Engagement with three or more healthy lifestyle behaviours is associated with improved quality of life over 7.5 years in people with multiple sclerosis

BACKGROUND AND PURPOSE

People with multiple sclerosis (pwMS) report reduced quality of life (QoL). Engagement with healthy lifestyle behaviours, including consuming a healthy diet, regular physical activity, and adequate vitamin D exposure, is associated with higher QoL. We aim to assess whether individual lifestyle behaviours are more beneficial to QoL than others, and whether there are additive benefits to QoL by engaging in multiple healthy behaviours concurrently.

METHODS

Data from pwMS who completed an online survey at baseline, and at 2.5-, 5- and 7.5-year follow-up, were analysed. Behaviours assessed were consumption of a no-meat/dairy-plus-omega-3 supplementation diet, meditation practice, physical activity, non-smoking, and vitamin D exposure. Mental QoL (mQoL) and physical QoL (pQoL) were assessed by the Multiple Sclerosis Quality of Life (MSQOL-54) questionaire. Linear regression analyses were performed to assess associations of individual behaviours at baseline and follow-up time points with QoL, as well as between number of behaviours and QoL.

RESULTS

At baseline, healthy diet and regular physical activity were associated with higher mQoL (5.3/100 and 4.0/100) and higher pQoL (7.8/100 and 6.7/100). Prospectively, diet was positively associated with mQoL, and physical activity with both mQoL and pQoL. At baseline, engagement with ≥3 behaviours was positively associated with mQoL and pQoL, with additive positive associations for each additional behaviour. Prospectively, engagement with ≥3 behaviours was positively associated with mQoL and pQoL, with strongest associations observed with engagement with five behaviours.

CONCLUSION

Consumption of a healthy diet, and regular physical activity, are both potential interventions to improve QoL. Engagement with multiple lifestyle behaviours may provide additional benefits and should be encouraged and supported for multiple sclerosis management.

Study protocol for an online lifestyle modification education course for people living with multiple sclerosis: the multiple sclerosis online course (MSOC)

BACKGROUND

People living with multiple sclerosis (plwMS) seek access to information on evidence-based lifestyle-related risk factors associated with multiple sclerosis (MS). As the internet has made delivery of lifestyle information increasingly accessible and cost-effective, we designed the Multiple Sclerosis Online Course (MSOC) to deliver a multimodal lifestyle modification program for plwMS. Two MS online courses were developed: the intervention course based on lifestyle recommendations of the Overcoming Multiple Sclerosis (OMS) program and the standard-care course representing standard lifestyle recommendations from other MS websites. We examined for feasibility in a pilot randomised controlled trial (RCT), where satisfactory completion and accessibility were achieved across both study arms. From this success, a protocol for a larger RCT was developed to examine the effectiveness of MSOC in improving health-related quality of life (HRQoL) and other health outcomes in plwMS.

METHODS/DESIGN

This single-blinded RCT will recruit n = 1,054 plwMS. Participants in the intervention arm will receive access to a MSOC with seven modules providing evidence-based information on the OMS program. Participants in the control group will receive access to a MSOC of identical format, with seven modules providing general MS-related information and lifestyle recommendations sourced from popular MS websites, e.g. MS societies. Participants will complete questionnaires at baseline and at 6, 12, and 30 months after course completion. The primary endpoint is HRQoL, as measured by MSQOL-54 (both physical and mental health domains) at 12 months following course completion. Secondary outcomes are changes to depression, anxiety, fatigue, disability, and self-efficacy as measured by Hospital Anxiety and Depression Scale, Patient-Determined Disease Steps and University of Washington Self-Efficacy Scale, respectively, assessed at each timepoint. Further assessments will include quantitative post-course evaluation, adoption and maintenance of behaviour change from follow-up survey data, and qualitative analysis of participants' outcomes and reasons for course completion or non-completion.

DISCUSSION

This RCT aims to determine whether an online intervention course delivering evidence-based lifestyle modification recommendations based on the Overcoming Multiple Sclerosis program to plwMS is more effective at improving HRQoL, and other health outcomes post-intervention, compared with an online standard-care course.

TRIAL REGISTRATION

This trial was registered prospectively with the Australian New Zealand Clinical Trials Registry, www.anzctr.org.au , identifier ACTRN12621001605886.

DATE OF REGISTRATION

25 November 2021.

Applying multidimensional computerized adaptive testing to the MSQOL-54: a simulation study

BACKGROUND

The Multiple Sclerosis Quality of Life-54 (MSQOL-54) is one of the most commonly-used MS-specific health-related quality of life (HRQOL) measures. It is a multidimensional, MS-specific HRQOL inventory, which includes the generic SF-36 core items, supplemented with 18 MS-targeted items. Availability of an adaptive short version providing immediate item scoring may improve instrument usability and validity. However, multidimensional computerized adaptive testing (MCAT) has not been previously applied to MSQOL-54 items. We thus aimed to apply MCAT to the MSQOL-54 and assess its performance.

METHODS

Responses from a large international sample of 3669 MS patients were assessed. We calibrated 52 (of the 54) items using bifactor graded response model (10 group factors and one general HRQOL factor). Then, eight simulations were run with different termination criteria: standard errors (SE) for the general factor and group factors set to different values, and change in factor estimates from one item to the next set at < 0.01 for both the general and the group factors. Performance of the MCAT was assessed by the number of administered items, root mean square difference (RMSD), and correlation.

RESULTS

Eight items were removed due to local dependency. The simulation with SE set to 0.32 (general factor), and no SE thresholds (group factors) provided satisfactory performance: the median number of administered items was 24, RMSD was 0.32, and correlation was 0.94.

CONCLUSIONS

Compared to the full-length MSQOL-54, the simulated MCAT required fewer items without losing precision for the general HRQOL factor. Further work is needed to add/integrate/revise MSQOL-54 items in order to make the calibration and MCAT performance efficient also on group factors, so that the MCAT version may be used in clinical practice and research.

Higher diet quality is associated with short and long-term benefits on SF-6D health state utilities: a 5-year cohort study in an international sample of people with multiple sclerosis

BACKGROUND/PURPOSE

Health state utilities (HSU) are a subjective measure of an individual's health-related quality of life (HRQoL), adjusted by societal or patient relative preference weights for living in different states of health-related quality of life (HRQoL), derived from patient-reported responses to multi-attribute utility instrument (MAUI), and can be used as inputs for cost-utility analyses and in clinical assessment. This research assessed associations of diet with subsequent HSU in a large international cohort of people living with multiple sclerosis (MS), a progressive autoimmune condition of the central nervous system.

METHODS

HSUs were generated from responses to Short-Form Six-Dimension (SF-6D) MAUI, and quality-of-the-diet by Diet Habits Questionnaire (DHQ). Cross-sectional, and short- and long-term prospective associations of DHQ with HSU evaluated by linear regression at 2.5- and 5-years. Pooled prospective associations between DHQ and HSU evaluated using linear and quantile regression. Analyses adjusted for relevant demographic and clinical covariates.

RESULTS

Among 839 participants, baseline DHQ scores showed short- and long-term associations with subsequent HSU, each 10-unit increase in total DHQ score associated with 0.008-0.012 higher HSU (out of 1.00). These associations were dose-dependent, those in the top two quartiles of baseline DHQ scores having 0.01-0.03 higher HSU at follow-up, 0.03 being the threshold for a minimally clinically important difference. Fat, fiber, and fruit/vegetable DHQ subscores were most strongly and consistently associated with better HSU outcomes. However, baseline meat and dairy consumption were associated with 0.01-0.02 lower HSU at subsequent follow-up.

CONCLUSIONS

A higher quality-of-the-diet showed robust prospective relationships with higher HSUs 2.5- and 5-years later, substantiating previous cross-sectional relationships in this cohort. Subject to replication, these results suggest interventions to improve the quality-of-the-diet may be effective to improve HRQoL in people living with MS.

Self-reported ongoing adherence to diet is associated with lower depression, fatigue, and disability, in people with multiple sclerosis

Introduction

Increasingly, dietary improvements have been shown to have positive associations with health outcomes in people with multiple sclerosis (pwMS). However, adhering to a MS-specific or high-quality diet may be a challenge. We therefore assessed the level of diet-adherence necessary to improve health outcomes of depression, fatigue, and disability.

Methods

Data from an international population of pwMS followed over 7.5 years (n = 671) were analyzed. Self-reported diet quality via diet habits questionnaire (DHQ), and adherence to six MS-diets [Ashton Embry Best Bet, McDougall, Overcoming MS (OMS), Paleolithic (Paleo), Swank, and Wahls] were queried at two timepoints. Four levels of diet adherence were assessed: non-adherence at either timepoint; ceased at second timepoint; commenced at second timepoint; and ongoing at both timepoints. Associations between adherence to OMS and high-quality diet (DHQ score > median) with depression, fatigue, and disability, were assessed by log-binomial regression models adjusted for confounders.

Results

Forty-two percent of pwMS reported ongoing-adherence to a MS-diet at both timepoints, OMS (33%), Swank (4%), Wahls (1.5%), other (<1%). Of these, only OMS-diet adherence was analyzed for associations due to data availability. Ongoing-adherence to the OMS-diet or a high-quality diet, was associated with lower depression compared to non-adherence [OMS: Risk ratios (RR) = 0.80, p = 0.021; DHQ: RR = 0.78, p = 0.009] and ceased-adherence (OMS: RR = 0.70, p = 0.008; DHQ: RR = 0.70, p = 0.010), respectively. Ongoing-adherence to OMS-diet was associated with lower fatigue (RR = 0.71, p = 0.031) and lower severe disability (RR = 0.43, p = 0.033) compared to ceased-adherence.

Conclusion

Results suggest potential benefits of adherence to the OMS- or a high-quality diet on MS health outcomes, with ongoing-adherence likely best. Diet modification and maintenance may serve as a point of intervention to manage MS symptoms, especially depression, in pwMS.

Using Online 24-h Dietary Methodology to Validate the Psychometric Properties of a Dietary Scoring Tool with an International Sample of Adults Living with Multiple Sclerosis

Understanding the dietary characteristics of people living with multiple sclerosis (plwMS) may assist in the planning of nutrition interventions for multiple sclerosis; yet dietary assessment methods in existing studies are not well established. The aim of this study was to validate the psychometric properties (construct validity and internal consistency) of the Dietary Habits Questionnaire (DHQ) against repeated online 24-h recall dietary assessments. The DHQ is a 24-item tool that is scored using ten dietary sub-scores. Total DHQ scores can range from 20−100 and are considered indicative of the quality of dietary intake with higher scores reflecting increased quality. People living with a relapsing-remitting MS phenotype who had completed a modified DHQ were recruited from the international Health Outcomes and Lifestyle In a Sample of people with Multiple sclerosis (HOLISM) cohort. Repeated 24-h recall via the online Automated Self-administered Assessment-24 (ASA-24) tool were modelled to reflect usual dietary intakes using the Multiple Source Method. DHQ scores of eight sub-scores: three key nutrients, three food groups and two food preparation practices, were calculated and statistically compared with ASA-24 usual intake data. Principal component analysis of the ASA-24 data was undertaken to understand dietary patterns of the sample. Of the 105 participants, valid 24-h recall data were available for 96 plwMS (n = 66 1 day, n = 30 ≥ 2 day). The median total DHQ score was 84.50 (IQR: 77.04, 91.83) points. The highest absolute correlations were between the DHQ scores and ASA-24 data for cereal (r = 0.395, p < 0.001), fruit and vegetables (r = 0.436, p < 0.001), and total dietary fiber (r = 0.482, p < 0.001). Five dietary patterns emerged from the data explaining 42.12% variance and reflecting exposure of plwMS to the influence of ‘MS diets’. The DHQ appears to be appropriate for screening participants with relapsing-remitting MS. Evidence-based dietary models focusing on food are required to monitor the quality of an overall dietary pattern and set priorities for the planning nutrition interventions for plwMS.

Attrition Within Digital Health Interventions for People With Multiple Sclerosis: Systematic Review and Meta-analysis

Background

Digital health interventions have revolutionized multiple sclerosis (MS) care by supporting people with MS to better self-manage their disease. It is now understood that the technological elements that comprise this category of digital health interventions can influence participant engagement in self-management programs, and people with MS can experience significant barriers, influenced by these elements, to remaining engaged during a period of learning. It is essential to explore the influence of technological elements in mitigating attrition.

Objective

This study aimed to examine the study design and technological elements of documented digital health interventions targeted at people with MS—digital health interventions that were intended to support a program of engagement over a defined period—and to explore how these correlated with attrition among participants of randomized controlled trials (RCTs).

Methods

We conducted a systematic review and meta-analysis of RCTs (n=32) describing digital health self-management interventions for people with MS. We analyzed attrition in included studies, using a random-effects model and meta-regression to measure the association between potential moderators.

Results

There were no measured differences in attrition between the intervention and control arms; however, some of the heterogeneity observed was explained by the composite technological element score. The pooled attrition rates for the intervention and control arms were 14.7% and 15.6%, respectively.

Conclusions

This paper provides insight into the technological composition of digital health interventions designed for people with MS and describes the degree of attrition in both study arms. This paper will aid in the design of future studies in this area, particularly for digital health interventions of this type.

Viability of a MSQOL-54 general health-related quality of life score using bifactor model

Background

MSQOL-54 is a multidimensional, widely-used, health-related quality of life (HRQOL) instrument specific for multiple sclerosis (MS). Findings from the validation study suggested that the two MSQOL-54 composite scores are correlated. Given this correlation, it could be assumed that a unique total score of HRQOL may be calculated, with the advantage to provide key stakeholders with a single overall HRQOL score. We aimed to assess how well the bifactor model could account for the MSQOL-54 structure, in order to verify whether a total HRQOL score can be calculated.

Methods

A large international database (3669 MS patients) was used. By means of confirmatory factor analysis, we estimated a bifactor model in which every item loads onto both a general factor and a group factor. Fit of the bifactor model was compared to that of single and two second-order factor models by means of Akaike information and Bayesian information criteria reduction. Reliability of the total and subscale scores was evaluated with Mc Donald’s coefficients (omega, and omega hierarchical).

Results

The bifactor model outperformed the two second-order factor models in all the statistics. All items loaded satisfactorily (≥ 0.40) on the general HRQOL factor, except the sexual function items. Omega coefficients for total score were very satisfactory (0.98 and 0.87). Omega hierarchical for subscales ranged between 0.22 to 0.57, except for the sexual function (0.70).

Conclusions

The bifactor model is particularly useful when it is intended to acknowledge multidimensionality and at the same time take account of a single general construct, as the HRQOL related to MS. The total raw score can be used as an estimate of the general HRQOL latent score.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-021-01857-y.

125Clinical & demographic determinants of self-reported diet program adherence in people living with multiple sclerosis

Background

A range of diets have been recommended for people living with MS, ranging from low or no-meat Swank-inspired diets, to the modified Palaeolithic Wahls diet. While the clinical efficacy of these diets to modulate MS progression is uncertain, the popularity of these diets amongst people living with MS is manifest.

Methods

Data derived from the 5-year review of the HOLISM international cohort study. Self-reported adherence to diets were queried, ranging 1-5. Adherence was restricted to ≥ 12months adherence, and then dichotomised: those reporting 4-5/5 adherence defined 2nd-most adherent, 3-5/5 adherence defined 3rd-most adherent. Determinants of adherence were evaluated by log-binomial regression, adjusted for age, sex, socioeconomic status (SES), education, and fatigue. Due to low numbers, only the Overcoming MS (OMS), Swank and Wahls diets were quantitatively evaluated.

Results

458/952 (48.1%) reported following MS-specific diets for ≥12months; 61.8% followed OMS, 12.7% Swank, 3.5% Wahls, 0.9% Ashton-Embry, 0.9% McDougal, 5.7% other. OMS adherence (2nd-most) was more common among males, higher SES, lower disability, less fatigue, and fewer comorbidities. Wahls adherence (2nd-most) was more common among participants with progressive MS or greater disability. Swank adherence (2nd-most) did not vary by any parameter. Analogous results were found using the 3rd-most adherent definition.

Conclusions

These results indicate that MS-specific diet adherence is common in this patient population, but uptake is highly heterogenous between demographic and clinical subgroups. Further study of diet uptake among MS patients is indicated, particularly as the efficacy of these diets in MS is yet uncertain.

Key messages

There is evidence for a marked tribalisation of diet adherence between the OMS, Swank, and Wahls diets, the former being more common among less clinically active RRMS participants and Wahls more common among more clinically active progressive participants.

509Healthy-lifestyle-scores associated with lower subsequent fatigue risk in multiple sclerosis using inverse probability treatment weighting

Background

Several lifestyle factors have been associated with the onset and progression of multiple sclerosis (MS). Combining these lifestyle factors into scoring indices is an efficient way to assess their collective relationship with clinical outcomes. We examined the association of two lifestyle scores with clinically significant fatigue and change thereof over two years’ follow-up.

Methods

Data on sociodemographic, lifestyle and clinical characteristics surveyed from the international HOLISM cohort of people with MS at baseline and 2.5-year follow-up. Fatigue was defined by Fatigue Severity Scale (FSS), and healthy lifestyle by the Healthy Lifestyle Index Score (HLIS), and SNAP (Smoking, Nutrition, Alcohol, Physical Activity) score. Analyses by standard logistic and inverse probability treatment weighting (IPTW) models adjusted for age, sex, MS type, disability, comorbidity number, immunomodulatory medication use, prescription antifatigue medication use, and ongoing relapse symptoms; change in fatigue models also adjusted for baseline fatigue.

Results

1,160 participants completed the FSS questionnaire at both timepoints, and roughly 62% had fatigue at each timepoint. By logistic regression, baseline HLIS and SNAP were each associated with lower risk of being fatigued at follow-up, persisting on adjustment. Using doubly-robust IPTW these associations were attenuated but high HLIS (OR = 0.89, 95% CI = 0.81-0.97) and SNAP (OR = 0.82, 95% CI = 0.73-0.90) were each associated with lower risk of fatigue at follow-up. Evaluating change in fatigue, however, there was no consistent association of either HLIS or SNAP score by either statistical method.

Conclusions

In this sample of people with MS, healthy lifestyle scores were associated with less fatigue 2.5 years later, though not with change in fatigue over this interval.

178Depression but not physical activity mediates the fatigue-mental quality of life relationship in multiple sclerosis

Background

Fatigue is among the most prevalent symptoms of multiple sclerosis (MS), and significantly detrimental to mental quality of life. We examined the role of depression and physical activity as mediators in the fatigue-QoL relationship in MS.

Methods

Using an international study cohort measuring a wide range of lifestyle and clinical factors, determinants of fatigue (Fatigue Severity Scale) and mental quality of life (MSQoL-54; QoL) were assessed in 2,104 participants using log-binomial and linear regression, respectively. Structural equation modelling (SEM) was used to assess the mediating role of depression and physical activity between fatigue and mental QoL.

Results

The median mental QoL score in the sample was 73.8/100. The mean fatigue score was 40.5/63, with 65.6% having clinically significant fatigue. In SEM analyses evaluating depression as a mediator of the fatigue-QoL relationship, mental QoL was 14.17-points lower in those with clinically significant fatigue, of which the indirect effect via depression accounted for over 30.8% (p &lt; 0.001). This mediation effect was most pronounced for the Role Limitations from Emotional Issues (44.9%, p &lt; 0.001) and Emotional Wellbeing (41.6%, p &lt; 0.001) subdomains. Evaluating physical activity as a mediator of the fatigue-QoL relationship, mental QoL was 11.03-points lower in those with clinically significant fatigue, of which the indirect effect via physical activity accounted for only 1.0% (p = 0.001).

Conclusions

This study provides evidence that depression accounts for a majority of the fatigue-mental QoL relationship, while physical activity only plays a small role. While replication and longitudinal studies are required for validation, our findings may inform the development of treatments for reducing the impacts of fatigue and improving QoL in people with MS.

Key messages

Fatigue’s negative impact on emotional quality of life in multiple sclerosis is not a function of reduced ambulation but instead its impact on depression. Reducing depression may thus markedly improve quality of life in this population.

1293Identifying Shared Symptoms and Comorbidities to Inform Risk Reduction Strategies Across Prevalent Neurological disorders

Background

The global burden of neurological disorders continues to grow. Many have a long disease course and symptoms that can impact daily living and reduce quality of life. Common symptoms are reported across neurological disorders, however, have not been assessed in detail. Assessment of shared symptoms and conditions across neurological disorders may provide insight into similar risk reduction and disease management opportunities.

Methods

Data from an Australian cohort (n = 192,091) were analysed. Log-binomial regression assessed shared symptoms and comorbidities in ten pre-defined categories across people with Alzheimer’s disease (AD), stroke, motor neuron disease (MND), multiple sclerosis (MS), or Parkinson’s disease (PD). Then, to identify sub-categories of symptoms and conditions that were driving the shared associations across disorders.

Results

Positive associations shared across neurological disorders were observed for cancers, digestive system, mental health, kidney and urinary, lung and breathing, and other conditions, categories. Bladder and urinary problems, incontinence, fatigue, muscle weakness, depression, and sleep apnoea, were associated with at least 3 of 5 neurological disorders.

Conclusions

Six overarching symptoms and condition categories were shared across neurological disorders. Bladder and urinary problems, incontinence, fatigue, muscle weakness, depression, and sleep apnoea were associated across most neurological disorders.

Key messages

Shared symptoms and conditions were identified across five neurological disorders. These findings may inform risk prevention and disease management strategies with broad applicability.

102Assessing the characteristics of health state utilities among people living with multiple sclerosis

Background

While many studies have examined the impacts of multiple sclerosis (MS) on health-related quality-of-life (HRQoL), none have used the SF-6D multi-attribute utility instrument in a large international cohort (&gt;2,000 subjects) of people with MS. Our objective was to derive SF-6D health state utilities (HSUs) for participants of the HOLISM international cohort and to describe the distribution and determinants thereof.

Methods

HSUs were generated using the SF-6D for the Version-1 United States SF-36 for participants with sufficient SF-36 data (n = 2,185/2,466 (88.6%)). Determinants of HSU were evaluated by linear regression, adjusted for age, sex, MS type, disability (Patient-Determined MS Severity Scale), fatigue (Fatigue Severity Scale), and prescription antidepressant use.

Results

Mean HSU for the sample was 0.67 (SD = 0.13) and diminished with increasing MS-related disability. These findings were robust to adjustment, supporting the SF-6D’s discriminatory power in people with MS. Severe disability and clinically significant fatigue were each associated with 11%-lower HSU (95%CI=-0.13,-0.10 & -0.12,-0.10), and depression risk (Patient Health Questionnaire-2) with 10%-lower HSU (95%CI=-0.11,-0.08). Employment, higher socioeconomic and married/partnered statuses, larger social-network size, greater physical activity, vitamin D and omega-3 supplementations were associated with significantly higher HSU, and overweight/obese BMI and tobacco smoking with lower HSU. Age, sex, and education were not associated.

Conclusions

The SF-6D revealed significant discriminatory power for the HOLISM international cohort. Modifiable lifestyle factors including diet, physical activity and supplement use for the international cohort were robustly associated with increased HSU and thus HRQoL. Confirmatory longitudinal HSU evidence could provide further support to our baseline findings using the SF-6D.

Key messages

Health state utilities in this sample of people living with MS were moderate and were significantly lower among those with greater disability, fatigue, and depression, while some lifestyle factors like physical activity and supplement use were associated with higher utility scores.

Higher-quality diet and non-consumption of meat are associated with less self-determined disability progression in people with multiple sclerosis: A longitudinal cohort study

Background and purpose

Modifiable lifestyle factors, including diet, may affect clinical outcomes in multiple sclerosis (MS). This study assessed the relationships between diet, and disability, fatigue, and depression risk in people with MS.

Methods

Participants from the Health Outcomes and Lifestyle In a Sample of people with Multiple sclerosis (HOLISM) international cohort were assessed over 2.5 years. Dietary data were obtained using a modified Diet Habits Questionnaire (DHQ), disability using the calculated Patient‐determined MS Severity Score (P‐MSSS), fatigue using the Fatigue Severity Scale, and depression risk using the Patient Health Questionnaire‐2. Participants reported whether they were experiencing symptoms due to a recent relapse. Cross‐sectional and prospective relationships of diet and disease outcomes were explored, adjusted for relevant confounders.

Results

Among 1,346 participants, higher DHQ scores showed significant dose‐dependent associations with lower frequencies of severe disability, fatigue, and depression risk, cross‐sectionally. Prospectively, higher baseline DHQ scores were associated with a lower risk of increasing disability, those above the median having 41% and 36% lower risk of increasing disability, and 0.30 P‐MSSS points less disability progression, but were not associated with fatigue or depression risk. Meat consumption was associated with 0.22 P‐MSSS points higher disability cross‐sectionally, while prospectively, baseline meat consumption was associated with 76% higher risk of increasing disability and 0.18 P‐MSSS points higher disability progression. Dairy consumption showed mixed associations cross‐sectionally and prospectively.

Conclusions

These results show that better quality of diet, as well as not consuming meat, were associated with reduced disability progression in people with MS. Substantiation of these findings in other settings may inform opportunities to manage disability progression in people with MS using dietary modifications.

Assessing measurement invariance of MSQOL-54 across Italian and English versions

PURPOSE

The Multiple Sclerosis Quality of Life-54 (MSQOL-54) is a specific multiple sclerosis (MS) health-related quality of life inventory consisting of 52 items organized into 12 subscales plus two single items. No study was found in literature assessing its measurement invariance across language versions. We investigated whether MSQOL-54 items provide unbiased measurements of underlying constructs across Italian and English versions.

METHODS

Three constrained levels of measurement invariance were evaluated: configural invariance where equivalent numbers of factors/factor patterns were required; metric invariance where equivalent factor loadings were required; and scalar invariance where equivalent item intercepts between groups were required. Comparative fit index (CFI), root mean square error of approximation (RMSEA), and standardized root mean square residual (SRMR) fit indices and their changes between nested models were used to assess tenability of invariance constraints.

RESULTS

Overall, the dataset included 3669 MS patients: 1605 (44%) Italian, mean age 41 years, 62% women, 69% with mild level of disability; 2064 (56%) English-speaking (840 [41%] from North America, 797 [39%] from Australasia, 427 [20%] from UK and Ireland), mean age 46 years, 83% women, 54% with mild level of disability. The configural invariance model showed acceptable fit (RMSEA = 0.052, CFI = 0.904, SRMR = 0.046); imposing loadings and intercepts equality constraints produced negligible worsening of fit (ΔRMSEA < 0.001, ΔCFI = - 0.002, ΔSRMR = 0.002 for metric invariance; ΔRMSEA = 0.003, ΔCFI = - 0.013, ΔSRMR = 0.003 for scalar invariance).

CONCLUSIONS

These findings support measurement invariance of the MSQOL-54 across the two language versions, suggesting that the questionnaire has the same meaning and the same measurement paramaters in the Italian and English versions.

The experiences of patients with advanced cancer and caregivers presenting to Emergency Departments: A qualitative study

BACKGROUND

Despite being a common event in the course of an advanced cancer illness, there is little understanding of patients' perceptions of hospital Emergency Department presentations.

AIM

To explore the experiences and perceptions of Emergency Departments held by patients with advanced cancer and their informal caregivers.

DESIGN

Cross-sectional study involving semi-structured interviews with advanced cancer patients and their informal caregivers. Qualitative data analysis was underpinned by a phenomenological approach utilising a data-driven inductive thematic frame.

SETTING/PARTICIPANTS

In total, 19 patients with advanced cancer who presented to Emergency Departments in the previous 6 months and 10 informal caregivers from an Australian public hospital and community palliative care service were interviewed.

RESULTS

Patients reported that Emergency Department presentations were largely prompted by worsening symptoms or were a means to expedite hospital admission, with many instructed to attend by their health care provider. The experience in the Emergency Department was described as a time of anxiety and uncertainty with concerns over communication, the general environment and delays in the symptom management highlighted. Long waits were common. Despite this, patients described relief at receiving care. While the Emergency Department was viewed as a safety net for the health system, many believed advanced cancer patients should have alternative options.

CONCLUSION

Relatively simple changes of regular communication updates and early symptom relief would improve patient experience of Emergency Department care. However, since an Emergency Department presentation is frequently serving as a default to access medical care, a significant re-orientation of the health care system is required to meet patient needs.

Barriers to the operation of mental health legislation in Australian emergency departments: a qualitative analysis

This study aimed to describe the perceived barriers faced by emergency clinicians in utilising mental health legislation in Australian hospital emergency departments. A semi-structured interview methodology was used to assess what barriers emergency department doctors and nurses perceive in the operation of mental health legislation. Key findings from the interview data were drawn in accordance with the most commonly represented themes. A total of 36 interviews were conducted with 20 members of the Australasian College for Emergency Medicine and 16 members of the College for Emergency Nursing Australasia representing the various Australian jurisdictions. Most concerning to clinicians were the effects of access block and overcrowding on the appropriate use of mental health legislation, and the substandard medical care that mental health patients received as a result of long periods in the emergency department. Many respondents were concerned about the lack of applicability of mental health legislation to the emergency department environment, variation in legislation between States and Territories causing problems for clinicians working interstate, and a lack of knowledge and training in mental health legislation. Many felt that clarification of legislative issues around duty of care and intoxicated or violent patients was required. The authors conclude that access block has detrimental effects on emergency mental health care as it does in other areas of emergency medicine. Consideration should be given to uniform national mental health legislation to better serve the needs of people with mental health emergencies.

ECHO: the Western Australian Emergency Care Hospitalisation and Outcome linked data project

OBJECTIVE

To describe and assess the quality of the data resources linked for the Western Australian Emergency Care Hospitalisation and Outcome (ECHO) project.

METHODS

The ECHO project links electronic records from the WA Emergency Department Information System to the St John Ambulance Service Pre-Hospital Care Database, the WA Hospital Morbidity Data System and the WA Mortality Database. Linkages are created using standard probabilistic matching techniques with extensive clerical review. Commencing with all metropolitan Perth public emergency departments from July 2000, these linkages will be updated annually for at least five successive years. The proportion of actual linkages between emergency department records and ambulance, admission and death records was assessed in comparison to expected linkage rates.

RESULTS

Of 578,200 total emergency department records, there were 144,897 emergency presentations recorded as arriving by ambulance, of which 135,332 (93.4%) were linked to an ambulance record pertaining to the same episode. Of the 165,650 presentations recorded as admitted, 162,216 (97.9%) were linked to a hospital morbidity record relating to the same episode. Furthermore, 96.2% of the 2,084 cases recorded as 'dead on arrival' and 98.9% of the 624 cases recorded as 'died in emergency' were linked to a corresponding death record.

CONCLUSIONS

Linkage quality consistent with international standards has been achieved, resulting in an information infrastructure capable of supporting an extensive research agenda focusing on the interaction and outcomes of both pre-hospital and within-hospital emergency medical care services.

Toxins not neutralized by brown snake antivenom

The Australian snakes of the genus Pseudonaja (dugite, gwardar and common brown) account for the majority of snake bite related deaths in Australia. Without antivenom treatment, the risk of mortality is significant. There is an accumulating body of evidence to suggest that the efficacy of the antivenom is limited. The current study investigates the protein constituents recognized by the antivenom using 2-DE, immuno-blot techniques and rat tracheal organ bath assays. The 2-DE profiles for all three snake venoms were similar, with major species visualized at 78-132 kDa, 32-45 kDa and 6-15 kDa. Proteins characterized by LC-MS/MS revealed a coagulant toxin ( approximately 42 kDa) and coagulant peptide ( approximately 6 kDa), as well as two PLA(2) ( approximately 14 kDa). Peptides isolated from approximately 78 kDa and 15-32 kDa protein components showed no similarity to known protein sequences. Protein recognition by the antivenom occurred predominantly for the higher molecular weight components with little recognition of 6-32 kDa MW species. The ability of antivenom to neutralize venom activity was also investigated using rat tracheal organ bath assays. The venoms of Pseudonaja affinis affinis and Pseudonaja nuchalis incited a sustained, significant contraction of the trachea. These contractions were attributed to PLA(2) enzymatic activity as pre-treatment with the PLA(2) inhibitor 4-BPB attenuated the venom-induced contractions. The venom of Pseudonaja textilis incited tracheal contractility through a non-PLA(2) enzymatic activity. Neither activity was attenuated by the antivenom treatment. These results represent the first proteomic investigation of the venoms from the snakes of the genus Pseudonaja, revealing a possible limitation of the brown snake antivenom in binding to the low MW protein components.

The influence of extrinsic and intrinsic risk factors on the probability of sustaining an injury

This study was designed to quantify the relative contributions of extrinsic and intrinsic risk factors to the probability of an injury event. A case-control design was used with data collected from injured patients at an emergency department (n=797) and a community sample matched on area of residence and time of injury (n=797). Principal components analysis was used to develop scales for the measurement of 'intrinsic' risk taking tendencies that were slightly modified versions of previously published measures. Two principal components were identified: 'health risk taking' (HRT) and 'adventurous risk taking' (ART). Logistic regression analysis identified variables that significantly predicted membership of the group of injured cases. The main hypothesis was supported by the results: that 'extrinsic' factors such as location, activity, drug and alcohol use and the type of people present at the time of the injury were related to a greater risk of injury than 'intrinsic' variables (health and adventurous risk taking tendencies). The results suggest that injury research and prevention efforts should continue to focus on the identification and modification of situational risk factors for injury rather developing programs that focus on high-risk individuals. High-risk alcohol use, use of prescribed drugs and aspects of work and recreational environments were identified as warranting particular attention.

Alcohol consumption, setting, gender and activity as predictors of injury: a population-based case-control study

OBJECTIVE

A population-based case-control design was employed to quantify the risk of injury after consumption of alcohol as a function of setting, concurrent activity and usual drinking habits.

METHOD

A total of 797 cases (66.6% men) and 797 controls (57.7% women) were interviewed. The response rate was 83% for eligible cases approached for an interview. Cases were injured patients from a hospital emergency department. Community controls used were each paired with a case on suburb of residence, and interviewed regarding their activities in the 6-hour period preceding their paired case's injury.

RESULTS

Self-reported alcohol consumption was consistent with both medical records and breath-analyzer tests. Drinking any alcohol and using prescribed medication in the prior 6 hours were both associated with significantly increased risk of injury when controlling for demographic and setting variables. Use of illicit drugs (mainly cannabis) was associated with reduced risk of injury. Setting (e.g., recreational, work) and activity (e.g., sport, travel, work) variables were also independently associated with risk of injury. The risk of injury for women was significantly elevated for any consumption of alcohol; for men it was elevated only when consumption exceeded 90 grams.

CONCLUSIONS

These data confirm earlier findings that risk of injury for women for a given level of consumption is greater than for men. They extend earlier findings by identifying significant setting, activity and drug use variables predictive of injury. In addition, when these latter variables are controlled, it is found that for women, but not for men, the risk of injury is significantly elevated even at low levels of alcohol intake.

Kinetic analysis of 25-hydroxyvitamin D3 metabolism in strontium-induced rickets in the chick

Kinetic data analysis was used to derive a six-compartment computer model which describes the in vivo [3H]25-hydroxyvitamin D3 ([3H]25-OHD3) metabolism in control and strontium rachitic chicks. Plasma concentrations of 25-OHD3 (13 pmol/ml) and 25, 25-dihydroxyvitamin D3 (0.9 pmol/ml) were 18 and 125% greater than controls, respectively, whereas the corresponding level for 1alpha,25-dihydroxyvitamin D3 (0.3 pmol/ml) was only 30% of control. Plasma disappearance of 25-HOD3 was fitted using a two-compartment model in which the metabolite extrapolated half-life was nearly twice as large for strontium rachitic chicks (71 compared to 41 h). Intestinal sequestration of 1alpha,25-dihydroxyvitamin D3 was assumed to be irreversible and was fitted by a single exponential term in which metabolite uptake rate and tissue concentration in strontium rickets was suppressed to 20 and 10% of control, respectively. In contrast, uptake of 25-OHD3 by the intestine was observed to occur by a reversible process in which metabolite concentration was 45% greater in the strontium rachitic compared to control group. The developed compartment model accepts time-dependent control or perturbed metabolite data for the plasma and (or) intestinal pools and provides quantitative values for metabolite pool size, flux rate, and turnover time.