Evaluating a rehabilitative intervention for substance-dependent patients with and without their accompanying children in Germany (KontextSucht): study protocol for a non-randomised trial

INTRODUCTION

People suffering from substance use disorders often live in social contexts with children or are parents themselves. Addicted parents show specific substance-related problems while raising their children, which often leads to various lifelong consequences for the children. The German rehabilitative treatment system allows bringing children to inpatient treatment centres. This mixed-methods study evaluates a newly developed intervention, called 'KontextSucht' or 'AddictionContext', for parents in rehabilitation treatment centres concerning the effectiveness of the intervention in parenting and abstinence outcome.

METHODS AND ANALYSIS

The study uses a two-stage parallel mixed-methods design. A feasibility study (stage 1) and a benefit assessment (stage 2) will be conducted to evaluate the intervention. Both parts of the study will be carried out with qualitative and quantitative work packages. German-speaking parents of children 0-14 years will be included in this study. Qualitative data will be analysed using qualitative content analyses, whereas quantitative data will be analysed descriptively using regression analysis as well as linear mixed models.

ETHICS AND DISSEMINATION

All participants will receive detailed information on the study and sign informed consent before data collection. The research team has obtained the approval of the Ethical Review Committee at the Technical University of Munich in Germany and will follow all legislation rules regarding data protection. The study results will be published in peer-reviewed national and international journals. Furthermore, the study results will be included in an intervention manual distributed to treatment centres.

TRIAL REGISTRATION NUMBER

DRKS00030950.

Participation of adolescents with and without physical disabilities and chronic diseases: A comprehensive conceptualization

BACKGROUND

In 2001, the International Classification of Functioning and Disability (ICF) introduced participation as a main goal of rehabilitation processes. However, to date, a comprehensive concept of participation in the rehabilitative context is missing, particularly in German-speaking countries. We thus aimed to refine and extend the existing concepts of participation in this brief communication.

METHODS

In preceding studies, we conducted semi-structured interviews with adolescents who either had chronic diseases and/or physical disabilities or had no impairments and focus groups with parents and experts. Based on these diverse perspectives and findings, we refine the term participation.

RESULTS

Participation is a construct that is embedded in a social context and consists of objective (i.e., attendance) and subjective (i.e., satisfaction and involvement) dimensions. These dimensions are reflected in different domains and areas that are relevant to adolescents' lives. In addition, the subjective relevance of respective areas in life needs to be regarded as a weighing component when evaluating participation.

CONCLUSION

Our results reflect international models on participation, refine the existing concept, and underline the multidimensional character of participation. These findings are urgently needed to develop appropriate instruments, for example, for assessing whether rehabilitative processes are effective regarding the goal of participation.

Development, piloting and evaluation of an app-supported psychosocial prevention intervention to strengthen participation in working life: a study protocol of a mixed-methods approach

INTRODUCTION

Rates of incapacity to work due to mental disorders have increased in many European countries. The consequences of persistent stress can impact individuals' physical and psychological well-being and gradually develop into chronic stress. Mental disorders or symptoms of burn-out syndrome can have severe consequences. Mental disorders leading to work incapacity significantly burden the health system. Prevention interventions can protect against burn-out, depression, anxiety and other mental health disorders. Digital health is a promising approach to increase the utilisation of effective prevention interventions. This mixed-methods study evaluates a newly developed app-supported psychosocial prevention intervention called 'RV Fit Mental Health' to strengthen participation in working life.

METHODS AND ANALYSIS

The study uses a three-stage parallel mixed-methods design. This study accompanies the development (stage 1), piloting (stage 2) and evaluation (stage 3) of the new intervention. Within the stages, there is a quantitative as well as a qualitative research strand. Employed persons with an incipient mental disorder will be included. Additionally, experts within the project or connected areas will be included. Quantitative data will be analysed using multifactorial variance analyses in a pre-post design. Qualitative data will be analysed using qualitative content analysis. The study is a comprehensive research approach to investigate the development, piloting and evaluation of an app-supported psychosocial app-based prevention intervention. The rigour of the study will be achieved through data triangulation.

ETHICS AND DISSEMINATION

All participants will receive detailed study information and give written informed consent before data collection. Ethical approval was obtained from the Technical University of Munich Ethics Committee. All data collection will follow all legislative rules regarding data protection, also following the Declaration of Helsinki. The study results will be disseminated in peer-reviewed journals and presented at international conferences.

TRIAL REGISTRATION NUMBERS

DRKS00030818 and DRKS00033080.

A pilot study to develop a participation self-assessment tool for adolescents: The Social Participation Inventory (SPI)

OBJECTIVE

Participation is one of the key goals of re/habilitative processes. Since participation impacts adolescents' social-emotional development and overall health, this goal is particularly important for them. However, to date, no German-speaking self-assessment tool for participation among adolescents is available. This study sought therefore to develop such a tool and to test its psychometric properties.

METHODS

Based on a preliminary qualitative study, we developed 133 items for a pilot version of the Social Participation Inventory (SPI). The SPI assesses the objective dimension (i.e., attendance) and the subjective dimension (i.e., involvement and satisfaction) of participation. To test the psychometric properties of the SPI, we conducted a quantitative cross-sectional survey and applied the SPI to n = 151 adolescents with and without disabilities and/or chronic diseases.

RESULTS

By using principal component analyses, we examined the SPI's consistency and verified the theoretical considerations regarding the two components of participation (i.e., objective and subjective dimensions). Items that did not load sufficiently on components were removed after careful theoretical-based consideration. The condensed version of the SPI consists of 39 items that assess participation and 18 items to assess the perceived importance of respective areas of life. The SPI shows very good overall reliability (Cronbach's α = .920) and good validity.

CONCLUSION

This study provides a new psychometrically tested participation self-assessment scale for adolescence with and without disabilities and/or chronic diseases. Further research is needed to re-evaluate its psychometric properties and to evaluate the application of the SPI in clinical and scientific contexts.

Review of Validated Methods to Evaluate Diet History in Diet Therapy and Counselling: An Overview and Analysis of Screeners Based on Food-Based Dietary Guidelines

Evidence-based dietetic practice calls for systematically developed assessment methods for nutritional assessment in dietetic counselling and therapy (DCT). Screeners can provide a quick and easy way to determine a client's diet quality and contribute to quality assurance in DCT. The aim of this systematic review was to give a comparative overview of screeners based on national food-based dietary guidelines (FBDGs) and to derive recommendations for developing an FBDG-based screener for DCT. The literature search in PubMed (MEDLINE), embase and Web of Science was conducted between May and July 2022, and updated in March 2023, in accordance with the consensus-based standards for the selection of health measurement instruments (COSMIN). The analysis focused on characteristics of screener design and measurement properties for screener testing. In total, 13 studies on 11 screeners based on FBDGs were included; 7 screeners were targeted to DCT. The content and scoring of screeners were based on the corresponding national FBDGs. The validity and/or reliability of screeners were investigated in 11 studies; responsiveness was not tested for any screener and practicality was considered in all studies. Based on the screeners reviewed, a systematic rationale to develop, enhance and test screeners based on national FBDGs was established.

Outcome of conventional radiotherapy in small centrally located tumours or lymph nodes: minimal toxicity, remarkable survival but challenging loco-regional control

BACKGROUND

In peripheral lung tumours, stereotactic body radiotherapy (SBRT) is superior to conventional RT. SBRT has also shown high loco-regional control (LC) in centrally located tumours, but there is a high risk of severe toxicity. The STRICTSTARLung trial (NCT05354596) examines if risk-adapted SBRT for central tumours is feasible. In this study, we examined overall survival (OS), Disease-free survival (DSF), LC, and toxicity in patients with central tumours that could have been candidates for SBRT but received conventional RT.

MATERIAL AND METHODS

Retrospectively, we evaluated 49 lung cancer patients that between 2008 and 2021 received RT (60-70Gy in 2 Gy fractions) for a solitary tumour or lymph node with a diameter <5cm located <2cm from the bronchial tree, oesophagus, aorta or heart. All tumours were pathologically verified; 30 were primary lung tumours (T1b-T4) and 19 were solitary lymph nodes (T0N1-N2). Chemotherapy was administered as concomitant (29) or sequential (4). OS and LC were analysed using Kaplan Meier. Cox proportional hazards model for OS and disease-free survival (DFS) was performed including tumour volume, histology, sex, T- vs N-site and chemotherapy. Toxicity was scored.

RESULTS

In 42 patients, the tumour was located <1 cm to mediastinum. Median follow-up time was 44 months (range: 7-123). The median OS was 51 months. OS at 1-, 3- and 5-year was 88% (SE:5), 59% (SE:7) and 50% (SE:8). Loco-regional recurrences occurred in 16 patients resulting in 1-, and 3-year LC rates of 77% (SE:6) and 64% (SE:8). The majority occurred within 3 years after RT. Only stage showed significant impact on OS and DFS. No patients experienced grade 4-5 toxicity. Seven patients developed grade 3 toxicity (5 oesophageal stenosis, 2 pneumonitis).

CONCLUSION

Conventional RT for patients with small central lung tumours or solitary lymph nodes is feasible. Median OS was 51 months, and toxicity was low with no grade 4-5 events.

Concept of an Intervention for Sustainable Weight Loss in Postmenopausal Women with Overweight-Secondary Analysis of a Randomized Dietary Intervention Study

INTRODUCTION

The approach of an individual diet has great potential for sustainable weight reduction. Social support, participation and empowerment are also key factors for high motivation and compliance. So, the impact of an individual diet in combination with group sessions on weight loss in postmenopausal women with overweight was investigated.

METHODS

In this reanalysis of a controlled intervention study, postmenopausal women (n = 54; BMI 30.9 ± 3.4 kg/m²; 59 ± 7 years) were recruited receiving an energy restricted diet for 12 weeks, followed by a six-month follow-up phase. The women received 51 individual meal plans based on their habits and were trained in four group sessions.

RESULTS

Forty-six women completed the intervention phase, and 29 completed the follow-up. Average weight loss was -5.8 ± 3.0 kg (p < 0.001) after 12 weeks and was still significant at follow-up (-4.9 ± 5.4 kg, p < 0.001). Also, decreases in fat-free mass (-1.1 ± 1.2 kg, p < 0.001) and resting energy expenditure (-1096 ± 439 kJ/24 h, p < 0.001) were observed.

CONCLUSIONS

The individual nutrition approach with a focus on nutritype in combination with group sessions was effective for long-lasting weight loss in postmenopausal women. An important factor is close individual and group support.

What does social participation mean? A qualitative study exploring the concept of participation from the perspectives of experts and parents

OBJECTIVES

This study aimed to assess the theoretical framework regarding social participation from the perspectives of experts and parents of youth aged between 10 and 17 years, and therefore, provides new insights into the concept of social participation.

DESIGN

A qualitative study was conducted to understand the construct of social participation in more detail. Eight focus groups were held with experts (n=21) and parents (n=24) and analysed based on content analysis.

PARTICIPANTS

We used purposive and snowball sampling to obtain a comprehensive sample of (A) parents of adolescents with and without chronic and/or physical-motor impairments and (B) experts involved in participatory research and/or treatment of adolescents with chronic and/or physical-motor impairments. The final sample consisted of 3 focus groups with a total of 21 experts and 5 focus groups with 24 parents. This included 10 parents who had disabled children.

RESULTS

The concept of social participation consists of subjective and objective components. The focus from the experts' perspective is clearly on the subjective level; that is, revolving around the question 'Does the adolescent feel involved?' In contrast, the parents' focus is more on normative expectations. The possibility of participation in all areas of life through the adjustment of environmental factors was identified as a central factor.

CONCLUSIONS

The results underline the importance of the subjective feelings of adolescents, as well as the significance of normative requirements. To capture the subjective component of participation, suitable measurements are needed.

TRIAL REGISTRATION NUMBER

DRKS00014739.

A phase IIb, open-label, randomized controlled dose ranging multi-centre trial to evaluate the safety, tolerability, pharmacokinetics and exposure-response relationship of different doses of delpazolid in combination with bedaquiline delamanid moxifloxacin in adult subjects with newly diagnosed, uncomplicated, smear-positive, drug-sensitive pulmonary tuberculosis

BACKGROUND

Linezolid is an effective, but toxic anti-tuberculosis drug that is currently recommended for the treatment of drug-resistant tuberculosis. Improved oxazolidinones should have a better safety profile, while preserving efficacy. Delpazolid is a novel oxazolidinone developed by LegoChem Biosciences Inc. that has been evaluated up to phase 2a clinical trials. Since oxazolidinone toxicity can occur late in treatment, LegoChem Biosciences Inc. and the PanACEA Consortium designed DECODE to be an innovative dose-ranging study with long-term follow-up for determining the exposure-response and exposure-toxicity relationship of delpazolid to support dose selection for later studies. Delpazolid is administered in combination with bedaquiline, delamanid and moxifloxacin.

METHODS

Seventy-five participants with drug-sensitive, pulmonary tuberculosis will receive bedaquiline, delamanid and moxifloxacin, and will be randomized to delpazolid dosages of 0 mg, 400 mg, 800 mg, 1200 mg once daily, or 800 mg twice daily, for 16 weeks. The primary efficacy endpoint will be the rate of decline of bacterial load on treatment, measured by MGIT liquid culture time to detection from weekly sputum cultures. The primary safety endpoint will be the proportion of oxazolidinone class toxicities; neuropathy, myelosuppression, or tyramine pressor response. Participants who convert to negative liquid media culture by week 8 will stop treatment after the end of their 16-week course and will be observed for relapse until week 52. Participants who do not convert to negative culture will receive continuation phase treatment with rifampicin and isoniazid to complete a six-month treatment course.

DISCUSSION

DECODE is an innovative dose-finding trial, designed to support exposure-response modelling for safe and effective dose selection. The trial design allows assessment of occurrence of late toxicities as observed with linezolid, which is necessary in clinical evaluation of novel oxazolidinones. The primary efficacy endpoint is the change in bacterial load, an endpoint conventionally used in shorter dose-finding trials. Long-term follow-up after shortened treatment is possible through a safety rule excluding slow-and non-responders from potentially poorly performing dosages.

TRIAL REGISTRATION

DECODE was registered in ClinicalTrials.gov before recruitment start on 22 October 2021 (NCT04550832).

Geographic Atrophy in AMD: Prognostic Factors Based on Long-Term Follow-Up

INTRODUCTION

The aim of this large-scale long-term retrospective study was to show the enlargement rate (ER) of geographic atrophy (GA) in age-related macular degeneration (AMD), defined as complete retinal pigment epithelium and outer retinal atrophy (cRORA), to find predictors of progression in a clinical routine setting and to compare GA evaluation methods.

METHODS

All patients available in our database with follow-up of at least 24 months and cRORA in at least one eye, regardless of neovascular AMD being present, were included. SD-OCT and fundus autofluorescence (FAF) evaluations were performed according to a standardized protocol. The cRORA area ER, the cRORA square root area ER, the FAF GA area, and the condition of the outer retina (inner-/outer-segment [IS/OS] line and external limiting membrane [ELM] disruption scores) were determined.

RESULTS

204 eyes of 129 patients were included. Mean follow-up time was 4.2 ± 2.2 (range 2-10) years. 109 of 204 (53.4%) eyes were classified as MNV-associated GA in AMD (initially or during follow-up); 95 of 204 (46.6%) eyes were classified as pure GA in AMD. The primary lesion was unifocal in 146 (72%) eyes and multifocal in 58 (28%) eyes. A strong correlation was observed between the area of cRORA (SD-OCT) and the FAF GA area (r = 0.924; p < 0.001). Mean ER was 1.44 ± 1.2 mm2/year, mean square root ER 0.29 ± 0.19 mm/year. There was no significant difference in mean ER between eyes without (pure GA) and with intravitreal anti-VEGF injections (MNV-associated GA) (0.30 ± 0.19 mm/year vs. 0.28 ± 0.20 mm/year; p = 0.466). Eyes with multifocal atrophy pattern at baseline had a significantly higher mean ER compared to eyes with unifocal pattern (0.34 ± 0.19 mm/year vs. 0.27 ± 1.19 mm/year; p = 0.008). There were moderate significant correlations between ELM and IS/OS disruption scores and visual acuity at baseline, 5 and 7 years (all r values ca. -0.5; p < 0.001). In multivariate regression analysis, a multifocal cRORA pattern at baseline (p = 0.022) and a smaller baseline lesion size (p = 0.036) were associated with a higher mean ER.

CONCLUSION

SD-OCT-evaluated cRORA area might serve as a GA parameter comparable to traditional FAF measurement in clinical routine. The dispersion pattern and baseline lesion size might be predictors of ER, whereas anti-VEGF treatment seems not to be associated with ER.

The Adolescent Concept of Social Participation-A Qualitative Study on the Concept of Social Participation from Adolescents with and without Physical Disabilities

PURPOSE

The construct of social participation is still not clearly defined. To reach a better understanding of social participation, the perspectives of adolescents must be taken into account. This study explores the adolescent concept of social participation and expands knowledge of the meaning of subjective components of the term.

METHODS

Thirty-four semi-structured interviews were conducted with adolescents with and without physical disabilities or chronic diseases between the ages of 12 and 17 and analyzed according to grounded theory.

RESULTS

Adolescents describe social participation as involving reflexive interaction with their social environment. Furthermore, forming a social environment plays an important role. All components of the concept are embedded in a context that influences the ways adolescents participate. Adolescents differentiate between active and passive forms of social participation. The concept of reflexive interaction is situated within an interdependent structure of components such as the "feeling of belonging" and the feeling of "well-being" among adolescents.

CONCLUSION

The results expand the current state of knowledge regarding the theoretical differentiation of social participation by exploring subjective components of the term. This offers the possibility of supplementing the theoretical frameworks of social participation and supports the understanding of the critical importance of social participation for adolescents.

Peripapillary and macular microvasculature in neovascular age-related macular degeneration in long-term and recently started anti-VEGF therapy versus healthy controls

Aim

To investigate the peripapillary and macular microvasculature in neovascular age-related macular degeneration (nAMD) in recently started versus long-term anti-vascular endothelial growth factor (VEGF) therapy and healthy controls.

Methods

Eyes with nAMD treated in a treat-and-extend regimen were assigned to group 1 (<5 injections) or 2 (≥20 injections) whereas group 3 constituted the healthy age-matched controls. Blood flow signals were acquired using PLEX^® Elite 9000 swept-source optical coherence tomography angiography (OCTA) of the macular and peripapillary regions. Mean ganglion cell complex (GCC) thickness values were quantified using spectral-domain optical coherence tomography (SD-OCT).

Results

Including 80 eyes whereof 40 controls, macular superficial perfusion density was significantly reduced in group 1 and 2 compared to controls (p < 0.001; p = 0.010) without a difference between groups 1 and 2. Peripapillary perfusion parameters did not correlate with post-operative intraocular pressure (IOP) or number of anti-VEGF injections. Mean peripapillary flux index was significantly lower in group 2 than in controls (p = 0.023) and significantly decreased in the nasal quadrants for both AMD groups compared to group 3 (p = 0.013; p < 0.001). Mean peripapillary perfusion density was significantly reduced in both AMD groups compared to controls (0.515 ± 0.02 versus 0.556 ± 0.03, p < 0.0001).

Conclusion

Frequency of anti-VEGF treatment in nAMD and post-operative IOP showed no correlation with peripapillary perfusion parameters, but anti-VEGF treated nAMD patients exhibited partly altered peripapillary perfusion compared to healthy controls. Reduced macular perfusion density of the inner retina in anti-VEGF treated nAMD compared to healthy controls might be discussed as an anti-VEGF treatment effect or a characteristic of nAMD.

Prospective Study Comparing Quantitative Self-Monitoring Metamorphopsia Measurement Tools in Myopic Choroidal Neovascularization (mCNV)

Purpose

To assess the ability of two self-monitoring digital devices to detect metamorphopsia in myopic choroidal neovascularization (mCNV) and compare their usability.

Patients and Methods

This was a 12-month prospective observational study at a tertiary care eye hospital, Switzerland. Twenty-three Caucasian patients with mCNV were recruited, 21 eyes were analyzed. Primary and secondary outcome measures: Primary outcome measures were the metamorphopsia index scores as assessed by the two self-monitoring digital devices (Alleye App and AMD - A-Metamorphopsia-Detector software) at baseline, at 6 and 12 months and individual optional visits in between. Secondary outcome measures included best corrected visual acuity and morphological parameters (including disease activity) as evaluated by spectral-domain optical coherence tomography and fundus autofluorescence imaging. Location of mCNV was graded using the Early Treatment of Diabetic Retinopathy Study grid overlay. A usability questionnaire was administered at 12 months. Bland-Altman plots evaluated the limits of agreement of both devices. Linear regression analysis assessed the correlation between the difference and the average of the two scores.

Results

A total of 202 tests were performed. Disease activity of mCNV was observed at least once in 14 eyes. Both scores concordantly detected metamorphopsia exhibiting a displaced scale of measurement yielding a coefficient of determination of 0.99. Concordance rate for pathological scores was 73.3%. Both scores were not significantly different in active and inactive mCNV. Overall, the usability scores were higher for the Alleye App than the AMD - A-Metamorphopsia-Detector software (4.61±0.56 vs 3.31±1.20; p<0.001). In subjects aged >75 years, scores were slightly lower (4.08±0.86 vs 2.97±1.16; p= 0.032).

Conclusion

Whilst both self-monitoring devices concordantly identified metamorphopsia, they might act as an adjunct to hospital visits, but due to slight reactivations in mCNV and presence of metamorphopsia also in inactive disease the ability of detecting early mCNV activity might be limited.

Isotope effects on the dynamics of amorphous ices and aqueous phosphoric acid solutions

The glass transitions of amorphous ices as well as of aqueous phosphoric acid solutions were reported to display very large ¹H/²H isotope effects. Using dielectric spectroscopy, in both types of glassformers for equimolar protonated/deuterated mixtures an almost ideal isotope-mixing behavior rather than a bimodal relaxation is found. For the amorphous ices this finding is interpreted in terms of a glass-to-liquid rather than an orientational glass transition scenario. Based on calorimetric results revealing that major ¹⁶O/¹⁸O isotope effects are missing, the latter scenario was previously favored for the amorphous ices. Considering the dielectric results on ¹⁸O substituted amorphous ices and by comparison with corresponding results for the aqueous phosphoric acid solutions, it is argued that the present findings are compatible with the glass-to-liquid scenario. To provide additional information regarding the deeply supercooled state of ¹H/²H isotopically mixed and ¹⁸O substituted glassformers, the aqueous phosphoric acid solutions are studied using shear mechanical spectroscopy as well, a technique which so far could not successfully be applied to characterize the glass transitions of the amorphous ices.

External Limiting Membrane Disruption Predicts Long-Term Outcome in Strict Treat-And-Extend Regimen in Neovascular Age-Related Macular Degeneration

The use of anti-vascular-endothelial growth factor agents for neovascular age-related macular degeneration (nAMD) in different treatment schemes is widely common in clinical practice. However, there is currently limited data on the long-term outcomes of a strict treat-and-extend regimen (TER) and imaging biomarkers to predict both functional outcome and the potential for a TER exit due to success. In this retrospective study we followed treatment-naïve subjects with nAMD starting treatment with either ranibizumab or aflibercept in a TER without loading dose but with predefined exit criteria for up to 8 years. We evaluated both the functional outcome and several spectral-domain optical coherence tomography parameters in a follow-up mode using a standardized protocol. Within the 211 eyes followed for a mean of 60.3 ± 20.9 months, follow-up adherence was high with major part of discontinuations of TER being due to success. Mean best-corrected visual acuity (BCVA) increased from initially 63.9 ± 15.5 ETDRS letters to 70.0 ± 14.7 after 1 year (+6.1 letters, p < 0.001) and to 68.5 ± 18.1 (+4.6 letters, p = 0.028) at 5 years. A worse BCVA (p = 0.001) and a better external limiting membrane (ELM) disruption score at baseline predicted (p = 0.019) BCVA gain at 5 years. The probability of reaching the exit criteria was significantly associated with a better ELM disruption score (p = 0.044) and the absence of a central pigment epithelial detachment (PED) (p = 0.05) at baseline. Significant visual gains were sustained in a long-term TER in a real-world setting. Integrity of ELM at baseline predicted BCVA gain at 5 years and the potential for TER exit due to success.

Model Approach for Displaying Dynamic Filament Displacement during Impregnation of Continuous Fibres Based on the Theory of Similarity – Theory and Modelling

The underlying process for the production of textile reinforced thermoplastics is the impregnation of dry textile reinforcements with a thermoplastic matrix. The process parameters such as temperature, time and pressure of the impregnation are mainly determined by the permeability of the reinforcement. This results from a complex interaction of hydrodynamic compaction and relaxation behavior caused by textile and process parameters. The foundation for the description and optimization of impregnation progresses is therefore the determination of the pressure-dependent permeability of fibre textiles. Previous experimental investigations have shown that the dynamic compaction behavior during the impregnation of fibre reinforcements with thermoplastics or thermosets can be successfully characterized. However, for most cases, an analytical representation has not been possible due to the complexity of the process. Although it may be possible to reproduce this behavior by numerical calculations, the results need to be confirmed by experiments. This paper lays the analytical foundation for building a scaled model system, based on the theory of similarity, to observe, measure, and evaluate the dynamic compaction behavior of textile reinforcements under controlled process conditions.

The association between migration and smoke-free families: how do migrants from different world regions compare?

BACKGROUND

Studies on adolescent secondhand smoke exposure within the family often dichotomously operationalize migration background without paying attention to social and cultural diversity within migrant populations. As a result, little is known about variation within migrant groups in smoke-free family environments (SFFEs). This study analyses the association between SFFEs and parental migration from different world regions.

METHODS

Data from 14- to 16-year-old adolescents (N = 17 144) on SFFEs and parental migration were obtained from cross-sectional repeated SILNE-R surveys. A multivariable multinomial regression was applied, presenting relative risks (RRs) with 95% confidence intervals (CIs) for maternal or paternal tobacco smoking and home smoking bans. Variation in migration background was measured according to parental sex and place of birth.

RESULTS

Approximately 18% of adolescents are exposed to maternal smoking, and 25% are exposed to paternal smoking. Almost half of the respondents do not live in SFFEs but are subject to permissive (5%) or partial (39%) smoking bans at home. We found that adolescents of Eastern European descent are at a higher risk of being exposed to both paternal and maternal smoking. A sex difference in parental smoking was found among Arabic/Islamic migrants, where mothers are less likely to be smokers. Maternal and paternal African origins are associated with prohibitive smoking bans at home. Eastern European mothers show higher odds of permissiveness and freely allowing smoking at home.

CONCLUSION

Notable within-differences according to parental sex and place of birth were found for SFFEs and should be taken into account when implementing equity-sensitive tobacco prevention programs.

Electronic cigarette use among 14- to 17-year-olds in Europe

BACKGROUND

Studies comparing adolescent e-cigarette use in different countries are scarce. We study students' e-cigarette and conventional cigarette ever-use, their social correlates and e-liquid use in seven EU countries.

METHODS

SILNE-R data (N=12 167, response rate 79.4%) of 14-17-year-olds from Amersfoort (NL), Coimbra (PT), Dublin (IR), Hanover (GE), Latina (IT), Namur (BE) and Tampere (FI) were used. E-cigarette and conventional cigarette ever-use, dual-use, type of e-liquid and social correlates were measured with a school survey and analyzed with cross-tabulations and multinomial logistic regression.

RESULTS

About 34% had tried e-cigarettes, but the variation was large between the cities (Latina 50%; Hanover 23%). Of e-cigarette ever-users, 37% had used nicotine e-liquid, 43% exclusively non-nicotine liquid and 20% did not know the content. Nicotine e-liquid was more prevalent among monthly e-cigarette users and weekly smoking e-cigarette users. The social correlates were mainly the same for exclusive e-cigarette ever-use, exclusive conventional cigarette ever-use and dual-use. Boys had greater odds for exclusive e-cigarette and dual-use compared to girls. Of social correlates, low academic achievement and parental smoking were positively associated with all categories of use, but parental education and immigrant background were not. The strongest association was found between peer smoking (most/all best friends smoke) and dual-use (OR 34.29).

CONCLUSIONS

Students' e-cigarette ever-use varies greatly between EU countries. E-cigarettes seem not to be a substitute for conventional cigarettes but more a complementary product. Tobacco control policies might also prevent e-cigarette use but specific regulations on e-cigarettes are needed to prevent nicotine addiction originating from them.

Polypoidal Choroidal Vasculopathy after Stereotactic Radiotherapy for Neovascular Age-Related Macular Degeneration: A Case Report with Long-Term Follow-Up

Several adjunct therapies to the gold standard anti-vascular endothelial growth factor (anti-VEGF) intravitreal injections have been discussed for the treatment of neovascular age-related macular degeneration (nAMD). Low-dose stereotactic radiotherapy (SRT) showed the potential to lower the treatment burden by reducing the anti-VEGF treatment frequency at least over 2–3 years but was associated with retinal microvascular abnormalities in a few cases. We report a 6-year follow-up of a case with bilateral nAMD under anti-VEGF treatment which developed multiple polypoid choroidal vasculopathy (PCV) lesions in the eye adjunct treated with low-dose SRT. The fellow eye suffering from nAMD for the same period of time but never been treated with SRT did not show PCV during the long-term follow-up. We hope to increase the awareness of possible choroidal changes such as PCV in similar patients by sharing this report.

Optimal beam angle selection and knowledge-based planning significantly reduces radiotherapy dose to organs at risk for lung cancer patients

BACKGROUND

Lung cancer patients struggle with high toxicity rates. This study investigates if IMRT plans with individually set beam angles or uni-lateral VMAT plans results in dose reduction to OARs. We investigate if introduction of a RapidPlan model leads to reduced dose to OARs. Finally, the model is validated prospectively.

MATERIAL AND METHODS

Seventy-four consecutive lung cancer patients treated with IMRT were included. For all patients, new IMRT plans were made by an experienced dose planner re-tuning beam angles aiming for minimized dose to the lungs and heart. Additionally, VMAT plans were made. The IMRT plans were selected as input for a RapidPlan model, which was used to generate 74 new IMRT plans. The new IMRT plans were used as input for a second RapidPlan model. This model was clinically implemented and used for generation of clinical treatment plans. Dosimetric parameters were compared using a Wilcoxon signed rank test or a 1-sided student's t-test. p < .05 was considered significant.

RESULTS

IMRT plans significantly reduced mean doses to lungs (MLD) and heart (MHD) by 1.6 Gy and 1.7 Gy in mean compared to VMAT plans. MLD was significantly (p < .001) reduced from 10.8 Gy to 9.4 Gy by using the second RapidPlan model. MHD was significantly (p < .001) reduced from 4.9 Gy to 3.9 Gy. The model was validated in prospectively collected treatment plans showing significantly lower MLD after the implementation of the second RapidPlan model.

CONCLUSION

Introduction of RapidPlan and beam angles selected based on the target and OARs position reduces dose to OARs.

A comparison of two methods for segmentation of functional volumes in radiotherapy planning of lung cancer patients

BACKGROUND

In radiotherapy (RT) of lung cancer, dose to functional lung (FL) volumes segmented with two different methods (perfusion SPECT (Q-SPECT) and 4D-CT (4D) ventilation (V)) have been shown to correlate with the incidence of radiation pneumonitis (RP). This study aims to compare the FL volumes identified by both methods.

MATERIAL AND METHODS

Thirty lung cancer patients had a 4D and Q-SPECT prior to treatment. Seventeen of these patients also had a ventilation SPECT (V-SPECT). FL sub-volumes were segmented automatically, using cut-off values. The volumes were compared in terms of overlap fraction (OF) relative to the minimal volume, and intersection fraction (IF) of the FL volume relative to the total lung volume (V_Lung).

RESULTS

Cut-off values suggested in literature for Q-SPECT and 4D-V resulted in volumes differing in size by a median 18% [6%;31%], and a median OF and IF of 0.48 [0.23;0.70] and 0.09 [0.02;0.25], respectively. Segmenting volumes of comparable size of about 1/3 of V_Lung (FL-m(1/3), m = method) resulted in a median OF and IF of 0.43 [0.23;0.58] and 0.12 [0.06;0.19], respectively. Twenty-five patients (83%) had a reasonable overlap between FL-Q(1/3) and FL-4D-V(1/3) volumes, with OF values above 0.33. IF increased significantly (p = .036) compared to using fixed cut-off values. Similarly, volumes of comparable size of about 1/3 V_Lung were produced for V-SPECT, and FL-Q(1/3), FL-V(1/3), and FL-4D-V(1/3) were compared. The overlaps and intersections of FL-V(1/3) with FL-Q(1/3) volumes were significantly (p<.001) larger than the corresponding overlaps and intersections of FL-Q(1/3) with FL-4D(1/3) and FL-V(1/3) with FL-4D(1/3).

CONCLUSION

The Q-SPECT and 4D-V methods do not segment entirely the same FL volumes. A reasonable overlap of the volumes along with the findings of other studies that both correlate to RP incidence, suggests that a combination of both volumes, e.g. using the IF, may be useful in RT treatment planning.

Strongest Correlation Between Contrast Sensitivity and Morphological Characteristics in Bilateral nAMD

In patients with neovascular age-related macular degeneration (nAMD) there is often an inconsistency between their subjective visual impairment and a still relatively preserved standard Early Treatment of Diabetic Retinopathy Study (ETDRS) best corrected visual acuity. Therefore, in order to better capture the specific functional defects in nAMD, other tests need to be evaluated. In a previous study, we reported contrast sensitivity of the better eye to best correlate with near distance and distance vision related quality of life in patients with bilateral nAMD. Here, we evaluated Pelli-Robson contrast sensitivity, ETDRS visual acuity, low luminance visual acuity and Radner maximum reading speed and correlated them with several morphologic parameters as measured on fundus autofluorescence imaging, optical coherence tomography and optical tomography angiography in 54 patients. A multiple regression analysis was performed which correlated each visual function parameter with the anatomic features. The results showed the strongest correlations between the total area of macular geographic atrophy as well as the percentage of geographic atrophy in the central 1 mm and contrast sensitivity. Further, the regression model selected the total area of macular geographic atrophy, the photoreceptor inner and outer segments interface disruption score, the presence of subretinal fibrosis in the central 1 mm and the central retinal thickness as the variables that explained 71% of the variation in contrast sensitivity when including all eyes. Hence, our results suggest that among the evaluated measures of vision, contrast sensitivity is best correlated with the morphologic impairment in bilateral nAMD. Thus, contrast sensitivity may complement ETDRS visual acuity in clinical trials and serve as a standard diagnostic tool in clinical practice.

Predictors for 2-Year Functional and Morphological Outcomes of a Treat-and-Extend Regimen with Ranibizumab in Patients with Diabetic Macular Edema

PURPOSE

The purpose of the study was to investigate longer term functional and morphological outcomes and their predictors in diabetic macular edema (DME) following a treat-and-extend regimen (TER) without loading dose under ranibizumab.

METHODS

Patient data were reviewed and analyzed retrospectively over a period of 24 months after initiation of TER. Best-corrected visual acuity (BCVA), treatment frequency, and quantitative and qualitative spectral-domain optical coherence tomography parameters were assessed.

RESULTS

118 eyes of 87 patients were included. A mean of 9.74 ± 2.13 injections in the first and 7.63 ± 2.29 in the second year were applied. There were significant gains of BCVA and reductions in central retinal thickness from baseline to 12 and 24 months (all p < 0.001). Percentage of eyes with an intact inner segment/outer segment (IS/OS) junction increased from 15.3% at baseline to 42.1% at 24 months (p < 0.001). An intact IS/OS junction at baseline increased the probability of having a dry retina after 12 months by 79.3% (p = 0.017) and after 24 months by 88.1% (p = 0.040). Less IS/OS disruption at baseline predicted longer maximum recurrence-free treatment intervals at 2 years (r = -0.345, p < 0.001) and better BCVA at 1 year (r = -0.347, p < 0.001). Baseline bigger intraretinal cysts were associated with more IS/OS disruption at 24 months (r = 0.305, p = 0.007). Younger age and lower BCVA at baseline were predictive for a higher BCVA gain at 24 months (p = 0.046, p < 0.001).

CONCLUSION

Ranibizumab applied in a TER without loading dose in DME significantly improves visual acuity and retinal anatomical structure throughout 2 years. The evaluated predictors might help guide routine clinical treatment in DME.

[The association between school tobacco policies and the perceived smoking prevalence of adolescents]

BACKGROUND

In the German context, there is hardly any quantitative data about the implementation of school tobacco polices that include the perspective of both teachers and students. The aim of the study is to investigate the associations between implemented school tobacco policies and the perceived prevalence of smoking at the level of school staff and adolescents.

METHODS

The repeated cross-sectional study (2013 and 2017) is based on pooled responses of 13- to 17-year-old adolescents (N = 2393) and school staff (N = 85) from 25 schools located in the West German metropolitan region of Hanover. In linear regression models, average marginal effects (AMEs) with 95% confidence intervals (CI95%) and robust standard errors for perceived tobacco prevalence are reported separately for school tobacco policies assessed by teachers and students (scale 0-6). All models were controlled for sociodemographic, school-, and smoking-specific covariates.

RESULTS

On average, adolescents perceive a smoking prevalence of 30% ([Formula: see text]; s: 24.0) for their school. A comprehensive school tobacco policy is consistently associated with lower school smoking prevalence both from the point of view of teachers (AME: -3.54 CI95% -6.49 to -0.58) and students (AME: -1.69 CI95% -2.52 to -0.86). The number of smoking friends (e.g., "most of them are smokers" +14%: AME: 14.13 CI95% 10.46 to 17.80) and the type of school are the most relevant determinants of a high school smoking prevalence. School types with a nonacademic track report a 15% (AME: 15.03 CI95% 10.13 to 19.93) higher prevalence compared to grammar schools.

DISCUSSION

Progressive school tobacco control policies should focus more on school types with nonacademic tracks, certain groups at risk, and those schools that do not strictly enforce school tobacco policies.

Circulating microRNAs associated with liver fibrosis in chronic hepatitis C patients

A major challenge in hepatitis C research is the detection of early potential for progressive liver disease. MicroRNAs (miRNAs) are small RNAs that regulate gene expression and can be biomarkers of pathological processes. In this study, we compared circulating miRNAs identified in hepatitis C virus (HCV)-infected patients presenting two extremes of liver disease: mild/moderate fibrosis and cirrhosis. The patients in the cirrhosis group subsequently developed hepatocellular carcinoma (HCC). We identified 163 mature miRNAs in the mild/moderate fibrosis group and 171 in the cirrhosis group, with 144 in common to both groups. Differential expression analysis revealed 5 upregulated miRNAs and 2 downregulated miRNAs in the cirrhosis group relative to the mild/moderate fibrosis group. Functional analyses of regulatory networks (target gene and miRNA) identified gene categories involved in cell cycle biological processes and metabolic pathways related to cell cycle, cancer, and apoptosis. These results suggest that the differentially expressed circulating miRNAs observed in this work (miR-215-5p, miR-483-5p, miR-193b-3p, miR-34a-5p, miR-885-5p, miR-26b-5p and miR -197-3p) may be candidates for biomarkers in the prognosis of liver disease.

•

Circulating miRNome was performed in patients infected with HCV-1a or 1b.

•

Mature miRNAs were identified in patients with mild/moderate fibrosis and cirrhosis.

•

Five upregulated and two downregulated miRNAs were observed in the cirrhosis group.

•

Regulatory networks identified gene categories involved in cell cycle.

•

A routine baseline circulating biomarkers detection can have a prognostic value.

School tobacco policies and adolescent smoking in six European cities in 2013 and 2016: A school-level longitudinal study

Assessment of the effectiveness of school tobacco policies (STPs) in reducing adolescent smoking remains inconclusive. Previous studies took insufficient account of different dimensions of STPs, the different views of students and staff, and policy changes over time. This study assessed how a multidimensional STP, as perceived by students and staff, was associated with adolescent smoking over time in six European cities. The SILNE and SILNE-R surveys were conducted among students (n = 18,502) and staff (n = 438) in 38 schools in 2013 and 2016. Three dimensions (comprehensiveness, enforcement, and communication) were assessed and we calculated total STP scores. Multilevel logistic regressions estimated associations of STPs with adolescent smoking on and just outside school premises and with weekly smoking. Further analyses estimated associations between 2013 and 2016 STP changes and smoking outcomes in 2016, controlling for STP and smoking prevalence in 2013. On average, there were few increases in STP scores over time. Greater STP enforcement, as perceived by students, was associated with lower odds of weekly smoking (OR:0.93, 95%CI:0.89-0.97) and of smoking on school premises (OR:0.80, 95%CI:0.72-0.90). Higher total STP scores were associated with lower odds of smoking on school premises (OR:0.76, 95%CI:0.67-0.86), but not of smoking just outside premises or smoking weekly. Greater increases in STP scores over time were associated with lower odds of smoking on school premises in 2016 (OR:0.65, 95%CI:0.47-0.89). Well-enforced STPs may help reduce adolescent smoking at school. Schools should be supported in adopting comprehensive policies that also extend to the surroundings of their premises.

Explaining Mechanisms That Influence Smoke-Free Implementation at the Local Level: A Realist Review of Smoking Bans

INTRODUCTION

While studies have been undertaken to understand the adoption of outdoor and indoor smoking bans, not much is known about why implementation of smoke-free (SF) environments differs at local levels. As most European countries remain at the level of indoor bans, we aim to translate existing evidence into practical recommendations on how to improve SF (outdoor) implementation within European municipalities.

METHODS

We applied six methodological steps of a realist review consistent with the RAMESES publication standards for realist syntheses. Literature search was conducted in PubMed/MEDLINE and Web of Science. In total, 3829 references were screened, of which 43 were synthesized. Studies dating from 2004 to 2015 with rigor evidence of SF implementation at the local level were selected. Implementation outcomes were SF enforcement, monitoring, nonsmoking compliance, and public support in cities.

RESULTS

The explanatory realist framework links four innovation stages with three context-mechanism-outcome (CMO)configurations. We identified "triggering trust," "increasing priorities," and "limiting opposing interests" as underlying mechanisms, when (1) establishing, (2) developing, (3) contesting, and (4) implementing local smoking bans. The CMO propositions (CMOs) support practical recommendations, such as (1) providing authorities with local data when establishing and developing bans, (2) developing long-term strategies and implementing state-funded SF programs to prioritize sustained enforcement, and (3) limiting opposing interests through the use of the child protection frame.

CONCLUSIONS

This is the first realist review on the implementation of SF enviroments at the local level. The process-oriented theory explains how and why CMOs determine SF development in cities and municipalities from planning until implementation.

IMPLICATIONS

In 2015, only 16% of the world's population lived under the jurisdiction of comprehensive SF laws. The findings of this realist review are useful to implement WHO goals of the Framework Convention on Tobacco Control (FCTC) and specifically SF environments at more local levels and to adjust them to specific contextual circumstances. This paper unpacks three mechanisms that could be triggered by SF strategies developed at local levels and that can result in improved policy implementation. Such evidence is needed to enhance SF strategies at the level of cities and municipalities and to achieve WHO "Healthy Cities Network" objectives.

'It was a big monetary cut'-A qualitative study on financial toxicity analysing patients' experiences with cancer costs in Germany

Receiving information about expected costs promptly after a cancer diagnosis through psycho-oncology care or social counselling is crucial for patients to be prepared for the financial impact. Nevertheless, less is known about financial impacts for cancer patients in countries with statutory health insurance. This study aims to explore the full scope of costs that constitute the financial impact of a cancer diagnosis in Germany and to identify the reasons for high financial decline. Semistructured interviews with 39 cancer patients were conducted between May 2017 and April 2018. Narratives were analysed via qualitative content analysis. Several factors influenced cancer patients' indirect costs and direct medical and non-medical costs. For many patients, these changes resulted in higher indirect costs caused by income losses, especially when surcharges for shift work, travel expenses or company benefits ceased and were not reimbursed. Higher direct medical costs were caused by co-payments and additional non-refundable costs. Non-medical costs were reported to increase for some patients and to decrease for others, as for example, leisure activity costs either increasing because of pampering oneself to cope with the diagnosis and undergoing therapy or decreasing because of not being able to participate in leisure activities during therapy. When analysing the financial impacts of individuals' total costs, we found that some patients experienced no financial decline or an overall financial increase. Most patients experienced overall higher costs, and income loss was the main driver of a high financial decline. Nevertheless, decreased non-medical costs due to lower work-related and leisure activity costs could compensate for these higher costs. Cancer patients are confronted with a variety of changes in their financial situations, even in countries with statutory health insurance. Screening for cancer patients with a high risk of financial decline should consider any effects on indirect costs and direct medical and nonmedical costs.