Analyzing Repeated Measurements Using Mixed Models

Value of inflammatory markers for monitoring disease severity and progression in granuloma induced by cosmetic oil injections

OBJECTIVE

Cosmetic oil injections can cause foreign body granulomas, leading to inflammation-driven extrarenal production of activated vitamin D (1,25(OH)2D3) and severe hypercalcemia. This study investigates longitudinal changes in inflammatory markers: interleukin 2 receptor (IL-2R), peptidyl dipeptidase (ACE), and ferritin in patients with oil-induced granuloma.

MATERIALS AND METHODS

109 male patients were stratified according to baseline calcium status. 28 % had hypercalcemia, and 72 % normocalcemia. Normocalcemic patients were subdivided based on serum parathyroid hormone (PTH) concentrations into suppressed (< 2.0 pmol/L, n = 30) or normal (≥ 2.0 pmol/L, n = 49) concentrations. Blood samples were collected over 48 months and longitudinal changes in inflammatory markers and calcium homeostasis were examined using Pearson correlation and mixed model analyses.

RESULTS

IL-2R, ACE, and ferritin were positively correlated with serum concentration of ionized calcium, while IL-2R was associated with serum 1,25(OH)2D3. In patients with hypercalcemia, IL-2R decreased at 6 (p = 0.041), 24 (p = 0.048), and 36 months (p = 0.035). ACE increased at 48 months (p = 0.008). In patients with normocalcemia and suppressed PTH, IL-2R increased at 24 months (p = 0.021), while serum ferritin increased in patients with normocalcemia and normal PTH at 6 (p = 0.040), 12 (p = 0.008), 24 (p = 0.028), and 48 months (p = 0.005).

CONCLUSIONS

Positive correlations were observed at baseline between ionized calcium concentrations and IL-2R, ionized calcium and ferritin, and 1,25(OH)₂D₃ and IL-2R. Hypercalcemia and suppressed PTH was associated with elevated IL-2R and ferritin concentrations at baseline. Over time, IL-2R and ferritin concentrations decreased in patients with hypercalcemia, some treated with immunomodulatory drugs. IL-2R and ferritin concentrations increased in untreated patients with normocalcemia.

Transcutaneous electrical nerve stimulation of the occipital nerves as treatment for chronic cluster headache

BACKGROUND

Chronic cluster headache (CCH) is an excruciatingly painful condition that can be difficult to treat sufficiently with the available medical treatment options. The greater occipital nerves (GON) are of major interest in treating CCH, and various invasive treatment modalities, such as stimulating or blocking the nerves, have been applied. Because the terminal segment of the GON has a superficial course, the nerve is also accessible for non-invasive transcutaneous stimulation. Transcutaneous electrical nerve stimulation (TENS) has been suggested as a treatment for different chronic headaches, but evidence of the efficacy in patients with CCH is scarce. Additionally, no consensus exists on the optimal placement of the transcutaneous stimulation electrodes or the treatment usage pattern.

METHODS

In this explorative open-label clinical study, 36 patients with CCH were treated with TENS of the GON for 8-12 consecutive weeks between August 2021 and October 2023 as a separate part of the study protocol for a trial on stimulation of the GON (Clinicaltrials.gov identifier: NCT05023460). After a baseline period, TENS was used primarily as a preventive treatment, stimulating for 30 min twice daily at a minimum. The primary outcome was a change in attack frequency and safety with TENS treatment. Secondary outcomes were change in attack duration and pain intensity on the numeric rating scale, abortive treatments, and the Patient Global Impression of Change (PGIC) with TENS treatment. The change in attack frequency, duration, pain intensity, and use of abortive treatment was analyzed by comparing the baseline data with 4-weekly data from TENS treatment. The study aimed to systematically investigate the effect of TENS of the GON as a preventive treatment for CCH.

RESULTS

Weekly attack frequency decreased from a median of 15.7 (95% confidence interval [CI] 11.2-22.1) at baseline to 11.0 (95% CI 7.4-16.4) with TENS. In all, 13 of the 36 (36%) patients had a minimum 30% reduction in attack frequency. In the group of 30% responders, the number of weekly attacks decreased from 15.8 (95% CI 9.8-24.5) at baseline to 5.8 (95% CI 3.3-10.5) attacks with TENS. Five patients became entirely or nearly attack-free. For the entire cohort, attack duration and pain intensity were also significantly reduced with TENS. The use of oxygen was reduced by 42%, and triptan injections decreased by 55%. Overall, 15 (42%) patients reported a clinically important improvement with TENS treatment, rated on the PGIC scale. The 100 Hz stimulation programs were preferred over 10 Hz. No serious adverse events were registered.

CONCLUSION

Transcutaneous electrical nerve stimulation of the GON significantly reduced the frequency, intensity, and duration of weekly headache attacks in patients with severe CCH. Not all patients benefitted from TENS, but the treatment responders had a substantial improvement in their cluster headache. TENS treatment was well-tolerated with little or no side effects and could be a relevant supplement to conventional preventive treatment. A standard TENS apparatus is low cost, making the treatment accessible to most patients. This paper includes a detailed, comprehensive description of our clinical application of the therapy.

The role of obesity in physiological stress, balance, and proprioception during repetitive manual material handling tasks

Manual laborers often experience fatigue-related incidents, which increase their risk of balance disturbances and falls. Previous research indicates that obese individuals may reach critical fatigue levels during repetitive lifting. This study examines whether this BMI-based fatigue pattern also applies to other manual handling activities. Therefore, assessing balance impairment under high physiological stress conditions will help quantify the increased fall risk in obese individuals. Thirty participants performed carrying and pushing/pulling tasks, with weights determined using the Liberty Mutual Equations to align with NIOSH criteria. Balance tests were conducted before and after each task. A two-way ANOVA compared energy expenditure rate (EER) across BMI classifications and sex, while a mixed-effects model analyzed the effects of EER, BMI, and sex on balance and proprioception tests. Results indicated a positive correlation between BMI and EER for both carrying (p = 0.003) and pushing/pulling (p = 0.013). In the mixed-effects model, BMI (p = 0.032) and EER (p = 0.037) were positively correlated with knee proprioception loss, whereas EER was negatively correlated with balance (p = 0.020). These findings confirm that obese individuals face critical fatigue levels, as well as impaired proprioception and balance, during repetitive handling tasks.

Six-year follow-up of glycemic control and cardiovascular risk factors after a one-year intensive lifestyle intervention in type 2 diabetes: An extension of the randomized U-TURN trial

PURPOSE

This study aimed to describe the effects of a 1-year lifestyle intervention on hemoglobin A1c (HbA1c) and cardiovascular risk factors 5 years after cessation of the lifestyle intervention in persons with type 2 diabetes (T2D).

METHODS

From April 2015 to August 2016, 98 persons with T2D (duration < 10 years) were randomly allocated (2:1, stratified by sex) to a 1-year lifestyle intervention group (INT) (n = 64) or a standard care group (StC) (n = 34). All participants received standard care with blinded, target-driven medical therapy. INT included up to 5-6 weekly supervised aerobic and strength training sessions and dietary plans targeting a body mass index ≤ 25 kg/m². No intervention was given during the follow-up period. Forty-nine (77%) and 19 (56%) participants in INT and StC attended the 6-year follow-up. Based on the original intention-to-treat population, the primary outcome was the change in HbA1c from baseline to 6-year follow-up. Secondary outcomes included weight, Low density lipoprotein (LDL) cholesterol, blood pressure (BP), and cardiorespiratory fitness.

RESULTS

Ninety-eight participants (mean age 54.6 years; 46% women; mean baseline Hemoglobin A1c (HbA1c): 49.8 mmol/mol) were analyzed. HbA1c changed 6% and 13% in the INT and StC from baseline to 6-year follow-up (between group difference: -6% (95%CI: -14 to 3); p = 0.18). While no differences were observed for most secondary outcomes, the diastolic BP decreased 6.0 (95%CI: 2.1 to 9.8) mmHg more in the StC compared to INT.

CONCLUSION

The sustained effect of the lifestyle intervention on glycemic control and cardiovascular risk factors was marginal, and it was surprisingly associated with inferior diastolic BP regulation.

Cardiac Electrophysiological Effects of the Sodium Channel-Blocking Antiepileptic Drugs Lamotrigine and Lacosamide

Background: The two antiepileptic drugs lacosamide and lamotrigine exert their antiepileptic effect by inhibiting sodium channels. Lacosamide enhances the inactivation of sodium channels, while lamotrigine inhibits the activation of the channel. Interactions with sodium channels also play an interesting role in cardiac pro- and antiarrhythmia, with inhibition of inactivation, in particular, being regarded as potentially proarrhythmic. Therefore, the ventricular electrophysiologic effects of lacosamide and lamotrigine were investigated in an established experimental whole-heart model. Methods: A total of 67 rabbit hearts were allocated to four groups. Retrograde aortic perfusion was performed using the Langendorff setup. The action potential duration at 90% repolarization (APD90), QT intervals, spatial dispersion of repolarization, effective refractory period, post-repolarization refractoriness, and VT incidence were determined. The electrophysiological effects of lacosamide and lamotrigine were investigated in increasing concentrations on the natively perfused heart. On the other hand, perfusion with the IKr-blocker sotalol was performed to increase arrhythmia susceptibility, followed by perfusion with lacosamide or lamotrigine to investigate the effects of both in a setting of increased arrhythmia susceptibility. Perfusion with lacosamide and lamotrigine tended to decrease APD90 and QT-interval. As expected, perfusion with sotalol led to a significant increase in APD90, QT interval, and arrhythmia incidence. Additive perfusion with lacosamide led to a further increase in arrhythmia incidence, while additive perfusion with lamotrigine led to a decrease in VT incidence. Conclusions: In this model, lacosamide showed proarrhythmic effects, especially in the setting of an additive prolonged QT interval. Lamotrigine showed no significant proarrhythmia under baseline conditions and rather antiarrhythmic effects with additive QT prolongation.

Longitudinal changes in minerals are influenced by immunosuppressive treatment in men with granuloma disease

PURPOSE

To investigate whether granuloma formation following self-administered cosmetic oil injections affects mineral homeostasis, specifically calcium, magnesium, phosphate, iron, sodium, and potassium, and to assess the potential impact of prednisolone treatment on these mineral levels.

METHODS

In this retrospective study, we reviewed blood samples from baseline through a follow-up period of 48 months in patients referred to a tertiary center at Herlev Hospital, Denmark. Changes in serum minerals over time were assessed by a linear mixed model for repeated measures.

RESULTS

A total of 111 patients were included. Men who injected > 2,000 mL paraffin oil had higher total and ionized calcium (p = 0.029 and p < 0.001), lower PTH (p < 0.001), but also lower magnesium (p < 0.001) and higher sodium (p = 0.048) compared to those who had injected < 500 mL. Men with manifest hypercalcemia at baseline (n = 32) compared to men with normocalcemia (n = 79) experienced an increase in serum PTH and phosphate concentrations over time (p = 0.042 at 48 months), and also a transient increase in iron concentration, although this reached baseline levels again after 24 months. Prednisolone lowered calcium in hypercalcemic men but also decreased serum magnesium (p = 0.027 after 36 months), phosphate, and increased serum iron concentration.

CONCLUSION

Men who had injected large volumes of paraffin oil were more likely to have hypercalcemia, lower magnesium, and higher sodium concentrations. Minor aberration in serum minerals was more frequent in patients with more pronounced disease and this may likely be a poor prognostic sign although the mechanism behind this observation remains unclear.

Traffic Light Labels and Dietary Behavior Change: A Randomized Clinical Trial

Importance

Evidence from everyday dining situations regarding the effects of traffic light labels (TLLs) on dietary improvement remains inconsistent.

Objective

To evaluate the effects of TLLs on dietary consumption and choices in cafeteria settings.

Design, Setting, and Participants

This 2-arm, parallel randomized clinical trial was conducted at a company staff cafeteria in Shanghai, China, from September to December 2022. Of 153 adult participants, 76 were randomly assigned to the intervention group and 77 to the control group. Data analysis was conducted from July to October 2024.

Intervention

The intervention group gained access to TLLs offering a comprehensive rating of added sugar, fat, and sodium for each dish on the lunch menu, while the control group did not.

Main Outcomes and Measures

Primary outcomes were lunch intake of added sugar, fat, and sodium. Secondary outcomes included the mean traffic light score (calculated based on the number of dishes consumed, with higher scores indicating worse overall dietary choices) and number of green-coded (reaching dietary recommendations), yellow-coded (between the recommendation and mean intake of the Chinese population), and red-coded (above the upper limit of intake) dishes. The primary and secondary outcomes were automatically calculated based on the precollected recipe dataset of the cafeteria and the Chinese food composition database when participants ordered meals using an applet during weekday lunchtime. Weekly median values of these outcomes were used for analyses, which were conducted for the intention-to-treat population.

Results

Among 153 participants, the mean (SD) age was 32.7 (7.5) years, and 97 (63.4%) were female. At week 12, compared with the control group, the intervention group demonstrated no statistically significant decrease in dietary consumption of added sugar (mean difference, -0.15 [95% CI, -0.75 to 0.46] g), fat (mean difference, -1.54 [95% CI, -6.13 to 3.05] g), or sodium (mean difference, -116.12 [95% CI, -454.78 to 222.54] mg). Similarly, no statistically significant differences were observed in dietary choices based on the mean traffic light score (mean difference, -0.05 [95% CI, -0.12 to 0.03]) or the number of green-coded (odds ratio [OR], 1.15 [95% CI, 0.99-1.32]), yellow-coded (OR, 1.04 [95% CI, 0.90-1.20]), and red-coded (OR, 0.84 [95% CI, 0.57-1.23]) dishes.

Conclusions and Relevance

In this randomized clinical trial, TLLs indicating added sugar, fat, and sodium ratings on menus failed to improve dietary consumption and choices in a company cafeteria setting. This finding suggests that TLLs on menus may not effectively promote dietary improvement in this setting.

Trial Registration

Chinese Clinical Trial Registry Identifier: ChiCTR2100051771.

Residential greenspace and lung function throughout childhood and adolescence in five European birth cohorts. A CADSET initiative

Whether greenspace affects lung function is unclear. We explored associations between the level of greenness or presence of urban green space near the home with lung function measures taken repeatedly during childhood and adolescence in five European birth cohorts. Lung function was measured by spirometry between six and 22 years (2-3 times), and 9,206 participants from BAMSE (Sweden), GINI/LISA South and GINI/LISA North (Germany), PIAMA (The Netherlands) and INMA (Spain) contributed at least one lung function measurement. The mean Normalized Difference Vegetation Index (NDVI) in a 300 m buffer and presence of urban green space within a 300 m buffer (yes/no) were estimated at the home address at the time of each spirometry measurement. Cohort-specific associations were assessed using adjusted linear mixed models and combined in a random-effects meta-analysis. Residential greenness was not associated with forced expiratory volume in one second (FEV1), forced vital capacity (FVC) or FEV1/FVC in the meta-analysis (2.3 ml [-3.2, 7.9], 6.2 ml [-3.4, 15.7] and -0.1 [-0.3, 0.1] per 0.1 increase in NDVI, respectively), nor was having a nearby urban green space (-8.6 ml [-22.3, 5.0], -7.6 ml [-24.7, 9.4] and 0.0 [-0.4, 0.3], respectively). Heterogeneity was low to moderate (I2 = 0 -39 %). Asthma, atopy, air pollution, sex, socioeconomic status and urbanization did not modify the null associations. Using repeated data from five large independent European birth cohorts, we did not find associations between vegetation levels around the home or the presence of an urban green space and lung function levels during childhood and adolescence.

Recognising and Managing Distress Among Farming Clients: An Evaluation of Brief Training for Rural Financial Counsellors and Other Non-Clinical Rural Support Workers

OBJECTIVE

To evaluate the impact of a tailored, brief, 3-h training program to help Rural Financial Counsellors and other non-clinical rural support workers recognise and manage distress experienced by their farming clients.

SETTING

Rural, regional and remote Australia.

PARTICIPANTS

Rural support workers (N = 75; primarily Rural Financial Counsellors and Family and Business mentors) undertaking a 2-part, online training programme for recognising and managing distress in farmers.

DESIGN

Individual questionnaires were collected before the first workshop, after the second workshop, and 3 months post completion of both workshops.

RESULTS

Seventy-five participants provided pre-training data. A series of mixed models for repeated measures identified significant improvements in participants' confidence in recognising and managing farmers' distress pre- to post-training. Specifically, increases in confidence in differentiating mild distress from distress requiring professional help (F = 11.30, p < 0.001), skills to use time well (F = 14.17, p < 0.001), recognising distress (F = 9.16, p < 0.001), dealing with the needs of distressed farmers (F = 22.93, p < 0.001), talking to farmers about their wellbeing (F = 16.47, p < 0.001), knowing when to refer farmers for additional support (F = 19.10, p < 0.001), knowing where to refer farmers for additional support (F = 14.00, p < 0.001), were maintained at the 3-month follow-up. Pre- post-training, participants' behavioural intentions to refer their clients to a farmer-specific mental health intervention (www.ifarmwell.com.au) increased (F = 48.26, p < 0.001), which was maintained at 3-month follow-up. The training did not significantly change participants' quality of life or work stress.

CONCLUSIONS

Findings suggest that a brief, tailored training programme significantly increases rural support workers' confidence in recognising and managing distress in their farming clients.

Transitioning to oral feeding: A retrospective cohort study of a family-centered, hunger-based tube weaning program

BACKGROUND

We investigated the effectiveness of a novel, hunger-based outpatient tube weaning program for children with feeding-tube dependency.

METHODS

This interdisciplinary program induced hunger via rapid reduction in tube-fed calories, followed by 2 weeks of daily outpatient mealtime support and regular follow-up. Forty-one children (6.9 months to 12.8 years) participated in this retrospective cohort study.

RESULTS

Before the program, children received a median of 90.0% (interquartile range [IQR]: 75.0%-100%) of caloric intake via tube feeds. At the end of the 2-week program, children received 16.0% (IQR: 0.0%-30.0%) of caloric intake via tube feeds, which further reduced to 1.5% (IQR: 0.0%-33.0%) at 6-months, and 0.0% (IQR: 0.0%-35.0%) at 1-year follow-up. The percentage of participants who ate >30 different foods increased from 4.9% at baseline to 81.5% at 1-year follow-up. The baseline median weight z score of -1.24 (IQR: -1.69 to -0.69) decreased to -1.81 (IQR: -2.77 to -1.02) at 1-year follow-up. A linear mixed-effects model demonstrated that weight z score was significantly higher at baseline and 2-weeks compared to the 1-year follow-up (P < 0.001 and P = 0.001, respectively), but was not significantly different between 6 months and 1 year (P = 0.44). Age was not associated with percentage of caloric intake via tube feeds or number of foods eaten.

CONCLUSION

Children who participated in the hunger-based tube-weaning program had increased and more varied oral intake 1 year following the intervention. The median weight z score decreased over the year after intervention but did not significantly decrease between 6 and 12 months after the program.

Videoconference-Delivered Acceptance and Commitment Therapy for Family Caregivers of People With Dementia: Pilot Randomized Controlled Trial

BACKGROUND

Family caregivers of individuals with dementia face significant mental health challenges. Acceptance and commitment therapy (ACT) has emerged as a promising intervention for improving these caregivers' mental health. While various delivery modes of ACT have been explored, there is a need for evidence on the efficacy of videoconference-delivered ACT programs for this population.

OBJECTIVE

This pilot randomized controlled trial, conducted in the United States, aims to assess the effects of a videoconference-delivered, therapist-guided ACT program on reducing depressive symptoms and improving other mental health outcomes among family caregivers with depression who give care to individuals with dementia, compared to a control group that received psychoeducation materials only.

METHODS

This 2-arm, parallel-group pilot randomized controlled trial randomly assigned 33 family caregivers to either a 10-week videoconference-delivered ACT program (n=16, 48%) or a control group that received psychoeducation materials alone (n=17, 52%). Depressive symptoms (primary outcome) were measured using the Patient Health Questionnaire-9. Secondary outcomes included anxiety, stress, psychological quality of life (QoL), caregiver burden, predeath grief, guilt, and ACT process measures. Outcomes were assessed in the pretest, posttest (10-12 weeks after pretest), and a 3-month follow-up (3 months after posttest, approximately 5-6 months after pretest). An intent-to-treat approach was used for all outcome analyses. Linear mixed-effects models for repeated measures were used to analyze outcomes.

RESULTS

The ACT group reported significantly greater improvements in stress (P=.043) and psychological QoL (P=.014) in the posttest compared to the control group. Within the ACT group, participants experienced a significant decrease in depressive symptoms, with a mean (SE) change of -6.09 (1.16) points (95% CI -8.42 to -3.76; P<.001) in the posttest and -6.71 (1.45) points (95% CI -9.63 to -3.81; P<.001) in the 3-month follow-up. These changes exceed the estimated minimal clinically important difference on the Patient Health Questionnaire-9. In addition, the ACT group reported significant improvements in anxiety, stress, psychological QoL, caregiver burden, predeath grief, guilt, values-driven action, and experiential avoidance at both posttest and 3-month follow-up. A sensitivity analysis, excluding 1 participant with near-outlier data, revealed statistically significant between-group differences in depressive symptoms at posttest (P=.037); stress at posttest (P<.001) and in 3-month follow-up (P=.001); psychological QoL at posttest (P<.001); caregiver burden at posttest (P=.003) and in 3-month follow-up (P=.003); predeath grief in 3-month follow-up (P=.031); and values-driven action at posttest (P=.032).

CONCLUSIONS

The videoconference-delivered ACT program showed promise in improving mental health outcomes and ACT processes among family caregivers with depression who give care to individuals with dementia. Future studies should aim to replicate these findings with larger, more diverse caregiver populations and explore the long-term efficacy of videoconference-delivered ACT programs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05043441; https://clinicaltrials.gov/study/NCT05043441.

Metformin treatment for patients with hand osteoarthritis: protocol for the multicentre, randomised, placebo-controlled METRO trial

INTRODUCTION

Hand osteoarthritis (OA) is a prevalent joint disorder with limited treatment options. Accumulating evidence suggests that the antidiabetic drug metformin has beneficial effects on knee OA and may likewise be beneficial for hand OA. The objective of this randomised, double-blinded, placebo-controlled trial is to investigate the effect of metformin 1000 mg two times a day, or maximum tolerated dose, compared with placebo on reducing finger joint pain after 16 weeks of treatment.

METHODS AND ANALYSIS

The participants will be enrolled from the OA clinic at the Parker Institute at Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark and from the Department of Rheumatology, Hospitalsenhed Midt, Silkeborg, Denmark. 150 participants with painful hand OA according to the American College of Rheumatology criteria will be randomly allocated in a 1:1 ratio to receive either metformin or a matching placebo for 16 weeks. The initial dose of 500 mg of metformin or placebo once daily is increased by 500 mg every week until the target dose of 1000 mg two times a day, or the maximum tolerated dose, is reached. The participants will have clinical visits every 4 weeks, except the week 12 visit, which is by telephone. The primary endpoint is the between-group difference in least squares means for the change in the Visual Analogue Scale (VAS) finger joint pain scores between the metformin and placebo groups at 16 weeks. The main analysis will be conducted on the intention-to-treat population, comprising all participants assessed and randomly assigned at baseline. Least squares means and the differences between them, along with their respective 95% CIs, will be derived from a mixed-effects model for repeated measurements (outcomes collected at baseline and at weeks 4, 8, 12 and 16). Adverse events will be registered systematically.

ETHICS AND DISSEMINATION

Approval has been obtained from the European Medicines Agency (EudraCT: 2023-509181-38-00), which also includes approval from the local health research ethics committee. Written informed consent will be obtained from all participants. Study findings will be published in international peer-reviewed journals and will be presented in relevant media and at international scientific conferences.

TRIAL REGISTRATION NUMBER

EudraCT, 2023-509181-38-00; ClinicalTrials.gov, NCT06367283.

Does the Brazilian version of the strengthening families program (Familias Fortes) reduce adolescent substance use and change parental behavior? Evidence from a 2-year follow-up study

BACKGROUND

The Brazilian adaptation of the Strengthening Families Program (SFP), known as Famílias Fortes (FF-BR 10-14), has demonstrated positive short-term effects on parental behavior. This study aims to evaluate the 12- and 24-month follow-ups of the FF-BR 10-14, focusing on parental outcomes and substance use prevention.

METHODS

This is a parallel-cluster randomized controlled trial (RCT) involving 1610 participants (805 adolescents aged 10-14 and 805 caregivers). Conducted across 60 Social Assistance Reference Centers (SARC) in 12 municipalities in Brazil, the trial evaluates the effectiveness of the FF-BR 10-14 program. This study presents data collected at three time points: baseline, 12 and 24 months of follow-up. Multilevel mixed-effects models assessed the program effects on parental and adolescent outcomes (drug use and family behavior), with adjustments for sociodemographic factors.

RESULTS

The results reveal no statistically significant differences between the groups in terms of adolescent drug use after either follow-up. However, participating in the program shows a reduction in negligent parental style (aOR 0.46, 95%CI 0.22;0.97), parental binge drinking (aOR 0.24, 95%CI 0.08; 0.74), as well as an increase in parental ability to set clear rules regarding their children's drug use (β 0.43, 95%CI 0.03; 0.83) and an improvement in adolescents' skills to resolve family conflicts (β 0.79, 95%CI 0.11; 1.46) and to manage stress (β 0.65, 95%CI 0.16; 1.15).

CONCLUSION

The Famílias Fortes program shows positive effects on mediators, such as parenting practices and adolescent coping skills, but not on the primary outcomes of adolescent substance use. These findings highlight the program's role in improving the family environment and supporting prevention efforts through intermediary behaviors.

TRIAL REGISTRATION

The study was registered in the Brazilian Ministry of Health Register of Clinical Trials (REBEC), under protocol no. RBR-5hz9g6z ( https://ensaiosclinicos.gov.br/rg/RBR-5hz9g6z ) - July 8th, 2022.

Effectiveness of an individualised treatment plan compared with a standard exercise programme in women with late-term shoulder impairments after primary breast cancer treatment: a randomised controlled trial

BACKGROUND AND PURPOSE

Research focuses on lymphedema, yet up to 50% face chronic shoulder issues 6 years post-treatment, while rehabilitation for this group is unclear. This trial aimed to assess the clinical effects of a shoulder expert assessment followed by an individualised treatment plan (Intervention Group; IG) compared with standardised exercises delivered as a pamphlet (Control comparator Group; CG), on changes in Shoulder Pain and Disability Index (SPADI) from baseline to week 12.

MATERIAL AND METHODS

This 12-week, assessor-blinded, parallel-group randomised controlled trial included women with late-term shoulder impairments 3-7 years post-breast cancer. Participants were randomized (1:1 allocation) and stratified by surgery and radiotherapy. Outcomes were assessed at baseline, 4, 8, and 12 weeks. Primary endpoint was SPADI overall score change at 12 weeks, analysed using a mixed model. The trial was designed to detect a between-group difference of 8 points on SPADI overall score after 12 weeks. Secondary outcomes were SPADI pain/function, global perceived effect, changes in shoulder pain numeric rating scale, active and passive shoulder range of motion.

RESULTS

After 12-weeks, no between-group difference in SPADI was found between IG and CG (-10.5 and -14.4, respectively), corresponding to a difference of -3.9 points (95% CI -11.9 to 4.1; P = 0.34).

INTERPRETATION

The effects on shoulder pain and disability symptoms of a shoulder expert assessment followed by an individualised treatment plan was not superior to standardised exercises delivered as a pamphlet in women with late-term shoulder impairments 3-7 years post-breast cancer.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05277909).

Effect of a single-dose denosumab on mineral homeostasis in infertile men: insights from a pilot intervention study and a randomized controlled trial

BACKGROUND

Denosumab, a drug that inhibits RANKL to reduce bone resorption in osteoporotic postmenopausal women, has been shown to improve semen quality in a subgroup of infertile men. This study aimed to investigate the effects of denosumab on mineral homeostasis in young infertile men.

METHODS

Secondary data from two clinical trials designed to test the effect on semen quality were used: (1) a pilot intervention study with 12 men receiving a single-dose of 60 mg denosumab and (2) a single-center, double-blinded, randomized clinical trial, where 100 infertile men were randomized 1:1 to receive denosumab 60 mg once sc. or placebo. A linear mixed model for repeated measures was employed to analyze data from follow-up samples.

RESULTS

In the pilot intervention study, denosumab treatment induced a decrease in ionized calcium 5, 20, 40, and 80 days after treatment compared with baseline (all p < 0.05). Serum phosphate decreased on all time points up to and including day 40 (all p < 0.05), while alkaline phosphatase was only lowered at 40 days and onwards (p = 0.014). Serum PTH increased significantly at all time points up to and including day 80 (p = 0.026). One hundred eighty days after treatment, all reported analyses were comparable to baseline levels. The observed temporal changes were confirmed in the RCT with differences in serum calcium (p < 0.001) and phosphate (p < 0.001) on day 14, PTH (p < 0.002), and alkaline phosphatase (p < 0.001) on days 80 and 160. Denosumab treatment had no significant effect on vitamin D status, renal function, or serum albumin concentration after 80 and 160 days.

CONCLUSIONS

Small but significant changes in mineral homeostasis and bone mineral content were observed but the changes were transient and normalized after treatment cessation. A single injection of denosumab in infertile men appears to have no major long-term impact on bone or mineral homeostasis.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03030196. Registered January 24, 2017.

Remibrutinib in Chronic Spontaneous Urticaria

BACKGROUND

Chronic spontaneous urticaria is an idiopathic syndrome defined by recurring itch, hives, or angioedema (or a combination of these symptoms) for more than 6 weeks. Remibrutinib, an oral, highly selective Bruton's tyrosine kinase inhibitor, showed efficacy and favorable safety in phase 2b trials. Data from phase 3 trials are needed.

METHODS

In the identical, multicenter, double-blind, randomized, placebo-controlled REMIX-1 and REMIX-2 trials, we evaluated the efficacy and safety of remibrutinib in patients with symptomatic chronic spontaneous urticaria after treatment with second-generation H1-antihistamines. Patients were randomly assigned in a 2:1 ratio to receive oral remibrutinib at a dose of 25 mg twice daily or placebo. The primary end point was the change from baseline to week 12 in the urticaria activity score during a 7-day period (UAS7), which comprises severity scores for itch and hives during 1 week (scores range from 0 to 42, with higher scores indicating greater severity). Key secondary end points included adverse events and a UAS7 of 6 or lower at weeks 2 and 12 and a UAS7 of 0 at week 12.

RESULTS

A total of 470 patients in REMIX-1 and 455 in REMIX-2 were randomly assigned to receive either remibrutinib (313 and 300 patients, respectively) or placebo (157 and 155 patients, respectively). The remibrutinib group had a significantly greater decrease in the UAS7 at week 12 than the placebo group (least-squares mean [±SE] change, -20.0±0.7 vs. -13.8±1.0 [P<0.001] in REMIX-1 and -19.4±0.7 vs. -11.7±0.9 [P<0.001] in REMIX-2), which appeared to be sustained through week 24. At week 12, significantly more patients in the remibrutinib group than in the placebo group had a UAS7 of 6 or lower (REMIX-1, 49.8% vs. 24.8% [P<0.001]; REMIX-2, 46.8% vs. 19.6% [P<0.001]) and a UAS7 of 0 (REMIX-1, 31.1% vs. 10.5% [P<0.001]; REMIX-2, 27.9% vs. 6.5% [P<0.001]). The percentages of patients with any adverse event and with serious adverse events were similar in the remibrutinib group and the placebo group, although a higher percentage of patients in the remibrutinib group than in the placebo group had petechiae (3.8% vs. 0.3% in the combined groups).

CONCLUSIONS

Treatment with oral remibrutinib resulted in a significant improvement in a composite measure of itching and hives at week 12. (Funded by Novartis Pharmaceuticals; REMIX-1 and REMIX-2 ClinicalTrials.gov numbers, NCT05030311 and NCT05032157, respectively.).

Impact of Artificial Intelligence-Enhanced Optical Coherence Tomography Software on Percutaneous Coronary Intervention Decisions

Background

Integration of intravascular imaging into percutaneous coronary intervention (PCI) workflow demands physician time and expertise. Artificial intelligence (AI)-enabled software that automates the identification of key intravascular imaging parameters has the potential to streamline physician workflow, increase accuracy, and reduce variability in PCI planning decisions. This study investigated if AI-enabled software, Ultreon (Abbott), compared with traditional software, AptiVue (Abbott), improved physician decision-making accuracy, variability, and efficiency in optical coherence tomography (OCT)-based PCI planning.

Methods

In this multireader, multicase study, 30 interventional cardiologists of varying OCT imaging experience evaluated 21 pre-PCI OCT pullbacks using both Ultreon and AptiVue platforms. Physician PCI planning decisions about lesion morphology, length, and diameter were compared to published best practices. Decision accuracy, variability, and time efficiency were assessed using statistical models.

Results

Physician OCT-based planning decisions were more accurate using Ultreon compared to AptiVue in the identification of calcium severity by 1.77 (95% CI, 1.27-2.50; P < .001), vessel preparation strategy by 2.00 (95% CI, 1.12-3.4; P = .018), and stent diameter by 2.83 (95% CI, 1.79-4.50; P < .001). Physicians exhibited less variability in assessments using Ultreon, especially for distal and proximal stent landing zone, and planned stent length (P < .0001). The efficiency of OCT assessments was improved with Ultreon, reducing the duration of OCT assessments by 0.5 minutes (P < .0001). The benefits were observed irrespective of the physician's prior OCT experience.

Conclusions

Physician OCT-based PCI planning decisions were more accurate, less variable, and more efficient with AI-enhanced Ultreon software. This could potentially aid in the fuller adoption of intravascular imaging in PCI workflow.

Early-stage vs established knee osteoarthritis: A comparative observational study on prevalence and changes in pain, function and quality of life after supervised exercise and education among 10,365 patients

OBJECTIVE

Compare prevalence and changes in outcomes among established and early-stage knee osteoarthritis (KOA) patients undertaking supervised exercise and education.

METHODS

Patients from Good Life with osteoArthritis in Denmark (GLA:D®) were stratified into three groups: established KOA (ACR/EULAR criteria), early-stage KOA (diagnostic-model-outcome ≥70%, Criteria for the Early Diagnosis of knee Osteoarthritis) or potential early-stage KOA (diagnostic-model-outcome 30-69%). Mixed-effects models and the proportion of patients by group achieving minimal clinically important improvements (MCIIs) were used to investigate changes in VAS pain intensity (0-100mm), Knee injury and Osteoarthritis Outcome Score (KOOS) Quality of Life (QoL; 0-100), 40 m Walk test and 30 s chair-stand test at 3 and 12 months.

RESULTS

Compared to established KOA (61% of 10,365 patients), early-stage KOA (27%) had similar knee pain at baseline (mean (standard deviation); 51 (22) vs 45 (22)), and improvement in pain (mean (95% confidence interval) -15 (-15 to -14) vs -14 (-15 to -13), ≥MCII: 55% vs 54%) and KOOS QoL (≥MCII: 50% vs 50%) at 12 months, and in walking speed (≥MCII: 56% vs 52%) and chair-stands (≥MCII: 55% vs 52%) at 3 months. Compared to either group, potential early-stage KOA (10%) had lower baseline pain (34 (32.7)) and less improvement in pain (-9.8 (-11.3 to -8.2; ≥MCII: 47%)), but comparable improvements in KOOS QoL (≥MCII: 50%), walking speed (≥MCII: 51%) and chair-stands (≥MCII: 51%).

CONCLUSION

Patients with early-stage KOA achieved comparable improvements at 3 and 12 months to those with established KOA, supporting supervised exercise and education as a viable management strategy for early-stage KOA.

Handling missing values in patient-reported outcome data in the presence of intercurrent events

INTRODUCTION

As patient-reported outcomes (PROs) are increasingly used in the evaluation of medical treatments, it is important that PROs are carefully analyzed and interpreted. This may be challenging due to substantial missing values. The missingness in PROs is often closely related to patients' disease status. In that case, using observed information about intercurrent events (ICEs) such as disease progression and death will improve the handling of missing PRO data. Therefore, the aim of this study was to develop imputation models for repeated PRO measurements that leverage information about ICEs.

METHODS

We assumed a setting in which missing PRO measurements are missing at random given observed measurements, as well as the occurrence and timing of ICEs, and potentially other (baseline or time-varying) covariates. We then showed how these missingness assumptions can be translated into concrete imputation models that also account for a longitudinal data structure. The resulting models were applied to impute anonymized PRO data from a single-arm clinical trial in patients with advanced lung cancer.

RESULTS

In our trial example, accounting for death and other ICEs in the imputation of missing data led to lower estimated mean health-related quality of life (while alive) compared to an available case analysis and a naive linear mixed model imputation.

CONCLUSION

Information about the timing and occurrence of ICEs contribute to a more plausible handling of missing PRO data. To account for ICE information when handling missing PROs, the missing data model should be separated from the analysis model.

Debulking Surgery After Muscular Paraffin Oil Injections: Effects on Calcium Homeostasis and Patient Satisfaction

CONTEXT

Cosmetic paraffin oil injections can lead to granuloma formation, causing hypercalcemia and kidney failure.

OBJECTIVE

This study explores whether debulking surgery is an effective treatment for improving calcium homeostasis, inflammation, and clinical symptoms.

METHODS

In a retrospective study, we reviewed 33 patients undergoing debulking surgery. Changes in calcium, inflammatory markers, and renal function from baseline up to 12 months after surgery were assessed. Patients were interviewed after surgery.

RESULTS

The patients were 34.6 years of age (SD 6.9) and had 1104 grams (SD 591) of granuloma tissue removed following injection of 1329 mL (SD 803) paraffin oil 7.9 years (SD 3.2) earlier. Seventeen patients had hypercalcemia and experienced a significant decline in ionized calcium from 1.48 mmol/L (SD 0.16) at baseline to 1.33 mmol/L (SD 0.03) at 12 months (P < .002), although only 4 men (23.5%) became normocalcemic. Serum ferritin was reduced by 50% after 12 months (P = .048). Sixteen patients were normocalcemic and had no change in calcium homeostasis but experienced a 20% drop in serum ferritin levels (P = .025) after surgery. Fifteen patients completed all their planned surgeries within the study period and experienced a decline in serum ionized calcium (P = .031), ferritin (P = .011), and interleukin 2-receptor (P = .037). A survey showed that 55% of patients reported postoperative satisfaction scores of 10/10, and 59% of the patients reported reduced pain.

CONCLUSION

Surgery improved calcium homeostasis in a fraction of patients and reduced inflammation and subjective symptoms such as pain and mental well-being in a patient group left with few treatment options except high-dose prednisolone.

Preliminary insights into the effects of spinal manipulation therapy of different force magnitudes on blood biomarkers of oxidative stress and pro-resolution of inflammation mediators

BACKGROUND

Evidence has been reported that spinal manipulation therapy (SMT) leads to spine segmental hypoalgesia through neurophysiological and peripheral mechanisms related to regulating inflammatory biomarker function. However, these studies also showed substantial inter-individual variability in the biomarker responses. Such variability may be due to the incomplete understanding of the fundamental effects of force-based manipulations (e.g., patient-specific force-time characteristics) on a person's physiology in health and disease. This study investigated the short-term effects of distinct SMT force-time characteristics on blood oxidative stress and pro-resolution of inflammation biomarkers.

METHODS

Nineteen healthy adults between 18 and 45 years old were recruited between February and March 2020 before the COVID-19 pandemic and clustered into three groups: control (preload only), target total peak force of 400 N, and 800 N. A validated force-sensing table technology (FSTT®) determined the SMT force-time characteristics. Blood samples were collected at pre-intervention, immediately after SMT, and 20 min post-intervention. Parameters of the oxidant system (total oxidant status, lipid peroxidation and lipid hydroperoxide), the antioxidant system (total antioxidant capacity and bilirubin), and lipid-derived resolvin D1 were evaluated in plasma and erythrocytes through enzyme-linked immunosorbent assay and colorimetric assays.

RESULTS

The COVID-19 global pandemic impacted recruitment, and our pre-established target sample size could not be reached. As a result, there was a small sample size, which decreased the robustness of the statistical analysis. Despite the limitations, we observed that 400 N seemed to decrease systemic total oxidant status and lipid peroxidation biomarkers. However, 800 N appeared to transitorily increase these pro-oxidant parameters with a further transitory reduction in plasma total antioxidant capacity and resolvin D1 mediator.

CONCLUSION

Despite the small sample size, which elevates the risk of type II error (false negatives), and the interruption of recruitment caused by the pandemic, our findings appeared to indicate that different single SMT force-time characteristics presented contrasting effects on the systemic redox signalling biomarkers and pro-resolution of inflammation mediators in healthy participants. The findings need to be confirmed by further research; however, they provide baseline information and guidance for future studies in a clinical population.

A randomized, double-blind, placebo-controlled trial of IL-7 in critically ill patients with COVID-19

BACKGROUND

Lymphopenia and failure of lymphocytes to mount an early IFN-γ response correlate with increased mortality in COVID-19. Given the essential role of CD4 helper and CD8 cytotoxic cells in eliminating viral pathogens, this profound loss in lymphocytes may impair patients' ability to eliminate the virus. IL-7 is a pleiotropic cytokine that is obligatory for lymphocyte survival and optimal function.

METHODS

We conducted a prospective, double-blind, randomized, placebo-controlled trial of CYT107, recombinant human IL-7, in 109 critically ill, patients with lymphopenia who have COVID-19. The primary endpoint was to assess CYT107's effect on lymphocyte recovery with secondary clinical endpoints including safety, ICU and hospital length-of-stay, incidence of secondary infections, and mortality.

RESULTS

CYT107 was well tolerated without precipitating a cytokine storm or worsening pulmonary function. Absolute lymphocyte counts increased in both groups without a significant difference between CYT107 and placebo. Patients with COVID-19 receiving CYT107 but not concomitant antiviral medications, known inducers of lymphopenia, had a final lymphocyte count that was 43% greater than placebo (P = 0.067). There were significantly fewer treatment-emergent adverse events in CYT107 versus placebo-treated patients (P < 0.001), consistent with a beneficial drug effect. Importantly, CYT107-treated patients had 44% fewer hospital-acquired infections versus placebo-treated patients (P = 0.014).

CONCLUSION

Given that hospital-acquired infections are responsible for a large percentage of COVID-19 deaths, this effect of CYT107 to decrease nosocomial infections could substantially reduce late morbidity and mortality in this highly lethal disease. The strong safety profile of CYT107 and its excellent tolerability provide support for trials of CYT107 in other potential pandemic respiratory viral infections.

TRIAL REGISTRATION

NCT04379076, NCT04426201, NCT04442178, NCT04407689, NCT04927169.

FUNDING

Funding for the trial was provided by RevImmune and the Cancer Research Institute.

Survival and quality of life in patients with lower risk myelodysplastic syndromes exposed to erythropoiesis-stimulating agents: an observational cohort study

BACKGROUND

In our previous study on erythropoiesis-stimulating agent (ESA) treatment in lower risk myelodysplastic syndromes from the European MDS (EUMDS) Registry, we showed that patients treated with ESAs had longer survival compared with patients who receive red blood cell transfusion (RBCT). In this study, with a longer follow up time and more patients included, we aimed to assess long-term effects on survival and health-related quality of life (HRQoL) of exposure to ESAs with or without RBCT in patients with lower risk myelodysplastic syndromes.

METHODS

The EUMDS Registry is a non-interventional, longitudinal, real-world registry prospectively enrolling newly diagnosed patients older than 18 years with lower risk (International Prognostic Scoring System low or intermediate-1) myelodysplastic syndromes from 16 European countries and Israel. The analysis was restricted to patients with haemoglobin concentrations less than 100 g/L enrolled between Jan 1, 2008, and July 1, 2019, with last censoring of data on Dec 31, 2021. Patient management was recorded every 6 months, including treatment, transfusions, and HRQoL. ESA treatment followed local guidelines. The patients were separated into four groups at each study visit: no ESA or RBCT, ESA only, ESA plus RBCT, and RBCT only. The data were analysed longitudinally over time according to ESA and RBCT status during each 6-month interval, using propensity score matching. The main outcomes were median overall survival and leukaemia-free survival, and HRQoL. This study is registered with ClinicalTrials.gov, NCT00600860, as is ongoing.

FINDINGS

2448 patients (the ESA-unexposed group [n=1265] and ESA-exposed group [n=1183]) were diagnosed before July 1, 2019; 1520 (62·1%) were male and 928 (37·9%) were female. Median follow-up time was 3·9 years (IQR 1·6-6·5). After applying eligibility criteria and propensity matching, there were 426 patients in the ESA-unexposed group and 744 patients in the ESA-exposed group. Median overall survival in the ESA exposed group was 44·9 months (95% CI 40·2-50·5) compared with 34·8 months (28·6-39·2) in the ESA unexposed group; the absolute difference was 10·1 months (95% CI 2·2-18·0; hazard ratio [HR] 0·70 [95% CI 0·59-0·83]; p<0·0001). Patients without RBCT in the presence or absence of ESA exposure maintained significantly better HRQoL than those with RBCT, irrespective of ESA exposure (linear mixed effect model of EQ-5d-3L index score, RBCT coefficient -0·04 [95% CI -0·06 to 0·03], p<0·0001; linear mixed effect model of VAS, -4·57 [-6·02 to -3·13], p<0·0001).

INTERPRETATION

ESA treatment in patients with lower risk myelodysplastic syndromes significantly improves overall survival when started before or early after the onset of regular transfusion therapy. Avoiding RBCT is associated with significantly better HRQoL.

FUNDING

H2020 European Research Council, Novartis Pharmacy B V Oncology Europe, Amgen, BMS/Celgene International, Janssen Pharmaceutica, Takeda Pharmaceuticals International, and Gilead Sciences.

Parsing reward sensitivity reveals distinct relationships with energy intake, metabolic markers, physical activity and fitness

Rewards are rewarding owing to their hedonic or metabolic value. Individual differences in sensitivity to rewards are predictive of mental health problems but may reflect variation in metabolic types. We have assessed the association of two distinguishable aspects of reward sensitivity, openness to rewards (the striving towards multiple rewards) and insatiability by reward (the strong pursuit and fixation to a particular reward), with measures of metabolism and activity in a longitudinal study of representative birth cohort samples. We used data of the Estonian Children Personality Behaviour and Health Study (original n = 1238) collected at age 15, 18 and 25. Reward sensitivity and physical activity were self-reported during a laboratory visit, when also blood sampling, measurement of blood pressure, height and weight, aerobic exercise testing and the diet interview, after the participants had kept food diary, took place. In the younger cohort, physical activity was also assessed by accelerometry at age 18 and 25. Across adolescence and young adulthood, openness to rewards was positively associated with physical activity and negatively with blood pressure and serum levels of glucose, insulin and cholesterol levels. In contrast, insatiability by reward was positively associated with serum triglyceride levels and negatively with energy intake and cardiorespiratory fitness. In conclusion, the two facets of reward sensitivity have a fairly different association with a variety of metabolic and health-related measures. This may explain the variable findings in literature, and suggests that individual differences in reward sensitivity are part of a complex physiological variability, including energy expenditure profiles.

Socially interactive industrial robots: a PAD model of flow for emotional co-regulation

This article presents the development of a socially interactive industrial robot. An Avatar is used to embody a cobot for collaborative industrial assembly tasks. The embodied covatar (cobot plus its avatar) is introduced to support Flow experiences through co-regulation, interactive emotion regulation guidance. A real-time continuous emotional modeling method and an aligned transparent behavioral model, BASSF (Boredom, Anxiety, Self-efficacy, Self-compassion, Flow) is developed. The BASSF model anticipates and co-regulates counterproductive emotional experiences of operators working under stress with cobots on tedious industrial tasks. The targeted Flow experience is represented in the three-dimensional Pleasure, Arousal, and Dominance (PAD) space. We present how, despite their noisy nature, PAD signals can be used to drive the BASSF model with its theory-based interventions. The empirical results and analysis provides empirical support for the theoretically defined model, and clearly points to the need for data pre-filtering and per-user calibration. The proposed post-processing method helps quantify the parameters needed to control the frequency of intervention of the agent; still leaving the experimenter with a run-time adjustable global control of its sensitivity. A controlled empirical study (Study 1, N = 20), tested the model's main theoretical assumptions about Flow, Dominance, Self-Efficacy, and boredom, to legitimate its implementation in this context. Participants worked on a task for an hour, assembling pieces in collaboration with the covatar. After the task, participants completed questionnaires on Flow, their affective experience, and Self-Efficacy, and they were interviewed to understand their emotions and regulation during the task. The results from Study 1 suggest that the Dominance dimension plays a vital role in task-related settings as it predicts the participants' Self-Efficacy and Flow. However, the relationship between Flow, pleasure, and arousal requires further investigation. Qualitative interview analysis revealed that participants regulated negative emotions, like boredom, also without support, but some strategies could negatively impact wellbeing and productivity, which aligns with theory. Additional results from a first evaluation of the overall system (Study 2, N = 12) align with these findings and provide support for the use of socially interactive industrial robots to support wellbeing, job satisfaction, and involvement, while reducing unproductive emotional experiences and their regulation.

A randomized, placebo-controlled, cross-over trial of ketamine in Rett syndrome

BACKGROUND

Preclinical studies and anecdotal case reports support the potential therapeutic benefit of low-dose oral ketamine as a treatment of clinical symptoms in Rett syndrome (RTT); however, no controlled studies have been conducted in RTT to evaluate safety, tolerability and efficacy.

DESIGN

This was a sequentially initiated, dose-escalating cohort, placebo-controlled, double blind, randomized sequence, cross-over study of oral ketamine in 6-12-year-old girls with RTT to evaluate short-term safety and tolerability and explore efficacy.

METHODS

Participants were randomized to either five days treatment with oral ketamine or matched placebo, followed by a nine-day wash-out period and then crossed-over to the opposite treatment. Ketamine was dosed twice daily at 0.75 mg/kg/dose (Cohort 1) or 1.5 mg/kg/dose (Cohort 2). An independent safety monitoring committee evaluated safety and approved proceeding to the next dose cohort. Caregivers, participants, outcome assessors, and study staff except pharmacists were blinded to allocation. The primary endpoint was safety and tolerability. Exploratory efficacy endpoints included change in clinician- and caregiver-rated measures of RTT features, brain activity on electroencephalography, and wearable biosensors to measure respiration, heart rate, sleep, and activity.

RESULTS

Twenty-three participants enrolled (11 in Cohort 1, 12 in Cohort 2) from 3/12/2019-11/22/2021. One participant was excluded from analysis due to not meeting inclusion criteria on blinded review prior to analysis. One participant was withdrawn from the study due to an adverse event (vomiting) after the first dose of ketamine. Although planned for four dose cohorts, the trial was stopped after Cohort 2 due to enrollment challenges associated with the COVID-19 pandemic. Ketamine was safe and tolerated in both cohorts, with 1 related treatment emergent adverse event of vomiting. No difference was observed in efficacy between ketamine and placebo. Electroencephalography showed the expected increase in high frequency power with ketamine.

CONCLUSIONS

Short-term, low-dose oral ketamine was safe and well tolerated in girls with RTT. No clinical efficacy of ketamine in treating symptoms of RTT was observed with 5 days of treatment, despite electroencephalography evidence of ketamine target engagement during the first dose. Further studies are needed to evaluate safety and efficacy of higher dose and longer exposure to ketamine in RTT.

TRIAL REGISTRATION

Registered at clinicaltrials.gov NCT03633058.

The effects of recent stressful life events on outcomes in individuals at clinical high risk for psychosis: results from the longitudinal EU-GEI high-risk study

BACKGROUND

Recent stressful life events (SLE) are a risk factor for psychosis, but limited research has explored how SLEs affect individuals at clinical high risk (CHR) for psychosis. The current study investigated the longitudinal effects of SLEs on functioning and symptom severity in CHR individuals, where we hypothesized CHR would report more SLEs than healthy controls (HC), and SLEs would be associated with poorer outcomes.

METHODS

The study used longitudinal data from the EU-GEI High Risk study. Data from 331 CHR participants were analyzed to examine the effects of SLEs on changes in functioning, positive and negative symptoms over a 2-year follow-up. We compared the prevalence of SLEs between CHR and HCs, and between CHR who did (CHR-T) and did not (CHR-NT) transition to psychosis.

RESULTS

CHR reported 1.44 more SLEs than HC (p < 0.001), but there was no difference in SLEs between CHR-T and CHR-NT at baseline. Recent SLEs were associated with poorer functioning and more severe positive and negative symptoms in CHR individuals (all p < 0.01) but did not reveal a significant interaction with time.

CONCLUSIONS

CHR individuals who had experienced recent SLEs exhibited poorer functioning and more severe symptoms. However, as the interaction between SLEs and time was not significant, this suggests SLEs did not contribute to a worsening of symptoms and functioning over the study period. SLEs could be a key risk factor to becoming CHR for psychosis, however further work is required to inform when early intervention strategies mitigating against the effects of stress are most effective.

Ventilation distribution during spontaneous breathing trials predicts liberation from mechanical ventilation: the VISION study

BACKGROUND

Predicting complete liberation from mechanical ventilation (MV) is still challenging. Electrical impedance tomography (EIT) offers a non-invasive measure of regional ventilation distribution and could bring additional information.

RESEARCH QUESTION

Whether the display of regional ventilation distribution during a Spontaneous Breathing Trial (SBT) could help at predicting early and successful liberation from MV.

STUDY DESIGN AND METHODS

Patients were monitored with EIT during the SBT. The tidal image was divided into ventral and dorsal regions and displayed simultaneously. We explored the ventral-to-dorsal ventilation difference in percentage, and its association with clinical outcomes. Liberation success was defined pragmatically as passing SBT followed by extubation within 24 h without reintubation for 7 days. Failure included use of rescue therapy, reintubation within 7 days, tracheostomy, and not being extubated within 24 h after succesful SBT. A training cohort was used for discovery, followed by a validation cohort.

RESULTS

Among a total of 98 patients analyzed, 85 passed SBT (87%), but rapid liberation success occurred only in 40; 13.5% of extubated patients required reintubation. From the first minutes to the entire SBT duration, the absolute ventral-to-dorsal difference was consistently smaller in liberation success compared to all subgroups of failure (p < 0.0001). An absolute difference at 5 min of SBT > 20% was associated with failure of liberation, with sensitivity and specificity of 71% and 78% and positive predictive value 81% in a validation cohort.

CONCLUSION

During SBT, a large ventral-to-dorsal difference in ventilation indicated by EIT may help to rapidly identify patients at risk of liberation failure.

Individual and joint associations between sleep duration and physical activity with cognitive function: A longitudinal analysis among middle-aged and older adults in China

INTRODUCTION

Studies using cross-sectional data or with a short follow-up period fail to distinguish whether the associations between sleep duration and physical activity with cognitive function result from reverse causation.

METHODS

The longitudinal study examined the individual and joint associations, with specific temporality, between sleep duration and physical activity with cognitive function, using time-lagged linear mixed models and generalized additive mixed models.

RESULTS

A total of 14,694 participants aged ≥ 50 years were included, with an average lagged time of 4.5 (standard deviation 1.3) years. Long sleep duration was independently associated with cognitive decline, while short sleep duration and physical activity were not. The analysis of joint effects showed that increased physical activity slowed the rate of cognitive decline among participants reporting long sleep duration, consistent with the results of the stratified analyses.

DISCUSSION

Interventions on improving sleep should consider concurrent physical activity to maximize benefits for slowing cognitive decline.

HIGHLIGHTS

Long sleep duration was independently associated with worse cognitive function, while short sleep duration was not. Elevated levels of physical activity were not independently associated with better cognitive function. Increased physical activity appeared to mitigate the negative impact of long sleep duration on cognitive function.

Association between driving pressure, systemic inflammation and non-pulmonary organ dysfunction in patients with acute respiratory distress syndrome, a prospective pathophysiological study

BACKGROUND

Driving pressure is thought to determine the effect of low tidal ventilation on survival in patients with acute respiratory distress syndrome. The leading cause of mortality in these patients is non-pulmonary multiorgan dysfunction, which is believed to worsen due to the biological response to mechanical ventilation (biotrauma). Therefore, we aimed to analyze the association between driving pressure, biotrauma, and non-pulmonary multiorgan dysfunction. Additionally, we analyzed this relationship for tidal volume/predicted body weight.

METHODS

Observational study that included adult patients with acute respiratory distress syndrome undergoing invasive mechanical ventilation admitted to the Hospital Clinic of Barcelona, Spain, between June 2019 and February 2021. We conducted mixed-effects models to assess the effects of driving pressure and tidal volume/predicted body weight on the evolution of 22 log-transformed biomarker variables during the first, third, and fifth days after study enrollment. These 22 systemic biomarkers characterized epithelial and endothelial pulmonary dysfunction, inflammation, and coagulation disorders in the included patients. In the same fashion, the association between driving pressure and non-pulmonary multiorgan dysfunction was evaluated by the non-pulmonary sequential organ failure assessment score (non-pulmonary SOFA) and its associated variables. Finally, we performed mediation analyses to assess whether the relationship between biomarkers and driving pressure was mediated by other ventilator-induced lung injury parameters.

RESULTS

Thirty-eight patients were included. Driving pressure was independently associated with soluble Receptor for advanced glycation end-products, Interleukin (IL)-8, IL-6, IL-10, IL-17, Interferon-ɣ, Chemokine (C-C motif)-2, Vascular endothelial growth factor, Tissue factor, Protein C, Protein S, and higher dose of norepinephrine. However, this relationship attenuated over time. In contrast, tidal volume/predicted body weight was not associated with any of the 22 biomarkers tested . A concomitant increase in positive end-inspiratory plateau pressure or tidal volume did not mediate the effect of driving pressure on biomarkers. Conversely, the association between compliance of the respiratory system and pulmonary epithelial dysfunction was primarily mediated by driving pressure.

CONCLUSIONS

Driving pressure, but not tidal volume/predicted body weight, was correlated with epithelial and endothelial pulmonary dysfunction, inflammation, coagulation disorders, and hemodynamic dysfunction. However, this relationship diminished over time.

Association between chest-to-head circumference ratio at birth and childhood neurodevelopment: the Japan Environment and Children's Study

Children born growth-restricted are well recognized to be at an increased risk of poor neurodevelopmental outcomes. This prospective study examined the influence of chest-to-head circumference ratio at birth on neurodevelopment in the first three years among children enrolled in the Japan Environment and Children's Study. We analyzed information of 84,311 children (43,217 boys, 41,094 girls). Children were divided into low, normal, and high chest-to-head circumference ratio groups. Neurodevelopment was assessed every six months (from 6 months to 3 years) using the Ages and Stages Questionnaire (Japanese translation), with delays defined as scores below 2 standard deviations from the mean. Additionally, we evaluated the contributions of chest and head circumference to the observed association. Linear mixed-effect regression revealed increased risk of delays in communication, gross motor, fine motor, problem-solving, and personal-social skills in the low-ratio group compared to the normal-ratio group. Adjusted risk ratios were in the range of 1.14 - 1.39 in boys and 1.16 - 1.37 in girls, with no such increase observed in the high-ratio group. The heightened risk in the low-ratio group was likely associated with a relatively narrow chest rather than a large head. The area under the ROC curves in predicting any developmental delay at three years for newborn measurements ranged from 0.513 to 0.526 in boys and 0.509 to 0.531 in girls. These findings suggest that a low chest-to-head circumference ratio may indicate children who are at risk for neurodevelopmental deficits. However, the ability to predict poor neurodevelopmental outcomes at three years of age is limited.

The Impact of Dexamphetamine Treatment for Obesity on Executive Function: A Double-Blind Randomised Controlled Pilot Study

BACKGROUND

Amphetamines increase dopamine levels in mid-brain regions which, in turn, impact top-down executive function. Repeated exposure is linked to substance use disorders. Nonetheless, amphetamines are used to manage attention-deficit/hyperactivity disorder (ADHD) and eating-related disorders. In ADHD, amphetamines upregulate a system characterised by low dopaminergic tone, assisting to improve executive function. A similar process might be at play with eating disorders; however, the effect of amphetamine treatment on executive function in this case has not been thoroughly considered.

METHODS

Participants (N = 52, Mage = 47.06, SD = 12.29) with a body mass index of 25-60 were randomised to treatment (6-week dexamphetamine titration) or control (placebo) groups. They completed an executive function measure-Barkley Deficits in Executive Functioning Scale (BDEFS-SF)-and response inhibition task-Stop-Signal Task (SST)-at Baseline, throughout titration, at Maintenance, and at Follow-up. Mixed effects models examined whether BDEFS-SF score or the SST variable, stop-signal reaction time (SSRT), changed across sessions as a function of treatment.

RESULTS

There was no effect of group (p = 0.440), but an effect of session (p = 0.024) on BDEFS-SF, with scores at Time 2 (p = 0.011, 95% CI [0.47, 3.49]) and Maintenance (p = 0.022, 95% CI [-4.89, -0.39]), respectively, higher and lower than other timepoints. There was no group by session interaction (p = 0.659). R2 (conditional) = 0.74; ICC = 0.73. There was an effect of group (p = 0.039) and session (p < 0.001) on SSRT, but no interaction (p = 0.707). Baseline SSRT was significantly longer than the mean of all subsequent timepoints (p < 0.001, 95% CI [16.29, 33.84]). R2 (conditional) = 0.47; ICC = 0.39.

CONCLUSIONS

There was no discernible impact of amphetamine treatment for obesity on executive function. Our results suggest some variation related to sample size and/or practice effects. Thus, while treatment appears unlikely to render individuals susceptible to substance use disorders, parallels with ADHD might be overstated.

Effect of heated mittens on physical hand function in people with hand osteoarthritis: randomised controlled trial

OBJECTIVE

To assess the effect of electrically heated mittens on physical hand function in people with osteoarthritis of the hands compared with control mittens.

DESIGN

Randomised controlled trial.

SETTING

Osteoarthritis outpatient clinic, Copenhagen, Denmark.

PARTICIPANTS

200 people with hand osteoarthritis aged 42-90 years. 100 participants were assigned to the intervention group and 100 to the control group.

INTERVENTIONS

Electrically heated mittens or control mittens (heating elements disconnected) worn for at least 15 minutes daily for six weeks.

MAIN OUTCOME MEASURES

The primary outcome was change in hand function measured on the function subscale of the Australian/Canadian hand osteoarthritis index (AUSCAN; score 0-100 points) at six weeks. Key secondary outcomes included changes in the AUSCAN hand pain subscale (score 0-100 points), global rating of hand osteoarthritis related problems (0-100 visual analogue scale), and grip strength (newtons) at six weeks. Analysis of secondary outcomes was performed using a hierarchical gatekeeping approach.

RESULTS

91 participants in the intervention group and 95 in the control group completed the trial. The mean age of participants was 71 years, 87% (n=173) were women, and mean body mass index was 24.9 (SD 4.4). Median disease duration was 10 years (interquartile range 5-15 years). The between group difference for change in AUSCAN function at week 6 was 3.0 points (95% confidence interval (CI) -0.4 to 6.3; P=0.09) in favour of heated mittens. For the key secondary outcome, change in AUSCAN hand pain score from baseline, a group difference was observed of 5.9 points (95% CI 2.2 to 9.5) in favour of heated mittens. Changes in global rating of hand osteoarthritis related problems and grip strength did not differ between the groups with an observed difference between groups of 2.8 points (95% CI -3.7 to 9.2) and 2.3 newtons (95% CI -16.3 to 21.0) in favour of heated mittens, respectively.

CONCLUSION

Use of electrically heated mittens for six weeks was not related to a positive change in physical hand function compared with control mittens. Heated mittens provided no additional benefits on global rating of hand osteoarthritis related problems and grip strength. A small benefit was detected for hand pain, but this could have been overestimated.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04576403.

A Tai chi and qigong mind-body program for low back pain: A virtually delivered randomized control trial

Background

Mind-body treatments have the potential to manage pain, yet their effectiveness when delivered online for the treatment of low back pain (LBP) is unknown. We sought to evaluate whether a virtually delivered mind-body program integrating tai chi, qigong, and meditation (VDTQM) is effective for treating LBP.

Methods

This randomized controlled trial compared VDTQM (n=175) to waitlist control (n=175). Eligible participants were at least 18 years old, had LBP for at least 6 weeks, were not pregnant, had not previously taken tai chi classes, and had not undergone spine surgery within 6 months. The treatment group received a 12-week VDTQM program in live online 60-minute twice-weekly group classes from September 2022 to December 2022. All participants continued their usual activities and care. Primary outcome was pain-related disability assessed by the Oswestry Disability Index (ODI) score. Secondary outcomes included pain intensity, sleep quality, and quality of life (QOL). Intent-to-treat analyses were conducted.

Results

Of the 350 participants 278 (79%) were female, mean age was 58.8 years (range: 21-92), 244 (69.7%) completed the 8-week survey, 248 (70.9%) the 12-week, and 238 (68%) the 16 -week. No participants withdrew due to adverse treatment effects. Compared with control group, treatment group experienced statistically and clinically significant improvement in ODI score by -4.7 (95% CI: -6.24 to -3.16, p<.01), -6.42 (95% CI: -7.96 to -4.88, p<.01), and -8.14 (95% CI: -9.68 to -6.59, p<.01) points at weeks 8, 12, and 16, respectively. Treatment group also experienced statistically significant improvement at all time points in the other outcomes.

Conclusions

Among adults with LBP, VDTQM treatment resulted in small to moderate improvements in pain-related disability, pain intensity, sleep quality, and QOL. Improvements persisted 1 month after treatment concluded. These findings suggest VDTQM may be a viable treatment option for patients with LBP.Trial registration: clincaltrials.gov Identifier: NCT05801588.

Efficacy and safety of an oral complementary medicine combination in people with symptomatic knee osteoarthritis: Protocol for the double-blind, randomized, placebo-controlled ATLAS trial

Objective

To investigate the efficacy and safety of an oral complementary medicine combination formulation relative to placebo, on changes in pain intensity from baseline to week 12, in people with knee osteoarthritis (OA).

Design

A placebo-controlled, double-blind, two-arm, superiority, phase II, Randomized Controlled Trial (RCT) (ACTRN12623000380695). We will recruit 82 participants (∼41 per arm), aged ≥40 years, with a clinical diagnosis of symptomatic knee OA and radiographic change on x-ray (Kellgren-Lawrence Grade ≥2). Participants will be randomly allocated to receive either a complementary medicine formulation containing a daily dose of Boswellia serrata extract (Boswellin® Super, 250 ​mg/day), pine bark extract (Fenoprolic™ 70 Organic 100 ​mg/day), curcumin (500 ​mg/day), piperine (5 ​mg/day), and methylsulfonylmethane (MSM, 1500 ​mg/day), or placebo, for 12-weeks. The primary endpoint will be change from baseline in average knee pain intensity at 12-weeks (visual analogue scale). Secondary endpoints will include change in knee pain from baseline to 12-weeks in the Knee Injury and Osteoarthritis Outcome Score (KOOS), global assessment of disease activity, global rating of change, and health-related quality of life (AQoL-8D).

Ethics and dissemination

This protocol has been approved by the University of Sydney Human Research Ethics Committee (#2021/877). Dissemination will occur through lay summaries, infographics, conference abstracts, oral presentations, theses, and scientific publications.

Conclusion

This RCT will provide credible evidence about the efficacy and safety of this complementary medicine combination and inform updates to international clinical practice standards on the use of complementary medicines in the management of symptomatic knee OA.

The impact of an illness perception conversation on open-label placebo response in knee osteoarthritis: A randomised controlled trial

OBJECTIVE

To compare the effect of an illness perception conversation (IPC), relative to a research participation conversation (RPC), on 2-week changes in knee pain in patients with knee osteoarthritis.

METHOD

This was a randomised single-blind trial. Patients were randomised to two matched conversations. An IP conversation concerning the participant's knee pain-related illness perception (IP) or an RPC concerning the participant's motivation for participating in research. Both conversations were followed by an open-label intraarticular saline injection in the most symptomatic knee. The primary outcome was change in knee pain from baseline to 2 weeks follow-up on a 100 mm visual analogue scale (VAS). Key secondary outcomes included the Knee injury and Osteoarthritis Outcome Score (KOOS) subscales: Activities of daily living (ADL) and Quality of life (QoL). Main analyses were based on the intention-to-treat population using repeated measures mixed effects linear models.

RESULTS

103 patients were randomised to the IPC group (n = 52) and the RPC group (n = 51). VAS knee pain scores changed statistically significantly from baseline to end of treatment in both groups, -13.7 (standard error [SE]: 3.2) in the IPC group and -13.0 (SE: 3.1) in the RPC group with an adjusted between-group difference of -0.7 (95% CI: -8.3 to 6.9; P = 0.85). Likewise, no group differences were seen in KOOS ADL and KOOS QoL.

CONCLUSION

A conversation concerning knee pain-related IP did not augment the pain-relieving effect of an open-label placebo injection when compared to a similar control conversation concerning motivations for participating in research.

TRIAL REGISTRATION

NCT05225480.

HED-Start: A Brief Positive Psychology Cluster-Randomized Controlled Trial to Improve Psychological Adjustment in Patients New on Hemodialysis

BACKGROUND

Initiation onto hemodialysis marks a critical transition with intense psychosocial demands. Interventions using cognitive-behavioral therapy to improve distress have been variably effective but require trained staff and are typically delivered only to those who screen positive for clinically significant distress. Interventions guided by positive psychology are lacking.

PURPOSE

To investigate the effectiveness of a brief positive-skills RCT in improving psychological adjustment in new hemodialysis patients.

METHODS

Using a parallel (2:1) design, blinded cluster-randomized controlled trial (cRCT) design, incident patients (<6 months at NKF dialysis centers) undergoing hemodialysis were randomized to intervention or usual care (UC). HED-Start intervention comprised four group sessions delivered by healthcare staff on positive emotions, acceptance, and life-orientated goal setting. Measures were taken at baseline (pre-randomization) and at 12 weeks: distress/mood (HADS; SPANE); quality of life (KDQOL-SF, WHOQOL-BREF); benefit-finding (BFS, BIPQ); life-oriented skills (HEIQ, CD-RISC-2); self-efficacy (CD-SES).

RESULTS

A total of 147 participants enrolled in the trial (response rate, 51.0%; retention [assessment], 90.5%). Study arms were comparable on all baseline and outcome variables except for age, diabetic nephropathy, and hypertensive nephrosclerosis which were subsequently controlled for. Repeated measures ANCOVAs (intention to treat) were used. HED-Start yielded significant reductions over time in depression, and increased quality of life, self-efficacy, benefit finding, and skills relative to UC (moderate effect sizes). Rates of clinically significant depression significantly decreased in HED-Start (p < .001) and increased in UC (p = .002).

CONCLUSIONS

The significant positive effects of HED-Start, a low-intensity and cost intervention, on several adjustment indices, suggest that programs focusing on positive life skills can value add to existing renal care services.

Effectiveness of treatment for concussion-related convergence insufficiency: The CONCUSS study protocol for a randomized clinical trial

PURPOSE

To describe CONCUSS, a randomized clinical trial (RCT) designed to compare the following: the effectiveness of immediate office-based vergence/accommodative therapy with movement (OBVAM) to delayed OBVAM as treatments for concussion-related convergence insufficiency (CONC-CI) to understand the impact of time (watchful waiting), the effect of OBVAM dosage (12 versus 16 therapy sessions), and to investigate the underlying neuro-mechanisms of OBVAM on CONC-CI participants.

METHODS

CONCUSS is an RCT indexed on https://clinicaltrials.gov/study/NCT05262361 enrolling 100 participants aged 11-25 years with medically diagnosed concussion, persistent post-concussive symptoms 4-24 weeks post-injury, and symptomatic convergence insufficiency. Participants will receive standard concussion care and will be randomized to either immediate OBVAM or delayed (by six weeks) OBVAM. At the Outcome 1 examination (week 7), clinical assessments of success as determined by changes in the near point of convergence (NPC), positive fusional vergence (PFV), and symptoms will be compared between the two treatment groups. After the Outcome 1 visit, those in the delayed group receive 16 visits of OBVAM, while those in the immediate OBVAM group receive four more therapy visits. Outcome 2 assessment will be used to compare both groups after participants receive 16 sessions of OBVAM. The primary measure is the between-group differences of the composite change in the NPC and PFV at the Outcome 1 visit. Secondary outcome measures include individual clinical measures, objective eye-tracking parameters, and functional brain imaging.

CONCLUSIONS

Major features of the study design include formal definitions of conditions and outcomes, standardized diagnostic and treatment protocols, a delayed treatment arm, masked outcome examinations, and the incorporation of objective eye movement recording and brain imaging as outcome measures. CONCUSS will establish best practices in the clinical care of CONC-CI. The objective eye movement and brain imaging, correlated with the clinical signs and symptoms, will determine the neuro-mechanisms of OBVAM on CONC-CI.

Integrating endovascular techniques into established open neurosurgery practice: a temporal analysis of treatment evolution in a dual-trained neurosurgical unit

OBJETIVE

In Europe, units with Dual-trained Neurovascular Surgeons (DTNS) skilled in both open neurosurgery (ON) and endovascular neurosurgery (EN) are scarce. For instance, in Spain, our unit is unique within the public health system, where all neurovascular procedures are carried out by DTNS. Our study aims to evaluate the evolution in treating ruptured intracranial aneurysms (rICAs) and assess the impact of this evolution on clinical outcomes.

METHODS

A retrospective cohort study was performed on rICAs treated in our unit from October 2012 to June 2023. We reviewed clinical and radiological data to analyze the evolution of ON and EN over time, as well as their impact on patient outcomes. Univariate, multivariate, and mixed-effects models were utilized to discern temporal changes.

RESULTS

The modified Fisher Scale (mFS) and the modified World Federation of Neurological Surgeons scale (mWFNS) showed strong correlation with the outcome at 6 months outcomes, both with p < 0.00001. However, the surgical intervention method, ON versus EN, did not significantly affect outcomes (p > 0.85). In adjusted multivariate logistic regression, mFS (-1.579, p: 0.011) and mWFNS (-0.872, p < 0.001) maintained their significance. rICAs location was significant when comparing ON to EN p = 0.0001. A significant temporal trend favored the selection of EN p = 0.0058). Mixed-effects time series modeling indicated that while patient characteristics and rICA specifics did not predict treatment choice, the year of treatment was significantly correlated (0.161, p = 0.002). Logistic regression with interaction terms for time and treatment type did not produce significant results.

CONCLUSION

Our findings suggest that despite an increased adoption of EN techniques, there has been no change in patient outcomes. Even with the rise of EN, our unit continues to perform ON for a higher proportion of rICAs than most national hospitals. We propose that a "dual approach" offers advantages in a patient individualized treatment decision protocol in the European context.

Association of sociodemographic characteristics with the timeliness of surgery for patients with open tibial fractures

BACKGROUND

The American College of Surgeons recommends operative debridement of open tibial fractures within 24 h of presentation. It is unknown what the compliance rates are with this recommendation and what factors contribute to delays to operation.

METHODS

To determine the characteristics associated with delays to operation for open tibial fractures, we conducted a retrospective cohort study utilizing American College of Surgeons Trauma Quality Improvement Program data from 2017 to 2021. Individuals aged 18 and older presenting to a trauma center with an open tibial fracture were included. Associations were determined with a hierarchal regression model nesting patients within facilities.

RESULTS

Of the 24,102 patients presenting to 491 trauma centers, 66.3 % identified as White, 21.7 % as Black, 1.5 % as Asian, 1.1 % as American Indian, and 10.6 % as Other race. In total, 15.8 % identified as Hispanic. Patients were most often men (75.9 %) and privately insured (47.6 %). The median time to OR was 10.2 h (IQR 4.4-17.7) with 84.6 % receiving surgery within 24 h. In adjusted analyses, Black and American Indian patients had 5.5 % (CI 1.3 %-9.9 %) and 17.8 % (CI 2.2 %-35.8 %) longer wait times, respectively, and a decreased odds of receiving surgery within 24 h (AOR 0.85, CI 0.8-0.9; AOR 0.69, CI 0.5-0.9) when compared to White patients. Female patients had 6.5 % (CI 3.0 %-10.2 %) longer wait times than men. Patients with Medicaid had 5.5 % (CI 1.2 %-9.9 %) longer wait times than those with private insurance. Greater time to OR was associated with increasing age (p < 0.001), increasing injury severity (p < 0.001), and the presence of altered mentation (p < 0.001).

CONCLUSION

We identified longer wait times to operative irrigation and debridement of open tibial fractures for Black and American Indian patients, women, and those with Medicaid. The implementation of health equity focused quality metrics may be necessary to achieve equity in trauma care.

Total Hip Replacement or Resistance Training for Severe Hip Osteoarthritis

BACKGROUND

Total hip replacement is routinely recommended for severe hip osteoarthritis, but data from randomized trials are lacking regarding comparison of the effectiveness of this procedure with that of nonsurgical treatment such as resistance training.

METHODS

We conducted a multicenter, randomized, controlled trial to compare total hip replacement with resistance training in patients 50 years of age or older who had severe hip osteoarthritis and an indication for surgery. The primary outcome was the change in patient-reported hip pain and function from baseline to 6 months after the initiation of treatment, assessed with the use of the Oxford Hip Score (range, 0 to 48, with higher scores indicating less pain and better function). Safety was also assessed.

RESULTS

A total of 109 patients (mean age, 67.6 years) were randomly assigned to total hip replacement (53 patients) or resistance training (56 patients). In an intention-to-treat analysis, the mean increase (indicating improvement) in the Oxford Hip Score was 15.9 points in patients assigned to total hip replacement and 4.5 points in patients assigned to resistance training (difference, 11.4 points; 95% confidence interval, 8.9 to 14.0; P<0.001). At 6 months, 5 patients (9%) who had been assigned to total hip replacement had not undergone surgery, and 12 patients (21%) who had been assigned to resistance training had undergone total hip replacement. The incidence of serious adverse events at 6 months was similar in the two groups; the majority of such events were known complications of total hip replacement.

CONCLUSIONS

In patients 50 years of age or older who had severe hip osteoarthritis and an indication for surgery, total hip replacement resulted in a clinically important, superior reduction in hip pain and improved hip function, as reported by patients, at 6 months as compared with resistance training. (Funded by the Danish Rheumatism Association and others; PROHIP ClinicalTrials.gov number, NCT04070027.).

COVID-19 and working from home-related changes in physical activity in Sydney, Australia

ISSUES ADDRESSED

Evidence on how COVID-19 lockdowns impacted physical activity (PA) is mixed. This study explores changes in PA following initial mobility restrictions, and their subsequent relaxation, in a sample of Sydney (Australia) residents using a natural experiment methodology.

METHODS

Participants' health and travel behaviours were collected pre-pandemic in late 2019 (n = 1937), with follow-up waves during the pandemic in 2020 (n = 1706) and 2021 (n = 1514). Linear mixed-effects models were used to analyse changes in weekly duration of PA between the three waves.

RESULTS

Compared with pre-pandemic, average weekly PA increased in 2021 by 42.6 min total PA (p = .001), 16 min walking PA (p = .02), and 26.4 min moderate-vigorous PA (MVPA) (p = .003). However, average weekly sessions of PA decreased in 2020 and remained lower in 2021. For participants who were sufficiently active in 2019, weekly total PA (-66.3 min) MVPA (-43.8 min) decreased in 2020 compared to pre-pandemic. Conversely, among participants who were insufficiently active in 2019, average weekly PA increased in both 2020 (total PA, +99.1 min; walking PA, +46.4 min; MVPA +52.8 min) and 2021 (total PA, +117.8 min; walking PA, +58.4 min; MVPA +59.2 min), compared to 2019. Participants who did more work from home increased their average weekly total PA in 2021 compared to pre-pandemic (+45.3 min).

CONCLUSION

These findings reveal the complex variability in PA behaviour brought about by the pandemic. SO WHAT?: Strategies to support the population in achieving sufficient PA must focus on maintaining an appetite for PA as we move out of the pandemic and on promoting more frequent PA sessions.

Assessment of the 2021 AASLD Practice Guidance for Albumin Infusion in Elective Therapeutic Paracentesis: A Regression Discontinuity Design

INTRODUCTION

The 2021 American Association for the Study of Liver Disease (AASLD) Practice Guidance recommends albumin infusion when removing ≥5 L of ascites to prevent post-paracentesis circulatory dysfunction. However, the optimal criteria and scenarios for initiating albumin infusion subsequent to therapeutic paracentesis (TP) have been subject to limited scientific inquiry.

METHODS

We conducted a retrospective cohort study at a US academic healthcare center. Participants received elective, outpatient TP between July 2019 and December 2022. Patients with spontaneous bacterial peritonitis, post-TP clinical adjustments, and/or hospitalization were excluded. The institution strictly followed the AASLD Guidance. We used a sharp regression discontinuity (RD) design to estimate the effect of albumin infusion at the AASLD Guidance-recommended cutoff of 5 L on serum creatinine and sodium trajectory after TP.

RESULTS

Over the study period, 1,457 elective TPs were performed on 235 unique patients. Albumin infusion at the threshold of 5 L of ascites removal reduced serum creatinine levels by 0.046 mg/dL/d (95% confidence interval 0.003-0.116, P = 0.037) and increased serum sodium levels by 0.35 mEq/L/d (95% confidence interval 0.15-0.55, P = 0.001) compared with those who did not receive albumin infusion. The RD plots indicated worsened serum creatine/sodium levels after draining 3 L of fluid, approaching levels similar to or worse than with albumin infusion at 5 L or more.

DISCUSSION

Our RD models supported the 2021 AASLD Guidance with robust estimation of causal effect sizes at the cutoff level of 5 L. Nevertheless, the findings also highlight the need to further evaluate the efficacy of albumin infusion in patients who undergo elective TP and have 3-5 L of ascites removed.

Online versus in-person gatekeeper suicide prevention training: comparison in a community sample

BACKGROUND

Suicide prevention gatekeeper Training (GKT) is a frequently used suicide prevention intervention, however, there is still limited information about its long-term impact and effectiveness of online delivery.

AIMS

The current study aimed to test the effectiveness of online GKT compared to in-person GKT in improving participant training outcomes.

METHODS

A non-randomised comparison of pre-, post- and six-month follow-up data was conducted. In total 545 people participated in GKT, 317 in SafeTALK in-person sessions and 228 in online "Start" GKT by LivingWorks. Main outcome measures included: perceived knowledge; perceived preparedness; gatekeeper efficacy; and gatekeeper reluctance to intervene.

RESULTS

Linear mixed model analysis demonstrated a significant effect for time for both modes of delivery for all four outcome measures. Post-hoc testing revealed that significant improvement in all outcomes were maintained above baseline at six-months following online and in-person training.

CONCLUSIONS

Online training performed as good, or better than in-person GKT, on measured outcomes demonstrating utility and effectiveness of the modality for use in suicide prevention training practices. Findings additionally indicate that online training may reach participants that in-person programs do not. This study provides evidence that Online GKT has significant utility in addressing a crucial need for online alternatives to evidence-based suicide prevention training.

Deep-learning generated B-line score mirrors clinical progression of disease for patients with heart failure

BACKGROUND

Ultrasound can detect fluid in the alveolar and interstitial spaces of the lung using the presence of artifacts known as B-lines. The aim of this study was to determine whether a deep learning algorithm generated B-line severity score correlated with pulmonary congestion and disease severity based on clinical assessment (as identified by composite congestion score and Rothman index) and to evaluate changes in the score with treatment. Patients suspected of congestive heart failure underwent daily ultrasonography. Eight lung zones (right and left anterior/lateral and superior/inferior) were scanned using a tablet ultrasound system with a phased-array probe. Mixed effects modeling explored the association between average B-line score and the composite congestion score, and average B-line score and Rothman index, respectively. Covariates tested included patient and exam level data (sex, age, presence of selected comorbidities, baseline sodium and hemoglobin, creatinine, vital signs, oxygen delivery amount and delivery method, diuretic dose).

RESULTS

Analysis included 110 unique subjects (3379 clips). B-line severity score was significantly associated with the composite congestion score, with a coefficient of 0.7 (95% CI 0.1-1.2 p = 0.02), but was not significantly associated with the Rothman index.

CONCLUSIONS

Use of this technology may allow clinicians with limited ultrasound experience to determine an objective measure of B-line burden.

Serum NfL and GFAP are weak predictors of long-term multiple sclerosis prognosis: A 6-year follow-up

BACKGROUND

Serum neurofilament light chain (sNfL) and glial fibrillary acidic protein (sGFAP) are promising biomarkers that might be associated with clinical and radiological markers of multiple sclerosis (MS) severity. However, it is not known whether they can accurately identify patients at risk of disability progression in the medium and long term.

OBJECTIVES

We wanted to determine the association between sNfL and sGFAP, Expanded Disability Status Scale score changes, and conversion to secondary progressive MS (SPMS) in a cohort of 133 patients with relapsing remitting MS.

METHODS

Blood samples were collected at inclusion to measure SNfL and sGFAP by single molecule array and their prognostic value was assessed using a linear mixed model.

RESULTS

In this cohort, 37 patients (27.8 % of 133) experienced disability progression and 12 patients (9.0 %) converted to SPMS during the follow-up (mean follow-up duration: 6.4 years). Only sNfL (p = 0.03) was associated with conversion to SPMS, and neither SNfL nor sGFAP was associated with disability progression.

CONCLUSION

Serum NfL and GFAP do not seem to accurately predict MS outcome in the long term. More studies are needed to determine how serum biomarkers, associated with other clinical and MRI biomarkers, might be used to improve MS prognostication.

Combined Physiotherapy and Cognitive Behavioral Therapy for Functional Movement Disorders: A Randomized Clinical Trial

Importance

Functional movement disorders (FMDs) are frequent and disabling neurological disorders with a substantial socioeconomic impact. Few randomized studies have analyzed the effectiveness of combined physiotherapy and psychotherapy in patients' quality of life.

Objective

To assess the efficacy of multidisciplinary treatment (physiotherapy plus cognitive behavioral therapy) in FMDs.

Design, Setting, and Participants

This was a parallel, rater-blinded, single-center, randomized clinical trial. Recruitment took place from June 2022 to April 2023, and follow-up visits were performed at months 3 and 5, concluding in October 2023. Participants were recruited from a national referral center for movement disorders: the Movement Disorders Unit from the Hospital Universitario Virgen Rocio in Seville, Spain. Patients had to be 18 years or older with a confirmed FMD diagnosis and capable of giving consent to participate. Patients who did not meet eligibility criteria or refused to participate were excluded. Any uncontrolled psychiatric disorder was considered an exclusion criterion.

Interventions

Patients were randomly assigned, in a ratio of 1:1 to multidisciplinary treatment (physiotherapy plus cognitive behavioral therapy), or a control intervention (psychological support intervention).

Main Outcomes and Measures

Primary outcomes: between-group differences in changes from baseline to month 3 and month 5 in patients' quality of life (EQ-5D-5L score: EQ Index and EQ visual analog scale [EQ VAS]; and 36-Item Short-Form Survey Physical Component Summary [SF-36 PCS] and SF-36 Mental Component Summary [MCS]). Linear mixed models were applied, controlling by baseline severity and applying Bonferroni correction.

Results

Of 70 patients screened with an FMD, 40 were enrolled (mean [SD] age, 43.5 [12.8] years; age range, 18-66 years; 32 female [80%]; mean [SD] age at FMD onset, 38.4 [12.1] years), and 38 completed all the follow-up visits and were included in the analysis for primary outcomes. Multidisciplinary treatment improved SF-36 PCS with a mean between-group difference at 3 months of 4.23 points (95% CI, -0.9 to 9.4 points; P = .11) and a significant mean between-group difference at 5 months of 5.62 points (95% CI, 2.3-8.9 points; P < .001), after multiple-comparisons adjustment. There were no significant differences in other quality-of-life outcomes such as SF-36 MCS (mean between-group difference at 3 and 5 months: 0.72 points; 95% CI, -5.5 to 7.0 points; P = .82 and 0.69 points; 95% CI, 2.3-8.9 points; P = .83, respectively), EQ VAS (9.34 points; 95% CI, -0.6 to 19.3 points; P = .07 and 13.7 points; 95% CI, -1.7 to 29.0 points; P = .09, respectively) and EQ Index (0.001 point; 95% CI, -0.1 to 0.1 point; P = .98 and 0.08 points; 95% CI, 0-0.2 points; P = .13, respectively). At months 3 and 5, 42% and 47% of patients, respectively, in the multidisciplinary group reported improved health using the EQ-5D system, compared with 26% and 16% of patients, respectively, in the control group.

Conclusions and Relevance

Results show that multidisciplinary treatment (physiotherapy plus cognitive behavioral therapy) effectively improves FMD symptoms and physical aspects of patients' quality of life. Further studies must be performed to evaluate the potential cost-effectiveness of this approach in FMD.

Trial Registration

ClinicalTrials.gov Identifier: NCT05634486.

Age at separation, residential mobility, and depressive symptoms among twins in late adolescence and young adulthood: a FinnTwin12 cohort study

BACKGROUND

Separating with close siblings and leaving the parental home at an early age represents a major life event for an adolescent (reflected by age at separation in a twin pair) and may predispose them to poor mental health. This study aims to examine the association of age at separation and residential mobility on depressive symptoms in late adolescence and young adulthood and to explore possible underlying genetic effects.

METHODS

Residential mobility consisted of the number and total distance of moves before age 17. Based on 3071 twins from the FinnTwin12 cohort, we used linear regression to assess the association of age at separation and residential mobility with General Behavior Inventory (GBI) scores at age 17 and in young adulthood. A higher GBI score indicated more depressive symptoms occurred. Then, the mixed model for repeated measures (MMRM) was used to visualize the scores' trajectory and test the associations, controlling for "baseline" state. Twin analyses with a bivariate cross-lagged path model were performed between the difference in GBI scores, between cotwins, and separation status for the potential genetic influence.

RESULTS

Compared to twins separated before age 17, twins who separated later had significantly lower GBI scores at age 17 and in young adulthood. In MMRM, separation at a later age and a higher number of moves were associated with a higher GBI score in young adulthood. A small genetic effect was detected wherein GBI within-pair differences at age 17 were associated with separation status before age 22 (coefficient: 0.01).

CONCLUSION

The study provides valid evidence about the influence of siblings and family on depressive symptoms in later adolescence and young adulthood while finding some evidence for a reverse direction effect. This suggests more caution in the interpretation of results. A strong association between residential mobility and depressive symptoms was affirmed, although further detailed research is needed.

Brain responses to intermittent fasting and the healthy living diet in older adults

Diet may promote brain health in metabolically impaired older individuals. In an 8-week randomized clinical trial involving 40 cognitively intact older adults with insulin resistance, we examined the effects of 5:2 intermittent fasting and the healthy living diet on brain health. Although intermittent fasting induced greater weight loss, the two diets had comparable effects in improving insulin signaling biomarkers in neuron-derived extracellular vesicles, decreasing the brain-age-gap estimate (reflecting the pace of biological aging of the brain) on magnetic resonance imaging, reducing brain glucose on magnetic resonance spectroscopy, and improving blood biomarkers of carbohydrate and lipid metabolism, with minimal changes in cerebrospinal fluid biomarkers for Alzheimer's disease. Intermittent fasting and healthy living improved executive function and memory, with intermittent fasting benefiting more certain cognitive measures. In exploratory analyses, sex, body mass index, and apolipoprotein E and SLC16A7 genotypes modulated diet effects. The study provides a blueprint for assessing brain effects of dietary interventions and motivates further research on intermittent fasting and continuous diets for brain health optimization. For further information, please see ClinicalTrials.gov registration: NCT02460783.

The Effects of Peri-Operative Adverse Events on Clinical and Patient-Reported Outcomes After Surgery for Degenerative Cervical Myelopathy: An Observational Cohort Study from the Canadian Spine Outcomes and Research Network

BACKGROUND AND OBJECTIVES

There is a lack of data examining the effects of perioperative adverse events (AEs) on long-term outcomes for patients undergoing surgery for degenerative cervical myelopathy. We aimed to investigate associations between the occurrence of perioperative AEs and coprimary outcomes: (1) modified Japanese Orthopaedic Association (mJOA) score and (2) Neck Disability Index (NDI) score.

METHODS

We analyzed data from 800 patients prospectively enrolled in the Canadian Spine Outcomes and Research Network multicenter observational study. The Spine AEs Severity system was used to collect intraoperative and postoperative AEs. Patients were assessed at up to 2 years after surgery using the NDI and the mJOA scale. We used a linear mixed-effect regression to assess the influence of AEs on longitudinal outcome measures as well as multivariable logistic regression to assess factors associated with meeting minimal clinically important difference (MCID) thresholds at 1 year.

RESULTS

There were 167 (20.9%) patients with minor AEs and 36 (4.5%) patients with major AEs. The occurrence of major AEs was associated with an average increase in NDI of 6.8 points (95% CI: 1.1-12.4, P = .019) and reduction of 1.5 points for mJOA scores (95% CI: -2.3 to -0.8, P < .001) up to 2 years after surgery. Occurrence of major AEs reduced the odds of patients achieving MCID targets at 1 year after surgery for mJOA (odds ratio 0.23, 95% CI: 0.086-0.53, P = .001) and for NDI (odds ratio 0.34, 95% CI: 0.11-0.84, P = .032).

CONCLUSION

Major AEs were associated with reduced functional gains and worse recovery trajectories for patients undergoing surgery for degenerative cervical myelopathy. Occurrence of major AEs reduced the probability of achieving mJOA and NDI MCID thresholds at 1 year. Both minor and major AEs significantly increased health resource utilization by reducing the proportion of discharges home and increasing length of stay.