Association of the 36-Item Short Form Health Survey Physical Component Summary Score With Patient Satisfaction and Improvement 2 Years After Total Knee Arthroplasty

Efficacy and underlying mechanisms of three-circle post standing qigong on insomnia in college students: a four-arm, double-blind, randomized controlled trial protocol

BACKGROUND

Insomnia is common in college students, but its impact on health and wellbeing is often neglected. Enhancing sleep quality through targeted interventions could improve overall health and reduce the risk of consequent co-morbidities and mental health problems. Qigong exercises have been shown to significantly improve sleep quality and relieve insomnia. Three-circle Post Standing (TCPS) can help integrate body, breath, and mind, a fundamental principle of Qigong that promotes holistic wellbeing. In this clinical trial, we aim to (1) evaluate the feasibility, safety, and therapeutic efficacy of administering TCPS to improve sleep quality and quality of life in college students with insomnia; (2) explore the neurophysiological mechanisms underlying the mind adjustments mediated by TCPS in insomnia; (3) investigate body and breath pathophysiology mediated by TCPS in insomnia; and (4) assess the long-term efficacy of TCPS in terms of sleep quality and quality of life.

METHODS

This will be a prospective, parallel, four-arm, double-blind randomized controlled trial to investigate the effects and underlying mechanisms of TCPS on college students with insomnia. One hundred college students meeting diagnostic criteria for insomnia will be randomly assigned to receive either 14 weeks of standardized TCPS training (two weeks of centralized training followed by 12 weeks of supervised training) or sham-control Post Standing training. Efficacy outcomes including sleep quality, quality of life, neurophysiological assessments, plantar pressure, biomechanical balance, and physical measures will be collected at baseline, eight weeks (mid-point of supervised training), and 14 weeks (end of supervised training). Sleep quality and quality of life will also be evaluated during the four- and eight-week follow-up.

DISCUSSION

This trial will be an important milestone in the development of new therapeutic approaches for insomnia and should be easily implementable by college students with insomnia. The neuro- and pathophysiological assessments will provide new insights into the mechanisms underlying TCPS.

CLINICAL TRIAL REGISTRATION

This trial has been registered in the China Clinical Trials Registry (registration number: ChiCTR2400080763).

Functional decline in older breast cancer survivors treated with and without chemotherapy and non-cancer controls: results from the Hurria Older PatiEnts (HOPE) prospective study

PURPOSE

This study aimed to assess whether physical functional decline in older women with early-stage breast cancer is driven by cancer, chemotherapy, or a combination of both.

METHODS

We prospectively sampled three groups of women aged ≥ 65: 444 with early-stage breast cancer receiving chemotherapy (BC Chemo), 98 with early-stage breast cancer not receiving chemotherapy (BC Control), and 100 non-cancer controls (NC Control). Physical function was assessed at two timepoints (T1 [baseline] and T2 [3, 4, or 6 months]) using the Physical Functioning Subscale (PF-10) of the RAND 36-item Short Form. The primary endpoint was the change in PF-10 scores from T1 to T2, analyzed continuously and dichotomously (Yes/No, with "yes" indicating a PF-10 decline > 10 points, i.e., a substantial and clinically meaningful difference).

RESULTS

Baseline PF-10 scores were similar across all groups. The BC Chemo group experienced a significant decline at T2, with a median change in PF-10 of -5 (interquartile range [IQR], -20, 0), while BC Control and NC Control groups showed a median change of 0 (IQR, -5, 5; p < 0.001). Over 30% of BC Chemo participants had a substantial decline in PF-10 vs. 8% in the BC Control and 5% in the NC Control groups (p < 0.001).

CONCLUSION

In this cohort of older adults with early-stage breast cancer, the combination of breast cancer and chemotherapy contributes to accelerated functional decline. Our findings reinforce the need to develop interventions aimed at preserving physical function, particularly during and after chemotherapy.

IMPLICATIONS FOR CANCER SURVIVORS

The high prevalence of accelerated functional decline in older women undergoing breast cancer chemotherapy underscores the urgency to develop interventions aimed at preserving physical function and improving health outcomes.

CLINICAL TRIAL

NCT01472094, Hurria Older PatiEnts (HOPE) with Breast Cancer Study.

Development and preliminary evaluation of the Comprehensive Health Self-Assessment Questionnaire (CHSAQ) for individuals in the Chinese People Liberation Army

OBJECTIVE

There is currently no widely accepted multidimensional health assessment questionnaire for individuals in the Chinese People Liberation Army (PLA). This study developed a multidimensional health survey questionnaire (Comprehensive Health Self-Assessment Questionnaire, CHSAQ) suitable for personnel in the PLA and conducted a preliminary examination of its reliability, validity, and discriminative ability.

METHODS

After 183 items from 32 dimensions were selected to form the initial version of the CHSAQ, three groups of soldiers were selected from May 2022 to April 2023 and completed three survey rounds (with 183, 131, and 55 valid items). The items were screened based on classic test theory. After screening, the final questionnaire entries were formed, the structure of the questionnaire was explored through exploratory factor analysis and confirmatory factor analysis, and its reliability, structural validity, and discriminative ability were evaluated.

RESULTS

The final questionnaire consisted of 8 dimensions and 55 items on job satisfaction, anxiety and depression, daily activities, physical function, the otolaryngology system, the integumentary system, sleep disorders, and the visual system. The total cumulative variance contribution rate was 64.648% according to exploratory factor analysis. According to the confirmatory factor analysis, the normed fit index (NFI) was 0.880, and the comparison fit index (CFI) was 0.893 (close to 0.90). The Cronbach's α coefficient of the total questionnaire was 0.970, the split half reliability coefficient was 0.937, and the retest reliability coefficient was 0.902. The results are presented as different pairwise comparisons.

CONCLUSION

Our study developed a self-report questionnaire for evaluating the comprehensive health status of personnel in the PLA in accordance with the standard procedure for questionnaire development. Our findings also showed that the CHSAQ for individuals in the PLA has good reliability and structural validity.

Global mapping of institutional and hospital-based (Level II-IV) arthroplasty registries: a scoping review

PURPOSE

Four joint arthroplasty registries (JARs) levels exist based on the recorded data type. Level I JARs are national registries that record primary data. Hospital or institutional JARs (Level II-IV) document further data (patient-reported outcomes, demographic, radiographic). A worldwide list of Level II-IV JARs must be created to effectively assess and categorize these data.

METHODS

Our study is a systematic scoping review that followed the PRISMA guidelines and included 648 studies. Based on their publications, the study aimed to map the existing Level II-IV JARs worldwide. The secondary aim was to record their lifetime, publications' number and frequency and recognise differences with national JARs.

RESULTS

One hundred five Level II-IV JARs were identified. Forty-eight hospital-based, 45 institutional, and 12 regional JARs. Fifty JARs were found in America, 39 in Europe, nine in Asia, six in Oceania and one in Africa. They have published 485 cohorts, 91 case-series, 49 case-control, nine cross-sectional studies, eight registry protocols and six randomized trials. Most cohort studies were retrospective. Twenty-three per cent of papers studied patient-reported outcomes, 21.45% surgical complications, 13.73% postoperative clinical and 5.25% radiographic outcomes, and 11.88% were survival analyses. Forty-four JARs have published only one paper. Level I JARs primarily publish implant revision risk annual reports, while Level IV JARs collect comprehensive data to conduct retrospective cohort studies.

CONCLUSIONS

This is the first study mapping all Level II-IV JARs worldwide. Most JARs are found in Europe and America, reporting on retrospective cohorts, but only a few report on studies systematically.

Minimum Clinically Important Difference (MCID) and Patient Acceptable Symptomatic State (PASS) Applied to the SF-36 in Patients Who Underwent Arthroscopic Rotator Cuff Repair

The 36-Item Short-Form Health Survey questionnaire (SF-36) is a reliable tool to assess the health-related quality of life of patients. If a mean difference between pre-operative evaluation and final follow-up is found to be statistically significant, then the change in score is not random. However, a statistically significant mean change may not correspond to a clinical amelioration for the patient or mean that the patient's state of health is to be considered acceptable. For this reason, interest in the concepts of minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) has grown within recent years. The goal of the present work of research was to determine the MCID and PASS values for the SF-36 in patients who received rotator cuff repair (RCR). Forty-six patients (18 women and 28 men, mean age 58.5 ± 12.9) previously diagnosed with rotator cuff disease were enrolled. All of these patients underwent RCR. They were evaluated pre-operatively and six months after the surgical intervention as a final follow-up. The SF-36 questionnaire was assessed at each evaluation. The MCID cut-offs of the total, physical, and mental dimensions of the SF-36 for patients who underwent RCR were 23.1, 32.5, and 18.1, respectively. A 23.1 improvement in the SF-36 score at six months following RCR can be correlated with patients having reached a clinically significant improvement in health status. If 81.9 or more is attained in the SF-36 score after surgical repair, the symptom state can be judged as satisfactory by the majority of patients.

Association of Days Alive and at Home at Day 90 After Intensive Care Unit Admission With Long-term Survival and Functional Status Among Mechanically Ventilated Patients

IMPORTANCE

Many conventional end points in randomized clinical trials of interventions for critically ill patients do not account for patient-centered concerns such as time at home, physical function, and quality of life after critical illness.

OBJECTIVE

To establish whether days alive and at home at day 90 (DAAH90) is associated with long-term survival and functional outcomes in mechanically ventilated patients.

DESIGN, SETTING, AND PARTICIPANTS

The RECOVER prospective cohort study was conducted from February 2007 to March 2014, using data from 10 intensive care units (ICUs) in Canada. Patients were included in the baseline cohort if they were aged 16 years or older and underwent invasive mechanical ventilation for 7 or more days. The follow-up cohort analyzed here comprised RECOVER patients who were alive and had functional outcomes ascertained at 3, 6, and 12 months. Secondary data analysis occurred from July 2021 to August 2022.

EXPOSURES

Composite of survival and days alive and at home at day 90 after ICU admission (DAAH90).

MAIN OUTCOMES AND MEASURES

Functional outcomes at 3, 6, and 12 months were evaluated with the Functional Independence Measure (FIM), the 6-Minute Walk Test (6MWT), the Medical Research Council (MRC) Scale for Muscle Strength, and the 36-Item Short Form Health Survey physical component summary (SF-36 PCS). Mortality was evaluated at 1 year from ICU admission. Ordinal logistic regression was used to describe the association between DAAH90 tertiles and outcomes. Cox proportional hazards regression models were used to examine the independent association of DAAH90 tertiles with mortality.

RESULTS

The baseline cohort comprised 463 patients. Their median age was 58 years (IQR, 47-68 years), and 278 patients (60.0%) were men. In these patients, Charlson Comorbidity Index score, Acute Physiology and Chronic Health Evaluation II score, ICU intervention (eg, kidney replacement therapy or tracheostomy), and ICU length of stay were independently associated with lower DAAH90. The follow-up cohort comprised 292 patients. Their median age was 57 years (IQR, 46-65 years), and 169 patients (57.9%) were men. Among patients who survived to day 90, lower DAAH90 was associated with higher mortality at 1 year after ICU admission (tertile 1 vs tertile 3: adjusted hazard ratio [HR], 0.18 [95% CI, 0.07-0.43]; P < .001). At 3 months of follow-up, lower DAAH90 was independently associated with lower median scores on the FIM (tertile 1 vs tertile 3, 76 [IQR, 46.2-101] vs 121 [IQR, 112-124.2]; P = .04), 6MWT (tertile 1 vs tertile 3, 98 [IQR, 0-239] vs 402 [IQR, 300-494]; P < .001), MRC (tertile 1 vs tertile 3, 48 [IQR, 32-54] vs 58 [IQR, 51-60]; P < .001), and SF-36 PCS (tertile 1 vs tertile 3, 30 [IQR, 22-38] vs 37 [IQR, 31-47]; P = .001) measures. Among patients who survived to 12 months, being in tertile 3 vs tertile 1 for DAAH90 was associated with higher FIM score at 12 months (estimate, 22.4 [95% CI, 14.8-30.0]; P < .001), but this association was not present for ventilator-free days (estimate, 6.0 [95% CI, -2.2 to 14.1]; P = .15) or ICU-free days (estimate, 5.9 [95% CI, -2.1 to 13.8]; P = .15) at day 28.

CONCLUSIONS AND RELEVANCE

In this study, lower DAAH90 was associated with greater long-term mortality risk and worse functional outcomes among patients who survived to day 90. These findings suggest that the DAAH90 end point reflects long-term functional status better than standard clinical end points in ICU studies and may serve as a patient-centered end point in future clinical trials.

Preoperative Oswestry Disability Index Cannot Reliably Predict Patient Satisfaction After Single and Double Level Lumbar Transforaminal Interbody Fusion Surgery

Introduction

The role of patient-reported outcomes in preoperative assessment is not well studied. There is recent interest in studying whether Patient-reported outcomes scores can be used either independently, or in conjunction with clinical findings, in the assessment of patients for surgery.

Aims

To investigate if improvement in clinically significant scores correlate with post-operative patient satisfaction in 1-2 level transforaminal lumbar interbody fusion (TLIF) surgery. We also aim to define a threshold Oswestry Disability Index (ODI) which correlate with achieving post-operative MCID and patient satisfaction.

Methods

1001 patients who underwent single or double level TLIF (Minimally invasive and Open) in our institution with at least 2 years follow up were included in this study. We studied self-reported measures including patient satisfaction and ODI score.

Results

At 2-year follow-up, the overall mean ODI score improved from 49.7 ± 18.3 to 13.9 ± 15.2 (P < 0.001) with 74.6% of patients meeting the MCID. Patient satisfaction was achieved in 95.3% of all patients. In the MIS group, the preoperative cut-off was determined to be 37.2 at maximal Youden index associated with AUC of 0.72 (95% CI 0.65-0.86). In the open group, the preoperative cut-off was determined to be 37.2 at maximal Youden index associated with AUC of 0.70 (95% CI 0.62-0.77). Using the preoperative cut-offs found, there was no significant difference in patient satisfaction in both MIS and open groups.

Conclusions

Overall, our patients undergoing TLIF had good 2-year ODI score improvement and patient satisfaction after surgery. While meeting the MCID for ODI score correlates with patients' satisfaction postoperatively, 75% of patients not meeting the MCID for ODI score remained satisfied with the surgery. We are unable to define a threshold pre-operative ODI which correlates with achieving post-operative MCID and patient satisfaction.

Menopausal symptoms and quality of life in female survivors treated with hematopoietic stem cell transplantation

OBJECTIVES

To assess the severity of menopausal symptoms and the correlation among different quality of life questionnaires and compare the quality of life of patients who underwent hematopoietic stem cell transplantation (HSCT) for hematological disorders with the norm group in order to facilitate personalized and directed therapeutic intervention for patients.

METHODS

We recruited women who had premature ovarian failure (POF) after HSCT for hematologic diseases in the gynecological endocrinology outpatient clinic of Peking University People's Hospital. Women with HSCT were included in the study if they had 6 months of spontaneous amenorrhea with serum follicle-stimulating hormone levels greater than 40 mIU/mL taken 4 weeks apart. The patients who had other causes of POF were excluded. During the survey, all women were required to fill out the questionnaires [Quality of Life Questionnaire (MENQOL), Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), and 36-item Short-Form (SF-36)] online. We analyzed the severity of menopausal symptoms, anxiety, and depression in Participants. In addition, differences on the SF-36 scale scores between the study group and norm groups were examined.

RESULTS

In total, 227 (93.41%) patients completed the survey and were analyzed. The severity of all symptoms is "none and mild" in MRS, MENQOL, GAD-7, and PHQ-9. On the MRS, the most common symptoms were irritability, physical and mental exhaustion, and sleep problems. The severest symptoms were sexual problems (53, 73.82%), followed by sleep problems (44, 19.38%) and mental and physical exhaustion (39, 17.18%). In the MENQOL, the most common symptoms were psychosocial and physical symptoms. The severest symptoms were sexual symptoms (35, 48.75%) followed by psychosocial symptoms (23, 10.13%). Moderate-severe scores were shown in 11.89% (27) and 18.72% (42) cases in the GAD-7 and PHQ-9, respectively. Based on SF-36, in comparison with the norm group, the HSCT participants had higher vitality scores and lower role physical, physical functioning, and role emotional scores aged 18-45. In addition, the HSCT participants had lower mental health scores aged 18-25, and lower general health scores aged 25-45. No strong correlation was observed between questionnaires in our study.

CONCLUSION

Overall, menopausal symptoms are milder in female patients after HSCT. There is no single scale that comprehensively assesses the patient's quality of life after HSCT. We need to assess the severity of various symptoms in patients using different scales.

Methodological Standards for the Design, Implementation, and Analysis of Randomized Trials in Cardiac Surgery: A Scientific Statement From the American Heart Association

Cardiac surgery presents specific methodological challenges in the design, implementation, and analysis of randomized controlled trials. The purposes of this scientific statement are to review key standards in cardiac surgery randomized trial design and implementation, and to provide recommendations for conducting and interpreting cardiac surgery trials. Recommendations include a careful evaluation of the suitability of the research question for a clinical trial, assessment of clinical equipoise, feasibility of enrolling a representative patient cohort, impact of practice variations on the safety and efficacy of the study intervention, likelihood and impact of crossover, and duration of follow-up. Trial interventions and study end points should be predefined, and appropriate strategies must be used to ensure adequate deliverability of the trial interventions. Every effort must be made to ensure a high completeness of follow-up; trial design and analytic techniques must be tailored to the specific research question and trial setting.

Predictors of two-year patient satisfaction following elective knee surgery

BACKGROUND

Patient satisfaction metrics are increasingly being utilized as tools to evaluate the quality of healthcare and affect reimbursements. The objectives of this study were to (1) identify factors associated with two-year patient satisfaction after elective knee surgery, (2) compare the Surgical Satisfaction Questionnaire-8 (SSQ-8) and a numeric satisfaction scale (NSS), and (3) determine if two-year patient satisfaction can be predicted based on preoperative factors.

METHODS

A total of 365 patients undergoing elective knee surgery at a single center were administered questionnaires to assess demographics, medical history, and various patient-reported outcomes preoperatively and at two years postoperatively. Patient satisfaction was measured at two years postoperatively with SSQ-8 and NSS. Bivariate and multivariate statistical analyses were performed to identify significant associations and independent predictors of satisfaction.

RESULTS

SSQ-8 and NSS scores were significantly correlated (r_s = 0.68, P < 0.0001). Lower SSQ-8 and NSS scores were associated with black race, higher BMI, more comorbidities, unemployment, smoking, higher ASA score, and greater Met Expectations (P < 0.05). Better scores on patient-based outcome measures and better improvement from baseline were significantly correlated with higher satisfaction on both SSQ-8 and NSS. Multivariable analysis identified greater Met Expectations and higher two-year Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference scores as independent predictors of greater SSQ-8 scores (adjusted r² = .52). Greater Met Expectations and better two-year PROMIS Social Satisfaction scores were independent predictors of NSS score (adjusted r² = .41). In contrast, when only preoperative variables were considered, the multivariable regression model accounted for only 14% of the variance in SSQ-8 and 6% of the variance in NSS.

CONCLUSION

While there are multiple preoperative factors that are associated with two-year patient satisfaction after knee surgery, those factors contribute relatively little to satisfaction. Meeting expectations and better patient-based outcomes at two years are more important.

A long-term cross-sectional study with modified forgotten joint score to assess the perception of artificial joint after total knee arthroplasty

BACKGROUND AND PURPOSE

The ultimate goal for an arthroplasty surgeon is to provide the patient a joint that feels more like a natural joint. The Modified Forgotten Joint Score (MFJS) is a newly introduced functional scoring system that has a superior ability to assess this property among arthroplasty patients. The objective of this study is to evaluate the long-term temporal association of the MFJS and total knee arthroplasty (TKA).

METHODS

We assessed 360 patients post TKA with MFJS questionnaire. The patient groups were distributed at follow-up intervals of 3 weeks (n = 55), 6 months (n = 45), 1 year (n = 57), 2 years (n = 40), 3 years (n = 49), 5 years (n = 49), 7 years (n = 39), and 10 years (n = 26). Higher score suggests a forgotten artificial joint.

RESULTS

Post-operative mean MFJS scores were 64.4 ± 7.6 at 3 weeks, 87.7 ± 5.6 at 6 months, 89.2 ± 3.1 at 1 year, 89.9 ± 2.6 at 2 years, 89.4 ± 3.2 at 3 years, 89.1 ± 4 at 5 years, 84.5 ± 8.8 at 7 years, and 82.7 ± 11.9 at 10 years. The score at 3 weeks was significantly lesser than the average scores at other follow-up intervals. The score at 6 months was significantly higher compared to the score at 10 years. The average score at 1 year, 2 years, 3 years, and 5 years were significantly higher compared to the average score at 7 years and 10 years.

CONCLUSION

The trend of the MFJS score was found to drastically improve from 3 weeks to 6 months and peak in 2 years after which the score tends to attain a plateau up to 5 years following which there is a decline in the score at 7- and 10-years post-surgery. Age did not have an influence on the variation in functional score in any of the follow-up groups. MFJS has a strong positive correlation with the well-recognised KOOS scoring system.

LEVEL OF EVIDENCE

IV.

Effect of Digoxin vs Bisoprolol for Heart Rate Control in Atrial Fibrillation on Patient-Reported Quality of Life: The RATE-AF Randomized Clinical Trial

IMPORTANCE

There is little evidence to support selection of heart rate control therapy in patients with permanent atrial fibrillation, in particular those with coexisting heart failure.

OBJECTIVE

To compare low-dose digoxin with bisoprolol (a β-blocker).

DESIGN, SETTING, AND PARTICIPANTS

Randomized, open-label, blinded end-point clinical trial including 160 patients aged 60 years or older with permanent atrial fibrillation (defined as no plan to restore sinus rhythm) and dyspnea classified as New York Heart Association class II or higher. Patients were recruited from 3 hospitals and primary care practices in England from 2016 through 2018; last follow-up occurred in October 2019.

INTERVENTIONS

Digoxin (n = 80; dose range, 62.5-250 μg/d; mean dose, 161 μg/d) or bisoprolol (n = 80; dose range, 1.25-15 mg/d; mean dose, 3.2 mg/d).

MAIN OUTCOMES AND MEASURES

The primary end point was patient-reported quality of life using the 36-Item Short Form Health Survey physical component summary score (SF-36 PCS) at 6 months (higher scores are better; range, 0-100), with a minimal clinically important difference of 0.5 SD. There were 17 secondary end points (including resting heart rate, modified European Heart Rhythm Association [EHRA] symptom classification, and N-terminal pro-brain natriuretic peptide [NT-proBNP] level) at 6 months, 20 end points at 12 months, and adverse event (AE) reporting.

RESULTS

Among 160 patients (mean age, 76 [SD, 8] years; 74 [46%] women; mean baseline heart rate, 100/min [SD, 18/min]), 145 (91%) completed the trial and 150 (94%) were included in the analysis for the primary outcome. There was no significant difference in the primary outcome of normalized SF-36 PCS at 6 months (mean, 31.9 [SD, 11.7] for digoxin vs 29.7 [11.4] for bisoprolol; adjusted mean difference, 1.4 [95% CI, -1.1 to 3.8]; P = .28). Of the 17 secondary outcomes at 6 months, there were no significant between-group differences for 16 outcomes, including resting heart rate (a mean of 76.9/min [SD, 12.1/min] with digoxin vs a mean of 74.8/min [SD, 11.6/min] with bisoprolol; difference, 1.5/min [95% CI, -2.0 to 5.1/min]; P = .40). The modified EHRA class was significantly different between groups at 6 months; 53% of patients in the digoxin group reported a 2-class improvement vs 9% of patients in the bisoprolol group (adjusted odds ratio, 10.3 [95% CI, 4.0 to 26.6]; P < .001). At 12 months, 8 of 20 outcomes were significantly different (all favoring digoxin), with a median NT-proBNP level of 960 pg/mL (interquartile range, 626 to 1531 pg/mL) in the digoxin group vs 1250 pg/mL (interquartile range, 847 to 1890 pg/mL) in the bisoprolol group (ratio of geometric means, 0.77 [95% CI, 0.64 to 0.92]; P = .005). Adverse events were less common with digoxin; 20 patients (25%) in the digoxin group had at least 1 AE vs 51 patients (64%) in the bisoprolol group (P < .001). There were 29 treatment-related AEs and 16 serious AEs in the digoxin group vs 142 and 37, respectively, in the bisoprolol group.

CONCLUSIONS AND RELEVANCE

Among patients with permanent atrial fibrillation and symptoms of heart failure treated with low-dose digoxin or bisoprolol, there was no statistically significant difference in quality of life at 6 months. These findings support potentially basing decisions about treatment on other end points.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02391337 and clinicaltrialsregister.eu Identifier: 2015-005043-13.