Transvaginal ultrasound and magnetic resonance imaging in the diagnosis of endometrioma: a systematic review and meta-analysis of diagnostic test accuracy studies

INTRODUCTION

The diagnosis of endometriomas in patients with endometriosis is of primary importance because it influences the management and prognosis of infertility and pain. Imaging techniques are evolving constantly. This study aimed to systematically assess the diagnostic accuracy of transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) in detecting endometrioma using the surgical visualisation of lesions with or without histopathological confirmation as reference standards in patients of reproductive age with suspected endometriosis.

METHODS

PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature and ClinicalTrials.gov databases were searched from their inception to 12 October 2022, using a manual search for additional articles. Two authors independently performed title, abstract and full-text screening of the identified records, extracted study details and quantitative data and assessed the quality of the studies using the 'Quality Assessment of Diagnostic Accuracy Study 2' tool. Bivariate random-effects models were used to determine the pooled sensitivity and specificity, compare the two imaging modalities and evaluate the sources of heterogeneity.

RESULTS

Sixteen prospective studies (10 assessing TVUS, 4 assessing MRI and 2 assessing both TVUS and MRI) were included, representing 1976 participants. Pooled TVUS and MRI sensitivities for endometrioma were 0.89 (95% confidence interval 'CI', 0.86-0.92) and 0.94 (95% CI, 0.74-0.99), respectively (indirect comparison p-value of 0.47). Pooled TVUS and MRI specificities for endometrioma were 0.95 (95% CI, 0.92-0.97) and 0.94 (95% CI, 0.89-0.97), respectively (indirect comparison p-value of 0.51). These studies had a high or unclear risk of bias. A direct comparison (all participants undergoing TVUS and MRI) of the modalities was available in only two studies.

CONCLUSION

TVUS and MRI have high accuracy for diagnosing endometriomas; however, high-quality studies comparing the two modalities are lacking.

OMERACT Core outcome measurement set for shared decision making in rheumatic and musculoskeletal conditions: a scoping review to identify candidate instruments

OBJECTIVES

Shared decision making (SDM) is a central tenet in rheumatic and musculoskeletal care. The lack of standardization regarding SDM instruments and outcomes in clinical trials threatens the comparative effectiveness of interventions. The Outcome Measures in Rheumatology (OMERACT) SDM Working Group is developing a Core Outcome Set for trials of SDM interventions in rheumatology and musculoskeletal health. The working group reached consensus on a Core Outcome Domain Set in 2020. The next step is to develop a Core Outcome Measurement Set through the OMERACT Filter 2.2.

METHODS

We conducted a scoping review (PRISMA-ScR) to identify candidate instruments for the OMERACT Filter 2.2 We systematically reviewed five databases (Ovid MEDLINE®, Embase, Cochrane Library, CINAHL and Web of Science). An information specialist designed search strategies to identify all measurement instruments used in SDM studies in adults or children living with rheumatic or musculoskeletal diseases or their important others. Paired reviewers independently screened titles, abstracts, and full text articles. We extracted characteristics of all candidate instruments (e.g., measured construct, measurement properties). We classified candidate instruments and summarized evidence gaps with an adapted version of the Summary of Measurement Properties (SOMP) table.

RESULTS

We found 14,464 citations, read 239 full text articles, and included 99 eligible studies. We identified 220 potential candidate instruments. The five most used measurement instruments were the Decisional Conflict Scale (traditional and low literacy versions) (n=38), the Hip/Knee-Decision Quality Instrument (n=20), the Decision Regret Scale (n=9), the Preparation for Decision Making Scale (n=8), and the CollaboRATE (n=8). Only 44 candidate instruments (20%) had any measurement properties reported by the included studies. Of these instruments, only 57% matched with at least one of the 7-criteria adapted SOMP table.

CONCLUSION

We identified 220 candidate instruments used in the SDM literature amongst people with rheumatic and musculoskeletal diseases. Our classification of instruments showed evidence gaps and inconsistent reporting of measurement properties. The next steps for the OMERACT SDM Working Group are to match candidate instruments with Core Domains, assess feasibility and review validation studies of measurement instruments in rheumatic diseases or other conditions. Development and validation of new instruments may be required for some Core Domains.

Barriers and enablers to the implementation of patient-reported outcome and experience measures (PROMs/PREMs): protocol for an umbrella review

BACKGROUND

Patient-reported outcome and experience measures (PROMs and PREMs, respectively) are evidence-based, standardized questionnaires that can be used to capture patients' perspectives of their health and health care. While substantial investments have been made in the implementation of PROMs and PREMs, their use remains fragmented and limited in many settings. Analysis of multi-level barriers and enablers to the implementation of PROMs and PREMs has been hampered by the lack of use of state-of-the-art implementation science frameworks. This umbrella review aims to consolidate available evidence from existing quantitative, qualitative, and mixed-methods systematic and scoping reviews covering factors that influence the implementation of PROMs and PREMs in healthcare settings.

METHODS

An umbrella review of systematic and scoping reviews will be conducted following the guidelines of the Joanna Briggs Institute (JBI). Qualitative, quantitative, and mixed methods reviews of studies focusing on the implementation of PROMs and/or PREMs in all healthcare settings will be considered for inclusion. Eight bibliographical databases will be searched. All review steps will be conducted by two reviewers independently. Included reviews will be appraised and data will be extracted in four steps: (1) assessing the methodological quality of reviews using the JBI Critical Appraisal Checklist; (2) extracting data from included reviews; (3) theory-based coding of barriers and enablers using the Consolidated Framework for Implementation Research (CFIR) 2.0; and (4) identifying the barriers and enablers best supported by reviews using the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach. Findings will be presented in diagrammatic and tabular forms in a manner that aligns with the objective and scope of this umbrella review, along with a narrative summary.

DISCUSSION

This umbrella review of quantitative, qualitative, and mixed-methods systematic and scoping reviews will inform policymakers, researchers, managers, and clinicians regarding which factors hamper or enable the adoption and sustained use of PROMs and PREMs in healthcare settings, and the level of confidence in the evidence supporting these factors. Findings will orient the selection and adaptation of implementation strategies tailored to the factors identified.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023421845.

Exploring the prevalence of post-traumatic stress disorder and post-traumatic stress symptoms in parents within 12 months of child burn injury: A systematic review

Our systematic review aimed to investigate the prevalence of post-traumatic stress symptoms (PTSS) and post-traumatic stress disorder (PTSD) among parents within 12 months of their child's burn injury. A literature search was conducted in PubMed, Embase, Web of Science, Psychinfo and CINAHL on January 6, 2023, for quantitative studies reporting the prevalence of PTSD and/or PTSS in parents within 12 months following their child's burn injury. Risk of bias was assessed using the Mixed Methods Appraisal Tool version 2018. A narrative synthesis of prevalence was presented. We identified 15 articles that met our inclusion criteria. The prevalence of PTSS within 12 months following the burn injury ranged from 6% to 49%. Prevalence estimates of PTSD within the 12 months following a burn injury were limited, ranging from 4.4% to 22%. Our findings highlight the significant impact of burn injuries on parental mental health, with a considerable proportion of parents experiencing PTSS within 12 months following their child's burn injury. Prevalence estimates for PTSD were limited and warrants further investigation. Our review also underscores the need for standardization of PTSS/PTSD terminology. Timely and targeted psychological support is needed for parents in the aftermath of their child's burn injury.

Methods used to account for caregivers' sex and gender within studies examining the financial burden of caregivers of children and adolescents : Results from a scoping review

Background

Interest in the financial burden of informal caregivers has been growing. Unfortunately, it remains unclear which method(s) should be used when quantifying this burden.

Purpose

We conducted a scoping review aimed at identifying which methods have been used to conduct such work and quantified their performance. We were also interested in examining how sex and gender considerations were considered within selected studies.

Data Sources

Using a standardized approach, we identified studies published between 2012 and 2022 that aimed to document the financial burden of caregivers to child and adolescent patients. Our search strategy was applied to the MEDLINE, Embase, CINHAL, and Academic Search Premier databases.

Study Selection

Manuscript selection was performed by pairs of reviewers.

Data Extraction

Data extraction was performed by one reviewer with a second reviewer performing quality control. Results were reported using a narrative approach.

Data Synthesis

We identified 9801 unique citations, of which 200 were included in our review. Selected studies covered various disease area (eg, infection/parasitic diseases [n = 31, 16%]) and included quantitative (n = 180, 90%), qualitative (n = 4, 2%) and mixed study designs (n = 16, 8%). Most studies (n = 182, 91%) used questionnaires/surveys, either alone or in combination with other methods, to assess caregivers' financial burden. Less than half (n = 93, 47%) of studies reported on caregivers' sex and none reported on their gender.

Conclusion

We conducted an unrestricted review of published studies examining caregiver's financial burden which allowed us to identify general methodological trends observed in this literature. We believe this work may help improve future studies focusing on this important issue.

A systematic review of tools for predicting complications in patients with influenza-like illness

Objective

To identify tools that predict the risk of complications for patients presenting to an outpatient clinic or an emergency department (ED) with influenza-like illness.

Methods

We searched Medline, Embase, Cochrane Library and CINAHL from inception to July 2023. We included articles reporting on the derivation or validation of a score or algorithm used to stratify the risk of hospitalization or mortality among patients with influenza-like illness in the ED or outpatient clinic.

Results

Twelve articles reporting on eight scores and six predictive models were identified. For predicting the need for hospitalization, the area under the curve (AUC) of the PMEWS and the CURB-65 ranged respectively from 0.76 to 0.94, and 0.65 to 0.88. The Community Assessment Tool had an AUC of 0.62. For predicting inpatient mortality, AUC was 0.66 for PMEWS and 0.79 for CURB-65, 0.79 for the SIRS criteria and 0.86 for the qSOFA score. Two scores were developed without external validation during the Covid-19 pandemic. The CovHos score and the Canadian Covid discharge score had an AUC ranged from 0.70 to 0.91. The predictive models performed adequately (AUC from 0.76 to 0.92) but will require external validation for clinical use. Tool diversity and study population heterogeneity precluded meta-analysis.

Conclusion

Although the CURB, PMEWS and qSOFA scores appear to predict accurately the risk of complications of influenza-like illness, none were reliable enough to justify their widespread ED use. Refinement of an existing tool or development of a new tool to optimize the management of these patients is needed.

Teledentistry for improving access to, and quality of oral health care: A protocol for an overview of systematic reviews and meta-analyses

Digital technologies are becoming essential to address and optimize the suboptimal performance of healthcare systems. Teledentistry involves the use of information and communication technology to improve access to oral health care and the quality of oral health care delivery. Several systematic reviews (SRs) have been conducted to synthesize evidence on the effectiveness of teledentistry but with conflicting results. The aim of this review is to comprehensively summarize available SRs and provide evidence on the impact of teledentistry on access to oral care, patients' and oral healthcare providers' outcomes, quality of oral health care and costs. This protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO CRD42022373964). Six electronic databases including MEDLINE (Ovid), Embase (Embase.com), CINAHL (EBSCO), Web of Science, Cochrane Library and Epistemonikos will be searched for SRs of quantitative, qualitative, and mixed reviews evaluating teledentistry modalities involving both patients and/or oral health care providers (OHCPs). We will include studies published in English or French. The outcomes will include patients' outcomes (e.g., access to oral health care, patient-reported outcomes, and patient-reported experiences); patient indicators (e.g., clinical outcomes, adherence to treatment, adverse outcomes and costs); and OHCP indicators (e.g., diagnostic accuracy, barriers and enablers costs and equity). Two independent reviewers will perform data screening, data extraction and will assess the quality of included studies using AMSTAR 2 and ROBIS tools. Data will be synthesized narratively and presented by tables and graphs. We will report any overlap of primary studies in the SRs. A statement on the strength of evidence for each outcome will be provided if possible. This review will inform decision-makers, patients, OHCPs, and researchers on the potential effectiveness, benefits, and challenges of teledentistry and support them in making recommendations for its use. Results will be disseminated through peer-reviewed publications, presentations at conferences, and on social media.

Postpandemic Evaluation of the Eco-Efficiency of Personal Protective Equipment Against COVID-19 in Emergency Departments: Proposal for a Mixed Methods Study

BACKGROUND

The COVID-19 pandemic has had a profound impact on emergency department (ED) care in Canada and around the world. To prevent transmission of COVID-19, personal protective equipment (PPE) was required for all ED care providers in contact with suspected cases. With mass vaccination and improvements in several infection prevention components, our hypothesis is that the risks of transmission of COVID-19 will be significantly reduced and that current PPE use will have economic and ecological consequences that exceed its anticipated benefits. Evidence is needed to evaluate PPE use so that recommendations can ensure the clinical, economic, and environmental efficiency (ie, eco-efficiency) of its use.

OBJECTIVE

To support the development of recommendations for the eco-efficient use of PPE, our research objectives are to (1) estimate the clinical effectiveness (reduced transmission, hospitalizations, mortality, and work absenteeism) of PPE against COVID-19 for health care workers; (2) estimate the financial cost of using PPE in the ED for the management of suspected or confirmed COVID-19 patients; and (3) estimate the ecological footprint of PPE use against COVID-19 in the ED.

METHODS

We will conduct a mixed method study to evaluate the eco-efficiency of PPE use in the 5 EDs of the CHU de Québec-Université Laval (Québec, Canada). To achieve our goals, the project will include four phases: systematic review of the literature to assess the clinical effectiveness of PPE (objective 1; phase 1); cost estimation of PPE use in the ED using a time-driven activity-based costing method (objective 2; phase 2); ecological footprint estimation of PPE use using a life cycle assessment approach (objective 3; phase 3); and cost-consequence analysis and focus groups (integration of objectives 1 to 3; phase 4).

RESULTS

The first 3 phases have started. The results of these phases will be available in 2023. Phase 4 will begin in 2023 and results will be available in 2024.

CONCLUSIONS

While the benefits of PPE use are likely to diminish as health care workers' immunity increases, it is important to assess its economic and ecological impacts to develop recommendations to guide its eco-efficient use.

TRIAL REGISTRATION

PROSPERO CRD42022302598; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=302598.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/50682.

Implementation model for a national learning health system (IMPLEMENT-National LHS): a concept analysis and systematic review protocol

INTRODUCTION

Despite efforts and repeated calls to improve the organisation and quality of healthcare and services, and in view of the many challenges facing health systems, the results and capacity to adapt and integrate innovations and new knowledge remain suboptimal. Learning health systems (LHS) may be an effective model to accelerate the application of research for real quality improvement in healthcare. However, while recognising the enormous potential of LHS, the literature suggests the model remains more of an aspiration than a reality.

METHODS AND ANALYSIS

To reach a fine understanding of the implementation of the concepts involved in LHS, we will use a hybrid method which combines concept analyses with systematic review methodology. We will use a two-step analysis, a content analysis to analyse the definitions, uses and attributes of the concept and a systematic review to analyse the concept's implementation mechanisms. We will search eight databases and grey literature and present a broad synthesis of the available evidence regarding design, implementation and evaluation of LHS in a multilevel perspective. We will follow the latest Preferred Reporting Items for Systematic Review and Meta-Analysis statement for conducting and reporting a systematic review. Two reviewers will independently screen the titles and abstracts against the eligibility criteria followed by full-text screening of potentially relevant articles for final inclusion decision. Conflicts will be resolved with a senior author. We will include published primary studies that use qualitative, quantitative or mixed methods. The assessment of risk of bias will be made using the Mixed-Methods Appraisal Tool.

ETHICS AND DISSEMINATION

This systematic review is exempt from ethics approval. The results formulated will highlight evidence-based interventions that support the implementation of a national LHS. They will be of particular interest to decision makers, researchers, managers, clinicians and patients allowing finally to implement the promising proposal of LHSs at national scale.

PROSPERO REGISTRATION NUMBER

CRD42023393565.

Clinical Integration of Digital Patient-Reported Outcome Measures in Primary Health Care for Chronic Disease Management: Protocol for a Systematic Review

BACKGROUND

Health measurement guides policies and health care decisions are necessary to describe and attain the quintuple aim of improving patient experience, population health, care team well-being, health care costs, and equity. In the primary care setting, patient-reported outcome measurement allows outcome comparisons within and across settings and helps improve the clinical management of patients. However, these digital patient-reported outcome measures (PROMs) are still not adapted to the clinical context of primary health care, which is an indication of the complexity of integrating these tools in this context. We must then gather evidence of their impact on chronic disease management in primary health care and understand the characteristics of effective implementation.

OBJECTIVE

We will conduct a systematic review to identify and assess the impact of electronic PROMs (ePROMs) implementation in primary health care for chronic disease management. Our specific objectives are to (1) determine the impact of ePROMs in primary health care for chronic disease management and (2) compare and contrast characteristics of effective ePROMs' implementation strategies.

METHODS

We will conduct a systematic review of the literature in accordance with the guidelines of the Cochrane Methods Group and in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for its reporting. A specific search strategy was developed for relevant databases to identify studies. Two reviewers will independently apply the inclusion criteria using full texts and will extract the data. We will use a 2-phase sequential mixed methods synthesis design by conducting a qualitative synthesis first, and use its results to perform a quantitative synthesis.

RESULTS

This study was initiated in June 2022 by assembling the research team and the knowledge transfer committee. The preliminary search strategy will be developed and completed in September 2022. The main search strategy, data collection, study selection, and application of inclusion criteria were completed between October and December 2022.

CONCLUSIONS

Results from this review will help support implementation efforts to accelerate innovations and digital adoption for primary health care and will be relevant for improving clinical management of chronic diseases and health care services and policies.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42022333513; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=333513.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48155.

Impact of primary health care reforms in Quebec Health Care System: a systematic literature review protocol

INTRODUCTION

During the last decade the Quebec Public Health Care System (QPHCS) had an important transformation in primary care planning activity. The increase of the service demand together with a significant reduction of supply in primary care may be at risk of reducing access to health care services, with a negative impact on costs and health outcomes. The aims of this systematic literature review are to map and aggregate existing literature and evidence on the primary care provided in Quebec, showing the benefits and limitations associated with the health policies developed in the last two decades, and highlighting areas of improvement.

METHODS AND ANALYSIS

PubMed, EMBASE, Web of Science and CINAHL will be searched for articles and government reports between January 2000 and January 2022 using a prespecified search strategy. This protocol adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Protocols and has been registered with PROSPERO. A wide range of electronic databases and grey literature sources will be systematically searched using predefined keywords. The review will include any study design, with the exclusion of protocols, with a focus on the analysis of health care policies, outcomes, costs and management of the primary health care services, published in either English or French languages. Two authors will independently screen titles, abstracts, full-text articles and select studies meeting the inclusion criteria. A customised data extraction form will be used to extract data from the included studies. Results will be presented in tabular format developed iteratively by the research team.

ETHICS AND DISSEMINATION

Research ethics approval is not required as exclusively secondary data will be used. Review findings will synthesise the characteristics and the impact of the reforms of QPHCS of the last two decades. Findings will therefore be disseminated in peer-reviewed journals, conference presentations and through discussions with stakeholders.

PROSPERO REGISTRATION NUMBER

CRD42023421145.

Barriers and Enablers to Implementing Teledentistry From the Perspective of Dental Health Care Professionals: Protocol for a Systematic Quantitative, Qualitative, and Mixed Studies Review

BACKGROUND

There is growing literature on the potential of digital technologies for improving access to, ensuring continuity and quality of health care, and to strengthen health systems. Some studies have reported the cost-effectiveness of teledentistry, its reliability for remote dental screening, diagnosis, consultation, and treatment planning. Nonetheless, current evidence suggests that teledentistry implementation faces many challenges and is not yet adopted by dental health care providers (DHCPs). Developing strategies to improve teledentistry adoption requires an understanding of the factors that promote or hinder its successful implementation.

OBJECTIVE

This systematic review aims to identify and synthetize barriers and enablers to implementing teledentistry as perceived by DHCPs in their clinical practices, using the Theoretical Domains Framework (TDF) and the Capacity, Opportunity, and Motivation Behavior (COM-B) model.

METHODS

This protocol follows the PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Protocols) checklist. Literature will be searched in the following databases: PubMed, Cochrane Library, Web of Science, CINAHL, Embase, and PsycINFO. We will perform additional searches on Google, Google Scholar, and ProQuest Dissertations & Theses Global, screen the references of the included studies to capture additional relevant studies, and contact the authors of studies if we need more details. We will consider studies using qualitative, quantitative, and mixed methods. There will be no restrictions on the publication date and dental setting. We will include studies published in French, English, and Portuguese. Two independent reviewers will select the study, extract data, and assess methodological quality using the Mixed Methods Appraisal Tool's checklist. Data analysis will include a descriptive and a thematic content analysis. We will synthetize and categorize the barriers and enablers using the TDF and COM-B model and present a narrative synthesis of our results using tables, figures, and quotes.

RESULTS

By March 2023, the literature search has retrieved 7355 publications. We will identify the range of barriers and enablers to implementing teledentistry through DHCPs' perspectives. Considering the critical need for theory-based implementation interventions to improve the use of evidence-informed practices, we will synthesize the factors influencing the adoption of teledentistry based on the TDF domains and the 3 essential conditions predicting behavior change in accordance with the COM-B model. As needed, we will include additional determinants if not included in the TDF. We will conduct some subgroups analyses if studies are sufficient. We expect to complete the review by July 2024.

CONCLUSIONS

This review will provide some insights on the determinants of teledentistry implementation as perceived by DHCPs in dental settings. These findings will cater to patients, families, DHCPs, researchers, academic and professional decision-makers, and policy makers. The results of the systematic review could be used to develop theory-led interventions in improving teledentistry implementation.

TRIAL REGISTRATION

PROSPERO CRD42021293376; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=293376.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/44218.

Risk of Bias Mitigation for Vulnerable and Diverse Groups in Community-Based Primary Health Care Artificial Intelligence Models: Protocol for a Rapid Review

BACKGROUND

The current literature identifies several potential benefits of artificial intelligence models for populations' health and health care systems' efficiency. However, there is a lack of understanding on how the risk of bias is considered in the development of primary health care and community health service artificial intelligence algorithms and to what extent they perpetuate or introduce potential biases toward groups that could be considered vulnerable in terms of their characteristics. To the best of our knowledge, no reviews are currently available to identify relevant methods to assess the risk of bias in these algorithms. The primary research question of this review is which strategies can assess the risk of bias in primary health care algorithms toward vulnerable or diverse groups?

OBJECTIVE

This review aims to identify relevant methods to assess the risk of bias toward vulnerable or diverse groups in the development or deployment of algorithms in community-based primary health care and mitigation interventions deployed to promote and increase equity, diversity, and inclusion. This review looks at what attempts to mitigate bias have been documented and which vulnerable or diverse groups have been considered.

METHODS

A rapid systematic review of the scientific literature will be conducted. In November 2022, an information specialist developed a specific search strategy based on the main concepts of our primary review question in 4 relevant databases in the last 5 years. We completed the search strategy in December 2022, and 1022 sources were identified. Since February 2023, two reviewers independently screened the titles and abstracts on the Covidence systematic review software. Conflicts are solved through consensus and discussion with a senior researcher. We include all studies on methods developed or tested to assess the risk of bias in algorithms that are relevant in community-based primary health care.

RESULTS

In early May 2023, almost 47% (479/1022) of the titles and abstracts have been screened. We completed this first stage in May 2023. In June and July 2023, two reviewers will independently apply the same criteria to full texts, and all exclusion motives will be recorded. Data from selected studies will be extracted using a validated grid in August and analyzed in September 2023. Results will be presented using structured qualitative narrative summaries and submitted for publication by the end of 2023.

CONCLUSIONS

The approach to identifying methods and target populations of this review is primarily qualitative. However, we will consider a meta-analysis if quantitative data and results are sufficient. This review will develop structured qualitative summaries of strategies to mitigate bias toward vulnerable populations and diverse groups in artificial intelligence models. This could be useful to researchers and other stakeholders to identify potential sources of bias in algorithms and try to reduce or eliminate them.

TRIAL REGISTRATION

OSF Registries qbph8; https://osf.io/qbph8.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46684.

Association Between Enteral Supplementation With High-Dose Docosahexaenoic Acid and Risk of Bronchopulmonary Dysplasia in Preterm Infants: A Systematic Review and Meta-analysis

IMPORTANCE

High-dose docosahexaenoic acid (DHA), a long-chain polyunsaturated fatty acid, may affect the risk of bronchopulmonary dysplasia (BPD). However, high-level summative evidence supporting such clinical association in very preterm infants is lacking.

OBJECTIVE

To examine the association between enteral supplementation with high-dose DHA during the neonatal period and the risk of BPD in preterm infants born at less than 29 weeks' gestation.

DATA SOURCES

PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, medRxiv, and ClinicalTrials.gov were searched from inception to August 1, 2022, for eligible articles with no language restrictions.

STUDY SELECTION

Randomized clinical trials (RCTs) were eligible for inclusion (1) if their interventions involved direct administration of a minimum DHA supplementation of 40 mg/kg/d or breast milk or formula feeding of at least 0.4% of total fatty acids, and (2) if they reported data on either BPD, death, BPD severity, or a combined outcome of BPD and death.

DATA EXTRACTION AND SYNTHESIS

Two investigators completed independent review of titles and abstracts, full text screening, data extraction, and quality assessment using the Cochrane Risk of Bias 2.0. Risk ratios (RRs) with 95% CIs were pooled using random-effect meta-analyses.

MAIN OUTCOMES AND MEASURES

Primary outcome was BPD using trial-specific definitions, which was further stratified for RCTs that used a more stringent BPD definition based on systematic pulse oximetry assessment at 36 weeks' postmenstrual age. Other outcomes were BPD, death, BPD severity, or combined BPD and death.

RESULTS

Among the 2760 studies screened, 4 RCTs were included, which involved 2304 infants (1223 boys [53.1%]; mean [SD] gestational age, 26.5 [1.6] weeks). Enteral supplementation with high-dose DHA was associated with neither BPD (4 studies [n = 2186 infants]; RR, 1.07 [95% CI, 0.86-1.34]; P = .53; I2 = 72%) nor BPD or death (4 studies [n = 2299 infants]; RR, 1.04 [95% CI, 0.91-1.18]; P = .59; I2 = 61%). However, an inverse association with BPD was found in RCTs that used a more stringent BPD definition (2 studies [n = 1686 infants]; RR, 1.20 [95% CI, 1.01-1.42]; P = .04; I2 = 48%). Additionally, DHA was inversely associated with moderate-to-severe BPD (3 studies [n = 1892 infants]; RR, 1.16 [95% CI, 1.04-1.29]; P = .008; I2 = 0%).

CONCLUSIONS AND RELEVANCE

Results of this study showed that enteral supplementation with high-dose DHA in the neonatal period was not associated overall with BPD, but an inverse association was found in the included RCTs that used a more stringent BPD definition. These findings suggest that high-dose DHA supplementation should not be recommended to prevent BPD in very preterm infants.

The use of early neuromuscular blockage in acute respiratory distress syndrome: A systematic review and meta-analyses of randomized clinical trials

BACKGROUND

Acute Respiratory Distress Syndrome (ARDS) as defined by the Berlin definition has an approximate mortality rate of 40% and no curative treatment. Mutliple therapies have been studied to reduce mortality but only neuromuscular blocking agents show potential benefits on mortality and other complications of ARDS.

OBJECTIVE

This review aimed to investigate the efficacy of neuromuscular blockers in ARDS METHODS: Medline, Embase, Cochrane Central and Web of Science were queried on October 1st, 2021. Randomized clinical trials comparing neuromuscular blockers to any comparator in treating ARDS were included. Primary outcome was mortality. Secondary outcomes were ventilator-free days, intensive care (ICU) length of stay (LOS) and complications. Results between sedation levels were examined with a Bayesian Network for Meta-analysis method.

RESULTS

We included 6 trials compiling a total of 1557 patients. Neuromuscular blockers compared to any comparator in treating ARDS showed a reduction in mortality (RR 0.79 [95% CI, 0.62 to 0.99]). No difference in ventilator-free days (MD 0.68 [95% CI, -0.50 to 1.85]) or ICU LOS (MD 0.77 [95% CI, -2.99 to 4.54]) were found. A Bayesian Network Meta-analysis yielded no difference in mortality when using light sedation compared to heavy sedation in ARDS. (OR 0.58 [95% CrI, 0.07 to 4.46].) CONCLUSION: Neuromuscular blockers safely reduce mortality. Light sedation potentially has a similar impact on mortality as heavy sedation that carries some burden. A non-inferiority trial comparing both sedation levels may be warranted considering the added value of light sedation.

High doses of enteral docosahexaenoic acid omega-3 supplementation for prevention of bronchopulmonary dysplasia in very preterm infants: a protocol for a systematic review and meta-analysis

INTRODUCTION

Docosahexaenoic acid (DHA) supplementation in the neonatal period has been proposed to prevent bronchopulmonary dysplasia (BPD) in very preterm infants. We aim to determine the effects of an enteral supplementation with high doses of DHA on the risk for BPD at 36 weeks' postmenstrual age (PMA) in very preterm infants born less than 29 weeks' gestation compared with a control.

METHODS AND ANALYSIS

We will conduct a systematic review and meta-analysis of randomised controlled trials (RCTs) searching PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, MedRxiv, ClinicalTrials.gov (up to 1 November 2021) as well as reference lists and citations of included articles and previous reviews. RCTs targeting infants born less than 29 weeks' gestation and evaluating the effect of high doses of DHA enteral supplementation in the neonatal period compared with a control will be eligible. Primary outcome will be BPD defined as the need for oxygen and/or ventilation at 36 weeks' PMA. Two authors will independently screen for inclusion, extract data and assess data quality using the Cochrane instrument (risk-of-bias tool 2.0). We will perform meta-analysis using random effects models. Prespecified subgroup analyses are planned for the infant gestational age and sex, the marine source of DHA, mode of administration and duration of exposure. Sensitivity analysis will be performed according to the accuracy of the BPD definition (ie, physiological definition) and according to the risk of bias of the RCTs.

ETHICS AND DISSEMINATION

This protocol for a systematic review and meta-analysis does not require ethics approval, as no primary data are collected. This study will assess the effectiveness of high doses of enteral DHA supplementation on BPD and provide evidence to clinicians and families for decision-making. Findings will be disseminated through conferences, media interviews and publications to peer review journals.

PROSPERO REGISTRATION NUMBER

CRD42021286705.

Interactive conversational agents for health promotion, prevention, and care: A mixed methods systematic scoping review protocol (Preprint)

Background

Interactive conversational agents, also known as “chatbots,” are computer programs that use natural language processing to engage in conversations with humans to provide or collect information. Although the literature on the development and use of chatbots for health interventions is growing, important knowledge gaps remain, such as identifying design aspects relevant to health care and functions to offer transparency in decision-making automation.

Objective

This paper presents the protocol for a scoping review that aims to identify and categorize the interactive conversational agents currently used in health care.

Methods

A mixed methods systematic scoping review will be conducted according to the Arksey and O’Malley framework and the guidance of Peters et al for systematic scoping reviews. A specific search strategy will be formulated for 5 of the most relevant databases to identify studies published in the last 20 years. Two reviewers will independently apply the inclusion criteria using the full texts and extract data. We will use structured narrative summaries of main themes to present a portrait of the current scope of available interactive conversational agents targeting health promotion, prevention, and care. We will also summarize the differences and similarities between these conversational agents.

Results

The search strategy and screening steps were completed in March 2022. Data extraction and analysis started in May 2022, and the results are expected to be published in October 2022.

Conclusions

This fundamental knowledge will be useful for the development of interactive conversational agents adapted to specific groups in vulnerable situations in health care and community settings.

International Registered Report Identifier (IRRID)

DERR1-10.2196/40265

Benefits and limitations of business process model notation in modelling patient healthcare trajectory: a scoping review protocol

INTRODUCTION

The adoption of business process model notation (BPMN) in modelling healthcare trajectory can enhance the efficiency and efficacy of healthcare organisations, improve patient outcomes while restraining costs. Existing systematic reviews have been inconclusive regarding the effectiveness of BPMN in modelling healthcare trajectory. The aims of this scoping review are to map and aggregate existing evidence on the benefits and limitations associated with BPMN in healthcare trajectory, highlighting areas of improvement on BPMN and its extensions in healthcare. We will assess BPMN's ability to model key dimensions or concepts of the healthcare process and to meet the needs of stakeholders. The review will highlight the advantages of this approach to support clinical activities and decision-making processes associated with the healthcare trajectory, proposing a conceptual framework for improving the use of BPMN in healthcare.

METHODS AND ANALYSIS

This study will be performed in accordance with the methodological framework suggested by Arksey and O'Malley. A wide range of electronic databases and grey literature sources will be systematically searched using predefined keywords. The review will include any study design focusing on the application of the BPMN approach for optimising healthcare trajectories, published in either English or French from 1 January 2004 to 9 December 2021. Two reviewers will independently screen titles, abstracts and full-text articles and select articles meeting the inclusion criteria. A customised data extraction form will be used to extract data. The results will be presented using descriptive statistics and thematic analysis on qualitative data.

ETHICS AND DISSEMINATION

Research ethics approval is not required. Review findings will be used to advance understanding about BPMN, its extensions and application in healthcare trajectory optimisation. The review will develop recommendations on tailoring BPMN strategies for optimising care pathways and decision-making processes. Findings will be disseminated in peer-reviewed journals, conferences and discussions with relevant organisations and stakeholders.

Definition and conceptualization of the patient-centered care pathway, a proposed integrative framework for consensus: a Concept analysis and systematic review

BACKGROUND

Confusion exists over the definition of the care pathway concept and existing conceptual frameworks contain various inadequacies which have led to implementation difficulties. In the current global context of rapidly changing health care systems, there is great need for a standardized definition and integrative framework that can guide implementation. This study aims to propose an accurate and up-to-date definition of care pathway and an integrative conceptual framework.

METHODS

An innovative hybrid method combining systematic review, concept analysis and bibliometric analysis was undertaken to summarize qualitative, quantitative, and mixed-method studies. Databases searched were PubMed, Embase and ABI/Inform. Methodological quality of included studies was then assessed.

RESULTS

Forty-four studies met the inclusion criteria. Using concept analysis, we developed a fine-grained understanding, an integrative conceptual framework, and an up-to-date definition of patient-centered care pathway by proposing 28 subcategories grouped into seven attributes. This conceptual framework considers both operational and social realities and supports the improvement and sustainable transformation of clinical, administrative, and organizational practices for the benefit of patients and caregivers, while considering professional experience, organizational constraints, and social dynamics. The proposed attributes of a fluid and effective pathway are (i) the centricity of patients and caregivers, (ii) the positioning of professional actors involved in the care pathway, (iii) the operation management through the care delivery process, (iv) the particularities of coordination structures, (v) the structural context of the system and organizations, (vi) the role of the information system and data management and (vii) the advent of the learning system. Antecedents are presented as key success factors of pathway implementation. By using the consequences and empirical referents, such as outcomes and evidence of care pathway interventions, we went beyond the single theoretical aim, proposing the application of the conceptual framework to healthcare management.

CONCLUSIONS

This study has developed an up-to-date definition of patient-centered care pathway and an integrative conceptual framework. Our framework encompasses 28 subcategories grouped into seven attributes that should be considered in complex care pathway intervention. The formulation of these attributes, antecedents as success factors and consequences as potential outcomes, allows the operationalization of this model for any pathway in any context.

Guidelines of the French Society of Otorhinolaryngology-Head and Neck Surgery (SFORL) and the French Society of Audiology (SFA) for Speech-in-Noise Testing in Adults

OBJECTIVES

This document presents the fundamentals of speech audiometry in noise, general requirements for implementation and criteria for choice among the tests available in French according to the health-professional's needs.

MATERIAL AND METHODS

The recommendations are based on a systematic analysis of the literature carried out by a multidisciplinary group of doctors, audiologists and audioprosthetists from all over France. They are graded A, B, C or expert opinion according to decreasing level of scientific evidence.

RESULTS

Eight tests of speech audiometry in noise can be used in France.

CONCLUSION

To be complete, evaluation of hearing status requires testing understanding of speech in noise. The examination must begin with a minimum of two measurements familiarizing the subject with the test procedure. For initial diagnosis, adaptive procedures establishing the 50% speech reception threshold (SRT50) in noise are to be preferred in order to obtain a rapid and standardized measurement of perception of speech in noise. When the aim is to measure real-life speech comprehension, tests based on sentences, cocktail-party noise and free-field stimulation are to be preferred. Prosthetic gain is evaluated exclusively in free field. This is the only way to evaluate the contribution of binaurality and to measure perception in noise in an environment as close as possible to real life. In order to avoid acoustic interference in free field, at least five loudspeakers should be used, in particular for evaluating the effectiveness of directional microphones, CROS devices enabling sounds picked up in the damaged ear to be rerouted to the functional ear, or bimodal fitting (i.e., when hearing is enabled by two modalities: for example, hearing aid for one ear, cochlear implant for the other).

Evaluation of Intensive vs Standard Blood Pressure Reduction and Association With Cognitive Decline and Dementia: A Systematic Review and Meta-analysis

IMPORTANCE

Optimal blood pressure (BP) targets for the prevention of cognitive impairment remain uncertain.

OBJECTIVE

To explore the association of intensive (ie, lower than usual) BP reduction vs standard BP management with the incidence of cognitive decline and dementia in adults with hypertension.

DATA SOURCES AND STUDY SELECTION

A systematic review and meta-analysis of randomized clinical trials that evaluated the association of intensive systolic BP lowering on cognitive outcomes by searching MEDLINE, Embase, CENTRAL, Web of Science, CINAHL, PsycINFO, the International Clinical Trials Registry Platform, and ClinicalTrials.gov from database inception to October 27, 2020.

DATA EXTRACTION AND SYNTHESIS

Data screening and extraction were performed independently by 2 reviewers based on Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The risk of bias was assessed using the Cochrane risk of bias 2 tool. Random-effects models with the inverse variance method were used for pooled analyses. The presence of potential heterogeneity was evaluated with the I2 index.

MAIN OUTCOMES AND MEASURES

The primary outcome was cognitive decline. Secondary outcomes included the incidence of dementia, mild cognitive impairment (MCI), cerebrovascular events, serious adverse events, and all-cause mortality.

RESULTS

From 7755 citations, we identified 16 publications from 5 trials with 17 396 participants (mean age, 65.7 years [range, 63.0-80.5 years]; 10 562 [60.5%] men) and 2 additional ongoing trials. All 5 concluded trials included in quantitative analyses were considered at unclear to high risk of bias. The mean follow-up duration was 3.3 years (range, 2.0 to 4.7 years). Intensive BP reduction was not significantly associated with global cognitive performance (standardized mean difference, 0.01; 95% CI, -0.04 to 0.06; I2 = 0%; 4 trials; 5246 patients), incidence of dementia (risk ratio [RR], 1.09; 95% CI, 0.32 to 3.67; I2 = 27%; 2 trials; 9444 patients) or incidence of MCI (RR, 0.91; 95% CI, 0.73 to 1.14; I2 = 74%; 2 trials; 10 774 patients) when compared with standard treatment. However, a reduction of cerebrovascular events in the intensive group was found (RR, 0.79; 95% CI, 0.67 to 0.93; I2 = 0%; 5 trials; 17 396 patients) without an increased risk of serious adverse events or mortality.

CONCLUSIONS AND RELEVANCE

In this study, there was no significant association between BP reduction and lower risk of cognitive decline, dementia, or MCI. The certainty of this evidence was rated low because of the limited sample size, the risk of bias of included trials, and the observed statistical heterogeneity. Therefore, current available evidence does not justify the use of lower BP targets for the prevention of cognitive decline and dementia.

Health utilities in burn injury survivors: A systematic review

BACKGROUND

An estimated 11 million burn injuries with medical attention occur every year worldwide. Although potentially deadly, burn injuries are now considered a chronic disease with multiple lifetime physical and psychological sequelae. However, it remains unclear how these events affect patients' utility scores. We aimed to conduct a systematic review to summarize the utility scores of burn injury survivors.

METHODS

We conducted on March 18^th, 2020 a systematic review of the published literature using a search strategy designed in collaboration with a research librarian. Our search strategy aimed to identify studies that provided burn injury survivors' utility scores via a standardized indirect instrument.

RESULTS

We identified 15 studies that reported burn injury survivors' utility scores. Most studies used the EQ-5D instruments to assess patients' utility scores. Results varied substantially between studies, ranging from a low of 0.06 to a high of 0.972. Our review identified two key trends. First, utility scores seem to be negatively correlated with the severity of the burn injury. Second, utility scores in adults tend to increase in function of the time since injury.

CONCLUSION

Unfortunately, due to differences in study design and settings, patient populations and instruments used to assess patients' utility scores, we were unable to combine all study results into a single value. In spite of this limit, results we identified support previous trends identified by others regarding the relationship between utility scores and the burn injury severity and/or the time since injury.

A Systematic Review of Methods Used for Confounding Adjustment in Observational Economic Evaluations in Cardiology Conducted between 2013 and 2017

Background. Observational economic evaluations (i.e., economic evaluations in which treatment allocation is not randomized) are prone to confounding bias. Prior reviews published in 2013 have shown that adjusting for confounding is poorly done, if done at all. Although these reviews raised awareness on the issues, it is unclear if their results improved the methodological quality of future work. We therefore aimed to investigate whether and how confounding was accounted for in recently published observational economic evaluations in the field of cardiology. Methods. We performed a systematic review of PubMed, Embase, Cochrane Library, Web of Science, and PsycInfo databases using a set of Medical Subject Headings and keywords covering topics in "observational economic evaluations in health within humans" and "cardiovascular diseases." Any study published in either English or French between January 1, 2013, and December 31, 2017, addressing our search criteria was eligible for inclusion in our review. Our protocol was registered with PROSPERO (CRD42018112391). Results. Forty-two (0.6%) out of 7523 unique citations met our inclusion criteria. Fewer than half of the selected studies adjusted for confounding (n = 19 [45.2%]). Of those that adjusted for confounding, propensity score matching (n = 8 [42.1%]) and other matching-based approaches were favored (n = 8 [42.1%]). Our results also highlighted that most authors who adjusted for confounding rarely justified their methodological choices. Conclusion. Our results indicate that adjustment for confounding is often ignored when conducting an observational economic evaluation. Continued knowledge translation efforts aimed at improving researchers' knowledge regarding confounding bias and methods aimed at addressing this issue are required and should be supported by journal editors.

Phosphorylation of GATA4 serine 105 but not serine 261 is required for testosterone production in the male mouse

BACKGROUND

GATA4 is a transcription factor essential for male sex determination, testicular differentiation during fetal development, and male fertility in the adult. GATA4 exerts part of its function by regulating multiple genes in the steroidogenic enzyme pathway. In spite of these crucial roles, how the activity of this factor is regulated remains unclear.

OBJECTIVES

Studies in gonadal cell lines have shown that GATA4 is phosphorylated on at least two serine residues-serine 105 (S105) and serine 261 (S261)-and that this phosphorylation is important for GATA4 activity. The objective of the present study is to characterize the endogenous role of GATA4 S105 and S261 phosphorylation in the mouse testis.

MATERIALS AND METHODS

We examined both previously described GATA4 S105A mice and a novel GATA4 S261A knock-in mouse that we generated by CRISPR/Cas9 gene editing. The male phenotype of the mutants was characterized by assessing androgen-dependent organ weights, hormonal profiles, and expression of multiple testicular target genes using standard biochemical and molecular biology techniques.

RESULTS

The fecundity of crosses between GATA4 S105A mice was reduced but without a change in sex ratio. The weight of androgen-dependent organs was smaller when compared to wild-type controls. Plasma testosterone levels showed a 70% decrease in adult GATA4 S105A males. This decrease was associated with a reduction in Cyp11a1, Cyp17a1, and Hsd17b3 expression. GATA4 S261A mice were viable and testis morphology appeared normal. Testosterone production and steroidogenic enzyme expression were not altered in GATA4 S261A males.

DISCUSSION AND CONCLUSION

Our analysis showed that blocking GATA4 S105 phosphorylation is associated with decreased androgen production in males. In contrast, S261 phosphorylation by itself is dispensable for GATA4 function. These results confirm that endogenous GATA4 action is essential for normal steroid production in males and that this activity requires phosphorylation on at least one serine residue.

Cross-modal reorganization and speech perception in cochlear implant users

Recent work suggests that once the auditory cortex of deaf persons has been reorganized by cross-modal plasticity, it can no longer respond to signals from a cochlear implant (CI) installed subsequently. To further examine this issue, we compared the evoked potentials involved in the processing of visual stimuli between CI users and hearing controls. The stimuli were concentric circles replaced by a different overlapping shape, inducing a shape transformation, known to activate the ventral visual pathway in human adults. All CI users had their device implanted for >1 year, but obtained different levels of auditory performance following training to establish language comprehension. Seven of the 13 patients showed good capacities for speech recognition with the CI (good performers) while the six others demonstrated poor speech recognition abilities (poor performers). The evoked potentials of all patients showed larger amplitudes, with different distributions of scalp activations between the two groups. The poor performers exhibited broader, anteriorly distributed, high P2 amplitudes over the cortex whereas the good performers showed significantly higher P2 amplitudes over visual occipital areas. These results suggest the existence of a profound cross-modal reorganization in the poor performers and an intramodal reorganization in the good performers. We interpret these data on the basis of enhanced audiovisual coupling as the key to a long-term functional improvement in speech discrimination in CI users.

Thiophene-based vitronectin receptor antagonists

A series of alpha(v)beta(3) antagonists based on a thiophene scaffold were synthesized via two routes and evaluated for in vitro biological activity. We have identified several structurally similar antagonists with different selectivities towards alpha(IIb)beta(3), alpha(v)beta(5) and alpha(5)beta(1) at the cellular level. In addition, these antagonists exerted an antiangiogenic effect in the chick chorioallantoic membrane (CAM) assay.

A novel RGD antagonist that targets both alphavbeta3 and alpha5beta1 induces apoptosis of angiogenic endothelial cells on type I collagen

Integrin-mediated cell adhesion is necessary for endothelial cell proliferation and apoptosis, which is a major determinant in tumor-induced angiogenesis. In this study, we compared two novel, structurally similar, Arg-Gly-Asp (RGD) peptidomimetic compounds having different integrin selectivities, for their inhibition of endothelial cell proliferation and induction of apoptosis on functionally relevant extracellular matrices (ECM) for angiogenesis. BCH-14661 was specific for integrin alphavbeta3, whereas BCH-15046 nonselectively antagonized integrins alphavbeta3, alphavbeta5, and alpha5beta1. Both compounds were potent inducers of endothelial cell apoptosis when plated on RGD-dependent ECM (vitronectin, VN), which was dependent on the ability to induce cell detachment. However, with endothelial cells plated on RGD-independent ECM (type I collagen, COL), only BCH-15046 was able to significantly prevent growth and induce apoptosis. This effect was not dependent on the induction of detachment. Experiments using the matrix metalloproteinase (MMP) inhibitor GM 6001 revealed that cleavage of COL was not required for the ability of BCH-15046 to induce apoptosis. However, the inhibition of growth factor-stimulated endothelial cell proliferation, required MMPs, and correlated with BCH-15046s' potent inhibition of endothelial cell attachment to denatured collagen. Antibody inhibition experiments showed that adhesion to denatured collagen required integrins alphavbeta3 and beta1, but not alphavbeta5. In addition, BCH-15046 exerted a significant inhibition of VEGF-stimulated angiogenesis in the chick chorioallontoic membrane in vivo. These results suggest that integrin antagonism of both alphavbeta3 and alpha5beta1 are important for MMP-independent induction of apoptosis on COL and MMP-dependent inhibition of endothelial cell-denatured collagen interactions required for proliferation.

Long-term follow-up of cochlear implant users with ossified cochlea

OBJECTIVE

Cochlear implantation surgery in ossified cochlea is a challenge, even for the experienced otologist. Short-term assessments of auditory perception show that implantation in partial or even extensive ossified cochlea could be achieved with varying success, but no long-term follow-up results have been published yet.

DESIGN AND METHODS

This paper proposes a retrospective review of eight Nucleus cochlear implant users with ossified cochlea who have been followed on a 12- to 60-month period.

MAIN OUTCOME MEASURE

Auditory performances of users are reported at each control on a scale of 100 units divided into 4 skill zones of 25 units based on Erber's proposition, that is, detection, discrimination, identification, and recognition.

RESULTS

Three of the eight subjects showed some progression in their auditory performances during the follow-up. The five other subjects showed no long-term progress in their auditory performance.

CONCLUSIONS

Open-set comprehension could be achieved with the insertion of 9 to 10 electrodes of the Nucleus device. Auditory performance in users with ossified cochlea seems to be influenced by the same factors as in users with patent cochlea.

Defective p56Lck activity in T cells from an adult patient with idiopathic CD4+ lymphocytopenia

Idiopathic CD4(+) lymphocytopenia (ICL) is defined by a stable loss of CD4(+) T cells in the absence of any known cause of immune deficiency. This syndrome is still of undetermined origin. It affects adult patients, some of them displaying opportunistic infections similar to HIV-infected subjects. The hypothesis that the cellular immune defect may be due to biochemical failures of the CD3-TCR pathway is investigated here in a patient associating a severe selective CD4(+) lymphocytopenia with an increased CD8(+) T cell count discovered in the course of a cryptococcal meningitidis. A 40% reduction of T cell proliferation to CD3-TCR stimulation is observed only in the CD4(+) subpopulation. The early CD3-induced protein tyrosine phosphorylations are conserved in both CD4(+) and CD8(+) subsets, and the levels of the T cell protein tyrosine kinases p56(Lck), p59(Fyn) and ZAP-70 are normal. However, we find a 50% reduction of p56(Lck) kinase activity in the patient's T cells compared to a healthy control donor. p59(Fyn) activity does not appear to be altered. Nevertheless, we do not find any genetic abnormality of p56(Lck). These results thus suggest that a defect of an unknown protein regulating p56(Lck) activity takes place in this patient's T cells. Taken together, these findings reveal p56(Lck) alteration in ICL and confirm the critical role of this kinase in the maintenance of the peripheral CD4(+) T cell subpopulation.

Subtilase-like pro-protein convertases: from molecular specificity to therapeutic applications

Limited proteolysis of most large protein precursors is carried out in vivo by the subtilisin-like pro-protein convertases. Many important biological processes such as peptide hormone synthesis, viral protein processing and receptor maturation involve proteolytic processing by these enzymes, making them potential targets for the development of novel therapeutic agents. However, the efficient development of such molecules requires a better understanding of the molecular mechanisms of proteolytic protein processing. Herein, we review the most recent findings on the molecular aspects of subtilisin-like convertase activity, such as the structural analysis of the proteases, the mechanisms of enzyme/substrate specificity, their interaction with other proteins such as 7B2, and the comparative tissue and cellular distribution of the enzymes and their substrates. These data are then used as a background for the review of the known biological functions of subtilisin-like pro-protein convertases, the reported clinical cases involving proteolytic processing defects and, finally, the ongoing development of new therapeutic inhibitor molecules based on this knowledge.

Miniglucagon (glucagon 19-29), a potent and efficient inhibitor of secretagogue-induced insulin release through a Ca2+ pathway

Using the MIN6 B-cell line, we investigated the hypothesis that miniglucagon, the C-terminal () fragment processed from glucagon and present in pancreatic A cells, modulates insulin release, and we analyzed its cellular mode of action. We show that, at concentrations ranging from 0.01 to 1000 pM, miniglucagon dose-dependently (ID50 = 1 pM) inhibited by 80-100% the insulin release triggered by glucose, glucagon, glucagon-like peptide-1-(7-36) amide (tGLP-1), or glibenclamide, but not that induced by carbachol. Miniglucagon had no significant effects on cellular cAMP levels. The increase in 45Ca2+ uptake induced by depolarizing agents (glucose or extracellular K+), by glucagon, or by the Ca2+channel agonist Bay K-8644 was blocked by miniglucagon at the doses active on insulin release. Electrophysiological experiments indicated that miniglucagon induces membrane hyperpolarization, probably by opening potassium channels, which terminated glucose-induced electrical activity. Pretreatment with pertussis toxin abolished the effects of miniglucagon on insulin release. It is concluded that miniglucagon is a highly potent and efficient inhibitor of insulin release by closing, via hyperpolarization, voltage-dependent Ca2+ channels linked to a pathway involving a pertussis toxin-sensitive G protein.

Leukemic CD3+ LGL share functional properties with their CD8+ CD57+ cell counterpart expanded after BMT

Leukemic T-LGL (large granular lymphocyte) composed of clonal CD3+ TCR alphabeta+ CD8+ CD57+ cells were compared with oligoclonally CD3+ CD8hi+ CD57- lymphocytes expanded after BMT. Leukemic CD3+ CD8hi+ CD57+ LGL showed several phenotypic differences such as an upregulation of CD16 and adhesion molecules (mainly CD11c, CD58 and CD54), activation markers and an exclusive CD45RA isoform expression. Unstimulated CD3+ CD8+ CD57+ LGL from both leukemic and BMT donors spontaneously developed an ex vivo CTL-like CD3-redirected cytotoxicity but no NK cell activity. Different stimuli (PHA, PMA or rhIL-2) induced similar cytotoxic profiles after a 6-day culture involving a CD3-redirected lysis predominating over a low NK cell activity. However, culture of leukemic LGL with these stimuli allowed either a 2 week persistence (PMA or rhIL-2) of CD8+ CD57+ LGL or their disappearance after 3 days (PHA). Furthermore, leukemic CD8hi+ CD57+ T lymphocytes produced an inhibitor of cytotoxic functions as previously described for BMT recipients' CD8+ CD57+ cells. Thus, despite some phenotypic differences between both cell sources, leukemic CD57+ T-LGL display the same functional characteristics of cytotoxic effector and immunoregulatory T cells as CD8+ CD57+ T cells from BMT recipients which might represent their normal counterpart.

[Deficiency of the CD3-TCR signal pathway in three patients with idiopathic CD4+ lymphocytopenia]

Idiopathic CD4+ lymphocytopenia (ICL) is a rare syndrome affecting adults and defined by a stable loss of CD4+ T cells in the absence of any known cause of immune deficiency. Defective T-cell proliferations to mitogens and antigens have been described in some of such patients displaying clinical signs of immune deficiency such as opportunistic infections. We investigated here the hypothesis that T-cell depletion and dysfunction could be due to biochemical defects of the CD3-TCR pathway in CD4+ and/or CD8+ subsets from three patients with severe stable ICL (below 150 CD4+ T cells/microliter) and opportunistic infections. Patient 1 had a general T lymphocytopenia, whereas patients 2 and 3 displayed a selective loss of CD4+ T cells. We observed in all patients a major reduction of the proliferative response to CD3-TCR stimulation that affected only the depleted T-cell subpopulation. Moreover, in two cases, impaired early biochemical events of the CD3-TCR pathway were detected. In patient 1 and 3, we found a defect (of distinct intensity) of CD3-induced protein tyrosine phosphorylation in CD4+ cells compared to control cells, whereas this process was normally induced in CD4+ T cells from patient 2. Taken together, this study reveals that the heterogeneity of the ICL syndrome was situated at the cellular level, and involved in two cases abnormalities of transducing molecules of the CD3-TCR pathway.

Molecular cloning and tissue distribution of rat sarcosine dehydrogenase

Sarcosine dehydrogenase (SarDH) is a mitochondrial flavoenzyme involved in the oxidative degradation of choline to glycine. The absence of SarDH activity in humans is genetically transmitted and is the cause of an amino acid metabolism disorder called sarcosinemia. Tryptic fragments of the purified enzyme from rat liver were subjected to Edman degradation and the sequences obtained were used to clone the cDNA encoding the full length protein. The deduced amino acid sequence of SarDH shares an overall similarity of 47% with dimethylglycine dehydrogenase (Me2GlyDH), another flavoenzyme involved in the mitochondrial choline catabolism with a similar FAD-binding domain. Covalent binding of FAD to SarDH was demonstrated by the observation of strong fluorescence at 530 nm under excitation at 450 nm of the enzyme immunoprecipitated under denaturing conditions from liver extracts. The localization of SarDH immunoreactivity in the mitochondrial matrix was confirmed by Western-blot analysis of purified mitochondrial fractions. Finally, the tissue distribution of SarDH was investigated by Northern-blot analysis of total RNA and Western-blot analysis of total protein from several rat tissues. A strong expression in the liver, but also in the lung, pancreas, kidney, thymus, and oviduct was observed. We therefore suggest that the enzymes of the choline catabolism pathway are important also for metabolism in nonhepatic tissues.

CD8hi+CD57+ T lymphocytes are enriched in antigen-specific T cells capable of down-modulating cytotoxic activity

Major expansions of CD8hi+CD57+ T lymphocytes frequently occur during human immunodeficiency virus (HIV) infection and after transplantation. To investigate mechanisms of such cell expansion, we compared the activation and functional status of CD8hi+CD57+ and CD57-peripheral blood lymphocytes (PBL) from normal, bone marrow transplantation (BMT) and HIV+ donors. The CD8hi+CD57+ PBL from BMT and HIV+ donors preferentially displayed CD38 and HLA-DR activation markers without correlation between CD8hi+CD57+ percentages and HIV load, the CD45RA+ isoform in all ex vivo conditions but acquired CD45RO after in vitro expansion, CD11b and CD11c in BMT and HIV+ donors but decreased expression of CD62-L, VLA-2 and VLA-6. The CD8hi+CD57+ cells were positive for perforin and granzyme B and spontaneously mediated cytolytic activity in a CD3-redirected assay. In contrast the inhibitor of cytolytic functions (ICF) produced by CD8hi+CD57+ cells down-modulated the CD3-redirected cytolytic activity but only at low levels of CD3 cross-linking. While CD3-triggering induced a low, if any, short-term proliferation of CD8+CD57+ cells, this subset could be amplified after long-term stimulation either with mitogens or with HIV antigens, thereby enriched in HIV-specific T cells producing tumor necrosis factor-alpha. Altogether these data suggest that CD8hi+CD57+ cells represent a terminal differentiation state of activated effector cytotoxic T lymphocytes which are enriched in antigen-specific T cells and down-modulate their own cytolytic potential, thus participating in a negative control of effector cell functions during persistent viral infections or transplantations.

Factors affecting auditory performance of postlinguistically deaf adults using cochlear implants

A model of auditory performance and a model of ganglion cell survival in postlinguistically deafened adult cochlear implant users are suggested to describe the effects of aetiology, duration of deafness, age at implantation, age at onset of deafness, and duration of implant use. The models were compared with published data and a composite data set including 808 implant users. Qualitative agreement with the model of auditory performance was found. Duration of deafness had a strong negative effect on performance. Age at implantation had a slight negative effect on performance, increasing after age 60 years. Age at onset of deafness had little effect on performance up to age 60. Duration of implant use had a positive effect on performance. Aetiology had a relatively weak effect on performance.

The neuroendocrine precursor 7B2 is a sulfated protein proteolytically processed by a ubiquitous furin-like convertase

The neuroendocrine granule-associated protein 7B2, unlike many other neuroendocrine precursor proteins stored in secretory granules, carries in its primary structure the Arg-Xaa-Arg/Lys-Arg processing site usually found in constitutively secreted precursor proteins and recognized by the ubiquitously expressed convertase, furin. pro7B2 (30 kDa), when expressed in endocrine (AtT-20, PC12, and GH4C1) or non-endocrine (Ltk-) cell lines using recombinant vaccinia viruses, was converted to a 23-kDa form. Mutation of the P4 Arg to Gly completely prevented this conversion. When excess pro7B2 was coexpressed with the pro-protein convertases PC1, PC2, or furin, only furin could induce complete processing. In addition, coexpression of pro7B2 in LoVo cells, which are devoid of endogenous furin activity, with each one of the three convertases, showed that only furin was able to induce processing of this precursor. pro7B2 processing in AtT-20 was completely abolished when protein transport into Golgi compartments was blocked by cell incubation at either 15 or 37 degrees C in the presence of monensin or brefeldin A. Furthermore, pulse-chase experiments in the presence of Na2[35S]SO4 showed that pro7B2 is Tyr-sulfated in the trans-Golgi network before it is processed. These results demonstrate that pro7B2 is first processed by a furin-like enzyme within the trans-Golgi network into a 23-kDa form that is then sequestered into secretory granules.