Central-line-associated bloodstream infection burden among Dutch neonatal intensive care units.

BACKGROUND: The establishment of an epidemiological overview provides valuable insights needed for the (future) dissemination of infection-prevention initiatives. AIM: To describe the nationwide epidemiology of central-line-associated bloodstream infections (CLABSI) among Dutch Neonatal Intensive Care Units (NICUs). METHODS: Data from 2935 neonates born at <32 weeks' gestation and/or with a birth weight <1500 g admitted to all nine Dutch NICUs over a two-year surveillance period (2019-2020) were analysed. Variations in baseline characteristics, CLABSI incidence per 1000 central-line days, pathogen distribution and CLABSI care bundles were evaluated. Multi-variable logistic mixed-modelling was used to identify significant predictors for CLABSI. RESULTS: A total of 1699 (58%) neonates received a central line, in which 160 CLABSI episodes were recorded. Coagulase-negative staphylococci were the most common infecting organisms of all CLABSI episodes (N=100, 63%). An almost six-fold difference in the CLABSI incidence between participating units was found (2.91-16.14 per 1000 line-days). Logistic mixed-modelling revealed longer central line dwell-time (adjusted odds ratio (aOR):1.08, P<0.001), umbilical lines (aOR:1.85, P=0.03) and single rooms (aOR:3.63, P=0.02) to be significant predictors of CLABSI. Variations in bundle elements included intravenous tubing care and antibiotic prophylaxis. CONCLUSIONS: CLABSI remains a common problem in preterm infants in The Netherlands, with substantial variation in incidence between centres. Being the largest collection of data on the burden of neonatal CLABSI in The Netherlands, this epidemiological overview provides a solid foundation for the development of a collaborative platform for continuous surveillance, ideally leading to refinement of national evidence-based guidelines. Future efforts should focus on ensuring availability and extraction of routine patient data in aggregated formats.

Influence of transition from open bay units to single room units in a neonatal intensive care unit on hospital transmission of multi-drug-resistant Enterobacterales.

BACKGROUND: It was shown previously that changing the design of a hospital neonatal intensive care unit (NICU) from open bay units (OBUs) to single room units (SRUs) was not associated with a reduction in Gram-negative multi-drug-resistant organism (MDRO) colonization rates. It was therefore hypothesized that colonization mainly occurs vertically, or through parents and healthcare workers, and not through environmental factors, and that transition to SRUs would not decrease the number of clusters of MDROs with an epidemiological link. To investigate this, core-genome multi-locus sequence typing (cgMLST) was applied on MDROs cultured from infants at the study hospital. METHODS: This retrospective cohort study included all infants carrying MDROs admitted to the NICU of a tertiary care academic hospital 2 years prior to the transition from OBUs to SRUs in May 2017, and 1.5 years after the transition (2018-2020). RESULTS: In total, 55 infants were diagnosed with MDRO carriership. Isolates were available from 49 infants for cgMLST. In the OBU period, one cluster involving four of 20 (20%) infants was identified, and in the SRU period, four clusters involving nine of 29 (31%) infants were identified. It was possible to make an epidemiological link in all four SRU MDRO clusters, but this was not possible for the OBU cluster. In the latter case, transmission from an environmental source on the ward seemed likely. CONCLUSION: After transition to SRUs, there was no decrease in the number of clusters of MDROs with an epidemiological link, suggesting that nursing infants in an NICU with an SRU design is not, in itself, protective against the acquisition of MDROs.

Possible alleviation of symptoms and side effects through clinicians' nocebo information and empathy in an experimental video vignette study.

To alleviate anti-cancer treatment burden in advanced breast cancer, patient-clinician communication strategies based on nocebo-effect mechanisms are promising. We assessed distinct/combined effects on psychological outcomes (e.g. anxiety; main outcome) and side-effect expectations of (1) nocebo information about the (non)pharmacological origin of side effects, and (2) clinician-expressed empathy through reassurance of continuing support. Furthermore, we explored whether information and empathy effects on side-effect expectations were mediated by decreased anxiety. In a two-by-two experimental video-vignette design, 160 cancer patients/survivors and healthy women watched one of four videos differing in level of nocebo information (±) and empathy (±). Regression and mediation analysis were used to determine effects of information/empathy and explore anxiety's mediating role. Anxiety was not influenced by empathy or information (Stai-state: p = 0.295; p = 0.390, VAS p = 0.399; p = 0.823). Information improved (specific) side-effect coping expectations (p < 0.01). Empathy improved side-effect intensity expectations (p < 0.01 = specific; p < 0.05 = non-specific/partial) and specific side-effect probability expectations (p < 0.01), and increased satisfaction, trust, and self-efficacy (p < 0.001). No mediating effects were found of anxiety on expectations. Mainly empathy, but also nocebo information improved psychological outcomes and-mainly specific-side-effect expectations. Exploring the power of these communication elements in clinical practice is essential to diminish the anti-cancer treatment burden in advanced breast cancer.

Impact of transition from open bay to single room design neonatal intensive care unit on multidrug-resistant organism colonization rates.

BACKGROUND: The influence of the neonatal intensive care unit (NICU) design on the acquisition of multidrug-resistant organisms (MDROs) has not been well-documented. AIM: To examine the effect of single room unit (SRU) versus open bay unit (OBU) design on the incidence of colonization with MDROs and third-generation cephalosporin-resistant bacteria (3G-CRB) in infants admitted to the NICU. METHODS: Retrospective cohort study, including all infants admitted to the NICU of a tertiary care academic hospital two years prior to and two years following the transition from OBU to SRU in May 2017. Weekly cultures of throat and rectum were collected to screen for MDRO carriership. Incidence of colonization (percentage of all infants and incidence density per 1000 patient-days) with MDROs and 3G-CRB were compared between OBU and SRU periods. FINDINGS: Incidence analysis of 1293 NICU infants, identified 3.2% MDRO carriers (2.5% OBU, 4.0% SRU, not significant), including 2.3% extended-spectrum ß-lactamase-producing Enterobacterales carriers, and 18.6% 3G-CRB carriers (17% OBU, 20% SRU, not significant). No differences were found in MDRO incidence density per 1000 patient-days between infants admitted to OBU (1.56) compared to SRU infants (2.63). CONCLUSION: Transition in NICU design from open bay to SRUs was not associated with a reduction in colonization rates with MDROs or 3G-CRB in our hospital. Further research on preventing the acquisition and spread of resistant bacteria at high-risk departments such as the NICU, as well as optimal ward design, are needed.

Receptivity to transformative change in the Dutch urban water management sector.

Worldwide, the need for transformative change in urban water management is acknowledged by scientists and policy makers. The effects of climate change and developments such as urbanization, the European Water Framework Directive, and societal concerns about the sustainability of urban water system force the sector to adapt. In The Netherlands, a shift towards integration of spatial planning and water management can be observed. Despite major changes in water management policy and approach, changes in the physical urban water management infrastructure remain limited to incremental solutions and demonstration projects. Policy studies show that institutional factors and professional perceptions are important factors for application of innovations in urban water management. An online survey among Dutch urban water management professionals demonstrates that according to most respondents, optimization of the current system is sufficient to achieve both European and national objectives for sustainable urban water management. The respondents are most concerned with the effects of climate change on urban water systems. In contrast to current policy of the national government, priority factors that should be addressed to achieve a more sustainable urban water system are improving knowledge of local urban water systems, capacity building, developing trust between stakeholders, and improving involvement of elected officials and citizens.

Stability of preferences with regard to adjuvant chemotherapy: impact of treatment decision, experience and the passing of time.

Research has shown that patients' preferences for adjuvant chemotherapy do not change as a result of experience. However, the preferences of experienced patients are usually more favourable than those of inexperienced patients. These results indicate a shift in preferences after the decision to proceed with adjuvant chemotherapy has been made, but before actual experience. We tested this assumption in early-stage breast and colorectal cancer patients. We asked patients to provide their preferences for chemotherapy before surgery and thus before they knew whether chemotherapy would be advised (T(1)), after surgery but before the start of chemotherapy (T(2)) and about 1 month after chemotherapy (T(3)). Patients who did not undergo chemotherapy co-operated at similar points in time. Preferences were measured on a nine-point scale, ranging from (1) 'very strong preference for no chemotherapy' to (9) 'very strong preference for chemotherapy'. As hypothesized, the preferences of patients who would be treated with chemotherapy became more favourable after the treatment decision had been made (n = 7, P = 0.06). The preferences of patients for whom chemotherapy was not part of the treatment plan showed the opposite effect (n = 38, P = 0.03). We did not find any effect of experiencing treatment (n = 22, P = 0.62) or the passing of time (n = 81, P = 0.25) on the stability of preferences. We conclude that the frequently observed discrepancy in treatment preferences between experienced and inexperienced patients seems to be an effect of the treatment decision and not of experience of the treatment.

How important is the opinion of significant others to cancer patients' adjuvant chemotherapy decision-making?

GOALS: Decisions regarding adjuvant chemotherapy are difficult, since value tradeoffs are involved. Little is known about the importance of the significant others in patients' decision-making regarding adjuvant treatment. We surveyed patients with breast and colorectal cancer about the importance they assigned to the opinions of their significant others and assessed correlates of these importance scores. MATERIALS AND METHODS: One hundred and twenty-three patients rated on a five-point scale how much they cared about the opinion of six significant others. MAIN RESULTS: Most important was the opinion of their treating specialist, followed by that of their partner, children, other family, friends, and colleagues. Women assigned higher scores to the opinion of their children, younger patients to that of their specialist, and patients who were about to undergo chemotherapy to that of their family. Patients with breast cancer and patients without paid employment assigned slightly more importance to the opinion of their partner. CONCLUSIONS: Information on the influence of significant others may help clinicians when involving patients in treatment decision-making and discussing patients' treatment preferences.

Explaining differences in attitude toward adjuvant chemotherapy between experienced and inexperienced breast cancer patients.

PURPOSE: Previous studies have shown that patients who have experienced adjuvant chemotherapy (experienced patients) have a more favorable attitude towards chemotherapy than those who have not (inexperienced patients). However, not much is known about the reasons underlying this difference. According to the Theory of Planned Behavior, the attitude towards a particular behavior (eg, accepting chemotherapy) is based on beliefs about the likelihood of outcomes of the behavior and the evaluations of these outcomes. We used this theory to explore in what way the beliefs of experienced patients differed from those of inexperienced patients. PATIENTS AND METHODS: A cross-sectional survey was undertaken among 719 patients who had been treated for early-stage breast cancer between 1998 and 2003. Patients were asked, first, to indicate the likelihood of six positive and six negative outcomes of undergoing chemotherapy and, second, to give their evaluation of these outcomes. RESULTS: Four hundred forty-six women filled in the questionnaire (response rate, 62%). As hypothesized, experienced patients (ie, patients who had been treated with adjuvant chemotherapy as part of their primary treatment plan) had a more positive attitude towards chemotherapy. Experienced patients provided higher likelihood estimates of treatment advantages, such as life prolongation. In addition, they evaluated the positive outcomes of chemotherapy more favorably. With regard to the negative outcomes of chemotherapy, few differences were observed between treatment groups. CONCLUSION: Experienced patients have more confidence in the positive outcomes of chemotherapy than inexperienced patients. This might be the result of a cognitive mechanism to justify the way in which patients were treated.

The impact of the perception of treatment choice on satisfaction with treatment, experienced chemotherapy burden and current quality of life.

Previous research has shown that involving patients in the decision-making process may improve their quality of life (QoL). Our purposes were to assess: (1) whether early-stage breast cancer patients perceived that they had treatment choice with regard to adjuvant chemotherapy, (2) what reasons patients provide for their perception of having had no choice of treatment and (3) whether the perception of treatment choice is related to satisfaction with the assigned treatment, experienced chemotherapy burden and current QoL. A total of 448 patients, treated between 1998 and 2003, filled in the questionnaire (response rate: 62%). Patients who indicated that they had not perceived a choice regarding chemotherapy could tick off one or more reasons out of 10 reasons, or provide their own reason(s). Quality of life was measured on a Visual Analogue Scale, by means of the EuroQol, and by means of the Hospital Anxiety and Depression Scale. Of the 405 patients who had answered the question on treatment choice, 316 patients (78%) had perceived no choice. The most frequently indicated reason for lack of choice was: "I follow the doctor's advice." We found no differences in the levels of satisfaction with assigned treatment and in how much of a burden they found chemotherapy between patients who perceived a choice of treatment and those who did not. In general, the perception of choice seemed to have no impact on QoL. However, we found an interaction effect, which indicated that the impact of perception of treatment choice on QoL was dependent upon whether the patient had been treated with chemotherapy or not. Within the group of patients who had not been treated with chemotherapy, the perception of having had a choice was related to lower current QoL. In cases when the decision to be treated or not has potential consequences for the chance of survival, patients' QoL may not be improved by the perception of having had a choice of treatment.

Stability of patients' preferences for chemotherapy: the impact of experience.

BACKGROUND: Studies have shown that utilities for a particular treatment, elicited by means of a hypothetical treatment scenario, may remain stable within the same patients when examined before, during, and after experiencing that treatment (within-group stability). However, other studies have found that utilities for a particular health state may differ between patient groups who are and who are not experiencing the particular health state (between-group differences). OBJECTIVE: The authors evaluated this apparent contradiction in the case of adjuvant chemotherapy for breast cancer. A related purpose was to examine whether a chemotherapy scenario adequately reflects the patients' own experiences with chemotherapy. METHOD: Forty-three patients with early-stage breast cancer evaluated their actually experienced health state and a chemotherapy scenario before, during, and after undergoing adjuvant chemotherapy (chemotherapy group). A control group of 51 patients for whom chemotherapy was not part of the treatment plan was interviewed at similar points in time. Utilities were elicited by means of a visual analog scale (VAS), a chained time trade-off (TTO), and a chained standard gamble (SG). RESULTS: The utilities for the chemotherapy scenario remained relatively stable over time in the 2 patient groups. Furthermore, the chemotherapy scenario was evaluated more positively by patients in the chemotherapy group than by control patients (e.g., utilities before chemotherapy: VAS 0.69 vs. 0.50, TTO 0.88 vs. 0.50, SG 0.92 vs. 0.58, all Ps < 0.01). Finally, patients in the chemotherapy group evaluated their actually experienced health states during chemotherapy higher than the chemotherapy scenario that was assessed at the same time (VAS 0.79 vs. 0.69, TTO 0.93 vs. 0.87, SG 0.97 vs. 0.96, all Ps < 0.05). CONCLUSIONS: Both within-group stability and between-group differences were found. A possible explanation for within-group stability may be that the chemotherapy scenario did not fully correspond to the patients' actual experiences with chemotherapy ("noncorresponding description"). Therefore, preferences did not change even when the patients' own clinical health status had changed. The between-group differences may be explained by "anticipated adaptation." Both explanations may work together to explain why utilities remain stable within the same patients but differ between different patient groups.

Patients' preferences for adjuvant chemotherapy in early-stage breast cancer: is treatment worthwhile?

When making decisions about adjuvant chemotherapy for early-stage breast cancer, costs and benefits of treatment should be carefully weighed. In this process, patients' preferences are of major importance. The objectives of the present study were: (1) to determine the minimum benefits that patients need to find chemotherapy acceptable, and (2) to explore potential preference determinants, namely: positive experience of the treatment, reconciliation with the treatment decision, and demographic variables. Preferences were elicited from patients scheduled for adjuvant chemotherapy (chemotherapy group: n = 38) before (T(1)), during (T(2)), and 1 month after chemotherapy (T(3)), and were compared to responses from patients not scheduled for chemotherapy (no-chemotherapy group: n = 38). The patients were asked, for a hypothetical situation, to indicate the minimum benefit (in terms of improved 5-year disease-free survival) to find adjuvant chemotherapy acceptable. In the chemotherapy group, the median benefit was 1% at all 3 measurement points. In the no-chemotherapy group the attitude towards chemotherapy became more negative over time, although not statistically significantly so (T(1): 12%, T(2): 15%, T(3): 15%; P = 0.10). At all measurement points, the patients in the chemotherapy group indicated that they would accept chemotherapy for significantly (P< 0.01) less benefit than the patients in the no-chemotherapy group. Of the demographic variables, age was related to preferences, but only at T(2)and only in the no-chemotherapy group. The more positive attitude towards chemotherapy and the stability of preferences in the chemotherapy group indicated that reconciliation with the treatment decision was a more important determinant of patients' preferences than positive experience of the treatment.

Value of the time trade off method for measuring utilities in patients with rheumatoid arthritis.

OBJECTIVE: To assess the feasibility, reliability, and validity of the time trade off (TTO) in patients with rheumatoid arthritis (RA). METHODS: The TTO was applied in 194 patients with RA with increasing difficulty in performing activities of daily living. The test-retest reliability was determined in 35 of these patients and was calculated by the intraclass correlation coefficient (ICC). Construct validity was evaluated with the following sets of variables: measures of utility (rating scale), quality of life (RAND 36 item Health Status Survey (RAND-36) and RAQoL), functional status (Health Assessment Questionnaire, grip strength, and walk test), and disease activity (doctor's global assessment, disease activity score, pain, and morning stiffness). RESULTS: Ten patients (5%) did not complete the TTO. The median value of the TTO was 0.77 (range 0.03-1. 0). The test-retest ICC of the TTO was 0.85 (p<0.001). Construct validity testing of the TTO showed poor to moderate correlations (Spearman's r(s) between 0.19 and 0.36, p<0.01) with all outcome measures except for the subscale role limitation (physical problem) of the RAND-36, the walk test, the doctor's global assessment of disease activity, and morning stiffness. Multiple regression analysis showed that only 17% of the variance of the TTO scores could be explained. CONCLUSIONS: The TTO method appeared to be feasible and reliable in patients with RA. The poor to moderate correlations of the TTO with measures of quality of life, functional ability, and disease activity suggest that the TTO considers additional attributes of health status. This may have implications for the application of the TTO in clinical trials in patients with RA.

Dopamine characteristics in different rat genotypes: the relation to absence epilepsy.

Dopaminergic neurotransmission has been shown to participate in the control of absence epilepsy. This type of epilepsy, a generalized non-convulsive form, is associated with bursts of bilateral synchronous spike wave discharges (SWDs) recorded in the EEG. In a previous study, it was suggested that two features of the apomorphine-susceptible (APO-SUS) rat genotype, a relatively low dopaminergic reactivity of the nigrostriatal system and relatively high dopaminergic reactivity of the mesolimbic system, contribute to the high incidence of SWDs. Indeed, apomorphine-unsusceptible (APO-UNSUS) rats, characterized by opposite dopaminergic features, show considerably less SWDs than APO-SUS rats. The first goal of the present study was to assess the baseline SWD incidence in four rat genotypes (WAG/Rij, ACI, APO-SUS and APO-UNSUS) in order to replicate previous findings. It was expected that both the APO-SUS and WAG/Rij rats would show a considerably higher SWD incidence in comparison to the APO-UNSUS and ACI rats. For this purpose, rats were registered for a 19 hour period. Assuming that haloperidol decreases dopaminergic transmission in the nigrostriatal system via inhibition of the dopamine receptors and enhances dopaminergic transmission in the mesolimbic system via inhibition of the noradrenergic receptors, it was postulated that haloperidol would enhance the difference in dopaminergic reactivity between both systems in favor of the accumbens. Therefore, the second purpose in the present study was to investigate whether haloperidol (2 mg/kg, IP) could further potentiate SWD incidence when injected in the APO-SUS rats, already characterized by a relatively low dopaminergic reactivity of the nigrostriatal system and relatively high dopaminergic reactivity of the mesolimbic system, in comparison to the APO-UNSUS rat genotype. Finally, the third aim was to study if another epileptic rat genotype, the WAG/Rij, would show similar increases in SWD incidence following an injection with haloperidol as expected for the APO-SUS. First, previous findings were replicated: the value of the hourly number of SWDs decreased in the following order: APO-SUS > WAG/Rij > APO-UNSUS and ACI. Secondly, earlier data were extended by the fact that the APO-SUS responded to a systemic injection of haloperidol with an increase in SWD number and duration, in contrast to the APO-UNSUS rats. The hypothesis that the SWD incidence would be mostly affected by haloperidol in the APO-SUS rats, was confirmed by these findings. It is suggested that haloperidol increases the SWD incidence in APO-SUS rats by enhancing the difference between the dopaminergic reactivity in the nigrostriatal and mesolimbic system. Finally, further research is required to provide evidence in favor of the hypothesis that the relative dominance of the dopaminergic mesolimbic system is smaller in WAG/Rij than in APO-SUS.

Unstable preferences: a shift in valuation or an effect of the elicitation procedure?

OBJECTIVE: Many studies suggest that impaired health states are valued more positively when experienced than when hypothetical. This study investigated to what extent this discrepancy occurs and examined four possible explanations: non-corresponding description of the hypothetical health state, new understanding due to experience with the health state, valuation shift due to a new status quo, and instability of preference. PATIENTS AND METHODS: Fifty-five breast cancer patients evaluated their actually experienced health state, a radiotherapy scenario, and a chemotherapy control scenario before, during, and after postoperative radiotherapy. Utilities were elicited by means of a visual analog scale (VAS), a chained time tradeoff (TTO), and a chained standard gamble (SG). RESULTS: The discrepancy was found for all methods and was statistically significant for the TTO (predicted utilities: 0.89, actual utilities: 0.92, p < or = 0.05). During radiotherapy, significant differences (p < or = 0.01) were found between the utilities for the radiotherapy scenario and the actual health state by means of the VAS and the SG, suggesting non-corresponding description as an explanation. The utilities of the radiotherapy scenario and the chemotherapy control scenario remained stable over time, and thus new understanding, valuation shift, and instability could be ruled out as explanations. CONCLUSION: Utilities obtained through hypothetical scenarios may not be valid predictors of the value judgments of actually experienced health states. The discrepancy in this study seems to have been due to differences between the situations in question (non-corresponding descriptions).

The effect of individually assessed preference weights on the relationship between holistic utilities and nonpreference-based assessment.

In the assessment of health-related quality of life, nonpreference-based methods usually show only moderate correlations with utility-based measures. One cause may be that patients assign different weights to the various domains of health-related quality of life, for which nonpreference-based methods usually do not allow. Utilities reflect a weighted sum of these domains. The aim of this study is to assess whether the relationship between utility-based methods and nonpreference-based measures improves through the use of individual importance weights for the various domains of health-related quality of life. For this purpose, weights were obtained from 41 early-stage breast cancer patients, both before and during treatment, for seven pre-selected health status attributes representing important domains of health-related quality of life during chemotherapy. The importance weights were combined with the level of functioning on the attributes. These scores were regressed against patients' utilities for their actually experienced health state during chemotherapy, measured by means of a visual analog scale (VAS), a time trade-off (TTO), and a standard gamble (SG). Before weighting, the seven attribute scores were more strongly related to TTO and SG utilities than the nonpreference-based questionnaires. However, when they were combined with the importance weights, only the correlation with the SG utilities improved, and only so with the importance weights obtained before chemotherapy. In this study, assigning individually assessed preference weights to self-reported level of functioning did not result in stronger relationships with utilities.

Response shift in quality of life measurement in early-stage breast cancer patients undergoing radiotherapy.

In medicine, response shift refers to a change--as a result of an event such as a therapy--in the meaning of one's self-evaluation of quality of life. Due to response shift, estimates of side effects of radiotherapy may be attenuated if patients adapt to treatment toxicities. The purpose of our study was to assess to what extent two components of response shift, scale recalibration and changes in values, occur in early-stage breast cancer patients undergoing radiotherapy and to examine what the implications would be for treatment evaluation. In the week before start of post-operative radiotherapy, 46 patients filled out a questionnaire consisting of quality of life items of the SF-36 and the Rotterdam symptom checklist (RSCL) (pretest). During radiotherapy, patients were asked to fill out the questionnaire twice: a posttest (quality of life at that moment) and a thentest (quality of life before treatment, retrospectively), supposedly using the same internal standard. Changes in values were studied by asking the patients on the two occasions to rate the importance of seven attributes representing various domains of quality of life. Patients were also asked whether their quality of life with respect to the measured aspects had changed since the pretest (subjective transition scores). Significant scale recalibration effects were observed in the areas of fatigue and overall quality of life. When the groups were divided according to their subjective transition scores, significant scale recalibration effects were found in case of worsened quality of life for fatigue and overall quality of life, and in case of improved quality of life for fatigue and psychological well-being. The mean importance ratings remained fairly stable over time, except for 'skin reactions', which obtained less importance at the end of radiotherapy than before. In conclusion, effects of scale recalibration were observed that would have significantly affected quality of life evaluations, in that the impact of radiotherapy on fatigue and overall quality of life would have been underestimated. Changes in internal values were observed only for 'skin reactions'.

Patients' utilities for cancer treatments: a study of the chained procedure for the standard gamble and time tradeoff.

OBJECTIVE: Temporary health states cannot be measured in the traditional way by means of techniques such as the time tradeoff (TTO) and the standard gamble (SG), where health states are chronic and are followed by death. Chained methods have been developed to solve this problem. This study assesses the feasibility of a chained TTO and a chained SG, and the consistency and concordance between the two methods. PATIENTS AND METHODS: Seventy female early-stage breast cancer patients were interviewed. In using both chained methods, the temporary health state to be evaluated was weighed indirectly with the aid of a temporary anchor health state. The patients were asked to evaluate their actual health states, a hypothetical radiotherapy scenario, and a hypothetical chemotherapy scenario. RESULTS: Sixty-eight patients completed the interview. The use of the anchor health state yielded some problems. A significant difference between the means of the TTO and the SG was found for the anchor health state only. For the other health states, the results were remarkably close, because the design avoided some of the bias effects in traditional measurements. CONCLUSION: The feasibility and the consistency of the chained procedure were satisfactory for both methods. The problems regarding the anchor health state can be solved by adapting the methods and by the use of a carefully chosen anchor health state. The chained method avoids biases present in the conventional method, and thereby the TTO and the SG may be reconciled. Moreover, there are several psychological advantages to the method, which makes it useful for diseases with uncertain prognoses.