Charlotte N. Steins Bisschop

Plate fixation versus intramedullary fixation for displaced mid-shaft clavicle fractures: a systematic review.

PurposeThe optimal surgical approach for displaced midshaft clavicle fracture remains controversial. The objective of this systematic review is to compare functional outcome and complications after plate fixation and intramedullary fixation for displaced midshaft clavicle fractures.MethodsA computer aided search of PUBMED and Embase was carried out on January 11th 2011. Every study that was published in the English, German, French or Dutch language was considered for inclusion. A total of four studies could be included of which two compared intramedullary fixation versus plate fixation, and two compared intramedullary fixation and plate fixation versus conservative treatment for displaced midshaft clavicle fractures. Studies that compared plate fixation with intramedullary fixation in patients with fresh unilateral displaced midshaft clavicle fractures were included. Dislocation or displacement had to be mentioned in the inclusion criteria of the study for inclusion in this review. The modified version of the Cochrane Bone, Joint and Muscle Trauma Group’s former quality assessment tool was used. Furthermore, the studies included were scored according to the GRADE approach to assess the quality. The chosen studies were summarised in a data-extraction form. Because of the different study designs and characteristics data were summarised separately for each study.ConclusionsHigh quality evidence from one study and low quality evidence from three studies showed no difference in functional outcome or complications after plate fixation or intramedullary fixation for displaced midshaft clavicle fractures.

Invasive placentation and uterus preserving treatment modalities: a systematic review

PurposeWe present a systematic review to evaluate failure rates (secondary hysterectomy or maternal mortality) and success rates (subsequent menstruation or pregnancy) after different uterus preserving treatment modalities in women with invasive placentation.MethodsA review of English, German or Dutch language-published research, using Medline and Embase databases, was performed. Studies of any design were included.ResultsTen cohort studies and 50 case series or case reports were included. Expectant management reported a secondary hysterectomy in 55/287 (19%), maternal mortality in 1/295 (0.3%), a subsequent menstruation in 44/49 (90%) and a subsequent pregnancy in 24/36 (67%). Embolization of the uterine arteries described a secondary hysterectomy in 8/45 (18%), a subsequent menstruation in 8/13 (62%) and a subsequent pregnancy in 5/33 (15%). Methotrexate therapy presented a secondary hysterectomy in 1/16 (6%), a subsequent menstruation in 4/5 (80%) and a subsequent pregnancy in 1/2 (50%). Uterus preserving surgery showed a secondary hysterectomy in 24/77 (31%), maternal mortality in 2/55 (4%), a subsequent menstruation in 28/34 (82%) and a subsequent pregnancy in 19/26 (73%).ConclusionsThis review indicates that different uterus preserving treatment modalities may be effective in managing invasive placentation. Despite the extensive review of the literature, no conclusions about the superiority of any modality can be drawn.

Weight change in middle adulthood and breast cancer risk in the EPIC-PANACEA study

Long‐term weight gain (i.e., weight gain since age 20) has been related to higher risk of postmenopausal breast cancer, but a lower risk of premenopausal breast cancer. The effect of weight change in middle adulthood is unclear. We investigated the association between weight change in middle adulthood (i.e., women aged 40–50 years) and the risk of breast cancer before and after the age of 50. We included female participants of the European Prospective Investigation into Cancer and Nutrition cohort, with information on anthropometric measures at recruitment and after a median follow‐up of 4.3 years. Annual weight change was categorized using quintiles taking quintile 2 and 3 as the reference category (−0.44 to 0.36 kg/year). Multivariable Cox proportional hazards regression analysis was used to examine the association. 205,723 women were included and 4,663 incident breast cancer cases were diagnosed during a median follow‐up of 7.5 years (from second weight assessment onward). High weight gain (Q5: 0.83–4.98 kg/year) was related to a slightly, but significantly higher breast cancer risk (HRQ5_versus_Q2/3: 1.09, 95% CI: 1.01−1.18). The association was more pronounced for breast cancer diagnosed before or at age 50 (HRQ5_versus_Q2/3: 1.37, 95% CI: 1.02−1.85). Weight loss was not associated with breast cancer risk. There was no evidence for heterogeneity by hormone receptor status. In conclusion, high weight gain in middle adulthood increases the risk of breast cancer. The association seems to be more pronounced for breast cancer diagnosed before or at age 50. Our results illustrate the importance of avoiding weight gain in middle adulthood.

Weight change later in life and colon and rectal cancer risk in participants in the EPIC-PANACEA study

BACKGROUND A moderate association exists between body mass index (BMI) and colorectal cancer. Less is known about the effect of weight change. OBJECTIVE We investigated the relation between BMI and weight change and subsequent colon and rectal cancer risk. DESIGN This was studied among 328,781 participants in the prospective European Prospective Investigation into Cancer-Physical Activity, Nutrition, Alcohol, Cessation of Smoking, Eating study (mean age: 50 y). Body weight was assessed at recruitment and on average 5 y later. Self-reported weight change (kg/y) was categorized in sex-specific quintiles, with quintiles 2 and 3 combined as the reference category (men: -0.6 to 0.3 kg/y; women: -0.4 to 0.4 kg/y). In the subsequent years, participants were followed for the occurrence of colon and rectal cancer (median period: 6.8 y). Multivariable Cox proportional hazards regression analyses were used to study the association. RESULTS A total of 1261 incident colon cancer and 747 rectal cancer cases were identified. BMI at recruitment was statistically significantly associated with colon cancer risk in men (HR: 1.04; 95% CI: 1.02, 1.07). Moderate weight gain (quintile 4) in men increased risk further (HR: 1.32; 95% CI: 1.04, 1.68), but this relation did not show a clear trend. In women, BMI or weight gain was not related to subsequent risk of colon cancer. No statistically significant associations for weight loss and colon cancer or for BMI and weight changes and rectal cancer were found. CONCLUSIONS BMI attained at adulthood was associated with colon cancer risk. Subsequent weight gain or loss was not related to colon or rectal cancer risk in men or women.

Cardiopulmonary Exercise Testing in Cancer Rehabilitation A Systematic Review

This systematic review aims to get insight into the feasibility of cardiopulmonary exercise testing (CPET) in patients with cancer prior to a physical exercise programme. We will focus on quality (defined as the adherence to international guidelines for methods of CPET) and safety of CPET. Furthermore, we compare the peak oxygen uptake (V̇O2peak) values of patients with cancer with reference values for healthy persons to put these values into a clinical perspective. A computer aided search with ‘cardiopulmonary exercise testing’ and ‘cancer’ using MEDLINE, EMBASE, Pedro, CINAHL® and SPORTDiscus™ was carried out. We included studies in which CPET with continuous gas exchange analysis has been performed prior to a physical exercise programme in adults with cancer. Twenty studies describing 1158 patients were eligible. Reported adherence to international recommendations for CPET varied per item. In most studies, the methods of CPET were not reported in detail. Adverse events occurred in 1% of patients. The percentage V̇O2peak of reference values for healthy persons varied between 65% and 89% for tests before treatment, between 74% and 96% for tests during treatment and between 52% and 117% for tests after treatment. Our results suggest that CPET is feasible and seems to be safe for patients with cancer prior to a physical exercise programme. We recommend that standard reporting and quality guidelines should be followed for CPET methods. The decreased V̇O2peak values of patients with cancer indicate that physical exercise should be implemented in their standard care.

Effects of an Exercise Program in Colon Cancer Patients undergoing Chemotherapy.

PURPOSE Fatigue is a common problem among colon cancer patients and typically increases during chemotherapy. Exercise during chemotherapy might have beneficial effects on fatigue. To investigate the short- and long-term effects of an exercise program in colon cancer patients during adjuvant treatment, the Physical Activity During Cancer Treatment study was conducted. METHODS In this multicenter randomized controlled trial, 33 colon cancer patients undergoing chemotherapy (21 men and 12 women) were randomly assigned to either a group receiving an 18-wk supervised exercise program (n = 17) or to usual care (n = 16). The primary outcome was fatigue as measured by the Multidimensional Fatigue Inventory and the Fatigue Quality List. Secondary outcomes were quality of life, physical fitness, anxiety, depression, body weight, and chemotherapy completion rate. Outcome assessment took place at baseline, postintervention (18 wk) and at 36 wk. RESULTS Intention-to-treat mixed linear model analyses showed that patients in the intervention group experienced significantly less physical fatigue at 18 wk and general fatigue at 36 wk (mean between group differences, -3.2; 95% confidence interval [CI], -6.2 to -0.2; effect size [ES], -0.9 and -2.7; 95% CI, -5.2 to -0.1; ES, -0.8, respectively), and reported higher physical functioning (12.3; 95% CI, 3.3-21.4; ES, 1.0) compared with patients in the usual care group. CONCLUSION The Physical Activity During Cancer Treatment trial shows that an 18-wk supervised exercise program in colon cancer patients during chemotherapy is safe and feasible. The intervention significantly reduced physical fatigue at 18 wk and general fatigue at 36 wk. Considering the number of patients included in the present study, replication in a larger study population is required.

Mode of delivery in non-cephalic presenting twins: a systematic review.

PurposeThis systematic review aims to determine if there are evidence-based recommendations for the optimal mode of delivery for non-cephalic presenting first- and/or second twins. We investigated the impact of the mode of delivery on neonatal outcome for twin deliveries with (1) the first twin (twin A) in non-cephalic presentation, (2) the second (twin B) in non-cephalic presentation and (3) both twins in non-cephalic presentation.MethodsA computer-aided search of Medline, Embase, Cinahl and Cochrane databases was carried out and quality of the studies was assessed with the Cochrane Collaboration’s tool for assessing risk of bias and the GRADE approach.ResultsOne high-quality clinical trial (60 twin pairs) and 16 moderate/low-quality observational studies (3,167 twin pairs) showed no difference in neonatal outcome between vaginal and caesarean delivery in twin A and/or B.ConclusionOur results do not suggest benefit of caesarean over vaginal delivery for selected twin gestations with twin A and/or twin B in non-cephalic presentation. However, no final conclusion can be drawn due to the small sample sizes and statistic limitations of the included studies. Randomized studies with sufficient power are required to make a strong recommendation.

Control group design, contamination and drop-out in exercise oncology trials: a systematic review.

Purpose Important considerations for exercise trials in cancer patients are contamination and differential drop-out among the control group members that might jeopardize the internal validity. This systematic review provides an overview of different control groups design characteristics of exercise-oncology trials and explores the association with contamination and drop-out rates. Methods Randomized controlled exercise-oncology trials from two Cochrane reviews were included. Additionally, a computer-aided search using Medline (Pubmed), Embase and CINAHL was conducted after completion date of the Cochrane reviews. Eligible studies were classified according to three control group design characteristics: the exercise instruction given to controls before start of the study (exercise allowed or not); and the intervention the control group was offered during (any (e.g., education sessions or telephone contacts) or none) or after (any (e.g., cross-over or exercise instruction) or none) the intervention period. Contamination (yes or no) and excess drop-out rates (i.e., drop-out rate of the control group minus the drop-out rate exercise group) were described according to the three design characteristics of the control group and according to the combinations of these three characteristics; so we additionally made subgroups based on combinations of type and timing of instructions received. Results 40 exercise-oncology trials were included based on pre-specified eligibility criteria. The lowest contamination (7.1% of studies) and low drop-out rates (excess drop-out rate -4.7±9.2) were found in control groups offered an intervention after the intervention period. When control groups were offered an intervention both during and after the intervention period, contamination (0%) and excess drop-out rates (-10.0±12.8%) were even lower. Conclusions Control groups receiving an intervention during and after the study intervention period have lower contamination and drop-out rates. The present findings can be considered when designing future exercise-oncology trials.

Associations of visceral fat, physical activity and muscle strength with the metabolic syndrome

OBJECTIVE We investigated the association of visceral fat with the metabolic syndrome (MetS) and its separate components; the associations of both physical activity and muscle strength with the MetS and its separate components independent of visceral fat. Furthermore, we studied these associations within participants with low and high amounts of visceral fat. STUDY DESIGN 400 men (aged 40-80 years) were recruited into a cross-sectional study. MAIN OUTCOME MEASURES Logistic regression models were used to study the individual associations in all participants (OR). The associations of physical activity (active vs inactive) and muscle strength (high vs low) within participants with low and high levels of visceral fat (assessed by ultrasonography) were tested using Univariate Analysis of Variance (difference in mean levels of the separate components of MetS) and logistic regression (risk on MetS). RESULTS High levels of visceral fat were significantly associated with increased risk of MetS (OR 1.7 95%CI 1.5;1.9) and its separate components (p<0.05). We did not find strong individual associations for physical activity or muscle strength, neither within men with low or high levels of visceral fat. CONCLUSIONS High body fat levels were associated with an unhealthier metabolic risk profile and a higher risk of the MetS. Our cross-sectional data do not indicate associations for physical activity or for muscle strength with the MetS independent of visceral fat. Also no differential associations of physical activity or muscle strength in men with low or high levels of visceral fat were found.

Cost-effectiveness analysis of an 18-week exercise programme for patients with breast and colon cancer undergoing adjuvant chemotherapy: The randomised PACT study

Objective Meta-analyses show that exercise interventions during cancer treatment reduce cancer-related fatigue. However, little is known about the cost-effectiveness of such interventions. Here we aim to assess the cost-effectiveness of the 18-week physical activity during cancer treatment (PACT) intervention for patients with breast and colon cancer. The PACT trial showed beneficial effects for fatigue and physical fitness. Design Cost-effectiveness analyses with a 9-month time horizon (18 weeks of intervention and 18 weeks of follow-up) within the randomised controlled multicentre PACT study. Setting Outpatient clinics of 7 hospitals in the Netherlands (1 academic and 6 general hospitals) Participants 204 patients with breast cancer and 33 with colon cancer undergoing adjuvant treatment including chemotherapy. Intervention Supervised 1-hour aerobic and resistance exercise (twice per week for 18 weeks) or usual care. Main outcome measures Costs, quality-adjusted life years (QALY) and the incremental cost-effectiveness ratio. Results For colon cancer, the cost-effectiveness analysis showed beneficial effects of the exercise intervention with incremental costs savings of €4321 and QALY improvements of 0.03. 100% of bootstrap simulations indicated that the intervention is dominant (ie, cheaper and more effective). For breast cancer, the results did not indicate that the exercise intervention was cost-effective. Incremental costs were €2912, and the incremental effect was 0.01 QALY. At a Dutch threshold value of €20 000 per QALY, the probability that the intervention is cost-effective was 2%. Conclusions Our results suggest that the 18-week exercise programme was cost-effective for colon cancer, but not for breast cancer. Trial registration number ISRCTN43801571.