Cancer detection rate of breast-MR in supplemental screening after negative mammography in women with dense breasts. Preliminary results of the MA-DETECT-Study after 200 participants

BACKGROUND

Due to increased cancer detection rates (CDR), breast MR (breast MRI) can reduce underdiagnosis of breast cancer compared to conventional imaging techniques, particularly in women with dense breasts. The purpose of this study is to report the additional breast cancer yield by breast MRI in women with dense breasts after receiving a negative screening mammogram.

METHODS

For this study we invited consecutive participants of the national German breast cancer Screening program with breast density categories ACR C & D and a negative mammogram to undergo additional screening by breast MRI. Endpoints were CDR and recall rates. This study reports interim results in the first 200 patients. At a power of 80% and considering an alpha error of 5%, this preliminary population size is sufficient to demonstrate a 4/1000 improvement in CDR.

RESULTS

In 200 screening participants, 8 women (40/1000, 17.4-77.3/1000) were recalled due to positive breast MRI findings. Image-guided biopsy revealed 5 cancers in 4 patients (one bilateral), comprising four invasive cancers and one case of DCIS. 3 patients revealed 4 invasive cancers presenting with ACR C breast density and one patient non-calcifying DCIS in a woman with ACR D breast density, resulting in a CDR of 20/1000 (95%-CI 5.5-50.4/1000) and a PPV of 50% (95%-CI 15.7-84.3%).

CONCLUSION

Our initial results demonstrate that supplemental screening using breast MRI in women with heterogeneously dense and very dense breasts yields an additional cancer detection rate in line with a prior randomized trial on breast MRI screening of women with extremely dense breasts. These findings are highly important as the population investigated constitutes a much higher proportion of women and yielded cancers particularly in women with heterogeneously dense breasts.

[Skin cancer screening in the aging population in Saxony-Anhalt : Utilization, facilitating, and hindering factors]

BACKGROUND

Statutory skin cancer screening (gHKS) can counteract severe courses of various types of skin cancer. The example of malignant melanoma shows that screening is important for older adults in view of the average age of onset of this disease: 62 (women) and 68 years (men). For Saxony-Anhalt (ST), as a state particularly affected by demographic change, little gHKS data are available regarding its usage.

OBJECTIVES

For the study, gHKS participation rates for persons aged 55 and older are presented for ST in comparison to the rest of Germany. Reasons for and barriers to participation from those eligible as well as possible fields of action are shown.

MATERIALS AND METHODS

For the target group, outpatient billing data from the Central Institute for Statutory Health Insurance Physicians in Germany (Zi) on gHKS from 2011-2020 are cross-sectionally and longitudinally analysed. Guideline-based telephone interviews with 18 residents using qualitative content analysis according to Kuckartz serve to identify reasons for and barriers to the use of gHKS.

RESULTS

The gHKS was rarely and irregularly used in ST and other federal states of Germany from 2011-2020; the annual utilisation rate was about 8.0% (national average: 8.4%). Between 2011 and 2020, 50% of eligible people aged 55 years and older did not participate in the gHKS. The highest utilisation rates were among men aged 70-79 years. In addition to district-specific differences, which indicate possible gaps in care, information deficits appear to be the main reason for low participation.

CONCLUSION

The low utilisation of gHKS, partly due to a lack of information among those entitled to it, requires target group-specific information services.

Effect of Indian clubbell exercises on cricket fast bowlers' shoulder kinematics

Background

The glenohumeral joint's rotational range of motion (ROM) and muscle strength are essential to execute the cricket bowling action. Performing shoulder rotation exercises may increase the rotator cuff muscle strength and rotational ROM.

Objectives

The aim of this study was to test the effect of a six-week exercise programme on shoulder rotational ROM and muscle strength.

Methods

Twenty-one healthy male cricket fast bowlers were recruited, ranked and pair-matched on initial shoulder rotator muscle strength and assigned to either a shoulder exercise (SE) group or cricket training (CT) only group. The SE group incorporated Indian clubbell exercises in addition to their cricket training.

Results

Bowlers in both groups displayed a large increase on the dominant shoulder's internal rotation (IR) ROM, but only the SE group's bowlers displayed ROM improvements (p<0.001) bilaterally for both internal and external rotation. The CT group's fast bowler's non-dominant shoulder IR ROM significantly decreased (p=0.02) during the six weeks. Between groups, only the SE group's bowler's internal rotator muscle strength improved (p<0.001) bilaterally. The observed kinematic changes were statistically significantly greater at a 5% level for the SE group's bowlers (bilateral internal rotators muscle strength, non-dominant shoulder IR ROM and horizontal adduction ROM).

Conclusion

Maintenance of the shoulder's rotational ROM and muscle strength is vital for a fast bowler. Cricket bowlers who perform regular clubbell exercises might increase their shoulder's ROM and internal rotator cuffs' muscle strength, which may aid in stabilising their glenohumeral joint while bowling.

Global rural health disparities in Alzheimer's disease and related dementias: State of the science

INTRODUCTION

Individuals living in rural communities are at heightened risk for Alzheimer's disease and related dementias (ADRD), which parallels other persistent place-based health disparities. Identifying multiple potentially modifiable risk factors specific to rural areas that contribute to ADRD is an essential first step in understanding the complex interplay between various barriers and facilitators.

METHODS

An interdisciplinary, international group of ADRD researchers convened to address the overarching question of: "What can be done to begin minimizing the rural health disparities that contribute uniquely to ADRD?" In this state of the science appraisal, we explore what is known about the biological, behavioral, sociocultural, and environmental influences on ADRD disparities in rural settings.

RESULTS

A range of individual, interpersonal, and community factors were identified, including strengths of rural residents in facilitating healthy aging lifestyle interventions.

DISCUSSION

A location dynamics model and ADRD-focused future directions are offered for guiding rural practitioners, researchers, and policymakers in mitigating rural disparities.

HIGHLIGHTS

Rural residents face heightened Alzheimer's disease and related dementia (ADRD) risks and burdens due to health disparities. Defining the unique rural barriers and facilitators to cognitive health yields insight. The strengths and resilience of rural residents can mitigate ADRD-related challenges. A novel "location dynamics" model guides assessment of rural-specific ADRD issues.

Putting participants and study partners FIRST when clinical trials end early

Between 2018 and 2019, multiple clinical trials ended earlier than planned, resulting in calls to improve communication with and support for participants and their study partners ("dyads"). The multidisciplinary Participant Follow-Up Improvement in Research Studies and Trials (Participant FIRST) Work Group met throughout 2021. Its goals were to identify best practices for communicating with and supporting dyads affected by early trial stoppage. The Participant FIRST Work Group identified 17 key recommendations spanning the pre-trial, mid-trial, and post-trial periods. These focus on prospectively allocating sufficient resources for orderly closeout; developing dyad-centered communication plans; helping dyads build and maintain support networks; and, if a trial stops, informing dyads rapidly. Participants and study partners invest time, effort, and hope in their research participation. The research community should take intentional steps toward better communicating with and supporting participants when clinical trials end early. The Participant FIRST recommendations are a practical guide for embarking on that journey.

Preclinical Alzheimer Disease and the Electronic Health Record: Balancing Confidentiality and Care

Because information technologies are increasingly used to improve clinical research and care, personal health information (PHI) has wider dissemination than ever before. The 21st Century Cures Act in the United States now requires patient access to many components of the electronic health record (EHR). Although these changes promise to enhance communication and information sharing, they also bring higher risks of unwanted disclosure, both within and outside of health systems. Having preclinical Alzheimer disease (AD), where biological markers of AD are identified before the onset of any symptoms, is sensitive PHI. Because of the melding of ideas between preclinical and "clinical" (symptomatic) AD, unwanted disclosure of preclinical AD status can lead to personal harms of stigma, discrimination, and changes to insurability. At present, preclinical AD is identified mainly in research settings, although the consensus criteria for a clinical diagnosis may soon be established. There is not yet adequate legal protection for the growing number of individuals with preclinical AD. Some PHI generated in preclinical AD trials has clinical significance, necessitating urgent evaluations and longitudinal monitoring in care settings. AD researchers are obligated to both respect the confidentiality of participants' sensitive PHI and facilitate providers' access to necessary information, often requiring disclosure of preclinical AD status. The AD research community must continue to develop ethical, participant-centered practices related to confidentiality and disclosure, with attention to sensitive information in the EHR. These practices will be essential for translation into the clinic and across health systems and society at large.

Including General Audiences in a Virtual Scientific Dementia Conference: Will They Get Anything From It?

BACKGROUND

Study participants, patients, and care partners are key stakeholders in research and have asked for greater inclusion in the dissemination of scientific learning. However, the participation of general audiences in scientific conferences dedicated to Alzheimer's disease and Alzheimer's disease related dementias (AD/ADRD) is not widely supported or studied.

OBJECTIVE

Our objectives were to evaluate the interest, level of engagement, and impact of including general audiences in a virtual dementia conference.

METHODS

A diverse group of lay participants, identified via community-based health advocacy groups and research centers, were invited to attend the 2021 Alzheimer's Association International Conference (AAIC), with optional small-group discussions. Participants received complimentary access to all scientific sessions and were supported via navigation tips, recommended sessions, and a glossary of frequently used terms and acronyms.

RESULTS

Lay participants demonstrated a high level of engagement, even among those that were research-naïve, attending virtual sessions for an average of 11.7 hours across the five days and recommending a variety of sessions to each other on topics extending from prevention of dementia to new therapies and care. Most participants said they would attend the conference again and rated the quality of interaction as high, while requesting more opportunities to engage directly with researchers.

CONCLUSION

General audiences, in particular research participants, are advocating for greater participation in scientific conferences. This program can serve as a model to accomplish inclusion; thereby acknowledging their invaluable contribution to science.

Disclosing Individual Results in Dementia Research: A Proposed Study Participant’s Bill of Rights

This Study Participant’s Bill of Rights is a call to action for researchers in Alzheimer’s disease and related dementias (ADRD) to proactively design clinical studies that provide the option for research participants to learn their individual research results if they choose, and in a manner that ensures study integrity. This Bill of Rights was crafted by a committee of study participants, care partners, representatives of dementia advocacy organizations, and other stakeholders in dementia research for the Advisory Group on Risk Education for Dementia (AGREEDementia). The framework developed by the Multi-Regional Clinical Trials (MRCT) Return of Individual Research Results provides a useful context for researchers to plan their studies and disclosure.

The AHEAD 3-45 Study: Design of a prevention trial for Alzheimer's disease

INTRODUCTION

The Alzheimer's disease (AD) continuum begins with a long asymptomatic or preclinical stage, during which amyloid beta (Aβ) is accumulating for more than a decade prior to widespread cortical tauopathy, neurodegeneration, and manifestation of clinical symptoms. The AHEAD 3-45 Study (BAN2401-G000-303) is testing whether intervention with lecanemab (BAN2401), a humanized immunoglobulin 1 (IgG1) monoclonal antibody that preferentially targets soluble aggregated Aβ, initiated during this asymptomatic stage can slow biomarker changes and/or cognitive decline. The AHEAD 3-45 Study is conducted as a Public-Private Partnership of the Alzheimer's Clinical Trial Consortium (ACTC), funded by the National Institute on Aging, National Institutes of Health (NIH), and Eisai Inc.

METHODS

The AHEAD 3-45 Study was launched on July 14, 2020, and consists of two sister trials (A3 and A45) in cognitively unimpaired (CU) individuals ages 55 to 80 with specific dosing regimens tailored to baseline brain amyloid levels on screening positron emission tomography (PET) scans: intermediate amyloid (≈20 to 40 Centiloids) for A3 and elevated amyloid (>40 Centiloids) for A45. Both trials are being conducted under a single protocol, with a shared screening process and common schedule of assessments. A3 is a Phase 2 trial with PET-imaging end points, whereas A45 is a Phase 3 trial with a cognitive composite primary end point. The treatment period is 4 years. The study utilizes innovative approaches to enriching the sample with individuals who have elevated brain amyloid. These include recruiting from the Trial-Ready Cohort for Preclinical and Prodromal Alzheimer's disease (TRC-PAD), the Australian Dementia Network (ADNeT) Registry, and the Japanese Trial Ready Cohort (J-TRC), as well as incorporation of plasma screening with the C2N mass spectrometry platform to quantitate the Aβ 42/40 ratio (Aβ 42/40), which has been shown previously to reliably identify cognitively normal participants not likely to have elevated brain amyloid levels. A blood sample collected at a brief first visit is utilized to "screen out" individuals who are less likely to have elevated brain amyloid, and to determine the participant's eligibility to proceed to PET imaging. Eligibility to randomize into the A3 Trial or A45 Trial is based on the screening PET imaging results.

RESULT

The focus of this article is on the innovative design of the study.

DISCUSSION

The AHEAD 3-45 Study will test whether with lecanemab (BAN2401) can slow the accumulation of tau and prevent the cognitive decline associated with AD during its preclinical stage. It is specifically targeting both the preclinical and the early preclinical (intermediate amyloid) stages of AD and is the first secondary prevention trial to employ plasma-based biomarkers to accelerate the screening process and potentially substantially reduce the number of screening PET scans.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Improvement of functional outcome for patients with newly diagnosed grade 2 or 3 gliomas with co-deletion of 1p/19q - IMPROVE CODEL: the NOA-18 trial

Background

Given the young age of patients with CNS WHO grade 2 and 3 oligodendrogliomas and the relevant risk of neurocognitive, functional, and quality-of-life impairment with the current aggressive standard of care treatment, chemoradiation with PCV, of the tumour located in the brain optimizing care is the major challenge.

Methods

NOA-18 aims at improving qualified overall survival (qOS) for adult patients with CNS WHO grade 2 and 3 oligodendrogliomas by randomizing between standard chemoradiation with up to six six-weekly cycles with PCV and six six-weekly cycles with lomustine and temozolomide (CETEG) (n = 182 patients per group accrued over 4 years) thereby delaying radiotherapy and adding the chemoradiotherapy concept at progression after initial radiation-free chemotherapy, allowing for effective salvage treatment and delaying potentially deleterious side effects. QOS represents a new concept and is defined as OS without functional and/or cognitive and/or quality of life deterioration regardless of whether tumour progression or toxicity is the main cause. The primary objective is to show superiority of an initial CETEG treatment followed by partial brain radiotherapy (RT) plus PCV (RT-PCV) at progression over partial brain radiotherapy (RT) followed by procarbazine, lomustine, and vincristine (PCV) chemotherapy (RT-PCV) and best investigators choice (BIC) at progression for sustained qOS. An event concerning a sustained qOS is then defined as a functional and/or cognitive and/or quality of life deterioration after completion of primary therapy on two consecutive study visits with an interval of 3 months, tolerating a deviation of at most 1 month. Assessments are done with a 3-monthly MRI, assessment of the NANO scale, HRQoL, and KPS, and annual cognitive testing. Secondary objectives are evaluation and comparison of the two groups regarding secondary endpoints (short-term qOS, PFS, OS, complete and partial response rate). The trial is planned to be conducted at a minimum of 18 NOA study sites in Germany.

Discussion

qOS represents a new concept. The present NOA trial aims at showing the superiority of CETEG plus RT-PCV over RT-PCV plus BIC as determined at the level of OS without sustained functional deterioration for all patients with oligodendroglioma diagnosed according to the most recent WHO classification.

Trial registration

Clinicaltrials.govNCT05331521. EudraCT 2018–005027-16.

Effectiveness of cell culture-based influenza vaccines compared with egg-based vaccines: What does the literature say?

Introduction

Influenza vaccination is an effective way of reducing the burden of seasonal influenza. Chicken egg embryos are the most common source of influenza vaccines, but cell culture production has emerged as an alternative that could be advantageous. This article reviews the available literature on the efficacy/effectiveness of cell culture-based influenza vaccines compared with egg-based vaccines.

Methods

We conducted a review of the actual literature and analyzed those studies comparing the effectiveness of cell culture-based and egg-based vaccines in the last ten years.

Results

Eight studies were analyzed; 1 was a clinical trial and 7 were retrospective cohort studies. The clinical trial found no significant differences in the efficacy of both vaccines with respect to placebo. The results of the observational studies were inconsistent and relative effectiveness varied among studies, even though most were performed during the same season, and in some cases, in the same region and using the same data records. Furthermore, in most studies, the comparisons between vaccines were not statistically significant.

Conclusions

There is insufficient evidence that cell culture-based vaccines are superior to egg-based vaccines in terms of efficacy/effectiveness.

Stop of proton-pump inhibitor treatment in patients with liver cirrhosis (STOPPIT): study protocol for a prospective, multicentre, controlled, randomized, double-blind trial

Background

Proton-pump inhibitors (PPI) are liberally prescribed in patients with liver cirrhosis. Observational studies link PPI therapy in cirrhotic patients with an increased risk for infectious complications, hepatic encephalopathy and an increased risk for hospitalization and mortality. However, patients with liver cirrhosis are also considered to be at risk for peptic ulcer bleeding. The STOPPIT trial evaluates if discontinuation of a pre-existing PPI treatment delays a composite endpoint of re-hospitalization and/or death in patients (recently) hospitalized with liver cirrhosis compared to patients on continued PPI medication.

Methods

The STOPPIT-trial is a prospective, multicentre, randomized, double-blinded, placebo-controlled, parallel-group trial. In total, 476 patients with complicated liver cirrhosis who already receive long-term PPI therapy without evidence-based indication are 1:1 randomized to receive either esomeprazole 20 mg (control group) or placebo (intervention group) for 360 days. Patients with an indication for PPI therapy (such as a recent diagnosis of peptic ulcers, severe reflux esophagitis, severe hemorrhagic gastritis, recent endoscopic therapy for oesophageal varices) are excluded. The primary composite endpoint is the time-to re-hospitalization and/or death. Secondary endpoints include rates of re-hospitalization, mortality, occurrence of infections, hepatic decompensation and acute-on-chronic liver failure. The safety endpoint is defined as manifestation of an evidence-based indication for PPI re-therapy. The impact of PPI continuation or discontinuation on the intestinal microbiota will be studied. The recruitment will take place at 18 study sites throughout Germany. Recruitment has started in April 2021.

Discussion

The STOPPIT trial is the first clinical trial to study the effects of PPI withdrawal on relevant outcome variables in patients with complicated liver cirrhosis. If the hypothesis that PPI withdrawal improves clinical outcomes of cirrhosis patients is confirmed, this would argue for a strong restriction of the currently liberal prescription practice of PPIs in this population. If, on the other hand, the trial demonstrates an increased risk of gastrointestinal bleeding events in patients after PPI withdrawal, this could create a rationale for a more liberal, prophylactic PPI treatment in patients with liver cirrhosis.

Trial registration

EU clinical trials register EudraCT 2019-005008-16 (registered December 27, 2019). ClinicalTrials.gov NCT04448028 (registered June 25, 2020). German Clinical Trials Register DRKS00021290 (registered March 10, 2021).

Early-stage Alzheimer disease: getting trial-ready

Slowing the progression of Alzheimer disease (AD) might be the greatest unmet medical need of our time. Although one AD therapeutic has received a controversial accelerated approval from the FDA, more effective and accessible therapies are urgently needed. Consensus is growing that for meaningful disease modification in AD, therapeutic intervention must be initiated at very early (preclinical or prodromal) stages of the disease. Although the methods for such early-stage clinical trials have been developed, identification and recruitment of the required asymptomatic or minimally symptomatic study participants takes many years and requires substantial funds. As an example, in the Anti-Amyloid Treatment in Asymptomatic Alzheimer’s Disease Trial (the first phase III trial to be performed in preclinical AD), 3.5 years and more than 5,900 screens were required to recruit and randomize 1,169 participants. A new clinical trials infrastructure is required to increase the efficiency of recruitment and accelerate therapeutic progress. Collaborations in North America, Europe and Asia are now addressing this need by establishing trial-ready cohorts of individuals with preclinical and prodromal AD. These collaborations are employing innovative methods to engage the target population, assess risk of brain amyloid accumulation, select participants for biomarker studies and determine eligibility for trials. In the future, these programmes could provide effective tools for pursuing the primary prevention of AD. Here, we review the lessons learned from the AD trial-ready cohorts that have been established to date, with the aim of informing ongoing and future efforts towards efficient, cost-effective trial recruitment.

Consensus is growing that intervention in the very early stages of Alzheimer disease is necessary for disease modification. Here, the authors discuss the challenges of recruiting asymptomatic or mildly symptomatic participants for clinical trials, focusing on ‘trial-ready’ cohorts as a potential solution.

Trial-ready cohorts are an effective strategy for the identification of participants eligible for clinical trials in early-stage Alzheimer disease (AD).

Building these cohorts requires considerable planning and technological infrastructure to facilitate recruitment, remote longitudinal assessment, data management and data storage.

Trial-ready cohorts exist for genetically determined populations at risk of AD, such as those with familial AD and Down syndrome; the longitudinal data from these cohorts is improving our understanding of the disease progression in early stages, informing clinical trial design and accelerating recruitment to intervention studies.

So far, the challenges experienced by trial-ready cohorts for early-stage AD have included difficulties recruiting an ethnically and racially representative cohort; and for online cohorts, difficulty retaining participants.

The results of ongoing work will reveal the success of strategies to improve cohort diversity and retention, and the rates of referral to clinical trials.

The nutritional impact of a feeding protocol for infants on high flow nasal cannula therapy

BACKGROUND

Clinicians may be reluctant to feed patients on high-flow nasal cannula (HFNC) therapy, despite studies suggesting it is beneficial and safe. We describe the implementation of a feeding protocol for patients with bronchiolitis on HFNC and determine its effect on nutrition goals.

METHODS

Prospective bedside data on enteral volume, feed interruptions, and aspiration events were collected on patients with bronchiolitis who were <24 months of age, treated with HFNC, and fed per a developed protocol. Exclusion criteria included history of prematurity <32 weeks, congenital heart disease, or positive-pressure ventilation before feeding. Length of intensive care unit and hospital stay was compared with both a concurrent cohort (CC) of patients not fed per the protocol and a retrospective cohort (RC) admitted prior to protocol creation.

RESULTS

Seventy-eight patients met the criteria for the prospective study arm: 24 patients were included in the CC, and 74 were included in the RC. Seventy-one percent of prospective patients received enteral nutrition (EN) on HFNC day 1 vs 42% of the CC. In the prospective cohort, feed interruption occurred in 23% of patients and was associated with higher flow rates; however, no aspiration events occurred. Patients fed per protocol were fed 8-10 h sooner and discharged 1 day earlier than those in the RC.

CONCLUSION

The use of a feeding protocol for patients with bronchiolitis on HFNC was safe and associated with shorter time to initiate EN and shorter length of hospital stay.

The Advisory Group on Risk Evidence Education for Dementia: Multidisciplinary and Open to All

The brain changes of Alzheimer's disease and other degenerative dementias begin long before cognitive dysfunction develops, and in people with subtle cognitive complaints, clinicians often struggle to predict who will develop dementia. The public increasingly sees benefits to accessing dementia risk evidence (DRE) such as biomarkers, predictive algorithms, and genetic information, particularly as this information moves from research to demonstrated usefulness in guiding diagnosis and clinical management. For example, the knowledge that one has high levels of amyloid in the brain may lead one to seek amyloid reducing medications, plan for disability, or engage in health promoting behaviors to fight cognitive decline. Researchers often hesitate to share DRE data, either because they are insufficiently validated or reliable for use in individuals, or there are concerns about assuring responsible use and ensuring adequate understanding of potential problems when one's biomarker status is known. Concerns include warning people receiving DRE about situations in which they might be compelled to disclose their risk status potentially leading to discrimination or stigma. The Advisory Group on Risk Evidence Education for Dementia (AGREEDementia) welcomes all concerned with how best to share and use DRE. Supporting understanding in clinicians, stakeholders, and people with or at risk for dementia and clearly delineating risks, benefits, and gaps in knowledge is vital. This brief overview describes elements that made this group effective as a model for other health conditions where there is interest in unfettered collaboration to discuss diagnostic uncertainty and the appropriate use and communication of health-related risk information.

[Potential effect of the stimulus threshold level of the nociceptive flexion reflex (NFRT) on mortality and delirium incidence in the critically ill patient: a retrospective cohort analysis]

BACKGROUND

Mortality and delirium in critically ill patients are affected by the provided analgesics and sedatives. The deeper the sedation and the higher the dose of analgesics applied, the more difficult it is to assess pain and the depth of sedation. Therefore, instrumental measurement methods, such as the measurement of the stimulus threshold of the nociceptive flexion reflex (NFRT), are becoming increasingly more important.

OBJECTIVE

The aim of the present study is to investigate a potential association between the level of the nociceptive flexion reflex, mortality, and the occurrence of delirium.

MATERIAL AND METHODS

By retrospectively analyzing a pilot data set of 57 ICU patients from the interdisciplinary surgical ICU of Ulm University Hospital surveyed between 11/2018 and 03/2020, a possible association between the NFRT, mortality, and the occurrence of delirium was calculated in an adjusted logistic regression model. Depending on the cut-off value, the stimulus threshold corridors result in the following comparison pairs: < 20 mA vs. 20-40 mA/20-50 mA/20-60 mA, > 40 mA vs. 20-40 mA, > 50 mA vs. 20-50 mA and > 60 mA vs. 20-60 mA. Results are presented as odds ratios (OR) adjusted for age, sex, height, TISS-28, SAPS II, RASS, BPS, and applied analgesics. Pain assessment was performed, in addition to the Behavioral Pain scale, ≥ 3 times daily by measuring NFRT.

RESULTS

A statistically nonsignificant tendency for an increase in mortality incidence occurred with an NFRT > 50 mA, versus a stimulus threshold corridor of 20-50 mA (OR 3.3, CI: 0.89-12.43, p = 0.07). A trend toward a reduction in delirium incidence occurred at an NFRT < 20 mA, versus a stimulus threshold corridor of 20-40 mA (OR 0.40, CI: 0.18-0.92, p = 0.03).

CONCLUSION

Based on the level of the NFRT, no recommendation can be made at this point to adjust the analgesic regimen of critically ill patients, who are unable to communicate. The observation of a tendency towards an increase in mortality at high stimulus thresholds or a reduction in the occurrence of delirium at low stimulus thresholds of the NFRT must be verified in standardized studies.

The Trial-Ready Cohort for Preclinical/Prodromal Alzheimer's Disease (TRC-PAD) Project: An Overview

The Trial-Ready Cohort for Preclinical/prodromal Alzheimer’s Disease (TRC-PAD) project is a collaborative effort to establish an efficient mechanism for recruiting participants into very early stage Alzheimer’s disease trials. Clinically normal and mildly symptomatic individuals are followed longitudinally in a web-based component called the Alzheimer’s Prevention Trial Webstudy (APT Webstudy), with quarterly assessment of cognition and subjective concerns. The Webstudy data is used to predict the likelihood of brain amyloid elevation; individuals at relatively high risk are invited for in-person assessment in the TRC screeing phase, during which a cognitive battery is administered and Apolipoprotein E genotype is obtained followed by reassessment of risk of amyloid elevation. After an initial validation study, plasma amyloid peptide ratios will be included in this risk assessment. Based on this second risk calculation, individuals may have amyloid testing by PET scan or lumbar puncture, with those potentially eligible for trials followed in the TRC, while the rest are invited to remain in the APT Webstudy. To date, over 30,000 individuals have participated in the Webstudy; enrollment in the TRC is in its early stage.

Work-family-conflict in the context of the working conditions of university employees – comparison of professions

Introduction

Working conditions at universities are often considered precarious. Employees complain of fixed-term contracts and extensive unpaid overtime (Dorenkamp et al. 2016). Studies from various fields of work show that occupational groups with a high workload suffer particularly from a conflictual compatibility of work and family.

Objectives

The aim of this study was to assess the WFC in the context of working conditions.

Methods

N=844 university employees (55% women, 41% men) were asked about the burden of work/life balance using Work-family-conflict (WFC) - Family-work-conflict (FWC) -Scales (Netemeyer 1996). The dichotomously formulated question on overtime worked was supplemented by a five-step scaled item on the burden of overtime. The correlation analyses were calculated according to Spearman.

Results

Overtime performed by 83% of the total sample and 64% feel burdened by it. 95% of the scientists and physicians, 68% of the administrative staff, 63% of the service providers work overtime and 90% of the physicians and 72% of the scientists feel burdened by it. Significantly high correlations were found between the burden of overtime and the conflict of compatibility. The higher the burden of overtime, the higher the WFC and FWC. The highest correlation was found among physicians (r=.649), followed by scientists (r=.533), administration (r=.451), services (r= (total sample r=.562).

Conclusions

The additional work and strain caused by this, as well as the connections with the problem of compatibility, show need for action for employers regarding the working conditions of physicians and scientists. Especially with regard to reducing overtime and improving the compatibility of work and family.

[Subjective significance of olfactory dysfunction after laryngectomy : Let's ask our patients]

BACKGROUND AND OBJECTIVE

Laryngectomy is usually associated with olfactory dysfunction. How do laryngectomees personally experience and feel about this change?

MATERIALS AND METHODS

In cooperation with the Bundesverband der Kehlkopfoperierten (German Association of Throat Cancer Patients) and together with laryngectomized patients, a new questionnaire was created and distributed via the regional offices according to the population sizes of the federal states (n = 293) for the first time in spring 2018. The questionnaire covers patient characteristics and daily life without a larynx, as well as the specific areas of smell and taste, albeit without differentiation between ortho- and retronasal olfaction. The items were designed to be answered using patient-friendly visual rating scales, multiple-choice answers, and free text.

RESULTS

Return rate was 198/293 (67.6%). Median age of all participants was 69 years (48-88). Overall life situation was rated by 99/198 (50%) participants as "good" or "very good." The primary subjective impairment for the patients was loss of voice (137/198, 69.1%) and loss of olfaction (113/198, 59.1%). Adaption to life without a larynx has been completed within a maximum of 3 years for 161/198 (81.3%) patients. Principally, 127/198 (64.1%) affirmed being able to smell and 176 of 198 (88.9%) being able to taste; however, only 29/198 (14.6%) rated their sense of smell and 109/198 (55.1%) their sense of taste as "good" or "very good." Most frequently detected smell sensations were perfume (141), smoke (126), and feces (99). Univariate analysis showed a significant (p < 0.05) correlation between adaptation time <1 year and current subjective smell and taste.

CONCLUSION

Subjective loss of smell and taste after laryngectomy is a daily problem for patients in Germany, which should be focused on promptly and included in early rehabilitation strategies.

SAFEE: A Debriefing Tool to Identify Latent Conditions in Simulation-based Hospital Design Testing

In the process of hospital planning and design, the ability to mitigate risk is imperative and practical as design decisions made early can lead to unintended downstream effects that may lead to patient harm. Simulation has been applied as a strategy to identify system gaps and safety threats with the goal to mitigate risk and improve patient outcomes. Early in the pre-construction phase of design development for a new free-standing children’s hospital, Simulation-based Hospital Design Testing (SbHDT) was conducted in a full-scale mock-up. This allowed healthcare teams and architects to actively witness care providing an avenue to study the interaction of humans with their environment, enabling effectively identification of latent conditions that may lay dormant in proposed design features. In order to successfully identify latent conditions in the physical environment and understand the impact of those latent conditions, a specific debriefing framework focused on the built environment was developed and implemented. This article provides a rationale for an approach to debriefing that specifically focuses on the built environment and describes SAFEE, a debriefing guide for simulationists looking to conduct SbHDT.

First-line therapy with bendamustine/prednisone/bortezomib-A GMMG trial for non-transplant eligible symptomatic multiple myeloma patients

OBJECTIVES

The German-speaking Myeloma Multicenter Group (GMMG) conducted this trial to investigate efficacy and safety of the three-drug combination bendamustine/prednisone/bortezomib (BPV) as first-line therapy for elderly patients with multiple myeloma (MM).

METHODS

Elderly MM patients requiring first-line therapy and not eligible for intensive treatment were enrolled in this phase IIb multicenter study. Patients were treated with BPV regimen for a maximum of nine cycles.

RESULTS

Forty-six patients were included in the trial with a median age of 76 years. Nineteen patients had renal impairment at baseline. The ORR was 78.8% for patients treated with 3 and more BPV cycles and 71.1% for all evaluable patients. The median progression-free survival was 25 months, and overall survival at 24 months was 83.3%. The clinical benefit rate including MR was 91.2%. In patients with renal impairment at baseline, a renal response was observed in 11 pts. with complete recovery of the renal function in six patients. The most frequent CTC grade 3/4 AEs experienced by patients were hematological (17.5%) and infectious (9.8%) complications. No new safety signals were observed for the study drugs under investigation.

CONCLUSIONS

Bendamustine/prednisone/bortezomib may serve as a first-line regimen for transplant-ineligible elderly MM patients in particular for patients with renal impairment requiring a fast and durable renal response.

[From external assessment of pain to automated multimodal measurement of pain intensity : Narrative review of state of research and clinical perspectives]

BACKGROUND

In patients with limited communication skills, the use of conventional scales or external assessment is only possible to a limited extent or not at all. Multimodal pain recognition based on artificial intelligence (AI) algorithms could be a solution.

OBJECTIVE

Overview of the methods of automated multimodal pain measurement and their recognition rates that were calculated with AI algorithms.

METHODS

In April 2018, 101 studies on automated pain recognition were found in the Web of Science database to illustrate the current state of research. A selective literature review with special consideration of recognition rates of automated multimodal pain measurement yielded 14 studies, which are the focus of this review.

RESULTS

The variance in recognition rates was 52.9-55.0% (pain threshold) and 66.8-85.7%; in nine studies the recognition rate was ≥80% (pain tolerance), while one study reported recognition rates of 79.3% (pain threshold) and 90.9% (pain tolerance).

CONCLUSION

Pain is generally recorded multimodally, based on external observation scales. With regard to automated pain recognition and on the basis of the 14 selected studies, there is to date no conclusive evidence that multimodal automated pain recognition is superior to unimodal pain recognition. In the clinical context, multimodal pain recognition could be advantageous, because this approach is more flexible. In the case of one modality not being available, e.g., electrodermal activity in hand burns, the algorithm could use other modalities (video) and thus compensate for missing information.

Designing for Patient Safety and Efficiency: Simulation-Based Hospital Design Testing

OBJECTIVE

In the schematic design phase of a new freestanding children's hospital, Simulation-based Hospital Design Testing (SbHDT) was used to evaluate the proposed design of 11 clinical areas. The purpose of this article is to describe the SbHDT process and how it can help identify and mitigate safety concerns during the facility design process.

BACKGROUND

In the design of new healthcare facilities, the ability to mitigate risk in the preconstruction period is imperative. SbHDT in a full-scale cardboard mock-up can be used to proactively test the complex interface between people and the built environment.

METHOD

This study was a prospective investigation of SbHDT in the schematic design planning phase for a 400-bed freestanding children's hospital where frontline staff simulated episodes of care. Latent conditions related to design were identified through structured debriefing. Failure mode and effect analysis was used to categorize and prioritize simulation findings and was used by the architect team to inform design solutions. A second round of testing was conducted in order to validate design changes.

RESULTS

A statistically significant reduction in criticality scores between Round 1 (n = 201, median = 16.14, SD = 5.8) and Round 2 (n = 201, median score of 7.68, SD = 5.26, p < .001) was identified. Bivariate analysis also demonstrated a statistically significant reduction in very high/high criticality scores between Round 1 and Round 2.

CONCLUSIONS

SbHDT in the schematic phase of design planning was effective in mitigating risk related to design prototypes through effective identification of latent conditions and validation of design changes.

The Trial-Ready Cohort for Preclinical and Prodromal Alzheimer's Disease (TRC-PAD): Experience from the First 3 Years

BACKGROUND:

The Trial-Ready Cohort for Preclinical and Prodromal Alzheimer’s disease (TRC-PAD) aims to accelerate enrollment for Alzheimer’s disease (AD) clinical trials by remotely identifying and tracking individuals who are at high risk for developing symptoms of AD, and referring these individuals to in-person cognitive and biomarker evaluation with the purpose of engaging them in clinical trials. A risk algorithm using statistical modeling to predict brain amyloidosis will be refined as TRC-PAD advances with a maturing data set.

OBJECTIVES:

To provide a summary of the steps taken to build this Trial-Ready cohort (TRC) and share results of the first 3 years of enrollment into the program.

DESIGN:

Participants are remotely enrolled in the Alzheimer Prevention Trials (APT) Webstudy with quarterly assessments, and through an algorithm identified as potentially at high risk, referred to clinical sites for biomarker confirmation, and enrolled into the TRC.

SETTING:

Both an online study and in-clinic non-interventional cohort study.

PARTICIPANTS:

APT Webstudy participants are aged 50 or older, with an interest in participation in AD therapeutic trials. TRC participants must have a study partner, stable medical condition, and elevated brain amyloid, as measured by amyloid positron emission tomography or cerebrospinal fluid analysis. Additional risk assessments include apolipoprotein E genotyping.

MEASUREMENTS:

In the APT Webstudy, participants complete the Cognitive Function Index and Cogstate Brief Battery. The TRC includes the Preclinical Alzheimer’s Cognitive Composite, comprised of the Free and Cued Selective Reminding Test, the Delayed Paragraph Recall score on the Logical Memory IIa test from the Wechsler Memory Scale, the Digit-Symbol Substitution test from the Wechsler Adult Intelligence Scale-Revised, and the Mini Mental State Examination total score (1).

RESULTS:

During the first 3 years of this program, the APT Webstudy has 30,650 consented participants, with 23 sites approved for in person screening, 112 participants have been referred for in-clinic screening visits with eighteen enrolled to the TRC. The majority of participants consented to APT Webstudy have a family history of AD (62%), identify as Caucasian (92.5%), have over twelve years of formal education (85%), and are women (73%). Follow up rates for the first quarterly assessment were 38.2% with 29.5% completing the follow up Cogstate Battery.

CONCLUSIONS:

After successfully designing and implementing this program, the study team’s priority is to improve diversity of participants both in the APT Webstudy and TRC, to continue enrollment into the TRC to our target of 2,000, and to improve longitudinal retention, while beginning the process of referring TRC participants into clinical trials.

Recruitment into the Alzheimer Prevention Trials (APT) Webstudy for a Trial-Ready Cohort for Preclinical and Prodromal Alzheimer's Disease (TRC-PAD)

BACKGROUND:

The Alzheimer Prevention Trials (APT) Webstudy is the first stage in establishing a Trial-ready Cohort for Preclinical and Prodromal Alzheimer’s disease (TRC-PAD). This paper describes recruitment approaches for the APT Webstudy.

OBJECTIVES:

To remotely enroll a cohort of individuals into a web-based longitudinal observational study. Participants are followed quarterly with brief cognitive and functional assessments, and referred to Sites for in-clinic testing and biomarker confirmation prior to enrolling in the Trial-ready Cohort (TRC).

DESIGN:

Participants are referred to the APT Webstudy from existing registries of individuals interested in brain health and Alzheimer’s disease research, as well as through central and site recruitment efforts. The study team utilizes Urchin Tracking Modules (UTM) codes to better understand the impact of electronic recruitment methods.

SETTING:

A remotely enrolled online study.

PARTICIPANTS:

Volunteers who are at least 50 years old and interested in Alzheimer’s research.

MEASUREMENTS:

Demographics and recruitment source of participant where measured by UTM.

RESULTS:

30,650 participants consented to the APT Webstudy as of April 2020, with 69.7% resulting from referrals from online registries. Emails sent by the registry to participants were the most effective means of recruitment. Participants are distributed across the US, and the demographics of the APT Webstudy reflect the referral registries, with 73.1% female, 85.0% highly educated, and 92.5% Caucasian.

CONCLUSIONS:

We have demonstrated the feasibility of enrolling a remote web-based study utilizing existing registries as a primary referral source. The next priority of the study team is to engage in recruitment initiatives that will improve the diversity of the cohort, towards the goal of clinical trials that better represent the US population.

Mobile stroke unit use for prehospital stroke treatment-an update

BACKGROUND

Acute ischemic stroke is a treatable disease. Moreover, there is increasing evidence supporting mechanical recanalization for large-vessel occlusion, even beyond a strict time window. However, only small numbers of patients receive causal treatment.

METHODS

One of the main reasons that patients do not receive causal therapy is their late arrival at the correct target hospital, which, depending on the type of stroke, is either a regional stroke unit or a comprehensive stroke center for interventional treatment. In order to triage patients correctly, a fast and complex diagnostic work-up is necessary, allowing a stroke specialist to decide on the best therapy option. As treatment possibilities become more comprehensive with the need for individualized decisions, the gap between treatment options and practical implementation is increasing.

RESULTS

The "mobile stroke unit" concept encompasses the administration of prehospital acute stroke diagnostic work-up, therapy initiation, and triage to the correct hospital using a specially equipped ambulance, staffed with a team specialized in stroke. The concept, which was conceived and first put into practice in Homburg/Saar, Germany, in 2008, is currently spreading with more than 20 active mobile stroke unit centers worldwide. The use of mobile stroke units can reduce the time until stroke treatment by 50% with a tenfold increase of patients treated within the first 60 min of symptom onset.

CONCLUSION

The mobile stroke unit concept for acute stroke prehospital management is spreading worldwide. Intensive research is still needed to analyze the best setting for prehospital stroke management.