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Objective: Copeptin, a quantitative marker of endogenous stress, seems to provide incremental value in addition to cardiac troponin in the early rule-out of acute myocardial infarction (AMI). Prevalence, characteristics and outcome of acute chest pain patients with causes other than AMI and elevated copeptin are poorly understood., Methods: A total of 984 consecutive patients with non-cardiac chest pain were selected from a prospective multicentre study of acute chest pain patients presenting to the emergency department. Levels of copeptin were determined in a blinded fashion and considered elevated if above 13 pmol/L (the 97,5th centile of healthy individuals). The final diagnosis was adjudicated by two independent cardiologists. Median duration of follow-up was 756 days., Results: Elevated copeptin levels were seen in 215 patients (22%). In comparison to patients with normal copeptin levels, patients with elevated levels were older, had more pre-existing cardiac and non-cardiac disorders, more silent cardiomyocyte injury and increased haemodynamic stress as quantified by levels of high-sensitivity cardiac troponin T (9.6 ng/L (3.6-18.3) vs 5.8 ng/L (2.9-9.4)) and B-type natriuretic peptide (75 ng/L (37-187) vs 35 ng/L (15-77)) (both p<0.001), more electrocardiographic abnormalities, more often an adjudicated diagnosis of gastroesophageal reflux or bronchitis/pneumonia and higher 2- year mortality (HR 2.9, 95% CI 1.5  to 5.7). The increased mortality rate seemed to be largely explained by age and comorbidities., Conclusions: Elevated levels of copeptin are present in about one in five patients with non-cardiac chest pain and are associated with aging, cardiac and non-cardiac comorbidities as well as mortality., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Limited evidence exists on the nature and degree of emotional problems in pulmonary arterial hypertension (PAH) and their association with patients' health-related quality of life (HRQOL)., Methods: This cross-sectional study examined the presence of depression, anxiety, and stress symptoms, and their association with disease-specific and generic HRQOL. A total of 101 patients (73% women) with PAH (age, 55.4 ± 16.4 years; 42.6% in New York Heart Association [NYHA] class II) completed the Depression, Anxiety, and Stress Scale, the generic Medical Outcomes Study Short-Form 36-Item (SF-36) Health Survey, and the disease-specific Minnesota Living With Heart Failure Questionnaire (MLHFQ) HRQOL instrument. The association between emotional problems and HRQOL was determined using multivariable linear regression analyses, controlling for demographic and disease-related characteristics., Results: Of the patients, 32.6%, 48%, and 27.6% experienced depressive, anxiety or stress symptoms, respectively. HRQOL was >1 standard deviation below population norms for the SF-36 Physical Component Summary. Depressive symptoms, NYHA class, and being disabled explained 46% of the total variance of the MLHFQ. Emotional problems did not contribute to the SF-36 Physical Component Summary but explained part of the variance of the physical sub-scales of the SF-36 role limitations due to physical problems, bodily pain, and general health., Conclusions: The high presence of emotional problems warrants regular screening and appropriate psychotherapeutic and/or pharmacological treatment. Which strategies could improve PAH patients' HRQOL remains to be investigated., (Copyright © 2014 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Although medication nonadherence (MNA) is a major risk factor for poor outcomes, the evolution of MNA from pre- to 3 years post-transplant among the four major organ transplant groups remains unknown. Therefore, this study described this evolution and investigated whether pretransplant MNA predicts post-transplant immunosuppressive medication nonadherence (IMNA). Adult participants (single transplant, pretransplant and ≤1 post-transplant assessment, using medications pretransplant) in the Swiss Transplant Cohort Study (a prospective nation-wide cohort study) were included. Nonadherence, defined as any deviation from dosing schedule, was assessed using two self-report questions pretransplant and at 6, 12, 24 and 36 months post-transplant. Nonadherence patterns were modelled using generalized estimating equations. The sample included 1505 patients (average age: 52.5 years (SD: 13.1); 36.3% females; 924 renal, 274 liver, 181 lung, 126 heart). The magnitude and variability of self-reported MNA decreased significantly from pretransplant to 6 months post-transplant (OR = 0.21; 95% CI: 0.16-0.27). Post-transplant IMNA increased continuously from 6 months to 3 years post-transplant (OR = 2.75; 95% CI: 1.97-3.85). Pretransplant MNA was associated with threefold higher odds of post-transplant IMNA (OR = 3.10; 95% CI: 2.29-4.21). As pretransplant MNA predicted post-transplant IMNA and a continuous increase in post-transplant IMNA was observed, early adherence-supporting interventions are indispensible., (© 2014 Steunstichting ESOT.)

Using data from the Belgian Paget's Disease Registry of 142 patients treated with a 5 mg intravenous infusion of zoledronic acid, we examined disease remission over 3 years in 98 patients with Paget disease of bone (PDB) seen in routine practice. Median age was 76 years, most patients (60.2 %) were male, and all were Caucasian. Median time since PDB diagnosis was 11.5 years, few patients (5.1 %) had a family history of PDB, and 32.6 % had received prior bisphosphonate and/or other treatments. The most common pagetic locations were pelvis, spine, femur, tibia, and skull. The most common symptoms included pain, impaired mobility, bone deformities, and joint disease: 36.7 % of patients had comorbid osteoarthritis and 16.3 % comorbid osteoporosis. Response rates were 93.3 % at 1 year, 89.5 % at 2 years, and 91.6 % at 3 years, statistically similar to an extension study of the original zoledronic acid trials. Twenty-one patients experienced a relapse over the 3-year period at a median of 20.7 months posttreatment; of these, 13 regained remission by the end of the observation period. Relapse was not associated with osteoarthritis, osteoporosis, or other comorbidities. Safety data were similar to those reported elsewhere. In summary, in this somewhat frailer sample of patients with PDB, effectiveness and safety data were similar to those observed in the original trial populations. These findings, which are the first on the use of zoledronic acid for PDB in routine clinical practice, underscore the therapeutic benefits and relative safety of zoledronic acid in the management of PDB in "real-world" clinical settings.

Importance: Whether sex-specific chest pain characteristics (CPCs) would allow physicians in the emergency department to differentiate women with acute myocardial infarction (AMI) from women with other causes of acute chest pain more accurately remains unknown. OBJECTIVE To improve the management of suspected AMI in women by exploring sex-specific CPCs., Design, Setting, and Participants: From April 21, 2006, through August 12, 2012, we enrolled 2475 consecutive patients (796 women and 1679 men) presenting with acute chest pain to 9 emergency departments in a prospective multicenter study. The final diagnosis of AMI was adjudicated by 2 independent cardiologists., Interventions: Treatment of AMI in the emergency department., Main Outcomes and Measures: Sex-specific diagnostic performance of 34 predefined and uniformly recorded CPCs in the early diagnosis of AMI., Results: Acute myocardial infarction was the adjudicated final diagnosis in 143 women (18.0%) and 369 men (22.0%). Although most CPCs were reported with similar frequency in women and men, several CPCs were reported more frequently in women (P < .05). The accuracy of most CPCs in the diagnosis of AMI was low in women and men, with likelihood ratios close to 1. Thirty-one of 34 CPCs (91.2%) showed similar likelihood ratios for the diagnosis of AMI in women and men, and only 3 CPCs (8.8%) seemed to have a sex-specific diagnostic performance with P < .05 for interaction. These CPCs were related to pain duration (2-30 and >30 minutes) and dynamics (decreasing pain intensity). However, because their likelihood ratios were close to 1, the 3 CPCs did not seem clinically helpful. Similar results were obtained when examining combinations of CPCs (all interactions, P ≥ .05)., Conclusions and Relevance: Differences in the sex-specific diagnostic performance of CPCs are small and do not seem to support the use of women-specific CPCs in the early diagnosis of AMI. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00470587.

Background: Literature review suggests that adherence to immunosuppressive drugs may be lower in recipients of living than of deceased donor kidney grafts, possibly because of profile differences., Objective: To compare the level of immunosuppressive adherence levels between patients with deceased and living (-related; -unrelated) donor grafts in Switzerland., Methods: Using data from two similar cross-sectional studies at two transplant centers in Switzerland, the level of adherence between the two groups was compared. Medication adherence was assessed by self-report or electronic monitoring. Possible explanatory factors included age, beliefs regarding immunosuppressive drugs, depressive symptomatology, pre-emptive transplantation, and the number of transplants received, were also considered. Data were analyzed using logistic regression analysis., Results: Unadjusted non-adherence odds were 2 to 3 times higher in living-related than deceased donor transplantation (ORs: 2.09-3.05; p<0.05). Adjustment for confounders showed that these differences were associated most with the younger age of living-related subjects and the belief that immunosuppressive drugs are less important for living-related donations., Conclusion: There is a lower immunosuppressive adherence in recipients of living-related donor kidneys, possibly owing to differences in patient profile (ie, health beliefs regarding their immunosuppressive needs), knowledge of which may enhance adherence if addressed.

Background: Academic Service Partnerships (ASPs) are structural linkages between universities and service entities that aim to share vision and collaboration, thereby improving patient care quality and encouraging innovation., Purpose: To identify structured ASPs in nursing worldwide and to describe their characteristics., Method: Systematic literature review of PubMed-, CINAHL-, PsycINFO-, and Embase- listed studies published up to August 31, 2010. ASPs were described in view of a predefined set of criteria., Results: A total of 114 articles describing 119 ASPs were included. Of these, 85% were located in North America. The median duration of ASPs was 6 years (interquartile range, 2-6). The majority focused on education (86%) and clinical practice (50%). Community health facilities (57%) and hospitals (40%) were prime settings. Twenty-two percent of ASPs were defined by contracts, 3% were governed by bylaws, and 66% were part of strategic plans (28%). Funding sources were mentioned in 76%. However, although 66% of ASPs have been evaluated, the evaluations are generally neither consistent nor reliable., Conclusions: ASPs show variability in setup, and their development seems to be fueled by policy reports., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Current guidelines require a change (rise and/or fall) in levels of cardiac troponin (cTn) for the diagnosis of acute myocardial infarction (AMI). It is unknown whether absolute or relative changes provide higher accuracy when using high-sensitivity cTnI assays., Methods: In a prospective international multicentre study, we assessed the diagnostic accuracy of early absolute and relative changes in cTnI measured with two novel pre-commercial high-sensitivity assays (Siemens and Beckman Coulter) in 943 unselected patients presenting to the ED with suspected AMI. The final diagnosis of AMI was adjudicated using all available data including serial hs-cTnT levels by two independent cardiologists., Results: The diagnostic accuracy of absolute changes in the diagnosis of AMI as quantified by the area under the receiver operating characteristics curve (AUC) was very high (e.g. at 2 h, Siemens high-sensitivity cTnI AUC 0.93, 95%Cl 0.90-0.96; Beckman Coulter high-sensitivity cTnI AUC 0.93, 95%Cl 0.90-0.96) and superior to relative changes at all time points (p < 0.001). The results were consistent in clinically important subgroups. Direct comparison of the absolute changes in the two high-sensitivity cTnI assays showed similar accuracy. When combined with the baseline cTnI levels, the difference between absolute and relative changes became much smaller and remained statistically significant only for the Siemens assay., Conclusions: As single variables early absolute changes in high-sensitivity cTnI levels have significantly higher diagnostic accuracy than relative changes. When combined with the baseline cTn level, reflecting clinical practice, both absolute and relative changes provided very high accuracy with much smaller differences between both approaches., (© 2013.)

Background: Understanding outcomes after transplant requires a biopsychosocial model that includes biomedical and psychosocial factors. The latter, to date, are assessed only in a limited way as part of transplant registries or cohort studies. The Swiss Transplant Cohort Study (STCS) is a nationwide open cohort study (starting May 2008) to systematically and prospectively assess psychosocial factors. This article describes the framework underpinning STCS's psychosocial assessment., Methods: The STCS framework was adapted from the multidimensional conceptual perspective of Dew et al to describe transplant psychosocial domains and specific outcomes by adding a time perspective, a system perspective, and interaction among domains., Results: We propose a multidimensional, multilevel biopsychosocial framework representing mutually influencing domains from before to after transplant, and exemplify each domain by factors included in STCS and their measurement. The transplant patient, centrally positioned, is described by clinical and sociodemographic characteristics (eg, socioeconomic status, educational, professional, and relationship status). The following psychosocial domains further describe the patient: (1) physical/functional (eg, perceived health status, sleep quality, daytime sleepiness), (2) psychological (eg, depression, stress), (3) behavioral (eg, medication adherence, smoking, drug use, physical activity, sun protection), (4) social (eg, work capacity/return to work), and (5) global quality of life. Factors associated with health care system level (eg, trust in transplant team) are also included in the model., Conclusion: The STCS's psychosocial framework provides a basis for studying the interplay of biomedical, sociodemographic, psychosocial, behavioral, and health care system factors in view of transplant outcomes and therefore has the potential to guide biopsychosocial transplant research.

The authors used pooled data from 6 valsartan-related studies including 3983 adherent and 10,663 nonadherent patients to evaluate blood pressure (BP) outcomes in both groups after 90 days of treatment, applying hierarchical linear and logistic regression to identify determinants of BP outcomes. The principal findings were that: (1) BP outcomes were consistently better in adherent patients; (2) approximately a quarter of the variance in 90-day BP values was attributable to a physician class effect; (3) common and unique patient- and physician-related variables were associated with BP outcomes in both groups; (4) physician vigilance was associated with better outcomes, especially in adherent patients; and (5) adherent patients were more likely to exhibit target organ damage and associated events while being prescribed more complex medication regimens. Adherence to antihypertensive medication may be a function of prior line treatment failure, severity of illness, and sequelae, and the ensuing patient resolution to change medication behavior., (©2013 Wiley Periodicals, Inc.)

Objective: The aim of the study was to describe the (a) symptom experience of women with vulvar intraepithelial neoplasia and vulvar cancer (vulvar neoplasia) during the first week after hospital discharge, and (b) associations between age, type of disease, stage of disease, the extent of surgical treatment and symptom experience., Methods: This cross-sectional study was conducted in eight hospitals in Germany and Switzerland (Clinical Trial ID: NCT01300663). Symptom experience after surgical treatment in women with vulvar neoplasia was measured with our newly developed WOMAN-PRO instrument. Outpatients (n=65) rated 31 items. We used descriptive statistics and regression analysis., Results: The average number of symptoms reported per patient was 20.2 (SD 5.77) with a range of 5 to 31 symptoms. The three most prevalent wound-related symptoms were 'swelling' (n=56), 'drainage' (n=54) and 'pain' (n=52). The three most prevalent difficulties in daily life were 'sitting' (n=63), 'wearing clothes' (n=56) and 'carrying out my daily activities' (n=51). 'Tiredness' (n=62), 'insecurity' (n=54) and 'feeling that my body has changed' (n=50) were the three most prevalent psychosocial symptoms/issues. The most distressing symptoms were 'sitting' (Mean 2.03, SD 0.88), 'open spot (e.g. opening of skin or suture)' (Mean 1.91, SD 0.93), and 'carrying out my daily activities' (Mean 1.86, SD 0.87), which were on average reported as 'quite a bit' distressing. Negative associations were found between psychosocial symptom experience and age., Conclusions: WOMAN-PRO data showed a high symptom prevalence and distress, call for a comprehensive symptom assessment, and may allow identification of relevant areas in symptom management., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Apart from clinical outcomes, the "real-world" outcomes of intermittent short-course cyclosporine treatment remain poorly documented., Objective: To evaluate various outcomes of short-course cyclosporine treatment for severe psoriasis; and to describe dermatologists' use of the Rule of Tens., Methods: A 12-week pharmacoepidemiological study; 112 evaluable patients recruited by 43 dermatologists., Results: The mean initial cyclosporine dose was 2.88±0.74 mg/kg/day. At 12 weeks, 64.3% of patients were continued beyond the study period at mean dose of 2.51±0.91 mg/kg/day. Percent body surface affected, Psoriasis Area Severity Index score, and patient and physician rating of psoriasis severity decreased significantly, while quality of life (QoL) improved significantly. Median patient satisfaction at 12 weeks was 85 (0~100 scale). Patient-reported non-adherence was 43.9% and 56.1%, respectively at both the time points (p=0.18). In modeling on logarithmized outcomes variables, living along was consistently the single most important (negative) determinant of therapeutic and patient outcomes. Safety and tolerance parameters were similar to the ones reported in the literature. Only 7.3% of physicians correctly identified the measures included in the Rule of Tens and the Rule's criterion for inferring severe psoriasis., Conclusion: With adequate monitoring and patient adherence, cyclosporine treatment reduces the severity of severe psoriasis, improves QoL, and is appropriately tolerated; leading to high patient satisfaction. Social support is a key determinant of therapeutic and patient outcomes and patients living along may require clinical attention. The relevance of the Rule of Tens was not evident.

Background: Although fatigue affects over 75% of patients with advanced cancer, changes over time in symptoms and antecedents have not been described in the acute care setting., Objectives: To determine the prevalence, in patients with advanced cancer, of fatigue and anaemia on admission, describe strategies used to treat anaemia, observe changes in fatigue over ten days, and determine factors associated with fatigue., Design: Prospective, observational study., Settings and Participants: In two Swiss tertiary care hospitals, a convenience sample of patients (N=103) was recruited at admission and followed up at days six (n=76) and ten (n=53). Patients were admitted because of new and/or worsening symptoms, deteriorating health status, or complications. They received measures aimed at symptom control and disease modifying interventions., Methods: Clinical and sociodemographic data were collected on selected patients who were able to complete a test battery of validated measures. Assessment was undertaken on hospital admission and on days six and ten post-admission., Findings: At admission, according to the suggested cut-off score of 43 for the FACIT-Fatigue scale, 87% of participants were experiencing cancer-related fatigue. Fatigue varied greatly within and among patients. Data on anaemia were available for 100 patients, of whom 62% were anaemic on admission. Severe and life threatening anaemia were mostly treated with red blood cell transfusions. Over time, fatigue decreased for patients who improved enough to be discharged (p<0.001) but not for those who withdrew from the study, most of whom did so due to worsening health. In multiple regression analysis, younger patients and patients with lower functional status, higher scores for depression, and more other anaemia-related symptoms experienced more fatigue. The variables examined explained 62% of variance in fatigue., Conclusions: Fatigue was common in hospitalized patients with advanced cancer and the majority were anaemic. Based on these data, monitoring and treating fatigue and anaemia over a ten-day hospital stay seem to be supported. The variable trajectories call for interventions carefully tailored to individual patients. The results should be considered as a first step to exploring fatigue in these patients., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: In spite of the high prevalence of allergic rhinitis (AR) and the evidence-based guidelines for treatment, little is known about the patients' perceived knowledge level, expectations, preferences for treatment, and fear for side effects of treatment for AR. This study aimed at gaining insight into these patient-related factors., Methods: This explorative cross-sectional survey study included a convenience sample of 170 patients with rhinitis and clinical suspicion of allergy at the department of Otorhinolaryngology and Allergology. Patients' perceived knowledge level, expectations, patient preferences, and fear of side effects of allergy treatment were collected via a self-report questionnaire developed for the purpose of this study., Results: 22% of all patients (38/170) reported to have knowledge about anti-allergic treatment. 40% (55/170) of rhinitis patients expected to be cured by the prescribed treatment, whereas 43% (73/170) of patients expected suppression of allergic symptoms. Nasal spray was the preferred route of anti-allergic drug administration in 30% (52/170) of patients, followed by oral treatment (24%; 42/170), combination therapy (16%; 30/170), and injection therapy (15%; 27/170). More patients would choose a combination treatment with step-down approach (31%; 53/170) than mono-therapy with a step-up approach (20%; 34/170). Fear for side effects was reported mainly for nasal corticosteroids (48%; 81/170) and less for oral antihistamines (33%; 36/170), leucotriene antagonists (21%, 36/170) and immunotherapy (19%, 33/170)., Conclusions: Patients consulting for rhinitis have high expectations of anti-allergic treatment, prefer a nasal spray above oral treatment, prefer combined treatment rather than monotherapy, and fear adverse events of anti-allergic treatment.

Background: The aim of this study was to explore differences in health care costs for asylum seekers from countries experiencing violent conflict and those from countries experiencing no violent conflict. METHDODS: Data were collected from a representative sample of refugees in an urban Swiss canton who were assigned to a Health Maintenance Organisation that covered all their health care costs. Cost differences for individuals coming from countries experiencing violent conflicts and from countries experiencing no violent conflict were tested by using multiple regression techniques and by controlling for confounding demographic, clinical and migration-related variables., Results: Health care costs were higher for patients from countries with violent conflict. The higher costs could be attributed in part to increased frequencies of somatic diseases, however, the higher costs were linked primarily to the duration of the asylum seeker's enrolment in the insurance programme, the number of visits to the medical facility, and the procedural status of the person's application for asylum., Conclusions: Despite a higher prevalence of illness in patients from countries with violent conflict, the length of time spent in administrative "asylum seeker" status seemed to be the main driver of health care costs. Language barriers may be skewing results, with respect to the importance of specific diagnoses (especially mental health disorders), in driving costs upward. These results indicate a need for more comprehensive screening strategies for asylum seekers in receiving countries, particularly for those from countries in conflict.

Background: Education, coaching and guidance of patients are important components of heart failure management., Aim: The aim of this study was to compare a computer assisted learning (CAL) program with standard education (brochures and oral information from nurses) on knowledge and self-care in hospitalized heart failure patients. Satisfaction with the CAL program was also assessed in the intervention group., Methods: A quasi-experimental design was used, with a convenience sample of in-hospital heart failure patients. Knowledge and self-care were measured using the Dutch Heart Failure Knowledge Scale and the European Heart Failure Self-care Behaviour Scale at hospital admission, at discharge and after a 3-month follow-up. Satisfaction with the CAL program was assessed at hospital discharge using a satisfaction questionnaire. Within and between groups, changes in knowledge and self-care over time were tested using a mixed regression model., Results: Of 65 heart failure patients screened, 37 were included in the study: 21 in the CAL group and 16 in the usual care group. No significant differences in knowledge (p=0.65) or self-care (p=0.40) could be found between groups. However, both variables improved significantly over time in each study group (p<0.0001)., Conclusions: Both educational strategies increased knowledge and improved self-care. The design did not allow isolation of the effects of standard education usual care from CAL. Economic and clinical outcomes of both methods should be evaluated in further research., (Copyright © 2010. Published by Elsevier B.V.)

Purpose: This prospective study described symptom prevalence and changes of symptoms over ten days in patients with advanced cancer admitted to two Swiss tertiary care hospitals because of symptoms, deterioration of health status, or complications., Method: Prevalence, frequency, severity of and distress from 31 symptoms were assessed repeatedly with the Memorial Symptom Assessment Scale in 103 patients at admission, and on day six (n = 76) and ten (n = 53) of the hospital stay. Repeated measures regression models were used for analysis., Results: The mean number of symptoms experienced was 13.0 (SD = 6.1) at admission, 9.7 (SD = 5.4) on day six, 9.3 (SD = 4.9) on day ten. Lack of energy was most prevalent (82% of patients) and most frequent, pain was most severe and distressing; symptom scores of all but 4 symptoms (weight loss, "I don't look like myself," vomiting, itching) were >2 on a scale from 0 to 4. Over time, the average number of symptoms decreased significantly for the whole group (P < .0001) and for patients discharged after day six (P = .006), but not for patients dropping out after day six due to worsening health status (P = .78). Individual trajectories showed that symptom prevalence varied greatly within and among patients., Conclusions: High symptom prevalence at admission, identification of areas in symptom management with the potential for improvement, and wide variability in symptom prevalence among patients call for comprehensive symptom assessment and individual treatment, especially in patients with a worsening health status., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Introduction: In solid organ transplantation (TX), perceived health status (PHS) is a relevant patient-reported outcome. For patients on TX waiting lists, PHS information is limited. The aim of this study was therefore to compare PHS of heart, liver, lung, and renal TX candidates., Methods: We used a cross-sectional descriptive design, including consecutive heart, liver, lung and renal TX candidates listed at a university hospital in Belgium. PHS was evaluated using the generic EuroQoL instrument, assessing patients' perceptions of their general PHS, and evaluating the health-related domains of mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Data were analyzed using multivariable ordinal logistic regression., Results: The study included 314 TX candidates: 29 heart, 75 liver, 67 lung, and 143 renal. Analyses controlling for possible PHS-impacting variables (age, gender, marital status, education, comorbidities) yielded significantly disparate results between the four candidate groups. Renal candidates reported best PHS, followed by liver candidates, whereas heart and lung candidates, whose score differences were not significant, had worst PHS., Conclusion: The EQ-5D seems to be a valuable tool to identify differences in health-related problems in the four different organ candidate groups. The results can be used to create intervention programs focusing on effective clinical management for these patients pre- and post-transplant., (© 2009 John Wiley & Sons A/S.)

Background: Language barriers have a major impact on both the quality and the costs of health care. While there is a growing body of evidence demonstrating the detrimental effects of language barriers on the quality of health care provision, less is known about their impact on costs. This purpose of this study was to investigate the association between language barriers and the costs of health care., Methods: The data source was a representative set of asylum seekers whose health care was provided by a Swiss Health Maintenance Organisation (HMO). A cross-sectional survey was conducted: data was collected on all the asylum seekers' health care costs including consultations, diagnostic examinations, medical interventions, stays in the clinic, medication, and interpreter services. The data were analysed using path analysis., Results: Asylum seekers showed higher health care costs if there were language barriers between them and the health professionals. Most of these increased costs were attributable to those patients who received interpreter services: they used more health care services and more material. However, these patients also had a lower number of visits to the HMO than patients who faced language barriers but did not receive interpreter services., Conclusion: Language barriers impact health care costs. In line with the limited literature, the results of this study seem to show that interpreter services lead to more targeted health care, concentrating higher health care utilisation into a smaller number of visits. Although the initial costs are higher, it can be posited that the use of interpreter services prevents the escalation of long-term costs. A future study specially designed to examine this presumption is needed.

Context: For kidney transplant patients, a lifelong intake of medication is mandatory. Health care workers' prioritization of adverse effects often differs from that of their patients, although patients' experience of adverse effects of medication can trigger nonadherence. Understanding how patients experience symptoms is therefore important., Objective: To present a new method to be used in research to evaluate symptom experience related to adverse effects in adult kidney transplant recipients on maintenance immunosuppressive therapy., Design: Cross-sectional secondary data analysis., Patients and Setting: Three hundred fifty-six adult kidney transplant recipients from 2 Swiss transplant outpatient clinics., Main Outcome Measures: Symptom experience was measured with the Modified Transplant Symptom Occurrence and Symptom Distress Scale. For each item, ridit scores were calculated. A coordinate system with occurrence and distress ratings of each symptom classified symptoms into 4 quadrants: symptoms could have high occurrence/high distress, low occurrence/high distress, high occurrence/low distress, and low occurrence/low distress symptoms. Items farther from the origin represented more extreme profiles., Results: The proposed method arranges symptoms clearly in sequence of their importance. In our study, fatigue and joint and back pain were the most frequent and distressing symptoms. Symptom profiles for men and women differed: for men impotence and anxiety were key whereas for women listlessness and changed appearance seemed to play important roles., Conclusions: The 2-dimensional diagram of symptom profiles enables researchers and clinicians to evaluate the impact of symptoms associated with immunosuppressive medications.

Background: Non-adherence to immunosuppressive medication is strongly associated with poor outcomes. Identifying the factors influencing it is a first step in developing adherence interventions. This study's objective was to investigate the prevalence of self-reported and collaterally-reported non-adherence to immunosuppressives, and, based on the Integrative Model of Behavioral Prediction, to explore the association between non-adherence, intention to adhere, attitudes, norms and self-efficacy., Methods: This cross-sectional study included a convenience sample of 114 renal transplant recipients in follow-up care, one to five yr post-transplant. Non-adherence was measured by self-reports and collateral reports. Factors of the Integrative Model of Behavioral Prediction were assessed using a self-report questionnaire., Results: Self-reports showed non-adherence of 23.7%; collateral reports showed 3.8%; and a combination of the two showed 26.4%. Logistic regression analysis showed that the attitude "Not all immunosuppressive drugs are necessary to prevent rejection" was less frequent in patients with higher intentions to adhere, with an odds ratio (OR) of 0.05 (95% CI 0.01-0.50). The barrier of "Forgetfulness/Interruption of daily routine" was associated with non-adherence, with an OR of 3.74 (95% CI 1.55-9.03)., Conclusions: Forgetfulness is the most powerful barrier against adherence. Intention to adhere plays a minor role in non-adherence in renal transplant recipients.

Objectives: To examine how geriatric evaluation and management units (GEMUs) are organized and to examine the effectiveness of admission on a GEMU., Design: Systematic review and meta-analysis based on literature search of multiple databases and the references lists of all identified articles and by contacting authors., Setting: GEMUs., Participants: Elderly people admitted to a GEMU., Measurements: Quality of the studies was assessed on 10 criteria. The outcome parameters were mortality, institutionalization, functional decline, readmission, and length of stay at different follow-up points. A random-effects meta-analysis was performed using Hedges' gu and variance of relative risk (RR)., Results: GEMUs are organized in a heterogeneous way and the included studies gave no thorough description of comprehensive geriatric assessment (CGA). Involvement of a multidisciplinary team was a key element in all GEMUs. The individual trials showed that admission to a GEMU has one or more favorable effects on the outcomes of interest, with two significant effects in the meta-analysis: less functional decline at discharge from the GEMU (RR=0.87, 95% confidence interval (CI)=0.77-0.99; P=.04) and a lower rate of institutionalization 1 year after discharge (RR=0.78, CI=0.66-0.92; P=.003). For the other outcomes in the meta-analysis, a GEMU did not induce significantly different outcomes than usual care., Conclusion: This meta-analysis shows a significant effect in favor of the GEMU group on functional decline at discharge and on institutionalization after 1 year. There is heterogeneity between the studies, poor quality of some randomized controlled trials, and shortage of information about CGA. Multidisciplinary CGA offered in a GEMU may add value to the care for frail older persons admitted to the hospital, but the limitations confirm the need for well-designed studies using explicit CGA and more-structured and -coherent assessment instruments such as the Minimum Data Set Resident Assessment Instrument.

Context: Immunosuppressive regimens increase kidney transplant patients' risk of contracting life-threatening influenza. However, little information exists about the prevalence and correlates of influenza vaccinations in this population., Objective: To determine the prevalence and explore correlates of influenza vaccination in kidney transplant recipients. DESIGN, SAMPLE, AND SETTING: This cross-sectional study used data from the Supporting Medication Adherence in Renal Transplantation study. The convenience sample consisted of 356 adult kidney transplant recipients (58.1% male; mean age, 52.9 [SD 13.53] years) recruited from 2 Swiss transplant outpatient clinics. Influenza vaccination status was assessed by self-report (yes/no)., Main Outcome Measure: Known correlates of vaccination in chronically ill patients (older age, cohabitation, higher education, higher socioeconomic status, financial stability, more comorbid diseases, nonsmoking status, and clinical site where care is received) were entered into a multiple logistic regression model., Results: Of the 356 patients, only 83 (23.3%) reported having been vaccinated against influenza in the previous year. Positive vaccination status was significantly related to older age (odds ratio, 1.04; 95% confidence interval, 1.02-1.06)., Conclusion: Despite national and international guidelines recommending influenza vaccination in kidney transplant recipients, the prevalence of influenza vaccination in this sample was low. This study's results suggest that transplant centers need to implement policies to maximize influenza vaccination of their patients.

Little is known of the long-term clinical effects of non adherence on transplanted kidneys, especially regarding newer immunosuppressive regimens. In a study of 356 adult Swiss kidney transplant patients, non adherence was measured at inclusion by means of self-reporting, electronic monitoring, collateral reporting and blood assay. Long-term clinical outcomes regarding graft loss and creatinine levels were collected prospectively over a period of 5 years. A Cox proportional hazards model and mixed regression analysis were used, respectively, to examine the effects of non adherence on kidney survival and kidney function. The majority of patients (62%) were on immunosuppressive regimens that included mycophenolate mofetil, tacrolimus or sirolimus. No associations were found between non adherence and kidney graft survival or graft function. Notwithstanding weaknesses of this study, this negative result suggests that high adherence may protect patients against detrimental clinical outcomes, and/or that immunosuppressive regimens containing newer drugs allow wider non adherence margins than those based on previous generation medications such as cyclosporine, azathioprine and corticosteroids.

Background/significance: The use of complementary and alternative medicine (CAM) has increased considerably in the general population in recent decades. However, the prevalence of CAM use in renal transplant patients has not yet been assessed., Aim: To determine the prevalence and correlates of CAM use among renal transplant patients (RTX) who are more than one year post transplant., Methods: This secondary data analysis used data from Part 1 of the Supporting Medication Adherence in Renal Transplantation (SMART) study, which tested prevalence, determinants and consequences of non-adherence regarding immunosuppressive medication in kidney transplant (renal TX) patients. The study's convenience sample consisted of 356 patients recruited from two Swiss outpatient transplant clinics during their annual examination visits (mean age: 53+/-13; male: 58%). The use of CAM as well as the specific kind of CAM used was assessed through structured interviews. Assessed CAM use correlates were age, gender, education, depressive symptomatology, comorbidity and smoking status. Relationships between CAM use and candidate correlates were explored using multiple logistic regression., Results: The prevalence of CAM use in this sample of renal TX patients was 11.8%. Most frequently used alternative medicines were Homeopathy (42.9%) and Chinese medicine (23.8%). Two patients used St John's wort. The percentage of patients using Homeopathy (5.1%) and herbal medicine (2%) was similar to that of the general Swiss population (HO: 6.1% & HM: 2.6%). Significant correlates for CAM use were younger age (p=0.017; OR=0.96; 95%CI=0.93-0.99) and female gender (p=0.035; OR=2.13; 95%CI=1.05-4.3)., Conclusion: Every eighth renal transplant recipient in this sample used some form of CAM. Of these, some used herbal medicines, of which some are known to interfere with certain immunosuppressive treatment (St John's wort/Chinese medicines). These findings indicate that it is important for health care providers working in renal TX to assess CAM use.

Objectives: To determine the characteristics and the effectiveness of hospital fall prevention programs., Design: Systematic literature search of multiple databases (Medline, Cinahl, Precinahl, Invert, the Cochrane Library) and of the reference list of each identified publication., Setting: Inclusion of prospective controlled-design studies reporting the effectiveness of fall prevention programs in hospitals., Participants: Two reviewers., Measurements: The methodological qualities of the studies were assessed based on 10 criteria. For the meta-analysis, the relative risk of a fall per occupied bed day (RR(fall)) and the relative risk of being a faller (RR(faller)) were calculated., Results: Eight studies met the inclusion criteria, of which four studies tested multifactorial interventions. Although these studies took place in hospitals, most were conducted on long-stay (mean length of stay (LOS) >1.5 years) and rehabilitation units (mean LOS 36.9 days). For analysis of the number of falls, one unifactorial and two multifactorial studies showed a significant reduction of 30% to 49% in the intervention group, with the greatest effect obtained in the unifactorial study that assessed a pharmacological intervention. The pooled RR(fall) for the four multifactorial studies became nonsignificant after adjustment for clustering (RR(fall)=0.82, 95% confidence interval (CI)=0.65-1.03). No studies reported a significant reduction, either single or pooled, in the number of fallers in the intervention group (pooled RR(faller)-0.87, 95% CI=0.70-1.08)., Conclusion: This meta-analysis found no conclusive evidence that hospital fall prevention programs can reduce the number of falls or fallers, although more studies are needed to confirm the tendency observed in the analysis of individual studies that targeting a patient's most important risk factors for falls actively helps in reducing the number of falls. These interventions seem to be useful only on long-stay care units.

Background: System factors increasingly are suggested as important yet understudied correlates of nonadherence., Objective: To explore the relationship between healthcare system and prevalence of nonadherence with immunosuppressive regimen by studying variation in nonadherence between European and US kidney transplant recipients and as well as nonadherence in European countries., Methods: We performed a secondary data analysis on data collected in 3 independent cross-sectional studies using comparable methodology including patients from the United States, the Netherlands, Belgium, and Switzerland. Nonadherence was measured using 1 item of the Siegal questionnaire. Patients were categorized as nonadherent if they reported missing a dose of immunosuppression in the last 4 weeks. Analyses were performed by multiple mixed logistic regression, with center as a random effect and clinical and demographical differences between groups as fixed effects., Results: 1563 U.S. and 614 European patients from 3 different countries (Belgium [n=187], the Netherlands [n=85], and Switzerland [n=342]) were included. Prevalence of nonadherence in the United States and Europe was 19.3% and 13.2.%, respectively. This higher nonadherence in US patients was confirmed in a multiple logistic regression analysis (OR = 1.78; 95% CI, 1.10-2.89). Nonadherence differed between Belgium (16%) and the Netherlands (14.1%) (OR = 0.27; 95% CI, 0.09-0.80) and between Belgium and Switzerland (11.4%; OR = 0.17; 95% CI, 0.0-0.42)., Conclusion: This is the first study showing differences in prevalence of nonadherence between European and US patients and among European patients. Further research should aim at unraveling the dynamics explaining these differences.

Background: Although non-adherence to an immunosuppressive regimen (NAH) is a major risk factor for poor outcome after renal transplantation (RTx), very few studies have examined non-adherence intervention in this context. This pilot randomized controlled trial (RCT) tested the efficacy of an educational-behavioural intervention to increase adherence in non-adherent RTx patients. We also assessed how NAH evolves over time., Methods: Eighteen RTx non-adherent patients (age: 45.6 +/- 1.2 yr; 78.6% male) were randomly assigned to either an intervention group (IG) (n = 6) or an enhanced usual care group (EUCG) (n = 12), the latter receiving the usual clinical care. The IG received one home visit and three telephone interviews. We assessed NAH through electronic monitoring (EM) of medication intake during a nine-month period (three months intervention, six months follow-up)., Results: Five of 18 patients withdrew. Inclusion in the study resulted in a remarkable decrease in NAH in both groups over the first three months (IG chi(2) = 3.97, df = 1, p = 0.04; EUCG chi(2) = 3.40, df = 1, p = 0.06). The IG showed the greatest decrease in NAH after three months, although this did not reach statistical significance (at 90 d, chi(2) = 1.05, df = 1, p = 0.31). Thereafter, NAH increased gradually in both groups, reaching comparable levels at the end of the six-month follow-up (i.e. at nine months)., Conclusion: Our findings suggest an inclusion effect. Although the intervention in this pilot RCT appeared to add further benefit in medication compliance, a lack of statistical power prevented us from making a strong statistical statement.

Background: Severe alcohol use is recognized as a major public health concern, even though light to moderate alcohol use might have beneficial effects on health. Alcohol use has been studied to some extent in solid organ transplant populations, yet evidence is lacking on alcohol use and its correlates in the renal transplant population. The aim of this study was therefore to determine the prevalence, severity and correlates of alcohol use in renal transplant recipients., Methods: This cross-sectional study is a secondary analysis of the Supporting Medication Adherence in Renal Transplantation (SMART) study. Alcohol use was assessed by patient's self-report. At risk and binge drinkers were classified using World Health Organization criteria. The following correlates of alcohol use were explored: adherence with immunosuppression (Siegal questionnaire; electronic monitoring), smoking, coping style (UCL), depressive symptomatology (BDI) and busyness/routine in life style (ACQ Busyness Scale)., Results: Two hundred and eighty-four patients were included in this analysis, 58.1% male, with a mean age of 54 yr (range 20-84) and a median of seven (interquartile ranges [IQR] 8) yr post-transplantation. A total of 52.8% of study participants reported to drink alcohol at least once a week. Two hundred and eighty of 284 subjects (98.5%) were drinking at low risk, four at moderate risk (1.5%). None of the participants were drinking severely. Correlates of alcohol use were male gender and being professionally active., Conclusion: Alcohol use is less prevalent in renal transplant recipients than in the general population. Severe alcohol use does not seem to represent a serious problem in renal transplant patients.

This literature review summarizes the evidence on the prevalence, determinants, clinical and economic consequences of nonadherence with immunosuppressive drugs in renal transplant patients. A literature search yielded 38 articles measuring nonadherence by self-report, collateral report, assay, refill prescriptions or electronic monitoring. The weighted mean prevalence of self-reported nonadherence was 28%. Nonadherence is associated with poor clinical outcomes, contributing to 20% of late acute rejection episodes and 16% of the graft losses (weighted means). In addition, nonadherence results in lower lifetime costs because of shorter survival, yet also in a lower number of quality adjusted life years. Consistent determinants of nonadherence were younger age, social isolation, and cognitions (e.g. low self-efficacy, certain health beliefs). Determinants concerning the health care system/team seem to be under-investigated. Because the evidence summarized in this review is based on older immunosuppressive regimens, further research should focus on prevalence, determinants and consequences of nonadherence with newer immunosuppressive regimens.

Background: Personal or telephone contact methods are often used to increase attendance for mammography screening. A meta-analysis of the literature was performed to assess the overall effect of direct-contact recruitment on mammography participation., Methods: Two independent reviewers conducted two different search strategies. Each reviewer screened the search results for (quasi-)randomized-controlled trials that tested single women-targeted interventions. Twenty-one of 22 candidate studies that met the inclusion criteria could be included. These studies described 25 eligible interventions. Guided by a standardized protocol, a reviewer assessed the methodologic quality of each intervention and extracted the following data: (1) the number of women (from experimental and control groups) before and after the intervention, (2) details of the study population, (3) the type of intervention, and (4) the control condition. On the basis of a quality ranking, a cumulative random-effects meta-analysis was performed using relative risk as an indicator of intervention effect., Results: Depending on the cumulative step, the analysis revealed that direct-contact strategies improved attendance from 21% (95% confidence interval [CI]; 10%-34%) to 46% (95% CI; 32%-61%)., Conclusions: Evidence from experimental studies supports the effect of direct-contact strategies in which women are invited to participate in mammography screening. Future research will have to define the specific modalities in which these interventions can be adopted in a cost-effective manner.