Predicting time to asystole following withdrawal of life-sustaining treatment: a systematic review

The planned withdrawal of life-sustaining treatment is a common practice in the intensive care unit for patients where ongoing organ support is recognised to be futile. Predicting the time to asystole following withdrawal of life-sustaining treatment is crucial for setting expectations, resource utilisation and identifying patients suitable for organ donation after circulatory death. This systematic review evaluates the literature for variables associated with, and predictive models for, time to asystole in patients managed on intensive care units. We conducted a comprehensive structured search of the MEDLINE and Embase databases. Studies evaluating patients managed on adult intensive care units undergoing withdrawal of life-sustaining treatment with recorded time to asystole were included. Data extraction and PROBAST quality assessment were performed and a narrative summary of the literature was provided. Twenty-three studies (7387 patients) met the inclusion criteria. Variables associated with imminent asystole (<60 min) included: deteriorating oxygenation; absence of corneal reflexes; absence of a cough reflex; blood pressure; use of vasopressors; and use of comfort medications. We identified a total of 20 unique predictive models using a wide range of variables and techniques. Many of these models also underwent secondary validation in further studies or were adapted to develop new models. This review identifies variables associated with time to asystole following withdrawal of life-sustaining treatment and summarises existing predictive models. Although several predictive models have been developed, their generalisability and performance varied. Further research and validation are needed to improve the accuracy and widespread adoption of predictive models for patients managed in intensive care units who may be eligible to donate organs following their diagnosis of death by circulatory criteria.

Psychoeducational interventions for people living with chronic communicable disease: a systematic review

OBJECTIVE

Psychoeducation is increasingly recognised for its value in facilitating adaption to a chronic disease diagnosis. This study aimed to synthesise available literature on the psychoeducation interventions available to adults living with chronic communicable disease.

METHODS

PubMed, CINAHL, Embase, SocINDEX, PsycINFO and PsycArticles were systematically searched up to May 2023. Peer-reviewed studies, published in English, investigating the impact of psychoeducational interventions on adults living with chronic communicable disease were included, across a range of outcome measures. Narrative synthesis was performed. The Effective Public Health Practice Project tool and Critical Appraisal Skills Programme tool were used to assess risk of bias.

RESULTS

In total, 22 studies were included in the review. The majority (n=16) of study populations focused on people living with HIV, followed by hepatitis C (n=5) and genital herpes (n=1). Interventions were delivered online (n=2), via telephone (n=1) and in-person (n=19). The majority of interventions were delivered in group sessions (n=16) and studies emphasised the value of group cohesion for social support, encouraging participants to share their own knowledge in addition to standard didactic presentations. Four studies facilitated peer-led delivery of the psychoeducation. Studies aiming to improve psychological well-being were beneficial in reducing depressive symptoms and/or emotional distress or showed improvement in the participant group overall. There was some evidence to suggest psychoeducation can improve readiness to attend treatment and medication adherence.

CONCLUSION

The findings of this review highlight potential benefits of psychoeducation but indicate more robust clinical trials will be required to examine their effectiveness and elucidate the mechanisms by which they best operate. Future interventions incorporating a broader focus on resilience enhancement and coping skills specific to stigmatisation could more comprehensively serve the needs of adults living with chronic communicable disease, particularly with HIV. The role of peer support in group psychoeducation merits further exploration.

PROSPERO REGISTRATION NUMBER

CRD42021243058.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

The Running Injury Continuum: A qualitative examination of recreational runners' description and management of injury

INTRODUCTION

A critical step in understanding and preventing running-related injuries (RRIs) is appropriately defining RRIs. Current definitions of RRIs may not represent the full process of injury development, failing to capture lower levels of injury that many athletes continue to train through. Understanding runners' description and management of the injury development process may allow for a more appropriate examination of all levels of injury. This study aimed to examine recreational runners' description and management of the injury development process.

METHODS

A qualitative focus group study was undertaken. Seven semi-structured focus groups with male (n = 13) and female (n = 18) recreational runners took place. Focus groups were audio and video recorded, and transcribed verbatim. Transcripts were reflexively thematically analysed. A critical friend approach was taken to data coding. Multiple methods of trustworthiness were executed.

RESULTS

Runners describe injury on a nine-level continuum, ranging from injury-free to career-ending injury. There are lower and higher levels of injury. Each level of injury is described across four categories of descriptors; physical description, outcome (effect on running and daily life), psychological description, and management.

CONCLUSION

The Running Injury Continuum is a tool that can be used for injury surveillance (for healthcare professionals and researchers) and for research investigating RRI risk factors. Healthcare professionals, researchers and coaches must ensure they monitor the development of all levels of RRIs, across all categories of descriptors. Runners need to be educated regarding appropriate self-management strategies for lower level injuries, with access to evidence-based information being a critical management tool.

Barriers to Care for Pediatric Rural Medulloblastoma Patients Receiving Craniospinal Proton Radiotherapy without In-State Facilities

PURPOSE/OBJECTIVE(S)

Medulloblastoma represents ∼20% of all pediatric brain malignancies. The preferred treatment modality for craniospinal irradiation (CSI) has evolved to be proton beam therapy to reduce late toxicities including secondary malignancy. Access to proton therapy centers is more limited in states without one. Barriers to access for rural patients are underreported in the literature.

MATERIALS/METHODS

Patients <25 years old with a diagnosis of medulloblastoma were identified from a tumor registry at a rural academic center. A chart review was conducted to identify specific barriers to proton beam CSI. Descriptive analyses were performed to describe this cohort and their barriers.

RESULTS

We identified a total of 18 patients diagnosed between 2000 and 2022. The mean age was 10 years old (range 11 months - 20 years). 2 patients were excluded who had minimal documentation. 7 patients were diagnosed before 1/1/2014, a cutoff after which protons were considered more often in this patient population. Patient demographics were 39% female, 61% male, 22% Black, and 72% White, 6% Hispanic. 3 patients received protons. 2 patients had recurrence and 3 patients developed secondary malignancy. Out of 18 patients, proton therapy was discussed with 11 patients. The rates of documented barriers to radiotherapy for the cohort at large (n = 18) and for those where proton therapy was discussed in particular (n = 11) are as follows (cohort at large / had discussion): 4(22%) / 4(36%) difficulty obtaining insurance approval, 4(22%) / 4(36%) inpatient medical needs, 5(28%) / 5(46%) outpatient medical needs, 4(22%) / 4(36%) family scheduling conflicts, 3(17%) / 3(27%) travel costs/financial burdens, 4(22%) / 4(36%) not a clinical trial candidate, 3(17%) / 3(27%) radiotherapy delay, 9(50%) / 5(46%) other barriers to non-radiotherapy care. For the cohort at large or for those with proton therapy discussions, there were no significant associations between white and underrepresented minorities for the aforementioned barriers to care.

CONCLUSION

To our knowledge, this is the first study that identifies patient barriers to accessing proton beam CSI for medulloblastoma patients from a rural tertiary care center without in-state proton radiotherapy centers. This study yields insight into the particular barriers encountered by these patients and their families, allowing clinical teams to identify potential issues in an effort to overcome those barriers. Advocacy for access to care on behalf of this vulnerable patient population may be required by our field on a state and national level.

Rural Pediatric Radiation Oncology in the Era of COVID-19: A Single Institution Analysis

PURPOSE/OBJECTIVE(S)

Health inequities have recently gained prominence in public consciousness as a result of the COVID-19 pandemic. Rural access to care was particularly impacted regarding delays in cancer screening, diagnosis, and treatment. The fractionated nature of radiotherapy creates transportation burdens in this population. We reviewed our institutional experience with pediatric radiotherapy at a tertiary academic center serving a primarily rural population over a large geographic area.

MATERIALS/METHODS

The financial burden of radiotherapy in pediatric patients in our database was modeled using cost-analysis. The cost of transportation using distance to our facility and the IRS-assessed tax value per mile was calculated. Correlative analyses were conducted to evaluate the association of radiotherapy delivered pre- vs. post-COVID with patient race, age at diagnosis, and distance from our institution. Analyses were conducted with two-tailed Pearson correlations for transportation cost vs. age at diagnosis. Mann-Whitney U testing was used to analyze transportation cost vs. patient race. Fisher's Exact Test was used to analyze the trends between tumor primary sites pre- and post-COVID.

RESULTS

There was a statistically significant increase in brain tumors vs. all others from 9.1% to 66.7% post-COVID (p = 0.029). When comparing patients treated prior to the onset of the COVID-19 pandemic in 2020 to those treated during the peak years of the pandemic in 2020-2021, there was no difference in the average distance traveled for treatment. However, the mean cost of transportation for pediatric patients undergoing radiotherapy prior to COVID-19 was $266 USD (median = $331), vs. a mean of $535 (median = $378) for patients treated during 2020-2021. For patients treated in 2022, after the height of COVID-19, the mean cost of transportation was $501 (median = $432). No statistically significant differences were found between the cost of transportation and patient race or age at diagnosis before vs. after the onset of COVID-19.

CONCLUSION

Our results highlight the importance of understanding barriers to care and what type of resources are most impactful to rural pediatric patients at our center. The rise of transportation costs for radiotherapy following the COVID-19 pandemic may indicate an additional barrier to care, potentially associated with increasing inflation, for rural pediatric patients that is underreported in the literature. The rise in the relative prevalence of brain tumors at our institution during this period warrants further investigation.

A SEER Database Cohort of 547 Patients with Non-Squamous Cell Carcinoma of the Penis: Clinical Characteristics and Outcomes

PURPOSE/OBJECTIVE(S)

Little research has investigated the prevalence and distribution of the diverse pathologies of non-squamous cell carcinoma (non-SCC) of the penis. Although rare in clinical practice, these cancers have become a focus of greater importance among patients, clinicians, and researchers, particularly in developing countries. The principal objective of this study was to analyze the major types of penile non-squamous cell carcinoma, elucidate common treatment pathways, and highlight outcomes including 5-year survival.

MATERIALS/METHODS

The Surveillance, Epidemiology and End Results (SEER) database was queried between 2000 to 2018 to identify a retrospective cohort of patients with penile non-SCC. Demographic information, cancer characteristics, diagnostic methods, treatments administered, and survival were investigated.

RESULTS

A total of 547 cases of penile non-SCC were included in the analysis. The most prevalent non-SCC cancers included epithelial neoplasms, not otherwise specified (15.4%), unspecified neoplasms (15.2%), basal cell neoplasms (13.9%), blood vessel tumors (13.0%), nevi and melanomas (11.7%), and ductal and lobular neoplasms (9.9%). Data for the nine most prevalent neoplasms are included in Table 1. Over half (56.7%) of patients elected to undergo surgical intervention. Patients rarely received systemic therapy (3.8%) or radiation (4.0%). Five-year survival was 35.5%. Median survival was 5.2 years (62.7 months). Patients who underwent surgery had greater annual survival for 0 to 10 years compared to those who did not have surgery. Significant differences in survival were found between patients who had regional, localized, and distant metastases (p<0.05). A significant difference in survival was found for patients married at diagnosis versus those who were unmarried at diagnosis (p<0.05). Lower survival rates were observed for patients older than 70 years.

CONCLUSION

Although less prevalent than squamous cell carcinoma, penile non-SCC encompasses a diverse set of neoplasms. Patients in this cohort had a high utilization of surgical management leading to superior outcomes compared to those not receiving surgery. Radiation is an uncommonly pursued treatment pathway. Patient demographics and socioeconomic variables such as marital status may be valuable when investigating cancer outcomes. This updated database analysis can help inform diagnosis, management, and clinical outcomes for this rare group of malignancies.

Squamous Cell Carcinoma of the Bladder: Analysis of Treatments and Outcomes

PURPOSE/OBJECTIVE(S)

Squamous cell carcinoma (SCC) of the bladder is a rare disease composing 2-5% of all bladder cancers. Currently, no consensus exists regarding treatment recommendations for this rare malignancy, although established regimens include various permutations of chemotherapy, radiation, laser treatments, immunotherapies, and surgeries, ranging from pelvic exenteration to local excision. The present study aims to analyze outcomes of the aforementioned treatments to guide clinical decision-making for patients with the disease.

MATERIALS/METHODS

Patients with bladder SCC diagnosed between 2000 and 2018 were reviewed utilizing data from the Surveillance, Epidemiology, and End Results Registry (SEER) program. Data was analyzed using SPSS and Python. Examined variables included presence of metastases at diagnosis, surgery, radiotherapy, and chemotherapy reception. Five-year overall survival (OS) curves were analyzed using Kaplan-Meier probability stratified by treatment modality.

RESULTS

A total of 5,635 patients with bladder SCC were identified; the most abundantly reported demographics were white race (86%), patient age > 70 years (61%), and male sex (63%). Median survival was 13 months and was significantly decreased in patients treated with chemotherapy or radiation (median survival of nine months or 12 months, respectively). Patients treated with radiation and surgery saw a decreased 10-year survival rate of about 10% if no chemotherapy was administered; this difference narrowed to about a 4% decrease in patients treated with chemotherapy. All radical surgical procedures (to include partial and total cystectomy, and total and posterior exenteration) resulted in a statistically significant increase in survival, except for patients that underwent radical cystectomy including anterior exenteration (p = 0.101). Patients that underwent surgery saw an increased median survival of 15 months. Heatmap analysis demonstrated a significant correlation between tumor size and distant metastases (r = 0.898). Preliminary unsupervised cluster analysis identified two distinct patient subgroups characterized most strongly by race and treatment modality used.

CONCLUSION

Bladder SCC carries a high mortality burden, with a median survival time of 13 months after diagnosis. Based on this study's analysis, radical surgery may be the most effective treatment for this disease. This study also sets a precedent for future research, as more advanced machine learning methods (including cluster and binary tree analysis, as was done in this analysis) can be used to identify the most explanatory variables related to improved patient outcomes.

Running towards injury? A prospective investigation of factors associated with running injuries

BACKGROUND

Given the high incidence and heavy burden of running related injuries, large-scale, prospective multifactorial investigations examining potential risk factors are warranted. This study aimed to identify factors associated with running related injuries and to evaluate their potential in injury screening.

STUDY DESIGN

Prospective cohort study.

MATERIALS AND METHODS

Two hundred and seventy-four recreational runners were recruited. Clinical measures (strength, range of motion, foot position), injury and training history (via questionnaire), impact loading (via accelerometery) and running technique measures were collected at baseline. Runners were tracked for injury for one year via fortnightly check-ins. A binary logistic regression, (injury versus no injury), was performed for each variable univariably, and then adjusting for age, sex and mileage. A multivariable regression was also performed to evaluate the model's discriminative ability.

RESULTS

Of the 225 runners included in the final analysis 52% experienced a running related injury. Injury history in the past year, less navicular drop, and measures of running technique (knee, hip, and pelvis kinematics) were associated with increased odds of injury (p < .05). The multivariable logistic regression model was statistically significant, χ2(11) = 56.45, p < .001, correctly classifying 74% of cases with a sensitivity and specificity of 72% and 76%, respectively. The area under the receiver operating characteristic curve was 0.79 (CI95% = 0.73-0.85), demonstrating acceptable discriminative ability.

CONCLUSIONS

This study found a number of clinical and running technique factors to be associated with prospective running related injuries among recreational runners. With the exception of injury history, the factors identified as being significantly associated with injury may be modifiable and therefore, could form the basis of interventions. Range of motion, spatiotemporal parameters and strength measures were not associated with injury and thus their utilisation in injury prevention practices should be reconsidered.

Aetiological Factors of Running-Related Injuries: A 12 Month Prospective "Running Injury Surveillance Centre" (RISC) Study

BACKGROUND

Running-related injuries (RRIs) are a prevalent issue for runners, with several factors proposed to be causative. The majority of studies to date are limited by retrospective study design, small sample sizes and seem to focus on individual risk factors in isolation. This study aims to investigate the multifactorial contribution of risk factors to prospective RRIs.

METHODS

Recreational runners (n = 258) participated in the study, where injury history and training practices, impact acceleration, and running kinematics were assessed at a baseline testing session. Prospective injuries were tracked for one year. Univariate and multivariate Cox regression was performed in the analysis.

RESULTS

A total of 51% of runners sustained a prospective injury, with the calf most commonly affected. Univariate analysis found previous history of injury < 1 year ago, training for a marathon, frequent changing of shoes (every 0-3 months), and running technique (non-rearfoot strike pattern, less knee valgus, greater knee rotation) to be significantly associated with injury. The multivariate analysis revealed previous injury, training for a marathon, less knee valgus, and greater thorax drop to the contralateral side to be risk factors for injury.

CONCLUSION

This study found several factors to be potentially causative of injury. With the omission of previous injury history, the risk factors (footwear, marathon training and running kinematics) identified in this study may be easily modifiable, and therefore could inform injury prevention strategies. This is the first study to find foot strike pattern and trunk kinematics to relate to prospective injury.

The archaeological potential of the northern Luangwa Valley, Zambia: The Luwumbu basin

The Luangwa Basin, Zambia, which forms part of the Zambezi drainage, is strategically located between the Central African plateau and the East African Rift system. The Luangwa River and major tributaries, such as the Luwumbu River, are perennial water sources supporting essential resources that sustain human communities and a rich and diverse fauna and flora. The archaeological record of Luangwa is relatively unknown, despite early archaeological exploration hinting at its potential. Recent research in the southern Luangwa valley, however, suggests that it preserves a long record of hominin occupation spanning the Early to Late Stone Age. The research described here details fieldwork carried out in northeastern Luangwa, in the Luwumbu Basin, that confirms that a relatively deep package of Quaternary deposits, containing evidence of the Stone Age occupation of the region persists in the upper piedmont zone.

Comparison of impact accelerations between injury-resistant and recently injured recreational runners

Introduction/Purpose

Previous injury has consistently been shown to be one of the greatest risk factors for running-related injuries (RRIs). Runners returning to participation following injury may still demonstrate injury-related mechanics (e.g. repetitive high impact loading), potentially exposing them to further injuries. The aim of this study was to determine if the magnitude (Peak_accel) and rate of loading (Rate_accel) at the tibia and sacrum differ between runners who have never been injured, those who have acquired injury resistance (runners who have not been injured in the past 2 years) and those who have been recently injured (RRI sustained 3–12 months ago).

Methods

Runners completed an online survey capturing details of their RRI history over the previous 2 years. Never injured runners were matched by sex, quarterly annual mileage and typical training speed to runners who had acquired injury resistance and to runners who had been recently injured. Differences in Peak_accel and Rate_accel of the tibia and sacrum were assessed between the three groups during a treadmill run at a set speed, with consideration for sex.

Results

A total of 147 runners made up the three injury status groups (n: 49 per group). There was a significant main effect of injury status for Peak_accel and Rate_accel at the sacrum, with recently injured runners demonstrating significantly greater Rate_accel than never injured and acquired injury resistant runners. There was also a significant main effect for sex, with females demonstrating greater tibial Peak_accel, sacrum Peak_accel and Rate_accel than males.

Conclusion

Rate_accel at the sacrum distinguishes recently injured runners from never injured runners and runners who may have acquired injury resistance, potentially highlighting poor impact acceleration attenuation in recently injured runners.

Relative and absolute reliability of shank and sacral running impact accelerations over a short- and long-term time frame

Whilst running is hugely popular, running-related injuries (RRIs) are prevalent. High impact loading has been proposed to contribute to RRIs, with accelerometers becoming increasingly popular in estimating segmental loading for injury detection and biofeedback training. However, there is a lack of research examining the reliability of measures of impact acceleration across short- and long-term time periods, both prior to and following exerted running. The aim of this study was to assess the absolute and relative reliability of shank and sacral impact accelerations over a short- and long-term time period. Peak (Peakaccel) and rate (Rateaccel) of impact acceleration at the shank and sacrum were assessed in 18 recreational runners over short- and long-term time frames, across fixed and self-selected speeds. The relative and absolute reliabilities were investigated for pre- and post-exerted states of running. There was high-to-excellent relative reliability, and predominantly moderate absolute reliability for shank and sacrum Peakaccel and Rateaccel in the short- and long-term time frames between pre- and post-exerted states. High to excellent relative reliability of Peakaccel and Rateaccel at the shank and sacrum are appropriate and acceptable measures across short- and long-term time frames. These findings were consistent with different levels of speed and exertion. The minimal detectable change % was large for both sensors and associated measurements, indicating that their use may be limited to intervention studies that elicit large change (>30%) in these measures.

Promoting resilience in healthcare workers during the COVID-19 pandemic with a brief online intervention

INTRODUCTION

The psychological wellbeing of healthcare workers has been impacted by the high levels of stress many have experienced during the Coronavirus Disease 2019 (COVID-19) pandemic. This study aimed to examine the feasibility and acceptability of a brief online course focused on introducing evidence-based skills that could increase resilience and decreases emotional distress in healthcare workers during the pandemic.

MATERIALS AND METHODS

Employees of a large healthcare system completed a mental health survey at baseline, and then one month and two months after some employees participated in an online resilience-enhancement course consisting of three 12-19 min videos focused on mindfulness, mentalization, and self-compassion.

RESULTS

A total of 554 participants completed the baseline survey, endorsing moderate to high levels of emotional distress. Of those who completed all three assessments and participated in the course (n = 38), significant improvements in resilience and reductions in emotional distress were found one and two months later, in comparison to those who did not participate in the course (n = 110).

DISCUSSION

These findings suggest that a brief, online intervention can improve the mental health of healthcare workers during a crisis such as the COVID-19 pandemic.

Age effects on clinical and neurocognitive risk factors for suicide attempt in depression - Findings from the AFSP lifespan study

BACKGROUND

Studies of risk factors for suicidal behavior are typically restricted to narrow age ranges, making it difficult to determine if they have the same relevance or potency across the full adult lifespan.

METHODS

This study examined selected clinical and neurocognitive risk factors for suicidal behavior - borderline personality traits, aggression, depressive rumination, memory performance, and language fluency- in a multi-site sample (N = 309, ages 16-80) of depressed patients with a recent (last 5 years) suicide attempt or no history of attempt, and demographically similar non-psychiatric controls. We examined cross-sectional age and attempter/non-attempter differences on these risk factors, and whether certain risk factors were more prominent discriminators of past suicide attempt earlier or later in the lifespan. Correlations with age were computed, and logistic regression was used to classify attempter status based on each risk factor and its interaction with age.

RESULTS

Nearly all risk factors were negatively correlated with age. Borderline traits, aggression, memory, and category fluency each predicted attempter status (p < 0.05), but these effects were not different across ages. In contrast, the association between rumination and suicide attempt status differed across the lifespan, becoming a stronger discriminator of past suicidal behavior at older ages.

LIMITATIONS

The cross-sectional design limits our developmental findings.

CONCLUSIONS

Despite age-related changes in symptom severity or neurocognitive performance, key risk factors for suicidal behavior previously identified in studies with more restricted age-ranges are salient throughout the adult lifespan. In contrast, depressive rumination may be particularly salient in later life.

Risk Factors for Injuries in Runners: A Systematic Review of Foot Strike Technique and Its Classification at Impact

Background:

It has been suggested that foot strike technique (FST) at initial contact is related to running-related injuries (RRIs).

Purpose:

To explore the relationship between FST and RRIs.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

A systematic electronic search was performed using MEDLINE, PubMed, SPORTDiscus, Scopus, and Web of Science databases. Included were studies published in the English language that explored the relationship between FST and RRIs between January 1960 and November 2020. Results were extracted and collated. The Grading of Recommendations, Assessment, Development and Evaluation approach was applied to synthesize the quality of evidence.

Results:

We reviewed 13 studies exploring the relationship between FST and RRIs. Of these, 6 studies reported FST categorically (foot strike pattern [FSP]), and 7 reported continuous measures (foot contact angle, ankle flexion angle, and strike index). Three of the 6 studies looking at categorical FSP found rearfoot strikers have a significantly greater retrospective injury rate than do non– rearfoot strikers, with 1 other study noting a greater risk associated with midfoot and forefoot strike. Regarding the continuous measures of FST, only 1 of the 7 studies reported a significant relationship with RRIs.

Conclusion:

There was low evidence to suggest a relationship between FST (or its subcategories of categorical FSP and continuous measures) and RRIs. While two-thirds of the categorical studies found a relationship between FSP and RRIs, these studies were very low quality, with limitations such as retrospective study design, low participant numbers, and poor FSP assessment methods. More large-scale prospective studies are required.

Do Injury-Resistant Runners Have Distinct Differences in Clinical Measures Compared with Recently Injured Runners?

INTRODUCTION

Although lower extremity muscle strength, joint motion, and functional foot alignment are commonly used, time-efficient clinical measures that have been proposed as risk factors for running-related injuries, it is unclear if these factors can distinguish injury resistance in runners.

PURPOSE

This study compares clinical measures, with consideration of sex, between recently injured runners (3 months to 1 yr prior), those with a high level of injury resistance who have been uninjured for at least 2 yr, and never-injured runners.

METHODS

Averaged bilateral values and between-limb symmetry angles of lower limb isometric muscle strength, joint motion, navicular drop, and foot posture index (FPI) were assessed in a cohort of recreational runners, and their injury history was recorded. Differences in clinical measures between injury groupings were examined, with consideration of sex.

RESULTS

Of the 223 runners tested, 116 had been recently injured, 61 had been injured >2 yr ago and were deemed to have acquired reinjury resistance, and 46 were never injured. Plantarflexion was greater in both recently injured (P = 0.001) and acquired reinjury resistance runners (P = 0.001) compared with never-injured runners. Recently injured runners displayed higher hip abduction strength compared with never-injured runners (P = 0.019, η2 = 0.038, small effect size). There were no statistically significant differences in the remaining measures between the injury groupings. With the exception of FPI, there was no interaction between sex and injury grouping for any of the measures.

CONCLUSION

Commonly used clinical measures of strength, joint motion, and functional foot alignment were not superior in injury-resistant runners compared with recently injured runners, questioning their relevance in identifying future injury resistance of runners.

Overturning circulation, nutrient limitation, and warming in the Glacial North Pacific

Although the Pacific Ocean is a major reservoir of heat and CO₂, and thus an important component of the global climate system, its circulation under different climatic conditions is poorly understood. Here, we present evidence that during the Last Glacial Maximum (LGM), the North Pacific was better ventilated at intermediate depths and had surface waters with lower nutrients, higher salinity, and warmer temperatures compared to today. Modeling shows that this pattern is well explained by enhanced Pacific meridional overturning circulation (PMOC), which brings warm, salty, and nutrient-poor subtropical waters to high latitudes. Enhanced PMOC at the LGM would have lowered atmospheric CO₂-in part through synergy with the Southern Ocean-and supported an equable regional climate, which may have aided human habitability in Beringia, and migration from Asia to North America.

Clinic time required to manage cardiac implantable electronic device patients: a time and motion workflow evaluation

Background

The population with cardiac implantable electronic devices (CIEDs) is growing, creating workload for device clinics to manage these patients. However, the CIED follow-up workflow is poorly understood. This study sought to characterize the workflow and staff time for CIED patient management.

Methods

A time and motion workflow evaluation was performed in 6 U.S. CIED clinics, which manage an average of 4,217 patients. Each task involved in CIED management was repeatedly timed, including all manufacturers, during 1 business week at each clinic. Mean staff time for a remote transmission and an in-person visit were calculated, including all clinical and administrative (e.g: scheduling, documentation) activities related to the encounter. Annual staff time for follow-up of 1 patient was modeled using CIED transmission data for the 6 clinics, guidelines for CIED follow-up, and published literature.

Results

124 clinic visits and 1,374 remote monitoring activities were observed. Staff time required per remote transmission ranged from 12.1–13.4 minutes (depending on the CIED type), and time per visit was 43.4–51.0 minutes. Including all remote and in-person follow-ups, the estimated total staff time per year to manage one pacemaker, ICD, CRT, and ICM patient was 2.3, 2.4, 2.4, and 9.3 hours, respectively (Table 1).

Conclusion

CIED clinic workflow is complex and requires significant staff time. Remote monitoring is an efficient complement to in-office visits, allowing for continuous follow-up of patients. Future research should examine heterogeneity in clinic processes to identify the most efficient workflow.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Medtronic

Brain cytochrome-c-oxidase as a marker of mitochondrial function: A pilot study in major depression using NIRS

BACKGROUND

Brain mitochondrial dysfunction is implicated in the pathophysiology of mood disorders. Brain cytochrome-c-oxidase (COX) activity is associated with the mitochondrial function. Near-infrared spectroscopy (NIRS) noninvasively measures oxidized COX (oxCOX) and tissue oxygenation index (TOI) reflecting cerebral blood flow and oxygenation.

METHODS

oxCOX and TOI were assessed in prefrontal cortex (Fp1/2, Brodmann area 10) in patients in a major depressive episode (N = 13) with major depressive disorder (MDD; N = 7) and bipolar disorder (BD; N = 6) compared with the controls (N = 10). One patient with MDD and all the patients with BD were taking medications. Computational modeling estimated oxCOX and TOI related indices of mitochondrial function and cerebral blood flow, respectively.

RESULTS

oxCOX was lower in patients than controls (p = .014) correlating inversely with depression severity (r = -.72; p = .006), driven primarily by lower oxCOX in BD compared with the controls. Computationally modeled mitochondrial parameters of the electron transport chain, such as the nicotinamide adenine dinucleotide ratio (NAD⁺ /NADH; p = .001) and the proton leak rate across the inner mitochondrial membrane (k_lk2 ; p = .008), were also lower in patients and correlated inversely with depression severity. No such effects were found for TOI.

CONCLUSIONS

In this pilot study, oxCOX and related mitochondrial parameters assessed by NIRS indicate an abnormal cerebral metabolic state in mood disorders proportional to depression severity, potentially providing a biomarker of antidepressant effect. Because the effect was driven by the medicated BD group, findings need to be evaluated in a larger, medication-free population.

Improving North Atlantic Marine Core Chronologies Using 230Th Normalization

Producing independent and accurate chronologies for marine sediments is a prerequisite to understand the sequence of millennial-scale events and reveal potential temporal offsets between marine and continental records, or between different marine records, possibly from different regions. The last 40 ky is a generally well-constrained period since radiocarbon (14C) can be used as an absolute dating tool. However, in the northern North Atlantic, calendar ages cannot be directly derived from 14C ages, due to temporal and spatial variations of surface reservoir ages. Alternatively, chronologies can be derived by aligning Greenland ice-core time series with marine surface records. Yet this approach suffers from the lack of clearly defined climatic events between 14.7 and 23.3 cal ky BP (hereafter ka), a crucial period encompassing Heinrich Stadial 1 and the onset of the last deglaciation. In this study, (i) we assess the benefits of 230Th normalization to refine the sedimentation history between surface temperature alignment tie points and (ii) revisit the chronologies of three North Atlantic marine records. Our study supports the contention that the marked increase in the Greenland Ca2+ record at 17.48 ka ± 0.21 ky (1σ) occurred within dating uncertainty of sea surface temperature cooling in the North Atlantic at the onset of Heinrich Stadial 1. This sharp feature might be useful for future chronostratigraphic alignments to remedy the lack of chronological constraint between 14.7 and 23.3 ka for North Atlantic marine records that are subject to large changes in 14C surface reservoir age.

CO2 storage and release in the deep Southern Ocean on millennial to centennial timescales

The cause of changes in atmospheric carbon dioxide (CO₂) during the recent ice ages is yet to be fully explained. Most mechanisms for glacial-interglacial CO₂ change have centred on carbon exchange with the deep ocean, owing to its large size and relatively rapid exchange with the atmosphere¹. The Southern Ocean is thought to have a key role in this exchange, as much of the deep ocean is ventilated to the atmosphere in this region². However, it is difficult to reconstruct changes in deep Southern Ocean carbon storage, so few direct tests of this hypothesis have been carried out. Here we present deep-sea coral boron isotope data that track the pH-and thus the CO₂ chemistry-of the deep Southern Ocean over the past forty thousand years. At sites closest to the Antarctic continental margin, and most influenced by the deep southern waters that form the ocean's lower overturning cell, we find a close relationship between ocean pH and atmospheric CO₂: during intervals of low CO₂, ocean pH is low, reflecting enhanced ocean carbon storage; and during intervals of rising CO₂, ocean pH rises, reflecting loss of carbon from the ocean to the atmosphere. Correspondingly, at shallower sites we find rapid (millennial- to centennial-scale) decreases in pH during abrupt increases in CO₂, reflecting the rapid transfer of carbon from the deep ocean to the upper ocean and atmosphere. Our findings confirm the importance of the deep Southern Ocean in ice-age CO₂ change, and show that deep-ocean CO₂ release can occur as a dynamic feedback to rapid climate change on centennial timescales.

Are comorbid anxiety disorders a risk factor for suicide attempts in patients with mood disorders? A two-year prospective study

BACKGROUND

Comorbid anxiety disorders have been considered a risk factor for suicidal behavior in patients with mood disorders, although results are controversial. The aim of this two-year prospective study was to determine if lifetime and current comorbid anxiety disorders at baseline were risk factors for suicide attempts during the two-year follow-up.

METHODS

We evaluated 667 patients with mood disorders (504 with major depression and 167 with bipolar disorder) divided in two groups: those with lifetime comorbid anxiety disorders (n=229) and those without (n=438). Assessments were performed at baseline and at 3, 12, and 24 months. Kaplan-Meier survival analysis and log-rank test were used to evaluate the relationship between anxiety disorders and suicide attempts. Cox proportional hazard regression was performed to investigate clinical and demographic variables that were associated with suicide attempts during follow-up.

RESULTS

Of the initial sample of 667 patients, 480 had all three follow-up interviews. During the follow-up, 63 patients (13.1%) attempted suicide at least once. There was no significant difference in survival curves for patients with and without comorbid anxiety disorders (log-rank test=0.269; P=0.604). Female gender (HR=3.66, P=0.001), previous suicide attempts (HR=3.27, P=0.001) and higher scores in the Buss-Durkee Hostility Inventory (HR=1.05, P≤0.001) were associated with future suicide attempts.

CONCLUSIONS

Our results suggest that comorbid anxiety disorders were not risk factors for suicide attempts. Further studies were needed to determine the role of anxiety disorders as risk factors for suicide attempts.

A Novel Polyurethane Film for Biomedical Use

Polyurethane films were prepared from toluene diisocyanate (TDI), and poly(propylene-ethylene)glycol without catalyst. These films had a decrease in tensile strength and an increase in ultimate elongation when the TDI content of the polymers was decreased. The effects of aging and accelerated aging on completion of polymerization and on mechanical properties were examined. In the case of accelerated aging samples, complete polymerization with no change in mechanical properties was observed. Blood compatibility tests were carried out and the examination of the surfaces revealed no clotting, aggregation of blood cells, or fibrin formation.

Polyurethane Membranes

Poly(ether urethane) membranes were synthesized from toluene diisocyanate (TDI), and poly(propylene-ethylene) glycol. Catalysts, chain extenders, solvents, or other reagents were not used during the preparation to make the biomedical grade membranes. Density, water content, oxygen diffusivity, and the surface thrombogenicity were examined and the presence of the extractables was searched. A decrease in density and an increase in water content and oxygen permeability was observed with an increase in polyol content of the mem branes. Extraction of leachables in solvents was observed which was prevented by accelerated aging that had no effect on the other properties examined.

Constituents of Cuscuto Reflexa are anti-HIV Agents

Crude water extracts of Cuscuta reflexa exhibited anti-HIV activity. Fractionation of the crude extract led to the isolation of nine pure compounds with closely related structures, showing interesting structure activity relationships. 3,5,7,4′-Tetrahydroxyflavanone (aromadendrin) inhibited infection by binding to V3 loop of gp 120 and inhibiting its interaction with CD4, whereas 3,5,7,3′,4′-pentahydroxyflavanone (taxifolin), with an extra OH group in the 3′ position in ring B was less specific and exhibited less selectivity in cell cultures. In general, flavanones containing an extra OH group in the 3′ position (taxifolin, taxifolin-7-O-β-D-glucopyranoside and coccinoside B) were less specific and inhibited viral protease, reverse transcriptase, CD4 /gp120 interaction in vitro and bound to non specific proteins. Other compounds isolated from C reflexa were derivatives of quinic acids; 3,4-O-dicaffeoylquinic acid was more active than 3-O-caffeoyl quinic acid. The anti-HIV activity of crude extract may be the result of combinatory effects with compounds of different modes of action.

Inhibition of the Production of HIV-1 from Chronically Infected H9 Cells by Metal Compounds and Their Complexes with L-cysteine or N-acetyl-L-cysteine

A number of metal compounds and their complexes with cysteine and N-acetyl-cysteine (NAC) were tested for their ability to inhibit HIV replication in vitro, specifically in chronically infected H9 cells (which produce virus continuously). Out of seven metal compounds tested, only bismuth nitrate and bismuth sodium tartrate inhibited virus production in chronically infected H9 cells. The complexes made with metals and cysteine or NAC had slightly improved selective indices.

A high-intensity, intermittent exercise protocol and dynamic postural control in men and women

CONTEXT

Deficits in dynamic postural control predict lower limb injury. Differing fatiguing protocols negatively affect dynamic postural control. The effect of high-intensity, intermittent exercise on dynamic postural control has not been investigated.

OBJECTIVE

To investigate the effect of a high-intensity, intermittent exercise protocol (HIIP) on the dynamic postural control of men and women as measured by the Star Excursion Balance Test (SEBT).

DESIGN

Descriptive laboratory study.

SETTING

University gymnasium.

PATIENTS OR OTHER PARTICIPANTS

Twenty male (age = 20.83 ± 1.50 years, height = 179.24 ± 7.94 cm, mass = 77.67 ± 10.82 kg) and 20 female (age = 20.45 ± 1.34 years, height = 166.08 ± 5.83 cm, mass = 63.02 ± 6.67 kg) athletes.

INTERVENTION(S)

We recorded SEBT measurements at baseline, pre-HIIP, and post-HIIP. The HIIP consisted of 4 repetitions of 10-m forward sprinting with a 90° change of direction and then backward sprinting for 5 m, 2 repetitions of 2-legged jumping over 5 hurdles, 2 repetitions of high-knee side stepping over 5 hurdles, and 4 repetitions of lateral 5-m shuffles. Participants rested for 30 seconds before repeating the circuit until they reported a score of 18 on the Borg rating of perceived exertion scale.

MAIN OUTCOME MEASURE(S)

A mixed between- and within-subjects analysis of variance was conducted to assess time (pre-HIIP, post-HIIP) × sex interaction effects. Subsequent investigations assessed the main effect of time and sex on normalized maximal SEBT scores. We used intraclass correlation coefficients to determine the test-retest reliability of the SEBT and paired-samples t tests to assess the HIIP effect on circuit times.

RESULTS

We found a time × sex effect (F(8,69) = 3.5; P range, <.001-.04; η(2) range, 0.057-0.219), with women less negatively affected. We also noted a main effect for time, with worse normalized maximal SEBT scores postfatigue (F(8,69) = 22.39; P < .001; η(2) range, 0.324-0.695), and for sex, as women scored better in 7 SEBT directions (F(8,69) = 0.84; P range, <.001-008; η(2) range, 0.088-0.381). The intraclass correlation coefficients demonstrated high (0.77-0.99) test-retest repeatability. Paired-samples t tests demonstrated increases in circuit time post-HIIP (P < .001).

CONCLUSIONS

The HIIP-induced fatigue negatively affected normalized maximal SEBT scores. Women had better scores than men and were affected less negatively by HIIP-induced fatigue.