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Ellen Ricke,1 Eric W Bakker2 1Department of Social Psychology, University of Groningen, Groningen, the Netherlands; 2Department of Epidemiology and Data Science | Division EBM, Academic Medical Centre, Amsterdam, the NetherlandsCorrespondence: Ellen Ricke, Department of Social Psychology, University of Groningen, Grote Kruisstraat 2/1, Groningen, 9712 TS, the Netherlands, Tel +31 6 211 817 02, Email E.Ricke@rug.nlPurpose: Pulmonary rehabilitation (PR) is considered a cost-effective method of improving health-related quality of life in patients with chronic obstructive pulmonary disease (COPD). However, increasing demand and increasing costs of supply demands for sustainable and affordable care. One of the possible solutions to keep care affordable is self-management. A challenge here is non-adherence. Understanding who are adherent and who are non-adherent could be helpful to differentiate between patients who need more or less support. Therefore, the aim of this study was to develop and validate a model to predict adherence to PR in patients with COPD.Patients and methods: A multivariable logistic regression model for exercise adherence was developed. Eight candidate predictors, that were prespecified, were obtained in a prospective cohort study from 196 patients with COPD following PR in 53 primary physiotherapy practices in the Netherlands and Belgium, between January 2021 and August 2022. To create a parsimonious model, variable selection using backward selection was performed with a p-value of > 0.05 for elimination. Model performance was assessed by discrimination, calibration and clinical utility. Internal validation was assessed by bootstrapping (n = 500).Results: The final model included four predictors: intention, depression, MRC-score and alliance. The optimism-corrected AUC after bootstrap internal validation was 0.79 (95% CI, 0.72– 0.85). Calibration plots suggested good calibration and decision curve analysis showed great net benefit in a wide range of risk thresholds.Conclusion: The exercise adherence prediction model has potential for clinical utility to predict adherence in patients with COPD. Information from such a model can be used to manage the patient instead of managing the disease, and thereby to determine the treatment frequency for each individual patient. As a result, healthcare capacity might be better distributed, potentially reducing pressure on healthcare without compromising the effectiveness of PR for the individual patient.Keywords: chronic obstructive pulmonary disease, sustainable healthcare, pulmonary rehabilitation, self-management

BACKGROUND: The aim of this observational study was to examine whether the course of pregnancy and birth and accompanying outcomes among low-risk pregnant women changed in the COVID-19 pandemic compared to the prepandemic period.METHODS: We analyzed data from the Dutch Midwifery Case Registration System (VeCaS). Differences in the course of pregnancy and birth, and accompanying maternal and neonatal outcomes, were calculated between women pregnant during the initial months of the COVID-19 pandemic (March 1 to August 3, 2020) and the prepandemic period (March 1-August 3, 2019). We also conducted a stratified analysis by parity.RESULTS: We included 5913 low-risk pregnant women of whom 2963 (50.1%) were pregnant during the first surge of the COVID-19 pandemic, and 2950 (49.9%) in the prepandemic period. During the COVID-19 pandemic, more women desired and had a home birth. More women used pain medication and fewer had an episiotomy in the COVID-19 period than prior. Multiparous women had a higher suspected rate of fetal growth restriction during COVID; however, the actual rate of small for gestational age infants was not significantly increased. We observed no differences for onset and augmentation of labor or for mode of birth, though the rate of vaginal births increased.CONCLUSIONS: During the COVID-19 pandemic, there was a higher rate of planned and actual home birth, and suspected growth restriction and a lower rate of episiotomy among low-risk pregnant women in the Netherlands.

Purpose: There is a growing number of children with medical complexity (CMC). After hospitalization, care often has to be continued at home, making transitional care very important. However, many parents do not feel empowered in their role as caregiver for the child. To move forward in this field, we explored prognostic factors associated with parental empowerment after discharge of hospitalized children. Design and methods: In a cross-sectional study, we collected data on potential prognostic factors found in the literature and on parental empowerment by means of the Family Empowerment Scale (FES). Linear regression analyses were performed to explore the associations between the prognostic factors and the FES. Results: Data from 228 patients and their parents were analyzed. Out of twelve factors included in the study, three showed significant associations with parental empowerment. Parents of CMC felt more empowered compared to parents of children with less complex conditions (β = 0.20, p = 0.00). We found a positive association between the age of the child and parental empowerment (β = 0.01, p = 0.00). Employed couples felt more empowered compared to unemployed couples (β = 0.30, p = 0.00). These three variables explained 11% of variance in the FES scores. Conclusions: Parental empowerment is associated with the patient's age, child's medical complexity, and parental employment status. Practice implications: Attention should be paid to the discharge preparation of parents of children with less medical complexity. Awareness is required for parents of younger children and parental employment status, because they are at risk for lower parental empowerment.

Purpose Supervised exercise is a potentially promising supportive care intervention for people with metastatic breast cancer (MBC), but research on the patients’ perspective is limited. The aim of the current focus group study was to gain an in-depth understanding of MBC patients’ perceived barriers, facilitators, and preferences for supervised exercise programs. Methods Eleven online focus groups with, in total, 44 MBC patients were conducted in four European countries (Germany, Poland, Spain, Sweden). Main topics of the semi-structured discussions covered attitudes towards participation in supervised exercise programs, perceived facilitators, experienced barriers, and exercise preferences. Interviews were transcribed verbatim, translated into English, and coded based on a preliminary coding framework, supplemented by themes emerging during the sessions. The codes were subsequently examined for interrelations and re-organized into overarching clusters. Results Participants had positive attitudes towards exercise, but experienced physical limitations and insecurities that inhibited their participation. They expressed a strong desire for exercise tailored to their needs, and supervision by an exercise professional. Participants also highlighted the social nature of group training as an important facilitator. They had no clear preference for exercise type, but rather favored a mixture of different activities. Flexible training modules were considered helpful to increase exercise program adherence. Conclusions MBC patients were generally interested in supervised exercise programs. They preferred group exercise that facilitates social interaction, but also expressed a need for individualized exercise programs. This suggests the relevance to develop flexible exercise programs that are adjusted to the individual’s needs, abilities, and preferences.

Approximately half of all recruits drop out of Marine recruit training. Identifying associated and predisposing factors for dropout would be helpful to understand dropout patterns and induce preventive strategies. Grit has been suggested to be a predictor of who is likely to succeed and who is not. We aimed to investigate the association between baseline grit scores and dropout of Marine recruit training in the Netherlands Armed Forces. We performed an exploratory study using data of three platoons Marine recruit training of the Royal Netherlands Marine Corps. Individual grit levels were measured using the NL-Grit scale, including two subscales. The primary outcome of this study was successful completion or dropout of Marine recruit training. Data were available from 270 recruits, of whom 119 (44%) dropped out of training. The odds ratio for dropout were 1.01 (95% CI 0.84–1.21, p =.917) and 1.07 (95% CI 0.89–1.29, p =.481) per standard deviation increase of consistency of interests and perseverance of effort, respectively. Our study did not confirm the proposed association between baseline grit levels and dropout of Marine recruit training in Dutch Marine recruits using the NL-Grit scale.

Background and aims: Recently, there has been an increase in the number of patients treated with immunotherapy. However, the number of studies investigating combination immunotherapies is still limited, resulting in a gap of knowledge regarding the incidence of nutritional side effects, differences in the durations of these side effects, and differences in weight loss between patients undergoing single and combination immunotherapies. Methods: In this historical cohort study, which was performed from 2017 to 2019, a total of 50 patients who received one type and 50 patients who received two types of immunotherapy were randomly selected, resulting in a sample of 100 patients. The primary objectives were to assess (a) the incidence of nutritional side effects, (b) the differences in the durations of these side effects, and (c) the differences in weight loss between the two groups. The secondary objectives were to assess the time to the first side effect, the time to the first unplanned hospital admission, unplanned hospital admissions, consultations from a dietitian, and nutritional interventions. Data were collected from the electronic patient record. Differences between groups were explored using the two-sample t-test, Mann–Whitney U test, Fisher exact test, or Wilcoxon rank sum test, depending on the type of data and the test assumptions. The time to the first side effect and the time to the first unplanned hospital admission are presented as Kaplan–Meier curves, and differences were calculated using a Cox proportional hazards model. Results: Patients undergoing a combination of two types of immunotherapy were found to have side effects for statistically significantly longer durations than patients receiving one type of immunotherapy (20 days versus 10 days, p = 0.045). Moreover, patients undergoing a combination of two types of immunotherapy were found to lose more weight (6.2 kg versus 1.2 kg, p < 0.001). At least one side effect was reported in 86% of the patients in the one-therapy group and in 90% of the patients in the combination-therapy group. Furthermore, a high incidence of decreased appetite (70% and 86%), nausea (52% and 68%), vomiting (22% and 46%), and diarrhea/colitis (56% and 54%) was found in both groups. However, the time to the first side effect and the time to the first hospital admission were not statistically significantly different between the one-therapy and combination-therapy groups. Of the total cohort, 26% were admitted unexpectedly during the immunotherapy because they developed immunotherapy-related side effects, whereas 38% of the patients in our sample consulted a dietitian. Conclusions: Nutritional side effects are common in patients treated with immunotherapy. Generally, treatment with a combination of two types of immunotherapy is associated with an increased incidence of nutritional side effects. These side effects last longer and patients lose more weight compared to those receiving one type of immunotherapy.

Introduction: Falls are a worldwide health problem among community-dwelling older adults. Emerging evidence suggests that foot problems increase the risk of falling, so the podiatrist may be crucial in detecting foot-related fall risk. However, there is no screening tool available which can be used in podiatry practice. The predictive value of existing tools is limited, and the implementation is poor. The development of risk models for specific clinical populations might increase the prediction accuracy and implementation. Therefore, the aim of this study was to develop and internally validate an easily applicable clinical prediction model (CPM) that can be used in podiatry practice to predict falls in community-dwelling older adults with foot (-related) problems. Methods: This was a prospective study including community-dwelling older adults (≥65 years) visiting podiatry practices. General fall-risk variables, and foot-related and function-related variables were considered as predictors for the occurrence of falls during the 12-month follow-up. Logistic regression analysis was used for model building, and internal validation was done by bootstrap resampling. Results: 407 participants were analyzed; the event rate was 33.4%. The final model included fall history in the previous year, unsteady while standing and walking, plantarflexor strength of the lesser toes, and gait speed. The area under the receiver operating characteristic curve was 0.71 (95% CI: 0.66–0.76) in the sample and estimated as 0.65 after shrinkage. Conclusion: A CPM based on fall history in the previous year, feeling unsteady while standing and walking, decreased plantarflexor strength of the lesser toes, and reduced gait speed has acceptable accuracy to predict falls in our sample of podiatry community-dwelling older adults and is easily applicable in this setting. The accuracy of the model in clinical practice should be demonstrated through external validation of the model in a next study.

Objective: The objective was to assess swallowing, mouth opening and speech function during the first year after radiation-based treatment (RT(+)) after introduction of a dedicated preventive rehabilitation program for stage III–IV oropharyngeal carcinoma (OPC). Methods: Swallowing, mouth opening and speech function were collected before and at six- and twelve-month follow-up after RT(+) for OPC as part of ongoing prospective assessments by speech-language pathologists. Results: Objective and patient-perceived function deteriorated until 6 months and improved until 12 months after treatment, but did not return to baseline levels with 25%, 20% and 58% of the patients with objective dysphagia, trismus and speech problems, respectively. Feeding tube dependency and pneumonia prevalence was low. Conclusion: Despite successful implementation, a substantial proportion of patients still experience functional limitations after RT(+) for OPC, suggesting room for improvement of the current rehabilitation program. Pretreatment sarcopenia seems associated with worse functional outcomes and might be a relevant new target for rehabilitation strategies.

Purpose This individual participant data meta-analysis (IPD-MA) assesses exercise effects on self-reported cognitive functioning (CF) and investigates whether effects differ by patient-, intervention-, and exercise-related characteristics. Methods IPD from 16 exercise RCTs, including 1987 patients across multiple types of non-metastatic cancer, was pooled. A one-stage IPD-MA using linear mixed-effect models was performed to assess exercise effects on self-reported CF (z-score) and to identify whether the effect was moderated by sociodemographic, clinical, intervention- and exercise-related characteristics, or fatigue, depression, anxiety, and self-reported CF levels at start of the intervention (i.e., baseline). Models were adjusted for baseline CF and included a random intercept at study level to account for clustering of patients within studies. A sensitivity analysis was performed in patients who reported cognitive problems at baseline. Results Minimal significant beneficial exercise effects on self-reported CF (β=−0.09 [−0.16; −0.02]) were observed, with slightly larger effects when the intervention was delivered post-treatment (n=745, β=−0.13 [−0.24; −0.02]), and no significant effect during cancer treatment (n=1,162, β=−0.08 [−0.18; 0.02]). Larger effects were observed in interventions of 12 weeks or shorter (β=−0.14 [−0.25; −0.04]) or 24 weeks or longer (β=−0.18 [−0.32; −0.02]), whereas no effects were observed in interventions of 12–24 weeks (β=0.01 [−0.13; 0.15]). Exercise interventions were most beneficial when provided to patients without anxiety symptoms (β=−0.10 [−0.19; −0.02]) or after completion of treatment in patients with cognitive problems (β=−0.19 [−0.31; −0.06]). No other significant moderators were identified. Conclusions This cross-cancer IPD meta-analysis observed small beneficial exercise effects on self-reported CF when the intervention was delivered post-treatment, especially in patients who reported cognitive problems at baseline. Implications for Cancer Survivors This study provides some evidence to support the prescription of exercise to improve cognitive functioning. Sufficiently powered trials are warranted to make more definitive recommendations and include these in the exercise guidelines for cancer survivors.

Summary Objective To assess which structural abnormalities on knee MRI are associated with development of osteophytes in middle-aged subjects without radiographic knee osteoarthritis. Design We included subjects from the Osteoarthritis Initiative, aged 40–55 years, Kellgren & Lawrence grade 0 in both knees, and knee MRIs from both knees available at baseline, 24, 48 and 72 months. Structural exposures on MRI assessed using MOAKS included cartilage damage, bone marrow lesions, meniscal tear, meniscal extrusion, and Hoffa/effusion synovitis. We assessed whether each structural exposure was associated with the development of osteophytes on MRI in the medial and lateral tibiofemoral, and patellofemoral compartment. We estimated hazard ratios (HR) including 95% confidence intervals (CI) for osteophyte development using a mixed complementary log–log regression model adjusted for age, sex, and body mass index. Results We included 680 knees from 340 subjects with a mean (SD) age of 50 years (3.0), and 51% men. In the medial tibiofemoral compartment, the absolute risk of osteophyte development in the first 24-month period was 4% in knees without, and 15% in knees with medial meniscal tear. Corresponding adjusted HR was 6.6 (95%CI = 3.4–12.9). In the lateral tibiofemoral compartment, the adjusted HR for developing osteophytes having a lateral meniscal tear was 3.3 (95%CI = 1.3–8.4). In the patellofemoral compartment, patellofemoral cartilage damage was most clearly associated with developing osteophytes (HR = 2.6, 95%CI = 1.8–3.7). Conclusions Meniscal tear seem to be the strongest structural risk factor for the development of tibiofemoral osteophytes, and patellofemoral cartilage damage for the development of patellofemoral osteophytes, respectively. Local biomechanical factors are important in early osteophyte development.

This study aimed to evaluate the effectiveness of glasses that emit blue light in reducing the need for recovery, general fatigue, and stress levels in security guards who work night shifts. Light manipulation is seen as a promising strategy to mitigate complaints related to shift work, such as sleepiness and impaired cognitive performance. In a randomized controlled cross-over study design, 86 Dutch security guards used light-emitting glasses (exposure duration: 30 min) during night shifts in a five week period versus a five week control period without glasses. Measurements (Need for Recovery Scale; Checklist Individual Strength; stress level assessed by a fitness tracker) were performed at baseline, at five weeks, and again at 11 weeks. The chronotype was measured at baseline as a potential covariate. A mixed model for repeated measure analyses showed no significant reduction in the need for recovery, nor a reduction in general fatigue scores, during the intervention period. Paired Samples T-Test analyses showed no significant changes in stress levels for the intervention period. Conclusively, blue light exposure using light-emitting glasses for security guards during night shifts showed no directly measurable effect on the reduced need for recovery, overall fatigue, and stress levels.

Background and Purpose:Measuring the attitude of nurses toward the importance of involving families in nursing care is essential to implement family-centered care. We aim to examine the reliability and factor structure of the Families’ Importance in Nursing Care—Nurses’ Attitudes questionnaire (FINC-NA-R).Methods:The psychometric properties of the FINC-NA-R were tested and the Dutch-revised version was used to assess the attitude of the nurses.Results:Principal component analysis confirmed a four-factor structure and the removal of four items achieved strong evidence of structural validity and internal consistency.Conclusions:The Dutch FINC-NA-R appeared to be a valid instrument to measure the attitude of nurses toward family-centered care.

Background:The purpose of the present study was to evaluate whether unilateral intracompartmental pressure (ICP) measurements correctly represent the contralateral ICP value in patients suspected to have bilateral chronic exertional compartment syndrome (CECS) in the anterior compartment of the leg.Methods:A retrospective cohort study was performed that included military service members who had been referred to a secondary care department for bilateral anterolateral exercise-related leg pain. The obtained ICP values were utilized to assess 2 possible measurement strategies to perform unilateral ICP measurements: the right-leg strategy (i.e., always testing the right leg) and the most-symptomatic-leg strategy (i.e., always testing the most symptomatic). The diagnostic cutoff value for CECS in this cohort was 35 mmHg in the first minute after provocation. Four outcome categories were created to describe the pressure classification of the second leg if only 1 leg would have been measured: correct (category 1: both values ≥35 mmHg; category 2: both values 5 mmHg from the 35-mmHg cutoff value compared with 40% of the 52 patients in categories 3 and 4.Conclusions:In military service members with bilateral chronic anterolateral exertional pain, a unilateral ICP measurement seems to be justified, especially among those with pressure values >5 mmHg above or below the diagnostic cutoff value. When a unilateral pressure measurement is within 5 mmHg above or below the cutoff value, a bilateral ICP measurement may be warranted.Level of Evidence:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The active participation of nurses in evidence-based practice (EBP) is challenging and topical, as shown by the worldwide calls for appropriate, accessible, affordable care and the de-implementation of unnecessary care. Nurses’ perceived support from their managers and work environments may affect their self-efficacy and outcome expectancy in EBP, as well as hinder them in EBP. Associations between these issues have not yet been explored. This study examines the association of self-efficacy and outcome expectancy levels in EBP, as well as the perceived support for EBP from nurse leaders and in the working environment, among Dutch hospital nurses. Methods. Questionnaires measuring nurses’ self-efficacy, outcome expectancy, and perceived support for EBP from nurse leaders and their work environment were completed by 306 nurses in eight hospitals between March 2021 and June 2021. We used multilevel regression analyses to determine the associations and covariates. Results. This study shows that EBP-supportive leaders and work environments positively contribute to nurses’ self-efficacy and outcome expectancy in EBP, along with the covariates undertaking EBP activities and educational level. Conclusions. To improve nurses’ active participation in EBP, nurses need to increase their self-efficacy and outcome expectancy in EBP. Supportive leaders and a supportive work environment do have an impact. Hence, these factors need attention when implementing EBP among nurses.

In this study, we aimed to (a) evaluate postnatal changes in bone development in relation to growth and (b) to determine factors associated with bone development, from birth to 24 months of corrected age. The metacarpal speed of sound (mcSOS) and metacarpal bone transmission time (mcBTT) were used to evaluate bone development in 98 preterm infants, during hospitalization and follow-up. The mcSOS and mcBTT values not only declined in the first 6 weeks of hospitalization but also during follow-up. The mcSOS reached its lowest point at 12 months (β=-34.64), while the mcBTT reached a plateau between 12 and 24 months (β=0.06). Univariable analysis showed that gender (p=0.28), time (ppp=0.009), length (p=0.063), length standard deviation scores (SDS) (p=0.027), head circumference (p=0.005), and head circumference SDS (p=0.007) were significant positive. The multivariable model revealed that time (β= -3.364, p=β=-0.007, pβ=1.163, pβ=-0.021, pβ= 0.066, pβ=0.049, pConclusion: The most important finding is that mcSOS decreased and the mcBTT reached a plateau to 24 months. In both mcSOS and mcBTT, the growth parameters were significant factors.Clinical Trial Registration: N/A What is known:• Metabolic bone disease is one of the possible long term adverse outcomes after preterm birth.• Metacarpal speed of sound (mcSOS) and metacarpal bone transmission time (mcBTT) decline in the early postnatal period. What is new:• During follow-up, mcSOS further decreased and reached its lowest point at 12 months, while the mcBTT reached a plateau up to 24 months.• Postnatal nutrition in relation to comorbidity does not meet the optimal mineralization rate of the developing preterm bone.

BackgroundA new potential target for multimodal pain management is the group-II metabotropic glutamate receptor subtypes, which can be activated by N-acetylcysteine. We investigated whether pre-emptive administration of N-acetylcysteine leads to a reduction in postoperative pain after laparoscopic inguinal hernia repair.MethodsSixty American Society of Anesthesiologists I-II patients scheduled for elective inguinal hernia repair were randomized to receive either N-acetylcysteine (150 mg/kg) or placebo intravenously 1 hour before surgery. The primary outcome was the visual analogue score during movement in the morning (approximately 24 hours) after surgery. Among secondary outcomes were postoperative opioid consumption and safety of intravenous N-acetylcysteine.ResultsIn total, 23 patients were analyzed per group. Pain scores were similar at all timepoints with a 24 hours median score of 34 (IQR of 19.0 to 42.5) in the N-acetylcysteine group and a median score of 26 (16.0 to 50.0) in the placebo group. The percentage of patients using opioids after surgery was 22% versus 39% day 1 (p=0.63); 9% versus 26% day 2 (p=0.14); 9% versus 17% day 3 (p=0.35) in the N-acetylcysteine group compared with placebo group. Side effects resembling anaphylactoid reactions in response to the administration of N-acetylcysteine were present in more than half of the patients.ConclusionsWithout finding important differences between N-acetylcysteine and placebo group in pain scores postoperatively, but with a high percentage of bothersome side effects for the N-acetylcysteine group, we would not recommend the use of pre-emptive intravenous N-acetylcysteine to reduce postoperative pain in laparoscopic inguinal hernia repair patients based on this study.Trial registration numberNCT03354572.

Dijksma, I, Hof, MHP, Lucas, C, and Stuiver, MM. Development and validation of a dynamically updated prediction model for attrition from Marine recruit training. J Strength Cond Res XX(X): 000-000, 2021-Whether fresh Marine recruits thrive and complete military training programs, or fail to complete, is dependent on numerous interwoven variables. This study aimed to derive a prediction model for dynamically updated estimation of conditional dropout probabilities for Marine recruit training. We undertook a landmarking analysis in a Cox proportional hazard model using longitudinal data from 744 recruits from existing databases of the Marine Training Center in the Netherlands. The model provides personalized estimates of dropout from Marine recruit training given a recruit's baseline characteristics and time-varying mental and physical health status, using 21 predictors. We defined nonoverlapping landmarks at each week and developed a supermodel by stacking the landmark data sets. The final supermodel contained all but one a priori selected baseline variables and time-varying health status to predict the hazard of attrition from Marine recruit training for each landmark as comprehensive as possible. The discriminative ability (c-index) of the prediction model was 0.78, 0.75, and 0.73 in week one, week 4 and week 12, respectively. We used 10-fold cross-validation to train and evaluate the model. We conclude that this prediction model may help to identify recruits at an increased risk of attrition from training throughout the Marine recruit training and warrants further validation and updates for other military settings.

Background: Women at risk of cardiovascular disease (CVD) may be missed with current eligibility criteria for CVD risk screening, particularly those from ethnic minority groups, among whom high risk is prevalent at a younger age. Early menopause (EM; menopause before 45 years) is associated with increased risk of CVD, and may be a potential eligibility criterion for CVD risk screening. Aims and objectives: To determine the contribution of EM to current criteria from patient history (having a family history of CVD, current smoking, obesity and age over 50 years) for identifying women eligible for CVD risk screening in a multi-ethnic population. Methods and results: We used baseline data (2011–2015) from 4512 women aged 45–70 years of Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish and Moroccan ethnic origin from the HELIUS study (Amsterdam, Netherlands). Models based on current eligibility criteria with and without EM were compared on area under the curve (AUC) with regard to estimated 10-year CVD risk using the Dutch SCORE. Overall, models with EM had a higher AUC, but changes were not statistically significant. In our total sample of women aged between 45 and 70 years, the AUC changed from 0.70 (95%CI 0.69–0.72) to 0.71 (95%CI 0.69–0.72). Among women aged 45–50 years the AUC changed from 0.66 (95%CI 0.58–0.74) to 0.68 (95%CI 0.59–0.74). Results were consistent across ethnic groups. Conclusions: The addition of EM to current eligibility criteria did not improve the detection of women at high CVD risk in a multi-ethnic sample of women aged 45–70 years.

Swallowing muscle strength exercises are effective in restoring swallowing function. In order to perform the exercises with progressive load, the swallow exercise aid (SEA) was developed. Precise knowledge on which muscles are activated with swallowing exercises, especially with the SEA, is lacking. This knowledge would aid in optimizing the training program to target the relevant swallowing muscles, if necessary. Three healthy volunteers performed the three SEA exercises (chin tuck against resistance, jaw opening against resistance and effortful swallow) and three conventional exercises [conventional effortful swallow (cES), Shaker and Masako] in supine position inside an MRI scanner. Fast muscle functional MRI scans (generating quantitative T2-maps) were made immediately before and after the exercises. Median T2 values at rest and after exercise were compared to identify activated muscles. After the three SEA exercises, the suprahyoid, infrahyoid, sternocleidomastoid, and lateral pterygoid muscles showed significant T2 value increase. After the Shaker, the lateral pterygoid muscles did not show such an increase, but the three other muscle groups did. The cES and Masako caused no significant increase in any of these muscle groups. During conventional (Shaker) exercises, the suprahyoid, infrahyoid, and sternocleidomastoid muscles are activated. During the SEA exercises, the suprahyoid, infrahyoid, sternocleidomastoid, and lateral pterygoid muscles are activated. The findings of this explorative study further support the potential of the SEA to improve swallowing rehabilitation.

Background In the Dutch Armed Forces (DAF), low back pain is the third most reported musculoskeletal disorder. For the prognosis of chronic low back pain (CLBP) only limited evidence is available. This observation results in a lack of clarity on prognostic factors that might affect recovery from CLBP in service members.The main objective is to identify general and military-related factors that are associated with the level of recovery in DAF service members with CLBP who followed a rehabilitation program. Methods One hundred five consecutive service members with CLBP who completed the rehabilitation program have been included in this prospective observational cohort study. The primary outcome measurement, level of disability, was used to distinguish a recovered and non-recovered group. Level of pain and self-perceived recovery were used as secondary outcome measurements. Disability and pain were measured at baseline and 12 weeks follow-up and self-perceived recovery only at follow-up. Differences were evaluated within and between the groups using the Student’s t-test, according to the normality of the data distribution. Bivariate logistic regression analyses were used for identifying the prognostic factors related to various outcomes of recovery. Results After following the rehabilitation program, 64.8% of the service members recovered from CLBP. In the recovered group, there are significant effect sizes of -6.72 (CI: -7.57 - -5.87) in the level of disability and − 2.58 (CI: -3.17- -1.98) in level of pain, whereas the non-recovered group shows a non-significant effect size of -0.49 (CI: -1.27 - -0.29) in level of disability and a significant effect size of -0.94 (CI: -1.62 - -0.25) in level of pain. The self-perceived recovery in the recovered group is on average “much improved” and in the non-recovered group “slightly improved”. The results of the bivariate regression analyses show no significant independent prognostic factors related to recovery. Conclusion In this study, no significant independent prognostic factors could be identified that are associated to the various outcomes of recovery in service members with CLBP who followed a rehabilitation program.

Multiple studies found hamstring tendon (HT) autograft diameter to be a risk factor for anterior cruciate ligament (ACL) reconstruction failure. This study aimed to determine which preoperative measurements are associated with HT autograft diameter in ACL reconstruction by directly comparing patient characteristics and cross-sectional area (CSA) measurement of the semitendinosus and gracilis tendon on magnetic resonance imaging (MRI). Fifty-three patients with a primary ACL reconstruction with a four-stranded HT autograft were included in this study. Preoperatively we recorded length, weight, thigh circumference, gender, age, preinjury Tegner activity score, and CSA of the semitendinosus and gracilis tendon on MRI. Total CSA on MRI, weight, height, gender, and thigh circumference were all significantly correlated with HT autograft diameter (p

PURPOSE: To evaluate the feasibility and outcomes of a tailored, goal-directed, and exercise-based physical therapy program for patients with metastatic breast cancer (MBC).METHODS: This was an observational, uncontrolled feasibility study. The physical therapy intervention was highly tailored to the individual patient's goals, abilities, and preferences and could include functional, strength, aerobic, and relaxation exercises. Feasibility outcomes were participation rate (expected: 25%), safety, and adherence (percentage of attended sessions relative to scheduled sessions). Additional outcomes were goal attainment, self-reported physical functioning, fatigue, health-related quality of life, and patient and physical therapist satisfaction with the program.RESULTS: Fifty-five patients (estimated participation rate: 34%) were enrolled. Three patients did not start the intervention due to early disease progression. An additional 22 patients discontinued the program prematurely, mainly due to disease progression. Median intervention adherence was 90% and no major intervention-related adverse events occurred. A goal attainment score was available for 42 patients (of whom 29 had completed the program and 13 had prematurely dropped out). Twenty-two (52%) of these patients achieved their main goal fully or largely and an additional 15 patients (36%) partially. Eighty-five percent would "definitely recommend" the program to other patients with MBC. We observed a modest improvement in patient satisfaction with physical activities (Cohen's dz 0.33).CONCLUSION: The tailored intervention program was feasible in terms of uptake, safety, and outcomes and was highly valued by patients and physical therapists. However, disease progression interfered with the program, leading to substantial dropout.TRIAL REGISTRATION: NTR register: NTR6475.

Objective: Chemoradiotherapy (CRT) for head and neck cancer (HNC) is associated with high toxicity that adversely affects physical functioning, body composition, fatigue, quality of life and treatment outcomes. Exercise interventions during treatment might counteract these negative effects. We therefore assessed the feasibility of an exercise programme for HNC patients during CRT.Methods: Forty patients were offered a tailored 10-week endurance and resistance training with supervised and home-based sessions. Feasibility endpoints were (1) adherence (main outcome): ≥60% attendance; (2) recruitment: ≥30%; (3) retention rate: ≥85% and (4) compliance rate: ≥60%. Physical performance, muscle strength, body composition, quality of life and fatigue were assessed pre- and post-intervention.Results: Overall adherence was 54%. The recruitment rate was 36%, and the retention rate was 65%. Compliance to the supervised intervention protocol was 66%. Statistically significant decreases were found in mean grip strength, fat-free mass and clinically relevant deteriorations on several domains of quality of life, and fatigue subscales were found.Conclusion: We conclude that this exercise programme for HNC patients during CRT in its current form is feasible for only a minority of patients. We suggest adaptations to improve adherence and retention rates for a definitive multicentre trial.Trial registration: This study is registered at the Netherlands Trial Register (NTR7305), 6 June 2018, retrospectively registered.

Background: Higher levels of physical activity are associated with a lower risk of cardiovascular disease in the general population. Whether the same holds for women who underwent treatment for breast cancer is unclear. Objectives: The aim of this study was to evaluate the association between physical activity in a typical week in the past 12 months and cardiac dysfunction in breast cancer survivors. Methods: We used data from a cohort of breast cancer survivors who were treated at ages 40 to 50 years (N = 559). The association between physical activity and global longitudinal strain (GLS) and left ventricular ejection fraction (LVEF) was evaluated using both linear and modified Poisson regression analyses adjusted for relevant confounders. Results: In total, 559 breast cancer survivors were included, with median age of 55.5 years and a median time since treatment of 10.2 years. GLS was less favorable in inactive survivors (-17.1%) than in moderately inactive (-18.4%), moderately active (-18.2%), and active survivors (-18.5%), with an adjusted significant difference for active versus inactive survivors (β = -1.31; 95% CI: -2.55 to -0.06)). Moderately active (n = 57/130) and active survivors (n = 87/124) had significantly lower risks of abnormal GLS (defined as >-18%) compared with inactive survivors (n = 17/26) (RR: 0.65 [95% CI: 0.45-0.94] and RR: 0.61 [95% CI: 0.43-0.87], respectively). LVEF, in normal ranges in all activity categories, was not associated with physical activity. Conclusions: In long-term breast cancer survivors, higher physical activity levels were associated with improved GLS but not LVEF, with the relatively largest benefit for doing any activity versus none. This finding suggests that increasing physical activity may contribute to cardiovascular health benefits, especially in inactive survivors.

INTRODUCTION: An optimal relative dose intensity (RDI) of adjuvant chemotherapy is associated with better survival in patients with breast cancer. Little is known about the role of physical fitness in attaining an adequate RDI in patients with early-stage breast cancer. We investigated the association between pretreatment physical fitness and RDI in this population.METHODS: We pooled individual patient data from two randomized exercise trials that studied exercise programs in early breast cancer: the Physical Exercise During Adjuvant Chemotherapy Effectiveness Study (n = 230) and the Physical Activity during Chemotherapy Treatment (n = 204) study. Logistic regression models were used to evaluate the association between pretreatment fitness and achieving an optimal RDI (≥85%). In addition, we added an interaction term to the model to explore the potential moderating effect of participating in an exercise program.RESULTS: Data were available for 419 patients (mean age at diagnosis, 50.0 ± 8.6 yr). In the total sample, lower pretreatment physical fitness was associated with significantly lower odds of achieving ≥85% RDI: age-adjusted odds ratio (OR) of 0.66 (95% confidence interval (CI), 0.46-0.94). In patients allocated to the supervised exercise intervention during chemotherapy (n = 173), the association between pretreatment physical fitness and RDI was almost completely mitigated (OR, 0.95 (95% CI, 0.54-1.56)), whereas it was more pronounced in patients who received care as usual (n = 172; OR, 0.31 (95% CI, 0.13-0.63); Pinteraction = 0.022).CONCLUSIONS: Early-stage breast cancer patients with relatively lower levels of pretreatment physical fitness have lower odds of achieving an optimal dose of chemotherapy. Given that physical fitness is modifiable and our results suggest that following a moderate-to-high intensity exercise training during chemotherapy could improve treatment completion, clinicians should not refrain from referring patients to supportive exercise programs because of low fitness.

IntroductionMusculoskeletal injuries (MSIs) are among the main causes of dropout from military training. The main purpose of this study was to provide an overview of dropout rates and MSI incidence rates during elite military training. Second, this study aimed to explore restricted training days due to MSIs and to describe MSI-care by military physicians.MethodsIn a retrospective observational study, we collected dropout rates and injury surveillance data from the electronic patient records of two elite units of the Netherlands Armed Forces (NAF): the Royal Netherlands Marine Corps (RNLMC) and the Airmobile Brigade (AMB), from 1 January 2015 until 31 December 2017.ResultsIn the RNLMC, total dropout rate was 53.9% and dropout due to MSIs was 23%. The most frequently affected locations were foot, knee and leg. In the AMB total dropout rate was 52.6% and dropout due to MSIs was 25%. In the AMB, the most frequently affected locations were back, knee and leg. Average restricted training days due to MSIs ranged between 8.3 and 20.8 days/injury. MSI-care by military physicians consisted mostly of the provision of injury-specific information and (self-)management options, imposing a specific activity restriction and referral to physiotherapy.ConclusionOur study findings showed that one out of four recruits who dropout from elite military training in the NAF, do so due to MSIs. Redesigning training programmes with the objective to reduce MSIs should be given high priority, as this may reduce dropout substantially.

Objectives: Expiratory muscle strength training (EMST) is a threshold based device-driven treatment for improving expiratory pressure. EMST proved to be effective in different patient groups to improve cough function. To date, EMST has not been tested in the total laryngectomy population (TL). Methods: This prospective, randomized case-series study examined feasibility, safety, and compliance of EMST in a group of TL participants and its effects on pulmonary function, physical exertion, fatigue, and vocal functioning. Ten TL participants were included in the study to perform a 4 till 8 weeks of EMST. Objective and subjective outcome measures included manometry, spirometry, cardio pulmonary exercise testing (CPET), voice recordings, and patient reported outcome measures. Group means were reported and estimates of the effect are shown with a 95% confidence interval, using single sample t-tests. Results: Nine participants completed the full study protocol. Compliance to the training program was high. All were able to perform the training, although it requires adjustments of the device and skills of the participants. Maximum expiratory pressure (MEP) and vocal functioning in loudness improved over time. After EMST no changes were seen in other objective and subjective outcomes. Conclusions: EMST appears to be feasible and safe after total laryngectomy. MEP improved over time but no improvement in the clinically relevant outcome measures were seen in this sample of relatively fit participants. Further investigation of the training in a larger group of participants who report specifically pulmonary complaints is recommended to investigate if the increase in MEP results in clinical benefits. Level of Evidence: 4

Background: Hip fracture in the elderly is associated with increased morbidity and mortality. Pneumonia during hospitalization is not uncommon and is associated with poorer outcomes, such as an increased risk of readmission and higher mortality rates. We aim to identify independent predictive factors for developing pneumonia during hospitalization in this group and also assessed the effect pneumonia has on hospital-stay, in-hospital and 30-day mortality. Methods: Retrospective cohort study with prospectively collected data from hospitalized elderly hip fracture patients between January 2015 and January 2017. Examined predictors were age, gender, pre-fracture living situation, pre-fracture mobility score, pre-fracture ADL-status, history of dementia, diabetes, congestive heart failure, chronic obstructive pulmonary disease and prior stroke, ASA-score, anemia at admission, surgery within 48 hours, surgical procedure and anesthesia used. Multivariable regression analysis including resampling methods (bootstrapping) was used to examine the effects of predictors. Results: Of 407 patients, 62 (15.2%) were treated for pneumonia during hospitalization. Only gender, surgery within 48 hours and history of COPD differed significantly at baseline between the groups with and without pneumonia. Adjusted for age and gender, we observed a 1.6 times longer hospital-stay (95% CI 1.4-1.9, p

In this prospective observational study, the incidence, risk factors and the time to event of urinary retention in children receiving intravenous opioids were evaluated. Urinary retention was confirmed by ultrasound following the inability to void for 8 h or earlier in patients experiencing discomfort. In total, 207 opioid episodes were evaluated, of which 199 (96.1%) concerned morphine, in 187 children admitted to the pediatric ward or pediatric intensive care unit. The median age was 7.6 years (IQR 0.9–13.8), and 123 (59.4%) were male. The incidence of urinary retention was 31/207 (15.0%) opioid episodes, in which 14/32 (43.8%) patients received continuous sedation for mechanical ventilation and 17/175 (9.7%) received no sedation. Multivariable logistic regression analysis showed a significant association with continuous sedation (OR 6.8, 95% CI 2.7–17.4, p 0.001) and highest daily fluid intake (OR 0.8 per 10% deviation of normal intake, 95% CI 0.7–0.9, p 0.01). Opioid dosage, age and gender were not significantly associated. Most events (28/31, 90.3%) occurred within 24 h.Conclusion: The incidence of urinary retention in children receiving intravenous opioids is low, indicating that placement of urinary catheters is not routinely necessary in these patients. However, micturition and bladder volumes must be monitored, especially in sedated children and during the first 24 h of opioid administration. What is Known:• Great variation exists in the routine placement of urinary catheters in children receiving IV opioids. What is New:•Confirmed by ultrasound, the incidence of urinary retention in children receiving intravenous opioids in this study was 15%, indicating that placement of urinary catheters is not routinely necessary in these patients.•Children receiving continuous sedation for invasive mechanical ventilation showed a sevenfold greater risk of developing urinary retention than non-sedated patients.

Background Cancer survivors' perspectives on a successful return to work (RTW) may not be captured in the common measure of RTW, namely time until RTW. Objective The purpose of this study was therefore to develop an RTW outcome measure that reflects employed cancer survivors' perspectives, with items that could be influenced by an employer, i.e. the Successful Return-To-Work questionnaire for Cancer Survivors (I-RTW_CS), and to assess its construct validity and reproducibility. Methods First, three focus groups with cancer survivors (n = 14) were organized to generate issues that may constitute successful RTW. Second, a two-round Delphi study among 108 cancer survivors was conducted to select the most important issues. Construct validity of the I-RTW_CS was assessed using correlations with a single-item measure of successful RTW and the Quality of Working Life Questionnaire for Cancer Survivors (QWLQ-CS; n = 57). Reproducibility (test-retest reliability) was assessed using the intraclass correlation coefficient (ICC; n = 50). Results Forty-eight issues were generated, of which seven were included: 'enjoyment in work'; 'work without affecting health'; 'confidence of employer without assumptions about work ability'; 'open communication with employer'; 'feeling welcome at work'; 'good work-life balance'; and 'joint satisfaction with the situation (employer and cancer survivor)'. Correlations with single-item successful RTW and QWLQ-CS were 0.58 and 0.85, respectively. The reproducibility showed an ICC of 0.72. Conclusions The I-RTW_CS provides an RTW outcome measure that includes cancer survivors' perspectives and weights its items on an individual basis, allowing a more meaningful evaluation of cancer survivors' RTW. This study provides preliminary evidence for its construct validity and reproducibility.

Idiopathic pulmonary fibrosis (IPF) is characterized by progressive loss of pulmonary function and exercise capacity, leading to loss of quality of life and often social isolation. A new walking aid, the walk-bike, showed an improvement in exercise performance in COPD patients. Aims of this pilot study were to evaluate feasibility of a homebased walk-bike intervention study in IPF patients and to explore the effect of the walk-bike on quality of life (QoL) and exercise capacity. Twenty-three patients with IPF were included in a randomized multicenter crossover study with 8 weeks of standard care and 8 weeks of walk-bike use at home. Ten patients completed both study phases. Study barriers included reluctance to participate and external factors (e.g. weather and road conditions) that hampered adherence. Patients’ satisfaction and experience with the walk-bike varied greatly. After training with the walk-bike, health-related QoL (St. George’s Respiratory and King’s Brief Interstitial Lung Disease questionnaires) demonstrated a tendency towards improvement, exercise capacity did not. A clinically important difference was found between 6-minute walk test with the walk-bike and the standard test; median (range) respectively 602 m (358-684) and 486 m (382-510). Conclusions: Due to practical barriers a larger study with the walk-bike in patients with IPF seems not feasible. Individual patients may benefit from the use of a walk-bike as it improved action radius and showed a tendency towards improvement in QoL. No effect on exercise capacity was observed. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (2): 192-202)

INTRODUCTION: The aim of this study was to investigate reasons why people consulted an occupational therapist following cancer treatment, and to examine the outcome of occupational therapy interventions, in the context of multidisciplinary rehabilitation.METHODS: Data from 181 patients were collected retrospectively. The International Classification of Human Functioning and Health (ICF) was used to describe the reasons for occupational therapy consultation. Patients had completed the Canadian Occupational Performance Measurement (COPM) before and after the occupational therapy intervention. Change scores were calculated with a 95% confidence interval and a two-sided p-value obtained from a paired t-test.RESULTS: The reasons for occupational therapy consultation were predominantly within the ICF domain "Activities and Participation". On average, patients improved 3.0 points (95% CI 2.8-3.2) on the performance scale of the COPM, and 3.4 points (95% CI 3.2-3.7) on the satisfaction scale (both: p = CONCLUSION: The result of this study supports the added value of occupational therapy to cancer rehabilitation, and emphasise the positive effect of occupational therapy on everyday functioning. Controlled clinical studies are needed to strengthen the evidence.

OBJECTIVE: Seventy percent of patients with colorectal cancer (CRC) are aged 65 years or older. Netherlands Comprehensive Cancer Organization (n.d.) [1] Surgery is an important treatment modality, depending on cancer stage and the resectability of the tumor. Frail older patients are at an increased risk for complications and reduced self-care capacity after surgery. Increasing physical fitness preoperatively (prehabilitation) might improve treatment outcomes, but challenges remain with regard to uptake, attrition, and non-compliance. The objectives of this study were to investigate the barriers, facilitators, and preferences for preoperative exercise programs in older patients scheduled for CRC surgery.METHODS: This was a qualitative study, using in-depth interviews of fifteen patients aged 65 years and older and surgically treated for CRC, thirteen informal care givers (ICs) and nine health care providers (HCPs) with experience in prehabilitation. Data analysis was done through thematic coding analysis.RESULTS: Limited time, not receiving or misunderstanding information, physical ailments, and emotional impact of the diagnosis are barriers to preoperative exercise. Not having physical complaints (Patients, ICs, HCPs), understandable information provided by a physician (Patients, ICs), and low cost programs (ICs, HCPs) facilitate exercise. Exercise should not be too intensive (Patients, ICs) and should be adjusted to personal preferences and be provided close to home (Patients, ICs, HCPs).CONCLUSIONS: To engage frail older adults with CRC in preoperative exercise programs information on exercise should improve. Exercise programs should be easily accessible and take personal preferences, needs and abilities into account.

IntroductionMusculoskeletal injuries (MSIs) have direct impact on occupational readiness and task performance in military populations. Until this date, no epidemiologic data have been published concerning MSI incidence in the Netherlands Armed Forces (NAF). The aim of this study was to assess the MSI incidence and related costs in the NAF.MethodsIn this descriptive epidemiologic study, we collected injury surveillance data from the electronic patient records of multiple military units of the NAF. Using data of all new consultations with a military physician from January 1, 2014 to December 31, 2016, we calculated MSI incidence rates per 100 person-years, with a 95% confidence interval (CI). Physician care costs were determined based on the number of physician consults and the charge per appointment. We used two methods to determine productivity costs; the top-down microcosting method and the friction cost method.ResultsOur study sample included 22% (n = 8,847) of the total NAF population of 2016 (n =40,178). In this sample, consultations of MSIs accounted for 23.2% (n = 7,815) of all new consultations (n = 33,666). MSI incidence rates per unit ranged from 12.5 to53.3 per 100 person-years. In the total sample, MSI incidence rates were highest in the back (6.73, 95% CI 6.39–7.10), knee (5.04, 95% CI 4.74–5.35), and foot (4.79, 95% CI 4.50–5.10). The estimated costs for physician visits for MSIs in our sample were €0.69 million. Limited duty days accounted for €1.10 million productivity costs using top-down microcosting method.ConclusionOur study provided evidence that MSIs result in substantial financial burden. Injuries of the back, knee, and foot account for the majority of demands on curative care for MSIs.

Background Since the introduction of arthroplasty fast-track protocols, many studies have investigated their effect on complications and length of hospital stay. However, few fast-track studies have examined the long-term effects on cost and health-related quality of life after total knee arthroplasty (TKA). This study aimed to specifically analyze, after implementation of fast-track TKA, cost-effectiveness with functional outcome, length of stay, thromboembolic complications, medical costs, and quality of life after 12 months. Methods A retrospective cohort of 403 TKA patients treated by a fast-track pathway were compared with 283 patients in a non-fast-track pathway. Length of stay and thromboembolic complications were registered postoperatively. Healthcare costs were based on hospital production costs and calculated on average. Costs were compared with EQ-5D questionnaires to derived quality-adjusted life year (QALY) scores. Results No between-protocol differences were found in functional outcome and quality of life after TKA. The fast-track protocol reduced the length of stay from a median five days to median three days, and did not influence the thromboembolic complication rate (2.6%). After one-year follow-up for fast-track pathway patients, QALY was 0.85 vs. 0.84 for non-fast-track. A reduction of 268,- euro per patient was calculated in favor of the fast-track protocol. Conclusion Fast-track protocol implementation is a cost-effective strategy for patients undergoing TKA, with high QALY and reduced costs. Fast-track TKA treatment is safe, with low thromboembolic complications. This is the first study to measure fast-track implementation effects on functional outcome and quality of life up to 12 months postoperatively, and calculate equivalent QALYs for both groups. Level of evidence Level III.

PURPOSE: In this study, we investigated factors associated with program adherence and patient satisfaction with a home-based physical activity program (Onco-Move, N = 77) and a supervised exercise program with a home-based component (OnTrack, N = 76).METHODS: We assessed adherence via self-report (home-based program) and attendance records (supervised program). We used logistic regression analysis to identify sociodemographic, clinical and behavioural variables associated with program adherence. Patient satisfaction was assessed with self-report and is reported descriptively.RESULTS: Fifty-one percent of Onco-Move and 62% of OnTrack participants were adherent to the home-based program, while 59% of OnTrack participants were adherent to the supervised sessions. Higher baseline physical fitness was associated with higher adherence to home-based components. Higher disease stage and having a partner were associated with adherence to OnTrack supervised sessions. Overall satisfaction with the exercise programs was high, but ratings of coaching provided by professionals for the home-based components were low. Patients offered suggestions for improving delivery of the programs.CONCLUSIONS: These findings point to factors relevant to program adherence and suggest ways in which such programs can be improved. Providing additional time and training for health care professionals could improve the quality and hopefully the effectiveness of the interventions. The use of online diaries and smartphone apps may provide additional encouragement to participants. Finally, allowing greater flexibility in the planning and availability of supervised exercise training in order to accommodate the variability in cancer treatment schedules and the (acute) side effects of the treatments could also enhance program adherence.TRIAL REGISTRATION: Netherlands Trial Register, NTR2159. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2159.

Background: Catheter-associated bloodstream infections and urinary tract infections are frequently encountered health care-associated infections. We aimed to reduce inappropriate use of catheters to reduce health care-associated infections. Methods: In this multicentre, interrupted time-series and before and after study, we introduced a de-implementation strategy with multifaceted interventions in seven hospitals in the Netherlands. Adult patients admitted to internal medicine, gastroenterology, geriatic, oncology, or pulmonology wards, and non-surgical acute admission units, and who had a (central or peripheral) venous or urinary catheter were eligible for inclusion. One of the interventions was that nurses in the participating wards attended educational meetings on appropriate catheter use. Data on catheter use were collected every 2 weeks by the primary research physician during the baseline period (7 months) and intervention period (7 months), which were separated by a 5 month transition period. The primary outcomes were percentages of short peripheral intravenous catheters and urinary catheters used inappropriately on the days of data collection. Indications for catheter use were based on international guidelines. This study is registered with Netherlands Trial Register, NL5438. Findings: Between Sept 1, 2016, and April 1, 2018, we screened 6157 patients for inclusion, of whom 5696 were enrolled: 2650 patients in the baseline group, and 3046 in the intervention group. Inappropriate use of peripheral intravenous catheters occurred in 366 (22·0%, 95% CI 20·0 to 24·0) of 1665 patients in the baseline group and in 275 (14·4%, 12·8 to 16·0) of 1912 patients in the intervention group (incidence rate ratio [IRR] 0·65, 95% CI 0·56 to 0·77, p

BACKGROUND Over the past decades, clinical pathways (CPs) for hip and knee arthroplasty have been strongly and continuously evolved based on scientific evidence and innovation. AIM The present systematic review, including meta-analysis, aimed to compare the safety and efficacy of enhanced recovery pathways (ERP) with regular pathways for patients with hip and/or knee arthroplasty. METHODS A literature search in healthcare databases (Embase, PubMed, Cochrane Library, CINAHL, and Web of Science) was conducted from inception up to June 2018. Relevant randomized controlled trials as well as observational studies comparing ERP, based on novel evidence, with regular or standard pathways, prescribing care as usual for hip and/or knee arthroplasty, were included. The effect of both CPs was assessed for (serious) adverse events [(S)AEs], readmission rate, length of hospital stay (LoS), clinician-derived clinical outcomes, patient reported outcome measures (PROMs), and financial benefits. If possible, a meta-analysis was performed. In case of considerable heterogeneity among studies, a qualitative analysis was performed. RESULTS Forty studies were eligible for data extraction, 34 in meta-analysis and 40 in qualitative analysis. The total sample size consisted of more than 2 million patients undergoing hip or knee arthroplasty, with a mean age of 66 years and with 60% of females. The methodological quality of the included studies ranged from average to good. The ERP had lower (S)AEs [relative risk (RR): 0.9, 95% confidence interval (CI): 0.8-1] and readmission rates (RR: 0.8, 95%CI: 0.7-1), and reduced LoS [median days 6.5 (0.3-9.5)], and showed similar or improved outcomes for functional recovery and PROMs compared to regular pathways. The analyses for readmission presented a statistically significant difference in the enhanced recovery pathway in favor of knee arthroplasties (P = 0.01). ERP were reported to be cost effective, and the cost reduction varied largely between studies (€109 and $20573). The overall outcomes of all studies reported using Grading of Recommendation, Assessment, Development and Evaluation, presented moderate or high quality of evidence. CONCLUSION This study showed that implementation of ERP resulted in improved clinical and patient related outcomes compared to regular pathways in hip and knee arthroplasty, with a potential reduction of costs.

Background Immunomodulatory therapies that improve the outcome of sepsis are not available. We sought to determine whether treatment of critically ill patients with sepsis with low-dose erythromycin—a macrolide antibiotic with broad immunomodulatory effects—decreased mortality and ameliorated underlying disease pathophysiology. Methods We conducted a target trial emulation, comparing patients with sepsis admitted to two intensive care units (ICU) in the Netherlands for at least 72 h, who were either exposed or not exposed during this period to treatment with low-dose erythromycin (up to 600 mg per day, administered as a prokinetic agent) but no other macrolides. We used two common propensity score methods (matching and inverse probability of treatment weighting) to deal with confounding by indication and subsequently used Cox regression models to estimate the treatment effect on the primary outcome of mortality rate up to day 90. Secondary clinical outcomes included change in SOFA, duration of mechanical ventilation and the incidence of ICU-acquired infections. We used linear mixed models to assess differences in 15 host response biomarkers reflective of key pathophysiological processes from admission to day 4. Results In total, 235 patients started low-dose erythromycin treatment, 470 patients served as controls. Treatment started at a median of 38 [IQR 25–52] hours after ICU admission for a median of 5 [IQR 3–8] total doses in the first course. Matching and weighting resulted in populations well balanced for proposed confounders. We found no differences between patients treated with low-dose erythromycin and control subjects in mortality rate up to day 90: matching HR 0.89 (95% CI 0.64–1.24), weighting HR 0.95 (95% CI 0.66–1.36). There were no differences in secondary clinical outcomes. The change in host response biomarker levels from admission to day 4 was similar between erythromycin-treated and control subjects. Conclusion In this target trial emulation in critically ill patients with sepsis, we could not demonstrate an effect of treatment with low-dose erythromycin on mortality, secondary clinical outcomes or host response biomarkers.

IntroductionMid-portion Achilles tendinopathy (mid-AT) is currently the preferred term for persistent Achilles tendon pain, defined as located 2–7 cm proximal to the calcaneus, and with loss of function related to mechanical loading. Histologically, mid-AT is considered to represent a degenerative condition. Therefore, monitoring of tendon structure additional to pain and function may be warranted, to prevent progression of degeneration or even tendon rupture. The aim of this study was to determine the association between pain and function, relative to the Achilles tendon structure, in soldiers treated with a conservative programme for mid-AT.MethodsA total of 40 soldiers (40 unilateral symptomatic tendons) were included in this study. Pain and function were evaluated with the Victorian Institute of Sports Assessment -Achilles (VISA-A) questionnaire. Tendon structure was quantified using ultrasound tissue characterisation (UTC). We quantified both the Achilles tendon mid-portion (2–7 cm) and the area of maximum degeneration (AoMD) within the tendon mid-portion. VISA-A and UTC measurements were taken at baseline and after 26 weeks of follow-up. Spearman’s rho was used to determine the correlation between VISA-A and UTC. Correlations were calculated for baseline, follow-up and change score values.ResultsNegligible correlations were found for all analyses, ranging from −0.173 to 0.166 between mid-portion tendon structure and VISA-A, and from −0.137 to 0.150 between AoMD and VISA-A. While VISA-A scores improved, on average, from 59.4 points at baseline to 93.5 points at follow-up, no detectable improvement in aligned fibrillar structure was observed in our population.ConclusionPain and function are poorly associated with Achilles tendon structure in soldiers treated with a conservative programme for mid-AT. Therefore, we advise clinicians to use great caution in communicating relationships between both clinical entities.Trial registration numberNL69527.028.19.

Contains fulltext : 291817.pdf (Publisher’s version ) (Open Access) BACKGROUND: Several conditions and diseases can result in speech problems that can have a negative impact on everyday functioning, referred to as communicative participation. Subjective problems with acquired speech problems are often assessed with the speech handicap index (SHI). To assess generic participation problems, the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P) questionnaire is frequently used. The English questionnaire Communicative Participation Item Bank-short form (CPIB short form) is a 10-item valid, reliable instrument that assesses communicative participation. In the absence of a Dutch equivalent, translation and validation of the CPIB short form was required. AIMS: To translate the CPIB short form into Dutch, and to determine its psychometric properties for the group of adults with speech problems resulting from a neurological aetiology or head and neck cancer. METHODS & PROCEDURES: Translation of the CPIB short form was performed following the instructions of the European Organisation for Research and Treatment for Cancer (EORTC). In a cross-sectional multi-centre study, participants completed the Dutch CPIB short form together with the SHI and USER-P, and the CPIB a second time after 2 weeks. We assessed internal consistency and test-retest reliability of the CPIB. Construct validity was assessed based on correlations with SHI, USER-P and speech assessments. OUTCOMES & RESULTS: In the validation study, 122 participants were included: 51 with dysarthria due to different neurological disorders, 48 with speech problems due to head and neck cancer treatment and 23 healthy controls. Internal consistency of the items was high (Cronbach's alpha = 0.962), the intraclass correlation coefficient (ICC) for test-retest reliability was high 0.908 (95% CI = 0.870-0.935). Construct validity was supported by a strong correlation between the Dutch CPIB short form and the SHI total score (SHI total r(s) = 0.887) and a moderate correlation between the Dutch CPIB-10 and the USER-P subscales (USER-P Frequency r(s) = 0.365; USER-P restrictions and USER-P satisfaction r(s) = 0.546). A moderate correlation was found between the Dutch CPIB-10 and the speech performance assessments (degree of distortedness r = -0.0557; p ≤ 0.001; degree of intelligibility r = 0.0562). CONCLUSIONS & IMPLICATIONS: The Dutch CPIB short form provides a valid and reliable tool for clinical practice and research purposes. It allows clinicians to start using this PROM in clinical and research practice to systematically investigate the impact of the speech problems on communicative participation in a Dutch-speaking population. WHAT THIS PAPER ADDS: What is already known on the subject Communicative participation allows people to take part in life situations, but can be affected by acquired speech problems. The CPIB is a patient-reported outcome measure for the assessment of this concept. For the English language the 46-item bank and a 10-item short form is available. What this paper adds to existing knowledge This paper describes the process of translation of the CPIB short form into Dutch, and confirms its reproducibility and validity. What are the potential or actual clinical implications of this work? With this validated Dutch version of the CPIB short form available, professionals can implement this tool in clinical and research practice to systematically evaluate communicative participation.

Objective: To investigate the construct validity of the Steep Ramp Test (SRT) by longitudinally comparing the correlation between maximum short exercise capacity of the SRT and direct measurements of peak oxygen consumption (VO 2peak) during or shortly after treatment in patients with breast cancer and the potential effect of chemotherapy-induced symptom burden. Design: Cross-sectional. Setting: Multicenter. Participants: We used data from 2 studies that included women with breast cancer treated with chemotherapy, resulting in 274 observations. A total of 161 patients (N=161) performed the cardiopulmonary exercise test and the SRT in 2 test sessions on different time points around chemotherapy treatment. Interventions: Not applicable. Main Outcome Measures: Fatigue was assessed with the Multidimensional Fatigue Inventory, and nausea and vomiting and pain by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30. The longitudinal correlation between the maximum short exercise capacity and VO 2peak was investigated using a linear mixed model. Interaction terms were added to the model to investigate whether the correlation varied by symptom burden. Results: We found a statistically significant moderate correlation between VO 2peak and maximum short exercise capacity (0.61; 95% confidence interval, 0.51-0.70; P2peak with the maximum short exercise capacity with increasing symptom burden. Pain and fatigue did not significantly modify the correlation. Conclusions: The SRT can only be used as a proxy for changes in aerobic capacity with great caution and with attention for the level of nausea and vomiting.

Background Up to 60% of breast cancer patients treated with chemotherapy is confronted with cognitive problems, which can have a significant impact on daily activities and quality of life (QoL). We investigated whether exercise training improves cognition in chemotherapy-exposed breast cancer patients 2–4 years after diagnosis. Methods Chemotherapy-exposed breast cancer patients, with both self-reported cognitive problems and lower than expected performance on neuropsychological tests, were randomized to an exercise or control group. The 6-month exercise intervention consisted of supervised aerobic and strength training (2 h/week), and Nordic/power walking (2 h/week). Our primary outcome was memory functioning (Hopkins Verbal Learning Test-Revised; HVLT-R). Secondary outcomes included online neuropsychological tests (Amsterdam Cognition Scan; ACS), self-reported cognition (MD Anderson Symptom Inventory for multiple myeloma; MDASI-MM), physical fitness (relative maximum oxygen uptake; VO2peak), fatigue (Multidimensional Fatigue Inventory), QoL (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire; EORTC QLQ C-30), depression (Patient Health Questionnaire-9, Hospital Anxiety and Depression Scale; HADS), and anxiety (HADS). HVLT-R total recall was analyzed with a Fisher exact test for clinically relevant improvement (≥ 5 words). Other outcomes were analyzed using multiple regression analyses adjusted for baseline and stratification factors. Results We randomized 181 patients to the exercise (n = 91) or control group (n = 90). Two-third of the patients attended ≥ 80% of the exercise sessions, and physical fitness significantly improved compared to control patients (B VO2peak 1.4 ml/min/kg, 95%CI:0.6;2.2). No difference in favor of the intervention group was seen on the primary outcome. Significant beneficial intervention effects were found for self-reported cognitive functioning [MDASI-MM severity (B-0.7, 95% CI − 1.2; − 0.1)], fatigue, QoL, and depression. A hypothesis-driven analysis in highly fatigued patients showed positive exercise effects on tested cognitive functioning [ACS Reaction Time (B-26.8, 95% CI − 52.9; − 0.6) and ACS Wordlist Learning (B4.4, 95% CI 0.5; 8.3)]. Conclusions A 6-month exercise intervention improved self-reported cognitive functioning, physical fitness, fatigue, QoL, and depression in chemotherapy-exposed breast cancer patients with cognitive problems. Tested cognitive functioning was not affected. However, subgroup analysis indicated a positive effect of exercise on tested cognitive functioning in highly fatigued patients. Trial Registration Netherlands Trial Registry: Trial NL5924 (NTR6104). Registered 24 October 2016, https://www.trialregister.nl/trial/5924.

Background Early mobilisation of critically ill adults has been proven effective and is safe and feasible for critically ill children. However, barriers and perceived benefits of paediatric intensive care unit (PICU) staff involvement in mobilising critically ill children are largely unknown. In this study, we explored the barriers and perceived benefits regarding early mobilisation of critically ill children as perceived by PICU staff. Methods A cross-sectional survey study among staff from seven PICUs in the Netherlands has been carried out. Results Two hundred and fifteen of the 641 health care professionals (33.5%) who were invited to complete a questionnaire responded, of whom 159 (75%) were nurses, 40 (19%) physicians, and 14 (6%) physical therapists. Respondents considered early mobilisation potentially beneficial to shorten the duration of mechanical ventilation (86%), improve wake/sleep rhythm (86%) and shorten the length of stay in the PICU (85%). However, staff were reluctant to mobilize patients on extracorporeal membrane oxygenation (ECMO) (63%), and patients with traumatic brain injury (49%). Perceived barriers to early mobilisation were hemodynamic instability (78%), risk of dislocation of lines/tubes (74%), and level of sedation (62%). In total, 40.3% of PICU nurses stated that physical therapists provided enough support in their PICU, but 84.6% of the physical therapists believed support was sufficient. Conclusion Participating PICU staff considered early mobilisation as potentially beneficial in improving patient outcomes, although barriers were noted in certain patient groups. Relevance to Practice We identified barriers to early mobilisation which should be addressed in implementation research projects in order to make early mobilisation in critically ill children work.

Low muscle quality and a sedentary lifestyle are indicators for a slow recovery after a total knee arthroplasty (TKA). Mitochondrial function is an important part of muscle quality and a key driver of sarcopenia. However, it is not known whether it relates to recovery. In this pilot study, we monitored activity after TKA using a wrist mounted activity tracker and assessed the relation of mitochondrial function on the rate of recovery after TKA. Additionally, we compared the increase in activity as a way to measure recovery to traditional outcome measures. Patients were studied 2 weeks before TKA and up to 6 months after. Activity was monitored continuously. Baseline mitochondrial function (citrate synthase and complex [CP] 1-5 abundance of the electron transport chain) was determined on muscle tissue taken during TKA. Traditional outcome measures (Knee Injury and Osteoarthritis Outcome Score [KOOS], timed up-and-go [TUG] completion time, grip, and quadriceps strength) were performed 2 weeks before, 6 weeks after, and 6 months after TKA. Using a multivariate regression model with various clinical baseline parameters, the following were significantly related to recovery: CP5 abundance, grip strength, and activity (regression weights 0.13, 0.02, and 2.89, respectively). During recovery, activity correlated to the KOOS-activities of daily living (ADL) score (r = 0.55, p = 0.009) and TUG completion time (r = -0.61, p = 0.001). Mitochondrial function seems to be related to recovery, but so are activity and grip strength, all indicators of sarcopenia. Using activity trackers before and after TKA might give the surgeon valuable information on the expected recovery and the opportunity to intervene if recovery is low.

IntroductionMid-portion Achilles tendinopathy (mid-AT) is common in soldiers, significantly impacting activity levels and operational readiness. Currently, Victorian Institute of Sport Assessment—Achilles (VISA-A) represents the gold standard to evaluate pain and function in mid-AT. Our objective was to estimate VISA-A thresholds for minimal important change (MIC) and patient-acceptable symptom state for return to the presymptom activity level (PASS-RTA), in soldiers treated with a conservative programme for mid-AT.MethodsA total of 40 soldiers (40 unilateral symptomatic Achilles tendons) were included in this prospective cohort study. Pain and function were evaluated using VISA-A. Self-perceived recovery was assessed with the Global Perceived Effect scale. The predictive modelling method (MIC-predict) was used to estimate MIC VISA-A post-treatment (after 26 weeks) and after 1 year of follow-up. The post-treatment PASS-RTA VISA-A was estimated using receiver operating characteristic statistics. The PASS-RTA was determined by calculating Youden’s index value closest to 1.ResultsThe adjusted MIC-predict was 6.97 points (95% CI 4.18 to 9.76) after 26 weeks and 7.37 points (95% CI 4.58 to 10.2) after 1 year of follow-up post-treatment.The post-treatment PASS-RTA was 95.5 points (95% CI 92.2 to 97.8).ConclusionsA VISA-A change score of 7 points, post-treatment and at 1 year of follow-up, can be considered a minimal within-person change over time, above which soldiers with mid-AT perceive themselves importantly changed. Soldiers consider their symptoms to be acceptable for return to their presymptom activity level at a post-treatment VISA-A score of 96 points or higher.Trial registration numberNL69527.028.19.

Contains fulltext : 291410.pdf (Publisher’s version ) (Open Access) BACKGROUND: Physical exercise in cancer patients is a promising intervention to improve cognition and increase brain volume, including hippocampal volume. We investigated whether a 6-month exercise intervention primarily impacts total hippocampal volume and additionally hippocampal subfield volumes, cortical thickness and grey matter volume in previously physically inactive breast cancer patients. Furthermore, we evaluated associations with verbal memory. METHODS: Chemotherapy-exposed breast cancer patients (stage I-III, 2-4 years post diagnosis) with cognitive problems were included and randomized in an exercise intervention (n = 70, age = 52.5 ± 9.0 years) or control group (n = 72, age = 53.2 ± 8.6 years). The intervention consisted of 2x1 hours/week of supervised aerobic and strength training and 2x1 hours/week Nordic or power walking. At baseline and at 6-month follow-up, volumetric brain measures were derived from 3D T1-weighted 3T magnetic resonance imaging scans, including hippocampal (subfield) volume (FreeSurfer), cortical thickness (CAT12), and grey matter volume (voxel-based morphometry CAT12). Physical fitness was measured with a cardiopulmonary exercise test. Memory functioning was measured with the Hopkins Verbal Learning Test-Revised (HVLT-R total recall) and Wordlist Learning of an online cognitive test battery, the Amsterdam Cognition Scan (ACS Wordlist Learning). An explorative analysis was conducted in highly fatigued patients (score of ≥ 39 on the symptom scale 'fatigue' of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire), as previous research in this dataset has shown that the intervention improved cognition only in these patients. RESULTS: Multiple regression analyses and voxel-based morphometry revealed no significant intervention effects on brain volume, although at baseline increased physical fitness was significantly related to larger brain volume (e.g., total hippocampal volume: R = 0.32, B = 21.7 mm(3), 95 % CI = 3.0 - 40.4). Subgroup analyses showed an intervention effect in highly fatigued patients. Unexpectedly, these patients had significant reductions in hippocampal volume, compared to the control group (e.g., total hippocampal volume: B = -52.3 mm(3), 95 % CI = -100.3 - -4.4)), which was related to improved memory functioning (HVLT-R total recall: B = -0.022, 95 % CI = -0.039 - -0.005; ACS Wordlist Learning: B = -0.039, 95 % CI = -0.062 - -0.015). CONCLUSIONS: No exercise intervention effects were found on hippocampal volume, hippocampal subfield volumes, cortical thickness or grey matter volume for the entire intervention group. Contrary to what we expected, in highly fatigued patients a reduction in hippocampal volume was found after the intervention, which was related to improved memory functioning. These results suggest that physical fitness may benefit cognition in specific groups and stress the importance of further research into the biological basis of this finding.