Multiple imputation of missing repeated outcome measurements did not add to linear mixed-effects models

Development and validation of delirium prediction model for critically ill adults parameterized to ICU admission acuity

Background

Risk prediction models allow clinicians to forecast which individuals are at a higher risk for developing a particular outcome. We developed and internally validated a delirium prediction model for incident delirium parameterized to patient ICU admission acuity.

Methods

This retrospective, observational, fourteen medical-surgical ICU cohort study evaluated consecutive delirium-free adults surviving hospital stay with ICU length of stay (LOS) greater than or equal to 24 hours with both an admission APACHE II score and an admission type (e.g., elective post-surgery, emergency post-surgery, non-surgical) in whom delirium was assessed using the Intensive Care Delirium Screening Checklist (ICDSC). Risk factors included in the model were readily available in electric medical records. Least absolute shrinkage and selection operator logistic (LASSO) regression was used for model development. Discrimination was determined using area under the receiver operating characteristic curve (AUC). Internal validation was performed by cross-validation. Predictive performance was determined using measures of accuracy and clinical utility was assessed by decision-curve analysis.

Results

A total of 8,878 patients were included. Delirium incidence was 49.9% (n = 4,431). The delirium prediction model was parameterized to seven patient cohorts, admission type (3 cohorts) or mean quartile APACHE II score (4 cohorts). All parameterized cohort models were well calibrated. The AUC ranged from 0.67 to 0.78 (95% confidence intervals [CI] ranged from 0.63 to 0.79). Model accuracy varied across admission types; sensitivity ranged from 53.2% to 63.9% while specificity ranged from 69.0% to 74.6%. Across mean quartile APACHE II scores, sensitivity ranged from 58.2% to 59.7% while specificity ranged from 70.1% to 73.6%. The clinical utility of the parameterized cohort prediction model to predict and prevent incident delirium was greater than preventing incident delirium by treating all or none of the patients.

Conclusions

Our results support external validation of a prediction model parameterized to patient ICU admission acuity to predict a patients’ risk for ICU delirium. Classification of patients’ risk for ICU delirium by admission acuity may allow for efficient initiation of prevention measures based on individual risk profiles.

Impact of symptom focusing and somatosensory amplification on persistent physical symptoms: A three-year follow-up study

OBJECTIVE

The somatosensory amplification theory considers symptom focusing and somatosensory amplification as important perpetuating factors of persistent physical symptoms. We investigated whether symptom focusing and somatosensory amplification were associated with symptom severity and mental and physical functioning over a three-year period in patients with persistent physical symptoms (PPS).

METHODS

Baseline, 6-, 12-, 24- and 36-months follow-up data from the PROSPECTS study, a prospective cohort consisting of 325 patients with PPS, were used. We applied longitudinal mixed model analyses to investigate if symptom focusing (CBRQ Symptom Focusing Subscale) and somatosensory amplification (Somatosensory Amplification Scale) at baseline were associated with symptom severity (PHQ-15), mental and physical functioning (RAND-36 MCS and PCS) over three years, using all measurements.

RESULTS

Symptom focusing was associated with increased symptom severity and lower mental and physical functioning over time. Somatosensory amplification at baseline was associated with increased symptom severity and lower mental and physical functioning over time. Effect sizes were small. Associations with baseline symptom focusing decreased over time, associations with baseline somatosensory amplification were more stable. There was no interaction effect of both constructs, but they partly overlapped.

CONCLUSION

This is the first study to show that over an extended period, symptom focusing and somatosensory amplification are associated with symptom severity and lower mental and physical functioning in patients with PPS. These results support the impact of both symptom focusing and somatosensory amplification on the perpetuation of symptoms and lowered mental and physical functioning in individuals with PPS.

Health and wellness coaching positively impacts individuals with chronic pain and pain-related interference

Objectives

Health and wellness coaching (HWC) interventions have been reported to improve health outcomes for individuals with chronic diseases such as diabetes, cardiovascular disease, or cancer. However, HWC also holds potential as an effective intervention within a biopsychosocial chronic pain management framework. The aim of the present study was to evaluate the effects of HWC on individuals with chronic pain.

Methods

Participants were referred by their primary care provider or insurance company to a comprehensive telephonic 12-month pain management HWC program. Relationships between pain outcomes and physical and psychological factors were retrospectively analyzed. Mixed linear-effects modeling explored whether physical and psychological variables were associated with pain outcomes over time.

Results

Four hundred nineteen participants (female, 58.9%; mean age, 54.8) enrolled in the program and 181 completed the intervention. After 12 months in the program, statistically and clinically significant reductions were observed for pain intensity (Hedges’ g = 1.00) and pain-related interference (Hedges’ g = 1.13). Linear mixed-effects modeling indicated that improvements in physical functioning and psychological factors were associated with improvements in pain intensity.

Discussion

Our results provide a novel analysis on the effects of HWC on chronic pain and pain-related interference. HWC appears to be a promising intervention to improve pain-related outcomes in a population with chronic pain. Further investigation of HWC as an intervention for chronic pain is warranted.

Impact of biologic DMARDs on quality of life: 12-month results of a rheumatic diseases cohort using the Brazilian EQ-5D tariff

OBJECTIVES

To evaluate the association between biological Disease-Modifying Anti-Rheumatic Drugs (bDMARDs) use and quality of life (QoL) in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), and ankylosing spondylitis (AS).

PATIENTS AND METHODS

We evaluated adult patients prescribed biological DMARDs whose quality of life was evaluated at six and 12 months. The EuroQol 5 dimensions (EQ-5D) was used with the Brazilian tariff.

RESULTS

Patients receiving bDMARDs had significant improvements in quality of life after 6 and 12 months (p < 0.001), regardless of the rheumatic condition and the therapeutic regimen (bDMARDs vs bDMARDs plus synthetic DMARDs) (ANCOVA; p > 0.05). At the end of one year, 62.6% of the participants presented significant clinical improvement in QoL. According to a sensitivity analysis, QoL results in the complete case analysis and in the multiple imputation model yielded similar conclusions. Patients with two or more comorbidities and worse QoL and disability status on baseline presented worse QoL at 12 months when compared to those with better disability status on baseline. Baseline clinical disease measured by activity indexes (BASDAI and CDAI) did not influence QoL after 12 months of bDMARD treatment. Pain and malaise were the EQ-5D domain that most influenced quality of life.

CONCLUSION

Patients with rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis displayed significantly better QoL levels following treatment with DMARDs.

Improving body functions through participation in community activities among young people with physical disabilities

AIM

To examine the impact of engagement in a self-chosen community-based activity on three relevant body functions (motor, cognitive, and affective) as well as on the performance of the selected activity.

METHOD

An individual-based interrupted time series design with multiple baselines was used. Seven young people (four males, three females) aged 15 to 25 years (median 18y; interquartile range 17-20y) with physical disabilities participated in an 8-week community activity of choice (e.g. swimming, playing piano). Change in three relevant body functions, underpinning the specific chosen activity, including motor (e.g. Functional Reach Test, Trunk Impairment Scale, dynamometers), cognitive and affective (Behavior Assessment System for Children), as well as activity performance (Canadian Occupational Performance Measure) were measured repeatedly, providing individual outcome trajectories. Linear and mixed-effects models were used.

RESULTS

Significant improvements in at least one aspect of motor function (6 out of 6), cognition (3 out of 3), affect (5 out of 7), and performance (7 out of 7) were observed. Specifically, the intervention had a moderate to large effect on hyperactivity (1.45, 95% confidence interval [CI] 1.0-1.9) with a smaller effect on anxiety (0.21, 95% CI 0.10-0.32) and inadequacy (0.21, 95% CI 0.02-0.39). Concurrently, a notable effect size for activity performance (4.61, 95% CI 0.76-8.46) was observed. Average change across motor outcomes was substantial (3.7 SDs from baseline), yet non-significant.

INTERPERTATION

Findings provide initial evidence of the benefits resulting from participation-based interventions, emphasizing the merit of meaningful 'real-life' young people-engaging therapy.

WHAT THIS PAPER ADDS

Participation-based interventions can impact body-function level outcomes. Significant improvements in the performance of chosen activities were observed. Significant improvements were also seen in cognitive and affective body functions. Improvements in motor-related outcomes were substantial but not statistically significant.

Effect of vitamin D3 supplementation on vascular and metabolic health of vitamin D-deficient overweight and obese children: a randomized clinical trial

BACKGROUND

Obese children are vulnerable to vitamin D deficiency and impaired cardiovascular health; vitamin D replenishment might improve their cardiovascular health.

OBJECTIVES

The aims were to determine, in vitamin D-deficient overweight and obese children, whether supplementation with vitamin D3 1000 or 2000 IU/d is more effective than 600 IU/d in improving arterial endothelial function, arterial stiffness, central and systemic blood pressure (BP), insulin sensitivity (1/fasting insulin concentration), fasting glucose concentration, and lipid profile and to explore whether downregulation of adipocytokines and markers of systemic inflammation underlies vitamin D effects.

METHODS

We conducted a randomized, double-masked, controlled clinical trial in 225 10- to 18-y-old eligible children. Change in endothelial function at 6 mo was the primary outcome.

RESULTS

Dose-response increases in serum 25-hydroxyvitamin D concentrations were significant and tolerated without developing hypercalcemia. Changes at 3 and 6 mo in endothelial function, arterial stiffness, systemic-systolic BP, lipids, and inflammatory markers did not differ between children receiving 1000 or 2000 IU vitamin D and children receiving 600 IU. Some secondary outcomes differed between groups. Compared with the 600-IU group, central-systolic, central-diastolic, and systemic-diastolic BP was lower at 6 mo in the 1000-IU group [-2.66 (95% CI: -5.27, -0.046), -3.57 (-5.97, -1.17), and -3.28 (-5.55, -1.00) mm Hg, respectively]; insulin sensitivity increased at 3 and 6 mo and fasting glucose concentration declined at 6 mo (-2.67; 95% CI: -4.88, -0.46 mg/dL) in the 2000-IU group.

CONCLUSIONS

Correction of vitamin D deficiency in overweight and obese children by vitamin D3 supplementation with 1000 or 2000 IU/d versus 600 IU/d did not affect measures of arterial endothelial function or stiffness, systemic inflammation, or lipid profile, but resulted in reductions in BP and fasting glucose concentration and in improvements in insulin sensitivity. Optimization of children's vitamin D status may improve their cardiovascular health. This trial was registered at clinicaltrials.gov as NCT01797302.

Chronic Pain Self-Management Support With Pain Science Education and Exercise (COMMENCE) for People With Chronic Pain and Multiple Comorbidities: A Randomized Controlled Trial

OBJECTIVE

To investigate the effectiveness of chronic pain self-management support with pain science education and exercise (COMMENCE) on improving function, pain interference, work status, pain intensity, fatigue, psychological factors associated with pain, health care visits, satisfaction, and perceived change compared with usual care.

DESIGN

Parallel group randomized controlled trial with 1- and 12-week follow-ups.

SETTING

Community health center.

PARTICIPANTS

Adults (N=102) with chronic noncancer pain referred for self-management support. Eighty of 102 participants completed 12-week follow-up assessments. No participants withdrew with adverse events.

INTERVENTIONS

Participants were randomized to COMMENCE or usual care.

MAIN OUTCOME MEASURES

Primary: Function measured using the Short Musculoskeletal Function Assessment-Dysfunction Index. Secondary: Short Musculoskeletal Function Assessment-Bother Index, Patient Reported Outcomes Measurement Information System pain interference, work status, numeric pain, and fatigue rating scales, Tampa Scale of Kinesiophobia, Pain Catastrophizing Scale, Pain Self-Efficacy Scale, Neurophysiology of Pain Questionnaire, number of health care visits, satisfaction, and global rating of change.

RESULTS

COMMENCE resulted in greater improvements in function (mean difference [MD] at 12-wk follow-up=-8.0; 95% CI, -14.7 to -1.3), bother with functional difficulties (MD, -12.0; 95% CI, -20.8 to -3.2), pain intensity (MD, -1.0; 95% CI, -2.1 to -0.1), catastrophizing (MD , -8.2; 95% CI, -14.5 to -2.0), self-efficacy (MD, 7.0; 95% CI, 0.8-13.2), knowledge (MD, 2.8; 95% CI, 1.6-3.9), satisfaction (MD, 1.2; 95% CI, 0.7-1.8), and perceived change (MD, 1.4; 95% CI, 0.8-2.1). There were no significant between-group differences in pain interference, work, fatigue, depressive symptoms, or health care visits.

CONCLUSION

COMMENCE is more effective than usual care at improving function, pain, catastrophic thinking, self-efficacy, pain knowledge, satisfaction, and perceived change but not pain interference, work status, fatigue, depressive symptoms, or health care visits.

A Longitudinal Assessment of Two Suicide Prevention Training Programs for the Construction Industry

As part of a suite of early intervention training and support services, Mates in Construction (MATES) provide two general awareness programs to promote mental health and suicide awareness and encourage help-offering and help-seeking in construction workers. General awareness training (GAT) is a one-hour session delivered to all construction workers on large to medium worksites, while MATES awareness training (MAT) maintains similar content but is of shorter duration and delivered informally to small workplaces. This study aimed to compare the effectiveness of the two programs using a before, after and follow-up design. Construction workers undertaking MAT or GAT training completed a short survey before and after their training and again at follow-up. Linear mixed-effect modelling indicated that GAT and MAT training provided similar results in improving suicide awareness and help-seeking intentions. Some variables showed a significant increase from pre-intervention to the three-month follow-up, indicating the long-term impact of some aspects of the training. The findings demonstrating the effectiveness of MAT training have important implications for MATES, as the training can be delivered to much smaller workplaces, making the program more widely available to the construction industry.

The use of induction therapy in liver transplantation is highly variable and is associated with posttransplant outcomes

The use of induction immunosuppression in liver transplantation (LT) remains controversial. This was a retrospective cohort study of adult, first-time liver-alone recipients (N = 69 349) at 114 US centers between 2005 and 2018 using data from the United Network for Organ Sharing. The comparative effectiveness of nondepleting and depleting induction (NDI and DI) was assessed. Overall, 27% of recipients received induction with 65.7% of the variance in the receipt of induction being attributed to transplant center alone. NDI and DI were associated with a lower risk of death/graft failure compared to no induction (adjusted hazard ratio 0.90 [95% confidence interval (CI): 0.86-0.95] and 0.91 [95% CI: 0.85-0.97], respectively; P < .001). In nondialysis recipients at the mean transplant estimated glomerular filtration rate (eGFR), NDI was associated with an adjusted gain in eGFR by 6 months of +3.8 mL/min per 1.73 m² and DI of +3.33 mL/min per 1.73 m² compared to no induction (P < .001). Recipients with lower eGFR at LT had greater predicted improvement in eGFR (interaction P < .001). Only NDI was associated with a reduced risk of acute rejection in the first year post-LT (odds ratio 0.87, 95% CI: 0.8-0.94). Significant variability in induction practices exists, with center being a major determinant. The absolute incremental benefits of NDI and DI over no induction were small.

Handling of Missing Outcome Data in Traumatic Brain Injury Research: A Systematic Review

Traumatic brain injury (TBI) research commonly measures long-term functional outcome, but studies often suffer from missing data as patients are lost to follow-up. This review assesses the extent and handling of missing outcome data in the TBI literature and provides a practical guide for future research. Relevant electronic databases were searched from January 1, 2012 to October 27, 2017 for TBI studies that used the Glasgow Outcome Scale or Glasgow Outcome Scale-Extended (GOS/GOSE) as an outcome measure. Studies were screened and data extracted in line with Cochrane guidance.

A total of 195 studies, 21 interventional, 174 observational, with 104,688 patients were included. Using the reported follow-up rates in a mixed model, on average 91% of patients were predicted to return to follow-up at 6 months post-injury, 84% at 1 year, and 69% at 2 years. However, 36% of studies provided insufficient information to determine the number of subjects at each time-point. Of 139 studies that did report missing outcome data, only 50% attempted to identify why data were missing, with just 4 reporting their assumption on the “missingness mechanism.” The handling of missing data was heterogeneous, with the most common method being its exclusion from analysis. These results confirm substantial variability in the standard of reporting and handling of missing outcome data in TBI research. We conclude that practical guidance is needed to facilitate meaningful and accurate study interpretation, and therefore propose a framework for the handling of missing outcome data in future TBI research.

Effect of cannabis use in people with chronic non-cancer pain prescribed opioids: findings from a 4-year prospective cohort study

BACKGROUND

Interest in the use of cannabis and cannabinoids to treat chronic non-cancer pain is increasing, because of their potential to reduce opioid dose requirements. We aimed to investigate cannabis use in people living with chronic non-cancer pain who had been prescribed opioids, including their reasons for use and perceived effectiveness of cannabis; associations between amount of cannabis use and pain, mental health, and opioid use; the effect of cannabis use on pain severity and interference over time; and potential opioid-sparing effects of cannabis.

METHODS

The Pain and Opioids IN Treatment study is a prospective, national, observational cohort of people with chronic non-cancer pain prescribed opioids. Participants were recruited through community pharmacies across Australia, completed baseline interviews, and were followed up with phone interviews or self-complete questionnaires yearly for 4 years. Recruitment took place from August 13, 2012, to April 8, 2014. Participants were asked about lifetime and past year chronic pain conditions, duration of chronic non-cancer pain, pain self-efficacy, whether pain was neuropathic, lifetime and past 12-month cannabis use, number of days cannabis was used in the past month, and current depression and generalised anxiety disorder. We also estimated daily oral morphine equivalent doses of opioids. We used logistic regression to investigate cross-sectional associations with frequency of cannabis use, and lagged mixed-effects models to examine temporal associations between cannabis use and outcomes.

FINDINGS

1514 participants completed the baseline interview and were included in the study from Aug 20, 2012, to April 14, 2014. Cannabis use was common, and by 4-year follow-up, 295 (24%) participants had used cannabis for pain. Interest in using cannabis for pain increased from 364 (33%) participants (at baseline) to 723 (60%) participants (at 4 years). At 4-year follow-up, compared with people with no cannabis use, we found that participants who used cannabis had a greater pain severity score (risk ratio 1·14, 95% CI 1·01-1·29, for less frequent cannabis use; and 1·17, 1·03-1·32, for daily or near-daily cannabis use), greater pain interference score (1·21, 1·09-1·35; and 1·14, 1·03-1·26), lower pain self-efficacy scores (0·97, 0·96-1·00; and 0·98, 0·96-1·00), and greater generalised anxiety disorder severity scores (1·07, 1·03-1·12; and 1·10, 1·06-1·15). We found no evidence of a temporal relationship between cannabis use and pain severity or pain interference, and no evidence that cannabis use reduced prescribed opioid use or increased rates of opioid discontinuation.

INTERPRETATION

Cannabis use was common in people with chronic non-cancer pain who had been prescribed opioids, but we found no evidence that cannabis use improved patient outcomes. People who used cannabis had greater pain and lower self-efficacy in managing pain, and there was no evidence that cannabis use reduced pain severity or interference or exerted an opioid-sparing effect. As cannabis use for medicinal purposes increases globally, it is important that large well designed clinical trials, which include people with complex comorbidities, are conducted to determine the efficacy of cannabis for chronic non-cancer pain.

FUNDING

National Health and Medical Research Council and the Australian Government.

Effectiveness of Later-Stage Exercise Programs vs Usual Medical Care on Physical Function and Activity After Total Knee Replacement: A Randomized Clinical Trial

IMPORTANCE

Several functional limitations persist after total knee replacement (TKR). Intensive exercise programs could resolve these limitations but are not well tolerated by many patients until a later stage (>2 months) after surgery. Evidence for exercise at a later stage after TKR is limited.

OBJECTIVES

To compare the effectiveness of later-stage exercise programs after TKR and to explore heterogeneity of treatment effects.

DESIGN, SETTING, AND PARTICIPANTS

Three-arm single-blind randomized clinical trial (January 7, 2015, to November 9, 2017) using an intent-to-treat approach with follow-ups at 3 months and 6 months. The setting was Allegheny County, Pennsylvania (an outpatient physical therapy clinic and 4 community centers). Participants had primary TKR performed more than 2 months previously, were 60 years or older, experienced moderate functional limitations, and were medically cleared to exercise.

INTERVENTIONS

Clinic-based physical therapy exercise (physical therapy arm), community-based group exercise (community arm), and usual care (control arm). The control arm continued their usual care, whereas the exercise arms participated in supervised exercise programs lasting 12 weeks.

MAIN OUTCOMES AND MEASURES

The primary outcome was arm differences in the Western Ontario and McMaster Universities Osteoarthritis Index-Physical Function (WOMAC-PF) at 3 months. The secondary outcomes included performance-based tests germane to knee replacement and additional surveys of physical function. Data were analyzed by linear mixed models and responder analysis.

RESULTS

A total of 240 participants (mean [SD] age, 70 [7] years; 61.7% female) were allocated to physical therapy (n = 96), community exercise (n = 96), or control (n = 48). All 3 arms demonstrated clinically important improvement. At 3 months, between-arm analyses for the WOMAC-PF demonstrated no differences between physical therapy and community (-2.2; 98.3% CI, -4.5 to 0.1), physical therapy and control (-2.1; 98.3% CI, -4.9 to 0.7), and community and control (0.1; 98.3% CI, -2.7 to 2.9). Performance-based tests demonstrated greater improvement in the physical therapy arm compared with both the community (0.1 z score units; 98.3% CI, 0.0-0.2) and control (0.3 z score units; 98.3% CI, 0.1-0.4) arms and the community arm compared with the control arm (0.2 z score units; 98.3% CI, 0.0-0.3). The physical therapy arm had more than 17.7% responders than the community arm and more than 19.0% responders than the control arm. There was no difference in responder rates between the community and control arms.

CONCLUSIONS AND RELEVANCE

Based on the primary outcome, participation in late-stage exercise programs after TKR offered no benefit over usual care. The benefits of physical therapy identified by the secondary outcomes and responder analysis require confirmation.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02237911.

Whole-Body Electromyostimulation Combined With Individualized Nutritional Support Improves Body Composition in Patients With Hematological Malignancies - A Pilot Study

Patients undergoing the complex treatment for hematological malignancies are exposed to a high physiological and psychological distress inducing fatigue and physical inactivity. In line with cancer-related metabolic changes patients are predisposed for skeletal muscle mass loss that leads to a functional decline, affects therapeutic success, and quality of life. Benefits of physical exercise and nutritional interventions on muscle maintenance are observed in solid cancer patients, but marginally investigated in patients with hematological cancer. We here studied the effects of a combined supportive exercise and nutrition intervention using whole-body electromyostimulation (WB-EMS) training and individualized nutritional support in patients actively treated for hematological malignancy. In a controlled pilot trial, 31 patients (67.7% male; 58.0 ± 16.7 years) with various hematological cancers were allocated to a control group (n = 9) receiving nutritional support of usual care regarding a high protein intake (>1.0 g/kg/d) or to a physical exercise group (n = 22) additionally performing WB-EMS training twice weekly for 12 weeks. Bodyweight and body composition assessed by bioelectrical impedance analysis were measured every 4 weeks. Physical function, blood parameters, quality of life and fatigue were assessed at baseline and after 12 weeks. No WB-EMS-related adverse effects occurred. Patients attending the exercise program presented a higher skeletal muscle mass than controls after 12-weeks (1.51 kg [0.41, 2.60]; p = 0.008). In contrast, patients of the control group showed a higher fat mass percentage than patients of the WB-EMS group (-4.46% [-7.15, -1.77]; p = 0.001) that was accompanied by an increase in serum triglycerides in contrast to a decrease in the WB-EMS group (change ± SD, control 36.3 ± 50.6 mg/dl; WB-EMS -31.8 ± 68.7 mg/dl; p = 0.064). No significant group differences for lower limb strength, quality of life, and fatigue were detected. However, compared to controls the WB-EMS group significantly improved in physical functioning indicated by a higher increase in the 6-min-walking distance (p = 0.046). A combined therapeutic intervention of WB-EMS and protein-rich nutritional support seems to be safe and effective in improving skeletal muscle mass and body composition in hematological cancer patients during active oncological treatment. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT02293239.

Promoting Psychological Well-Being at Work by Reducing Stress and Improving Sleep: Mixed-Methods Analysis

Background

Workplace programs designed to improve the health and psychological well-being of employees are becoming increasingly popular. However, there are mixed reports regarding the effectiveness of such programs and little analysis of what helps people to engage with such programs.

Objective

This evaluation of a particularly broad, team-based, digital health and well-being program uses mixed methods to identify the elements of the program that reduce work stress and promote psychological well-being, sleep quality, and productivity of employees.

Methods

Participation in the Virgin Pulse Global Challenge program during May to September 2016 was studied. Self-reported stress, sleep quality, productivity, and psychological well-being data were collected both pre- and postprogram. Participant experience data were collected through a third final survey. However, the response rates for the last 2 surveys were only 48% and 10%, respectively. A random forest was used to estimate the probability of the completion of the last 2 surveys based on the preprogram assessment data and the demographic data for the entire sample (N=178,350). The inverse of these estimated probabilities were used as weights in hierarchical linear models in an attempt to address any estimation bias caused by the low response rates. These linear models described changes in psychological well-being, stress, sleep, and productivity over the duration of the program in relation to gender and age, engagement with each of the modules, each of the program features, and participant descriptions of the Virgin Pulse Global Challenge. A 0.1% significance level was used due to the large sample size for the final survey (N=18,653).

Results

The final analysis suggested that the program is more beneficial for older people, with 2.9% greater psychological well-being improvements observed on average in the case of women than men (P<.001). With one exception, all the program modules contributed significantly to the outcome measures with the following average improvements observed: psychological well-being, 4.1%-6.0%; quality of sleep, 3.2%-6.9%; work-related stress, 1.7%-6.8%; and productivity, 1.9%-4.2%. However, only 4 of the program features were found to have significant associations with the outcome measures with the following average improvements observed: psychological well-being, 3.7%-5.6%; quality of sleep, 3.4%-6.5%; work-related stress, 4.1%-6.4%; and productivity, 1.6%-3.2%. Finally, descriptions of the Virgin Pulse Global Challenge produced 5 text topics that were related to the outcome measures. Healthy lifestyle descriptions showed a positive association with outcomes, whereas physical activity and step count tracking descriptions showed a negative association with outcomes.

Conclusions

The complementary use of qualitative and quantitative survey data in a mixed-methods analysis provided rich information that will inform the development of this and other programs designed to improve employee health. However, the low response rates and the lack of a control group are limitations, despite the attempts to address these problems in the analysis.

A Group Randomized Trial to Reduce Obesity among Appalachian Church Members: The Walk by Faith Study

Background: Appalachia is a rural, socioeconomically disadvantaged region with high rates of cancer and obesity. Using community-based participatory research principles, the Appalachia Community Cancer Network tested an initiative to reduce weight among overweight and obese participants by partnering with churches, an important community-based institution in Appalachia.Methods: A group randomized trial was conducted with counties or groups of counties in five Appalachian states. These groups were randomly assigned to receive either monthly diet and exercise education sessions ("Walk by Faith"; WbF) or an educational program focused on cancer screening and education ("Ribbons of Faith"; RoF) to examine effects on weight change. Participants completed questionnaires and biometric measurements at baseline and 12 months. The primary outcome of the study was weight change from baseline to 12 months.Results: The relative difference in weight loss from baseline to 12 months for WbF compared with RoF was 1.4% but was not statistically significant (P = 0.13). However, results varied by sex and marital status. WbF men experienced a significant 2.8% decrease in body weight, married WbF women a 1.5% decrease, and unmarried WbF women a 1.5% increase compared with their respective RoF subgroups (interaction P = 0.016). Among WbF participants, greater participation in monthly educational sessions was associated with greater weight loss (P = 0.002).Conclusions: WbF facilitated weight loss mainly in male participants. Level of participation in WbF activities correlated with weight loss.Impact: Findings suggest that additional research is needed to better understand factors associated with participation in health promotion programs for underserved rural communities. Cancer Epidemiol Biomarkers Prev; 27(11); 1289-97. ©2018 AACR.

Effects of whole-body electromyostimulation combined with individualized nutritional support on body composition in patients with advanced cancer: a controlled pilot trial

BACKGROUND

Physical exercise and nutritional treatment are promising measures to prevent muscle wasting that is frequently observed in advanced-stage cancer patients. However, conventional exercise is not always suitable for these patients due to physical weakness and therapeutic side effects. In this pilot study, we examined the effect of a combined approach of the novel training method whole-body electromyostimulation (WB-EMS) and individualized nutritional support on body composition with primary focus on skeletal muscle mass in advanced cancer patients under oncological treatment.

METHODS

In a non-randomized controlled trial design patients (56.5% male; 59.9 ± 12.7 years) with advanced solid tumors (UICC III/IV, N = 131) undergoing anti-cancer therapy were allocated to a usual care control group (n = 35) receiving individualized nutritional support or to an intervention group (n = 96) that additionally performed a supervised physical exercise program in form of 20 min WB-EMS sessions (bipolar, 85 Hz) 2×/week for 12 weeks. The primary outcome of skeletal muscle mass and secondary outcomes of body composition, body weight and hand grip strength were measured at baseline, in weeks 4, 8 and 12 by bioelectrical impedance analysis and hand dynamometer. Effects of WB-EMS were estimated by linear mixed models. Secondary outcomes of physical function, hematological and blood chemistry parameters, quality of life and fatigue were assessed at baseline and week 12. Changes were analyzed by t-tests, Wilcoxon signed-rank or Mann-Whitney-U-tests.

RESULTS

Twenty-four patients of the control and 58 of the WB-EMS group completed the 12-week trial. Patients of the WB-EMS group had a significantly higher skeletal muscle mass (0.53 kg [0.08, 0.98]; p = 0.022) and body weight (1.02 kg [0.05, 1.98]; p = 0.039) compared to controls at the end of intervention. WB-EMS also significantly improved physical function and performance status (p < 0.05). No significant differences of changes in quality of life, fatigue and blood parameters were detected between the study groups after 12 weeks.

CONCLUSIONS

Supervised WB-EMS training is a safe strength training method and combined with nutritional support it shows promising effects against muscle wasting and on physical function in advanced-stage cancer patients undergoing treatment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02293239 (Date: November 18, 2014).

Physical activity after commitment lotteries: examining long-term results in a cluster randomized trial

To overcome self-control difficulties, people can commit to their health goals by voluntarily accepting deadlines with consequences. In a commitment lottery, the winners are drawn from all participants, but can only claim their prize if they also attained their gym-attendance goals. In a 52-week, three-arm trial across six company gyms, we tested if commitment lotteries with behavioral economic underpinnings would promote physical activity among overweight adults. In previous work, we presented an effective 26-week intervention. In the present paper we analyzed maintenance of goal attainment at 52-week follow-up and the development of weight over time. We compared weight and goal attainment (gym attendance ≥ 2 per week) between three arms that-in the intervention period- consisted of (I) weekly short-term lotteries for 13 weeks; (II) the same short-term lotteries in combination with an additional long-term lottery after 26 weeks; and (III) a control arm without lottery-deadlines. After a successful 26-week intervention, goal attainment declined between weeks 27 and 52 in the long-term lottery arm, but remained higher than in the control group. Goal attainment did not differ between the short-term lottery arm and control arm. Weight declined slightly in all arms in the first 13 weeks of the trial and remained stable from there on. Commitment lotteries can support regular gym attendance up to 52 weeks, but more research is needed to achieve higher levels of maintenance and weight loss.

Effect of expressive and neutral writing on respiratory sinus arrhythmia response over time

BACKGROUND AND OBJECTIVES

Parasympathetic activity, as indexed by respiratory sinus arrhythmia (RSA), underlies key aspects of emotional and cognitive self-regulation. Examining time-varying RSA response during expressive writing about trauma may help inform theory about mechanisms of this intervention. The present study investigated changes in RSA during expressive writing.

METHODS

Participants (N = 246, M_age = 21.5 years, 72% female) were randomly assigned to expressive or neutral writing conditions and wrote for three 20-min sessions. RSA was measured continuously during the first and third writing session.

RESULTS

Linear mixed model analyses of RSA changes within and across sessions by writing groups found that neutral writers, but not expressive writers, exhibited change in RSA. The overall RSA changes during expressive and neutral writing are consistent with theory about the relationship between cognitive and emotional processing mechanisms and vagal activation.

LIMITATIONS

As the present study was not a clinical sample selected on trauma exposure, findings should be considered preliminary. Additionally, engagement of affective and cognitive processes was only hypothesized, as manipulation checks were not performed.

CONCLUSIONS

The present study illustrates the benefits of examining changes in RSA over time. Future work with clinical samples should include additional measures and tasks to better define these mechanisms and rule out alternative hypotheses.

Early Intervention Services Improve School-age Functional Outcome Among Neonatal Intensive Care Unit Graduates

OBJECTIVE

To evaluate the effect of community-based early intervention (EI) services the on functional outcomes of high-risk infants at school age.

METHODS

This was a retrospective cohort study using data from the US Department of Education's National Early Intervention Longitudinal Study. Participants were enrolled in 1997 to 1998 with follow-up through 5 years and had a neonatal intensive care unit (NICU) admission, birth weight >400 g, and gestational age >23 weeks. Kindergarten outcomes were teacher assessments of academic and physical skills compared with classmates. Because treatment assignment is determined according to level of clinical need, we used repeated measures, marginal structural models with inverse probability of treatment weighting to account for confounding by indication.

RESULTS

Of 405 participants, 47% had academic ratings average/above average and 71% had physical skills ratings average/above average. Odds of average/above average academic skills were lower for those with delayed EI enrollment (adjusted odds ratio [aOR], 0.65; 95% confidence interval [CI], 0.43-0.99) and trending, although not significantly, higher for those with greater service duration (aOR, 1.47; 95% CI, 0.98-2.22) and breadth (odds ratio, 1.74; 95% CI, 0.95-3.20). Odds of average/above average physical skills were lower for those with delayed EI enrollment (aOR, 0.61; 95% CI, 0.40-0.93) and higher for those with greater intensity (aOR, 1.06; 95% CI, 1.00-1.13) and breadth (aOR, 1.86; 95% CI, 1.03-3.35), approaching significance for those with greater service duration (aOR, 1.41; 95% CI, 0.96-2.09).

CONCLUSIONS

Longer, more intense services were associated with higher kindergarten skills ratings in children at risk for disabilities. Our novel findings support the effectiveness of large-scale EI programs and reinforce the importance of referral after NICU discharge.

Predicting the course of persistent physical symptoms: Development and internal validation of prediction models for symptom severity and functional status during 2 years of follow-up

OBJECTIVE

Increased knowledge about predictors of the course of persistent physical symptoms (PPS) is needed to identify patients at risk for long-term PPS in clinical settings. Therefore, we developed prediction models for the course of PPS in terms of symptom-severity and related functional status during a 2-year follow-up period.

METHODS

We used data of the PROSPECTS cohort study, consisting of 325 PPS patients from several health care settings. Symptom severity (PHQ-15), physical functioning (RAND 36 PCS) and mental functioning (RAND 36 MCS) were assessed at baseline and 6, 12 and 24 months afterwards. We applied mixed model analyses to develop prediction models for all outcomes, using all follow-up measurements. Potential predictors were based on empirical and theoretical literature and measured at baseline.

RESULTS

For symptom severity, physical functioning and mental functioning we identified predictors for the adverse course of PPS included physical comorbidity, higher severity and longer duration of PPS at baseline, anxiety, catastrophizing cognitions, embarrassment and fear avoidance cognitions, avoidance or resting behaviour and neuroticism. Predictors of a favourable course included limited alcohol use, higher education, higher levels of physical and mental functioning at baseline, symptom focusing, damage cognitions and extraversion. Explained interpersonal variance for all three models varied between 70.5 and 76.0%. Performance of the models was comparable in primary and secondary/tertiary care.

CONCLUSION

The presented prediction models identified several relevant demographic, medical, psychological and behavioural predictors for adverse and favourable courses of PPS. External validation of the presented models is needed prior to clinical implementation.

Recurrent Cancer Is Associated With Dissatisfaction With Care—A Longitudinal Analysis Among Ovarian and Endometrial Cancer Patients

Objective

The primary aim of this study was to assess the longitudinal impact of a recurrence of gynecological cancer on satisfaction with information provision and care. The secondary aim was to assess the impact of a recurrence on illness perceptions, anxiety, and depression and health-related quality of life.

Methods

This study is a longitudinal analysis from the ROGY Care trial, conducted between 2011 and 2014, including patients with endometrial (n = 215) and ovarian (n = 149) cancer. Patients were invited to complete questionnaires directly after initial treatment and after 6, 12, and 24 months. Satisfaction with information provision and care, illness perceptions, anxiety, and depression were compared before and after the recurrence. Linear mixed-model analyses were conducted to assess the differences in outcomes of patients with a recurrence compared with patients without a recurrence.

Results

During 2-year follow-up, 25 patients with endometrial cancer (12%) and 64 patients with ovarian cancer (43%) had recurrent disease, of whom 9 endometrial and 26 ovarian cancer patients completed at least 1 questionnaire after their recurrence was determined. Patients reported lower satisfaction with care after the diagnosis of a recurrence (doctor interpersonal skills, exchange of information between caregivers, and general satisfaction with care) compared with patients without recurrence. In addition, patients reported lower health-related quality of life, more anxiety and depression, and more threatening illness perceptions after diagnosis of a recurrence.

Conclusions

After diagnosis of recurrent disease, endometrial and ovarian cancer patients were less satisfied with care compared with patients without a recurrence. Our findings suggest that patients with recurrent cancer are in need of care that is better tailored to their needs.

Internet-Based Cognitive Behavioral Therapy Realizes Long-Term Improvement in the Sexual Functioning and Body Image of Breast Cancer Survivors

The study aim was to evaluate the long-term efficacy of Internet-based cognitive behavioral therapy (CBT) for sexual dysfunctions in 84 breast cancer survivors. The positive effects of the intervention on overall sexual functioning, sexual desire, sexual arousal, vaginal lubrication, discomfort during sex, sexual distress, and body image observed immediately posttreatment were maintained at three- and nine-month follow-ups. Although sexual pleasure decreased during follow-up, it did not return to baseline levels. Our findings provide evidence that Internet-based CBT has a sustained, positive effect on sexual functioning and body image of breast cancer survivors with a sexual dysfunction.

Long-term health-related quality of life after pancreatic resection for malignancy in patients with and without severe postoperative complications

BACKGROUND

Surgery for pancreatic cancer yields significant morbidity and mortality risks and survival is limited. Therefore, the influence of complications on quality of life (QoL) after pancreatic surgery is important. This study compares QoL in patients with and without severe complications after surgery for pancreatic (pre-)malignancy.

METHODS

This prospective cohort study scored complications after pancreatic surgery according to the Clavien-Dindo system and the definitions of the International Study Group of Pancreatic Surgery. QoL was measured by the RAND36 questionnaire, the European Organization for Research and Treatment of Cancer core questionnaire (QLQ-C30) and the pancreas specific QLQ-PAN26. QoL in patients with severe complications was compared with QoL in patients with no or mild complications over a period of 12 months. Analysis was performed with linear mixed models for repeated measurements.

RESULTS

Between March 2012 and July 2016, 137 patients were included. Sixty-eight patients (50%) had at least 1 severe complication. There were no statistically significant and clinically relevant differences between both groups in QoL up to 12 months after surgery.

CONCLUSION

In this study, no differences in QoL between patients with and without severe postoperative complications were encountered during the first 12 months after surgery for pancreatic (pre-)malignancy.

TRIAL REGISTRATION

http://www.clinicaltrials.gov Identifier: NCT02175992.

Enduring effects of a 5-week behavioral activation program for subthreshold depression among late adolescents: an exploratory randomized controlled trial

BACKGROUND

No significant effect of psychological treatment has been reported from meta-analysis of subthreshold depression patients and control subjects at 1-year follow-up. However, behavioral activation is a simpler and more cost-effective treatment than cognitive behavioral therapy. The primary purpose of this study was to assess by comparison to an assessment-only control group whether the effects of behavioral activation program for depressive symptoms can persist up to 1-year follow-up without the use of antidepressants or other psychotherapy.

PATIENTS AND METHODS

Late adolescent students were the population targeted in this study. Participants were allocated randomly to an intervention group (n=62) or a control group (n=56). Treatment consisted of five-weekly 60-minute sessions. Participants underwent a structured interview and completed self-report scales at 1 year post-assessment.

RESULTS

Late adolescent students receiving treatment had significantly lower mean Beck Depression Inventory, second edition scores at 1-year follow-up than control group students. The effect size (Hedges' g) for between-group differences at 1-year follow-up was -0.41.

CONCLUSION

Our behavioral activation program is simple and short. Nevertheless, the results obtained at 1-year follow-up of the control group and late adolescent students receiving treatment indicated a significant difference in their Beck Depression Inventory, second edition scores. Our 5-week behavioral activation program based on behavioral characteristics for subthreshold depression might be promising for subthreshold depression. The sample examined for this study imposed some study limitations.

Evaluating the impact of prediction models: lessons learned, challenges, and recommendations

An important aim of clinical prediction models is to positively impact clinical decision making and subsequent patient outcomes. The impact on clinical decision making and patient outcome can be quantified in prospective comparative-ideally cluster-randomized-studies, known as 'impact studies'. However, such impact studies often require a lot of time and resources, especially when they are (cluster-)randomized studies. Before envisioning such large-scale randomized impact study, it is important to ensure a reasonable chance that the use of the prediction model by the targeted healthcare professionals and patients will indeed have a positive effect on both decision making and subsequent outcomes. We recently performed two differently designed, prospective impact studies on a clinical prediction model to be used in surgical patients. Both studies taught us new valuable lessons on several aspects of prediction model impact studies, and which considerations may guide researchers in their decision to conduct a prospective comparative impact study. We provide considerations on how to prepare a prediction model for implementation in practice, how to present the model predictions, and how to choose the proper design for a prediction model impact study.

One-Year Outcome for Responders of Cognitive-Behavioral Therapy for Pediatric Obsessive-Compulsive Disorder

OBJECTIVE

This study describes 1-year treatment outcomes from a large sample of cognitive-behavioral therapy (CBT) responders, investigates age as a possible moderator of these treatment outcomes, and evaluates clinical relapse at the 1-year follow-up.

METHOD

This study is the planned follow-up to the Nordic Long-term OCD [obsessive-compulsive disorder] Treatment Study (NordLOTS), which included 177 children and adolescents who were rated as treatment responders following CBT for OCD. Participants were assessed with the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) at 6- and 12-month follow-up. Treatment response and remission were defined as CY-BOCS total scores ≤15 and ≤10, respectively. Linear mixed-effects models were used to analyze all outcomes.

RESULTS

At 1 year, a total of 155 children and adolescents (87.6%) were available for follow-up assessment, with 142 of these (91.6%) rated below a total score of ≤15 on the CY-BOCS. At 1-year follow-up, 121 (78.1%) were in remission. On average, CY-BOCS total scores dropped by 1.72 points during the first year after terminating treatment (p = .001). A total of 28 participants (15.8%) relapsed (CY-BOCS ≥ 16) at either the 6- or 12-month assessment; only 2 patients required additional CBT.

CONCLUSION

Results suggest that manualized CBT in a community setting for pediatric OCD has durable effects for those who respond to an initial course of treatment; children and adolescents who respond to such treatment can be expected to maintain their treatment gains for at least 1 year following acute care. Clinical trial registration information- Nordic Long-term Obsessive-Compulsive Disorder (OCD) Treatment Study; www.controlled-trials.com; ISRCTN66385119.

Web-Based Aftercare for Women With Bulimia Nervosa Following Inpatient Treatment: Randomized Controlled Efficacy Trial

Background

Relapse rates in bulimia nervosa (BN) are high even after successful treatment, but patients often hesitate to take up further treatment. An easily accessible program might help maintain treatment gains. Encouraged by the effects of Web-based eating disorder prevention programs, we developed a manualized, Web-based aftercare program (IN@) for women with BN following inpatient treatment.

Objective

The objective of this study was to determine the efficacy of the web-based guided, 9-month, cognitive-behavioral aftercare program IN@ for women with BN following inpatient treatment.

Methods

We conducted a randomized controlled efficacy trial in 253 women with DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) BN and compared the results of IN@ with treatment as usual (TAU). Assessments were carried out at hospital admission (T0), hospital discharge/baseline (T1), postintervention (T2; 9 months after baseline), 9-month follow-up (T3; 18 months after baseline). The primary outcome, abstinence from binge eating and compensatory behaviors during the 2 months preceding T2, was analyzed by intention to treat, using logistic regression analyses. Frequencies of binge eating and vomiting episodes, and episodes of all compensatory behaviors were analyzed using mixed effects models.

Results

At T2, data from 167 women were available. There were no significant differences in abstinence rates between the TAU group (n=24, 18.9%) and the IN@ group (n=27, 21.4%; odds ratio, OR=1.29; P=.44). The frequency of vomiting episodes in the IN@ group was significantly (46%) lower than in the TAU group (P=.003). Moderator analyses revealed that both at T2 and T3, women of the intervention group who still reported binge eating and compensatory behaviors after inpatient treatment benefited from IN@, whereas women who were already abstinent after the inpatient treatment did not (P=.004; P=.002). Additional treatment utilization was high in both groups between baseline and follow-up.

Conclusions

Overall, data from this study suggest moderate effects of IN@. High rates of outpatient treatment utilization after inpatient treatment may have obscured potential intervention effects on abstinence. An aftercare intervention might be more beneficial as part of a stepped-care approach.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 08870215; http://www.isrctn.com/ISRCTN08870215 (Archived by WebCite at http://www.webcitation.org/6soA5bIit)

Multiple imputation of missing covariate values in multilevel models with random slopes: a cautionary note

Multiple imputation (MI) has become one of the main procedures used to treat missing data, but the guidelines from the methodological literature are not easily transferred to multilevel research. For models including random slopes, proper MI can be difficult, especially when the covariate values are partially missing. In the present article, we discuss applications of MI in multilevel random-coefficient models, theoretical challenges posed by slope variation, and the current limitations of standard MI software. Our findings from three simulation studies suggest that (a) MI is able to recover most parameters, but is currently not well suited to capture slope variation entirely when covariate values are missing; (b) MI offers reasonable estimates for most parameters, even in smaller samples or when its assumptions are not met; and

The incidence and predictors of depressive and anxiety symptoms in older adults with vision impairment: a longitudinal prospective cohort study

PURPOSE

Depression and anxiety are highly prevalent in older adults with vision impairment. Because symptoms of depression and anxiety appear to fluctuate, it is important to identify patients who are at risk of developing these symptoms for early diagnosis and treatment. Therefore, the aim of this study was to determine the incidence of subthreshold depression and anxiety, and to investigate predictors of developing symptoms of depression and anxiety in older adults with vision impairment who had no subthreshold depression or anxiety at baseline.

METHODS

A longitudinal prospective cohort study with a follow-up of 24 months in 540 older adults with vision impairment (mean age 75 years, 56% female, 48% macular degeneration, 15% glaucoma) from outpatient low-vision rehabilitation organisations was performed. The cumulative incidences of subthreshold depression and anxiety were calculated and linear mixed models with maximum likelihood estimation were used to determine two prediction models. Main outcome measures were: fluctuations in (i) depressive symptoms (Center for Epidemiologic Studies Depression Scale, CES-D) and (ii) anxiety symptoms (Hospital Anxiety and Depression Scale-Anxiety subscale, HADS-A).

RESULTS

The annual cumulative incidences of subthreshold depression and anxiety were 21.3% (95% Confidence Interval (CI) 18.7-23.9%) and 9.5% (95% CI 7.4-11.6%), respectively. Risk factors for developing depressive symptoms were: living alone, having just enough money to cover expenses, having macular degeneration, having problems with adaptation to vision loss, reduced health related quality of life, and experiencing symptoms of anxiety. For developing anxiety symptoms, a relatively younger age, experiencing symptoms of depression, not living alone and experiencing hindrance at work proved to be risk factors.

CONCLUSIONS

This study shows that the incidence of subthreshold depression and anxiety in older adults with vision impairment is twice as high compared with older adults in general and confirms that depression and anxiety symptoms fluctuate over time. It is of great importance that low vision rehabilitation staff monitor older adults with vision impairment who are most vulnerable for developing these symptoms, based on the risk factors that were found in this study, to be able to offer early interventions to prevent and treat mental health problems in this population.

Immunological effects of behavioral activation with exercise in major depression: an exploratory randomized controlled trial

Major depression (MD) is associated with peripheral inflammation and increased cardiovascular risk. Regular physical exercise can have anti-inflammatory effects. The present study examined whether behavioral activation with exercise affects inflammatory processes in MD. Ninety-eight patients with MD were randomly assigned to cognitive-behavioral therapy (CBT) emphasizing exercise during behavioral activation (CBT-E), CBT with pleasurable low-energy activities as an active control condition (CBT-C) or a passive waiting list control group (WL). Plasma levels of C-reactive protein (CRP), interleukin (IL)-6, IL-10, lipopolysaccharide (LPS)-stimulated IL-6 production, and blood immune cell counts were analyzed at baseline and weeks 8 (post-behavioral activation) and 16 (post-treatment). Thirty non-depressed age- and sex-matched controls were included to examine potential immunological alterations in MD at baseline. Patients with MD exhibited higher levels of CRP, higher neutrophil and monocyte counts, lower IL-10 levels and reduced LPS-stimulated IL-6 production compared to controls (P<0.001-0.045). Multilevel modeling indicated that CBT-E was associated with increased anti-inflammatory IL-10 at weeks 8 and 16 compared to CBT-C and WL (P=0.004-0.018). CBT-E did not significantly affect other immunological makers in the total sample. A subgroup analysis including patients with potentially higher cardiovascular risk (CRP ⩾1 μg ml^-1) indicated that CRP was reduced in CBT-E compared to CBT-C (P<0.007) and marginally reduced compared to WL (P<0.085) after week 16. The present findings provide new insights into immunological effects of behavioral treatments against depression. Behavioral activation in conjunction with exercise may have the potential to reverse, in part, immunological alterations in MD.

Five-year follow-up results of the PROFHER trial comparing operative and non-operative treatment of adults with a displaced fracture of the proximal humerus

Aims

The PROximal Fracture of the Humerus Evaluation by Randomisation (PROFHER) randomised clinical trial compared the operative and non-operative treatment of adults with a displaced fracture of the proximal humerus involving the surgical neck. The aim of this study was to determine the long-term treatment effects beyond the two-year follow-up.

Patients and Methods

Of the original 250 trial participants, 176 consented to extended follow-up and were sent postal questionnaires at three, four and five years after recruitment to the trial. The Oxford Shoulder Score (OSS; the primary outcome), EuroQol 5D-3L (EQ-5D-3L), and any recent shoulder operations and fracture data were collected. Statistical and economic analyses, consistent with those of the main trial were applied.

Results

OSS data were available for 164, 155 and 149 participants at three, four and five years, respectively. There were no statistically or clinically significant differences between operative and non-operative treatment at each follow-up point. No participant had secondary shoulder surgery for a new complication. Analyses of EQ-5D-3L data showed no significant between-group differences in quality of life over time.

Conclusion

These results confirm that the main findings of the PROFHER trial over two years are unchanged at five years.

Cite this article: Bone Joint J 2017;99-B:383–92.

Long-term effects of a weight loss intervention with or without exercise component in postmenopausal women: A randomized trial

The aim of this study was to determine the long-term effects of a weight loss intervention with or without an exercise component on body weight and physical activity. Women were randomized to diet (n = 97) or exercise (N = 98) for 16 weeks. During the intervention, both groups had achieved the set goal of 5-6 kg weight loss. All women were re-contacted twelve months after study cessation for follow-up where body weight and physical activity were measured (PASE questionnaire and ActiGraph accelerometer). At follow-up, body weight and physical activity (measured by the PASE questionnaire and accelerometer) were measured again. At follow-up, both mainly exercise (- 4.3 kg, p < 0.001) and diet (- 3.4 kg, p < 0.001) showed significantly reduced body weight compared to baseline. Both the mainly exercise and diet group were significantly more physically active at one year follow-up compared to baseline (PASE: + 33%, p < 0.001 and + 12%, p = 0.040, respectively; ActiGraph: + 16%, p = 0.012. and + 2.2%, p = 0.695 moderate-to-vigorous activity, respectively). Moreover, the increase in physical activity was statistically significantly when comparing exercise to diet (+ 0.6%, p = 0.035). ActiGraph data also showed significantly less sedentary time in mainly exercise group compared to baseline (- 2.1%, p = 0.018) and when comparing exercise to diet (- 1.8%, p = 0.023). No significant within group differences were found for the diet group. This study shows largely sustained weight loss one year after completing a weight loss program with and without exercise in overweight postmenopausal women. Although the mainly exercise group maintained more physically active compared to the diet group, maintenance of weight loss did not differ between groups.

Carotid Intima-media Thickness Measurements: Relations with Atherosclerosis, Risk of Cardiovascular Disease and Application in Randomized Controlled Trials

Advances in the field of carotid ultrasound have been incremental, resulting in a steady decrease in measurement variability. Improvements in edge detection algorithms point toward increasing automation of CIMT measurements. The major advantage of CIMT is that it is completely noninvasive and can be repeated as often as required. It provides a continuous measure since all subjects have a measurable carotid wall. It is also relatively inexpensive to perform, and the technology is widely available. A graded relation between raising LDL cholesterol and increased CIMT is apparent. Increased CIMT has been shown consistently to relate the atherosclerotic abnormalities elsewhere in the arterial system. Moreover, increased CIMT predicts future vascular events in both populations from Caucasian ancestry and those from Asian ancestry. Furthermore, lipid‑lowering therapy has been shown to affect CIMT progression within 12–18 months in properly designed trials with results congruent with clinical events trials. In conclusion, when one wants to evaluate the effect of a pharmaceutical intervention that is to be expected to beneficially affect atherosclerosis progression and to reduce CV event risk, the use of CIMT measurements over time is a valid, suitable, and evidence‑based choice.

Efficacy and safety of intermittent preventive treatment in schoolchildren with sulfadoxine/pyrimethamine (SP) and SP plus piperaquine in Democratic Republic of the Congo: a randomised controlled trial

In endemic areas, malaria and its adverse effects in schoolchildren may be prevented by intermittent preventive treatment (IPTsc). However, the most appropriate drug regimen for IPTsc remains to be identified. A randomised controlled trial was conducted in Kinshasa, DRC. Enrolled schoolchildren were assigned to a passive control arm (n = 212), sulfadoxine/pyrimethamine (SP) (n = 202) or SP plus piperaquine (SP/PQ) (n = 202). The primary endpoint was haemoglobin (Hb) change. Secondary endpoints were anaemia, parasitaemia prevalence and clinical malaria incidence. Data were analysed by modified intention-to-treat (mITT) and per-protocol. A linear mixed mode was used due to repeated measurements. Of 616 enrolled children, 410 (66.6%) were eligible for mITT analysis. The control arm was used as reference. After 12 months, the Hb level increased by 0.20 g/dL (95% CI -0.61 to 0.47; P = 0.168) and 0.39 g/dL (0.12-0.66; P <0.01) in the SP and SP/PQ arms, respectively. SP treatment reduced anaemia, malaria parasitaemia and clinical malaria by 10% (0-20%; P = 0.06), 19% (2-33%; P = 0.042) and 25% (-32 to 57%; P = 0.37), respectively. The corresponding values for SP/PQ were 28% (19-37%; P <0.001), 40% (26-52%; P <0.001) and 58% (17-79%; P <0.01). No deaths or severe adverse events (SAEs) were observed. SP/PQ offered substantial protection against anaemia, malaria parasitaemia and clinical malaria and showed no SAEs. SP/PQ, a combination of two long-acting non-artemisinin-based antimalarials, may be a valuable option for IPTsc in Africa.

Cesarean Delivery, Overweight throughout Childhood, and Blood Pressure in Adolescence

OBJECTIVES

To investigate whether children delivered by cesarean had a higher risk of being overweight from early until late childhood and whether they had a higher blood pressure in adolescence compared with children delivered vaginally.

STUDY DESIGN

We used data from a Dutch birth cohort study with prenatal inclusion in 1996 and 1997. Mode of delivery (cesarean or vaginal delivery) was ascertained at 3 months after birth by questionnaire. During clinical examinations, height and weight (at age 4, 8, 12, and 16 years) and blood pressure (at age 12 and 16 years) were measured. We used mixed model analysis to estimate associations of cesarean delivery with overweight and blood pressure z scores in 2641 children who participated in at least 1 of the 4 examinations.

RESULTS

Children born by cesarean delivery (n = 236, 8.9%) had a 1.52 (95% CI 1.18, 1.96) higher odds of being overweight throughout childhood than children delivered vaginally. Children born by cesarean delivery had no higher systolic blood pressure z-score (0.11 SD, 95% CI -0.04, 0.26), nor a different diastolic blood pressure z-score (-0.00 SD, 95% CI -0.10, 0.09) in adolescence than children delivered vaginally.

CONCLUSIONS

Compared with children delivered vaginally, children delivered by cesarean had a 52% higher risk of being overweight throughout childhood, but this was not accompanied by a higher blood pressure in adolescence.

Effect of early supervised physiotherapy on recovery from acute ankle sprain: randomised controlled trial

OBJECTIVE

 To assess the efficacy of a programme of supervised physiotherapy on the recovery of simple grade 1 and 2 ankle sprains.

DESIGN

 A randomised controlled trial of 503 participants followed for six months.

SETTING

 Participants were recruited from two tertiary acute care settings in Kingston, ON, Canada.

PARTICIPANTS

 The broad inclusion criteria were patients aged ≥16 presenting for acute medical assessment and treatment of a simple grade 1 or 2 ankle sprain. Exclusions were patients with multiple injuries, other conditions limiting mobility, and ankle injuries that required immobilisation and those unable to accommodate the time intensive study protocol.

INTERVENTION

 Participants received either usual care, consisting of written instructions regarding protection, rest, cryotherapy, compression, elevation, and graduated weight bearing activities, or usual care enhanced with a supervised programme of physiotherapy.

MAIN OUTCOME MEASURES

 The primary outcome of efficacy was the proportion of participants reporting excellent recovery assessed with the foot and ankle outcome score (FAOS). Excellent recovery was defined as a score ≥450/500 at three months. A difference of at least 15% increase in the absolute proportion of participants with excellent recovery was deemed clinically important. Secondary analyses included the assessment of excellent recovery at one and six months; change from baseline using continuous scores at one, three, and six months; and clinical and biomechanical measures of ankle function, assessed at one, three, and six months.

RESULTS

 The absolute proportion of patients achieving excellent recovery at three months was not significantly different between the physiotherapy (98/229, 43%) and usual care (79/214, 37%) arms (absolute difference 6%, 95% confidence interval -3% to 15%). The observed trend towards benefit with physiotherapy did not increase in the per protocol analysis and was in the opposite direction by six months. These trends remained similar and were never statistically or clinically important when the FAOS was analysed as a continuous change score.

CONCLUSIONS

 In a general population of patients seeking hospital based acute care for simple ankle sprains, there is no evidence to support a clinically important improvement in outcome with the addition of supervised physiotherapy to usual care, as provided in this protocol.Trial registration ISRCTN 74033088 (www.isrctn.com/ISRCTN74033088).

Neutrophil expression of glucocorticoid-induced leucine zipper (GILZ) anti-inflammatory protein is associated with acute respiratory distress syndrome severity

Background

Glucocorticoid-induced leucine zipper (GILZ) is a potent anti-inflammatory protein involved in neutrophil apoptosis and the resolution of inflammation. Given the numerous pathophysiologic roles of neutrophils in the acute respiratory distress syndrome (ARDS), we postulated that neutrophil GILZ expression might be induced during ARDS, to modulate the inflammatory process and participate in lung repair.

Methods

This single-center, prospective, observational cohort study took place in the surgical intensive care unit of Bichat Hospital (Paris, France) and involved 17 ARDS patients meeting the Berlin criteria at inclusion, and 14 ventilated controls without ARDS. Serial blood samples were obtained every 2 days until extubation or death (from 1 to 9 samples per patient). GILZ protein and gene expression was quantified in blood neutrophils, along with markers of inflammation (CRP, extracellular DNA) or its resolution (Annexin A1).

Results

Neutrophil GILZ expression was detected at the transcriptional and/or translational level in 9/17 ARDS patients (in particular 7/10 severe ARDS) and in 2/14 ventilated controls. The highest mRNA levels were observed in the most severely ill patients (p < 0.028). GILZ was expressed in about ¾ of the corticosteroid-treated patients and its expression could also occur independently of corticosteroids, suggesting that inflammatory signals may also induce neutrophil GILZ expression in vivo.

Conclusions

In this pilot study, we show for the first time that blood neutrophils from patients with ARDS can express GILZ, in keeping with an anti-inflammatory and regulatory endogenous role of GILZ in humans. Contrary to some markers of inflammation or its resolution, the levels of gilz gene expression were related to ARDS severity.

Vitamin D over the first decade and susceptibility to childhood allergy and asthma

BACKGROUND

Vitamin D (25(OH)D) deficiency has been implicated as a possible risk factor for asthma development, but studies at selected time points measuring 25(OH)D levels during childhood have yielded conflicting findings. Prospective studies tracking 25(OH)D levels during the initiation phase of asthma in early childhood have not been reported.

OBJECTIVE

We sought to elucidate relationships between 25(OH)D levels from birth to age 10 years and susceptibility to allergic sensitization, respiratory tract infections, and asthma.

METHODS

Asthma-, allergy-, and respiratory tract infection-associated phenotypes (including pathogen identification) were characterized in a high-risk birth cohort. Plasma 25(OH)D concentrations were quantified at birth and at clinical follow-ups at the ages of 0.5, 1, 2, 3, 4, 5, and 10 years, and relationships with clinical outcomes were examined.

RESULTS

Cross-sectional analyses demonstrated inverse associations between 25(OH)D concentrations and the risk for concurrent sensitization at age 0.5, 2, and 3 years, and mixed-effects regression demonstrated inverse longitudinal associations of 25(OH)D levels with both sensitization and eczema. Multivariate regression modeling suggested that the number of 25(OH)D-deficient follow-ups was positively associated with risk for asthma/wheeze, eczema, and sensitization at 10 years; adjustment for sensitization (particularly by 2 years) in the asthma/wheeze models reduced 25(OH)D associations with these latter outcomes. 25(OH)D levels were also inversely associated with early nasopharyngeal colonization with Streptococcus species and age of first febrile lower respiratory illness, both of which are known asthma risk factors.

CONCLUSION

25(OH)D deficiency in early childhood is associated with increased risk for persistent asthma, potentially through modulating susceptibility to early allergic sensitization, upper respiratory tract colonization with bacterial pathogens, or both. These relationships are only evident if 25(OH)D status is monitored prospectively and longitudinally.

Paper-Based Survivorship Care Plans May be Less Helpful for Cancer Patients Who Search for Disease-Related Information on the Internet: Results of the Registrationsystem Oncological Gynecology (ROGY) Care Randomized Trial

Background

The Institute of Medicine recommends Survivorship Care Plans (SCPs) for all cancer survivors. However, it is unclear whether certain patient groups may or may not benefit from SCPs.

Objective

The aim was to assess whether the effects of an automatically generated paper SCP on patients’ satisfaction with information provision and care, illness perceptions, and health care utilization were moderated by disease-related Internet use.

Methods

Twelve hospitals were randomized to either SCP care or usual care in the pragmatic cluster randomized Registrationsystem Oncological GYnecology (ROGY) Care trial. Newly diagnosed endometrial cancer patients completed questionnaires after diagnosis (N=221; response: 74.7%, 221/296), 6 months (n=158), and 12 months (n=147), including patients’ satisfaction with information provision and care, illness perceptions, health care utilization (how many times patients visited a medical specialist or primary care physician about their cancer in the past 6 months), and disease-related Internet use (whether patients used the Internet to look for information about cancer).

Results

In total, 80 of 221 (36.2%) patients used the Internet to obtain disease-related information. Disease-related Internet use moderated the SCP care effect on the amount of information received about the disease (P=.03) and medical tests (P=.01), helpfulness of the information (P=.01), and how well patients understood their illness (P=.04). All stratified analyses were not statistically significant. However, it appeared that patients who did not seek disease-related information on the Internet in the SCP care arm reported receiving more information about their disease (mean 63.9, SD 20.1 vs mean 58.3, SD 23.7) and medical tests (mean 70.6, SD 23.5 vs mean 64.7, SD 24.9), finding the information more helpful (76.7, SD 22.9 vs mean 67.8, SD 27.2; scale 0-100), and understanding their illness better (mean 6.6, SD 3.0 vs mean 6.1, SD 3.2; scale 1-10) than patients in the usual care arm did. In addition, although all stratified analyses were not significant, patients who did seek disease-related information on the Internet in the SCP care arm appeared to receive less information about their disease (mean 65.7, SD 23.4 vs mean 67.1, SD 20.7) and medical tests (mean 72.4, SD 23.5 vs mean 75.3, SD 21.6), did not find the information more helpful (mean 78.6, SD 21.2 vs mean 76.0, SD 22.0), and reported less understanding of their illness (mean 6.3, SD 2.8 vs mean 7.1, SD 2.7) than patients in the usual care arm did.

Conclusions

Paper SCPs appear to improve the amount of information received about the disease and medical tests, the helpfulness of the information, and understanding of the illness for patients who do not search for disease-related information on the Internet. In contrast, paper SCPs do not seem beneficial for patients who do seek disease-related information on the Internet.

Trial Registration

ClinicalTrials.gov NCT01185626; https://clinicaltrials.gov/ct2/show/NCT01185626 (Archived by WebCite at http://www.webcitation.org/6fpaMXsDn)

Impact of an Automatically Generated Cancer Survivorship Care Plan on Patient-Reported Outcomes in Routine Clinical Practice: Longitudinal Outcomes of a Pragmatic, Cluster Randomized Trial

Purpose

This study was conducted to longitudinally assess the impact of an automatically generated survivorship care plan (SCP) on patient-reported outcomes in routine clinical practice. Primary outcomes were patient satisfaction with information and care. Secondary outcomes included illness perceptions and health care use.

Methods

Twelve hospitals were randomly assigned to SCP care or usual care in a pragmatic, cluster randomized trial. Newly diagnosed patients with endometrial cancer completed questionnaires after diagnosis (n = 221; 75% response), 6 months (n = 158), and 12 months (n = 147). An SCP application was built in the Web-based ROGY (Registration System Oncological Gynecology). By clicking the SCP button, a patient-tailored SCP was generated.

Results

In the SCP care arm, 74% of patients received an SCP. They reported receiving more information about their treatment (mean [M] = 57, standard deviation [SD] = 20 v M = 47, SD = 24; P = .03), other services (M = 35, SD = 22 v M = 25, SD = 22; P = .03), and different places of care (M = 27, SD = 25 v M = 23, SD = 26; P = .04) than the usual care arm (scales, 0 to 100). However, there were no differences regarding satisfaction with information or care. Patients in the SCP care arm experienced more symptoms (M = 3.3, SD = 2.0 v M = 2.6, SD = 1.6; P = .03), were more concerned about their illness (M = 4.4, SD = 2.3 v M = 3.9, SD = 2.1; P = .03), were more affected emotionally (M = 4.0, SD = 2.2 v M = 3.7, SD = 2.2; P = .046), and reported more cancer-related contact with their primary care physician (M = 1.8, SD = 2.0 v M = 1.1, SD = 0.9; P = .003) than those in the usual care arm (scale, 1 to 10). These effects did not differ over time.

Conclusion

The present trial showed no evidence of a benefit of SCPs on satisfaction with information and care. Furthermore, SCPs increased patients' concerns, emotional impact, experienced symptoms, and the amount of cancer-related contact with the primary care physician. Whether this may ultimately lead to more empowered patients should be investigated further.

Chronic pain self-management support with pain science education and exercise (COMMENCE): study protocol for a randomized controlled trial

Background

Previous research suggests that self-management programs for people with chronic pain improve knowledge and self-efficacy but result in negligible effects on function. This study will investigate the effectiveness self-management support with pain science education and exercise on improving function for people with chronic pain in comparison to a wait-list control. A secondary objective is to determine which variables help to predict response to the intervention.

Methods/Design

This study will be an unblinded, randomized controlled trial with 110 participants comparing a 6-week program that includes self-management support, pain science education and exercise to a wait-list control. The primary outcome will be function measured by the Short Musculoskeletal Function Assessment - Dysfunction Index. Secondary outcomes will include pain intensity measured by a numeric pain rating scale, pain interference measured by the eight-item PROMIS pain interference item-bank, how much patients are bothered by functional problems measured by the Short Musculoskeletal Function Assessment - Bother Index, catastrophic thinking measured by the Pain Catastrophizing Scale, fear of movement/re-injury measured by the 11-item Tampa Scale of Kinesiophobia, sense of perceived injustice measured by the Injustice Experience Questionnaire, self-efficacy measured by the Pain Self-Efficacy Questionnaire, pain sensitivity measured by pressure pain threshold and cold sensitivity testing, fatigue measured by a numeric fatigue rating scale, pain neurophysiology knowledge measured by the Neurophysiology of Pain Questionnaire, healthcare utilization measured by number of visits to a healthcare provider, and work status. Assessments will be completed at baseline, 7 and 18 weeks. After the 18-week assessment, the groups will crossover; however, we anticipate carry-over effects with the treatment. Therefore, data from after the crossover will be used to estimate within-group changes and to determine predictors of response that are not for direct between-group comparisons. Mixed effects modelling will be used to determine between-group differences for all primary and secondary outcomes. A series of multiple regression models will be used to determine predictors of treatment response.

Discussion

This study has the potential to inform future self-management programming through evaluation of a self-management program that aims to improve function as the primary outcome.

Trial registration

ClinicalTrials.gov NCT02422459, registered on 13 April 2015.

Athletic coaches as violence prevention advocates

Adolescent relationship abuse (ARA) is a significant public health problem. Coaching Boys Into Men (CBIM) is an evidence-based ARA prevention program that trains coaches to deliver violence prevention messages to male athletes. Assessing acceptability and impact of CBIM on coaches may inform prevention efforts that involve these important adults in health promotion among youth. As part of a two-armed cluster-randomized controlled trial of CBIM in 16 high schools in Northern California, coaches completed baseline and postseason surveys (n = 176) to assess their attitudes and confidence delivering the program. Coaches in the intervention arm also participated in interviews (n = 36) that explored program acceptability, feasibility, and impact. Relative to controls, intervention coaches showed increases in confidence intervening when witnessing abusive behaviors among their athletes, greater bystander intervention, and greater frequency of violence-related discussions with athletes and other coaches. Coaches reported the program was easy to implement and valuable for their athletes. Findings illustrate the value of exploring attitudinal and behavioral changes among ARA prevention implementers, and suggest that coaches can gain confidence and enact behaviors to discourage ARA among male athletes. Coaches found the program to be feasible and valuable, which suggests potential for long-term uptake and sustainability.

Massage Impact on Pain in Opioid-dependent Patients in Substance Use Treatment

Background:

Chronic pain is a common cause of health care utilization and high levels of pain are pronounced in individuals engaged in methadone maintenance treatment. Although massage has been demonstrated to alleviate chronic pain symptoms, its use as an adjunctive therapy to modify pain during opioid-replacement treatment is absent from the literature.

Purpose:

To consider the efficacy of Swedish massage in reducing pain in opioid-dependent patients with chronic pain receiving methadone treatment.

Setting:

Trial was conducted at a nonprofit methadone treatment center serving low-income patients.

Research Design:

A randomized clinical trial with randomized to either 1) massage plus treatment-as-usual (TAU) (n = 27) or 2) TAU (n = 24). Durability of treatment effect was evaluated at Week 12.

Intervention:

Eight weekly 50-minute Swedish massage sessions plus TAU or TAU alone.

Main Outcome Measures:

Pain, anxiety, depression, physical functioning, decreased substance use, and improvement in treatment engagement.

Results:

Randomized participants were comparable at Baseline for demographic, pain, physical, and emotional variables. Massage group reported improved pain scores; worst pain had a clinically significant 2-point improvement while the other pain scores did not. Overall improvements were not observed in treatment engagement or levels of anxiety, depression, or physical functioning. A subgroup of the participants, who felt they could be pain-free, consistently reported improvements in pain from Baseline to Week 8, and this was most pronounced and clinically significant in the massage group.

Conclusions:

These preliminary findings do not support an overall clinically significant positive effect of Swedish massage on reduction in pain ratings or improvement in anxiety, depression, or treatment engagement in a substance-using, opioid-dependent population with chronic pain. Future nonpharmacologic pain research in marginalized substance-using populations may wish to consider some of the challenges and limitations faced in this project.

Sleep problems and cognitive behavior therapy in pediatric obsessive-compulsive disorder have bidirectional effects

OBJECTIVES

To investigate the presence of sleep problems and their reaction to CBT in pediatric obsessive compulsive disorder (OCD). Moreover, we investigated whether sleep problems predict the outcome of CBT on OCD-symptoms.

METHODS

269 children and adolescents, age 7-17 years, with DSM-IV primary OCD that took part in the first step of a stepwise treatment trial, were assessed with regard to both individual sleep problems and a sleep composite score (SCS) using the Child Behavior Checklist (CBCL). Their OCD symptoms were rated using the Children Yale-Brown Obsessive Compulsive Scale (CY-BOCS).

RESULTS

We found elevated symptoms of sleep deprivation and nightmares before treatment. However most sleep problems (e.g. nightmares (p=.03), too little sleep (p<.001), trouble sleeping (p<.001) and parasomnias p=.03)) as well as being over-tired (p<.001) reduced during CBT treatment. Co-morbidities had no effect on the reduction of SCS. Moreover, elevated levels of sleep problems using the SCS (p<.001), as well as any sleep problem at baseline (p<.001) predicted less effect of CBT on the OCD symptoms.

CONCLUSION

Sleep problems in paediatric OCD are frequent and interfere with treatment outcome. They need to be assessed using better methods in future trials. Moreover, lack of resolution of sleep problems need to be recognized and treated as it seems probable that continued sleep problems may have a negative impact on CBT efficacy.

Steroid injections added to the usual treatment of lumbar radicular syndrome: a pragmatic randomized controlled trial in general practice

Background

Lumbosacral radicular syndrome (LRS) is a self-limiting, benign, painful and impairing condition caused by lumbar disc herniation and inflammatory processes around the nerve root. Segmental epidural steroid injections (SESIs) are helpful to reduce radicular pain on a short-term basis. It is unknown whether SESIs are an effective addition to usual pain treatment of LRS in general practice. In our study, we assessed the effectiveness of SESIs on pain and disability as an addition to usual care for acute LRS in general practice.

Methods

A pragmatic, single-blinded, randomized controlled trial in Dutch general practice was conducted. Circumstances of daily practice were closely followed. Care as usual (CAU) was compared to care as usual combined with an additional SESI in 63 patients in the acute phase of LRS. To detect a minimal clinically important difference of 1.2 points on a numerical rating scale for back pain and a common within-group standard deviation of 1.7 with a two-tailed alpha of 0.05 and a power of 0.80, we needed 33 subjects in each group. Statistical analysis was carried out using mixed models.

Results

A small significant effect in favour of the intervention, corrected for age, sex and baseline values, was found for back pain, impairment and Roland-Morris disability score. The differences, though statistically significant, were too small to be considered clinically relevant. Patients from the intervention group were significantly more satisfied with the received treatment than patients from the control group.

Conclusion

We found a small, statistically significant, but not clinically relevant positive effect of SESIs on back pain, impairment and disability in acute LRS. We do not recommend implementing SESIs as an additional regular treatment option in general practice.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-341) contains supplementary material, which is available to authorized users.

Impact of treatment strategies on cephalosporin and tetracycline resistance gene quantities in the bovine fecal metagenome

The study objective was to determine the effects of two treatment regimens on quantities of ceftiofur and tetracycline resistance genes in feedlot cattle. The two regimens were ceftiofur crystalline-free acid (CCFA) administered to either one or all steers within a pen and subsequent feeding/not feeding of therapeutic doses of chlortetracycline. A 26-day randomized controlled field trial was conducted on 176 steers. Real-time PCR was used to quantify bla_CMY-2, bla_CTX-M, tet(A), tet(B), and 16S rRNA gene copies/gram of feces from community DNA. A significant increase in ceftiofur resistance and a decrease in tetracycline resistance elements were observed among the treatment groups in which all steers received CCFA treatment, expressed as gene copies/gram of feces. Subsequent chlortetracycline administration led to rapid expansion of both ceftiofur and tetracycline resistance gene copies/gram of feces. Our data suggest that chlortetracycline is contraindicated when attempting to avoid expansion of resistance to critically important third-generation cephalosporins.