Effectiveness and cost-effectiveness of a blended exercise intervention for patients with hip and/or knee osteoarthritis:Study protocol of a randomized controlled trial

Background Exercise therapy in patients with hip and/or knee osteoarthritis is effective in reducing pain, increasing physical activity and physical functioning, but costly and a burden for the health care budget. A web-based intervention is cheap in comparison to face-to-face exercise therapy and has the advantage of supporting in home exercises because of the 24/7 accessibility. However, the lack of face-to-face contact with a professional is a disadvantage of web-based interventions and is probably one of the reasons for low adherence rates. In order to combine the best of two worlds, we have developed the intervention e-Exercise. In this blended intervention face-to-face contacts with a physical therapist are partially replaced by a web-based exercise intervention. The aim of this study is to investigate the short- (3 months) and long-term (12 months) (cost)-effectiveness of e-Exercise compared to usual care physical therapy. Our hypothesis is that e-Exercise is more effective and cost-effective in increasing physical functioning and physical activity compared to usual care. Methods/Design This paper presents the protocol of a prospective, single-blinded, multicenter cluster randomized controlled trial. In total, 200 patients with OA of the hip and/or knee will be randomly allocated into either e-Exercise or usual care (physical therapy). E-Exercise is a 12-week intervention, consisting of maximum five face-to-face physical therapy contacts supplemented with a web-based program. The web-based program contains assignments to gradually increase patients’ physical activity, strength and stability exercises and information about OA related topics. Primary outcomes are physical activity and physical functioning. Secondary outcomes are health related quality of life, self-perceived effect, pain, tiredness and self-efficacy. All measurements will be performed at baseline, 3 and 12 months after inclusion. Retrospective cost questionnaires will be sent at 3, 6, 9 and 12 months and used for the cost-effectiveness and cost-utility analysis. Discussion This study is the first randomized controlled trial in the (cost)-effectiveness of a blended exercise intervention for patients with osteoarthritis of the hip and/or knee. The findings will help to improve the treatment of patients with osteoarthritis. Keywords: Osteoarthritis, Physical activity, Blended care e-Healt

The relationship between older adults' self-management abilities, well-being and depression

This study aimed to identify the relationship between self-management abilities, well-being and depression. Our study was conducted among older adults (>65 years of age) who were vulnerable to loss of function after hospital discharge. Three months after hospital admission, 296/456 patients (65 % response rate) were interviewed in their homes. The 30-item Self-Management Ability Scale was used to measure six self-management abilities: taking initiative, investing in resources for long-term benefits, taking care of a variety of resources, taking care of resource multifunctionality, being self-efficacious and having a positive frame of mind. Well-being was measured with the Social Production Function (SPF) Instrument for the Level of Well-being (SPF-IL) and Cantril's ladder. The Geriatric Depre

Understanding implementation of comprehensive geriatric care programs: a multiple perspective approach is preferred

Background: The Prevention and Reactivation Care Program (PReCaP) provides a novel approach targeting hospital-related functional decline among elderly patients. Despite the high expectations, the PReCaP was not effective in preventing functional decline (ADL and iADL) among older patients. Although elderly PReCaP patients demonstrated slightly better cognitive functioning (Mini Mental State Examination; 0.4 [95% confidence interval (CI) 0.2–0.6]), lower depression (Geriatric Depression Scale 15; –0.9 [95% –1.1 to –0.6]), and higher perceived health (Short-form 20; 5.6 [95% CI 2.8–8.4]) 1 year after admission than control patients, the clinical relevance was limited. Therefore, this study aims to identify factors impacting on the effectiveness of the implementation of the PReCaPand geriatric care ‘as usual’. Methods: We conducted semi-structured interviews with 34 professionals working with elderly patients in three hospitals, selected for their comparable patient case mix and different levels of geriatric care. Five non-participatory observations were undertaken during multidisciplinary meetings. Patient files (n = 42), hospital protocols, and care plans were screened for elements of geriatric care. Clinical process data were analysed for PReCaP components. Results: The establishment of a geriatric unit and employment of geriatricians demonstrates commitment to geriatric care in hospital A. Although admission processes are comparable, early identification of frail elderly patients only takes place in hosptial A. Furthermore, nursing care in the hospital A geriatric unit excels with regard to maximizing patient independency, an important predictor for hospital-related functional decline. Transfer nurses play a key role in arranging post-discharge geriatric follow-up care. Geriatric consultations are performed by g

The role of acquired immunity in the spread of human papillomavirus (HPV): Explorations with a microsimulation model

__Background:__ Knowledge of the natural history of human papillomavirus (HPV), in particular the role of immunity, is crucial in estimating the (cost-) effectiveness of HPV vaccination and cervical cancer screening strategies, because naturally acquired immunity after clearing an infection may already protect part of the risk population against new HPV infections. __Methods:__ We used STDSIM, an established stochastic microsimulation model, quantified to the Netherlands. We explored different assumptions regarding the natural history of HPV-16 and HPV-18, and estimated the transmission probabilities and durations of acquired immunity necessary to reproduce age-specific prevalence. __Results:__ A model without acquired immunity cannot reproduce the age-specific patterns of HPV. Also, it is necessary to assume a high degree of individual variation in the duration of infection and acquired immunity. According to the model estimates, on average 20% of women are immune for HPV-16 and 15% for HPV-18. After an HPV-16 infection, 50% are immune for less than 1 year, whereas 20% exceed 30 years. For HPV-18, up to 12% of the individuals are immune for less than 1 year, and about 50% over 30 years. Almost half of all women will never acquire HPV-16 or HPV-18. __Conclusions:__ Acquired immunity likely plays a major role in HPV epidemiology, but its duration shows substantial variation. Combined with the lifetime risk, this explains to a large extent why many women will never develop cervical cancer

Mesoscopic proximity effect in double barrier Superconductor/Normal Metal junctions

We report transport measurements down to T=60mK of SININ and SNIN structures in the diffusive limit. We fabricated Al-AlOx/Cu/AlOx/Cu (SININ) and Al/Cu/AlOx/Cu (SNIN) vertical junctions. For the first time, a zero bias anomaly was observed in a metallic SININ structure. We attribute this peak of conductance to coherent multi-reflections of electrons between the two tunnel barriers. This conductance maximum is quantitatively fitted by the relevant theory of mesoscopic SININ structures. When the barrier at the SN interface is removed (SNIN structure), we observe a peak of conductance at finite voltage accompagnied by an excess of sub-gap conductance.Comment: 4 pages, 4 figures, editorially approved for publication in Phys. Rev. B Rapid Com

Novel Leptin Receptor Mutations Identified in Two Girls with Severe Obesity Are Associated with Increased Bone Mineral Density

Background: Recessive mutations in the leptin receptor (LEPR) are a rare cause of hyperphagia and severe early-onset obesity. To date, the phenotype has only been described in 25 obese children, some of whom also had altered immune function, hypogonadotropic hypogonadism, reduced growth hormone secretion, hypothalamic hypothyroidism or reduced adult height. We provide a detailed description of the phenotype of 2 affected girls to add to this knowledge. Methods: Whole-exome sequencing and targeted sequencing were used to detect the LEPR mutations. RNA analysis was performed to assess the effect of splice-site mutations. Results: In 2 unrelated girls with severe obesity, three novel LEPR mutations were detected. Longitudinal growth data show normal childhood growth, and in the older girl, a normal adult height despite hypogonadotropic hypogonadism and the lack of an obvious pubertal growth spurt. Bone age is remarkably advanced in the younger (prepubertal) girl, and bone mineral density (BMD) is high in both girls, which might be directly or indirectly related to leptin resistance. Conclusion: The spectrum of clinical features of LEPR deficiency may be expanded with increased BMD. Future observations in LEPR-deficient subjects should help further unravel the role of leptin in human bone biology

Exercise and myocardial injury in hypertrophic cardiomyopathy

Objective: Troponin and high signal intensity on T2-weighted (HighT2) cardiovascular magnetic resonance imaging (CMRi) are both markers of myocardial injury in hypertrophic cardiomyopathy (HCM). The interplay between exercise and disease development remains uncertain in HCM. We sought to assess the occurrence of postexercise troponin rises and its determinants. Methods: Multicentre project on patients with HCM and mutation carriers without hypertrophy (controls). Participants performed a symptom limited bicycle test with hs-cTnT assessment pre-exercise and 6 hours postexercise. Pre-exercise CMRi was performed in patients with HCM to assess measures of hypertrophy and myocardial injury. Depending on baseline troponin (13 ng/L), a rise was defined as a >50% or >20% increase, respectively. Results: Troponin rises occurred in 18% (23/127) of patients with HCM and 4% (2/53) in mutation carriers (p=0.01). Comparing patients with HCM with and without a postexercise troponin rise, maximum heart rates (157±19 vs 143±23, p=0.004) and maximal wall thickness (20 mm vs 17 mm, p=0.023) were higher in the former, as was the presence of late gadolinium enhancement (85% vs 57%, p=0.02). HighT2 was seen in 65% (13/20) and 19% (15/79), respectively (p<0.001). HighT2 was the only independent predictor of troponin rise (adjusted odds ratio 7.9; 95% CI 2.7 to 23.3; p<0.001). Conclusions: Postexercise troponin rises were seen in about 20% of patients with HCM, almost five times more frequent than in mutation carriers. HighT2 on CMRi may identify a group of particularly vulnerable patients, supporting the concept that HighT2 reflects an active disease state, prone to additional injury after a short episode of high oxygen demand

How to Handle Concomitant Asymptomatic Prosthetic Joints During an Episode of Hematogenous Periprosthetic Joint Infection:a Multicenter Analysis

BACKGROUND: Prosthetic joints are at risk of becoming infected during an episode of bacteremia, especially during Staphylocococcus aureus bacteremia. However, it is unclear how often asymptomatic periprosthetic joint infection (PJI) occurs, and whether additional diagnostics should be considered. METHODS: In this multicenter study, we retrospectively analyzed a cohort of patients with a late acute (hematogenous) PJI between 2005-2015 who had concomitant prosthetic joints in situ. Patients without at least 1 year of follow-up were excluded. RESULTS: We included 91 patients with a hematogenous PJI and 108 concomitant prosthetic joints. The incident PJI was most frequently caused by Staphylococcus aureus (43%), followed by streptococci (26%) and Gram-negative rods (18%). Of 108 concomitant prosthetic joints, 13 were symptomatic, of which 10 were subsequently diagnosed as a second PJI. Of the 95 asymptomatic prosthetic joints, 1 PJI developed during the follow-up period and was classified as a "missed" PJI at the time of bacteremia with S. aureus (1.1%). Infected prosthetic joints were younger than the noninfected ones in 67% of cases, and prosthetic knees were affected more often than prosthetic hips (78%). CONCLUSIONS: During an episode of hematogenous PJI, concomitant asymptomatic prosthetic joints have a very low risk of being infected, and additional diagnostic work-up for these joints is not necessary