Cellular immune responses to platelet factor 4 and heparin complexes in patients with heparin-induced thrombocytopenia.

Essentials The immunogenesis of Heparin-induced thrombocytopenia (HIT) is not well understood. Immunization to platelet factor 4 (PF4)-heparin occurs early in life, before any heparin exposure. PF4 and PF4-heparin complexes induce the proliferation of CD14+ cells. Reduced levels of regulatory cytokines contribute to immune dysregulation in HIT. SUMMARY: Background Heparin-induced thrombocytopenia (HIT) is an adverse reaction to heparin characterized by thrombocytopenia and thrombotic complications. HIT is caused by pathogenic antibodies that bind to complexes of platelet factor 4 (PF4) and heparin, leading to platelet activation and inducing a hypercoagulable state. Previous studies have shown immunity to PF4-heparin complexes occurs early in life, even before heparin exposure; however, the immunogenesis of HIT is not well characterized. Objectives To investigate cellular proliferation in response to PF4-heparin complexes in patients with HIT. Patients/Methods Peripheral blood mononuclear cells (PBMCs) from healthy controls (n = 30), postoperative cardiac surgery patients who had undergone cardiopulmonary bypass (CPB) (n = 17) and patients with confirmed HIT (n = 41) were cultured with PF4 and PF4-heparin complexes. Cellular proliferation was assessed by [3 H]thymidine uptake and 5-ethynyl-2'-deoxyuridine detection. Results and Conclusions PBMCs proliferated in the presence of PF4, and this was enhanced by the addition of heparin in all study groups. CPB and HIT patients showed significantly greater proliferative responses than healthy controls. PBMC proliferation was antigen-specific, depended on the presence of platelets, and only CD14+ cells were identified as proliferating cells. Culture supernatants were tested for the levels of regulatory cytokines, and both CPB and HIT patients produced significantly lower levels of interleukin-10 and transforming growth factor-ß1 than healthy controls. These findings further demonstrate cellular immune sensitization to PF4-heparin complexes occurs before heparin exposure, and suggests immune dysregulation can contribute to HIT.

Transfusion-related alloimmunization in children: epidemiology and effects of chemotherapy.

BACKGROUND & OBJECTIVES: Alloimmunization rates following red blood cell (RBC) transfusion in paediatric oncology are not known. This study aimed to: (1) describe frequency and specificity of alloantibodies in paediatric oncology patients after RBC transfusions; (2) determine the effect of chemotherapy on alloimmunization rate. MATERIALS & METHODS: Retrospective cohort study of paediatric patients at a tertiary care hospital is evaluated by two groups: control group, paediatric patients without cancer; study group, paediatric oncology patients who received chemotherapy. Alloimmunization was defined as clinically significant IgG alloantibody formation against RBC antigens. RESULTS: A total of 1273 children were evaluated including 324 in study group, 909 controls, and 40 haemoglobinopathy patients. Overall, frequency of alloimmunization was 1·5%: 0·3% (95% CI: 0, 1·90) in study group; 1·3% (95% CI: 0·73, 2·32) in control group and 15% in haemoglobinopathies. The association between chemotherapy and alloimmunization was not significant; P value = 0·20 Fisher's exact test, OR 0·23 (95% CI: 0·03, 1·79). CONCLUSION: This is the first study exploring RBC alloimmunization in paediatric patients by diagnosis. Alloimmunization frequency was low. It was not possible to determine an association between chemotherapy and alloimmunization due to the low event rate.

FcγRIIa proteolysis as a diagnostic biomarker for heparin-induced thrombocytopenia.

BACKGROUND: A significant challenge in the management of heparin-induced thrombocytopenia (HIT) patients is making a timely and accurate diagnosis. The readily available enzyme immunoassays (EIAs) have low specificities. In contrast, platelet activation assays have higher specificities, but they are technically demanding and not widely available. In addition, ~ 10% of samples referred for HIT testing are initially classified as indeterminate by the serotonin release assay (SRA), which further delays accurate diagnosis. HIT is characterized by platelet activation, which leads to FcγRIIa proteolysis. This raises the possibility that identification of the proteolytic fragment of FcγRIIa could serve as a surrogate marker for HIT. OBJECTIVES: To determine the specificity of platelet FcγRIIa proteolysis induced by sera from patients with HIT, and to correlate the results with those of the SRA. METHODS/PATIENTS: Sera from HIT patients and control patients with other thrombocytopenic/prothrombotic disorders were tested for their ability to proteolyse FcγRIIa. The results were correlated with anti-platelet factor 4 (PF4)/heparin antibodies (EIA), and heparin-dependent platelet activation (SRA). RESULTS: Only HIT patient samples (20/20) caused heparin-dependent FcγRIIa proteolysis, similar to what was shown by the SRA. None of the samples from the other patient groups or hospital controls caused FcγRIIa proteolysis. Among nine additional samples that tested indeterminate in the SRA, FcγRIIa proteolysis resolved five samples that had a positive anti-PF4/heparin EIA result; three had no FcγRIIa proteolysis, and two were shown to have heparin-dependent FcγRIIa proteolysis CONCLUSIONS: This study suggests that heparin-dependent FcγRIIa proteolysis is at least as specific as the SRA for the diagnosis of HIT.

Elicitation of utility scores in Canada for immune thrombocytopenia treated with romiplostim or watch and rescue.

OBJECTIVES: The objective of this study was to obtain utilities, or preference-based quality-of-life values, from the Canadian general public, for potential health states experienced by immune thrombocytopenia (ITP) patients receiving either romiplostim (a new thrombopoietin mimetic agent) or 'watch and rescue' therapy. Utilities are needed to conduct a cost-utility analysis of romiplostim for formulary and reimbursement decisions. METHODS: An electronic Time Trade-off (TTO) survey was developed and administered to a sample of the general public in Canada, with 12 distinct health states derived from two randomized clinical trials of romiplostim vs watch and rescue treatment. Two pilot tests assessed interpretability and respondent burden. In the final survey, each subject was administered the TTO for four randomly-selected health states. Descriptive statistics were computed for utility scores, and differences between health states were evaluated with an analysis of variance model. RESULTS: Eight hundred and twenty-one adults completed the TTO survey. Mean age was 36.4 (SD = 15) years; 63% were female. Mean (SD) utility scores ranged from 0.476 (0.271) for the most severe health state (significant bleeding) to 0.633 (0.282) for the least severe health state depicting successful treatment with romiplostim. Statistical significance was found on the mean difference between the most severe health state and five other health states (p < 0.05). After adjusting utilities for matching Canadian demographic parameters, no substantial difference was found between original utility scores and adjusted scores. CONCLUSIONS: This study provides evidence of the Canadian general public's preference for 12 ITP health states pertaining to romiplostim treatment or watch and rescue. This study had a number of limitations, the main ones being the lack of perfect match in demographics between this sample and the Canadian population, as well as the fact that the scenario descriptions were based on both published literature and expert opinion. Despite those limitations, the obtained utility scores may be used in cost-utility models of romiplostim as a treatment for ITP patients in Canada.

Patella retention versus replacement in total knee arthroplasty; functional and clinimetric aspects.

INTRODUCTION: Whether to resurface the patella or not in total knee arthroplasty still remains undecided. Classical scores and questionnaires might not be responsive or demanding enough. This study used two accelerometer based systems to study the hypothesis whether performance based tests are able to detect a difference in patients with or without a resurfaced patella. METHOD: In this retrospective study 53 patients were included and divided into a resurfaced group (n = 31) and a non-resurfaced group (n = 22). Both groups were matched on age and longevity of follow up. Patients were clinically assessed using the Knee Society Score (KSS) at various time points. At final follow up patients were also assessed once using the Dynaport Knee Test and the Minimod Gait Test. RESULTS: The Dynaport Knee Test showed a significant functional advantage for patients with a resurfaced patella [44 vs. 39.7 (P = 0.042)], whereas KSS and The Minimod were not significant (P values ranging from 0.07 to 0.75). Similar to other reports in literature, using the KSS, it was not possible to identify significant difference between patella resurfacing or retaining in total knee arthroplasty, however using a performance based test it was possible to determine significant difference. The found advantage of patella resurfacing may be less due to pain relief but due to a functional benefit during demanding motion tasks. This finding indicates that current measurement tools may not be accurate or specific enough to detect this difference. Therefore, we recommend complementing the classic evaluation tools with an objective functional test, when conducting a randomized trial to answer the indecision whether to resurface the patella or not.

The baseline serum lipoprotein profile is related to plant stanol induced changes in serum lipoprotein cholesterol and triacylglycerol concentrations.

OBJECTIVE: Baseline characteristics of subjects might be related to the effect of plant stanols on the serum lipoprotein profile. The aim of the study was to examine effects of subjects' baseline characteristics (baseline serum concentrations of lipids and lipoproteins at the start of the study, lathosterol, campesterol and sitosterol; gender, age, BMI, smoking, use of oral contraceptives and menopause) on the effects of plant stanol esters on the serum lipoprotein profile. METHODS: We used data of five studies performed at our Department. A random intercept model was used for statistical analysis, using serum lipid and lipoprotein concentrations after plant stanol ester consumption, as dependent variables. RESULTS: After plant stanol ester consumption, higher baseline serum concentrations of total and LDL cholesterol resulted in larger absolute decreases in their respective serum concentrations. For the ratio of total to HDL cholesterol and triacylglycerol, higher baseline serum levels resulted in larger absolute and relative decreases in their serum levels. HDL cholesterol concentrations increased in subjects with low baseline concentrations and decreased in those with high baseline concentrations. Effects however were small. No relationships were observed with baseline serum cholesterol-standardized lathosterol and campesterol concentrations, although LDL cholesterol concentrations tended to decrease more at higher baseline sitosterol concentrations. No effects of other baseline characteristics were found. CONCLUSIONS: People with an unfavorable serum lipid and lipoprotein profile benefit even more of plant stanols than people with a more favorable profile.

Associations of dietary methyl donor intake with MLH1 promoter hypermethylation and related molecular phenotypes in sporadic colorectal cancer.

Intake of dietary factors that serve as methyl group donors may influence promoter hypermethylation in colorectal carcinogenesis. We investigated whether dietary folate, vitamin B2 and vitamin B6, methionine and alcohol were associated with mutL homologue 1 (MLH1) hypermethylation and the related molecular phenotypes of MLH1 protein expression, microsatellite instability (MSI) and BRAF mutations in patients with colorectal carcinomas. Within the Netherlands Cohort Study on diet and cancer (n = 120 852), 648 cases (367 men and 281 women) and 4059 subcohort members were available for data analyses from a follow-up period between 2.3 and 7.3 years after baseline. Gender-specific adjusted incidence rate ratios (RRs) were calculated over categories of dietary intake in case-cohort analyses. The intakes of folate, vitamin B2, methionine and alcohol were not associated with risk of tumors showing MLH1 hypermethylation, those lacking MLH1 protein expression or with MSI. Among men, we observed strong positive associations between folate and BRAF-mutated tumors (RR = 3.04 for the highest versus lowest tertile of intake, P(trend) = 0.03) and between vitamin B6 and tumors showing MLH1 hypermethylation (highest versus lowest tertile: RR = 3.23, P(trend) = 0.03). Among women, the relative risks of tumors with BRAF mutations or MLH1 hypermethylation were also increased in the highest tertiles of folate and vitamin B6 intake, respectively, but these did not reach statistical significance. The positive associations between folate intake and tumors harboring BRAF mutations and between vitamin B6 intake and those showing MLH1 hypermethylation were most pronounced among men and may suggest that these vitamins enhance colorectal cancer risk through genetic as well as epigenetic aberrations.

[Results of a study on fatigue in breast cancer patients receiving adjuvant chemotherapy: the first four days after treatment are the worst]. / Ergebnisse einer Untersuchung von Fatigue bei Brustkrebspatientinnen mit adjuvanter Chemotherapie: Die ersten vier Tage nach dem Zyklus sind am belastendsten.

A large number of breast cancer patients receiving adjuvant chemotherapy is suffering from fatigue. Until now there has been a lack of knowledge concerning the course of fatigue in breast cancer patients between two cycles of adjuvant chemotherapy. Therefore a prospective cohort study was conducted including 151 breast cancer patients from six hospitals in The Netherlands. The object of the study was to investigate the course of fatigue between the third and the fourth cycles of adjuvant chemotherapy, and to prove whether that course is influenced by different chemotherapy schedules. The patients were treated either with a doxorubicin containing schedule (21 or 28 days) or with a combination of cyclophosphamide, methotrexate, and 5-fluorouracil (CMF, 28 days). To assess fatigue patients were asked to write a diary cotaining the Shortened Fatigue Questionnaire (SFQ) from the beginning of the third cycle to the start of the fourth one. All days after completion of the third chemotherapy treatment were analysed. The main hypothesis to be tested was that the maximum fatigue level occurs in the first four days after treatment. Results revealed a chaotic pattern of fatigue between both cycles of chemotherapy in each of the treatment group. Smooth (splines) curves showed an average highest level of fatigue on day 3 post treatment. For the regimens with 28-days-intervalls another peak of fatigue was registered on day 11. A significant larger number of patients experienced maximum fatigue levels before day 5. The course of fatigue in the CMF group was significantly different compared with both doxorubicin groups. Women of the CMF group experienced lower fatigue peaks than patients of other groups. The results confirm the main hypothesis. The first days after treatment with chemotherapy are the worst ones for breast cancer patients. The course of fatigue is significantly related to the type of chemotherapy. Knowing these effects patients can better prepare oneself and their daily living for the time of adjuvant chemotherapy.

Functional improvement after unicompartmental knee replacement: a follow-up study with a performance based knee test.

In literature no reports appear on functional recovery of unicompartmental knee replacement using both subjective and objective methods. Functional aspects are especially of importance, since prosthetic replacement is considered more often in younger patients, who require an optimal knee function for activities such as sports. In a prospective study on 38 patients with a mean age of 62.2 years functional improvement was measured. Using Knee Society Score (KSS) as a clinician based score and the Dynaport Knee Test as a functional test measurements were performed at preoperative, 3 and 6 months, 1 and 2 years, after surgery. The Dynaport Knee Test is an accelerometer-based system that objectively measures functional aspects of gait during various tasks of daily life. It consists of four sub scores. The KSS assesses pain and function. Both scores range from 0 to 100. The mean KSS preoperative was 44.0 and improved significantly to 81.7 at 3 months (P<0.001) and to 87.4 (P=0.025) at 6 months. No significant differences were noted after 6 months. The mean preoperative Dynaport Knee Test score was 35.8 and at 3 months 43.6 (P<0.001), 48.6 at 6 months (P<0.001). No significant differences were noted after 6 months follow-up. Of the Dynaport sub scores, the low demanding tasks Lift and Move and Locomotion, cease to improve beyond 6 months. The high demanding task Transfers only improved up to 3 months. However, the other high demanding tasks Rise and Descend showed improvement beyond 1 year after surgery, since the improvement from 6 months to 2 years was significant (P=0.023). This study has found that functional recovery continues beyond 6 months and even up to 2 years. It seems only more challenging tests can discriminate on improvement beyond a point where questionnaires cease to improve. The use of objective measurement methods is advocated next to the clinician based scores and self reported questionnaires.

Interactive effect of family history and environmental factors on respiratory tract-related morbidity in infancy.

BACKGROUND: Family and environmental factors affect the development of respiratory morbidity. How these factors interact is unclear. OBJECTIVE: We sought to clarify the interactive effect of family history of asthma and environmental factors on the occurrence of respiratory morbidity. METHODS: Two hundred twenty-one infants with a positive family history of asthma (PFH) and 308 with a negative family history of asthma (NFH) were prenatally selected and followed until the age of 2 years. Exposure to environmental factors and the occurrence of respiratory morbidity were recorded. By using multiple logistic regression analysis, increased risk was expressed in odds ratios (ORs) adjusted for relevant covariables. RESULTS: Infants with a PFH had more respiratory morbidity than infants with an NFH. Adjusted ORs ranged from 1.7 (95% CI, 1.0-2.8) for expiratory wheezing to 4.9 (95% CI, 1.7-13.6) for croup. Parental smoking increased the OR of a PFH for wheezing ever (OR, 5.8 [95% CI, 2.5-13.8]) and attacks of wheezing (OR, 6.8 [95% CI, 2.7-16.9]), as did Der p 1 (OR, 10.2 [95% CI, 2.8-36.3] and OR, 7.1 [95% CI, 7.1-21.0], respectively). Exposure to both parental smoking and Der p 1 further increased this OR (OR, 30.8 [95%, CI, 6.9-137.2] and OR, 26.2 [95% CI, 5.9-115.6], respectively). Breast-feeding decreased the ORs of PFH for tonsillitis and acute otitis media: the increased ORs for these diagnoses in formula-fed infants with PFHs versus those with NFHs (OR, 9.2 [95% CI, 2.1-39.7] and OR, 2.9 [95% CI, 1.1-7.2], respectively) was attenuated in breast-fed infants (OR, 1.8 [95% CI, 0.8-3.8] and OR, 0.7 [95% CI, 0.4-1.3]). CONCLUSION: Parental smoking and Der p 1 increase the effect of a PFH on respiratory morbidity. Breast-feeding reduces this effect. CLINICAL IMPLICATIONS: Extra attention should be given to stimulate mothers to breast-feed their children in case they cannot stop smoking or taking sanitation measures.

Course of fatigue between two cycles of adjuvant chemotherapy in breast cancer patients.

The purpose of this study was to determine the course of fatigue in patients with breast cancer between 2 cycles of adjuvant chemotherapy, from the day of administration until the day of the next infusion. In a prospective cohort study, a sample of 151 patients with breast cancer receiving adjuvant chemotherapy was recruited from 6 hospitals in mainly the south of the Netherlands. Patients reported their experience of fatigue in a diary, the Shortened Fatigue Questionnaire, on a daily basis between the third and fourth treatment with adjuvant chemotherapy. Patients were treated with either a doxorubicin containing schedule or with cyclophosphamide, methotrexate, and 5-fluorouracil (CMF, 28 days). In the 28-day regimens, infusions were given on day 1 and day 8. The days after completion of the third and the start of the fourth treatment with chemotherapy were statistically analyzed. We tested the hypothesis that the maximum fatigue score occurs in the first 4 days after treatment. The mean age of the sample was 47.2 years (SD = 8.8). Most women (84%) were married or lived together with a partner. The majority (80%) of all patients had been diagnosed with stage II breast cancer. The division between mastectomies (47%) and lumpectomies (52%) was approximately equal. Sixty percent of the patients received radiotherapy before the third treatment with chemotherapy and/or in the period they kept the diary. A chaotic pattern of fatigue between the 2 cycles of chemotherapy emerged. Smooth (splines) curves showed an average highest level of fatigue on day 3 from the start. For the 28-day regimens, another distinct peak was seen around day 11. A relatively larger number of patients experienced peak fatigue levels before day 5. The course of fatigue in the CMF group was significantly different compared with the doxorubicin regimens. The fatigue peak in the CMF group was lower. Women taking cyclophosphamide orally experienced the peak level of fatigue significantly later. Influences of other variables were not observed in any chemotherapy group. Cancer-related fatigue has a chaotic nature. The first days after treatment with chemotherapy are the worst. The type of chemotherapy has a significant impact on the course of fatigue. Improved understanding of the nature and course of fatigue could equip healthcare providers better for informing patients about what they may expect. Future research should include interventions aimed at reducing or coping with fatigue.

Timing and risk factors for clinical fractures among postmenopausal women: a 5-year prospective study.

BACKGROUND: Many risk factors for fractures have been documented, including low bone-mineral density (BMD) and a history of fractures. However, little is known about the short-term absolute risk (AR) of fractures and the timing of clinical fractures. Therefore, we assessed the risk and timing of incident clinical fractures, expressed as 5-year AR, in postmenopausal women. METHODS: In total, 10 general practice centres participated in this population-based prospective study. Five years after a baseline assessment, which included clinical risk factor evaluation and BMD measurement, 759 postmenopausal women aged between 50 and 80 years, were re-examined, including undergoing an evaluation of clinical fractures after menopause. Risk factors for incident fractures at baseline that were significant in univariate analyses were included in a multivariate Cox survival regression analysis. The significant determinants were used to construct algorithms. RESULTS: In the total group, 12.5% (95% confidence interval (CI) 10.1-14.9) of the women experienced a new clinical fracture. A previous clinical fracture after menopause and a low BMD (T-score <-1.0) were retained as significant predictors with significant interaction. Women with a recent previous fracture (during the past 5 years) had an AR of 50.1% (95% CI 42.0-58.1) versus 21.2% (95% CI 20.7-21.6) if the previous fracture had occurred earlier. In women without a fracture history, the AR was 13.8% (95% CI 10.9-16.6) if BMD was low and 7.0% (95% CI 5.5-8.5) if BMD was normal. CONCLUSION: In postmenopausal women, clinical fractures cluster in time. One in two women with a recent clinical fracture had a new clinical fracture within 5 years, regardless of BMD. The 5-year AR for a first clinical fracture was much lower and depended on BMD.

Do clinical findings in lower respiratory tract infection help general practitioners prescribe antibiotics appropriately? An observational cohort study in general practice.

BACKGROUND: Antibiotics are over-prescribed for lower respiratory tract infection (LRTI). The influence of clinicians' history and examination findings on antibiotic prescribing for LRTI has not been directly assessed, and the extent to which these clinical findings predict appropriate antibiotic prescribing is unknown. A clearer understanding is crucial to achieving evidence-based prescribing. OBJECTIVES: To directly assess the influence of general practitioners' history and examination findings on antibiotic prescribing for LRTI, and to explore the extent to which these clinical findings predict appropriate antibiotic prescribing. METHODS: In this observational cohort study 25 GPs in The Netherlands were recruited during routine consultations and 247 adult patients with a clinical diagnosis of LRTI. The GPs recorded clinical information. Odds ratios (ORs) with 95% confidence intervals (CIs) for clinical variables predicting a prescription for an antibiotic were calculated. The relationship between antibiotic prescription and radiographic evidence of pneumonia was explored in order to gauge appropriateness of antibiotic prescribing. RESULTS: Auscultation abnormalities (OR 11.5; 95% CI 5.4-24.7), and diarrhoea (OR>11) were strongly associated with antibiotic prescribing. An antibiotic was prescribed for 195 (79%) patients. Assuming that an antibiotic definitely needs to be prescribed only for patients with pneumonia, antibiotics may have been inappropriately prescribed for 166/193 (86%) of the patients. Antibiotics were not prescribed for 5 of the 32 (16%) patients with a radiographic diagnosis of pneumonia. CONCLUSIONS: Abnormal findings on auscultation in patients with LRTI strongly predict antibiotic prescribing and this is probably inappropriate for most patients. These results should prompt GPs to consider the extent to which finding 'crackles/rhonchi on auscultation' influences their decisions to prescribe antibiotics for their patients with LRTI, and to consider the predictive value of individual clinical signs in reaching evidence-based prescribing decisions.

Increased mortality in partners of female myocardial infarction patients.

BACKGROUND: Many studies have been performed on the impact of Alzheimer's disease, stroke and cancer on carers. Information on the influence of a myocardial infarction in a patient on the health of the partner is still scarce. METHODS: Exposed and non-exposed partners were compared with respect to the occurrence of mortality and predefined diseases, using Cox proportional hazards survival analysis. RESULTS: None of the disease incidence rates differed between exposed partners and control partners. Over 12 times as many male partners of (female) heart patients died as compared to their male control partners, when they had a low educational level. CONCLUSION: When exposed to myocardial infarction in a patient, the risk of dying in low educated male partners was over 12 times as large as for male low educated unexposed partners.

Psychological effects of a short behavior modification program in patients with acute myocardial infarction or coronary artery bypass grafting. A randomized controlled trial.

OBJECTIVE: The effects of a short intervention on behavioral risk factor modification in patients with coronary artery disease (CAD) on Type A behavior, vital exhaustion, and depression were studied in a randomized controlled trial. METHODS: Acute myocardial infarction patients or patients who underwent coronary artery bypass grafting (CABG) were randomly assigned to an 8-week multiple risk modification group program (n = 94) or to a control group (n = 90) that received usual care with standard physical exercise training. Patients were assessed before intervention, directly after intervention, and at 9-month follow-up. RESULTS: The intervention was effective in reducing hostility and total Type A behavior at postintervention (P = .01) and at 9-month follow-up (P = .03). The intervention had no overall impact on vital exhaustion and depression, measured by the Beck Depression Inventory (BDI), whereas we unexpectedly found that the percentage of patients with major depression was reduced in the control group but not in the intervention group. CONCLUSION: The results indicate that a short behavioral intervention for coronary patients can result in relatively large and persistent reductions in cognitive aspects of Type A behavior and hostility, in particular. In view of the unwanted findings on the diagnosis of depression, however, we do not unequivocally advise the intervention to the general population of AMI and CABG patients.

Alcohol energy intake and habitual physical activity in older adults.

Alcohol forms a significant component of many diets and it supplements rather than displaces daily energy intake. Surprisingly, alcohol intake does not systematically increase body weight. The present study assessed whether a higher level of habitual physical activity in the daily environment is associated with a higher alcohol intake. Alcohol intake as part of total food intake was measured with a 7 d dietary record while at the same time physical activity was monitored with a tri-axial accelerometer for movement registration. Subjects were twenty women and twenty-four men, aged 61+/-5 years, of BMI 27.1+/-4.6 kg/m(2). Between subjects, there was a positive association between the level of habitual physical activity and alcohol intake (r 0.41; P<0.01). The subjects with higher alcohol intake had a higher activity level. On days with and days without alcohol consumption there was no difference in physical activity within subjects. In conclusion, it was shown that subjects with higher alcohol consumption are habitually more active. This may explain the lack of increasing body weight through additional energy intake from alcohol.

Missed opportunities for prevention of venous thromboembolism: an evaluation of the use of thromboprophylaxis guidelines.

OBJECTIVES: To identify and characterize cases of potentially preventable venous thromboembolism (VTE): cases for which thromboprophylaxis was indicated, according to the American College of Chest Physicians (ACCP) consensus guidelines for VTE prevention, yet was administered inadequately. DESIGN: A historical cohort study to examine all cases of deep vein thrombosis and pulmonary embolism from 1996 to 1997 at a large teaching hospital. Of these, we determined the proportion that was potentially preventable. We examined the reasons for inadequacy of prophylaxis and the setting in which preventable VTE occurred. RESULTS: Of 253 objectively diagnosed cases of VTE in 245 patients, 44 cases (17.4%) were considered potentially preventable. This represented two thirds of all VTE cases for which thromboprophylaxis had been indicated (n = 65). Of preventable cases, the most frequent reason for inadequacy of prophylaxis was omission of prophylaxis (47.7%), followed by inadequate duration of prophylaxis (22.7%), and by incorrect type of prophylaxis (20.5%). Surgical and medical indications for thromboprophylaxis that were common among preventable cases included nonorthopedic surgery, admission to hospital for pneumonia, and stroke with lower limb paralysis. Underlying risk factors for VTE that were common among preventable cases included recent immobility, active cancer, and obesity. CONCLUSIONS: One of six cases of all VTE and two of three cases of VTE for which thromboprophylaxis had been indicated could potentially have been prevented had physicians followed the recommended ACCP guidelines. Inadequacy of prophylaxis was most often caused by omission of prophylaxis. Missed opportunities for prevention occurred most commonly in the settings of nonorthopedic surgery, pneumonia, and stroke.

The influence of children's vocal expressions, age, medical diagnosis and information obtained from parents on nurses' pain assessments and decisions regarding interventions.

This article reports on a study that examines the influence of task-related factors on nurses' pain assessments and decision regarding interventions. In an experimental design pediatric nurses (n = 202), were exposed to different cases, each case being a combination of a vignette and a videotape. For every case subjects were asked to assess the child's pain and to state whether they would administer an analgesic. The results indicated that pediatric nurses attributed more pain and were more inclined to administer non-narcotic analgesics to children who vocally expressed their pain than to children who were less expressive. Furthermore, the interaction results between the child's expression and the medical diagnosis revealed a trend indicating that nurses attributed the most pain to the child when the diagnosis was severe and the child vocally expressed his pain.