Comparing the Effectiveness of the Blended Delivery Mode With the Face-to-Face Delivery Mode of Smoking Cessation Treatment: Noninferiority Randomized Controlled Trial.

BACKGROUND: Tobacco consumption is a leading cause of death and disease, killing >8 million people each year. Smoking cessation significantly reduces the risk of developing smoking-related diseases. Although combined treatment for addiction is promising, evidence of its effectiveness is still emerging. Currently, there is no published research comparing the effectiveness of blended smoking cessation treatments (BSCTs) with face-to-face (F2F) treatments, where web-based components replace 50% of the F2F components in blended treatment. OBJECTIVE: The primary objective of this 2-arm noninferiority randomized controlled trial was to determine whether a BSCT is noninferior to an F2F treatment with identical ingredients in achieving abstinence rates. METHODS: This study included 344 individuals who smoke (at least 1 cigarette per day) attending an outpatient smoking cessation clinic in the Netherlands. The participants received either a blended 50% F2F and 50% web-based BSCT or only F2F treatment with similar content and intensity. The primary outcome measure was cotinine-validated abstinence rates from all smoking products at 3 and 15 months after treatment initiation. Additional measures included carbon monoxide-validated point prevalence abstinence; self-reported point prevalence abstinence; and self-reported continuous abstinence rates at 3, 6, 9, and 15 months after treatment initiation. RESULTS: None of the 13 outcomes showed statistically confirmed noninferiority of the BSCT, whereas 4 outcomes showed significantly (P<.001) inferior abstinence rates of the BSCT: cotinine-validated point prevalence abstinence rate at 3 months (difference 12.7, 95% CI 6.2-19.4), self-reported point prevalence abstinence rate at 6 months (difference 19.3, 95% CI 11.5-27.0) and at 15 months (difference 11.7, 95% CI 5.8-17.9), and self-reported continuous abstinence rate at 6 months (difference 13.8, 95% CI 6.8-20.8). The remaining 9 outcomes, including the cotinine-validated point prevalence abstinence rate at 15 months, were inconclusive. CONCLUSIONS: In this high-intensity outpatient smoking cessation trial, the blended mode was predominantly less effective than the traditional F2F mode. The results contradict the widely assumed potential benefits of blended treatment and suggest that further research is needed to identify the critical factors in the design of blended interventions. TRIAL REGISTRATION: Netherlands Trial Register 27150; https://onderzoekmetmensen.nl/nl/trial/27150. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-doi.org/10.1186/s12889-016-3851-x.

eHealth Technologies for Monitoring Pediatric Asthma at Home: Scoping Review.

BACKGROUND: eHealth monitoring technologies offer opportunities to more objectively assess symptoms when they appear in daily life. Asthma is the most common chronic disease in childhood with an episodic course, requiring close follow-up of pediatric asthma control to identify disease deterioration, prevent exacerbations, and enhance quality of life. eHealth technologies in pediatric asthma care show promising results regarding feasibility, acceptability, and asthma-related health outcomes. However, broad systematic evaluations of eHealth technologies in pediatric asthma are lacking. OBJECTIVE: The objective of this scoping review was to identify the types and applications of eHealth technologies for monitoring and treatment in pediatric asthma and explore which monitoring domains show the most relevance or potential for future research. METHODS: A scoping review was conducted using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. A systematic and comprehensive search was performed on English papers that investigated the development, validation, or application of eHealth technologies for home monitoring or treatment of pediatric asthma in the following databases: PubMed, Cochrane Library, IEEE, Scopus, CINAHL, PsycINFO, and ACM Digital Library. Two authors independently assessed eligibility and extracted data. Data were presented by a descriptive analysis of characteristics and a narrative report for each eHealth domain. RESULTS: The review included 370 manuscripts. The following 10 monitoring domains were identified: air quality, airway inflammation markers, lung function, physical activity, sleep, audiovisual, other physiological measurements, questionnaires, medication monitoring, and digital environment (ie, digital platforms, applications, websites, and software tools to monitor or support monitoring). Rising numbers of studies were seen, and the numbers accelerated in the last few years throughout most domains, especially medication monitoring and digital environment. Limited studies (35/370, 9.5%) of multiparameter monitoring strategies, using three or more domains, were found. The number of monitoring validation studies remained stable, while development and intervention studies increased. Intervention outcomes seemed to indicate the noninferiority and potential superiority of eHealth monitoring in pediatric asthma. CONCLUSIONS: This systematic scoping review provides a unique overview of eHealth pediatric asthma monitoring studies, and it revealed that eHealth research takes place throughout different monitoring domains using different approaches. The outcomes of the review showed the potency for efficacy of most monitoring domains (especially the domains of medication monitoring, lung function, and digital environment). Future studies could focus on modifying potentially relevant hospital-based diagnostics for the home setting to investigate potential beneficial effects and focus on combining home-monitoring domains to facilitate multiparameter decision-making and personalized clinical decision support.

Adherence to Blended or Face-to-Face Smoking Cessation Treatment and Predictors of Adherence: Randomized Controlled Trial.

BACKGROUND: Blended face-to-face and web-based treatment is a promising way to deliver smoking cessation treatment. Since adherence has been shown to be an indicator of treatment acceptability and a determinant for effectiveness, we explored and compared adherence and predictors of adherence to blended and face-to-face alone smoking cessation treatments with similar content and intensity. OBJECTIVE: The objectives of this study were (1) to compare adherence to a blended smoking cessation treatment with adherence to a face-to-face treatment; (2) to compare adherence within the blended treatment to its face-to-face mode and web mode; and (3) to determine baseline predictors of adherence to both treatments as well as (4) the predictors to both modes of the blended treatment. METHODS: We calculated the total duration of treatment exposure for patients (N=292) of a Dutch outpatient smoking cessation clinic who were randomly assigned either to the blended smoking cessation treatment (n=130) or to a face-to-face treatment with identical components (n=162). For both treatments (blended and face-to-face) and for the two modes of delivery within the blended treatment (face-to-face vs web mode), adherence levels (ie, treatment time) were compared and the predictors of adherence were identified within 33 demographic, smoking-related, and health-related patient characteristics. RESULTS: We found no significant difference in adherence between the blended and the face-to-face treatments. Participants in the blended treatment group spent an average of 246 minutes in treatment (median 106.7% of intended treatment time, IQR 150%-355%) and participants in the face-to-face group spent 238 minutes (median 103.3% of intended treatment time, IQR 150%-330%). Within the blended group, adherence to the face-to-face mode was twice as high as that to the web mode. Participants in the blended group spent an average of 198 minutes (SD 120) in face-to-face mode (152% of the intended treatment time) and 75 minutes (SD 53) in web mode (75% of the intended treatment time). Higher age was the only characteristic consistently found to uniquely predict higher adherence in both the blended and face-to-face groups. For the face-to-face group, more social support for smoking cessation was also predictive of higher adherence. The variability in adherence explained by these predictors was rather low (blended R2=0.049; face-to-face R2=0.076). Within the blended group, living without children predicted higher adherence to the face-to-face mode (R2=0.034), independent of age. Higher adherence to the web mode of the blended treatment was predicted by a combination of an extrinsic motivation to quit, a less negative attitude toward quitting, and less health complaints (R2=0.164). CONCLUSIONS: This study represents one of the first attempts to thoroughly compare adherence and predictors of adherence of a blended smoking cessation treatment to an equivalent face-to-face treatment. Interestingly, although the overall adherence to both treatments appeared to be high, adherence within the blended treatment was much higher for the face-to-face mode than for the web mode. This supports the idea that in blended treatment, one mode of delivery can compensate for the weaknesses of the other. Higher age was found to be a common predictor of adherence to the treatments. The low variance in adherence predicted by the characteristics examined in this study suggests that other variables such as provider-related health system factors and time-varying patient characteristics should be explored in future research. TRIAL REGISTRATION: Netherlands Trial Register NTR5113; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5113.

The additional value of an algorithm for atrial fibrillation at the stroke unit.

BACKGROUND AND PURPOSE: The rate of newly detected (paroxysmal) atrial fibrillation (AF) during inpatient cardiac telemetry is low. The objective of this study was to evaluate the additional diagnostic yield of an automated detection algorithm for AF on telemetric monitoring compared with routine detection by a stroke unit team in patients with recent ischemic stroke or TIA. METHODS: Patients admitted to the stroke unit of Medisch Spectrum Twente with acute ischemic stroke or TIA and no history of AF were prospectively included. All patients had telemetry monitoring, routinely assessed by the stroke unit team. The ST segment and arrhythmia monitoring (ST/AR) algorithm was active, with deactivated AF alarms. After 24 h the detections were analyzed and compared with routine evaluation. RESULTS: Five hundred and seven patients were included (52.5% male, mean age 70.2 ± 12.9 years). Median monitor duration was 24 (interquartile range 22-27) h. In 6 patients (1.2%) routine analysis by the stroke unit team concluded AF. In 24 patients (4.7%), the ST/AR Algorithm suggested AF. Interrater reliability was low (κ, 0.388, p < 0.001). Suggested AF by the algorithm turned out to be false positive in 11 patients. In 13 patients (2.6%) AF was correctly diagnosed by the algorithm. None of the cases detected by routine analysis were missed by the algorithm. CONCLUSIONS: Automated AF detection during 24-h telemetry in ischemic stroke patients is of additional value to detect paroxysmal AF compared with routine analysis by the stroke unit team alone. Automated detections need to be carefully evaluated.

Severe Hallux Valgus Angle Attended With High Incidence of Nonunion in Arthrodesis of the First Metatarsophalangeal Joint: A Follow-Up Study.

The incidence of nonunion after first metatarsophalangeal joint (MTP-1) arthrodesis was found to be high in our clinic. By raising awareness for the problem, making a uniform surgical treatment protocol, banning the commonly used convex-concave reamers, and promoting solely the use of hand instruments to prepare the joint for arthrodesis, we tried to decrease the numbers of nonunion. This prospective cohort study included all patients who underwent MTP-1 fusion between January 2018 and March 2019. Patients were treated according to a standardized protocol, using hand instruments to prepare the joint for fusion. Anthropometric and therapy-related data were collected and compared with an earlier 2015-2016 cohort that was retrospectively assessed. Furthermore, the frequency of nonunion between convex-concave reamers and hand instruments was compared. A total of 53 patients underwent MTP-1 fusion surgery. The incidence of nonunion was 3.8%, significantly lower than the 24.1% in 2015 to 2016 (p = .002). Multivariate regression analysis showed a 7.11 times higher risk of nonunion in 2015 to 2016 compared with 2018 to 2019 (95% confidence interval [CI] 1.55 to 32.55) (p = .012). Furthermore, an increase of 10° in HVA showed a 1.52 risk of occurrence of nonunion (95% CI 1.07 to 2.17) (p = .021). The use of convex/concave reamers was univariately associated with a 3.61 times higher risk of nonunion (95% CI 1.14 to 11.43) (p = .029); however, after correction for preoperative HVA, the preparation method was no longer associated with the occurrence of nonunion (p = .108). Patients suffering from severe hallux valgus had nonunion in 32.1% of cases. Incidence of nonunion after MTP-1 arthrodesis was significantly reduced by raising awareness and by standardizing the treatment protocol. There was no significant difference in nonunion frequency between the methods of joint surface preparation. Severe hallux valgus is prone to nonunion, and more research into this indication for MTP-1 fusion and outcome is needed.

Patient's Skeletal Muscle Radiation Attenuation and Sarcopenic Obesity are Associated with Postoperative Morbidity after Neoadjuvant Chemoradiation and Resection for Rectal Cancer.

BACKGROUND/AIMS: To investigate the relation between skeletal muscle measurements (muscle mass, radiation attenuation, and sarcopenic obesity), postoperative morbidity, and survival after treatment of locally advanced rectal cancer. METHODS: This explorative retrospective study identified 99 consecutive patients who underwent neoadjuvant chemoradiation and surgery between January 2007 and May 2012. Skeletal muscle mass was measured as total psoas area and total abdominal muscle area (TAMA) at 3 anatomical levels using the patient's preoperative computed tomography scan. Radiation attenuation was measured using corresponding mean Hounsfield units for TAMA. Sarcopenic obesity was defined as body mass index above 25 kg·m-2 combined with skeletal muscle mass index below the sex-specific median. Postoperative complications were graded by using the -Clavien-Dindo classification. RESULTS: Twenty-five patients (25.3%) developed a grade 3-5 complication. Lower radiation attenuation was independently associated with overall (p = 0.003) and grade 3-5 complications (p = 0.002). Sarcopenic obesity was associated with overall complications (all p < 0.05). Skeletal muscle measurements and survival were not significantly related. CONCLUSION: Radiation attenuation was associated with overall and grade 3-5 postoperative morbidity after neoadjuvant chemoradiation and non-laparoscopic resection for rectal cancer. Sarcopenic obesity was associated with overall complications.

Study protocol for a non-inferiority trial of a blended smoking cessation treatment versus face-to-face treatment (LiveSmokefree-Study).

BACKGROUND: Smoking cessation can significantly reduce the risk of developing smoking-related diseases. Several face-to-face and web-based treatments have shown to be effective. Blending of web-based and face-to-face treatment is expected to improve smoking cessation treatment. The primary objective of this study is to compare the prolonged abstinence rate of the blended smoking cessation treatment with the face-to-face treatment. Secondary objectives are to assess the benefits of blended treatment in terms of cost effectiveness and patient satisfaction, and to identify mechanisms underlying successful smoking cessation. METHODS/DESIGN: This study will be a single-center randomized controlled non-inferiority-trial with parallel group design. Patients (n = 344) will be randomly assigned to either the blended or the face-to-face group. Both treatments will consist of ten sessions with equal content held within 6 months. In the blended treatment five out of ten sessions will be delivered online. The treatments will cover the majority of behavior change techniques that are evidence-based within smoking cessation counseling. All face-to-face sessions in both treatments will take place at the outpatient smoking cessation clinic of a hospital. The primary outcome parameter will be biochemically validated prolonged abstinence at 15 months from the start of the smoking cessation treatment. DISCUSSION: This RCT will be the first study to examine the effectiveness of a blended smoking cessation treatment. It will also be the first study to explore patient satisfaction, adherence, cost-effectiveness, and the clinically relevant influencing factors of a blended smoking cessation treatment. The findings of this RCT are expected to substantially strengthen the base of evidence available to inform the development and delivery of smoking cessation treatment. TRIAL REGISTRATION: Nederlands Trialregister NTR5113 . Registered 24 March 2015.

Lack of Evidence Regarding Markers Identifying Acute Heart Failure in Patients with COPD: An AI-Supported Systematic Review.

Background: Due to shared symptoms, acute heart failure (AHF) is difficult to differentiate from an acute exacerbation of COPD (AECOPD). This systematic review aimed to identify markers that can diagnose AHF underlying acute dyspnea in patients with COPD presenting at the hospital. Methods: All types of observational studies and clinical trials that investigated any marker's ability to diagnose AHF in acutely dyspneic COPD patients were considered eligible for inclusion. An AI tool (ASReview) supported the title and abstract screening of the articles obtained from PubMed, Scopus, Web of Science, the Cochrane Library, Embase, and CINAHL until April 2023. Full text screening was independently performed by two reviewers. Twenty percent of the data extraction was checked by a second reviewer and the risk of bias was assessed in duplicate using the QUADAS-2 tool. Markers' discriminative abilities were evaluated in terms of sensitivity, specificity, positive and negative predictive values, and the area under the curve when available. Results: The search identified 10,366 articles. After deduplication, title and abstract screening was performed on 5,386 articles, leaving 153 relevant, of which 82 could be screened full text. Ten distinct studies (reported in 16 articles) were included, of which 9 had a high risk of bias. Overall, these studies evaluated 12 distinct laboratory and 7 non-laboratory markers. BNP, NT-proBNP, MR-proANP, and inspiratory inferior vena cava diameter showed the highest diagnostic discrimination. Conclusion: There is not much evidence for the use of markers to diagnose AHF in acutely dyspneic COPD patients in the hospital setting. BNPs seem most promising, but should be interpreted alongside imaging and clinical signs, as this may lead to improved diagnostic accuracy. Future validation studies are urgently needed before any AHF marker can be incorporated into treatment decision-making algorithms for patients with COPD. Protocol Registration: CRD42022283952.

Artificial intelligence in systematic reviews: promising when appropriately used.

BACKGROUND: Systematic reviews provide a structured overview of the available evidence in medical-scientific research. However, due to the increasing medical-scientific research output, it is a time-consuming task to conduct systematic reviews. To accelerate this process, artificial intelligence (AI) can be used in the review process. In this communication paper, we suggest how to conduct a transparent and reliable systematic review using the AI tool 'ASReview' in the title and abstract screening. METHODS: Use of the AI tool consisted of several steps. First, the tool required training of its algorithm with several prelabelled articles prior to screening. Next, using a researcher-in-the-loop algorithm, the AI tool proposed the article with the highest probability of being relevant. The reviewer then decided on relevancy of each article proposed. This process was continued until the stopping criterion was reached. All articles labelled relevant by the reviewer were screened on full text. RESULTS: Considerations to ensure methodological quality when using AI in systematic reviews included: the choice of whether to use AI, the need of both deduplication and checking for inter-reviewer agreement, how to choose a stopping criterion and the quality of reporting. Using the tool in our review resulted in much time saved: only 23% of the articles were assessed by the reviewer. CONCLUSION: The AI tool is a promising innovation for the current systematic reviewing practice, as long as it is appropriately used and methodological quality can be assured. PROSPERO REGISTRATION NUMBER: CRD42022283952.

Gamma-Glutamyl Transferase: A Friend against Cholestatic Itch? A Retrospective Observational Data Analysis in Patients with Extrahepatic Cholestasis.

Methods: We included 235 patients with chronic extrahepatic cholestasis due to pancreatic cancer, cholangiocarcinoma, or papillary carcinoma. Results: GGT was significantly higher in patients without pruritus (median 967, IQR 587-1571) compared to patients with pruritus (median 561 IQR 266-1084 IU/l) (p < 0.01). In contrast, median alkaline phosphatase (AP) was 491 U/L (IQR; 353-684) in patients with pruritus and was not significantly different from 518 U/L (IQR; 353-726) in patients without pruritus (p = 0.524). Direct bilirubin was significantly higher in patients with pruritus compared to patients without pruritus (168 µmol/L (IQR; 95-256) vs. 120 µmol/L (IQR; 56.75-185.5)) (p < 0.01). After correcting for the extent of cholestasis via direct bilirubin, the negative association between GGT and pruritus remained significant and became stronger (p < 0.001). Conclusion: Serum GGT activity is inversely associated with the presence of cholestatic itch in patients with chronic extrahepatic cholestasis.

Exploring Patterns of COPD Exacerbations and Comorbid Flare-Ups.

Background: Comorbidities are known to complicate disease management in patients with Chronic Obstructive Pulmonary Disease (COPD). This is partly due to lack of insight into the interplay of acute exacerbations of COPD (AECOPD) and comorbid flare-ups. This study aimed to explore patterns of AECOPDs and comorbid flare-ups. Methods: Data of increased symptoms were extracted from a 12-month daily symptom follow-up database including patients with COPD and comorbidities (chronic heart failure (CHF), anxiety, depression) and transformed to visualizations of AECOPDs and comorbid flare-up patterns over time. Patterns were subsequently categorized using an inductive approach, based on both predominance (ie, which occurs most often) of AECOPDs or comorbid flare-ups, and their simultaneous (ie, simultaneous start in ≥ 50%) occurrence. Results: We included 48 COPD patients (68 ± 9 years; comorbid CHF: 52%, anxiety: 40%, depression: 38%). In 25 patients with AECOPDs and CHF flare-ups, the following patterns were identified: AECOPDs predominant (n = 14), CHF flare-ups predominant (n = 5), AECOPDs nor CHF flare-ups predominant (n = 6). Of the 24 patients with AECOPDs and anxiety and/or depression flare-ups, anxiety and depression flare-ups occurred simultaneously in 15 patients. In 9 of these 24 patients, anxiety or depression flare-ups were observed independently from each other. In 31 of the included 48 patients, AECOPDs and comorbid flare-ups occurred mostly simultaneously. Conclusion: Patients with COPD and common comorbidities show a variety of patterns of AECOPDs and comorbid flare-ups. Some patients, however, show repetitive patterns that could potentially be used to improve personalized disease management, if recognized.

Association of the asthma control questionnaire with exercise-induced bronchoconstriction.

INTRODUCTION: Asthma is a common chronic disease in childhood which features bronchial hyperresponsiveness to exercise (EIB). In daily clinical practice, the report of EIB is used to assess the level of control of asthma. The asthma control questionnaire (ACQ) is a tool to evaluate the control of asthma in children. The aim of this study was to evaluate the relationship between the ACQ and EIB. MATERIALS AND METHODS: Two hundred children, aged 12.5 ± 2.5 years, with a pediatrician-diagnosed mild-to-moderate asthma filled out an ACQ and performed an exercise provocation test in cold air. EIB was defined as a fall in FEV(1) of 15%. RESULTS: Eighty six of the 200 children had a positive exercise challenge. There was no relationship between the categorical ACQ and the occurrence of EIB (p = .39). There was no difference in the occurrence of EIB between genders (p = .12). The positive predictive value of the ACQ for EIB was 51% and the negative predictive value for EIB was 59%. In comparison to the girls, the boys carried an odds ratio (OR) of 0.48 for having an indifferent control of asthma (p = .04; confidence interval (CI): 0.23-0.96), and an OR of 0.46 for having a not well-controlled asthma (p = .03; CI: 0.23-0.93). CONCLUSION: This study shows that the ACQ is not related to EIB in children with asthma. Remarkable is the percentage (41%) of children who, despite well-controlled asthma according to the ACQ, had EIB, which implies that their asthma is not well-controlled. Boys were more likely to report well-controlled asthma, although boys and girls were equally likely to have EIB.

Detection of Major Cardioembolic Sources in Real-World Patients with Ischemic Stroke or Transient Ischemic Attack of Undetermined Cause.

BACKGROUND/AIM: Current guidelines recommend transthoracic echocardiography (TTE) and ambulatory rhythm monitoring following ischemic stroke or transient ischemic attack (TIA) of undetermined cause for identifying cardioembolic sources (CES). Due to ongoing controversies about this routine strategy, we evaluated its yield in a real-world setting. METHODS: In a tertiary medical center, we retrospectively evaluated consecutive patients with ischemic stroke or TIA of undetermined cause, who (after standard work-up) underwent TTE, ambulatory rhythm monitoring, or both. CES were classified as major if probably related to ischemic events and warranting a change of therapy. RESULTS: Between January 2014 and December 2017, 674 patients had ischemic stroke or TIA of undetermined cause. Of all 484 patients (71.8%) who underwent TTE, 9 (1.9%) had a major CES. However, 7 of them had already been identified for cardiac evaluation due to new major electrocardiographic abnormalities or cardiac symptoms. Thus, only 2 patients (0.4%) truly benefitted from unselected TTE screening. Ambulatory rhythm monitoring was performed in 411 patients (61.0%) and revealed AF in 10 patients (2.4%). CONCLUSION: Detecting a major CES is essential because appropriate treatment lowers the risk of recurrent stroke. Nonetheless, in this real-world study that aimed at routine use of TTE and ambulatory rhythm monitoring in patients with ischemic stroke or TIA of undetermined cause, the prevalence of major CES was low. Most patients with major CES on TTE already had an indication for referral to a cardiologist, suggesting that major CES might also have been identified with a much more selective use of TTE.

Does immediate smart feedback on therapy adherence and inhalation technique improve asthma control in children with uncontrolled asthma? A study protocol of the IMAGINE I study.

BACKGROUND: Many asthmatic children suffer from uncontrolled asthma with frequent exacerbations, despite an optimal treatment plan using inhalation medication. Studies have shown that therapy adherence and inhalation technique are often suboptimal in asthmatic children, but these have traditionally been hard to measure. A novel device functioning as an add-on to the inhaler has been developed to measure both aspects by recording vibration patterns during inhalation. This data can be converted to smart feedback and provided to patients immediately via a mobile application. The aim of this study is to improve asthma control in children between 6 and 18 years old by providing immediate smart feedback on the intake of inhalation medication. Asthma control will be measured by forced expiratory volume in 1 s, (Childhood) Asthma Control Test ((c-)ACT) score, and lung function variability and reversibility. METHODS: The study will be performed in Medisch Spectrum Twente (Enschede, The Netherlands). The goal is to include 68 uncontrolled moderate to severe asthmatic children between 6 and 18 years old who receive controller inhalation medication through the Nexthaler®, Ellipta®, or Spiromax®. The study consists of three phases. Phase 1 is observational and will last 4 weeks to observe the baseline adherence and inhalation technique as monitored by the add-on device. A randomised controlled trial lasting 6 weeks will be performed in phase 2. Patients in the intervention group will receive immediate smart feedback about the performed inhalations via a mobile application. In the control group, adherence and inhalation technique will be monitored, but patients will not receive feedback. In phase 3, also lasting 6 weeks, the feedback will be ceased for all children and revision of current therapy may occur, depending on the findings in phase 2. Asthma control can be assessed by means of spirometry (both at home and in the hospital) and (c-)ACT questionnaires. DISCUSSION: Immediate smart feedback may improve therapy adherence and inhalation technique, and thus asthma control in children and prevent unnecessary switches to targeted biologics. Performing this study in children is desired, since they are known to react differently to feedback and medication than adults. TRIAL REGISTRATION: Dutch Trial Register NL7705 . Registered on 29 April 2019.

Retrospective validation of a new volumetric capnography parameter for the exclusion of pulmonary embolism at the emergency department.

Volumetric capnography might be used to exclude pulmonary embolism (PE) without the need for computed tomography pulmonary angiography. In a pilot study, a new parameter (CapNoPE) combining the amount of carbon dioxide exhaled per breath (carbon dioxide production (V CO2 )), the slope of phase 3 of the volumetric capnogram (slope 3) and respiratory rate (RR) showed promising diagnostic accuracy (where CapNoPE=(V CO2 ×slope 3)/RR). To retrospectively validate CapNoPE for the exclusion of PE, the volumetric capnograms of 205 subjects (68 with PE) were analysed, based on a large multicentre dataset of volumetric capnograms from subjects with suspected PE at the emergency department. The area under the curve (AUC) of the receiver operating characteristic (ROC) curve and diagnostic accuracy of the in-pilot established threshold (1.90 Pa·min) were calculated. CapNoPE was 1.56±0.97 Pa·min in subjects with PE versus 2.51±1.67 Pa·min in those without PE (p<0.001). The AUC of the ROC curve was 0.714 (95% CI 0.64-0.79). For the cut-off of ≥1.90 Pa·min, sensitivity was 64.7%, specificity was 59.9%, the negative predictive value was 77.4% and the positive predictive value was 44.4%. The CapNoPE parameter is decreased in patients with PE but its diagnostic accuracy seems too low to use in clinical practice.

BMI predicts exercise induced bronchoconstriction in asthmatic boys.

BACKGROUND: Exercise induced bronchoconstriction (EIB) is a frustrating morbidity of asthma in children. Obesity has been associated with asthma and with more severe EIB in asthmatic children. OBJECTIVES: To quantify the effect of BMI on the risk of the occurrence of EIB in children with asthma. METHODS: Data were collected from six studies in which exercise challenge tests were performed according to international guidelines. We included 212 Children aged 7-18 years, with a pediatrician-diagnosed mild-to-moderate asthma. RESULTS: A total of 103 of 212 children (49%) had a positive exercise challenge (fall of FEV1 ≥ 13%). The severity of EIB, as measured by the maximum fall in FEV1 , was significantly greater in overweight and obese children compared to normal weight children (respectively 23.9% vs 17.9%; P = 0.045). Asthmatic children with a BMI z-score around +1 had a 2.9-fold higher risk of the prevalence of EIB compared to children with a BMI z-score around the mean (OR 2.9; 95%CI: 1.3-6.1; P < 0.01). An increase in BMI z-score of 0.1 in boys led to a 1.4-fold increased risk of EIB (OR 1.4; 95%CI: 1.0-1.9; P = 0.03). A reduction in pre-exercise FEV1 was associated with a higher risk of EIB (last quartile six times higher risk compared to highest quartile (OR 6.1 [95%CI 2.5-14.5]). CONCLUSIONS: The severity of EIB is significantly greater in children with overweight and obesity compared to non-overweight asthmatic children. Furthermore, this study shows that the BMI-z-score, even with a normal weight, is strongly associated with the incidence of EIB in asthmatic boys.

Volumetric capnography in the exclusion of pulmonary embolism at the emergency department: a pilot study.

The analysis of the [Formula: see text] in expired air as a function of the exhaled volume (volumetric capnography) might result in a more specific exclusion tool for pulmonary embolism (PE) in addition to the Wells-score and D-dimer. A novel combination of volumetric capnography parameters ([Formula: see text]) should be decreased in PE and could possibly be used to decrease the number of requested computed tomography pulmonary angiograms (CTPA). Volumetric capnography measurements were performed on consecutive patients seen in the emergency department for which, due to suspected PE (due to increased D-dimer level or Wells-score), a CTPA was ordered. A total of 30 subjects were included, of which in 13 PE was seen on CTPA. Median [Formula: see text] was 4.36 kPa (IQR 3.92-4.88) in the no PE group versus 4.07 kPa (IQR 3.37-4.39) in the PE group (p = 0.086). Median of the novel parameter [Formula: see text] was 1.85 min.kPa dl-1 (IQR 1.21-3.00) in the no PE group versus 1.18 min.kPa dl-1 (IQR 0.61-1.38) in the PE group (p = 0.006). Using a threshold for the new parameter of 1.90 min.kPa dl-1 or higher to exclude PE resulted in a negative predictive value of 100% (95% CI: 77%-100%) and would have potentially excluded PE in 47% (95% CI: 26%-69%) of the no PE group without the need for CTPA. This pilot study introduces a novel parameter [Formula: see text] which is significantly decreased in PE subjects. Future studies regarding validation and addressing aspects such as reproducibility and normalization after treatment are needed to confirm its usability in excluding PE in the emergency department.

[Value of a multidisciplinary team for patients with a urological malignancy]. / Toegevoegde waarde van het uro-oncologische multidisciplinair overleg.

OBJECTIVE: To evaluate degree of agreement between treatment proposals from urologist and a multidisciplinary team (MDT) for patients with an urological malignancy. DESIGN: Retrospective cohort study. METHOD: All letters from patients with an urological malignancy of prostate, bladder, kidney or testicle who were discussed at the MDT in Ziekenhuisgroep Twente from January 2011 until January 2013 were collected. This study studied the level and frequency of agreement between treatment proposals from urologist and MDT. Level of agreement was expressed by using Cohen's Kappa. Also treatments proposed by the MDT were compared to the final treatment choice of the patient. RESULTS: A total of 788 letters were analysed. For 9%, the MDT disagreed with the treatment recommended by the urologist. This disagreement was most often observed in patients with malignancy of kidney (κ: 0.507; p < 0.001). Agreement for patients with malignancy of bladder, testicle and prostate were substantial (respectively κ: 0.719; p < 0.001, κ: 0.803; p < 0.001, κ: 0.634; p < 0.001). Treatment proposals "brachytherapy" and "external radiotherapy" for prostate malignancy showed only moderate agreement (κ: 0.564 and κ: 0.568; p < 0.001 respectively). 93% of all patients elected to take (one of) the treatment proposals made by the MDT. CONCLUSION: A multidisciplinary approach seems particularly useful for patients with malignancy of kidney. The additative value of MDT was less visible for patients with malignancy of prostate, which could be due to less consistent guidelines. Final treatment decision might be influenced by explanation and guidance of the treating urologist.