With rising cancer survival rates and an increasing number of cancer survivors, the sustainability of secondary care follow-up care is under pressure. Transferring certain follow-up tasks to primary care is suggested as a potential solution, but there is no consensus on the optimal strategy for this. To identify preferences of primary and secondary healthcare providers regarding the transfer of follow-up care for breast, colorectal, and prostate cancer, using a discrete choice experiment (DCE). A DCE was conducted among 153 primary and secondary healthcare professionals in the Netherlands. Attributes related to patient and follow-up characteristics included: type of cancer, age, time post-treatment, any protocolled care for comorbidities, recurrence risk, and types of check-up protocols. A conditional logit model and latent class analysis were used to assess preferences and identify subgroups. Healthcare providers favored the transfer of follow-up care to primary care for prostate cancer patients. Across all cancer types, preferences for substitution were greater in patients aged above 75 years, longer post-treatment, a low recurrence risk, and who were already enrolled in protocolized chronic care. Transfer of basic check-up care was preferred, while extensive check-up was negatively valued, especially by GPs. Future follow-up should focus on patient groups and tasks for which consensus exists that primary care involvement is feasible and appropriate, forming the basis for sustainable, collaborative, and patient-centered models of care.

Vitamin B12 supplementation among people without proven deficiency has become popularized, driven by perceptions of (i) frequent underdiagnosis of deficiency, (ii) promotion as a natural enhancer of well-being, and (iii) a favourable safety profile. Here, we examine whether these claims align with current evidence. We present guidance from major health authorities, which advises against routine testing in asymptomatic individuals without risk factors. The prevalence of B12 deficiency varies greatly, mainly because definitions of B12 deficiency are not standardized and may include clinical, biochemical, or functional criteria. Biochemical deficiency (typically serum B12 < 148 pmol/L) is the predominant definition in epidemiological and clinical research studies. Using this criterion, deficiency appears uncommon in general populations of high-income countries (~2%), but substantially more frequent in settings with limited access to animal-source foods or B12-fortified products (up to 69%). Studying the effects of supplementation is also challenged by variation in the regimens used, which range from 0.02 to 1 mg/day orally and from 1 to 5 mg/week intramuscularly, with durations spanning ~4 weeks to ~7 years. This limits cross-study comparability. Overall, supplementation has not shown consistent benefits in populations without overt clinical or biochemical B12 deficiency, with no clear improvements in fatigue, mood, cognition, or cardiovascular outcomes. Benefits, when reported, appear confined to selected subgroups (e.g., hyperhomocysteinemia or low-normal B12 status). B12 supplementation is generally well tolerated. There are rare reports of acneiform and hypersensitivity responses, although these cannot be completely distinguished from reactions to, e.g., excipients. Observational studies associate B12 supplementation and higher circulating B12 levels with increased risks of malignancy. However, these findings are inconsistent, and current evidence is insufficient to establish causality, as potential reverse causation remains a major concern.

BACKGROUND:Therapeutic advances have significantly extended survival for certain groups of patients with incurable cancer, creating a growing population living long-term with incurable cancer. However, the absence of standardized definitions and terminology has contributed to limited recognition of this distinct group and their specific care needs. AIM:To achieve consensus on definitions and terminology for patients living long-term with incurable cancer by incorporating perspectives of patients, informal caregivers, healthcare professionals, and other relevant stakeholders. DESIGN:A modified hybrid Delphi study, comprising focus groups and a three-round Delphi consensus process. SETTING/PARTICIPANTS:Three focus groups were conducted with patients (n = 11), informal caregivers (n = 4), and healthcare professionals (n = 6). The multidisciplinary expert group comprised medical specialists (n = 5), epidemiologists (n = 3), and patient advocates (n = 2). The Delphi study involved 78 panelists (73 unique respondents) divided into three subpanels: patients and informal caregivers (n = 22), healthcare professionals (n = 36), and other stakeholders (n = 20). All participants were from the Netherlands. RESULTS:We achieved 88% consensus on the terminology: Patients living long-term with incurable cancer. Consensus was reached on the definition (94%) for patients living for two or more years with: (1) incurable metastatic cancer, (2) incurable hematological malignancies, (3) incurable locally advanced cancer, or (4) patients with exceptionally long survival for their cancer type, despite not meeting the 2-year criterion. CONCLUSIONS:This modified hybrid Delphi study established the first consensus-based framework for patients living long-term with incurable cancer, providing essential groundwork for improved recognition and tailored care approaches for this population.

BACKGROUND:Creatine, an endogenous compound essential for energy metabolism and cellular function, has been associated with numerous beneficial effects in sports and overall health. Here, we investigated relationships between plasma creatine concentration, estimated intramuscular creatine concentration, and all-cause mortality in the general population. METHODS:In a Dutch prospective population-based cohort, plasma creatine concentration, 24-h urinary creatinine excretion and muscle mass (assessed with bio-electrical impedance analysis) were measured in 5127 participants. Total creatine pool size, calculated from 24-h creatinine excretion (assuming a 1.7% daily excretion of the total creatine pool), was divided by muscle mass to estimate intramuscular creatine concentrations. Transcellular gradient was calculated as intramuscular concentration divided by plasma concentration. Hazard ratios for mortality per doubling were assessed using multivariable Cox proportional hazard models, adjusting for common cardiovascular risk factors for mortality. RESULTS:Median plasma creatine concentrations were 41 [30-54] μmol/L in females and 28 [21-38] μmol/L in males. Mean intramuscular creatine concentrations were 30 ± 5.0 mmol/kg in females and 27.4 ± 5.0 mmol/kg in males. Median transcellular creatine gradients were 734 [550-1011] in females and 955 [715-1324] in males. Higher intramuscular creatine concentrations were associated with lower mortality in females (HR (95% CI) = .43 (.2; .66)); with a weaker trend in males (HR (95% CI) = .73 (.53; 1.02)). Plasma creatine concentrations were not associated with mortality. CONCLUSION:Higher estimated intramuscular creatine concentrations are strongly associated with lower all-cause mortality in females, with a weaker trend in males. Future research should explore causality, as well as further explore the remarkable sex difference.

BACKGROUND:Patients with chronic kidney disease (CKD) are at risk for vitamin C (VitC) deficiency. OBJECTIVES:We aimed to investigate VitC status and its determinants across the spectrum of CKD and healthy individuals. METHODS:In this cross-sectional study, we measured plasma VitC concentrations (<10 μmol/L = deficient, 10‒35 μmol/L = inadequate) in 62 individuals on dialysis, 41 with CKD stage 4/5, 42 kidney transplant recipients (KTRs) (together: CKD population), and in 447 living kidney donors, and 385 healthy controls (together: healthy population). In the CKD population, we assessed VitC intake (<75 mg/d = inadequate) using 24-h dietary recalls. We measured VitC removal by hemodialysis. We investigated potential determinants of plasma VitC with linear regression in the CKD population and in the healthy population separately. RESULTS:Median (Q1‒Q3) plasma VitC was highest in healthy controls [58 (43‒69) μmol/L, 14% inadequate/deficient], followed by kidney donors [50 (36‒66) μmol/L, 22% inadequate/deficient], KTR [37 (19‒46) μmol/L, 48% inadequate/deficient], dialysis [33 (19‒47) μmol/L, 58% inadequate/deficient], and CKD stage 4/5 [22 (14‒34) μmol/L, 80% inadequate/deficient]. Daily dietary VitC intake was similar in KTR [55.5 (33.5‒144.2) mg, 55% inadequate] and CKD stage 4/5 [53.0 (23.9‒142.0) mg, 56% inadequate], and higher in dialysis [113 (72‒209) mg, 26% inadequate] due to supplementation. VitC removal was 58 (27‒123) mg in conventional and 128 (97‒156) mg in nocturnal hemodialysis sessions. In the healthy population, estimated glomerular filtration rate was positively associated with plasma VitC [standardized β coefficient: 0.18 (0.08, 0.27), P < 0.001], independent of potential confounders. CONCLUSIONS:VitC inadequacy and deficiency are common in CKD. Inadequate intake and removal by dialysis may contribute. In healthy individuals estimated glomerular filtration rate was inversely associated with plasma VitC. Our findings highlight the importance of monitoring VitC status in CKD, and represent a potential target for intervention. Future research could evaluate the potential health effects of improving VitC status in CKD.

Globally, 9 million women are diagnosed with cancer each year. Breast cancer is the most commonly diagnosed cancer worldwide, followed by colorectal cancer in high-income countries and cervical cancer in low-income countries. Survival from cancer is improving and more women are experiencing long-term effects of cancer treatment, such as premature ovarian insufficiency or early menopause. Managing menopausal symptoms after cancer can be challenging, and more severe than at natural menopause. Menopausal symptoms can extend beyond hot flushes and night sweats (vasomotor symptoms). Treatment-induced symptoms might include sexual dysfunction and impairment of sleep, mood, and quality of life. In the long term, premature ovarian insufficiency might increase the risk of chronic conditions such as osteoporosis and cardiovascular disease. Diagnosing menopause after cancer can be challenging as menopausal symptoms can overlap with other common symptoms in patients with cancer, such as fatigue and sexual dysfunction. Menopausal hormone therapy is an effective treatment for vasomotor symptoms and seems to be safe for many patients with cancer. When hormone therapy is contraindicated or avoided, emerging evidence supports the efficacy of non-pharmacological and non-hormonal treatments, although most evidence is based on women older than 50 years with breast cancer. Vaginal oestrogen seems safe for most patients with genitourinary symptoms, but there are few non-hormonal options. Many patients have inadequate centralised care for managing menopausal symptoms after cancer treatment, and more information is needed about cost-effective and patient-focused models of care for this growing population.

Chronic kidney disease (CKD) patients with limited health literacy are at risk for faster disease progression. To counteract this problem, we developed ‘Grip on your Kidneys’ (GoYK), an intervention targeting patients and health care professionals. We assessed the effect on self-management, patient activation, clinical parameters, consultation quality, and the professionals’ use of health literacy strategies. We further evaluated the process. A quasi-experimental study included 147 patients with CKD and 48 professionals from Dutch general practices and nephrology clinics. Patients and professionals in the intervention group (IG) received GoYK. Control patients received care-as-usual from the participating professionals. Data were collected with questionnaires and from patient records at baseline (T0), 4 months (T1) and 9 months (T2). No effects on self-management and patient activation were found. Conversely, at T2, the proportion of patients with hypertension decreased in the intervention group (odds ratio = 0.45, 95

In decision making for cancer treatment, information is crucial for patients and health care professionals. Although conversations about treatment decisions take place in hospitals, many patients also appreciate the insights of their general practitioner (GP). GPs indicated that, in order to have meaningful conversations about treatment decisions with their patients, they need additional information about treatment options and considerations, such as expected benefits and side effects.In this practice innovation, we developed and implemented a new written communication format from medical specialists to GPs, aimed at providing accurate treatment information to facilitate GPs in supporting patients with cancer in decision-making. The new format added 3 specific headings to standard letters in the electronic patient files (EPFs): (1) treatment options, (2) treatment considerations, and (3) treatment intent.This innovation was implemented in a large university hospital in [LOCATION] between 2020 and 2021. We performed a process evaluation of the implementation using the RE-AIM model, based on assessment of written communication obtained from patients’ EPFs, and telephonic interviews with specialists and GPs.In [LOCATION], all inhabitants are registered with a GP, who acts as a gatekeeper to specialist care, and has a comprehensive overview of a patient’s history, based on digital communication with hospitals after referral for specialist care. EPFs are used to generate digital letters to communicate between medical specialists in a hospital and GPs outside the hospital. Incorporating new headings in the communication format in the EPF successfully encouraged medical specialists to share such information when used appropriately. Treatment options, considerations, and treatment intent were stated more often in the new format compared with the old format. GPs appreciated the new format, highlighting the value of including treatment considerations, which enhanced their comprehension of the medical specialist's thought processes.Recognition of the problem and motivation for improvement facilitated the implementation. Specialists stated the format to be time-efficient compared with the old format; however, technical improvements could make it easier to use. Automaticity to use of the old format, inadequate information, and technical issues were a barrier for implementation.In summary, a straightforward innovation can improve communication between medical specialists and GPs and promote the role of the GPs in decision making for cancer treatment.

In older patients with cancer, the balance between harms and benefits of treatment is delicate. There is a higher risk of adverse outcomes of cancer treatment due to comorbidity and geriatric impairments, while clinical benefit is uncertain due to their frequent exclusion in clinical trials [1,2]. Potential benefits of treatment (for example, increased survival) may come at a cost (for example, increased treatment side-effects or loss of function). As a result, treatment decisions are often preference sensitive, which means that the optimal treatment choice depends on a patient's personal values and priorities [3].

Dat het risico op veneuze trombose verhoogd is bij pilgebruik en bij trombofilie weet waarschijnlijk elke huisarts. Maar hoe groot zijn de risico’s eigenlijk? In deze casuïstiek bespreken we hoe het precies zit en waarom testen op factor V Leiden in het kader van anticonceptieadvies niet hoeft.

OBJECTIVES:Guidelines recommend upper and lower gastrointestinal endoscopic evaluation for patients without a clear physiological explanation for iron deficiency anemia (IDA). However, the consequences of watchful waiting in older patients with unexplained IDA in general practice are unknown. The aim of this study was to investigate characteristics and survival of patients with an unexplained IDA in general practice who refrain from medical specialist evaluation. DESIGN:Historical prospective study. SETTING AND PARTICIPANTS:Patients aged ≥70 years with IDA coded in their medical records were selected from the Dutch Academic General Practitioner Development Network (AHON) database. METHODS:Based on their medical records, patients with an unexplained IDA were classified as (1) referred for medical specialist evaluation, or (2) no or noninvasive evaluation in general practice. RESULTS:Compared to patients who were referred for medical specialist evaluation (n = 235, 47.8%), patients who had no or noninvasive evaluation (n = 257; 52.5%) were older (median respectively 79 vs 82 years old, P < .01) and more likely to have congestive heart failure (respectively 17.4% and 26.1%, P = .02) and dementia (respectively 2.6% and 8.9%, P < .01). Two-year survival was significantly higher in patients who were referred for medical specialist evaluation compared to patients who had no or noninvasive evaluation (respectively, 83.9% and 75.5%, P = .02). CONCLUSIONS AND IMPLICATIONS:Although mortality was significantly higher in the older and more comorbid patients who had no or noninvasive evaluation in general practice, survival was still high in this patient group. Therefore, non-guideline adherence and a wait-and-see approach could be discussed in a shared-decision-making consultation.

For physicians, it is important to know which treatment outcomes are prioritized overall by older patients with cancer, since this will help them to tailor the amount of information and treatment recommendations. Older patients might prioritize other outcomes than younger patients. Our objective is to summarize which outcomes matter most to older patients with cancer. A systematic review was conducted, in which we searched Embase and Medline on 22 December 2020. Studies were eligible if they reported some form of prioritization of outcome categories relative to each other in patients with all types of cancer and if they included at least three outcome categories. Subsequently, for each study, the highest or second-highest outcome category was identified and presented in relation to the number of studies that included that outcome category. An adapted Newcastle-Ottawa Scale was used to assess the risk of bias. In total, 4374 patients were asked for their priorities in 28 studies that were included. Only six of these studies had a population with a median age above 70. Of all the studies, 79% identified quality of life as the highest or second-highest priority, followed by overall survival (67%), progression- and disease-free survival (56%), absence of severe or persistent treatment side effects (54%), and treatment response (50%). Absence of transient short-term side effects was prioritized in 16%. The studies were heterogeneous considering age, cancer type, and treatment settings. Overall, quality of life, overall survival, progression- and disease-free survival, and severe and persistent side effects of treatment are the outcomes that receive the highest priority on a group level when patients with cancer need to make trade-offs in oncologic treatment decisions.

Dataset of the literature search belonging to the publication "Patient preferences for treatment outcomes in oncology with a focus on the older patient- a systematic review."

Abstract Background Chronic kidney disease (CKD) patients with limited health literacy (LHL) experience a faster kidney decline. To counteract this, we developed Grip on your Kidneys (GoyK). This intervention targets patients’ communication and self-management. It trains health care professionals (HCPs) competences to support patients with LHL. This study aims to test the effectiveness of GoyK on patients’ health and self-management, HCPs’ communication competences, and the quality of consultations. Methods A clustered and non-blinded quasi-experimental study was conducted, including 161 patients with mild to severe CKD and 48 HCPs from Dutch general practices and nephrology clinics. Patients (n = 77) and HCPs (n = 30) in the intervention group received GoyK. In the control group, patients (n = 76) had routine visits with HCPs (n = 19). Between March 2021 and June 2022, data were collected with questionnaires and from patient records at baseline (T0), 4 months (T1) and 9 months (T2). Primary outcomes were patients’ self-management and HCPs’ use of health literacy communication strategies. Preliminary results At T1, the intervention improved the days per week patients exercised (B = 1.00, 95% confidence interval, CI = 0.35-1.65, P = 0.003), and Likert-scale reported (1-4) fluid intake (B = 0.37, CI = 0.10-0.63, p = 0.006). The intervention had a positive effect on several outcomes related to how patients perceived the consultation quality, and improved the reported use of communication strategies by HCPs at T1 (B = 0.68, CI = 0.35-1.01, p = <0.001). We found no effects on other patient outcomes, like activation for self-management or salt intake. Conclusions Our health literacy intervention, targeting CKD patients with LHL and HCPs, improved lifestyle behaviors of patients and the quality of consultations. A further strengthening of other self-management behaviors and on HCPs’ competences is needed, also to reach sustainable effects in the care for patients with LHL. Key messages • A health literacy intervention, targeting patients and professionals simultaneously, improved the patients’ self-management and care consultations. • Training of HCPs improved their competences to support patients with LHL, and care organizations and studies need to implement education on this topic.

Objectives: For shared decision making, it is crucial to identify patients' priorities regarding health outcomes. Our aim was to study whether healthcare professionals know these priorities. Methods: In this cross-sectional study we included older patients who had to make a treatment decision, their general practitioners (GPs) and their medical specialists. Agreement between the patients' main health outcome as prioritised by using the Outcome Prioritization Tool (OPT) and the perception of the same outcome by their healthcare professionals. Results: Eighty-seven patients were included. Median age was 76 years, 87.4% of patients presented with malignant disease. The majority prioritised maintaining independence (51.7%), followed by extending life (27.6%). The agreement between patients and healthcare professionals was low (GPs 41.7%, kappa 0.067, p = 0.39), medical specialists 40.3%, kappa 0.074, p = 0.33). Positively related to agreement was patient's age > 75, and a longer relation with their patients (for GPs), and the patient having no partner (for medical specialist). Having a malignant disease, dependent living and functional deficits were negatively related to agreement. Conclusions: Healthcare professionals have poor perceptions of their patients' priorities. Practice implications: To realise patient-centered care, it is crucial to discuss priorities explicitly with all patients. (c) 2021 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY license

Zelfstandige behandelcentra die zich hebben gespecialiseerd in vitamine B12-problematiek adviseren patiënten met vitamine B12-deficiëntie te behandelen met injecties. De NHG-Standaard Anemie adviseert echter tabletten. Recente wetenschappelijke publicaties laten zien dat er geen reden is om de NHG-Standaard op dit punt te herzien. Vitamine B12-deficiëntie kan in principe oraal worden behandeld.

The number of patients that can no longer be cured but may expect to live with their cancer diagnosis for a substantial period is increasing. These patients with 'prolonged incurable cancer' are often overlooked in research and clinical practice. Patients encounter problems that are traditionally seen from a palliative or survivorship perspective but this may be insufficient to cover the wide range of physical and psychosocial problems that patients with prolonged incurable cancer may encounter. Elements from both fields should, therefore, be delivered concordantly to further optimize care pathways for these patients. Furthermore, to ensure future high-quality care for this important patient population, enhanced clinical awareness, as well as further research, are urgently needed.