Effectiveness of nurse-delivered cardiovascular risk management in primary care: a randomised trial.

BACKGROUND: A substantial part of cardiovascular disease prevention is delivered in primary care. Special attention should be paid to the assessment of cardiovascular risk factors. According to the Dutch guideline for cardiovascular risk management, the heavy workload of cardiovascular risk management for GPs could be shared with advanced practice nurses. AIM: To investigate the clinical effectiveness of practice nurses acting as substitutes for GPs in cardiovascular risk management after 1 year of follow-up. DESIGN OF STUDY: Prospective pragmatic randomised trial. SETTING: Primary care in the south of the Netherlands. Six centres (25 GPs, six nurses) participated. METHOD: A total of 1626 potentially eligible patients at high risk for cardiovascular disease were randomised to a practice nurse group (n = 808) or a GP group (n = 818) in 2006. In total, 701 patients were included in the trial. The Dutch guideline for cardiovascular risk management was used as the protocol, with standardised techniques for risk assessment. Changes in the following risk factors after 1 year were measured: lipids, systolic blood pressure, and body mass index. In addition, patients in the GP group received a brief questionnaire. RESULTS: A larger decrease in the mean level of risk factors was observed in the practice nurse group compared with the GP group. After controlling for confounders, only the larger decrease in total cholesterol in the practice nurse group was statistically significant (P = 0.01, two-sided). CONCLUSION: Advanced practice nurses are achieving results, equal to or better than GPs for the management of risk factors. The findings of this study support the involvement of practice nurses in cardiovascular risk management in Dutch primary care.

Sex-specific effect of the alpha-adducin (G460W) and AGTR1 (A1166C) polymorphism on carotid intima-media thickness.

OBJECTIVE: In a primary care population covering a broad spectrum of cardiovascular risk (HIPPOCRATES project) the relationship between carotid intima-media thickness (CIMT) and six cardiovascular polymorphisms were analyzed in a cross-sectional study. METHODS: CIMT was assessed in 618 participants, who were genotyped for the AGTR1 (A1166C), AGT (M235T), ACE (4656(rpt)), NOS3 (E298D), GNB3 (C825T) and ADD1 (G460W) polymorphisms. Linear regression analyses were performed to assess the relationship between CIMT and the polymorphisms. RESULTS: The study population included 289 men (46.8%) and 329 (53.2%) women of whom 52.3% were treated with cardiovascular medication. CIMT was significantly associated with age, female sex, use of cardiovascular medication, waist circumference and dyslipidemia. After correction for these covariates, multivariate linear regression analyses showed that only in women the C-allele of AGTR1 was associated with a thicker CIMT (P = 0.03). The T-allele of ADD1 was associated with a smaller CIMT in both men and women, but this only reached statistical significance in women (P = 0.03). CONCLUSION: Although the effect of both genetic variants on CIMT was small, this study showed a statistically significant effect of AGTR1 and ADD1 in women. However, our findings should be viewed as hypothesis-generating and require further confirmation in prospective epidemiological primary care studies.

The association between arterial stiffness and the angiotensin II type 1 receptor (A1166C) polymorphism is influenced by the use of cardiovascular medication.

OBJECTIVE: To examine in a population with a high prevalence of hypertension, the association between six cardiovascular polymorphisms, arterial stiffness and medication use. METHODS: In this cross-sectional study (Hypertension: Interaction and Prevalence of POlymorphisms related to Cardiovascular Risk and the Association to Treatment Efficacy Study project), arterial stiffness was assessed by measuring pulse wave velocity (PWV) in 575 patients in one primary care practice. Patients were genotyped for the angiotensin II type 1 receptor [AGTR1 (A1166C)], angiotensinogen (M235T), angiotensin-converting enzyme (4656rpt), endothelial nitric oxide synthase (E298D), G-protein beta3 (C825T), and alpha-adducin (G460W) polymorphisms. Linear regression analyses were performed to assess the association between polymorphisms and PWV. RESULTS: Thirty percent of the patients (273 men, 302 women) had a carotid-femoral pulse wave velocity above 12 m/s and more than 60% of the patients had a carotid-femoral/carotid-radial PWV (CF/CR ratio) above 1. The CF/CR ratio was significantly associated with age, sex, dislipidemia, cardiovascular medication use and pulse pressure. After correction for these covariates, multivariate linear regression analyses showed that the C allele of AGTR1 was associated with a lower CF/CR ratio. This association was significantly influenced by cardiovascular medication use (P = 0.011), and showed a dose-allele effect, the CF/CR ratio decreasing with the number of C alleles (P = 0.04). CONCLUSION: In a primary care population, this study showed an independent protective dose-allele effect for the presence of C alleles of the AGTR1 polymorphism on PWV. This association, which was influenced by the use of cardiovascular medication, needs further investigations to identify the underlying mechanisms.

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.

Inflammatory Bowel Disease in South Limburg (the Netherlands) 1991-2002: Incidence, diagnostic delay, and seasonal variations in onset of symptoms.

BACKGROUND AND AIMS: Increasing incidence in Inflammatory Bowel Disease (IBD) has been suggested. Recent data on population based incidence rates within Europe are however scarce. Primary aim was to investigate prospectively the incidence of IBD within a well-defined geographical and administrative area of the Netherlands, the South Limburg IBD registry. Secondary aims were to study the duration of symptoms before diagnosis (lag time) and seasonal influences on the incidence of IBD. METHODS: The incidence was examined using standardized registration of all newly diagnosed IBD patients, between 1-1-1991 and 1-1-2003. Medical records were reviewed to verify the diagnosis. At inclusion, diagnostic lag time was registered in months. RESULTS: Age standardized incidence rates per 100,000 person-years (p-y) were: Crohn's Disease, male 4.84, female 7.58; Ulcerative Colitis, male 8.51, female 6.92; and Indeterminate Colitis, male 1.05, female 0.93. Incidence rates did not significantly changes over time in either Crohn's Disease, Ulcerative Colitis or Indeterminate Colitis. Lag time was 5 (0-360) months in Crohn's Disease, 3.0 (0-480) months in Ulcerative Colitis and 3.0 (0-180) months in Indeterminate Colitis. Lag time was not significantly different between the periods 1991-1993 and 2000-2002, and no statistical differences in the onset of symptoms per calendar month or season were found. CONCLUSIONS: Our results, from the South Limburg region (the Netherlands), show no significant change in incidence rates of IBD. The incidence found is relatively high compared to other European countries. Lag time did not change during the study period, and seasonal influence of incidence rates could not be confirmed.

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.

The effect of alcohol intake on cardiovascular disease and mortality disappeared after taking lifetime drinking and covariates into account.

BACKGROUND: Current alcohol intake has been associated with cardiovascular morbidity and mortality. The effect of past and lifetime drinking has received less attention. In the present study, the impact of current, past and lifetime drinking on cardiovascular events and all-cause mortality has been assessed. Secondly, the effect of accounting for covariates within these relationships has been studied. METHODS: The Lifestyle and Health study is a prospective cohort study in 2 regions of the Netherlands. Men and women aged 45 to 70 years registered in 34 general practices were followed over the period July 1996 to June 2001. At baseline, an extensive questionnaire had to be filled in. It included 3 questionnaires about alcohol intake: a Weekly Recall, a Quantity-Frequency about last year, and the Lifetime Drinking History questionnaire. Health problems were registered by the general practitioners. RESULTS: During follow-up, 679 men and 397 women had a cardiovascular event and 330 men and 204 women died. Current drinking was associated with lower risks of cardiovascular events (women) and all-cause mortality (men and women) compared with never drinkers. The relationships were strongest for alcohol intake measured with the Weekly Recall. Lifetime alcohol intake and alcohol intake in the distant past did not seem to be related to all-cause mortality or cardiovascular events. Adjustments for covariates weakened the relationships. CONCLUSIONS: Potential positive effects of drinking seem to be of a transient nature, as lifetime drinking and drinking in the past could not be related to all-cause mortality or cardiovascular events. The alleged benefits of current drinking at baseline diminished with increasing methodological quality and rigor.

Chronic low back pain: physical training, graded activity with problem solving training, or both? The one-year post-treatment results of a randomized controlled trial.

Several treatment principles for the reduction of chronic low back pain associated disability have been postulated. To examine whether a combination of a physical training and an operant-behavioral graded activity with problem solving training is more effective than either alone in the long-term, a cluster randomized controlled trial was conducted. In total 172 patients, 18-65 years of age, with chronic disabling non-specific low back pain referred for rehabilitation treatment, were randomized in clusters of four consecutive patients to 10 weeks of aerobic training and muscle strengthening of back extensors (active physical treatment; APT), 10 weeks of gradual assumption of patient relevant activities based on operant-behavioral principles and problem solving training (graded activity plus problem solving training; GAP), or APT combined with GAP (combination treatment; CT). The primary outcome was the Roland Disability Questionnaire adjusted for centre of treatment, cluster, and baseline scores. Secondary outcomes were patients' main complaints, pain intensity, self-perceived improvement, depression and six physical performance tasks. During the one-year follow-up, there were no significant differences between each single treatment and the combination treatment on the primary outcome, the Roland Disability Questionnaire. Among multiple other comparisons, only one significant difference emerged, with GAP and APT showing higher self-perceived improvement than CT. We conclude that the combination treatment integrating physical, graded activity with problem solving training is not a better treatment option for patients with chronic low back pain.

[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.

House dust mite allergen avoidance and self-management in allergic patients with asthma: randomised controlled trial.

BACKGROUND: The efficacy of bed covers that are impermeable to house dust mites has been disputed. AIM: The aim of the present study was to investigate whether the combination of 'house dust mite impermeable' covers and a self-management plan, based on peak flow values and symptoms, leads to reduced use of inhaled corticosteroids (ICS) than self-management alone. DESIGN OF STUDY: Prospective, randomised, double blind, placebo-controlled trial. SETTING: Primary care in a south-eastern region of the Netherlands. METHOD: Asthma patients aged between 16 and 60 years with a house dust mite allergy requiring ICS were randomised to intervention and placebo groups. They were trained to use a self-management plan based on peak flow and symptoms. After a 3-month training period, the intervention commenced using house dust mite impermeable and placebo bed covers. The follow-up period was 2 years. Primary outcome was the use of ICS; secondary outcomes were peak expiratory flow parameters, asthma control, and symptoms. RESULTS: One hundred and twenty-six patients started the intervention with house dust mite impermeable or placebo bed covers. After 1 and 2 years, significant differences in allergen exposure were found between the intervention and control groups (P<0.001). No significant difference between the intervention and control groups was found in the dose of ICS (P = 0.08), morning peak flow (P = 0.52), peak flow variability (P = 0.36), dyspnoea (P = 0.46), wheezing (P = 0.77), or coughing (P = 0.41). There was no difference in asthma control between the intervention and control groups. CONCLUSION: House dust mite impermeable bed covers combined with self-management do not lead to reduced use of ICS compared with self-management alone.

Improving cardiovascular risk management: a randomized, controlled trial on the effect of a decision support tool for patients and physicians.

BACKGROUND: There is nonoptimal adherence of general practitioners (GPs) and patients to cardiovascular risk reducing interventions. GPs find it difficult to assimilate multiple risk factors into an accurate assessment of cardiovascular risk. In addition, communicating cardiovascular risk to patients has proved to be difficult. AIMS: Improving primary prevention of cardiovascular disease (CVD) in primary care by enhancing patient involvement in the use of a decision support tool. DESIGN: Cluster randomized trial. METHODS: Thirty-four GPs included patients (40-75 years old) without CVD. In an interactive, small group training session lasting 4 h, the GPs in the intervention group were trained to use the guidelines on cardiovascular risk and a decision support tool. The control group received educational materials about the guidelines on paper. GPs' clinical performance and patients' risk perception and self-reported lifestyles were measured at baseline and after 6 months. RESULTS: Thirty-four GPs recorded 490 consultations, 276 in the intervention and 214 in the control group. After 6 months, no significant effect of the intervention on the GPs' performance or the patients' risk perception was found. There was only an effect on self-reported lifestyle, in that more men in the intervention group than in the control group increased their physical activity (odds ratio 3.8, 95% confidence interval 1.7-8.7). CONCLUSION: The 4-h interactive, small group training did not guarantee correct application of the decision support tool and as such failed to improve GPs' performance or correct patients' risk perception. The positive effect on physical activity justifies further research on patient involvement.

Psychosocial predictors of increases in fruit and vegetable consumption.

OBJECTIVES: To examine psychosocial predictors of changes in fruit and vegetable consumption. METHODS: Baseline psychosocial variables were used to explain differences in changes in consumption in 83 healthy women with children after they received free fruit and vegetables for one month. RESULTS: One-month changes in fruit consumption (mean 144; SE 16 g/day) were positively associated with perceived costs and perceived health benefits for the children, and negatively associated with perceived behavioral control. Changes in vegetable consumption (68 (11) g/day) were positively related with the intention to eat at least 200 g of vegetables and taste preferences of the children. CONCLUSIONS: Fruit and vegetable consumption may be encouraged by influencing the above variables.

The effect of sibutramine on energy expenditure and body composition in obese adolescents.

CONTEXT: Childhood obesity is now considered to be an epidemic. Drug therapy in this age group remains a topic of research. OBJECTIVE: The objective of this study was to examine the effect of treatment with sibutramine (10 mg) on body composition and energy expenditure in obese adolescents. DESIGN: The study was conducted as a randomized, double-blind, placebo-controlled trial. SETTING: The study was set in an obesity research center. PATIENTS: The patients were 24 obese adolescents (age 12-17 yr, 11 boys); four patients withdrew. INTERVENTION: Intervention was sibutramine (Meridia) or placebo in combination with an energy-restricted diet and exercise plan for 12 wk, followed by an identical, but medication-free, treatment period (follow-up). MAIN OUTCOME MEASURE: Change in body mass index (BMI) sd score (BMI-SDS) was the principal measure of efficacy. Body composition and total energy expenditure were measured by stable isotopes and further calculated according to the four-component model, using underwater weighing and dual x-ray absorptiometry. Basal metabolic rate (BMR) was measured by ventilated hood and adjusted for sex and body composition (BMRadj). RESULTS: After intervention, the decrease in BMI-SDS was comparable in both groups. During follow-up, BMI further decreased in the placebo group but stabilized in the sibutramine group. Changes in the percentage of fat mass were not different between both groups. BMRadj decreased in the placebo group and remained constant in the sibutramine group. During follow-up, BMRadj decreased in the sibutramine group and increased in the placebo group. Changes in total energy expenditure were not significantly different. CONCLUSION: The effect of sibutramine on BMI-SDS was not significant. Sibutramine may diminish the decrease in BMRadj associated with energy restriction in obese adolescents.

Uncovering and responding to needs for sexual and reproductive health care among poor urban female adolescents in Nicaragua.

BACKGROUND: To meet the needs of female adolescents from low-income urban areas for sexual and reproductive health (SRH) care, vouchers providing free-of-charge access to SRH care at 19 primary care clinics were distributed in Managua, Nicaragua. These vouchers substantially increased the use of services, demonstrating that many adolescents are willing to use such services, if readily accessible. The voucher redemption made it possible to identify the nature of existing, but largely unmet, needs for SRH care. METHOD: The medical files from 3301 consultations with female adolescents were analysed using descriptive statistical methods and multiple logistic regression. RESULTS: Female adolescents presented SRH problems that merited medical attention. The mean number of problems presented was 1.5 per consultation: 34% of the vouchers were used for contraceptives, 31% for complaints related to sexually transmitted infection (STI) or reproductive tract infection (RTI), 28% for advice/counselling, 28% for antenatal check-up and 18% for pregnancy testing. A new category of health care users emerged: sexually active girls who were neither pregnant nor mothers and who sought contraceptives or STI/RTI treatment. Contraceptive use doubled among the sexually active non-pregnant voucher redeemers. Consultation with a female doctor younger than 36 years was associated with a higher chance of having contraceptives prescribed. CONCLUSION: Accessible and appropriate SRH care has the potential to make an important contribution to the increased contraceptive use, decreased risk of unwanted teenage pregnancies and decreased prevalence of STIs/RTIs among underserved adolescents. Once adolescents access the services, providers have a crucial role in ensuring current and continuing needs are met.

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.

The usability of six physical performance tasks in a rehabilitation population with chronic low back pain.

OBJECTIVE: To examine the influence of task experience on the difference between test and retest and to assess test-retest reliability and limits of agreement of six performance tasks in chronic low back pain patients. These measures will be used to define the clinical usability. DESIGN: Test-retest of six performance tasks in a group of patients with no experience and a group of patients after previous experience with these tasks. SETTING: Three rehabilitation centres. SUBJECTS: Fifty-three patients with non-specific chronic low back pain. MAIN MEASURES: Five-minute walking, 50-ft (15 m) fast walking, sit-to-stand, loaded forward reach, 1-min stair-climbing and Progressive Isoinertial Lifting Evaluation (PILE). To assess the influence of task experience, differences between test and retest between both groups were tested using Mann-Whitney test. For both groups together, intraclass correlation coefficients (ICCs) and the limits of agreement using Bland and Altman plots were calculated. RESULTS: Thirty patients with no task experience and 23 patients who had already undertaken the tasks on at least two occasions participated. Both groups showed similar differences between test and retest. The test-retest reliability for the total study population was good to very high: ICC varied from 0.74 to 0.99. For the total study population, the limits of agreement expressed as percentage of the mean score of each task was low to moderate for 5-min walking and 1-min stair-climbing (21% and 20% respectively), moderate for 50-ft (15 m) fast walking, sit-to-stand and forward reach (33%, 29% and 36% respectively) and high for the PILE (48%). CONCLUSIONS: Task experience did not significantly influence test-retest differences. All tasks showed sufficient test-retest reliability. Based on the natural variability of the tasks, the 5-min walking and stair-climbing task, and to a lesser degree the 50-ft (15 m) walking, sit-to-stand and loaded forward reach, seem clinically useful. There are major concerns about the usability of the PILE.