Veronique Verhoeven

The value of neuraminidase inhibitors for the prevention and treatment of seasonal influenza: a systematic review of systematic reviews.

Controversy has arisen regarding the effectiveness of neuraminidase inhibitors (NIs), especially against influenza-related complications. A literature search was performed to critically assess the evidence collected by the available systematic reviews (SRs) regarding the benefits and disadvantages of NIs (oseltamivir, zanamivir) compared to placebos in healthy and at-risk individuals of all ages for prophylaxis and treatment of seasonal influenza. A SR was done using the Cochrane Database of Systematic Reviews, Health Technology Assessment Database, Database of Abstracts of Reviews of Effects, and Medline (January 2006–July 2012). Two reviewers selected SRs based on randomized clinical trials, which were restricted to intention-to-treat results, and they assessed review (AMSTAR) and study quality indicators (GRADE). The SRs included (N = 9) were of high quality. The efficacy of NIs in prophylaxis ranged from 64% (16–85) to 92% (37–99); the absolute risk reduction ranged from 1.2% to 12.1% (GRADE moderate to low). Clinically relevant treatment benefits of NIs were small in healthy adults and children suffering from influenza-like illness (GRADE high to moderate). Oseltamivir reduced antibiotic usage in healthy adults according to one SR, but this was not confirmed by other reviews (GRADE low). Zanamivir showed a preventive effect on antibiotic usage in children (95% (77–99);GRADE moderate) and on the occurrence of bronchitis in at-risk individuals (59% (30–76);GRADE moderate). No evidence was available on the treatment benefits of NIs in elderly and at-risk groups and their effects on hospitalization and mortality. In oseltamivir trials, nausea, vomiting and diarrhea were significant side-effects. For zanamivir trials, no adverse effects have been reported. The combination of diagnostic uncertainty, the risk for virus strain resistance, possible side effects and financial cost outweigh the small benefits of oseltamivir or zanamivir for the prophylaxis and treatment of healthy individuals. No relevant benefits of these NIs on complications in at-risk individuals have been established.

Chlamydial infection: an accurate model for opportunistic screening in general practice

Objectives: To estimate the prevalence of Chlamydia trachomatis in women in general practice and to assess risk factors associated with infection. Methods: The study was carried out in 2001–2 in different general practices in Antwerp, Belgium. Sexually active women, visiting their general practitioner for routine gynaecological care (mostly pill prescription or PAP smear), were offered opportunistic screening for chlamydia. 787 participants aged 15–40 delivered a self taken vaginal sample and filled in a questionnaire which included questions on demographic variables, urogenital symptoms, sexual history, and sexual behaviour. Samples were tested for presence of chlamydial DNA by means of a ligase chain reaction (LCR) assay, and positives were confirmed by two other amplification assays (PCR and SDA). Results: Overall prevalence was 5.0% (95% CI: 3.5 to 6.5). Determinants of infection in logistic regression analysis were age 18–27 years, >1 partner in the past year, no use of contraceptives, frequent postcoital bleeding, having a symptomatic partner, painful micturition, and living in the inner city. The area under the ROC curve in the full model was 0.88. Selective screening based on a combination of the five first determinants detects 92.3% of infections in this sample; 37.5% of the population would need to be screened. Conclusion: Targeted screening for chlamydial infection is possible, even in a heterogeneous group of general practice attendants. Implementing this model would require considerable communication skills from healthcare providers.

Efficacy of daily intake of Lactobacillus casei Shirota on respiratory symptoms and influenza vaccination immune response: a randomized, double-blind, placebo-controlled trial in healthy elderly nursing home residents

BACKGROUND Age is associated with immune dysregulation, which results in an increased infection rate and reduced effectiveness of vaccination. OBJECTIVE We assessed whether an intervention with Lactobacillus casei Shirota (LcS) in elderly nursing home residents reduced their susceptibility to respiratory symptoms and improved their immune response to influenza vaccination. DESIGN Between October 2007 and April 2008, a randomized, double-blind, placebo-controlled trial was conducted in 737 healthy people aged ≥ 65 y in 53 nursing homes in Antwerp, Belgium. Volunteers were randomly assigned to receive a probiotic (n = 375; 2 bottles of fermented milk that contained ≥ 6.5 × 10(9) live LcS/bottle) or a placebo (n = 362; similar drink with no bacteria) for 176 d. After 21 d, all subjects received an influenza vaccination. Primary outcome parameters were the number of days with respiratory symptoms, the probability of respiratory symptoms, and antiinfluenza antibody titer by hemagglutination inhibition after vaccination. RESULTS Univariate and multivariate modeling showed no effect of the probiotic on clinical outcome parameters. Generalized linear mixed modeling showed no effect of the probiotic itself on the probability of respiratory symptoms [OR of probiotic: 0.8715; 95% CI: 0.6168, 1.2887). No significant difference regarding the influenza-vaccination immune response was shown. CONCLUSION The results of this study show that daily consumption of a fermented milk drink that contains LcS has no statistically or clinically significant effect on the protection against respiratory symptoms. This trial was registered at clinicaltrials.gov as NCT00849277.

Probiotics enhance the clearance of human papillomavirus-related cervical lesions: a prospective controlled pilot study

Probiotics have been proposed for a number of urogenital infectious conditions. In this study, we examine a possible effect on human papillomavirus (HPV)-related precancerous lesions in cervical cytology. We conducted a prospective controlled pilot study, in which 54 women with an HPV+low-grade squamous intraepithelial lesion diagnosis in their PAP smear were followed for 6 months. The intervention group consumed a daily probiotic drink during the study period; the control group received no treatment, according to common care policy. Outcome measures were the control PAP smear and HPV status after 6 months. Probiotic users had a twice as high chance of clearance of cytological abnormalities (60 vs. 31%, P=0.05). HPV was cleared in 19% of control patients versus 29% of probiotic users (P=0.41). This exploratory pilot study suggests that the probiotic studied promotes the clearance of HPV-related cytological abnormalities. If confirmed, this would represent an entirely new option to manage cervical cancer precursors.

Walk on the sunny side of life — Epidemiology of hypovitaminosis D and mental health in elderly nursing home residents

ObjectivesOld age is a well-known risk factor for both depression and hypovitaminosis D, and an association between both conditions has been postulated. We document the prevalence of vitamin D deficiency in nursing home residents, and we examine the link with self-reported depressive symptoms and pharmacotherapy for depression.DesignCross- sectional. Setting: nursing homes in Antwerp, Belgium.ParticipantsHealthy elderly (n=589), with a mean age of 84 years.MeasurementsWe detected depressive symptoms by means of SF-36, a validated quality of life assessment; we registered the use of antidepressants and anxiolytics, and we measured serum 25(OH)D concentrations in all participants.ResultsAlmost our entire study population appeared to be vit D deficient. Comparison of the most severely and least deficient subgroups showed a consistent tendency towards more depressive symptoms and more use of antidepressants in the group with the lowest vit D level.ConclusionNursing home residents are particularly vulnerable to preventable vit D deficiency. The relevance of the association with depressive symptoms and the possibilities for treatment are critically reviewed in the discussion.

Everything you always wanted to know about HPV (but could not ask your doctor)

OBJECTIVE To investigate specific information needs of people who search for information about the human papillomavirus (HPV) on the Internet. METHODS We performed a qualitative analysis of the e-mail questions asked by the visitors of a website with evidence-based information about HPV. The website, hosted by Antwerp University, provided basic information on epidemiology and natural history of HPV in women and men, diagnostic and treatment options, screening, and vaccination. If visitors did not find an answer to their questions, they could mail their question to an e-mail address associated with the website. RESULTS We received 713 questions posed by 527 e-mail correspondents. The following themes emerged as most important: transmission of HPV, the HPV vaccine, the natural history of the virus, the vicious circle (re-infection between partners), HPV detection in men and women, treatment of men and women, incubation time, pregnancy/fertility, genital warts (in)fidelity, and symptoms of HPV infection. CONCLUSION Both men and women are seeking health information on HPV on the Internet, often after being counseled by a health care provider. PRACTICE IMPLICATIONS Practitioners should be prepared for questions on the themes that concern people most. Practitioners may play a role in guidance towards reliable sources of information.

Can red yeast rice and olive extract improve lipid profile and cardiovascular risk in metabolic syndrome?: a double blind, placebo controlled randomized trial

BackgroundMetabolic syndrome (MetS) comprises a spectrum of clinical phenotypes in which dyslipidemia, dysglycemia and hypertension are clustered and where all share a high level of oxidative stress and an increased risk of cardiovascular disease. This study examines the effect of a nutritional supplement combining red yeast rice and olive fruit extract on the lipid profile and on oxidative stress in a population of patients with MetS.MethodsIn a double blind placebo controlled randomized trial, 50 persons with MetS, as defined by the ATPIII criteria, received the study product or placebo for 8 weeks. The study product contained 10.82 mg of monacolins and 9,32 mg of hydroxytyrosol per capsule, and is commercialized as Cholesfytol plus. The primary outcome measure was the difference in LDL reduction between intervention and control groups. Furthermore, differences in changes of CH, HDL, ApoA1, ApoB, HbA1c and oxLDL were measured, as well as side-effects, CK elevation, changes in clinical parameters and in cardiovascular risk.ResultsIn the intervention group, LDL cholesterol was lowered by 24% whereas it increased by 1% in the control group (p < 0.001). Other effects observed were a change in total cholesterol (−17% in the intervention group vs +2% in the control group, p < 0.001), apolipoprotein B (−15% vs +6%, p < 0.001), and TG (−9% vs + 16%, p = 0.02). Oxidized LDL decreased by 20% vs an increase of 5% in the control group (p < 0.001). Systolic and diastolic arterial blood pressure decreased significantly by 10 mmHg (vs 0% in the control group, p = 0.001) and 7 mmHg (vs 0% in the control group, p = 0.05) respectively. One person in the intervention group, who suffered from Segawa’s syndrome, dropped out because of severe muscle ache.ConclusionsThe combination of active products in this study may be an alternative approach to statins in people who do not need, or cannot or do not want to be treated with chemical statins. Side effects, effects on oxidative stress and on glucose metabolism need to be examined more thoroughly.Trial registrationClinicaltrials.gov NCT02065180 (February 2014).

The Prevalence of the Human Papillomavirus in Cervix and Vagina in Low-risk and High-risk Populations

Concordance of HPV between vagina and cervix may be influenced by sample taking and by differences in flow of cervical epithelial cells. To investigate the latter aspect, from 96 women visiting their general practitioner, and 63 sex workers visiting a STI clinic, both vaginal and cervical samples for HPV detection were obtained by the doctor to standardize sample taking. To identify factors that may influence the flow of cervical epithelial cells to the vagina, a questionnaire on intimate hygiene was obtained. The overall HPV prevalence was 22.8%; 14.3% in the general population (14.3% in the cervix, 11.9% in the vagina), compared with 34.4% in sex workers (31.1% in the cervix, 27.9% in the vagina). There was excellent agreement between HPV prevalence in vaginal and cervical samples. The overall agreement was 94.5% (kappa=0.83, 95% CI: 0.77–0.89); in the general population agreement reached 97.6%, compared with 90.0% in sex workers. Vaginal infection may influence concordance, but for validation of this finding larger studies are necessary. The high concordance found between HPV prevalence in vagina and cervix warrants further study of the applicability of self-sampling to improve coverage rates by attracting women who would otherwise not obtain a pap test.

Concomitant Chlamydia trachomatis and human papilloma virus infection cannot be attributed solely to sexual behaviour

Human papillomavirus (HPV) is a common genital sexually transmitted infection, and persistent high-risk HPV infection is strongly linked to cervical cancer [1]. However, infection with HPV is mainly transient and only a small proportion of women infected with HPV have persistent infection that progresses to cervical intraepithelial neoplasia and invasive cervical cancer. Therefore, it is likely that cofactors are involved, which increase susceptibility to HPV infection by facilitating HPV persistence or by inducing progression to invasive cancer [2]. A correlation between Chlamydia trachomatis (CT) infection and dysplastic or neoplastic cervical abnormalities has been observed by several authors [3–7] and this finding has led to the hypothesis that CT is a cofactor in HPVrelated carcinogenesis. However, it has also been suggested that the association between CT and HPV may merely be a reflection of their shared route of sexual transmission and the fact that both are markers of sexual risk behaviour [8, 9]. The availability of a large database of 825 women under the age of 40 years, who participated in a CT prevalence study [10], made it possible for us to examine a possible association between CT and HPV infection in a study that controlled for sexual behaviour. The database used in this study contained stored vaginal samples that had been taken by the patients themselves and detailed information, including data on various markers of sexual behaviour, from patient questionnaires. Using this database, we conducted a cross-sectional study in which patient data pertaining to 22 stored CT-positive samples (i.e., all available) were matched with the data related to 44 samples from women without chlamydial infection. Women with and without CT were individually matched for age (±1 year), age at time of first sexual encounter with penetration (±1 year), number of partners in the past year, and condom use in order to obtain two groups of patients that were as similar as possible, except for their CT status. Matching was performed to maximise equality between CT-positive and CT-negative subjects with regard to relevant sexual behaviour characteristics. This strategy was preferred because of the limited number of cases available. HPV detection was performed using probes for all known high-risk types as well as for eight low-risk types. Diagnostic accuracy was maximised by use of highstandard molecular diagnostic methods for CT and HPV detection as described elsewhere [11, 12]. Stepwise logistic regression analysis was performed using SPSS package version 11.5 (SPSS, Chicago, IL, USA) to examine the association between HPV and CT. In addition to the matching variables, other determinants of sexual behaviour and possible confounders were included, i.e., history of sexually transmitted disease diagnoses, history of emergency contraception use, history of unintended pregnancy, marital status, education, and parity [1]. The baseline characteristics of the study participants are shown in Table 1. Concordance between CT-positive and CT-negative subjects with respect to the matching variables was satisfactory: 84.1% for age ±1 year (95.5% for age ±2 years), 86.4% for age at time of first sexual intercourse ±1 year (93.2% for age ±2 years), 95.5% for number of partners, and 97.8% for condom use. Matching variables were added to the multivariate analysis to account for possible residual confounding. V. Verhoeven (*) . D. Avonts . P. Van Royen Academic Centre for General Practice, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium e-mail: veronique.verhoeven@ua.ac.be Tel.: +32-3-8202518 Fax: +32-3-8202526

The Additional Value of Bioelectrical Impedance Analysis-Derived Muscle Mass as a Screening Tool in Geriatric Assessment for Fall Prevention

Background: The decline in skeletal muscle in old age is a factor in the development of functional limitations. Objective: The objective of this study was to assess if there is a correlation between muscle mass based on bioelectrical impedance analysis (BIA) detection and the fall incidence in nursing home residents and to examine the risk factors for falling in nursing home residents. Methods: This prospective cohort study was part of a longitudinal study on nutritional issues in 52 nursing homes in Antwerp (Belgium) from October 2007 to April 2008. Two hundred and seventy-six people aged 65 years and older were included. Each subject was assessed with BIA, the timed get-up-and-go test, the Katz score, the Mini Nutritional Assessment – Short Form and the 36-Item Short Form Health Survey. The primary outcome parameter was fall incidence during the study. Results: The prevalence of sarcopenia varied from 24.3 to 81.5% depending on which definition was used. No association was found between BIA-derived muscle mass and fall incidence. Logistic regression analysis showed that gait speed (odds ratio 1.029; p = 0.003) and mental health (odds ratio 0.981; p = 0.015) are significantly associated with fall incidence in nursing homes. A receiver operating characteristic curve showed that none of the BIA-derived muscle parameters are good predictors of the risk of falling. Conclusions: This study shows that there is no association between sarcopenia based on BIA and fall incidence and that BIA-derived muscle mass has no additional value in predicting fall incidents compared to the timed get-up-and-go test.