Improving Risk Assessment in Acquired Heart Disease: Biomarkers and Beyond

The aim of this thesis was to identify characteristics associated with adverse clinical outcome, and to present novel prediction models that may aid in risk stratification of patients at different stages of cardiovascular disease. First, we focused on patients with coronary artery disease, with or without left ventricular dysfunction. Specifically, we examined patients undergoing PCI, and identified characteristics associated with poor outcome after PCI. Secondly, we focused on patients with established (chronic) heart failure, and investigated what strategy or which combination of biomarkers should be used for risk assessment. Finally, we examined patients with severely reduced cardiac function, that require prevention of sudden cardiac death by means of an ICD with our without cardiac resynchronization therapy (CRT); here, we aimed to reveal characteristics associated with response and poor clinical outcome

What We Mean When We Talk About Adherence In Respiratory Medicine

The Respiratory Effectiveness Group (REG; www.effectivenessevaluation.org) supported the Expert Adherence Panel Meeting at which many of the concepts presented in this paper were first discussed. REG also supported the manuscript submission costs. ALD, EvG, and MdB have received funding from the European Community's 7th Framework (FP7/2007-2013) under grant agreement no. 282593. Teva supported the meeting costs at which the concepts in this paper were discussed by the co-authors and the open access publication fee for this article. The authors had full editorial control over the ideas presented.Peer reviewedPublisher PD

Model structure analysis to estimate basic immunological processes and maternal risk for parvovirus B19

After a steep monotone rise with age, the seroprevalence profiles for human parvovirus B19 (PVB19) display a decrease or plateau between the ages of 20 and 40, in each of 5 European countries. We investigate whether this phenomenon is induced by waning antibodies for PVB19 and, if this is the case, whether secondary infections are plausible, or whether boosting may occur. Several immunological scenarios are tested for PVB19 by fitting different compartmental dynamic transmission models to serological data using data on social contact patterns. The social contact approach has already been shown informative to estimate transmission rates and the basic reproduction number for infections transmitted predominantly through nonsexual social contacts. Our results show that for 4 countries, model selection criteria favor the scenarios allowing for waning immunity at an age-specific rate over the assumption of lifelong immunity, assuming that the transmission rates are directly proportional to the contact rates. Different views on the evolution of the immune response to PVB19 infection lead to altered estimates of the age-specific force of infection and the basic reproduction number. The scenarios which allow for multiple infections during one lifetime predict a higher frequency of PVB19 infection in pregnant women and of associated fetal deaths. When prevaccination serological data are available, the framework developed in this paper could prove worthwhile to investigate these different scenarios for other infections as well, such as cytomegalovirus

Effectiveness, usability and acceptability of a smart inhaler programme in patients with asthma:protocol of the multicentre, pragmatic, open-label, cluster randomised controlled ACCEPTANCE trial

Introduction Suboptimal asthma control is associated with incorrect inhaler use and poor medication adherence, which could lead to unfavourable clinical and economic outcomes. Smart inhaler programmes using electronic monitoring devices (EMDs) could support self-management and increase medication adherence and asthma control. However, evidence on long-term benefits and acceptability is scarce. This study aims to investigate the effectiveness of a smart inhaler asthma self-management programme on medication adherence and clinical outcomes in adults with uncontrolled asthma, to evaluate its acceptability and to identify subgroups who would benefit most based on patient characteristics.Methods and analysis This open-label cluster randomised controlled trial of 12 months will be conducted in primary care in the Netherlands. General practices will be randomly assigned to either intervention or control group. We aim to include 242 patients. The intervention consists of (1) an EMD attached to the patient’s inhaler that measures medication use; (2) a smartphone application to set medication reminders, receive motivational messages and track asthma symptoms; and (3) a portal for healthcare professionals to view data on medication use. The control group is passively monitored by the EMD but cannot view their inhaler data or receive feedback. Eligible patients are adults with suboptimal controlled asthma (Asthma Control Questionnaire score ≥0.75) with evidence of non-adherence established by the EMD during a 6-week run-in period. Primary outcome is the difference in mean medication adherence between intervention and control group. Secondary outcomes include asthma control, asthma-related quality of life, exacerbations, acceptance, cost-effectiveness and whether the effect of the intervention on medication adherence and asthma control is modified by patient characteristics (eg, self-efficacy, medication beliefs and eHealth literacy).Trial registration numberNL7854

Epilepsy, psychiatry and learning difficulty

Objectives: To compare economic outcomes between patients with asthma or chronic obstructive pulmonary disease (COPD) receiving continuous maintenance inhaled corticosteroid/long-acting beta agonist (ICS/LABA) treatment with Symbicort and those switching from Symbicort to DuoResp. Methods: This was a historical cohort study using anonymised data from two UK primary care databases, the Optimum Patient Care Research Database and the Clinical Practice Research Datalink. Included patients had ≥ 2 years of continuous data (1-year baseline pre- and 1-year outcome post-index date). Patients switching to DuoResp were matched (1:3) with those continuing on Symbicort. Mean asthma/ COPD-related healthcare costs (medication, primary care and hospital visits) were calculated in 2014 £ and compared between groups, adjusting for confounders. Risk domain control of disease (RDC), a composite measure defining absence of exacerbations, adjusted for rhinitis, was used to assess disease control. Costeffectiveness was assessed based on total treatment costs and the absolute proportion of patients achieving RDC. Results: Patients who switched to DuoResp had lower baseline respiratory-related costs than the Symbicort group when ICS costs were included (p= 0.036). In the outcome year, switching to DuoResp was associated with significantly lower mean costs per patient in total respiratory medication (-£80; p<0.001), primary care consultations (-£13; p<0.001) and total respiratory-related costs including ICS (-£92; p<0.001). The adjusted proportion of patients achieving RDC was 58% for DuoResp versus 54% for Symbicort. Adjusted mean cost was £492 (95% CI: £461, £523) for DuoResp users and £597 (£575, £620) for Symbicort users, for a difference of -£105 (-£132, -£78) after adjusting for all baseline costs. Bootstrap sensitivity analysis found DuoResp to be less costly and more effective than Symbicort with 93.7% consistency. Conclusions: Compared with patients with asthma or COPD continuing Symbicort treatment, those switching to DuoResp demonstrated a favourable cost-effectiveness ratio in the UK primary care setting