Erasmus University Medical Center Rotterdam Research Articles

Adjuvant Use of PlasmaJet Device During Cytoreductive Surgery for Advanced-Stage Ovarian Cancer: Results of the PlaComOv-study, a Randomized Controlled Trial in The Netherlands

ObjectiveStandard surgical treatment of advanced-stage ovarian carcinoma with electrosurgery cannot always result in complete cytoreductive surgery (CRS), especially when many small metastases are found on the mesentery and intestinal surface. We investigated whether adjuvant use of a neutral argon plasma device can help increase the complete cytoreduction rate.Patients and Methods327 patients with FIGO stage IIIB–IV epithelial ovarian cancer (EOC) who underwent primary or interval CRS were randomized to either surgery with neutral argon plasma (PlasmaJet) (intervention) or without PlasmaJet (control group). The primary outcome was the percentage of complete CRS. The secondary outcomes were duration of surgery, blood loss, number of bowel resections and colostomies, hospitalization, 30-day morbidity, and quality of life (QoL).ResultsComplete CRS was achieved in 119 patients (75.8%) in the intervention group and 115 patients (67.6%) in the control group (risk difference (RD) 8.2%, 95% confidence interval (CI) –0.021 to 0.181; P = 0.131). In a per-protocol analysis excluding patients with unresectable disease, complete CRS was obtained in 85.6% in the intervention group and 71.5% in the control group (RD 14.1%, 95% CI 0.042 to 0.235; P = 0.005). Patient-reported QoL at 6 months after surgery differed between groups in favor of PlasmaJet surgery (95% CI 0.455–8.350; P = 0.029). Other secondary outcomes did not differ significantly.ConclusionsAdjuvant use of PlasmaJet during CRS for advanced-stage ovarian cancer resulted in a significantly higher proportion of complete CRS in patients with resectable disease and higher QoL at 6 months after surgery. (Funded by ZonMw, Trial Register NL62035.078.17.)Trial RegistrationApproved by the Medical Ethics Review Board of the Erasmus University Medical Center Rotterdam, the Netherlands, NL62035.078.17 on 20-11-2017. Recruitment started on 30-1-2018.

Routes of transmission of VIM-positive Pseudomonas aeruginosa in the adult intensive care unit-analysis of 9\xa0years of surveillance at a university hospital using a mathematical model

BackgroundHospital outbreaks of multidrug resistant Pseudomonas aeruginosa are often caused by Pseudomonas aeruginosa clones which produce metallo-β-lactamases, such as Verona Integron-encoded Metallo-β-lactamase (VIM). Although different sources have been identified, the exact transmission routes often remain unknown. However, quantifying the role of different transmission routes of VIM-PA is important for tailoring infection prevention and control measures. The aim of this study is to quantify the relative importance of different transmission routes by applying a mathematical transmission model using admission and discharge dates as well as surveillance culture data of patients.MethodsWe analyzed VIM-PA surveillance data collected between 2010 and 2018 of two intensive-care unit (ICU) wards for adult patients of the Erasmus University Medical Center Rotterdam using a mathematical transmission model. We distinguished two transmission routes: direct cross-transmission and a persistent environmental route. Based on admission, discharge dates, and surveillance cultures, we estimated the proportion of transmissions assigned to each of the routes.ResultsOur study shows that only 13.7% (95% CI 1.4%, 29%) of the transmissions that occurred in these two ICU wards were likely caused by cross-transmission, leaving the vast majority of transmissions (86.3%, 95% CI 71%, 98.6%) due to persistent environmental contamination.ConclusionsOur results emphasize that persistent contamination of the environment may be an important driver of nosocomial transmissions of VIM-PA in ICUs. To minimize the transmission risk from the environment, potential reservoirs should be regularly and thoroughly cleaned and disinfected, or redesigned.

Adequacy of blood pressure control in high-risk hypertensive patients: The DEGREE study

IntroductionHypertension is a modifiable risk factor in patients at the highest risk for cardiovascular events. New invasive treatment options are becoming available that might be particularly appealing for high-risk patients. Therefore, the aim of this study was to determine the prevalence of high-risk patients on routine therapy that do not meet guideline recommended ambulatory blood pressure (ABP) targets. MethodsThis single-center, cross-sectional study was conducted at the Erasmus University Medical Center (Rotterdam, The Netherlands). Inclusion criteria were: (1) age 18–80 years, (2) drugs prescribed for hypertension or history of hypertension and (3) high cardiovascular risk as defined according to the European Society of Cardiology/European Society of Hypertension (ESC/ESH) guidelines. Patients underwent standardized office blood pressure (OBP) and same-day 24-h ABP measurements. Blood pressure (BP) control was defined according to the 2018 ESC/ESH and 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines. ResultsA total of 100 patients were enrolled (median age 71 years, 35% female). Mean OBP was 142.2/81.9 ± 18.6/12.6 mmHg and mean 24-h ABP was 126.1/70.1 ± 14.3/9.2 mmHg. Patients were on 2.0 [25th–75th percentile: 1.0–3.3] Defined Daily Doses of antihypertensive drugs. ESC/ESH guideline 24-h ABP and OBP targets were not met in 41.8% (95%CI: 31.5–52.6%) and 52.7% (95%CI: 42.0–63.3%), respectively. ACC/AHA guideline 24-h ABP and OBP targets were not met in 59.3% (95%CI: 48.5–69.5%) and 79.1% (95%CI: 69.3–86.9%), respectively. ConclusionsBP remains uncontrolled in 40–60% of high-risk hypertensive patients despite routine use of guideline-recommended therapy. Our findings support the search towards novel invasive BP lowering treatment options.

High C-Reactive Protein Levels Are Relatedto Better Survival in Patients with Uveal Melanoma.

PurposeTo determine whether peripheral blood leukocyte numbers and serum markers of inflammation can be used to predict which patients with primary uveal melanoma will develop metastasis.DesignRetrospective study.ParticipantsMedical records of patients with uveal melanoma (UM) who received treatment for primary UM between February 1992 and December 2020 at the Erasmus University Medical Center (Rotterdam, The Netherlands) and the Rotterdam Eye Hospital (Rotterdam, The Netherlands) were reviewed.MethodsInclusion criteria were the presence of a melanoma of the choroid or ciliary body and the availability of data from peripheral blood samples taken before treatment of the melanoma. Data including patient demographics, C-reactive protein (CRP) levels; erythrocyte sedimentation rate (ESR); number of leukocytes, neutrophils, monocytes, and lymphocytes; and histopathologic findings were obtained from medical records. Neutrophil-to-lymphocyte ratio (NLR) and lymphocyte-to-monocyte ratio (LMR) were calculated.Main Outcome MeasuresMetastasis-free survival.ResultsOf the 807 patients with UM, serum and leukocyte data were available for 183 of them at the time of primary tumor treatment. In the total group, no correlation was found between ESR before treatment; the number of leukocytes; percentages of neutrophils, monocytes, and lymphocytes; or NLR or LMR values and any of the clinical characteristics or metastasis-free survival. Among patients who underwent enucleation, those with negative BAP1 findings showed significantly lower numbers of leukocytes (P < 0.05). In the entire cohort, a significant association was found between high CRP levels and longer metastasis-free survival (MFS; P = 0.049).ConclusionsThe total blood leukocyte number was related to loss of BAP1 staining in patients who underwent enucleation, with lower leukocyte counts correlating with absent BAP1 staining. Higher CRP levels were associated with a longer MFS in the entire cohort. Neither the NLR nor the LMR is a good predictor for metastasis developing in patients with UM.

Periocular tinea caused by zoonotic Trichophyton benhamiae

A 52-year-old immunocompetent woman was referred to the outpatient dermatology department of the Erasmus University Medical Center (Rotterdam, Netherlands) with a large, sharply demarcated erythematous plaque with yellow crustae around the right eye and on the upper right eyelid, without systemic symptoms and despite previous treatment (figure). Up until the appointment at our department, she was treated with oral valacyclovir (1000 mg three times a day) for 15 days, oral erythromycin (500 mg four times a day) for 6 days, and both fusidic acid cream and acyclovir cream two times a day.

No Evident Systemic Terminal Complement Pathway Activation in Hidradenitis Suppurativa

No Evident Systemic Terminal Complement Pathway Activation in Hidradenitis Suppurativa

The Process of Developing and Implementing a Simplified Guideline for Hand Hygiene in the Operating Room

Background: Most studies on improving hand hygiene compliance (HHC) focus on clinical wards. The 5 Moments of Hand Hygiene, as stated by the WHO, are less easy to identify in an outpatient setting or procedure rooms. Therefore, observing compliance of these moments in an outpatient clinic or among healthcare workers (HCWs) in the operating room (OR), is far more difficult. Nonetheless, proper hand hygiene in the OR is of utmost importance to prevent postoperative wound infection. Objective: We developed and implement a scoring instrument with simplified moments of hand hygiene for nonsterile HCWs in the OR. Methods: All 13 hospitals of the Antibiotic Resistance Network Southwest Netherlands were asked to submit their guidelines on hand hygiene in the OR. These guidelines were, after discussion, combined into 1 guideline, describing different hand hygiene areas for different groups of nonsterile HCWs in the OR. After asking for feedback and incorporating these adjustments, the guideline was converted into a policy document. Based on this document, a paper scoring instrument was developed to observe HHC in the OR in a uniform way across all hospitals. The Erasmus University Medical Center Rotterdam, the Netherlands (Erasmus MC) acted as a pilot hospital where the implementation of the scoring instrument was studied. Results: The policy document has been approved by the infection committees of all 13 hospitals. The preliminary data of the pilot in the Erasmus MC, although still ongoing, are as follows. Hand hygiene in the OR was observed at 4 different time points. The anesthetist was observed once during 4 procedures in 3 different ORs. At the other 3 time points, the OR assistants (ie, OR nurses and circulating nurses) were observed during 4 procedures in 4 different ORs. Hand hygiene moments were easy to identify; the paper scoring instrument could be used to record observations of HHC in the OR. Conclusions: The guideline with the simplified moments of hand hygiene for nonsterile HCWs in the OR has been successfully implemented. The pilot test in the Erasmus MC already showed that, after defining the hand hygiene moments in the OR, the HHC in the OR is easier to observe and record using the scoring instrument. Moreover, the instrument has provided clarity for HCWs regarding the moments ate which they should disinfect their hands.Funding: NoneDisclosures: None

Lessons learnt from the introduction of nanopore sequencing

In this commentary the authors comment briefly on their own experiences with the initial introduction of nanopore sequencing—Oxford Nanopore Technologies (ONT), Oxford, UK—for microbiota-based sequencing [1]. The commentary is based on joint experiences and collaboration between the Department of Medical Microbiology & Infectious Diseases and the Unit of Clinical Bioinformatics at the Erasmus University Medical Center Rotterdam (Erasmus MC). Initial pilot investigations into the implementation of nanopore sequencing began around May 2017.

Lesional Inflammatory Profile in Hidradenitis Suppurativa Is Not Solely Driven by IL-1

Lesional Inflammatory Profile in Hidradenitis Suppurativa Is Not Solely Driven by IL-1

Chest Radiographic Screening for Sarcoidosis in the Diagnosis of Patients with Active Uveitis.

Although chest radiography is currently recommended for the initial evaluation of patients with new-onset uveitis, the efficacy of this diagnostic screening modality is not known. To evaluate the diagnostic value of chest radiographs in patients with active uveitis of recent onset in a tertiary center in Western Europe. A retrospective cross-sectional study was conducted by reviewing all chest imaging for adults with new-onset (<1 yr) uveitis of unknown origin undergoing initial evaluation in the Department of Ophthalmology at Erasmus University Medical Center (Rotterdam, the Netherlands). Radiographic findings were related to clinical and other imaging characteristics and to final diagnoses. Screening chest radiographs were abnormal for 30 of 200 patients (15%) included in this study. Twenty-two of the 200 patients (11%) had biopsy-confirmed sarcoidosis, and an additional 12 patients were presumed to have sarcoidosis. The finding of chest radiographic abnormalities interpreted as typical of sarcoidosis was specific (91%; 95% confidence interval, 85.9-94.4%) but not sensitive (64%; 95% confidence interval, 43.0-80.3%) for biopsy-confirmed sarcoidosis. The combination of elevated serum angiotensin-converting enzyme level and chest radiographic findings typical of sarcoidosis increased the sensitivity to 79%. Biopsy-confirmed sarcoidosis was more common in patients with panuveitis (17 of 84; 20%) compared to patients with other anatomical locations of uveitis (5 of 116, 4%; P < 0.001). One patient was diagnosed with active pulmonary and ocular tuberculosis. Abnormal chest radiographs were found in 15% of patients with active uveitis of unknown origin and onset within 1 year of referral to a tertiary center in the Netherlands. A majority of the abnormal chest radiographs showed findings compatible with a diagnosis of sarcoidosis.

Peptide clears senescent cells, revitalizes aging mice

As we age, our cells increasingly become senescent: Instead of dying, these decrepit cells stop dividing and begin secreting a cocktail of molecules that can cause problems for other cells. Scientists have long been searching for chemical treatments that can clear away the problematic cells. Now, a team of researchers led by Peter L. J. de Keizer at Erasmus University Medical Center Rotterdam are reporting that a cell-penetrating peptide they prepared can make senescent cells in mice suicidal, allowing the animals to remove them naturally. The peptide is a shortened form of a protein called FOXO4. In senescent cells, FOXO4 binds another protein, called p53. This interaction prevents cell death. When delivered to mice, the team found that the peptide disrupts the normal FOXO4-p53 interaction and the cells are directed to die (Cell 2017, DOI: 10.1016/j.cell.2017.02.031). The researchers tested the treatment on elderly mice and found that these animals had

Antithrombotic stewardship: a multidisciplinary team approach towards improving antithrombotic therapy outcomes during and after hospitalisation: a study protocol

IntroductionAntithrombotic therapy carries high risks for patient safety. Antithrombotics belong to the top 5 medications involved in potentially preventable hospital admissions related to medication. To provide a standard for antithrombotic...

Organ Donation After Euthanasia: A Dutch Practical Manual.

Many physicians and patients do not realize that it is legally and medically possible to donate organs after euthanasia. The combination of euthanasia and organ donation is not a common practice, often limited by the patient's underlying pathology, but nevertheless has been performed >40 times in Belgium and the Netherlands since 2005. In anticipation of patients' requests for organ donation after euthanasia and contributing to awareness of the possibility of this combination among general practitioners and medical specialists, the Maastricht University Medical Center and the Erasmus University Medical Center Rotterdam have developed a multidisciplinary practical manual in which the organizational steps regarding this combined procedure are described and explained. This practical manual lists the various criteria to fulfill and the rules and regulations the different stakeholders involved need to comply with to meet all due diligence requirements. Although an ethicist was involved in writing this paper, this report is not specifically meant to comprehensively address the ethical issues surrounding the topic. This paper is focused on the operational aspects of the protocol.

63PD - Comparison of Clinical Outcome of Stage I Non-Small Cell Lung Cancer Treated Surgically Or with Stereotactic Radiotherapy: Results From Propensity Score Analysis

Objectives: Guideline-specified curative therapies for a clinical stage I non-small cell lung cancer (NSCLC) are either lobectomy or Stereotactic Ablative Radiotherapy (SABR). As outcomes of prospective randomized clinical trials comparing these modalities are unavailable, we performed a propensity-score matched analysis to create two similar groups in order to compare clinical outcomes. Methods: We selected 577 patients, 96 VATS or open lobectomy were treated at Erasmus University Medical Center Rotterdam and 481 SABR patients were treated at VU University Medical Center Amsterdam with clinical stage I NSCLC. Results: Matching of patients according to propensity score resulted in a cohort that consisted of 73 patients in the surgery group and of 73 patients in the SABR group. Median follow-up in the surgery and SABR group was 49 months and 28 months, respectively. Overall survival of patients who underwent surgery was 95% and 80% at 12 and 60 months, respectively. For the SABR group this was 94% at 12 months and 53% at 60 months. No statistical significant difference (p = 0.089) in survival was found between these groups. Conclusions: In this study we found no significant differences in overall survival in propensity matched patients diagnosed with stage I NSCLC treated either surgically or with SABR. After 3 years there seems to be a trend toward improved survival in patients who were treated surgically.

Perceived sleep quality is worse than objective parameters of sleep in pregnant women with a mental disorder.

Disturbed sleep during pregnancy is associated with adverse obstetric outcomes and less mental well-being. In pregnant women with a mental disorder, who frequently suffer from sleep problems, it is unknown whether predominantly objective or subjective sleep quality is more affected. To clarify this, we compared objective and subjective parameters of sleep quality between patients and healthy controls during pregnancy. This observational study was embedded in an ongoing study among pregnant women with a mental disorder at the department of Psychiatry of Erasmus University Medical Center Rotterdam, the Netherlands. We compared 21 pregnant women with a confirmed mental disorder with 33 healthy controls (gestational age, 23-29 weeks). To measure objective parameters of sleep quality, all participants continuously wore a wrist actigraph for 7 days and nights. Subjective sleep quality was retrospectively assessed using the Pittsburgh Sleep Quality Index (PSQI) and on a daily basis with the Subjective Sleep Quality-scale (SSQ). Differences in parameters of sleep between patients and controls were tested using a multivariate linear regression analysis adjusted for parity, gestational age, educational level, and employment status. Objective parameters of sleep quality and subjective sleep quality as assessed by the PSQI did not differ significantly between patients and controls. Daily sleep reports showed that, relative to controls, patients had a significantly worse average SSQ-score (5.2 vs. 7.6, adjusted β = 0.12, 95%CI = 0.03-0.53, p < 0.01). Our exploratory study suggests that perceived sleep quality reported on a daily basis by pregnant women with a mental disorder is worse than the sleep quality as measured by wrist actigraphy.

Is physician awareness of impending death in hospital related to better communication and medical care?

In hospitals, where care is focused on cure and life prolongation, impending death is often recognized too late. Physician awareness of impending death is a prerequisite for communication with patients and relatives about dying in hospital and providing care that adequately addresses patients' needs. To examine to what extent physicians are aware of the impending death of their dying patients and if awareness is related with communication and medical care, with quality of life in the last 3 days and quality of dying. Retrospective survey among hospital physicians after patient deaths. Patients who died between June 2009 and February 2011 at Erasmus University Medical Center (Rotterdam, The Netherlands). Physician self-reported awareness of impending death, communication with patients and relatives, medical care, quality of life in the last 3 days, and quality of dying. The response rate was 44% (n=228). Physicians reported that they had been aware of the impending death in 67% of their dying patients. If they had been aware, discussing death with patients and relatives was more likely, as well as changing the treatment goal into comfort care or withholding treatment and prescribing opioids in the last 3 days of life. When physicians had been aware of impending death, they rated the quality of dying higher. In two-thirds of deaths, hospital physicians had been aware of impending death of their dying patients. Physician awareness was related with more communication and more appropriate care in the last days of life.

The influence of preoperative weight loss on the postoperative course after esophageal cancer resection

Preoperative weight loss might increase the risk of postoperative morbidity and mortality after esophagectomy for cancer. We hypothesized that patients with esophageal cancer with >10% weight loss during the 3 months before their diagnosis would be at an increased risk of postoperative complications, have a longer length of stay, and have worse overall survival. In the present hospital-based cohort study, all patients who had undergone surgery for esophageal cancer in 1990 to 2010 at the Erasmus University Medical Center Rotterdam were included. Weight loss was defined as "no, or limited" (≤10%) or "severe" (>10%). Logistic regression analysis was used to estimate the relative risk of complications, expressed as odds ratios (ORs) with 95% confidence intervals (CIs). Hazard ratios were calculated to assess the length of hospital stay and survival. The risk estimates were adjusted for potential confounding factors. Of 922 included patients, 155 (17%) had experienced severe weight loss. These patients had no increased risk of early surgical, early nonsurgical, or late surgical complications (OR, 0.83 and 95% CI, 0.54-1.24; OR, 0.90 and 95% CI, 0.63-1.30; OR, 1.14 and 95% CI, 0.79-1.66, respectively) and had no increased length of stay (hazard ratio, 1.09; 95% CI, 0.89-1.35). Preoperative weight loss was followed by increased 5-year mortality (hazard ratio, 1.34; 95% CI, 1.02-1.74). A >10% preoperative weight loss was followed by decreased 5-year survival after esophageal cancer surgery but no increased risk of postoperative complications.

Relation Between Mutations in FVIII Gene and Response to Desmopressin in Patients with Hemophilia A

Abstract 29▪▪This icon denotes a clinically relevant abstract Background:Hemophilia A is a rare X-linked bleeding disorder caused by a variety of mutations in the factor VIII (FVIII) gene resulting in lowered levels of FVIII. Desmopressin causes a 2- to 6-fold rise of FVIII in patients with mild (>5%FVIII) or moderate (1–5% FVIII) hemophilia A. To prevent bleeding during surgical procedures, FVIII levels should rise above 0.50 IU/ml. The response to desmopressin is known to have a great inter-individual variation. It is unknown if there is a relation between the type of FVIII gene mutation and the response to desmopressin. Objective:To assess the response to desmopressin in patients with mild or moderate hemophilia A and known mutations of the FVIII gene. Patients and methods:Patients with mild or moderate hemophilia from the Erasmus University Medical Center Rotterdam were retrospectively included. Inclusion criteria: male, age ≥12 years, known mutation in FVIII gene, previous intravenous or intranasal administration of desmopressin, FVIII levels available at baseline and at peak level after desmopressin. Desmopressin response was defined as complete if FVIII ≥0.50 IU/ml, partial if ≥0.30 but <0.50 IU/ml or none <0.30 IU/ml. Response was determined 1 hour (peak level) and 3–4 hours (sustained response) after desmopressin administration. Fold increase over baseline was calculated as FVIII peak level / FVIII baseline level. Five groups of mutations were composed: Arg2169His, Arg612Cys, Asn637Ser, Pro149Arg and 1 residual group containing all other mutations. Results:Eighty-three male patients were included; 70 patients with mild and 13 with moderate hemophilia A. The mean age was 33 years (range 12–86). The median FVIII baseline level was 0.16 IU/ml (IQR 0.08–0.25), median FVIII peak level 0.58 IU/ml (IQR 0.38–0.86) and median fold increase over baseline was 4.15 (IQR 3.11–5.50). Of the 83 patients, 51 (61%) had a complete response. FVIII levels 3–4 hours after desmopressin were available in 58 of 83 patients and the response sustained in 28 (48%) patients. Of the 21 patients with mutation Arg2169His, 8 (38%) showed a complete response after 1 hour. In only 1 (9%) patient the complete response sustained. A partial response was seen in 6 (29%) patients and in 5 (46%) of 11 patients the response sustained. Seven (33%) patients had no response. None of the patients with mutation Pro149Arg achieved a complete response after 1 hour. Four (67%) of 6 patients had a partial response, after 3–4 hours 2 (50%) of 4 patients sustained. Two (33%) patients did not respond at all (Table 1). Mutation Arg2169His and Pro149Arg had significant lower FVIII levels at baseline, peak and 3–4 hours after desmopressin, compared to Arg612Cys, Asn637Ser and the group with other mutations. Fold increase over baseline was highest in Arg2169His (5.3 fold) and lowest in Asn637Ser (3.4 fold) (p=0.047) (Table 2). [Display omitted] [Display omitted] Conclusions:Although desmopressin caused a 4–5 fold increase over baseline in hemophilia A patients with mutation Arg2169His or Pro149Arg, the clinical utility is limited. A complete response at peak level did not sustain in most of the patients with Arg2169His and a complete response in patients with Pro149Arg was not seen. Therefore if patients with hemophilia A and mutation Arg2169His or Pro149Arg are treated with desmopressin, it should only be used to prevent bleeding during minor and not major surgery. A desmopressin challenge with measurement of the sustained response should be performed in all patients prior to surgery. Disclosures:No relevant conflicts of interest to declare.

Tailored preconceptional dietary and lifestyle counselling in a tertiary outpatient clinic in the Netherlands

Adverse reproductive performance has been linked to unhealthy dietary intake and lifestyles. Our objectives were to investigate the prevalence of unhealthy dietary intake and lifestyles before conception and to evaluate whether tailored preconception counselling modifies these behaviours. Between October 2007 and April 2009, 419 couples received tailored preconception dietary and lifestyle counselling at the outpatient clinic of Obstetrics and Gynaecology of the Erasmus University Medical Center Rotterdam, the Netherlands. A subgroup (n = 110 couples) was counselled twice with a fixed time interval of 3 months. Self-administered questionnaires were used for tailored dietary and lifestyle counselling. A cumulative score based on six Dutch dietary guidelines was displayed in the personal Preconception Dietary Risk score (PDR score). In a similar manner, the Rotterdam Reproduction Risk score (R3 score) was calculated from lifestyle factors (women: 13 items, men: 10 items). Univariate and paired tests were used. Most couples (93.8%) were subfertile. At the second counselling, the percentage consuming the recommended intake of fruit had increased from 65 to 80 in women and from 49 to 68 in men and the percentage of women getting the recommended intake of fish increased from 39 to 52. As a consequence, the median PDR score was decreased [women: 2.6 (95% CI 2.4-2.9) to 2.4 (95% CI 2.1-2.6), men: 2.5 (95% CI 2.3-2.7) to 2.2 (95% CI 1.9-2.4), both P < 0.05]. The median R3 scores were also lower [women: 4.7 (95% CI 4.3-5.0) to 3.1 (95% CI 2.8-3.4), men: 3.0 (95% CI 2.8-3.3) to 2.0 (95% CI 1.7-2.3), both P < 0.01] due to less alcohol use (-14.6%), more physical exercise and folic acid use in women, and less alcohol use in men (-19.4%) (all P < 0.01). The R3 scores in women and men were decreased in all ethnicity, educational level, neighbourhood and BMI categories. However, low educated women appeared to show a larger reduction than better educated women and men with a normal BMI to show a larger decrease than overweight men. The reduction in the PDR score of women was similar in both ethnic groups. More than 85% women and men found the counselling useful and around 70% would recommend it to others. Tailored preconception counselling about unhealthy dietary and lifestyle behaviours of subfertile couples in an outpatient tertiary clinic is feasible and seems to decrease the prevalence of harmful behaviours in the short term. These results with subfertile couples are promising and illustrate their opportunities to contribute to reproductive performance and pregnancy outcome.

Manfred Kayser

Manfred Kayser