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Objective To evaluate whether a structured exercise programme improved functional and health related quality of life outcomes compared with usual care for women at high risk of upper limb disability after breast cancer surgery. Design Multicentre, pragmatic, superiority, randomised controlled trial with economic evaluation. Setting 17 UK National Health Service cancer centres. Participants 392 women undergoing breast cancer surgery, at risk of postoperative upper limb morbidity, randomised (1:1) to usual care with structured exercise (n=196) or usual care alone (n=196). Interventions Usual care (information leaflets) only or usual care plus a physiotherapy led exercise programme, incorporating stretching, strengthening, physical activity, and behavioural change techniques to support adherence to exercise, introduced at 7-10 days postoperatively, with two further appointments at one and three months. Main outcome measures Disability of Arm, Hand and Shoulder (DASH) questionnaire at 12 months, analysed by intention to treat. Secondary outcomes included DASH subscales, pain, complications, health related quality of life, and resource use, from a health and personal social services perspective. Results Between 26 January 2016 and 31 July 2017, 951 patients were screened and 392 (mean age 58.1 years) were randomly allocated, with 382 (97%) eligible for intention to treat analysis. 181 (95%) of 191 participants allocated to exercise attended at least one appointment. Upper limb function improved after exercise compared with usual care (mean DASH 16.3 (SD 17.6) for exercise (n=132); 23.7 (22.9) usual care (n=138); adjusted mean difference 7.81, 95% confidence interval 3.17 to 12.44; P=0.001). Secondary outcomes favoured exercise over usual care, with lower pain intensity at 12 months (adjusted mean difference on numerical rating scale −0.68, −1.23 to −0.12; P=0.02) and fewer arm disability symptoms at 12 months (adjusted mean difference on Functional Assessment of Cancer Therapy-Breast+4 (FACT-B+4) −2.02, −3.11 to −0.93; P=0.001). No increase in complications, lymphoedema, or adverse events was noted in participants allocated to exercise. Exercise accrued lower costs per patient (on average −£387 (€457; $533) (95% confidence interval −£2491 to £1718; 2015 pricing) and was cost effective compared with usual care. Conclusions The PROSPER exercise programme was clinically effective and cost effective and reduced upper limb disability one year after breast cancer treatment in patients at risk of treatment related postoperative complications. Trial registration ISRCTN Registry ISRCTN35358984 .

Gender aspects continue to play an important role in science education, conditioning study choices or shaping beliefs about one's own capacities and those of others. Performing arts based initiatives are on the forefront of innovative science education approaches and have participatory, dialogic and dialectic qualities to engage students in democratic, inclusive and reflective ways of learning. Both these dimensions can be brought together in order to explore how arts-based science education can contribute to address gender bias and stereotypes in educational and team-collaborative settings. ispartof: Gender and innovation in STE(A)M education status: published

Gender aspects continue to play an important role in science education, conditioning study choices or shaping beliefs about one's own capacities and those of others. Performing arts based initiatives are on the forefront of innovative science education approaches and have participatory, dialogic and dialectic qualities to engage students in democratic, inclusive and reflective ways of learning. Both these dimensions can be brought together in order to explore how arts-based science education can contribute to address gender bias and stereotypes in educational and team-collaborative settings.

4-Fluoramfetamine (4-FA) is een middel dat in korte tijd opkwam en veel stof deed opwaaien. Was ecstasy al jaren onbetwist nummer 1 van de uitgaansdrugs onder festival- en clubgangers, met het verschijnen van 4-FA op de Nederlandse drugsmarkt leek de concurrentie te zijn ingezet. Bestaande monitoringinstrumenten signaleerden in afgelopen jaren niet alleen een toenemende populariteit van 4-FA maar ook (in het kielzog hiervan) een toenemend aantal gezondheidsincidenten, die een opmaat waren voor een verbod op 25 mei 2017. Deze verkenning brengt het gebruik, de gebruikers en de ervaren gezondheidseffecten van 4-FA nader in beeld om preventie, beleid en onderzoek verder invulling te geven.

Several tobacco control measures are in place that aim to reduce the availability, accessibility and/or visibility of tobacco products at points of sale (POS). In response to a debate in the Dutch Parliament in October 2013, the Secretary of State for Health, Welfare and Sport agreed to review evidence on the impact of two of these measures, i.e., reducing the number of points of sale and restricting the display of tobacco products at points of sale. Special attention should be paid to tobacco vending machines. These data aim to support and facilitate a balanced discussion of different policy alternatives. This report synthesises data from a systematic review of research findings and information from grey literature and experts in a number of European countries to obtain a picture of the impact of the two measures.

Background and Aims Increased delta-9-tetrahydrocannabinol (THC) concentrations in cannabis may lead to higher THC exposure, cannabis dependence and treatment need, but users may also adapt the actual intake of THC through reduced inhalation of THC containing smoke (titration). We investigated whether consumers of stronger cannabis use less cannabis per joint or inhale less smoke than those using less potent cannabis and whether these factors predict cannabis dependence severity. Methods Heavy cannabis users (n = 98) brought their own cannabis, rolled a joint and smoked it ad libitum in a naturalistic setting. We analysed the content of the joint, its association with smoking behaviour and the cross-sectional and prospective (1.5-year follow-up) relations between smoking behaviour and cannabis dependence severity (total number of DSM-IV dependence symptoms). Results THC concentration in cannabis (range 1.10-24.70%) was correlated positively with cannabis dose per joint (b = 0.008, P = 0.01), but the resulting THC concentration per joint (range 0.24-15.72%) was associated negatively with inhalation volume (b = −0.05, P = 0.03). Smoking behaviour measures (number of puffs, inhaled volume, reduction of puff volume and puff duration while smoking) predicted follow-up dependence severity, independently of baseline dependence severity and monthly THC dose (number of joints × cannabis dose × cannabis THC concentration). Monthly THC dose only predicted follow-up dependence severity when unadjusted for baseline severity. Conclusions Cannabis users titrate their delta-9-tetrahydrocannabinol intake by inhaling lower volumes of smoke when smoking strong joints, but this does not fully compensate for the higher cannabis doses per joint when using strong cannabis. Thus, users of more potent cannabis are generally exposed to more delta-9-tetrahydrocannabinol. Smoking behaviour appears to be a stronger predictor for cannabis dependence severity than monthly delta-9-tetrahydrocannabinol dose.

Aims To compare the prevalence of mental disorders between frequent cannabis users with and without dependence and the general population. Design Cross-sectional comparison of interview data. Setting Enriched community sample of frequent cannabis users and a representative sample of non-users and non-frequent users from the general population. Participants A total of 521 young adult (aged 18-30 years) frequent cannabis users, 252 of whom were with DSM-IV cannabis dependence (D+) and 269 without DSM-IV cannabis dependence (D−), and 1072 young adults from the general population. Measurements Multinomial logistic regression was used to compare groups regarding the presence of DSM-IV mental disorders. Detailed measures of cannabis use, childhood adversity and other substance use were considered confounders. Findings Compared with the general population, externalizing disorders were more prevalent in D− [odds ratio (OR) = 8.91, P

To explore the European drug market from the demand side, we conducted web surveys in seven selected EU Member States (Bulgaria, Czech Republic, Italy, Netherlands, Portugal, Sweden and the United Kingdom) among last year users of (meth) amphetamine, ecstasy and cocaine. These users provided us with information on quantitative and qualitative aspects of their drug use such as their frequency of use and usual locations of purchase and use, thus offering us a window on patterns of drug use and availability. On the basis of past year use frequency, we divided users of each drug into three user type groups of infrequent (less than 11 use days), occasional (11-50 use days) and frequent (51-365 use days) users. We present findings per Member State as a whole and, wherever sample size allows, separately per user type. Our typology shows that infrequent users comprise the largest group for each drug and that the amount consumed on a typical use day increases with increasing frequency of use. We also estimated total annual consumption of (meth)amphetamine in the Czech Republic, the Netherlands and Sweden, and of ecstasy and cocaine in the Netherlands on the basis of the user type distinction. To this end, we calculated mean individual annual consumption within each user type group and combined these figures with absolute numbers of users of each type derived from general and targeted population survey data to arrive at estimates of total annual consumption. Individual annual consumption was higher among occasional than infrequent users and was highest among frequent users. In terms of total annual consumption, the smallest group of frequent users is responsible for the largest part of the total estimated amounts of each drug consumed. We discuss and compare our estimates to those from previous drug market research.

In this report we will start with a brief overview of recent developments relating to cannabis markets and policies in the seven countries participating in the project (chapter 1). Most of the information in this chapter is based on the National Reports of the EU Member States to the EMCDDA and can be found on the EMCDDA website (www.emcdda.europa.eu). One document is of special interest in this regard: the recently published Insight of the EMCDDA making a detailed account of the cannabis markets (Carpentier et al. 2012), which is partly based on the Reitox National reports for 2009. For Portugal and The Netherlands specific case studies of drug policy and cannabis policy, respectively, are described in Part III, report 1 and 2. We will then summarize the latest figures on cannabis use and trends in cannabis use (chapter 2). In chapter 3 an introduction is given into ways to classify or typology cannabis users and how we have defined different user groups in the present study. The remainder of this chapter and the next chapter (chapter 4) describe the findings of the web survey conducted in the seven countries with regard to characteristics of cannabis users, especially their consumption patterns, and the availability of cannabis to different user groups. In the last chapter (chapter 5) an integration will be made of existing data on the prevalence of cannabis use and web survey data on consumption patterns in order to estimate per user group the total amount of cannabis consumed annually in each country.

The Severity of Dependence Scale (SDS) measures with five items the degree of psychological dependence on several illicit drugs, including cannabis. Its psychometric properties have not yet been examined in young adult frequent cannabis users, an eminently high-risk group for cannabis dependence. Internal consistency and criterion validity of the SDS were investigated within an enriched community based sample of 577 Dutch frequent (≥ three days per week in the past 12 months) cannabis users between 18-30 years. Criterion validity was tested against the Composite International Diagnostic Interview (CIDI) 3.0 DSM-IV diagnosis cannabis dependence, and psychometric properties were assessed separately for males and females and for ethnic subgroups. Principal component analysis showed that all items of the scale loaded on a single factor and reliability of the SDS total score was good (Cronbach's α = 0.70). However, criterion validity against the CIDI diagnosis cannabis dependence was low: area under curve (AUC) was 0.68 (95% confidence interval: 0.64-0.73) and at the optimal differentiating cut-off (SDS ≥ 4), sensitivity was 61.3% and specificity 63.5%. Results were similar for subgroups on gender and ethnicity. While internal consistency of the SDS is good, its use as a screener to differentiate between dependence and non-dependence within populations of young adult frequent cannabis users is not recommended.

Uitgaan gaat vaak gepaard met alcohol- en drugsgebruik. Het uitgaansleven is daarom een belangrijke setting voor het volgen van ontwikkelingen in middelengebruik en het in kaart brengen van nieuwe trends onder jongeren en jongvolwassenen. Hoeveel en hoe vaak gebruiken stappers alcohol en drugs? Zijn er verschillen tussen bezoekers van clubs en grootschalige party’s en naar regio? En hoeveel club- en partybezoekers ontwikkelen problemen door hun drugsgebruik? Deze vragen komen aan de orde in "Feestmeter 2008-2009", een landelijk onderzoek naar de omvang en aard van het alcohol- en drugsgebruik in het uitgaansleven. Het rapport gaat over twee groepen jongeren en jongvolwassenen: zij die uitgaan in clubs en discotheken, en zij die grootschalige party’s en festivals bezoeken. Het alcoholgebruik is onder beide groepen uitgaanders fors. Ook het drugsgebruik ligt beduidend hoger dan onder hun ‘doorsnee’ leeftijdsgenoten. Na cannabis scoren vooral ecstasy, cocaïne en amfetamine hoog, terwijl het gebruik van ‘straatdrugs’ als heroïne of basecoke nauwelijks voorkomt. Opvallend is de grote variatie in het gebruik van drugs tussen verschillende party’s. Ook zijn er onder clubbezoekers soms opvallende regionale verschillen in middelengebruik. Met deze eerste Feestmeter is een start gemaakt om landelijk het middelengebruik in het uitgaansleven cijfermatig in kaart te brengen. Moge dit rapport een inspiratiebron zijn voor beleidsmakers, voorlichters en preventiewerkers.