The PRIME-NL study: evaluating a complex healthcare intervention for people with Parkinson's disease in a dynamic environment.

BACKGROUND: An innovative, integrative care model for people with Parkinson (PRIME Parkinson) has gradually been implemented in a selected region of the Netherlands since 2021. A prospective evaluation of this model (PRIME-NL study) was initiated in parallel, spanning the year prior to implementation (baseline) and the implementation period. Following publication of the original study protocol, the COVID-19 crisis delayed implementation of the full PRIME Parkinson care model by two years and hampered the recruitment of study participants. OBJECTIVE: To describe which methodological adjustments were made to the study protocol because of these developments. METHODS: We compare various outcomes between a region where PRIME Parkinson care was implemented (innovation region) versus the rest of the Netherlands (usual care region). We use healthcare claims data of virtually all people with Parkinson in the Netherlands and annual questionnaires in a representative subsample of 984 people with Parkinson, 566 caregivers and 192 healthcare professionals. Four major methodological adjustments had to be made since publication of the original protocol. First, we extended the evaluation period by two years. Second, we incorporated annual process measures of the stage of implementation of the new care model. Third, we introduced a real-time iterative feedback loop of interim results to relevant stakeholders. Fourth, we updated the statistical analysis plan. DISCUSSION: This manuscript provides transparency in how the design and analyses of the evaluation study had to be adapted to control for external influences in a dynamic environment, including eruption of the COVID-19 crisis. Our solutions could serve as a template for evaluating other complex healthcare interventions in a dynamic environment.

Pharmacodynamics of Temocillin in Neutropenic Murine Infection Models.

Temocillin is used for the treatment of various infections caused by Enterobacterales. The pharmacokinetic (PK)/pharmacodynamic (PD) index that is best correlated with the activity of beta-lactams is the percentage of time that the unbound concentration exceeds the MIC (%fT>MIC). However, the %fT>MIC needed for a bacteriostatic or killing effect of temocillin is unknown in thigh and lung infection models. In the present study, we studied the temocillin PK in plasma and epithelial lining fluid (ELF) of infected neutropenic mice and determined the plasma exposure-response relationships for Escherichia coli and Klebsiella pneumoniae. Neutropenic murine thigh and lung infection models were used. The bacterial loads in the thighs or lungs were determined. A sigmoid maximum-effect model was used to fit the plasma exposure-response relationship. A one-compartment model with first-order absorption best described temocillin PK (clearance [CL], 1.03 L/h/kg; volume of distribution [V], 0.457 L/kg). Protein binding was 78.2% ± 1.3% across different plasma concentrations. A static effect was achieved for all strains in both the thigh and lung infection models. However, the median %fT>MIC needed for a static effect was much lower in the lung infection model (27.8% for E. coli and 38.2% for K. pneumoniae) than in the thigh infection model (65.2% for E. coli and 64.9% for K. pneumoniae). A 1-log kill was reached for all strains in the lung infection model (median %fT>MIC values of 42.1% for E. coli and 44.1% for K. pneumoniae) and 7 out of 8 strains in the thigh infection model (median %fT>MIC values of 85.4% for E. coli and 74.5% for K. pneumoniae). These data support the use of temocillin in patients with pneumonia.

Pharmacokinetic and pharmacodynamic properties of polymyxin B in Escherichia coli and Klebsiella pneumoniae murine infection models.

BACKGROUND: Although polymyxin B has been in use since the late 1950s, there have been limited studies done to unravel its pharmacokinetics (PK) and pharmacodynamics (PD) index. METHODS: We determined, in neutropenic infected mice, the PK, plasma protein binding and PK/PD index best correlating with efficacy for Escherichia coli and Klebsiella pneumoniae strains. RESULTS: The pharmacokinetic profile showed non-linear PK; dose was significantly correlated with absorption rate and clearance. The inhibitory sigmoid dose-effect model for the fCmax/MIC index of E. coli fitted best, but was only modestly higher than the R2 of %fT>MIC and fAUC/MIC (R2 0.91-0.93). For K. pneumoniae the fAUC/MIC index had the best fit, which was slightly higher than the R2 of %fT>MIC and fCmax/MIC (R2 0.85-0.91). Static targets of polymyxin B fAUC/MIC were 27.5-102.6 (median 63.5) and 5.9-60.5 (median 11.6) in E. coli and in K. pneumoniae isolates, respectively. A 1 log kill effect was only reached in two E. coli isolates and one K. pneumoniae. The PTA with the standard dosing was low for isolates with MIC >0.25 mg/L. CONCLUSIONS: This study confirms that fAUC/MIC can describe the exposure-response relationship for polymyxin B. The 1 log kill effect was achieved in the minority of the isolates whereas polymyxin B PK/PD targets cannot be attained for the majority of clinical isolates with the standard dosing regimen, indicating that polymyxin B may be not effective against serious infections as monotherapy.

Cefepime pharmacodynamic targets against Enterobacterales employing neutropenic murine lung infection and in vitro pharmacokinetic models.

BACKGROUND: Very limited studies, so far, have been conducted to identify the pharmacodynamic targets of cefepime, a well-established fourth-generation cephalosporin. As a result, conventional targets representing the cephalosporin class are used for cefepime target attainment analysis. OBJECTIVES: We employed both a neutropenic murine lung infection model and an in vitro pharmacokinetic model (IVPM) to determine cefepime's pharmacodynamic target [percentage of the dosing interval during which unbound drug concentrations remain higher than the MIC (%fT>MIC)] for bacteriostatic and 1 log10 kill effects. METHODS: Ten strains with cefepime MICs ranging from 0.03 to 16 mg/L were studied in the lung infection. In the IVPM, five cefepime-resistant strains with cefepime/tazobactam (fixed 8 mg/L) MICs ranging from 0.25 to 8 mg/L were included. Through 24 h dose fractionation, both in lung infection and IVPM (in the latter case, tazobactam 8 mg/L continuous infusion was used to protect cefepime), varying cefepime exposures and corresponding pharmacodynamic effect scenarios were generated to identify the pharmacodynamic targets. RESULTS: Using a non-linear sigmoidal maximum-effect (Emax) model, the cefepime's plasma fT>MIC for 1 log10 kill in lung infection ranged from 17% to 53.7% and a combined exposure-response plot yielded 30%. In the case of IVPM, T>MIC ranged from 6.9% to 75.4% with a mean value of 34.2% for 1 log10 kill. CONCLUSIONS: Both in vivo and in vitro studies showed that cefepime's pharmacodynamic requirements are lower than generally reported for cephalosporins (50%-70% fT>MIC). The lower requirement for cefepime could be linked with factors such as cefepime's better permeation properties and multiple PBP affinity-driven enhanced bactericidal action.

Superior Efficacy of a Bedaquiline, Delamanid, and Linezolid Combination Regimen in a Mouse Tuberculosis Model.

BACKGROUND: The treatment success rate of drug-resistant (DR) tuberculosis is alarmingly low. Therefore, more effective and less complex regimens are urgently required. METHODS: We compared the efficacy of an all oral DR tuberculosis drug regimen consisting of bedaquiline (25 mg/kg), delamanid (2.5 mg/kg), and linezolid (100 mg/kg) (BDL) on the mycobacterial load in the lungs and spleen of tuberculosis-infected mice during a treatment period of 24 weeks. This treatment was compared with the standard regimen of isoniazid, rifampicin, pyrazinamide, and ethambutol (HRZE). Relapse was assessed 12 weeks after treatment. Two logistic regression models were developed to compare the efficacy of both regimens. RESULTS: Culture negativity in the lungs was achieved at 8 and 20 weeks of treatment with BDL and HRZE, respectively. After 14 weeks of treatment only 1 mouse had relapse in the BDL group, while in the HRZE group relapse was still observed at 24 weeks of treatment. Predictions from the final mathematical models showed that a 95% cure rate was reached after 20.5 and 28.5 weeks of treatment with BDL and HRZE, respectively. CONCLUSION: The BDL regimen was observed to be more effective than HRZE and could be a valuable option for the treatment of DR tuberculosis.

The Role of Behavioral Ecotoxicology in Environmental Protection.

For decades, we have known that chemicals affect human and wildlife behavior. Moreover, due to recent technological and computational advances, scientists are now increasingly aware that a wide variety of contaminants and other environmental stressors adversely affect organismal behavior and subsequent ecological outcomes in terrestrial and aquatic ecosystems. There is also a groundswell of concern that regulatory ecotoxicology does not adequately consider behavior, primarily due to a lack of standardized toxicity methods. This has, in turn, led to the exclusion of many behavioral ecotoxicology studies from chemical risk assessments. To improve understanding of the challenges and opportunities for behavioral ecotoxicology within regulatory toxicology/risk assessment, a unique workshop with international representatives from the fields of behavioral ecology, ecotoxicology, regulatory (eco)toxicology, neurotoxicology, test standardization, and risk assessment resulted in the formation of consensus perspectives and recommendations, which promise to serve as a roadmap to advance interfaces among the basic and translational sciences, and regulatory practices.

Moderators of the effect of psychosocial interventions on fatigue in women with breast cancer and men with prostate cancer: Individual patient data meta-analyses.

OBJECTIVE: Psychosocial interventions can reduce cancer-related fatigue effectively. However, it is still unclear if intervention effects differ across subgroups of patients. These meta-analyses aimed at evaluating moderator effects of (a) sociodemographic characteristics, (b) clinical characteristics, (c) baseline levels of fatigue and other symptoms, and (d) intervention-related characteristics on the effect of psychosocial interventions on cancer-related fatigue in patients with non-metastatic breast and prostate cancer. METHODS: Data were retrieved from the Predicting OptimaL cAncer RehabIlitation and Supportive care (POLARIS) consortium. Potential moderators were studied with meta-analyses of pooled individual patient data from 14 randomized controlled trials through linear mixed-effects models with interaction tests. The analyses were conducted separately in patients with breast (n = 1091) and prostate cancer (n = 1008). RESULTS: Statistically significant, small overall effects of psychosocial interventions on fatigue were found (breast cancer: ß = -0.19 [95% confidence interval (95%CI) = -0.30; -0.08]; prostate cancer: ß = -0.11 [95%CI = -0.21; -0.00]). In both patient groups, intervention effects did not differ significantly by sociodemographic or clinical characteristics, nor by baseline levels of fatigue or pain. For intervention-related moderators (only tested among women with breast cancer), statistically significant larger effects were found for cognitive behavioral therapy as intervention strategy (ß = -0.27 [95%CI = -0.40; -0.15]), fatigue-specific interventions (ß = -0.48 [95%CI = -0.79; -0.18]), and interventions that only targeted patients with clinically relevant fatigue (ß = -0.85 [95%CI = -1.40; -0.30]). CONCLUSIONS: Our findings did not provide evidence that any selected demographic or clinical characteristic, or baseline levels of fatigue or pain, moderated effects of psychosocial interventions on fatigue. A specific focus on decreasing fatigue seems beneficial for patients with breast cancer with clinically relevant fatigue.

Modeling the Sensitivity of Aquatic Macroinvertebrates to Chemicals Using Traits.

In this study, a trait-based macroinvertebrate sensitivity modeling tool is presented that provides two main outcomes: (1) it constructs a macroinvertebrate sensitivity ranking and, subsequently, a predictive trait model for each one of a diverse set of predefined Modes of Action (MOAs) and (2) it reveals data gaps and restrictions, helping with the direction of future research. Besides revealing taxonomic patterns of species sensitivity, we find that there was not one genus, family, or class which was most sensitive to all MOAs and that common test taxa were often not the most sensitive at all. Traits like life cycle duration and feeding mode were identified as important in explaining species sensitivity. For 71% of the species, no or incomplete trait data were available, making the lack of trait data the main obstacle in model construction. Research focus should therefore be on completing trait databases and enhancing them with finer morphological traits, focusing on the toxicodynamics of the chemical (e.g., target site distribution). Further improved sensitivity models can help with the creation of ecological scenarios by predicting the sensitivity of untested species. Through this development, our approach can help reduce animal testing and contribute toward a new predictive ecotoxicology framework.

Imputation to whole-genome sequence using multiple pig populations and its use in genome-wide association studies.

BACKGROUND: Use of whole-genome sequence data (WGS) is expected to improve identification of quantitative trait loci (QTL). However, this requires imputation to WGS, often with a limited number of sequenced animals for the target population. The objective of this study was to investigate imputation to WGS in two pig lines using a multi-line reference population and, subsequently, to investigate the effect of using these imputed WGS (iWGS) for GWAS. METHODS: Phenotypes and genotypes were available on 12,184 Large White pigs (LW-line) and 4943 Dutch Landrace pigs (DL-line). Imputed 660 K and 80 K genotypes for the LW-line and DL-line, respectively, were imputed to iWGS using Beagle v.4.1. Since only 32 LW-line and 12 DL-line boars were sequenced, 142 animals from eight commercial lines were added. GWAS were performed for each line using the 80 K and 660 K SNPs, the genotype scores of iWGS SNPs that had an imputation accuracy (Beagle R2) higher than 0.6, and the dosage scores of all iWGS SNPs. RESULTS: For the DL-line (LW-line), imputation of 80 K genotypes to iWGS resulted in an average Beagle R2 of 0.39 (0.49). After quality control, 2.5 × 106 (3.5 × 106) SNPs had a Beagle R2 higher than 0.6, resulting in an average Beagle R2 of 0.83 (0.93). Compared to the 80 K and 660 K genotypes, using iWGS led to the identification of 48.9 and 64.4% more QTL regions, for the DL-line and LW-line, respectively, and the most significant SNPs in the QTL regions explained a higher proportion of phenotypic variance. Using dosage instead of genotype scores improved the identification of QTL, because the model accounted for uncertainty of imputation, and all SNPs were used in the analysis. CONCLUSIONS: Imputation to WGS using the multi-line reference population resulted in relatively poor imputation, especially when imputing from 80 K (DL-line). In spite of the poor imputation accuracies, using iWGS instead of a lower density SNP chip increased the number of detected QTL and the estimated proportion of phenotypic variance explained by these QTL, especially when dosage scores were used instead of genotype scores. Thus, iWGS, even with poor imputation accuracy, can be used to identify possible interesting regions for fine mapping.

Significance testing and genomic inflation factor using high-density genotypes or whole-genome sequence data.

Significance testing for genome-wide association study (GWAS) with increasing SNP density up to whole-genome sequence data (WGS) is not straightforward, because of strong LD between SNP and population stratification. Therefore, the objective of this study was to investigate genomic control and different significance testing procedures using data from a commercial pig breeding scheme. A GWAS was performed in GCTA with data of 4,964 Large White pigs using medium density, high density or imputed whole-genome sequence data, fitting a genomic relationship matrix based on a leave-one-chromosome-out approach to account for population structure. Subsequently, genomic inflation factors were assessed on whole-genome level and the chromosome level. To establish a significance threshold, permutation testing, Bonferroni corrections using either the total number of SNPs or the number of independent chromosome fragments, and false discovery rates (FDR) using either the Benjamini-Hochberg procedure or the Benjamini and Yekutieli procedure were evaluated. We found that genomic inflation factors did not differ between different density genotypes but do differ between chromosomes. Also, the leave-one-chromosome-out approach for GWAS or using the pedigree relationships did not account appropriately for population stratification and gave strong genomic inflation. Regarding different procedures for significance testing, when the aim is to find QTL regions that are associated with a trait of interest, we recommend applying the FDR following the Benjamini and Yekutieli approach to establish a significance threshold that is adjusted for multiple testing. When the aim is to pinpoint a specific mutation, the more conservative Bonferroni correction based on the total number of SNPs is more appropriate, till an appropriate method is established to adjust for the number of independent tests.

Empowerment in adolescents and young adults with cancer: Relationship with health-related quality of life.

BACKGROUND: The difficulties adolescents and young adults (AYAs) encounter during a cancer experience may result in a reduction in or absence of empowerment. The aims of the current study were to assess levels of empowerment and associated (demographic, clinical, or psychological) factors and examine the association between empowerment and health-related quality of life (HRQOL) among AYA patients with cancer. METHODS: Patients aged 18 to 35 years at time of cancer diagnosis and who were seen by 1 of the members of the specialized multidisciplinary AYA team of the Radboud University Medical Center were invited to complete questionnaires regarding empowerment; HRQOL; and sociodemographic, clinical, and psychological characteristics (autonomy, coping, unmet social support needs, and psychological distress). RESULTS: A total of 83 AYA patients completed the questionnaires. The mean age of the participants at the time of diagnosis was 27.5 years. The vast majority had been treated with chemotherapy (86%), had a more advanced stage of disease, and had completed treatment at the time of participation (74%). The mean empowerment level was 154.1 (standard deviation, 17.8) with a range of 114 to 200. Multivariate analysis demonstrated that the autonomy subscales of self-awareness (ß = .35), capacity for managing new situations (ß = .19), and social support (ß = .35) were found to be positively associated with empowerment. Coping difficulties (ß = -.19) were found to be negatively associated with empowerment. Empowerment was independently associated with physical (ß = .31), psychological (ß = .50), social (ß = .39), religious (ß = .33), and total HRQOL (ß = .52; all P<.01). CONCLUSIONS: Low levels of empowerment were associated with low levels of autonomy and social support, female sex, and coping difficulties among AYA patients with cancer. Recognizing these patients as candidates for empowerment interventions ultimately could help to improve HRQOL in late adolescence and young adulthood. Cancer 2017;123:4039-47. © 2017 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

A human monoclonal antibody targeting the conserved staphylococcal antigen IsaA protects mice against Staphylococcus aureus bacteremia.

Due to substantial therapy failure and the emergence of antibiotic-resistant Staphylococcus aureus strains, alternatives for antibiotic treatment of S. aureus infections are urgently needed. Passive immunization using S. aureus-specific monoclonal antibodies (mAb) could be such an alternative to prevent and treat severe S. aureus infections. The invariantly expressed immunodominant staphylococcal antigen A (IsaA) is a promising target for passive immunization. Here we report the development of the human anti-IsaA IgG1 mAb 1D9, which was shown to bind to all 26 S. aureus isolates tested. These included both methicillin-susceptible and methicillin-resistant S. aureus (MSSA and MRSA, respectively). Immune complexes consisting of IsaA and 1D9 stimulated human as well as murine neutrophils to generate an oxidative burst. In a murine bacteremia model, the prophylactic treatment with a single dose of 5 mg/kg 1D9 improved the survival of mice challenged with S. aureus isolate P (MSSA) significantly, while therapeutic treatment with the same dose did not influence animal survival. Neither prophylactic nor therapeutic treatment with 5 mg/kg 1D9 resulted in improved survival of mice with S. aureus USA300 (MRSA) bacteremia. Importantly, our studies show that healthy S. aureus carriers elicit an immune response which is sufficient to generate protective mAbs against invariant staphylococcal surface antigens. Human mAb 1D9, possibly conjugated to for example another antibody, antibiotics, cytokines or chemokines, may be valuable to fight S. aureus infections in patients.

Towards Precision Ecotoxicology: Leveraging Evolutionary Conservation of Pharmaceutical and Personal Care Product Targets to Understand Adverse Outcomes Across Species and Life Stages.

Translation of environmental science to the practice aims to protect biodiversity and ecosystem services, and our future ability to do so relies on the development of a precision ecotoxicology approach wherein we leverage the genetics and informatics of species to better understand and manage the risks of global pollution. A little over a decade ago, a workshop focusing on the risks of pharmaceuticals and personal care products (PPCPs) in the environment identified a priority research question, "What can be learned about the evolutionary conservation of PPCP targets across species and life stages in the context of potential adverse outcomes and effects?" We review the activities in this area over the past decade, consider prospects of more recent developments, and identify future research needs to develop next-generation approaches for PPCPs and other global chemicals and waste challenges. Environ Toxicol Chem 2024;43:526-536. © 2023 SETAC. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.

Comparing Sensitivity of Different Bee Species to Pesticides: A TKTD modeling approach.

Risk assessment for bees is mainly based on data for honey bees; however, risk assessment is intended to protect all bee species. This raises the question of whether data for honey bees are a good proxy for other bee species. This issue is not new and has resulted in several publications in which the sensitivity of bee species is compared based on the values of the 48-h median lethal dose (LD50) from acute test results. When this approach is used, observed differences in sensitivity may result both from differences in kinetics and from inherent differences in species sensitivity. In addition, the physiology of the bee, like its overall size, the size of the honey stomach (for acute oral tests), and the physical appearance (for acute contact tests) also influences the sensitivity of the bee. The recently introduced Toxicokinetic-Toxicodynamic (TKTD) model that was developed for the interpretation of honey bee tests (Bee General Uniform Threshold Model for Survival [BeeGUTS]) could integrate the results of acute oral tests, acute contact tests, and chronic tests within one consistent framework. We show that the BeeGUTS model can be calibrated and validated for other bee species and also that the honey bee is among the more sensitive bee species. In addition, we found that differences in sensitivity between species are smaller than previously published comparisons based on 48-h LD50 values. The time-dependency of the LD50 and the specifics of the bee physiology are the main causes of the wider variation found in the published literature. Environ Toxicol Chem 2024;43:1431-1441. © 2024 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

EthoCRED: a framework to guide reporting and evaluation of the relevance and reliability of behavioural ecotoxicity studies.

Behavioural analysis has been attracting significant attention as a broad indicator of sub-lethal toxicity and has secured a place as an important subdiscipline in ecotoxicology. Among the most notable characteristics of behavioural research, compared to other established approaches in sub-lethal ecotoxicology (e.g. reproductive and developmental bioassays), are the wide range of study designs being used and the diversity of endpoints considered. At the same time, environmental hazard and risk assessment, which underpins regulatory decisions to protect the environment from potentially harmful chemicals, often recommends that ecotoxicological data be produced following accepted and validated test guidelines. These guidelines typically do not address behavioural changes, meaning that these, often sensitive, effects are not represented in hazard and risk assessments. Here, we propose a new tool, the EthoCRED evaluation method, for assessing the relevance and reliability of behavioural ecotoxicity data, which considers the unique requirements and challenges encountered in this field. This method and accompanying reporting recommendations are designed to serve as an extension of the "Criteria for Reporting and Evaluating Ecotoxicity Data (CRED)" project. As such, EthoCRED can both accommodate the wide array of experimental design approaches seen in behavioural ecotoxicology, and could be readily implemented into regulatory frameworks as deemed appropriate by policy makers of different jurisdictions to allow better integration of knowledge gained from behavioural testing into environmental protection. Furthermore, through our reporting recommendations, we aim to improve the reporting of behavioural studies in the peer-reviewed literature, and thereby increase their usefulness to inform chemical regulation.

Distress screening remains important during follow-up after primary breast cancer treatment.

BACKGROUND: To improve psychosocial care, the National Comprehensive Cancer Network recommends the use of the Distress Thermometer (DT) to detect distress among cancer patients. OBJECTIVES: The objectives of this study were to describe the prevalence of distress in breast cancer survivors (BCSs) and to investigate demographic, treatment, and psychosocial variables associated with distress and problems most often reported on the problem list. Moreover, we assessed how many BCSs requested referral to a professional for additional support. METHODS: In a cross-sectional study, 258 BCSs identified at an outpatient clinic of a university hospital were asked to complete the following questionnaires: DT, Quality of Life Questionnaire, Hospital Anxiety and Depression Scale, and Illness Cognition Questionnaire. RESULTS: Of the 258 identified BCSs, 129 (50 %) completed all questionnaires. After a mean follow-up period of 5.6 (SD, 10) years, 47 (36 %) of these 129 BCSs experienced distress as assessed by the DT. BCSs experienced significantly more distress in the first 2 years than in the period between 2 and 5 years after surgery. Also, more distress was experienced in BCSs treated with surgery, radiotherapy, and chemotherapy compared to those treated with surgery only. Problems most frequently encountered were fatigue (57 %), decrease in muscle strength (47 %), and lack of physical fitness (42 %). Thirty one (69 %) of the distressed BCSs requested or considered referral to a professional. Regression analysis showed that reduced quality of life, reduced cognitive function, and fatigue were predictors of distress. CONCLUSION: The current study found that more than one third of all BCSs experienced distress. Screening remains an important part of BCSs' care. The professional should be aware of the potential problems and distress patients may experience.

Usage of a generic web-based self-management intervention for breast cancer survivors: substudy analysis of the BREATH trial.

BACKGROUND: Generic fully automated Web-based self-management interventions are upcoming, for example, for the growing number of breast cancer survivors. It is hypothesized that the use of these interventions is more individualized and that users apply a large amount of self-tailoring. However, technical usage evaluations of these types of interventions are scarce and practical guidelines are lacking. OBJECTIVE: To gain insight into meaningful usage parameters to evaluate the use of generic fully automated Web-based interventions by assessing how breast cancer survivors use a generic self-management website. Final aim is to propose practical recommendations for researchers and information and communication technology (ICT) professionals who aim to design and evaluate the use of similar Web-based interventions. METHODS: The BREAst cancer ehealTH (BREATH) intervention is a generic unguided fully automated website with stepwise weekly access and a fixed 4-month structure containing 104 intervention ingredients (ie, texts, tasks, tests, videos). By monitoring https-server requests, technical usage statistics were recorded for the intervention group of the randomized controlled trial. Observed usage was analyzed by measures of frequency, duration, and activity. Intervention adherence was defined as continuous usage, or the proportion of participants who started using the intervention and continued to log in during all four phases. By comparing observed to minimal intended usage (frequency and activity), different user groups were defined. RESULTS: Usage statistics for 4 months were collected from 70 breast cancer survivors (mean age 50.9 years). Frequency of logins/person ranged from 0 to 45, total duration/person from 0 to 2324 minutes (38.7 hours), and activity from opening none to all intervention ingredients. 31 participants continued logging in to all four phases resulting in an intervention adherence rate of 44.3% (95% CI 33.2-55.9). Nine nonusers (13%), 30 low users (43%), and 31 high users (44%) were defined. Low and high users differed significantly on frequency (P<.001), total duration (P<.001), session duration (P=.009), and activity (P<.001). High users logged in an average of 21 times, had a mean session duration of 33 minutes, and opened on average 91% of all ingredients. Signing the self-help contract (P<.001), reporting usefulness of ingredients (P=.003), overall satisfaction (P=.028), and user friendliness evaluation (P=.003) were higher in high users. User groups did not differ on age, education, and baseline distress. CONCLUSIONS: By reporting the usage of a self-management website for breast cancer survivors, the present study gained first insight into the design of usage evaluations of generic fully automated Web-based interventions. It is recommended to (1) incorporate usage statistics that reflect the amount of self-tailoring applied by users, (2) combine technical usage statistics with self-reported usefulness, and (3) use qualitative measures. Also, (4) a pilot usage evaluation should be a fixed step in the development process of novel Web-based interventions, and (5) it is essential for researchers to gain insight into the rationale of recorded and nonrecorded usage statistics. TRIAL REGISTRATION: Netherlands Trial Register (NTR): 2935; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2935 (Archived by WebCite at http://www.webcitation.org/6IkX1ADEV).

The cancer empowerment questionnaire: psychological empowerment in breast cancer survivors.

New models of cancer care and survivorship ask for empowered patients. But how do we measure that patients can derive strength from themselves (intrapersonal) and their perceived social support (interpersonal)? The 40-item Cancer Empowerment Questionnaire (CEQ) measures psychological empowerment as an individual outcome measure. The CEQ was validated in 140 nonmetastatic female breast cancer survivors (mean 5.5 years postsurgery). Principal component analysis elicited four factors representing intrapersonal (personal strength) and interpersonal (social support, community, health care) aspects of empowerment. The CEQ provides a reliable (Cronbach's α=0.73-0.94) and valid first attempt to operationalize psychological empowerment in cancer care.