Epidemiology and demographic patterns of cardiovascular diseases and neoplasms deaths in Western Europe: a 1990-2019 analysis.

OBJECTIVES: Cardiovascular diseases (CVDs) and neoplasms have been considered as public health concerns worldwide. This study aimed to estimate the epidemiological patterns of death burden on CVDs and neoplasms and its attributable risk factors in Western Europe from 1990 to 2019 to discuss the potential causes of the disparities. STUDY DESIGN AND METHODS: We collected data on CVDs and neoplasms deaths in 24 Western European countries from the Global Burden of Disease Study. We analyzed patterns by age, sex, country, and associated risk factors. The results include percentages of total deaths, age-standardized death rates per 100,000 population, and uncertainty intervals (UIs). Time trends were assessed using annual percent change. RESULTS: In 2019, CVDs and neoplasms accounted for 33.54% and 30.15% of Western Europe's total deaths, with age-standardized death rates of 128.05 (95% UI: 135.37, 113.02) and 137.51 (95% UI: 142.54, 128.01) per 100,000. Over 1990-2019, CVDs rates decreased by 54.97%, and neoplasms rates decreased by 19.54%. Top CVDs subtypes were ischemic heart disease and stroke; top cancers for neoplasms were lung and colorectal. Highest CVD death burdens were in Finland, Greece, Austria; neoplasm burdens in Monaco, San Marino, Andorra. The major risk factors were metabolic (CVDs) and behavioral (neoplasms). Gender differences revealed higher CVDs death burden in males, while neoplasms burden varied by risk factors and age groups. CONCLUSION: In 2019, CVDs and neoplasms posed significant health risks in Western Europe, with variations in death burdens and risk factors across genders, age groups, and countries. Future interventions should target vulnerable groups to lessen the impact of CVDs and neoplasms in the region.

The long-term safety of chronic azithromycin use in adult patients with cystic fibrosis, evaluating biomarkers for renal function, hepatic function and electrical properties of the heart.

Background: Azithromycin maintenance therapy is widely used in cystic fibrosis (CF), but little is known about its long-term safety. We investigated whether chronic azithromycin use is safe regarding renal function, hepatic cell toxicity and QTc-interval prolongation.Methods: Adult CF patients (72 patients using azithromycin for a cumulative period of 364.8 years and 19 controls, 108.8 years) from two CF-centers in the Netherlands with azithromycin (non)-use for at least three uninterrupted years were studied retrospectively.Results: There was no difference in mean decline of estimated glomerular filtration rate (eGFR), nor in occurrence of eGFR-events. No drug-induced liver injury could be attributed to azithromycin. Of the 39 azithromycin users of whom an ECG was available, 4/39 (10.3%) had borderline and 4/39 (10.3%) prolonged QTc-intervals, with 7/8 patients using other QTc-prolonging medication. Of the control patients 1/6 (16.7%) had a borderline QTc-interval, without using other QTc-prolonging medication. No cardiac arrhythmias were observed.Conclusion: We observed no renal or hepatic toxicity, nor cardiac arrythmias during azithromycin use in CF patients for a mean study duration of more than 5 years. One should be aware of possible QTc-interval prolongation, in particular in patients using other QTc-interval prolonging medication.

Prescribing patterns, adherence and LDL-cholesterol response of type 2 diabetes patients initiating statin on low-dose versus standard-dose treatment: a descriptive study.

AIMS: The aim of this study was to describe and compare treatment modifications and discontinuation, adherence levels and response to treatment in patients with type 2 diabetes initiating on low-dose vs. standard-dose statin treatment. METHODS: A 2-year follow-up cohort study was performed using data from the Groningen Initiative to Analyse Type 2 Diabetes Treatment (GIANTT) database in patients with type 2 diabetes initiating statin treatment between January 2007 and December 2012. First, we determined whether there were differences in treatment modifications and discontinuation after statin initiation between patients starting on a low-dose vs. standard-dose. Second, we looked at differences in adherence and LDL-cholesterol response after 2 years follow-up between these groups. RESULTS: Around 22% of patients initiated statin treatment on a dose lower than recommended. More than half of them remained on a low dose during a 2-year follow-up period, whereas less than 15% received a dose increase. Of the patients initiating on standard-dose, also more than half remained on the same treatment during this period, whereas 8% received a dose decrease without subsequent increase. Over 25% of patients starting on low-dose or standard-dose treatment discontinued treatment, often within the first 180 days after initiation or after a first treatment change. Patients on low-dose treatment had lower adherence levels and were less likely to have adequate LDL-cholesterol response compared with patients on standard-dose after 2 years follow-up. CONCLUSIONS: Current patterns of statin treatment in patients with type 2 diabetes are suboptimal, with discontinuation, inadequate adherence levels and lack of treatment intensification seen in those who had inadequate LDL-cholesterol response after 2 years of follow-up. Patients starting on low-dose had more treatment modifications, discontinuation and adherence problems as compared with those starting on standard-dose treatment, which calls for a closer look at the rationale of starting patients on low-dose statin treatment.

Predictors of response in initial users of metformin and sulphonylurea derivatives: a systematic review.

AIM: To provide an overview of factors predicting metformin and sulphonylurea treatment response. BACKGROUND: A large variability between individuals in treatment response to metformin and sulphonylurea derivatives exists. Understanding which factors determine response to these drugs may pave the way for more individualized therapy. METHODS: We conducted a systematic search in the MEDLINE, Cochrane and EMBASE databases, between 2003 and 2012 for articles assessing demographic and clinical prediction factors of treatment response in initial users of metformin or sulphonylurea. A literature search of articles referenced within the studies identified was also performed. Treatment response was defined as change in HbA1c level, reaching target HbA1c levels or time to treatment change. Studies were assessed on quality, sample size and type of analysis. Results were summarized by tabulating positive, null and negative associations observed for included predictors. RESULTS: A total of 10 articles (six trial reports and four cohort studies) were obtained, including three of sufficient quality. For metformin, baseline HbA1c , older age, lower BMI and shorter disease duration were found to be predictors of better treatment response in at least three studies of sufficient quality. For sulphonylurea derivatives, baseline HbA1c and shorter duration were identified as predictors of better treatment response in at least two studies of sufficient quality. Race, smoking status, lipid levels, blood pressure, kidney function and comorbidities were not significantly associated with treatment response. CONCLUSIONS: Several demographic and clinical factors were identified as possible predictors of response to metformin and sulphonylurea, but the number of studies with sufficient quality was small. Generally, early treatment seems important for achieving better glycaemic outcomes.

Routine screening for Coxiella burnetii infection during pregnancy: a clustered randomised controlled trial during an outbreak, the Netherlands, 2010.

Between 2007 and 2010, the Netherlands experienced one of the largest outbreaks of Q fever. Since asymptomatic Coxiella burnetii infection has been associated with maternal and obstetric complications, evidence about the effectiveness of routine screening during pregnancy in outbreak areas is needed. We performed a clustered randomised controlled trial during the Dutch outbreak, in which 55 midwife centres were randomised to recruit pregnant women for an intervention or control strategy. In both groups a serum sample was taken between 20 and 32 weeks of gestation. In the intervention group (n=536), the samples were analysed immediately by indirect immunofluorescence assay for the presence of IgM and IgG (phase I/II) and treatment was given during pregnancy in case of an acute or chronic infection. In the control group (n=693), sera were frozen for analysis after delivery. In both groups 15% were seropositive. In the intervention group 2.2% of the women were seropositive and had an obstetric complication, compared with 1.4% in the control group (Odds ratio: 1.54 (95% confidence interval 0.60-3.96)). During a large Q fever outbreak, routine C. burnetii screening starting at 20 weeks of gestation was not associated with a relevant reduction in obstetric complications and should therefore not be recommended.

Screening for Coxiella burnetii infection during pregnancy: pros and cons according to the Wilson and Jungner criteria.

In Europe the incidence of human Q fever has dramatically increased over the previous years. Untreated infections with Coxiella burnetii, the causal agent of Q fever, have been associated with both obstetric and maternal complications. The majority of pregnant women with a C. burnetii infection remain asymptomatic, hence screening could be of value to prevent unwanted outcomes in this high-risk group. We applied the updated Wilson and Jungner criteria to review the evidence for routine screening for C. burnetii infection during pregnancy. Since much uncertainty remains about the incidence, clinical consequences, diagnostics and treatment of C. burnetii infection during pregnancy, routine screening for C. burnetii infection during pregnancy should not be recommended. Rigorous studies to assess the effectiveness of C. burnetii screening are warranted.

Incidence and antibiotic prescription rates for common infections in patients with diabetes in primary care over the years 1995 to 2003.

OBJECTIVE: To assess changes in incidence and in antibiotic prescription rates for infections of the lower respiratory tract (LRTI) and urinary tract (UTI) in patients with diabetes (DM) over the years 1995 to 2003. METHODS: This was a retrospective cohort study as part of the University Medical Center Utrecht General Practitioners Research Network. We included patients with DM aged > or = 45 years. We assessed incidence and antibiotic prescription rates for LRTI and UTI. Incidence rates were calculated as episodes per 1000 person-years. Antibiotic prescription rates were calculated per 100 episodes of LRTI and UTI. RESULTS: The study population increased over the years 1995 to 2003. The male-to-female ratio and mean age of the study population remained constant over these years. The incidence rate for LRTI remained stable (13%; p=0.442), and for UTI the incidence rate increased by 40% (p=0.037). Antibiotic prescription rates increased in LRTI by 60% (p<0.001) and in cystitis by 15% (p=0.029). CONCLUSIONS: Incidence rates for UTI and antibiotic prescription rates for LRTI in diabetes have increased over the years 1995 to 2003. In particular, attention should be paid to the increasing use of antibiotics in DM patients with LRTI.

Quantifying the potential role of unmeasured confounders: the example of influenza vaccination.

BACKGROUND: The validity of non-randomized studies using healthcare databases is often challenged because they lack information on potentially important confounders, such as functional health status and socioeconomic status. In a study quantifying the effects of influenza vaccination among community-dwelling elderly we assessed whether additional information on not routinely available covariates was indeed associated with exposure to influenza vaccination and could, therefore, have led to residual confounding in healthcare databases. METHODS: We randomly selected 500 persons aged 65 years and older from the computerized Utrecht General Practitioner database. Information on exposure status and on demographics, co-morbidity status, prior healthcare use and medication use was extracted from the database. A questionnaire was used to obtain additional information on not routinely available risk factors [e.g. functional health status (SF-20), smoking status and alcohol consumption]. Missing data from the questionnaire was imputed and multivariable logistic regression analysis was applied to quantify the influence of covariates on the prediction of exposure to influenza vaccination. Within an existing dataset the potential impact of functional health status on the relation between influenza vaccination and mortality was simulated. RESULTS: We obtained questionnaire data from 365 of 500 (73%) subjects. The model including routinely available data from the database appeared accurate in predicting exposure to influenza vaccination (c-statistic 0.86, 95% CI: 0.82-0.89). Functional health status was the only additional characteristic measured with the questionnaire that was not similar in vaccinated and unvaccinated subjects. However, extending the multivariable regression model with functional health status did not significantly improve the prediction of exposure to influenza vaccination, nor did it affect the relation between influenza vaccination and mortality. CONCLUSION: The potential for unmeasured confounding on the association between influenza vaccination and health outcomes as quantified in healthcare databases seems small for non-randomized intervention studies within extensive and reliable databases.

No intention to comply with influenza and pneumococcal vaccination: behavioural determinants among smokers and non-smokers.

OBJECTIVE: Smoking increases the risk for influenza and pneumococcal disease, but vaccination uptake is lower among smokers than non-smokers. We therefore aimed to determine reasons for not complying with vaccination among smokers and non-smokers. METHOD: In 2005 a self-administered questionnaire was sent to a random sample of Dutch patients (n=4,000) assessing medical, social and behavioural determinants. Independent factors associated with not complying with influenza and pneumococcal vaccination among smokers and non-smokers were assessed by multivariate logistic regression analysis. RESULTS: In all, 1,725 of 4,000 patients returned the questionnaire (response rate: 43%), 426 (25%) were smokers. Among smokers self-reported flu vaccine uptake was 42% and among non-smokers 52% among both only 0,2% received both vaccines. Most important predictors of not complying in smokers and non-smokers were patient's beliefs not to be susceptible to disease (odds ratio (OR) 4.0, 95% confidence interval (CI): 2.0, 8.0 and OR 2.8, CI: 2.0, 3.9), finding it difficult to go to the GP for vaccination (OR 2.5, CI: 1.3, 4.8 and OR 1.8, CI: 1.3, 2.6) and being against vaccination (OR 2.4 CI: 1.3, 4.4 and OR 1.8, CI: 1.3, 2.6), respectively. CONCLUSION: There are no substantial differences in determinants associated with not complying with influenza and pneumococcal vaccination between smokers and non-smokers but there is a trend towards stronger associations in smokers.

Application of guidelines on preoperative antibiotic prophylaxis in León, Nicaragua.

BACKGROUND: To determine adherence to the guideline for preoperative antibiotic use in Nicaragua. METHODS: An observational study in the University Hospital of León, Nicaragua. All surgical patients in the departments of general surgery, orthopaedics, gynaecology and obstetrics, and paediatrics during a four-week period were included. Patients with infections prior to surgery were excluded. Main outcome measures were the proportion of patients that received appropriate preoperative antibiotics based on wound classification, suspected pathogens, administered antibiotics (type and dose), therapy duration and timing according to the local protocol. RESULTS: In the study, 297 patients received a total of 395 antibiotics with 2595 doses for a total of 1087 days. Only 68% of patients received antibiotic prophylaxis for indications mentioned in the protocol. Antibiotics were given without indication or as treatment in 23%. In 9% of the cases no preoperative antibiotic therapy was given (no indication for 6%, but indicated for 3%). Of the 201 patients with an indication for prophylaxis, 25% received more antibiotic therapies than indicated. Antibiotic choice was discordant with the protocol in 69%, dose in 20%, and both the moment of administration and duration in 78%. Overall adherence was achieved in 7% of patients. Complete protocol violations were observed in 12%. The 243 patients in the prophylaxis group received 1707 doses, 83% of which were administered unnecessarily. CONCLUSION: Protocol violations are frequent in preoperative antibiotic prophylaxis in Nicaragua leading to considerable overprescription. Educational strategies to reinforce protocolised antibiotic use are essential for reducing costs and antibiotic resistance rates.

Resistance of uropathogens in symptomatic urinary tract infections in León, Nicaragua.

Management of urinary tract infections (UTI) in Central America and especially Nicaragua, is complicated by the lack of knowledge about the antibiotic resistance of uropathogens. We conducted a prevalence study to gain more insight into the aetiology, bacterial resistance and risk factors for symptomatic UTI in the region of León, Nicaragua. In 2002, all consecutive patients with UTI symptoms and pyuria >/=10 WBC/hpf were admitted to the study. Positive cultures from midstream urine specimens were defined as >/=10(5) cfu/ml of a single uropathogen. Susceptibility tests were performed with disc diffusion tests using the Kirby-Bauer method and broth microdilution using National Committee for Clinical Laboratory Standards criteria both in León and a reference laboratory in Utrecht. A positive culture was present in 62 of 208 study subjects (30%). Escherichia coli (56%), Klebsiella spp. (18%) and Enterobacter spp. (11%) were the most frequent pathogens isolated. Presence of cystocele, incontinence and increasing age were risk factors for bacterial UTI. E. coli was least resistant to ceftriaxone, amikacin and nitrofurantoin (>90% susceptible). We observed high resistance rates in E. coli to amoxicillin (82%, MIC(90) 128 mg/l), trimethoprim-sulphamethoxazole (TMP-SMX) (64%, MIC(90) 32 mg/l), cephalothin (58%, MIC(90), 32 mg/l), ciprofloxacin (30%; MIC(90), 32 mg/l), amoxicillin/clavulanate (21%, MIC(90) 8 mg/l) and gentamicin (12%, MIC(90) 2 mg/l). Our results suggests that community acquired uropathogens in Nicaragua are highly resistant to many antimicrobial agents. The use of amoxicillin, trimethoprim-sulphamethoxazole and cephalothin against uropathogens needs to be reconsidered. High quinolone resistance rates among E. coli in Nicaragua gives cause for great concern.

Effect of pentoxifylline on nitrogen balance and 3-methylhistidine excretion in parenterally fed endotoxemic rats.

Pentoxifylline interrupts early gene activation for tumor necrosis factor, interleukin-1, and interleukin-6 production and improves survival from experimental sepsis. These effects can alter nitrogen loss during critical illness. To determine the dose-dependent influence of pentoxifylline on nitrogen loss, 44 male Sprague-Dawley rats (220 to 265 g) were randomized to receive parenteral nutrition only (PN), PN plus continuous infusion of Escherichia coli 026:B6 lipopolysaccharide (LPS) at 9 mg x kg(-1) x d(-1), or PN plus LPS plus a continuous infusion of pentoxifylline at either 25 (PEN25) or 100 mg x kg(-1) x d(-1) (PEN100) for 48 h. Before randomization, all animals underwent intravenous cannulation and 40 h of PN adaptation. All animals received isocaloric, isonitrogenous PN (160 kcal x kg(-1) x d(-1) and 1.0 gN x kg(-1) x d(-1)) and were kept nil per os except for water ad libitum. Administration of LPS significantly worsened nitrogen balance for all three groups compared with PN control; however, pentoxifylline only modestly improved nitrogen balance compared with LPS (206 +/- 255, -497 +/- 331, -332 +/- 329, and -310 +/- 383 mg/48hr for the PN, LPS, PEN25, and PEN100 groups, respectively; P < 0.001). Pentoxifylline did not significantly change 3-methylhistidine urinary excretion compared with LPS (573 +/- 180, 705 +/- 156, 780 +/- 326, and 683 +/- 266 microg/48 h for the PN, LPS, PEN25, and PEN100 groups, respectively, P not significant). Pentoxifylline, given in therapeutic doses after an endotoxin challenge, modestly, but not significantly, improved nitrogen balance. Urinary 3-methylhistidine excretion was not influenced by pentoxifylline. A dose-dependent effect by pentoxifylline on these markers was not evident.

Prognostic factors for influenza-associated hospitalization and death during an epidemic.

To predict which patients with current high-risk disease in the community may benefit most from additional preventive or therapeutic measures for influenza, we determined prognostic factors for influenza-associated hospitalization and death in a general practice-based case-control study among this segment of the vaccine target population with high influenza vaccination rates. In 103 general practices followed during the 1996/7 influenza epidemic, cases were either hospitalized, or died due to influenza, bronchitis, pneumonia, diabetes, heart failure or myocardial infarction. Age- and gender-matched controls were randomly sampled from the remaining cohort. Information was collected by review of patient records. In total, 119 cases and 196 matched controls were included. Of the cases, 34, 25 and 4% were hospitalized for acute pulmonary and cardiac disease and diabetes, respectively, and 37% died. Multivariate conditional logistic regression analysis revealed that presence of chronic obstructive pulmonary disease, heart failure, previous hospitalization, high GP visiting rate and polypharmacy were independent prognostic factors. Several non-modifiable determinants can be used to ensure targeting additional preventive or therapeutic measures at the most vulnerable segment of the vaccine target group.

Adherence to guidelines on cervical cancer screening in general practice: programme elements of successful implementation.

BACKGROUND: There is still only limited understanding of whether and why interventions to facilitate the implementation of guidelines for improving primary care are successful. It is therefore important to look inside the 'black box' of the intervention, to ascertain which elements work well or less well. AIM: To assess the associations of key elements of a nationwide multifaceted prevention programme with the successful implementation of cervical screening guidelines in general practice. DESIGN OF STUDY: A nationwide prospective cohort study. SETTING: A random sample of one-third of all 4,758 general practices in The Netherlands (n = 1,586). METHOD: General practitioners (GPs) in The Netherlands were exposed to a two-and-a-half-year nationwide multifaceted prevention programme to improve the adherence to national guidelines for cervical cancer screening. Adherence to guidelines at baseline and after the intervention and actual exposure to programme elements were assessed in the sample using self-administered questionnaires. RESULTS: Both baseline and post-measurement questionnaires were returned by 988 practices (response rate = 62%). No major differences in baseline practice characteristics between study population, non-responders, and all Netherlands practices were observed. After the intervention all practices improved markedly (P<0.001) in their incorporation of nine out of 10 guideline indicators for effective cervical screening into practice. The most important elements for successful implementation were: specific software modules (odds ratios and 95% confidence intervalsfor all nine indicators ranged from OR = 1.85 [95% CI = 1.24-2.77] to OR = 10.2 [95% CI = 7.58-14.1]); two or more 'practice visits' by outreach visitors (ORs and 95% CIs for six indicators ranged from OR = 1.46 [95% CI= 1.01-2.12] to OR = 2.35 [95% CI = 1.63-3.38]); and an educational programme for practice assistants (ORs and 95% CIs for four indicators ranged from OR = 1.57 [95% CI = 1.00-1.92] to OR = 1.90 [95% CI = 1.25-2.88]). CONCLUSION: A multifaceted programme targeting GPs, including facilitating software modules, outreach visits, and educational sessions for PAs, contributes to the successful implementation of national guidelines for cervical screening.

Effectiveness of a co-ordinated nation-wide programme to improve influenza immunisation rates in The Netherlands.

OBJECTIVE: To assess t he effectiveness of a nation-widemultifaceted intervention programme involving general practitioners (GPs) on influenza immunisation practice. DESIGN: Pragmatic before-after trial using pre- and post-measurement questionnaires. SETTING AND SUBJECTS: Random sample of Dutch general practices. INTERVENTION: During a 2.5-year period (1995-1997) a variety of methods was implemented to enhance physician adoption of the immunisation guideline, including employment of facilitators, information-based methods, small-group consensus meetings, individual instructions and introduction of supportive computer software. MAIN OUTCOME MEASURES: Influenza immunisation practice and influenza vaccine uptake. RESULTS: In 988 practices all influenza vaccination characteristics markedly improved from 1995 to 1997. The most significant changes were found in computerised marking of high-risk patients (from 54% to 82% of practices), computerised selection (41% to 77%) and sending personal reminders (40% to 77%). Vaccine uptake increased from 9% to 16% of the practice population (78% increase, p < 0.001). Uptake was most prominent in urban and single-handed practices and in those with more patients insured through the National Health Service, low GP workload and low baseline uptake. CONCLUSION: Our data suggest that a co-ordinated approach involving primary care physicians can succeed in enlarging the public health impact of a population-based preventive measure.

Chromium and zinc concentrations in pediatric patients receiving long-term parenteral nutrition.

Serum, urine, and parenteral nutrition (PN) chromium and zinc concentrations in pediatric patients receiving long-term PN were studied. Serum, urine, and PN chromium and zinc concentrations were measured at baseline and four to six months later in four infants (less than 1 year old) and seven children (1-12 years old) receiving long-term PN. In the children, serum, urine, and PN solution zinc concentrations were measured monthly after the amino acid product was changed from a standard to a pediatric product with monthly dosages of 0, 20, 30, and 40 mg of cysteine hydrochloride per gram of amino acids. The mean +/- S.D. baseline serum chromium concentration was 4.9+/-1.9 microg/L (normal value, <0.3 microg/L); the urine chromium concentration ranged from 3.4 to 32.2 microg/L. The mean +/- S.D. prescribed chromium dosage was 0.18+/-0.05 microg/kg/day, and the dosage delivered in PN solutions was 0.41+/-0.23 microg/ kg/day. At baseline, the mean +/- S.D. serum zinc concentration was 1383+/-472 microg/L (normal range, 430 to 940 microg/L), and the prescribed and delivered zinc dosages were 177+/-10 and 238+/-145 microg/kg/ day, respectively. With 20, 30, and 40 mg of cysteine per gram of amino acids, the mean +/- S.D. serum zinc concentration was 1728+/-782, 1664+/-349, and 1685+/-268 microg/L, respectively, and the actual zinc dosages delivered were 209+/-10, 270+/-148, and 322+/-194 microg/kg/day, respectively. Serum and urine chromium concentrations were abnormally high in infants and children receiving PN solutions supplemented with normal doses of these trace elements; an escalating dosage of cysteine in the children tended to increase serum and urine zinc concentrations.

Improving population-based cervical cancer screening in general practice: effects of a national strategy.

OBJECTIVE: To assess the effects of a Dutch national prevention programme, aimed at general practitioners (GPs), on the adherence to organizational guidelines for effective cervical cancer screening in general practice. To identify the characteristics of general practices determining success. DESIGN: A prospective questionnaire study with pre- and post-measurement (before and 15 months after the introduction of the national programme). SETTING AND STUDY PARTICIPANTS: A random sample of one-third of all 4758 Dutch general practices. One GP was asked to participate per practice. INTERVENTION: A national GP prevention programme to improve population-based prevention of cervical cancer combining various methods for quality improvement in general practice, performed on a national, district and practice level. Outreach visitors were a key strategy in bringing about behavioural changes. MAIN OUTCOME MEASURES: The proportion of practices adhering to 10 recommendations (in four guidelines) to organize effective cervical cancer screening. RESULTS: After 15 months, all Dutch practices showed significant improvement in adherence to nine out of 10 recommendations. Two recommendations, in particular 'identifying women who should be medically excluded from screening' and 'sending a reminder to non-compliers' showed the largest absolute increases of 26% and 33%, respectively. Besides more intensive support of outreach visitors, practice characteristics such as 'computerization' and 'delegation of many clinical tasks to the practice assistant' were important in improving the adherence to guidelines. CONCLUSION: The national programme, with a combination of various methods for quality improvement, appeared to be effective in improving the organization of cervical screening in general practice. Computerization and, to a lesser extent, delegation of many clinical tasks to the practice assistant and more intensive support to practices, positively influenced the effectiveness of the national programme.

Cysteine supplementation results in normalization of plasma taurine concentrations in children receiving home parenteral nutrition.

We evaluated plasma sulfur amino acid concentrations in children with short gut syndrome receiving home parenteral nutrition (n = 6). Cysteine HCl addition to solutions formulated with a pediatric amino acid product will increase plasma taurine concentrations to within the normal reference range.

Complications of standard elective abdominal aortic aneurysm repair.

OBJECTIVE: To evaluate complications of standard elective repair of infrarenal abdominal aortic aneurysms. DESIGN: Prospective multicentre study. MATERIALS: Two-hundred and ninety-one consecutive patients undergoing standard elective surgery for an infrarenal aortic aneurysm. METHODS: Recording adverse events according to the recommendations of the Ad Hoc Committee on Reporting Standards. RESULTS: Seventy-five patients (26%) experienced some complication following elective aortic aneurysm surgery. Twenty-two patients had a mild complication (7.6%, 95% C.I. 4.8-11.2%), 27 a moderate (9.3%, 95% C.I. 6.2-13.2%) and 26 patients had a severe and/or fatal complication (8.9%, 95% C.I. 5.9-12.8%). The in-hospital mortality was 4.1% (12 patients, 95% C.I. 2.2-7.1%). Cardiac failure was the commonest primary cause for death (58%). Twenty-two per cent of the patients had a non-fatal complication: the most frequent being pulmonary (10%) and cardiac (10%). Patients with a history of cardiac events had a five times higher risk of a fatal outcome (95% C.I. 1.1-24.0) and a two and a half times higher risk of any severe fatal or non-fatal complication (95% C.I. 1.0-6.5). Other risk factors were advancing age and the presence of pulmonary disease. CONCLUSIONS: In addition to mortality, morbidity figures of standard aneurysm operations are important, as well as associated risk factors. This is especially true when evaluating early repair of small aneurysms and new endovascular techniques.

Results of aortic screening in the brothers of patients who had elective aortic aneurysm repair.

BACKGROUND: Brothers of patients with an abdominal aortic aneurysm (AAA) are at high risk. In the present study brothers of patients who underwent elective AAA surgery were invited for aneurysm screening and the psychological consequences studied. METHODS: All brothers over the age of 50 years were invited for abdominal ultrasonography. They were asked to complete a standard psychological well-being questionnaire both before, and 3 months after screening. RESULTS: Some 571 brothers were identified: 251 were dead, 35 lived abroad, 16 could not be contacted for other reasons, 46 refused to participate and 13 were already known to have an AAA. Some 210 subjects (37.8 per cent) accepted the offer of screening. A new AAA was detected in 26 (12.3 per cent, 95 per cent confidence interval 8-18 per cent) of the men screened resulting in an overall prevalence of 18 per cent (95 per cent confidence interval 13-26 per cent). Eight (3.8 per cent) aneurysms were 5 cm or more in diameter and elective surgery was performed in five patients (2.4 per cent). The psychological dimensions of well-being (depression, anxiety, energy, and positive well-being) had not changed significantly 3 months after screening. CONCLUSION: The prevalence of AAA in brothers of patients with AAA is far higher than in the overall male population of the same age. Screening does not seem to have a negative influence on psychological well-being.