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Background: In the absence of prognostic biomarkers, most patients with early-stage triple-negative breast cancer (eTNBC) are treated with combination chemotherapy. The identification of biomarkers to select patients for whom treatment de-escalation or escalation could be considered remains an unmet need. We evaluated the prognostic value of histopathologic traits in a unique cohort of young, (neo)adjuvant chemotherapy-naïve patients with early-stage (stage I or II), node-negative TNBC and long-term follow-up, in relation to stromal tumor-infiltrating lymphocytes (sTILs) for which the prognostic value was recently reported. Materials and methods: We studied all 485 patients with node-negative eTNBC from the population-based PARADIGM cohort which selected women aged <40 years diagnosed between 1989 and 2000. None of the patients had received (neo)adjuvant chemotherapy according to standard practice at the time. Associations between histopathologic traits and breast cancer-specific survival (BCSS) were analyzed with Cox proportional hazard models. Results: With a median follow-up of 20.0 years, an independent prognostic value for BCSS was observed for lymphovascular invasion (LVI) [adjusted (adj.) hazard ratio (HR) 2.35, 95% confidence interval (CI) 1.49-3.69], fibrotic focus (adj. HR 1.61, 95% CI 1.09-2.37) and sTILs (per 10% increment adj. HR 0.75, 95% CI 0.69-0.82). In the sTILs <30% subgroup, the presence of LVI resulted in a higher cumulative incidence of breast cancer death (at 20 years, 58%; 95% CI 41% to 72%) compared with when LVI was absent (at 20 years, 32%; 95% CI 26% to 39%). In the ≥75% sTILs subgroup, the presence of LVI might be associated with poor survival (HR 11.45, 95% CI 0.71-182.36, two deaths). We confirm the lack of prognostic value of androgen receptor expression and human epidermal growth factor receptor 2 -low status. Conclusions: sTILs, LVI and fibrotic focus provide independent prognostic information in young women with node-negat

Objective: To assess the cost-effectiveness of a cardiac rehabilitation (CR) program specifically designed for cardiac patients with obesity vs standard CR. Design: Cost-effectiveness analysis based on observations in a randomized controlled trial. Setting: Three regional CR centers in the Netherlands. Participants: Cardiac patients (N=201) with obesity (BMI≥30 kg/m2) referred to CR. Interventions: Participants were randomized to a CR program specifically designed for patients with obesity (OPTICARE XL; N=102) or standard CR. OPTICARE XL included aerobic and strength exercise and behavioral coaching on diet and physical activity during 12 weeks, followed by a 9-month after-care program with “booster” educational sessions. Standard CR consisted of a 6- to 12-week aerobic exercise program, supplemented with cardiovascular lifestyle education. Main Outcome Measures: An economic evaluation, with an 18-month time horizon, in terms of quality-adjusted life years (QALYs) and costs from the societal perspective was performed. Costs were reported in 2020 Euros, discounted at a 4% annual rate, and health effects were discounted at a 1.5% annual rate. Results: OPTICARE XL CR and standard CR resulted in comparable health gain per patient (0.958 vs 0.965 QALYs, respectively; P=.96). Overall, OPTICARE XL CR saved costs (-€4542) compared with the standard CR group. The direct costs for OPTICARE XL CR were higher than for standard CR (€10,712 vs €9951), whereas indirect costs were lower (€51,789 vs €57,092), but these differences were not significant. Conclusions: This economic evaluation showed no differences between OPTICARE XL CR and standard CR in health effects and costs in cardiac patients with obesity.

Objective: To examine the strength of the association between exercise capacity and health-related quality of life (HRQOL) during and after cardiac rehabilitation (CR) in patients with acute coronary syndrome (ACS) who completed CR. Design: Prospective cohort study. Setting: Outpatient CR center. Participants: Patients (N=607) with ACS who completed CR. Interventions: Multidisciplinary 12-week exercise-based CR program. Main Outcome Measures: At baseline (pre-CR), the 6-Minute Walk Test (6MWT) was performed to determine exercise capacity, and the MacNew Heart Disease Health-related Quality of Life questionnaire was used to assess HRQOL. Measurements were repeated immediately after completion of CR (post-CR): at 12 months and 18 months follow-up. Multivariable linear regression, including an interaction term for time and exercise capacity, was applied to study the association between exercise capacity and HRQOL at different time points relative to CR, whereas model parameters were estimated by methods that accounted for dependency of repeated observations within individuals. Results: Mean age in years ± SD was 58±8.9 and 82% of participants were male. Baseline mean 6MWT distance in meters ± SD was 563±77 and median (25th-75th percentile) global HRQOL was 5.5 (4.6-6.1) points. Mean 6MWT distance (P<.001) and the global (P<.001), physical (P<.001), emotional (P<.001) and social (P<.001) domains of HRQOL improved significantly during CR and continued to improve during follow-up post-CR. Independent of the timing relative to CR (ie, pre-CR, post-CR, or during follow-up), a difference of 10 m 6MWT distance was associated with a mean difference in the global HRQOL domain of 0.007 (95% confidence interval [CI], 0.001-0.014) points (P=.029) and a mean difference in the physical domain of 0.009 (95% CI, 0.001-0.017) points (P=.023). Conclusions: Better exercise capacity was significantly associated with higher scores on the global and physical domains of HRQOL, irrespective o

OBJECTIVE: To investigate the relation between body mass index class and changes in health-related quality of life in patients participating in cardiac rehabilitation. DESIGN: Prospective cohort study. PATIENTS: A total of 503 patients with acute coronary syndrome. METHODS: Data from the OPTICARE trial were used, in which health-related quality of life was measured with the MacNew Heart Disease HRQOL Instrument at the start, directly after, and 9 months after completion of cardiac rehabilitation. Patients were classed as normal weight, overweight, or obese. RESULTS: During cardiac rehabilitation, global health-related quality of life improved in patients in all classes of body mass index. Patients classed as overweight had a significantly greater improvement in social participation than those classed as normal weight (5.51-6.02 compared with 5.73-5.93, respectively; difference in change 0.30, p = 0.025). After completion of cardiac rehabilitation, health-related quality of life continued to improve similarly in patients in all classes of body mass index. CONCLUSION: Health-related quality of life improved during cardiac rehabilitation in patients of all classes of body mass index. Patients classed as overweight showed the greatest improvement. The beneficial effects were maintained during extended follow-up after completion of cardiac rehabilitation.

BACKGROUND: During transition to retirement there is often a rearrangement of daily life which might provide a key opportunity for interventions to promote a non-sedentary and active lifestyle. To be able to design effective interventions, it is essential to know which sedentary and physical behaviour domains (eg, at home or during leisure time) have potential to facilitate healthy ageing during the retirement transition. OBJECTIVE: To determine whether unfavourable sedentary and physical activity behaviour before retirement predict unfavourable sedentary and physical activity behaviour after retirement. DESIGN: Population-based cohort. SETTING AND PARTICIPANTS: Adults (n=3272) employed in 2010 but retired in 2014. METHODS: Self-reported preretirement job activity, sedentary leisure time, physical activity at home, and walking-cycling and exercise were assessed as predictors for unfavourable sedentary and physical activity behaviours after retirement using logistic regression. Unfavourable behaviours were defined based on the respective median of the cohort distribution. Furthermore, the OR for having multiple unfavourable behaviours after retirement was determined, based on the amount of unfavourable behaviours before retirement. All models were adjusted for gender and education. RESULTS: Unfavourable preretirement physical activity and sedentary behaviour at home or during leisure time were the strongest predictors of the same behaviours after retirement. Unfavourable job activity did not predict physical activity but did predict unfavourable sedentary behaviour after retirement (OR=1.66, 95% CI 1.41 to 1.96). Unfavourable exercise behaviour before retirement predicted unfavourable sedentary and physical activity after retirement in all domains. With all behaviours being unfavourable before retirement, the OR of having at least three unfavourable behaviours after retirement was 36.7 (95% CI 16.8 to 80.5). CONCLUSIONS: Adults with a higher number of unfavourable pr

While the beneficial effects of secondary prevention of cardiovascular disease are undisputed, implementation remains challenging. A gap between guideline-mandated risk factor targets and clinical reality was documented as early as the 1990s. To address this issue, research groups in the Netherlands have performed several major projects. These projects address innovative, multidisciplinary strategies to improve medication adherence and to stimulate healthy lifestyles, both in the setting of cardiac rehabilitation and at dedicated outpatient clinics. The findings of these projects have led to changes in prevention and rehabilitation guidelines.

It is known that cardiac rehabilitation (CR) successfully improves health (e.g. blood pressure and lipid profile), quality of life, and risk of mortality. In part 1 of this thesis we focused on changes in objectively measured moderate-to-vigorous intensity physical activity (MVPA), sedentary behaviour, fatigue and participation in society during cardiac rehabilitation (CR) in patients with coronary heart disease. Our results showed small improvements in MVPA and time spent in sedentary behaviour. However, by the end of CR, patients still spent relatively little time in physical activity and a long time sedentary. More substantial improvements were found for fatigue and participation in society. However, the prevalence of severely fatigued patients and th

Background Hospital length of stay after acute myocardial infarction (AMI) treated with primary percutaneous coronary intervention (pPCI) has reduced, resulting in more limited patient education during admission. Therefore, systematic participation in cardiac rehabilitation (CR) has become more essential. We aimed to identify patient-related factors that are associated with participation in and completion o

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__Abstract__ The majority of cardiac rehabilitation (CR) referrals consist of patients who have survived an acute coronary syndrome (ACS). Although major changes have been implemented in ACS treatment since the 1980s, which highly influenced mortality and morbidity, CR programs have barely changed and only few data are available on the optimal CR format in these patients. We postulated that standard CR programs followed by relatively brief maintenance programs and booster sessions, including behavioural techniques and focusing on incorporating lifestyle changes into daily life, can improve long-term adherence to lifestyle modifications. These strategies might result in improved (cardiac) mortality and morbidity in a cost-effective fashion. In the OPTImal CArdiac REhabilitation (OPTICARE) trial we will assess the effects of two advanced and extended CR programs that are designed to stimulate permanent adaption of a heart-healthy lifestyle, compared with current standard CR, in ACS patients. We will study the effects in terms of cardiac risk profile, levels of daily physical activity, quality of life and health care consumption.

Two common impairments in patients after stroke are loss of balance control and fatigue. We propose that both could be inter-related. The purpose of this study was to investigate the metabolic energy demand for balance control in patients after stroke during upright standing. Ten stroke patients and 12 able-bodied controls performed four 5-min upright standing tasks on a force plate; unperturbed (SU), blindfolded (SUB), on foam surface (SUF) and with feet parallel against each other (SUP). Metabolic energy expenditure, posturography measures and muscle activity (EMG) of lower leg muscles were measured. Patients required on average 125% (33Jkg(-1)s(-1)) more metabolic energy for upright standing under the various conditions than controls. In addition, balance manipulation significantly (p<0.05) affected energy expenditure (21% higher in SUB, 52% in SUF, 40% in SUP compared to SU). Although the increase in energy expenditure was on average twice as high in patients than controls no significant group by condition interaction effect was found. Overall correlations between posturography measures, EMG and energy expenditure (r=0.33-0.60) were significant (p<0.001). We conclude that impaired balance control puts an extra demand on the energy expenditure during motor activities in stroke patients. This should be considered when prescribing interventions aimed at reducing physiological strain., Houdijk, Han ter Hoeve, Nienke Nooijen, Carla Rijntjes, Danielle Tolsma, Maarten Lamoth, Claudine eng Comparative Study England 2010/06/25 06:00 Gait Posture. 2010 Jul;32(3):321-6. doi: 10.1016/j.gaitpost.2010.05.016. Epub 2010 Jun 22.

Background: While various body weight supported locomotor training (BWSLT) approaches are reported in the literature for individuals with spinal cord injury (SCI), none have evaluated outcomes in terms of gait quality. The purpose of this study was to compare changes in measures of gait quality associated with four different BWSLT approaches in individuals with chronic motor-incomplete SCI, and to identify how gait parameters differed from those of non-disabled (ND) individuals. Methods. Data were analyzed from 51 subjects with SCI who had been randomized into one of four BWSLT groups: treadmill with manual assistance (TM), treadmill with electrical stimulation (TS), overground with electrical stimulation (OG), treadmill with locomotor robot (LR). Subjects with SCI performed a 10-meter kinematic walk test before and after 12 weeks of training. Ten ND subjects performed the test under three conditions: walking at preferred speed, at speed comparable to subjects with SCI, and with a walker at comparable speed. Six kinematic gait quality parameters were calculated including: cadence, step length, stride length, symmetry index, intralimb coordination, and timing of knee extension. Results: In subjects with SCI, all training approaches were associated with improvements in gait quality. After training, subjects with SCI walked at higher cadence and had longer step and stride lengths. No significant differences were found among training groups, however there was an interaction effect indicating that step and stride length improved least in the LR group. Compared to when walking at preferred speed, gait quality of ND subjects was significantly different when walking at speeds comparable to those of the subjects with SCI (both with and without a walker). Post training, gait quality measures of subjects with SCI were more similar to those of ND subjects. Conclusion: BWSLT leads to improvements in gait quality (values closer to ND subjects) regardless of training approach. We