Clinical outcomes of different autografts used for all-epiphyseal, partial epiphyseal or transphyseal anterior cruciate ligament reconstruction in skeletally immature patients - a systematic review.

BACKGROUND: Different types of grafts can be used for anterior cruciate ligament reconstruction (ACLR). There is little published data regarding skeletally immature patients. The purpose of this systematic review was to assess the clinical outcomes and complications for different autograft types used in all-epiphyseal, transphyseal and partial epiphyseal/hybrid ACLR in skeletally immature children and adolescents. METHODS: PubMed, Embase and Cochrane databases were systematically searched for literature regarding ACLR using hamstrings, quadriceps or bone-patellar-tendon-bone (BPTB) autografts in skeletally immature patients. Studies were included if they examined at least one of the following outcomes: graft failure, return to sport(s), growth disturbance, arthrofibrosis or patient reported outcomes and had a minimum follow-up of 1 year. Case reports, conference abstracts and studies examining allografts and extra-articular or over-the-top ACL reconstruction techniques were excluded. Graft failure rates were pooled for each graft type using the quality effects model of MetaXL. A qualitative synthesis of secondary outcomes was performed. RESULTS: The database search identified 242 studies. In total 31 studies were included in this review, comprising of 1358 patients. Most patients (81%) were treated using hamstring autograft. The most common used surgical technique was transphyseal. The weighted, pooled failure rate for each graft type was 12% for hamstring tendon autografts, 8% for quadriceps tendon autografts and 6% for BPTB autografts. Confidence intervals were overlapping. The variability in time to graft failure was high. The qualitative analysis of the secondary outcomes showed similar results with good clinical outcomes and low complication rates across all graft types. CONCLUSIONS: Based on this review it is not possible to determine a superior graft type for ACLR in skeletally immature. Of the included studies, the most common graft type used was the hamstring tendon. Overall, graft failure rates are low, and most studies show good clinical outcomes with high return to sports rates.

Digital assessment of working memory and processing speed in everyday life: Feasibility, validation, and lessons-learned.

OBJECTIVES: Cognitive functioning is often impaired in mental and neurological conditions and might fluctuate throughout the day. An existing experience-sampling tool was upgraded to assess individual's cognition in everyday life. The objectives were to test the feasibility and validity of two momentary cognition tasks. METHODS: The momentary Visuospatial Working Memory Task (mVSWMT) and momentary Digit Symbol Substitution Task (mDSST) were add-ons to an experience sampling method (ESM) smartphone app. Healthy adults (n = 49) between 19 and 73 years of age performed the tasks within an ESM questionnaire 8 times a day, over 6 consecutive days. Feasibility was determined through completion rate and participant experience. Validity was assessed through contextualization of cognitive performance within intrapersonal and situational factors in everyday life. FINDINGS: Participants experienced the tasks as pleasant, felt motivated, and the completion rate was high (71%). Social context, age, and distraction influenced cognitive performance in everyday life. The mVSWMT was too difficult as only 37% of recalls were correct and thus requires adjustments (i.e. fixed time between encoding and recall; more trials per moment). The mDSST speed outcome seems the most sensitive outcome measure to capture between- and within-person variance. CONCLUSIONS: Short momentary cognition tasks for repeated assessment are feasible and hold promise, but more research is needed to improve validity and applicability in different samples. Recommendations for teams engaging in the field include matching task design with traditional neuropsychological tests and involving a multidisciplinary team as well as users. Special attention for individual needs can improve motivation and prevent frustration. Finally, tests should be attractive and competitive to stimulate engagement, but still reflect actual cognitive functioning.

Training general practitioners in early identification and anticipatory palliative care planning: a randomized controlled trial.

BACKGROUND: Most patients with advanced cancer, debilitating COPD or chronic heart failure (CHF) live at home. General practitioners (GPs) asked for guidance in how to recognize patients in need of palliative care in a timely way and to structure anticipatory care. For that reason, we developed a training for GPs in identifying patients in need of palliative care and in structuring anticipatory palliative care planning and studied its effect on out-of-hours contacts, contacts with their own GP, hospitalizations and place of death. METHODS: We performed a cluster randomised controlled trial. GPs in the intervention group were trained in identifying patients in need of palliative care and anticipatory care planning. Next, for each identified patient, they were offered a coaching session with a specialist in palliative care to fine-tune a structured care plan. The GPs in the control group did not receive training or coaching, and were asked to provide care as usual. After one year, characteristics of patients deceased of cancer, COPD or CHF in both study groups were compared with mixed effects models for out-of-hours contacts (primary outcome), contacts with their own GP, place of death and hospitalizations in the last months of their life (secondary outcomes). As a post-hoc analysis, of identified patients (of the intervention GPs) these figures were compared to all other deceased patients, who had not been identified as in need of palliative care. RESULTS: We did not find any differences between the intervention and control group. Yet, only half of the trained GPs (28) identified patients (52), which was only 24% of the deceased patients. Those identified patients had significantly more contacts with their own GP (B 4.5218; p <0.0006), were less often hospitalized (OR 0.485; p 0.0437) more often died at home (OR 2.126; p 0.0572) and less often died in the hospital (OR 0.380; p 0.0449). CONCLUSIONS: Although we did not find differences between the intervention and control group, we found in a post-hoc analysis that those patients that had been identified as in need of palliative care had more contacts with their GP, less hospitalizations, and more often died at home. We recommend future controlled studies that try to further increase identification of patients eligible for anticipatory palliative care. The Netherlands National Trial Register: NTR2815 date 07-04-2010.

Evaluation of cholesterol lowering treatment of patients with familial hypercholesterolemia: a large cross-sectional study in The Netherlands.

BACKGROUND: Heterozygous familial hypercholesterolemia (heFH) is a common autosomal dominant hereditary disorder caused by mutations in the LDL-receptor gene that lead to elevated plasma levels of low-density lipoprotein-cholesterol (LDL-c). Robust lowering of LDL-c levels is essential for risk reduction of premature cardiovascular diseases and early death. European and Dutch guidelines recommend to treat LDL-c to plasma levels <2.5mmol/l. In the present study we evaluated the treatment of heFH patients in The Netherlands. METHODS: A cross-sectional study was conducted in outpatient lipid clinics of three Academic Centers and two regional hospitals. Patient records of known heFH patients were retrieved and data were reviewed on the use of lipid-lowering medication, plasma lipids and lipoproteins, safety laboratory results and reasons for not achieving treatment goals. RESULTS: The data of 1249 patients with heFH were available. Nearly all patients (96%) were on statin treatment. The treatment goal for LDL-c <2.5mmol/l was achieved in 261 (21%) patients. Among those who did not reach LDL-c goals, 261 (27%) were on combination therapy of maximum statin dose and ezetimibe. Main reason (32%) why patients did not use maximum therapy despite an LDL-c >or=2.5mmol/l, was acceptance of a higher target LDL-c level by the treating physician. An alternative treatment goal of >50% LDL-c reduction, as recommended in the NICE guidelines, was achieved in 47% of patients with an LDL-c >or=2.5mmol/l and not using maximum therapy. CONCLUSION: Only a small proportion of patients with heFH reaches the LDL-c treatment target of <2.5mmol/l. These results emphasize the need for better monitoring, better utilization of available medication and for new treatment options in heFH to further decrease LDL-c levels.

Improved competence after a palliative care course for internal medicine residents.

Residents report that they received inadequate teaching in palliative care and low levels of comfort and skills when taking care of dying patients. This study describes the effects of a problem-based palliative care course on perceived competence and knowledge in a representative Dutch cohort of residents in internal medicine. Before and after the course, we carried out a questionnaire survey and knowledge test in 91 residents. The results show that many residents felt they had limited competence or were incompetent when taking care of patients in the palliative care phase. This was particularly true with respect to communication concerning euthanasia and physician-assisted suicide or hastened death (86% and 85% respectively reported limited competence or incompetence). Participants reported that they received inadequate training in palliative care and believed that specific education would make them feel more competent. The number of times that residents were engaged in palliative care situations and the years of clinical experience had a positive influence on perceived competence. Participating in the course improved perceived competence and knowledge in palliative care. No correlation was found between perceived competence and knowledge of palliative care.

The course of severe fatigue in disease-free breast cancer patients: a longitudinal study.

BACKGROUND: We investigated whether fatigue is a persistent problem, and whether persistent fatigue is related to former treatment modalities. In addition, we studied the predictors of persistent fatigue. METHODS: At baseline (n=150, mean time since cancer treatment=29 months) patients were asked to fill out several questionnaires on psychological, physical, social, cognitive and behavioral aspects (Ann. Oncol. 2002;13:589-598). During the 2 years after baseline patients were asked to fill out monthly a fatigue questionnaire (CIS-fatigue). Hundred-twenty-one patients completed the study, 10 dropped out and 19 had a disease recurrence. RESULTS: Twenty-four percent of the patients experienced persistent severe fatigue complaints during the 2-year observation period. Persistent fatigue seemed to be related to the duration of former treatment but unrelated to type of surgery, type of adjuvant therapy and time since treatment finished. High anxiety, high impairment in role functioning and low sense of control over fatigue symptoms at baseline were predictors of persistent fatigue. CONCLUSION: Fatigue appears to be a persistent problem for a quarter of a sample of disease-free breast cancer patients during a 2-year period. The predictors of persistent fatigue found in this study can be helpful for the development of interventions to reduce post-treatment fatigue.

A new international framework for palliative care.

In spite of recent advances in anti-cancer treatments, most adult cancer patients still ultimately die from their disease. There should therefore be free access to palliative care around the clock and seven days a week, for all cancer patients, as a fundamental human right. At present, the implementation of palliative care and patients' access to it are inconsistent across Europe and many other parts of the world. The World Health Organisation (WHO) made an important advance in 1986 by first defining palliative care and, then updating this definition in 2002. However, this definition could benefit from further refinement in order to reflect the increasing multi-professional specialisation in this subject, and to recognise the different models for delivering this type of care. We recommend that palliative care should be defined as follows: Palliative care is the person-centred attention to symptoms, psychological, social and existential distress in patients with limited prognosis, in order to optimise the quality of life of patients and their families or close friends. Based on this definition, we propose two further types of palliative care which reflect the reality of how palliative care is actually delivered: Basic palliative care is the standard of palliative care which should be provided by all healthcare professionals, in primary or secondary care, within their normal duties to patients with life-limiting disease. Specialised palliative care is a higher standard of palliative care provided at the expert level, by a trained multi-professional team, who must continually update their skills and knowledge, in order to manage persisting and more complex problems and to provide specialised educational and practical resources to other non-specialised members of the primary or secondary care teams. If a patient has difficult symptoms which cannot be controlled by his/her current healthcare team, he/she has a right to be referred, and the current healthcare provider has an obligation to refer, to the local palliative care team. Important priorities to ensure the standardisation of, and uniform access to, palliative care for all cancer patients include: Integration of palliative care services with the primary care and oncology teams. Establishment of a specialised palliative care service in each major cancer centre. Establishment of educational programmes covering palliative care for undergraduates, oncologists, primary care team members and specialists training in palliative care. Support for research using appropriate methodologies to underpin the scientific basis of palliative care. Establishment of quality assurance programmes. Recognition of palliative medicine as a medical specialty. Establishment of academic centres of excellence with chairs of palliative medicine and palliative care nursing. Removal of unnecessary restrictions on all drugs which are proven to be of benefit in symptom control, especially improving access to strong opioids. Improved information for patients and family carers to allow them to make choices and exercise autonomy.

Determinants of chronic fatigue in disease-free breast cancer patients: a cross-sectional study.

BACKGROUND: Quality of life after cancer treatment becomes more important as the number of long-term survivors increases. This study aimed to investigate complaints of fatigue after treatment for breast cancer. PATIENTS AND METHODS: The study patients were 150 women who had finished curative treatment for breast cancer by a mean of 29 months before commencement of this study. Measurements included computerised questionnaires and a daily Self-Observation List. RESULTS: Thirty-eight per cent of the sample were severely fatigued, compared with 11% in a matched sample of women without a history of cancer. No association was found between fatigue and former treatment. The 'severely fatigued disease-free breast cancer patient' scored more 'problematic' on psychological well-being, functional impairment, sleep disturbance, physical activity, social support, neuropsychological and social functioning compared with the 'non-severely fatigued disease-free breast cancer patient'. Furthermore, the severely fatigued patients had a lower sense of control with respect to their fatigue complaints and stronger breast cancer- and psychologically-related attributions with regard to the causes of fatigue compared with the non-severely fatigued patients. Regression analyses indicated that sleep disturbance, physical activity and causal attributions contributed significantly to the subjective experience of fatigue. CONCLUSIONS: Severe fatigue is a problem for almost 40% of the sample of breast cancer survivors. Severe fatigue is related to physical, psychological, social, cognitive and behavioural factors.

Fatigue in disease-free cancer patients compared with fatigue in patients with chronic fatigue syndrome.

The goal of our work was to assess fatigue in disease-free cancer patients with help of a validated fatigue questionnaire. Furthermore, we wished to analyse the relationship between severe fatigue and former treatment modalities, problems of concentration and motivation, physical activity, functional impairment, depression and anxiety and finally, to compare severely fatigued disease-free cancer patients and patients with Chronic Fatigue Syndrome (CFS). The participants were 85 adult cancer patients and 16 patients with CFS. The cancer patients were all disease-free and had been off treatment for a minimum of 6 months. They were asked to participate in this study by their physician when they came to the hospital for control visits. Patients who were willing to participate completed four questionnaires. The Checklist Individual Strength was used to measure fatigue. In addition, the Beck Depression Inventory, the Spielberger Trait Anxiety Inventory and the Nottingham Health Profile were used. Results indicate that 19% of the disease-free cancer patients were severely fatigued. Their fatigue experience is comparable to that of patients with CFS. Severe fatigue is associated with problems of concentration and motivation, reduced physical activity, emotional health problems and pain. Furthermore, a relation was found between fatigue and depression and anxiety. No relation was found between fatigue and type of cancer, former treatment modalities, duration of treatment and time since treatment ended. In conclusion, for one fifth of a group of disease-free cancer patients fatigue is a severe problem long after treatment. In addition to fatigue, these patients experience several psychological and physical problems.

Triglycerides in embryogenic conifer calli: a comparison with zygotic embryos.

Triglycerides in developing zygotic embryos of Norway spruce and loblolly pine were found to accumulate continuously during the course of development, comprising nearly 50% of the fresh weight of a mature embryo. Embryogenic calli of these two species contained dramatically lower levels of triglycerides. Abscisic acid treatments promoted both embryo production and triglyceride accumulation in Norway spruce cultures. A method used to determine triglyceride levels in human serum, commercially available in kit form, was adapted for use with plant tissues. Low levels of triglycerides in the cultured tissues may be related to difficulties in the development and germination of conifer somatic embryos.