Personalized Disease Prevention (PDP): study protocol for a cluster-randomized clinical trial

BACKGROUND

The US Preventive Services Task Force recommends 25 primary preventive services for middle-aged adults, but it can be difficult to do them all.

METHODS

The Personalized Disease Prevention (PDP) cluster-randomized clinical trial will evaluate whether patients and their providers benefit from an evidence-based decision tool to prioritize preventive services based on their potential to improve quality-adjusted life expectancy. The decision tool will be individualized for patient risk factors and available in the electronic health record. This Phase III trial seeks to enroll 60 primary care providers (clusters) and 600 patients aged 40-75 years. Half of providers will be assigned to an intervention to utilize the decision tool with approximately 10 patients each, and half will be assigned to usual care. Mixed-methods follow-up will include collection of preventive care utilization from electronic health records, patient and physician surveys, and qualitative interviews. We hypothesize that quality-adjusted life expectancy will increase by more in patients who receive the intervention, as compared with controls.

DISCUSSION

PDP will test a novel, holistic approach to help patients and providers prioritize the delivery of preventive services, based on patient risk factors in the electronic health record.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05463887. Registered on July 19, 2022.

Implementation Experience with a 30-Day Hospital Readmission Risk Score in a Large, Integrated Health System: A Retrospective Study

BACKGROUND

Driven by quality outcomes and economic incentives, predicting 30-day hospital readmissions remains important for healthcare systems. The Cleveland Clinic Health System (CCHS) implemented an internally validated readmission risk score in the electronic medical record (EMR).

OBJECTIVE

We evaluated the predictive accuracy of the readmission risk score across CCHS hospitals, across primary discharge diagnosis categories, between surgical/medical specialties, and by race and ethnicity.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Adult patients discharged from a CCHS hospital April 2017-September 2020.

MAIN MEASURES

Data was obtained from the CCHS EMR and billing databases. All patients discharged from a CCHS hospital were included except those from Oncology and Labor/Delivery, patients with hospice orders, or patients who died during admission. Discharges were categorized as surgical if from a surgical department or surgery was performed. Primary discharge diagnoses were classified per Agency for Healthcare Research and Quality Clinical Classifications Software Level 1 categories. Discrimination performance predicting 30-day readmission is reported using the c-statistic.

RESULTS

The final cohort included 600,872 discharges from 11 Northeast Ohio and Florida CCHS hospitals. The readmission risk score for the cohort had a c-statistic of 0.6875 with consistent yearly performance. The c-statistic for hospital sites ranged from 0.6762, CI [0.6634, 0.6876], to 0.7023, CI [0.6903, 0.7132]. Medical and surgical discharges showed consistent performance with c-statistics of 0.6923, CI [0.6807, 0.7045], and 0.6802, CI [0.6681, 0.6925], respectively. Primary discharge diagnosis showed variation, with lower performance for congenital anomalies and neoplasms. COVID-19 had a c-statistic of 0.6387. Subgroup analyses showed c-statistics of > 0.65 across race and ethnicity categories.

CONCLUSIONS

The CCHS readmission risk score showed good performance across diverse hospitals, across diagnosis categories, between surgical/medical specialties, and by patient race and ethnicity categories for 3 years after implementation, including during COVID-19. Evaluating clinical decision-making tools post-implementation is crucial to determine their continued relevance, identify opportunities to improve performance, and guide their appropriate use.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

0733 Elucidating Sleep-Related Health Disparities across The Socioeconomic Spectrum Leveraging a Large-Scale Sleep Registry

Introduction

Sleep disparities have been implicated as a contributor to overall health disparities in socially disadvantaged groups. Despite epidemiological studies reporting sleep deprivation and poorer sleep quality among those with low socioeconomic status and group minorities, little is known about the extent to which sleep disorders such as sleep-disordered breathing (SDB), varies across the socioeconomic spectrum.

Methods

A retrospective cohort study was conducted utilizing data from the Cleveland Clinic Sleep Laboratory Registry. All adults who underwent diagnostic or split (baseline diagnostic) polysomnogram (PSG) or home sleep apnea test (HSAT) were included in the study. Area Deprivation Index (ADI), a biomarker of neighborhood socioeconomic disadvantage, was calculated by national rank, i.e. 25th, 50th and 75th percentiles; higher quartiles reflect greater deprivation. Generalized linear models adjusted for age, race, sex, body mass index(kg/m2) and primary payer were used to investigate association of ADI with SDB breathing measures (apnea hypopnea index, (AHI) and sleep-related hypoxemia (percentage of total sleep time <90%SaO2, [TST<90]).

Results

The analytic sample included 81,212 sleep studies; 60,013(74%) were PSG and 21,199(26%) HSAT with age: 52.0[41.0, 62.3], 49% females, 19% black race, with BMI=34.5±8.5 kg/m2, 44% with Medicaid and Medicare. Median ADI National Rank 59.0[39.0, 81.0] with higher 4th quartiles in PSG versus HSAT:29.1% vs 16.3%,p<0.001. In the PSG group, ADI was associated with hypoxia measures: TST<90(coefficient p<0.0001), model R2=0.171; mean SaO2(p<0.0001), R2=0.189; minimum SaO2(p<0.0001), R2=0.169; all measures were higher with higher ADI quartiles. In the HSAT group, ADI was associated with mean SaO2(p<0.0001), R2=0.188 and minimum SaO2(p<0.0001), R2=0.181 with all measures being higher with higher ADI quartiles. AHI was associated with ADI(p=0.0032), R2=0.239; but least squares mean AHI did not differ among ADI quartiles in PSG and HSAT groups. Interactions were observed between ADI and age, BMI and male sex (p<0.05), but not race.

Conclusion

Sleep-related hypoxia was greater among patients living in areas of higher deprivation when considering rankings of neighborhoods by socioeconomic disadvantage. Further understanding of the reason for this sleep disorder-related disparity is needed, i.e. further characterizing theoretical domains and social and geographic determinants of income, education, employment, and housing quality with the overarching goal to improve disparities in health.

Support (If Any)

 

A brain network for deep brain stimulation induced cognitive decline in Parkinson's disease

Deep brain stimulation is an effective treatment for Parkinson's disease but can be complicated by side-effects such as cognitive decline. There is often a delay before this side-effect is apparent and the mechanism is unknown, making it difficult to identify patients at risk or select appropriate deep brain stimulation settings. Here, we test whether connectivity between the stimulation site and other brain regions is associated with cognitive decline following deep brain stimulation. First, we studied a unique patient cohort with cognitive decline following subthalamic deep brain stimulation for Parkinson's disease (n = 10) where reprogramming relieved the side-effect without loss of motor benefit. Using resting state functional connectivity data from a large normative cohort (n = 1000), we computed connectivity between each stimulation site and the subiculum, an a priori brain region functionally connected to brain lesions causing memory impairment. Connectivity between deep brain stimulation sites and this same subiculum region was significantly associated with deep brain stimulation induced cognitive decline (P < 0.02). We next performed a data-driven analysis to identify connections most associated with deep brain stimulation induced cognitive decline. Deep brain stimulation sites causing cognitive decline (versus those that did not) were more connected to the anterior cingulate, caudate nucleus, hippocampus, and cognitive regions of the cerebellum (PFWE < 0.05). The spatial topography of this deep brain stimulation-based circuit for cognitive decline aligned with an a priori lesion-based circuit for memory impairment (P = 0.017). To begin translating these results into a clinical tool that might be used for deep brain stimulation programming, we generated a 'heat map' in which the intensity of each voxel reflects the connectivity to our cognitive decline circuit. We then validated this heat map using an independent dataset of Parkinson's disease patients in which cognitive performance was measured following subthalamic deep brain stimulation (n = 33). Intersection of deep brain stimulation sites with our heat map was correlated with changes in the Mattis dementia rating scale 1 year after lead implantation (r = 0.39; P = 0.028). Finally, to illustrate how this heat map might be used in clinical practice, we present a case that was flagged as 'high risk' for cognitive decline based on intersection of the patient's deep brain stimulation site with our heat map. This patient had indeed experienced cognitive decline and our heat map was used to select alternative deep brain stimulation parameters. At 14 days follow-up the patient's cognition improved without loss of motor benefit. These results lend insight into the mechanism of deep brain stimulation induced cognitive decline and suggest that connectivity-based heat maps may help identify patients at risk and who might benefit from deep brain stimulation reprogramming.

Characterizing Head Impact Exposure in Men and Women During Boxing and Mixed Martial Arts

Background:

The accumulation of subconcussive impacts has been implicated in permanent neurological impairment. A gap in understanding the relationship between head impacts and neurological function is the lack of precise characterization and quantification of forces that individuals experience during sports training and competition.

Purpose:

To characterize impact exposure during training and competition among male and female athletes participating in boxing and mixed martial arts (MMA) via an instrumented custom-fit Impact Monitoring Mouthguard (IMM).

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

Twenty-three athletes (n = 4 women) were provided a custom-fit IMM. The IMM monitored impacts during sparring and competition. All training and competition sessions were videotaped. Video and IMM data were synchronized for post hoc data verification of true positives and substantiation of impact location. IMM data were collected from boxing and MMA athletes at a collaborating site. For each true-positive impact, peak linear acceleration and peak angular acceleration were calculated. Wilcoxon rank sum tests were used to evaluate potential differences in sport, activity type, and sex with respect to each outcome. Differences in impact location were assessed via Kruskal-Wallis tests.

Results:

IMM data were collected from 53 amateur training sessions and 6 competitions (session range, 5-20 minutes). A total of 896 head impacts (men, n = 786; women, n = 110) were identified using IMM data and video verification: 827 in practice and 69 during competition. MMA and boxers experienced a comparable number of impacts per practice session or competition. In general, MMA impacts produced significantly higher peak angular acceleration than did boxing impacts (P < .001) and were more varied in impact location on the head during competitions. In terms of sex, men experienced a greater number of impacts than women per practice session. However, there was no significant difference between men and women in terms of impact magnitude.

Conclusion:

Characteristic profiles of head impact exposure differed between boxing and MMA athletes; however, the impact magnitudes were not significantly different for male and female athletes.

Assessing Clinical Change in Individuals Exposed to Repetitive Head Impacts: The Repetitive Head Impact Composite Index

Background: There is a current lack of any composite measure for the effective tracking and monitoring of clinical change in individuals exposed to repetitive head impacts (RHI). The aim of this study is to create a composite instrument for the purposes of detecting change over time in cognitive and behavioral function in individuals exposed to RHI. Methods: The data to derive the composite instrument came from the Professional Fighters Brain Health Study (PFBHS), a longitudinal study of active and retired professional fighters [boxers and mixed martial arts (MMA) fighters] and healthy controls. Participants in the PFBHS underwent assessment on an annual basis that included computerized cognitive testing and behavioral questionnaires. Multivariate logistic regression models were employed to compare active fighters (n = 117) with controls (n = 22), and retired fighters (n = 26) with controls to identify the predictors that could be used to differentiate the groups over time. In a second step, linear discriminant analysis was performed to derive the linear discriminant coefficients for the three groups by using the predictors from the two separate logistic regression models. Results: The composite scale is a weighted linear value of 12 standardized scores consisting of both current and yearly change scores in domains including: processing speed, choice reaction time, semantic fluency, letter fluency, and Barrett Impulsiveness Scale. Because the weighting of values differed between active and retired fighters, two versions emerged. The mean and standard deviation ratio (MSDR) showed that the new index had better sensitivity compared to the individual measures, with the ratio of MSDR of the new index to that of the existing measures of at least 1.84. Conclusion: With the increasing need for tools to follow individuals exposed to RHI and the potential of clinical trials on the horizon for CTE, the RHICI is poised to serve as an initial approach to a composite clinical measure.

High Energy Side and Rear American Football Head Impacts Cause Obvious Performance Decrement on Video

The objective of this study was to compare head impact data acquired with an impact monitoring mouthguard (IMM) to the video-observed behavior of athletes' post-collision relative to their pre-collision behaviors. A total of n = 83 college and high school American football players wore the IMM and were video-recorded over 260 athlete-exposures. Ex-athletes and clinicians reviewed the video in a two-step process and categorized abnormal post-collision behaviors according to previously published Obvious Performance Decrement (OPD) definitions. Engineers qualitatively reviewed datasets to check head impact and non-head impact signal frequency and magnitude. The ex-athlete reviewers identified 2305 head impacts and 16 potential OPD impacts, 13 of which were separately categorized as Likely-OPD impacts by the clinical reviewers. All 13 Likely-OPD impacts were in the top 1% of impacts measured by the IMM (ranges 40-100 g, 3.3-7.0 m/s and 35-118 J) and 12 of the 13 impacts (92%) were to the side or rear of the head. These findings require confirmation in a larger data set before proposing any type of OPD impact magnitude or direction threshold exists. However, OPD cases in this study compare favorably with previously published impact monitoring studies in high school and college American football players that looked for OPD signs, impact magnitude and direction. Our OPD findings also compare well with NFL reconstruction studies for ranges of concussion and sub-concussive impact magnitudes in side/rear collisions, as well as prior theory, analytical models and empirical research that suggest a directional sensitivity to brain injury exists for single high-energy impacts.

Obtaining Patient Priorities in a Multiple Sclerosis Comprehensive Care Center: Beyond Patient-Reported Outcomes

Background:

In order to provide patient center care, our multiple sclerosis (MS) clinic assesses patient concerns before clinical encounters, first by asking the optional qualitative question “What is the most important thing you what your health-care provider to know today” (most important concern of the patient [MIPC]) and then completing quantitative patient-reported outcome measures (PROMs) including Quality of Life in Neurological Disorders (Neuro-QoL). Both sets of questions are designed to facilitate encounters that address patients’ values and preferences.

Objective:

Determine whether the qualitative MIPC responses provided unique information not included in PROMs or clinical assessments.

Methods:

We randomly selected 400 first-time MIPC responders and 400 first-time MIPC nonresponders from 2788 participants in our database. We categorized MIPC responses by content and number of unique concerns and appended them to the Neuro-QoL framework. Nonresponders were compared to those who provided 1 and 2 or more responses.

Results:

Several MIPCs MS symptoms categories were added to the Neuro-QoL Physical domain. Most important concern of the patients work and cost-of-care categories were added to the Social Domain. Domains regarding treatment satisfaction and disease management were added. Two hundred thirty (58%) MIPC respondents reported 1 concern, 140 (35%) expressed 2 to 6 concerns, and 30 (7%) reported MS-unrelated concerns and not analyzed. Physical symptoms were the most common MIPC (69.9%). Respondents with more concerns were more likely African American, lacked private insurance, and worse disability.

Conclusions:

Importantly, MIPC responders described idiosyncratic symptoms, disease management, and social concerns not included in the PROMS, suggesting the MIPC question offered patients a unique opportunity to share specific concerns with their providers.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Insights to the neural response to food cues in class III compared with class I and II obese adults using a sample of endometrial cancer survivors seeking weight loss

Background

The rates of severe or Class III obesity (BMI ≥ 40.0 kg/m²) and endometrial cancer (EC) incidence and mortality have been increasing significantly in the United States. Adults with severe obesity are more likely to die and women with severe obesity have a higher risk of EC development and mortality than those with Class I/II obesity (BMI: 30–<40 kg/m²). However, no prior studies have evaluated the neural response to food cues by obesity severity/class in adults with or without cancer.

Methods

We conducted a functional magnetic resonance imaging visual food cue task in 85 obese Stage I EC survivors who were seeking weight loss in a lifestyle intervention at baseline. We evaluated the neural response to high-calorie vs. non-food images after an overnight fast (fasted state) and after eating a standardized meal (fed state), and grouped patients by obesity class (Class I/II: n = 38; Class III: n = 47).

Results

In the fasted state, we found increased activation in several regions including the dorsolateral prefrontal cortex (DLPFC) in Class III and Class I/II patients (whole brain cluster corrected (WBCC), p < 0.05), which was significantly higher in Class III vs. Class I/II (p < 0.05). We found decreased activation in the insula in the fasted state, which was significantly lower in Class I/II vs. Class III (p = 0.03). In the fed state, we found increased activation in the DLPFC in Class III and Class I/II (WBCC, p < 0.05). The increased activation in cognitive control/inhibition regions (DLPFC) is consistent with the summative literature; however, the decreased activation in taste information processing regions (insula) was unexpected.

Conclusions

Our results provide novel insights on food cue response between different classes of obesity and highlight the importance of targeting the DLPFC in weight loss interventions, particularly in severely obese patients. Additional studies examining food-related neural circuitry between different classes of obesity are needed.

Multiple Sclerosis Performance Test: validation of self-administered neuroperformance modules

BACKGROUND AND PURPOSE

The purpose was to determine the test-retest reliability, practice effects, convergent validity and sensitivity to multiple sclerosis (MS) disability of neuroperformance subtests from the patient self-administered Multiple Sclerosis Performance Test (MSPT) designed to assess low contrast vision (Contrast Sensitivity Test, CST), upper extremity motor function (Manual Dexterity Test, MDT) and lower extremity motor function (Walking Speed Test, WST) and to introduce the concept of regression-based norms to aid clinical interpretation of performance scores using the MSPT cognition test (Processing Speed Test, PST) as an example.

METHODS

Substudy 1 assessed test-retest reliability, practice effects and convergent validity of the CST, MDT and WST in 30 MS patients and 30 healthy controls. Substudy 2 examined sensitivity to MS disability in over 600 MS patients as part of their routine clinic assessment. Substudy 3 compared performance on the PST in research volunteers and clinical samples.

RESULTS

The CST, MDT and WST were shown to be reliable, valid and sensitive to MS outcomes. Performance was comparable to technician-administered testing. PST performance was poorer in the clinical sample compared with the research volunteer sample.

CONCLUSIONS

The self-administered MSPT neuroperformance modules produce reliable, objective metrics that can be used in clinical practice and support outcomes research. Published studies which require patient voluntary consent may underestimate the rate of cognitive dysfunction observed in a clinical setting.

Computer-Assisted Immersive Visual Rehabilitation in Argus II Retinal Prosthesis Recipients

PURPOSE

The field of retinal prostheses is expanding. However, the best approach to training and assessing the functional benefit of postoperative vision has not been established. The purpose of this single-center prospective interventional case series was to evaluate the feasibility and effectiveness of using the Computer Assisted Rehabilitation Environment (CAREN) system as a visual rehabilitation tool in Argus II patients.

DESIGN

Single-center prospective interventional case series (clinicaltrials.gov identifier, NCT03444961).

PARTICIPANTS

Four Argus II recipients (3 men and 1 woman).

METHODS

Eight visual rehabilitation sessions using the CAREN system (twice weekly for 4 weeks).

MAIN OUTCOME MEASURES

Baseline and postintervention assessments consisted of visual function, mobility, and balance tests.

RESULTS

All patients successfully completed training on the CAREN system. While the Argus II device was active, walking speed increased from baseline to immediately after the intervention on flat and undulating surfaces and while localizing objects by 20%, 10%, and 18%, respectively. An improved ability to complete the timed up and go test successfully was observed.

CONCLUSIONS

Novel methods of visual rehabilitation for retinal prostheses recipients, such the CAREN system, are feasible and may result in improved ability to use the Argus II while performing functional tasks. Immersive technology may provide a solution for the standardization of effective rehabilitation approaches to augment retinal prosthesis performance. Heterogeneity of results indicates that a larger sample size would be beneficial.

Measuring Blunt Force Head Impacts in Athletes

INTRODUCTION

Although concussion continues to be a major source of acute and chronic injuries, concussion injury mechanisms and risk functions are ill-defined. This lack of definition has hindered efforts to develop standardized concussion monitoring, safety testing, and protective countermeasures. To overcome this knowledge gap, we have developed, tested, and deployed a head impact monitoring mouthguard (IMM) system.

MATERIALS AND METHODS

The IMM system was first calibrated in 731 laboratory tests. Versus reference, Laboratory IMM data fit a linear model, with results close to the ideal linear model of form y = x + 0, R2 = 1. Next, during on-field play involving n = 54 amateur American athletes in football and boxing, there were tens of thousands of events collected by the IMM. A total of 890 true-positive head impacts were confirmed using a combination of signal processing and National Institute of Neurological Disorders and Stroke/National Institutes of Health Common Data Elements methods.

RESULTS

The median and 99th percentile of peak scalar linear acceleration and peak angular acceleration were 20 and 50 g and 1,700 and 4,600 rad/s2, respectively. No athletes were diagnosed with concussion.

CONCLUSIONS

While these data are useful for preliminary human tolerance limits, a larger population must be used to quantify real-world dose response as a function of impact magnitude, direction, location, and accumulation. This work is ongoing.

Sleep, quality of life, and depression in endometrial cancer survivors with obesity seeking weight loss

PURPOSE

Incidence and mortality rates of uterine cancer are increasing and, obesity, which is also rising, has been associated with uterine cancer development and mortality. A recent study found that poor sleep quality is common among endometrial cancer survivors and those with obesity had more sleep disturbances than those having normal weight. However, it is unclear if higher levels of obesity (Class III, BMI ≥ 40 kg/m²), which are rising rapidly, are differentially associated with sleep as well as depression and quality of life in endometrial cancer survivors.

METHODS

We evaluated sleep, depression, and quality of life in 100 Stage I endometrial cancer survivors with obesity seeking weight loss enrolled in a lifestyle intervention (NCT01870947) at baseline.

RESULTS

The average age was 60 years and mean BMI was 42.1 kg/m² with 58% having a BMI ≥ 40 kg/m². Most survivors (72.3%) had poor sleep quality and most (71.2%) reported sleeping < 7 h/night. Survivors with class III compared with class I obesity had significantly more sleep disturbances and daytime dysfunction; and, those with poor sleep had higher depression and lower quality of life. Survivors with a BMI ≥ 50 kg/m² (~ 25%) had the highest levels of depression and lowest physical and emotional well-being.

CONCLUSIONS

Our results reveal that endometrial cancer survivors with class III compared with class I obesity have poorer sleep quality, higher depression, and lower quality of life. Given the rising rates of obesity and uterine cancer mortality, interventions to combat both obesity and poor sleep are needed.

Multiple Sclerosis Performance Test: Technical Development and Usability

Introduction

In the clinic, the assessment of patients with multiple sclerosis (MS) is typically qualitative and non-standardized.

Objectives

To describe the MS Performance Test (MSPT), an iPad Air^® 2 (Apple, Cupertino, CA, USA)-based neurological assessment platform allowing patients to input relevant information without the aid of a medical technician, creating a longitudinal, clinically meaningful, digital medical record. To report results from human factor (HF) and usability studies, and the initial large-scale implementation in a practice setting.

Methods

The HF study examined use-error patterns in small groups of MS patients and healthy controls (n = 14), the usability study assessed the effectiveness of patient interaction with the tool by patients with a range of MS disability (n = 60) in a clinical setting, and the implementation study deployed the MSPT across a diverse population of patients (n = 1000) in a large MS center for routine clinical care.

Results

MSPT assessments were completed by all users in the HF study; minor changes to design were recommended. In the usability study, 73% of patients with MS completed the MSPT, with an average administration time of 32 min; 85% described their experience with the tool as satisfactory. In the initial implementation for routine care, 84% of patients with MS completed the MSPT, with an average administration time of 28 min.

Conclusion

Patients with MS with varying disability levels completed the MSPT with minimal or no supervision, resulting in comprehensive, efficient, standardized, quantitative, clinically meaningful data collection as part of routine medical care, thus allowing for large-scale, real-world evidence generation.

Funding

Biogen.

Trial Registration

NCT02664324.

Electronic supplementary material

The online version of this article (10.1007/s12325-019-00958-x) contains supplementary material, which is available to authorized users.

Necessity of technicians for computerized neuropsychological assessment devices in multiple sclerosis

Objective:

Determine the influence of technician supervision on computer-administered cognitive tests in multiple sclerosis (MS).

Methods:

Eighty MS patients underwent assessment using the CogState Brief Battery (CSBB) and the Cleveland Clinic Cognitive Battery (C3B). Each was administered twice, once with a technician guiding assessment, and once with technician-absent. Twenty-eight healthy controls were also evaluated.

Results:

The influence of technician guidance was not statistically significant for group means on either test. For CSBB, administration problems were more common in the technician-absent condition.

Conclusion:

In this MS sample, reliable and valid test results were obtained from computer-assisted cognitive testing without technician guidance.

Abstract WP154: Forced- and Voluntary-Rate Aerobic Exercise Training Improve Cardiovascular Function in Individuals With Chronic Stroke

Introduction: Aerobic exercise (AE) has been shown to be efficacious in improving cardiovascular function following stroke; however, it is not routinely incorporated into post-stroke rehabilitation. Two modes of aerobic stationary bicycling (forced and voluntary rate) were applied to individuals with chronic stroke as part of a study to determine the effects of AE on motor recovery and cardiovascular function, compared to a no exercise control group. We hypothesized that both modes of AE training would elicit similar improvements in cardiorespiratory function, while no improvement would be evident in the control group.

Methods: Twenty-five individuals with chronic stroke were randomized to complete forced-rate aerobic exercise (FE, n=8), voluntary-rate aerobic exercise (VE, n=8), or no AE (n=9). All AE sessions were 45 minutes in length and occurred on a semi-recumbent cycle ergometer. All participants also completed upper extremity task practice, as the study was investigating the neuroplastic effects of AE on motor recovery. Participants in all groups underwent time-matched interventions, 3 times per week for 8 weeks. An exercise stress test and six-minute walk test were completed at baseline and end of treatment (EOT).

Results: Individuals in the FE and VE groups exercised at mean intensities of 56.5% and 55.9% of heart rate reserve, respectively. Peak oxygen consumption improved significantly from baseline to EOT for the FE and VE groups by 1.1 and 2.4 mL/kg/min, respectively, with no change in the control group. Ventilatory threshold improved by a mean of 1.1 mL/kg/min in FE participants, was unchanged in VE participants, and decreased by 1.5 mL/kg/min for those in the control group. Heart rate (HR) response during each stage of the stress test improved for 75% of the FE and VE participants and 44% of control group participants. During the 6-minute walk test, the FE, VE, and control groups improved by a mean of 190, 132, and 90 feet, respectively.

Conclusions: Individuals with chronic stroke tolerated both modes of intensive AE. The 8-week intervention elicited improvements in peak oxygen consumption, HR response, and activity tolerance. Both FE and VE were efficacious in improving cardiovascular fitness, while simultaneously enhancing motor recovery.

Processing speed test: Validation of a self-administered, iPad®-based tool for screening cognitive dysfunction in a clinic setting

Background:

Cognitive dysfunction is common in multiple sclerosis (MS) patients and has important consequences for daily activities, yet, unlike motor function, is not routinely assessed in the clinic setting. We developed the Processing Speed Test (PST), a self-administered iPad®-based tool to measure MS-related deficits in processing speed.

Objective:

To determine whether the PST is valid for screening cognitive dysfunction by comparing it to the paper-and-pencil Symbol Digit Modalities Test (SDMT).

Methods:

We assessed PST test–retest reliability, sensitivity of PST and SDMT in discriminating MS patients from healthy controls (HC), convergent validity between PST and SDMT, correlations between T2 lesion load and PST and SDMT, and PST performance with and without technician present during administration.

Results:

PST had excellent test–retest reliability, was highly correlated with SDMT, was slightly more sensitive than SDMT in discriminating MS from HC groups, and correlated better with cerebral T2 lesion load than did SDMT. Finally, PST performance was no different with or without a technician in the testing environment.

Conclusion:

PST has advantages over SDMT because of its efficient administration, scoring, and potential for medical record or research database integration. PST is a practical tool for routine screening of processing speed deficits in the MS clinic.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Characterizing Information Processing With a Mobile Device: Measurement of Simple and Choice Reaction Time

Information processing is typically evaluated using simple reaction time (SRT) and choice reaction time (CRT) paradigms in which a specific response is initiated following a given stimulus. The measurement of reaction time (RT) has evolved from monitoring the timing of mechanical switches to computerized paradigms. The proliferation of mobile devices with touch screens makes them a natural next technological approach to assess information processing. The aims of this study were to determine the validity and reliability of using of a mobile device (Apple iPad or iTouch) to accurately measure RT. Sixty healthy young adults completed SRT and CRT tasks using a traditional test platform and mobile platforms on two occasions. The SRT was similar across test modality: 300, 287, and 280 milliseconds (ms) for the traditional, iPad, and iTouch, respectively. The CRT was similar within mobile devices, though slightly faster on the traditional: 359, 408, and 384 ms for traditional, iPad, and iTouch, respectively. Intraclass correlation coefficients ranged from 0.79 to 0.85 for SRT and from 0.75 to 0.83 for CRT. The similarity and reliability of SRT across platforms and consistency of SRT and CRT across test conditions indicate that mobile devices provide the next generation of assessment platforms for information processing.

Home Arm Assistance Progression Initiative (HAAPI) Trial: Robotic-Assisted Telerehabilitation for Stroke

Date Presented 4/18/2015

Stroke survivors in rural areas lack access to the specialized occupational therapy needed for functional gains in the upper extremity (UE). The Home Arm Assistance Progression Initiative (HAAPI) trial demonstrates robotic-assisted telerehabilitation as a viable means to deliver occupational therapy remotely, maintain a client-centered relationship, improve quality of life (QoL), and promote UE neuromotor recovery.

The HAAPI (Home Arm Assistance Progression Initiative) Trial: A Novel Robotics Delivery Approach in Stroke Rehabilitation

BACKGROUND

Geographical location, socioeconomic status, and logistics surrounding transportation impede access of poststroke individuals to comprehensive rehabilitative services. Robotic therapy may enhance telerehabilitation by delivering consistent and state-of-the art therapy while allowing remote monitoring and adjusting therapy for underserved populations. The Hand Mentor Pro (HMP) was incorporated within a home exercise program (HEP) to improve upper-extremity (UE) functional capabilities poststroke.

OBJECTIVE

To determine the efficacy of a home-based telemonitored robotic-assisted therapy as part of a HEP compared with a dose-matched HEP-only intervention among individuals less than 6 months poststroke and characterized as underserved.

METHODS

In this prospective, single-blinded, multisite, randomized controlled trial, 99 hemiparetic participants with limited access to UE rehabilitation were randomized to either (1) the experimental group, which received combined HEP and HMP for 3 h/d ×5 days ×8 weeks, or (2) the control group, which received HEP only at an identical dosage. Weekly communication between the supervising therapist and participant promoted compliance and progression of the HEP and HMP prescription. The Action Research Arm Test and Wolf Motor Function Test along with the Fugl-Meyer Assessment (UE) were primary and secondary outcome measures, respectively, undertaken before and after the interventions.

RESULTS

Both groups demonstrated improvement across all UE outcomes.

CONCLUSIONS

Robotic + HEP and HEP only were both effectively delivered remotely. There was no difference between groups in change in motor function over time. Additional research is necessary to determine the appropriate dosage of HMP and HEP.

Abstract 144: Forced Aerobic Exercise Enhances Upper Extremity Task Practice in Patients with Stroke

Introduction: Aerobic exercise (AE) has been shown to improve cardiovascular health in individuals with stroke; however, the potential role of AE in enhancing neuroplasticity after stroke has not been systematically studied. We have implemented a forced exercise (FE) cycling intervention, initially developed for individuals with Parkinson’s disease, with a cohort of individuals with chronic stroke. We hypothesize that intensive AE training, when paired with repetitive task practice (RTP), will “prime” the central nervous system, to exploit the motor learning effects of task practice.

Hypothesis: Individuals who perform FE followed by RTP will demonstrate greater improvements in motor and non-motor function compared to the voluntary rate aerobic exercise (VE) + RTP and RTP only groups. Individuals in both AE groups (FE and VE) will demonstrate greater improvements in VO2peak compared to the RTP only group.

Methods: Fifteen individuals 6-12 months post-stroke were enrolled into one of the following groups: 1) Forced Exercise + RTP (FE + RTP); 2) Voluntary Exercise + RTP (VE + RTP); and 3) Time-matched RTP. Participants in the AE groups completed one 45-minute session of stationary cycling followed immediately by one 45-minute session of upper extremity RTP; however, the rate of cycling for the FE group was augmented to approximately 35% faster than their voluntary rate. All participants completed a total of 24 exercise sessions over an 8-week period.

Results: While all three groups made significant improvements in motor function as measured by the Fugl-Meyer Assessment (p=.03), the FE+RTP group exceeded the VE+RTP and RTP only groups, approaching statistical significance (p=0.06), despite the two AE groups completing 44% less RTP practice time than the RTP group. Improvements in self-reported quality of life and depressive symptomology also improved across all three groups, with trends favoring the FE group. VO2peak improved by 1.1 and 2.68 mL/kg/min for the FE+RTP and VE+RTP groups, respectively; while VO2peak decreased by 0.85mL/kg/min in the RTP group.

Conclusion: FE + RTP is a promising intervention to enhance motor and non-motor function, in addition to aerobic capacity in individuals 6-12 months after stroke.

Rationale and design of REWARD (revving-up exercise for sustained weight loss by altering neurological reward and drive): a randomized trial in obese endometrial cancer survivors

BACKGROUND

Obesity is a leading risk factor for endometrial cancer (EC), particularly Type I forms, which are increasing in the U.S. Although death rates from most cancers have been decreasing, overall mortality in EC is increasing in the U.S. EC survivors' poor fitness combined with their surgical treatments may make weight loss particularly challenging. High intensity exercise increases neurotrophins and neurological reward via altered striatal dopamine in animals, and, in humans, chronic high intensity exercise enhances meal-induced satiety and may reduce hedonic eating. "Assisted" exercise, a mode of exercise whereby a patient's voluntary exercise rate is augmented mechanically, may modulate brain dopamine levels in Parkinson's Disease patients but has not been previously evaluated as a treatment for obesity.

METHODS

We describe the rationale and design of the REWARD trial, which has the overarching goal of randomizing 120 obese EC survivors to "assisted" or voluntary rate cycling to evaluate the efficacy of "assisted" exercise in enhancing and sustaining weight loss. Patients in both arms will receive 3 days/week of supervised exercise and 1 day/week of a group dietary behavioral intervention for 16 weeks and, then, will be followed for 6 months.

OUTCOMES

The primary outcome is weight loss. Secondary outcomes include measures for body composition, fitness, eating behavior, exercise motivation and, quality of life as well as cognition and food reward and motivation as assessed by functional magnetic resonance imaging (fMRI) tasks.

CONCLUSIONS

If successful, the REWARD program could be extended to help sustain weight loss in obese cancer and non-cancer patients.

The Multiple Sclerosis Performance Test (MSPT): an iPad-based disability assessment tool

Precise measurement of neurological and neuropsychological impairment and disability in multiple sclerosis is challenging. We report a new test, the Multiple Sclerosis Performance Test (MSPT), which represents a new approach to quantifying MS related disability. The MSPT takes advantage of advances in computer technology, information technology, biomechanics, and clinical measurement science. The resulting MSPT represents a computer-based platform for precise, valid measurement of MS severity. Based on, but extending the Multiple Sclerosis Functional Composite (MSFC), the MSPT provides precise, quantitative data on walking speed, balance, manual dexterity, visual function, and cognitive processing speed. The MSPT was tested by 51 MS patients and 49 healthy controls (HC). MSPT scores were highly reproducible, correlated strongly with technician-administered test scores, discriminated MS from HC and severe from mild MS, and correlated with patient reported outcomes. Measures of reliability, sensitivity, and clinical meaning for MSPT scores were favorable compared with technician-based testing. The MSPT is a potentially transformative approach for collecting MS disability outcome data for patient care and research. Because the testing is computer-based, test performance can be analyzed in traditional or novel ways and data can be directly entered into research or clinical databases. The MSPT could be widely disseminated to clinicians in practice settings who are not connected to clinical trial performance sites or who are practicing in rural settings, drastically improving access to clinical trials for clinicians and patients. The MSPT could be adapted to out of clinic settings, like the patient’s home, thereby providing more meaningful real world data. The MSPT represents a new paradigm for neuroperformance testing. This method could have the same transformative effect on clinical care and research in MS as standardized computer-adapted testing has had in the education field, with clear potential to accelerate progress in clinical care and research.

Randomized controlled pilot study of a SystemCHANGE™ weight management intervention in stroke survivors: rationale and protocol

Background

Over 65% of stroke survivors are either overweight or obese and have multiple cardiovascular risk factors. However, few studies have examined the effects of comprehensive lifestyle behavior interventions to promote weight loss and control cardiovascular risk factors in stroke survivors. Thus, the purpose of this study is to examine a novel behavior change approach - SystemCHANGE™ - to promote weight loss and improve health and function in stroke survivors. SystemCHANGE™ focuses on redesigning the social environment to achieve a specific goal.

Methods

We will conduct a randomized controlled pilot study to examine the efficacy, feasibility, and safety of the SystemCHANGE™ weight management program in overweight and obese stroke survivors. The central hypothesis of the study is that the SystemCHANGE™ intervention will help overweight and obese stroke survivors lose 5% of their body weight, thereby improving health and function. Thirty-five stroke survivors will be randomized into either the 6-month SystemCHANGE™ intervention or a contact-control intervention. Outcome measures will be assessed at baseline and again at 3 and 6 months after the interventions. Body composition will be assessed using a Bod Pod. Patient-reported outcomes will be the Stroke Impact Scale and Reintegration to Normal Living Index. Objective outcomes will include the 6-Minute Walking Test and Rivermead Motor Assessment.

Discussion

This study will be the first randomized controlled trial to evaluate the efficacy and safety of a weight management intervention in stroke survivors using the SystemCHANGE™ approach. Furthermore, it will be the first empirically-examined comprehensive lifestyle intervention designed to target physical activity, nutrition, and sleep to promote weight loss in stroke survivors.

Trial registration

ClinicalTrials.gov Identifier: NCT01776034

Mesh migration following obturator hernia repair presenting as a bezoar inducing small intestinal obstruction

This is the first report on synthetic mesh migration following obturator hernia repair. Obturator hernias have a low incidence--with fewer than 700 published case studies to date--usually occur in elderly women and are difficult to diagnose. Since 1976, there have been no more than 29 reported cases in which synthetic materials were used in obturator hernia repair. Thus, information relevant to the surgical repair of this type of hernia is based on small numbers only. The use of synthetic mesh for the repair of obturator hernias is a recent development, and to date no complications have been reported with this type of repair. We report here on the outcome of a patient with mesh migration after obturator hernia repair. This report provides a short overview of mesh migration as a complication following the use of synthetic grafts for surgical repair.

Reach-to-grasp movements during obstacle avoidance

The transport and grip components are two controlled components of a prehensile movement. These components are coordinated so that objects of varying size and shape resting in diverse locations can be grasped easily. It has been suggested that the timing between these two components is a specified parameter, although the origin of such timing is unknown. The present study examines the interdependency of the reach and grasp components when the transport component is modified by placing an obstacle of varying height (9 cm and 11 cm) in the hand path between the starting position and the target object location. Subjects were asked to reach over a Plexiglas barrier and grasp a 2-cm dowel. To reach the object, the subject had to elevate the hand. At issue in this experiment is whether changes in hand path trajectory caused by obstacle avoidance produce corresponding changes in the kinematics of grip aperture. The findings showed that reaching in the presence of an obstacle resulted in the prolongation of most transport component time parameters except peak acceleration and a few amplitude parameters. Changes in the transport component also produced systematic prolongation in all time parameters of grip kinematics, including grip closure time. Temporal prolongation was also reflected in a significant decrease in grip opening and closing velocity; only relative time-to-peak closing velocity was maintained. Closure distance and maximum grip aperture were smaller for the obstacle conditions. Together with the observed smaller variability for the distance to peak aperture, these findings suggest that spatial localization of the hand aperture is an important prehensile movement control feature. Parameterization processes for the grip component are closely linked to those of the transport component, and their organization appears to be interdependent.

“Primatization” of Recombinant Antibodies for Immunotherapy of Human Diseases: A Macaque/Human Chimeric Antibody Against Human CD4

Immunoglobulin variable region genes from non-human primates, cynomolgus macaques, were shown to have 85%-98% homology with human immunoglobulin sequences and yet macaques are phylogenetically distant enough to respond against conserved human antigens. Immunoglobulin genes were isolated from monkeys immunized with human CD4 antigen and a human/monkey chimeric anti-CD4 antibody with 91-92% homology to human immunoglobulin framework regions was cloned and expressed. The antibody has an apparent affinity of 3.2 x 10(-11) M and exhibits potent immunosuppressive properties in vitro.

Hemodynamic events in a prospective randomized trial of propranolol versus placebo in the prevention of a first variceal hemorrhage

In a double-blind randomized trial, the hemodynamic events following the administration of propranolol (n = 51) or a placebo (n = 51) were prospectively studied in cirrhotic patients with esophageal varices. The hepatic venous pressure gradient, heart rate, and variceal size were determined at the baseline and 3, 12, and 24 months after the beginning of therapy. Baseline values were similar in both groups. At 3 months, the hepatic venous pressure gradient decreased significantly in propranolol-treated patients (from 18.1 +/- 4.2 to 15.7 +/- 3.4 mm Hg; P less than 0.05) but not in patients receiving the placebo (19.6 +/- 6.8 to 17.5 +/- 5.3 mm Hg; NS). At subsequent time intervals this gradient decreased significantly from the baseline value in both groups. Heart rate decreased significantly in the propranolol-treated group at all times (P less than 0.001). Variceal hemorrhage occurred in 13 patients (11 placebo-, 2 propranolol-treated; P less than 0.01), all of whom had a hepatic venous pressure gradient greater than 12 mm Hg. In 21 patients (14 propranolol-, 7 placebo-treated) the hepatic venous pressure gradient decreased to less than or equal to 12 mm Hg; none of them bled from esophageal varices, and their mortality rate also decreased. Because most of the bleeding events occurred during the first year (10 placebo-, 1 propranolol-treated; P less than 0.01), propranolol seems to have its protective effect during the period associated with the largest reduction in the hepatic venous pressure gradient. Because a reduction in the hepatic venous pressure gradient to less than 12 mm Hg protects from variceal bleeding and increases the rate of survival, this should be the aim of the pharmacological therapy of portal hypertension.

Synthetic pheromones that promote inter-male aggression in mice

Two volatile constituents of male mouse urine, dehydro-exo-brevicomin and 2-(sec-butyl)-dihydrothiazole, have been found active in bioassays of inter-male aggressive behavior. The two synthetic compounds act synergistically when added to castrated male urine but not when added to water, and they provoke fighting that is quantitatively and qualitatively comparable to that elicited by intact male urine.