The Alfred Health post-COVID-19 service, Melbourne, 2020-2022: an observational cohort study

OBJECTIVES

To determine the uptake of the Alfred Health Post-COVID service among people hospitalised with coronavirus disease 2019 (COVID-19) or referred by general practitioners; to describe their characteristics and symptoms at eight weeks and the clinical services they required.

STUDY DESIGN

Observational cohort study.

SETTING

Outpatient post-COVID-19 follow-up service in a tertiary Melbourne hospital.

PARTICIPANTS

All people admitted to Alfred Health (inpatients, hospital-in-the-home) with COVID-19, 19 March 2020 - 28 December 2022; people with persistent symptoms referred by general practitioners in the Alfred Health catchment area during 2022.

INTERVENTION

Questionnaire-based symptom assessment eight weeks after onset of COVID-19. Dyspnoea, fatigue, depression, anxiety, and post-traumatic stress disorder were assessed with standardised tools, as were health status and health-related quality of life; return to work or study, weight loss, and altered cognition and memory were also assessed. Screening was followed by physical assessment and management at the service (specialist general medicine review, physiotherapist, allied health assistant, neuropsychologist) and referral to other specialist medical services as required.

MAIN OUTCOME MEASURES

Proportion of eligible people who used the service for follow-up at eight weeks; proportions of service users who reported symptoms and return to pre-COVID-19 employment or study; clinical services required by service users.

RESULTS

Of 6712 people invited for screening, 726 completed questionnaires (11%). At least one persistent symptom was reported by 385 of 642 respondents (60% of respondents, 5.7% of invitees), most frequently memory (371 of 656, 57%) or concentration problems (431 of 656, 66%), dyspnoea (197 of 703, 28%), and extreme fatigue (189 of 673, 28%). Sixty-seven of 453 respondents had not returned to pre-COVID-19 work or study (15%). People were referred to a variety of medical and non-medical services for management, including specialist medical clinics, allied health, and rehabilitation. Among 71 people who also completed questionnaires at twelve months, the proportions who reported fatigue, anxiety, and memory and concentration changes were similar at both assessments.

CONCLUSIONS

After acute COVID-19 that required hospital admission or was followed by persistent symptoms in community care, a small proportion of people (5.7%) reported symptoms that required medical and allied health specialist assessment and management. Our findings may assist planning services for people with long COVID.

Effect of Pulmonary Rehabilitation on Exercise Capacity, Dyspnea, Fatigue, and Peripheral Muscle Strength in Patients With Post-COVID-19 Syndrome: A Systematic Review and Meta-analysis

OBJECTIVE

To establish the effects of pulmonary rehabilitation (PR) in patients with persistent symptoms after COVID-19 infection. In addition, to compare the modalities of PR services (face-to-face and telerehabilitation) and the duration of PR in weeks (4-8 weeks and >8 weeks).

DATA SOURCES

PubMed/MEDLINE, Embase (Elsevier), Central/Cochrane Library, SciELO Citation Index (Web of Science), and CINAHL.

STUDY SELECTION

Studies determining the effects of PR in patients with post-COVID-19 syndrome were included and grouped according to PR delivery modality.

DATA EXTRACTION

Data extraction and quality assessment were independently performed by 2 reviewers. The methodological quality was assessed using the Cochrane Risk of Bias Tool 1 (RoB-1).

DATA SYNTHESIS

The literature search retrieved 1406 articles, of which 7 studies explored the effects of PR on patients with post-COVID-19 syndrome, with 188 patients randomized to PR. The mean age of participants was 50 years and 49% were women. Meta-analysis showed an increase in exercise capacity with PR compared with control (6-minute walking test: mean difference: 60.56 m, 95% confidence interval: 40.75-80.36), a reduction in fatigue (Fatigue Severity Scale: -0.90, -1.49 to -0.31) but no change in dyspnea (-0.57, -1.32 to 0.17) and muscle strength (3.03, -1.89 to 7.96). There were no differences between telerehabilitation and face-to-face PR regarding effects on peripheral muscle strength (P=.42), dyspnea (P=.83), and fatigue (P=.34). There were no differences between programs 4-8 weeks and >8 weeks regarding exercise capacity (P=.83), peripheral muscle strength (P=.42), and dyspnea (P=.76).

CONCLUSIONS

PR improves exercise capacity and reduces fatigue in patients with post-COVID-19 syndrome. Duration of PR (4-8 weeks vs > 8 weeks) or PR modality (telerehabilitation vs face-to-face) did not affect outcomes but data were limited and based on subgroup analysis. Further evidence is required to determine the optimal delivery mode and duration of PR for post-COVID-19 syndrome.

Self-management interventions for people with pulmonary fibrosis: a scoping review

BACKGROUND

The most effective method for encouraging self-management in individuals with pulmonary fibrosis (PF) is unclear. This review aimed to identify common self-management components, the outcome measures used and the impact of these components in PF.

METHODS

A scoping review was conducted according to the Joanna Briggs Institute Manual for Evidence Synthesis using Medline, Embase, PsychInfo, CINAHL and the Cochrane Central Register of Controlled Trials. Eligible studies included those with educational, behavioural or support components aimed at facilitating self-management among adults with PF and employed quantitative and/or qualitative methods.

RESULTS

87 studies were included. Common self-management components included education (78%), managing physical symptoms (66%) and enhancing psychosocial wellbeing (54%). Components were predominantly delivered in a pulmonary rehabilitation setting (71%). No studies tested a PF-specific self-management package. Common outcome measures were 6-min walk distance (60%), St George's Respiratory Questionnaire (37%) and the Medical Research Council Dyspnoea scale (34%). Clinically significant improvements in these outcomes were seen in ≥50% of randomised controlled trials. Qualitative data highlighted the importance of healthcare professional and peer support and increased confidence in managing PF.

CONCLUSION

Self-management components are commonly incorporated into pulmonary rehabilitation programmes rather than being offered as standalone packages. Future research should focus on testing PF-specific self-management packages and employ standardised outcome assessments that include self-efficacy and health-related behaviours.

Barriers to and facilitators of the use of oxygen therapy in people living with an interstitial lung disease: a systematic review of qualitative evidence

BACKGROUND

Oxygen therapy is prescribed to treat hypoxaemia in people with interstitial lung disease (ILD); however, uptake and adherence remain an ongoing challenge. This systematic review aimed to identify the barriers to and facilitators of use of oxygen therapy in people with ILD, caregivers and health professionals.

METHODS

A systematic search for qualitative literature was undertaken using five electronic databases (MEDLINE, CINAHL, Embase, PsycINFO, PubMed). Qualitative analysis identified themes that were mapped to the Theoretical Domains Framework and the Consolidated Framework for Implementation Research and classified as barriers, facilitators or both.

RESULTS

A total of 13 studies were eligible for inclusion. Commonly represented domains were associated with the design of the oxygen delivery system, the associated cost, financing, stigmatisation, the physical environment and the individual needs that acted as barriers to and facilitators of the optimisation of oxygen therapy.

CONCLUSION

Effective implementation of oxygen therapy in ILD requires more robust evidence to strengthen international guidelines, sustainable and equitable funding models, and improved oxygen delivery systems that meet the needs of users. Increased information and support for users will be critical to optimise the uptake and outcomes of this important therapy.

Does pulmonary rehabilitation address treatable traits? A systematic review

BACKGROUND

There is growing interest in a "treatable traits" approach to pulmonary rehabilitation in chronic airways disease. The frequency with which pulmonary rehabilitation programmes address treatable traits is unknown.

METHODS

Randomised controlled trials of pulmonary rehabilitation compared to usual care in patients with stable chronic airways disease were included. The components of pulmonary rehabilitation delivered were extracted and mapped to treatable traits in pulmonary, extrapulmonary and behavioural/lifestyle domains. Meta-analysis was used to evaluate the impact of addressing >1 treatable trait on exercise capacity and health-related quality of life (HRQoL).

RESULTS

116 trials were included (6893 participants). Almost all pulmonary rehabilitation programmes addressed deconditioning (97% of trials). The most commonly addressed extrapulmonary traits were nutritional status (obesity and cachexia, 18% each) and mood disturbance (anxiety and depression, 10% each). Behavioural/lifestyle traits most frequently addressed were nonadherence (46%), poor inhalation technique (24%) and poor family/social support (19%). Exercise capacity and HRQoL outcomes did not differ between studies that addressed deconditioning alone and those that targeted additional traits, but heterogeneity was high.

CONCLUSION

Aside from deconditioning, treatable traits are infrequently addressed in existing trials of pulmonary rehabilitation. The potential of the treatable traits approach to improve pulmonary rehabilitation outcomes remains to be explored.

Efficacy of Repeating Pulmonary Rehabilitation in People with COPD: A Systematic Review

Background

Pulmonary rehabilitation is an effective intervention for people with chronic obstructive pulmonary disease (COPD). People with COPD undertake repeat programs, but synthesis of evidence regarding such practice has not been undertaken. The aim of this systematic review was to establish the effects of repeating pulmonary rehabilitation subsequent to an initial program in people with COPD.

Methods

Studies where participants with COPD undertook >1 pulmonary rehabilitation program were included, incorporating RCT (randomized controlled trial) and non-randomized studies. Electronic database searches were undertaken. Two authors independently undertook study identification, data extraction and risk of bias assessment. The primary outcome was health-related quality of life (HRQoL); secondary outcomes were exercise capacity, hospitalizations and exacerbations, adherence, mortality and adverse events. Narrative synthesis was undertaken for clinically heterogeneous trials. Data from RCTs and non-randomized studies were not combined for analysis.

Results

Ten included studies (2 RCTs) involved 907 participants with COPD (n=653 had undertaken >1 program). The majority of studies were at high risk of bias. One RCT (n=33) reported no difference in HRQol after a repeat program vs usual care following exacerbation (Chronic Respiratory Disease Questionnaire dyspnea domain score MD 0.4, 95% CI -0.5 to 3). In stable patients, clinically important and statistically significant improvements in HRQoL and exercise capacity were reported after repeat programs, but of a smaller magnitude than initial programs. There was evidence for reductions in exacerbations and hospitalizations, and shorter hospital length of stay for patients who repeated a program twice in 12 months compared to those who repeated once. No data for mortality or adverse events were available.

Conclusion

This systematic review provides limited evidence for benefits of repeating pulmonary rehabilitation in people with COPD, including improved HRQoL and exercise capacity, and reduced hospitalizations. However, most studies have high risk of bias, which reduces the certainty of these conclusions.

Study Registration

PROSPERO (CRD42020215093).

0128 Maternal Sleep Quality Across Pregnancy Predicts Newborn Neurodevelopment

Introduction

The prenatal period is characterized by immense fetal neuronal growth. Such rapid growth can increase fetal susceptibility to prenatal environmental insults (Barker, 1998). A promising prenatal process that may alter fetal development is maternal prenatal sleep quality. Poor prenatal sleep quality is a public health concern affecting approximately 78% of pregnant individuals (Lucena et al., 2018). In rodents, maternal sleep deprivation across gestation predicts offspring hippocampal neurogenesis, with pups exposed to sleep deprivation early and late in pregnancy exhibiting more anxiety and depression-like behaviors (Peng et al., 2015). In humans, poor sleep quality in other developmental stages predicts hippocampi and amygdalae changes (Marshall & Born, 2007; Saghir et al., 2018). However, the relation between prenatal sleep quality and offspring brain development in humans remains poorly understood. The present study examined associations between maternal sleep quality in early, mid, and late pregnancy, and newborn hippocampal and amygdala volume, regions implicated in memory and emotion.

Methods

Pregnant individuals (N=94; Mage=30.5; SDage=5.3) reported on sleep quality three times during pregnancy. Newborn (Mageinweeks=5.1; SDageinweeks=2.7) hippocampi and amygdalae volumes were assessed during an unsedated sleep cycle using magnetic resonance imaging (MRI). Tissue segmentation was collected using a multiatlas iterative algorithm that individually segmented the regions of interest and subsequently combined T1- and T2-weighted high-resolution images (See neonate multiatlas at https://www.nitrc.org/projects/unc_brain_atlas/). Bivariate correlations examined the association between prenatal sleep quality and hippocampus and amygdala volume. Partial correlations examined these associations in the presence of significant cofounding variables including intracranial volume, body weight percentile, sex, and postconceptional age.

Results

Partial correlations revealed that poor maternal sleep quality early in pregnancy predicted larger newborn bilateral hippocampal volume (all rs<.25; ps<.038). Associations with sleep later in gestation persisted for the right hippocampus (all rs<.25; ps<.038). Prenatal maternal sleep quality did not significantly predict newborn amygdala volume (all rs<-.06; ps>.58).

Conclusion

This study provides novel evidence linking prenatal sleep quality and newborn hippocampal volume in humans, suggesting the presence of an intergenerational link between prenatal sleep health and offspring well-being.

Support (If Any)

Support (if any): NIMH R01MH109662, NHLBI R01HL155744, and diversity training supplement for 1st author; F32MH125572 for 2nd author.

Pulmonary rehabilitation for interstitial lung disease: Referral and patient experiences

Objectives: The objectives of this study were to determine the proportion of patients with interstitial lung disease (ILD) referred to pulmonary rehabilitation (PR) and to understand their experiences of participation or non-participation. Methods: Adults (>18 years old) with a diagnosis of ILD were identified from the Alfred Health ILD registry in Melbourne. Information regarding PR referral and attendance were collected from medical records. Semi-structured interviews with open-ended questions were conducted with patients who had been referred to PR. Results: Of 336 patients eligible for inclusion, PR referral was identified in 137 patients (40.7%). Patients referred to PR had worse respiratory function than those not referred (forced vital capacity mean 64 (SD 23) vs 79 (19) % predicted) and more desaturation during a 6-min walk test (86.6 (7.8%) vs 88.5 (7.0%)). Semi-structured interviews identified three major themes: valued components of PR (supervision and individualization, improved confidence with exercise, education and peer support); limited knowledge about PR prior to attendance and barriers to attending PR (lack of perceived benefits, fear of exercise and accessibility). Discussion: Over 40% of patients who attended a specialist ILD clinic were referred to pulmonary rehabilitation, with higher referral rates in those with more severe disease. There are opportunities to improve patient knowledge regarding the role and expected benefits of PR in people with ILD.

Inspiratory muscle training in interstitial lung disease: a systematic scoping review

Inspiratory muscle training (IMT) has been described as one of the components of the treatment of chronic lung conditions such as obstructive and restrictive lung diseases. Although the number of studies showing results of IMT in patients with interstitial lung disease (ILD) is scarce when compared with studies in patients with COPD, evidence points to benefits of IMT in this population. This scoping review aimed to explore the role and the rationale of IMT in patients with ILD and to gather recent evidence on the effects of IMT in this population. The studies included in this review showed improvements in respiratory muscle function, quality of life, exercise capacity and dyspnea after ILD patients participated in programs that included stand-alone IMT or combined with pulmonary rehabilitation. There is still a gap in the literature to allow a clear conclusion on the indications of IMT as part of ILD treatment because of poor research design and small numbers of participants. Therefore, although IMT seems to have a positive effect in patients with ILD, current evidence prevents us from drawing a definite conclusion. Further studies need to be conducted using better research methodology to demonstrate and confirm the positive effects of IMT.

Rib cage distortion and dynamic hyperinflation during two exercise intensities in people with COPD

BACKGROUND

The relationship between rib cage (RC) motion abnormalities, dynamic hyperinflation (DH), and exercise capacity in people with COPD is controversial.

AIM

To investigate RC distortion and operational chest wall volumes during moderate and high constant-rate exercises in people with COPD.

METHODS

Seven male participants [median(Q1-Q3) age: 63(60.0-66.0) years; FEV₁: 39.0(38.0-63.0)% of predicted] performed a symptom-limited incremental exercise testing on cycle ergometer, followed by constant-rate tests (60 % and 80 % of peak work rate). Optoelectronic plethysmography was used to evaluate RC distortion: phase angle-PhAng, inspiratory phase ratio-PhRIB, expiratory phase ratio-PhREB; and chest wall volumes: end-inspiratory volume-Vei and end-expiratory volume-Vee.

RESULTS

PhRIB and PhREB significantly increased during both constant-rate exercise tests, without difference between them. In general, Vei of the chest wall significantly increased in both exercise intensities while Vee did not change.

CONCLUSIONS

The occurrence of RC distortion seemed not to limit the exercise capacity in people with COPD evaluated, and it was present even in the absence of DH.

Efficacy of inspiratory muscle training on inspiratory muscle function, functional capacity, and quality of life in patients with asthma: A randomized controlled trial

OBJECTIVE

To evaluate the efficacy of an inspiratory muscle training protocol on inspiratory muscle function, functional capacity, and quality of life in patients with asthma.

DESIGN

A single-blind, randomized controlled clinical trial.

SETTING

Community-based.

SUBJECTS

Patients with asthma, aged between 20 and 70 years old, non-smokers.

INTERVENTIONS

Participants were randomized into two groups: inspiratory muscle training group performed inspiratory muscle training 5 days a week for 8 weeks, consisting of six sets of 30 breaths per day with a training load ⩾50% of maximal inspiratory pressure, plus an educational program; the control group only received the educational program.

MAIN MEASUREMENTS

Maximal inspiratory pressure, inspiratory muscle endurance, and the distance performed on the incremental shuttle walking test were assessed pre-intervention, post-intervention and at follow-up (3 months after the end of the intervention). The asthma quality of life questionnaire was applied pre and post-intervention.

RESULTS

Data from 39 participants were analyzed. Maximal inspiratory pressure in percentage of predicted and endurance test duration were significantly higher post-intervention in the inspiratory muscle training group (∆ post-pre: 50.8% vs 7.3% of predicted - P < 0.001 and ∆ post-pre: 207.9 seconds vs 2.7 seconds - P < 0.001, respectively). There was no significant difference in the incremental shuttle walking distance between groups (∆ post-pre: 30.9 m vs -8.1 m, P = 0.165). Quality of life was perceived as significantly better, without a difference between groups (P > 0.05).

CONCLUSIONS

About 8 weeks of inspiratory muscle training in patients with controlled asthma significantly increased inspiratory muscle strength and endurance.

Ambulatory oxygen for treatment of exertional hypoxaemia in pulmonary fibrosis (PFOX trial): a randomised controlled trial

INTRODUCTION

Interstitial lung diseases are characterised by scarring of lung tissue that leads to reduced transfer of oxygen into the blood, decreased exercise capacity and premature death. Ambulatory oxygen therapy may be used to treat exertional oxyhaemoglobin desaturation, but there is little evidence to support its efficacy and there is wide variation in clinical practice. This study aims to compare the clinical efficacy and cost-effectiveness of ambulatory oxygen versus ambulatory air in people with fibrotic interstitial lung disease and exertional desaturation.

METHODS AND ANALYSIS

A randomised, controlled trial with blinding of participants, clinicians and researchers will be conducted at trial sites in Australia and Sweden. Eligible participants will be randomised 1:1 into two groups. Intervention participants will receive ambulatory oxygen therapy using a portable oxygen concentrator (POC) during daily activities and control participants will use an identical POC modified to deliver air. Outcomes will be assessed at baseline, 3 months and 6 months. The primary outcome is change in physical activity measured by number of steps per day using a physical activity monitor (StepWatch). Secondary outcomes are functional capacity (6-minute walk distance), health-related quality of life (St George Respiratory Questionnaire, EQ-5D-5L and King's Brief Interstitial Lung Disease Questionnaire), breathlessness (Dyspnoea-12), fatigue (Fatigue Severity Scale), anxiety and depression (Hospital Anxiety and Depression Scale), physical activity level (GENEActive), oxygen saturation in daily life, POC usage, and plasma markers of skeletal muscle metabolism, systematic inflammation and oxidative stress. A cost-effectiveness evaluation will also be undertaken.

ETHICS AND DISSEMINATION

Ethical approval has been granted in Australia by Alfred Hospital Human Research Ethics Committee (HREC/18/Alfred/42) with governance approval at all Australian sites, and in Sweden (Lund Dnr: 2019-02963). The results will be published in peer-reviewed scientific journals, presented at conferences and disseminated to consumers in publications for lay audiences.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03737409).

Effects of inspiratory muscle training on resting breathing pattern in patients with advanced lung disease

AIM

The aim of this study was to evaluate the effects of interval high intensity inspiratory muscle training (IMT) on resting breathing pattern in patients with advanced lung disease.

METHODS

IMT was performed daily and training load set at 50 % of the maximal inspiratory pressure. Participants were evaluated at pre-IMT, post 8 weeks of IMT and follow-up (3 months after the end of IMT). Breathing pattern (volume and time variables as well as percentages of contribution to tidal volume) was evaluated by Optoelectronic Plethysmography at rest. Friedman test was used to verify the differences between the three time-points (p < 0.05).

RESULTS

Nineteen patients (54 ± 16 years old; 5 males) were evaluated at pre-IMT and post-IMT and fourteen were assessed at follow-up. There was no significant difference (p > 0.05) in any comparison for all evaluated breathing pattern variables at the three time-points.

CONCLUSION

Resting breathing pattern was not significantly changed after 8 weeks of IMT in patients with advanced lung disease.

Home-based or remote exercise testing in chronic respiratory disease, during the COVID-19 pandemic and beyond: A rapid review

Objectives:

To identify exercise tests that are suitable for home-based or remote administration in people with chronic lung disease.

Methods:

Rapid review of studies that reported home-based or remote administration of an exercise test in people with chronic lung disease, and studies reporting their clinimetric (measurement) properties.

Results:

84 studies were included. Tests used at home were the 6-minute walk test (6MWT, two studies), sit-to-stand tests (STS, five studies), Timed Up and Go (TUG, 4 studies) and step tests (two studies). Exercise tests administered remotely were the 6MWT (two studies) and step test (one study). Compared to centre-based testing the 6MWT distance was similar when performed outdoors but shorter when performed at home (two studies). The STS, TUG and step tests were feasible, reliable (intra-class correlation coefficients >0.80), valid (concurrent and known groups validity) and moderately responsive to pulmonary rehabilitation (medium effect sizes). These tests elicited less desaturation than the 6MWT, and validated methods to prescribe exercise were not reported.

Discussion:

The STS, step and TUG tests can be performed at home, but do not accurately document desaturation with walking or allow exercise prescription. Patients at risk of desaturation should be prioritised for centre-based exercise testing when this is available.

Early mobilization in clinical practice: the reliability and feasibility of the 'Start To Move' Protocol

PURPOSE

The properties of a local Intensive Care Unit early mobilization protocol ('Start To Move As Soon As Possible') in critically ill patients, consisting of an objective diagnostic assessment linked to six treatment levels were evaluated. This study aimed to investigate whether the protocol can be reliably applied by different health-care providers (reliability), to examine the associations between prescribed and delivered treatments (feasibility) and to explore safety and patient satisfaction with the protocol.

METHODS

Cross-sectional observational study evaluating the reliability of the protocol between physiotherapist was evaluated with Cohen's kappa, percentage of agreement, and intraclass correlation coefficients in 61 patients. Feasibility was analyzed as agreement between prescribed and delivered treatments with Spearman's rank correlation coefficients in 60 patients. A satisfaction survey was used to evaluate patient satisfaction with the protocol.

RESULTS

Excellent agreement was observed between physiotherapists for diagnostic level assignment (Kappa = 0.92), while the majority of the treatment proposals per level showed moderate to substantial agreement between the physiotherapists (Kappa range: 0.40-0.89). Three hundred and thirteen treatments were prescribed. Perfect agreement was observed between prescribed and delivered treatments in level 0 (Spearman's rho 1.00) and excellent associations for levels 1-5 (0.941, 0.995, 0.951, 0.998, and 0.999), respectively. Unwanted safety events rate was 3%. Most patients (92%) were very satisfied with physiotherapy.

CONCLUSION

Excellent inter-rater agreement for diagnostic level assignment and moderate to substantial agreement for proposed treatments support the reliability of the protocol. Perfect to excellent associations between prescribed and delivered treatments supports its feasibility. Complications were rare, and most patients were very positive regarding the care provided by physiotherapists during their stay in the ICU.

0998 Health Care Utilization of Pediatric Sleep Disorders in Cerner Health Facts Database

Introduction

This study was aimed to identify health care utilization of sleep disorders in pediatrics and adults by using Cerner health facts database.

Methods

Health facts database has unidentified health records from all the participating facilities that have Cerner as their electronic medical records software. There are 68.7 million patients in the data warehouse with about 506.9 million encounters in about 100 healthcare systems. Sleep disorders are mostly seen in outpatient settings and therefore this study included outpatient records between the years 2010 to 2017.

Results

There were 20.5 million patients with total of 127.4 million outpatient encounters. In pediatric patients (ages 0-18 years), healthcare utilization of major sleep diagnoses per 100,000 encounters showed sleep related breathing disorders are the most commonly seen followed by parasomnia, insomnia, sleep movement disorders, hypersomnolence then circadian rhythm disorders (820.1, 258.1, 181.6, 68.3, 48.1 and 16.2 per 100,000 encounters). However, for adult patients the ranking was: sleep related breathing disorders, insomnia, sleep related movement disorders, hypersomnolence, parasomnia then circadian rhythm disorders (1352.6, 511.6, 166.3, 79.1, 25.7 and 4.2 per 100,000 encounters). Further analysis for the age groups showed bimodal pattern for sleep related breathing disorders and sleep movement disorders with the highest utilization were between the ages of 2-11 year and 40-60 years. Adolescents (age 12-18 years) showed increase utilization in the areas of circadian rhythm disorders.

Conclusion

Patients with sleep disorders have relatively low health care utilization despite high prevalence of these sleep disorders in the general population. This may highlight underrecognized sleep problem or decreased access to health care. In addition, this study highlights the effect of age on different sleep disorders which may have an impact on allocating resources.

Support

None

Health resource utilization of labor induction versus expectant management

BACKGROUND

Although induction of labor of low-risk nulliparous women at 39 weeks reduces the risk of cesarean delivery compared with expectant management, concern regarding more frequent use of labor induction remains, given that this intervention historically has been thought to incur greater resource utilization.

OBJECTIVE

The objective of the study was to determine whether planned elective labor induction at 39 weeks among low-risk nulliparous women, compared with expectant management, was associated with differences in health care resource utilization from the time of randomization through 8 weeks postpartum.

STUDY DESIGN

This is a planned secondary analysis of a multicenter randomized trial in which low-risk nulliparous women were assigned to induction of labor at 39 weeks or expectant management. We assessed resource utilization after randomization in 3 time periods: antepartum, delivery admission, and discharge through 8 weeks postpartum.

RESULTS

Of 6096 women with data available, those in the induction of labor group (n = 3059) were significantly less likely in the antepartum period after randomization to have at least 1 ambulatory visit for routine prenatal care (32.4% vs 68.4%), unanticipated care (0.5% vs 2.6%), or urgent care (16.2% vs 44.3%), or at least 1 antepartum hospitalization (0.8% vs 2.2%, P < .001 for all). They also had fewer tests (eg, sonograms, blood tests) and treatments (eg, antibiotics, intravenous hydration) prior to delivery. During the delivery admission, women in the induction of labor group spent a longer time in labor and delivery (median, 0.83 vs 0.57 days), but both women (P = .002) and their neonates (P < .001) had shorter postpartum stays. Women and neonates in both groups had similar frequencies of postpartum urgent care and hospital readmissions (P > .05 for all).

CONCLUSION

Women randomized to induction of labor had longer durations in labor and delivery but significantly fewer antepartum visits, tests, and treatments and shorter maternal and neonatal hospital durations after delivery. These results demonstrate that the health outcome advantages associated with induction of labor are gained without incurring uniformly greater health care resource use.

Using social network analysis to characterize the collaboration network of backyard poultry trainers in ackCalifornia

In order to better understand collaboration among trainers in the backyard poultry community (i.e. feed store managers, youth development programs (i.e. 4-H), veterinarians, government agencies, extension resources and backyard poultry club leaders), Social Network Analysis (SNA) was used as a tool to better characterize and quantify the current collaboration network structure of backyard poultry trainers in California. Invited trainer attendees of two "Train-the-Trainers" poultry workshops (n = 67) held in Northern and Southern California were given a survey that asked them to list contacts that they collaborated with on backyard poultry (BYP) related work. The collaboration network in this study included a total of 109 trainers, 18 practitioners, and 32 individuals who are both trainers and practitioners for a total of 170 nodes (11 individuals did not have affiliation information available). In order to help identify central actors or collaboration leaders, the surveys were analyzed using Social Network Analysis (SNA), which allows for a quantitative analysis of relationships among various stakeholders. While the SNA showed that the existing collaboration network is disconnected with a clustering coefficient of 0.043 and median total degree centrality of 1 (range 9) and therefore not conducive for collaboration, key insights that could help restructure and improve the network were identified. As an example, among different poultry groups, 4-H was identified as the organization with the second highest median coverage score and fifth highest median centrality score. In addition, 4-H group leaders act as both trainers and practitioners. Consequently, outreach to 4-H group leaders throughout the state would potentially have the greatest impact with respect to overall coverage both inside and outside the 4-H network due to their high centrality and boundary spanning roles. Using SNA to strengthen the collaboration network infrastructure of backyard poultry trainers ultimately offers a more targeted approach toward extension for backyard poultry owners, which could ultimately facilitate communication and knowledge-sharing with BYP owners during a disease outbreak.

Human platelets express endothelial protein C receptor, which can be utilized to enhance localization of factor VIIa activity

Essentials Factor VIIa binds activated platelets to promote hemostasis in hemophilia patients with inhibitors. The interactions and sites responsible for platelet-FVIIa binding are not fully understood. Endothelial cell protein C receptor (EPCR) is expressed on activated human platelets. EPCR binding enhances the efficacy of a FVIIa variant and could impact design of new therapeutics.

SUMMARY

Background High-dose factor VIIa (FVIIa) is routinely used as an effective bypassing agent to treat hemophilia patients with inhibitory antibodies that compromise factor replacement. However, the mechanism by which FVIIa binds activated platelets to promote hemostasis is not fully understood. FVIIa-DVQ is an analog of FVIIa with enhanced tissue factor (TF)-independent activity and hemostatic efficacy relative to FVIIa. Our previous studies have shown that FVIIa-DVQ exhibits greater platelet binding, thereby suggesting that features in addition to lipid composition contribute to platelet-FVIIa interactions. Objectives Endothelial cell protein C receptor (EPCR) also functions as a receptor for FVIIa on endothelial cells. We therefore hypothesized that an interaction with EPCR might play a role in platelet-FVIIa binding. Methods/results In the present study, we used flow cytometric analyses to show that platelet binding of both FVIIa and FVIIa-DVQ is partially inhibited in the presence of excess protein C or an anti-EPCR antibody. This decreased binding results in a corresponding decrease in the activity of both molecules in FXa and thrombin generation assays. Enhanced binding to EPCR was sufficient to account for the increased platelet binding of FVIIa-DVQ compared with wild-type FVIIa. As EPCR protein expression has not previously been shown in platelets, we confirmed the presence of EPCR in platelets using immunofluorescence, flow cytometry, immunoprecipitation, and mass spectrometry. Conclusions This work represents the first demonstration that human platelets express EPCR and suggests that modulation of EPCR binding could be utilized to enhance the hemostatic efficacy of rationally designed FVIIa analogs.

Can inspiratory muscle training improve weaning outcomes in difficult to wean patients? A protocol for a randomised controlled trial (IMweanT study)

INTRODUCTION

Respiratory muscle dysfunction has been associated with failure to wean from mechanical ventilation. It has therefore been hypothesised that these patients might benefit from inspiratory muscle training (IMT). Evidence, however, is thus far limited to data from small, single-centre studies with heterogeneity in inclusion criteria, training modalities and outcomes. The aim of this study is to evaluate the effects of a novel IMT method on weaning outcomes in selected patients with weaning difficulties.

METHODS

This study is designed as a double-blind, parallel-group, randomised controlled superiority trial with 1:1 allocation ratio. Patients with weaning difficulties will be randomly allocated into either an IMT group (intervention) or a sham-IMT group (control). Ninetypatients (45 in each group) will be needed to detect a 28% difference in the proportion of weaning success between groups (estimated difference in primary outcome based on previous studies) with a risk for type I error (α) of 5% and statistical power (1-β) of 80%. Patients will perform four sets of 6-10 breaths daily against an external load using a tapered flow resistive loading device (POWERbreathe KH2, HaB International, UK). Training intensity in the intervention group will be adjusted to the highest tolerable load. The control group will train against a low resistance that will not be modified during the training period. Training will becontinued until patients are successfully weaned or for a maximum duration of 28 days. Pulmonary and respiratory muscle function, weaning duration, duration of mechanical ventilation, ventilator-free days and length of stay in the intensive care unit will be evaluated as secondary outcomes. Χ2 tests and analysis of covariance with adjustments for baseline values of respective outcomesas covariates will be used to compare results after the intervention period between groups.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the local ethical committee (Ethische Commissie Onderzoek UZ/KU Leuven protocol ID: S60516). Results from this randomised controlled trial will be presented at scientific meetings as abstracts for poster or oral presentations and published in peerreviewed journals.

TRIAL STATUS

Enrolment into the study have started in August 2017. Data collection and data analysis are expected to be completed in September 2021.

TRIAL REGISTRATION NUMBER

NCT03240263.

Influence of microstructure on symmetry determination of piezoceramics

The origin of the complex reflection splitting in potassium sodium niobate doped with lithium and manganese was investigated using temperature-dependent high-resolution X-ray and neutron diffraction as well as electron probe microanalysis and scanning electron microscopy. Two structural models were developed from the diffraction data. A single-phase monoclinic Pm model is known from the literature and is able to reproduce the diffraction patterns perfectly. However, a model with phase coexistence of two classical orthorhombic Amm2 phases can also reproduce the diffraction data with equal accuracy. Scanning electron microscopy in combination with electron probe microanalysis revealed segregation of the A-site substituents potassium and sodium. This favours the model with phase coexistence and confirms the need for comprehensive analyses with complementary methods to cover a broad range of length scales as well as to assess both average and local structure.

Effects of pulmonary rehabilitation in lung transplant candidates: a systematic review

OBJECTIVES

The aim of this systematic review of randomised controlled trials (RCTs), and quasi-experimental and retrospective studies is to investigate the effects of pulmonary rehabilitation (PR) in patients with advanced chronic disease on the waiting list for lung transplantation.

SETTING

PR performed for inpatient or outpatient lung transplant candidates.

INTERVENTION

PR programme including aerobic exercise training and/or resistance exercise training.

PRIMARY AND SECONDARY OUTCOMES

Quality of life and exercise capacity (primary outcomes). Survival rate after transplant surgery; pulmonary function; respiratory muscle strength; psychological aspects; upper and lower extremity muscle strength and adverse effects (secondary outcomes). Two review authors independently selected the studies, assessed study quality and extracted data. Studies in any language were included.

RESULTS

This was a systematic review and studies were searched on the Cochrane Library, MEDLINE, EMBASE, CINAHL and PEDro. Experimental and retrospective studies evaluating the effects of PR in candidates for lung transplantation (>18 years old) with any lung diseases were included. 2 RCTs, and two quasi-experimental and two retrospectives studies, involving 1305 participants were included in the review. 5 studies included an enhancement reported in quality of life using the Short Form 36 questionnaire and showed improvements in some domains. All studies included exercise capacity evaluated through 6 min walk test and in five of them, there were improvements in this outcome after PR. Owing to the different characteristics of the studies, it was not possible to perform a meta-analysis.

CONCLUSIONS

Studies included in this review showed that PR is an effective treatment option for patients on the waiting list for lung transplantation and can improve quality of life and exercise capacity in those patients. Although individual studies reported positive effects of PR, this review shows that there is a need for more studies of a high methodological quality addressing PR effects in lung transplant candidates.

TRIAL REGISTRATION NUMBER

PROSPERO CDR42015025110.

Constipation: an emerging risk factor for Parkinson's disease?

Constipation is the most prominent and disabling manifestation of lower gastrointestinal (GI) dysfunction in Parkinson's disease (PD). The prevalence of constipation in PD patients ranges from 24.6% to 63%; this variability is due to the different criteria used to define constipation and to the type of population enrolled in the studies. In addition, constipation may play an active role in the pathophysiological changes that underlie motor fluctuations in advanced PD through its negative effects on absorption of levodopa. Several clinical studies now consistently suggest that constipation may precede the first occurrence of classical motor features in PD. Studies in vivo, using biopsies of the GI tract and more recently functional imaging investigations, showed the presence of α-synuclein (α-SYN) aggregates and neurotransmitter alterations in enteric tissues. All these findings support the Braak proposed model for the pathophysiology of α-SYN aggregates in PD, with early pathological involvement of the enteric nervous system and dorsal motor nucleus of the vagus. Therefore, constipation could have the potential sensitivity to be used as a clinical biomarker of the prodromal phase of the disease. The use of colonic biopsies to look at α-SYN pathology, once confirmed by larger prospective studies, might eventually represent a feasible, albeit partially invasive, new diagnostic biomarker for PD.

An activated factor VII variant with enhanced tissue factor-independent activity speeds wound healing in a mouse hemophilia B model

Essentials Disorders of hemostasis can lead to delayed and defective wound healing. In hemophilia B (HB) mice, 7 days of Factor (F)IX or VIIa are needed to normalize wound healing. One dose of a highly active FVIIa variant (DVQ) restored normal wound closure time in HB mice. Coagulation factors with enhanced activity may acquire biological effects not due to hemostasis.

SUMMARY

Introduction We have previously reported that hemophilia B (HB) mice have delayed healing of cutaneous wounds and alterations in wound histology. Administration of a single dose of either factor IX or recombinant activated FVII (rFVIIa) (NovoSeven) prior to wounding did not improve wound closure time or histology. The FVIIa analog DVQ (V158D, E296V and M298Q mutations) was designed to have higher tissue factor-independent activity than rVIIa. We hypothesized that a single dose of DVQ would be more effective in restoring wound healing in HB mice. Methods Cutaneous punch wounds were made on the backs of HB and wild-type mice, and the time to wound closure was monitored. HB mice were treated with a dose of rFVIIa (10 mg kg(-1) ) or DVQ (1 mg kg(-1) ) that corrected the tail bleeding time. Skin samples were taken at various time points after wounding, fixed, and stained, and the histology was examined. Results As previously reported, wound closure times in HB mice given one dose of rFVIIa were not improved over those in untreated HB mice. Surprisingly, healing times in HB mice treated with an equally hemostatic dose of DVQ were normalized to that in wild-type mice. However, DVQ did not correct all histologic abnormalities in HB mice. Conclusions As the doses of DVQ and rFVIIa were chosen to support comparable levels of hemostasis, our data suggest that the improved healing seen with DVQ is not solely attributable to its hemostatic activity. It is possible that the improved wound healing arises through the effect of DVQ on cell signaling mechanisms.

Coated platelets and severe haemophilia A bleeding phenotype: Is there a connection?

INTRODUCTION

Coated platelets are a subpopulation of platelets that possess highly prothrombotic properties. Previous observational data suggest that bleeding phenotype in severe haemophilia A is associated with coated platelet levels. Haemophilia A patients with higher coated platelet levels may have a mild bleeding phenotype; those with lower levels may have a more severe bleeding phenotype.

AIM

The aim of the study was to test the hypothesis that coated platelet levels are correlated with clinical bleeding phenotype.

METHODS

This cross-sectional, observational study enrolled 20 severe haemophilia A patients, including 15 with severe and five with a mild bleeding phenotype, and a control group of 12 healthy volunteers. The haemophilia bleeding phenotype was determined by the patient's medical history and haemophilia treatment centre records. Blood was obtained from each patient by venipuncture and platelets were analysed by flow cytometry.

RESULTS

Patients categorized as having a severe bleeding phenotype experienced a median eight bleeds per year compared to one bleed annually in the mild bleeding phenotype group. Both groups had similar total platelet counts and fibrinogen levels. There was no difference in coated platelet percentage between severe and mild bleeding phenotype (17 and 16% respectively), however, both groups had significantly lower % coated platelets compared to controls (44%, P < 0.0001).

CONCLUSION

Coated platelet levels were not associated with bleeding phenotype in this study; however, these data may suggest coated platelet levels are lower in haemophilia patients relative to healthy volunteers.