Facilitators and Barriers of Adherence to Multi-Disease Exacerbation Action Plans in COPD Patients - A Qualitative Study

Whereas exacerbation action plans to self-manage Chronic Obstructive Pulmonary Disease (COPD) significantly improve health outcomes, patients' adherence to those action plans is often poor. This study aimed to identify facilitators and barriers of adherence to tailored multi-disease exacerbation action plans. We also explored patients' perspectives toward disease management roles. Individual semi-structured interviews were conducted with a sample of COPD patients who completed a Dutch-Australian self-management intervention evaluating tailored exacerbation action plans for COPD and relevant comorbidities. Interviews were thematically analyzed using a deductive approach guided by the Capability, Opportunity and Motivation of Behavior (COM-B) model. In 2016, ten patients (5 Australian; 5 Dutch; 6 men; age 59-83 years) were interviewed at the end of their one-year follow-up. Facilitators of adherence included improved patients' comprehension of disease and treatment, positive feelings about the intervention, improved self-confidence, and professional support. Barriers included difficulties to recognize symptoms, dislike toward daily symptom monitoring, negative feelings about the intervention, negative mood state, and complexity of symptom diaries and action plans. Patients indicated three distinctive perspectives of their own and their healthcare professional's role in their disease management: 1) patients felt mainly responsible; 2) patients felt shared responsibility with their healthcare professional; and 3) patients felt not responsible as they perceived their healthcare professional to be mainly responsible. We successfully used the COM-B model as a guide to identify facilitators and barriers of patients' adherence to multi-disease exacerbation action plans. Improving patients' adherence in future self-management interventions by targeting specific facilitators or barriers should be considered.

Cost-utility analysis of a structured medication review compared to usual care in Parkinson's disease

PURPOSE

For controlling symptoms in Parkinson's disease (PD) together with treating additional comorbidities, patients often face complex medication regimens, with suboptimal adherence, drug-related problems, and diminished therapy efficacy as a common consequence. A medication review could potentially tackle these issues, among others by optimizing drug treatment. Even if no change in clinical outcomes is observed, this intervention might decrease health care costs by reducing drug-related problems and hospital admissions. This study aimed to gain more insight in the health benefits and costs of a structured medication review (SMR) in PD.

METHODS

A cost-utility analysis was performed, based on a multicenter randomized controlled trial with 202 PD patients with polypharmacy. The intervention group received an SMR, whereas the control group received usual care. The intervention effect after 6 months of follow-up was presented as incremental quality-adjusted life years (QALY) using the EQ-5D-5L questionnaire. Costs were based on real-world data. Missing data was imputed using multiple imputation techniques. Bootstrapping was used to estimate the uncertainty in all health and economic outcomes.

RESULTS

The QALY gain in the intervention group compared to the control group was - 0.011 (95% CI - 0.043; 0.020). Incremental costs were €433 (95% CI - 873; 1687). When adapting a willingness-to-pay threshold of €20,000/QALY and €80,000/QALY, the probability of SMRs being cost-effective was 18% and 30%, respectively.

CONCLUSION

A community pharmacist-led SMR in PD patients in the current setting shows no apparent benefit and is not cost-effective after 6 months, compared to usual care.

TRIAL REGISTRATION

Netherlands Trial Register, NL4360. Registered 17 March 2014.

Effect of physical exercise on the hippocampus and global grey matter volume in breast cancer patients: A randomized controlled trial (PAM study)

BACKGROUND

Physical exercise in cancer patients is a promising intervention to improve cognition and increase brain volume, including hippocampal volume. We investigated whether a 6-month exercise intervention primarily impacts total hippocampal volume and additionally hippocampal subfield volumes, cortical thickness and grey matter volume in previously physically inactive breast cancer patients. Furthermore, we evaluated associations with verbal memory.

METHODS

Chemotherapy-exposed breast cancer patients (stage I-III, 2-4 years post diagnosis) with cognitive problems were included and randomized in an exercise intervention (n = 70, age = 52.5 ± 9.0 years) or control group (n = 72, age = 53.2 ± 8.6 years). The intervention consisted of 2x1 hours/week of supervised aerobic and strength training and 2x1 hours/week Nordic or power walking. At baseline and at 6-month follow-up, volumetric brain measures were derived from 3D T1-weighted 3T magnetic resonance imaging scans, including hippocampal (subfield) volume (FreeSurfer), cortical thickness (CAT12), and grey matter volume (voxel-based morphometry CAT12). Physical fitness was measured with a cardiopulmonary exercise test. Memory functioning was measured with the Hopkins Verbal Learning Test-Revised (HVLT-R total recall) and Wordlist Learning of an online cognitive test battery, the Amsterdam Cognition Scan (ACS Wordlist Learning). An explorative analysis was conducted in highly fatigued patients (score of ≥ 39 on the symptom scale 'fatigue' of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire), as previous research in this dataset has shown that the intervention improved cognition only in these patients.

RESULTS

Multiple regression analyses and voxel-based morphometry revealed no significant intervention effects on brain volume, although at baseline increased physical fitness was significantly related to larger brain volume (e.g., total hippocampal volume: R = 0.32, B = 21.7 mm³, 95 % CI = 3.0 - 40.4). Subgroup analyses showed an intervention effect in highly fatigued patients. Unexpectedly, these patients had significant reductions in hippocampal volume, compared to the control group (e.g., total hippocampal volume: B = -52.3 mm³, 95 % CI = -100.3 - -4.4)), which was related to improved memory functioning (HVLT-R total recall: B = -0.022, 95 % CI = -0.039 - -0.005; ACS Wordlist Learning: B = -0.039, 95 % CI = -0.062 - -0.015).

CONCLUSIONS

No exercise intervention effects were found on hippocampal volume, hippocampal subfield volumes, cortical thickness or grey matter volume for the entire intervention group. Contrary to what we expected, in highly fatigued patients a reduction in hippocampal volume was found after the intervention, which was related to improved memory functioning. These results suggest that physical fitness may benefit cognition in specific groups and stress the importance of further research into the biological basis of this finding.

Limited Impact of Breast Cancer and Non-breast Malignancies on Survival in Older Patients with Early-Stage Breast Cancer: Results of a Large, Single-Centre, Population-Based Study

AIMS

To analyse the disease-free survival and overall survival in older adults with breast cancer after breast-conserving therapy, focusing on the relevance of non-breast malignancy (NBM) with respect to survival rates.

MATERIALS AND METHODS

Analyses were based on 1205 women aged 65 years and older with breast cancer treated with breast-conserving therapy between 1999 and 2015. Patients were divided into three age categories: 65-70, 71-75 and >75 years. Multivariate survival analysis was carried out using Cox regression analysis.

RESULTS

The two youngest age categories showed excellent results, with a 12-year disease-free survival of 84.6 and 86.3%, respectively. We noted a 17.2% incidence of NBM, particularly for colon cancer and lung cancer. Most (72.9%) occurred after a diagnosis of breast cancer. Of those 72.9%, about 50% died as a result of NBM within 2 years of the diagnosis of NBM. The overall 12-year NBM-specific survival was 92.0%. The 12-year overall survival was 60.0% for all and for the three abovementioned age categories was 73.3, 54.4 and 28.4%, respectively. The cause of death for all was predominantly non-malignancy-related morbidity.

CONCLUSION

The impact of breast cancer on life expectancy was limited, in particularly for women aged 65-75 years. The relevance of NBM on survival was limited.

Using a stepwise approach to simultaneously develop and validate machine learning based prediction models

Accurate diagnosis of a disease is essential in healthcare. Prediction models, based on classical regression techniques, are widely used in clinical practice. Machine Learning (ML) techniques might be preferred in case of a large amount of data per patient and relatively limited numbers of subjects. However, this increases the risk of overfitting, and external validation is imperative. However, in the field of ML, new and more efficient techniques are developed rapidly, and if recruiting patients for a validation study is time consuming, the ML technique used to develop the first model might have been surpassed by more efficient ML techniques, rendering this original model no longer relevant. We demonstrate a stepwise design for simultaneous development and validation of prediction models based on ML techniques. The design enables - in one study - evaluation of the stability and robustness of a prediction model over increasing sample size as well as assessment of the stability of sensitivity/specificity at a chosen cut-off. This will shorten the time to introduction of a new test in health care. We finally describe how to use regular clinical parameters in conjunction with ML based predictions, to further enhance differentiation between subjects with and without a disease.

Functional or not functional; that's the question: Can we predict the diagnosis functional movement disorder based on associated features?

Background and purpose

Functional movement disorders (FMDs) pose a diagnostic challenge for clinicians. Over the years several associated features have been shown to be suggestive for FMDs. Which features mentioned in the literature are discriminative between FMDs and non‐FMDs were examined in a large cohort. In addition, a preliminary prediction model distinguishing these disorders was developed based on differentiating features.

Method

Medical records of all consecutive patients who visited our hyperkinetic outpatient clinic from 2012 to 2019 were retrospectively reviewed and 12 associated features in FMDs versus non‐FMDs were compared. An independent t test for age of onset and Pearson chi‐squared analyses for all categorical variables were performed. Multivariate logistic regression analysis was performed to develop a preliminary predictive model for FMDs.

Results

A total of 874 patients were eligible for inclusion, of whom 320 had an FMD and 554 a non‐FMD. Differentiating features between these groups were age of onset, sex, psychiatric history, family history, more than one motor phenotype, pain, fatigue, abrupt onset, waxing and waning over long term, and fluctuations during the day. Based on these a preliminary predictive model was computed with a discriminative value of 91%.

Discussion

Ten associated features are shown to be not only suggestive but also discriminative between hyperkinetic FMDs and non‐FMDs. Clinicians can use these features to identify patients suspected for FMDs and can subsequently alert them to test for positive symptoms at examination. Although a first preliminary model has good predictive accuracy, further validation should be performed prospectively in a multi‐center study.

WEARCON: wearable home monitoring in children with asthma reveals a strong association with hospital based assessment of asthma control

Background

Asthma is one of the most common chronic diseases in childhood. Regular follow-up of physiological parameters in the home setting, in relation to asthma symptoms, can provide complementary quantitative insights into the dynamics of the asthma status. Despite considerable interest in asthma home-monitoring in children, there is a paucity of scientific evidence, especially on multi-parameter monitoring approaches. Therefore, the aim of this study is to investigate whether asthma control can be accurately assessed in the home situation by combining parameters from respiratory physiology sensors.

Methods

Sixty asthmatic and thirty non-asthmatic children were enrolled in the observational WEARCON-study. Asthma control was assessed according to GINA guidelines by the paediatrician. All children were also evaluated during a 2-week home-monitoring period with wearable devices; a physical activity tracker, a handheld spirometer, smart inhalers, and an ambulatory electrocardiography device to monitor heart and respiratory rate. Multiple logistic regression analysis was used to determine which diagnostic measures were associated with asthma control.

Results

24 of the 27 uncontrolled asthmatic children and 29 of the 32 controlled asthmatic children could be accurately identified with this model. The final model showed that a larger variation in pre-exercise lung function (OR = 1.34 95%-CI 1.07–1.68), an earlier wake-up-time (OR = 1.05 95%-CI 1.01–1.10), more reliever use (OR = 1.11 95%-CI 1.03–1.19) and a longer respiratory rate recovery time (OR = 1.12 95%-CI 1.05–1.20) were significant contributors to the probability of having uncontrolled asthma.

Conclusions

Home-monitoring of physiological parameters correlates with paediatrician assessed asthma control. The constructed multivariate model identifies 88.9% of all uncontrolled asthmatic children, indicating a high potential for monitoring of asthma control. This may allow healthcare professionals to assess asthma control at home.

Trial registration

Netherlands Trail Register, NL6087. Registered 14 February 2017.

Effect of the dr. Bart application on healthcare use and clinical outcomes in people with osteoarthritis of the knee and/or hip in the Netherlands; a randomized controlled trial

OBJECTIVE

To evaluate the short-term effects of use of the dr. Bart app, compared to usual care, on the number of secondary health care consultations and clinical outcomes in people with knee/hip OA in the Netherlands.

METHOD

A randomized controlled design involving participants ≥50 years with self-reported knee and/or hip OA recruited from the community. The number of secondary health care consultations (primary outcome) and secondary outcomes were assessed at baseline, 3 and 6 months via online questionnaires. Data were analyzed using longitudinal mixed models, corrected for baseline values. Due to the design of this study, blinding of participants and researchers was not possible.

RESULTS

In total, 427 eligible participants were allocated to either the dr. Bart group (n = 214) or usual care (n = 213). We found no difference between groups in the number of secondary (i.e., orthopaedic surgeon, rheumatologist, or physician assistant) health care consultations (incidence rate ratio (IRR) 1.20 (95% CI: 0.67; 2.19)). We found positive treatment effects of the dr. Bart app on symptoms (2.6 (95% CI: 0.4; 4.9)), pain (3.5 (95% CI: 0.9; 6.0)), and activities of daily living (2.9 (95% CI: 0.2; 5.6)) on a 0-100 scale, higher score indicating less complaints, but not in any other secondary outcome.

CONCLUSION

The dr. Bart app did not change the number of secondary health care consultations compared to usual care. However, we found small positive effects (not clinically relevant) on pain, symptoms, and activities of daily living in people with knee/hip OA.

TRIAL REGISTRATION

Dutch Trial Register (Trial Number NTR6693/NL6505) (https://www.trialregister.nl/trial/6505).

A randomized controlled efficacy study of the Medido medication dispenser in Parkinson's disease

Background

Complex medication schedules in Parkinson’s disease (PD) result in lower therapy adherence, which contributes to suboptimal therapy and clinical deterioration. Medication reminder systems might improve therapy adherence and subsequently improve symptoms of PD. This randomized controlled study assessed the effect of the electronic medication dispenser Medido on physical disability in PD, as a proxy for changes in therapy adherence.x

Methods

Eighty-seven patients were randomized into the Medido group or control group. The primary outcome of physical disability was measured by the AMC Linear Disability Scale (ALDS). Secondary outcomes were quality of life (QoL) (PDQ-39), health status (EQ5D-5L, VAS), non-motor symptoms (NMS-Quest), and QoL of the caregiver (PDQ-carer). Measurements were performed at baseline, and after 3 and 6 months follow-up.

Results

When using the Medido, a non-significant improvement of 3.0 points (95% CI -5.6;11.6) was seen in ALDS. The exploratory subgroup Hoehn & Yahr classification (H&Y) > 2.5 improved significantly on ALDS with 14.7 points (95% CI -28.5;-0.9, p = 0.029 for group x time interaction). QoL deteriorated with 1.0 point in PDQ-39 (p = 0.01 for group x time interaction) in favor of the control group. Non-significant differences were observed for VAS (0.4 points, p = 0.057) and NMS-Quest (1.3 points, p = 0.095) in favor of the Medido group. No changes over time were observed in EQ5D-5L and PDQ-carer.

Conclusions

Based on these data, no firm conclusion can be drawn, but use of the Medido medication dispenser may result in a clinical improvement of physical disability and seems particularly appropriate for more severe patients.

Trial registration

NTR3917. Registered 19 March 2013.

The Visual Analog Scale detects exercise-induced bronchoconstriction in children with asthma

Objective: Exercise-induced bronchoconstriction (EIB) is a specific morbidity of childhood asthma and an important sign of uncontrolled asthma. The occurrence of EIB is insufficiently identified by the Childhood Asthma Control Test (C-ACT) and Asthma Control Test (ACT). This study aimed to (1) evaluate the Visual Analog Scale (VAS) for dyspnea as a tool to detect EIB in asthmatic children and (2) assess the value of combining (C-)ACT outcomes with VAS scores. Methods: We measured EIB in 75 asthmatic children (mean age 10.8 years) with a standardized exercise challenge test (ECT) performed in cold and dry air. Children and parents reported VAS dyspnea scores before and after the ECT. Asthma control was assessed by the (C-)ACT. Results: Changes in VAS scores (ΔVAS) of children and parents correlated moderately with fall in forced expiratory volume in 1 second (FEV₁), respectively r_s=0.57 (p < .001) and r_s=0.58 (p < .001). At a ΔVAS cutoff value of ≥3 in children, sensitivity and specificity for EIB were 80% and 79% (AUC 0.82). Out of 38 children diagnosed with EIB, 37 had a (C-)ACT score of ≤19 and/or a ΔVAS of ≥3, corresponding with a sensitivity of 97% and a negative predictive value of 96%. Conclusion: This study shows that the VAS could be an effective additional tool for diagnosing EIB in children. A reported difference in VAS scores of ≥3 after a standardized ECT combined with low (C-)ACT scores was highly effective in detecting and excluding EIB.

The effect of a structured medication review on quality of life in Parkinson's disease: The study protocol

BACKGROUND

Treatment of Parkinson's disease (PD) is symptomatic and frequently consists of complicated medication regimes. This negatively influences therapy adherence, resulting in lower benefit of treatment, drug related problems and decreased quality of life (QoL). A potential effective intervention strategy is a structured medication review, executed by community pharmacists. However, little is known about the effects on clinical endpoints like QoL, as well as on feasibility and cost-effectiveness in PD patients.

OBJECTIVES

To assess the effect of a structured medication review on QoL in PD patients. Secondary objectives are measurements of physical disability, activities in daily life, non-motor symptoms, health state, personal carers' QoL and cost-effectiveness. Furthermore, a better insight in the process of performing medication reviews will be obtained from the perspective of community pharmacists.

METHODS

In this multicenter randomized controlled trial we aim to enroll 200 PD patients from the outpatient clinic of three Dutch hospitals. Community pharmacists will perform a structured medication review in half of the assigned patients; the other half will receive usual care. Data obtained by use of six validated questionnaires will be collected at baseline and after 3 and 6 months of follow-up. Semi-structured interviews with community pharmacists will be conducted till data saturation has been reached.

DISCUSSION

This trial targets a high-risk patient group for whom optimizing therapy by a structured medication review might be of added value. If effectiveness is proven, this could further promote the implementation of pharmaceutical care in a primary care setting.

Can Pediatricians Assess Exercise-Induced Bronchoconstriction From Post-exercise Videos?

Objective: Exercise-induced bronchoconstriction (EIB) is a highly prevalent morbidity of childhood asthma and defined by a transient narrowing of the airways during or after physical exercise. An exercise challenge test (ECT) is the reference standard for the diagnosis of EIB. Video evaluation of EIB symptoms could be a practical alternative for the assessment of EIB. We studied the ability of pediatricians to assess EIB from post-exercise videos. Methods: A clinical assessment was performed in 20 asthmatic children (mean age 11.6 years) and EIB was measured with a standardized ECT performed in cold, dry air. EIB was defined as a fall in forced expiratory volume in 1 s (FEV₁) of ≥10% post-exercise. Children were filmed before and after exercise in frontal position and bare chested. The clinical assessment results and videos were shown to 20 pediatricians (mean experience 14.4 years). Each assessed EIB severity in 5 random children providing 100 assessments, scored on a continuous rating scale (0-10) and in severity classifications (no, mild, moderate, severe) using a scoring list including physical asthma symptoms. Correlations between predicted scores and objective scores were calculated with Spearman's rho and Cohen's Kappa. A generalized linear model was used to assess the relationship between physical symptoms and fall in FEV₁. Results: Median fall in FEV₁ after exercise was 15.1% (IQR 1.2-65.1). Pediatricians detected EIB with a sensitivity of 78% (95% CI 66-87%) and a specificity of 40% (95% CI 27-55%). The positive predictive value for a pediatricians' diagnosis of EIB was 61% (95% CI 50-72%). The negative predictive value was 60% (95% CI 42-76%). The agreement between predicted EIB severity classifications and the validated classifications based on the ECT's, was fair [Kappa = 0.36 (95% CI 0.23-0.48)]. The correlation between predicted EIB severity scored on a continuous rating scale and fall in FEV₁ after exercise was weak (r_s = 0.39, p < 0.001). Independent predictive variables for fall in FEV₁ were wheezing (-11%), supraclavicular retractions (-8.4%) and a prolonged expiratory phase (-8.8%). Conclusion: The ability of pediatricians to assess EIB from post-exercise videos is fair at best, implicating that standardized ECT's are still vital in the assessment of EIB.

Multi-centre prospective study on diagnosing subtypes of lung cancer by exhaled-breath analysis

OBJECTIVES

Lung cancer is a leading cause of mortality. Exhaled-breath analysis of volatile organic compounds (VOC's) might detect lung cancer early in the course of the disease, which may improve outcomes. Subtyping lung cancers could be helpful in further clinical decisions.

MATERIALS AND METHODS

In a prospective, multi-centre study, using 10 electronic nose devices, 144 subjects diagnosed with NSCLC and 146 healthy subjects, including subjects considered negative for NSCLC after investigation, breathed into the Aeonose™ (The eNose Company, Zutphen, Netherlands). Also, analyses into subtypes of NSCLC, such as adenocarcinoma (AC) and squamous cell carcinoma (SCC), and analyses of patients with small cell lung cancer (SCLC) were performed.

RESULTS

Choosing a cut-off point to predominantly rule out cancer resulted for NSCLC in a sensitivity of 94.4%, a specificity of 32.9%, a positive predictive value of 58.1%, a negative predictive value (NPV) of 85.7%, and an area under the curve (AUC) of 0.76. For AC sensitivity, PPV, NPV, and AUC were 81.5%, 56.4%, 79.5%, and 0.74, respectively, while for SCC these numbers were 80.8%, 45.7%, 93.0%, and 0.77, respectively. SCLC could be ruled out with a sensitivity of 88.9% and an NPV of 96.8% with an AUC of 0.86.

CONCLUSION

Electronic nose technology with the Aeonose™ can play an important role in rapidly excluding lung cancer due to the high negative predictive value for various, but not all types of lung cancer. Patients showing positive breath tests should still be subjected to further diagnostic testing.

The Effect of Unenhanced MRI on the Surgeons' Decision-Making Process in Females with Suspected Appendicitis

Background

This prospective study evaluated the impact of the results of unenhanced magnetic resonance imaging (MRI) on the surgeon’s diagnosis of acute appendicitis in potentially fertile females.

Methods

112 female patients, aged 12–55, with suspected appendicitis underwent MRI of the abdomen. At three defined intervals; admission and clinical re-evaluation before and after revealing the MRI results, the surgeon recorded the attendance of each patient in operative treatment, observation or discharge. Appendicitis was confirmed or declined by pathology or by telephone follow-up in case of non-intervention.

Findings

Appendicitis was confirmed in 29 of 112 patients. At admission the surgeon’s disposition had a sensitivity of 97 % and specificity of 29 %. After knowing the MRI results, sensitivity was 97 % and specificity 64 %. The sensitivity and specificity of MRI alone were 89 and 100 %, with a negative and positive predictive value of 96 and 100 %, respectively.

Conclusion

We believe that MRI should perhaps be standard in all female patients during their reproductive years with suspected appendicitis. It avoids an operation in 32 % of cases and allows earlier planning for patients with an equivocal clinical picture. Trial number: OND1292733 (Narcis.nl).

Use of three-dimensional computed tomography overlay for real-time cryoballoon ablation in atrial fibrillation reduces radiation dose and contrast dye

AIMS

Cryoballoon pulmonary vein (PV) isolation in patients with atrial fibrillation has proven to be effective in short-term and long-term follow-up. To visualise the PV anatomy, pre-ablation contrast pulmonary venography is commonly performed. Three-dimensional (3D) computed tomography (CT) overlay is a new technique creating a live 3D image of the left atrium by integrating a previously obtained CT scan during fluoroscopy. To evaluate the benefits of 3D CT overlay during cryoballoon ablation, we studied the use of 3D CT overlay versus contrast pulmonary venography in a randomised fashion in patients with paroxysmal atrial fibrillation undergoing cryoballoon PV isolation.

METHODS AND RESULTS

Between October 2012 and June 2013, 30 patients accepted for PV isolation were randomised to cryoballoon PV isolation using either 3D CT overlay or contrast pulmonary venography. All patients underwent a pre-procedural cardiac CT for evaluation of the anatomy of the left atrium (LA) and the PVs. In the 3D CT overlay group, a 3D reconstruction of the LA and PVs was made. An overlay of the CT reconstruction was then projected over live fluoroscopy. Patients in the contrast pulmonary venography group received significantly more contrast agent (77.1 ± 21.2 cc vs 40.1 ± 17.6 cc, p < 0.001) and radiation (43.0 ± 21.9 Gy.cm2 vs 28.41 ± 11.7 Gy.cm2, p = 0.04) than subjects in the 3D CT overlay group. There was no difference in total procedure time, fluoroscopy time and the amount of cryoapplications between the two groups.

CONCLUSION

The use of 3D CT overlay decreases radiation and contrast dye exposure and can assist in guiding cryoballoon-based PV isolation.

The Distal Radial Fracture in Elderly Women and the Bone Mineral Density of the Lumbar Spine and Hip

The incidence of distal radial fractures in elderly women is high and is associated with osteoporosis and hip fracture. Osteoporosis can be detected by measuring the bone mineral density (BMD) of the lumbar spine or hip with dual energy X-ray absorptiometry. Low BMD of the lumbar spine or hip is a strong predictor for future vertebral deformities and hip fractures. At present, elderly women with a distal radial fracture are not investigated for osteoporosis on a routine basis.

The BMD of the lumbar spine and hip were assessed in 94 women (mean age, 69 years) with a distal radial fracture. A low BMD was found in 85% of the patients, and osteoporosis was diagnosed in 51%. The mean BMD decreased by 0.04 SD per year and there was a significant relationship between post-menopausal status and decreased BMD of the hip. The BMD in patients treated with bisphosphonate medication increased significantly in 1 year. As more than half of the elderly women with a distal radial fracture have osteoporotic BMD values for the lumbar spine or hip, it is our opinion that such patients should be screened for osteoporosis.

Chronic fatigue syndrome in women assessed with combined cardiac magnetic resonance imaging

Objective

In chronic fatigue syndrome (CFS), only a few imaging and histopathological studies have previously assessed either cardiac dimensions/function or myocardial tissue, suggesting smaller left ventricular (LV) dimensions, LV wall motion abnormalities and occasionally viral persistence that may lead to cardiomyopathy. The present study with cardiac magnetic resonance (CMR) imaging is the first to use a contrast-enhanced approach to assess cardiac involvement, including tissue characterisation of the LV wall.

Methods

CMR measurements of 12 female CFS patients were compared with data of 36 age-matched, healthy female controls. With cine imaging, LV volumes, ejection fraction (EF), mass, and wall motion abnormalities were assessed. T2-weighted images were analysed for increased signal intensity, reflecting oedema (i. e. inflammation). In addition, the presence of contrast enhancement, reflecting fibrosis (i. e. myocardial damage), was analysed.

Results

When comparing CFS patients and healthy controls, LVEF (57.9 ± 4.3 % vs. 63.7 ± 3.7 %; p < 0.01), end-diastolic diameter (44 ± 3.7 mm vs. 49 ± 3.7 mm; p < 0.01), as well as body surface area corrected LV end-diastolic volume (77.5 ± 6.2 ml/m² vs. 86.0 ± 9.3 ml/m²; p < 0.01), stroke volume (44.9 ± 4.5 ml/m² vs. 54.9 ± 6.3 ml/m²; p < 0.001), and mass (39.8 ± 6.5 g/m² vs. 49.6 ± 7.1 g/m²; p = 0.02) were significantly lower in patients. Wall motion abnormalities were observed in four patients and contrast enhancement (fibrosis) in three; none of the controls showed wall motion abnormalities or contrast enhancement. None of the patients or controls showed increased signal intensity on the T2-weighted images.

Conclusion

In patients with CFS, CMR demonstrated lower LV dimensions and a mildly reduced LV function. The presence of myocardial fibrosis in some CFS patients suggests that CMR assessment of cardiac involvement is warranted as part of the scientific exploration, which may imply serial non-invasive examinations.

Willingness to accept chemotherapy and attitudes towards costs of cancer treatment; A multisite survey study in the Netherlands

BACKGROUND

In the past years, interest in patient treatment preferences is growing. Our objectives were: (1) to assess and compare the minimal required benefit for patients with cancer, patients without cancer and healthcare professionals to make chemotherapy acceptable and (2) to obtain insight into attitudes towards societal costs of cancer treatment.

PATIENTS AND METHODS

We performed a prospective survey consisting of hypothetical scenarios among patients with cancer, patients without cancer and healthcare professionals. Participants were asked to indicate the minimal desired benefit in terms of chance of cure, life prolongation and symptom relief which would make intensive and mild chemotherapy regimens acceptable. In two other scenarios, attitudes towards monthly costs for chemotherapy treatment were examined.

RESULTS

The minimal benefit required to make chemotherapy acceptable did not differ between cancer and non-cancer patients, with respect to chance of cure (mean 57%), life prolongation (median 24 months) and symptom relief (mean 50%); healthcare providers were likely to accept the same chemotherapy regimen at lower thresholds (p < 0.01). Education level was an important explanatory variable and the differences between patients and healthcare professionals disappeared when corrected for education level. Opinions about the maximum acceptable costs for chemotherapy displayed a large spread between the groups.

CONCLUSIONS

Minimal benefits to accept chemotherapy were not different between cancer and non-cancer patients, but are beyond what can generally can be achieved. Healthcare professionals were willing to accept chemotherapy for less benefit. This difference may be attributed to a difference in education level between the groups. Healthcare professionals rated the maximum acceptable societal cost for chemotherapy lower than patients.

Abstract P3-07-68: Population-based validation study of Adjuvant! for primary breast cancer patients in the Netherlands

Background Adjuvant! is an online risk prediction tool that can support breast cancer patients and physicians in clinical decision-making regarding adjuvant systemic treatment. The aim of this study was to validate Adjuvant! on a Dutch population-based cohort of women diagnosed in 2003 and assess its calibration and discriminatory accuracy.

Methods All Dutch patients diagnosed with invasive primary breast cancer in 2003 in the Netherlands meeting the criteria of Adjuvant!; unilateral, unicentric invasive breast cancer, no evidence of metastatic or residual disease, pathologically staged I-III and no pT4 features, were included. Local treatment consisted of breast conserving therapy or ablative surgery and axillary staging. Adjuvant systemic treatment was given according to national guidelines. Patient, tumor and treatment characteristics were retrieved from the Netherlands Cancer Registry. Endpoints were ten-year overall survival, breast cancer specific survival and event free survival.

Findings A total of 8,195 patients were included. Out of all patients, 4,389 (53.6%) received some form of adjuvant systemic therapy. Throughout a ten-year follow-up, 2,156 (26.3%) patients died and 1,953 (23.8%) patients developed a recurrent disease (locoregional, distant or contralateral invasive cancer or DCIS). Ten-year observed overall survival was underestimated by -1.4% (95% CI -2.3 to -0.4, p=0.006), breast cancer specific survival was underestimated by -3.3% (95% CI -4.1 to -2.6, p&lt;0.0001) and event free survival was underestimated by -3.5% (95% CI -4.5 to -2.6, p&lt;0.0001). Discrimination was moderate for overall survival and breast cancer specific survival but poor for event free survival.

Interpretation Adjuvant! does not accurately predict breast cancer specific survival and event free survival in this Dutch population-based study. Dutch patients showed better ten-year survival rates than predicted by Adjuvant!. For specific patient groups, the model could be used to estimate overall survival. We conclude that Adjuvant! should be used with caution in clinical practice in the Netherlands but probably also in other countries and the US.

Citation Format: Siesling S, van Kleef JJ, Bretveld R, Groothuis-Oudshoorn CGM, van der Palen J, Jobsen JJ, Struikmans H. Population-based validation study of Adjuvant! for primary breast cancer patients in the Netherlands. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-07-68.

Safety and Tolerability of Nebulized Amoxicillin-Clavulanic Acid in Patients with COPD (STONAC 1 and STONAC 2)

The safety and tolerability of nebulized amoxicillin clavulanic acid were determined in patients with stable COPD and during severe exacerbations of COPD. Nine stable COPD patients received doses ranging from 50:10 mg up to 300:60 mg amoxicillin clavulanic acid and eight patients hospitalised for a COPD exacerbation received fixed doses 200/40 mg twice daily. Safety was evaluated by spirometry before and after inhalation. Tolerability was evaluated by questionnaire. Plasma and expectorated sputum samples were assayed for amoxicillin content. Seventeen patients underwent in total 100 nebulizations with amoxicillin clavulanic acid. In this safety and tolerability study no clinically relevant deteriorations in FEV1 were observed. Nebulized amoxicillin clavulanic acid produces sputum concentrations well above the Minimal Inhibiting Concentration of 90% for potential pathogenic micro-organisms, with low concentrations in the central compartment (low systemic exposure). Based on spirometry and reported side effects, inhalation of nebulized amoxicillin clavulanic acid seems to be safe and well tolerated, both in stable patients with COPD as in those experiencing a severe exacerbation. Levels of amoxicillin were adequate.

Protective effect of a low single dose inhaled steroid against exercise induced bronchoconstriction

OBJECTIVE

Daily use of inhaled corticosteroids (ICS) reduces exercise induced bronchoconstriction (EIB) in asthmatic children. A high single dose of ICS also provided acute protection against EIB. Objective of this study is to investigate whether a low single dose of ICS offers protection against EIB in asthmatic children.

METHODS

31 Mild asthmatic children not currently treated with inhaled corticosteroids, 5-16 years, with EIB (fall in FEV0.5/1 ≥ 13%) were included in a prospective intervention study. They performed two ECT's within 2 weeks. Four hours before the second test children inhaled 200 μg beclomethasone-dipropionate (BDP) with a breath-actuated inhaler (BAI).

RESULTS

The median fall in FEV0.5/1 after 200 μg BDP was significantly reduced from 30.9% at baseline to 16.0% (P < 0.001). Twenty children (64.5%) showed a good response to 200 μg BDP (≥ 50% decrease in fall of FEV0.5/1), while 8 children showed a moderate response (25-50%), and three children showed no response at all (< 25%).

CONCLUSION

A low single dose ICS offers acute protection against EIB in the majority of asthmatic children not currently treated with inhaled corticosteroids.

Reversibility of pulmonary function after inhaling salbutamol in different doses and body postures in asthmatic children

RATIONALE

Pulmonary medication is often delivered in the form of medical aerosols designed for inhalation. Recently, breath actuated inhalers (BAI's) gained popularity as they can be used without spacers. A major drawback of BAI's is the impaction in the upper airway. Stretching the upper airway by a forward leaning body posture with the neck extended ("sniffing position") during inhalation may reduce upper airway impaction and improve pulmonary deposition. Aim of this study was to investigate the reversibility of lung function with different doses salbutamol inhaled with a BAI in the forward leaning posture compared to the standard posture in asthmatic children.

METHODS

22 clinically stable asthmatic children, 5-14 years old, performed four reversibility measurements. Children inhaled 200 μg or 400 μg salbutamol with a BAI in the standard or in the forward leaning posture with the neck extended in a randomized single-blinded cross-over design.

RESULTS

Reversibility of lung function after inhaling salbutamol in the forward leaning posture was not significantly different compared to inhalation in the standard posture. Mean FEV1 reversibility was significantly greater after inhaling 400 μg salbutamol compared to 200 μg salbutamol in the standard posture (9.4% ± 9.5% versus 4.5% ± 7.5%, difference 4.9% (95CI 0.9; 9.0%); p = 0.021).

CONCLUSION

In clinically stable asthmatic children, inhalation of salbutamol with a BAI in a forward leaning posture does not increase reversibility of lung function. Inhalation of 400 μg compared to 200 μg salbutamol with a BAI does improve reversibility.

The impact of discussing exercise test results of young asthmatic children on adherence to maintenance medication

OBJECTIVE

Parents' awareness of their child's asthma may improve by discussing an exercise challenge test (ECT) result with them. We investigated the influence of discussing an ECT result with parents on adherence to inhaled maintenance medication, parental illness perceptions and medication beliefs in young asthmatic children.

METHODS

A total of 79 children, 4-7 years old and enrolled in our standard comprehensive asthma care program, performed an ECT to assess exercise induced bronchoconstriction (EIB). The result of the ECT was immediately discussed with the parents. Median medication adherence level was measured with electronic medication loggers from six weeks before the ECT till six weeks afterwards. Parental beliefs about medicines and illness perceptions were measured with the Beliefs about Medicines Questionnaire (BMQ) and the Brief Illness Perceptions Questionnaire (B-IPQ).

RESULTS

The median baseline adherence level was high (83%) and showed a small significant decline after the ECT. There was no significant difference in the decrease in median adherence level between the children with or without EIB. Most parents (82.1%) showed a positive necessity-concern ratio at baseline, as measured with the BMQ. There was no clinical relevant change in medication concerns and necessity scores or in illness perceptions.

CONCLUSION

Discussing ECT results with parents does not modify median adherence levels to inhaled maintenance medication nor medication beliefs of highly adherent young asthmatic children who are already enrolled in a comprehensive asthma care program.

Long Term Results of Kissing Stents in the Aortic Bifurcation

BACKGROUND

To evaluate the long-term outcome after aortoiliac kissing stent placement and to analyze variables, which potentially influence the outcome of endovascular reconstruction of the aortic bifurcation.

METHODS

All patients treated with aortoiliac kissing stents at our institution between April 1995 and August 2011 were retrospectively identified from a prospective single-center database. Data regarding patient characteristics (age, gender, smoking, cardio- and cerebrovascular risk factors, hyperlipidaemia, diabetes mellitus and use of antihypertensive medication), symptoms, pre-interventional examination and imaging, procedural details and follow-up were retrieved. Patency rates were calculated with Kaplan-Meier analysis. Factors affecting the patency were determined with Cox uni- and multivariate analysis.

RESULTS

A total of 215 patients (63% men, mean age 61 ± 10 years) were included. The median follow-up period was 31 (IQR 47.1) months. Primary, primary assisted, and secondary patency rates were 97%, 97%, and 99%, respectively, at one month; 92%, 95% and 94% at four months; 75%, 86%, and 91% at two years; 70%, 81%, and 91% at 5 years; and 67%, 81%, and 91% at ten years. Younger age and previous aortoiliac treatment were predictors for reduced primary and primary assisted patency. Smoking, previous aortoiliac intervention, TASC C and D lesions were predictors for reduced secondary patency.

CONCLUSIONS

Reconstruction of the aortoiliac bifurcation with kissing stents is feasible, safe and effective in all types of lesions with satisfying long term patencies. TASC C and D lesions are associated with a higher occlusion rate. Younger age and previous aortoiliac interventions are predictors for reduced primary and primary assisted patency.

Reversibility after inhaling salbutamol in different body postures in asthmatic children: a pilot study

RATIONALE

Pulmonary medication is mostly delivered in the form of medical aerosols to minimize systemic side effects. A major drawback of inhaled medication is that the majority of inhaled particles impacts in the oropharynx at the sharp bend of the airway. Stretching the airway by a forward leaning body posture with the neck extended ("sniffing position") may improve pulmonary deposition and clinical effects.

METHODS

41 asthmatic children who were planned for standard reversibility testing at the pulmonary function lab, alternately inhaled 200 μgr salbutamol with an Autohaler(®) in the standard or in the forward leaning body posture. Forced Expiratory Volume in 1 s (FEV1), Forced Vital Capacity (FVC), Peak Expiratory Flow (PEF), Mean Expiratory Flow at 25% of vital capacity (MEF25) and Mean Expiratory Flow at 75% of vital capacity (MEF75) were analysed.

RESULTS

The children in the forward leaning body posture group showed a significantly higher mean FEV1 reversibility than the control group after inhalation of 200 μgr salbutamol (10.2% versus 4.1%, p = 0.019). Additionally, mean MEF75 was significantly more reversible in the forward leaning body posture group versus the standard body posture group (32.2% resp. 8.9%, p = 0.013).

CONCLUSION

This pilot study showed a higher reversibility of FEV1 and MEF75 after inhaling salbutamol in a forward leaning body posture compared to the standard body posture in asthmatic children. This suggests that pulmonary effects of salbutamol can be improved by inhaling in a forward leaning body posture with the neck extended. This effect is possibly due to a higher pulmonary deposition of salbutamol and should be confirmed in a randomized controlled trial.

Isosorbide dinitrate ointment vs botulinum toxin A (Dysport) as the primary treatment for chronic anal fissure: a randomized multicentre study

AIM

Nitric oxide donors, such as isosorbide dinitrate ointment (ISDN), are considered as first-choice agents in the treatment of chronic anal fissure. Injection with botulinum toxin A in the internal anal sphincter is often used as a second-line therapy, although it may give better results and fewer side effects than nitric oxide donors. The aim of this randomized clinical trial was to investigate whether botulinum toxin A (Dysport) is more effective than ISDN in the primary treatment of chronic anal fissure.

METHOD

From April 2005 until October 2009, 60 patients (32 men) with a median age of 42 (25-82) years were randomized to receive either ISDN 10 mg/ml (1%) (n = 33) or injection with 60 units of Dysport (n = 27). The primary end-point was the percentage of complete fissure healing after 8 weeks.

RESULTS

After a median of 9 weeks complete fissure healing was noted in 18 of 27 patients in the Dysport group and in 11 of 33 patients in the ISDN group (P = 0.010). Absolute improvement of pain scores after 9 weeks was similar in both groups (P = 0.733). Patients treated with Dysport had fewer side effects than patients treated with ISDN (P = 0.028). Of the patients with a healed fissure, 28% of the Dysport group and 50% of the ISDN group had a recurrence within 1 year (P = 0.286; hazard ratio 2.08; 95% CI = 0.54-7.97).

CONCLUSION

Dysport is more effective than ISDN ointment and has fewer side effects in the primary treatment of chronic anal fissure. The recurrence rate within 1 year in both treatment groups is high.

Is T-wave alternans testing feasible in candidates for prophylactic implantable defibrillators?

AIMS

Previous studies have demonstrated that microvolt T-wave alternans (TWA) screening in patients with ischaemic and dilated cardiomyopathy is effective in identifying patients at high or low risk of sudden cardiac death. It remains unclear which percentage of potential recipients of an implantable cardioverter defibrillator (ICD) are able to perform TWA testing using an exercise protocol which is, at this moment, the golden standard. In this study, we evaluated the feasibility of TWA in the risk stratification of potential ICD recipients with ischaemic or dilated cardiomyopathy.

METHODS AND RESULTS

Medical charts of 165 primary prevention ICD recipients were reviewed to decide if patients were able to perform a TWA exercise test or not. Reasons to waiver a test were: atrial fibrillation or flutter, pacemaker dependency, recent (cardiovascular) surgery (<1 month) and inability to exercise. Of the potential ICD recipients 35% had one or more of these contraindications and were therefore not suitable for testing.

CONCLUSION

In several studies, TWA is a promising risk stratifier for predicting sudden cardiac death; however, in our population, 35% of the potential ICD candidates could not be tested. In order to fulfil its promise as a predictor for SCD, an alternative means to measure TWA needs to be evaluated.

The (a)-Symptomatic Vertebral Fracture: A Frequently Discovered Entity With Clinical Relevance in Fracture Patients Screened on Osteoporosis

OBJECTIVE

Description of the prevalence of vertebral fractures in a fracture and osteoporosis outpatient clinic (FO-Clinic) and evaluation of the value of spinal radiographs by screening on osteoporosis.

DESIGN

Retrospective data collection, description, and analysis.

METHODS

All patients admitted to the FO-Clinic during the period of December 2005 until October 2006 were enrolled in this study. At the FO-Clinic spinal radiographs were obtained and bone mineral density (BMD) was measured by Dual energy X-ray-Absorptiometry (DXA).

RESULTS

During the study period, a total of 176 patients were screened at our FO-Clinic. In 41.5% of these patients, a vertebral fracture was diagnosed. There appeared to be an indication for anti-osteoporotic medication in 95 of the 176 patients. Of these 95 patients, 77% could be identified by spinal radiographs. Moreover, only 36% of all patients with a vertebral fracture did suffer from osteoporosis.

CONCLUSION

The prevalence of vertebral fractures in patients screened at an FO-Clinic is high and spinal radiographs can identify up to 77% of patients in which anti-osteoporotic medication should be considered. However, fracture risk is not only dependent on bone quality but also on bone density. Therefore, the preferred method of screening on osteoporosis is DXA with vertebral fracture assessment and, if necessary, spinal radiographs. If DXA is not available, spinal radiographs might be used as a first step in osteoporosis screening.

Incidence and predictors of phantom shocks in implantable cardioverter defibrillator recipients

BACKGROUND

Implantable cardioverter defibrillators (ICDs) are designed to deliver shocks or antitachycardia pacing (ATP) in the event of ventricular arrhythmias. During follow-up, some ICD recipients experience the sensation of ICD discharge in the absence of an actual discharge (phantom shock). The aim of this study was to evaluate the incidence and predictors of phantom shocks in ICD recipients.

METHODS

Medical records of 629 consecutive patients with ischaemic or dilated cardiomyopathy and prior ICD implantation were studied.

RESULTS

With a median follow-up of 35 months, phantom shocks were reported by 5.1 % of ICD recipients (5.7 % in the primary prevention group and 3.7 % for the secondary prevention group; p=NS). In the combined group of primary and secondary prevention, there were no significant predictors of the occurrence of phantom shocks. However, in the primary prevention group, phantom shocks were related to a history of atrial fibrillation (p=0.03) and NYHA class <III (p=0.05). In the secondary prevention group, there were no significant predictors for phantom shocks.

CONCLUSION

Phantom shocks occur in approximately 5 % of all ICD recipients. In primary prevention patients, a relation with a history of atrial fibrillation and NYHA class <III were significant predictors for the occurrence of phantom shocks. In the secondary prevention patients, no significant predictors were found.

Timing of radiotherapy in breast-conserving therapy: a large prospective cohort study of node-negative breast cancer patients without adjuvant systemic therapy

Background:

To investigate the issue of timing of radiation therapy (RT) after lumpectomy in relation to recurrences and outcome.

Methods:

Analysis was done on 1107 breast-conserving therapies (BCT) with 1070 women, all without lymph node metastasis and without any adjuvant systemic therapy. Timing was defined as time from lumpectomy till RT. Patients were categorised into tertiles: <45 days, 45–56 days, and 57–112 days.

Results:

Local control did not show a difference between the tertiles. The distant metastasis-free survival as well as the disease-specific survival showed a decreased outcome starting the RT to early after the lumpectomy.

Conclusion:

The results of this cohort study further refines the hypothesis that timing of RT in BCT might have an impact on outcome. It suggests that a randomised trial in timing of RT in BCT seems necessary to give a definite answer.

Gain in lung function after weight reduction in severely obese children

AIM

The primary objective of this prospective cohort study was to determine the effect of weight loss on pulmonary function values in extremely obese children.

METHODS

Obese children participated in a 26-week in-hospital or outpatient multidisciplinary treatment programme. Waist circumference was measured and pulmonary function tests were performed at enrolment and after 6 months.

RESULTS

The data of 112 children were analysed. The children had a mean age of 14.4 (range 8.5-18.9) years and 62.5% were girls. The mean SD score-body mass index (SDS-BMI) was +3.38 at baseline and +2.91 after the intervention. Lung function improved significantly: functional vital capacity increased by 3.08% (95% CI 1.16% to 5.00%) of the predicted value, forced expiratory volume in 1 s (FEV(1)) by 2.91% (95% CI 1.11% to 4.71%) of the predicted value, total lung capacity by 2.27% (95% CI 1.16% to 5.00%) of the predicted value, and expiratory reserve volume (ERV) by 14.8% (95% CI 8.66% to 20.88%) of the predicted value. The increase in ERV correlated with the reduction in SDS-BMI and with the reduction in waist circumference. FEV(1) did not correlate with the reduction in either SDS-BMI or waist circumference.

CONCLUSIONS

Weight loss in severely obese children correlated with an improvement in lung function, especially ERV. The improvement in ERV correlated with the decrease in SDS-BMI and waist circumference.

Splanchnic artery stenosis and abdominal complaints: clinical history is of limited value in detection of gastrointestinal ischemia

Background

Splanchnic artery stenosis is common and mostly asymptomatic and may lead to gastrointestinal ischemia (chronic splanchnic syndrome, CSS). This study was designed to assess risk factors for CSS in the medical history of patients with splanchnic artery stenosis and whether these risk factors can be used to identify patients with high and low risk of CSS.

Methods

All patients referred for suspected CSS underwent a standardized workup, including a medical history with questionnaire, duplex ultrasound, gastrointestinal tonometry, and angiography. Definitive diagnosis and treatment advice was made in a multidisciplinary team. Patients with confirmed CSS were compared with no-CSS patients.

Results

A total of 270 patients (102 M, 168 F; mean age, 53 years) with splanchnic artery stenosis were analyzed, of whom 109 (40%) had CSS and 161 no CSS. CSS-patients more often reported postprandial pain (87% vs. 72%, p = 0.007), weight loss (85% vs. 70%, p = 0.006), adapted eating pattern (90% vs. 79%, p = 0.005) and diarrhea (35% vs. 22%, p = 0.023). If none of these risk factors were present, the probability of CSS was 13%; if all were present, the probability was 60%. Adapted eating pattern (odds ratio (OR) 3.1; 95% confidence interval (CI) 1.08–8.88) and diarrhea (OR 2.6; 95% CI 1.31–5.3) were statistically significant in multivariate analysis.

Conclusions

In patients with splanchnic artery stenosis, the clinical history is of limited value for detection of CSS. A diagnostic test to detect ischemia is indispensable for proper selection of patients with splanchnic artery stenosis who might benefit from treatment.

TWENTE Study: The Real-World Endeavor Resolute Versus Xience V Drug-Eluting Stent Study in Twente: study design, rationale and objectives

Background. New-generation drug-eluting stents (DES) may solve several problems encountered with first-generation DES, but there is a lack of prospective head-to-head comparisons between new-generation DES. In addition, the outcome of regulatory trials may not perfectly reflect the outcome in 'real world' patients.Objectives. To compare the efficacy and safety of two new-generation DES in a 'real world' patient population.Methods. A prospective, randomised, single-blinded clinical trial to evaluate clinical outcome after Endeavor Resolute vs. Xience V stent implantation. The primary endpoint is target vessel failure at one-year follow-up. In addition, the study comprises a two-year and an open-label five-year follow-up. (Neth Heart J 2010;18:360-4.).

Evaluation of the finger wrinkling test: a pilot study

Purpose

Tilt table testing mainly evaluates the systemic cardiovascular part of the autonomic nervous system, while it is assumed that the finger wrinkling test assesses the peripheral part of the autonomic nervous system. In this study we explored whether the finger wrinkling test could be a useful test for autonomic dysfunction and whether the clinical evaluation of wrinkling can be improved by digital analysis of photographs.

Methods

As much as 20 healthy subjects and 15 patients underwent tilt table testing and finger wrinkling testing. During the finger wrinkling test the right hand was immersed in water at 40°C. The degree of wrinkling was assessed with a 5-point clinical scale at baseline, 5, 15 and 30 min of immersion. Photographs were taken at the same intervals. Several features were evaluated using digital analysis: length and gradient of automatically detected wrinkle and mean, maximum, minimum, variance and derivative of grey value of pixels.

Results

Clinical scoring of wrinkling allowed differentiation between healthy subjects and patients with a normal and an abnormal response to tilt table testing. Relevant features obtained with digital analysis were mean grey value and the gradient of automatically detected wrinkle. McNemar’s test showed no difference in test results between the tilt table test and the finger wrinkling test with a kappa of 0.68.

Conclusion

The finger wrinkling test can be used as a screening test before tilt table testing. Visual evaluation of wrinkling is still superior to digital analysis of photographs.

(Cost)-effectiveness of self-treatment of exacerbations on the severity of exacerbations in patients with COPD: the COPE II study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic disease with a high prevalence and rapidly increasing incidence rates. The effect of self-treatment of COPD exacerbations on the severity of exacerbations during a 1-year period was examined and a cost-effectiveness analysis was performed.

METHODS

Patients were randomly allocated to four 2-hour self-management sessions, with or without training in self-treatment of exacerbations. Patients in the self-treatment group received an action plan with the possibility to initiate a course of prednisolone (with or without antibiotics). During follow-up, all participants kept a daily symptom diary. These provided the data to calculate the frequency of exacerbations, the number of exacerbation days and mean daily severity scores.

RESULTS

Data were analysed for 142 randomised patients (self-treatment: n = 70; control: n = 72). The frequency of exacerbations was identical in both study groups (mean (SD) 3.5 (2.7)). Patients in the self-treatment group reported fewer exacerbation days (median 31 (interquartile range (IQR) 8.9-67.5) in the self-treatment group vs 40 (IQR 13.3-88.2) in the control group; p = 0.064); the difference was significant in the group of patients with a high number of exacerbation days per year (>137 (90th percentile of the whole study population); p = 0.028). The mean severity score of an exacerbation day was equal in both groups. No between-group differences were found in health-related quality of life. Cost-effectiveness analyses showed that applying self-treatment saved euro154 per patient, with a trend towards a lower probability for hospital admissions (0.20/patient/year in the self-treatment group vs 0.33/patient/year in the control group; p = 0.388) and a significant reduction of health care contacts (5.37/patient/year in the self-treatment group vs 6.51/patient/year in the control group; p = 0.043).

CONCLUSION

Self-treatment of exacerbations incorporated in a self-management programme leads to fewer exacerbation days and lower costs.

Self-management education for patients with chronic obstructive pulmonary disease

BACKGROUND

There is great interest in chronic obstructive pulmonary disease (COPD) and the associated large burden of disease. COPD is characterised by frequent day by day fluctuations, and repetitive clinical exacerbations are typical. Self-management is a term applied to educational programmes aimed at teaching skills needed to carry out medical regimens specific to the disease, guide health behaviour change, and provide emotional support for patients to control their disease and live functional lives. In COPD, the value of self-management education is not yet clear. The first Cochrane review about self-management was published in 2003. It was intended to shed light on the effectiveness of self-management programmes in COPD and the relative efficacy of their constitutive elements. No conclusions about the effectiveness of self-management could be drawn because of the large variation in outcome measures used in the limited number of included studies. This article describes the first update of this review.

OBJECTIVES

The objective of this review was to assess the settings, methods and efficacy of COPD self-management education programmes on health outcomes and use of health care services.

SEARCH STRATEGY

We searched the Cochrane Airways Group trial register, MEDLINE (January 1985 to January 2006), reference lists, and abstracts of medical conferences.

SELECTION CRITERIA

Controlled trials (randomised and non-randomised) of self-management education in patients with COPD. Studies focusing mainly on pulmonary rehabilitation and studies without usual care as a control group were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed study quality and extracted data. Investigators were contacted for additional information.

MAIN RESULTS

The reviewers included 15 group comparisons drawn from 14 trials. They assessed a broad-spectrum of interventions and health outcomes with different follow-up times. Meta-analyses could often not appropriately be performed because of heterogeneity among studies. The studies showed a significant reduction in the probability of at least one hospital admission among patients receiving self-management education compared to those receiving usual care (OR 0.64; 95% CI (0.47 to 0.89)). This translates into a one year NNT ranging from 10 (6 to 35) for patients with a 51% risk of exacerbation, to an NNT of 24 (16 to 80) for patients with a 13% risk of exacerbation. On the disease specific SGRQ, differences reached statistical significance at the 5% level on the total score (WMD -2.58; 95% CI (-5.14 to -0.02)) and impact domain (WMD -2.83; 95% CI (-5.65 to -0.02)), but these difference did not reach the clinically relevant improvement of 4 points. A small but significant reduction was detected in dyspnoea measured with the BORG-scale (WMD -0.53; 95% CI (-0.96 to -0.10)). No significant effects were found either in number of exacerbations, emergency department visits, lung function, exercise capacity, and days lost from work. Inconclusive results were observed in doctor and nurse visits, on symptoms other than dyspnoea, the use of courses of oral corticosteroids and antibiotics, and the use of rescue medication.

AUTHORS' CONCLUSIONS

It is likely that self-management education is associated with a reduction in hospital admissions with no indications for detrimental effects in other outcome parameters. This would in itself already be enough reason for recommending self-management education in COPD. However, because of heterogeneity in interventions, study populations, follow-up time, and outcome measures, data are still insufficient to formulate clear recommendations regarding the form and contents of self-management education programmes in COPD. There is an evident need for more large RCTs with a long-term follow-up, before more conclusions can be drawn.