Impact of acute exacerbations of COPD on patients' health status beyond pulmonary function: A scoping review

This scoping review summarized the evidence regarding the impact of acute exacerbations of COPD (AECOPD) on patients' health status beyond pulmonary function. PubMed, Embase, and Web of Science were searched. Prospective cohort studies assessing the health status of patients with COPD in a stable phase of the disease and after a follow-up period (where at least one AECOPD occurred) were included. An integrated assessment framework of health status (i.e., physiological functioning, complaints, functional impairment, quality of life) was used. Twenty-two studies were included. AECOPD acutely affected exercise tolerance, quadriceps muscle strength, physical activity levels, symptoms of dyspnoea and fatigue, and impact of the disease. Long-term effects on quadriceps muscle strength, symptoms of dyspnoea and depression, and quality of life were found. Repeated exacerbations negatively impacted the fat-free mass, levels of dyspnoea, impact of the disease and quality of life. Conflicting evidence was found regarding the impact of repeated exacerbations on exercise tolerance and physical activity levels. AECOPD have well-established acute and long-term adverse effects on health status beyond pulmonary function; nevertheless, the recovery trajectory and the impact of repeated exacerbations are still poorly studied. Further prospective research is recommended to draw firm conclusions on these aspects.

Project SELfit: training socio-emotional skills in a school environment in Porto

Issue/Problem

Mental disorders are the main cause of years lived with disability (YLD) in 5-14-year-old people around the world, in Western Europe, and particularly in Portugal. Young people who experience anxiety during childhood have a 3,5-fold likelihood of suffering from depression or anxiety during adulthood. COVID-19 has aggravated this situation, namely regarding socio-emotional competencies.

Description of the problem

SELfit, a project based on the Socio-emotional learning (SEL) methodology, aims promoting mental health, by training teachers and community nurses to develop socio-emotional skills in students from primary schools. The project includes a theoretical and a practical/training session, and monthly supervision sessions by a team that includes a psychologist, a public health doctor and public health nurses. The period of implementation is between February to July 2022.

Results

A total of 8 community nurses and 13 teachers from 3 primary schools in Porto enrolled in this project, which corresponds to a total around 272 students from 5 to 8-year-old. Knowledge of nurses and teachers regarding mental health literacy, and social emotional learning was assessed, before and after the theoretical session. The mean percentage of correct answers before was 49% (54% regarding nurses and 45% teachers) compared to 84% (92% regarding nurses and 78% teachers) after. Concerning socio-emotional skills of the primary school students, possible improvement will be evaluated at the end of the project (July 2022).

Lessons

Mental health literacy and social emotional learning knowledge increased 35%, which highlights the importance of these theoretical sessions promoting mental health literacy. By the end of this project, it is expected to exist an improvement on socio-emotional skills of the primary school students. This is a very important project, expected to be implement and replicated in other schools in Porto and in Portugal.

Key messages

• Mental disorders are the main cause of years lost due to disability (YLD) in primary school students in Portugal; hence, it was chosen for this mental health promotion project.

• This is a pioneer project in Porto, involving both community nurses and primary teachers, in which all are involved in training and promoting social-emotional learning in a school context.

Impact of booster vaccination on COVID-19 outcomes in Portuguese population aged 80 or more years old

Background

Vaccination is essential to control SARS-CoV-2 transmission and complications. The study aimed to estimate the number of SARS-CoV-2 infections, COVID-19 hospitalizations and deaths averted by booster vaccination in Portuguese population aged 80 or more years old.

Methods

We developed an ecological study for the period of the Omicron variant of concern predominance (week 2 to week 16, 2022). Data on vaccine coverage and effectiveness, and number of events of different severity reported to the national COVID-19 surveillance system were used to estimate the number of averted events, prevented fraction and number needed to vaccinate. Uncertainty intervals (UI) were obtained using Monte Carlo simulations.

Results

By week 2 2022, vaccination coverage in the target population reached 91.2%. Booster vaccine effectiveness was 4.1% (CI95%: -0.1 to 9.0), 87.5% (CI95%: 84.9 to 89.7) and 83.2 (CI95%: 80.3 to 85.7) against infection, hospitalization and death, respectively. During the study period, 70862 SARS-CoV-2 infections, 2697 COVID-19 hospitalizations and 2106 deaths were reported. Booster vaccination averted 2731 (UI95%: -298 to 5838) infections, 10629 (UI95%: 9173 to 12127) hospitalizations and 6608 (UI95%: 5725 to 7546) COVID-19 related deaths among individuals aged 80 years or more resident in Portugal. Prevented fractions were 3.7% (UI95%: 0 to 7.6%), 79.7% (UI95%: 77.3 to 81.7%) and 75.8% (UI95%: 73.2 to 78.1%), respectively. It would require to vaccinate 59 individuals (UI95%: 52 to 69) to prevent one hospitalization and 94 individuals (UI95%: 82 to 109) to prevent one death in the target population.

Conclusions

The booster vaccination strategy had considerable impact on preventing severe outcomes in the Portuguese population aged 80 and more years old.

Key messages

• High vaccine coverage combined with high vaccine effectiveness resulted in considerable reduction of severe COVID-19 outcomes.

• Information on number of outcomes of different severity levels averted by COVID-19 booster vaccination allows to strength public health communication.

Excess costs of multiple sclerosis: A register-based study in Sweden

Background and Objective

Population-based estimates of the socioeconomic burden of multiple sclerosis (MS) are limited, especially regarding primary healthcare. This study aimed to estimate the excess costs of people with MS that could be attributed to MS, including primary healthcare.

Methods

An observational study was conducted of the 2806 working-aged people with MS in Stockholm, Sweden and 28,060 propensity score matched references without MS. Register-based resource use was quantified for 2018. Annual healthcare costs (primary, specialised outpatient, and inpatient healthcare visits along with prescribed drugs) and productivity losses (operationalised by sickness absence and disability pension days) were quantified using bottom-up costing. Costs were compared between the people with MS and references with independent t-tests with bootstrapped 95% confidence intervals (CIs) to isolate the excess costs of MS.

Results

The mean annual excess costs of MS for healthcare were €7381 (95% CI: 6991-7816) per person with MS with disease modifying therapies as the largest component (€4262, 95% CI: 4026-4497). There was a mean annual excess cost for primary healthcare of €695 (95% CI: 585-832) per person with MS, comprising 9.4% of the excess healthcare costs of MS. The mean annual excess costs of MS for productivity losses were €13,173 (95% CI: 12,325-14,019) per person with MS, predominately from disability pension (79.3%).

Conclusions

The socioeconomic burden of MS in Sweden from healthcare consumption and productivity losses was quantified, updating knowledge on the cost structure of the substantial excess costs of MS.

Key messages

• Primary healthcare contributes around a tenth of the excess healthcare costs of MS in Sweden, primarily owing to contacts with healthcare professionals other than physicians.

• Overall, the excess costs of MS in Sweden from lost production are larger in magnitude than the excess costs for healthcare consumption.

Exit from Brain Device Research: A Modified Grounded Theory Study of Researcher Obligations and Participant Experiences

As clinical trials end, little is understood about how participants exiting from clinical trials approach decisions related to the removal or post-trial use of investigational brain implants, such as deep brain stimulation (DBS) devices. This empirical bioethics study examines how research participants experience the process of exit from research at the end of clinical trials of implanted neural devices. Using a modified grounded theory study design, we conducted semi-structured, in-depth interviews with 16 former research participants from clinical trials of DBS and responsive neurostimulation (RNS). Open-ended questions elicited motivations for joining the trial, understanding of study procedures at the time of initial informed consent, the process of exiting from research, and decisions about device removal or post-trial device use. Thematic analysis identified categories related to: limited preparedness for the end of research participation, straightforwardness of decisions to explant or keep the device, reconciling with the end of research participation, reconciling post-trial expectations, and achieving a sense of closure after exit from research. A preliminary theoretical model describes contextual factors influencing the process and experience of exit from research. Experiences of clinical trial participants should guide research practices to enhance the ethical design and conduct of clinical trials in DBS and other brain devices.

Sickness absence and disability pension within different employment status in multiple sclerosis

Introduction

Limitations associated with Multiple Sclerosis (MS) can restrain work capacity and productivity, reducing the possibility to remain in work. Whilst access to sickness compensation might be an option, transitions to other types of employment, such as self-employment, might be considered. We aim to investigate the association of Sickness Absence (SA) and Disability Pension (DP) with employment status among people with multiple sclerosis (PwMS) before and after MS diagnosis compared with people without MS.

Methods

A prospective longitudinal study was conducted using Swedish register data of 2,779 MS patients diagnosed with MS in 2008-2012 in working ages (20-59 years) and 13,863 population-based matched references. Levels of SA and DP one year before and four years after MS diagnosis were analyzed. Risk of annual SA and DP levels of more than 180 days were compared among the MS patients and references and, their different types of employment, by means of Cox proportional hazard models and adjusted for socio-demographic variables and SA and DP before MS diagnosis.

Results

In general, people with MS had higher levels of SA and DP before and shortly after MS diagnosis compared to references. PwMS showed a significantly higher probability of reaching over 180 days of SA (Hazard Ratio [HR]=4.89, 95% Confidence interval [CI]=4.43-5.40) and over 180 days of DP (HR = 6.31, 95% CI = 5.46-7.30)) than the references, regardless of type of employment. Moreover, when compared to employed references, self-employed PwMS had similar likelihood to reach over 180 days of SA than employed PwMS, (HR = 4.27, 95% CI = 3.81-4.77) and (HR = 3.83, 95% CI = 2.73-5.38), respectively. In contrast, self-employed references showed less probability (HR = 0.49, 95% CI = 0.31-0.78) to reach over 180 days of SA compared to the employed references.

Conclusions

In contrast to references, employed and self-employed PwMS had similar probabilities of reaching over 180 days of SA.

Key messages

This study emphasizes that in Sweden also self-employed have access to sickness compensation, independently of employment status condition. Access to sickness compensation is utilized by PwMS.

Trajectories of sickness absence and disability pension by type of occupation in multiple sclerosis

Background

Multiple sclerosis (MS) can impact working life, sickness absence (SA), and disability pension (DP). Different types of occupations involve different demands, which may be associated with trajectories of SA and DP among people with MS (PwMS). We aim to explore if annual levels of SA and DP differ according to type of occupation among PwMS and references. Further, we aim to gain knowledge of how trajectories of SA and DP are associated with type of occupation among PwMS.

Methods

A nationwide Swedish register-based prospective cohort study with six-year follow-up was conducted, including 6,100 individuals with prevalent MS and 38,641 matched population references. Mean annual SA and DP net days during follow-up years were calculated and stratified by type of occupation. Trajectories of SA and DP were identified with group-based trajectory modelling. Multinomial logistic regressions were estimated for associations between identified trajectories and different types of occupations.

Results

An increase of SA and DP over time in all types of occupations was observed in both PwMS and references, with higher levels of SA and DP among PwMS. Managers had the lowest levels of SA and DP in both groups. Three SA and DP trajectory groups were identified: Persistently Low (55.2%), Moderate Increasing (31.9%), and High Increasing (12.8%). Managers (Odds Ratio [OR] 0.37, 95%CI 0.26-0.52) and those working in Science & Technology (OR 0.64, 95% CI 0.50-0.82) had less probability of belonging to the Moderate Increasing group. Similarly, Managers (OR 0.52, 95%CI 0.30-0.89) and Science & Technology (OR 0.58, 95%CI 0.39-0.88) had also less probability of belonging to the High Increasing group.

Conclusions

Our findings suggest that the type of occupation plays a role in the level and course of SA and DP among PwMS.

Key messages

Over time SA and DP levels increased among PwMS regardless of type of occupation. PwMS in Managers or Science and Technology had less probability of belonging to the increasing trajectories.

Assessment of the anterior superior alveolar nerve and its impact on surgery of the lateral nasal wall

BACKGROUND

The anterior superior alveolar nerve (ASAN) plays a major role in innervation of the lateral nasal wall. Its damage during nasal surgery can cause dental paraesthesia and numbness around the upper lip.

METHODOLOGY

Retrospective evaluation of the computed tomographic (CT) scans of 50 consecutive patients analysing 100 sides. We measured the mean distance from the shoulder of the inferior turbinate to the descending portion of the anterior superior alveolar nerve, to the anterior superior alveolar canal and the anterior-posterior distance between the 'shoulder' of the inferior turbinate and the pyriform aperture.

RESULTS

The mean distance from the shoulder of the inferior turbinate to the descending portion of the anterior superior alveolar nerve was 6.4 ± 2.33 mm, with no difference between sides The mean relative height of the shoulder in relation to the anterior superior alveolar nerve canal was 4.78 ± 2.31mm with no significant difference between the two sides. The anterior-posterior distance between the 'shoulder' of inferior turbinate and the pyriform aperture was 6.96± 2.28mm, with no significant difference between the two sides.

CONCLUSIONS

We found the anterior superior alveolar nerve to be a constant landmark in the lateral nasal wall. Therefore, the course of the ASAN should be assessed on a CT scan when a surgical approach through the pyriform aperture or anterior medial wall of the maxillary sinus is planned.

Estimating the Risk of Deep Brain Stimulation in the Modern Era: 2008 to 2020

BACKGROUND

Deep brain stimulation (DBS) was first approved by the United States Food and Drug Administration in 1997. Although the fundamentals of DBS remain the same, hardware, software, and imaging have evolved significantly.

OBJECTIVE

To test our hypothesis that the aggregate complication rate in the medical literature in the past 12 years would be lower than what is often cited based on early experience with DBS surgery.

METHODS

PubMed, PsycINFO, and EMBASE were queried for studies from 2008 to 2020 that included patients treated with DBS from 2007 to 2019. This yielded 34 articles that evaluated all complications of DBS surgery, totaling 2249 patients.

RESULTS

The overall complication rate in this study was 16.7% per patient. There was found to be a systemic complication rate of 0.89%, intracranial complication rate of 2.7%, neurological complication rate of 4.6%, hardware complication rate of 2.2%, and surgical site complication rate of 3.4%. The infection and erosion rate was 3.0%.

CONCLUSION

This review suggests that surgical complication rates have decreased since the first decade after DBS was first FDA approved. Understanding how to minimize complications from the inception of a technique should receive more attention.

Double blind randomized controlled trial of deep brain stimulation for obsessive-compulsive disorder: Clinical trial design

Obsessive-compulsive disorder (OCD), a leading cause of disability, affects ~1–2% of the population, and can be distressing and disabling. About 1/3 of individuals demonstrate poor responsiveness to conventional treatments. A small proportion of these individuals may be deep brain stimulation (DBS) candidates. Candidacy is assessed through a multidisciplinary process including assessment of illness severity, chronicity, and functional impact. Optimization failure, despite multiple treatments, is critical during screening. Few patients nationwide are eligible for OCD DBS and thus a multi-center approach was necessary to obtain adequate sample size. The study was conducted over a six-year period and was a NIH-funded, eight-center sham-controlled trial of DBS targeting the ventral capsule/ventral striatum (VC/VS) region. There were 269 individuals who initially contacted the sites, in order to achieve 27 participants enrolled. Study enrollment required extensive review for eligibility, which was overseen by an independent advisory board. Disabling OCD had to be persistent for ≥5 years despite exhaustive medication and behavioral treatment. The final cohort was derived from a detailed consent process that included consent monitoring. Mean illness duration was 27.2 years. OCD symptom subtypes and psychiatric comorbidities varied, but all had severe disability with impaired quality of life and functioning. Participants were randomized to receive sham or active DBS for three months. Following this period, all participants received active DBS. Treatment assignment was masked to participants and raters and assessments were blinded. The final sample was consistent in demographic characteristics and clinical features when compared to other contemporary published prospective studies of OCD DBS. We report the clinical trial design, methods, and general demographics of this OCD DBS sample.

Changes in Patients' Desired Control of Their Deep Brain Stimulation and Subjective Global Control Over the Course of Deep Brain Stimulation

Objective: To examine changes in patients’ desired control of the deep brain stimulator (DBS) and perception of global life control throughout DBS.

Methods: A consecutive cohort of 52 patients with Parkinson’s disease (PD) was recruited to participate in a prospective longitudinal study over three assessment points (pre-surgery, post-surgery months 3 and 6). Semi-structured interviews assessing participants’ desire for stimulation control and perception of global control were conducted at all three points. Qualitative data were coded using content analysis. Visual analog scales were embedded in the interviews to quantify participants’ perceptions of control over time.

Results: Participants reported significant increases in their perception of global control over time and significant declines in their desired control of the stimulation. These changes were unrelated to improvements in motor symptoms. Improvements in global control were negatively correlated with a decline in desired stimulation control. Qualitative data indicate that participants have changed, nuanced levels of desired control over their stimulators. Increased global life control following DBS may be attributed to increased control over PD symptoms, increased ability to engage in valued activities, and increased overall self-regulation, while other domains related to global control remained unaffected by DBS.

Conclusions: There are few empirical data documenting patients’ desire for stimulation control throughout neuromodulation and how stimulation control is related to other aspects of control despite the growing application of neuromodulation devices to treat a variety of disorders. Our data highlight distinctions in different types of control and have implications for the development of patient-controlled neurostimulation devices.

Clinical profile and microbiological aetiology diagnosis in adult patients hospitalized with community-acquired pneumonia

Early introduction of appropriate antibiotherapy is one of the major prognostic-modifying factors in community acquired pneumonia (CAP). Despite established guidelines for empirical therapy, several factors may influence etiology and, consequently, antibiotic choices. The aims of this study were to analyze the etiology of CAP in adults admitted to a northern Portugal University Hospital and evaluate the yield of the different methods used to reach an etiological diagnosis, as well as analyze of the impact of patient demographic and clinical features on CAP etiology. We retrospectively analyzed 1901 cases of CAP with hospitalization. The diagnostic performance increased significantly when blood and sputum cultures were combined with urinary antigen tests. The most frequent etiological agent was Streptococcus pneumoniae (45.7%), except in August, when it was overtaken by gram-negative bacilli (GNB) and Legionella pneumophila infections. Viral infections were almost exclusive to winter and spring. A negative microbiological result was associated with increasing age, non-smoking and lack of both blood/sputum cultures. Younger age was a predictor for S. pneumoniae, Influenza and L. pneumophila infections. Active smoking without any previously known respiratory disease was a risk factor for legionellosis. COPD was associated with Haemophilus influenzae cases, while dementia was typical in GNB and S. aureus patients. Diabetes mellitus (DM) and heart disease were negative predictors of S. pneumoniae and H. influenzae, respectively. P. aeruginosa was an independent risk factor for mortality (OR 13.02, 95% CI 2.94-57.7). This study highlights the importance of a comprehensive microbiological diagnostic workup and provides clues to predicting the most probable CAP causative agents, based on a patient's clinical profile. These may be taken into account when establishing first line antibiotherapy.

The Need for Digital Health Solutions in Deep Brain Stimulation for Parkinson's Disease in the Time of COVID-19 and Beyond

OBJECTIVES

Deep brain stimulation (DBS) is a well-established therapy for the management of patients with advanced Parkinson's disease and other movement disorders. Patients implanted with DBS require life-long management of the medical device as well as medications. Patients are often challenged to frequently visit the specialized DBS centers and such challenges are aggravated depending on geography, socioeconomic factors, and support systems. We discuss the need for digital health solutions to overcome these barriers to better and safely take care of patients, especially in the current COVID-19 pandemic.

MATERIALS AND METHODS

A review of the literature was conducted for technology and logistics necessary in forming a digital health program.

RESULTS

Digital health encounters can take place in both a synchronous and asynchronous manner. Factors involving patients include cognitive capacity, physical safety, physical capacity, connectivity, and technological security. Physician factors include examining the patient, system diagnostics, and adjusting stimulation or medications. Technology is focused on bridging the gap between patient and physician through integrating the DBS lead, implantable pulse generator (IPG), programmer, novel devices/applications to grade motor function, and teleconference modalities.

CONCLUSIONS

For patients with Parkinson's disease, digital health has the potential to drastically change the landscape after DBS surgery. Furthermore, technology is fundamental in connectivity, diagnostic evaluation, and security in order to create stable and useful patient-focused care.

Pregnancy outcomes in women with mechanical heart valves

Background

Mechanical heart valves (MHV) and their absolute need for adequate anticoagulation poses a challenge for pregnancy, either due to warfarin fetotoxicity or an increased risk of maternal thromboembolism. This represents a unique patient (P) group where data is scarce and maternal and fetal risks and benefits must be carefully weighed.

Purpose

To assess maternal and perinatal outcomes in women with MHV on different anticoagulant regimens and compare them with patients with other types of valvular heart disease (VHD).

Methods

A retrospective analysis of 131 pregnancies in 83 women with VHD (mean age 26.5±5.6 years) was carried out in a tertiary referral centre from 2000 to 2019. 92 pregnancies with VHD, including 11 with biological prosthetic valves, and 39 pregnancies in 22 P with MHV were identified. The main outcome measures were major maternal complications and perinatal outcome.

Results

MHV implanted were in mitral position (89.7%), aortic (2.6%), or both (7.7%). History of rheumatic heart disease was identified in 16 P (72.7%) and a congenital etiology was present in 2 P (9.1%). 9 P (40.9%) were on warfarine and 13 P (59.1%) on acenocumarol. Regarding anticoagulation strategy, 21 P (65.6%) remained on oral anticoagulation and 10 P (31.3%) had been switched to some form of heparin during part or the entire pregnancy. Mechanical valve thrombosis complicated pregnancy in 4 patients (10.2%), all cases on heparin, and resulted in maternal death in 1 P. MHV P had more hemorrhagic complications (15.4 vs 2.2%, p=0.004) requiring transfusion or surgical revision. MHV P tended to experience more NHYA class worsening demanding initiation or intensification of cardiac medication (17.9 vs 5.4%, p=0.023). Also in the MHV group there was a higher incidence of miscarriage (46.2 vs 12.0%, p≤0.0005), comprising spontaneous abortion (31.6 vs 7.6%, p<0.0005) and fetal malformations (18.4 vs 5.4%, p=0.028), including warfarin embryopathy (10.3 vs 1.1%, p=0.012). The live birth rate was higher in women on heparin compared with those on warfarin (85.9 vs 79.2%, p=0.002). The presence of multivalve disease (p=0.04), mechanical protheses (p<0.001), ACO (p<0.001) and previous impaired LVEF (p=0.02) were related to miscarriage. In multivariate analysis, ACO was the unique independent predictor of unsuccessful pregnancy (p=0.01). Only 29% of the patients with an MHV had a pregnancy free of serious adverse events compared with other types of VHD (81.5%, p<0.0005).

Conclusions

MHV remains a challenging condition for pregnancy with only 29% chance of experiencing an uncomplicated pregnancy with a live birth. The increased morbimortality warrant extensive prepregnancy counseling with prosthesis type discussion,centralization of care and further larger studies to come up with evidence-based recommendations.

Funding Acknowledgement

Type of funding source: None

Influenza burden estimates in Portugal: seasons 2013/14 to 2018/19

Background

Reliable influenza burden estimates are essential for a true understanding of the influenza epidemics' impact; informed decision-making and effective risk communication. This study aimed to estimate the influenza burden in Portugal in 2013/14 - 2018/19 seasons.

Methods

We estimated seasonal influenza burden, ranging from medically attended influenza cases in primary care to influenza-attributable deaths, using surveillance data. Data were collected for influenza like illness (ILI) epidemic periods, determined by the Moving Epidemic Method. Medically attended influenza cases were estimated by multiplying the number of ILI cases in primary care by the percentage of influenza-positive samples. Hospitalized severe acute respiratory infections (SARI) positive for influenza estimates were computed, multiplying the number of SARI by the percentage of influenza-positive samples. To determine influenza-attributable deaths, a Poisson regression model was used.

Results

The median number of medically attended influenza cases in primary care was 33,668 (325.8 cases per 10,000 population), ranging between 21,393 in 2017/18, [Influenza B and A(H1) co-dominance] and 61,768 in 2014/15 [Influenza B and A(H3) co-dominance]. The median number of SARI positive for influenza was 8,724 (84.4 cases per 10,000 population), ranging between 7,099 in 2013/14 [A(H1) and A(H3) co-dominance], and 9,125 in 2014/15. The median number of influenza-attributable deaths was 3,311 (32.0 cases per 10,000 population), ranging between 96 in 2015/16 [A(H1) dominance], and 5,224 in 2014/15.

Conclusions

Higher mortality, and higher rate of medically attended influenza cases, were found in seasons with A(H3) circulation. Little variability was observed in the number of influenza-positive SARI. The relationship between the number of SARI and the number of deaths requires further investigation. This work highlights the need of health surveillance systems for a better understanding of the influenza impact.

Key messages

Lower burden of influenza is found in seasons with A(H1) co-dominance. Higher burden of influenza is found in seasons with A(H3) circulation. Health surveillance systems are essential to provide data for a better understanding of the epidemiology and extent of seasonal influenza.

Descriptive analyse of a case control study in Portugal: identify to prevent

Background

Prenatal exposure to environmental risk factors are one of the known causes of congenital anomalies (CA). In 2015, a cluster of anorectal anomalies, a rare malformation, in Setúbal district raised interest in researchers. The aim of study was to assess the impact of prenatal exposure of the mothers on the occurrence of CA in the offspring.

Methods

A Case-control study (1:2) was implemented between 2016-2019. Newborns with CA (cases) and newborns without CA (controls) are identified and recruited. Parents were personally interviewed by a health professional using a standardized questionnaire. A descriptive analyses was performed and cases and controls were described based on maternal residence during pregnancy. Chi-square test was used to compare cases and controls.

Results

97 cases and 194 controls were identified. There was a male predominance in the case group (60 vs. 34) and no difference in gestational age between case and control groups. The mean birth weight was similar (3115g in cases vs. 3221g in controls). There was no difference related to mean mother's age nor the presence of maternal chronic disease. Smoking had more expression in the case group (21,2% vs. 16,3%). Moita (37,8%) is the municipality with higher frequency of cases. Musculoskeletal anomalies were the most frequent (35.4%), followed by genital (22.2%) and other anomalies (11%). During the study period, five cases with anorectal anomalies were reported, 4 of them born at 2016 and in 3 the mothers residence place was Moita.

Conclusions

In this study, the high proportion of cases from Moita suggests a possible environmental exposure to a teratogenic agent. Also smoking during pregnancy could be a high risk to anorectal anomalies, as suggested in other studies. More investment in public health measures could protect population from harmful environments.

Key messages

Pprenatal exposure to environemental risk factors increase the risk of congenital anomalies. Mothers residence and place of work could be a risk factor to pregnancy.

Bias correction in self-reported high blood pressure prevalence based on objectively measured data

Background

Reliable and precise estimates of high blood pressure (HBP) prevalence are essential to inform decision-making and policies evaluation. Self-reported HBP may be underestimated by surveys due to misclassification of health status by participants. Misclassification may lead to inaccurate inference. We aimed to assess a feasibility of correcting misclassification bias in self-reported HBP in the Portuguese component of the European Health Interview Survey (INS2014) using data on objective blood pressure measurements from a smaller health examination survey (INSEF).

Methods

We assumed that “true” measured HBP status was missing at random for INS2014 participants (n = 13937). Using a multiple imputation method of logistic regression for monotone missing data patterns, HBP was imputed for INS2014 sample. Auxiliary data on measured HBP from INSEF (n = 4910) was used. Crude and corrected HBP prevalence rates stratified by sex and age group were calculated.

Results

HBP prevalence based on INS2014 increased significantly after multiple imputation correction, from 22.0% [CI95%:20.6-23.5%] to 38.8% [35.4-41.9%] for men and from 26.8% [25.3-28.3%] to 33.0% [30.5-35.4%] for women. Corrected estimates were similar to the objectively measured from INSEF, 39.6% for men and 32.7% for women. Corrected HBP prevalence in INS2014 increased from 4.1% [2.9-5.9%] to 7.9% [4.0-11.8%] in 25-34 years old (yo); from 9.3% [7.8-11.0%] to 17.6% [14.0-21.3%] in 35-44 yo; from 22.5% [20.3-24.8%] to 38.7% [34.2-43.2%] in 45-54 yo; from 39.8% [37.2-42.4%] to 53.8% [49.1-58.5%] in 55-64 yo and from 54.3% [51.5-57.1%] to 67.7% [63.1-72.3%] in 65-74 yo. Corrected rates were similar to the obtained by INSEF (5.7%, 17.0%, 35.8%, 54.8% and 71.3%, respectively).

Conclusions

Our results highlight the importance of bias analysis when using self-reported data on HBP. Multiple imputation is a feasible approach to adjust misclassification bias in health outcomes collected by population surveys.

Key messages

The magnitude and direction of misclassification bias in self-reported health outcomes should be investigated. Multiple imputation is a feasible approach to misclassification bias correction in self-reported survey data.

Neural tube defects: how many cases could have been prevented in Portugal?

Neural tube defects (NTD) occurs when the neural tube does not close properly until the 28th day of foetal life. About 70% of NTD can be prevent if women start folic acid (FA) before pregnancy and until the end of 1st trimester. Portugal has this primary prevention since 1998, however the secondary prevention of NTD with TOPFA is still high (80%). The aim of this study is to describe when FA intake was started and estimate the number of cases that would have be prevented if FA intake started before pregnancy as recommended.

A cross-sectional study using data from the National Registry of Congenital Anomalies between 2004-2017 was performed. The temporal evolution of the beginning of FA intake was analysed with Cochran-Armitage test for proportions. The proportion of preventable cases was estimated considering the 70% prevention fraction and the number of NTD cases registered in RENAC that occurred in pregnancies without the recommended FA supplementation.

On average, 13.8% of all women started FA before pregnancy, 46.2% during 1st trimester and 6.1% did not take folic acid. A statistically significant trend (p < 0.001) was observed in the group that started before pregnancy with increase from 6.8% in 2004 to 17.9% in 2017. The prevalence of NTD was 4.2 cases / 10,000 births, ranging from 2 cases / 10,000 births (2007) to 7 cases / 10,000 births (2014). Between women who had a pregnancy with NTD, 16.8% started FA before pregnancy, 42.2% in the 1st trimester and 9.7% did not take the supplement. If all women had started FA before pregnancy, an estimated 202 NTD cases could have been prevented.

In Portugal, the proportion of women who adhere to this measure is very low, similarly to other European countries, compromising the primary prevention of NTD. Perhaps due to the high percentage of TOPFA, the idea that this anomalies continue to affect our children has been lost. Primary prevention of NTDs should be encouraged with measures that promote FA supplementation.

Key messages

Primary prevention of NTD is possible. Proportion of women who adhere to primary prevention is low.

Predictive equations of maximum respiratory mouth pressures: A systematic review

BACKGROUND

Maximum inspiratory (Pimax) and expiratory (Pemax) mouth pressures are commonly used to detect respiratory muscle weakness resorting to predictive equations established for healthy people. There are several predictive equations, but they are widespread in the literature. This study aimed to review the existent predictive equations of maximum inspiratory (Pimax) and expiratory (Pemax) mouth pressures for adults. Additionally, we aimed to identify which ones were generated based on international standards.

METHODS

A systematic review of predictive equations of Pimax and Pemax for healthy adults was conducted. A comprehensive search was performed of Cochrane Library, EBSCO, PubMed, Scopus and Web of Science to identify studies that presented at least one equation for Pimax or Pemax developed for healthy adults. The quality of studies was assessed by two reviewers with the Quality Assessment of Diagnostic Accuracy Studies (Quadas-2).

RESULTS

Risk of bias was high in 8 of the 20 studies included. Forty-two Pimax and 34 Pemax equations were found, mostly using the variables age (n=39), weight (n=20) and height (n=8). These equations explained 3 to 96% of the Pimax/Pemax variance. They were developed with individuals from 11 countries (Portugal not included). Twelve Pimax and eight Pemax equations complied with international standards.

CONCLUSIONS

This review gathered the predictive equations that have been developed for both Pimax and Pemax, however most were generated from unstandardized procedures. Future studies should explore the suitability of these equations for populations for which specific ones are not available, such as the Portuguese population, and develop new equations if necessary.

Consensus Paper: Experimental Neurostimulation of the Cerebellum

The cerebellum is best known for its role in controlling motor behaviors. However, recent work supports the view that it also influences non-motor behaviors. The contribution of the cerebellum towards different brain functions is underscored by its involvement in a diverse and increasing number of neurological and neuropsychiatric conditions including ataxia, dystonia, essential tremor, Parkinson's disease (PD), epilepsy, stroke, multiple sclerosis, autism spectrum disorders, dyslexia, attention deficit hyperactivity disorder (ADHD), and schizophrenia. Although there are no cures for these conditions, cerebellar stimulation is quickly gaining attention for symptomatic alleviation, as cerebellar circuitry has arisen as a promising target for invasive and non-invasive neuromodulation. This consensus paper brings together experts from the fields of neurophysiology, neurology, and neurosurgery to discuss recent efforts in using the cerebellum as a therapeutic intervention. We report on the most advanced techniques for manipulating cerebellar circuits in humans and animal models and define key hurdles and questions for moving forward.

From beams to glass: determining compositions to study provenance and production techniques

Combining a stylistic approach with chemical analyses and focusing not only on composition but also on production technology, this research aims to identify possible centres of post-medieval production of glass as well as decorative production techniques used in stained glass, in particular the grisaille.

The use of several combined analytical techniques allowed for the unveiling of the composition of glass and the structure of grisailles. Sorting out the grisaille structure sheds light on the processes employed to produce paints, while compositions of glass objects are used to propose production provenances. Both contribute to the study and critical analysis of how glass heritage has developed over time, including materials and technical practices, uncovering the transfer of technology and movement of people and goods.

Can We Justify It? Trends in the Utilization of Spinal Fusions and Associated Reimbursement

BACKGROUND

Previous reports have suggested an increasing rate of utilization of spinal fusions, but contemporary data have not been analyzed, and there has been little investigation of putative drivers of increased utilization.

OBJECTIVE

To investigate whether there is an ongoing trend of increased utilization of spinal fusions in recent data, and if there may be associations with an increasing proportion of elderly in the population, changing patterns of payer-types, and changing reimbursement rates.

METHODS

We analyze 7.1 million cases from the National Inpatient Sample between 1998 and 2014. We measure annual utilization per 100 000 persons and conduct trend analyses with subgroup analysis of the senior (65 + ) population. Spine surgery utilization is compared with nonspine surgical procedures (coronary artery bypass grafting, hernia repair, hip, and knee replacement). We assess trends in charges, payer type, Medicare reimbursement rates, and hospital type.

RESULTS

There was an 88% increase in the utilization rate of spinal fusion procedures from 1998 to 2014 (from 74 to 139 cases per 100 000 persons) with a significant upward trend (P < .001) that persisted in the 65 + subgroup (P < .001). An increasing proportion of spinal fusions is paid for by public payers, but per-procedure reimbursement for spinal fusions by Medicare has decreased recently (5% reduction from 2014 to 2016).

CONCLUSION

Utilization of spinal fusions continues to increase and is not explained by increased proportion of elderly in the population, increased utilization of surgeries across specialties, or increased Medicare reimbursement. In fact, increased utilization of spinal fusions temporally correlated with decreasing per-procedure Medicare reimbursement.

Serum antiphospholipid antibody levels as biomarkers for diagnosis of pulmonary tuberculosis patients

SETTING

Salvador, Bahia, Brazil.

OBJECTIVE

To evaluate the immunoglobulin (Ig)M and total IgG antibody response to cardiolipin (CL), phosphatidylcholine (PTC), phosphatidylethanolamine (PE), phosphatidylinositol (PI) and sulfatide (SL-I) as biosignatures that can be used to diagnose pulmonary tuberculosis (TB) and its applicability for monitoring the efficacy of anti-tuberculosis treatment.

DESIGN

Serum samples from 37 adult pulmonary TB patients and 48 controls (16 healthy household contacts, 19 household contacts with latent tuberculous infection [LTBI] and 13 non-TB patients with lung disease) were screened using enzyme-linked immunosorbent assays (ELISAs) for IgM and total IgG against phospholipids.

RESULTS

Levels of IgM response to CL, PE and PI, and IgG response to CL, PE, PI and PTC were significantly higher in TB patients than in control groups. Anti-CL IgG had the best performance characteristics, with a sensitivity and specificity of respectively 86.5% and 87.2%. This IgG anti-CL ELISA test detected 86.5% (32/37) of the TB patients, whereas the number detected using sputum smear was only 65.9% (24/37). After anti-tuberculosis treatment, the median value for all anti-phospholipid antibodies decreased significantly compared with baseline values (P < 0.05).

CONCLUSION

Our results suggest that the total IgG anti-CL level could be useful to complement conventional bacteriological tests for the rapid diagnosis of adult pulmonary TB.

Abstract P3-15-02: Latin American participation in practice-changing breast cancer trials in the last 25 years

Introduction: Latin America (LATAM) is among the so-called emerging regions for conducting clinical trials. Complex not-harmonized regulatory frameworks and lengthy approval timelines (among other factors) present challenges for increased LATAM trial participation.

Objective: to assess LATAM contribution to clinical trials, we conducted a descriptive analysis of the region participation in practice-changing breast cancer (BC) trials.

Methodology: we defined practice-changing trial as any one that supported FDA approval of a new drug or a new indication for a previously approved drug; we excluded trials that only led to approval of changes in regimen/doses. Through the FDA website we searched all drugs approved for BC treatment between January 1992 and December 2017. For each FDA-approved drug we identified applicable practice-changing trials in the latest package insert. We analyzed each applicable published article for data of interest: drug approval year, indication, participating countries, number of sites per country, trial start year of enrollment, authors per country, among others. If all these data was not available in the article we searched for it in clinicaltrials.gov. If all data was neither in the article nor clinicaltrials.gov, the trial was excluded from our analysis.

Results: 31 trials that led to the approval of 17 drugs were included in our analysis. LATAM participated in 21 trials (67.7%), mean number of LATAM countries per trial = 3.3 and mean number of sites per trial = 13.5. The region participated in 90% of (neo)adjuvant and in 57% of metastatic trials. Additional data is in Table 1. As an average, LATAM contributed with 4.9% of all trial sites. Argentina, Brazil and Mexico had 84% of LATAM sites, Peru and Colombia 8%, and the remaining 8% were distributed among 15 LATAM countries. The 5-year periods with highest number of trials in the region was 2001-05 and 2006-10 (Table 2). Fifteen LATAM authors (87% from Argentina and Brazil) from a total of 530 authors (2.8%) were identified in the primary publication, none of them as first or last author.

Conclusion: over the last 25 years the number of practice-changing BC trials conducted in LATAM has increased since 1990s, remained stable from 2001-10 and recently decreased. LATAM participated in the majority of (neo)adjuvant trials; longer time for enrollment and duration of these trials could explain this finding since these would allow for inclusion of regions with longer regulatory timelines. Region's contribution in terms of countries, sites and authors is minor. Disparities within LATAM countries are remarkable and, as expected, the 3 largest countries are the key contributors. A comparison with other emerging regions will be presented.

LATAM participation in practice- changing BC trialsCharacteristicsTotalLATAMNumber of trials3121Mean number of sites/trial188.513.5Indication  (Neo) adjuvant trials109Metastatic trials2112Drug Type  Endocrine therapy105Chemotherapy64Anti HER2109CDK4/6 inhibitors42Other11

LATAM participation per 5-year periodPeriod (per year of trial enrollment start)Number of LATAM trialsLATAM sites per trial1986-1990001991-1995210.51996-2000414.32001-2005614.72006-2010614.72011-2015312.0

Citation Format: Machado A, Migliaro A, Fresco R. Latin American participation in practice-changing breast cancer trials in the last 25 years [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-15-02.

Abstract PD3-12: Central nervous system as first site of relapse in patients with HER2 positive early breast cancer treated in the BCIRG-006 trial

Introduction: Central Nervous System (CNS) metastases as first site of relapse is seen in 2-3% of patients with HER2+ early breast cancer (EBC) during or after treatment with adjuvant trastuzumab. Data about long-term follow-up outcomes in this population is scarce. Methodology: BCIRG-006 was designed to assess the efficacy and safety of two trastuzumab-based regimens compared to a standard (non-trastuzumab) regimen in the adjuvant treatment of HER2+ EBC. 3,222 patients were randomized to standard AC-T or two trastuzumab-based regimens (AC-TH or TCH). Ten year follow-up outcomes were previously presented; we have used this data to assess the frequency and course of CNS relapses as first site of distant recurrence. DFS and OS in these patients were estimated and compared using the Kaplan-Meier method and Log-Rank test respectively. Univariate and multivariate analyses for DFS were conducted considering patient's age, nodal status, tumor size and estrogen receptor (ER) status in the primary tumor. Results: Of the 3,222 patients randomized, 575 (17.8%) experienced a distant relapse and in 17.5% of these (n=101) CNS was the first site of recurrence. With a median follow-up of 10.3 years, the frequency of CNS relapses did not differ when comparing the trastuzumab containing arms with the control arm (OR 0.86, 95% CI: 0.56-1.33; p= 0.519). No difference was observed either between AC-TH and TCH (OR 1.14, 95% CI: 0.67-1.94; p= 0.704). There were no differences in DFS (HR 1.21, 95% CI: 0.74-1.99; p= 0.621) nor in OS (HR 0.74, 95% CI: 0.43-1.27; p= 0.377) between AC-T, AC-TH and TCH arms. Positive axillary nodes (≥4 nodes) and ER negative status at baseline remained independent risk factors for CNS relapse after univariate and multivariate analysis (HR 0.60, 95% CI: 0.8-0.95; p= 0.007 for nodal status and HR 0.56, 95% CI: 0.37-0.85; p= 0.029 for ER status). Conclusion: Among the pivotal adjuvant trastuzumab trials, BCIRG-006 is the one with the longest median FUP in which data about CNS relapses has been presented. CNS relapse in patients in this trial was an infrequent event. Its frequency and outcomes were similar across the three treatment arms. Patients with ER negative and/or ≥ 4 positive nodes are at higher risk of CNS relapse irrespective of trastuzumab therapy and may be the patient population where research efforts should be focused.

BC outcomes in patients with CNS metastases per treatment arm in the BCIRG-006 trial AC-T N=1073 n(%)AC-TH N=1074 n(%)TCH N=1075 n(%)p valueFrequency of CNS relapse37 (3.44%)30 (2.79%)34 (3.16%)0.519 ^Median DFS (months; 95% CI)23.8 (13.3-30.4)19.9 (16.6-25.1)19.9 (15.0-27.2)0.621 ⫲Median OS (months; 95% CI)42.5 (28.3-62.7)53.2 (31.2-103.6)30.3 (23.4-39.0)0.377 ⫲

^ comparing control vs. trastuzumab-containing arm using Fisher's Exact test.

⫲ comparing control vs. trastuzumab-containing arms using Log Rank test.

Citation Format: Chan A, Spera G, Machado A, Fung H, Bee V, Fresco R, Slamon DJ. Central nervous system as first site of relapse in patients with HER2 positive early breast cancer treated in the BCIRG-006 trial [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD3-12.

Optimal positioning of optodes on the scalp for personalized functional near-infrared spectroscopy investigations

BACKGROUND

Application of functional Near InfraRed Spectroscopy (fNIRS) in neurology is still limited as a good optical coupling and optimized optode coverage of specific brain regions remains challenging, notably for prolonged monitoring.

METHODS

We propose to evaluate a new procedure allowing accurate investigation of specific brain regions. The procedure consists in: (i) A priori maximization of spatial sensitivity of fNIRS measurements targeting specific brain regions, while reducing the number of applied optodes in order to decrease installation time and improve subject comfort. (ii) Utilization of a 3D neuronavigation device and usage of collodion to glue optodes on the scalp, ensuring good optical contact for prolonged investigations. (iii) Local reconstruction of the hemodynamic activity along the cortical surface using inverse modelling.

RESULTS

Using realistic simulations, we demonstrated that maps derived from optimal montage acquisitions showed, after reconstruction, spatial resolution only slightly lower to that of ultra high density montages while significantly reducing the number of optodes. The optimal montages provided overall good quantitative accuracy especially at the peak of the spatially reconstructed map. We also evaluated real motor responses in two healthy subjects and obtained reproducible motor responses over different sessions.

COMPARISON WITH EXISTING METHODS

We are among the first to propose a mathematical optimization strategy, allowing high sensitivity measurements.

CONCLUSIONS

Our results support that using personalized optimal montages should allow to conduct accurate fNIRS studies in clinical settings and realistic lifestyle conditions.

Patients' shifting goals for deep brain stimulation and informed consent

OBJECTIVE

To determine using a repeated-measures, prospective design whether deep brain stimulation (DBS) results in changes in the importance of symptom and behavioral goals individually identified by patients with Parkinson disease (PD) before DBS surgery.

METHODS

Fifty-two participants recruited from a consecutive series completed a semistructured interview soliciting their rank-ordered symptom and behavioral goals and corresponding visual analog scales measuring perceived symptom severity and limits to goal attainment. Rank orders were reassessed at 2 times after DBS. Changes in rank order over time were examined with χ² analyses. The relationships between change in symptom severity/limits to behavioral goal attainment and change in rank order were examined with mixed-effects linear regression models.

RESULTS

Most participants changed the rank order of their symptom (81%) and behavioral (77%) goals 3 months after DBS surgery. Change in rank order of symptom goals was significantly related to change in severity ratings such that improvements in self-reported symptom severity were associated with reductions in rank. In contrast, no such relationship was evident for the behavioral goals.

CONCLUSION

These data illustrate how patients' primary goals for DBS shift early in stimulation and highlight the important differences between symptom and behavioral goals. Changes in the rank order of symptom goals were related to changes in symptom severity, whereas subtler shifts in behavioral goals were unrelated to improvements after DBS. This observation suggests that DBS does not affect goals that may be more reflective of core personal values. The findings provide empiric data that can help improve the informed consent process.

Abstract P3-17-01: Geographic variation in adverse event reporting patterns in breast cancer clinical trials

Introduction: Adverse event (AE) reporting in clinical trials (CT) informs the safety of investigational products. Once approved, safety information in the monograph and prescribing information mainly derive from CT data. Some studies have shown geographic variations in the AE reporting patterns in multinational CT; none of them assessed this variation in cancer CT. We conducted a study to analyze the geographic AE reporting patterns in two breast cancer (BC) CT conducted by Translational Research in Oncology (TRIO).

Objective: To perform a quantitative and qualitative comparison of non-serious AE (NSAE) and serious AE (SAE) reporting patterns between several geographic regions, in breast cancer CT conducted by TRIO.

Methodology: We retrospectively analyzed aggregated NSAE/SAE data (as reported by investigators) from all patients randomized in two completed phase 3, multinational CT of anticancer therapies in advanced BC. Participating countries were grouped in 7 regions according to their geographic location (East Asia, Eastern Europe, Latin America and Caribbean, Middle East and Africa, Non-Eastern Europe, North America, Oceania). Regions were kept masked and numbered from 1 thru 7. AE data were extracted from the clinical data bases. For each region we calculated the mean number of NSAE and SAE per patient (pt), the mean number of NSAE and SAE per cycle/per pt, and the percentage (%) of pt experiencing selected AE (fatigue, febrile neutropenia and emesis). Comparisons between regions were done using unequal variance t-test and Fisher´s exact test.

Results: 1,863 patients from 35 countries and 310 sites were included. Mean number of pt per region was 331. We found significant variation in the number of NSAE/SAE reported across several regions. Two regions (1 and 6) reported the highest mean number of AE while region 4 the lowest rates. The mean number of NSAE reported in region 4 is approximately 3-fold lower than regions 1 and 6 (mean NSAE 22.8 [region 1] vs. 7.9 [region 4]; p &lt;.0001; mean NSAE cycle/pt 9.7 [region 1] vs. 3.2 [region 4]; p &lt;.0001). Region 4 reported 8-fold lower rates of SAE than region 1 (mean number SAE 0.1 vs. 0.8, p&lt;.0001) (Table 1). % of pt experiencing AE fatigue, febrile neutropenia and nausea/vomiting also varied significantly across regions, especially between regions 1 and 4 (Table 2).

NSAE and SAE reporting in selected regions (regions 1 and 4) Region 1 (mean)Region 4 (mean)p-valueNSAE per pt22.87.9&lt;.0001SAE per pt0.80.1&lt;.0001NSAE per cycle/per pt9.73.2&lt;.0001SAE per cycle/per pt0.10.03&lt;.0001

Clinical Outcomes Following Surgical Management of Coexisting Parkinson Disease and Cervical Spondylotic Myelopathy

BACKGROUND

Distinguishing the causes of weakness and gait instability in patients with Parkinson disease (PD) and cervical spondylotic myelopathy (CSM) is a diagnostic and therapeutic challenge due to symptomatic similarities. No study has reported outcomes following decompression in patients with PD and CSM.

OBJECTIVE

To report outcomes following cervical decompression for patients with coexisting PD and CSM.

METHODS

A retrospective matched cohort study of all patients with PD and CSM undergoing cervical decompression at a tertiary-care center between January 1996 and December 2014 was conducted. PD patients were matched to patients with CSM alone by age, gender, American Society of Anesthesiologists classification, and operative parameters. Myelopathy was assessed by Nurick and modified Japanese Orthopaedic Association (mJOA) scales. The effect of PD on mJOA was modeled using multivariable regression.

RESULTS

Twenty-one matched pairs were included. PD patients experienced poorer improvement in Nurick (0.0 vs -1.0, P < .01) and mJOA (0.9 vs 2.5, P < .01) composite scores. However, no significant changes in absolute improvement in the upper extremity motor, upper extremity sensory, or sphincter mJOA components were observed. Multivariable regression identified PD as a significant predictor of decreased improvement in mJOA (β = -0.89, P < .01) and failure to achieve a minimal clinically important difference in change in mJOA (OR 0.18, P = .03).

CONCLUSION

This study is the first to characterize outcomes following cervical decompression in patients with PD and CSM. PD patients experienced symptomatic improvement but less overall improvement in myelopathy compared to controls. However, PD patients demonstrated improvement in upper extremity motor, upper extremity sensory, and sphincter symptoms no worse than control patients.

Effectiveness of the Moreau strain of Bacillus Calmette-Guerin (BCG) for nonmuscle invasive bladder cancer

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Background: Intravesical instillation therapy of Bacillus Calmette-Guerin (BCG) for intermediate and high-risk non-muscle invasive bladder cancer (NMIBC) after complete transurethral resection has been widely shown to be more effective than any other adjuvant treatment. However, there are several different BCG strains not appropriately evaluated in clinical setting, but in current use. BCG Moreau is by far the most utilized strain in Brazil and has been recently introduced to the European market to cover the issue of BCG shortage, but there is insufficient data regarding its oncologic efficacy. Methods: We retrospectively analyzed 336 consecutive patients, who received adjuvant intravesical instillation therapy with BCG Moreau for intermediate- and high-risk NMIBC between January 2005 and February 2015 at a single institution. The end points of this study were time to first recurrence and progression to muscle-invasive disease. Results: Median age was 62 years (interquartile range 54-76, mean 64.3 years). In addition to induction BCG therapy, 228 (67.9%) patients received maintenance BCG. However, 35 (15.4%) patients interrupted maintenance BCG due to toxicity. Overall, after at least a complete induction BCG therapy, 87 (25.9%) patients presented with disease recurrence and 33 (9.8%) patients had disease progression. When analyzing on patients who received BCG maintenance in addition to induction therapy, 31 (13.6%) patients had disease recurrence and 10 (4.4%) had disease progression. The 5-year recurrence-free survival and progression-free survival rate was 69.8% (95% CI 52.8-77.2) and 86.2% (95% CI 69.9-93.2), respectively. Conclusions: BCG Moreau has shown to be safe and effective as adjuvant intravesical treatment in intermediate and high-risk NMIBC patients. Since results are comparable to other strains, wider use of BCG Moreau may be encouraged and prospective clinical trials stimulated for higher level of evidence.

Spinal Cord Stimulation for Spasticity: Historical Approaches, Current Status, and Future Directions

INTRODUCTION

Millions of people worldwide suffer with spasticity related to irreversible damage to the brain or spinal cord. Typical antecedent events include stroke, traumatic brain injury, and spinal cord injury, although insidious onset is also common. Regardless of the cause, the resulting spasticity leads to years of disability and reduced quality of life. Many treatments are available to manage spasticity; yet each is fraught with drawbacks including incomplete response, high cost, limited duration, dose-limiting side effects, and periodic maintenance. Spinal cord stimulation (SCS), a once promising therapy for spasticity, has largely been relegated to permanent experimental status.

METHODS

In this review, our goal is to document and critique the history and assess the development of SCS as a treatment of lower limb spasticity. By incorporating recent discoveries with the insights gained from the early pioneers in this field, we intend to lay the groundwork needed to propose testable hypotheses for future studies.

RESULTS

SCS has been tested in over 25 different conditions since a potentially beneficial effect was first reported in 1973. However, the lack of a fully formed understanding of the pathophysiology of spasticity, archaic study methodology, and the early technological limitations of implantable hardware limit the validity of many studies. SCS offers a measure of control for spasticity that cannot be duplicated with other interventions.

CONCLUSIONS

With improved energy-source miniaturization, tailored control algorithms, novel implant design, and a clearer picture of the pathophysiology of spasticity, we are poised to reintroduce and test SCS in this population.

The effectiveness of case management interventions for patients suffering from substance use disorders

Introduction

Substance use disorder (SUD) is a growing health problem which needs a very complex range of care due to the chronic and relapsing nature of the disorder and the multiple psychosocial problems involved. There are often difficulties in current outpatient programs to deliver and coordinate ongoing care and access to different health care providers. To improve treatment outcomes various case management (CM) models have been developed, at first in other psychiatric domains but also for patients with SUD.

Aims

The aim was to assess the effectiveness of CM for patients with SUD using existing studies.

Methods

Systematic review of CM interventions for patients with SUD by analyzing randomized controlled studies on this matter found on the electronic database PubMed published between 1996 and 2016.

Results and conclusions

Most of the analyzed studies showed improvement on the chosen outcome measures, although, these varied in the different studies. Mainly the treatment adherence improved, but substance use only reduced in a third of the studies. Overall functioning improved in about half of the studies. Further, studies are necessary to determine inclusion criteria for CM treatment for patients suffering from SUD in order to orientate patients most likely to benefit from this approach to the specific CM programs. There are still only few studies on this intervention and SUD. Further, studies are needed to examine the effect of treatment intensity of the CM intervention. Also longitudinal studies are needed to ensure the effectiveness of these treatments.

Disclosure of interest

The authors have not supplied their declaration of competing interest.