Higher BPV was not associated with higher lifetime dementia risk at age 60, 70, or 80 years. At age 90 years, BPV was associated with 35% higher dementia risk (hazard ratio [HR], 1.35; 95% CI, 1.02-1.79). Meta-regression of HRs calculated separately for each age (60-90 years) indicated that associations of high BPV with higher dementia risk were present only at older ages, whereas the association of SBP with dementia gradually shifted direction linearly from being incrementally to inversely associated with older ages.

Conclusions and Relevance

In this cohort study, high BPV indicated increased lifetime dementia risk in late life but not in midlife. This result suggests that high BPV may indicate increased dementia risk in older age but might be less viable as a midlife dementia prevention target.

Use of the Smoking Cessation App Ex-Smokers iCoach and Associations With Smoking-Related Outcomes Over Time in a Large Sample of European Smokers: Retrospective Observational Study

BACKGROUND

Digital interventions are increasingly used to support smoking cessation. Ex-smokers iCoach was a widely available app for smoking cessation used by 404,551 European smokers between June 15, 2011, and June 21, 2013. This provides a unique opportunity to investigate the uptake of a freely available digital smoking cessation intervention and its effects on smoking-related outcomes.

OBJECTIVE

We aimed to investigate whether there were distinct trajectories of iCoach use, examine which baseline characteristics were associated with user groups (based on the intensity of use), and assess if and how these groups were associated with smoking-related outcomes.

METHODS

Analyses were performed using data from iCoach users registered between June 15, 2011, and June 21, 2013. Smoking-related data were collected at baseline and every 3 months thereafter, with a maximum of 8 follow-ups. First, group-based modeling was applied to detect distinct trajectories of app use. This was performed in a subset of steady users who had completed at least 1 follow-up measurement. Second, ordinal logistic regression was used to assess the baseline characteristics that were associated with user group membership. Finally, generalized estimating equations were used to examine the association between the user groups and smoking status, quitting stage, and self-efficacy over time.

RESULTS

Of the 311,567 iCoach users, a subset of 26,785 (8.6%) steady iCoach users were identified and categorized into 4 distinct user groups: low (n=17,422, 65.04%), mild (n=4088, 15.26%), moderate (n=4415, 16.48%), and intensive (n=860, 3.21%) users. Older users and users who found it important to quit smoking had higher odds of more intensive app use, whereas men, employed users, heavy smokers, and users with higher self-efficacy scores had lower odds of more intensive app use. User groups were significantly associated with subsequent smoking status, quitting stage, and self-efficacy over time. For all groups, over time, the probability of being a smoker decreased, whereas the probability of being in an improved quitting stage increased, as did the self-efficacy to quit smoking. For all outcomes, the greatest change was observed between baseline and the first follow-up at 3 months. In the intensive user group, the greatest change was seen between baseline and the 9-month follow-up, with the observed change declining gradually in moderate, mild, and low users.

CONCLUSIONS

In the subset of steady iCoach users, more intensive app use was associated with higher smoking cessation rates, increased quitting stage, and higher self-efficacy to quit smoking over time. These users seemed to benefit most from the app in the first 3 months of use. Women and older users were more likely to use the app more intensively. Additionally, users who found quitting difficult used the iCoach app more intensively and grew more confident in their ability to quit over time.

Detection of colon cancer recurrences during follow-up care by general practitioners versus surgeons

BACKGROUND

In the I CARE study, colon cancer patients were randomized to receive follow-up care from either general practitioner (GP) or surgeon. Here, we address a secondary outcome, namely detection of recurrences, and effect on time to detection of transferring care from surgeon to GP.

METHODS

Pattern, stage and treatment of recurrences were described after 3 years. Time to event was defined as date of surgery, until date of recurrence or last follow-up, with death as competing event. Effects on time to recurrence and death were estimated as hazard ratios (HRs) using Cox regression. Restricted mean survival times were estimated.

RESULTS

Of 303 patients, 141 were randomized to the GP and 162 to the surgeon. Patients were male (67%) with a mean age of 68.0 years (SD 8.4). During follow-up, 46 recurrences were detected; 18 in the GP (13%) versus 28 in the surgeon group (17%). Most recurrences were detected via abnormal follow-up tests (74%) and treated with curative intent (59%). HR for recurrence was 0.75 [95% CI 0.41-1.36] in GP versus surgeon group. Patients in the GP group remained in the disease-free state slightly longer (2.76 versus 2.71 years). 38 patients died during follow-up; 15 in the GP (11%) versus 23 in the surgeon group (14%). 21 deaths (55%) were related to colon cancer. There were no differences in overall deaths between the groups (HR 0.76 [95% CI 0.39-1.46]).

CONCLUSION

Follow-up provided by GPs versus surgeons leads to similar detection of recurrences. Also, no differences in mortality were found.

Personalized approach using wearable technology for early detection of atrial fibrillation in high-risk primary care patients (PATCH-AF): Study protocol for a cluster randomized controlled trial

BACKGROUND

Atrial fibrillation (AF) is a common cardiac arrhythmia with a lifetime risk of one in 4. Unfortunately, AF often remains undetected, particularly when it is paroxysmal, for which single time-point evaluation is less effective. Recently, unobtrusive cardiac arrhythmia monitoring devices have become available, providing the opportunity to conduct prolonged electrocardiographic (ECG) monitoring in a patient-friendly manner. We hypothesize that applying these devices in at risk patients may improve AF detection, particularly when used during repeated episodes. We therefore aim to evaluate the diagnostic yield of yearly screening for atrial fibrillation when using a wearable device for continuous ECG monitoring for 7 days in primary care patients ≥ 65 years deemed at high-risk of AF (CHA₂DS₂VASc score ≥3 for men or ≥4 for women) compared with usual care over a study period of 3 years.

METHODS

Primary care based, cluster-randomized controlled trial with 10 general practices randomized to the intervention group and 10 general practices randomized to control group. In each group, we aim to enroll 930 patients, ≥65 years and a CHA₂DS₂VASc score ≥3 for men or ≥ 4 for women. The intervention consists of continuous ECG monitoring for 7 days at start of the study (t = 0), after one (t = 1) and 2 years (t = 2). The control practices will follow usual diagnostic care procedures.

RESULTS

Results are expected in 2025.

CONCLUSIONS

This study differs from previous randomized controlled trials, as it involves longitudinal screening of a risk-stratified population. In case of a beneficial diagnostic yield, the PATCH-AF study will add to the evidence for AF screening.

TRIAL REGISTRATION

The PATCH-AF study is registered at The Netherlands Trial Register (NTR number NL9656).

Symptoms and seeking supportive care and associations with quality of life after treatment for colon cancer: Results from the I CARE cohort study

OBJECTIVE

Patients treated for colon cancer report many symptoms that affect quality of life (QoL). Survivorship care aims at QoL improvement. In this study, we assess associations between symptoms and seeking supportive care and lower QoL and QoL changes overtime during survivorship care.

METHODS

A prospective cohort of colon cancer survivors. Questionnaires are administered at inclusion and 6 months later to evaluate symptoms, functioning and seeking supportive care including associations with QoL, using the EORTC QLQ-C30.

RESULTS

The mean QoL score at the first questionnaire was 82 (scale 1-100), which improved over time. Pain, bowel symptoms and problems in physical, role, cognitive or social functioning are associated with lower QoL at inclusion but are not associated with QoL changes over time. Seeking support for lower bowel symptoms, physical functioning or fatigue is associated with lower QoL. After 6 months, seeking support for upper bowel symptoms or physical functioning is associated with a tendency towards less QoL improvement.

CONCLUSION

QoL of colon cancer survivors improves over 6 months, but seeking support for specific symptoms barely contribute to this improvement.

IMPLICATIONS

This study confirms the importance of addressing symptoms, problems related to functioning and seeking supportive care during survivorship care.

Effect of general practitioner-led versus surgeon-led colon cancer survivorship care, with or without eHealth support, on quality of life (I CARE): an interim analysis of 1-year results of a randomised, controlled trial

BACKGROUND

Colon cancer is associated with an increased risk of physical and psychosocial morbidity, even after treatment. General practitioner (GP) care could be beneficial to help to reduce this morbidity. We aimed to assess quality of life (QOL) in patients who received GP-led survivorship care after treatment for colon cancer compared with those who received surgeon-led care. Furthermore, the effect of an eHealth app (Oncokompas) on QOL was assessed in both patient groups.

METHODS

We did a pragmatic two-by-two factorial, open-label, randomised, controlled trial at eight hospitals in the Netherlands. Eligible patients were receiving primary surgical treatment for stage I-III colon cancer or rectosigmoid carcinoma and qualified for routine follow-up according to Dutch national guidelines. Patients were randomly assigned (1:1:1:1)-via computer-generated variable block randomisation stratified by age and tumour stage-to survivorship care overseen by a surgeon, survivorship care overseen by a surgeon with access to Oncokompas, survivorship care overseen by a GP, or survivorship care overseen by a GP with access to Oncokompas. Blinding of the trial was not possible. The primary endpoint of the trial was QOL at 5 years, as measured by the change from baseline in the European Organistion for Research and Treatment of Cancer QLQ-C30 summary score. Here, we report an unplanned interim analysis of QOL at the 12-month follow-up. Grouped comparisons were done (ie, both GP-led care groups were compared with both surgeon-led groups, and both Oncokompas groups were compared with both no Oncokompas groups). Differences in change of QOL between trial groups were estimated with linear mixed-effects models. A change of ten units was considered clinically meaningful. Analysis was by intention to treat. This trial is registered with the Netherlands Trial Register, NTR4860.

FINDINGS

Between March 26, 2015, and Nov 21, 2018, 353 patients were enrolled and randomly assigned. There were 50 early withdrawals (27 patient decisions and 23 GP withdrawals). Of the remaining 303 participants, 79 were assigned to surgeon-led care, 83 to surgeon-led care with Oncokompas, 73 to GP-led care, and 68 to GP-led care with Oncokompas. Median follow-up was 12·2 months (IQR 12·0-13·0) in all groups. At baseline, QOL was high in all trial groups. At 12 months, there was no clinically meaningful difference in change from baseline in QOL between the GP-led care groups and the surgeon-led care groups (difference in summary score -2·3 [95% CI -5·0 to 0·4]) or between the Oncokompas and no Oncokompas groups (-0·1 [-2·8 to 2·6]).

INTERPRETATION

In terms of QOL, GP-led survivorship care can be considered as an alternative to surgeon-led care within the first year after colon cancer treatment. Other outcomes, including patient and physician preferences, will be important for decisions about the type of survivorship care.

FUNDING

Dutch Cancer Society (KWF).

Evaluation of general practitioners' single-lead electrocardiogram interpretation skills: a case-vignette study

BACKGROUND

Handheld single-lead electrocardiograms (1L-ECG) present a welcome addition to the diagnostic arsenal of general practitioners (GPs). However, little is known about GPs' 1L-ECG interpretation skills, and thus its reliability in real-world practice.

OBJECTIVE

To determine the diagnostic accuracy of GPs in diagnosing atrial fibrillation or flutter (AF/Afl) based on 1L-ECGs, with and without the aid of automatic algorithm interpretation, as well as other relevant ECG abnormalities.

METHODS

We invited 2239 Dutch GPs for an online case-vignette study. GPs were asked to interpret four 1L-ECGs, randomly drawn from a pool of 80 case-vignettes. These vignettes were obtained from a primary care study that used smartphone-operated 1L-ECG recordings using the AliveCor KardiaMobile. Interpretation of all 1L-ECGs by a panel of cardiologists was used as reference standard.

RESULTS

A total of 457 (20.4%) GPs responded and interpreted a total of 1613 1L-ECGs. Sensitivity and specificity for AF/Afl (prevalence 13%) were 92.5% (95% CI: 82.5-97.0%) and 89.8% (95% CI: 85.5-92.9%), respectively. PPV and NPV for AF/Afl were 45.7% (95% CI: 22.4-70.9%) and 98.8% (95% CI: 97.1-99.5%), respectively. GP interpretation skills did not improve in case-vignettes where the outcome of automatic AF-detection algorithm was provided. In detecting any relevant ECG abnormality (prevalence 22%), sensitivity, specificity, PPV and NPV were 96.3% (95% CI: 92.8-98.2%), 68.8% (95% CI: 62.4-74.6%), 43.9% (95% CI: 27.7-61.5%) and 97.9% (95% CI: 94.9-99.1%), respectively.

CONCLUSIONS

GPs can safely rule out cardiac arrhythmias with 1L-ECGs. However, whenever an abnormality is suspected, confirmation by an expert-reader is warranted.

General practitioners' involvement during survivorship care of colon cancer in the Netherlands: primary health care utilization during survivorship care of colon cancer, a prospective multicentre cohort study

BACKGROUND

Primary health care use increases when cancer is diagnosed. This increase continues after cancer treatment. More generalist care is suggested to improve survivorship care. It is unknown to what extent cancer-related symptoms are currently presented in primary care in this survivorship phase.

OBJECTIVE

To analyse primary health care utilization of colon cancer patients during and after treatment with curative intent.

METHODS

In a prospective multicentre cohort study among patients with curatively treated colon cancer, we describe the primary health care utilization during the first 5 years of follow-up. Data were collected at general practitioner (GP) practices during 6 months.

RESULTS

Of 183 included participants, 153 (84%) consulted their GP resulting in 606 contacts (mean 3.3, standard deviation 3.01) with on average 0.9 contact for colon-cancer-related (CCR) problems in the 6-month study period. Median time after surgery at inclusion was 7.6 months (range 0-58). Abdominal pain and chemotherapy-related problems were the most frequently reported CCR reasons. Of the CCR contacts, 83% was managed in primary care. As time after surgery passed, the number of CCR contacts declined in patients without chemotherapy and remained constant in patients who received chemotherapy.

CONCLUSION

Colon cancer survivors contact their GP frequently also for reasons related to cancer. Currently, a formal role for GPs in survivorship care is lacking, but nevertheless GPs provide a substantial amount of care. Working agreements between primary and secondary care are necessary to formalize the GP's role in order to improve the quality of survivorship care.

The influence of clinical variables on the risk of developing chronic conditions in ICU survivors

PURPOSE

To assess the association of clinical variables and the development of specified chronic conditions in ICU survivors.

MATERIALS AND METHODS

A retrospective cohort study, combining a national health insurance claims database and a national quality registry for ICUs. Claims data from 2012 to 2014 were combined with clinical data of patients admitted to an ICU during 2013. To assess the association of clinical variables (ICU length of stay, mechanical ventilation, acute physiology score, reason for ICU admission, mean arterial pressure score and glucose score) and the development of chronic conditions (i.e. heart diseases, COPD or asthma, Diabetes mellitus type II, depression and kidney diseases), logistic regression was used.

RESULTS

49,004 ICU patients were included. ICU length of stay was associated with the development of heart diseases, asthma or COPD and depression. The reason for ICU admission was an important risk factor for the development of all chronic conditions with adjusted ORs ranging from 2.05 (CI 1.56; 2.69) for kidney diseases to 5.14 (CI 3.99; 6.62) for depression.

CONCLUSIONS

Clinical variables, especially the reason for ICU admission, are associated with the development of chronic conditions after ICU discharge. Therefore, these clinical variables should be considered when organizing follow-up care for ICU survivors.

A cardiovascular risk prediction model for older people: Development and validation in a primary care population

Cardiovascular risk prediction is mainly based on traditional risk factors that have been validated in middle‐aged populations. However, associations between these risk factors and cardiovascular disease (CVD) attenuate with increasing age. Therefore, for older people the authors developed and internally validated risk prediction models for fatal and non‐fatal CVD, (re)evaluated the predictive value of traditional and new factors, and assessed the impact of competing risks of non‐cardiovascular death. Post hoc analyses of 1811 persons aged 70‐78 year and free from CVD at baseline from the preDIVA study (Prevention of Dementia by Intensive Vascular care, 2006‐2015), a primary care‐based trial that included persons free from dementia and conditions likely to hinder successful long‐term follow‐up, were performed. In 2017‐2018, Cox‐regression analyses were performed for a model including seven traditional risk factors only, and a model to assess incremental predictive ability of the traditional and eleven new factors. Analyses were repeated accounting for competing risk of death, using Fine‐Gray models. During an average of 6.2 years of follow‐up, 277 CVD events occurred. Age, sex, smoking, and type 2 diabetes mellitus were traditional predictors for CVD, whereas total cholesterol, HDL‐cholesterol, and systolic blood pressure (SBP) were not. Of the eleven new factors, polypharmacy and apathy symptoms were predictors. Discrimination was moderate (concordance statistic 0.65). Accounting for competing risks resulted in slightly smaller predicted absolute risks. In conclusion, we found, SBP, HDL, and total cholesterol no longer predict CVD in older adults, whereas polypharmacy and apathy symptoms are two new relevant predictors. Building on the selected risk factors in this study may improve CVD prediction in older adults and facilitate targeting preventive interventions to those at high risk.

Effects of Primary Cardiovascular Prevention on Vascular Risk in Older Adults

INTRODUCTION

Primary cardiovascular prevention through simultaneously targeting multiple risk factors may be even more effective than single risk factor modification in older adults. The effects of multicomponent cardiovascular prevention on cardiovascular risk are explored.

STUDY DESIGN

Post hoc analysis of the cluster randomized Prevention of Dementia by Intensive Vascular care trial.

SETTING/PARTICIPANTS

Community-dwelling older adults aged 70-78 years, free from cardiovascular disease at baseline (n=2,254, 63.9% of the Prevention of Dementia by Intensive Vascular care trial population).

INTERVENTION

Between 2006 and 2015, the intervention group received nurse-led vascular care every 4 months at the general practitioner practice, the control group received care as usual.

MAIN OUTCOME MEASURES

Cardiovascular disease events and Systematic COronary Risk Evaluation in Older People (SCORE-OP), an index based on six risk factors for cardiovascular mortality. Effects were adjusted for clustering and assessed using mixed effects Cox proportional-hazard models and linear mixed models respectively.

RESULTS

There was no effect of the intervention on cardiovascular disease events (hazard ratio=0.99, 95% CI=0.71, 1.38). During a median follow-up of 6.1 years, SCORE-OP increased from 14.0% and 13.9% to 23.9% and 25.0% in the intervention and control group, respectively (adjusted mean difference in increment in SCORE-OP between the study groups 0.60%, 95% CI= -0.01, 1.20). Exploratory analyses showed a larger reduction of 2.4 mmHg (95% CI=0.9, 3.9) in systolic blood pressure and 1.9% (95% CI=0.4, 3.4) in current cigarette smoking in the intervention group compared with the control group.

CONCLUSIONS

Multicomponent cardiovascular prevention did not improve the overall risk profile in older adults in a primary prevention setting, relative to usual care. However, exploratory analyses showed an effect on blood pressure and smoking cessation. Possibly, contrast between study groups was too small because of the Hawthorne (being part of a study) effect and increasing quality of (preventive) health care for older adults, to yield an effect on the risk profile.

Effectiveness of a targeted lifestyle intervention in primary care on diet and physical activity among South Asians at risk for diabetes: 2-year results of a randomised controlled trial in the Netherlands

OBJECTIVES

In South Asian populations, little is known about the effects of intensive interventions to reduce the risk of type 2 diabetes on health behaviour. We examined the effectiveness at 2 years of a culturally targeted lifestyle intervention on diet, physical activity and determinants of behaviour change among South Asians at risk for diabetes.

DESIGN

Randomised controlled trial with de facto masking.

SETTING

Primary care.

PARTICIPANTS

A total of 536 18- to 60-year-old South Asians at risk for diabetes (ie, with impaired glucose tolerance, impaired fasting glucose or relatively high insulin resistance) were randomised to the intervention (n=283) or a control (n=253) group. Data of 314 participants (n=165 intervention, n=149 control) were analysed.

INTERVENTIONS

The culturally targeted intervention consisted of individual counselling using motivational interviewing (six to eight sessions in the first 6 months plus three to four booster sessions), a family session, cooking classes and a supervised physical activity programme. The control group received generic lifestyle advice.

OUTCOME MEASURES

We compared changes in physical activity, diet and social-cognitive underlying determinants between the two groups at 2-year follow-up with independent-sample t-tests, chi-square tests and Fisher's exact tests.

RESULTS

At the 2-year follow-up, participants in the intervention group were more moderately to vigorously active than at baseline, but compared with changes in the control group, the difference was not significant (change min/week 142.9 vs 0.5, p=0.672). Also, no significant difference was found between the two groups in changes on any of the components of the diet or the social-cognitive determinants of diet and physical activity.

CONCLUSIONS

The culturally targeted lifestyle intervention led to high drop-out and was not effective in promoting healthy behaviour among South Asians at risk for diabetes. Given the high a priori risk, we recommend to develop new strategies, preferably more acceptable, to promote healthy behaviour.

TRIAL REGISTRATION

NTR1499; Results. www.trialregister.nl/trialreg/admin/rctview.asp?TC=1499.

Web-Based Interventions Targeting Cardiovascular Risk Factors in Middle-Aged and Older People: A Systematic Review and Meta-Analysis

Background

Web-based interventions can improve single cardiovascular risk factors in adult populations. In view of global aging and the associated increasing burden of cardiovascular disease, older people form an important target population as well.

Objective

In this systematic review and meta-analysis, we evaluated whether Web-based interventions for cardiovascular risk factor management reduce the risk of cardiovascular disease in older people.

Methods

Embase, Medline, Cochrane and CINAHL were systematically searched from January 1995 to November 2014. Search terms included cardiovascular risk factors and diseases (specified), Web-based interventions (and synonyms) and randomized controlled trial. Two authors independently performed study selection, data-extraction and risk of bias assessment. In a meta-analysis, outcomes regarding treatment effects on cardiovascular risk factors (blood pressure, glycated hemoglobin A1c (HbA1C), low-density lipoprotein (LDL) cholesterol, smoking status, weight and physical inactivity) and incident cardiovascular disease were pooled with random effects models.

Results

A total of 57 studies (N=19,862) fulfilled eligibility criteria and 47 studies contributed to the meta-analysis. A significant reduction in systolic blood pressure (mean difference –2.66 mmHg, 95% CI –3.81 to –1.52), diastolic blood pressure (mean difference –1.26 mmHg, 95% CI –1.92 to –0.60), HbA1c level (mean difference –0.13%, 95% CI –0.22 to –0.05), LDL cholesterol level (mean difference –2.18 mg/dL, 95% CI –3.96 to –0.41), weight (mean difference –1.34 kg, 95% CI –1.91 to –0.77), and an increase of physical activity (standardized mean difference 0.25, 95% CI 0.10-0.39) in the Web-based intervention group was found. The observed effects were more pronounced in studies with short (<12 months) follow-up and studies that combined the Internet application with human support (blended care). No difference in incident cardiovascular disease was found between groups (6 studies).

Conclusions

Web-based interventions have the potential to improve the cardiovascular risk profile of older people, but the effects are modest and decline with time. Currently, there is insufficient evidence for an effect on incident cardiovascular disease. A focus on long-term effects, clinical endpoints, and strategies to increase sustainability of treatment effects is recommended for future studies.

Measuring renewed expertise for integrated care among health- and social-care professionals: Development and preliminary validation of the ICE-Q questionnaire

Accumulations of health and social problems challenge current health systems. It is hypothesized that professionals should renew their expertise by adapting generalist, coaching, and population health orientation capacities to address these challenges. This study aimed to develop and validate an instrument for evaluating this renewal of professional expertise. The (Dutch) Integrated Care Expertise Questionnaire (ICE-Q) was developed and piloted. Psychometric analysis evaluated item, criterion, construct, and content validity. Theory and an iterative process of expert consultation constructed the ICE-Q, which was sent to 616 professionals, of whom 294 participated in the pilot (47.7%). Factor analysis (FA) identified six areas of expertise: holistic attitude towards patients (Cronbach's alpha [CA] = 0.61) and considering their social context (CA = 0.77), both related to generalism; coaching to support patient empowerment (CA = 0.66); preventive action (CA = 0.48); valuing local health knowledge (CA = 0.81); and valuing local facility knowledge (CA = 0.67) point at population health orientation. Inter-scale correlations ranged between 0.01 and 0.34. Item-response theory (IRT) indicated some items were less informative. The resulting 26-item questionnaire is a first tool for measuring integrated care expertise. The study process led to a developed understanding of the concept. Further research is warranted to improve the questionnaire.

[Web-based interventions targeting cardiovascular risk factors in older people; a systematic review and meta-analysis]

OBJECTIVE

To evaluate whether web-based interventions for cardiovascular risk factor management reduce the risk of cardiovascular disease in older people.

DESIGN

Systematic review and meta-analysis.

METHOD

Embase, Medline, Cochrane Library and CINAHL were systematically searched from January 1995 to 3 November 2014. We included all randomised controlled trials for web-based interventions targeting cardiovascular risk factors in populations with a mean age of 50 and older. The outcome measures were cardiovascular risk factors (blood pressure, HbA1c, LDL cholesterol, weight, smoking status and physical activity) and the incidence of cardiovascular disease. We used random-effects models to pool the results of the studies.

RESULTS

A total of 57 studies (19,862 participants) fulfilled eligibility criteria, and 47 of these were suitable for meta-analysis. We found a significant reduction in systolic blood pressure (-2.66 mmHg, 95% CI -3.81 to -1.52), diastolic blood pressure (-1.26 mmHg, 95% CI -1.92 to -0.60), HbA1c level (-0.13%, 95% CI -0.22 to -0.05), LDL cholesterol level (-0.06 mmol/l, 95% CI -0.10 to -0.01), weight (-1.34 kg, 95% CI -1.91 to -0.77), and an increase in physical activity (standardized mean difference 0.25, 95% CI 0.10-0.39) in the intervention group when compared with the control group. Treatment effects were more pronounced in studies of short duration (< 12 months) and when combining the web-based intervention with human support by a health care professional. No difference in the incidence of cardiovascular disease was found between groups.

CONCLUSION

Web-based interventions have a beneficial effect on the cardiovascular risk profile, but this effect is modest and declines with time. Currently, there is insufficient evidence that this can prevent cardiovascular disease. A focus on long-term effects, effect-sustainability and clinical endpoints is recommended for future studies.

Ethnic differences in arterial stiffness the Helius study

OBJECTIVE

Well-known ethnic differences in cardiovascular risk exist, which may be explained by ethnic differences in arterial stiffness. Our aim was to assess ethnic differences in arterial stiffness, to explore whether these differences are accounted for by conventional cardiovascular risk factors, and study whether they differ across age.

METHODS

Cross-sectional data of 1797 Dutch, 1846 South-Asian Surinamese, 1840 African Surinamese, and 1673 Ghanaian participants of the observational HELIUS study (aged 18-70 years) were used. Arterial stiffness was assessed by duplicate pulse wave velocity (PWV) measurements using the Arteriograph system.

RESULTS

Linear regression showed that South-Asian Surinamese had higher PWVs as compared with Dutch (age-adjusted mean difference (95% CI) was 0.55 (0.39-0.70) m/s in men and 0.82 (0.63-1.01) m/s in women). These differences were largely, but not completely, explained by conventional risk factors (particularly age and MAP). These ethnic differences were not found at young age (<35 years). African Surinamese and Ghanaians had higher PWVs as compared with Dutch across the entire age range (ranging from 0.22 (0.06-0.39) m/s in African Surinamese men to 1.07 (0.89-1.26) m/s in Ghanaian women), but these differences disappeared or reversed after adjustment for risk factors.

CONCLUSIONS

PWV levels paralleled the well-known ethnic differences in cardiovascular risk. After adjustment for cardiovascular risk factors, however, these ethnic differences in PWV largely disappear. Together with the absence of ethnic differences in PWV at young age, our results support the hypothesis that higher PWV in South-Asian and African ethnic groups develops due to higher exposure to cardiovascular risk factors.

The validation of a social functioning questionnaire in an African postconflict context

This study evaluated the reliability and criterion validity of the Byumba Social Functioning Questionnaire (BSFQ), an instrument to measure social functioning in Rwanda. The instrument was locally composed in concordance with a well-described method for culture-specific and sex-specific function assessment. Respondents in a Northern Province of Rwanda (N = 393) were assessed with the BSFQ and a 19-item scale (SF-19) drawn from the Medical Outcomes Study 36-Item Short-Form (SF-36). The BSFQ's internal consistency was just acceptable for women but poor for men, while the SF-19 had good to excellent internal consisteny. BSFQ total scores showed a strong floor effect, while the SF-19 showed more variation in total score distribution. The BSFQ did not perform as well as we expected, and appears not to be suitable for measuring social functioning in the study context. This outcome seems to reflect the conceptualization of social functioning used in constructing the BSFQ. Implications for the development of culture-specific measures of functional status are discussed.

Dietary patterns within a population are more reproducible than those of individuals

Insight into the stability of dietary behavior over time is important, because only a single measurement of diet is often available to study the association between eating behavior and the occurrence of chronic diseases many years after baseline data collection. Little is known about changes in dietary patterns over time. The current study examined the (internal) stability and reproducibility of dietary patterns and the transition of individuals between patterns over time from 3 surveys within one study population by using cluster analysis. The dietary intake of participants in the Doetinchem Cohort Study in 6113, 4916, and 4520 adults in 1993-1997, 1998-2002, and 2003-2007, respectively, was measured using a validated food-frequency questionnaire. Stability and reproducibility of dietary patterns were studied by examining the optimal number of clusters per survey by comparing the contribution of food groups to total energy intake within the clusters over time and by studying transitions of individuals between clusters over time. A low-fiber bread pattern and a high-fiber bread pattern were identified in all 3 surveys. Over time, dietary patterns were comparable in terms of foods contributing most to total energy intake, suggesting good reproducibility. Nevertheless, only 41.8% of the participants were consistently assigned to the same dietary pattern for all 3 surveys. This implies that, over time, similar dietary patterns were found at the group level, but that ignoring individual transitions between dietary patterns during follow-up may lead to misclassification of a large proportion of the study population.

Differences in Body Fat Distribution Play a Role in the Lower Levels of Elevated Fasting Glucose amongst Ghanaian Migrant Women Compared to Men

BACKGROUND

Despite higher levels of obesity, West African migrant women appear to have lower rates of type 2 diabetes than their male counterparts. We investigated the role of body fat distribution in these differences.

METHODS

Cross-sectional study of Ghanaian migrants (97 men, 115 women) aged 18-60 years in Amsterdam, the Netherlands. Weight, height, waist and hip circumferences were measured. Logistic regression was used to explore the association of BMI, waist and hip measurements with elevated fasting glucose (glucose≥5.6 mmol/L). Linear regression was used to study the association of the same parameters with fasting glucose.

RESULTS

Mean BMI, waist and hip circumferences were higher in women than men while the prevalence of elevated fasting glucose was higher in men than in women, 33% versus 19%. With adjustment for age only, men were non-significantly more likely than women to have an elevated fasting glucose, odds ratio (OR) 1.81, 95% CI: 0.95, 3.46. With correction for BMI, the higher odds among men increased and were statistically significant (OR 2.84, 95% CI: 1.32, 6.10), but with consideration of body fat distribution (by adding both hip and waist in the analysis) differences were no longer significant (OR 1.56 95% CI: 0.66, 3.68). Analysis with fasting glucose as continuous outcome measure showed somewhat similar results.

CONCLUSION

Compared to men, the lower rates of elevated fasting glucose observed among Ghanaian women may be partly due to a more favorable body fat distribution, characterized by both hip and waist measurements.

Sex differences in the association between serum ferritin and fasting glucose in type 2 diabetes among South Asian Surinamese, African Surinamese, and ethnic Dutch: the population-based SUNSET study

OBJECTIVE

Moderately elevated iron stores below the levels commonly associated with hemochromatosis have been implicated in the etiology of diabetes. Studies suggest that iron status (measured by serum ferritin) differs significantly according to sex, but inconsistent findings have been reported. Our aim is to test the association between serum ferritin and the prevalence of type 2 diabetes and fasting glucose concentrations in a population-based, multiethnic, cross-sectional study including men and women of African Surinamese, South Asian Surinamese, and ethnic Dutch origin.

RESEARCH DESIGN AND METHODS

We analyzed data on 508 ethnic Dutch, 597 African Surinamese, and 339 South Asian Surinamese aged 35-60 years. Type 2 diabetes was defined as a fasting plasma glucose level ≥7.0 mmol/L or a self-reported diagnosis.

RESULTS

Serum ferritin was positively associated with type 2 diabetes and fasting glucose, but differences in the associations according to sex were observed. Serum ferritin concentration was positively associated with type 2 diabetes among women in all ethnic groups (odds ratio [OR] ethnic Dutch: 1.07 [95% CI 1.01-1.13]; OR South Asian Surinamese: 1.05 [1.00-1.10]; OR African Surinamese: 1.05 [1.01-1.10]), but not among men. Serum ferritin was also more strongly associated with fasting glucose in women than in men. Moreover, the magnitude of sex differences in the association between serum ferritin and fasting glucose, but not type 2 diabetes, was more pronounced in the African Surinamese group than in the other ethnic groups (P for interaction ≤0.0001).

CONCLUSIONS

We found a positive association between serum ferritin and type 2 diabetes and fasting glucose in our multiethnic population, which appeared stronger among women than men. Further evaluation of the variation in sex differences between ethnic groups is warranted, particularly among the African Surinamese, to understand the mechanisms behind these sex differences.

Smoking prevalence among migrants in the US compared to the US-born and the population in countries of origin

OBJECTIVES

Smoking among migrants is known to differ from the host population, but migrants' smoking is rarely ever compared to the prevalence of smoking in their country of origin. The goal of this study is to compare the smoking prevalence among migrants to that of both the US-born population and the countries of origin. Further analyses assess the influence of sex, age at time of entry to the US and education level.

METHODS

Data of 248,726 US-born and migrants from 14 countries were obtained from the Tobacco Use Supplement to the Current Population Survey (TUS-CPS) from 2006-2007. Data on 108,653 respondents from the corresponding countries of origin were taken from the World Health Survey (WHS) from 2002-2005.

RESULTS

The prevalence of smoking among migrants (men: 14.2%, women: 4.1%) was lower than both the US-born group (men: 21.4%, women: 18.1%) and countries of origin (men: 39.4%, women: 11.0%). The gender gap among migrants was smaller than in the countries of origin. Age at time of entry to the US was not related to smoking prevalence for migrants. The risk of smoking for high-educated migrants was closer to their US counterparts.

CONCLUSIONS

The smoking prevalence among migrants is consistently lower than both the country of origin levels and the US level. The theory of segmented assimilation is supported by some results of this study, but not all. Other mechanisms that might influence the smoking prevalence among migrants are the 'healthy migrant effect' or the stage of the smoking epidemic at the time of migration.

Screening South Asians for type 2 diabetes and prediabetes: (1) comparing oral glucose tolerance and haemoglobin A1c test results and (2) comparing the two sets of metabolic profiles of individuals diagnosed with these two tests

BACKGROUND

The glycated haemoglobin A1c (HbA1c) level may be used for screening for type 2 diabetes and prediabetes instead of a more burdensome oral glucose tolerance test (OGTT). However, among the high-risk South Asian population, little is known about the overlap of the methods or about the metabolic profiles of those disconcordantly diagnosed.

METHODS

We included 944 South Asians (18-60 years old), whom we screened with the HbA1c level and the OGTT in The Hague, the Netherlands. We calculated the area under the receiver-operator characteristic curve (AUROC) with a 95% confidence interval of HbA1c using the American Diabetes Association classifications, and determined the sensitivity and specificity with 95% confidence intervals at different thresholds. Moreover, we studied differences in metabolic characteristics between those identified by HbA1c and by the OGTT alone.

RESULTS

The overlap between HbA1c and OGTT classifications was partial, both for diabetes and prediabetes. The AUROC of HbA1c for OGTT defined diabetes was 0.86 (0.79-0.93). The sensitivity was 0.46 (0.29-0.63); the specificity 0.98 (0.98-0.99). For prediabetes, the AUROC was 0.73 (0.69-0.77). Each of the 31 individuals with diabetes and 353 with prediabetes identified with the HbA1c level had a high body mass index, large waist circumference, high blood pressure, and low insulin sensitivity, all of which were similar to the values shown by those among the 19 with diabetes or 62 with prediabetes who only met the OGTT criteria, but not the HbA1c criteria.

CONCLUSIONS

The HbA1c level identified a partially different group than the OGTT did. However, both those identified with the HbA1c level and those identified with the OGTT alone were at increased metabolic risk.

TRIAL REGISTRATION

Dutch Trial Register: NTR1499.

Effectiveness of a web-based health risk assessment with individually-tailored feedback on lifestyle behaviour: study protocol

Background

Physical inactivity, unhealthy dietary habits, smoking and high alcohol consumption are recognized risk factors for cardiovascular disease and cancer. Web-based health risk assessments with tailored feedback seem promising in promoting a healthy lifestyle. This study evaluates the effectiveness of a web-based health risk assessment with individually-tailored feedback on lifestyle behaviour, conducted in a worksite setting.

Methods/Design

The web-based health risk assessment starts with a questionnaire covering socio-demographic variables, family and personal medical history, lifestyle behaviour and psychological variables. Prognostic models are used to estimate individual cardiovascular risks. In case of high risk further biometric and laboratory evaluation is advised. All participants receive individually-tailored feedback on their responses to the health risk assessment questionnaire. The study uses a quasi-experimental design with a waiting list control group. Data are collected at baseline (T0) and after six months (T1). Within each company, clusters of employees are allocated to either the intervention or the control group. Primary outcome is lifestyle behaviour, expressed as the sum of five indicators namely physical activity, nutrition, smoking behaviour, alcohol consumption, and symptoms of burnout. Multilevel regression analysis will be used to answer the main research question and to correct for clustering effects. Baseline differences between the intervention and control group in the distribution of characteristics with a potential effect on lifestyle change will be taken into account in further analyses using propensity scores.

Discussion

This study will increase insight into the effectiveness of health risk assessments with tailored feedback and into conditions that may modify the effectiveness. This information can be used to design effective interventions for lifestyle behaviour change among employees.

Trial registration

Dutch Trial Register NTR8148.

Quality of life and salivary output in patients with head-and-neck cancer five years after radiotherapy

BACKGROUND

To describe long-term changes in time of quality of life (QOL) and the relation with parotid salivary output in patients with head-and-neck cancer treated with radiotherapy.

METHODS

Forty-four patients completed the EORTC-QLQ-C30(+3) and the EORTC-QLQ-H&N35 questionnaires before treatment, 6 weeks, 6 months, 12 months, and at least 3.5 years after treatment. At the same time points, stimulated bilateral parotid flow rates were measured.

RESULTS

There was a deterioration of most QOL items after radiotherapy compared with baseline, with gradual improvement during 5 years follow-up. The specific xerostomia-related items showed improvement in time, but did not return to baseline. Global QOL did not alter significantly in time, although 41% of patients complained of moderate or severe xerostomia at 5 years follow-up. Five years after radiotherapy the mean cumulated parotid flow ratio returned to baseline but 20% of patients had a flow ratio <25%. The change in time of xerostomia was significantly related with the change in flow ratio (p = 0.01).

CONCLUSION

Most of the xerostomia-related QOL scores improved in time after radiotherapy without altering the global QOL, which remained high. The recovery of the dry mouth feeling was significantly correlated with the recovery in parotid flow ratio.

Grading Facial Nerve Function

OBJECTIVE

To compare the interobserver variability of a new grading system to the currently recommended House-Brackmann Grading Scale.

STUDY DESIGN

Prospective case-control study.

SETTING

Tertiary referral center.

PATIENTS

All patients with a facial nerve paresis/paralysis (whatever the cause).

INTERVENTION

All patients were evaluated for their facial nerve function by three observers, independently, using both the new system and the House-Brackmann Grading Scale.

MAIN OUTCOME MEASURE

The level of agreement between the three observers using both scales.

RESULTS

With the movement, rest, secondary defects, and subjective scoring grading scale, a higher percentage of agreement between the observers was noticed than with the House-Brackmann Grading Scale.

CONCLUSION

The movement, rest, secondary defects, and subjective scoring grading system is more useful for grading facial nerve dysfunction in clinical practice than the House-Brackmann Grading Scale.

Comparison of behavior modification with and without swaddling as interventions for excessive crying

OBJECTIVE

To test the hypothesis that swaddling is an effective method to reduce crying, we compared a standardized approach of regularity and stimulus reduction with the same approach supplemented with swaddling.

STUDY DESIGN

Healthcare nurses coached 398 excessively crying infants up to 12 weeks of age for 3 months. Outcome measurements were crying as measured by Barr's 24-hour diary and parental perception of crying.

RESULTS

Crying decreased by 42% in both groups after the first intervention week. Swaddling had no added benefit in the total group. Young infants (1-7 weeks of age at randomization) benefited significantly more from swaddling as shown by a larger decrease of crying over the total intervention period. Older infants (8-13 weeks of age at randomization) showed a significantly greater decrease in crying when offered the standardized approach without swaddling. The actual difference in crying time was 10 minutes.

CONCLUSION

For older babies, swaddling did not bring any benefit when added to regularity and stimuli reduction in baby care, although swaddling was a beneficial supplementation in excessively crying infants <8 weeks of age.