W.J.M. Scholte op Reimer

Antibiotic-based catheter lock solutions for prevention of catheter-related bloodstream infection: a systematic review of randomised controlled trials

Catheter-related bloodstream infection (CRBSI) is associated with high rates of morbidity. This systematic review assesses the efficacy of antibiotic-based lock solutions to prevent CRBSI. A secondary goal of our review is to determine which antibiotic-based lock solution is most effective in reducing CRBSI. We searched Medline and the Cochrane Library for relevant trials up to April 2009. Data from the original publications were used to calculate the overall relative risk of CRBSI. Data for similar outcomes were combined in the analysis where appropriate, using a random-effects model. Sixteen trials were included in the review, nine conducted in haemodialysis patients, six in oncology patients (mainly children) and one study concerned critically ill neonates. Three haemodialysis patients needed to be treated with antibiotics to prevent one CRBSI, given a mean insertion time of 146 days (range: 37-365) and an average baseline risk of 3.0 events per 1000 catheter-days. In the oncology patients a number needed to treat (NNT) was calculated of eight patients to prevent one BSI, given a mean insertion time of 227 days (range: 154-295) and average baseline risk of 1.7 events per 1000 catheter-days. There are indications that antibiotic-based lock solutions as compared to heparin lock solutions are effective in the prevention of CRBSI in haemodialysis patients. In trials studying oncology patients the estimated effect showed only a marginal significant benefit in favour of antibiotic-based lock solutions. Our review supports the Centers for Disease Control and Prevention in not recommending routine use of antibiotic-based catheter lock solutions.

Acceptance of insulin therapy: a long shot? Psychological insulin resistance in primary care

Diabet. Med. 29, 796–802 (2012)

Smoking Cessation has no Influence on Quality of Life in Patients with Peripheral Arterial Disease 5 Years Post-vascular Surgery

OBJECTIVES Smoking is an important modifiable risk factor in patients with peripheral arterial disease (PAD). We investigated differences in quality of life (QoL) between patients who quitted smoking during follow-up and persistent smokers. DESIGN Cohort study. METHODS Data of 711 consecutively enrolled patients undergoing vascular surgery were collected in 11 hospitals in the Netherlands. Smoking status was obtained at baseline and at 3-year follow-up. A 5-year follow-up to measure QoL was performed with the EuroQol-5D (EQ-5D) and Peripheral Arterial Questionnaire (PAQ). RESULTS After adjusting for clinical risk factors, patients, who quit smoking within 3 years after vascular surgery, did not report an impaired QoL (EQ-5D: odds ratio (OR) = 0.63, 95% confidence interval (CI) = 0.28-1.43; PAQ: OR = 0.76, 95% CI = 0.35-1.65; visual analogue scale (VAS): OR = 0.88, 95% CI = 0.42-1.84) compared with patients, who continued smoking. Current smokers were significantly more likely to have an impaired QoL (EQ-5D: OR = 1.86, 95% CI = 1.09-3.17; PAQ: OR = 1.63, 95% CI = 1.00-2.65), although no differences in VAS scores were found (OR = 1.17, 95% CI = 0.72-1.90). CONCLUSIONS There was no effect of smoking cessation on QoL in PAD patients undergoing vascular surgery. Nevertheless, given the link between smoking, complications and mortality in this patient group, smoking cessation should be a primary target in secondary prevention.

Smoking cessation after an acute coronary syndrome: immediate quitters are successful quitters.

BackgroundCardiovascular disease (CVD) prevention guidelines stress the importance of smoking cessation and recommend intensive follow-up. To guide the development of such cessation support strategies, we analysed the characteristics that are associated with successful smoking cessation after an acute coronary syndrome (ACS).MethodsWe used data from the Randomised Evaluation of Secondary Prevention for ACS patients coordinated by Outpatient Nurse SpEcialists (RESPONSE) trial (n = 754). This was designed to quantify the impact of a nurse-coordinated prevention program, focusing on healthy lifestyles, traditional CVD risk factors and medication adherence. For the current analysis we included all smokers (324/754, 43 %). Successful quitters were defined as those who reported abstinence at 1 year of follow-up.ResultsThe majority of successful quitters quit immediately after the ACS event and remained abstinent through 1 year of follow-up, without extra support (128/156, 82 %). Higher education level (33 vs. 15 %, p < 0.01), no history of CVD (87 vs. 74 %, p < 0.01) and being on target for LDL-cholesterol level at 1 year (78 vs. 63 %, p < 0.01) were associated with successful quitting.ConclusionThe majority of successful quitters at 1 year stopped immediately after their ACS. Patients in this group showed that it was within their own ability to quit, and they did not relapse through 1 year of follow-up. Our study indicates that in a large group of patients who quit immediately after a life-threatening event, no relapse prevention program is needed.

Statin treatment after a recent TIA or stroke: is effectiveness shown in randomized clinical trials also observed in everyday clinical practice?

Lingsma HF, Steyerberg EW, Scholte op Reimer WJM, van Domburg R, Dippel DWJ, the Netherlands Stroke Survey Investigators. Statin treatment after a recent TIA or stroke: is effectiveness shown in randomized clinical trials also observed in everyday clinical practice?
Acta Neurol Scand: 2010: 122: 15–20.
© 2009 The Authors Journal compilation

Process of Care Partly Explains the Variation in Mortality Between Hospitals After Peripheral Vascular Surgery

OBJECTIVES The aim of this study is to investigate whether variation in mortality at hospital level reflects differences in quality of care of peripheral vascular surgery patients. DESIGN Observational study. MATERIALS In 11 hospitals in the Netherlands, 711 consecutive vascular surgery patients were enrolled. METHODS Multilevel logistic regression models were used to relate patient characteristics, structure and process of care to mortality at 1 year. The models were constructed by consecutively adding age, sex and Lee index, then remaining risk factors, followed by structural measures for quality of care and finally, selected process of care parameters. RESULTS Total 1-year mortality was 11%, ranging from 6% to 26% in different hospitals. Large differences in patient characteristics and quality indicators were observed between hospitals (e.g., age>70 years: 28-58%; beta-blocker therapy: 39-87%). Adjusted analyses showed that a large part of variation in mortality was explained by age, sex and the Lee index (Akaikes information criterion (AIC)=59, p<0.001). Another substantial part of the variation was explained by process of care (AIC=5, p=0.001). CONCLUSIONS Differences between hospitals exist in patient characteristics, structure of care, process of care and mortality. Even after adjusting for the patient population at risk, a substantial part of the variation in mortality can be explained by differences in process measures of quality of care.

Nurses' perspectives on nurse-coordinated prevention programmes in secondary prevention of cardiovascular disease: a pilot survey

Background: Secondary prevention of coronary artery disease (CAD) is increasingly provided by nurse-coordinated prevention programs (NCPP). Little is known about nurses’ perspectives on these programs. Aim: To investigate nurses’ perspectives/experiences in NCPPs in acute coronary syndrome patients. Methods: Thirteen nurses from NCPPs in 11 medical centers in the RESPONSE trial completed an online survey containing 45 items evaluating 3 outcome categories: (1) conducting NCPP visits; (2) effects of NCPP interventions on risk profiles and (3) process of care. Results: Nurses felt confident in counseling/motivating patients to reduce CAD risk. Interventions targeting LDL, blood pressure and medication adherence were reported as successful, corresponding with significant improvements of these risk factors. Improving weight, smoking and physical activity was reported as less effective. Screening for anxiety/depression was suggested as an improvement. Conclusions: Nurses acknowledge the importance and effectiveness of NCPPs, and correctly identify which components of the program are the most successful. Our study provides a basis for implementation and quality improvement for NCCPs.

Smoking cessation in European patients with coronary heart disease. Results from the EUROASPIRE IV survey: A registry from the European Society of Cardiology

OBJECTIVE We investigated smoking cessation rates in coronary heart disease (CHD) patients throughout Europe; current and as compared to earlier EUROASPIRE surveys, and we studied characteristics of successful quitters. METHODS Analyses were done on 7998 patients from the EUROASPIRE-IV survey admitted for myocardial infarction, unstable angina and coronary revascularisation. Self-reported smoking status was validated by measuring carbon monoxide in exhaled air. RESULTS Thirty-one percent of the patients reported being a smoker in the month preceding hospital admission for the recruiting event, varying from 15% in centres from Finland to 57% from centres in Cyprus. Smoking rates at the interview were also highly variable, ranging from 7% to 28%. The proportion of successful quitters was relatively low in centres with a low number of pre- event smokers. Overall, successful smoking cessation was associated with increasing age (OR 1.50; 95% CI 1.09-2.06) and higher levels of education (OR 1.38; 95% CI 1.08-1.75). Successful quitters more frequently reported that they had been advised (56% vs. 47%, p < .001) and to attend (81% vs. 75%, p < .01) a cardiac rehabilitation programme. CONCLUSION Our study shows wide variation in cessation rates in a large contemporary European survey of CHD patients. Therefore, smoking cessation rates in patients with a CHD event should be interpreted in the light of pre-event smoking prevalence, and caution is needed when comparing cessation rates across Europe. Furthermore, we found that successful quitters reported more actions to make healthy lifestyle changes, including participating in a cardiac rehabilitation programme, as compared with persistent smokers.