Loes C. M. Bertens

Value of composite reference standards in diagnostic research

Combining several tests is a common way to improve the final classification of disease status in diagnostic accuracy studies but is often used ambiguously. This article gives advice on proper use and reporting of composite reference standards

Prevalence and underlying causes of dyspnoea in older people: a systematic review

BACKGROUND chronic dyspnoea is common in older people and is often of cardiac or pulmonary aetiology. Information on the exact prevalence and distribution of underlying causes is scarce. Our aim was to review the literature on prevalence and underlying causes of dyspnoea in the older population. METHODS two MEDLINE searches were conducted: the first on studies on the prevalence of dyspnoea in older persons aged ≥65 years using the Medical Research Council (MRC) dyspnoea scale and the second on the underlying causes of dyspnoea in this population. Quality assessment was performed for all included studies. Random effects models based on the logit transformed prevalences were used to calculate pooled prevalence with 95% confidence intervals (95% CI). RESULTS a total of 21 articles from 20 different populations reported the prevalence in the general older population with a median sample size of 600 (Interquartile range 262-1289). The pooled prevalence was 36% (95% CI: 27-47%) for an MRC of ≥2, 16% (95% CI: 12-21%) for an MRC of ≥3 and 4% (95% CI: 2-9%) for an MRC of ≥4. Prevalence rates were higher in women than in men. Only one article investigated the underlying causes of dyspnoea in older persons; in 70% of these patients, the dyspnoea was considered to be of cardiac or pulmonary origin. CONCLUSION dyspnoea is very common in older people, but estimates vary considerably between studies. Only one study describes the underlying causes.

Unrecognized Heart Failure and Chronic Obstructive Pulmonary Disease (COPD) in Frail Elderly Detected Through a Near-Home Targeted Screening Strategy

Background: Reduced exercise tolerance and dyspnea are common in older people, and heart failure (HF) and chronic obstructive pulmonary disease (COPD) are the main causes. We want to determine the prevalence of previously unrecognized HF, COPD, and other chronic diseases in frail older people using a near-home targeted screening strategy. Methods: Community-dwelling frail persons aged ≥65 years underwent a 2-step screening strategy. First, they received a questionnaire inquiring about dyspnea and exercise tolerance. Those with exercise intolerance and/or dyspnea were invited to visit their primary care physicians office for a screening program, including medical history taking, physical examination, blood tests, electrocardiography, spirometry, and echocardiography. The final diagnosis of every patient was determined by a panel consisting of 3 physicians. Results: Of the 570 elderly who filled out the questionnaire, 395 (69%) had reduced exercise tolerance or dyspnea. Of these, 389 underwent the screening program: 127 (33.5%, 95% confidence interval, 28.9–38.4%) were newly diagnosed with HF (mainly HF with a preserved ejection fraction [23.5%]), and previously unrecognized COPD was detected in 16.8% (95% confidence interval, 13.4–20.9%). In total, 165 patients (43.9%) received a new diagnosis of either HF, COPD, or both. Other new diagnoses (in 32.7% of the screening program patients) included atrial fibrillation (1.8%), valvular disease (21.4%), (persisting) asthma (3.1%), anemia (12.7%), and thyroid disease (0.6%). No clear explanation for the complaints of 47 patients (12.2%) was found using our strategy. Conclusion: Unrecognized chronic diseases might be detected in community-dwelling frail elderly using a near-home screening strategy that is simple to implement. It remains to be proven, however, whether optimizing treatment of the newly detected diagnoses in this fragile population with multimorbidities and polypharmacy improves quality of life and reduces morbidity and mortality.

COPD detected with screening: Impact on patient management and prognosis

It is uncertain whether screening of older persons for chronic obstructive pulmonary disease (COPD) is worthwhile because the effects on patient management and prognosis are unknown. We aimed to assess the short-term consequences of detecting COPD in frail elderly subjects with dyspnoea, considering pulmonary drug use, hospitalisations and all-cause mortality. Community-dwelling frail elderly subjects, aged 65 years and older, with dyspnoea, participating in a screening study on COPD and heart failure were included. Final diagnoses were assigned by an expert panel based on all data from the screening strategy, including spirometry. Follow-up data were collected from the general practitioners. Of the 386 patients, 84 (21.8%) were received a new diagnosis of COPD. Overall, changes in pulmonary drug prescription during 6 months of follow-up were infrequent (n = 53, 13.7%; among new cases of COPD, 15 (17.9%) out of 84). Of all participants, 25.9% were hospitalised in the first year of follow-up, with the highest rate in patients with newly detected COPD (32.1%). Many new cases of COPD could be detected by screening frail elderly subjects with dyspnoea, but the impact on patient management seems limited. Our study underlines the importance of obtaining follow-up data to assess the true impact of a (screen-detected) diagnosis of COPD on patient management and outcome. Follow-up data are important when assessing the true impact of a new diagnosis of COPD on management and outcomes http://ow.ly/wVL0P

Triage of frail elderly with reduced exercise tolerance in primary care (TREE). a clustered randomized diagnostic study

BackgroundExercise reduced tolerance and breathlessness are common in the elderly and can result in substantial loss in functionality and health related quality of life. Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are common underlying causes, but can be difficult to disentangle due to overlap in symptomatology. In addition, other potential causes such as obesity, anaemia, renal dysfunction and thyroid disorders may be involved.We aim to assess whether screening of frail elderly with reduced exercise tolerance leads to high detection rates of HF, COPD, or alternative diagnoses, and whether detection of these diseases would result in changes in patient management and increase in both functionality and quality of life.Methods/DesignA cluster randomized diagnostic trial. Primary care practices are randomized to the diagnostic-treatment strategy (screening) or care as usual.Patient population: Frail (defined as having three or more chronic or vitality threatening diseases and/or receiving five or more drugs chronically during the last year) community-dwelling persons aged 65 years and older selected from the electronic medical files of the participating general practitioners. Those with reduced exercise tolerance or moderate to severe dyspnoea (≥2 score on the Medical Research Counsel dyspnoea scale) are included in the study.The diagnostic screening in the intervention group includes history taking, physical examination, electrocardiography, spirometry, blood tests, and echocardiography. Subsequently, participants with new diagnoses will be managed according to clinical guidelines. Participants in the control arm receive care as usual. All participants fill out health status and other relevant questionnaires at baseline and after 6 months of follow-up.DiscussionThis study will generate information on the yield of screening for previously unrecognized HF, COPD and other chronic diseases in frail elderly with reduced exercise tolerance and/or exercise induced dyspnoea. The cluster randomized comparison will reveal whether this yield will result in subsequent improvements in functional health and/or health related quality of life.Trial registrationClinicalTrials.gov NCT01148719

A nomogram was developed to enhance the use of multinomial logistic regression modeling in diagnostic research.

OBJECTIVES We developed a nomogram to facilitate the interpretation and presentation of results from multinomial logistic regression models. STUDY DESIGN AND SETTING We analyzed data from 376 frail elderly with complaints of dyspnea. Potential underlying disease categories were heart failure (HF), chronic obstructive pulmonary disease (COPD), the combination of both (HF and COPD), and any other outcome (other). A nomogram for multinomial model was developed to depict the relative importance of each predictor and to calculate the probability for each disease category for a given patient. Additionally, model performance of the multinomial regression model was assessed. RESULTS Prevalence of HF and COPD was 14% (n = 54), HF 24% (n = 90), COPD 20% (n = 75), and Other 42% (n = 157). The relative importance of the individual predictors varied across these disease categories or was even reversed. The pairwise C statistics ranged from 0.75 (between HF and Other) to 0.96 (between HF and COPD and Other). The nomogram can be used to rank the disease categories from most to least likely within each patient or to calculate the predicted probabilities. CONCLUSIONS Our new nomogram is a useful tool to present and understand the results of a multinomial regression model and could enhance the applicability of such models in daily practice.

Antenatal non-medical risk assessment and care pathways to improve pregnancy outcomes: a cluster randomised controlled trial

Social deprivation negatively affects health outcomes but receives little attention in obstetric risk selection. We investigated whether a combination of (1) risk assessment focused on non-medical risk factors, lifestyle factors, and medical risk factors, with (2) subsequent institution of risk-specific care pathways, and (3) multidisciplinary consultation between care providers from the curative and the public health sector reduced adverse pregnancy outcomes among women in selected urban areas in the Netherlands. We conducted a cluster randomised controlled trial in 14 urban municipalities across the Netherlands. Prior to the randomisation, municipalities were ranked and paired according to their expected proportion of pregnant women at risk for adverse outcomes at birth. The primary outcome was delivery of a preterm and/or small for gestational age (SGA) baby, analysed with multilevel mixed-effects logistic regression analysis adjusting for clustering and individual baseline characteristics. A total of 33 community midwife practices and nine hospitals participated throughout the study. Data from 4302 participants was included in the Intention To Treat (ITT) analysis. The intervention had no demonstrable impact on the primary outcome: adjusted odds ratio (aOR) 1.17 (95% CI 0.84–1.63). Among the secondary outcomes, the intervention improved the detection of threatening preterm delivery and fetal growth restriction during pregnancy [aOR 1.27 (95% CI 1.01–1.61)]. Implementation of additional non-medical risk assessment and preventive strategies into general practices is feasible but did not decrease the incidence of preterm and/or SGA birth in the index pregnancy in deprived urban areas.Trial registration Netherlands National Trial Register (NTR-3367).

Geographical differences in perinatal health and child welfare in the Netherlands: rationale for the healthy pregnancy 4 all-2 program

BackgroundGeographical inequalities in perinatal health and child welfare require attention. To improve the identification, and care, of mothers and young children at risk of adverse health outcomes, the HP4All-2 program was developed. The program consists of three studies, focusing on creating a continuum for risk selection and tailored care pathways from preconception and antenatal care towards 1) postpartum care, 2) early childhood care, as well as 3) interconception care. The program has been implemented in ten municipalities in the Netherlands, aiming to target communities with a relatively disadvantageous position with regard to perinatal and child health outcomes. To delineate the position of the ten participating municipalities, we present municipal and regional differences in the prevalence of perinatal mortality, perinatal morbidity, children living in deprived neighbourhoods, and children living in families on welfare.MethodsData on all singleton births in the Netherlands between 2009 and 2014 were analysed for the prevalence of perinatal mortality and morbidity. In addition, national data on children living in deprived neighbourhoods and children living in families on welfare between 2009 and 2012 were analysed. The prevalence of these outcomes were calculated and ranked for 62 geographical areas, the 50 largest municipalities and the 12 provinces, to determine the position of the municipalities that participate in HP4All-2.ResultsConsiderable geographical differences were present for all four outcomes. The municipalities that participate in HP4All-2 are among the 25 municipalities with the highest prevalence of perinatal mortality, perinatal morbidity, children living in deprived neighbourhoods, or children in families on welfare.ConclusionThis study illustrates geographical differences in perinatal health and/or child welfare outcomes and demonstrates that the HP4All-2 program targets municipalities with a relative unfavourable position. By targeting these municipalities, the program is expected to contribute most to improving the care for young children and their mothers at risk, and hence to reducing their risks and health inequalities.

Targeted social care for highly vulnerable pregnant women: protocol of the Mothers of Rotterdam cohort study

Introduction Social vulnerability is known to be related to ill health. When a pregnant woman is socially vulnerable, the ill health does not only affect herself, but also the health and development of her (unborn) child. To optimise care for highly vulnerable pregnant women, in Rotterdam, a holistic programme was developed in close collaboration between the university hospital, the local government and a non-profit organisation. This programme aims to organise social and medical care from pregnancy until the second birthday of the child, while targeting adult and child issues simultaneously. In 2014, a pilot in the municipality of Rotterdam demonstrated the significance of this holistic approach for highly vulnerable pregnant women. In the ‘Mothers of Rotterdam’ study, we aim to prospectively evaluate the effectiveness of the holistic approach, referred to as targeted social care. Methods and analysis The Mothers of Rotterdam study is a pragmatic prospective cohort study planning to include 1200 highly vulnerable pregnant women for the comparison between targeted social care and care as usual. Effectiveness will be compared on the following outcomes: (1) child development (does the child show adaptive development at year 1?) and (2) maternal mental health (is maternal distress reduced at the end of the social care programme?). Propensity scores will be used to correct for baseline differences between both social care programmes. Ethics and dissemination The prospective cohort study was approved by the Erasmus Medical Centre Ethics Committee (ref. no. MEC-2016–012) and the first results of the study are expected to be available in the second half of 2019 through publication in peer-reviewed international journals. Trial registration number NTR6271; Pre-results.

Ground Steel Target Plates in Combination with Direct Transfer of Clinical Candida Isolates Improves Frequencies of Species-Level Identification by Matrix-Assisted Laser Desorption Ionization–Time of Flight Mass Spectrometry in Comparison with Polished Steel Target Plates

MALDI-TOF MS identification of yeast isolates is fast and reliable, but the optimal workflow is debated (1, 2).…Matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) identification (ID) of Candida yeast isolates is fast and reliable, but the optimal workflow is debated ([1][1], [2][2]). Two different steel target plates are available for the Microflex system (Bruker