A narrative review of lifestyle management guidelines for metabolic dysfunction-associated steatotic liver disease

BACKGROUND AIMS

Metabolic dysfunction-associated steatotic liver disease (MASLD) management guidelines have been published worldwide; we aimed to summarize, categorize and compare their lifestyle intervention recommendations.

APPROACH RESULTS

We searched MASLD/nonalcoholic fatty liver disease (NAFLD) management guidelines published between 1 January 2013 and 31 June 2024 via databases including PubMed/MEDLINE, Cochrane, and CINAHL. In total, 35 qualifying guidelines were included in the final analysis. Guideline recommendations were categorized into five domains (i.e., weight reduction goals, physical activity, nutrition, alcohol, and tobacco smoking) and were ranked based on how frequently they appeared. A recommendation was defined as widely adopted if recommended in ≥24 (≥66.6%) of the guidelines. These included increase physical activity; reduce body weight by 7-10% to improve steatohepatitis and/or fibrosis; restrict caloric intake; undertake 150-300 or 75-150 minutes/week of moderate or vigorous-intensity physical activity, respectively; and decrease consumption of commercially produced fructose. The least mentioned topics, in ≤9 of the guidelines, evaluated environmental determinants of health, mental health, referring patients for psychological or cognitive behavioral therapy, using digital health interventions (DHIs), and assessing patients' social determinants of health.

CONCLUSIONS

Most guidelines recommend weight reduction through physical activity and improving nutrition, as these have proven positive effects on health outcomes when sustained. However, gaps regarding mental health and the social and environmental determinants of MASLD were found. To optimize behavioral modifications and treatment, we recommend carrying out studies that will provide further evidence on social support, environmental factors, and mental health, and further exploring DHIs.

Association of physical activity and fine motor performance in individuals with type 2 diabetes mellitus and/or non-alcoholic fatty liver disease

BACKGROUND

Fine motor performance may serve as an early warning sign for reduced cognitive function. Physical activity can help preserve cognitive function; however, the relationship between fine motor performance and physical activity is not well understood. Therefore, this study examined the relationship between fine motor performance and physical activity in individuals at risk for developing cognitive impairment (those with diabetes and/or non-alcoholic fatty liver disease (NAFLD)).

PATIENTS AND METHODS

Individuals aged 25-69 with and without diabetes and NAFLD were enrolled. For this cross-sectional study, all participants completed the Human Activity Profile and fine motor performance tasks (Grooved Pegboard Test and Trail Making Test).

RESULTS

There were 93 participants in the study (NAFLD only (n = 29); diabetes + NAFLD (n = 34), controls (n = 30)). Individuals with both diabetes and NAFLD were less physically active and performed slower on the fine motor performance task. A statistically significant correlation was found between physical activity and motor speed among those with NAFLD only (r = 0.436, p<.05), which remained statistically significant after controlling for body mass index (r = 0.385; p<.05).

CONCLUSIONS

This study suggests that those with diabetes + NAFLD have lower levels of physical activity and slower fine motor performance. The relationship between physical activity and fine motor performance was only statistically significant in the group of individuals with NAFLD only. Future research needs to explore the mechanisms that impact fine motor performance and physical activity in individuals at risk for mild cognitive impairment. Individuals with diabetes and/or NAFLD should be identified, advised and encouraged to engage in physical activity.Key MessagesThose with NAFLD and T2DM have lower levels of physical activity and slower fine motor performance compared to controls and those with NAFLD only.Future research needs to explore the mechanisms that impact fine motor performance and physical activity in those with T2DM with or without NAFLD.Individuals with impaired fine motor performance should be identified and encouraged to engage in physical activity.

Lifestyle interventions in nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is a dynamic chronic liver disease that develops in close association with metabolic irregularities. Between 2016 and 2019, the global prevalence among adults was reported as 38% and among children and adolescents it was about 10%. NAFLD can be progressive and is associated with increased mortality from cardiovascular disease, extrahepatic cancers and liver complications. Despite these numerous adverse outcomes, no pharmacological treatments currently exist to treat nonalcoholic steatohepatitis, the progressive form of NAFLD. Therefore, the main treatment is the pursuit of a healthy lifestyle for both children and adults, which includes a diet rich in fruits, nuts, seeds, whole grains, fish and chicken and avoiding overconsumption of ultra-processed food, red meat, sugar-sweetened beverages and foods cooked at high heat. Physical activity at a level where one can talk but not sing is also recommended, including leisure-time activities and structured exercise. Avoidance of smoking and alcohol is also recommended. Policy-makers, community and school leaders need to work together to make their environments healthy by developing walkable and safe spaces with food stores stocked with culturally appropriate and healthy food items at affordable prices as well as providing age-appropriate and safe play areas in both schools and neighbourhoods.

A model for personalized diagnostics for non-specific low back pain: the role of the myofascial unit

Low back pain (LBP) is the leading cause of disability worldwide. Most LBP is non-specific or idiopathic, which is defined as symptoms of unknown origin without a clear specific cause or pathology. Current guidelines for clinical evaluation are based on ruling out underlying serious medical conditions, but not on addressing underlying potential contributors to pain. Although efforts have been made to identify subgroups within this population based on response to treatment, a comprehensive framework to guide assessment is still lacking. In this paper, we propose a model for a personalized mechanism-based assessment based on the available evidence that seeks to identify the underlying pathologies that may initiate and perpetuate central sensitization associated with chronic non-specific low back pain (nsLBP). We propose that central sensitization can have downstream effects on the "myofascial unit", defined as an integrated anatomical and functional structure that includes muscle fibers, fascia (including endomysium, perimysium and epimysium) and its associated innervations (free nerve endings, muscle spindles), lymphatics, and blood vessels. The tissue-level abnormalities can be perpetuated through a vicious cycle of neurogenic inflammation, impaired fascial gliding, and interstitial inflammatory stasis that manifest as the clinical findings for nsLBP. We postulate that our proposed model offers biological plausibility for the complex spectrum of clinical findings, including tissue-level abnormalities, biomechanical dysfunction and postural asymmetry, ecological and psychosocial factors, associated with nsLBP. The model suggests a multi-domain evaluation that is personalized, feasible and helps rule out specific causes for back pain guiding clinically relevant management. It may also provide a roadmap for future research to elucidate mechanisms underlying this ubiquitous and complex problem.

Severe, Persistent, Disruptive Fatigue Post-SARS-CoV-2 Disproportionately Affects Young Women

Introduction

Post-acute SARS-CoV-2 (PASC) symptoms are often persistent, disruptive, and difficult to treat effectively. Fatigue is often among the most frequently reported symptoms and may indicate a more challenging road to recovery.

Purpose

To describe the natural history, symptomology, and risk profile of long-term post-acute SARS-CoV-2.

Patients and Methods

Participants treated for SARS-CoV-2 within a large, community health system in the US were enrolled prospectively in a longitudinal, observational PASC study examining participants at enrollment and 6 months. Medical history, symptom reporting, validated measures of cognition, and patient-reported outcomes (PROs), were performed for all participants and repeated during study follow-up visits.

Results

A total of 323 participants completed baseline evaluations. Sixty one participants indicated clinically significant fatigue (23.1% at baseline); a representative sample of 141 enrollees also completed a baseline Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) in-depth fatigue reporting questionnaire, 37 had severe fatigue. The severely fatigued (FACIT-F ≤29.7) were significantly younger, female, had more anxiety and depression, had a higher resting heart rate, reported more sick days, and were less physically active post-COVID. They were more likely to have a diagnosis of chronic kidney disease (13.5% vs 2.9%) but less likely to have a history of cancer (8.1% vs 23.1). Participants who were severely fatigued reported health, diet, weight, and sleep were worse than those not severely fatigued post-COVID (p = 0.02 to 0.0002). Fatigue was significantly correlated with impairment of all PROs administered after COVID-19 infection.

Conclusion

Fatigue is a common symptom post-COVID-19 infection and is associated with lower reported well-being and function. Those with severe fatigue tended to be younger and female and have a past medical history of anxiety, depression, kidney disease, and more sedentary lifestyles.

A Comparison of Approaches for Segmenting the Reaching and Targeting Motion Primitives in Functional Upper Extremity Reaching Tasks

There is growing interest in the kinematic analysis of human functional upper extremity movement (FUEM) for applications such as health monitoring and rehabilitation. Deconstructing functional movements into activities, actions, and primitives is a necessary procedure for many of these kinematic analyses. Advances in machine learning have led to progress in human activity and action recognition. However, their utility for analyzing the FUEM primitives of reaching and targeting during reach-to-grasp and reach-to-point tasks remains limited. Domain experts use a variety of methods for segmenting the reaching and targeting motion primitives, such as kinematic thresholds, with no consensus on what methods are best to use. Additionally, current studies are small enough that segmentation results can be manually inspected for correctness. As interest in FUEM kinematic analysis expands, such as in the clinic, the amount of data needing segmentation will likely exceed the capacity of existing segmentation workflows used in research laboratories, requiring new methods and workflows for making segmentation less cumbersome. This paper investigates five reaching and targeting motion primitive segmentation methods in two different domains (haptics simulation and real world) and how to evaluate these methods. This work finds that most of the segmentation methods evaluated perform reasonably well given current limitations in our ability to evaluate segmentation results. Furthermore, we propose a method to automatically identify potentially incorrect segmentation results for further review by the human evaluator. Clinical impact: This work supports efforts to automate aspects of processing upper extremity kinematic data used to evaluate reaching and grasping, which will be necessary for more widespread usage in clinical settings.

Evidence for an association of serum microanalytes and myofascial pain syndrome

BACKGROUND

Myofascial Pain Syndrome (MPS) is a common pain disorder. Diagnostic criteria include physical findings which are often unreliable or not universally accepted. A precise biosignature may improve diagnosis and treatment effectiveness. The purpose of this study was to assess whether microanalytic assays significantly correlate with characteristic clinical findings in people with MPS.

METHODS

This descriptive, prospective study included 38 participants (25 women) with greater than 3 months of myofascial pain in the upper trapezius. Assessments were performed at a university laboratory. The main outcome measures were the Beighton Index, shoulder range of motion, strength asymmetries and microanalytes: DHEA, Kynurenine, VEGF, interleukins (IL-1b, IL-2, IL-4, IL-5, IL-7, IL-8, IL-13), growth factors (IGF-1, IGF2, G-CSF, GM-CSF), MCP-1, MIP-1b, BDNF, Dopamine, Noradrenaline, NPY, and Acetylcholine. Mann-Whitney test and Spearman's multivariate correlation were applied for all variables. The Spearman's analysis results were used to generate a standard correlation matrix and heat map matrix.

RESULTS

Mean age of participants was 32 years (20-61). Eight (21%) had widespread pain (Widespread Pain Index ≥ 7). Thirteen (34%) had MPS for 1-3 years, 14 (37%) 3-10 years, and 11 (29%) for > 10 years. The following showed strong correlations: IL1b,2,4,5,7,8; GM-CSF and IL 2,4,5,7; between DHEA and BDNF and between BDNF and Kynurenine, NPY and acetylcholine. The heat map analysis demonstrated strong correlations between the Beighton Index and IL 5,7, GM-CSF, DHEA. Asymmetries of shoulder and cervical spine motion and strength associated with select microanalytes.

CONCLUSION

Cytokine levels significantly correlate with selected clinical assessments. This indirectly suggests possible biological relevance for understanding MPS. Correlations among some cytokine clusters; and DHEA, BDNF kynurenine, NPY, and acetylcholine may act together in MPS. These findings should be further investigated for confirmation that link these microanalytes with select clinical findings in people with MPS.

Regular Exercise Is Associated With Low Fatigue Levels and Good Functional Outcomes After COVID-19: A Prospective Observational Study

OBJECTIVE

The aim of the study is to identify the impact of postacute SARS-CoV-2 infection on patient outcomes.

DESIGN

This is a prospective, repeated measure, observational study of consented adults with positive SARS-CoV-2 quantitative polymerase chain reaction or antigen test more than 28 days after infection. Only data from the initial study visit are reported, including disease history, symptoms checklist, patient questionnaires, cognitive tests, social/medical histories, vitals, grip strength, and 2-min walk distance.

RESULTS

Two hundred eighteen patients were studied: 100 hospitalized (57.3 ± 15.4 yrs, 62% male, body mass index: 31.3 ± 8.0) and 118 nonhospitalized (46.2 ± 14.6 yrs, 31% male, body mass index: 29.7 ± 7.5). Post-COVID patients reported mean 1.76 symptoms; ≥15% reported fatigue, memory loss, and shortness of breath. Grip strength was 14% lower than norms ( P < 0.0001). Fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue), mood (Patient Health Questionnaire), and well-being (EuroQol 5 Dimension 5 Level) scores were lower than the population norms ( P < 0.05). Hospitalized versus nonhospitalized post-COVID patients performed worse on cognitive assessments (processing speed test-Wechsler Adult Intelligence Scale-Fourth Edition Symbol Search) and reported less regular exercise (≥30 mins ≥3× per week; P < 0.05). In addition, 30% had severe fatigue (by the Functional Assessment of Chronic Illness Therapy-Fatigue); those patients reported less exercise ( P < 0.05). In multivariate models, lack of exercise was independently associated with multiple post-COVID-19 impairments.

CONCLUSIONS

Low levels of exercise are an independent risk factor for post-COVID sequelae. Patients who report less exercise have low grip strength, higher levels of fatigue, memory loss, shortness of breath, depression, and poorer quality of life.

Clinics in Liver Disease: Update on Nonalcoholic Steatohepatitis: Sarcopenia and Nonalcoholic Fatty Liver Disease

Dual diagnoses of sarcopenia and nonalcoholic fatty liver disease (NAFLD) increase the risk of all cause mortality and severe liver disease, regardless of nationality. General agreement about diagnostic criteria for sarcopenia includes loss of skeletal muscle mass, weakness, and reduced physical performance. Histopathology demonstrates loss of type 2 muscle fibers, more than type 1 fibers and myosteatosis, a risk factor for severe liver disease. Low skeletal mass and NAFLD are inversely related; the mechanism is through decreased insulin signaling and insulin resistance, critical for metabolic homeostasis. Weight loss, exercise, and increased protein intake have been effective in reducing NAFLD and sarcopenia.

Post-Acute SARS-CoV-2 Symptoms are Fewer, Less Intense Over Time in People Treated with Mono-Clonal Antibodies for Acute Infection

Introduction

Many with post-acute SARS-CoV-2 (PASC) have persistent symptoms impacting physical and cognitive function, decreased health and health-related life quality. Monoclonal antibody (mAb) treatment was available to acutely infected patients which might improve these outcomes.

Purpose

To compare patient perception of PASC symptoms for those receiving bamlanivimab or casirivimab and imdevimab (mAbs) to those not receiving this treatment (non-mAbs). To compare changes between these groups in symptoms, function and quality of life over a 6-month follow-up.

Patients and Methods

Consented adults >28 days post-infection with positive SARS-CoV-2 qPCR or antigen test and SARS-CoV-2 infection between March of 2020 and July of 2022 were enrolled. This prospective, repeated measure observational study reports baseline through 6-month follow-up. Extensive sociodemographic data, detailed medical history, COVID-19 symptom history, and standardized measures of well-being, depression, anxiety, stigma, cognition, symptom assessment, distress, and health status were collected.

Results

323 participants [101 mAb, 221 non-mAb, 52.7±15.5 years, 47.7% male, body mass index (BMI) 31.4±8.4] were analyzed. Fewer symptoms at baseline were reported in mAb versus non-mAb participants (1.06±1.31 vs 1.78±2.15, respectively p=0.0177) 6 months: (0.911±1.276 mAb vs.1.75±2.22 non-mAb, p=0.0427). Both groups showed significant within-group decreases in symptom number (52 to 21 mAb, 126 to 63 non-mAb) and symptom burden (p=0.0088 mAb, p<0.00001 non-mAb). mAb patients had significantly shorter infection-to-baseline interval (days) (120.4±55.3 mAb vs 194.0±89.3 non-mAb, p<0.00001); less frequent history of myocardial infarction (0.0 vs 3.9%, p=0.0464); headache (2.0% vs.11.8%, p=0.0046), rash (3.1% vs 9.9%, p=0.0377), and miscellaneous muscle complaints (2.0% vs 12.3%, p=0.0035), plus significantly better 6-month mood. (2.2% vs 13.2%, p=0.0390).

Conclusion

mAb treated participants had reduced symptom burden and consistently reported fewer symptoms than non-mAb at all time points despite less time since acute illness. Both groups reported a statistically significant decrease in symptoms by 6-month visit with no statistically significant differences between them at follow-up.

Computer-assisted approaches for measuring, segmenting, and analyzing functional upper extremity movement: a narrative review of the current state, limitations, and future directions

The analysis of functional upper extremity (UE) movement kinematics has implications across domains such as rehabilitation and evaluating job-related skills. Using movement kinematics to quantify movement quality and skill is a promising area of research but is currently not being used widely due to issues associated with cost and the need for further methodological validation. Recent developments by computationally-oriented research communities have resulted in potentially useful methods for evaluating UE function that may make kinematic analyses easier to perform, generally more accessible, and provide more objective information about movement quality, the importance of which has been highlighted during the COVID-19 pandemic. This narrative review provides an interdisciplinary perspective on the current state of computer-assisted methods for analyzing UE kinematics with a specific focus on how to make kinematic analyses more accessible to domain experts. We find that a variety of methods exist to more easily measure and segment functional UE movement, with a subset of those methods being validated for specific applications. Future directions include developing more robust methods for measurement and segmentation, validating these methods in conjunction with proposed kinematic outcome measures, and studying how to integrate kinematic analyses into domain expert workflows in a way that improves outcomes.

Systematic Review of Functional Outcomes in Cancer Rehabilitation

OBJECTIVE

To systematically review the evidence regarding rehabilitation interventions targeting optimal physical or cognitive function in adults with a history of cancer and describe the breadth of evidence as well as strengths and limitations across a range of functional domains.

DATA SOURCES

PubMed, Cumulative Index to Nursing and Allied Health Plus, Scopus, Web of Science, and Embase. The time scope was January 2008 to April 2019.

STUDY SELECTION

Prospective, controlled trials including single- and multiarm cohorts investigating rehabilitative interventions for cancer survivors at any point in the continuum of care were included, if studies included a primary functional outcome measure. Secondary data analyses and pilot/feasibility studies were excluded. Full-text review identified 362 studies for inclusion.

DATA EXTRACTION

Extraction was performed by coauthor teams and quality and bias assessed using the American Academy of Neurology (AAN) Classification of Evidence Scheme (class I-IV).

DATA SYNTHESIS

Studies for which the functional primary endpoint achieved significance were categorized into 9 functional areas foundational to cancer rehabilitation: (1) quality of life (109 studies), (2) activities of daily living (61 studies), (3) fatigue (59 studies), (4) functional mobility (55 studies), (5) exercise behavior (37 studies), (6) cognition (20 studies), (7) communication (10 studies), (8) sexual function (6 studies), and (9) return to work (5 studies). Most studies were categorized as class III in quality/bias. Averaging results found within each of the functional domains, 71% of studies reported statistically significant results after cancer rehabilitation intervention(s) for at least 1 functional outcome.

CONCLUSIONS

These findings provide evidence supporting the efficacy of rehabilitative interventions for individuals with a cancer history. The findings should be balanced with the understanding that many studies had moderate risk of bias and/or limitations in study quality by AAN criteria. These results may provide a foundation for future work to establish clinical practice guidelines for rehabilitative interventions across cancer disease types.

Incorporating the Concept of Relevance in Clinical Rehabilitation Research and Its Reviews May Improve Uptake by Stakeholders

ABSTRACT

The "relevance" of research to stakeholders is an important factor in influencing the uptake of new knowledge into practice; however, this concept is neither well defined nor routinely incorporated in clinical rehabilitation research. Developing a uniform definition, measurement standards, stakeholder engagement strategies, and guiding frameworks that bolster relevance may help incorporate the concept as a key element in research planning and design. This article presents a conceptual argument for why relevance matters, proposes a working definition, and suggests strategies for operationalizing the construct in the context of clinical rehabilitation research. We place special emphasis on the importance of promoting relevance to patients, caregivers, and clinicians and provide preliminary frameworks and innovative study designs that can assist clinical rehabilitation researchers in doing so. We argue that researchers who include a direct statement regarding why and to whom a study is relevant and who incorporate considerations of relevance throughout all phases of study design produce more useful research for patients, caregivers, and clinicians, increasing its chance of uptake into practice. Consistent consideration of relevance, particularly to nonacademic audiences, during the conceptualization, study design, presentation, and dissemination of clinical rehabilitation research may promote the uptake of findings by patients, caregivers, and providers.

Responsiveness and interpretation of the PROMIS Cancer Function Brief 3D Profile

BACKGROUND

Measuring function with valid and responsive tools in patients with cancer is essential for driving clinical decision-making and for the end points of clinical trials. Current patient-reported outcome measurements of function fall short for many reasons. This study evaluates the responsiveness of the Patient-Reported Outcomes Measurement Information System (PROMIS) Cancer Function Brief 3D Profile, a novel measure of function across multiple domains.

METHODS

Two hundred nine participants across five geographically distinct tertiary care centers completed the assessment and pain rating at two outpatient cancer rehabilitation clinic visits. Patients and providers completed a global rating of change measure at the second visit to indicate whether the patient was improving or worsening in function. Multiple response indices and linear models measured whether the measure was responsive to self-reported and clinician-rated changes over time. Correlations between changes in function and changes in anchors (pain rating and performance status) were also calculated.

RESULTS

Function as measured by the PROMIS Cancer Function Brief 3D Profile changed appropriately as both patients and clinicians rated change. Small to moderate effect sizes supported the tool's responsiveness. Function was moderately correlated with pain and more strongly correlated with performance status, and changes in function corresponded with changes in anchor variables. No floor/ceiling effect was found.

CONCLUSIONS

The PROMIS Cancer Function Brief 3D Profile is sensitive to changes over time in patients with cancer. The measure may be useful in clinical practice and as an end point in clinical trials.

LAY SUMMARY

We gave patients a questionnaire by which they told their physicians how well they were functioning, including how fatigued they were. This study tested that questionnaire to see whether the scores would change if patients got better or worse.

Interrelationship between physical activity and depression in nonalcoholic fatty liver disease

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is associated with a sedentary lifestyle and depressive symptoms. It is also well established that physical inactivity and depressive symptoms are related. However, an investigation of the interaction between all of these factors in NAFLD has not been previously conducted.

AIM

To investigate the interrelationship between physical inactivity and depressive symptoms in individuals with NAFLD.

METHODS

Data from the Rancho Bernardo Study of Healthy Aging were utilized. 589 individuals were included in the analyses (43.1% male; 95.8% non-Hispanic white; aged 60.0 ± 7.0 years). NAFLD was defined by using the hepatic steatosis index, depression using the Beck Depression Inventory, and physical activity by self-report of number of times per week of strenuous activity. Multivariable generalized linear regression models with Gamma distribution were performed to investigate the proposed relationship.

RESULTS

About 40% of the sample had evidence of NAFLD, 9.3% had evidence of depression, and 29% were physically inactive. Individuals with NAFLD and depression were more likely to be physically inactive (60.7%) compared to individuals with neither NAFLD nor depression (22.9%), individuals with depression without NAFLD (37.0%), and individuals with NAFLD without depression (33.3%). After accounting for various comorbidities (i.e., age, sex, diabetes, hypertension, obesity), individuals with NAFLD and higher levels of physical activity were at a decreased odds of having depressive symptoms [16.1% reduction (95% confidence interval: -25.6 to -5.4%), P = 0.004], which was not observed in those without NAFLD.

CONCLUSION

Individuals with NAFLD have high levels of physical inactivity, particularly those with depressive symptoms. Because this group is at high risk for poor outcomes, practitioners should screen for the coexistence of depressive symptoms and NAFLD. This group should receive appropriate interventions aimed at increasing both participation and levels of intensity of physical activity.

Outcomes of hospitalized patients with COVID-19 during the course of the pandemic in a fully integrated health system

BACKGROUND

Given the rapid spread of COVID-19 and its associated morbidity and mortality, healthcare providers throughout the world have been forced to constantly update and change their care delivery models.

OBJECTIVE

To assess the outcomes of COVID-19 hospitalized patients during the course of the pandemic in a well-integrated health system.

METHODS

The study used data from the electronic health medical records to assess trends in clinical profile and outcomes of hospitalized adult COVID-19 patients hospitalized in our 5-hospital health system from March 2020-May 2021 (n = 6865). Integration of the health system began in February 2020 and was fully actualized by March 30, 2020.

RESULTS

Mortality decreased from 15% during first peak (March-May 2020; the rate includes 19% in March-April and 10% in May 2020) to 6% in summer-fall 2020, increased to 13% during the second peak (November 2020-January 2021), and dropped to 7% during the decline period (February-May 2021) (p<0.01). Resource utilization followed a similar pattern including a decrease in ICU use from 35% (first peak) to 16% (decline period), mechanical ventilation from 16% (first peak, including 45% in March 2020) to 9-11% in subsequent periods (p<0.01). Independent predictors of inpatient mortality across multiple study periods included older age, male sex, higher multi-morbidity scores, morbid obesity, and indicators of severe illness on admission such as oxygen saturation ≤90% and high qSOFA score (all p<0.05). However, admission during the first peak remained independently associated with increased mortality even after adjustment for patient-related factors: odds ratio = 1.8 (1.4-2.4) (p<0.0001).

CONCLUSIONS

The creation of a fully integrated health system allowed us to dynamically respond to the everchanging COVID-19 landscape. In this context, despite the increasing patient acuity, our mortality and resource utilization rates have improved during the pandemic.

Narrative review of clinical practice guidelines for treating people with moderate or severe traumatic brain injury

BACKGROUND:

Practice guidelines (CPGs) provide informed treatment recommendations from systematic reviews and assessment of the benefits and harms that are intended to optimize patient care. Review of CPGs addressing rehabilitation for people with moderate/severe traumatic brain injury (TBI), has not been fully investigated.

OBJECTIVE:

Identify published, vetted, clinical practice guidelines that address rehabilitation for people with moderate/severe TBI.

METHODS:

Six data bases were accessed using key word search terms: “Traumatic Brain Injury” and “Clinical Practice Guidelines” and “Rehabilitation”. Further inclusions included “adult” and “moderate or severe”. Exclusions included: “mild” and “concussive injury”. Three reviewers read abstracts and manuscripts for final inclusion. The AGREE II template was applied for additional appraisal.

RESULTS:

There were 767 articles retrieved using the search terms, 520 were eliminated because of content irrelevance; and 157 did not specify rehabilitation treatment or did not follow a process for CPGs. A total of 17 CPGs met all criteria and only 4 of these met all AGREE II criteria.

CONCLUSION:

There are few CPGs addressing rehabilitation for people with moderate/severe TBI. More interventional trials are needed to determine treatment effectiveness. Timely and methodologically sound vetting of studies are needed to ensure CPG reliability and facilitate access to quality, effective treatment for people with moderate/severe TBI.

Translating 2019 ACSM Cancer Exercise Recommendations for a Physiatric Practice: Derived Recommendations from an International Expert Panel

In 2018, the American College of Sports Medicine (ACSM) reconvened an international, multi-disciplinary group of professionals to review pertinent published literature on exercise for people with cancer. The 2018 roundtable resulted in the publication of three articles in 2019. The three articles serve as an important update to the original ACSM Roundtable on Cancer, which convened in 2010. Although the focus of the three 2019 articles is on exercise, which is only one part of comprehensive cancer rehabilitation, the evidence presented in the 2019 ACSM articles has direct implications for physiatrists and other rehabilitation professionals who care for people with cancer. As such, the narrative review presented here has two primary objectives. First, we summarize the evidence within the three ACSM articles and interpret it within a familiar rehabilitation framework, namely the Dietz model of Cancer Rehabilitation, in order to facilitate implementation broadly within rehabilitation practice. Second, via expert consensus, we have tabulated relevant exercise recommendations for specific cancer populations at different points in the cancer care continuum and translated them into text, tables, and figures for ease of reference. Notably, the authors of this article are members of the Cancer Rehabilitation Physician Consortium (CRPC), a group of physicians who subspecialize in cancer rehabilitation medicine (CRM).

Neutralizing Monoclonal Antibody Treatment Reduces Hospitalization for Mild and Moderate COVID-19: A Real-World Experience

Background

Neutralizing monoclonal antibody (NmAb) treatments have received emergency use authorization to treat patients with mild or moderate COVID-19 infection. To date, no real- world data about the efficacy of NmAb has been reported from clinical practice. We assessed the impact of NmAb treatment given in the outpatient clinical practice setting on hospital utilization.

Methods

Electronic medical records were used to identify adult COVID-19 patients who received NmAbs [bamlanivimab (BAM) or casirivimab and imdevimab (REGN-COV2)] and historic COVID-19 controls. Post-index hospitalization rates were compared.

Results

707 confirmed COVID-19 patients received NmAb and 1709 historic COVID-19 controls were included; 553 (78%) received BAM, 154 (22%) received REGN-COV2. Patients receiving NmAb infusion had significantly lower hospitalization rate (5.8% vs. 11.4%, p<0.0001); a shorter length of stay if hospitalized (mean 5.2 days vs. 7.4 days, p=0.02), and fewer ED visits within 30 days post-index (8.1% vs 12.3%, p=0.003) than controls. Hospitalization-free survival was significantly longer in NmAb patients compared to controls (p<0.0001). There was a trend towards a lower hospitalization rate among patients who received NmAb within 2-4 days after symptom onset. In multivariate analysis, having received a NmAb transfusion was independently associated with a lower risk of hospitalization after adjustment for age, sex, race, BMI and referral source: adjusted hazard ratio (95% CI) = 0.54 (0.38 – 0.79), p=0.0012. Overall mortality was not different between the two groups.

Conclusions and Relevance

NmAb treatment reduced hospital utilization especially when received within a few days of symptom onset. Further study is needed to validate these findings.

Narrative Review of Clinical Practice Guidelines for Rehabilitation of People With Spinal Cord Injury: 2010-2020

ABSTRACT

Clinical practice guidelines provide reliable, vetted, and critical information to bring research to practice. Some medical specialties (e.g., physical medicine and rehabilitation) provide multidomain treatment for various conditions. This presents challenges because physical medicine and rehabilitation is a small specialty, a diverse patient base in terms sociodemographics and diagnosis, treatments are difficult to standardize, and rehabilitation research is underfunded. We wished to identify quality and applicability of clinical practice guidelines and searched "Spinal Cord Injury AND Clinical Practice Guidelines AND Rehabilitation" and vetting process.Three hundred fifty-nine articles were identified of which 58 met all criteria for full-text review of which 13 were included in the final selection. Additional publications were accessed from a nondatabase search. Five articles addressed postacute care, community treatment. Nine articles had no recorded vetting process but addressed rehabilitation as an outcome and were included separately. Many of the clinical practice guidelines were developed without evidence from randomized controlled trials, one had input from stakeholders, and some are out of date and do not address important aspects of changes in demographics of the affected population and the use of newer technologies such as sensors and robotics and devices. Identification of these gaps may help stimulate treatment that is clinically relevant, accessible, and current.

Scoping review of peer reviewed publications addressing rehabilitation for people sustaining traumatic spinal cord injury

Study Design: Scoping review Objective: To study the design, clinical setting and outcome measures used in spinal cord injury rehabilitation publications. Methods: A literature search on PubMed and Medline was conducted focusing on articles published between 1990-2016 and using "traumatic SCI", "functional outcomes", "rehabilitation", "work" and "return to work" as outcomes. Studies were categorized based on design (intervention, including RCTs vs. non-intervention studies), settings (inpatient vs. outpatient vs. transition), and outcome measures used (impairment vs. function vs. participation/integration vs. quality of life vs. symptoms). Work-related studies were categorized independently. Results: Five hundred forty-four articles met the inclusion criteria. Of these, 234 were interventional studies, including 23 RCTs. Studies were evenly divided among inpatient, outpatient and transition settings. Of the 234 interventional studies, 143 used functional evaluations. Sixty-one different functional instruments were used, with a predominant use of the Functional Independence Measure (61 times) and an additional use of SCI-specific measures, i.e. Spinal Cord Independence Measure and Craig Handicap Assessment and Reporting Technique (13 times each). Fifty-one studies measured mobility, while only three measured hand functions. The work-related sub-analysis revealed 32 intervention studies (no RCTs), of which 15 used functional evaluations and only three focused on tetraplegia. Conclusion: Our study revealed a paucity of intervention trials and RCTs, indicating a dearth of knowledge that would be needed to establish evidence-based practice guidelines. This is particularly true for tetraplegia. While standard measures of function were frequently used, providing valuable data, there is no consensus about what exact outcome measure to use. Using newer measurement techniques, for instance based on the application of item response theory, should be considered to enhance uniformity.

American College of Sports Medicine Roundtable Report on Physical Activity, Sedentary Behavior, and Cancer Prevention and Control

INTRODUCTION

The American College of Sports Medicine convened an International Multidisciplinary Roundtable on Exercise and Cancer in March 2018 to evaluate and translate the evidence linking physical activity and cancer prevention, treatment, and control. This article discusses findings from the Roundtable in relation to the biologic and epidemiologic evidence for the role of physical activity in cancer prevention and survival.

RESULTS

The evidence supports that there are a number of biologically plausible mechanisms, whereby physical activity can influence cancer risk, and that physical activity is beneficial for the prevention of several types of cancer including breast, colon, endometrial, kidney, bladder, esophageal, and stomach. Minimizing time spent in sedentary behavior may also lower risk of endometrial, colon and lung cancers. Conversely, physical activity is associated with higher risk of melanoma, a serious form of skin cancer. Further, physical activity before and after a cancer diagnosis is also likely to be relevant for improved survival for those diagnosed with breast and colon cancer; with data suggesting that postdiagnosis physical activity provides greater mortality benefits than prediagnosis physical activity.

CONCLUSIONS

Collectively, there is consistent, compelling evidence that physical activity plays a role in preventing many types of cancer and for improving longevity among cancer survivors, although the evidence related to higher risk of melanoma demonstrates the importance of sun safe practices while being physically active. Together, these findings underscore the importance of physical activity in cancer prevention and control. Fitness and public health professionals and health care providers worldwide are encouraged to spread the message to the general population and cancer survivors to be physically active as their age, abilities, and cancer status will allow.

Exercise is medicine in oncology: Engaging clinicians to help patients move through cancer

Multiple organizations around the world have issued evidence-based exercise guidance for patients with cancer and cancer survivors. Recently, the American College of Sports Medicine has updated its exercise guidance for cancer prevention as well as for the prevention and treatment of a variety of cancer health-related outcomes (eg, fatigue, anxiety, depression, function, and quality of life). Despite these guidelines, the majority of people living with and beyond cancer are not regularly physically active. Among the reasons for this is a lack of clarity on the part of those who work in oncology clinical settings of their role in assessing, advising, and referring patients to exercise. The authors propose using the American College of Sports Medicine's Exercise Is Medicine initiative to address this practice gap. The simple proposal is for clinicians to assess, advise, and refer patients to either home-based or community-based exercise or for further evaluation and intervention in outpatient rehabilitation. To do this will require care coordination with appropriate professionals as well as change in the behaviors of clinicians, patients, and those who deliver the rehabilitation and exercise programming. Behavior change is one of many challenges to enacting the proposed practice changes. Other implementation challenges include capacity for triage and referral, the need for a program registry, costs and compensation, and workforce development. In conclusion, there is a call to action for key stakeholders to create the infrastructure and cultural adaptations needed so that all people living with and beyond cancer can be as active as is possible for them.