Perception of enhanced learning in medicine through integrating of virtual patients: an exploratory study on knowledge acquisition and transfer.

INTRODUCTION: Virtual Patients (VPs) have been shown to improve various aspects of medical learning, however, research has scarcely delved into the specific factors that facilitate the knowledge gain and transfer of knowledge from the classroom to real-world applications. This exploratory study aims to understand the impact of integrating VPs into classroom learning on students' perceptions of knowledge acquisition and transfer. METHODS: The study was integrated into an elective course on "Personalized Medicine in Cancer Treatment and Care," employing a qualitative and quantitative approach. Twenty-two second-year medical undergraduates engaged in a VP session, which included role modeling, practice with various authentic cases, group discussion on feedback, and a plenary session. Student perceptions of their learning were measured through surveys and focus group interviews and analyzed using descriptive statistics and thematic analysis. RESULTS: Quantitative data shows that students highly valued the role modeling introduction, scoring it 4.42 out of 5, and acknowledged the practice with VPs in enhancing their subject matter understanding, with an average score of 4.0 out of 5. However, students' reflections on peer dialogue on feedback received mixed reviews, averaging a score of 3.24 out of 5. Qualitative analysis (of focus-group interviews) unearthed the following four themes: 'Which steps to take in clinical reasoning', 'Challenging their reasoning to enhance deeper understanding', 'Transfer of knowledge ', and ' Enhance Reasoning through Reflections'. Quantitative and qualitative data are cohered. CONCLUSION: The study demonstrates evidence for the improvement of learning by incorporating VPs with learning activities. This integration enhances students' perceptions of knowledge acquisition and transfer, thereby potentially elevating students' preparedness for real-world clinical settings. Key facets like expert role modeling and various authentic case exposures were valued for fostering a deeper understanding and active engagement, though with some mixed responses towards peer feedback discussions. While the preliminary findings are encouraging, the necessity for further research to refine feedback mechanisms and explore a broader spectrum of medical disciplines with larger sample sizes is underscored. This exploration lays a groundwork for future endeavors aimed at optimizing VP-based learning experiences in medical education.

The awareness, visibility and support for young carers across Europe: a Delphi study.

BACKGROUND: Across Europe, young carers (YCs) and their need for support receive limited attention in the media, policy and empirical research, even though, similar to adult carers, they also provide care to ill family members. The Delphi study, a qualitative research methodology, which provides the focus for this article, had the overall aim of exploring existing successful strategies to support YCs. Compared to YCs, even less is known about adolescent young carers (AYCs), a group that is in a critical life transition phase. The study forms part of an EU Horizon 2020 funded research project on AYCs aged 15-17 years old. METHODS: A two-round Delphi study was conducted with 66 experts on YCs from 10 European countries. Topics included: (i) visibility and awareness-raising of YCs at local, regional, and national levels, (ii) current interventions to support YCs, and (iii) future strategies to support YCs. RESULTS: Experts reported a lack of visibility and awareness about YCs in general, and AYCs in particular. Although awareness is slowly increasing in most countries, with the UK ranked highest, experts acknowledged that it remains challenging to identify YCs in many countries. Furthermore, the level and type of support available for YCs differs, with most countries mainly offering support on a local level. Diverse views were expressed regarding future strategies to support YCs. Experts highlighted the importance of specific legislation to formalise the rights of YCs, and the issue of whether young people should be safeguarded from caregiving or if this should be considered part of regular family life. They also emphasised the relevance of available integrated support services for YCs, including schools, family, health and social care. CONCLUSIONS: In most European countries, there is a lack of awareness and visibility on YCs. Identification of YCs is a crucial first step and there is need for a common definition of YCs, together with greater opportunities for young adults to identify themselves as YCs.

Exploring Perceptions and Practices of Interprofessional Shared Decision-Making Education in Palliative Care Settings.

Background: Palliative care teams provide support to patients and their caregivers during terminal illness, which requires interprofessional collaboration. One of the foundational skills is to assist patients with decision-making. This can be facilitated through interprofessional shared decision-making (IP-SDM). So far, IP-SDM education frameworks have only been used to a limited extent in the area of palliative care. Aim: This study aims to explore perceptions and practices of faculty members, health professionals, and students toward IP-SDM education in palliative care and to indicate associated factors to implement an IP-SDM in undergraduate health professions education in palliative care settings. Methods: We used a cross-sectional study design in which the data was obtained via an online self-administered questionnaire adapted from existing validated tools. The questionnaire was distributed to faculty members and health professionals (n = 125) and students (n = 334) at King Abdulaziz Medical City in Jeddah, Saudi Arabia. The sampling technique was a non-probability convenience sampling. Bivariate statistics, such as independent sample t-tests, one-way ANOVA, correlation coefficient, and linear multiple regression were conducted. Findings: The response rate was 54% (85 faculty members and health professionals and 164 students). Perceptions on IP-SDM did not differ between participants. From those who had previous experience with IP-SDM, the mean practices score was slightly higher for faculty members and health professionals (M = 83.1, SD = 15.9) than for students (M = 74.1, SD = 11.5), which was significant (p < 0.05). Factors such as gender, age, discipline, nationality, level of education, years of study, and previous experience that were associated with perceptions and practices were varied among participants. Conclusion: The findings show high levels of perception with low levels of practice of IP-SDM in palliative care. Other factors that could be associated with the topic should be addressed in further studies.

A Qualitative Study of Stakeholders' Perspectives of Implementing Interprofessional Shared Decision-Making Education in Palliative Care.

Introduction Shared decision-making (SDM) in palliative care is a highly complex process that requires an interdisciplinary team. Interprofessional team members need education on how to facilitate discussion of patient/family wishes at the end of life in hospital settings. So far, interprofessional shared decision-making (IP-SDM) education frameworks have been used to a limited extent in the area of education on palliative care. The aim of this study was to explore policymakers', health professionals', faculty members', and students' perspectives on implementing an IP-SDM educational framework in palliative care to identify aspects that should be prioritized to further develop interprofessional education for SDM in palliative care. Methods We used the qualitative method to capture the micro, meso, and macro factors using Oandasan and Reeves' model for the implementation of IP-SDM education regarding palliative care. Data collection tools included in-depth, face-to-face interviews with individual policymakers and focus group interviews with health professionals, faculty members, and undergraduate health professionals. The interview guide explores the teaching of SDM in palliative care, factors that could facilitate or hinder the implementation of IP-SDM education for health professions students in palliative care, and interventions to facilitate the implementation of this approach. This study was conducted at the Oncology and Palliative Care Department at King Abdulaziz Medical City in the Ministry of National Guard Health Affairs and at King Saud bin Abdulaziz University for Health Sciences in Jeddah, Saudi Arabia. Results The results indicated a high demand for IP-SDM in palliative care. The findings revealed factors that can facilitate or hinder the implementation of IP-SDM education in palliative care for undergraduate health professions students that is going to the local community. Factors include culture, religion, gender, power issues, team hierarchy, and respect among team members. Also, our findings have revealed potential solutions to the hindering factors. Conclusions IP-SDM education in palliative care is a highly relevant topic for improving patient outcomes. However, it might be a complex process to implement, especially given the challenges of palliative care settings. We recommend starting such a course in the early clinical phases of undergraduate health professional education.

Recruitment of Adolescent Young Carers to a Psychosocial Support Intervention Study in Six European Countries: Lessons Learned from the ME-WE Project.

Young carers provide a substantial amount of care to family members and support to friends, yet their situation has not been actively addressed in research and policy in many European countries or indeed globally. Awareness of their situation by professionals and among children and young carers themselves remains low overall. Thus, young carers remain a largely hidden group within society. This study reports and analyses the recruitment process in a multi-centre intervention study offering psychosocial support to adolescent young carers (AYCs) aged 15-17 years. A cluster-randomised controlled trial was designed, with recruitment taking place in Italy, the Netherlands, Slovenia, Sweden, Switzerland and the United Kingdom exploiting various channels, including partnerships with schools, health and social services and carers organisations. In total, 478 AYCs were recruited and, after screening failures, withdrawals and initial dropouts, 217 were enrolled and started the intervention. Challenges encountered in reaching, recruiting and retaining AYCs included low levels of awareness among AYCs, a low willingness to participate in study activities, uncertainty about the prevalence of AYCs, a limited school capacity to support the recruitment; COVID-19 spreading in 2020-2021 and related restrictions. Based on this experience, recommendations are put forward for how to better engage AYCs in research.

[A child with a bald spot on her scalp]. / Een baby met een kale plek op het hoofd.

A 6-month-old girl with an isolated bald spot was seen at the general practice. We diagnosed aplasia cutis congenita, a rare disorder with a wide variation in clinical symptoms. Most lesions can be managed conservatively. Larger defects, however, require surgery.

Flipped Classroom Formats in a Problem-Based Learning Course: Experiences of First-Year Bachelor European Public Health Students.

Objectives: Students would like to see more creativity and flexibility in the performance of problem-based learning (PBL). Therefore, we applied flipped classroom formats in a course of the Bachelor European Public Health at Maastricht University to investigate the experiences of the students. The main objective was to stimulate interaction between students mutual, and between students and teachers. Methods: 304 first-year students following the course on "Ageing in Europe" in three academic years, were asked to fill out questions focussing on prior knowledge, preparation work, and group session parameters, e.g., duration, content, extent of interaction and format group session. Results: In-class activities, such as debate, making a mind map, giving a pitch, role-play e.g., were highly appreciated by students, especially the interactivity and discussions with the experts during these sessions. Students felt they applied knowledge. Conclusion: Flipped classroom formats can be used to extend the Maastricht University PBL design and students do recommend this. It can be a relevant and challenging answer on the articulated request for more creativity and flexibility in the regular PBL format.

Research and Innovation for and with Adolescent Young Carers to Influence Policy and Practice-The European Union Funded "ME-WE" Project.

Young carers are children and adolescents who provide care to other family members or friends, taking over responsibilities that are usually associated with adulthood. There is emerging but still scarce knowledge worldwide about the phenomenon of young carers and the impact of a caring role on their health, social and personal development spheres. This paper provides an overview of the main results from the ME-WE project, which is the first European research and innovation project dedicated to adolescent young carers (AYCs) (15-17 years). The project methods relied on three main activities: (1) a systematization of knowledge (by means of a survey to AYCs, country case studies, Delphi study, literature review); (2) the co-design, implementation and evaluation of a primary prevention intervention addressing AYCs' mental health (by means of Blended Learning Networks and a clinical trial in six European countries); (3) the implementation of knowledge translation actions for dissemination, awareness, advocacy and lobbying (by means of national and international stakeholder networks, as well as traditional and new media). Project results substantially contributed to a better understanding of AYCs' conditions, needs and preferences, defined tailored support intervention (resilient to COVID-19 related restrictions), and significant improvements in national and European policies for AYCs.

Dose-dependent cholesterol-lowering effects of phytosterol/phytostanol-enriched margarine in statin users and statin non-users under free-living conditions.

OBJECTIVE: To assess the effectiveness (extent to which an intervention works in daily medical practice) of the use of phytosterol/phytostanol-enriched margarines to lower total and non-HDL cholesterol levels in users and non-users of statins. DESIGN: Retrospective cohort study. SETTING: Data were obtained from questionnaires on health and food intake from a population-based longitudinal cohort linked to pharmacy-dispensing records. SUBJECTS: The analysis included 3829 men and women (aged 31-71 years) who were examined during 1998-2002 and re-examined at 5-year follow-up during 2003-2007. RESULTS: Recommended doses of margarines were consumed by only 9 % of the subjects. Serum total cholesterol decreased by respectively -0·16 (95 % CI -0·26, -0·05) mmol/l, -1·40 (95 % CI -1·51, -1·30) mmol/l and -1·64 (95 % CI -1·91, -1·37) mmol/l in subjects who started to use phytosterols/phytostanols only, statins only or a combination of both compounds at some point in time between examination and re-examination, compared with subjects who did not start using phytosterols/phytostanols or statins. Cholesterol-lowering effects of the phytosterols/phytostanols were similar in statin users and statin non-users and increased with increasing intake of enriched margarine (no intake, 0; low intake, -0·017 (95 % CI -0·16, 0·13) mmol/l; medium intake, -0·089 (95 % CI -0·22, 0·038) mmol/l; high intake, -0·32 (95 % CI -0·50, -0·14) mmol/l). CONCLUSIONS: Although recommended intake levels of the enriched margarines were not reached by all persons, these data show that under customary conditions of use phytosterols/phytostanols are effective in lowering cholesterol levels in both statin users and non-users.

Effects of the use of phytosterol/-stanol-enriched margarines on adherence to statin therapy.

PURPOSE: The use of margarines enriched with phytosterols or phytostanols is recommended as an appropriate adjunctive therapy for patients with certain lipid profiles, but may result in a behavioral modification leading to a change in person's adherence to lipid-lowering drug treatment. This study aimed to examine the influence of the use of margarines enriched with phytosterols/-stanols on adherence to statin therapy. METHODS: Retrospective data from food frequency questionnaires were used to assess phytosterol/-stanol-enriched margarine intake from a population based, longitudinal cohort between 1998 and 2007. Intake data were linked to pharmacy-dispensing records. Multivariate Cox proportional-hazards models were used to calculate hazard ratios for discontinuation of statin therapy. Drug-taking compliance was compared between users and non-users of enriched margarine using the Mann-Whitney U-test. Pre-defined subgroup analyses were performed to evaluate differences in adherence between prevalent statin users and starters of statins. RESULTS: Among 4848 subjects, 522 used statins only and 60 combined these drugs with phytosterol/-stanol-enriched margarine. Overall statin discontinuation rates were not significantly different between the users and non-users of enriched margarine, but more combination users discontinued statin therapy within 12 months in the subgroup of starters (HR(adj) : 2.52 [95%CI: 1.06-6.00]). Drug-taking compliance was high in both users and non-users of enriched margarine and was slightly lower in combination users (P<0.10). CONCLUSIONS: These results imply that persons who combine enriched margarines with statins may neglect taking their drug according to the prescription. Further investigations in larger populations are important, especially among patients susceptible to a low adherence to drug therapy.

A tiered approach for risk-benefit assessment of foods.

Risk-benefit analyses are introduced as a new paradigm for old problems. However, in many cases it is not always necessary to perform a full comprehensive and expensive quantitative risk-benefit assessment to solve the problem, nor is it always possible, given the lack of required date. The choice to continue from a more qualitative to a full quantitative risk-benefit assessment can be made using a tiered approach. In this article, this tiered approach for risk-benefit assessment will be addressed using a decision tree. The tiered approach described uses the same four steps as the risk assessment paradigm: hazard and benefit identification, hazard and benefit characterization, exposure assessment, and risk-benefit characterization, albeit in a different order. For the purpose of this approach, the exposure assessment has been moved upward and the dose-response modeling (part of hazard and benefit characterization) is moved to a later stage. The decision tree includes several stop moments, depending on the situation where the gathered information is sufficient to answer the initial risk-benefit question. The approach has been tested for two food ingredients. The decision tree presented in this article is useful to assist on a case-by-case basis a risk-benefit assessor and policymaker in making informed choices when to stop or continue with a risk-benefit assessment.

[Respiratory complaints in the time of COVID-19]. / Luchtwegklachten in tijden van corona.

The current guidelines for diagnosis and treatment of primary respiratory infections are still useful during the COVID-19 epidemic.Telephone triage of patients with respiratory complaints aims to identify patients with complications or an increased risk of complications.There are no indications to test for SARS-CoV-2 virus in general practice.During this COVID-19 epidemic, protective clothing is recommended in all physical contacts with patients with respiratory complaints.There is no reason to be cautious about using NSAIDs in patients suspected of COVID-19.Amoxicillin is first choice treatment for respiratory infections during the COVID-19 epidemic; there is lack of evidence to support azithromycin as a first choice.Respiratory rate > 24 / min or saturation <92-94% indicate imminent respiratory decompensation and may be reasons for referral.

Coping with paediatric illness: Child's play? Exploring the effectiveness of a play- and sports-based cognitive behavioural programme for children with chronic health conditions.

Little is known about how play affects the development of children with a chronic condition. Studying play poses major methodological challenges in measuring differences in play behaviour, which results in a relative scarcity of research on this subject. This pilot study seeks to provide novel directions for research in this area. The effectiveness of a play- and sports-based cognitive behavioural programme for children (8-12 years) with a chronic condition was studied. The children and parents completed a battery of measurement tools before and after the programme. Moreover, the application of automated computer analyses of behaviour was piloted. Behaviour (Child Behavior Checklist) seemed to be positively affected by the programme. An increase in psychological well-being was observed (KIDSCREEN). Perceived competence (Self-Perception Profile for Children) and actual motor competence (Canadian Agility and Movement Skill Assessment) did not show any positive trends. These results of 13 participants suggest that children might learn to better cope with their illness by stimulating play behaviour. For the analysis of the effectiveness of programmes like this, we therefore propose to focus on measuring behaviour and quality of life. In addition, pilot measurements showed that automated analysis of play can provide important insights into the participation of children.

Dairy intake, blood pressure, and incident hypertension in a general Dutch population.

Diet and lifestyle are important for maintaining a healthy blood pressure (BP). The role of dairy in the prevention of hypertension, however, is not yet clear. We studied the relation of dairy intake with BP in 21,553 Dutch participants aged 20-65 y who did not use antihypertensive medication. In addition, the risk of hypertension was examined in 3454 of these participants with a 5-y follow-up. Dairy consumption was assessed at baseline (1993-1997) using a semiquantitative FFQ that included 178 foods and beverages. Baseline BP and odds ratios (OR) (95% CI) for incident hypertension were calculated in categories of energy-adjusted dairy intake with adjustment for age, sex, socioeconomic status, BMI, smoking, alcohol use, and dietary intakes. Participants had a median intake of 344 g/d (approximately 2.3 servings) for total dairy and 174 g/d (approximately 1.2 servings) for low-fat dairy. Mean BP was 120/76 mm Hg. Intake of total dairy, specific dairy groups (i.e. low-fat, high-fat, fermented) and dairy products (i.e. cheese, yogurt) were not consistently related to BP. Of 3454 participants who were followed, 713 developed hypertension. The risk of hypertension tended to be inversely related to low-fat dairy intake, with multivariate OR (95% CI) of 1.00, 0.78 (0.61, 1.00), 0.81 (0.63, 1.03), and 0.82 (0.64, 1.06; P-trend: 0.24) in consecutive quartiles. We conclude that variations in BP in a general middle-aged Dutch population cannot be explained by overall dairy intake. A beneficial effect of low-fat dairy on risk of hypertension, however, cannot be excluded, which warrants further investigation in prospective population-based studies.

Risk factors for child sexual abuse victimization: A meta-analytic review.

Experiencing child sexual abuse (CSA) is a major public health problem with serious consequences for CSA victims. For effective assessment and (preventive) intervention, knowledge on risk factors and their effects is crucial. Here, the aim was to synthesize research on associations between (putative) risk factors and CSA victimization. In total, 765 (putative) risk factors were extracted from 72 studies, which were classified into 35 risk domains. A series of three-level meta-analyses produced a significant mean effect for 23 of the 35 risk domains ranging from r = .101 to r = .360. The strongest effects were found for prior victimization of the child and/or its family members, such as prior CSA victimization of the child and/or siblings (r = .360), prior victimization of the child other than child abuse (r = .340), prior or concurrent forms of child abuse in the child's home environment (r = .267), and a parental history of child abuse victimization (r = .265). Other identified risks were related to parental problems (e.g., intimate partner violence, r = .188), parenting problems (e.g., low quality of parent-child relation, r = .292), a non-nuclear family structure (e.g., having a stepfather, r = .118), family problems (e.g., social isolation, r = .191), child problems (e.g., having a mental/physical chronic condition, r = .193), and other child characteristics (e.g., being female, r = .290). Moderator analyses suggested that contact CSA victimization may be better predicted than noncontact CSA victimization. It was concluded that an ecological perspective on preventing CSA victimization is necessary. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Integrated risk-benefit analyses: method development with folic acid as example.

With the introduction of novel and functional foods, there is increasing need for an integrated quantitative risk-benefit assessment of foods. Consensus about a quantitative risk-benefit assessment mirroring the risk assessment approach has been reached during a recent EFSA workshop. In line, we propose a risk-benefit model that consists of: (1) hazard and benefit identification, (2) hazard and benefit characterization through dose-response functions, (3) exposure assessment, and (4) risk-benefit integration. The DALY, which combines morbidity and mortality serves as common health measure. The overall health impact of bread fortified with folic acid in the Netherlands has been simulated. The case study showed how the risk-benefit approach may assist a policy maker in decisions on food fortification programs. It illustrates general problems regarding the data demands, the assumptions and uncertainties. A simple sensitivity analysis showed which assumptions were most crucial. Modest fortification (140 microg/100 g bread) seems reasonable to improve public health but the results hinge on the assumptions one makes for the association between colorectal cancer and high folate intake. A precautious policymaker may very well decide against folic acid fortification. The often debated increase in masked vitamin B(12)-deficiency appears negligible compared to the health gain resulting from prevented neural tube defects.

2017 Dutch Report Card+: Results From the First Physical Activity Report Card Plus for Dutch Youth With a Chronic Disease or Disability.

Background: The Dutch Active Healthy Kids (AHK) Report Card+ (RC+) consolidates and translates research and assesses how the Netherlands is being responsible in providing physical activity (PA) opportunities for youth (< 18 years) with a chronic disease or disability. The aim of this article is to summarize the results of the Dutch RC+. Methods: Nine indicators were graded using the AHK Global Alliance RC development process, which includes a synthesis of best available research, surveillance, policy and practice findings, and expert consensus. Two additional indicators were included: weight status and sleep. Results: Grades assigned were: Overall Physical Activity, D; Organized Sports Participation, B-; Active Play, C-; Active Transportation, A-; Sedentary Behavior, C; Sleep C; For Weight Status, Family and Peers, School, Community and Built Environment, Government Strategies, and Investments all INC. Conclusions: The youth with disabilities spend a large part of the day sedentary, since only 26% of them met the PA norm for healthy physical activity. Potential avenues to improve overall physical activity are changing behaviors regarding sitting, screen time, and active play. The Netherlands is on track regarding PA opportunities for youth with disabilities, however they are currently not able to participate unlimited in sports and exercise.

Is blended learning and problem-based learning course design suited to develop future public health leaders? An explorative European study.

BACKGROUND: Public health leaders are confronted with complex problems, and developing effective leadership competencies is essential. The teaching of leadership is still not common in public health training programs around the world. A reconceptualization of professional training is needed and can benefit from innovative educational approaches. Our aim was to explore learners' perceptions of the effectiveness and appeal of a public health leadership course using problem-based, blended learning methods that used virtual learning environment technologies. CASE PRESENTATION: In this cross-sectional evaluative study, the Self-Assessment Instrument of Competencies for Public Health Leaders was administered before and after an online, blended-learning, problem-based (PBL) leadership course. An evaluation questionnaire was also used to measure perceptions of blended learning, problem-based learning, and tutor functioning among 19 public health professionals from The Netherlands (n = 8), Lithuania (n = 5), and Austria (n = 6).Participants showed overall satisfaction and knowledge gains related to public health leadership competencies in six of eight measured areas, especially Political Leadership and Systems Thinking. Some perceptions of blended learning and PBL varied between the institutions. This might have been caused by lack of experience of the educational approaches, differing professional backgrounds, inexperience of communicating in the online setting, and different expectations towards the course. CONCLUSIONS: Blended, problem-based learning might be an effective way to develop leadership competencies among public health professionals in international and interdisciplinary context.

[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.

Assessment of maximal handgrip strength: how many attempts are needed?

BACKGROUND: Handgrip strength (HGS) is used to identify individuals with low muscle strength (dynapenia). The influence of the number of attempts on maximal HGS is not yet known and may differ depending on age and health status. This study aimed to assess how many attempts of HGS are required to obtain maximal HGS. METHODS: Three cohorts (939 individuals) differing in age and health status were included. HGS was assessed three times and explored as continuous and dichotomous variable. Paired t-test, intraclass correlation coefficients (ICC) and Bland-Altman analysis were used to test reproducibility of HGS. The number of individuals with misclassified dynapenia at attempts 1 and 2 with respect to attempt 3 were assessed. RESULTS: Results showed the same pattern in all three cohorts. Maximal HGS at attempts 1 and 2 was higher than at attempt 3 on population level (P < 0.001 for all three cohorts). ICC values between all attempts were above 0.8, indicating moderate to high reproducibility. Bland-Altman analysis showed that 41.0 to 58.9% of individuals had the highest HGS at attempt 2 and 12.4 to 37.2% at attempt 3. The percentage of individuals with a maximal HGS above the gender-specific cut-off value at attempt 3 compared with attempts 1 and 2 ranged from 0 to 50.0%, with a higher percentage of misclassification in middle-aged and older populations. CONCLUSIONS: Maximal HGS is dependent on the number of attempts, independent of age and health status. To assess maximal HGS, at least three attempts are needed if HGS is considered to be a continuous variable. If HGS is considered as a discrete variable to assess dynapenia, two attempts are sufficient to assess dynapenia in younger populations. Misclassification should be taken into account in middle-aged and older populations.