Absence of Fitness Improvement Is Associated with Outcomes in Heart Failure Patients.

PURPOSE: To examine the clinical impact of cardiorespiratory fitness (CRF) and improvements in CRF after cardiac rehabilitation (CR) in heart failure (HF) patients for their risk of all-cause mortality and unplanned hospitalization. Secondly, to investigate possible factors associated with the absence of improvement in CRF after rehabilitation. METHODS: We included 155 HF patients receiving CR between October 2009 and January 2015. Patients performed an incremental bicycle test to assess CRF through peak oxygen uptake (VO2-peak) before and after CR-based supervised exercise training. Patients were classified as responders or non-responders based on pre-to-post CR changes in VO2-peak (≥6% and <6%, respectively). Cox proportional hazards models evaluated all-cause mortality and unplanned hospitalization during 5 years of follow-up. Patient characteristics, HF features and co-morbidities were used to predict changes in VO2-peak using logistic regression analysis. RESULTS: Seventy HF patients (45%) were classified as responder. Non-responders had a significantly higher risk of all-cause mortality or hospitalization (HR = 2.15, 95% CI = 1.17-3.94) compared to responders. This was even higher in non-responders with low CRF at baseline (HR = 4.88, 95% CI = 1.71-13.93). Factors associated with non-response to CR were age (OR = 1.07/year, 95% CI = 1.03-1.11), baseline VO2-peak (OR = 1.16/ml/min/kg, 95% CI = 1.06-1.26) and adherence to CR (OR = 0.98/percentage, 95% CI = 0.96-0.998). CONCLUSION: Independent from baseline CRF, the inability to improve VO2-peak by CR doubled the risk of death or unplanned hospitalization. The combination of lower baseline CRF and non-response was associated with even poorer clinical outcomes. Especially older HF patients with higher baseline VO2-peak and lower adherence have a higher probability of becoming a non-responder

Cohort Profile: The Nijmegen Exercise Study (NES)

The Nijmegen Exercise Study (NES) provides a longitudinal collection of data on lifestyle characteristics and the development and progression of chronic diseases. The NES is a population-based cohort enriched with highly physically active individuals. The cohort contains individuals both with and without chronic diseases, with physical activity levels ranging from inactive to extremely active. Baseline data collection is ongoing. Since 2011, baseline data have been collected in 23 643 participants with a mean age of 48.7 years (range: 18–94) of whom 46.0% are female. Annual follow-up data have been collected in 11 484 participants (48.6%) with a median follow-up duration of 8.0 (5.0, 10.9) years. Additional, centre-based evaluation is ongoing and has so far been performed in a subset of 1743 participants. Baseline and follow-up questionnaires provide trends in demographics, socioeconomic status, lifestyle characteristics, medical history, medication use, and historical and current physical activity and sedentary behaviour. Centre-based evaluation includes anthropometrics, blood pressure, arterial stiffness, carotid artery characteristics, venous blood biomarkers, accelerometer-based physical activity patterns, handgrip strength, and 4-metre gait speed. Data are available to scientific researchers upon request. Please contact the corresponding author ([email protected]) for data availability inquiries and visit our website for additional information (www.radboudumc.nl/nes)

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Increasingly strong reduction in breast cancer mortality due to screening

Item does not contain fulltextBACKGROUND: Favourable outcomes of breast cancer screening trials in the 1970s and 1980s resulted in the launch of population-based service screening programmes in many Western countries. We investigated whether improvements in mammography and treatment modalities have had an influence on the effectiveness of breast cancer screening from 1975 to 2008. METHODS: In Nijmegen, the Netherlands, 55,529 women received an invitation for screening between 1975 and 2008. We designed a case-referent study to evaluate the impact of mammographic screening on breast cancer mortality over time from 1975 to 2008. A total number of 282 breast cancer deaths were identified, and 1410 referents aged 50-69 were sampled from the population invited for screening. We estimated the effectiveness by calculating the odds ratio (OR) indicating the breast cancer death rate for screened vs unscreened women. RESULTS: The breast cancer death rate in the screened group over the complete period was 35% lower than in the unscreened group (OR=0.65; 95% CI=0.49-0.87). Analysis by calendar year showed an increasing effectiveness from a 28% reduction in breast cancer mortality in the period 1975-1991 (OR=0.72; 95% CI=0.47-1.09) to 65% in the period 1992-2008 (OR=0.35; 95% CI=0.19-0.64). CONCLUSION: Our results show an increasingly strong reduction in breast cancer mortality over time because of mammographic screening

Overdiagnosis and overtreatment of breast cancer: Microsimulation modelling estimates based on observed screen and clinical data

There is a delicate balance between the favourable and unfavourable side-effects of screening in general. Overdiagnosis, the detection of breast cancers by screening that would otherwise never have been clinically diagnosed but are now consequently treated, is such an unfavourable side effect. To correctly model the natural history of breast cancer, one has to estimate mean durations of the different pre-clinical phases, transition probabilities to clinical cancer stages, and sensitivity of the applied test based on observed screen and clinical data. The Dutch data clearly show an increase in screen-detected cases in the 50 to 74 year old age group since the introduction of screening, and a decline in incidence around age 80 years. We had estimated that 3% of total incidence would otherwise not have been diagnosed clinically. This magnitude is no reason not to offer screening for women aged 50 to 74 years. The increases in ductal carcinoma in situ (DCIS) are primarily due to mammography screening, but DCIS still remains a relatively small proportion of the total breast cancer problem

The Influence of Age and Sex on Genetic Associations with Adult Body Size and Shape: A Large-Scale Genome-Wide Interaction Study

Genome-wide association studies (GWAS) have identified more than 100 genetic variants contributing to BMI, a measure of body size, or waist-to-hip ratio (adjusted for BMI, WHRadjBMI), a measure of body shape. Body size and shape change as people grow older and these changes differ substantially between men and women. To systematically screen for age-and/or sex-specific effects of genetic variants on BMI and WHRadjBMI, we performed meta-analyses of 114 studies (up to 320,485 individuals of European descent) with genome-wide chip and/or Metabochip data by the Genetic Investigation of Anthropometric Traits (GIANT) Consortium. Each study tested the association of up to similar to 2.8M SNPs with BMI and WHRadjBMI in four strata (men &lt;= 50y, men &gt; 50y, women &lt;= 50y, women &gt; 50y) and summary statistics were combined in stratum-specific meta-analyses. We then screened for variants that showed age-specific effects (G x AGE), sex-specific effects (G x SEX) or age-specific effects that differed between men and women (G x AGE x SEX). For BMI, we identified 15 loci (11 previously established for main effects, four novel) that showed significant (FDR&lt; 5%) age-specific effects, of which 11 had larger effects in younger (&lt; 50y) than in older adults (&gt;= 50y). No sex-dependent effects were identified for BMI. For WHRadjBMI, we identified 44 loci (27 previously established for main effects, 17 novel) with sex-specific effects, of which 28 showed larger effects in women than in men, five showed larger effects in men than in women, and 11 showed opposite effects between sexes. No age-dependent effects were identified for WHRadjBMI. This is the first genome-wide interaction meta-analysis to report convincing evidence of age-dependent genetic effects on BMI. In addition, we confirm the sex-specificity of genetic effects on WHRadjBMI. These results may providefurther insights into the biology that underlies weight change with age or the sexually dimorphism of body shape.</p