Recruitment and retention of adolescents for an ecological momentary assessment measurement burst mental health study: The MHIM engagement strategy

INTRODUCTION

Recruitment and long-term retention of adolescent participants in longitudinal research are challenging and may be especially so in studies involving remote measurement and biosampling components. The ability to effectively recruit and retain participants can be supported by the use of specific evidence-based engagement strategies that are built in from the earliest stages.

METHODS

Informed by a review of the evidence on effective engagement strategies and consultations with adolescents (via two Young Person Advisory Groups [YPAGs]; ages 11-13 and 14-17), the current protocol describes the planned participant engagement strategy for the Mental Health in the Moment Study: a multimodal measurement burst study of adolescent mental health across ages 11-19.

RESULTS

The protocol incorporates engagement strategies in four key domains: consultations/co-design with the target population, incentives, relationship-building and burden/barrier reduction. In addition to describing general engagement strategies in longitudinal studies, we also discuss specific concerns regarding engagement in data collection methods such as biosampling and ecological momentary assessment where a paucity of evidence exists.

CONCLUSION

Engagement strategies for adolescent mental health studies should be based on existing evidence and consultations with adolescents. We present our approach in developing the planned engagement strategies and also discuss limitations and future directions in engaging adolescents in longitudinal research.

PATIENT OR PUBLIC CONTRIBUTION

The study design for this project places a strong emphasis on the active engagement of adolescents throughout its development. Specifically, the feedback and suggestions provided by the YPAGs have been instrumental in refining our strategies for maximising the recruitment and retention of participants.

Attrition Rates in HIV Viral Load Monitoring and Factors Associated With Overdue Testing Among Children Within South Africa's Antiretroviral Treatment Program: Retrospective Descriptive Analysis

BACKGROUND

Numerous studies in South Africa have reported low HIV viral load (VL) suppression and high attrition rates within the pediatric HIV treatment program.

OBJECTIVE

Using routine laboratory data, we evaluated HIV VL monitoring, including mobility and overdue VL (OVL) testing, within 5 priority districts in South Africa.

METHODS

We performed a retrospective descriptive analysis of National Health Laboratory Service (NHLS) data for children and adolescents aged 1-15 years having undergone HIV VL testing between May 1, 2019, and April 30, 2020, from 152 facilities within the City of Johannesburg, City of Tshwane, eThekwini, uMgungundlovu, and Zululand. HIV VL test-level data were deduplicated to patient-level data using the NHLS CDW (Corporate Data Warehouse) probabilistic record-linking algorithm and then further manually deduplicated. An OVL was defined as no subsequent VL determined within 18 months of the last test. Variables associated with the last VL test, including age, sex, VL findings, district type, and facility type, are described. A multivariate logistic regression analysis was performed to identify variables associated with an OVL test.

RESULTS

Among 21,338 children and adolescents aged 1-15 years who had an HIV VL test, 72.70% (n=15,512) had a follow-up VL test within 18 months. Furthermore, 13.33% (n=2194) of them were followed up at a different facility, of whom 3.79% (n=624) were in a different district and 1.71% (n=281) were in a different province. Among patients with a VL of ≥1000 RNA copies/mL of plasma, the median time to subsequent testing was 6 (IQR 4-10) months. The younger the age of the patient, the greater the proportion with an OVL, ranging from a peak of 52% among 1-year-olds to a trough of 21% among 14-year-olds. On multivariate analysis, 2 consecutive HIV VL findings of ≥1000 RNA copies/mL of plasma were associated with an increased adjusted odds ratio (AOR) of having an OVL (AOR 2.07, 95% CI 1.71-2.51). Conversely, patients examined at a hospital (AOR 0.86, 95% CI 0.77-0.96), those with ≥2 previous tests (AOR 0.78, 95% CI 0.70-0.86), those examined in a rural district (AOR 0.63, 95% CI 0.54-0.73), and older age groups of 5-9 years (AOR 0.56, 95% CI 0.47-0.65) and 10-14 years (AOR 0.51, 95% CI 0.44-0.59) compared to 1-4 years were associated with a significantly decreased odds of having an OVL test.

CONCLUSIONS

Considerable attrition occurs within South Africa's pediatric HIV treatment program, with over one-fourth of children having an OVL test 18 months subsequent to their previous test. In particular, younger children and those with virological failure were found to be at increased risk of having an OVL test. Improved HIV VL monitoring is essential for improving outcomes within South Africa's pediatric antiretroviral treatment program.

Regulatory Issues in Electronic Health Records for Adolescent HIV Research: Strategies and Lessons Learned

BACKGROUND

Electronic health records (EHRs) are a cost-effective approach to provide the necessary foundations for clinical trial research. The ability to use EHRs in real-world clinical settings allows for pragmatic approaches to intervention studies with the emerging adult HIV population within these settings; however, the regulatory components related to the use of EHR data in multisite clinical trials poses unique challenges that researchers may find themselves unprepared to address, which may result in delays in study implementation and adversely impact study timelines, and risk noncompliance with established guidance.

OBJECTIVE

As part of the larger Adolescent Trials Network (ATN) for HIV/AIDS Interventions Protocol 162b (ATN 162b) study that evaluated clinical-level outcomes of an intervention including HIV treatment and pre-exposure prophylaxis services to improve retention within the emerging adult HIV population, the objective of this study is to highlight the regulatory process and challenges in the implementation of a multisite pragmatic trial using EHRs to assist future researchers conducting similar studies in navigating the often time-consuming regulatory process and ensure compliance with adherence to study timelines and compliance with institutional and sponsor guidelines.

METHODS

Eight sites were engaged in research activities, with 4 sites selected from participant recruitment venues as part of the ATN, who participated in the intervention and data extraction activities, and an additional 4 sites were engaged in data management and analysis. The ATN 162b protocol team worked with site personnel to establish the necessary regulatory infrastructure to collect EHR data to evaluate retention in care and viral suppression, as well as para-data on the intervention component to assess the feasibility and acceptability of the mobile health intervention. Methods to develop this infrastructure included site-specific training activities and the development of both institutional reliance and data use agreements.

RESULTS

Due to variations in site-specific activities, and the associated regulatory implications, the study team used a phased approach with the data extraction sites as phase 1 and intervention sites as phase 2. This phased approach was intended to address the unique regulatory needs of all participating sites to ensure that all sites were properly onboarded and all regulatory components were in place. Across all sites, the regulatory process spanned 6 months for the 4 data extraction and intervention sites, and up to 10 months for the data management and analysis sites.

CONCLUSIONS

The process for engaging in multisite clinical trial studies using EHR data is a multistep, collaborative effort that requires proper advanced planning from the proposal stage to adequately implement the necessary training and infrastructure. Planning, training, and understanding the various regulatory aspects, including the necessity of data use agreements, reliance agreements, external institutional review board review, and engagement with clinical sites, are foremost considerations to ensure successful implementation and adherence to pragmatic trial timelines and outcomes.

The Prevalence of Tooth Wear and Their Associated Etiologies Among Adult Subjects Visiting Umm Al-Qura University Dental Clinic in Makkah City, Saudi Arabia

In the past two decades, changing trends in socioeconomic status, dietary habits, and individual lifestyles of individuals have led to the emergence of tooth wear as an oral health problem. The present study aimed to investigate the prevalence and the associated etiologies of tooth wear in a convenience sample of adult patients visiting outpatient clinics of the Faculty of Dentistry at Umm Al-Qura University. This cross-sectional study was conducted on adult patients (18-40 years old) visiting outpatient clinics of the Faculty of Dentistry, Umm Al-Qura University. Two trained examiners visually assessed patients' tooth wear using Smith and Knight's Tooth Wear Index (TWI). Following the clinical examination, patients completed a self-administered questionnaire detailing risk factors such as the frequency of intake of acidic food and medicines, general health, chewing habits, dietary factors, and oral health-associated preventive behaviors. The resulting collected data were tabulated and statistically analyzed using Statistical Product and Service Solutions (SPSS, version 21; IBM SPSS Statistics for Windows, Armonk, NY). The total prevalence of tooth wear was 74%, and the recorded mean wear score (TWI) was 0.380 ± 0.386; anterior teeth exhibited greater wear than posterior teeth. Numerous associations were recorded between tooth wear and the tested variables in demographics, habits, diet, and medications, but most of them were not statistically significant. When toothbrushing habits were explored, the only factors to played a significant role in abrading the tooth structure were the type of brush bristles used (P-value = 0.026) and the frequency of brush renewal (P = 0.043). Patients who frequently ate citrus fruits and other acidic foods recorded high wear scores (0.509 ± 0.311 and 0.508 ± 0.402, respectively), although the difference was not statistically significant. When chewing occurred on both sides of the mouth, less tooth wear was recorded than if chewing was on the right or left side only (0.371 ± 0.260, 0.422 ± 0.273, and 0.520 ± 0.419, respectively). The study data support an association between tooth wear and patient occupation, use of hard-bristled and new toothbrushes, eating of citrus and other acidic food, and chewing on one side, as all of these factors increased the risk of tooth wear.

Tooth surface loss: causes, management and prevention

OBJECTIVES

Tooth wear (TW), also referred to as tooth surface loss (TSL), occurs due to causes other than caries. This involves the loss of hard tissues, namely enamel, dentin and/or cementum. Types of TW/TSL are abrasion, abfraction, attrition and erosion. These multifactorial conditions can be caused things such as lifestyle, diet or even habits and may not be symptomatic. The focus of this article is to provide clinicians with detailed examples and explanations of the causes of tooth loss to aid in early diagnosis. Through early identification, the preventive measures outlined can be implemented to avoid excessive TW. The provision of a treatment flowchart and general treatment recommendations aims to help clinicians determine when to restore these lesions and the most appropriate treatment measures for the 4 types of wear.

MATERIALS AND METHODS

The PubMed (MEDLINE) search engine was used to gather information on TW restricted to a five-year period (26 August 2018 - 25 July 2022). Only English-language studies and reviews with the best balance of sensitivity and specificity were considered. A Boolean search of the PubMed dataset was implemented to combine a range of keywords: ("tooth wear" OR tooth attrition OR tooth erosion OR tooth abrasion OR tooth abfraction). Additional articles were also selected through Google Scholar.

RESULTS

By this process, many articles and studies were obtained, and the 48 most relevant published studies were chosen and used in the current review. The selected articles are in the reference list.

CONCLUSION

TW affects an increasing number of individuals and can have detrimental effects physically, mentally and emotionally. It is important to stress early diagnosis and management of tooth wear through monitoring, prevention and treatment where indicated.

Listening to School Nurses' Voices: A Mixed Methods Study on the Continued Impact of COVID-19 on School Nursing Practice

School closures in March 2020 due to the COVID-19 pandemic precipitated losses of critical student resources as physical, mental, emotional, and social needs escalated. Identifying the challenges, strategies, and changes in school nurse (SN) practice in Massachusetts during this pandemic is fundamental to understanding how to manage future anticipated pandemics while protecting children, communities, and SNs. The purpose of this mixed-methods descriptive study in the second year of the global pandemic was to (a) listen to SN voices through a novel online survey including the prompts of challenges, strategies, and practice changes and (b) describe the SN experience of COVID-19 response in Massachusetts schools, including identification of intent to leave school nursing. Responses were analyzed using descriptive qualitative analysis (n  =  73). The prompts each elicited subthemes that coalesced to a cohesive theme: Finding one's way required the support of others to pave untraversed roads.

Nudges and Prompts Increase Engagement in Self-Guided Digital Health Treatment for Depression and Anxiety: Results From a 3-Arm Randomized Controlled Trial

BACKGROUND

Accessible and effective approaches to mental health treatment are important because of common barriers such as cost, stigma, and provider shortage. The effectiveness of self-guided treatment is well established, and its use has intensified because of the COVID-19 pandemic. Engagement remains important as dose-response relationships have been observed. Platforms such as Facebook (Meta Platform, Inc), LinkedIn (Microsoft Corp), and X Corp (formerly known as Twitter, Inc) use principles of behavioral economics to increase engagement. We hypothesized that similar concepts would increase engagement in self-guided digital health.

OBJECTIVE

This 3-arm randomized controlled trial aimed to test whether members of 2 digital self-health courses for anxiety and depression would engage with behavioral nudges and prompts. Our primary hypothesis was that members would click on 2 features: tips and a to-do checklist. Our secondary hypothesis was that members would prefer to engage with directive tips in arm 2 versus social proof and present bias tips in arm 3. Our tertiary hypothesis was that rotating tips and a to-do checklist would increase completion rates. The results of this study will form a baseline for future artificial intelligence-directed research.

METHODS

Overall, 13,224 new members registered between November 2021 and May 2022 for Evolution Health's self-guided treatment courses for anxiety and depression. The control arm featured a member home page without nudges or prompts. Arm 2 featured a home page with a tip-of-the-day section. Arm 3 featured a home page with a tip-of-the-day section and a to-do checklist. The research protocol for this study was published in JMIR Research Protocols on August 15, 2022.

RESULTS

Arm 3 had significantly younger members (F2,4564=40.97; P<.001) and significantly more female members (χ24=92.2; P<.001) than the other 2 arms. Control arm members (1788/13,224, 13.52%) completed an average of 1.5 course components. Arm 2 members (865/13,224, 6.54%) clicked on 5% of tips and completed an average of 1.8 course components. Arm 3 members (1914/13,224, 14.47%) clicked on 5% of tips, completed 2.7 of 8 to-do checklist items, and completed an average of 2.11 course components. Completion rates in arm 2 were greater than those in arm 1 (z score=3.37; P<.001), and completion rates in arm 3 were greater than those in arm 1 (z score=12.23; P<.001). Engagement in all 8 components in arm 3 was higher than that in arm 2 (z score=1.31; P<.001).

CONCLUSIONS

Members engaged with behavioral nudges and prompts. The results of this study may be important because efficacy is related to increased engagement. Due to its novel approach, the outcomes of this study should be interpreted with caution and used as a guideline for future research in this nascent field.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/37231.

A survey examining the relationship between burnout, professional empowerment, and personality traits of midwives of an inner London NHS Trust

INTRODUCTION

Besides the well-known negative effects on physical and psychological well-being, burnout has been associated with high attrition and absenteeism in the midwifery profession. This study explores whether burnout in midwifery can be explained by the midwives' type of personality and the sense of empowerment they experience at work. Moreover, the study identifies areas of improvement in relation to these topics and elements that can be conducive to strengthening the midwifery workforce.

METHODS

A cross-sectional exploratory study design was used, including an online survey completed by 120 midwives working for an NHS Trust in London. The response rate was 24%. Three validated questionnaires were used: the Copenhagen Burnout Inventory (CBI), the Perception of Empowerment in Midwifery Scale (PEMS), and the Big Five Personality Trait Short Questionnaire (BFPTSQ).

RESULTS

A multiple linear regression analysis indicated empowerment and personality traits are significant predictors of levels of burnout. Furthermore, emotional stability was shown to partially mediate the relationship between empowerment and burnout. The study also examined the midwifery burnout levels of this NHS Trust, which were found to be significantly high and similar to a previous study conducted by the Royal College of Midwives.

CONCLUSIONS

The empowerment experienced by midwives and their personality traits significantly predict the levels of burnout in the midwifery workforce. Only empowerment and emotional stability were significant contributors to the regression model. Multiple strategies can be implemented to support midwives in these two areas. These interventions could also be of great help to reinforce the role of the midwife, making it more appealing to society and, in particular, younger generations with an interest in human-orientated professions.

Evaluating neurosurgical training: a national survey examining the British trainee experience

PURPOSE

Neurosurgery training in the UK has undergone significant changes over the past few years, including the new competency-based curriculum and a reduction of elective operating due to the pandemic. We conducted a comprehensive survey to assess UK neurosurgical trainees' experiences and perceptions to develop targeted action plans.

METHODS

An online anonymised survey was developed and distributed amongst the BNTA mailing list. Question types included 10-point Likert scales and free text options. Descriptive statistics, non-parametric testing of Likert scores, and Spearman's rank correlation were used to analyse responses. Pearson's chi-squared test was used for subgroup analysis of categorical data.

RESULTS

A total of 75 trainees with a National Training Number (NTN) responded. Overall trainees feel they are well trained, well supported, and have caught up with training emerging out of COVID. Funding for training varied between deaneries. There is significant concern amongst trainees regarding the workforce crisis. This, as well as financial concerns are leading to more than a quarter of trainees considering quitting. Half of the trainees are considering going OOP. More than one third of the trainees and more than half of the female trainees are considering working Less Than Full Time (LTFT). Most important supportive mechanisms towards completion of training were social support, along with personal satisfaction from work. An independent mentoring scheme is a preferred additional support mechanism.

CONCLUSIONS

Overall training experience for neurosurgery trainees in UK and Ireland was positive. There are significant concerns regarding the workforce crisis and costs of training, with a large proportion of neurosurgery trainees considering resigning. OOP and LTFT are popular means of becoming more competitive for consultant posts and to spend time with their families. Deanery experience, senior and peer support does, and will improve trainee experience and protect against attrition.

Designing mHealth Apps to Incorporate Evidence-Based Techniques for Prolonging User Engagement

Maintaining user engagement with mobile health (mHealth) apps can be a challenge. Previously, we developed a conceptual model to optimize patient engagement in mHealth apps by incorporating multiple evidence-based methods, including increasing health literacy, enhancing technical competence, and improving feelings about participation in clinical trials. This viewpoint aims to report on a series of exploratory mini-experiments demonstrating the feasibility of testing our previously published engagement conceptual model. We collected data from 6 participants using an app that showed a series of educational videos and obtained additional data via questionnaires to illustrate and pilot the approach. The videos addressed 3 elements shown to relate to engagement in health care app use: increasing health literacy, enhancing technical competence, and improving positive feelings about participation in clinical trials. We measured changes in participants' knowledge and feelings, collected feedback on the videos and content, made revisions based on this feedback, and conducted participant reassessments. The findings support the feasibility of an iterative approach to creating and refining engagement enhancements in mHealth apps. Systematically identifying the key evidence-based elements intended to be included in an app's design and then systematically testing the implantation of each element separately until a satisfactory level of positive impact is achieved is feasible and should be incorporated into standard app design. While mHealth apps have shown promise, participants are more likely to drop out than to be retained. This viewpoint highlights the potential for mHealth researchers to test and refine mHealth apps using approaches to better engage users.

Patient Engagement With and Perspectives on a Mobile Health Home Spirometry Intervention: Mixed Methods Study

BACKGROUND

Patient engagement attrition in mobile health (mHealth) remote patient monitoring (RPM) programs decreases program benefits. Systemic disparities lead to inequities in RPM adoption and use. There is an urgent need to understand patients' experiences with RPM in the real world, especially for patients who have stopped using the programs, as addressing issues faced by patients can increase the value of mHealth for patients and subsequently decrease attrition.

OBJECTIVE

This study sought to understand patient engagement and experiences in an RPM mHealth intervention in lung transplant recipients.

METHODS

Between May 4, 2020, and November 1, 2022, a total of 601 lung transplant recipients were enrolled in an mHealth RPM intervention to monitor lung function. The predictors of patient engagement were evaluated using multivariable logistic and linear regression. Semistructured interviews were conducted with 6 of 39 patients who had engaged in the first month but stopped using the program, and common themes were identified.

RESULTS

Patients who underwent transplant more than 1 year before enrollment in the program had 84% lower odds of engaging (odds ratio [OR] 0.16, 95% CI 0.07-0.35), 82% lower odds of submitting pulmonary function measurements (OR 0.18, 95% CI 0.09-0.33), and 78% lower odds of completing symptom checklists (OR 0.22, 95% CI 0.10-0.43). Patients whose primary language was not English had 78% lower odds of engaging compared to English speakers (OR 0.22, 95% CI 0.07-0.67). Interviews revealed 4 prominent themes: challenges with devices, communication breakdowns, a desire for more personal interactions and specific feedback with the care team about their results, understanding the purpose of the chat, and understanding how their data are used.

CONCLUSIONS

Care delivery and patient experiences with RPM in lung transplant mHealth can be improved and made more equitable by tailoring outreach and enhancements toward non-English speakers and patients with a longer time between transplant and enrollment. Attention to designing programs to provide personalization through supplementary provider contact, education, and information transparency may decrease attrition rates.

Factors affecting retirement and workforce attrition in neurosurgery: results of a Council of State Neurosurgical Societies national survey

OBJECTIVE

By 2030, the US will not have enough neurosurgeons to meet the clinical needs of its citizens. Replacement of neurosurgeons due to attrition can take more than a decade, given the time-intensive training process. To identify potential workforce retention targets, the authors sought to identify factors that might impact neurosurgeons' retirement considerations.

METHODS

The Council of State Neurosurgical Societies surveyed practicing AANS-registered neurosurgeons via email link to an online form with 25 factors that were ranked using a Likert scale of importance regarding retirement from the field (ranging from 1 for not important to 3 for very important). All participants were asked: "If you could afford it, would you retire today?"

RESULTS

A total of 447 of 3200 neurosurgeons (14%) responded; 6% had been in practice for less than 5 years, 19% for 6-15 years, 57% for 16-30 years, and 18% for more than 30 years. Practice types included academic (18%), hospital employed (31%), independent with academic appointment (9%), and full independent practice (39%). The most common practice size was between 2 and 5 physicians (46%), with groups of 10 or more being the next most common (20%). Career satisfaction, income, and the needs of patients were rated as the most important factors keeping neurosurgeons in the workforce. Increasing regulatory burden, decreasing clinical autonomy, and the burden of insurance companies were the highest rated for factors important in considering retirement. Subgroup analysis by career stage, practice size, practice type, and geographic region revealed no significant difference in responses. When considering if they would retire now, 45% of respondents answered "yes." Subgroup analysis revealed that midcareer neurosurgeons (16-25 years in practice) were more likely to respond "yes" than those just entering their careers or in practice for more than 25 years (p = 0.03). This effect was confirmed in multivariate logistic regression (p = 0.04). These surgeons found professional satisfaction (p = 0.001), recertification requirements (p < 0.001), and maintaining high levels of income (p = 0.008) important to maintaining employment within the neurosurgical workforce.

CONCLUSIONS

This study demonstrates that midcareer neurosurgeons may benefit from targeted retention efforts. This effort should focus on maximizing professional satisfaction and financial independence, while decreasing the regulatory burden associated with certification and insurance authorization. End-of-career surgeons should be surveyed to determine factors contributing to resilience and persistence within the neurosurgical workforce.

Attrition in Conversational Agent-Delivered Mental Health Interventions: Systematic Review and Meta-Analysis

BACKGROUND

Conversational agents (CAs) or chatbots are computer programs that mimic human conversation. They have the potential to improve access to mental health interventions through automated, scalable, and personalized delivery of psychotherapeutic content. However, digital health interventions, including those delivered by CAs, often have high attrition rates. Identifying the factors associated with attrition is critical to improving future clinical trials.

OBJECTIVE

This review aims to estimate the overall and differential rates of attrition in CA-delivered mental health interventions (CA interventions), evaluate the impact of study design and intervention-related aspects on attrition, and describe study design features aimed at reducing or mitigating study attrition.

METHODS

We searched PubMed, Embase (Ovid), PsycINFO (Ovid), Cochrane Central Register of Controlled Trials, and Web of Science, and conducted a gray literature search on Google Scholar in June 2022. We included randomized controlled trials that compared CA interventions against control groups and excluded studies that lasted for 1 session only and used Wizard of Oz interventions. We also assessed the risk of bias in the included studies using the Cochrane Risk of Bias Tool 2.0. Random-effects proportional meta-analysis was applied to calculate the pooled dropout rates in the intervention groups. Random-effects meta-analysis was used to compare the attrition rate in the intervention groups with that in the control groups. We used a narrative review to summarize the findings.

RESULTS

The systematic search retrieved 4566 records from peer-reviewed databases and citation searches, of which 41 (0.90%) randomized controlled trials met the inclusion criteria. The meta-analytic overall attrition rate in the intervention group was 21.84% (95% CI 16.74%-27.36%; I2=94%). Short-term studies that lasted ≤8 weeks showed a lower attrition rate (18.05%, 95% CI 9.91%- 27.76%; I2=94.6%) than long-term studies that lasted >8 weeks (26.59%, 95% CI 20.09%-33.63%; I2=93.89%). Intervention group participants were more likely to attrit than control group participants for short-term (log odds ratio 1.22, 95% CI 0.99-1.50; I2=21.89%) and long-term studies (log odds ratio 1.33, 95% CI 1.08-1.65; I2=49.43%). Intervention-related characteristics associated with higher attrition include stand-alone CA interventions without human support, not having a symptom tracker feature, no visual representation of the CA, and comparing CA interventions with waitlist controls. No participant-level factor reliably predicted attrition.

CONCLUSIONS

Our results indicated that approximately one-fifth of the participants will drop out from CA interventions in short-term studies. High heterogeneities made it difficult to generalize the findings. Our results suggested that future CA interventions should adopt a blended design with human support, use symptom tracking, compare CA intervention groups against active controls rather than waitlist controls, and include a visual representation of the CA to reduce the attrition rate.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42022341415; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022341415.

Mental distress, food insecurity and university student dropout during the COVID-19 pandemic in 2020: evidence from South Africa

Background

Student dropout has been a key issue facing universities for many years. The COVID-19 pandemic was expected to exacerbate these trends; however, international literature has produced conflicting findings. Limited literature from Africa has investigated the impact of COVID-19 on student dropout trends, despite the documented devastation, including increased risk of food insecurity and mental distress, caused by the pandemic.

Objective

This work seeks to understand the impact of food insecurity and mental distress on student dropout during the COVID-19 pandemic.

Methods

Using a cross-sectional research design, first-year undergraduate students from a large South African university were recruited via email to participate in a survey between September and October 2020. The Household Food Insecurity Access Scale (HFIAS) was used to measure food insecurity and the Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS) was used to measure mental distress. Multivariate regression was used to investigate factors associated with student dropout.

Results

The student dropout rate was 10.5% (95% CI: 8.2-13.2). The prevalence of severe food insecurity was 25.7% (95% CI: 22.3-29.4) and the prevalence of severe mental distress symptoms was 26.7% (95% CI: 23.3-30.4). Dropout rates and levels of food insecurity were highest among students residing in remote areas during the lockdown at 19.2% and 43.6%, respectively. The multivariate logistic regression revealed that being male increased the probability of dropout almost three-fold (odds ratio (OR) = 2.70; 95% CI: 1.48-4.89, p =0.001)). Being moderately food insecure increased the odds of dropout more than two-fold (OR=2.50; 95% CI:1.12-5.55, p=0.025), and experiencing severe mental distress symptoms increased the odds of dropout seven-fold (OR=7.08; 95% CI:2.67-18.81, p<0.001).

Conclusion

While acknowledging that various factors and complexities contribute to student dropout, the increased vulnerability to food insecurity and mental distress, stemming from issues such as widespread job losses and isolation experienced during the pandemic, may have also had an impact on dropout. This work reiterates the importance of directing additional support to students who are food insecure and those who are experiencing mental distress in order to mitigate university student dropout.

Monitoring of Fabric Integrity and Attrition Rate of Dual-Active Ingredient Long-Lasting Insecticidal Nets in Tanzania: A Prospective Cohort Study Nested in a Cluster Randomized Controlled Trial

Pyrethroid-treated long-lasting insecticidal nets (LLINs) have been the main contributor to the reduction in malaria in the past two decades in sub-Saharan Africa. The development of pyrethroid insecticide resistance threatens the future of LLINs, especially when nets become holed and pyrethroid decays. In this study, three new classes of dual-active ingredient (AI) LLINs were evaluated for their physical durability: (1) Royal Guard, combining pyriproxyfen, which disrupts female fertility, and a pyrethroid, alpha-cypermethrin; (2) Interceptor G2, which combines the pyrrole chlorfenapyr and a pyrethroid (alpha-cypermethrin); (3) Olyset Plus, which incorporates the pyrethroid permethrin and the synergist piperonyl butoxide, to enhance the pyrethroid potency; and Interceptor, a reference net that contains alpha-cypermethrin as the sole active ingredient. About 40,000 nets of each type were distributed in February 2019 to different villages in Misungwi. A total of 3072 LLINs were followed up every 6-12 months up to 36 months to assess survivorship and fabric integrity. The median functional survival was less than three years with Interceptor, Interceptor G2, and Royal Guard showing 1.9 years each and Olyset Plus showing 0.9 years. After 36 months, 90% of Olyset Plus and Royal Guard and 87% of Interceptor G2 were no longer in use (discarded) due to wear and tear, compared to 79% for Interceptor. All dual-AI LLINs exhibited poor textile durability, with Olyset Plus being the worst.

Long-term retention on antiretroviral treatment after enrolment in prevention of vertical HIV transmission services: a prospective cohort study in Dar es Salaam, Tanzania

INTRODUCTION

To prevent vertical HIV transmission and ensure healthy mothers and children, pregnant women with HIV must remain on antiretroviral treatment (ART) for life. However, motivation to remain on ART may decline beyond the standard 2-year breastfeeding/postpartum period. We assessed attrition and retention in ART care among women with HIV up to 6 years since enrolment in vertical transmission prevention services in Dar es Salaam, Tanzania.

METHODS

A prospective cohort of 22,631 pregnant women with HIV were enrolled in vertical transmission prevention services between January 2015 and December 2017 in routine healthcare settings and followed-up to July 2021. Kaplan-Meier was used to estimate time to ART attrition (died, stopped ART or was lost to follow-up [no show ≥90 days since scheduled appointment]) and the proportion retained in care. Cox proportional hazard models were used to estimate adjusted hazard ratios (aHR) of ART attrition in relation to predictors.

RESULTS

Participants were followed-up to 6 years for a median of 3 years (IQR: 0.1-4). The overall ART attrition rate was 13.8 per 100 person-years (95% CI: 13.5-14.1), highest in the first year of enrolment at 27.1 (26.3-27.9), thereafter declined to 9.5 (8.9-10.1) in year 3 and 2.7 (2.1-3.5) in year 6. The proportion of women retained in care were 78%, 69%, 63%, 60%, 57% and 56% at 1, 2, 3, 4, 5 and 6 years, respectively. ART attrition was higher in young women aged <20 years (aHR 1.63, 95% CI: 1.38-1.92) as compared to 30-39 year-olds and women enrolled late in the third versus first trimester (aHR 1.29, 95% CI: 1.16-1.44). In contrast, attrition was lower in older women ≥40 years, women who initiated ART before versus during the index pregnancy and women attending higher-level health facilities.

CONCLUSIONS

ART attrition among women with HIV remains highest in the first year of enrolment in vertical transmission prevention services and declines markedly following a transition to chronic HIV care. Targeted interventions to improve ART continuity among women with HIV during and beyond prevention of vertical transmission are vital to ending paediatric HIV and keeping women and children alive and healthy.

First impressions matter: The influence of initial assessments on psychological treatment initiation and subsequent dropout

OBJECTIVE

This study investigated if patients' experience of an initial assessment may be associated with outcome expectations, and with subsequent treatment attendance.

METHOD

The sample comprised n = 6051 patients with depression/anxiety disorders, nested within k = 148 assessing therapists. Multilevel modelling (MLM) was used to examine therapist effects on treatment initiation and subsequent dropout, adjusting for patient-level characteristics. We tested associations between early outcome expectancy measured at an initial assessment with attendance at a first therapy session, and with dropout after initiation. Variability in mean expectancy ratings in the caseloads of assessing therapists was examined using the intracluster correlation coefficient (ICC).

RESULTS

Therapist effects partly explained the variance in treatment initiation and dropout. Pre-treatment outcome expectations significantly predicted treatment initiation but not dropout for the subgroup of patients who started treatment. Approximately 16% of variability in mean expectancy ratings was explained by therapist effects (ICC = 0.159) after controlling for patient-level covariates.

CONCLUSIONS

Patients assessed by some therapists are more likely to have higher outcome expectations, which influences their decision to initiate treatment thereafter. Once patients start therapy, early expectancy measured at assessment no longer influences their attendance, but the "first impression" from an initial assessment does influence their subsequent likelihood of dropout.

Determining the Impact of Roller Compaction Processing Conditions on Granulate and API Properties: Impact of Formulation API Load

Previous work demonstrated that roller compaction of a 40%w/w theophylline-loaded formulation resulted in granulate consisting of un-compacted fractions which were shown to constitute between 34 and 48%v/v of the granulate dependent on processing conditions. The active pharmaceutical ingredient (API) primary particle size within the un-compacted fraction was also shown to have undergone notable size reduction. The aim of the current work was to test the hypothesis that the observations may be more indicative of the relative compactability of the API due to the formulation being above the percolation threshold. This was done by assessing the impact of varied API loads in the formulation on the non-granulated fraction of the final granulate and the extent of attrition of API particles within the non-granulated fraction. The influence of processing conditions for all formulations was also investigated. The results verify that the observations, both of this study and the previous work, are not a consequence of exceeding the percolation threshold. The volume of un-compacted material within the granulate samples was observed to range between 34.7 and 65.5% depending on the API load and roll pressure, whilst the API attrition was equivalent across all conditions.

Attrition from Face-to-Face Pediatric Outpatient Chronic Pain Interventions: A Narrative Review and Theoretical Model

There is limited understanding of attrition (premature treatment withdrawal and non-completion) from pediatric chronic pain services. This narrative review aimed to summarize attrition prevalence from face-to-face pediatric outpatient chronic pain interventions, identify associated factors and develop a theoretical model to account for attrition in this setting. A comprehensive search of the published literature revealed massive variability (0-100%) in the reported attrition rates from pediatric chronic pain interventions that varied in type and format (individual vs. group, single discipline vs. interdisciplinary, psychological only vs. multiple combined interventions, of different durations). The factors associated with attrition from pediatric chronic pain programs varied between the studies: some have assessed patient sex, psychological and other comorbidities, avoidance strategies, missed schooling, family composition/tensions, caregiver catastrophizing, scheduling, caregiver leave and clinic access. A theoretical model is presented depicting youth, caregiver and service factors that may impact attrition from pediatric chronic pain interventions. Where available, literature is drawn from the pediatric chronic pain context, but also from adult chronic pain and pediatric weight management fields. The implications for research and clinical practice are discussed, including improved reporting, patient screening and targeted supports to promote intervention completion. This review contributes to a better understanding of attrition, which is crucial for optimizing pediatric chronic pain service outcomes.

A retrospective cohort analysis of people living with HIV/AIDS enrolled in HIV care at a reference center in Antananarivo, Madagascar

Background

The impact of the "Treat all" policy on the individual and in terms of public health is closely related to early diagnosis and retention in care. Patient-level data are scarce in Madagascar. In this study, we aimed to describe the profile of a cohort of newly diagnosed people living with HIV/AIDS (PLHIV), identify their outcomes, and assess factors associated with attrition from care and advanced HIV disease (AHD) at presentation.

Methods

We conducted a retrospective cohort study of PLHIV aged ≥15 years newly diagnosed at the University Hospital Joseph Raseta Befelatanana Antananarivo from 1 January 2010 to 31 December 2016.

Results

A total of 490 PLHIV were included in the cohort analysis. In total, 67.1% were male. The median age (interquartile range) at enrollment in care was 29 years (24-38). Overall, 36.1% of PLHIV were diagnosed with AHD at baseline. The proportion of patients with WHO stage IV at baseline increased significantly from 3.3% in 2010 to 31% in 2016 (p = 0.001 for trend). The probability of retention in care after the diagnosis at 12 months, 24 months, and 36 months was 71.8%, 65.5%, and 61.3%, respectively. Age ≥ 40 years (aHR: 1.55; 95% CI: 1.05-2.29; p = 0.026), low level of education (aHR:1.62; 95% CI: 1.11-2.36; p = 0,013), unspecified level of education (aHR:2.18; 95% CI: 1.37-3.47; p = 0.001) and unemployment (aHR:1.52; 95% CI: 1.07-2.16; p = 0.019) were independently associated with attrition from care. Factors associated with AHD at baseline were age ≥ 40 (aOR: 2.77; 95% CI: 1.38-5.57, p = 0.004), unspecified level of education (aOR: 3.80; 95% CI: 1.58-9.16, p = 0.003) and presence of clinical symptoms at baseline (aOR: 23.81; 95% CI: 10.7-52.98; p < 0.001). Sex workers were independently less likely to have an AHD at presentation (aOR: 0.23; 95% CI: 0.05-0.96, p = 0.044).

Conclusion

Sociodemographic determinants influenced retention in care more than clinical factors. The presence of clinical symptoms and sociodemographic determinants were the main factors associated with AHD at baseline.

Predicting ranger attrition

Elite military programs such as the 75th Ranger Regiment's Ranger Assessment and Selection Program (RASP) see rates of attrition often in excess of 50%, and amplify the need to identify and screen candidates based on their probability of successful matriculation. Models were developed (and cross-validated) to predict attrition from RASP using the physical abilities, cognitive abilities, and personality scores collected during candidate admissions screening. We report both regression weights and standardized odds ratios for optimum models of candidate success over three program timeframes to enable an understanding of the relative importance of each predictor. In spite of physical abilities scores being used to select RASP candidates, they were the strongest predictors of RASP attrition. Personality scores accounted for more variance in predicting candidate success than cognitive ability scores. Personality predictors, especially dimensions related to Openness, were better at predicting week one attrition than attrition in later weeks. The use of a single, aggregated candidate probability score for making admissions decisions is discussed, along with additional practical and scientific implications.

Long-term follow-up of web-based and group-based behavioural intervention in NAFLD in a real world clinical setting

BACKGROUND

The long-term results of web-based behavioural intervention in non-alcoholic fatty liver disease (NAFLD) have not been described in patients followed in specialised centres.

AIMS

To analyse the long-term effectiveness of web education compared with the results achieved by a group-based behavioural intervention in the same years 2012-2014.

METHODS

We followed 679 patients with NAFLD (web-based, n = 290; group-based, n = 389) for 5 years. Weight loss ≥10% was the primary outcome; secondary outcomes were attrition, changes in liver enzymes and in biomarkers of steatosis (Fatty liver Index) and fibrosis (Fibrosis-4 index).

RESULTS

The cohorts differed in age, education, working status and presence of diabetes. Attrition was higher in the web-based cohort (hazard ratio: 1.53; 95% CI: 1.24-1.88), but not different after adjustment for confounders. Among patients in active follow-up, 50% lost ≥5% of initial body weight and 19% lost ≥10%, without difference between cohorts. Alanine aminotransferase levels fell to within the normal range in 51% and 45% of web- and group-based cohorts, respectively. Fatty Liver Index declined progressively and, by year 5, it ruled out steatosis in 4.8%, whereas 24.9% were in the indeterminate range. Fibrosis-4 index increased in both cohorts, driven by age, but the prevalence of cases ruling-in advanced fibrosis remained very low (around 1%). Improvements in the class of both surrogate biomarkers were associated with ≥5% weight loss.

CONCLUSIONS

Although burdened by attrition, web-based behavioural intervention is feasible and effective in NAFLD, expanding the cohort involved in behavioural programs and reducing the risk of progressive disease.

Quantifying uptake and completion of pulmonary rehabilitation programs in people with chronic obstructive pulmonary disease known to tertiary care

BACKGROUND

People with symptomatic chronic obstructive pulmonary disease (COPD) benefit from pulmonary rehabilitation programs (PRPs), but program attrition is common.

METHODS

For people with COPD who presented to tertiary care and appeared appropriate for a PRP, we prospectively mapped their PRP journey, explored factors influencing attendance to pre-program assessment and captured program attrition.

RESULTS

Of the 391 participants, 31% (95% CI 27 to 36) were referred to a PRP (n = 123; age 68 ± 10years, 62 males [50%], FEV1 45 ± 19%predicted). Of those referred, 94 (76% [69 to 84]) attended a pre-program assessment. Ex-smokers and those who had a healthcare professional (HCP) explain they would be referred were more likely to attend a pre-program assessment (odds ratio [95%CI]; 2.6 [1.1 to 6.1]; and 4.7 [1.9 to 11.7], respectively). Of the 94 who attended, 63 (67% [58 to 77]) commenced; and of those who commenced, 35 (56% [43 to 68]) completed a PRP. All who completed (n = 35, 100%) were provided at least one strategy to maintain training-related gains.

CONCLUSION

Attrition occurs throughout the PRP journey. Interactions with HCPs about PRPs positively influenced attendance. Understanding how HCPs can best contextualise PRPs to encourage referral acceptance and uptake is an important area for further work.

Full Mouth Rehabilitation for a Patient With Generalized Attrition: The Hobo Technique in Action

This case report addresses the critical issue of severe tooth wear and its impact on the vertical dimension of occlusion in a 75-year-old patient. The patient presented with worn-down teeth, chewing difficulties, and aesthetic concerns, prompting a comprehensive treatment plan utilizing the Hobo twin-stage technique. The approach involved careful diagnosis, root canal therapy, and the creation of provisional restorations, monitored through an occlusal splint. The prosthetic phase incorporated strategically designed porcelain-fused-to-metal crowns, aiming for optimal tooth alignment and balanced movement. The successful outcome not only restored function and aesthetics but also enhanced the patient's confidence. This case underscores the effectiveness of a systematic approach in managing severe tooth wear, emphasizing the importance of regular follow-ups and good oral hygiene for long-term success.

Phylogenetic Biodiversity Metrics Should Account for Both Accumulation and Attrition of Evolutionary Heritage

Phylogenetic metrics are essential tools used in the study of ecology, evolution and conservation. Phylogenetic diversity (PD) in particular is one of the most prominent measures of biodiversity, and is based on the idea that biological features accumulate along the edges of phylogenetic trees that are summed. We argue that PD and many other phylogenetic biodiversity metrics fail to capture an essential process that we term attrition. Attrition is the gradual loss of features through causes other than extinction. Here we introduce 'EvoHeritage', a generalisation of PD that is founded on the joint processes of accumulation and attrition of features. We argue that whilst PD measures evolutionary history, EvoHeritage is required to capture a more pertinent subset of evolutionary history including only components that have survived attrition. We show that EvoHeritage is not the same as PD on a tree with scaled edges; instead, accumulation and attrition interact in a more complex non-monophyletic way that cannot be captured by edge lengths alone. This leads us to speculate that the one dimensional edge lengths of classic trees may be insufficiently flexible to capture the nuances of evolutionary processes. We derive a measure of EvoHeritage and show that it elegantly reproduces species richness and PD at opposite ends of a continuum based on the intensity of attrition. We demonstrate the utility of EvoHeritage in ecology as a predictor of community productivity compared with species richness and PD. We also show how EvoHeritage can quantify living fossils and resolve their associated controversy. We suggest how the existing calculus of PD-based metrics and other phylogenetic biodiversity metrics can and should be recast in terms of EvoHeritage accumulation and attrition.

Protocol optimization and reducing dropout in online research

Online research has advantages over in-person research; it's cost-efficient, scalable, and may increase diversity. Researchers collecting data online can assess protocol performance with classification models like a decision tree. However, challenges include attrition, lack of testing environment controls, technical limitations, and lack of face-to-face rapport and real time feedback. It is necessary to consider human factors of the teleresearch process from recruitment to data collection. Here we document the impact of protocol optimizations on social media engagement and retention between a pilot sample of Veterans (n = 26) and a post-optimization sample of both Veterans and civilians (n = 220) recruited from Facebook advertisements. Two-sided tests for equality of proportions were statistically significant: advertisement views leading to clicks increased by 23.8% [X2(1) = 130.3, p < 0.001] and completion of behavioral tasks increased by 31.2% [X2(1) = 20.74, p < 0.001]. However, a proportion of participants dropped out of the study before completion for both samples. To explore why, a C5.0 decision tree was used to find features that classify participant dropout. The features chosen by the algorithm were nicotine use (100%) and cannabis use (25.6%). However, for those completing the study, data quality of cognitive performance was similar for users and nonusers. Rather than determining eligibility, participants who endorse using nicotine, or both nicotine and cannabis, may have individual differences that require support in online protocols to reduce drop out, such as extra breaks. An introduction page that humanizes participants' lifestyle habits as a naturalistic benefit of remote research may also be helpful. Strategies are discussed to increase engagement and improve data quality. The findings have implications for the feasibility of conducting remote research, an increasingly popular approach that has distinct challenges compared to in-person studies.

Combined ventricular dysfunction and atrioventricular valve regurgitation after the Norwood procedure are associated with attrition prior to superior cavopulmonary connection

Background

Infants with hypoplastic left heart syndrome (HLHS) or a variant are at risk of ventricular dysfunction (VD) and atrioventricular valve regurgitation (AVVR) prior to superior cavopulmonary connection (SCPC). Although the impact of these complications in isolation has been described, their effect in combination on attrition is poorly defined.

Methods

A retrospective observational study of patients with HLHS or variants undergoing a Norwood procedure between 2008 and 2020 at a single center was performed. VD and AVVR were defined as moderate or severe when seen on 2 sequential echocardiograms outside the perioperative period. Attrition was defined as death, listing for heart transplant, or unsuitability for SCPC or transplant. Descriptive statistics and regression models were used for analysis.

Results

A total of 397 patients were included, of whom 75% had HLHS and 57% had received a Blalock-Thomas-Taussig shunt. Isolated VD occurred in 9% of patients, AVVR occurred in 13%, and both occurred in 6%. Attrition prior to SCPC occurred in 19% of the overall cohort, in 52% of patients with combined VD and AVVR (odds ratio [OR], 5.2; 95% confidence interval [CI], 2.3-12.0; P < .01), 26% of those with VD (OR, 1.5; 95% CI, 0.7-3.3; P = .32), 25% of those with AVVR (OR, 1.5; 95% CI, 0.7-2.9; P = .27), and 15% in those with neither (OR, 0.3; 95% CI, 0.2-0.6; P < .01). Other factors associated with attrition included prematurity, total bypass time at Norwood, and extracorporeal membrane oxygenation after Norwood, whereas later year of Norwood was protective (P < .01 for all).

Conclusions

The presence of combined VD and AVVR markedly increases the likelihood of attrition prior to SCPC, identifying a high-risk group.

Evaluating a Remote Monitoring Program for Respiratory Diseases: Prospective Observational Study

BACKGROUND

Patients with chronic respiratory diseases and those in the postdischarge period following hospitalization because of COVID-19 are particularly vulnerable, and little is known about the changes in their symptoms and physiological parameters. Continuous remote monitoring of physiological parameters and symptom changes offers the potential for timely intervention, improved patient outcomes, and reduced health care costs.

OBJECTIVE

This study investigated whether a real-time multimodal program using commercially available wearable technology, home-based Bluetooth-enabled spirometers, finger pulse oximeters, and smartphone apps is feasible and acceptable for patients with chronic respiratory diseases, as well as the value of low-burden, long-term passive data collection.

METHODS

In a 3-arm prospective observational cohort feasibility study, we recruited 60 patients from the Royal Free Hospital and University College Hospital. These patients had been diagnosed with interstitial lung disease, chronic obstructive pulmonary disease, or post-COVID-19 condition (n=20 per group) and were followed for 180 days. This study used a comprehensive remote monitoring system designed to provide real-time and relevant data for both patients and clinicians. Data were collected using REDCap (Research Electronic Data Capture; Vanderbilt University) periodic surveys, Remote Assessment of Disease and Relapses-base active app questionnaires, wearables, finger pulse oximeters, smartphone apps, and Bluetooth home-based spirometry. The feasibility of remote monitoring was measured through adherence to the protocol, engagement during the follow-up period, retention rate, acceptability, and data integrity.

RESULTS

Lowest-burden passive data collection methods, via wearables, demonstrated superior adherence, engagement, and retention compared with active data collection methods, with an average wearable use of 18.66 (SD 4.69) hours daily (77.8% of the day), 123.91 (SD 33.73) hours weekly (72.6% of the week), and 463.82 (SD 156.70) hours monthly (64.4% of the month). Highest-burden spirometry tasks and high-burden active app tasks had the lowest adherence, engagement, and retention, followed by low-burden questionnaires. Spirometry and active questionnaires had the lowest retention at 0.5 survival probability, indicating that they were the most burdensome. Adherence to and quality of home spirometry were analyzed; of the 7200 sessions requested, 4248 (59%) were performed. Of these, 90.3% (3836/4248) were of acceptable quality according to American Thoracic Society grading. Inclusion of protocol holidays improved retention measures. The technologies used were generally well received.

CONCLUSIONS

Our findings provide evidence supporting the feasibility and acceptability of remote monitoring for capturing both subjective and objective data from various sources for respiratory diseases. The high engagement level observed with passively collected data suggests the potential of wearables for long-term, user-friendly remote monitoring in respiratory disease management. The unique piloting of certain features such as protocol holidays, alert notifications for missing data, and flexible support from the study team provides a reference for future studies in this field.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/28873.

The Effectiveness of the StaySafe Intervention Using a Paradigm for Predicting Missing Outcome Data

Sample attrition is a confounding issue in the analysis of data collected in follow-up studies. The present study uses a regression procedure that includes a propensity score as a predictor in estimating imputed data. The utility of the procedure was addressed by comparing results from this augmented data with those from the original data. Data were from a randomized controlled study testing the utility of a tablet-based intervention designed to improve decision-making with respect to health risk behaviors. Outcomes included self-reported testing for HIV, STD, and hepatitis. Two samples were used (163 in community facilities and 348 in residential facilities). Seventy-eight in the community sample and 238 in the residential sample completed follow-up surveys. Propensity scores based on a stepwise logistic regression were used to make the calibration sample and the missing data sample as close as possible. Multilevel analysis was performed for each outcome and multiple imputation compared estimated mean differences for the augmented and original analyses. The model imputing missing data was effective for the three outcomes and increased power. Least square mean differences between augmented and original data appeared to be essentially the same for most of the outcomes. This protocol has been registered with https://www.clinicaltrials.gov/(NCT02777086).

Cognitive behavioral therapy for insomnia treatment attrition in patients with weekly nightmares

STUDY OBJECTIVES

This study's objective was to evaluate the effect of nightmares (NMs) on attrition and symptom change following cognitive behavioral therapy for insomnia (CBT-I) treatment using data from a successful CBT-I randomized controlled trial delivered to participants with recent interpersonal violence exposure.

METHODS

The study randomized 110 participants (107 women; mean age: 35.5 years) to CBT-I or to an attention-control group. Participants were assessed at 3 time periods: baseline, post-CBT-I (or attention control), and at time 3 (T3) post-cognitive processing therapy received by all participants. NM reports were extracted from the Fear of Sleep Inventory. Participants with weekly NMs were compared with those with fewer than weekly NMs on outcomes including attrition, insomnia, posttraumatic stress disorder, and depression. Change in NM frequency was examined.

RESULTS

Participants with weekly NMs (55%) were significantly more likely to be lost to follow-up post-CBT-I (37%) compared with participants with infrequent NMs (15.6%) and were less likely to complete T3 (43%) than patients with less frequent NMs (62.5%). NMs were unrelated to differential treatment response in insomnia, depression, or posttraumatic stress disorder. Treatment with CBT-I was not associated with reduced NM frequency; however, change in sleep-onset latency from post-CBT-I to T3 predicted fewer NMs at T3.

CONCLUSIONS

Weekly NMs were associated with attrition but not a reduced change in insomnia symptoms following CBT-I. NM symptoms did not change as a function of CBT-I, but change in sleep-onset latency predicted lower NM frequency. CBT-I trials should screen for NMs and consider augmenting CBT-I to specifically address NMs.

CITATION

Hamilton NA, Russell JA, Youngren WA, et al. Cognitive behavioral therapy for insomnia treatment attrition in patients with weekly nightmares. J Clin Sleep Med. 2023;19(11):1913-1921.

Emergency medicine physician workforce attrition differences by age and gender

BACKGROUND

Emergency care workforce concerns have gained national prominence given recent data suggesting higher than previously estimated attrition. With little known regarding characteristics of physicians leaving the workforce, we sought to investigate the age and number of years since residency graduation at which male and female emergency physicians (EPs) exhibited workforce attrition.

METHODS

We performed a repeated cross-sectional analysis of EPs reimbursed by Medicare linked to date of birth and residency graduation date data from the American Board of Emergency Medicine for the years 2013-2020. Stratified by gender, our primary outcomes were the median age and number of years since residency graduation at the time of attrition, defined as the last year during the study time frame that an EP provided clinical services. We constructed a multivariate logistic regression model to examine the association between gender and EP workforce attrition.

RESULTS

A total of 25,839 (70.2%) male and 10,954 (29.8%) female EPs were included. During the study years, 5905 male EPs exhibited attrition at a median (interquartile range [IQR]) age of 56.4 (44.5-65.4) years, and 2463 female EPs exhibited attrition at a median (IQR) age of 44.0 (38.0-53.9) years. Female gender (adjusted odds ratio 2.30, 95% confidence interval 1.82-2.91) was significantly associated with attrition from the workforce. Male and female EPs had respective median (IQR) post-residency graduation times in the workforce of 17.5 (9.5-25.5) years and 10.5 (5.5-18.5) years among those who exhibited attrition and one in 13 males and one in 10 females exited clinical practice within 5 years of residency graduation.

CONCLUSIONS

Female physicians exhibited attrition from the EM workforce at an age approximately 12 years younger than male physicians. These data identify widespread disparities regarding EM workforce attrition that are critical to address to ensure stability, longevity, and diversity in the EP workforce.

Attrition rate and predictors of a monitoring mHealth application in adolescents with obesity

BACKGROUND

Integrating mobile health (mHealth) into paediatric obesity treatment can provide opportunities for more personalized and lifetime treatment. However, high attrition rates pose a significant challenge. The current study attempts to better understand attrition by exploring (1) attrition rates of a monitoring mHealth application for usage over 14 days and (2) testing predictors of attrition in adolescents with obesity.

METHODS

Participants were 69 adolescents between 12 and 16 years old who engaged in a multidisciplinary obesity treatment centre (either outpatient or inpatient) in two countries (Belgium and France). To assess the attrition rates, frequency distributions were used. To test the predictors of attrition, zero-inflated negative binomial regression was performed.

RESULTS

Attrition rates were high, in the outpatient group, more than half of the participants (53.3%) used the app for only 0-7 days. In the inpatient group, this percentage was 24.1%. Only deficits in initiating (a component of executive functions) were a negative predictor of attrition, indicating that deficits in initiating lead to lower attrition rates.

CONCLUSIONS

This study provides evidence for high attrition rates in mHealth interventions for adolescents with obesity and was the first to investigate psychological predictors of attrition to an mHealth monitoring tool in adolescents with obesity in treatment. Findings regarding predictors of attrition should be approached with caution due to the small sample size.

Heart Rate Variability Assessment of Land Navigation and Load Carriage Activities in Specialist Police Selection

Police tactical group (PTG) personnel are exposed to physical, mental, and emotional stressors. Consequently, PTG selection courses (SCs) impart similar challenges, often resulting in candidate attrition. Holistic assessment may provide additional support to stakeholders given these risks. Heart Rate Variability (HRV) is an objective holistic stress measure that may be applicable in PTG SCs but has not been thoroughly researched. Therefore, this study aimed to report HRV data in an end-user accessible format and determine the relationship between HRV and attrition. A total of 18 qualified Australian State law enforcement officers completed a 1-day physical readiness assessment. Of those, six males progressed to an additional two-day course, on which this study is focused. This two-day selection consisted of additional physical challenges and occupational assessments. HRV was obtained from 2-lead ECGs and defined as the percentage of R-R intervals that varied by ≥50 ms (pRR50). Data were summarized in a heat map of consecutive short-term analyses. Three candidates withdrew. A logistic regression based on heat map data found high HRV was significant for predicting attrition, χ2 (6) = 8.318, p = 0.004. HRV may provide insight for PTG stakeholders monitoring attrition. While the sample size was limited and replication is needed, this study tentatively establishes value for HRV monitoring in PTG SCs.

Mobile and Web-Based Partnered Intervention to Improve Remote Access to Pain and Posttraumatic Stress Disorder Symptom Management: Recruitment and Attrition in a Randomized Controlled Trial

BACKGROUND

Increasing access to nonpharmacological interventions to manage pain and posttraumatic stress disorder (PTSD) is essential for veterans. Complementary and integrative health (CIH) interventions can help individuals manage symptom burden with enhanced accessibility via remotely delivered health care. Mission Reconnect (MR) is a partnered, self-directed intervention that remotely teaches CIH skills.

OBJECTIVE

The purpose of this paper is to describe the recruitment, onboarding phase, and attrition of a fully remote randomized controlled trial (RCT) assessing the efficacy of a self-directed mobile and web-based intervention for veterans with comorbid chronic pain and PTSD and their partners.

METHODS

A total of 364 veteran-partner dyads were recruited to participate in a mixed methods multisite waitlist control RCT. Qualitative attrition interviews were conducted with 10 veterans with chronic pain and PTSD, and their self-elected partners (eg, spouse) who consented but did not begin the program.

RESULTS

At the point of completing onboarding and being randomized to the 2 treatment arms, of the 364 recruited dyads, 97 (26.6%) failed to complete onboarding activities. Reported reasons for failure to complete onboarding include loss of self-elected partner buy-in (n=8, 8%), difficulties with using remote data collection methods and interventions (n=30, 31%), and adverse health experiences unrelated to study activities (n=23, 24%). Enrolled veterans presented at baseline with significant PTSD symptom burden and moderate-to-severe pain severity, and represented a geographically and demographically diverse population. Attrition interviews (n=10) indicated that misunderstanding MR including the intent of the intervention or mistaking the surveys as the actual intervention was a reason for not completing the MR registration process. Another barrier to MR registration was that interviewees described the mailed study information and registration packets as too confusing and excessive. Competing personal circumstances including health concerns that required attention interfered with MR registration. Common reasons for attrition following successful MR registration included partner withdrawal, adverse health issues, and technological challenges relating to the MR and electronic data collection platform (Qualtrics). Participant recommendations for reducing attrition included switching to digital forms to reduce participant burden and increasing human interaction throughout the registration and baseline data collection processes.

CONCLUSIONS

Challenges, solutions, and lessons learned for study recruitment and intervention delivery inform best practices of delivering remote self-directed CIH interventions when addressing the unique needs of this medically complex population. Successful recruitment and enrollment of veterans with chronic pain and PTSD, and their partners, to remote CIH programs and research studies requires future examination of demographic and symptom-associated access barriers. Accommodating the unique needs of this medically complex population is essential for improving the effectiveness of CIH programs. Disseminating lessons learned and improving access to remotely delivered research studies and CIH programs is paramount in the post-COVID-19 climate.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03593772; https://clinicaltrials.gov/ct2/show/NCT03593772.

Risk factors of tooth wear in permanent dentition: A scoping review

BACKGROUND

Tooth wear (TW) prevalence is high and increasing and has important consequences on the patient's quality of life. Knowledge of risk factors is crucial to promote diagnosis, prevention strategies and timely interceptive treatment. Many studies have identified TW risk factors.

OBJECTIVE

This scoping review aims to map and describe suspected available factors associated with TW in permanent dentition based on quantitative measurement.

METHODS

The scoping review was conducted using the PRISMA extension of the Scoping Reviews checklist. The search was conducted in October 2022 from the Medline® (PubMed® interface) and Scopus® databases. Two independent reviewers selected and characterised the studies.

RESULTS

2702 articles were identified for assessment of titles and abstracts, and 273 articles were included in the review. The results show a need to standardise TW measurement indices and the study design. The included studies highlighted various factors, classified into nine domains: sociodemographic factors, medical history, drinking habits, eating habits, oral hygiene habits, dental factors, bruxism and temporomandibular disorders, behavioural factors, and stress. Results related to chemical TW (erosion) risk factors underline the importance of eating disorders, gastroesophageal reflux and lifestyle, particularly drinking and eating behaviours, which supports developing public health information campaigns and interventions. Besides chemical, this review identifies evidence of several mechanical TW risk factors, such as toothbrushing and bruxism; the influence of this last factor needs to be further explored.

CONCLUSIONS

TW management and prevention require a multidisciplinary approach. Dentists are in the first line to detect associated diseases such as reflux or eating disorders. Consequently, practitioners' information and guideline diffusion should be promoted, and a TW risk factors checklist (the ToWeR checklist) is proposed to help diagnostic approaches.

Predictors of treatment attrition of cognitive health interventions in first episode psychosis

AIM

Dropping out of psychological interventions is estimated to occur in up to a third of individuals with psychosis. Given the high degree of attrition in this population, identifying predictors of attrition is important to develop strategies to retain individuals in treatment. We observed a particularly high degree of attrition (48%) in a recent randomized controlled study assessing cognitive health interventions for first-episode psychosis participants with comorbid social anxiety. Due to the importance of developing interventions for social anxiety in first episode psychosis, the aim of the present study was to identify putative predictors of attrition through a secondary analysis of data.

METHODS

Participants (n = 96) with first episode psychosis and comorbid social anxiety were randomized to receive cognitive behavioural therapy for social anxiety or cognitive remediation. Differences between completers and non-completers (<50% intervention completed) were compared using t-tests or chi-square analyses; statistically significant variables were entered into a multivariate logistic regression model.

RESULTS

Non-completers tended to be younger, had fewer years of education and had lower levels of social anxiety compared to completers. Lower baseline social anxiety and younger age were statistically significant predictors of non-completion in the logistic regression model.

CONCLUSIONS

Age and social anxiety were predictors of attrition in cognitive health interventions in first episode psychosis populations with comorbid social anxiety. In the ongoing development of social anxiety interventions for this population, future studies should investigate specific engagement strategies, intervention formats and outcome monitoring to improve participant retention in treatment.

Attrition from paediatric weight management impacts anthropometric outcomes at 2 years, but not health-related quality of life

The study objective is to evaluate the influence of attrition from a paediatric weight management program (PWM) on health indicators over a 2-year period. In this observational study, children and youth with obesity were recruited at entry into a family-based behaviour modification PWM and had four research study visits, independent of clinic visits, over 2 years. Participants were divided into attrition groups based on length of clinic enrolment. Body composition, cardiometabolic health and health-related quality of life (HRQoL) were assessed. Among 269 children enrolled, 19% had no clinic treatment visit, 16% had treatment visits only up to 6 months, 23% up to 1 year and 42% had at least one clinic visit after 1 year (No Attrition). Greater declines in BMI z-score and body fat were seen at 2 years in children with No Attrition, while improvements in HRQoL were similar for all attrition groups. Children who attended at least one treatment visit reported improved HRQoL up to 2 years, regardless of duration in clinic. In contrast, declines in body fat and BMI z-score were greater at 2 years for those with at least one visit after 1 year. Continued efforts to reduce attrition are likely to improve anthropometric health outcomes during PWM.

Determinants of completion and early dropout in an adult weight management service: a prospective observational study

BACKGROUND

High attrition rates in weight management interventions (WMIs) undermine their effectiveness but are poorly understood. This study aimed to identify determinants of completion and early dropout in National Health Service (NHS) WMIs.

METHODS

In this prospective observational study, 329 patients recruited at initial consultation appointments satisfied the eligibility criteria: age ≥18 years and body mass index (BMI) ≥30 kg/m2 . Multivariate logistic regression analyses were performed to identify the odds ratios (OR, given with 95% confidence interval) of completion and early dropout.

RESULTS

Intervention completion rate was 39.8% (131 of 329). Variables that increased the likelihood of completion included engagement in support sessions, OR10.6 (4.7-23.6, p < 0.001); male sex, OR2.5 (1.4-4.5, p = 0.002); osteoarthritis, OR1.9 (1.1-3.3, p = 0.014); and one or more missed intervention appointments marked as 'could not attend' (notified nonattendance), OR1.8 (1.1-2.9, p = 0.032). Odds of early dropout were higher for participants with anxiety and depression OR2.0 (1.0-4.0, p = 0.039). Dietetic 1:1 participants were less likely to drop out early compared with group programme participants, OR0.3 (0.2-0.7, p = 0.002), but were less likely to complete the full intervention, OR0.5 (0.3-0.9, p = 0.02). Age, BMI, social deprivation and travel distance were among the variables not associated with completion or early dropout.

CONCLUSIONS

This study provides further evidence of the importance of support for participants of WMIs and the need for services to consider how support networks can be incorporated. Patients with poorer mental health may be more likely to drop out early and consequently benefit less from WMIs. Future research should qualitatively explore why these factors contribute to attrition to improve WMI effectiveness.

Recruitment and Retention Strategies Used in Dietary Randomized Controlled Interventions with Cancer Survivors: A Systematic Review

BACKGROUND

The purpose of this review was to systematically evaluate the quality of reporting of recruitment and retention methods in diet-related intervention trials among cancer survivors.

METHODS

A systematic search of five databases in Spring 2023 identified dietary intervention randomized controlled trials with a minimum of 50 cancer survivors, an intervention of at least eight weeks, and at least six months of study duration. Outcomes investigated include methodologic description and reporting of recruitment and retention rates.

RESULTS

Seventeen trials met inclusion criteria. Recruitment methods included cancer registry and clinician referral, hospital records, flyers, and media campaigns, and were reported in 88.2% of studies. Eleven of 17 studies (64.7%) met a priori recruitment goals. Eleven studies identified an a priori retention goal and seven met the goal. Retention goals were met more often for studies of less than one year (71.4%) versus greater than one year (50%), and for studies with remote or hybrid delivery (66.7%) versus only in-person delivery (50%).

CONCLUSIONS

Recruitment goals and methods are frequently reported; reporting of retention methods and goals is limited. Efforts are needed to improve reporting of retention methods and rates to inform best practices and enhance the rigor of future dietary intervention trials.

Understanding Attrition in Text-Based Health Promotion for Fathers: Survival Analysis

BACKGROUND

Web-based interventions targeting parents with health and parenting support frequently report high rates of attrition. The SMS4dads text messaging program, developed in Australia, has delivered texts to over 10,000 fathers. The brief text messages, which are sent 3 times per week from 16 weeks of gestation to 48 weeks after birth, include regular reminders that participants can leave the program by texting back "STOP" to any message. Although acceptance of the program is high, almost 1 in 5 ask it to be removed. Analyzing the factors influencing attrition from digital parenting programs such as SMS4dads may assist in developing more effective interventions.

OBJECTIVE

This study aimed to examine factors associated with attrition in a text-based intervention targeting fathers.

METHODS

Demographic characteristics, requests to complete a psychological scale, individual message content, participant feedback, and automatically collected data registering clicks on links embedded in the texts were examined to identify attrition factors among 3261 participants enrolled in SMS4dads from 4 local health districts in New South Wales, Australia, between September 2020 and December 2021.

RESULTS

Participants who were smokers, recorded risky alcohol consumption, had a lower education level, or signed up prenatally had 30% to 47% higher hazard of dropout from the program, whereas participant age, Aboriginal or Torres Strait Islander status, rurality, and psychological distress score (as Kessler Psychological Distress Scale [K10] category) were not associated with dropout. Primary reasons for dropping out reported by 202 of 605 respondents included "other reasons" (83/202, 41.1%), followed by "not helpful" (47/202, 23.3%) and "too busy" (44/202, 21.8%). Program features such as repeated requests to complete a psychological scale (K10) and the content of individual messages were not linked to increased dropout rates. Analysis of a sample (216/2612) of inactive participants who had not engaged (clicked on any embedded links) for at least 10 weeks but who had not opted out identified a further 1.5% of participants who would opt to leave the program if asked.

CONCLUSIONS

Identifying which features of the participant population and of the program are linked to dropout rates can provide guidance for improving program adherence. However, with limited information from feedback surveys of those exiting early, knowing which features to target does not, by itself, suggest ways to increase engagement. Planning ahead to include robust measures of attrition, including more detailed feedback from participants, could provide more effective guidance. A novel element in this study was seeking feedback from inactive participants to estimate dropout from this group and thereby provide an overall dropout rate of 20%. The retention rate of 80%, relatively high compared with other web-based parenting programs for fathers, suggests that tailoring the content to specifically address fathers' role may be an important consideration in reducing fathers' disengagement.

Proportion of Attrition and Associated Factors Among Children Receiving Antiretroviral Therapy in Public Health Facilities, Southern Ethiopia

Purpose

Acquired immunodeficiency syndrome (AIDS) is a major global public health concern. Despite the improved access and utilization of antiretroviral therapy (ART), attrition from care among children continues to be a major obstacle to the effectiveness of ART programs. Hence, this study aimed to assess the proportion of attrition and associated factors among children receiving ART in public health facilities of Gamo and South Omo Zones, Southern Ethiopia.

Patients and Methods

A retrospective follow-up study was conducted in public health facilities of Gamo and South Omo Zones in Southern Ethiopia from April 12, 2022, to May 10, 2022. The proportion of attrition was determined by dividing the number of attrition by the total number of participants. Descriptive statistics were calculated. A binary logistic regression model was used to identify factors associated with attrition. Statistical significance was set at p-value <0.05.

Results

The median age of the participants was 5.5 (IQR: 2-9) years. The proportion of attrition from ART care was 32.4% (95% confidence interval (CI): 27.57% to 37.69%). Death of either of the parents (adjusted odds ratio (AOR) = 2.19; 95% CI:1.14, 4.18), or both parents (AOR = 3.19; 95% CI: 1.20, 8.52), hemoglobin level <10mg/dL (AOR = 2.39, 95% CI: 1.21, 4.70), a cluster of differentiation (CD)4 count ≤200 cells/mm3 (AOR = 6.78, 95% CI: 3.16, 14.53), CD4 count 200-350 cells/mm3 (AOR = 2.65, 95% CI: 1.16, 6.03), suboptimal adherence (AOR = 6.38; 95% CI: 3.36, 12.19), and unchanged initial regimen (AOR = 6.88; 95% CI: 3.58, 13.19) were factors associated with attrition.

Conclusion

Attrition from care is identified to be a substantial public health problem. Therefore, designing interventions to improve the timely tracing of missed follow-up schedules and adherence support is needed, especially for children with either/both parents died, unchanged initial regimen, low CD4, and/or low hemoglobin level.

Undertreatment in patients with advanced urothelial cancer: systematic literature review and meta-analysis

Aim: To assess rates of no systemic treatment (NST), attrition across lines of therapy, and factors influencing treatment selection in patients with locally advanced or metastatic urothelial cancer (la/mUC). Methods: Systematic literature review to identify real-world studies reporting NST or attrition rates in la/mUC from 2017-2022 (including data reported since 2015). Results: Of 2439 publications screened, 29 reported NST rates, ranging from 40-74% in eight European-based studies, 14-60% in 12 US-based studies, and 9-63% in nine studies in other locations (meta-analysis estimate, 39%). Factors associated with NST or no second-line therapy included older age, female sex, poor performance status, poor renal function and distant metastases. Conclusion: A substantial proportion of patients with la/mUC do not receive guideline-recommended treatment.

Examining the Effect of a Parent-to-Parent Intervention for Low-Income Youth with Serious Emotional and Behavioral Challenges

BACKGROUND

Numerous barriers to mental health utilization exist for families of children who present with serious emotional and behavioral challenges. Evidence-based practices that facilitate equitable outcomes across diverse populations are essential to identify. This study examined possible differential service outcomes in a Medicaid-funded, parent-to-parent intervention called Parent Support Partner (PSP).

METHOD

Data from four hundred and sixty-four parents who received PSP services were evaluated for possible demographic differences in service completion. Within-group analyses were utilized for an analysis of outcomes (parent change, child functioning; treatment acceptability) within a subset (N = 153) of those who completed services.

RESULTS

No racial disparities were found in those who completed PSP (43%) when compared to those who did not (57%). Regression analyses uncovered significant improvements in parent competence and confidence, as well as overall child functioning (global functioning across domains such as school, home, behaviors). Consistent with identifying evidence-based practices, findings were seen consistently across the diverse sample of those who completed PSP services. Improvements in parents' sense of competence and confidence were correlated with perceptions of treatment acceptability.

DISCUSSION

PSP is an innovative and promising intervention with demonstrated high levels of acceptability found to increase parent confidence and self-competence to advocate for treatments that can improve the mental health functioning of their child. Future investigations of factors associated with increasing PSP service completion and outcomes in larger and more diverse populations are necessary. Implications for considering and possibly adopting this evidence-informed practice within the nursing profession are provided.

Identifying factors associated with UK veterinary nurse resignations through examination of veterinary practice data

BACKGROUND

This study aimed to identify demographic, practice and job-specific factors that are associated with veterinary nurses resigning from UK companion animal veterinary practices.

METHODS

Employment data from nurses working across a group of practices at the end of 2020 were included. Nurses were categorised into those who remained at, or resigned from, their practice in 2021. Proposed risk factors for future resignations were analysed using multivariable binary logistic regression modelling.

RESULTS

In total, 278 of 1642 (16.9%) nurses across 418 practices resigned in 2021. The most frequently recorded reasons for nurses resigning included 'career progression' (n = 102; 36.7%), 'personal reasons' (n = 36; 12.9%) and 'better pay or benefits' (n = 33; 11.9%). Factors associated with lower odds of future nurse resignations included longer tenure (p < 0.001), higher practice property and facilities rating (p = 0.049) and being a head or student nurse (p = 0.008).

LIMITATIONS

Data were collected retrospectively and were not recorded for research purposes.

CONCLUSIONS

This study highlights key factors that are predictive of veterinary nurse resignations. With known difficulties in staff retention within veterinary practices, analysis of these data is an important addition to the evidence base surrounding the complex issue of nurse retention and could help steer future retention strategies.

Retention and Predictors of Attrition Among People Living With HIV on Antiretroviral Therapy in Guinea: A 13-Year Historical Cohort Study in Nine Large-Volume Sites

Objectives: The objective of this study was to estimate the retention rate of patients in an ART program and identify the predictors of attrition. Methods: This was a historical cohort study of HIV patients who started ART between September 2007 and April 2020, and were followed up on for at least 6 months in nine large-volume sites. Kaplan Meier techniques were used to estimate cumulative retention and attrition probabilities. Cox proportional hazards models were used to identify predictors of attrition. Results: The cumulative probability of retention at 12 and 24 months was 76.2% and 70.2%, respectively. The attrition rate after a median follow-up time of 3.1 years was 35.2%, or an incidence of 11.4 per 100 person-years. Having initiated ART between 2012 and 2015; unmarried status; having initiated ART with CD4 count <100 cells/μL; and having initiated ART at an advanced clinical stage were factors significantly associated with attrition. Conclusion: The retention rate in our study is much lower than the proposed national target (90%). Studies to understand the reasons for loss to follow-up are needed.

Advanced HIV disease and associated attrition after re-engagement in HIV care in Myanmar from 2003 to 2019: a retrospective cohort study

BACKGROUND

The burden of advanced HIV disease (AHD) and predictors of outcomes among people living with HIV (PLHIV) re-engaging in care are not well known.

METHODS

We conducted a retrospective cohort study of PLHIV who re-engaged in care after being lost to follow-up (LFU), from 2003 to 2019, in Myanmar. We calculated the incidence rates of attrition after re-engagement and performed Cox regression to identify risk factors for attrition.

RESULTS

Of 44 131 PLHIV who started antiretroviral treatment, 12 338 (28.0%) were LFU at least once: 7608 (61.6%) re-engaged in care, 4672 (61.4%) with AHD at re-engagement. The death and LFU rates were 2.21-fold (95% CI 1.82 to 2.67) and 1.46-fold (95% CI 1.33 to 1.61) higher among patients who re-engaged with AHD (p>0.001). Death in patients who re-engaged with AHD was associated with male sex (adjusted HR [aHR] 2.63; 95% CI 1.31 to 5.26; p=0.006), TB coinfection (aHR 2.26; 95% CI 1.23 to 4.14; p=0.008) and sex work (aHR 7.49, 95% CI 2.29 to 22.52; p<0.001). History of intravenous drug use was identified as a predictor of being LFU.

CONCLUSIONS

Re-engagement in HIV care in Myanmar is frequent and those who re-engage carry a high burden of AHD. As AHD at re-engagement is associated with higher attrition rates, implementation of differentiated interventions that enable earlier linkage to care and prompt identification and management of AHD in this population is necessary.

Chewing Ability and the Quality of Life: A Cross-Sectional Study to Assess the Relationship Between Tooth Wear and Oral Health

INTRODUCTION

It is important to understand how a very common prevalent condition of tooth wear (TW) impacts a person's day-to-day oral health. An emerging concept of measuring the parameter of oral health-related quality of life (OHRQoL), which evidently impacts the daily living of a person, makes it practical to examine the correlation between TW and OHRQoL. For measuring the OHRQoL, we can apply various methods, and the most effective is the use of the Oral Health Impact Profile (OHIP) questionnaire. Accordingly, the aim of this study was to assess the correlation between TW and the OHRQoL among adult patients attending a dental college and hospital.

METHODS

A cross-sectional research was performed on patients who visited the outpatient department of Teerthanker Mahaveer Dental College and Research Centre, Moradabad, India. Initially, the sociodemographic details of patients, including their oral hygiene and dietary habits, were recorded. This step was followed by the assessment of TW using the Smith and Knight TW index. Then, the translated and validated version of the OHIP questionnaire was filled up, in which the patients were asked to rate each question on a Likert scale, with five points ranging from 0 to 4, where 0 = never, 1 = hardly ever, 2 = occasionally, 3 = fairly often, and 4 = very often.

RESULTS

Based on a clinical examination on 630 subjects and the OHIP questionnaire responses from the participants, a significantly remarkable association (p ≤ 0.05) was found using a chi-square test between TW and the OHRQoL. In particular, TW was linked to other sociodemographic data and various lifestyle, dietary, and drinking habits. Along with the OHRQoL, TW also showed a positive correlation with gender. Using the chi-square test, a statistically significant association between age and TW was observed, with p-value = 0.004. Meanwhile, the place of residence did not show any association with TW. Educational qualifications of patients, visits to dental clinics, and reasons for dental visits showed very significant association with TW. Oral hygiene aids, materials used, frequency of brushing, and brushing technique did not have any association with TW as per the results obtained. A highly significant association was found between consumption of fruit drinks, citric drinks, and beverages and TW in the adult patients. Among all the domains of the OHIP questionnaire, the physical pain domain was the most affected, followed by the physical disability domain.

CONCLUSION

We conclude that TW has a direct association and positive correlation with the OHRQoL. As TW was increasing, so were the OHIP values, which indicated a lesser OHRQoL. The study also presents information on how to maintain a regular and healthy dietary lifestyle and oral hygiene to combat the impacts of TW.

Incidence and predictors of attrition among adults receiving first line anti-retroviral therapy at public health facility in Adea Berga district, Oromia, Ethiopia

Background

According to current estimates, there are 665,723 people in Ethiopia who have human immunodeficiency syndrome. As Ethiopia inches closer to attaining the 95/95/95 targets for treatment coverage and reaching epidemic control, however, attrition from anti-retroviral treatment is still one of the key programmatic challenges.

Objective

To assess the incidence of attrition rate and its predictors among adult HIV patients receiving anti retro viral treatment at Public Health Facility in Adea Berga/Enchini District.

Method

A 6-year (June 28, 2015 to June 27, 2021) institution-based retrospective cohort study was used to recruit 540 study participants by using simple random sampling. Data were obtained from chart review, coded, entered into Epi Data, and exported to Stata 14.2 software for analysis. At least 1 month missed appointment is considered as attrition and the predictors of attrition were identified using bivariable and multivariable Cox proportional hazard models and an adjusted hazard ratio (AHR). Bivariate and multivariate analyses were conducted to find predictors of attrition, p-value < 0.05 was considered statistically significant.

Results

From the total 540 study participant, 158 (29.26%) patients were discontinuing from follow up making the incidence rate of attrition 9.50 per 100 person years .Being WHO clinical stage III or IV (AHR = 1.96,), non-practice of Appointment spacing model (AHR = 3.98), poor or fair ART adherence level (AHR = 6.47), age groups (15-24) years (AHR = 1.73) and Others ART linkage points[index case testing, tuberculosis clinic and referral from private/public health institutions] (AHR = 1.76) were significantly associated.

Conclusions

The study showed that the incidence of attrition among adults receiving antiretroviral therapy was high. Patient sociodemographic, clinical, and treatment-related factors were significantly associated with patients on ART.

Attrition and withdrawal in multiple myeloma randomized controlled trials: A systematic review

OBJECTIVES

Patients with multiple myeloma (MM) enrolled in randomized control trials (RCTs) discontinue treatment for various reasons; however, no prior study has analyzed reasons for discontinuation. We performed a systematic review of MM RCTs to investigate reasons for treatment discontinuation, imbalances between trial cohorts, and reporting practices.

METHODS

A comprehensive search for RCTs in MM from 2015 to 2021 identified 45 studies meeting inclusion criteria.

RESULTS

Of 21 236 randomized patients, 10 161 (47.8%) discontinued therapy by primary endpoint ascertainment. Causes of discontinuation included progression (n = 4790; 22.6% of randomized patients); toxicity (n = 2569; 12.1%); patient/physician withdrawal (n = 1200; 5.7%) and death (n = 495; 2.3%). Of randomized patients, 20 914 (98.5%) were included in the RCT analysis. Imbalances of attrition, defined as trials with greater than 5% absolute difference in discontinuation rate for reasons other than death, progression, and toxicity between intervention and control arms, were found in 11 (24.4%) studies.

CONCLUSIONS

Although progression is the most common reason for RCT treatment discontinuation in patients with MM, over 10% discontinued due to toxicity. Furthermore, 24.4% of trials showed substantial imbalances between trial cohorts; raising concern for informative censoring and emphasizes the importance of detailed characterization of withdrawal in MM RCTs.