How to increase awareness of additional vaccinations; the case of maternal pertussis vaccination.

BACKGROUND: Effective and safe vaccines are available outside national immunization programs (NIP). Increased awareness and vaccine uptake can improve public health. Before the inclusion of maternal pertussis vaccination (MPV) in the Dutch NIP in December 2019, extra communication efforts were undertaken. Here we examine the success of these efforts, investigating women's awareness of and their decision-making process regarding MPV. METHODS: Between December 2018 and January 2019, one year before the introduction of MPV in the NIP, and about three years after MPV was recommended by the Dutch Health Council, pregnant and non-pregnant women (i.e. child younger than two years) were invited to fill out an online questionnaire. Participant's decision-making processes regarding MPV were assessed with an adapted Precaution Adoption Process Model (PAPM), including stages of awareness, engagement, information-seeking, and vaccination behaviour. Furthermore, factors related to the decision-making process were examined. RESULTS: In total, 942 women were included, of whom 62% were non-pregnant. Most of the pregnant and nonpregnant women were aware of MPV during pregnancy (respectively 69 and 56%). Most aware women had heard about MPV through their midwife and the Public Health Institute (PHI) website. Women unaware of MPV reported a need for information, preferably from their midwives. Most aware women felt MPV was important to them (88%) and were classified as "engaged". Of the eligible and "engaged" pregnant women, 58% were vaccinated, versus 38% of "engaged" non-pregnant women. CONCLUSIONS: As the most preferred and trusted source of information, midwives are essential to increasing awareness of MPV. The PHI website is considered to be a reliable information source and is often consulted. To increase awareness, appropriate healthcare workers should be encouraged to actively inform target groups about available, additional vaccinations.

Prospective study for establishing minimal clinically important differences in patients with surgery for lower extremity metastases.

BACKGROUND: The clinical relevance of patient-reported outcomes score changes is often unclear. Especially in patients undergoing surgery due to lower extremity metastases - where surgery is performed in the palliative setting and the goal is to optimize functional mobility, relieve pain and improve overall quality of life. This study assessed the minimal clinically important difference (MCID) of Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference, Cancer-specific Physical Function, and Global (Physical and Mental Health) in patients treated surgically for impending or completed pathologic fractures. METHODS: Patients undergoing surgery for osseous metastasis of the lower extremity because of an impending or completed pathologic fracture were consecutively enrolled in this tertiary center study. Patients completed the three PROMIS questionnaires preoperatively (n = 56) and at postoperative follow-up (n = 33) assessment one to three months later. Of the 23 patients that did not complete the postoperative survey, 5 patients died within 1-3 months and 18 patients were alive at 3-months but did not respond or show up at their postoperative consult. Thirty-one patients (94%) of the 33 included patients reported at least minimal improvement and two patients (6.1%) no change 1-3 months after the surgery based on an anchor-based approach. RESULTS: The PROMIS MCIDs (95% confidence interval) for Pain Interference was 7.5 (3.4-12), Physical Function 4.1 (0.6-7.6), Global Physical Health 4.2 (2.0-6.6), and Global Mental Health 0.8 (-4.5-2.9). CONCLUSION: This prospective study successfully defined a MCID for PROMIS Pain Interference of 7.5 (3.4-12), PROMIS Physical Function of 4.1 (0.6-7.6), and Global Physical Health of 4.2 (2.0-6.6) in patients with (impending) pathological fractures due to osseous metastases in the lower extremity; no MCID could be established for PROMIS Global Mental Health. Defining a narrower MCID value for each subpopulation requires a large, prospective, multicenter study. Nevertheless, the provided MCID values allow guidance to clinicians to evaluate the impact of surgical treatment on a patient's QoL. LEVEL OF EVIDENCE: Level II Diagnostic study.

Adipose tissue density on CT as a prognostic factor in patients with cancer: a systematic review.

BACKGROUND: Predicting oncologic outcomes is essential for optimizing the treatment for patients with cancer. This review examines the feasibility of using Computed Tomography (CT) images of fat density as a prognostic factor in patients with cancer. METHODS: A systematic literature search was performed in PubMed, Embase and Cochrane up to March 2020. All studies that mentioned using subcutaneous or visceral adipose tissue (SAT and VAT, respectively) CT characteristics as a prognostic factor for patients with cancer were included. The primary endpoints were any disease-related outcomes in patients with cancer. RESULTS: After screening 1043 studies, ten studies reporting a total of 23 - ten for SAT and thirteen for VAT - comparisons on survival, tumor recurrence and postsurgical infection were included. All ten studies included different types of malignancy: six localized, two metastatic disease, and two both. Five different anatomic landmarks were used to uniformly measure fat density on CT: lumbar (L)4 (n = 4), L3 (n = 2), L4-L5 intervertebral space (n = 2), L5-S1 intervertebral space (n = 1), and the abdomen (n = 1). Overall, six of ten SAT comparisons (60%) and six of thirteen VAT comparisons (46%) reported a significant (p < .05) association of increased SAT or VAT density with an adverse outcome. All remaining nonsignificant comparisons, except one, deviated in the same direction of being predictive for adverse outcomes but failed to reach significance. The median hazard ratio (HR) for the nine SAT and thirteen VAT associations where HRs were given were 1.45 (95% confidence interval [CI] 1.01-1.97) and 1.90 (95% CI 1.12-2.74), respectively. The binomial sign test and Fisher's method both reported a significant association between both SAT and VAT and adverse outcomes. CONCLUSION: This review may support the feasibility of using SAT or VAT on CT as a prognostic tool for patients with cancer in predicting adverse outcomes such as survival and tumor recurrence. Future research should standardize radiologic protocol in prospective homogeneous series of patients on each cancer diagnosis group in order to establish accurate parameters to help physicians use CT scan defined characteristics in clinical practice.

Functional constipation in children: a systematic review on prognosis and predictive factors.

BACKGROUND AND AIM: Knowledge regarding prognosis and factors influencing the clinical course of functional constipation in children is important to enable general practitioners and paediatricians to give accurate patient information, to compare treatment strategies, and identify children with high risk for unfavourable outcome. The objective of the study was to investigate and summarize the quantity and quality of evidence on prognosis of childhood constipation with and without treatment and its predictive factors. METHODS: An extensive literature search in MEDLINE and Embase was performed to identify prospective follow-up studies evaluating the prognosis or prognostic determinants of functional constipation. Methodological quality was assessed using a standardised list. Results on prognosis of constipation were statistically pooled, and the influence of prognostic factors was summarised in a best evidence synthesis. RESULTS: The search strategy resulted in a total of 2882 abstracts. Only 14 publications met our inclusion criteria, of which 21% scored high methodological quality. Included studies showed large heterogeneity in study populations and outcome measures. Without regard to these differences, 49.3% +/- 11.8% of all of the children followed for 6 to 12 months were found to recover and taken off laxatives. The percentage of children who were free from complaints, regardless of laxative use, after 6 to 12 months was 60.6% +/- 19.2%. There is substantial evidence that defecation frequency and a positive family history are not associated with recovery from constipation. CONCLUSIONS: The few studies published on prognosis of childhood functional constipation and predictive factors showed large heterogeneity and poor methodological quality. Overall, 60.6% of children are found to be free from symptoms after 6 to 12 months. Recovery rate showed no relation with defecation frequency or positive family history. Based on the present literature, we are unable to identify a group of children with high risk for poor prognosis.

No change in rectal sensitivity after gut-directed hypnotherapy in children with functional abdominal pain or irritable bowel syndrome.

OBJECTIVES: Gut-directed hypnotherapy (HT) has recently been shown to be highly effective in treating children with functional abdominal pain (FAP) and irritable bowel syndrome (IBS). This study was conducted to determine the extent to which this treatment success is because of an improvement in rectal sensitivity. METHODS: A total of 46 patients (aged 8-18 years) with FAP (n=28) or IBS (n=18) were randomized to either 12 weeks of standard medical therapy (SMT) or HT. To assess rectal sensitivity, a pressure-controlled intermittent distension protocol (barostat) was performed before and after the therapy. RESULTS: Rectal sensitivity scores changed in SMT patients from 15.1+/-7.3 mm Hg at baseline to 18.6+/-8.5 mm Hg after 12 weeks of treatment (P=0.09) and in HT patients from 17.0+/-9.2 mm Hg to 22.5+/-10.1 mm Hg (P=0.09). The number of patients with rectal hypersensitivity decreased from 6 of 18 to 0 of 18 in the HT group (P=0.04) vs. 6 of 20 to 4 of 20 in the SMT group (P=0.67). No relationship was established between treatment success and rectal pain thresholds. Rectal sensitivity scores at baseline were not correlated with intensity, frequency, or duration of abdominal pain. CONCLUSIONS: Clinical success achieved with HT cannot be explained by improvement in rectal sensitivity. Furthermore, no association could be found between rectal barostat findings and clinical symptoms in children with FAP or IBS. Further studies are necessary to shed more light on both the role of rectal sensitivity in pediatric FAP and IBS and the mechanisms by which hypnotherapy results in improvement of clinical symptoms.

Reduction of adult height in childhood acute lymphoblastic leukemia survivors after prophylactic cranial irradiation.

BACKGROUND: Impaired linear growth is a well-recognized complication in long-term childhood ALL survivors who received cranial irradiation. However, as many patients achieve a final height between the 5th and the 95th centile, the true incidence of linear growth impairment might be underestimated. METHODS: Reduction of adult height (RAH) was estimated in adult childhood ALL survivors with and without cranial irradiation. RAH was calculated as the difference between target height (TH) and final height (FH). TH was calculated according to the formula TH = {[(height father + height mother +/- 12)/2] + 3}. RAH was assessed in 79 adult childhood ALL survivors in first complete remission who had received cranial irradiation 25 Gy (Group I, n = 53), 18 Gy (Group II, n = 10) or chemotherapy alone (controls, n = 16). RESULTS: RAH was 8.6 +/- 8.2 cm in Group I (P = 0.001 vs. controls), 6.2 +/- 3.2 cm in Group II (P = 0.01 vs. controls), and 1.7 +/- 4.6 in controls (chemotherapy only). There was no significant difference between Group I and Group II. In Group I females had more RAH than males (P = 0.02). RAH was related to younger age at diagnosis (P = 0.001). CONCLUSIONS: The deficit between target height and final height highlights the reduction of adult height in the majority of male and female childhood ALL survivors who had received prophylactic cranial irradiation, in particular in those who were diagnosed at a younger age. This reduction would have been masked if patients FH was only compared with standard methods. RAH might be a sensitive predictor for growth hormone deficiency as these results suggest that radiation-induced growth hormone deficiency in these patients is the rule rather than the exception.

[A teenager presenting with vomiting, general malaise and weight loss]. / Een tiener met braken, algehele malaise en gewichtsverlies.

A 16-year-old girl had symptoms of vomiting, malaise and weight loss for two months. Blood tests revealed an elevated activity of liver enzymes and hyperthyroidism. Although the patient at first denied the possibility of pregnancy, a pregnancy was subsequently confirmed. Hyperemesis gravidarum was diagnosed based on the combination of the clinical symptoms, pregnancy and increased serum human chorionic gonadotrophin and oestradiol. Hyperemesis gravidarum also explained the demonstrated biochemical hyperthyroidism and elevated liver enzyme levels. Rapid alleviation of all the clinical symptoms was seen after termination of this unwanted pregnancy. Although vomiting, malaise and weight loss in children can have many different causes, in girls at a sexually mature age a pregnancy with possible hyperemesis gravidarum should certainly also be considered and a gynaecological examination performed.