Practical guidance for engaging patients in health research, treatment guidelines and regulatory processes: results of an expert group meeting organized by the World Health Organization (WHO) and the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO)

Exploring facilitators and barriers for delivering person-centered care in a socio-economically diverse context: Perspectives of speech-language pathologists and audiologists

OBJECTIVE

The study aimed to explore facilitators and barriers in delivering person-centered care from the perspective of speech-language pathologists and audiologists in a socio- economically diverse workplace across micro, meso, and macro levels.

METHOD

A national cross-sectional e-survey was conducted among pooled speech-language pathologists and/or audiologists from South Africa. The e-survey included quantitative components to describe participant demographics which was analysed using descriptive and inferential statistics. The qualitative data was analyzed using metaphor and thematic analysis approaches to describe respondents' perspectives of barriers and facilitators in delivering person-centered care.

RESULTS

The e-survey was completed by 63 clinicians (36.5% Audiologists; 36.5% Speech-Language Therapists; 27.0% dually qualified Speech-Language Therapists and Audiologists) mostly between the ages of 26 to 35 years old (33.3%). Respondents were working in various settings including the public sector (41.3%), private sector (44.4%) and in academia (14.3%). Facilitators and barriers were identified within all three systems (macro, meso and micro). The metaphor analysis resulted in six categories: uncertainty of Person centered care; its essential nature; associated challenges; relational aspect; analogies referring to animals; and food-related analogies. Thematic analysis of open-ended questions revealed five barriers, with three relating to micro systems; i) clinician factors, ii) client factors, iii) clinician and client interaction, and two related to factors within the meso system; iv) resources, and v) workplace. Only two themes were identified as facilitators towards PCC, clinician factors (mirco) and workplace factors (meso).'

CONCLUSIONS

Insights gained from exploring Speech-Language Pathologists' and Audiologists' perceptions of implementing PCC in a socio-economically diverse setting highlight the need to address contextual (meso and macro systems) and personal (micro system) factors to promote and deliver PCC effectively. Notably, for the public sector, resources emerged as a major concern and barrier on the macro system level. Despite these challenges, the investigation revealed two noteworthy facilitators: clinician factors, at the micro level, and workplace factors, at the meso level. This nuanced understanding emphasizes the necessity of tailored interventions targeting both individual and systemic aspects to enhance the successful implementation of person-centered care.

PRACTICAL IMPLICATIONS

Strategies should focus on enhancing clinicians' communication skills, collaboration, and teamwork, as well as addressing resource limitations through the adaptation of tools and implementation of PCC ISO standards.

The effect of exercise therapy as a tool for preventing and treating musculoskeletal disorders among school-aged children: a randomised controlled trial

BACKGROUND

Children spend a lot of time in school, and there are many ergonomic hazards and postural malalignments that put children at greater risk of developing musculoskeletal disorders (MSDs). This study aimed to investigate the effect of exercise therapy on preventing and treating musculoskeletal disorders among school-aged children.

METHOD

This randomised controlled trial included 212 (121 boys and 91 girls) school-aged children aged 13-15 years assigned to treatment (n = 106) and prevention (n = 106) groups, where the treatment group contained individuals with MSDs and prevention group contained individuals without MSDs. In each group, half of the individuals received exercise therapy (50 min per session, four times per week, for an 8-week), and others continued their daily lives. MSDs and physical activity were assessed by the Teen Nordic Musculoskeletal Screening Questionnaire and the International Physical Activity Questionnaire-Short Form, respectively, at baseline and after the experimental protocol.

RESULTS

There was a statistically significant reduction in the frequency of MSDs in the treatment group and occurring MSDs in the prevention group (P ≤ .05). Also, there was significant improvement in all variables of walking, moderate physical activity, vigorous physical activity, and total in intervention groups spatially in students who received exercise therapy (P ≤ .05).

CONCLUSIONS

This study demonstrated the effectiveness of exercise therapy in reducing and preventing MSDs and improving physical activity levels among school-aged children aged 13-15 years.

TRIAL REGISTRATIONS

Ethical Committee of Shahrekord University (IR.SKU.REC.1401.022) (registration date: 31/05/2022). Clinical Trail Registration (IRCT20220705055375N1), (registration date: 29/07/2022).

Enhancing audiology students' understanding of person-centered care: insights from an multi-national virtual student conference

OBJECTIVE

This project sought to investigate the impact of a multi-national peer learning initiative in facilitating a student-led conference on person-centred care (PCC). The primary objective was to assess students' comprehension of PCC elements before and after engaging in the opportunity, with a concurrent evaluation of the efficacy of the opportunity.

DESIGN

A mixed-methods study protocol was followed. Following the conference, participants completed a four-part survey including (a) demographics, (b) retrospective pre-post Likert scale, (c) Likert rating of conference experience and (d) five open-ended questions.

STUDY SAMPLE

One hundred and four participants (92.4% female) with a mean age of 21 years (0.07 SD) participated in the study.

RESULTS

A significant difference in awareness pre-post conference was demonstrated across all topics (WSR, p < 0.001) with participants satisfied with the conference. Qualitative analysis revealed three main themes: (a) application of PCC; (b) perspectives of PCC; and () barriers to PCC; with nine sub-themes.

CONCLUSION

The conference was beneficial in enhancing students' awareness of topics and principles of PCC. Innovative pedagogical approaches should be considered in order to enhance healthcare education allowing future clinicians to better meet the dynamic needs of their clients.

Patients' preferences for fracture risk communication: the Risk Communication in Osteoporosis (RICO) study

The RICO study indicated that most patients would like to receive information regarding their fracture risk but that only a small majority have actually received it. Patients globally preferred a visual presentation of fracture risk and were interested in an online tool showing the risk.

PURPOSE

The aim of the Risk Communication in Osteoporosis (RICO) study was to assess patients' preferences regarding fracture risk communication.

METHODS

To assess patients' preferences for fracture risk communication, structured interviews with women with osteoporosis or who were at risk for fracture were conducted in 11 sites around the world, namely in Argentina, Belgium, Canada at Hamilton and with participants from the Osteoporosis Canada Canadian Osteoporosis Patient Network (COPN), Japan, Mexico, Spain, the Netherlands, the UK, and the USA in California and Washington state. The interviews used to collect data were designed on the basis of a systematic review and a qualitative pilot study involving 26 participants at risk of fracture.

RESULTS

A total of 332 women (mean age 67.5 ± 8.0 years, 48% with a history of fracture) were included in the study. Although the participants considered it important to receive information about their fracture risk (mean importance of 6.2 ± 1.4 on a 7-point Likert scale), only 56% (i.e. 185/332) had already received such information. Globally, participants preferred a visual presentation with a traffic-light type of coloured graph of their FRAX® fracture risk probability, compared to a verbal or written presentation. Almost all participants considered it important to discuss their fracture risk and the consequences of fractures with their healthcare professionals in addition to receiving information in a printed format or access to an online website showing their fracture risk.

CONCLUSIONS

There is a significant communication gap between healthcare professionals and patients when discussing osteoporosis fracture risk. The RICO study provides insight into preferred approaches to rectify this communication gap.

Diagnostic Value of Radiographic Singh Index Compared to Dual-Energy X-Ray Absorptiometry Scan in Diagnosing Osteoporosis: A Systematic Review

Objectives

Since various medications can control the rate of fractures and subsequent complications of osteoporosis, the early detection of the disease is crucial. This systematic study aimed to compare the diagnostic accuracy of Singh index (SI) with dual-energy X-ray absorptiometry (DEXA) as a benchmark standard for diagnosing osteoporosis.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) were utilized in the current study. A detailed search was carried out using PubMed and Scopus from inception to 30 May 2022. Examining quality of the studies was performed by the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2).

Results

A total of 22 studies were included. In general, 50% of the studies considered SI a poor screening tool for detecting osteoporosis due to a negligible inter-observer agreement between SI and DEXA or a poor correlation of SI with the bone mineral density (BMD) category or DEXA T-score. A moderate inter-observer agreement was reported for SI in 5 (55.6%) studies. Among the studies assessing the sensitivity and specificity of SI compared to DEXA (n=13), six studies estimated a low sensitivity for SI.

Conclusion

While there is supporting evidence indicating the potential usefulness of SI for predicting femoral neck fractures in individuals with suspected osteoporosis, numerous studies challenge its reliability and diagnostic value as a screening tool for identifying femoral neck osteoporosis. Further primary studies are required to verify the effectiveness of the SI index in identifying populations at risk of osteoporosis.

Novel 3D-printing bilayer GelMA-based hydrogel containing BP,β-TCP and exosomes for cartilage-bone integrated repair

The integrated repair of cartilage and bone involves the migration and differentiation of cells, which has always been a difficult problem to be solved. We utilize the natural biomaterial gelatin to construct gelatin methacryloyl (GelMA), a hydrogel scaffold with high cell affinity. GelMA is mixed with different components to print a bi-layer porous hydrogel scaffold with different modulus and composition in upper and lower layers through three-dimensional (3D) printing technology. The upper scaffold adds black phosphorus (BP) and human umbilical cord mesenchymal stem cells (hUMSCs) exosomes (exos) in GelMA, which has a relatively lower elastic modulus and is conducive to the differentiation of BMSCs into cartilage. In the lower scaffold, in addition to BP and hUMSCs exos,β-tricalcium phosphate (β-TCP), which has osteoconductive and osteoinductive effects, is added to GelMA. The addition ofβ-TCP significantly enhances the elastic modulus of the hydrogel scaffold, which is conducive to the osteogenic differentiation of bone marrow mesenchymal stem cells(BMSCs).In vitroexperiments have confirmed that the bi-layer scaffolds can promote osteogenesis and chondrogenic differentiation respectively. And in the rabbit cartilage-bone injury model, MRI and micro-CT results show that the 3D printed bi-layer GelMA composite scaffold has a repair effect close to normal tissue.

Empowerment and enablement and their associations with change in health-related quality of life after a supported osteoarthritis self-management programme - a prospective observational study

BACKGROUND

Osteoarthritis is a leading cause of disability worldwide. Current treatment supports coping strategies to improve health-related quality of life (HRQoL). The need to predict response to treatment has been raised to personalise care. This study aims to examine change in HRQoL from baseline to three and nine months follow-up after participating in a Supported Osteoarthritis Self-Management Programme (SOASP) and to examine if empowerment and/or enablement were associated with change in HRQoL after a SOASP.

METHODS

Patients participating in a SOASP were recruited consecutively between April 2016 and June 2018. The EQ-5D was used to measure HRQoL, the Swedish Rheumatic Disease Empowerment Scale (SWE-RES-23) (score range 1-5) to measure empowerment and the Patient Enablement Instrument (PEI) (score range 0-12) to measure enablement. The instruments were answered before (EQ-5D, SWE-RES-23) and after (EQ-5D, SWE-RES-23, PEI) the SOASP. A patient partner was involved in the research process to enhance the patient perspective. Changes in outcome were examined with paired sample t-test and standardized effect sizes (Cohen´s d). Multiple linear regression analysis was performed to assess potential associations.

RESULTS

One hundred forty-three patients participated in baseline measurement. Mean EQ-5D-5 L index score increased significantly from baseline to three months corresponding to a standardised effect size (Cohen´s d) of d = 0.43, 95% CI [0.24, 0.63] (n = 109), and from baseline to nine months d = 0.19, 95% CI [0.01, 0.37] (n = 119). The average EQ VAS score increased significantly from baseline to three months corresponding to a standardised effect size of d = 0.26, 95% CI [0.07, 0.45] (n = 109), and from baseline to nine months d = 0.18, 95% CI [0.00, 0.36] (n = 119). Neither SWE-RES-23 nor PEI at three months follow-up nor the change in the SWE-RES-23 score from baseline to three months follow-up were associated with change in either EQ-5D-5 L index (p > 0.05) or the EQ VAS (p > 0.05).

CONCLUSIONS

Health-related quality of life increased after participating in a SOASP. Empowerment and enablement as measured with the SWE-RES-23 and the PEI were not associated with change in HRQoL among patients participating in a SOASP.

TRIAL REGISTRATION

ClinicalTrials.gov. Identification number: NCT02974036. First registration 28/11/2016, retrospectively registered.

Investigating the predictors of perceived social support to control COVID-19: A qualitative study

Background

Considering the adverse effects of COVID-19 pandemic, the present study aimed to explore the barriers and facilitators of perceived social support to prevent the further spread of the disease.

Methods

In the present qualitative study, a content analysis was done. To this aim, 37 Iranian subjects who had active accounts on Instagram were initially invited to participate in the study. The data were collected through face-to-face (n = 25) and telephone conversations (n = 12). A purposive sampling was used and the data collection continued until data saturation. Finally, 41 interviews were held which took 17-48 min.

Results

The data analysis led to the extraction of two main categories, the barriers and facilitators of perceived social support, as well as 12 subcategories. Economic issues, familial factors, socio-cultural factors, personal and psychological factors, ineffective quarantine rules, and poor management were the main barriers to perceived social support. The facilitators were divided into six categories, including familial influences, personal factors, government support, and improved occupational, social, spiritual, and emotional condition.

Conclusion

The findings showed that a combination of environmental and social variables might influence the COVID-19 disease, either decreasing or increasing its spread. A sound knowledge of these variables, influenced by the social context and real-life experiences during the pandemic, allows to take the right measures and enrich training programs. The prevalence of the disease can be controlled by increasing environmental and social facilitators and decreasing the influence of barriers.

The Australian and New Zealand Society for Sarcopenia and Frailty Research (ANZSSFR) sarcopenia diagnosis and management task force: Findings from the consumer expert Delphi process

OBJECTIVES

To develop guidelines, informed by health-care consumer values and preferences, for sarcopenia prevention, assessment and management for use by clinicians and researchers in Australia and New Zealand.

METHODS

A three-phase Consumer Expert Delphi process was undertaken between July 2020 and August 2021. Consumer experts included adults with lived experience of sarcopenia or health-care utilisation. Phase 1 involved a structured meeting of the Australian and New Zealand Society for Sarcopenia and Frailty Research (ANZSSFR) Sarcopenia Diagnosis and Management Task Force and consumer representatives from which the Phase 2 survey was developed. In Phase 2, consumers from Australia and New Zealand were surveyed online with opinions sought on sarcopenia outcome priorities, consultation preferences and interventions. Findings were confirmed and disseminated in Phase 3. Descriptive statistical analyses were performed.

RESULTS

Twenty-four consumers (mean ± standard deviation age 67.5 ± 12.8 years, 18 women) participated in Phase 2. Ten (42%) identified as being interested in sarcopenia, 7 (29%) were health-care consumers and 6 (25%) self-reported having/believing they have sarcopenia. Consumers identified physical performance, living circumstances, morale, quality of life and social connectedness as the most important outcomes related to sarcopenia. Consumers either had no preference (46%) or preferred their doctor (40%) to diagnose sarcopenia and preferred to undergo assessments at least yearly (54%). For prevention and treatment, 46% of consumers preferred resistance exercise, 2-3 times per week (54%).

CONCLUSIONS

Consumer preferences reported in this study can inform the implementation of sarcopenia guidelines into clinical practice at local, state and national levels across Australia and New Zealand.

Interprofessional Collaboration in Complex Patient Care Transition: A Qualitative Multi-Perspective Analysis

Healthcare professionals often feel challenged by complex patients and the associated care needs during care transition. Interprofessional collaboration (IPC) is considered an effective approach in such situations. However, a fragmented healthcare system can limit IPC. This study explored experiences of Swiss healthcare professionals regarding complex patient care transition and the potential of IPC. Professionals from nursing, medicine, psychology, physiotherapy, dietetics and nutrition, social service, occupational therapy, and speech therapy were included. A qualitative between-method triangulation design was applied, with two focus group discussions and ten individual interviews. The combination of different data-collection methods allowed us to explore complex patient care transition and to systematically add perspectives of healthcare professionals from different care settings. Three main themes were identified: (1) Participants described their vision of an ideal complex patient care transition, i.e., the status they would like to see implemented; (2) participants reported challenges in complex patient care transition as experienced today; and (3) participants suggested ways to improve complex patient care transition by IPC. This study highlighted that healthcare professionals regarded IPC as an effective intervention to improve complex patient care transition. It emerged that sustainable implementation of IPC across care organizations is currently limited in Switzerland. In the absence of strong and direct promotion of IPC by the healthcare system, professionals in clinical practice can further promote IPC by finding hands-on solutions to overcome organizational boundaries.

Patients' experience with a community pharmacy fall prevention service

Background

Pharmacists can contribute to fall prevention, by offering services such as fall risk screenings, counselling, and medication reviews. Patient acceptance of the role of pharmacists in fall prevention is crucial.

Objectives

The aim of this study was to explore patients' experience with a community pharmacy fall prevention service.

Methods

Interviews were conducted with patients one month after they participated in a pharmacy fall prevention service, in the Netherlands. Patient inclusion criteria for the service were: age ≥ 70 years, use of ≥5 drugs including ≥1 fall risk-increasing drug. The service included a fall risk screening followed by counselling and a medication review. The semi-structured interview guide was based on the consolidated framework for implementation research and included the following topics: outcomes, patient's motivation, and contact with the pharmacy technician.

Results

Of the 91 participants of the fall prevention service, 87 patients were interviewed with a median age of 78.0 years (first quartile [Q1] - third quartile [Q3]: 74.0-84.75) and 46.3% were female. Many patients expressed positive feedback about receiving a medication review. Most patients whose medication was deprescribed expressed to be positive about this. Others were reassured about the appropriateness of their medication use. Patients reported that the service enhanced their awareness about fall prevention. Only a few patients were motivated to adapt their lifestyle. Patients appreciated the attention and contact.

Conclusions

Patients see a potential benefit for a community pharmacy falls prevention service, including a medication review. Patient education appeared to enhance their fall risk awareness.

Disease Burden and Treatment Preferences Amongst Postmenopausal Women with Severe Osteoporosis in Greece

OBJECTIVE

The objectives of this study were to elicit self-reported health status, quantify osteoporosis-related burden, and understand preferences for treatment attributes among postmenopausal women with severe osteoporosis in Greece.

METHODS

Postmenopausal women with self-reported severe osteoporosis, defined as having suffered at least one osteoporotic fracture and reporting a T-score of ≤-2.5, were asked to evaluate their health status, osteoporosis management, and disease-related physical, emotional, and financial burden. Participants were also asked to rate a series of treatment attributes and state their preference for unlabeled anabolic treatments, based on scenarios describing key treatment characteristics.

RESULTS

Approximately one third (31%) of the 186 participants who responded to the survey in full had been living with severe osteoporosis for more than 10 years. Three quarters of participants (72%) considered their overall quality of life (QoL) to be worse than it had been 10 years prior, and the vast majority (89%) attributed this deterioration to osteoporosis. Direct, out of pocket, disease-related costs of at least €100 per month were reported by 86% of participants. Patients attached the greatest value to a treatment that would decrease probability of future fractures, followed by increase in bone density, safety, and mode and frequency of administration. When asked to select their preferred treatment scenario between two anabolic treatments, 70% of participants opted for the scenario that shared treatment characteristics with romosozumab over a scenario that shared treatment characteristics with teriparatide.

CONCLUSION

Our study revealed that osteoporosis placed a considerable burden on QoL for postmenopausal women with severe osteoporosis in Greece. Patients reported valuing treatment efficacy, measured through reduction in future fractures and increase in bone density, and safety, as key treatment attributes.

Resolution of the consensus of the Russian Federation experts on the diagnosis and treatment of osteoarthritis, 2022

Osteoarthritis (OA) is the most common joint disease due to the increasing life expectancy of the world's population. Every 2nd patient over the age of 50 suffers from knee or hip OA, and this is directly related to the increased burden on healthcare. Accumulated data on the comorbid profile of patients with OA dictate the need to identify disease phenotypes in order to provide personalized care. Individual clinical manifestations of OA also require a differential approach: the pain treatment requires consideration of the patient's psycho-emotional profile and the possibility of involving nociceptive pathways in the process. However, due to the ambiguity of existing clinical guidelines, most experts note a number of difficulties in prescribing treatment for patients with OA.

The resolution presents an agreed opinion of experts on the algorithms for managing patients with OA, starting from the primary level, with the gradual involvement of related specialists. Some issues of a personalized approach are considered depending on the presence of comorbid pathology and the severity of individual symptoms of the disease. The prospects of the combined use of pharmacological and non-drug methods of treatment are noted; emphasis was placed on the importance of rehabilitation measures at the first level of medical care, provided to patients with OA, long before the development of structural changes.

The proposed algorithms for managing patients can be considered as the basis for future recommendations for managing patients with this pathology.

Recurrent Respiratory Papillomatosis: Quality of Life Data from an International Patient Registry

OBJECTIVES

Quality of life studies in recurrent respiratory papillomatosis (RRP) have traditionally relied upon clinician-designed survey instruments. This study's objective is to report quality of life outcomes from a patient-designed questionnaire.

METHODS

Patients who provided health information and completed a quality of life questionnaire were identified from the RRPF-CoRDS patient registry. Demographic, clinical, and quality of life measures were collected. Means and standard deviations were calculated for continuous data, and frequencies and percentages were calculated for categorical data. Outcomes for patients with juvenile-onset RRP (JORRP) and adult-onset RRP (AORRP) were compared using Student's t-tests for continuous data and χ² analyses for categorical data.

RESULTS

Seventy-three patients with RRP were identified (JORRP: 32; AORRP: 41). Common clinical symptoms included raspy voice (78.1%) and dyspnea (61.6%). The majority (97.3%) of patients reported feeling debilitated by their diagnosis, and 94.5% of patients reported avoiding participation in career and/or social activities due to their voice quality. Due to their RRP, 65.7% reported missing at least five work days each month. Social anxiety was reported in 79.5% of patients, though only 28.8% of the cohort reported utilizing mental health services. The median (range) lifetime number of surgeries received was 20 (1 - 3). Most patients (57.5%) reported paying at least 5% of their annual income towards RRP-related medical care.

CONCLUSION

RRP presents high mental and fiscal burden. Our results highlight data from a quality of life questionnaire designed by RRP patients, and may help to elucidate potential disconnects between what clinicians and RRP patients consider most impactful.

LEVEL OF EVIDENCE

4 Laryngoscope, 2022.

Management of hand osteoarthritis: from an US evidence-based medicine guideline to a European patient-centric approach

Hand osteoarthritis is the most common joint condition and is associated with significant morbidity. It is of paramount importance that patients are thoroughly assessed and examined when complaining of hand stiffness, pain, deformity or disability and that the patient's concerns and expectations are addressed by the healthcare professional. In 2019 the American College of Rheumatology and Arthritis Foundation (ACR/AF) produced guidelines which included recommendations for the treatment of hand osteoarthritis. An ESCEO expert working group (including patients) was convened and composed this paper with the aim to assess whether these guidelines were appropriate for the treatment of hand osteoarthritis therapy in Europe and whether they met with the ESCEO patient-centered approach. Indeed, patients are the key stakeholders in healthcare and eliciting the patient's preference is vital in the context of an individual consultation but also for informing research and policy-making. The patients involved in this working group emphasised the often-neglected area of aesthetic changes in hand osteoarthritis, importance of developing pharmacological therapies which can alleviate pain and disability and the need of the freedom to choose which approach (out of pharmacological, surgical or non-pharmacological) they wished to pursue. Following robust appraisal, it was recommended that the ACR/AF guidelines were suitable for a European context (as described within the body of the manuscript) and it was emphasised that patient preferences are key to the success of individual consultations, future research and future policy-making.

Multimodal Multidisciplinary Management of Patients with Moderate to Severe Pain in Knee Osteoarthritis: A Need to Meet Patient Expectations

Knee osteoarthritis (OA) is one of the most common and disabling medical conditions. In the case of moderate to severe pain, a single intervention may not be sufficient to allay symptoms and improve quality of life. Examples include first-line, background therapy with symptomatic slow-acting drugs for OA (SYSADOAs) or non-steroidal anti-inflammatory drugs (NSAIDs). Therefore, the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) performed a review of a multimodal/multicomponent approach for knee OA therapy. This strategy is a particularly appropriate solution for the management of patients affected by knee OA, including those with pain and dysfunction reaching various thresholds at the different joints. The multimodal/multicomponent approach should be based, firstly, on different combinations of non-pharmacological and pharmacological interventions. Potential pharmacological combinations include SYSADOAs and NSAIDs, NSAIDs and weak opioids, and intra-articular treatments with SYSADOAs/NSAIDs. Based on the available evidence, most combined treatments provide benefit beyond single agents for the improvement of pain and other symptoms typical of knee OA, although further high-quality studies are required. In this work, we have therefore provided new, patient-centered perspectives for the management of knee OA, based on the concept that a multimodal, multicomponent, multidisciplinary approach, applied not only to non-pharmacological treatments but also to a combination of the currently available pharmacological options, will better meet the needs and expectations of patients with knee OA, who may present with various phenotypes and trajectories.

Patient Preferences for Rituximab Additional Risk Minimization Measures: Results From an International Online Survey

OBJECTIVE

Patients' opinions are essential in optimizing risk minimization measures (RMMs) because they bring their real-life experience of disease management and medicines' use into the regulatory assessments. The aim of the survey launched in 2018 by the European Medicines Agency, in collaboration with the Pharmacovigilance Risk Assessment Committee, was to consult targeted patient groups treated with rituximab for nononcology indications to evaluate their preferences on how to receive information on progressive multifocal leukoencephalopathy and (serious) infections. Additional RMMs such as educational materials for physicians and patients including a patient alert card (PAC) and a patient brochure (PB) are in place to minimize these risks.

METHODS

A question-based online survey in English created on the EU-Survey platform and disseminated primarily via relevant European patient organizations.

RESULTS

Most patients (47 of 61) had knowledge of these potential adverse effects. Mostly, they were informed by a healthcare professional. Both a PAC and a PB were supported as useful tools to raise awareness of these adverse effects and thus minimize the potential risks among patients. Where the participants had to choose only 1 of these educational materials, 43 of them preferred a PAC, a shorted description that is always held by the patient and reaches the relevant healthcare professional when needed.

CONCLUSIONS

Collecting patients' preferences supports periodic assessment of additional RMMs and increase transparency of regulatory processes. Considering the limitations of this initial survey, further investigation is needed to generalize the results into patients' safety outcomes.

Elaborate the Mechanism of Ancient Classic Prescriptions (Erzhi Formula) in Reversing GIOP by Network Pharmacology Coupled with Zebrafish Verification

Osteoporosis is a degenerative disease that endangers human health. At present, chemical drugs used for osteoporosis have serious side effects. Therefore, it is valuable to search herbs with high safety and good curative effect in antiosteoporosis. Erzhi formula (EZF), an ancient classic compound, has been reported to have a beneficial effect in antiosteoporosis, but its mechanism is unclear. In this paper, the active compounds of EZF were found in Systems Pharmacology Database, and gene targets related to osteoporosis were obtained in GeneCards. The GO functional and KEGG pathway enrichment analysis were performed by Metascape. The network of “components-targets-signal pathway” was constructed by Cytoscape. Next, molecular docking between the active components and hub genes related to the PI3K-Akt signaling pathway was conducted by Autodock. In the verification experiment, the zebrafish induced by prednisolone (PNSL) was used to reproduce glucocorticoid-induced osteoporosis (GIOP) model, and then the reversal effects of EZF were systematically evaluated according to the behavior, skull staining area, bone mineralization area (BMA), average optical density (AOD), and cumulative optical density (COD). Finally, it was shown that 24 components in EZF could regulate 39 common gene targets to exert antiosteoporosis effect. Besides, the main regulatory mechanisms of EZF were 4 signaling pathways: PI3K-Akt, JAK-STAT, AGE-RAGE, and cancer pathway. In PI3K-Akt signaling pathway, wedelolactone, dimethyl wedelolactone, specnuezhenide, ursolic acid, acacetin, beta-sitosterol, apigenin, and kaempferol can bind tightly with EGF, IL-2, and IL-4 genes. Compared with the model group, the moving distance, swimming speed, and cumulative swimming time of zebrafish in EZF group were significantly increased (P < 0.05). Meanwhile, the BMA and COD of zebrafish were significantly improved after the intervention of EZF (P < 0.05). In summary, the 24 components of EZF exert their antiosteoporosis effects by regulating 39 related gene targets, among which the PI3K signaling pathway is crucial. EZF can promote bone formation and reversed GIOP through “multicomponent/multitarget/multipathway” and the medium dose of EZF may be the most suitable concentration for the treatment of GIOP in zebrafish model.

Ferroptosis: A New Regulatory Mechanism in Osteoporosis

Osteoporosis can be caused by a multitude of factors and is defined by a decrease in bone density and mass caused by the destruction of bone microstructure, resulting in increased bone brittleness. Thus, it is a systemic bone disease in which patients are prone to fracture. The role of ferroptosis in the pathogenesis of osteoporosis has become a topic of growing interest. In this review, we discuss the cell morphology, basic mechanisms of ferroptosis, the relationship between ferroptosis and osteoclasts and osteoblasts, as well as the relationship between ferroptosis and diabetic osteoporosis, steroid-induced osteoporosis, and postmenopausal osteoporosis. Emerging biomedical research has provided new insights into the roles of ferroptosis and osteoporosis, such as in cellular function, signaling pathways, drug inhibition, and gene silencing. The pathophysiology and mechanism of ferroptosis and osteoporosis need to be further studied and elucidated to broaden our understanding of iron metabolism and immune regulation. Studies using animal models of osteoporosis in vivo and cell models in vitro will help clarify the relationship between ferroptosis and osteoporosis and provide research ideas for the elucidation of new mechanisms and development of new technologies and new drugs for the treatment of osteoporosis in the future.

Making community voices heard in a research-health service alliance, the evolving role of the Community Advisory Group: a case study from the members' perspective

BACKGROUND

The Melbourne Genomics Health Alliance (the Alliance) is a collaboration of leading hospitals, research and academic organisations, supported by its member organisations and the Victorian Government. The Alliance was set up by its members in 2013 to steer the translation of genomics, making it an integral part of health care in Victoria, Australia. The Community Advisory Group (CAG) was formed soon after, to give input and advice across the program. This was to ensure consideration of community values, perspectives and priorities, and knowledge translation for patient care. The CAG was charged with providing a strong community voice for the duration of the program. Appointed members were experienced consumer advocates with developed connections to the community.

MAIN BODY

The Alliance progressed from an initial Demonstration Project (2013-2015) to a multifaceted program (2016-2020). The CAG worked strategically to help address complex issues, for example, communication, privacy, informed consent, ethics, patient experience, measurement and evaluation standards and policies, data storage and re-use of genomic data. Many aspects of translating genomics into routine care have been tackled, such as communicating with patients invited to have genomic testing, or their caregivers, and obtaining informed consent, clinical questions across 16 areas of health care, training and education of health and laboratory professionals, genomic data management and data-sharing. Evidence generated around clinical utility and cost-effectiveness led to government funding of testing for complex genetic conditions in children.

CONCLUSION

The CAG activities, recorded in a CAG-inspired Activity register, span the full spectrum of information sharing and consultation to co-design and partnership. The CAG were involved at multiple levels of participation and in all tiers of activity including governance, development of policies and procedures, program planning and evaluation. Working relationships were built up and a level of trust instilled to advance the Alliance work program in ensuring an effective patient-care model of delivery of genomics. CAG input into project deliverables has been tangible. Less tangible contributions included presentations at external meetings and conferences, direct interactions at meetings with Alliance members, interactions with visitors and external experts, taking part in consultations with experts, state and federal government.

The lockdown and its consequences-Perspectives and needs of people at increased risk of severe illness from COVID-19 : Results from a qualitative longitudinal study

BACKGROUND

There is a lack of knowledge on how people at increased risk of severe illness from Coronavirus disease 2019 (COVID-19) experienced the infection control measures. This study aimed to explore their perspectives and needs during the coronavirus outbreak.

METHODS

A qualitative longitudinal interview study was conducted in Austria during lockdown due to COVID-19 containment and afterwards. People older than 65 years of age and/or affected by a chronic medical condition participated in individual telephone interviews at two time points. Thematic analysis was used to analyze the data and saturation was defined as no new emerging concepts in at least 10 subsequent interviews.

RESULTS

Thematic saturation was reached when 33 individuals (75.8% female, mean age ± standard deviation [SD] 73.7±10.9 years) were included. A total of 44 lower level concepts were extracted and summarized into 6 higher level concepts. They included (i) a general positive attitude toward COVID-19 measures, (ii) challenges of being isolated from the community, (iii) deterioration of health status, (iv) difficulties with measures due to their health condition, (v) lack of physical contact and (vi) lack of information versus overload. Participants suggested environmental adaptations for strengthening resilience in people at increased risk of severe illness from COVID-19.

CONCLUSION

Strategies and interventions are needed to support people at risk under pandemic conditions. Their perceptions and needs should be addressed to reduce the potential deterioration of health conditions and ensure well-being even during prolonged periods of crisis.

Knee Osteoarthritis Pain Management with an Innovative High and Low Molecular Weight Hyaluronic Acid Formulation (HA-HL): A Randomized Clinical Trial

INTRODUCTION

The objective of this study was to compare a single intra-articular injection of an innovative high and low molecular weight hyaluronic acid formulation (HA-HL) versus placebo in treating moderate-to-severe symptomatic knee osteoarthritis.

METHODS

Subjects with primary osteoarthritis knee pain (Kellgren and Lawrence grade 2-3) were randomly assigned to intra-articular HA-HL or placebo in a prospective, double-blind, 24-week study. The primary outcome variable was change from screening to week 24 of a Visual Analogue Scale (VAS) pain score. Secondary outcomes included Lequesne's algofunctional index, EuroQol 5-Dimension Questionnaire, 5-level version (EQ-5D-5L), Outcome Measures in Arthritis Clinical Trials-Osteoarthritis Research Society International (OMERACT-OARSI) response and rescue medication usage.

RESULTS

In a total of 692 randomized patients, a rapid decrease was observed in mean VAS pain score from baseline to week 1 (26 ± 24 mm in the HA-HL group vs. 23 ± 23 mm in the placebo group); pain intensity continued to decrease during 24 weeks of follow-up, reaching a mean change from baseline of 35 ± 28 mm vs. 32 ± 27 mm at week 24. Mixed model analysis demonstrated statistically significant differences between groups in favor of the HA-HL group at weeks 1, 6, 12, and 24. HA-HL was also more effective than placebo in improving Lequesne's algofunctional index, OMERACT-OARSI response, and health-related quality of life. The use of rescue medication (paracetamol 500 mg tablets; ≤ 6 per day) was lower in the HA-HL group. Both treatments were similarly well tolerated.

CONCLUSIONS

A single intra-articular injection of an innovative high and low molecular weight hyaluronic acid formulation (HA-HL) is effective in providing fast, sustained, and clinically relevant reductions in pain, functional limitation, and health-related quality of life that were apparent at 1 week after the intra-articular injection and maintained throughout the 24-week follow-up in subjects with painful knee osteoarthritis, with a good safety profile.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03200288.

Tailored Education Increased Capability and Motivation for Fall Prevention in Older People After Hospitalization

Recently hospitalized older people are at risk of falls and face barriers to undertaking fall prevention strategies after they return home from hospital. The authors examined the effects of tailored education delivered by physiotherapists on the knowledge (capability) and the motivation of older people to engage in fall prevention after hospital discharge. Utilizing data gathered from a recent trial, data was analyzed from 390 people who were 60 years and over without impaired cognition (>7/10 abbreviated mental test score) and discharged from three Australian hospitals. Motivation and capability were measured at baseline in the hospital and at 6-months after hospital discharge by blinded assistants using structured surveys. Bivariate analysis using generalized linear modeling explored the impact of education on the capability and motivation. Engagement in fall prevention strategies was entered as an independent variable during analysis to determine associations with capability and motivation. The education significantly improved capability [-0.4, 95% CI (-0.7, -0.2), p < 0.01] and motivation [-0.8, 95% CI (-1.1, -0.5), p < 0.01] compared with social-control at the time of hospital discharge. In contrast, social-control participants gained capability and motivation over the 6-months, and no significant differences were found between groups in capability [0.001, 95% CI (-0.2, 0.2), p = 0.9] and motivation [-0.01, 95% CI (-0.3, 0.3), p = 0.9] at follow-up. Tailored fall prevention education is recommended around hospital discharge. Participants still needed to overcome barriers to falls prevention engagement post hospitalization. Thus, tailored education along with direct clinical services such as physiotherapy and social supports is warranted for older people to avoid falls and regain function following hospitalization.

Adolescent and young adult patients as co-researchers: A scoping review

BACKGROUND

As part of a research project aimed at evaluating a hospital-based adolescent transition programme, we asked ourselves what is known about the ethical and methodological challenges of research involving adolescent patients as co-researchers. The aim of our review was to summarize empirical evidence and identify knowledge gaps about the involvement of young patients as co-researchers.

METHODS

We conducted a scoping review through searches in MEDLINE, EMBASE, PsychINFO, AMED.

RESULTS

We found reports of young patients being actively engaged as co-researchers in any stage of a research project, although commonly they were not involved in every stage. Including young patients as co-researchers is resource demanding and time-consuming. Involving young patients as co-researchers contributes to the fulfilment of their right to participation and may improve the relevance of research. Benefits for the young co-researcher include empowerment, skills building and raised self-esteem. Few authors go into detail about ethical considerations when involving young co-researchers. None of the included articles discuss legal considerations.

DISCUSSION AND CONCLUSION

No lists of recommendations are given, but recommendations can be deduced from the articles. There is need for time, funding and flexibility when including young patients as co-researchers. Knowledge gaps concern legal and ethical dilemmas of including a vulnerable group as co-researchers. More reflection is needed about what meaningful participation is and what it entails in this context.

PATIENT OR PUBLIC CONTRIBUTION

This review is part of a research project where the hospital youth council has been involved in discussions of focus area and methods.

Exploring approaches to identify, incorporate and report patient preferences in clinical guidelines: Qualitative interviews with guideline developers

BACKGROUND

Clinical guidelines informed by patient preferences are more likely to be used and widely advocated, yet research shows that few guidelines reflect patient preferences.

OBJECTIVE

Explore how developers generate guidelines informed by patient preferences.

PATIENT INVOLVEMENT

Seventeen patients were involved as interview participants.

METHODS

Using a basic descriptive approach, we conducted and analyzed semi-structured telephone interviews with 50 participants who were involved in developing guidelines on various topics. The sample included 17 patients, 16 clinicians and 17 managers from a total of 7 countries.

RESULTS

Participants used one or more approaches to identify preferences, patient panelists, focus groups, surveys and review of published research, despite acknowledging they identified similar preferences. Participants said they incorporated preferences in all guideline development steps, but provided little detail of specific processes. Few participants said their guidelines explicitly reported how patients were engaged, preferences identified, or how preferences influenced development processes or the guideline. Enablers were patient and clinician training, supportive coordinators and chairs, involving experienced patients, and assistance from qualitative and review experts. Barriers were finding and preparing patients, clinician skepticism about benefits, and token patient involvement. Participants recommended research on how to generate preference-informed guidelines.

DISCUSSION

Ideal approaches to identify, incorporate and report patient preferences in guidelines are unclear and unproven.

PRACTICAL VALUE

Findings revealed specific ways that developers can enhance their processes (e.g. patient training, supportive coordinators and chairs, involve experts in qualitative researcher and systematic reviews) and key issues that warrant ongoing research (e.g. how best to incorporate and report preferences).

Engagement of older adults with multimorbidity as patient research partners: Lessons from a patient-oriented research program

Background

Patient "engagement" in health research broadly refers to including people with lived experience in the research process. Although previous reviews have systematically summarized approaches to engaging older adults and their caregivers in health research, there is currently little guidance on how to meaningfully engage older adults with multimorbidity as research partners.

Objectives

This paper describes the lessons learned from a patient-oriented research program, the Aging, Community and Health Research Unit (ACHRU), on how to engage older adults with multimorbidity as research partners. Over the past 7-years, over 40 older adults from across Canada have been involved in 17 ACHRU projects as patient research partners.

Methods

We developed this list of lessons learned through iterative consensus building with ACHRU researchers and patient partners. We then met to collectively identify and summarize the reported successes, challenges and lessons learned from the experience of engaging older adults with multimorbidity as research partners.

Results

ACHRU researchers reported engaging older adult partners across many phases of the research process. Five challenges and lessons learned were identified: 1) actively finding patient partners who reflect the diversity of older adults with multimorbidity, 2) developing strong working relationships with patient partners, 3) providing education and support for both patient partners and researchers, 4) using flexible approaches for engaging patients, and 5) securing adequate resources to enable meaningful engagement.

Conclusion

The lessons learned through this work may provide guidance to researchers on how to facilitate meaningful engagement of this vulnerable and understudied subgroup in the patient engagement literature.

Long-Term Accumulation of Metals in the Skeleton as Related to Osteoporotic Derangements

The concentrations of metals in the environment are still not within the recommended limits as set by the regulatory authorities in various countries because of human activities. They can enter the food chain and bioaccumulate in soft and hard tissues/organs, often with a long half-life of the metal in the body. Metal exposure has a negative impact on bone health and may result in osteoporosis and increased fracture risk depending on concentration and duration of metal exposure and metal species. Bones are a long-term repository for lead and some other metals, and may approximately contain 90% of the total body burden in birds and mammals. The present review focuses on the most common metals found in contaminated areas (mercury, cadmium, lead, nickel, chromium, iron, and aluminum) and their effects on bone tissue, considering the possibility of the long-term bone accumulation, and also some differences that might exist between different age groups in the whole population.

Evaluation of a Multidisciplinary Cachexia and Nutrition Support Service- The Patient and Carers Perspective

The Barwon Health Cachexia & Nutrition Support Service (CNSS) is an outpatient service focused on improving clinical outcomes and quality of life for patients with or at high risk of cancer cachexia. Patients see a multidisciplinary team, comprising a palliative medicine physician, physiotherapist, dietitian, and nurse practitioner. This study evaluated the service from patient and carer perspectives. In 2016/17, semistructured interviews were conducted with 12 patients and 9 carers attending the service, focusing on: (1) reflection on experience of the CNSS, and (2) describing how a cachexia-specific service can meet their needs and concerns. Analysis generated 4 superordinate themes: evolving perception of service value, empowerment through person-centered care, communication to patients and carers regarding health/disease information, and the importance of the multidisciplinary team-based approach. Generally, patients and carers reported overall positive experiences with the service, particularly with regard to improved communication and management of the patient. Findings confirmed the patient-centered and individualized approaches were particularly valued. These insights are a critical step in the development of recommendations for future clinical management of cancer cachexia.

Update on the ESCEO recommendation for the conduct of clinical trials for drugs aiming at the treatment of sarcopenia in older adults

BACKGROUND

In 2016, an expert working group was convened under the auspices of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) and formulated consensus recommendations for the conduct of clinical trials for drugs to prevent or treat sarcopenia.

AIMS

The objective of the current paper is to provide a 2020 update of the previous recommendations in accordance with the evidence that has become available since our original recommendations.

METHODS

This paper is based on literature reviews performed by members of the ESCEO working group and followed up with face to face meetings organized for the whole group to make amendments and discuss further recommendations.

RESULTS

The randomized placebo-controlled double-blind parallel-arm drug clinical trials should be the design of choice for both phase II and III trials. Treatment and follow-up should run at least 6 months for phase II and 12 months for phase III trials. Overall physical activity, nutrition, co-prescriptions and comorbidity should be recorded. Participants in these trials should be at least 70-years-old and present with a combination of low muscle strength and low physical performance. Severely malnourished individuals, as well as bedridden patients, patients with extremely limited mobility or individuals with physical limitations clearly attributable to the direct effect of a specific disease, should be excluded. Multiple outcomes are proposed for phase II trials, including, as example, physical performance, muscle strength and mass, muscle metabolism and muscle-bone interaction. For phase III trials, we recommend a co-primary endpoint of a measure of functional performance and a Patient Reported Outcome Measure.

CONCLUSION

The working group has formulated consensus recommendations on specific aspects of trial design, and in doing so hopes to contribute to an improvement of the methodological robustness and comparability of clinical trials. Standardization of designs and outcomes would advance the field by allowing better comparison across studies, including performing individual patient-data meta-analyses, and different pro-myogenic therapies.

Opportunities and Challenges of Web-Based and Remotely Administered Surveys for Patient Preference Studies in a Vulnerable Population

The application of web-based and remotely administered surveys is becoming increasingly popular due to the fact that it offers numerous advantages over traditional paper-based or computer-based surveys completed in the presence of the researcher. However, it is unclear whether complex preference elicitation tasks administered online in highly vulnerable patient populations are also feasible. This commentary discusses opportunities and challenges of conducting quantitative patient preference studies in lung cancer patients using web-based modes of data collection. We refer to our recent experience in the context of the Patient Preference in Benefit-Risk Assessments during the Drug Life Cycle (PREFER) project. Among the main advantages were the possibility of reaching a wider and geographically distant population in a shorter timeframe while reducing the financial costs of testing, the greater flexibility offered and the reduced burden on the patients. Some limitations were also identified and should be the object of further research, including the potential lack of inclusiveness of the research, the lack of control over who is completing the survey, a poor comprehension of the study material, and ultimately a lower level of engagement with the study. Despite these limitations, experience from the PREFER project suggests that online quantitative methods for data collection may provide a valuable method to explore preferences in vulnerable patient populations beyond the COVID-19 pandemic.

Implementing models of care for musculoskeletal conditions in health systems to support value-based care

Models of Care (MoCs), and their local Models of Service Delivery, for people with musculoskeletal conditions are becoming an acceptable way of supporting effective implementation of value-based care. MoCs can support the quadruple aim of value-based care through providing people with musculoskeletal disease improved access to health services, better health outcomes and satisfactory experience of their healthcare; ensure the health professionals involved are experiencing satisfaction in delivering such care and health system resources are better utilised. Implementation of MoCs is relevant at the levels of clinical practice (micro), service delivery organisations (meso) and health system (macro) levels. The development, implementation and evaluation of MoCs has evolved over the last decade to more purposively engage people with lived experience of their condition, to operationalise the Chronic Care Model and to employ innovative solutions. This paper explores how MoCs have evolved and are supporting the delivery of value-based care in health systems.

A discrete-choice experiment to assess patients' preferences for osteoarthritis treatment: An ESCEO working group

OBJECTIVE

To evaluate the preferences of patients with osteoarthritis for treatment.

METHODS

A discrete-choice experiment was conducted among adult OA patients who were presented with 12 choice sets of two treatment options and asked in each to select the treatment they would prefer. Based on literature reviews, expert consultation, patient survey and expert meeting, treatment options were characterized by seven attributes: improvement in pain, improvement in walking, ability to manage domestic activities, ability to manage social activities, improvement in overall energy and well-being, risk of moderate/severe side effects and impact on disease progression. Random parameters logit model was used to estimate patients' preferences and a latent class model was conducted to explore preferences classes.

RESULTS

253 OA patients from seven European countries were included (74% women; mean age 71.3 years). For all seven treatment attributes, significant differences were observed between levels. Given the range of levels of each attribute, the most important treatment attribute in this group was impact on disease progression (29.5%) followed by walking improvement (17.1%) and pain improvement (16.3%). The latent class model identified two preference classes. In the first class (probability of 56%), patients valued impact of disease progression the most (39%). In the second class, walking improvement and improvement in overall energy and well-being were the most important (23%).

CONCLUSION

This study suggests that all seven treatment attributes were important for OA patients. Overall, given the range of levels, the most important outcomes were impact on disease progression and improvement in pain and walking.

Inhibition of the estrogen receptor alpha signaling delays bone regeneration and alters osteoblast maturation, energy metabolism, and angiogenesis

AIMS

The estrogen-ERα axis participates in osteoblast maturation. This study was designed to further evaluated the roles of the estrogen-ERα axis in bone healing and the possible mechanisms.

MAIN METHODS

Female ICR mice were created a metaphyseal bone defect in the left femurs and administered with methylpiperidinopyrazole (MPP), an inhibitor of ERα. Bone healing was evaluated using micro-computed tomography. Colocalization of ERα with alkaline phosphatase (ALP) and ERα translocation to mitochondria were determined. Levels of ERα, ERβ, PECAM-1, VEGF, and β-actin were immunodetected. Expression of chromosomal Runx2, ALP, and osteocalcin mRNAs and mitochondrial cytochrome c oxidase (COX) I and COXII mRNAs were quantified. Angiogenesis was measured with immunohistochemistry.

KEY FINDINGS

Following surgery, the bone mass was time-dependently augmented in the bone-defect area. Simultaneously, levels of ERα were specifically upregulated and positively correlated with bone healing. Administration of MPP to mice consistently decreased levels of ERα and bone healing. As to the mechanisms, osteogenesis was enhanced in bone healing, but MPP attenuated osteoblast maturation. In parallel, expressions of osteogenesis-related ALP, Runx2, and osteocalcin mRNAs were induced in the injured zone. Treatment with MPP led to significant inhibition of the alp, runx2, and osteocalcin gene expressions. Remarkably, administration of MPP lessened translocation of ERα to mitochondria and expressions of mitochondrial energy production-related coxI and coxII genes. Furthermore, exposure to MPP decreased levels of PECAM-1 and VEGF in the bone-defect area.

SIGNIFICANCE

The present study showed the contributions of the estrogen-ERα axis to bone healing through stimulation of energy production, osteoblast maturation, and angiogenesis.

[Participatory research in the German Rheumatism League. Content implementation and practical realisation of participatory research in a patient organisation]

The German Rheumatism League ("Deutsche Rheuma-Liga") is the largest patient organisation in Germany, with about 300,000 members. In the sense of participatory research, the Deutsche Rheuma-Liga involves trained patient representatives in research projects funded by either the Deutsche Rheuma-Liga or other organisations. In order to invigorate the principle of participatory research in the field of rheumatology in Germany various measures have been undertaken: the principle of participatory research has been implemented as obligatory in the funding guidelines of the German Rheumatism League. A training course for German-speaking patients was created, and reference cards and an explanatory brochure were provided. In a letter campaign, about 70 universities and hospitals with rheumatology departments were contacted and informed about the benefits of participatory research. Since 2014, three training courses with 21 participants have been conducted. The trained patient representatives have participated in more than 30 projects up to the end of 2019. The overall experience of the patient representatives actively involved in research projects was mainly positive, and participatory research was perceived as being interesting and enriching. The implementation of participatory research in the German Rheumatism League can be described as successful. The article describes the measures taken to implement the principle of participatory research into the structures of the German Rheumatism League and summarises the experiences of patients and the patient organisation during five years of active participation in research projects.

Involving patients and nurses in choosing between two validated questionnaires to identify chemotherapy-induced peripheral neuropathy before implementing in clinical practice-A qualitative study

AIMS AND OBJECTIVES

To explore from a nurse and patient perspective what questionnaire-"Functional assessment of cancer treatment gynecological group neurotoxicity" or "Oxaliplatin-Associated Neuropathy Questionnaire"-best describes chemotherapy-induced peripheral neuropathy and its influence on everyday life in a comprehensive and meaningful way, prior to implementation in daily practice.

BACKGROUND

Patients experience chemotherapy-induced peripheral neuropathy during and after chemotherapy for colorectal cancer with oxaliplatin. This neuropathy is difficult to describe for patients and to identify for nurses. To address the specific needs of patients and improve identification of neuropathy and its influence on everyday life, we wanted to implement a questionnaire in clinical practice.

DESIGN

A phenomenological hermeneutic frame of reference was used.

METHOD

Semi-structured interviews with 15 patients and two focus groups with eight cancer nurses were used for data collection. Data were organised and interpreted by content analytical steps in a hermeneutical process. COREQ checklist was used in reporting of the study.

RESULTS

The analysis resulted in two main themes (a) "To dig deeper" with sub-themes "to identify the line between acceptable and nonacceptable chemotherapy-induced peripheral neuropathy," and "searching for a precise description." (b). "When everything is interrelated" with sub-themes "to be aware of different perspectives and understandings" and "recognise potential pitfalls."

CONCLUSION

Involving patients and nurses in choosing between the two questionnaires revealed that neither alone was sufficient to describe the patients' experiences. Instead, it seems essential to implement both questionnaires, using the answers as a basis for a dialogue to address the patients' specific needs.

RELEVANCE FOR CLINICAL PRACTICE

Using patients and nurses perspectives in a complementary way may provide a solid foundation before starting an implementation process in clinical practice. However, attention must be paid to potential barriers and facilitators as well as the fact that a successful implementing process requires leadership and information sharing.

How to identify, incorporate and report patient preferences in clinical guidelines: A scoping review

BACKGROUND

Clinical guidelines optimize care delivery and outcomes. Guidelines support patient engagement and adherence if they reflect patient preferences for treatment options, risks and benefits. Many guidelines do not address patient preferences. Developers require insight on how to develop such guidelines.

OBJECTIVE

To conduct a scoping review on how to identify, incorporate and report patient preferences in guidelines.

SEARCH

We searched MEDLINE, EMBASE, Scopus, CINAHL, OpenGrey and GreyLit from 2010 to November 2019.

ELIGIBILITY

We included English language studies describing patient preferences and guidelines.

DATA EXTRACTION AND SYNTHESIS

We reported approaches for and determinants and impacts of identifying patient preferences using summary statistics and text, and interpreted findings using a conceptual framework of patient engagement in guideline development.

RESULTS

Sixteen studies were included: 2 consulted patients and providers about patient engagement approaches, and 14 identified patient preferences (42.9%) or methods for doing so (71.4%). Studies employed single (57.1%) or multiple (42.9%) methods for identifying preferences. Eight (57.1%) incorporated preferences in one aspect of guideline development, while 6 (42.9%) incorporated preferences in multiple ways, most commonly to identify questions, benefits or harms, and generate recommendations. Studies did not address patient engagement in many guideline development steps. Included studies were too few to establish the best approaches for identifying or incorporating preferences. Fewer than half of the studies (7, 43.8%) explored barriers. None examined reporting preferences in guidelines.

CONCLUSIONS

Research is needed to establish the single or multiple approaches that result in incorporating and reporting preferences in all guideline development steps.

How do guideline developers identify, incorporate and report patient preferences? An international cross-sectional survey

Background

Guidelines based on patient preferences differ from those developed solely by clinicians and may promote patient adherence to guideline recommendations. There is scant evidence on how to develop patient-informed guidelines. This study aimed to describe how guideline developers identify, incorporate and report patient preferences.

Methods

We employed a descriptive cross-sectional survey design. Eligible organizations were non-profit agencies who developed at least one guideline in the past five years and had considered patient preferences in guideline development. We identified developers through the Guidelines International Network and publicly-available guideline repositories, administered the survey online, and used summary statistics to report results.

Results

The response rate was 18.3% (52/284). Respondents included professional societies, and government, academic, charitable and healthcare delivery organizations from 18 countries with at least 1 to ≥6 years of experience generating patient-informed guidelines. Organizations most frequently identified preferences through patient panelists (86.5%) and published research (84.6%). Most organizations (48, 92.3%) used multiple approaches to identify preferences (median 3, range 1 to 5). Most often, organizations used preferences to generate recommendations (82.7%) or establish guideline questions (73.1%). Few organizations explicitly reported preferences; instead, they implicitly embedded preferences in guideline recommendations (82.7%), questions (73.1%), or point-of-care communication tools (61.5%). Most developers had little capacity to generate patient-informed guidelines. Few offered training to patients (30.8%), or had dedicated funding (28.9%), managers (9.6%) or staff (9.6%). Respondents identified numerous barriers to identifying preferences. They also identified processes, resources and clinician- and patient-strategies that can facilitate the development of patient-informed guidelines. In contrast to identifying preferences, developers noted few approaches for, or barriers or facilitators of incorporating or reporting preferences.

Conclusions

Developers emphasized the need for knowledge on how to identify, incorporate and report patient preferences in guidelines. In particular, how to use patient preferences to formulate recommendations, and transparently report patient preferences and the influence of preferences on guidelines is unknown. Still, insights from responding developers may help others who may be struggling to generate guidelines informed by patient preferences.

Patient engagement in clinical guidelines development: input from > 1000 members of the Canadian Osteoporosis Patient Network

Patient engagement in clinical guidelines development is essential. The results of a self-administered online survey identified themes important to people living with osteoporosis and will inform the development of Osteoporosis Canada clinical guidelines recommendations.

INTRODUCTION

Patient engagement is essential in the development of high-quality and relevant guidelines for osteoporosis management. Osteoporosis Canada (OC) is updating its national clinical practice guidelines in collaboration with people living with osteoporosis in the process.

METHODS

Using electronic mail, we contacted 6937 members of the Canadian Osteoporosis Patient Network (COPN) to provide input on the selection of relevant content, outcomes, and research questions via a self-administered online survey. Close-ended questions were analyzed using descriptive statistics, and conventional content analysis was conducted for open-ended questions.

RESULTS

A total of 1108 individuals completed the survey (97% women, 86% stated they lived with osteoporosis). Most participants considered it critical to have recommendations on physical activity and exercise (74%), fall prevention (69%), nutrition (68%), and initial bone mineral density testing (67%). In addition to preventing fractures, over 75% of respondents stated that consideration of preserving quality of life and ability to perform daily activities, preventing admission to long-term care and fracture-related death, and avoiding serious harms from medications were essential outcomes to consider in evaluating the evidence. In terms of selection of research questions, seven themes emerged from the content analysis including pharmacotherapy, screening and monitoring, diet and supplements, education, exercise, alternative therapies, and pain management.

CONCLUSIONS

Patients emphasized that autonomy, mobility, and quality of life are highly valued outcomes and must be integral to practice guideline development. As expected, guidance on pharmacotherapy, screening and monitoring, and fracture prevention were priorities identified to be included in osteoporosis management guidelines.

Considerations for Integrating Advance Care Planning Into the Electronic Health Record: A Primer for Clinicians

Opportunities for expanding advance care planning (ACP) throughout the health-care system make it critical that primary care (PC) providers have a basic understanding of how the electronic health record (EHR) can aid promoting ACP discussions and documentation. This article will offer PC providers 5 useful tips for implementing ACP in outpatient settings utilizing the EHR.

Musculoskeletal pain stakeholder engagement and partnership development: determining patient-centered research priorities

BACKGROUND

Musculoskeletal (MSK) pain is a global public health problem with increased societal burden. Increased attention has focused toward patient and other stakeholder perspectives when determining future MSK pain research priorities, however infrastructure and capacity building within the community are needed for individuals and organizations to participate in patient-centered outcomes research. The purpose of this manuscript is to describe our collaborative experiences with several MSK pain stakeholders and processes to identify a top priority research topic.

METHODS

Lunch meetings and formalized workshops were used to develop infrastructure for engaging patients and other stakeholders with early capacity building for partners to identify MSK pain research ideas based on their personal experiences. Additional capacity building and engagement through literature searching further prepared partners to contribute informed decisions about MSK pain research topics and subsequent selection of an important research question.

RESULTS

Several key deliverables (e.g., Governance Document, Communication Plan) were developed and completed over the course of this project to provide partnership structure. Other key deliverables included a list of preliminary comparative effectiveness research ideas (n = 8) and selection of shared decision making for MSK pain as the top priority research topic with patient partners identifying pain self-efficacy as an important outcome domain.

CONCLUSIONS

Our patient partners provided the catalyst for identifying shared decision making as a high priority research topic based on a wide spectrum of stakeholder perspectives and unique experiences. Patient partners were primarily identified using a single rehabilitation health system and clinician partners were heavily weighted by physical therapists which may have introduced selection bias.

Advance care planning for vulnerable older adults within an Accountable Care Organization: study protocol for the IMPACT randomised controlled trial

INTRODUCTION

Patients with multimorbidity plus additional impairments (eg, mobility limitations, disability, cognitive impairments or frailty) are at the highest risk for poor healthcare outcomes. Advanced care planning (ACP) provides patients and their surrogates the opportunity to discuss their goals, values and priorities for healthcare-particularly in the context of end-of-life care. ACP discussions promote more person-centred care; however, it is currently underused. There is a tremendous need for systematic, scalable approaches to individualised ACP that promotes patient and family engagement. Here we describe the study protocol for a randomised effectiveness trial of a nurse navigator and informatics intervention designed to improve the documentation and quality of ACP discussions.

METHODS AND ANALYSIS

This is a randomised, pragmatic, effectiveness trial; patients aged 65 years and older who have multimorbidity plus impairments in either physical function (eg, mobility limitations or disability) or cognition, and/or frailty within an affiliated Accountable Care Organization were eligible. The electronic health record was used to develop an automatic prescreening system for eligible patients (n=765) and participants were randomised in a 1:1 ratio to either the nurse navigator-led ACP pathway or usual care. Our primary outcomes are documentation of ACP discussions within the EHR along with the quality of ACP discussions. Secondary outcomes include a broad range of ACP actions (eg, usage of ACP billing codes, choosing a surrogate decision-maker and advance directive documentation). Outcomes will be measured over 12 months of follow-up.

ETHICS AND DISSEMINATION

This study has been approved by the appropriate Institutional Review Boards and is guided by input from patient and clinical advisory boards. The results of this study will inform a scalable solution to ACP discussions throughout our healthcare system and statewide.

TRIALS REGISTRATION NUMBER

NCT03609658.

Determinants, consequences and potential solutions to poor adherence to anti-osteoporosis treatment: results of an expert group meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) and the International Osteoporosis Foundation (IOF)

Many patients at increased risk of fractures do not take their medication appropriately, resulting in a substantial decrease in the benefits of drug therapy. Improving medication adherence is urgently needed but remains laborious, given the numerous and multidimensional reasons for non-adherence, suggesting the need for measurement-guided, multifactorial and individualized solutions.

INTRODUCTION

Poor adherence to medications is a major challenge in the treatment of osteoporosis. This paper aimed to provide an overview of the consequences, determinants and potential solutions to poor adherence and persistence to osteoporosis medication.

METHODS

A working group was organized by the European Society on Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal diseases (ESCEO) to review consequences, determinants and potential solutions to adherence and to make recommendations for practice and further research. A systematic literature review and a face-to-face experts meeting were undertaken.

RESULTS

Medication non-adherence is associated with increased risk of fractures, leading to a substantial decrease in the clinical and economic benefits of drug therapy. Reasons for non-adherence are numerous and multidimensional for each patient, depending on the interplay of multiple factors, suggesting the need for multifactorial and individualized solutions. Few interventions have been shown to improve adherence or persistence to osteoporosis treatment. Promising actions include patient education with counselling, adherence monitoring with feedback and dose simplification including flexible dosing regimen. Recommendations for practice and further research were also provided. To adequately manage adherence, it is important to (1) understand the problem (initiation, implementation and/or persistence), (2) to measure adherence and (3) to identify the reason of non-adherence and fix it.

CONCLUSION

These recommendations are intended for clinicians to manage adherence of their patients and to researchers and policy makers to design, facilitate and appropriately use adherence interventions.