First trans-diagnostic experiences with a novel micro-choice based concentrated group rehabilitation for patients with low back pain, long COVID, and type 2 diabetes: a pilot study

BACKGROUND

The health care is likely to break down unless we are able to increase the level of functioning for the growing number of patients with complex, chronic illnesses. Hence, novel high-capacity and cost-effective treatments with trans-diagnostic effects are warranted. In accordance with the protocol paper, we aimed to examine the acceptability, satisfaction, and effectiveness of an interdisciplinary micro-choice based concentrated group rehabilitation for patients with chronic low back pain, long COVID, and type 2 diabetes.

METHODS

Patients with low back pain > 4 months sick-leave, long COVID, or type 2 diabetes were included in this clinical trial with pre-post design and 3-month follow-up. The treatment consisted of three phases: (1) preparing for change, (2) the concentrated intervention for 3-4 days, and (3) integrating change into everyday life. Patients were taught and practiced how to monitor and target seemingly insignificant everyday micro-choices, in order to break the patterns where symptoms or habits contributed to decreased levels of functioning or increased health problems. The treatment was delivered to groups (max 10 people) with similar illnesses. Client Satisfaction Questionnaire (CSQ-8)) (1 week), Work and Social Adjustment Scale (WSAS), Brief Illness Perception Questionnaire (BIPQ), and self-rated health status (EQ-5D-5L) were registered at baseline and 3-month follow-up.

RESULTS

Of the 241 included participants (57% women, mean age 48 years, range 19-84), 99% completed the concentrated treatment. Treatment satisfaction was high with a 28.9 (3.2) mean CSQ-8-score. WSAS improved significantly from baseline to follow-up across diagnoses 20.59 (0.56) to 15.76 (0.56). BIPQ improved from: 22.30 (0.43) to 14.88 (0.47) and EQ-5D-5L: 0.715 (0.01) to 0.779 (0.01)), all P<0.001.

CONCLUSIONS

Across disorders, the novel approach was associated with high acceptability and clinically important improvements in functional levels, illness perception, and health status. As the concentrated micro-choice based treatment format might have the potential to change the way we deliver rehabilitation across diagnoses, we suggest to proceed with a controlled trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05234281.

Relationship between exercise capacity and fatigue, dyspnea, and lung function in non-hospitalized patients with long COVID

Long COVID is a global health problem that impairs patients' functional status. More than 200 reported symptoms have been identified where fatigue, dyspnea, and exercise impairment are most common. This study aimed to describe exercise capacity, fatigue, dyspnea, and lung function in previously non-hospitalized patients with long COVID, and examine the relationship between exercise capacity and fatigue, dyspnea, and lung function. Sixty-five patients, 54 women (83%), mean age of 39 standard deviation (12) years, were included and completed spirometry, cardiopulmonary exercise test, stair climbing test (SCT), 30 second sit-to-stand test (30STST), and questionnaires regarding fatigue and dyspnea. Fatigue was reported by 95% of the participants, whereas 65% reported severe fatigue, and 66% reported dyspnea. Mean exercise capacity measured with peak oxygen uptake (V̇O2peak % pred.) was ≥85% in 65% of the participants. Mean forced expiratory volume in 1 s. and forced vital capacity were 96.6 (10.7)% and 100.8 (10.9)%, respectively, while reduced diffusion capacity for carbon monoxide (DLCO ) was found in eight participants (13%). Reduced V̇O2peak  kg-1 and increased time on SCT were significantly associated with increased dyspnea and reduced DLCO but not with fatigue, while 30STST was associated with increased fatigue and dyspnea in previously non-hospitalized patients with long COVID.

A safe and effective micro-choice based rehabilitation for patients with long COVID: results from a quasi-experimental study

At least 65 million people suffer from long COVID. Treatment guidelines are unclear, especially pertaining to recommendations of increased activity. This longitudinal study evaluated safety, changes in functional level and sick leave following a concentrated rehabilitation program for patients with long COVID. Seventy-eight patients (19-67 years) participated in a 3-day micro-choice based rehabilitation program with 7-day and 3-month follow-up. Fatigue, functional levels, sick leave, dyspnea and exercise capacity were assessed. No adverse events were reported and 97.4% completed the rehabilitation. Fatigue measured with Chalder Fatigue Questionnaire decreased at 7-days [mean difference (MD = - 4.5, 95% CI - 5.5 to - 3.4) and 3-month (MD = - 5.5, 95% CI - 6.7 to - 4.3). Sick leave rates and dyspnea were reduced (p < 0.001) and exercise capacity and functional level increased (p < 0.001) at 3-month follow-up regardless of severity of fatigue at baseline. Micro-choice based concentrated rehabilitation for patients with long COVID was safe, highly acceptable and showed rapid improvements in fatigue and functional levels, sustaining over time. Even though this is a quasi-experimental study, the findings are of importance addressing the tremendous challenges of disability due to long COVID. Our results are also highly relevant for patients, as they provide the base for an optimistic outlook and evidence supported reason for hope.

Concentrated transdiagnostic and cross-disciplinary group treatment for patients with depression and with anxiety: a pilot study

BACKGROUND

A number of treatment approaches have shown efficacy for depression and/or anxiety, yet there is a paucity of research on potentially cost-effective concentrated approaches. Based on our previous experience with concentrated treatment in disorders such as Obsessive-Compulsive Disorder and chronic fatigue, we proposed that this novel approach could be useful for other conditions, including depression and/or anxiety. As a pre-requisite for a future randomized controlled trial, the aim of this study was to investigate the acceptability, satisfaction and effectiveness of a transdiagnostic, interdisciplinary group treatment delivered during 5 consecutive days to groups of 6-10 patients with depression and/or anxiety.

METHODS

This was a non-randomized clinical intervention pilot study in line with a published protocol. Forty-two consecutively referred patients, aged 19-47 (mean age 31.7, SD = 8.12) were included and completed treatment. All had a severity of their problems that entitled them to care in the specialist public mental health care. Self-reported age when the symptoms became a problem was 20.9 years. Mean number of prior treatment courses was 2.77 (SD = 2.19; range 0-8). Acceptability was defined as the proportion of eligible patients who accepted and completed the treatment. Satisfaction was evaluated by Client Satisfaction Questionnaire-8. Secondary objectives were to assess the treatment effectiveness by questionnaires at pre-treatment, seven days post-treatment and three months follow-up.

RESULTS

The treatment was highly acceptable (91.3% accepted, all completed), and patients were highly satisfied with the treatment, including the amount. Functional impairment, as measured by Work and Social Adjustment Scale (WSAS) improved significantly (p < .0005) from "severe" (mean 25.4 SD = 6.59) to "less severe" (mean 13.37, SD = 9.43) at 3 months follow-up. Using the Generalized Anxiety Disorder Scale (GAD-7) and the Patient Health Questionnaire (PHQ-9), the effect sizes at 3 months follow-up were 1.21 for anxiety and 1.3 for depression. More than 80% reported reduced utilization of mental health care, and 67% had not used, or had used the family doctor less, for anxiety or depression. 52% had not used, or had reduced, medication for their disorder.

CONCLUSIONS

The concentrated, interdisciplinary treatment approach yielded promising results. Long-term follow up is warranted.

TRIAL REGISTRATION

This study is registered in Clinical Trials, identifier NCT05234281 and approval date 09/02/2022.

Evaluation of Novel Concentrated Interdisciplinary Group Rehabilitation for Patients With Chronic Illnesses: Protocol for a Nonrandomized Clinical Intervention Study

BACKGROUND

An aging population with a growing burden of chronic complex illnesses will seriously challenge the public health care system. Consequently, novel and efficacious treatment approaches are highly warranted. Based on our experiences with concentrated treatment formats for other health challenges, we developed a highly concentrated interdisciplinary group rehabilitation approach for chronic illnesses.

OBJECTIVE

We aim to explore the acceptability of the intervention and describe potential changes in functional impairment at follow-up.

METHODS

The cornerstones of the intervention are as follows: (1) prepare the patient for change prior to treatment, (2) focus on health promoting microchoices instead of symptoms, and (3) expect the patient to integrate the changes in everyday living with limited hands-on follow-up. The intervention will be delivered to patients with highly diverse primary symptoms, namely patients with low back pain, post-COVID-19 symptoms, anxiety and depression, and type 2 diabetes.

RESULTS

Recruitment started between August 2020 and January 2021 (according to the illness category). For initial 3-month results, recruitment is expected to be completed by the end of 2021.

CONCLUSIONS

If successful, this study may have a substantial impact on the treatment of low back pain, post-COVID-19 symptoms, anxiety and depression, and type 2 diabetes, which together constitute a major socioeconomic cost. Further, the study may widen the evidence base for the use of the concentrated treatment format in a diverse group of medical conditions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/32216.

Coupling Single Photons from Discrete Quantum Emitters in WSe2 to Lithographically Defined Plasmonic Slot Waveguides

We report the observation of the generation and routing of single plasmons generated by localized excitons in a WSe₂ monolayer flake exfoliated onto lithographically defined Au-plasmonic waveguides. Statistical analysis of the position of different quantum emitters shows that they are (3.3 ± 0.7) times more likely to form close to the edges of the plasmonic waveguides. By characterizing individual emitters, we confirm their single-photon character via the observation of antibunching in the signal ( g⁽²⁾(0) = 0.42) and demonstrate that specific emitters couple to modes of the proximal plasmonic waveguide. Time-resolved measurements performed on emitters close to and far away from the plasmonic nanostructures indicate that Purcell factors up to 15 ± 3 occur, depending on the precise location of the quantum emitter relative to the tightly confined plasmonic mode. Measurement of the point spread function of five quantum emitters relative to the waveguide with <50 nm precision is compared with numerical simulations to demonstrate the potential for greater increases in the coupling efficiency for ideally positioned emitters. The integration of such strain-induced quantum emitters with deterministic plasmonic routing is a step toward deep-subwavelength on-chip single quantum light sources.

["I would not even think of applying!" - Barriers to Claiming Benefits for Rehabilitation Services for Children and Adolescents from Families' Perspectives]

Background Medical rehabilitation is recognized as an effective health care service to promote and protect health and social participation of children and adolescents. Although the number of children and adolescents with chronic conditions is growing, applications for rehabilitation have declined substantially since 2008. The aim of the study is to identify barriers that prevent families from claiming benefits for rehabilitation services and to give recommendations for actions. Methods In this explorative study, guided qualitative interviews with families with children and adolescents eligible for benefits were conducted. The analysis of the transcribed interviews followed the iterative process of content analysis (deductive and inductive development of main and sub-categories). Results 14 families (with 16 index-children) participated in the study. The results showed high levels of psychosocial burden of families and yet barriers to access services on a structural, disease-specific, and individual level. We identified three main topics in which families recommended modifications: (a) information policy, (b) family centeredness perspectives and flexibility, and (c) cross-sectoral collaboration/health care management. Conclusions Results indicate that families perceive the current pediatric rehabilitation services to lack fitting and flexibility. In general, a new approach of information and counselling, a more family centered perspective and integration of rehabilitation services in a comprehensive and coordinated health care structure are needed.

[Supported own initiative of rehabilitation patients ("new credo") - longterm effects of the nonrandomized trial]

OBJECTIVE

Our project is closely related to the previous study "Rehabilitation aftercare - a new credo for rehabilitation clinics"; the intensified aftercare-strategy was developed by an interdisciplinary group of health professionals and scientists for patients with chronic back pain. Main objective is the resumption and maintenance of regular physical activity in everyday life of pa-tients undergoing rehabilitation. The aim of our present study was to evaluate the long-term (24-month-follow-up) efficacy of the "New Credo" (inpatient medical rehabilitation+intensified aftercare=IG) as compared with usual care (inpatient medical rehabilitation=CG).

METHODOLOGY

We conducted a prospective controlled multicentre trial (IG: 3 clinics vs. CG: 3 clinics) with 4 points of measurement (T0: before and T1: after rehabilitation as well as T3: 12 and T4: 24 month after discharge). We enrolled rehabilitants with a primary diagnosis of chronic back pain (ICD-10: M51-54) who had given their consent. Exclusion criteria were mental and/or psychological impairments as well as surgery in the past 6 months. Primary Outcomes included restriction of social participation (IMET) and functional capacity (FFbH-R). Treatment effects were evaluated using analyses of variance and adjusting for differences between baseline -values; furthermore we calculated effect sizes (SMDInter, SMDIntra, ORs).

RESULTS

Complete data were available for 123 IG-rehabilitants and 299 CG-participants (Completer-Analysis, response: 52%). Regarding restriction in functional capacity in everyday life (FFbH-R) multivariate analysis confirmed a treatment*time interaction, the appropriate effect-sizes showed no significant effects (SMDInter and SMDIntra). With respect to long-term effects 24 months after discharge no significant effects were found for social participation, however. With respect to secondary outcomes there are no significant differences between the groups (SMDInter, ORs); in fact rehabilitants of both groups showed similar effects (SMDIntra) in most cases.

CONCLUSION

In summary our results doesn't confirm that the intensified aftercare-programme is able to improve longer-term effectiveness of inpatient orthopaedic rehabilitation up to 24 month.

The seven Cs of the high acceptability of home-based VCT: results from a mixed methods approach in Zambia

HIV testing and counselling is a critical gateway to prevention and treatment. Yet, coverage remains insufficient, few couples are tested together and gender differences in access exist. We used an embedded mixed methods approach to investigate possible explanations for the high acceptance of home-based voluntary HIV counselling and testing (HB-VCT) in a pair-matched cluster-randomized trial in Zambia. A baseline survey included 1694 individuals in 36 clusters. Adults in 18 intervention clusters were offered HB-VCT by lay counsellors. Standard testing services were available in both trial arms. After the completion of the intervention, a follow-up survey was conducted in all trial clusters. In addition, 21 in-depth interviews and one focus group discussion were conducted with home-based VCT clients in the intervention arm. Informants favoured the convenience, confidentiality and credibility of HB-VCT. Counsellors were perceived as trustworthy owing to their closeness and conduct, and the consent process was experienced as convincing. Couple testing was selected by 70% of cohabiting couples and was experienced as beneficial by both genders. Levels of first-time testing (68% vs. 29%, p < 0.0001) and re-testing (94% vs. 74%, p < 0.0001) were higher in the intervention than in the control arm. Acceptance of HIV testing and counselling is dependent on stigma, trust and gender. The confidentiality of home-based VCT was essential for overcoming stigma-related barriers, and the selection of local counsellors was important to ensure trust in the services. The high level of couple counselling within HB-VCT may contribute to closing the gender gap in HIV testing, and has benefits for both genders and potentially for prevention of HIV transmission. The study demonstrates the feasibility of achieving high test coverage with an opt-in consent approach. The embedded qualitative component confirmed the high satisfaction with HB-VCT reported in the quantitative survey and was crucial to fully understand the intervention and its consequences.

Strong effects of home-based voluntary HIV counselling and testing on acceptance and equity: a cluster randomised trial in Zambia

Home-based voluntary HIV counselling and testing (HB-VCT) has been reported to have a high uptake, but it has not been rigorously evaluated. We designed a model for HB-VCT appropriate for wider scale-up, and investigated the acceptance of home-based counselling and testing, equity in uptake and negative life events with a cluster-randomized trial. Thirty six rural clusters in southern Zambia were pair-matched based on baseline data and randomly assigned to the intervention or the control arm. Both arms had access to standard HIV testing services. Adults in the intervention clusters were offered HB-VCT by local lay counsellors. Effects were first analysed among those participating in the baseline and post-intervention surveys and then as intention-to-treat analysis. The study was registered with www.controlled-trials.com, number ISRCTN53353725. A total of 836 and 858 adults were assigned to the intervention and control clusters, respectively. In the intervention arm, counselling was accepted by 85% and 66% were tested (n = 686). Among counselled respondents who were cohabiting with the partner, 62% were counselled together with the partner. At follow-up eight months later, the proportion of adults reporting to have been tested the year prior to follow-up was 82% in the intervention arm and 52% in the control arm (Relative Risk (RR) 1.6, 95% CI 1.4-1.8), whereas the RR was 1.7 (1.4-2.0) according to the intention-to-treat analysis. At baseline the likelihood of being tested was higher for women vs. men and for more educated people. At follow-up these differences were found only in the control communities. Measured negative life events following HIV testing were similar in both groups. In conclusion, this HB-VCT model was found to be feasible, with a very high acceptance and to have important equity effects. The high couple counselling acceptance suggests that the home-based approach has a particularly high HIV prevention potential.

Effects of home-based voluntary counselling and testing on HIV-related stigma: findings from a cluster-randomized trial in Zambia

HIV-related stigma continues to be a prominent barrier to testing, treatment and care. However, few studies have investigated changes in stigma over time and the factors contributing to these changes, and there is no evidence of the impact of HIV testing and counselling on stigma. This study was nested within a pair-matched cluster-randomized trial on the acceptance of home-based voluntary HIV counselling and testing conducted in a rural district in Zambia between 2009 and 2011, and investigated changes in stigma over time and the impact of HIV testing and counselling on stigma. Data from a baseline survey (n = 1500) and a follow-up survey (n = 1107) were used to evaluate changes in stigma. There was an overall reduction of seven per cent in stigma from baseline to follow-up. This was mainly due to a reduction in individual stigmatizing attitudes but not in perceived stigma. The reduction did not differ between the trial arms (β = -0.22, p = 0.423). Being tested for HIV was associated with a reduction in stigma (β = -0.57, p = 0.030), and there was a trend towards home-based Voluntary Counselling and Testing having a larger impact on stigma than other testing approaches (β = -0.78, p = 0.080 vs. β = -0.37, p = 0.551), possibly explained by a strong focus on counselling and the safe environment of the home. The reduction observed in both arms may give reason to be optimistic as it may have consequences for disclosure, treatment access and adherence. Yet, the change in stigma may have been affected by social desirability bias, as extensive community mobilization was carried out in both arms. The study underscores the challenges in measuring and monitoring HIV-related stigma. Adjustment for social desirability bias and inclusion of qualitative methods are recommended for further studies on the impact of HIV testing on stigma.

The burden of knowing: balancing benefits and barriers in HIV testing decisions. a qualitative study from Zambia

Background

Client-initiated HIV counselling and testing has been scaled up in many African countries, in the form of voluntary counselling and testing (VCT). Test rates have remained low, with HIV-related stigma being an important barrier to HIV testing. This study explored HIV testing decisions in one rural and one urban district in Zambia with high HIV prevalence and available antiretroviral treatment.

Methods

Data were collected through 17 in-depth interviews and two focus group discussions with individuals and 10 in-depth interviews with counsellors. Interpretive description methodology was employed to analyse the data.

Results

'To know your status' was found to be a highly charged concept yielding strong barriers against HIV testing. VCT was perceived as a diagnostic device and a gateway to treatment for the severely ill. Known benefits of prevention and early treatment were outweighed by a perceived burden of knowing your HIV status related to stigma and fear. The manner in which the VCT services were organised added to this burden.

Conclusions

This study draws on social stigma theory to enhance the understanding of the continuity of HIV related stigma in the presence of ART, and argues that the burden of knowing an HIV status and the related reluctance to get HIV tested can be understood both as a form of label-avoidance and as strong expressions of the still powerful embodied memories of suffering and death among non-curable AIDS patients over the last decades. Hope lies in the emerging signs of a reduction in HIV related stigma experienced by those who had been tested for HIV. Further research into innovative HIV testing service designs that do not add to the burden of knowing is needed.

Home-based voluntary HIV counselling and testing found highly acceptable and to reduce inequalities

Background

Low uptake of voluntary HIV counselling and testing (VCT) in sub-Saharan Africa is raising acceptability concerns which might be associated with ways by which it is offered. We investigated the acceptability of home-based delivery of counselling and HIV testing in urban and rural populations in Zambia where VCT has been offered mostly from local clinics.

Methods

A population-based HIV survey was conducted in selected communities in 2003 (n = 5035). All participants stating willingness to be HIV tested were offered VCT at home and all counselling was conducted in the participants' homes. In the urban area post-test counselling and giving of results were done the following day whereas in rural areas this could take 1-3 weeks.

Results

Of those who indicated willingness to be HIV tested, 76.1% (95%CI 74.9-77.2) were counselled and received the test result. Overall, there was an increase in the proportion ever HIV tested from 18% before provision of home-based VCT to 38% after. The highest increase was in rural areas; among young rural men aged 15-24 years up from 14% to 42% vs. for urban men from 17% to 37%. Test rates by educational attainment changed from being positively associated to be evenly distributed after home-based VCT.

Conclusions

A high uptake was achieved by delivering HIV counselling and testing at home. The highest uptakes were seen in rural areas, in young people and groups with low educational attainment, resulting in substantial reductions in existing inequalities in accessing VCT services.

Psychosexual development in children with disorder of sex development (DSD)--results from the German Clinical Evaluation Study

Psychosexual development is influenced by biological and psychosocial factors. Human beings show a great variability in psychosexual development both between and within gender-groups. However, there are relatively stable gender-related behaviors and self-perceptions, in which males and females differ distinctly. There is strong evidence that high concentrations of androgens lead to more male-typical behavior and that this also influences gender identity. Disorders of sex development (DSD) provide the opportunity to analyze the role of different factors on psychosexual development. We examined 166 children age 4 to 12 with DSD using instruments concerning gender role behavior, gender identity, and friendship. Results underline the hypothesis, that androgens play a decisive role in the masculinization of gender role behavior in children. There are also some relations between the experience of gender change and psychosexual outcomes which have to be discussed. Nevertheless, results indicated a high congruence between the children's gender identity and gender of rearing.