Development and validation of an interpretive guide for PROMIS scores

Epidemiology and patient-reported measurement outcome of pelvic fractures in children and adolescents - A population-based cohort study from the Swedish fracture register

BACKGROUND AND PURPOSE

Pediatric pelvic fractures are uncommon, representing 0.2-3% of total pediatric fractures. The long-term patient-reported outcome in the pediatric population has not been evaluated yet. The purpose of the study was to describe the epidemiology of pelvic and acetabular fractures in pediatric patients including long-term patient-reported outcomes.

PATIENTS AND METHODS

The Swedish Fracture Register (SFR) was used to identify all patients aged 6-17 years at injury with a pelvic fracture between 2015 and 2021. All patients were invited to answer Patient-Reported measurement instruments in 2021.

RESULTS

The study cohort consisted of 223 patients with a median age at fracture of 15 years and with 62 % boys. 201 sustained a pelvic and 22 acetabular fractures. Falls were the leading cause of fracture, followed by transport accidents. Most fractures (both pelvis and acetabulum) were type A (73 %), and 21 fractures (9 %) could not be classified according to AO. 85 % of fractures were treated non-surgically. All Type C fractures were treated surgically. Seven PROMIS® profile domains were completed by 31 % of the sample at a mean follow-up time of 3.5 years after pelvic/acetabular fracture. Most patients had "no concern" or "mild concern" but those who had surgery had an inferior t-score in most domains.

CONCLUSION

Most fractures occurred in older individuals, with falls during sports activities being the most common cause. This raises important questions about prevention strategies. The PROMIS-Pain-Interference scale indicated that the younger the age at fracture, the more pain was reported at follow-up.

Mental health of caregivers of children with medical complexity: group-based trajectory modelling

OBJECTIVE

To describe the mental health trajectories of caregivers of children with medical complexity (CMC) and explore child characteristics associated with below-average caregiver mental health.

DESIGN

A secondary analysis of prospectively collected data from 123 caregivers of children aged <16 years with medical complexity from a multicentre randomised trial conducted from December 2016 to June 2021.

MAIN OUTCOME MEASURE

The Patient-Reported Outcomes Measurement Information System Global Mental Health Scale was used to measure caregivers' self-reported mental health well-being. Group-based trajectory analysis was used to identify clusters of caregivers with similar changes in mental health across 24 months. Logistic regression was used to identify child-related predictors of mental health among caregivers.

RESULTS

A final model with three distinct groups was selected, corresponding to caregivers with average (n=39), moderately below-average (n=65) and severely below-average (n=19) mental health scores, all with stable trajectories and high posterior probabilities (>90%). Moderately and severely below-average caregiver mental health groups, merged into one group, were associated with a greater number of child medical technology devices (adjusted OR (aOR) 1.44, 95% CI 1.01 to 2.04), gross motor difficulties (aOR 3.51, 95% CI 1.02 to 12.05) and worse child emotional (aOR 0.93, 95% CI 0.87 to 0.99) and psychological well-being (aOR 0.93, 95% CI 0.88 to 0.99).

CONCLUSION

Most caregivers of CMC reported persistently below-average mental health. The intensity of caregiving, as indicated by medical technology and child functional needs, is a potential risk factor for below-average caregiver mental health. Future design and evaluation of interventions focused on support for caregivers of CMC are warranted.

Roxadustat versus placebo for patients with lower-risk myelodysplastic syndrome: MATTERHORN phase 3, double-blind, randomized controlled trial

In patients with lower-risk myelodysplastic syndromes/neoplasms (MDS), response to first-line therapy is limited and transient. The MATTERHORN randomized, double-blind, phase 3 trial evaluated roxadustat versus placebo for patients with transfusion-dependent, lower-risk MDS. Eligible patients had very low-, low-, or intermediate-risk MDS with or without prior erythropoiesis-stimulating agent treatment, and a transfusion burden of 1-4 packed red blood cell (pRBC) units every 8 weeks (Q8W). Patients were randomized (3:2) to oral roxadustat (2.5 mg/kg) or placebo, both three times weekly, with best supportive care. Primary efficacy endpoint was transfusion independence (TI) for ≥56 days within 28 weeks (TI responders). MATTERHORN was terminated due to interim analysis outcomes not meeting statistical significance. In total, 272 patients were screened, and 140 patients were enrolled (82, roxadustat, and 58, placebo). At final analysis, 38/80 (47.5%) patients and 19/57 (33.3%) in the roxadustat and placebo arms, respectively, were TI responders (p = .217). A greater percentage of patients in the roxadustat arm with a transfusion burden of ≥2 pRBC units Q4W were TI responders (36.1%; 13/36) compared with the placebo arm (11.5%; 3/26; p-nominal = .047). The seven on-study deaths (4, roxadustat, and 3, placebo) were considered unrelated to treatment. Three roxadustat patients progressed to acute myeloid leukemia. Despite MATTERHORN not meeting its primary endpoint, a numerically higher TI rate was achieved with roxadustat treatment compared with placebo. Further analyses are needed to confirm the MDS patient subgroups deriving clinical benefit from this novel treatment.

Clinical outcomes of open Latarjet-Patte procedures performed for recurrent anterior shoulder instability with primary bone loss versus failed arthroscopic Bankart repair

BACKGROUND

This study compares the outcomes of Latarjet-Patte procedures (LPs) performed for primary glenohumeral instability in the setting of critical bone loss (LP-BL) versus salvage surgery performed after a failed arthroscopic Bankart repair (LP-FB).

METHODS

LP's performed by senior author from 2017 to 2021 were separated into cohorts by LP indication. Data abstracted from electronic medical records included demographic information, preoperative clinical scores, radiological imaging, and complications. Postoperative clinical outcome scores collected after a 2-year minimum follow-up included: patient-reported outcomes measurement information system (PROMIS) upper extremity (UE), PROMIS pain interference, PROMIS pain intensity, American Shoulder and Elbow Surgeons (ASES), and visual analog scale pain scores.

RESULTS

A total of 47 patients (LP-BL: n=29, LP-FB: n=18) with a mean age of 29 years (range, 15-58 years) were included in this study. Both cohorts achieved good upper extremity functionality without significant differences as indicated by mean PROMIS UE (LP-BL: 52.6±10.0 vs. LP-FB: 54.6±7.6, P=0.442) and ASES score (LP-BL: 89.9±15.7 vs. LP-FB: 91.5±14.4, P=0.712). However, the LP-FB cohort reported lower levels of pain (LP-FB: 0.5±1.1 vs. LP-BL: 1.9±2.7, P=0.020) at their latest follow-up. There were no significant differences in complication rates including re-dislocation between cohorts (LP-BL: 2/29 [6.9%] vs. LP-FB: 2/18 [11.1%], P=0.629).

CONCLUSIONS

When performed after failed Bankart repair, the LP results in similar postoperative functional outcomes and similar rates of complications and re-dislocations when compared to the primary indication of recurrent glenohumeral instability in the setting of critical bone loss. Level of evidence: III.

Stigma, social support, and spirituality: associations with symptoms among Black, Latina, and Chinese American cervical cancer survivors

PURPOSE

Few studies have examined experiences of stigma and factors associated with symptoms among cervical cancer survivors from diverse racial and ethnic backgrounds. We investigated survivorship experiences and patient-reported outcomes in the SPADE symptom cluster (sleep disturbance, pain interference, anxiety, depression, and energy/fatigue) among Black, Latina, and Chinese American women diagnosed with cervical cancer.

METHODS

In two phases of research with cervical cancer survivors, we collected qualitative data through individual interviews (N=12; recruited through community referrals) and quantitative data from an observational cohort study (N=91; recruited through 4 national cancer registries). We coded interview transcripts to describe the survivors' experiences. We then evaluated associations between social support, spirituality, and SPADE symptom cluster domains using linear regression models.

RESULTS

Qualitative analysis yielded four themes: perceptions of stigma, empowerment, physical and psychological effects, and social support. These concepts revolved around internal and external stigmas, emotional responses, strengthened faith, and different social support types. Quantitative analyses indicated that greater spirituality was associated with lower symptom burden on all five SPADE domains (p<0.01). We observed nuanced associations between specific types of social support and SPADE domains.

CONCLUSIONS

The survivorship experiences of Black, Latina, and Chinese American women with cervical cancer are negatively influenced by perceptions of stigma. Higher scores on spirituality and varied types of social support were significantly associated with fewer symptoms in the SPADE symptom cluster.

IMPLICATIONS FOR CANCER SURVIVORS

Results suggest targets for future interventions to reduce symptom burden among women diagnosed with cervical cancer by leveraging spirituality and social support.

Association of Pharmacologic Treatment of Depression/Anxiety With Initial Patient-Reported Outcome Measures in Patients With Hip and Knee Osteoarthritis

INTRODUCTION

Depression and anxiety are common comorbidities that may exacerbate osteoarthritis (OA)-related pain. We aim to evaluate the effect of pharmacologic treatment of depression/anxiety on hip and knee patient-reported outcome measures (PROMs).

METHODS

A multi-institutional PROMs database was queried for patients with depression or anxiety and hip or knee OA who completed a PROMs questionnaire at an initial orthopaedic visit between January 2015 and March 2023. Data on demographics, comorbidities, and duration of pharmacologic treatment of depression/anxiety were obtained. Patients were stratified into three cohorts based on treatment duration. PROMs were compared across cohorts.

RESULTS

Two thousand nine hundred sixty patients who completed PROMs at their initial orthopaedic visit had both OA and depression/anxiety. One hundred thirty-four (4.5%) received pharmacologic treatment of depression/anxiety for < 1 year, versus 196 (6.6%) for more than 1 year. In unadjusted analyses, patients with pharmacologic treatment had significantly lower Patient-Reported Outcomes Measurement Information System (PROMIS)-Physical (39.8 [IQR 34.9, 44.9] vs 42.3 [37.4, 47.7], P < 0.001) and PROMIS-Mental (43.5 [36.3, 50.8] vs 48.3 [41.1, 53.3], P < 0.001) scores than those without treatment. After adjusting for demographics and comorbidities, only differences in PROMIS-Mental scores remained statistically significant, with pharmacologic treatment associated with lower scores (β = -2.26, 95% CI, [-3.29, -1.24], P < 0.001). On secondary analysis including duration of pharmacologic treatment, < 1 year of treatment was associated with significantly lower PROMIS-Mental scores than those not treated (β = -4.20, 95% CI [-5.77, -2.62], P < 0.001) while scores of patients with more than 1 year of treatment did not differ significantly from those without treatment.

CONCLUSION

:Our results indicate that pharmacologic treatment of depression/anxiety is associated with improved psychological health but not with improved physical symptoms related to OA. We observed a nonsignificant trend that patients with depression/anxiety who warrant pharmacologic treatment tend to have worse physical symptoms than those who do not; however, unadjusted analyses suggest this is a complex relationship beyond the isolated effect of pharmacologic treatment.

Depression and Anxiety Mediate the Relationship between Discrimination and Well-Being in a Sample of Latinx Adults with Type 2 Diabetes: Results from a Dual Mediation Analysis

Latinxs experience greater risk for type 2 diabetes, discrimination, and poor mental health. The pathways linking these factors, however, are not well understood. This study tested whether depression and anxiety mediated the relationship between discrimination and well-being. Bootstrapped mediation tests were conducted using a sample of Latinx adults with type 2 diabetes (n = 121) and regression models adjusted for demographic and health covariates. Depression and anxiety fully and jointly mediated the effect of discrimination on well-being; everyday discrimination was linked to elevated symptoms of depression and anxiety which were, in turn, independently linked to reduced emotional well-being. Moreover, the effect size for the anxiety pathway (β=-0.13) was 60% larger than for depression (β=-0.08). Dual mediation suggests depression, and especially anxiety, may be important targets for interventions seeking to mitigate the deleterious effects of discrimination. Findings have important implications for psychotherapeutic treatments and public health policy.

Suicide Ideation Among Transgender and Gender Diverse Adolescents: The Role of Parental Invalidation of Adolescents' Gender Identity

Transgender and gender diverse (TGD) youth experience chronic and acute stress associated with their gender identity contributing to their increased risk of suicide and suicide ideation (SI) compared to non-TGD peers. This study examined how invalidating and accepting gender-related experiences with a parent impact SI severity among TGD adolescents cross-sectionally and longitudinally, within-person. Participants were 15 TGD adolescents with past month SI recruited across community and clinical settings. Adolescents completed a baseline assessment of validated interviews and self-report measures on parental invalidation and SI severity. Over a 14-day follow-up period, adolescents reported instances of parental gender invalidation and acceptance, relative stress of those experiences, and SI severity multiple times/day via ecological momentary assessment (EMA). Bivariate associations of parental invalidation and acceptance with SI were examined at baseline, while multilevel models examined the relationship within-person over follow-up. Cross-sectionally, greater perceived invalidation and non-affirmation by their parents was associated with more severe SI. Over the follow up, instances of perceived parental invalidation were associated with passive SI within-person. Findings partially support the minority stress theory and social safety perspective by showing that perceived gender-invalidation from parents affects SI in TGD adolescents, both cross-sectionally and longitudinally. Further research is needed to identify specific emotional and cognitive factors, such as perceived stress, that contribute to the risk of SI among TGD youth and inform the development of targeted interventions for this vulnerable population.

Moderation Effects of Daily Behavior on Associations Between Symptoms and Social Participation Outcomes After Burn Injury: A 6-Month Digital Phenotyping Study

OBJECTIVE

To examine the moderation effects of daily behavior on the associations between symptoms and social participation outcomes after burn injury.

DESIGN

A 6-month prospective cohort study.

SETTING

Community.

PARTICIPANTS

Twenty-four adult burn survivors.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Symptoms and social participation outcomes were assessed weekly using smartphone surveys, including symptoms of pain (Patient-Reported Outcomes Measurement Information System [PROMIS] Pain Intensity and Pain Interference), anxiety (PROMIS Anxiety), and depression (Patient Health Questionnaire), as well as outcomes of social interactions and social activities (Life Impact Burn Recovery Evaluation [LIBRE] Social Interactions and Social Activities). Daily behaviors were automatically recorded by a smartphone application and smartphone logs, including physical activity (steps, travel miles, and activity minutes), sleep (sleep hours), and social contact (number of phone calls and message contacts).

RESULTS

Multilevel models controlling for demographic and burn injury variables examined the associations between symptoms and social participation outcomes and the moderation effects of daily behaviors. Lower (worse) LIBRE Social Interactions and LIBRE Social Activities scores were significantly associated with higher (worse) PROMIS Pain Intensity, PROMIS Pain Interference, PROMIS Anxiety, and Patient Health Questionnaire-8 scores (P<.05). Additionally, daily steps and activity minutes were associated with LIBRE Social Interactions and LIBRE Social Activities (P<.05), and significantly moderated the association between PROMIS Anxiety and LIBRE Social Activities (P<.001).

CONCLUSIONS

Social participation outcomes are associated with pain, anxiety, and depression symptoms after burn injury, and are buffered by daily physical activity. Future intervention studies should examine physical activity promotion to improve social recovery after burns.

Mitigation of Effect Modification by Psychological Status in Patients with Hearing Loss

Importance

Although patient-reported outcomes provide valuable insights, these subjective data may not align with objective test results. Hearing loss is a pervasive problem, such that concordance between subjective perceptions of hearing ability and objective audiogram assessments would be beneficial.

Objectives

To determine (1) whether psychological status is an effect modifier of the association between subjective patient reports of hearing ability and objective audiometry results, and (2) whether any effect modification observed in standard static questionnaires would be either mitigated or exacerbated by adaptive testing based on Item Response Theory analyses.

Design, Setting, and Participants

This diagnostic study at a tertiary care center and community-based practice included consecutive adults who presented with queries related to hearing loss. Participants were recruited and enrolled and data analyses occurred from 2022 to 2024.

Exposures

Participants prospectively reported their hearing-specific abilities through either a standard static or adaptive version of the Inner Effectiveness of Auditory Rehabilitation (EAR) scale, alongside validated measures of their mental health and audiometry. Word recognition scores (WRS) and pure tone averages (PTA) were used to analyze audiometric testing.

Main Outcomes and Measures

The association between subjective Inner EAR results and audiometry was evaluated. Stratified analyses were used to assess for effect modification by psychological status. The results of standard static and adaptive testing were compared.

Results

In this study of 395 patients (mean [range] age, 55.9 [18-89] years; 210 [53.2%] female), standard static Inner EAR mean scores were appropriately higher in patients with higher (better) WRS (50.7, 95% CI, 46.4-54.9), compared with patients with lower (worse) WRS (34.7, 95% CI, 24.3-45.1). However, among patients with worse mental health, there was no association between standard static Inner EAR scores and WRS. In contrast, adaptive Inner EAR mean scores were significantly higher for those with better WRS, regardless of mental health status. Thus, effect modification was observed in standard static assessments, whereas adaptive testing remained durably associated with audiometry, regardless of mental health.

Conclusions and Relevance

Psychological status was an effect modifier of the association between standard Inner EAR scale scores and audiometry, with a positive association observed only in those with better mental health. Adaptive testing scores, however, remained significantly associated with audiometry, even when mental status was worse. Adaptive testing may stabilize the association between subjective and objective hearing outcomes.

Irregular sleep is linked to poorer mental health: A pooled analysis of eight studies

OBJECTIVES

Greater sleep disturbances on average are a risk factor for impaired mental health. Recent research has shown that more intraindividual variability (i.e., inconsistency) in sleep (hereafter called "sleep intraindividual variability") may also be uniquely related to mental health, even above the influence of mean sleep patterns averaged across days. The current study examined associations between sleep intraindividual variability and symptoms of anxiety, depression, and insomnia across different facets of sleep intraindividual variability (sleep duration, efficiency, and timing) and sleep measurement types (sleep diary and actigraphy).

METHODS

We pooled eight datasets (N = 3053 participants) that assessed repeated measures of sleep diary- and/or actigraphy-determined sleep across multiple days, as well as one-time measures of mental health or sleep disorder symptoms (i.e., anxiety, depression, and insomnia). Multilevel regression analyses were conducted to examine associations between sleep intraindividual variability and mental health or sleep disorder symptoms.

RESULTS

Greater diary- and actigraphy-determined sleep duration intraindividual variability was associated with more depression symptoms (diary: b=0.02, p < .001; actigraphy: b=0.03, p = .006) and more insomnia symptoms (diary: b=0.02, p < .001; actigraphy: b=0.02, p < .001). Greater diary-determined sleep efficiency intraindividual variability was associated with fewer anxiety symptoms (b=-0.23, p = .019) and fewer insomnia symptoms (b=-0.15, p < .001). Greater diary- and actigraphy-determined sleep midpoint intraindividual variability was associated with more insomnia symptoms (diary: b=0.41, p = .044; actigraphy: b=0.66, p = .021).

CONCLUSIONS

More inconsistent sleep duration and sleep timing may be a correlate of poorer mental health. Future experimental work should examine whether stabilizing sleep patterns can improve mental health outcomes.

Evaluating the mental health status, help-seeking behaviors, and coping strategies of Canadian essential workers versus non-essential workers during COVID-19: a longitudinal study

OBJECTIVE

This study examined mental health symptoms, help-seeking, and coping differences between Canadian essential workers (EWs) versus non-EWs, as well as common COVID-related concerns and longitudinal predictors of mental health symptoms among EWs only.

DESIGN

An online, longitudinal survey (N = 1260; response rate (RR) =  78.5%) assessing mental health and psychosocial domains amongst Canadian adults was administered during the first wave of COVID-19 with a six-month follow-up (N = 821; RR = 53.7%).

METHODS

Cross tabulations and chi-square analyses examined sociodemographic, mental health, and coping differences between EWs and non-EWs. Frequencies evaluated common COVID-related concerns. Linear regression analyses examined associations between baseline measures with mental health symptoms six months later amongst EWs.

RESULTS

EWs reported fewer mental health symptoms and avoidance coping than non-EWs, and were most concerned with transmitting COVID-19. Both groups reported similar patterns of help-seeking. Longitudinal correlates of anxiety and perceived stress symptoms among EWs included age, marital status, household income, accessing a psychologist, avoidant coping, and higher COVID-19-related distress.

CONCLUSIONS

COVID-19 has had a substantial impact on the mental health of Canadian EWs. This research identifies which EWs are at greater risk of developing mental disorders, and may further guide the development of pandemic-related interventions for these workers.

Multiligament Knee Reconstruction With Suture Tape Augmentation: Patient-Reported Outcomes at Minimum 2-Year Follow-up

BACKGROUND

Multiligament knee injury (MLKI) is a severe subclass of orthopedic injury and can result in significant functional impairment. Novel MLKI graft constructs such as suture augmentation aim to enhance graft strength and optimize knee stability. The purpose of this study was to present patient-reported outcome measurements of a cohort at a minimum follow-up of 2 years after multiligament knee reconstruction (MLKR) with suture augmentation.

MATERIALS AND METHODS

A retrospective chart review was performed to identify patients who underwent MLKR with suture augmentation. Demographic and injury-specific variables were gathered preoperatively and postoperatively. Patients were contacted at a minimum of 2 years postoperatively to collect Patient-Reported Outcomes Measurement Information System, Multiligament Quality of Life, and Lysholm knee scores.

RESULTS

Twenty-seven patients underwent MLKR with suture augmentation, with 15 being female (55.6%) and 12 being male (44.4%). The mean pain score was 49.93±9.96, the mean physical function score was 49.56±10.94, and the mean mobility score was 47.56±8.58. The mean physical impairment score was 33.96±23.69, the mean emotional impairment score was 36.55±26.60, the mean activity limitation score was 28.00±25.61, and the mean societal involvement score was 30.09±27.45. The mean Lysholm knee score for the cohort was 67.93±22.36.

CONCLUSION

Patients who underwent MLKR with suture augmentation had satisfactory scores across all patient-reported outcome measurements. On the basis of these criteria, the average patient achieved an acceptable clinical outcome, demonstrating that MLKR with suture augmentation is a safe and efficacious surgical technique for the treatment of MLKI. [Orthopedics. 202x;4x(x):xx-xx.].

Ventral Hernia Reconstruction with GORE ENFORM Biomaterial

Introduction: Ventral hernia repair (VHR) is one of the most common surgeries performed in the United States. Degradable mesh is the recommended choice for patients presenting with high-risk co-morbidities or increased risk for infection. GORE® ENFORM BiomaterialTM is a biosynthetic degradable mesh that has recently been approved for use in ventral hernia reconstruction with no reports of its clinical outcomes. Methods: This study was a single surgeon case series. Patients were included in the study if they underwent VHR with GORE® ENFORM BiomaterialTM. The decision to use GORE® ENFORM BiomaterialTM was the senior surgeon's decision based on the patient's center for disease control classification. Patient comorbidities, hernia characteristics, postoperative hernia recurrence, and surgical site occurrences (SSOs) were collected at in-patient follow-up appointments and chart review. Patients were asked to complete preoperative and postoperative patient-reported outcomes (PROs) using the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Intensity short form 3a and the hernia-specific quality of life (HerQLes) survey. Results: A total of 15 patients were included in this study. The average length of follow-up was 315 days. Postoperatively, 26.7% of patients had an SSO with 4 surgical site infections. Two patients required an operative washout with mesh removal. One patient experienced hernia recurrence. Eight of the 15 patients completed preoperative and postoperative PROs. Conclusion: This is the first clinical study to report the outcomes of ventral hernia repair using ENFORM mesh. These results show that Enform mesh is an option to consider in complex ventral hernia reconstruction.

Enhancing immigrant families' mental health through the promotion of structural and community-based support

Immigrant communities in the United States are diverse and have many assets. Yet, they often experience stressors that can undermine the mental health of residents. To fully promote mental health and well-being among immigrant communities, it is important to emphasize population-level policies and practices that may serve to mitigate stress and prevent mental health disorders. In this paper, we describe the stressors and stress experienced by immigrant families, using Sunset Park, Brooklyn as an example. We discuss ways to build structures and policies in support of equitable environments that promote mental health at the population level and enable families and their children to thrive.

Exploring Social Impairment in Those with Opioid Use Disorder: Linking Impulsivity, Childhood Trauma, and the Prefrontal Cortex

Background

Challenges with social functioning, which is a hallmark of opioid use disorder (OUD), are a drawback in treatment adherence and maintenance. Yet, little research has explored the underlying mechanisms of this impairment. Impulsivity, a known risk factor for OUD, and corresponding neural alterations may be at the center of this issue. Childhood adversity, which has been linked to both impulsivity and poorer treatment outcomes, could also affect this relationship. This study aims to understand the relationship between impulsivity and social functioning in those recovering from OUD. Differences in the prefrontal cortex will be analyzed, as well as potential moderating effects of childhood trauma.

Methods

Participants with (N = 16) and without (N = 19) social impairment completed a survey (e.g., social functioning, Barrat's Impulsivity Scale, Adverse Childhood Experiences (ACEs) and cognitive tasks while undergoing neuroimaging. Functional near infrared spectroscopy (fNIRS), a modern, portable, wearable and low-cost neuroimaging technology, was used to measure prefrontal cortex activity during a behavioral inhibition task (Go/No-Go task).

Results

Those who social functioning survey scores indicated social impairment (n = 16) scored significantly higher on impulsivity scale (t(33)= -3.4, p < 0.01) and reported more depressive symptoms (t(33) = -2.8, p < 0.01) than those reporting no social impairment (n = 19). Social functioning was negatively correlated with impulsivity (r=-0.7, p < 0.001), such that increased impulsivity corresponded to decreased social functioning. Childhood trauma emerged as a moderator of this relationship, but only when controlling for the effects of depression, B=-0.11, p = 0.023. Although both groups had comparable Go/No-Go task performance, the socially impaired group displayed greater activation in the dorsolateral (F(1,100.8) = 7.89, p < 0.01), ventrolateral (F(1,88.8) = 7.33, p < 0.01), and ventromedial (F(1,95.6) = 7.56, p < 0.01) prefrontal cortex during impulse control.

Conclusion

In addition to being more impulsive, individuals with social impairment exhibited differential activation in the prefrontal cortex when controlling responses. Furthermore, the impact of impulsivity on social functioning varies depending on ACEs demonstrating that it must be considered in treatment approaches. These findings have implications for addressing social needs and impulsivity of those in recovery, highlighting the importance of a more personalized, integrative, and trauma-informed approach to intervention.

The Effect of Spacer Treatment of Infected Hip and Knee Arthroplasties on Patients' Mental Health: A Narrative Review of the Literature

BACKGROUND

The gold standard treatment for periprosthetic joint infections is the two-stage revision that includes the spacer placement before definitive reimplantation. The management of PJI affects patients' joint function and, subsequently, their mental health. Even though significant advances have been achieved, little to no attention has been paid to the psychological implications. So, based on standardized patient-reported outcome measures (PROMs), this study aimed to clarify the effect of spacer treatment of infected hip and knee arthroplasties on patients' mental health.

METHODS

We performed research on the literature on PJIs in the English language using the MEDLINE database with the search strings "spacer" OR "spacers" AND "hip" OR "knee" AND "SF-12" OR "SF-36" OR "EQ-5" OR "mental" OR "depression" OR "anxiety." The reference lists of selected articles were also hand-searched for any additional articles.

RESULTS

A total of 973 published papers were extracted, and 9 papers were finally included. A total of 384 patients who underwent spacer placement for PJI were identified. Of these 384 patients, 54% were female. The mean age ranged from 62 to 78.2 years. Of the11 papers identified for this review, 4 analyzed only hip spacers, including 119 patients; 4 only knee spacers, evaluating 153 patients; while a single study included 112 patients for both joints.

CONCLUSIONS

Patients with the spacer are living in a state of mental upset, albeit better than the preoperative state. Clinical improvement with the review is not assured. The alteration of mental state turns out not to be transient for all the patients.

Association of mental health-related patient reported outcomes with blood pressure in adults and children with primary proteinuric glomerulopathies

INTRODUCTION

The prevalence of mental health disorders including anxiety and depression is increasing and is linked to hypertension in healthy individuals. However, the relationship of psychosocial patient-reported outcomes on blood pressure (BP) in primary proteinuric glomerulopathies is not well characterized. This study explored longitudinal relationships between psychosocial patient-reported outcomes and BP status among individuals with proteinuric glomerulopathies.

METHODS

An observational cohort study was performed using data from 745 adults and children enrolled in the Nephrotic Syndrome Study Network (NEPTUNE). General Estimating Equations for linear regression and binary logistic analysis for odds ratios were performed to analyze relationships between the exposures, longitudinal Patient-Reported Outcome Measurement Information System (PROMIS) measures and BP and hypertension status as outcomes.

RESULTS

In adults, more anxiety was longitudinally associated with higher systolic and hypertensive BP. In children, fatigue was longitudinally associated with increased odds of hypertensive BP regardless of the PROMIS report method. More stress, anxiety, and depression were longitudinally associated with higher systolic BP index, higher diastolic BP index, and increased odds of hypertensive BP index in children with parent-proxy patient-reported outcomes.

DISCUSSION/CONCLUSION

Chronically poor psychosocial patient-reported outcomes may be significantly associated with higher BP and hypertension in adults and children with primary proteinuric glomerulopathies. This interaction appears strong in children but should be interpreted with caution, as multiple confounders related to glomerular disease may influence both mental health and BP independently. That said, access to mental health resources may help control BP, and proper disease and BP management may improve overall mental health.

Anxiety and depressive symptoms and migraine-related outcomes in children and adolescents

OBJECTIVE

The objective of this study was to explore the longitudinal relationship between anxiety and depressive symptoms and migraine outcomes in children and adolescents.

BACKGROUND

Children and adolescents with migraine experience more anxiety and depressive symptoms than their peers without migraine, but it is unknown if these symptoms are associated with differential migraine outcomes.

METHODS

In this prospective clinical cohort study, children and adolescents aged 8.0-18.0 years with migraine completed headache questionnaires and validated measures of anxiety and depressive symptoms (Patient-Reported Outcomes Measurement Information System) at an initial consultation and at their first follow-up visit with a neurologist. Changes in monthly headache frequency and changes in migraine-related disability (Pediatric Migraine Disability Assessment) were tracked at each time point. The relationships between these migraine outcomes and anxiety and depressive symptoms were estimated using models controlling for sex, age, headache frequency, and treatment type.

RESULTS

There were 123 consenting participants. In models adjusted for age, sex, baseline disability score, and treatment type, baseline anxiety and depressive symptom levels were not significantly associated with change in headache frequency (for anxiety symptoms: β = -0.05, 95% confidence interval [CI] = -0.268 to 0.166, p = 0.639; for depressive symptoms: β = 0.14, 95% CI = -0.079 to 0.359, p = 0.209). Similarly, in models adjusted for age, sex, baseline headache frequency, and treatment type, the change in disability was not associated with baseline anxiety (β = -0.45, 95% CI = -1.69 to 0.78, p = 0.470), nor with baseline depressive symptom scores (β = 0.16, 95% CI = -1.07 to 1.40, p = 0.796). In post hoc exploratory analyses (N = 84 with anxiety and N = 82 with depressive symptom data at both visits), there were also no significant associations between change in mental health symptoms and change in headache frequency (for anxiety symptoms: β = -0.084, 95% CI = -0.246 to 0.078, p = 0.306; for depressive symptoms: β = -0.013, 95% CI = -0.164 to 0.138, p = 0.865). Similarly, the change in disability scores between visits was not related to the change in anxiety (β = 0.85, 95% CI = -0.095 to 1.78, p = 0.077) nor depressive symptom scores (β = 0.32, 95% CI = -0.51 to 1.15, p = 0.446).

CONCLUSION

Baseline anxiety and depressive symptom levels were not associated with longitudinal migraine outcomes and neither were longitudinal changes in anxiety and depressive symptom levels; this contradicts popular clinical belief that mental health symptoms predict or consistently change in tandem with migraine outcomes.

Post-COVID postural orthostatic tachycardia syndrome (POTS): a new phenomenon

Background

The impact of COVID-19 has been far-reaching, and the field of neurology is no exception. Due to the long-hauler effect, a variety of chronic health consequences have occurred for some post-COVID patients. A subset of these long-hauler patients experienced symptoms of autonomic dysfunction and tested positive for postural orthostatic tachycardia syndrome (POTS) via autonomic testing.

Methods

We conducted a chart review of a convenience sample from patients seen by neurologists at our tertiary care center for suspicion of post-COVID POTS. Patients included in our study had clearly defined POTS based on clinical criteria and positive tilt table test, were 81.25% female, and had an average age of approximately 36. Out of 16 patients, 12 had a confirmed positive COVID test result, with the remaining 4 having strong clinical suspicion for COVID infection. Our analysis examined the most bothersome 3 symptoms affecting each patient per the neurologist's note at their initial visit for post-COVID POTS, clinical presentation, comorbidities, neurological exam findings, autonomic testing results, and COMPASS-31 autonomic questionnaire and PROMIS fatigue survey results.

Results

Palpitations (68.75%) and fatigue (62.5%) were the most common of the impactful symptoms reported by patients in their initial Cleveland Clinic neurology visit. The most frequent comorbidities in our sample were chronic migraines (37.5%), irritable bowel syndrome (IBS) (18.75%), and Raynaud's (18.75%). Neurological exam findings and autonomic testing results other than tilt table yielded variable findings without clear trends. Survey results showed substantial autonomic symptom burden (COMPASS-31 autonomic questionnaire average score 44.45) and high levels of fatigue (PROMIS fatigue survey average score 64.64) in post-COVID POTS patients.

Conclusion

Our sample of post-COVID POTS patients are similar to the diagnosed POTS general population including in comorbidities and autonomic testing. Fatigue was identified by patients as a common and debilitating symptom. We hope that our study will be an early step toward further investigation of post-COVID POTS with focus on the trends identified in this chart review.

Personalized Mobile Health-Enhanced Cognitive Behavioral Intervention for Maternal Distress: Examining the Moderating Role of Adverse Childhood Experiences

BACKGROUND

Maternal history of trauma is a risk factor for distress during pregnancy. The purpose of this paper was to examine the theorized differential impact of a cognitive behavioral intervention (Mothers and Babies Personalized; MB-P) on maternal distress and emotional regulation for those with ≥ 1 adverse childhood experiences (ACEs; vs no ACEs) from pregnancy to 3 months postpartum.

METHODS

Between August 2019 and August 2021, eligible pregnant individuals aged ≥ 18 years, < 22 weeks' gestation, and English-speaking were recruited from 6 university-affiliated prenatal clinics. Participants (N = 100) were randomized to MB-P (n = 49) or control (n = 51). Analyzable data were collected for 95 participants. Analyses tested progression of change (slope) and at individual timepoints (panel analysis) for perinatal mental health outcomes.

RESULTS

The majority of participants (n = 68, 71%) reported experiencing > 1 ACE (median = 1, range: 0-11). Participants demonstrated significant differential effects for depressive symptoms in absence of ACEs (standardized mean differences [SMD] = 0.82; 95% confidence interval [CI] = [0.13-1.51]) vs in presence of ACEs (SMD = 0.39; 95% CI = [-0.20 to 0.97]) and perceived stress in absence of ACEs (SMD = 0.92; 95% CI = [0.23-1.62]) vs in presence of ACEs (SMD = -0.05; 95% CI = [-0.63 to 0.53]). A panel analysis showed significantly reduced depressive symptoms postintervention and increased negative mood regulation at 3 months postpartum for individuals with ACEs.

CONCLUSIONS

Findings support effectiveness of the MB-P intervention to reduce prenatal distress for all pregnant individuals. Preliminary exploration suggests the possibility that individuals with ACEs may benefit from enhanced trauma-informed content to optimize the effects of a perinatal intervention.

What do Hyperhidrosis Quality of Life Index (HidroQoL©) scores mean? Transferring science into practice by establishing a score banding system

BACKGROUND

The Hyperhidrosis Quality of Life Index (HidroQoL©) is a measure of quality of life (QoL) impacts in hyperhidrosis (HH).

OBJECTIVES

We aimed to establish score banding systems for the HidroQoL total score for specific contexts representing different severity/impact categories by using the Dermatology Life Quality Index (DLQI) and the Hyperhidrosis Disease Severity Scale (HDSS) as anchors, including data from 357 patients from a phase III clinical trial.

METHODS

We used the HDSS, the established DLQI score bands and two single items (items 5 and 7) of the DLQI as anchors for the creation of banding systems for the HidroQoL. These anchors were chosen via consensus among an expert group according to relevance to patient experience. Due to the distribution of the HDSS and the single DLQI item 7, receiver operating characteristic curves were computed in order to create an optimal cut-off value of the HidroQoL total score. For the DLQI banding system and the single DLQI item 5, we created a banding system for the HidroQoL based on the distribution of their different categories.

RESULTS

A score of 30 and greater is proposed as the cut-off value for sweating that 'always interferes in daily activities', based on the HDSS as anchor. In terms of overall skin QoL effects, score bands of 0-6, 7-18, 19-25, 26-32 and 33-36 represent 'no effect', 'small effect', 'moderate effect', 'very large effect' and 'extremely large effect' on the patient's life, respectively.

CONCLUSIONS

In this study, we propose different banding systems for four different contexts: skin-specific QoL (DLQI banding), HH severity (HDSS), working and studying (single DLQI item 7) and social and leisure activities (single DLQI item 5). These banding systems and cut-off values can be used in clinical research and practice to place the patients in different severity categories.

Fix or Replace? Patient Preferences for the Treatment of Geriatric Lower Extremity Fractures: A Discrete Choice Experiment

Introduction

When considering treatment options for geriatric patients with lower extremity fractures, little is known about which outcomes are prioritized by patients. This study aimed to determine the patient preferences for outcomes after a geriatric lower extremity fracture.

Materials and Methods

We administered a discrete choice experiment survey to 150 patients who were at least 60 years of age and treated for a lower extremity fracture at a Level I trauma center. The discrete choice experiment presented study participants with 8 sets of hypothetical outcome comparisons, including joint preservation (yes or no), risk of reoperation at 6 months and 24 months, postoperative weightbearing status, disposition, and function as measured by return to baseline walking distance. We estimated the relative importance of these potential outcomes using multinomial logit modeling.

Results

The strongest patient preference was for maintained function after treatment (59%, P < .001), followed by reoperation within 6 months (12%, P < .001). Although patients generally favored joint preservation, patients were willing to change their preference in favor of joint replacement if it increased function (walking distance) by 13% (SE, 66%). Reducing the short-term reoperation risk (12%, P < .001) was more important to patients than reducing long-term reoperation risk (4%, P = .33). Disposition and weightbearing status were lesser priorities to patients (9%, P < .001 and 7%, P < .001, respectively).

Discussion

After a lower extremity fracture, geriatric patients prioritized maintained walking function. Avoiding short-term reoperation was more important than avoiding long-term reoperation. Joint preservation through fracture fixation was the preferred treatment of geriatric patients unless arthroplasty or arthrodesis provides a meaningful functional benefit. Hospital disposition and postoperative weightbearing status were less important to patients than the other included outcomes.

Conclusions

Geriatric patients strongly prioritize function over other outcomes after a lower extremity fracture.

Particulated Juvenile Articular Cartilage Allograft Transplantation for Patellofemoral Defects Shows Favorable Return-to-Sport Rates and Patient-Reported Outcomes

PURPOSE

To report return-to-sport rates, postoperative patient-reported outcomes (PROs), complication rates, and reoperation rates of a cohort of patients undergoing particulated juvenile articular cartilage (PJAC) allograft transplantation for patellofemoral articular cartilage defects.

METHODS

We performed a single-institution retrospective review of all patients with patellofemoral articular cartilage defects who received PJAC allograft transplantation from 2014 to 2022. Baseline demographic characteristics and surgical data, including concomitant surgical procedures, were collected. Clinical outcomes recorded included return-to-sport rates, complications, reoperations, and the following PRO scores: Kujala knee score, Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference score, and PROMIS Physical Function score.

RESULTS

Forty-one knees with a mean age of 23.4 ± 9.7 years and mean follow-up period of 30.3 months (range, 12-107 months) were included. The mean postoperative PROMIS Pain Interference, PROMIS Physical Function, and Kujala knee scores were 47.4 ± 7.7, 52.2 ± 10.8, and 81.7 ± 16.1, respectively, reflecting low residual anterior knee pain and a return to normal function. For patients playing organized sports at the high school and collegiate levels, the overall return-to-sport rate was 100% (17 of 17). During follow-up, complications developed in 12 knees (29.3%), the most common of which was anterior-based knee pain, and 6 knees (14.6%) required a total of 8 reoperations, which occurred from 6 to 32 months postoperatively.

CONCLUSIONS

The 100% return-to-sport rate and satisfactory PRO scores in our study suggest that PJAC allograft transplantation can effectively address patellofemoral cartilage defects in many patients. The complication and reoperation rates of 29.3% and 14.6%, respectively, are consistent with the challenging and heterogeneous etiology and treatment of patellofemoral articular defects.

LEVEL OF EVIDENCE

Level IV, case series.

Identification of Fatigue Subtypes and Their Correlates in Prevalent Heart Failure: A Secondary Analysis of the Atherosclerosis Risk in Communities Study

BACKGROUND

Among patients with heart failure (HF), fatigue is common and linked to quality of life and functional status. Fatigue is hypothesized to manifest as multiple types, with general and exertional components. Unique subtypes of fatigue in HF may require differential assessment and treatment to improve outcomes. We conducted this study to identify fatigue subtypes in persons with prevalent HF in the ARIC study (Atherosclerosis Risk in Communities) and describe the distribution of characteristics across subtypes.

METHODS

We performed a cross-sectional analysis of 1065 participants with prevalent HF at ARIC visit 5 (2011-2013). We measured exertional fatigue using the Modified Medical Research Council Breathlessness scale and general fatigue using the Patient Reported Outcomes Measurement Information System fatigue scale. We used latent class analysis to identify subtypes of fatigue. Number of classes was determined using model fit statistics, and classes were interpreted and assigned fatigue severity rating based on the conditional probability of endorsing survey items given class. We compared characteristics across classes using multinomial regression.

RESULTS

Overall, participants were 54% female and 38% Black with a mean age of 77. We identified 4 latent classes (fatigue subtypes): (1) high general/high exertional fatigue (18%), (2) high general/low exertional fatigue (27%), (3) moderate general/moderate exertional fatigue (20%), and (4) low/no general and exertional fatigue (35%). Female sex, Black race, lower education level, higher body mass index, increased depressive symptoms, and higher prevalence of diabetes were associated with higher levels of general and exertional fatigue.

CONCLUSIONS

We identified unique subtypes of fatigue in patients with HF who have not been previously described. Within subtype, general and exertional fatigue were mostly concordant in severity, and exertional fatigue only occurred in conjunction with general fatigue, not alone. Further understanding these fatigue types and their relationships to outcomes may enhance our understanding of the symptom experience and inform prognostication and secondary prevention efforts for persons with HF.

Establishing the Minimally Important Difference for the KOOS-Joint Replacement and PROMIS Global-10 in Patients After Total Knee Arthroplasty

Background

Despite the overall prevalence and success of total knee arthroplasty (TKA), a significant portion of patients are dissatisfied with their outcomes.

Purpose

To assess the responsiveness and determine the minimally important difference (MID) of 2 patient-reported outcome measures (PROMs)-the Knee injury and Osteoarthritis Outcome Score-Joint Replacement (KOOS-JR) and the Patient-Reported Outcomes Measurement Information System Global-10 (PROMIS 10)-in patients after TKA.

Study Design

Cohort study (diagnosis); Level of evidence, 3.

Methods

Included were patients who underwent TKA from August 2015 through August 2019 and completed baseline and postoperative KOOS-JR and PROMIS 10 surveys. The PROMIS 10 consists of 2 domains: physical health and mental health. Estimates for the reliable change index (RCI) and MID, using anchor-based and distribution-based methods, were calculated for each PROM. Regression modeling was used to determine whether patient and clinical factors predicted MID thresholds or MID achievement.

Results

A total of 1315 patients were included. Distribution-based MIDs, calculated using various methods from baseline scores, ranged from 19.3 to 31 for the KOOS-JR, and the RCI was 4.38. Of these patients, 293 (22.3%) demonstrated small or moderate improvement, and this cohort was included in the calculation of anchor-based MIDs. The anchor-based MIDs were 16.9 and 24.3 at 3-month and 1-year follow-up, respectively, and 66% of patients achieved the MID at 12 months. Higher preoperative PROM score, male sex, non-White race, and current smoker status were predictive of failing to achieve the anchor-based MID for KOOS-JR at 1 year postoperatively (P < .05). Higher preoperative PROM score and any 90-day adverse event predicted lower thresholds of important change in anchor-based MIDs. Higher baseline PROM scores, younger age, male sex, non-White ethnicity, higher American Society of Anesthesiologists classification, preoperative narcotics use, not smoking, and longer hospital stay were all associated with lower odds of achieving the MID on the KOOS-JR or either of the PROMIS 10 subscales.

Conclusion

The study results demonstrated relevant values for interpretation of the KOOS-JR and PROMIS 10. While patient demographics did not accurately predict which patients would achieve the MID, some potential factors predicting successful patient-reported outcomes after TKA were identified.

Two-Year Survivorship and Patient-Reported Outcomes of a Prospectively Enrolled Cohort of INFINITY Total Ankle Arthroplasties

BACKGROUND

The INFINITY total ankle implant is a widely and successfully used option for total ankle arthroplasty. The purpose of this study is to assess the 2-year survivorship, complication rates, patient-reported outcomes, and radiologic findings of prospectively enrolled patients undergoing a fixed-bearing total ankle arthroplasty (TAA). This study sought to determine if factors such as traditional vs patient-specific instrumentation, preoperative degree of arthritis, deformity, or etiology of arthritis impact surgical or clinical outcomes.

METHODS

A total of 143 prospectively enrolled patients (148 ankles) underwent TAA with a fixed-bearing total ankle implant between 2017 and 2019 at 9 different institutions by 9 different surgeons. A total of 116 completed 2-year follow-up. Patients were stratified by instrumentation used, degree of preoperative deformity, the Canadian Orthopaedic Foot and Ankle Society (COFAS) grading system, and etiology of arthritis. Outcomes used included implant survivorship and adverse events within 2 years of surgery. Additionally, patient-reported outcomes and radiographs were collected at 6-month, 1-year, and 2-year postoperatively. PROMs used included Ankle Osteoarthritis Score (AOS), Patient-Reported Outcomes Measurement Information System (PROMIS) global health score, the Foot and Ankle Outcome Score (FAOS), and patient satisfaction (rated from excellent to poor).

RESULTS

Implant survivorship at 2 years was 97.79%. There were 17 reoperations (11.5%), with 4 of the implants requiring revision (2.7%). Significant improvements in all PROMs were observed among all subgroups at all postoperative time points without significant variation between subgroups. Patients classified as COFAS type 2 arthritis preoperatively demonstrated significantly more improvement in FAOS Total Symptom Score at the 1- and 2-year measurements than COFAS type 3 patients at both time points.

CONCLUSION

Total ankle arthroplasty with a fixed-bearing implant system is a safe and reliable treatment option for patients with end-stage arthritis regardless of degree of deformity or COFAS grading.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Predictors at 6 and 12 Months for Social Participation Outcome at 24 Months in the Adult Burn Injury Population: A Burn Model System National Database Study

OBJECTIVE

To identify clinical factors (physical and psychological symptoms and post-traumatic growth) that predict social participation outcome at 24-month after burn injury.

DESIGN

A prospective cohort study based on Burn Model System National Database.

SETTING

Burn Model System centers.

PARTICIPANTS

181 adult participants less than 2 years after burn injury (N=181).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Demographic and injury variables were collected at discharge. Predictor variables were assessed at 6 and 12 months: Post-Traumatic Growth Inventory Short Form (PTGI-SF), Post-Traumatic Stress Disorder Checklist Civilian Version (PCL-C), Patient-Reported Outcomes Measurement Information System (PROMIS-29) Depression, Anxiety, Sleep Disturbance, Fatigue, and Pain Interference short forms, and self-reported Heat Intolerance. Social participation was measured at 24 months using the Life Impact Burn Recovery Evaluation (LIBRE) Social Interactions and Social Activities short forms.

RESULTS

Linear and multivariable regression models were used to examine predictor variables for social participation outcomes, controlling for demographic and injury variables. For LIBRE Social Interactions, significant predictors included the PCL-C total score at 6 months (β=-0.27, P<.001) and 12 months (β=-0.39, P<.001), and PROMIS-29 Pain Interference at 6 months (β=-0.20, P<.01). For LIBRE Social Activities, significant predictors consisted of the PROMIS-29 Depression at 6 months (β=-0.37, P<.001) and 12 months (β=-0.37, P<.001), PROMIS-29 Pain Interference at 6 months (β=-0.40, P<.001) and 12 months (β=-0.37, P<.001), and Heat Intolerance at 12 months (β=-4.55, P<.01).

CONCLUSIONS

Post-traumatic stress and pain predicted social interactions outcomes, while depression, pain and heat intolerance predicted social activities outcomes in people with burn injury.

Self-reported MeasUrement of Physical and PsychosOcial Symptoms Response Tool (SUPPORT-dialysis): systematic symptom assessment and management in patients on in-centre haemodialysis - a parallel arm, non-randomised feasibility pilot study protocol

INTRODUCTION

Patients with kidney failure experience symptoms that are often under-recognised and undermanaged. These symptoms negatively impact health-related quality of life and are associated with adverse clinical outcomes. Regular symptom assessment, using electronic patient reported outcomes measure (ePROMs) linked to systematic symptom management, could improve such outcomes. Clinical implementation of ePROMs have been successful in routine oncology care, but not used for patients on dialysis. In this study, we describe a pilot study of ePROM-based systematic symptom monitoring and management intervention in patients treated with in-centre haemodialysis.

METHODS AND ANALYSIS

This is a parallel-arm, controlled pilot of adult patients receiving in-centre maintenance haemodialysis. Participants in the intervention arm will complete ePROMs once a month for 6 months. ePROMs will be scored real time and the results will be shared with participants and with the clinical team. Moderate-severe symptoms will be flagged using established cut-off scores. Referral options for those symptoms will be shared with the clinical team, and additional symptom management resources will also be provided for both participants and clinicians. Participants in the control arm will be recruited at a different dialysis unit, to prevent contamination. They will receive usual care, except that they will complete ePROMs without the presentation of results to participants of the clinical team. The primary objectives of the pilot are to assess (1) the feasibility of a larger, randomised clinical effectiveness trial and (2) the acceptability of the intervention. Interviews conducted with participants and staff will be assessed using a content analysis approach.

ETHICS AND DISSEMINATION

Ethical approval for this study was obtained from the University Health Network (REB#21-5199) and the William Osler Health System (#23-0005). All study procedures will be conducted in accordance with the standards of University Health Network research ethics board and with the 1964 Helsinki declaration and its later amendments. Results of this study will be shared with participants, patients on dialysis and other stakeholders using lay language summaries, oral presentations to patients and nephrology professionals. We will also be publishing the results in a peer-reviewed journal and at scientific meetings.

PROTOCOL VERSION

4 (16 November 2022).

TRIAL REGISTRATION NUMBER

NCT05515991.

Patient-Reported Outcomes and Medical Provider Satisfaction Among Adult and Pediatric Ataxia-Telangiectasia Patients

PURPOSE

Ataxia-telangiectasia (A-T) is a rare genetic condition with malfunctioning DNA repair processes resulting in significant clinical findings, including progressive neurologic decline, elevated malignancy risk, immunodeficiency, oculocutaneous telangiectasias, and severe pulmonary disease. Research has been limited into the quality of life of such patients and yet to be completed are studies quantitatively analyzing psychosocial, physical, and cognitive patient-reported outcomes (PROs) within the A-T population.

METHODS

PRO evaluations of 90 international adult and pediatric A-T patients and their caregivers were completed via secure online administration of Patient-Reported Outcomes Measurement Information System (PROMIS) short forms evaluating anger, cognition, mood, social health, fatigue, pain, anxiety, and upper extremity function. The impact of age, gender, race/ethnicity, prior malignancy diagnosis, and current supportive treatment interventions on such PROs was additionally assessed. Finally, given the importance of medical providers in the care of A-T patients and the impact of patient satisfaction on healthcare outcomes, we further analyzed, via a novel survey, how patients and caregivers perceived their primary A-T healthcare provider's A-T expertise, trustworthiness, accessibility, and level of compassion.

RESULTS/CONCLUSION

It was found that a diagnosis of A-T complexly impacts patient PROs, but such data offers the potential for preventative and therapeutic interventions to improve the care of such patients. While most A-T patients and their caregivers feel their primary A-T medical provider has expertise and compassion in addition to being accessible and trustworthy, a significant percentage of study subjects did not agree that their provider was an expert in A-T or overall trustworthy.

Understanding the Orthopedic Conditions for Which Patients Are Seeking Medical Cannabis Certification

BACKGROUND

Amid the ongoing national crisis of opioid misuse in the United States, medical cannabis (MC) has emerged as a potential alternative for chronic pain conditions. This study was performed to understand which orthopedic conditions patients are seeking MC certification for.

METHODS

This prospective study was conducted at the Department of Medical Cannabis, Rothman Orthopaedic Institute, Philadelphia, PA, USA. It included consecutive patients with chronic musculoskeletal noncancer pain who were certified for MC, following the Pennsylvania state certification process. Data collected included demographic data, diagnoses, anatomic site of pain, and Patient-Reported Outcomes Measurement Information System (PROMIS) global health scale. The outcome measures from the PROMIS global health scale were used to generate Global Physical Health (GPH) quality of life (QoL) T scores and Global Mental Health (GMH) QoL T scores.

RESULTS

A total of 78 patients were available for analysis following initial MC certification, with 50 (64%) being female and 28 (36%) male. The average age was 63 years with 60% of patients in the 65+ age group. Ethnically, 73 (92%) identified as White, and 70 (90%) were not of Hispanic or Latino origin. The most common reason for seeking MC certification was low back pain (56%), followed by neck pain (21%) and then extremity complaints. The mean GPH QoL T score was 43.71 with a standard deviation of ± 9.86 (p-value = 0.001), while the mean GMH QoL T score was 46.85 with a standard deviation of 8.28 (p-value = 0.0015).

CONCLUSION

MC cannabis certification was more often sought by women than men and most common for spinal complaints, specifically lower back followed by cervical spine concerns.. This cohort of patients had lower GPH QoL and GMH QoL T scores compared the US general population, representing a significant reduction in the overall physical and mental health.

COVID-19 Vaccination-Related Delayed Adverse Events among Patients with Systemic Lupus Erythematosus

BACKGROUND

The safety profile of COVID-19 vaccination is well documented, but hesitancy among people with immune-mediated inflammatory diseases, often immunocompromised, remains high, partially due to a scarcity of data on safety over a longer term. We herein aimed to assess delayed adverse events (DAEs) occurring >7 days after COVID-19 vaccination in systemic lupus erythematosus (SLE) versus other rheumatic autoimmune diseases (rAIDs), non-rheumatic AIDs (nrAIDs), and healthy controls (HCs).

METHODS

Self-reported data were captured within the COVID-19 Vaccination in Autoimmune Diseases (COVAD)-2 online survey, which comprised >150 centres and responses from 106 countries, between February and June 2022. Logistic regression analysis adjusting for important confounders (age, sex, ethnicity) was used to compare groups.

RESULTS

Of 7203 eligible individuals, 882 (12.2%) patients had SLE, 3161 (43.9%) patients had rAIDs, 426 (5.9%) patients had nrAIDs, and 2734 (38.0%) were HCs. SLE patients had a median age of 39 years (IQR: 31-50); 93.7% were women. SLE patients reported, more frequently, major DAEs (OR: 1.6; 95% CI: 1.2-2.0; p = 0.001) and hospitalisation (OR: 2.2; 95% CI: 1.4-3.4; p < 0.001) compared to HCs, severe rashes (OR: 2.4; 95% CI: 1.3-4.2; p = 0.004) compared to people with rAIDS, and hospitalisation (OR: 2.3; 95% CI: 1.1-4.9; p = 0.029) as well as several minor DAEs compared to people with nrAIDs. Differences were observed between vaccines in terms of frequency of major DAEs and hospitalisations, with the latter seen more frequently in patients receiving the Moderna vaccine. People with SLE with no autoimmune multimorbidity less frequently reported overall minor DAEs compared to SLE patients with comorbid nrAIDs (OR: 0.5; 95% CI: 0.3-1.0; p = 0.036).

CONCLUSION

Hospitalisations post-vaccination were more frequent in SLE patients than in HCs. Monitoring of SLE patients following COVID-19 vaccination can help in identifying DAEs early, informing patients about expected DAEs, and supporting patients, especially those with autoimmune multimorbidity.

Longitudinal Natural History Study of Children and Adults with Rare Solid Tumors: Initial Results for First 200 Participants

Understanding of tumor biology and identification of effective therapies is lacking for many rare tumors. My Pediatric and Adult Rare Tumor (MyPART) network was established to engage patients, advocates, and researchers and conduct a comprehensive longitudinal Natural History Study of Rare Solid Tumors. Through remote or in-person enrollment at the NIH Clinical Center, participants with rare solid tumors ≥4 weeks old complete standardized medical and family history forms, patient reported outcomes, and provide tumor, blood and/or saliva samples. Medical records are extracted for clinical status and treatment history, and tumors undergo genomic analysis. A total of 200 participants (65% female, 35% male, median age at diagnosis 43 years, range = 2-77) enrolled from 46 U.S. states and nine other countries (46% remote, 55% in-person). Frequent diagnoses were neuroendocrine neoplasms (NEN), adrenocortical carcinomas (ACC), medullary thyroid carcinomas (MTC), succinate dehydrogenase (SDH)-deficient gastrointestinal stromal tumors (sdGIST), and chordomas. At enrollment, median years since diagnosis was 3.5 (range = 0-36.6), 63% participants had metastatic disease and 20% had no evidence of disease. Pathogenic germline and tumor mutations included SDHA/B/C (sdGIST), RET (MTC), TP53 and CTNNB1 (ACC), MEN1 (NEN), and SMARCB1 (poorly-differentiated chordoma). Clinically significant anxiety was observed in 20%-35% of adults. Enrollment of participants and comprehensive data collection were feasible. Remote enrollment was critical during the COVID-19 pandemic. Over 30 patients were enrolled with ACC, NEN, and sdGIST, allowing for clinical/genomic analyses across tumors. Longitudinal follow-up and expansion of cohorts are ongoing to advance understanding of disease course and establish external controls for interventional trials.

SIGNIFICANCE

This study demonstrates that comprehensive, tumor-agnostic data and biospecimen collection is feasible to characterize different rare tumors, and speed progress in research. The findings will be foundational to developing external controls groups for single-arm interventional trials, where randomized control trials cannot be conducted because of small patient populations.

Cortical GABA Levels Are Reduced in Post-Acute COVID-19 Syndrome

After recovering from the acute COVID-19 illness, a substantial proportion of people continue experiencing post-acute sequelae of COVID-19 (PASC), also termed "long COVID". Their quality of life is adversely impacted by persistent cognitive dysfunction and affective distress, but the underlying neural mechanisms are poorly understood. The present study recruited a group of mostly young, previously healthy adults (24.4 ± 5.2 years of age) who experienced PASC for almost 6 months following a mild acute COVID-19 illness. Confirming prior evidence, they reported noticeable memory and attention deficits, brain fog, depression/anxiety, fatigue, and other symptoms potentially suggestive of excitation/inhibition imbalance. Proton magnetic resonance spectroscopy (1H-MRS) was used to examine the neurochemical aspects of cell signaling with an emphasis on GABA levels in the occipital cortex. The PASC participants were compared to a control (CNT) group matched in demographics, intelligence, and an array of other variables. Controlling for tissue composition, biological sex, and alcohol intake, the PASC group had lower GABA+/water than CNT, which correlated with depression and poor sleep quality. The mediation analysis revealed that the impact of PASC on depression was partly mediated by lower GABA+/water, indicative of cortical hyperexcitability as an underlying mechanism. In addition, N-acetylaspartate (NAA) tended to be lower in the PASC group, possibly suggesting compromised neuronal integrity. Persistent neuroinflammation may contribute to the pathogenesis of PASC-related neurocognitive dysfunction.

Surgical management of traumatic sternal body nonunions: Technical tricks and clinical experience

BACKGROUND

Rarely, traumatic sternum fractures may result in nonunion, which can have drastic, negative implications. Literature on traumatic sternal nonunion reconstruction outcomes is limited to case reports. We present the surgical principles and report clinical outcomes for seven patients following surgical reconstruction of a traumatic sternal body nonunion.

METHODS

Consecutive adult patients with a nonunion after a traumatic sternum fracture who underwent reconstruction using locking plate technology and iliac crest bone graft at a Level I trauma center from 2013 to 2021 were identified. Demographic, injury, and surgery data was collected, and postoperative patient-reported outcome (PRO) scores were obtained. Patient-reported outcome scores included the one-question single assessment numeric evaluation (SANE), and the combined 10-question global physical health and global mental health values. Injuries were classified and all fractures were mapped onto a sternum template. Postoperative radiographs were reviewed for union.

RESULTS

Of the study's seven patients, five were female, and the mean age was 58 years. Mechanism of injury included motor vehicle collision (5) and blunt object chest trauma (2). The mean time from initial fracture to nonunion fixation was 9 months. Four of the seven patients achieved in-clinic follow-up at ≥12 months (mean = 14.3 months), while the other three achieved ≥6 months of in-clinic follow-up. Six patients completed outcomes surveys ≥12 months after surgery (mean = 28.9 months). Mean PRO scores at final follow-up included: SANE of 75 (out of 100), and global physical health and global mental health of 44 and 47, respectively (US population mean = 50).Six of seven patients achieved known radiographic union.

CONCLUSION

We describe an effective and practical method of achieving stable fixation in traumatic sternal body nonunions as evidenced by the positive clinical outcomes of a seven-patient series. Despite the variation in presentation and fracture morphology of this rare injury, the surgical technique and principles outlined can serve as a useful tool for chest wall surgeons.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Remote cognitive behavioral therapy utilizing an in-home virtual reality toolkit (Vx Therapy) reduces pain, anxiety, and depression in patients with chronic cervical and lumbar spondylytic pain: A potential alternative to opioids in multimodal pain management

Background Context

Virtual reality (VR) reduces pain through visual and auditory distraction without narcotic-related side effects or dependency. Cognitive behavioral therapy (CBT) improves pain-related disability and quality of life, but patient access remains a challenge. We hypothesized that in-home weekly CBT coordinated with daily use of a proprietary VR toolkit will reduce pain, anxiety, and depression for patients with non-operative chronic cervical and lumbar spondylitic pain with and without radiculopathy.

Methods

A total of 145 patients with chronic spondylitic pain (63 cervical, 46 noradicular lumbar, 36 radicular lumbar) were enrolled into a guided 14-week VR+CBT program (Vx Therapy) consisting of weekly encounters with a trained therapist and 50 modules. Pain/anxiety severity scores and time to pain recurrence were recorded prospectively by patients. PROMIS measures of overall daily pain intensity, behavior, interference, anxiety, and depression were recorded at baseline and conclusion of the program.

Results

A total of 52% of the 145 patients were male. The average (SD) age of the cohort was 51 (10.7) years (range: 24-76 years). Mean score for all PROMIS domains were significantly improved after 14 weeks of Vx Therapy (pain intensity 36±24 vs. 28±21, interference 39±25 vs. 24±21, behavior 35±21 vs. 25±16, anxiety 51±28 vs. 41±26, depression 58±32 vs. 48±32) for the entire cohort and each diagnosis group. Virtual reality acutely reduced pain on average by 33% (4.5±2.5 vs. 6.7±2.2, p<.05) across all 14 weeks, lasting a mean 2.8 hours after use. Duration of pain relief increased by the final vs. first month (4.5 hours vs. 2.5 hours, p<.05). Virtual reality acutely reduced anxiety on average by 46% (3.5±3 vs. 6.4±2, p<.05) across all 14 weeks lasting a mean 2.7 hours after use. The effect was similar for all 3 groups.

Conclusions

Fourteen weeks of a remote CBT guided in-home VR toolkit provided effective and sustained pain, anxiety, and depression relief in patients with chronic degenerative neck/back pain with and without radiculopathy. The non-invasive, non-pharmacological nature of Vx Therapy makes it an ideal option for pain management in the post-opioid epidemic era.

The Use of Patient-Reported Outcome Measures in Clinical Practice and Clinical Decision Making

Patient-reported outcome measures (PROMs) are highly effective measures of quality of care and outcomes that matter to patients regarding their physical, mental, and social health. While PROMs have played a notable role in research and registry reporting, they are also useful as clinical tools. Real-time PROM collection can be integrated into routine clinical care with immediate access to scores within the electronic health record. This can be integral when discussing treatment options and using decision aids. PROM scores can also be useful for postoperative monitoring. Various approaches to quantifying clinical efficacy have been developed, including the minimal clinically important difference, the substantial clinical benefit, and the patient acceptable symptom state (PASS). As the patient experience and patient-reported outcome measurement of health-related outcomes become increasingly emphasized in patient-centered, high value care, so too will the importance of methods to gauge clinical benefit using these instruments for improved clinical decision-making.

The Dosing of Mobile-Based Just-in-Time Adaptive Self-Management Prompts for Caregivers: Preliminary Findings From a Pilot Microrandomized Study

BACKGROUND

Caregivers of people with chronic illnesses often face negative stress-related health outcomes and are unavailable for traditional face-to-face interventions due to the intensity and constraints of their caregiver role. Just-in-time adaptive interventions (JITAIs) have emerged as a design framework that is particularly suited for interventional mobile health studies that deliver in-the-moment prompts that aim to promote healthy behavioral and psychological changes while minimizing user burden and expense. While JITAIs have the potential to improve caregivers' health-related quality of life (HRQOL), their effectiveness for caregivers remains poorly understood.

OBJECTIVE

The primary objective of this study is to evaluate the dose-response relationship of a fully automated JITAI-based self-management intervention involving personalized mobile app notifications targeted at decreasing the level of caregiver strain, anxiety, and depression. The secondary objective is to investigate whether the effectiveness of this mobile health intervention was moderated by the caregiver group. We also explored whether the effectiveness of this intervention was moderated by (1) previous HRQOL measures, (2) the number of weeks in the study, (3) step count, and (4) minutes of sleep.

METHODS

We examined 36 caregivers from 3 disease groups (10 from spinal cord injury, 11 from Huntington disease, and 25 from allogeneic hematopoietic cell transplantation) in the intervention arm of a larger randomized controlled trial (subjects in the other arm received no prompts from the mobile app) designed to examine the acceptability and feasibility of this intensive type of trial design. A series of multivariate linear models implementing a weighted and centered least squares estimator were used to assess the JITAI efficacy and effect.

RESULTS

We found preliminary support for a positive dose-response relationship between the number of administered JITAI messages and JITAI efficacy in improving caregiver strain, anxiety, and depression; while most of these associations did not meet conventional levels of significance, there was a significant association between high-frequency JITAI and caregiver strain. Specifically, administering 5-6 messages per week as opposed to no messages resulted in a significant decrease in the HRQOL score of caregiver strain with an estimate of -6.31 (95% CI -11.76 to -0.12; P=.046). In addition, we found that the caregiver groups and the participants' levels of depression in the previous week moderated JITAI efficacy.

CONCLUSIONS

This study provides preliminary evidence to support the effectiveness of the self-management JITAI and offers practical guidance for designing future personalized JITAI strategies for diverse caregiver groups.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04556591; https://clinicaltrials.gov/ct2/show/NCT04556591.

The Role of Autobiographical Resilience Memories in Emotion Regulation: An Account of Age Differences in Mnemonic and Positive Reappraisal

A lifetime of resilience through emotionally challenging experiences may benefit older adults, lending to emotion regulation mastery with time. Yet the influence of autobiographical experiences on momentary reappraisal, the reinterpretation of negative stimuli as more positive, has never been empirically tested. This online study examined the extent to which associating life memories of resilience with novel negative scenarios enhanced reappraisal efficacy and reduced difficulty to reappraise. Younger and older adults reappraised negative images by associating reappraisals to freely selected autobiographical resilience memories, cued autobiographical resilience memories, or by finding situational silver linings without mnemonic association (control). Changes in image emotional intensity ratings revealed no difference across reappraisal conditions for younger adults, while older adults most effectively down-regulated emotional intensity using the control reappraisal strategy. Older adults found autobiographical memories more helpful for mood regulation and less difficult to implement, and identified greater similarities between novel negative scenarios and their memories than younger adults. Surprisingly, greater similarity between resilience memories and negative images was associated with lower reappraisal efficacy for both age groups. Findings demonstrate the age-equivalent benefits of utilizing reappraisals associated with past narratives of resilience and suggest a sacrifice of immediate hedonic benefit for disproportionately greater subjective benefits with age.

Latent class symptom profiles of colorectal cancer survivors with cancer-related cognitive impairment

PURPOSE

Colorectal cancer (CRC) survivors experience cancer-related cognitive impairment and co-occurring symptoms after cancer treatments. There has been little data to inform the risk factors of complex symptom phenotypes in CRC survivors.

OBJECTIVES

To determine if subgroups of CRC survivors after cancer treatments could be identified based on the cognitive impairment and common co-occurring symptoms (depression, anxiety, sleep disturbance, fatigue, and pain); and to explore risk factors (sociodemographic and clinical characteristics, perceived stress, and social support) of these subgroups.

METHODS

Latent class profile analysis (LCPA) was used to identify subgroups based on self-reported symptoms in 64 CRC survivors. Cognitive impairment was measured by assessing subjective cognitive function using the Patient-Reported Outcome Measurement Information System (PROMIS) measure. The Kruskal-Wallis test and regression analyses were performed.

RESULTS

Three distinct latent classes were identified (Class 1: All Low '28.1%'; Class 2: High Psychological Symptoms (depression/anxiety) '25%'; Class 3: High Somatic Symptoms (fatigue, sleep disturbance, and pain) with High Cognitive Impairment'46.9%'). The pain was the most distinguishable symptom across the latent classes. The high symptom burden group was associated with less time since cancer diagnosis, higher perceived stress levels, and poor emotional social support.

CONCLUSION

Our study adds to the information on interindividual variability in symptom experience of CRC survivors with cognitive impairment. Findings suggest a need for increased attention to screening for co-occurring symptoms (e.g., high pain) and future interventions focused on stress management and social support.

The relationship between physical activity, structural deformity, and spinal mobility in adolescent idiopathic scoliosis patients

PURPOSE

Adolescent idiopathic scoliosis (AIS) patients experience structural spinal deformity, but the impact of AIS on physical activity is not widely studied. Reports of physical activity levels between children with AIS and their peers are mixed. This study sought to characterize the relationship between spinal deformity, spinal range of motion, and self-reported physical activity in AIS patients.

METHODS

Patients aged 11-21 completed self-reported measures of physical activity using the HSS Pedi-FABS and PROMIS Physical Activity questionnaires. Radiographic measures were obtained from standing biplanar radiographic imaging. Surface topographic (ST) imaging data was obtained using a whole-body ST scanning system. Hierarchical linear regression models analyzed the relationship between physical activity, ST, and radiographic deformity while controlling for age and BMI.

RESULTS

149 patients with AIS (mean age 14.5 ± 2.0 years, mean Cobb angle 39.7° ± 18.9°) were included. In the hierarchical regression predicting physical activity from Cobb angle, no factors were significant predictors of physical activity. When predicting physical activity from ST ROM measurements, age and BMI served as covariates. No covariates or ST ROM measurements were significant predictors of physical activity levels for either activity measure.

CONCLUSIONS

Physical activity levels of patients with AIS were not predicted by levels of radiographic deformity or surface topographic range of motion. Although patients may experience severe structural deformity and range of motion limitations, these factors do not appear to be associated with decreased physical activity level utilizing validated patient activity questionnaires.

LEVEL OF EVIDENCE

Level II.

Sleep Disturbance Among Adults With Overactive Bladder: A Cross-sectional Survey

OBJECTIVE

To examine differences in sleep disturbance, nocturia, and depression among adults with overactive bladder (OAB) by treatment type.

METHODS

A cross-sectional survey of adults with OAB assessed sleep disturbance, nocturia, and depression using patient-reported outcome measures, including the Patient Reported Outcomes Measurement Information System (PROMIS)-29 Profile v2.1 (Sleep Disturbance and Depression domains), Lower Urinary Tract Dysfunction Research Network Symptom Index-10, and PROMIS Sleep Disturbance Short Form 8B. Treatment groups included antimuscarinics, β-3 adrenergic agonists, and no treatment. Analysis of covariance (ANCOVA) was used to test for differences in study endpoints; Bonferroni-adjusted pairwise tests (P < .05/3) were performed to compare differences in least squares means between groups.

RESULTS

One hundred participants were included per treatment group. The overall mean (standard deviation) age across all groups was 47.8 (11.8) years. Symptom scores across all PROMIS domains in all three treatment groups were higher than the US general population. There were no statistically significant differences in outcomes across treatment groups.

CONCLUSION

Adults with OAB reported being affected by sleep disturbance and depression, regardless of treatment. The mirabegron group trended toward the lowest symptom impact across all outcomes, however, comparisons were not significant. Future research should examine temporal associations between OAB treatment, sleep disturbance, and outcomes.

Outcomes of Surgical Treatment for Sural Neuritis: A Retrospective Case Series

BACKGROUND

Somatic nerve pain is one of the most common complications following surgery of the foot and ankle but may also arise following traumatic injury or chronic nerve compression. The sural nerve is a commonly affected nerve in the foot and ankle; it is at risk given the proximity to frequently used surgical approaches, exposure to crush injuries, and traction from severe ankle inversion injuries. The purpose of this study is to investigate the outcomes of sural nerve neurectomy with proximal implantation for sural neuromas (SN) and chronic sural neuritis (CSN).

METHODS

Patients that underwent neurectomy with proximal implantation (20 muscle, 1 adipose tissue) by 2 foot and ankle specialists for isolated SN- and CSN-related pain at a single tertiary institution were included. Demographic data, baseline outcomes including 36-Item Short Form Health Survey (SF-36), Foot and Ankle Ability Measure (FAAM), and visual analog scale (VAS) were recorded. Final follow-up questionnaires using Patient Reported Outcomes Measurement Information System (PROMIS) lower extremity function, pain interference (PI), and neuropathic pain quality, FAAM, and VAS were administered using REDCap. Perioperative factors including neuropathic medications, diagnostic injections, the use of collagen wraps, and perioperative ketamine were collected from the medical record. Descriptive statistics were performed and potential changes in patient-reported outcome measure scores were evaluated using Wilcoxon signed-rank tests.

RESULTS

The 21 patients meeting inclusion criteria for this study had a median age of 47 years (interquartile range [IQR], 43-49) and had median follow-up duration of 33.7 months (IQR, 4.5-47.6). Median FAAM activities of daily living score improved from 40.6 (38.7-50.7) preoperatively to 66.1 (53.6-83.3) postoperatively, P = .032. FAAM sports scores improved from 14.1 (7.8-21.9) to 41.1 (25.0-60.9) postoperatively, P = .002. VAS scores improved from a median of 9.0 (8.0-9.0) to 3.0 (3.0-6.0), P < .001. At final follow-up, patients reported PROMIS lower extremity function score median of 43.8 (35.6-54.9), PROMIS neuropathic pain quality score of 54.1 (43.6-61.6), and PROMIS PI of 57.7 (41.1-63.8). Patients with both anxiety and depression reported less improvement in pain and physical. Other perioperative factors lacked sufficient numbers for statistical analysis.

CONCLUSION

Sural nerve neurectomy and proximal implantation (20 muscle, 1 adipose) provided significant improvement in pain and function for patients with sural neuromas and chronic sural neuritis at median follow-up of 33.7 months. Anxiety and depression were associated with significantly poorer outcomes following surgery. Patients with CRPS as well as recent nicotine use tended to report less improvement in pain and worse function after surgery, although this sample size was too limited for statistical analysis of these variables. Further research is needed to identify the ideal surgical candidates and perioperative factors to optimize patient outcomes.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

The Influence of Psychosocial Factors on Disability and Expected Improvement Before Surgery for Adult Traumatic Brachial Plexus Injury

PURPOSE

Psychosocial factors influence pain and recovery after extremity trauma and may be targets for early intervention. This may be of particular interest for patients with adult traumatic brachial plexus injury (BPI), given the broad and devastating impact of the injury. We hypothesized that there would be an association between depressive symptoms, anxiety, and pain interference with preoperative disability and expectations for improvement after BPI surgery.

METHODS

We enrolled 34 patients into a prospective multicenter cohort study for those undergoing surgery for adult traumatic BPI. Before surgery, participants completed Patient-Reported Outcome Measurement Information System scales for pain interference, anxiety, and depressive symptoms, and a validated BPI-specific measure of disability and expected improvement. We performed Pearson correlation analysis between pain interference, anxiety symptoms, and depressive symptoms with (A) disability and (B) expected improvement. We created separate linear regression models for (A) disability and (B) expected improvement including adjustment for severity of plexus injury, age, sex, and race.

RESULTS

Among 34 patients, there was a moderate, statistically significant, correlation between preoperative depressive symptoms and higher disability. This remained significant in a linear regression model adjusted for severity of plexus injury, age, sex, and race. There was no association between severity of plexus injury and disability. Depressive symptoms also were moderately, but significantly, correlated with higher expected improvement. This remained significant in a linear regression model adjusted for severity of plexus injury, age, sex, and race.

CONCLUSIONS

Depressive symptoms are associated with greater disability and higher expected improvement before BPI surgery. Screening for depressive symptoms can help BPI teams identify patients who would benefit from early referral to mental health specialists and tailor appropriate expectations counseling for functional recovery. We did not find an association between severity of BPI and patient-reported disability, suggesting either that the scale may lack validity or that the sample is biased.

LEVEL OF EVIDENCE

Prognostic II.

Pediatric ACEs and related life event screener (PEARLS) latent domains and child health in a safety-net primary care practice

BACKGROUND

Research examining the connections between individual adverse childhood experiences (ACEs) and how groupings of interrelated adversities are linked with subsequent health is scarce, limiting our understanding of risk during a period of rapid expansion of ACE screening in clinical practice. The study objective was to conduct a psychometric analysis to derive latent domains of ACEs and related life events and assess the association between each domain and health outcome.

METHODS

Participants (3 months-11 years) were recruited from the University of California San Francisco Benioff's Children Hospital Oakland Primary Care Clinic. Children were screened with the Pediatric ACEs and Related Life Events Screener (PEARLS) (n = 340), which assessed 17 total ACEs and related life events, including forms of abuse, household challenges, and social risks. Domains were constructed using confirmatory factor analysis and associations between the three identified domains and 14 health outcomes were assessed using multivariable linear and logistic regression models.

RESULTS

Three PEARLS domains were identified: Maltreatment (ω = 0.73, ɑ=0.87), Household Challenges (ω = 0.70, ɑ=0.82), and Social Context (ω = 0.55, ɑ=0.70). Measurement invariance was supported across both gender and screening format. All domains were associated with poorer general and behavioral health and stomachaches. Maltreatment and Social Context were additionally associated with eczema while only Social Context was associated with increased odds of reporting headaches and somatic symptoms.

CONCLUSION

In an underserved, urban west-coast pediatric population, the PEARLS found three adversity domains of Maltreatment, Household Challenges, and Social Context that all had an independent statistically significant association with poorer child health. The results provide a timely and more nuanced representation of risk that can inform clinical practice and policy using more targeted resources and interventions.

The Effects of COVID-19 Lockdown on Social Connectedness and Psychological Distress in U.S. Adults with Chronic Diseases

Lockdown measures enacted in 2020 to control the spread of COVID-19 led to increases in the prevalence of mental health problems. Due to their high-risk status, individuals with chronic diseases may be at increased risk and disproportionately adversely affected by the COVID-19 pandemic. The investigators examined associations between having a high-risk chronic condition, social connectedness, and general distress and COVID-19-specific distress among U.S. adults during the COVID-19 lockdown. Baseline measures of a longitudinal survey collected at the beginning of the pandemic (April to June 2020) were analyzed to identify factors associated with loss of social connectedness from pre- to post-lockdown. The associations between social connectedness and both general and COVID-19-specific psychological distress were adjusted for certain high-risk chronic illnesses and interaction effects. The sample available for analysis included 1354 subjects (262 high-risk chronic diseases and 1092 without chronic illness). Those reporting the loss of social connectedness were younger (median = 39 vs. 42) and more likely to be unemployed because of the pandemic (19.4% vs. 11.0%). Adjustment for interaction demonstrated a stronger negative association between social connectedness change and the psychosocial impact of COVID-19 for those with high-risk illness(es) (change in connectedness*chronic illness OR = 0.88, 95%CI: 0.79-0.98, p = 0.020). These findings inform our understanding of the distribution and intersection of responses to public health lockdown orders in the U.S. and build further evidence of the importance of social connectedness on psychological distress.

Are OMERACT recommendations followed in clinical trials on fibromyalgia? A systematic review of patient-reported outcomes and their measures

PURPOSE

Patient-Reported Outcomes (PROs) and its measures (PROMs) are key to outcome assessment in Fibromyalgia (FM) trials. The aim of this review was to investigate which domains and instruments were assessed in recent FM trials and to compare them to recommendations by the Outcome Measures in Rheumatology (OMERACT) initiative. In addition, we investigated the overlap with a generic health assessment approach, i.e. eight domains suggested by the Patient-Reported Outcome Measurement Information System® (PROMIS®).

METHODS

In compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic literature search in scientific databases including PubMed, PsycInfo, and Embase was conducted to identify studies that assessed at least two dimensions of health-related quality of life (HRQoL) from 2015 to June 2022. Non-randomized and randomized controlled trials were included in the analysis. We extracted PROs and PROMs used in each study.

RESULTS

From 1845 identified records, 107 records out of 105 studies met the inclusion criteria. Studies investigated 50 PROs using 126 different PROMs. Most frequently assessed domains were pain, depression, fatigue, and anxiety (> 95% of the studies). The disease-specific FIQ was the most frequently applied PROM (82%). Overall, only 9% of the studies covered all domains deemed mandatory by OMERACT. Very few studies covered all eight generic health domains suggested by PROMIS.

CONCLUSION

The majority of trials covered most OMERACT domains or generic PROMIS health domains. There was, however, great variability in the instruments used to assess the domains, which points at a limited degree of standardization in the field.

Feasibility of PROMIS using computerized adaptive testing during inpatient rehabilitation

BACKGROUND

There has been an increased significance on patient-reported outcomes in clinical settings. We aimed to evaluate the feasibility of administering patient-reported outcome measures by computerized adaptive testing (CAT) using a tablet computer with rehabilitation inpatients, assess workload demands on staff, and estimate the extent to which rehabilitation inpatients have elevated T-scores on six Patient Reported Outcomes Measurement Information System® (PROMIS®) measures.

METHODS

Patients (N = 108) with stroke, spinal cord injury, traumatic brain injury, and other neurological disorders participated in this study. PROMIS computerized adaptive tests (CAT) were administered via a web-based platform. Summary scores were calculated for six measures: Pain Interference, Sleep Disruption, Anxiety, Depression, Illness Impact Positive, and Illness Impact Negative. We calculated the percent of patients with T-scores equivalent to 2 standard deviations or greater above the mean.

RESULTS

During the first phase, we collected data from 19 of 49 patients; of the remainder, 61% were not available or had cognitive or expressive language impairments. In the second phase of the study, 40 of 59 patients participated to complete the assessment. The mean PROMIS T-scores were in the low 50 s, indicating an average symptom level, but 19-31% of patients had elevated T-scores where the patients needed clinical action.

CONCLUSIONS

The study demonstrated that PROMIS assessment using a CAT administration during an inpatient rehabilitation setting is feasible with the presence of a research staff member to complete PROMIS assessment.

Pain Self-Efficacy (PSEQ) score of <22 is associated with daily opioid use, back pain, disability, and PROMIS scores in patients presenting for spine surgery

BACKGROUND CONTEXT

Pain self-efficacy, or the belief that one can carry out activities despite pain, has been shown to be associated with back and neck pain severity. However, the literature correlating psychosocial factors to opioid use, barriers to proper opioid use, and Patient-Reported Outcome Measurement Information System (PROMIS) scores is sparse.

PURPOSE

The primary aim of this study was to determine whether pain self-efficacy is associated with daily opioid use in patients presenting for spine surgery. The secondary aim was to determine whether there exists a threshold self-efficacy score that is predictive of daily preoperative opioid use and subsequently to correlate this threshold score with opioid beliefs, disability, resilience, patient activation, and PROMIS scores.

PATIENT SAMPLE

Five hundred seventy-eight elective spine surgery patients (286 females; mean age of 55 years) from a single institution were included in this study.

STUDY DESIGN/SETTING

Retrospective review of prospectively collected data.

OUTCOME MEASURES

PROMIS scores, daily opioid use, opioid beliefs, disability, patient activation, resilience.

METHODS

Elective spine surgery patients at a single institution completed questionnaires preoperatively. Pain self-efficacy was measured by the Pain Self-Efficacy Questionnaire (PSEQ). Threshold linear regression with Bayesian information criteria was utilized to identify the optimal threshold associated with daily opioid use. Multivariable analysis controlled for age, sex, education, income, and Oswestry Disability Index (ODI) and PROMIS-29, version 2 scores.

RESULTS

Of 578 patients, 100 (17.3%) reported daily opioid use. Threshold regression identified a PSEQ cutoff score of <22 as predictive of daily opioid use. On multivariable logistic regression, patients with a PSEQ score <22 had two times greater odds of being daily opioid users than those with a score ≥22. Further, PSEQ <22 was associated with lower patient activation; increased leg and back pain; higher ODI; higher PROMIS pain, fatigue, depression, and sleep scores; and lower PROMIS physical function and social satisfaction scores (p<.05 for all).

CONCLUSIONS

In patients presenting for elective spine surgery, a PSEQ score of <22 is associated with twice the odds of reporting daily opioid use. Further, this threshold is associated with greater pain, disability, fatigue, and depression. A PSEQ score <22 can identify patients at high risk for daily opioid use and can guide targeted rehabilitation to optimize postoperative quality of life.

Comparison of the PROMIS and iHOT-12 in Determining Satisfaction Levels After Hip Arthroscopy for FAIS

Background

The Patient-Reported Outcomes Measurement Information System (PROMIS) has not been fully evaluated for outcomes assessment after hip arthroscopy to correct femoroacetabular impingement syndrome (FAIS).

Purpose/Hypothesis

The purpose of this study was to compare the accuracy of the PROMIS Physical Function (PF) and Pain Interference (PI) subscales with the 12-Item International Hip Outcome Tool (iHOT-12) to define patients with 3 unique substantial clinical benefit (SCB) scores-patients who reported ≥80%, ≥90%, and 100% satisfaction at 1 year after hip arthroscopy for FAIS. We hypothesized that the iHOT-12 would be more accurate than the PROMIS-PF and PROMIS-PI subscales in identifying these 3 patient groups.

Study Design

Cohort study (diagnosis); Level of evidence, 2.

Methods

We reviewed the records of patients who underwent hip arthroscopy for symptomatic FAIS at 3 centers from January 2019 through June 2021 and had 1-year clinical and radiographic follow-up data. Patients completed the iHOT-12, PROMIS-PF, and PROMIS-PI on initial assessment and at 1 year (±30 days) postoperatively. Postoperative satisfaction was reported on an 11-category scale with anchors defined as "0% satisfied" and "100% satisfied." Receiver operator characteristic analysis was performed to determine the absolute SCB values for the iHOT-12 and PROMIS subscales that would most accurately identify those patients who reported ≥80%, ≥90%, and 100% satisfaction. Area under the curve (AUC) values and 95% CIs for the 3 instruments were compared.

Results

Included were 163 patients (111 [68%] women and 52 [32%] men), with a mean age of 26.1 years. Corresponding absolute SCB scores for patients who reported ≥80%, ≥90%, and 100% satisfaction were as follows: iHOT-12, 68.4, 72.1, 74.7; PROMIS-PF, 45, 47.7, 49.9; and PROMIS-PI, 55.9, 52.4, 51.9. The AUC ranged between 0.67 and 0.82, with overlapping 95% CIs indicating a minimal difference in accuracy between the 3 instruments. Sensitivity and specificity values ranged between 0.61 and 0.82.

Conclusion

The PROMIS-PF and PROMIS-PI subscales were as accurate as the iHOT-12 in defining absolute SCB scores for patients reporting ≥80%, ≥90%, and 100% satisfaction at 1-year follow-up after hip arthroscopy for FAIS.