Therapeutic trials for long COVID-19: A call to action from the interventions taskforce of the RECOVER initiative

Although most individuals recover from acute SARS-CoV-2 infection, a significant number continue to suffer from Post-Acute Sequelae of SARS-CoV-2 (PASC), including the unexplained symptoms that are frequently referred to as long COVID, which could last for weeks, months, or even years after the acute phase of illness. The National Institutes of Health is currently funding large multi-center research programs as part of its Researching COVID to Enhance Recover (RECOVER) initiative to understand why some individuals do not recover fully from COVID-19. Several ongoing pathobiology studies have provided clues to potential mechanisms contributing to this condition. These include persistence of SARS-CoV-2 antigen and/or genetic material, immune dysregulation, reactivation of other latent viral infections, microvascular dysfunction, and gut dysbiosis, among others. Although our understanding of the causes of long COVID remains incomplete, these early pathophysiologic studies suggest biological pathways that could be targeted in therapeutic trials that aim to ameliorate symptoms. Repurposed medicines and novel therapeutics deserve formal testing in clinical trial settings prior to adoption. While we endorse clinical trials, especially those that prioritize inclusion of the diverse populations most affected by COVID-19 and long COVID, we discourage off-label experimentation in uncontrolled and/or unsupervised settings. Here, we review ongoing, planned, and potential future therapeutic interventions for long COVID based on the current understanding of the pathobiological processes underlying this condition. We focus on clinical, pharmacological, and feasibility data, with the goal of informing future interventional research studies.

Excess burden of respiratory and abdominal conditions following COVID-19 infections during the ancestral and Delta variant periods in the United States: An EHR-based cohort study from the RECOVER Program

Importance

The frequency and characteristics of post-acute sequelae of SARS-CoV-2 infection (PASC) may vary by SARS-CoV-2 variant.

Objective

To characterize PASC-related conditions among individuals likely infected by the ancestral strain in 2020 and individuals likely infected by the Delta variant in 2021.

Design

Retrospective cohort study of electronic medical record data for approximately 27 million patients from March 1, 2020-November 30, 2021.

Setting

Healthcare facilities in New York and Florida.

Participants

Patients who were at least 20 years old and had diagnosis codes that included at least one SARS-CoV-2 viral test during the study period.

Exposure

Laboratory-confirmed COVID-19 infection, classified by the most common variant prevalent in those regions at the time.

Main Outcomes and Measures

Relative risk (estimated by adjusted hazard ratio [aHR]) and absolute risk difference (estimated by adjusted excess burden) of new conditions, defined as new documentation of symptoms or diagnoses, in persons between 31-180 days after a positive COVID-19 test compared to persons with only negative tests during the 31-180 days after the last negative test.

Results

We analyzed data from 560,752 patients. The median age was 57 years; 60.3% were female, 20.0% non-Hispanic Black, and 19.6% Hispanic. During the study period, 57,616 patients had a positive SARS-CoV-2 test; 503,136 did not. For infections during the ancestral strain period, pulmonary fibrosis, edema (excess fluid), and inflammation had the largest aHR, comparing those with a positive test to those with a negative test, (aHR 2.32 [95% CI 2.09 2.57]), and dyspnea (shortness of breath) carried the largest excess burden (47.6 more cases per 1,000 persons). For infections during the Delta period, pulmonary embolism had the largest aHR comparing those with a positive test to a negative test (aHR 2.18 [95% CI 1.57, 3.01]), and abdominal pain carried the largest excess burden (85.3 more cases per 1,000 persons).

Conclusions and Relevance

We documented a substantial relative risk of pulmonary embolism and large absolute risk difference of abdomen-related symptoms after SARS-CoV-2 infection during the Delta variant period. As new SARS-CoV-2 variants emerge, researchers and clinicians should monitor patients for changing symptoms and conditions that develop after infection.

Intermediary Services to Assist People With Disabilities to Implement Individualized Funding Plans: A Rapid Systematic Review

A systematic review was conducted to describe, and evaluate the effectiveness and cost-effectiveness of, intermediary services to support people with a disability to implement individualized funding plans. We included six records, including one subanalysis of randomized trial data, three qualitative studies, and two systematic reviews (reporting on 73 and 18 studies, respectively). No studies directly compared “consumer-directed plan plus intermediary services” to “consumer-directed plan with no/alternative intermediary,” so effectiveness of these interventions is uncertain. There is qualitative evidence from the perspective of disability planners and workers that intermediary interventions are important enablers of successful plan implementation. There is also qualitative evidence from consumer and family perspectives that external support is required to successfully navigate self-directed systems and that strong, trusting, and collaborative relationships with both paid and unpaid individuals in the person’s support network were facilitators of successful plan implementation. There was evidence of disabling practices and attitudes among some support agencies, resulting in coordinators being very risk averse in order to safeguard their clients. Suggestions for future research include carefully planned and ethically robust comparative trial designs, clear description and consistent delivery of interventions, and long-term evaluation of impact. The protocol was published on PROSPERO (CRD42020177607).

Interventions for social and community participation for adults with intellectual disability, psychosocial disability or on the autism spectrum: An umbrella systematic review

Objective

This umbrella systematic review examined the effectiveness, facilitators, and barriers of interventions for social, community and civic participation for adults on the autism spectrum, or with intellectual or psychosocial disability.

Data Sources

Eight databases were searched to identify eligible reviews defined by the: Sample (≥50% adults on the autism spectrum or with intellectual or psychosocial disability), Phenomena of Interest (interventions in community settings that aimed to improve social, community or civic participation, or capacity to participate), Design (any), Evaluation (any method that evaluated impacts on participation or capacity to participate), and Research type (reviews as journal articles, dissertations or in grey literature, in English, published 2010-2020).

Review Methods

Rapid review methods were used. One researcher screened 27,890 records and 788 potentially eligible full texts. A second reviewer independently screened 20% of records, and ambiguous full text publications. Study quality was extracted, and review quality was assessed with the Assessing Methodological Quality of Systematic Reviews (AMSTAR) checklist. Data from 522 studies in 57 eligible systematic reviews were extracted for narrative synthesis. The Corrected Covered Area (CCA) was calculated to indicate overlap between reviews.

Results

There was a pooled sample of 28,154 study participants, predominantly from studies in North America, the UK and Europe. There was very low overlap between reviews (CCA = 0.3%). Reviews were predominantly low quality: 77.2% of reviews met <50% of AMSTAR criteria. Most studies were low (45.4%) or moderate (38.3%) quality. Three broad intervention categories improved participation, inclusion and belonging outcomes: (1) interventions to help people identify and connect with participation opportunities (e.g., person centred planning); (2) participation opportunities or activities (e.g., joining a community group, sports or outdoor activities, or arts-based activities); and (3) supports to build skills and capacity to participate socially and in the community.

Conclusions

The evidence highlighted that improved social and community participation requires purposeful strategies that identify meaningful participation preferences (e.g., where, when, how, and with whom) and provide support to build capacity or enable ongoing participation. Community capacity building, peer support and advocacy may also be needed to make the community more accessible, and to enable people to exercise genuine choice.

Disinvestment in the presence of uncertainty: Description of a novel, multi-group, disinvestment trial design and protocol for an application to reduce or cease use of mobilisation alarms for preventing falls in hospitals

Disinvestment is the removal or reduction of previously provided practices or services, and has typically been undertaken where a practice or service has been clearly shown to be ineffective, inefficient and/or harmful. However, practices and services that have uncertain evidence of effectiveness, efficiency and safety can also be considered as candidates for disinvestment. Disinvestment from these practices and services is risky as they may yet prove to be beneficial if further evidence becomes available. A novel research approach has previously been described for this situation, allowing disinvestment to take place while simultaneously generating evidence previously missing from consideration. In this paper, we describe how this approach can be expanded to situations where three or more conditions are of relevance, and describe the protocol for a trial examining the reduction and elimination of use of mobilisation alarms on hospital wards to prevent patient falls. Our approach utilises a 3-group, concurrent, non-inferiority, stepped wedge, randomised design with an embedded parallel, cluster randomised design. Eighteen hospital wards with high rates of alarm use (≥3%) will be paired within their health service and randomly allocated to a calendar month when they will transition to a “Reduced” (<3%) or “Eliminated” (0%) mobilisation alarm condition. Dynamic randomisation will be used to determine which ward in each pair will be allocated to either the reduced or eliminated condition to promote equivalence between wards for the embedded parallel, cluster randomised component of the design. A project governance committee will set non-inferiority margins. The primary outcome will be rates of falls. Secondary clinical, process, safety, and economic outcomes will be collected and a concurrent economic evaluation undertaken.

Postoperative management of zones V-VI extensor tendon repairs: A survey of practice in Malaysia and comparison to IFSHT member countries

Introduction

A survey of International Federation of Societies for Hand Therapy (IFSHT) member countries identified relative motion extension as the preferred approach to management of zones V-VI extensor tendon repairs. The aims of this survey were to identify and compare hand therapy practice patterns in Malaysia (a non-IFSHT member country) with findings of the IFSHT survey including an IFSHT subset of Asia-Pacific therapists and to investigate if membership status of the Malaysian Society for Hand Therapists (MSHT) influenced therapy practice patterns.

Methods

An online English-language survey was distributed to 90 occupational therapists and physiotherapists including MSHT members and non-members. Participation required management of at least one extensor tendon repair in the preceding year. Five approaches were surveyed: immobilisation, early passive motion (EPM) with dynamic splinting, and early active motion (EAM) delivered by resting hand (RH), palmar resting interphalangeal joints free (PR), and relative motion extension (RME) splints.

Results

Thirty-seven of the 53 therapists (68%) who commenced the survey completed it. The most used approach was dynamic/EPM (28%), followed by RH/immobilisation (22%) and RH/EAM (22%). A preference for RME/EAM was identified with implementation barriers being surgeon preference and hand therapist confidence.

Discussion

Approach selection for Malaysian therapists differed from the combined IFSHT and Asia-Pacific respondents, with the former using dynamic/EPM and RH/immobilisation compared to IFSHT respondents who predominately used RME/EAM and PR/EAM. This survey provides valuable insights into Malaysian hand therapists' practices. If implementation barriers and therapist confidence are addressed, Malaysian practice patterns may change to better align with current evidence.

Effectiveness of knowledge brokering and recommendation dissemination for influencing healthcare resource allocation decisions: A cluster randomised controlled implementation trial

BACKGROUND

Implementing evidence into clinical practice is a key focus of healthcare improvements to reduce unwarranted variation. Dissemination of evidence-based recommendations and knowledge brokering have emerged as potential strategies to achieve evidence implementation by influencing resource allocation decisions. The aim of this study was to determine the effectiveness of these two research implementation strategies to facilitate evidence-informed healthcare management decisions for the provision of inpatient weekend allied health services.

METHODS AND FINDINGS

This multicentre, single-blinded (data collection and analysis), three-group parallel cluster randomised controlled trial with concealed allocation was conducted in Australian and New Zealand hospitals between February 2018 and January 2020. Clustering and randomisation took place at the organisation level where weekend allied health staffing decisions were made (e.g., network of hospitals or single hospital). Hospital wards were nested within these decision-making structures. Three conditions were compared over a 12-month period: (1) usual practice waitlist control; (2) dissemination of written evidence-based practice recommendations; and (3) access to a webinar-based knowledge broker in addition to the recommendations. The primary outcome was the alignment of weekend allied health provision with practice recommendations at the cluster and ward levels, addressing the adoption, penetration, and fidelity to the recommendations. The secondary outcome was mean hospital length of stay at the ward level. Outcomes were collected at baseline and 12 months later. A total of 45 clusters (n = 833 wards) were randomised to either control (n = 15), recommendation (n = 16), or knowledge broker (n = 14) conditions. Four (9%) did not provide follow-up data, and no adverse events were recorded. No significant effect was found with either implementation strategy for the primary outcome at the cluster level (recommendation versus control β 18.11 [95% CI -8,721.81 to 8,758.02] p = 0.997; knowledge broker versus control β 1.24 [95% CI -6,992.60 to 6,995.07] p = 1.000; recommendation versus knowledge broker β -9.12 [95% CI -3,878.39 to 3,860.16] p = 0.996) or ward level (recommendation versus control β 0.01 [95% CI 0.74 to 0.75] p = 0.983; knowledge broker versus control β -0.12 [95% CI -0.54 to 0.30] p = 0.581; recommendation versus knowledge broker β -0.19 [-1.04 to 0.65] p = 0.651). There was no significant effect between strategies for the secondary outcome at ward level (recommendation versus control β 2.19 [95% CI -1.36 to 5.74] p = 0.219; knowledge broker versus control β -0.55 [95% CI -1.16 to 0.06] p = 0.075; recommendation versus knowledge broker β -3.75 [95% CI -8.33 to 0.82] p = 0.102). None of the control or knowledge broker clusters transitioned to partial or full alignment with the recommendations. Three (20%) of the clusters who only received the written recommendations transitioned from nonalignment to partial alignment. Limitations include underpowering at the cluster level sample due to the grouping of multiple geographically distinct hospitals to avoid contamination.

CONCLUSIONS

Owing to a lack of power at the cluster level, this trial was unable to identify a difference between the knowledge broker strategy and dissemination of recommendations compared with usual practice for the promotion of evidence-informed resource allocation to inpatient weekend allied health services. Future research is needed to determine the interactions between different implementation strategies and healthcare contexts when translating evidence into healthcare practice.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12618000029291.

Evaluating the clinical impact of a shortened infusion duration for ramucirumab: A population pharmacokinetic model-based approach

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Background: Ramucirumab is a human recombinant immunoglobin G1 monoclonal antibody (mAb) antagonist of vascular endothelial growth factor receptor-2. Ramucirumab dosed at 8 mg/kg every 2 weeks or 10 mg/kg every 3 weeks, either as monotherapy or in combination with chemotherapy, was initially studied with as an intravenous infusion over 60 minutes following premedication with a histamine-1 receptor antagonist. Lengthy intravenous infusions are inconvenient for patients and increase the workloads of nursing and administrative staff. Shortening the infusion duration of ramucirumab could therefore benefit both patients and healthcare professionals. The current analysis determined the impact such a change could have on the pharmacokinetic (PK) profile of ramucirumab. Additionally, the relationship between infusion rate and incidence of immediate infusion-related reactions (IRRs; occurring on the day of administration), common adverse events associated with mAb infusions, was assessed. Methods: A population pharmacokinetic model was established using concentration–time data collected from 2522 patients who received one of five different ramucirumab regimens involving an intravenous infusion over ~60 minutes in 17 clinical studies. The final PK model was used to simulate concentration–time profiles and exposure parameters following ramucirumab infusion durations of 30 vs 60 min. Phase II/III clinical study data from patients receiving ramucirumab were pooled to assess the association between ramucirumab infusion rate and incidence of immediate IRRs using multivariate logistic regression analysis. Results: Ramucirumab infusions of 30- and 60-min durations resulted in equivalent concentration–time profiles and, hence, equivalent systemic exposure to ramucirumab. Among 3216 patients receiving ramucirumab in phase II/III studies, 254 (7.9%) had at least one immediate any-grade IRR; 17 (0.5%) experienced grade ≥3 immediate IRRs. The incidence of immediate IRRs (any grade or grade ≥3) was similar across infusion rate quartiles. Under multivariate logistic analysis, infusion rate was not significantly associated with an increased risk of an immediate IRR (odds ratio per 1 mg/min increase 1.014, 95% confidence interval 0.999, 1.030; p=0.071). Conclusions: Administering ramucirumab using different infusion durations (30 vs 60 min) did not affect ramucirumab exposure. Analysis of clinical study data showed a faster infusion rate was not associated with an increased risk of immediate IRRs. It is considered unlikely that shortening the infusion duration of ramucirumab will impact its clinical efficacy or overall safety profile, and is now an option for administration in the U.S.

Capturing the costs of acute hand and wrist injuries: Lessons learnt from a prospective longitudinal burden of injury study

Introduction

Given the high incidence of hand and wrist injuries, they are exceptionally costly to the economy. This prospective, longitudinal study aimed to establish methods for capturing the burden of acute hand and wrist injury from an individual and societal perspective.

Methods

A prospective longitudinal design with baseline measures of injury type and severity, and repeated measures of disability, cost, and activity limitations and participation restrictions at six weeks, three months, and six months was selected. Participants were recruited from two large urban Australian public health care services. We sought to establish methods for capturing the burden of acute hand and wrist injury from an individual and societal perspective and compare survey completion by the method of administration.

Results

A total of 206 patients consented to participate in this study, representing 54% of those invited to participate. The survey completion rates were 18% at six weeks, 2.4% at twelve weeks, and 0.004% at six months following injury. From the limited data collected at six weeks, it was noted that nearly half of the patients reported a decrease in usual financial income, 14% reported absenteeism, and 62% reported presenteeism. Participants who elected to have data collected via phone call had the highest survey completion rate ( n = 6/10; 30%) at six-week’s follow-up.

Discussion

The study findings highlight the difficulties of completing longitudinal survey research investigating individual and societal burden with this population. Future research should be carefully designed to encourage participation and retention by considering patient and public involvement in study design, the time burden placed on the participants within and across selected survey time points, providing participants with incentives to participate, and highlighting the relevance and real-world applications of the findings.

0911 Association Between Chromosomal Abnormality And Sleep Disordered Breathing Characteristics In Children With Prader Willi Syndrome

Introduction

Prader-Willi Syndrome (PWS) is a genetic disorder caused by lack of expression of paternal genes from the chromosomal region 15 q11.2-q13. PWS is associated with excessive daytime sleepiness, sleep-disordered breathing (SDB), hypoventilation and circadian rhythm disturbance. Chromosomal deletion and uniparental disomy (UPD) are the two most common genetic etiologies of PWS. Differences in clinical features between these groups are recognized; however, limited literature exists regarding sleep characteristics.

Methods

The objective was to evaluate sleep characteristics of children with PWS between those with 15q11.2-q13 chromosomal deletion and those with other genetic etiologies. A retrospective chart review of in-laboratory polysomnograms (PSG) in children with PWS prior to growth hormone treatment was performed. The apnea hypopnea index (AHI), REM AHI, NREM AHI, Obstructive Apnea Index (OAI), Central Apnea Index (CAI), hypopnea index, arousal index, presence of hypoventilation, and positional AHI were assessed.

Results

Overall 33 PWS children were identified. Mean age was 5.9 ± 5.19 (range 1-16 years), 57% were male and 85% had SDB. Almost half (42%) had a 15q11.2-q13 chromosomal deletion. Of those without deletion, 30% had UPD. Sleep variables were similar in PWS with and without deletion: AHI (5.9±5.7 vs. 8.54±7.1; p=0.27), NREM AHI (3.3±4.6 vs. 6.2±6.3; p=0.16), CAI (1.1±1.5 vs. 1.9±3.8; p=0.43) SpO2 nadir 82.7±9.9% vs. 85.3±5.7%; p=0.36) and arousal index (10.3±7.8 vs. 15.4±7.8; p=0.09).

Conclusion

Sleep characteristics do not appear to clearly differ between genetic etiologies of PWS. Larger sample sizes are needed to support these findings.

Support

 

Implementation of evidence-based weekend service recommendations for allied health managers: a cluster randomised controlled trial protocol

BACKGROUND

It is widely acknowledged that health policy and practice do not always reflect current research evidence. Whether knowledge transfer from research to practice is more successful when specific implementation approaches are used remains unclear. A model to assist engagement of allied health managers and clinicians with research implementation could involve disseminating evidence-based policy recommendations, along with the use of knowledge brokers. We developed such a model to aid decision-making for the provision of weekend allied health services. This protocol outlines the design and methods for a multi-centre cluster randomised controlled trial to evaluate the success of research implementation strategies to promote evidence-informed weekend allied health resource allocation decisions, especially in hospital managers.

METHODS

This multi-centre study will be a three-group parallel cluster randomised controlled trial. Allied health managers from Australian and New Zealand hospitals will be randomised to receive either (1) an evidence-based policy recommendation document to guide weekend allied health resource allocation decisions, (2) the same policy recommendation document with support from a knowledge broker to help implement weekend allied health policy recommendations, or (3) a usual practice control group. The primary outcome will be alignment of weekend allied health service provision with policy recommendations. This will be measured by the number of allied health service events (occasions of service) occurring on weekends as a proportion of total allied health service events for the relevant hospital wards at baseline and 12-month follow-up.

DISCUSSION

Evidence-based policy recommendation documents communicate key research findings in an accessible format. This comparatively low-cost research implementation strategy could be combined with using a knowledge broker to work collaboratively with decision-makers to promote knowledge transfer. The results will assist managers to make decisions on resource allocation, based on evidence. More generally, the findings will inform the development of an allied health model for translating research into practice.

TRIAL REGISTRATION

This trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) ( ACTRN12618000029291 ). Universal Trial Number (UTN): U1111-1205-2621.

Impact of disinvestment from weekend allied health services across acute medical and surgical wards: 2 stepped-wedge cluster randomised controlled trials

BACKGROUND

Disinvestment (removal, reduction, or reallocation) of routinely provided health services can be difficult when there is little published evidence examining whether the services are effective or not. Evidence is required to understand if removing these services produces outcomes that are inferior to keeping such services in place. However, organisational imperatives, such as budget cuts, may force healthcare providers to disinvest from these services before the required evidence becomes available. There are presently no experimental studies examining the effectiveness of allied health services (e.g., physical therapy, occupational therapy, and social work) provided on weekends across acute medical and surgical hospital wards, despite these services being routinely provided internationally. The aim of this study was to understand the impact of removing weekend allied health services from acute medical and surgical wards using a disinvestment-specific non-inferiority research design.

METHODS AND FINDINGS

We conducted 2 stepped-wedge cluster randomised controlled trials between 1 February 2014 and 30 April 2015 among patients on 12 acute medical or surgical hospital wards spread across 2 hospitals. The hospitals involved were 2 metropolitan teaching hospitals in Melbourne, Australia. Data from n = 14,834 patients were collected for inclusion in Trial 1, and n = 12,674 in Trial 2. Trial 1 was a disinvestment-specific non-inferiority stepped-wedge trial where the 'current' weekend allied health service was incrementally removed from participating wards each calendar month, in a random order, while Trial 2 used a conventional non-inferiority stepped-wedge design, where a 'newly developed' service was incrementally reinstated on the same wards as in Trial 1. Primary outcome measures were patient length of stay (proportion staying longer than expected and mean length of stay), the proportion of patients experiencing any adverse event, and the proportion with an unplanned readmission within 28 days of discharge. The 'no weekend allied health service' condition was considered to be not inferior if the 95% CIs of the differences between this condition and the condition with weekend allied health service delivery were below a 2% increase in the proportion of patients who stayed in hospital longer than expected, a 2% increase in the proportion who had an unplanned readmission within 28 days, a 2% increase in the proportion who had any adverse event, and a 1-day increase in the mean length of stay. The current weekend allied health service included physical therapy, occupational therapy, speech therapy, dietetics, social work, and allied health assistant services in line with usual care at the participating sites. The newly developed weekend allied health service allowed managers at each site to reprioritise tasks being performed and the balance of hours provided by each professional group and on which days they were provided. Analyses conducted on an intention-to-treat basis demonstrated that there was no estimated effect size difference between groups in the proportion of patients staying longer than expected (weekend versus no weekend; estimated effect size difference [95% CI], p-value) in Trial 1 (0.40 versus 0.38; estimated effect size difference 0.01 [-0.01 to 0.04], p = 0.31, CI was both above and below non-inferiority margin), but the proportion staying longer than expected was greater with the newly developed service compared to its no weekend service control condition (0.39 versus 0.40; estimated effect size difference 0.02 [0.01 to 0.04], p = 0.04, CI was completely below non-inferiority margin) in Trial 2. Trial 1 and 2 findings were discordant for the mean length of stay outcome (Trial 1: 5.5 versus 6.3 days; estimated effect size difference 1.3 days [0.9 to 1.8], p < 0.001, CI was both above and below non-inferiority margin; Trial 2: 5.9 versus 5.0 days; estimated effect size difference -1.6 days [-2.0 to -1.1], p < 0.001, CI was completely below non-inferiority margin). There was no difference between conditions for the proportion who had an unplanned readmission within 28 days in either trial (Trial 1: 0.01 [-0.01 to 0.03], p = 0.18, CI was both above and below non-inferiority margin; Trial 2: -0.01 [-0.02 to 0.01], p = 0.62, CI completely below non-inferiority margin). There was no difference between conditions in the proportion of patients who experienced any adverse event in Trial 1 (0.01 [-0.01 to 0.03], p = 0.33, CI was both above and below non-inferiority margin), but a lower proportion of patients had an adverse event in Trial 2 when exposed to the no weekend allied health condition (-0.03 [-0.05 to -0.004], p = 0.02, CI completely below non-inferiority margin). Limitations of this research were that 1 of the trial wards was closed by the healthcare provider after Trial 1 and could not be included in Trial 2, and that both withdrawing the current weekend allied health service model and installing a new one may have led to an accommodation period for staff to adapt to the new service settings. Stepped-wedge trials are potentially susceptible to bias from naturally occurring change over time at the service level; however, this was adjusted for in our analyses.

CONCLUSIONS

In Trial 1, criteria to say that the no weekend allied health condition was non-inferior to current weekend allied health condition were not met, while neither the no weekend nor current weekend allied health condition demonstrated superiority. In Trial 2, the no weekend allied health condition was non-inferior to the newly developed weekend allied health condition across all primary outcomes, and superior for the outcomes proportion of patients staying longer than expected, proportion experiencing any adverse event, and mean length of stay.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12613001231730 and ACTRN12613001361796.

A randomized controlled trial of comparative effectiveness of elastic therapeutic tape, sham tape or eccentric exercises alone for lateral elbow tendinosis

Introduction

Lateral elbow tendinosis is a condition that is well known to cause difficult challenges for hand therapists due to its long-term recovery and morbidity. Elastic therapeutic tape is commonly used as a treatment modality, despite limited evidence.

Methods

A randomized controlled trial was conducted to evaluate the effectiveness of elastic therapeutic tape, in conjunction with eccentric exercises, in the treatment of lateral elbow tendinosis. Forty participants with this condition (12 men, 28 women) were randomly allocated to three groups: (i) elastic therapeutic tape and eccentric exercises, (ii) sham tape and eccentric exercises, and (iii) eccentric exercises alone. All groups received education on activity modification techniques. Interventions were undertaken over a 12-week period (four weekly sessions and four fortnightly sessions) and outcome measures were recorded at baseline, three months and six months post randomisation.

Results

At three and six months, improvements were made in all three groups as assessed with the Patient-Rated Tennis Elbow Evaluation, the Short Form 36, pain-free grip strength, and the Occupational Self Assessment. However, there were no statistically significant differences between groups in any of these measures. There were no significant side effects or symptom exacerbation with using the elastic therapeutic tape.

Conclusions

Whilst all groups improved on key outcomes, it is possible that exercise alone and/or natural recovery were responsible for improvements. It is positive to note that the use of elastic therapeutic tape was well tolerated by participants and not associated with any significant side effects or symptom exacerbation.

The use of elastic therapeutic tape and eccentric exercises for lateral elbow tendinosis: a case series

Introduction

‘Lateral elbow tendinosis’ or ‘lateral elbow tendinopathy’ have been suggested to be more appropriate diagnostic terms instead of ‘lateral epicondylitis’ as the condition is degenerative rather than inflammatory. For this reason, it is important that interventions target this degeneration at the common extensor tendon.

Methods

A descriptive, retrospective review of a series of four patients with lateral elbow tendinosis was conducted to examine functional outcomes with the use of elastic therapeutic tape, eccentric exercises and activity modification techniques.

Results

All patients recorded improved changes in pain and grip strength within three months of treatment using elastic therapeutic tape, eccentric exercises and activity modification techniques.

Conclusions

There may be clinical benefit in the use of elastic therapeutic tape, in conjunction with eccentric exercises and activity modification techniques, for the treatment of lateral elbow tendinosis. More rigorous and comprehensive studies are recommended to further investigate this intervention.

Data collection methods in health services research: hospital length of stay and discharge destination

BACKGROUND

Hospital length of stay and discharge destination are important outcome measures in evaluating effectiveness and efficiency of health services. Although hospital administrative data are readily used as a data collection source in health services research, no research has assessed this data collection method against other commonly used methods.

OBJECTIVE

Determine if administrative data from electronic patient management programs are an effective data collection method for key hospital outcome measures when compared with alternative hospital data collection methods.

METHOD

Prospective observational study comparing the completeness of data capture and level of agreement between three data collection methods; manual data collection from ward-based sources, administrative data from an electronic patient management program (i.PM), and inpatient medical record review (gold standard) for hospital length of stay and discharge destination.

RESULTS

Manual data collection from ward-based sources captured only 376 (69%) of the 542 inpatient episodes captured from the hospital administrative electronic patient management program. Administrative data from the electronic patient management program had the highest levels of agreement with inpatient medical record review for both length of stay (93.4%) and discharge destination (91%) data.

CONCLUSION

This is the first paper to demonstrate differences between data collection methods for hospital length of stay and discharge destination. Administrative data from an electronic patient management program showed the highest level of completeness of capture and level of agreement with the gold standard of inpatient medical record review for both length of stay and discharge destination, and therefore may be an acceptable data collection method for these measures.

Improving Older Trauma Patients’ Outcomes Through Targeted Occupational Therapy and Functional Conditioning

OBJECTIVE. Hospitalized older people are at risk of functional decline, and risk increases with length of stay (LOS). We measured the impact on LOS and discharge destination of targeted occupational therapy and a functional conditioning program (FCP) for older adults admitted to a metropolitan trauma unit.

METHOD. The intervention group consisted of 50 participants &gt;65 yr old living independently in the community before admission. Outcomes were compared with historical control group data (N = 105).

RESULTS. The intervention group’s mean LOS was 2 days less than that of the control group (p = .04). A higher proportion in the intervention group was also discharged to home, but the difference was not statistically significant. Referrals to occupational therapy increased significantly (p = .05), and participants were seen 1.5 days sooner (p = .003) than the control group. Referral to FCP was 7 times higher in the intervention group (p = .001).

CONCLUSION. Targeted occupational therapy and FCP can improve LOS in older trauma patients.

Effect of Proteasome Inhibitors With Different Chemical Structures on the Ubiquitin–Proteasome System In Vitro

Proteasome inhibitor therapeutics (PITs) have the potential to cause peripheral neuropathy. In a mouse model of PIT-induced peripheral neuropathy, the authors demonstrated that ubiquitin-positive multifocal protein aggregates with nuclear displacement appear in dorsal root ganglion cells of animals that subsequently develop nerve injuries. This peripheral-nerve effect in nonclinical models has generally been recognized as the correlate of grade 3 neuropathy in clinical testing. In differentiated PC12 cells, the authors demonstrated perturbations correlative with the development of neuropathy in vivo, including ubiquitinated protein aggregate (UPA) formation and/or nuclear displacement associated with the degree of proteasome inhibition. They compared 7 proteasome inhibitors of 3 chemical scaffolds (peptide boronate, peptide epoxyketone, and lactacystin analog) to determine if PIT-induced peripheral neuropathy is modulated by inhibition of the proteasome (ie, a mechanism-based effect) or due to effects independent of proteasome inhibition (ie, an off target or chemical-structure-based effect). The appearance of UPAs was assayed at IC90 ± 5% (90% inhibition concentration ± 5%) for 20S proteasome inhibition. Results show that each of the investigated proteasome inhibitors induced identical proteasome-inhibitor-specific ubiquitin-positive immunostaining and nuclear displacement in PC12 cells. Other agents—such as paclitaxel, cisplatin, and thalidomide, which cause neuropathy by other mechanisms—did not cause UPAs or nuclear displacement, demonstrating that the effect was specific to proteasome inhibitors. In conclusion, PIT-induced neuronal cell UPA formation and nuclear displacement are mechanism based and independent of the proteasome inhibitor scaffold. These data indicate that attempts to modulate the neuropathy associated with PIT may not benefit from changing scaffolds.