Functional status and well-being of patients with chronic conditions. Results from the Medical Outcomes Study

Evaluating the Impact of Minimally Invasive Surgery on Long-Term Quality of Life in Foregut Cancer Patients

INTRODUCTION

Compared to open surgery (OS), minimally invasive surgery (MIS) for foregut cancer improves perioperative outcomes. However, the impact of MIS on long-term quality of life (QOL) is unknown. We compare the long-term QOL of patients who underwent MIS and OS for foregut cancer.

METHODS

Surgically managed esophageal and gastric cancer patients were surveyed globally via online support groups. Physical (P-QOL) and mental (M-QOL) well-being were determined using the Short Form-12 questionnaire and compared based on the surgical approach (MIS vs OS). We defined "long-term" as greater than 3 months from surgery.

RESULTS

Out of 100 respondents with esophageal and gastric cancer, 64 survivors underwent surgical management greater than 3 months before the survey. They were 56.6 ± 9.9 years, 46.0% female, and 95.2% White, with a median survival of 33.0 (14.0-63.0) months. The most common diagnosis was esophageal adenocarcinoma (69.8%). Surgical procedures included esophagectomy (56.5%), esophagogastrectomy (29.0%), and gastrectomy (14.5%), of which 45.2% were OS and 48.4% were MIS. The cohort overall exhibited lower P-QOL (40.7 ± 10.4) and M-QOL (44.6 ± 15.2) compared to the general population (50.0 ± 10.0; p < 0.050). There was no difference in age, sex, race, education, income, diagnosis, and adjuvant therapy between OS and MIS cohorts (all p > 0.050). Long-term P-QOL (38.5 ± 11.6 OS vs. 42.8 ± 9.5 MIS, p = 0.123) and M-QOL (44.7 ± 15.3 OS vs. 44.9 ± 14.9 MIS, p = 0.901) was similar between patients who underwent OS and MIS for foregut cancer.

CONCLUSION

MIS is not associated with higher long-term QOL in patients who have undergone surgery for foregut malignancy.

Chronic health conditions and disability are prevalent among community users of a digital mental health service: a scoping survey

Objectives: Digital interventions can offer accessible and scalable treatment for chronic conditions, though often focus separately on physical or mental health. People accessing digital health services may live with multiple conditions or experience overlapping symptoms. This study aimed to describe the breadth and characteristics of chronic health conditions and self-reported disability among routine users of a digital mental health service, and to examine related motivations to engage with digital mental health interventions.

Methods: A cross-sectional survey of adults registered with a digital mental health service in the Australian community (THIS WAY UP) was conducted. Participant demography, chronic health conditions, self-reported disability and motivations for accessing digital treatment were collected and analyzed descriptively.

Results: 366 participants responded (77% female, mean age 50 ± 15 years). 71.6% of participants (242/338) reported ≥1 chronic health condition and one-third reported multimorbidity (112/338, 33.1%). Chronic pain, musculoskeletal and connective tissue disorders were most common. 26.9% of respondents (90/334) reported a disability, most commonly physical disabilities. 95% of those with chronic conditions reported negative mental health effects and 46% reported heightened interest in digital mental health treatments because of their condition. Primary motivations for digital service use were receiving a recommendation from a health professional and service accessibility.

Discussion: People who access digital mental health services in routine care report high rates of heterogenous chronic illness and related disability. There is interest in accessible digital treatments to support mental health at scale among people who live with varied chronic conditions and disabilities.

Mobilizing community health assets through intersectoral collaboration for social connection: Associations with social support and well-being in a nationwide population-based study in Catalonia

BACKGROUND

Limited social connection among older adults poses a global public health challenge, reducing sources of support and affecting health and well-being. National public health strategies that leverage local intersectoral collaboration between key sectors such as primary and social care, community organizations, and society, have been advocated, yet their impact remains underexplored.

OBJECTIVE

This study examines the regional variability in the uptake of a public health strategy in Catalonia that mobilizes community health assets, such as social clubs and leisure activities, through intersectoral collaboration and its associations with social support and mental well-being in older adults.

METHODS

We conducted a population-based cross-sectional study using the Catalan Health Survey (2017-2021) with 6011 adults aged ≥ 60 years across 31 Health Sectors. Survey data were linked with area-level uptake metrics, generated using data analytic techniques. Individuals were categorized into three uptake groups based on the number and territorial distribution of asset-based initiatives within their area of residence. Multilevel regressions tested associations with social support (OSSS-3) and mental well-being (SWEMWBS), controlling for individual, contextual, and temporal factors.

RESULTS

Participants' average age was 74.1 years ±  10.0 with 53.3% women. From 2017 to 2021, 2312 asset-based initiatives were registered across Health Sectors, ranging from 0 to 342 per sector. Residing in sectors with the highest uptake of initiatives (>15 initiatives per 10,000 population) was associated with higher social support (β = .34, p < .01) and mental well-being scores (β =  1.11, p < .01).

CONCLUSION

Residing in areas with greater health assets mobilized through intersectoral collaboration was associated with higher social support and well-being among older adults. This study represents one of the first national evaluations of an intersectoral strategy aimed at mitigating the mental health impacts of limited social networks. Future public health strategies should prioritize equitable access for inclusive benefits.

Evaluation of the Patient-Specific Functional Scale for monitoring paediatric injury patients at a zonal referral hospital in Northern Tanzania

BACKGROUND

Injuries are a major cause of morbidity and mortality among paediatric populations in low- and middle-income countries (LMICs). The Patient-Specific Functional Scale (PSFS) is a commonly used tool to assess functional recovery. This study aims to evaluate the psychometric properties of the PSFS for monitoring paediatric injury patients at a zonal referral hospital in Northern Tanzania.

METHODS

This retrospective cohort study used data from the Kilimanjaro Christian Medical Centre paediatric injury registry (November 2020 to June 2024) and included patients under 18 years treated for injuries at a zonal referral hospital in Northern Tanzania. Key outcomes were in-hospital mortality and injury-related morbidity, assessed using the PSFS and Glasgow Outcome Scale Extended Paediatric (GOS-E Ped). The PSFS's reliability was tested with Cronbach's alpha, its smallest meaningful change was calculated and its correlation with GOS-E Ped was analysed using Spearman's rank.

RESULTS

Among 1000 paediatric injury patients, the mortality rate was 6.6%. PSFS mean scores improved from 4.3 at discharge to 6.5 at 2 weeks and 9.0 at 3 months post hospital discharge. The PSFS showed good reliability (Cronbach's alpha: 0.90). A moderate negative correlation was found between PSFS and GOS-E Ped at 3 months (Spearman's ρ: -0.74). The minimally clinically important difference was 2.7, with a sensitivity of 0.73, specificity of 0.72 and an area under the curve of 0.83.

CONCLUSION

The PSFS was found to be a valid, reliable and responsive tool for assessing functional changes in paediatric injury patients, demonstrating strong internal consistency. The findings support its use to measure morbidity in this population.

Trends in Positive Life Orientation Among 70-Year-Olds: A Comparison of Two Finnish Cohorts Born 20 Years Apart

OBJECTIVES

We assessed if positive life orientation (PLO) has increased among older individuals and explored gender disparities in PLO changes.

METHODS

Two cohorts of 70-year-olds from Turku, Finland were included: the 1920 birth cohort (examined in 1991; n = 1,032) and the 1940 birth cohort (examined in 2011; n = 956). Participants completed an identical questionnaire assessing life satisfaction, feeling needed, future plans, zest for life, depression, and loneliness. A composite PLO score (range 0-1) was computed.

RESULTS

The 2011 cohort had a higher mean PLO score than the 1991 cohort (.87 vs. .83, p < .001). The 2011 cohort reported higher sense of being needed, more future plans, and reduced loneliness (all p < .001). No significant differences were found in life satisfaction, zest for life, or depression. Gender disparities in PLO persisted across both cohorts, with men scoring slightly higher but following similar trends as women.

DISCUSSION

PLO appears to have increased among older individuals.

CLINICAL IMPLICATIONS

Recognizing the rising trend of PLO in recent decades may influence the development of societal and healthcare policies to further improve overall well-being among older individuals.

Age-Specific Association of Co-Morbidity With Home-Time After Acute Stroke

OBJECTIVE

To examine the association of co-morbidity with home-time after acute stroke and whether the association is influenced by age.

METHODS

We conducted a province-wide study using linked administrative databases to identify all admissions for first acute ischemic stroke or intracerebral hemorrhage between 2007 and 2018 in Alberta, Canada. We used ischemic stroke-weighted Charlson Co-morbidity Index of 3 or more to identify those with severe co-morbidity. We used zero-inflated negative binomial models to determine the association of severe co-morbidity with 90-day and 1-year home-time, and logistic models for achieving ≥ 80 out of 90 days of home-time, assessing for effect modification by age and adjusting for sex, stroke type, comprehensive stroke center care, hypertension, atrial fibrillation, year of study, and separately adjusting for estimated stroke severity. We also evaluated individual co-morbidities.

RESULTS

Among 28,672 patients in our final cohort, severe co-morbidity was present in 27.7% and was associated with lower home-time, with a greater number of days lost at younger age (-13 days at age < 60 compared to -7 days at age 80+ years for 90-day home-time; -69 days at age < 60 compared to -51 days at age 80+ years for 1-year home-time). The reduction in probability of achieving ≥ 80 days of home-time was also greater at younger age (-22.7% at age < 60 years compared to -9.0% at age 80+ years). Results were attenuated but remained significant after adjusting for estimated stroke severity and excluding those who died. Myocardial infarction, diabetes, and cancer/metastases had a greater association with lower home-time at younger age, and those with dementia had the greatest reduction in home time.

CONCLUSION

Severe co-morbidity in acute stroke is associated with lower home-time, more strongly at younger age.

Physical and mental health trajectories: A longitudinal SF-36 analysis in Alpha-1 antitrypsin deficiency-associated COPD

BACKGROUND

The Short Form 36-Item Health Survey (SF-36) is a health-related quality of life (HRQoL) measure validated in people with chronic obstructive pulmonary disease (COPD). While physical health is often more impaired than mental health in people with COPD, research on alpha-1 antitrypsin deficiency (AATD)-associated COPD is limited. This longitudinal study examines changes in physical and mental health in individuals with AATD and associated factors.

METHODS

Analyses included participants of AlphaNet, a disease management program for individuals with AATD-associated lung disease who are prescribed augmentation therapy. Norm-based SF-36 scores for mental and physical component summaries (MCS and PCS) and 8 scales were analyzed. Linear mixed models evaluated mean changes in SF-36 scores over time.

RESULTS

The study included 2165 participants (mean age 56.9 ± 10.0 years, 47.0 % female). At enrollment, mean PCS score was 37.5 ± 9.6, and mean MCS score was 51.9 ± 10.5. Mean mMRC dyspnea score was 2.3 ± 1.3; 54.6 % had ≥2 exacerbations annually, and 46.5 % used oxygen regularly. Average follow-up was 6.6 ± 3.2 years. The HRQoL remained stable; MCS improved by 0.16 points/year (p < 0.0001), while the PCS score declined by 0.49 points/year (p < 0.0001). Subscales followed similar trends.

CONCLUSIONS

At baseline, mental HRQoL scores were higher than physical HRQoL scores, indicating better mental health than physical health in this cohort with AATD-associated lung disease. Stable HRQoL with a slight improvement in mental scores over time and a small decrease in physical scores may be a unique feature of this cohort. Further studies are needed to correlate these findings with disease-specific instruments and patient physiology.

Diabetes mellitus is associated with low exercise capacity and impaired peripheral vasodilation in patients with heart failure - a propensity score-matched study

AIMS

Diabetes mellitus (DM) and heart failure (HF) share vascular, skeletal and metabolic abnormalities that can reduce exercise capacity. We investigated whether exercise capacity differ in patients with type 2 DM compared to those without DM with HF of similar severity.

METHODS AND RESULTS

The Studies Investigating Co-morbidities Aggravating HF (SICA-HF) prospectively enrolled 615 patients with chronic HF, 259 (42.1 %) of whom had DM. We assembled a propensity score-matched cohort of 231 pairs of patients with HF with or without DM who were balanced on age, sex and variables reflecting HF severity. Patients with DM had lower median peak VO2 (15.7 [13.0-19.1] vs. 17.3 [14.1-21.0] ml/min/kg; p = 0.005). Forearm blood flow reserve (per 1 ml/min/100 ml increase) was associated with lower exercise capacity (peak VO2 ≤ 16.6 ml/min/kg) in patients with DM (OR, 0.92; 95 % CI, (0.85-0.98; p = 0.014), but not in those without DM (OR, 0.98; 95 % CI, 0.93-1.02). A similar heterogeneity was also observed for HDL cholesterol.

CONCLUSIONS

Diabetes is associated with a reduced exercise capacity in patients with HF. Most predictors of lower exercise capacity in HF are similar regardless of DM except impaired vascular function and lower HDL cholesterol which predict lower exercise capacity only in those with DM.

Long-term patient-reported values following cancer surgery: A global survey study

BACKGROUND AND OBJECTIVES

We evaluated the long-term quality of life (QOL) and priorities of an international cohort of cancer surgery survivors.

METHODS

Patients were surveyed through online support groups. We utilized the Short Form-12 questionnaire to evaluate QOL and a novel survey to assess the relative importance of longevity, experience, and costs.

RESULTS

A total of 592 patients from six continents responded. They were 58 ± 12 years old, 70% female, and 92% White. Patients averaged 37 months from their initial cancer diagnosis, with a maximum survivorship of 46 years. Across 17 disease sites, respondents generally ranked longevity, functional independence, and emotional well-being most important, while treatment experience and costs were ranked least important (W = 33.6%, p < 0.001). However, a subset of respondents ranked costs as significantly important. There were no differences in QOL based on demographics, except patients with higher education and income reported better QOL scores. Despite improvements in QOL throughout survivorship, both physical-QOL (41.1 ± 11.1 at 1 year vs. 42.3 ± 12.6 at 5 years, p = 0.511) and mental-QOL (41.3 ± 13.4 at 1 year vs. 44.6 ± 13.9 at 5 years, p = 0.039) remained below that of the general population (50 ± 10; both p < 0.001).

CONCLUSIONS

Cancer survivors experience enduring physical and mental impairment throughout survivorship. Future efforts should aim to provide sustained support across varied socioeconomic groups, ensuring equitable care and enhancement of QOL postcancer treatment.

Acceptability and Feasibility of the Telehealth Bariatric Behavioral Intervention to Increase Physical Activity Before Bariatric Surgery: A Single-Case Experimental Study (Part I)

BACKGROUND

Physical activity (PA) can play an important role in optimizing metabolic/bariatric surgery (MBS) outcomes. However, many MBS patients have difficulty increasing PA, necessitating the development of theory-driven counseling interventions. This study aimed to (1) assess the feasibility and acceptability of the TELEhealth BARIatric behavioral intervention (TELE-BariACTIV) trial protocol/methods and intervention, which was designed to increase moderate-to-vigorous intensity physical activity (MVPA) in adults awaiting MBS and (2) estimate the effect of the intervention on MVPA.

METHODS

This trial used a repeated single-case experimental design. Twelve insufficiently active adults awaiting MBS received 6 weekly 45-min PA videoconferencing counseling sessions. Feasibility and acceptability data (i.e., refusal, recruitment, retention, attendance, and attrition rates) were tracked and collected via online surveys, and interviews. MVPA was assessed via accelerometry pre-, during, and post-intervention.

RESULTS

Among the 24 patients referred to the research team; five declined to participate (refusal rate = 20.8%) and seven were ineligible or unreachable. The recruitment rate was 1.2 participants per month between 2021-09 and 2022-07. One participant withdrew during the baseline phase, and one after the intervention (retention rate = 83.3%). No participant dropouts occurred during the intervention and 98.6% of sessions were completed. Participants' anticipated and retrospective acceptability of the intervention was 3.2/4 (IQR, 0.5) and 3.0/4 (IQR, 0.2), respectively. There was a statistically significant increase in MVPA [Tau-U = 0.32(0.11; 0.51)] from pre- to post-intervention.

CONCLUSION

Despite a low recruitment rate, which could be explained by circumstances (COVID-19 pandemic), results support feasibility, acceptability, and preliminary efficacy of the TELE-Bari-ACTIV intervention for increasing MVPA in patients awaiting MBS.

Program ACTIVE II: 6- and 12-month outcomes of a treatment approach for major depressive disorder in adults with type 2 diabetes

AIMS

To evaluate the long-term effects of behavioral treatments on glycemic and psychological outcomes for patients with major depressive disorder (MDD) and type 2 diabetes (T2D).

METHODS

Program ACTIVE II was a multicenter randomized controlled comparative effectiveness trial of cognitive behavioral therapy (CBT), exercise (EXER), combination treatment (CBT + EXER) and usual care (UC) for adults with MDD and T2D.

RESULTS

Primary outcomes: change in A1c and depressive symptoms at 6- (N = 87) and 12-months (N = 75) from baseline. In those with a baseline A1c ≥7.0 %, CBT + EXER showed lasting A1c benefit at 6- (-1.2 %; SE: 0.6; p = 0.032) and 12-months (-1.4 %; SE: 0.6; p = 0.025) compared to UC. All groups had clinically significant improvements in depressive symptoms. At 6 months, CBT + EXER had significant improvements in diabetes-related distress regimen burden (p = 0.005); and social support (CIRS, p = 0.043) compared to UC.

CONCLUSIONS

The Program ACTIVE II CBT + EXER intervention demonstrated a sustained improvement in A1c for a subgroup of study participants with a baseline A1c ≥7.0 %. However, this finding should be considered preliminary because of small sample size. All 3 behavioral intervention groups demonstrated improvements in psychosocial outcomes one-year post-intervention. These findings point to the enduring benefits of community-based interventions to extend the availability of depression treatment for T2D patients.

Multimodal Approaches in the Treatment of Chronic Peripheral Neuropathy-Evidence from Germany

Patients with chronic peripheral neuropathy suffer greatly and their quality of life is often restricted. Drug therapy can be accompanied by undesirable side effects and intolerances, or the hoped-for effect does not materialize. Therefore, in addition to drug therapy, attempts are also made to treat the physical symptoms with complementary procedures. In the case of severe forms, the search for a suitable form of therapy is difficult. Complex treatments can be an innovative way to treat peripheral neuropathy. At the same time, several different therapy methods are carried out at high frequency by a specialized treatment team. This study aimed to provide an overview of possible complementary forms of therapy. The focus was on a comparison of two interdisciplinary complex therapies that are used in severe cases in an acute inpatient care setting in Germany. The six dimensions (energy, sleep, pain, physicality, emotional response and social isolation) of the Nottingham Health Profile (NHP) were used to assess quality of life. Both complex treatments (naturopathic complex therapy/multimodal pain therapy) showed a significant reduction in impairment in all dimensions of the NHP. In addition, a multivariate analysis was carried out to take into account several influencing variables at the same time. At the time of admission to the hospital, the degree of chronicity was recorded for each patient. This allowed statements to be made about the effect of the respective therapy depending on the chronification stage of the patient. It has been shown that patients with acutely exacerbated pain with the highest degree of chronicity also benefit from both complex treatments. The naturopathic complex treatment gives the treatment team more options. Aspects such as nutrition, methods from phytotherapy and traditional Chinese medicine can be integrated into inpatient care. Thus, a patient-centered, holistic therapy can take place. However, an interdisciplinary holistic therapy requires more time for both the practitioner and the patient. This should be taken into account in the health systems in the context of the diagnosis related groups.

Socioeconomic Factors Predict Long-Term Quality of Life of Cancer Survivors: An International Survey

INTRODUCTION

Despite advances in cancer treatment, the quality of life (QOL) of survivors varies significantly. We assessed the correlation between socioeconomic factors and long-term QOL in a global cohort of cancer survivors.

MATERIALS AND METHODS

Patients were offered surveys via online support groups. Using the Short Form-12 validated questionnaire, physical QOL (PQOL) and mental QOL (MQOL) well-being were compared to the general population. Socioeconomic factors were assessed with regression analysis for impact on QOL.

RESULTS

Seven hundred eighty two survivors from six continents responded. They were 57 ± 13 y and 68% female, 90.8% White, with 43 distinct cancer diagnoses. All survivors had PQOL and MQOL scores lower than the general population. Lower education level, household income, and non-White race all correlated with reduced PQOL and/or MQOL. Age was negatively correlated with PQOL (r = -0.08, P = 0.03) and positively correlated with MQOL (r = 0.142, P < 0.001). Care at large regional/academic centers was associated with higher MQOL (42 ± 14 versus 38 ± 11, P = 0.005). Age (β = -0.1, P = 0.04), education (β = 1.1, P = 0.005), and income (β = 2.0, P < 0.001) were predictors of PQOL, while age (β = 0.2, P < 0.001), income (β = 1.7, P = 0.002), and community hospital care (β = -3.6, P = 0.013) were predictors of MQOL.

CONCLUSIONS

In a large international survey of cancer survivors, we identified socioeconomic factors and their associations with QOL. Further work should be directed to provide durable support across all socioeconomic classes.

Cognitive behavioral therapies for depression and anxiety in people with chronic disease: A systematic review and meta-analysis

OBJECTIVE

Anxiety and depression in chronic disease are common and burdensome co-morbidities. There has been growing interest in cognitive and behavioral therapies (CBTs) for anxiety and depression in chronic disease, however their efficacy has not been well-established. This study examined the efficacy of CBTs for depression and/or anxiety symptoms within chronic disease and explored the moderating role of clinical and methodological characteristics.

METHODS

Following prospective registration, electronic databases were searched up to 2023 for randomized controlled trials (RCTs) examining CBTs for depression and/or anxiety in any adult chronic disease population.

RESULTS

We included 56 RCTs. The overall effect of CBTs was g = 0.61 (95% CI, 0.49, 0.72) for depression and g = 0.56 (95% CI, 0.42, 0.70) for anxiety. A range of methodological features significantly moderated the effect sizes obtained, including type of control group and the outcome measure used. Risk of Bias ratings indicated some concerns regarding RCT conduct and reporting.

CONCLUSIONS

CBTs lead to moderate improvements in both depression and anxiety symptoms among people with chronic disease. However, the efficacy of CBT should be interpreted considering certain study and sample characteristics. It is recommended that future studies make improvements to study methodology and reporting.

Health-related quality of life profiles in adolescents and young adults with chronic conditions

PURPOSE

To assess health-related quality of life (HRQOL) among adolescents and young adults (AYAs) with chronic conditions.

METHODS

AYAs (N = 872) aged 14-20 years completed NIH's Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures of physical function, pain interference, fatigue, social health, depression, anxiety, and anger. Latent profile analysis (LPA) was used to group AYAs into HRQOL profiles using PROMIS T-scores. The optimal number of profiles was determined by model fit statistics, likelihood ratio test, and entropy. Multinomial logistic regression models were used to examine how LPA's HRQOL profile membership was associated with patient demographic and chronic conditions. The model prediction accuracy on profile membership was evaluated using Huberty's I index with a threshold of 0.35 for good effect.

RESULTS

A 4-profile LPA model was selected. A total of 161 (18.5%), 256 (29.4%), 364 (41.7%), and 91 (10.4%) AYAs were classified into Minimal, Mild, Moderate, and Severe HRQOL Impact profiles. AYAs in each profile had distinctive mean scores with over a half standard deviation (5-points in PROMIS T-scores) of difference between profiles across most HRQOL domains. AYAs who were female or had conditions such as mental health condition, hypertension, and self-reported chronic pain were more likely to be in the Severe HRQOL Impact profile. The Huberty's I index was 0.36.

CONCLUSIONS

Approximately half of AYAs with a chronic condition experience moderate to severe HRQOL impact. The availability of risk prediction models for HRQOL impact will help to identify AYAs who are in greatest need of closer clinical care follow-up.

Value-based health care in heart failure: Quality of life and cost analysis

OBJECTIVES

To measure Quality of Life (QoL) and costs of Heart Failure (HF) outpatients in Brazil as an introduction to the Value-Based Health Care (VBHC) concept.

MATERIALS AND METHODS

Cross-sectional study, patients with HF, with ejection fraction <50%, were recruited from three hospitals in Brazil. Two QoL (36-Item Short Form Survey [SF-36] and Minnesota Living with Heart Failure Questionnaire [MLHFQ]) and two anxiety/depression questionnaires were applied. SF-36 scores were stratified by domains. Treatment costs were calculated using the Time-Driven Activity-Based Costing (TDABC) method. Results were stratified by NYHA functional class and sex.

RESULTS

From October 2018 to January 2021, 198 patients were recruited, and the median MLHFQ (49.5 [IQR 21.0, 69.0]) and SF-36 scores demonstrated poor QoL, worse at higher NYHA classes. A third of patients had moderate/severe depression and anxiety symptoms, and women had higher anxiety scores. Mean costs of outpatient follow-up were US$ 215 ± 238 for NYHA I patients, US$ 296 ± 399 for NYHA II and US$ 667 ± 1012 for NYHA III/IV. Lab/exam costs represented 30% of the costs in NYHA I, and 74% in NYHA III/IV (US$ 63.26 vs. US$ 491.05).

CONCLUSION

Patients with HF in Brazil have poor QoL and high treatment costs; both worsen as the NYHA classification increases. It seems that HF has a greater impact on the mental health of women. Costs increase mostly related to lab/exams. Accurate and crossed information about QoL and costs is essential to drive care and reimbursement strategies based on value.

Myocardial infarction and physical function: the REasons for Geographic And Racial Differences in Stroke prospective cohort study

Objective

To examine associations between myocardial infarction (MI) and multiple physical function metrics.

Methods

Among participants aged ≥45 years in the REasons for Geographic And Racial Differences in Stroke prospective cohort study, instrumental activities of daily living (IADL), activities of daily living (ADL), gait speed, chair stands, and Short Form-12 physical component summary (PCS) were assessed after approximately 10 years of follow-up. We examined associations between MI and physical function (no MI [n = 9,472], adjudicated MI during follow-up [n = 288, median 4.7 years prior to function assessment], history of MI at baseline [n = 745], history of MI at baseline and adjudicated MI during follow-up [n = 70, median of 6.7 years prior to function assessment]). Models were adjusted for sociodemographic characteristics, health behaviours, depressive symptoms, cognitive impairment, body mass index, diabetes, hypertension, and urinary albumin to creatinine ratio. We examined subgroups defined by age, gender, and race.

Results

The average age at baseline was 62 years old, 56% were women, and 35% Black. MI was significantly associated with worse IADL and ADL scores, IADL dependency, chair stands, and PCS, but not ADL dependency or gait speed. For example, compared to participants without MI, IADL scores (possible range 0-14, higher score represents worse function) were greater for participants with MI during follow-up (difference: 0.37 [95% CI 0.16, 0.59]), MI at baseline (0.26 [95% CI 0.12, 0.41]), and MI at baseline and follow-up (0.71 [95% CI 0.15, 1.26]), p < 0.001. Associations tended to be greater in magnitude among participants who were women and particularly Black women.

Conclusion

MI was associated with various measures of physical function. These decrements in function associated with MI may be preventable or treatable.

Racial Differences in Quality of Life in Patients With Heart Failure Treated With Sodium-Glucose Cotransporter 2 Inhibitors: A Patient-Level Meta-Analysis of the CHIEF-HF, DEFINE-HF, and PRESERVED-HF Trials

BACKGROUND

Health status outcomes, including symptoms, function, and quality of life, are worse for Black compared with White patients with heart failure. Sodium-glucose cotransporter 2 inhibitors (SGLT2is) reduce cardiovascular mortality and improve health status in patients with heart failure, but whether the health status benefit of SGLT2is is similar across races is not established. The objective of this study was to compare the treatment effect of SGLT2is (versus placebo) on health status for Black compared with White patients with heart failure.

METHODS

We combined patient-level data from 3 randomized clinical trials of SGLT2is: DEFINE-HF (Dapagliflozin Effect on Symptoms and Biomarkers in Patients With Heart Failure; n=263), PRESERVED-HF (Dapagliflozin in Preserved Ejection Fraction Heart Failure; n=324), and CHIEF-HF (A Study on Impact of Canagliflozin on Health Status, Quality of Life, and Functional Status in Heart Failure; n=448). These 3 United States-based trials enrolled a substantial proportion of Black patients, and each used the Kansas City Cardiomyopathy Questionnaire (KCCQ) to measure health status at baseline and after 12 weeks of treatment. Among 1035 total participants, selecting self-identified Black and White patients with complete information yielded a final analytic cohort of 935 patients. The primary endpoint was KCCQ Clinical Summary score. Twelve-week change in KCCQ with SGLT2is versus placebo was compared between Black and White patients by testing the interaction between race and treatment using multivariable linear regression models adjusted for trial, baseline KCCQ (as a restricted cubic spline), race, and treatment. The data that support the findings of this study are available from the corresponding author upon reasonable request.

RESULTS

Among 935 participants, 236 (25%) self-identified as Black, and 469 (50.2%) were treated with an SGLT2i. Treatment with an SGLT2i, compared with placebo, resulted in KCCQ Clinical Summary score improvements at 12 weeks of +4.0 points (95% CI, 1.7-6.3; P=0.0007) in White patients and +4.7 points (95% CI, 0.7-8.7; P=0.02) in Black patients, with no significant interaction by race and treatment (P=0.76). Other KCCQ scales showed similar results.

CONCLUSIONS

Treatment with an SGLT2i resulted in consistent and significant improvements in health status for both Black and White patients with heart failure.

Levothyroxine Monotherapy: What Works Better for the Individual With Hypothyroidism?

OBJECTIVE

I explore objective data not supporting the addition of liothyronine (medication) (LT3) to levothyroxine (medication) (LT4) in patients with hypothyroidism. Accurate identification of patients with symptomatic (almost exclusively overt) hypothyroidism is important in evaluating clinical outcomes of therapies. Recent studies have documented that nearly a third of individuals who are offered thyroid hormone are euthyroid at the time of initiation. Additionally, others are clinically diagnosed without biochemical confirmation, so a sizable proportion of those started on LT4 are not hypothyroid. The assumption that nonhypothyroid symptoms will resolve with LT4 is problematic. The true underlying cause of these symptoms remains unidentified and untreated.

METHODS

In a narrative fashion I will review the positive predictive value of and correlation of symptoms consistent with hypothyroidism and confirmed hypothyroidism likely to favorably respond to thyroid hormone replacement.

RESULTS

Following a review of the reliability of thyroid-stimulating hormone (TSH) in predicting a euthyroid state, the correlation of circulating triiodothyronine (serum measurement) (T3) levels with symptoms and predictive value of T3 to forecast the outcome of adding LT3 to LT4 will be reviewed. The utility of striving for high, middle, or low TSH set points within the expected range to predict changes in clinical quality of life and the ability of blinded patients to sense subtle differences along this spectrum will be documented. In addition, the clinical impact of single nucleotide polymorphisms in the type 2 deiodinase gene will be reviewed. Finally, the overall satisfaction of selected patients with their thyroid hormone treatments will be outlined and preferences for T3-containing treatments from blinded studies will be summarized.

CONCLUSION

Basing thyroid hormone treatment decisions on patient symptoms likely results in missed diagnoses We should encourage primary care physicians to assess a differential diagnosis, exclude other diagnoses, and not assume a thyroid etiology when TSH is normal. Modifying treatment to a particular TSH target or adjusting based on a low T3 level does not seem to enhance patient outcomes. Finally, pending further trials of "symptomatic" participants, using sustained release LT3 to mimic normal physiology, and including monocarboxylate 10 transporter and Type 2 deiodinase polymorphisms and objective outcomes, I will continue to depend on therapy with LT4 monotherapy and seek alternative explanations for my patients' nonspecific symptoms.

Understanding health behavior change by motivation and reward mechanisms: a review of the literature

The global rise of lifestyle-related chronic diseases has engendered growing interest among various stakeholders including policymakers, scientists, healthcare professionals, and patients, regarding the effective management of health behavior change and the development of interventions that facilitate lifestyle modification. Consequently, a plethora of health behavior change theories has been developed with the intention of elucidating the mechanisms underlying health behavior change and identifying key domains that enhance the likelihood of successful outcomes. Until now, only few studies have taken into account neurobiological correlates underlying health behavior change processes. Recent progress in the neuroscience of motivation and reward systems has provided further insights into the relevance of such domains. The aim of this contribution is to review the latest explanations of health behavior change initiation and maintenance based on novel insights into motivation and reward mechanisms. Based on a systematic literature search in PubMed, PsycInfo, and Google Scholar, four articles were reviewed. As a result, a description of motivation and reward systems (approach/wanting = pleasure; aversion/avoiding = relief; assertion/non-wanting = quiescence) and their role in health behavior change processes is presented. Three central findings are discussed: (1) motivation and reward processes allow to distinguish between goal-oriented and stimulus-driven behavior, (2) approach motivation is the key driver of the individual process of behavior change until a new behavior is maintained and assertion motivation takes over, (3) behavior change techniques can be clustered based on motivation and reward processes according to their functional mechanisms into facilitating (= providing external resources), boosting (= strengthening internal reflective resources) and nudging (= activating internal affective resources). The strengths and limitations of these advances for intervention planning are highlighted and an agenda for testing the models as well as future research is proposed.

Brain structure and function link to variation in biobehavioral dimensions across the psychopathological continuum

In line with the Research Domain Criteria (RDoC) , we set out to investigate the brain basis of psychopathology within a transdiagnostic, dimensional framework. We performed an integrative structural-functional linked independent component analysis to study the relationship between brain measures and a broad set of biobehavioral measures in a sample (n = 295) with both mentally healthy participants and patients with diverse non-psychotic psychiatric disorders (i.e. mood, anxiety, addiction, and neurodevelopmental disorders). To get a more complete understanding of the underlying brain mechanisms, we used gray and white matter measures for brain structure and both resting-state and stress scans for brain function. The results emphasize the importance of the executive control network (ECN) during the functional scans for the understanding of transdiagnostic symptom dimensions. The connectivity between the ECN and the frontoparietal network in the aftermath of stress was correlated with symptom dimensions across both the cognitive and negative valence domains, and also with various other health-related biological and behavioral measures. Finally, we identified a multimodal component that was specifically associated with the diagnosis of autism spectrum disorder (ASD). The involvement of the default mode network, precentral gyrus, and thalamus across the different modalities of this component may reflect the broad functional domains that may be affected in ASD, like theory of mind, motor problems, and sensitivity to sensory stimuli, respectively. Taken together, the findings from our extensive, exploratory analyses emphasize the importance of a dimensional and more integrative approach for getting a better understanding of the brain basis of psychopathology.

Physical functioning following spinal cord stimulation: a systematic review and meta-analysis

BACKGROUND

Spinal cord stimulation (SCS) has emerged as an important treatment for chronic pain disorders. While there is evidence supporting improvement in pain intensity with SCS therapy, efforts to synthesize the evidence on physical functioning are lacking.

OBJECTIVE

The primary objective of this meta-analysis was to assess long-term physical function following 12 months of SCS for chronic back pain.

EVIDENCE REVIEW

PubMed, EMBASE, Scopus, and CENTRAL databases were searched for original peer-reviewed publications investigating physical function following SCS. The primary outcome was physical function at 12 months following SCS therapy for chronic back pain compared with baseline. A random effects model with an inverse variable method was used. The Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) framework was used to determine the certainty of evidence.

FINDINGS

A total of 518 studies were screened, of which 36 were included. Twenty-two studies were pooled in the meta-analysis. There was a significant reduction in Oswestry Disability Index (ODI) scores at all time frames up to 24 months following implantation. Pooled results revealed significant improvement in ODI scores at 12 months with a mean difference of -17.00% (95% CI -23.07 to -10.94, p<0.001). There was a very low certainty of evidence in this finding as per the GRADE framework. There was no significant difference in subgroup analyses based on study design (randomised controlled trials (RCTs) vs non-RCTs), study funding, or stimulation type.

CONCLUSION

This meta-analysis highlights significant improvements in physical function after SCS therapy. However, this finding was limited by a very low GRADE certainty of evidence and high heterogeneity.

Weight change and mental health status in a behavioral weight loss trial

BACKGROUND

Obesity, depression, and anxiety often co-occur, but research on weight change and mental health status is limited. This analysis examined how the mental component score (MCS-12) from the Short Form health survey changed over 24 months in weight loss trial participants with vs. without treatment seeking for affective symptoms (TxASx) and by weight change quintiles.

METHODS

Participants with complete data (n = 1163) were analyzed from enrollees in a cluster-randomized, behavioral weight loss trial in rural U.S. Midwestern primary care practices. Participants received a lifestyle intervention with different delivery models, including in-clinic individual, in-clinic group, or telephone group counseling visits. Participants were stratified by baseline TxASx status and 24-month weight change quintiles. Mixed models were used to estimate MCS-12 scores.

RESULTS

There was a significant group-by-time interaction at the 24-month follow-up. The largest 0-24 month increase in MCS-12 scores (+5.3 points [12 %]) was observed in participants with TxASx who lost the most weight during the trial, while the largest decrease in MCS-12 scores (-1.8 points [-3 %]) was observed in participants without TxASx who gained the most weight (p < 0.001).

LIMITATIONS

Notable limitations included self-reported mental health, the observational analytical design, and a largely homogenous source population, as well as the possibility of reverse causation biasing some findings.

CONCLUSIONS

Mental health status generally improved, particularly among participants with TxASx who experienced significant weight loss. Those without TxASx who gained weight, however, had a decline in mental health status over 24 months. Replication of these findings is warranted.

Long-Term Survival Outcomes after Operative Management of Chronic Pancreatitis: Two Decades of Experience

BACKGROUND

Chronic pancreatitis is a debilitating, life-altering disease; however, the long-term outcomes after operative intervention have not been established.

STUDY DESIGN

Patients who underwent operative intervention at a single institution between 2000 and 2020 for chronic pancreatitis were included, and survival was assessed using the National Death Index.

RESULTS

A total of 493 patients who underwent 555 operative interventions for chronic pancreatitis during 2 decades were included. Of these patients, 48.5% underwent total pancreatectomy ± islet autotransplantation, 21.7% underwent a duodenal preserving pancreatic head resection and/or drainage procedure, 16.2% underwent a pancreaticoduodenectomy, and 12.8% underwent a distal pancreatectomy. The most common etiology of chronic pancreatitis was idiopathic (41.8%), followed by alcohol (28.0%) and known genetic polymorphisms (9.9%). With a median follow-up of 83.9 months, median overall survival was 202.7 months, with a 5- and 10-year overall survival of 81.3% and 63.5%. One hundred sixty-five patients were deceased, and the most common causes of death included infections (16.4%, n=27), cardiovascular disease (12.7%, n=21), and diabetes-related causes (10.9%, n=18). On long-term follow-up, 73.1% (n=331) of patients remained opioid free, but 58.7% (n=266) had insulin-dependent diabetes. On multivariate Cox proportional hazards modeling, only persistent opioid use (hazard ratio 3.91 [95% CI 2.45 to 6.24], p < 0.01) was associated with worse overall survival.

CONCLUSIONS

Our results represent the largest series to date evaluating long-term survival outcomes in patients with chronic pancreatitis after operative intervention. Our data give insight into the cause of death and allow for the development of mitigation strategies and long-term monitoring of comorbid conditions.

Effect of postoperative systemic prednisolone on short-term and long-term outcomes in chronic rhinosinusitis with nasal polyps: A multi-centered randomized clinical trial

Introduction

The objective of this study was to determine whether postoperative additive systemic steroid administration in chronic rhinosinusitis with nasal polyps (CRSwNP) impacted selected endoscopic, subjective and objective outcome measures.

Methods

This was a prospective, randomized, double-blind, placebo-controlled, noninferiority multicenter trial of n=106 patients with CRSwNP. All patients underwent primary functional endoscopic sinus surgery (FESS) followed by topical nasal steroids. Patients were randomized to a systemic steroid or placebo for 1 month. Patients were followed up for 2 years over 9 time points. The primary outcome measures were the differences between groups with respect to the nasal polyp score (NPS) and sinonasal quality of life (SNQoL). Secondary outcome measures included interactions with respect to the Lund-Kennedy score (LKS), sinonasal symptoms, general quality of life (GQoL), 16-item odor identification test scores, recurrence rates, need for revision surgery and mucus biomarker levels.

Results

106 patients were randomized to either the placebo or the systemic steroid group (n=53 per group). Postoperative systemic steroids were not superior to placebo with respect to all primary (p= 0.077) and secondary outcome measures (p&gt;0.05 for all). Reported adverse events were similar between the two groups.

Conclusion

In conclusion, the addition of postoperative systemic steroids after primary FESS did not confer a benefit over topical steroid nasal spray alone with respect to NPS, SNQOL, LKS, GQOL, sinonasal symptoms, smell scores, recurrence rates, the need for revision surgery or biomarkers over a short-term follow-up of up to 9 months and a long-term follow-up of up to 24 months in CRSwNP patients. Functional endoscopic surgery did, however, show a strong effect on all outcome measures, which remained relatively stable up to the endpoint at 2 years.

Association between objective neurocognitive functioning and neurocognitive complaints in recurrent high-grade glioma: longitudinal evidence of cognitive awareness from EORTC brain tumor trials

BACKGROUND

Patients' reduced awareness of neurocognitive functioning (NCF) may negatively affect the reliability of patient-reported outcomes (PROs) and clinical decision-making. This study evaluated cognitive awareness, defined as the association between NCF and neurocognitive complaints, over the disease course of patients with recurrent high-grade glioma (HGG).

METHODS

We assessed NCF using the EORTC core clinical trial battery and neurocognitive complaints using the Medical Outcome Study questionnaire. Patients were categorised as impaired or intact, based on their neurocognitive performance. Spearman's rank correlations were calculated between NCF and neurocognitive complaints at baseline and each 12 weeks, until 36. The association between changes in NCF and neurocognitive complaints scores between these follow-up assessments was determined using Pearson's correlation.

RESULTS

A total of 546 patients were included. Neurocognitively impaired patients (n = 437) had more neurocognitive complaints (range: 10.51 [p < 0.001] to 13.34 [p = 0.001]) than intact patients (n = 109) at baseline, at 12 and 24 weeks. In intact patients, NCF and neurocognitive complaints were correlated for only one domain at baseline (0.202, p = 0.036), while in impaired patients correlations were more frequently found in various domains and time points (range: 0.164 [p = 0.001] to 0.334 [p = 0.011]). Over the disease course, NCF and neurocognitive complaints were correlated for only one domain at baseline (0.357, p = 0.014) in intact patients while in impaired patients they were correlated for more domains and time points (range: 0.222 [p < 0.001] to 0.366 [p < 0.001]).

CONCLUSION

Neurocognitively impaired patients with recurrent HGG are aware of their neurocognitive limitations at study entry and during follow-up, which should be considered in clinical decision-making and when interpreting PRO results.

Impact on Mid-Term Health-Related Quality of Life after Duodenal Switch: a Systematic Review and Meta-Analysis

PURPOSE

Metabolic and bariatric surgery (MBS) could improve health-related quality of life (HrQoL) for selected patients with obesity. Although biliopancreatic diversion with duodenal switch (BPD-DS) is regarded as the most effective MBS technique in achieving weight loss, no consensus has been reached on the impact of BPD-DS on HrQoL. The aim of this meta-analysis is to assess the mid-term HrQoL after BPD-DS in the management of patients with obesity.

MATERIALS AND METHODS

Cochrane, Embase, APA PsycInfo, PubMed, Scopus, and Web of Science were searched for articles from their inception to August 2022 by two independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) system. The review was registered prospectively with PROSPERO (CRD42022352073).

RESULTS

From 223 studies screened, twelve studies met the eligibility criteria, with a total of 937 patients with obesity undergoing BPD-DS. Minimal clinically important differences (MCID) were reached for the physical component summary score (PCS) of the 36-Item Short-Form Health Survey (SF-36) (MD = 13.4) and impact of weight on quality of life (IWQOL)-Lite total score (MD = 48.7). Similarly, MCIDs were attained in the Laval questionnaire and SF-36 subscales.

CONCLUSION

Our meta-analysis demonstrated an improvement in mid-term HrQoL after BPD-DS. Despite the promising trends demonstrated in this meta-analysis, further studies with large sample sizes are needed to evaluate the impact of HrQoL on patients with obesity after BPD-DS.

Adaptation and Validation of the Well-Being Related to Food Questionnaire (Well-BFQ©) for the French-Speaking General Adult Population of Québec, Canada

Efforts to develop effective strategies that improve dietary intake are needed; however, this improvement in diet quality must not be at the expense of well-being. The Well-Being related to Food Questionnaire (Well-BFQ©) is a tool that has been developed in France to comprehensively measure food well-being. Even though the same language is spoken in France and in Québec, cultural and linguistic differences are present, which supports the importance of adapting and validating this tool before its use in the Québec population. This study aimed to adapt and validate the Well-BFQ© for the French-speaking general adult population of Québec, Canada. The Well-BFQ© underwent a full linguistic adaptation process, including an expert panel adaptation step, a pretest among 30 French-speaking adult (18-65 years) Quebecers, and a final proofreading. The questionnaire was thereafter administered to 203 French-speaking adult Quebecers (49.3% females, M_AGE = 34.9, SD = 13.5; 88.2% Caucasians; 54.2% with a university degree). The exploratory factor analysis showed a two-factor structure: (1) food well-being related to physical and psychological health (27 items) and (2) food well-being related to symbolic/pleasure of food (32 items). Internal consistency was adequate, with a Cronbach's α of 0.92 and 0.93, respectively, for the subscales, and 0.94 for the total scale. The total food well-being score, as well as the two subscale scores, were associated with psychological and eating-related variables in expected directions. Overall, the adapted version of the Well-BFQ© was found to be a valid instrument to measure food well-being in the French-speaking general adult population of Québec, Canada.

Validity of outcome measures used in randomized clinical trials and observational studies in degenerative lumbar spinal stenosis

It is unclear whether outcome measures used in degenerative lumbar spinal stenosis (DLSS) have been validated for this condition. Cross-sectional analysis of studies for DLSS included in systematic reviews (SA) and meta-analyses (MA) indexed in the Cochrane Library. We extracted all outcome measures for pain and disability. We assessed whether the studies provided external references for the validity of the outcome measures and the quality of the validation studies. Out of 20 SA/MA, 95 primary studies used 242 outcome measures for pain and/or disability. Most commonly used were the VAS (n = 69), the Oswestry Disability Index (n = 53) and the Zurich Claudication Questionnaire (n = 22). Although validation references were provided in 45 (47.3%) primary studies, only 14 validation studies for 9 measures (disability n = 7, pain and disability combined n = 2) were specifically validated in a DLSS population. The quality of the validation studies was mainly poor. The Zurich Claudication Questionnaire was the only disease specific tool with adequate validation for assessing treatment response in DLSS. To compare results from clinical studies, outcome measures need to be validated in a disease specific population. The quality of validation studies need to be improved and the validity in studies adequately cited.

Incidence of Respiratory Syncytial Virus Infection in Older Adults Before and During the COVID-19 Pandemic

Importance

Little is known about the burden and outcomes of respiratory syncytial virus (RSV)-positive acute respiratory infection (ARI) in community-dwelling older adults.

Objective

To assess the incidence of RSV-positive ARI before and during the COVID-19 pandemic, and to assess outcomes for RSV-positive ARI in older adults.

Design, Setting, and Participants

This was a community-based cohort study of adults residing in southeast Minnesota that followed up with 2325 adults aged 50 years or older for 2 RSV seasons (2019-2021) to assess the incidence of RSV-positive ARI. The study assessed outcomes at 2 to 4 weeks, 6 to 7 months, and 12 to 13 months after RSV-positive ARI.

Exposure

RSV-positive and -negative ARI.

Main Outcomes and Measures

RSV status was the main study outcome. Incidence and attack rates of RSV-positive ARI were calculated during each RSV season, including before (October 2019 to April 2020) and during (October 2020 to April 2021) COVID-19 pandemic, and further calculated during non-RSV season (May to September 2021) for assessing impact of COVID-19. The self-reported quality of life (QOL) by Short-Form Health Survey-36 (SF-36) and physical functional measures (eg, 6-minute walk and spirometry) at each time point was assessed.

Results

In this study of 2325 participants, the median (range) age of study participants was 67 (50-98) years, 1380 (59%) were female, and 2240 (96%) were non-Hispanic White individuals. The prepandemic incidence rate of RSV-positive ARI was 48.6 (95% CI, 36.9-62.9) per 1000 person-years with a 2.50% (95% CI, 1.90%-3.21%) attack rate. No RSV-positive ARI case was identified during the COVID-19 pandemic RSV season. Incidence of 10.2 (95% CI, 4.1-21.1) per 1000 person-years and attack rate of 0.42%; (95% CI, 0.17%-0.86%) were observed during the summer of 2021. Based on prepandemic RSV season results, participants with RSV-positive ARI (vs matched RSV-negative ARI) reported significantly lower QOL adjusted mean difference (limitations due to physical health, -16.7 [95% CI, -31.8 to -1.8]; fatigue, -8.4 [95% CI, -14.3 to -2.4]; and difficulty in social functioning, -11.9 [95% CI, -19.8 to -4.0] within 2 to 4 weeks after RSV-positive ARI [ie, short-term outcome]). Compared with participants with RSV-negative ARI, those with RSV-positive ARI also had lower QOL (fatigue: -4.0 [95% CI, -8.5 to -1.3]; difficulty in social functioning, -5.8 [95% CI, -10.3 to -1.3]; and limitation due to emotional problem, -7.0 [95% CI, -12.7 to -1.3] at 6 to 7 months after RSV-positive ARI [intermediate-term outcome]; fatigue, -4.4 [95% CI, -7.3 to -1.5]; difficulty in social functioning, -5.2 [95% CI, -8.7 to -1.7] and limitation due to emotional problem, -5.7 [95% CI, -10.7 to -0.6] at 12-13 months after RSV-positive ARI [ie, long-term outcomes]) independent of age, sex, race and/or ethnicity, socioeconomic status, and high-risk comorbidities.

Conclusions and Relevance

In this cohort study, the burden of RSV-positive ARI in older adults during the pre-COVID-19 period was substantial. After a reduction of RSV-positive ARI incidence from October 2020 to April 2021, RSV-positive ARI re-emerged during the summer of 2021. RSV-positive ARI was associated with significant long-term lower QOL beyond the short-term lower QOL in older adults.

Gulf War Illness: A Randomized Controlled Trial Combining Mindfulness Meditation and Auricular Acupuncture

Background

Many Gulf War (GW) Veterans report chronic symptoms including pain, fatigue, and cognitive impairment, commonly defined as Gulf War Illness (GWI). Complementary and integrative health (CIH) therapies may potentially improve multiple symptoms of GWI.

Objective

To examine the effectiveness of combining 2 commonly available CIH therapies, mindfulness meditation and auricular acupuncture, in improving health-related functioning and multiple symptom domains of GWI (e.g., pain, fatigue).

Methods

This study was a randomized controlled trial in which Veterans with GWI were randomly assigned to either the intervention group (n = 75), wherein they received 2 distinct CIH therapies - mindfulness meditation and auricular acupuncture, or the active control group, wherein they received a GW Health Education (GWHE) program (n = 74), each lasting 8 weeks. Self-report health measures were assessed at baseline, endpoint, and 3 month follow-up.

Results

In the intention-to-treat analyses, there were significant between-group differences for mental-health related functioning, fatigue, depression symptoms, and Kansas total severity scores for symptoms in which the CIH group had improved scores for these outcomes at endpoint compared to the GWHE group (all P ≤ .05). The CIH group also had significant reductions in pain interference at endpoint and follow-up compared to baseline (estimated marginal mean difference: -2.52 and -2.22, respectively; all P = .01), whereas no significant changes were observed in the GWHE group. For pain characteristics, the GWHE group had a worsening of pain at endpoint compared to baseline (estimated marginal mean difference: +2.83; P = .01), while no change was observed in the CIH group.

Conclusion

Findings suggest a possible beneficial effect of combining 2 CIH therapies, mindfulness meditation and auricular acupuncture, in reducing overall symptom severity and individual symptom domains of fatigue, musculoskeletal, and mood/cognition in Veterans with GWI.

Trial Registration

Clinical Trials identifier NCT02180243.

Is There Evidence of an Association Between Acute Health Care Utilization and Function in Older Adults Over Time? A Population-Based Cohort Study

Background and Objectives

Acute health care use varies by age, with older adults the highest users of acute health care services. Using data from The Irish Longitudinal Study on Ageing (TILDA), the aim of this study was to investigate the association between acute health care utilization (emergency department [ED] visit with or without hospitalization) at baseline and subjective and objective measures of function measured at 4-year follow-up.

Research Design and Methods

This study represents a secondary analysis of a prospective cohort study, where data from Wave 1 (baseline) and Wave 3 of TILDA were analyzed in conjunction with a public and patient involvement group of older adults. Acute health care utilization was defined as an ED visit with or without hospitalization in the previous 12 months. Function was assessed objectively using the Timed Up and Go (TUG) test and a measure of grip strength, and subjectively using self-report limitations in activities of daily living (ADL) and instrumental ADL (IADL).

Results

A total of 1 516 participants met the study inclusion criteria. Mean age was 70.9 ± 4.6 years and 48% were male. At baseline, 1 280 participants reported no acute health care use. One hundred and eighteen indicated an ED visit but no hospitalization in the previous 12 months and 118 reported both an ED visit and hospitalization. Adjusting for all covariates, compared to those with no acute health care utilization, those with an ED visit with no hospital admission had poorer TUG performance at follow-up (β = 0.67, 95% confidence interval: 0.34, 1.29, p = .039).

Discussion and Implications

This paper supports previous research that acute health care events, specifically ED usage, are associated with reduced function for older adults as assessed by TUG at follow-up. No associations were observed for grip strength, ADL, or IADL. Further research is required in this area, exploring ED visits and the possible benefits of evaluating older adults at this stage.

Quality of Life Trajectory and Its Mediators in Older Patients With Acute Decompensated Heart Failure Receiving a Multi-Domain Rehabilitation Intervention: Results From the Rehabilitation Therapy in Older Acute Heart Failure Patients Trial

BACKGROUND

As patients with heart failure experience worsening of their condition, including acute decompensated heart failure, quality of life deteriorates. However, the trajectory of quality of life changes and their determinants in the context of the Rehabilitation Therapy in Older Acute Heart Failure Patients trial physical rehabilitation intervention are unknown.

METHODS

Patients ≥60 years old admitted for acute decompensated heart failure (n=349) were randomized to either attention control or intervention. Quality of life outcomes (Kansas City Cardiomyopathy Questionnaire; 12-Item Short-Form Health Survey) were measured at baseline (inpatient), 1 month, and 3 months. Intervention effects were assessed using linear mixed effects regression, including covariates to model the main effects of the intervention and timing of outcome assessments. Mediation analysis determined if changes in Kansas City Cardiomyopathy Questionnaire were due to improvement in physical function (short physical performance battery, 6-minute walk distance).

RESULTS

Baseline Kansas City Cardiomyopathy Questionnaire summary score was similarly poor in the intervention and control arms (40.2±20.6 versus 41.5±20.6). Although the intervention experienced nominally greater Kansas City Cardiomyopathy Questionnaire improvement than control at 1 month (64.7±1.9 versus 61.1±1.9, P=0.13), the difference was not statistically significant until 3 months (67.7±1.9 versus 60.8±1.9, P=0.004). Twelve-Item Short-Form Health Survey Physical and Mental Composite Scores increased in both arms at 1 month and continued improvement only in the intervention. The 3-month improvement in short physical performance battery score explained 64.1% of the improvement in Kansas City Cardiomyopathy Questionnaire (P<0.001).

CONCLUSIONS

In older patients hospitalized for acute decompensated heart failure, quality of life improves in the first month after discharge. The quality of life benefit of a post-discharge physical rehabilitation intervention is detected early with large significant improvements at 3 months achieved primarily through improvement in short physical performance battery.

REGISTRATION

URL: https://clinicaltrials.gov; Unique identifier: NCT02196038.

High versus low blood pressure targets for cardiac surgery while on cardiopulmonary bypass

BACKGROUND

Cardiac surgery is performed worldwide. Most types of cardiac surgery are performed using cardiopulmonary bypass (CPB). Cardiac surgery performed with CPB is associated with morbidities. CPB needs an extracorporeal circulation that replaces the heart and lungs, and performs circulation, ventilation, and oxygenation of the blood. The lower limit of mean blood pressure to maintain blood flow to vital organs increases in people with chronic hypertension. Because people undergoing cardiac surgery commonly have chronic hypertension, we hypothesised that maintaining a relatively high blood pressure improves desirable outcomes among the people undergoing cardiac surgery with CPB.

OBJECTIVES

To evaluate the benefits and harms of higher versus lower blood pressure targets during cardiac surgery with CPB.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search of databases was November 2021 and trials registries in January 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing a higher blood pressure target (mean arterial pressure 65 mmHg or greater) with a lower blood pressure target (mean arterial pressure less than 65 mmHg) in adults undergoing cardiac surgery with CPB.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Primary outcomes were 1. acute kidney injury, 2. cognitive deterioration, and 3. all-cause mortality. Secondary outcomes were 4. quality of life, 5. acute ischaemic stroke, 6. haemorrhagic stroke, 7. length of hospital stay, 8. renal replacement therapy, 9. delirium, 10. perioperative transfusion of blood products, and 11. perioperative myocardial infarction. We used GRADE to assess certainty of evidence.

MAIN RESULTS

We included three RCTs with 737 people compared a higher blood pressure target with a lower blood pressure target during cardiac surgery with CPB. A high blood pressure target may result in little to no difference in acute kidney injury (risk ratio (RR) 1.30, 95% confidence interval (CI) 0.81 to 2.08; I² = 72%; 2 studies, 487 participants; low-certainty evidence), cognitive deterioration (RR 0.82, 95% CI 0.45 to 1.50; I² = 0%; 2 studies, 389 participants; low-certainty evidence), and all-cause mortality (RR 1.33, 95% CI 0.30 to 5.90; I² = 49%; 3 studies, 737 participants; low-certainty evidence). No study reported haemorrhagic stroke. Although a high blood pressure target may increase the length of hospital stay slightly, we found no differences between a higher and a lower blood pressure target for the other secondary outcomes. We also identified one ongoing RCT which is comparing a higher versus a lower blood pressure target among the people who undergo cardiac surgery with CPB.

AUTHORS' CONCLUSIONS

A high blood pressure target may result in little to no difference in patient outcomes including acute kidney injury and mortality. Given the wide CIs, further studies are needed to confirm the efficacy of a higher blood pressure target among those who undergo cardiac surgery with CPB.

Subjective health perception prioritizes psychological well-being over physical function in advanced ALS: A multigroup structural equation modeling analysis

BACKGROUND

Despite declining physical function, individuals with ALS report relative preservation of overall health perception, or health-related quality of life (HRQoL). This paradoxical finding is attributed to psychological adaptation to deficits.

OBJECTIVE

The aim of this cross-sectional study was to examine reprioritization of factors that determine HRQoL with disease progression.

METHODS

As standard care, patients with ALS self-reported ALSFRS-R (measure of bulbar, motor, and respiratory function), PHQ-9 (measure of depression), and EQ-5D-3L (utility index that includes a visual analog scale asking about health perception [EQ-VAS]). ALS was staged by the FT9 method and classified into early (stages 0-2) and late (stages 3-4) disease. Multigroup structural equation modeling was used to evaluate weights of physical (PHY) and psychological well-being (PSY) for early and late disease, on EQ-VAS (as a measure of overall HRQoL).

RESULTS

There were 578 patients (mean age 61.5 ± 11.9, 59% male) with ALS: 423 (73%) early and 155 (27%) late disease. A measurement model was established with good model fit (RMSEA = 0.076, CFI = 0.943, SRMR = 0.045). In adjusted models, standardized weights of PHY and PSY on HRQoL in early disease were 0.34 (standard error = 0.06) and 0.24 (0.06) respectively, whereas for late disease they were 0.39 (0.07) and 0.42 (0.07). Importantly, PHY and PSY were significantly correlated in early but not in late disease.

CONCLUSIONS

Our study found health perception is more representative of psychological well-being and less representative of physical function across the disease progression. Greater allocation for psychological health would be the most effective strategy to maximize subjective health status as ALS advances.

A Promising Approach to Optimizing Sequential Treatment Decisions for Depression: Markov Decision Process

The most appropriate next step in depression treatment after the initial treatment fails is unclear. This study explores the suitability of the Markov decision process for optimizing sequential treatment decisions for depression. We conducted a formal comparison of a Markov decision process approach and mainstream state-transition models as used in health economic decision analysis to clarify differences in the model structure. We performed two reviews: the first to identify existing applications of the Markov decision process in the field of healthcare and the second to identify existing health economic models for depression. We then illustrated the application of a Markov decision process by reformulating an existing health economic model. This provided input for discussing the suitability of a Markov decision process for solving sequential treatment decisions in depression. The Markov decision process and state-transition models differed in terms of flexibility in modeling actions and rewards. In all, 23 applications of a Markov decision process within the context of somatic disease were included, 16 of which concerned sequential treatment decisions. Most existing health economic models relating to depression have a state-transition structure. The example application replicated the health economic model and enabled additional capacity to make dynamic comparisons of more interventions over time than was possible with traditional state-transition models. Markov decision processes have been successfully applied to address sequential treatment-decision problems, although the results have been published mostly in economics journals that are not related to healthcare. One advantage of a Markov decision process compared with state-transition models is that it allows extended action space: the possibility of making dynamic comparisons of different treatments over time. Within the context of depression, although existing state-transition models are too basic to evaluate sequential treatment decisions, the assumptions of a Markov decision process could be satisfied. The Markov decision process could therefore serve as a powerful model for optimizing sequential treatment in depression. This would require a sufficiently elaborate state-transition model at the cohort or patient level.

Total pancreatectomy and islet cell autotransplantation: a 10-year update on outcomes and assessment of long-term durability

BACKGROUND

Total pancreatectomy and islet cell autotransplantation (TPIAT) offers an effective, lasting solution for the management of chronic pancreatitis up to 5-years post-operatively. Our aim was to assess durability of TPIAT at 10-years.

METHODS

Patients undergoing TPIAT for chronic pancreatitis eligible for 10-year follow-up were included. Primary outcomes, including endocrine function and narcotic requirements, were reported at 5-, 7.5-, and 10-years post-operatively.

RESULTS

Of the 231 patients who underwent TPIAT, 142 met inclusion criteria. All patients underwent successful TPIAT with an average of 5680.3 islet equivalents per body weight. While insulin independence tended to decrease over time (25.7% vs. 16.0% vs. 10.9%, p = 0.11) with an increase in HbA_1C (7.6% vs. 8.2% vs. 8.4%, p = 0.09), partial islet function persisted (64.9% vs. 68.0% vs. 67.4%, p = 0.93). Opioid independence was achieved and remained durable in the majority (73.3% vs. 72.2% vs. 75.5%, p = 0.93). Quality of life improvements persisted, with 85% reporting improvement from baseline at 10-years. Estimated median overall survival was 202.7 months.

CONCLUSION

This study represents one of the largest series reporting on long-term outcomes after TPIAT, demonstrating excellent long-term pain control and durable improvements in quality of life. Islet cell function declines over time however stable glycemic control is maintained.

Local Infiltrations in Patients with Radiculopathy or Chronic Low Back Pain Due to Segment Degeneration-Only A Diagnostic Value?

The purpose of this study was to investigate the differences in the therapeutic effectiveness of CT-assisted infiltration of a local anesthetic + corticosteroid between nerve root and facet joint capsule in patients with chronic complaints. In this prospective trial with a 12-month follow-up, a total of 250 patients with chronic low back pain and radiculopathy were assigned to two groups. In the first group, patients with specific lumbar pain due to spondyloarthritis received periarticular facet joint capsule infiltration (FJI). In the second group, patients with monoradicular pain received periradicular infiltration (PRI) via an extraforaminal selective nerve block. Clinical improvement after FJI and PRI regarding pain (NRS), function (ODI), satisfaction (McNab), and health related quality of life (SF-36) were compared. Minimally clinically important difference (MCID) served as the threshold for therapeutic effectiveness evaluation. A total of 196 patients were available for final analysis. With respect to the pain reduction and functional improvement (ODI, NRSoverall, and NRSback), the PRI group performed significantly better (ptreatment < 0.001) and longer over time (ptreatment × time 0.001) than the FJI group. Regarding pain and function, only PRI demonstrated a durable improvement larger than MCID. A significant and durable therapeutic value was found only after receiving PRI but not after FJI in patients with chronic pain.

Orthoplastic Reconstruction of Type IIIB Open Tibial Shaft Fractures Using Debrided, Devitalized Cortical Segments: Health-Related Quality-of-Life Outcomes

OBJECTIVE

To determine health-related quality of life (HRQoL) in patients who sustained type IIIB open tibial diaphyseal (OTA/AO-42) fractures and underwent orthoplastic reconstruction using mechanically relevant devitalized bone (ORDB) versus those who did not require the use of devitalized bone as part of their orthoplastic reconstruction.

DESIGN

Consecutive cohort study.

PATIENTS/PARTICIPANTS

The study included 74 patients who sustained a type IIIB open tibial diaphyseal fracture requiring orthoplastic reconstruction over a 4-year period in a major trauma center. All patients underwent a two-stage orthoplastic reconstruction protocol, with the second stage consisting of definitive fixation and flap coverage (free fascial anterolateral thigh flap) in a single sitting. Patients were contacted at a minimum of 30 months to measure HRQoL.

INTERVENTION

Patients requiring ORDB versus those who did not require the use of devitalized bone as part of their orthoplastic reconstruction.

MAIN OUTCOME MEASUREMENTS

The primary outcome measure was HRQoL ascertained using Euro-Qol (EQ)-5D and Short-Form (SF)-36 scores.

RESULTS

Thirty (n = 30) patients underwent ORDB with the remaining 44 not requiring devitalized bone as part of their reconstruction. The median age was 46.5 years [interquartile range (IQR) 29.0], with a median follow-up of 3.8 years (IQR 1.5). The median cohort EQ-5D was 0.743 (IQR 0.222), ORDB 0.743 (IQR 0.195) versus non-ORDB 0.748 (IQR 0.285), P = 0.71. The median physical component SF-36 score was 80 (IQR 50), ORDB 80 (IQR 34.5) versus non-ORDB 77.5 (IQR 58.75), P = 0.72. The median mental component SF-36 score was 80 (IQR 28), ORDB 80 (IQR 21) versus non-ORDB 80 (IQR 36), P = 0.29.

CONCLUSIONS

In patients who sustained a type IIIB open tibial shaft fracture and who underwent a 2-stage orthoplastic reconstruction, ORDB does not seem to be associated with inferior health-related quality of life based on EQ-5D or SF-36 scores. The results of this approach should be considered within the strict combined orthoplastic approach in the study unit.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A scale for measuring healthcare service quality incorporating patient-centred care and using a psychometric analytics framework

PURPOSE

Recent developments in healthcare contexts increasingly emphasize patient-centred approaches to service quality measures; however, few studies consider this dimension explicitly. The present study develops and psychometrically validates a scale of healthcare service quality explicitly incorporating a patient-centred care dimension from a communicational perspective. The paper also enriches the traditional content of service quality by including equity items and presents the underlying structure of service quality in an emerging country.

DESIGN/METHODOLOGY/APPROACH

The final sample consisted of 869 healthcare users (complete cases in the service quality items derived from 917 surveys received) from Colombia. The authors used a psychometric analytics framework comprising seven processes incorporating exploratory factor analysis, structural equation modelling, and machine learning methods to examine construct plausibility, reliability, construct validity, equity, and criterion/predictive validity (e.g. explaining/predicting subjective well-being and behavioural intentions).

FINDINGS

The final scale consists of 17 items and satisfies all psychometric properties. Its validation allows for the discovery and psychometrical confirmation of two essential dimensions: patient-centred communication (eight items) and process quality (nine items).

PRACTICAL IMPLICATIONS

The authors illustrate three practical uses of the scale: the possibility for diagnoses; hypothesis contrast based on confidence intervals; and estimation of the capacity of the service to satisfy specifications.

ORIGINALITY/VALUE

Both dimensions reveal users' relevant needs and complement previous studies that have focused on process aspects of healthcare service quality.

Assessment of functioning in Dutch primary care: Development study of a consultation tool for patients with chronic conditions and multimorbidity

BACKGROUND

In primary care, a shift from a disease-oriented approach for patients with multimorbidity towards a more person-centred approach is needed.

AIM

To transform a self-report questionnaire for patients with chronic conditions in primary care, the Primary Care Functioning Scale (PCFS), into an understandable, visually attractive and feasible consultation tool for patients and health care providers. The consultation tool consists of a web-based version of the PCFS, which is filled in by the patient and is processed to a feedback report that summarizes and visualizes the main findings. The feedback report can be discussed with the patient to facilitate a more person-centred conversation for patients with chronic conditions and multimorbidity in general practice.

DESIGN AND SETTING

In this qualitative study, we developed the consultation tool by using design thinking in a participatory developmental process.

METHODS

In the first phase, we constructed five different feedback report templates to summarize and display the results of a completed PCFS questionnaire in a series of two expert meetings with patients and general practitioners (GPs). In the second phase, we performed an exploratory qualitative interview study involving dyads of patients with chronic conditions and their practice nurses. In an iterative process, we explored their experiences with the consultation tool.

RESULTS

Patients, as well as GPs, preferred a clear manner of presenting the results of the questionnaire in a feedback report. In 18 interviews with patients and practice nurses during three different interview rounds, we adjusted the feedback report and consultation tool based on the input from patients and practice nurses. After the final interview round, patients and practice nurses consented that the consultation tool was useful for having a more in-depth consultation about functioning and patients' preferences when integrated into the regularly scheduled consultations.

CONCLUSION

We were able to develop an understandable and feasible consultation tool that is applicable in already existing chronic disease management programmes in general practice in the Netherlands.

PATIENT OR PUBLIC CONTRIBUTION

To increase the understandability and feasibility of the consultation tool, we collaborated with end-users and actively involved patients, GPs and practice nurses in a participatory development process.

Acceptability and feasibility of the TELEhealth BARIatric behavioural intervention to increase physical ACTIVity (TELE-BariACTIV): A single-case experimental study protocol (Preprint)

Background

Regular physical activity (PA) is recommended to optimize weight and health outcomes in patients who have undergone metabolic and bariatric surgery (MBS). However, >70% of patients have low PA levels before MBS that persist after MBS. Although behavioral interventions delivered face-to-face have shown promise for increasing PA among patients who have undergone MBS, many may experience barriers, preventing enrollment into and adherence to such interventions. Delivering PA behavior change interventions via telehealth to patients who have undergone MBS may be an effective strategy to increase accessibility and reach, as well as adherence.

Objective

This paper reports the protocol for a study that aims to assess the feasibility and acceptability of the protocol or methods and the Telehealth Bariatric Behavioral Intervention (TELE-BariACTIV). The intervention is designed to increase moderate-to-vigorous intensity PA (MVPA) in patients awaiting bariatric surgery and is guided by a multitheory approach and a patient perspective. Another objective is to estimate the effect of the TELE-BariACTIV intervention on presurgical MVPA to determine the appropriate sample size for a multicenter trial.

Methods

This study is a multicenter trial using a repeated (ABAB’A) single-case experimental design. The A phases are observational phases without intervention (A1=pre-MBS phase; A2=length personalized according to the MBS date; A3=7 months post-MBS phase). The B phases are interventional phases with PA counseling (B1=6 weekly pre-MBS sessions; B2=3 monthly sessions starting 3 months after MBS). The target sample size is set to 12. Participants are inactive adults awaiting sleeve gastrectomy who have access to a computer with internet and an interface with a camera. The participants are randomly allocated to a 1- or 2-week baseline period (A1). Protocol and intervention feasibility and acceptability (primary outcomes) will be assessed by recording missing data, refusal, recruitment, retention, attendance, and attrition rates, as well as via web-based acceptability questionnaires and semistructured interviews. Data collected via accelerometry (7-14 days) on 8 occasions and via questionnaires on 10 occasions will be analyzed to estimate the effect of the intervention on MVPA. Generalization measures assessing the quality of life, anxiety and depressive symptoms, and theory-based constructs (ie, motivational regulations for PA, self-efficacy to overcome barriers to PA, basic psychological needs satisfaction and frustration, PA enjoyment, and social support for PA; secondary outcomes for a future large-scale trial) will be completed via web-based questionnaires on 6-10 occasions. The institutional review board provided ethics approval for the study in June 2021.

Results

Recruitment began in September 2021, and all the participants were enrolled (n=12). Data collection is expected to end in fall 2023, depending on the MBS date of the recruited participants.

Conclusions

The TELE-BariACTIV intervention has the potential for implementation across multiple settings owing to its collaborative construction that can be offered remotely.

International Registered Report Identifier (IRRID)

DERR1-10.2196/39633

A View of the Development of Patient-Reported Outcomes Measures, Their Clinical Integration, Electronification, and Potential Impact on Rehabilitation Service Delivery

Recognition of the importance of a patient's perception of their status and experience has become central to medical care and its evaluation. This recognition has led to a growing reliance on the use of patient-reported outcome measures (PROMs). Nevertheless, although awareness of PROMs and acceptance of their utility has increased markedly, few of us have a good insight into their development; their utility relative to clinician-rated and performance measures such as the FIM and 6-minute walk test or how their "electronification" and incorporation into electronic health records (EHRs) may improve the individualization, value, and quality of medical care. In all, the goal of this commentary is to provide some insight into historical factors and technology developments that we believe have shaped modern clinical PROMs as they relate to medicine in general and to rehabilitation in particular. In addition, we speculate that while the growth of PROM use may have been triggered by an increased emphasis on the centrality of the patient in their care, future uptake will be shaped by their embedding in EHRs and used to improve clinical decision support though their integration with other sources of clinical and sociodemographic data.

Prospective pilot study of the Three Good Things positive psychology intervention in short-term stay hospitalised patients

BACKGROUND

The 'Three Good Things' (3GT) positive psychology protocol developed at Duke University has been shown to decrease depressive symptoms and emotional exhaustion in healthcare providers. Whether hospitalised patients may also benefit from the 3GT protocol has not previously been explored.

OBJECTIVES

To determine the impact and efficacy of the 3GT protocol with hospitalised patients experiencing serious/chronic illness.

DESIGN

Patient-level randomised control trial.

SETTING

Medical units of an academic, tertiary care medical centre.

PATIENTS

221 adults over the age of 18 years admitted to inpatient wards (intensive care units excluded) at Stanford Hospital between January 2017 and May 2018.

INTERVENTIONS

Patients were randomised to the 3GT intervention arm or the control arm with no intervention.

MEASUREMENTS AND MAIN RESULTS

There was no significant difference between the intervention and control groups in the primary outcomes of improved positivity scores, decreased negativity scores or increased positive-to-negative emotional ratios.

CONCLUSIONS

A journal-based application of the 3GT protocol did not result in a statistically significant improvement in patient's emotional health.

The predictive utility of functional status at discharge: a population-level cohort analysis

Background

Functional status is a patient-important, patient-centered measurement. The utility of functional status measures to inform post-discharge patient needs is unknown. We sought to examine the utility of routinely collected functional status measures gathered from older hospitalized patients to predict a panel of post-discharge outcomes.

Methods

In this population-based retrospective cohort study, Adults 65+ discharged from an acute hospitalization between 4 November 2008 and 18 March 2016 in Ontario, Canada and received an assessment of functional status at discharge using the Health Outcomes for Better Information and Care tool were included. Multivariable regression analysis was used to determine the relationship between functional status and emergency department (ED) re-presentation, hospital readmission, long term care facility (LTCF) admission or wait listing (‘LTCF readiness’), and death at 180 days from discharge.

Results

A total of 80 020 discharges were included. 38 928 (48.6%) re-presented to the ED, 24 222 (30.3%) were re-admitted, 5 037 (6.3%) were LTCF ready, and 9 047 (11.3%) died at 180 days. Beyond age, diminished functional status at discharge was the factor most associated with LTCF readiness (adjusted Odds Ratio [OR] 4.11 for those who are completely dependent for activities of daily living compared to those who are independent; 95% Confidence Interval [CI]: 3.70-4.57) and death (OR 3.99; 95% CI: 3.67-4.35). Functional status also had a graded relationship with each outcome and improved the discriminability of the models predicting death and LTCF readiness (p<0.01) but not ED re-presentation or hospital re-admission.

Conclusion

Routinely collected functional status at discharge meaningfully improves the prediction of long term care home readiness and death. The routine assessment of functional status can inform post-discharge care and planning for older adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02652-6.

The DEXA-CORT trial: study protocol of a randomised placebo-controlled trial of hydrocortisone in patients with brain tumour on the prevention of neuropsychiatric adverse effects caused by perioperative dexamethasone

Introduction

The synthetic glucocorticoid dexamethasone can induce serious neuropsychiatric adverse effects. Dexamethasone activates the glucocorticoid receptor (GR) but, unlike endogenous cortisol, not the mineralocorticoid receptor (MR). Moreover, dexamethasone suppresses cortisol production, thereby eliminating its MR binding. Consequently, GR overactivation combined with MR underactivation may contribute to the neuropsychiatric adverse effects of dexamethasone. The DEXA-CORT trial aims to reactivate the MR using cortisol to reduce neuropsychiatric adverse effects of dexamethasone treatment.

Methods and analysis

The DEXA-CORT study is a multicentre, randomised, double-blind, placebo-controlled trial in adult patients who undergo elective brain tumour resection treated perioperatively with high doses of dexamethasone to minimise cerebral oedema. 180 patients are randomised between treatment with either two times per day 10 mg hydrocortisone or placebo during dexamethasone treatment. The primary study outcome is the difference in proportion of patients scoring ≥3 points on at least one of the Brief Psychiatric Rating Scale (BPRS) questions 5 days postoperatively or earlier at discharge. Secondary outcomes are neuropsychiatric symptoms, quality of sleep, health-related quality of life and neurocognitive functioning at several time points postoperatively. Furthermore, neuropsychiatric history, serious adverse events, prescribed (psychiatric) medication and referrals or evaluations of psychiatrist/psychologist and laboratory measurements are assessed.

Ethics and dissemination

The study protocol has been approved by the Medical Research Ethics Committee of the Leiden University Medical Center, and by the Dutch competent authority, and by the Institutional Review Boards of the participating sites. It is an investigator-initiated study with financial support by The Netherlands Organisation for Health Research and Development (ZonMw) and the Dutch Brain Foundation. Results of the study will be submitted for publication in a peer-reviewed journal.

Trial registration number

NL6726 (Netherlands Trial Register); open for patient inclusion. EudraCT number 2017-003705-17.

Back to the Future? Immunoglobulin Therapy for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome

The findings of controlled trials on use of intravenous immunoglobulin G (IV IgG) to treat myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) are generally viewed as representing mixed results. On detailed review, a clearer picture emerges, which suggests that the potential therapeutic value of this intervention has been underestimated. Our analysis is consistent with the propositions that: (1) IgG is highly effective for a proportion of patients with severe and well-characterised ME/CFS; (2) responders can be predicted with a high degree of accuracy based on markers of immune dysfunction. Rigorous steps were taken in the research trials to record adverse events, with transient symptom exacerbation commonly experienced in both intervention and placebo control groups, suggesting that this reflected the impact of participation on people with an illness characterised by post-exertional symptom exacerbation. Worsening of certain specific symptoms, notably headache, did occur more commonly with IgG and may have been concomitant to effective treatment, being associated with clinical improvement. The findings emerging from this review are supported by clinical observations relating to treatment of patients with severe and very severe ME/CFS, for whom intramuscular and subcutaneous administration provide alternative options. We conclude that: (1) there is a strong case for this area of research to be revived; (2) pending further research, clinicians would be justified in offering a course of IgG to selected ME/CFS patients at the more severe end of the spectrum. As the majority of trial participants had experienced an acute viral or viral-like onset, we further suggest that IgG treatment may be pertinent to the care of some patients who remain ill following infection with SARS-CoV-2 virus.

The Relieving Effects of a Polyherb-Based Dietary Supplement ColonVita on Gastrointestinal Quality of Life Index (GIQLI) in Older Adults with Chronic Gastrointestinal Symptoms Are Influenced by Age and Cardiovascular Disease: A 12-Week Randomized Placebo-Controlled Trial

Chronic gastrointestinal symptoms (CGS) negatively affect the quality of life in about 15-30% of the population without effective drugs. Recent studies suggest that dietary supplement may improve CGS, but inconsistent results exist. The goal of this study is to evaluate the effect of a polyherbal-based supplement ColonVita on the gastrointestinal quality of life index (GIQLI) in 100 old adults with CGS (63.1 ± 9.6 years) who were randomly assigned to daily ColonVita or placebo tablets (n = 50/group) for 12 weeks in a double-blind, randomized controlled trial design. No significant fibrdifferences were found between ColonVita and placebo in the baseline total GIQLI score (101.12 ± 16.87 vs. 101.80 ± 16.48) (P > 0.05) or postintervention total GIQLI score (114.78 ± 9.62 vs. 111.74 ± 13.01) (P > 0.05). However, ColonVita significantly improved 16 scores of the 19 core GI symptoms compared with 10 items improved by placebo. The ColonVita group significantly improved the remission rate of 5 core GI symptoms compared to placebo and significantly improved the total GIQLI scores (118.09 ± 7.88 vs. 109.50 ± 16.71) (P < 0.05) and core GI symptom scores (64.61 ± 3.99 vs. 60.00 ± 8.65) (P < 0.05) in people ≥60 years of age (n = 49) but not in those under 60 y (n = 51). ColonVita significantly improved the total GIQLI scores and core GI symptom scores in people without cardiovascular diseases (CVD) (n = 56) (116.74 ± 9.38 vs. 110.10 ± 14.28) (P < 0.05) and (63.11 ± 4.53 vs. 59.93 ± 8.03) (P=0.07), respectively, but not in those with CVD (n = 44). Thus, ColonVita was beneficial for old adults with CGS, especially those ≥60 years of age and without CVD. Because a heterogenous pathogenesis of CGS-like irritable bowel syndrome (IBS) and inflammatory bowel disease (ISD) is differentially associated with CVD, different comorbidities may have influenced the outcomes of different trials that should be controlled in further studies.

Longitudinal changes in physical and mental health of older adults with chronic hepatitis B infection: Trajectories and predictors

Despite the increasing health burden of chronic hepatitis B (CHB) in aging populations, little is known about the course of health-related quality of life (HRQoL) changes. We aimed to assess individual-level longitudinal HRQoL changes in elderly patients with CHB and to examine their correlates. A prospective 5.1 years-cohort study was conducted in community-dwelling adults aged 55 years with hepatitis B surface antigen-positive. Participants underwent serial measurement of HRQoL using the short-form (12) health survey version 2. Of 503 participants, 82.7% remained in good physical health throughout the study period, whereas 9.1% had declining physical health and 8.2% were in poor physical health. We likewise identified three trajectories of mental health changes ("good mental health" [86.9%], "declining mental health" [6.8%], and "poor mental health" [6.4%]). Three baseline characteristics were independently associated with a lower likelihood of remaining physically or mentally healthy: sarcopenic obesity (odds ratio [OR] with 95% confidence interval [95% CI] of 7.5 [2.8-20.5] for poor physical health, 3.1 [1.1-8.4] for declining physical health, 4.3 [1.4-13.0] for poor mental health), a higher number of metabolic abnormalities (OR [95% CI] of 3.6 [1.6-8.0] for poor physical health) and depressed mood (OR [95% CI] of 21.7 [5.8-81.0] for poor physical health, 5.3 [1.4-19.9] for declining physical health, 83.1 [19.7-350.2] for poor mental health, 13.6 [2.9-64.8] for declining mental health). In conclusion, in a cohort of elderly patients with CHB, we demonstrated the heterogeneity and nonlinearity of HRQoL changes and their associations with variations in specific extrahepatic organs/systems.

Trends in Differences in Health Status and Health Care Access and Affordability by Race and Ethnicity in the United States, 1999-2018

IMPORTANCE

The elimination of racial and ethnic differences in health status and health care access is a US goal, but it is unclear whether the country has made progress over the last 2 decades.

OBJECTIVE

To determine 20-year trends in the racial and ethnic differences in self-reported measures of health status and health care access and affordability among adults in the US.

DESIGN, SETTING, AND PARTICIPANTS

Serial cross-sectional study of National Health Interview Survey data, 1999-2018, that included 596 355 adults.

EXPOSURES

Self-reported race, ethnicity, and income level.

MAIN OUTCOMES AND MEASURES

Rates and racial and ethnic differences in self-reported health status and health care access and affordability.

RESULTS

The study included 596 355 adults (mean [SE] age, 46.2 [0.07] years, 51.8% [SE, 0.10] women), of whom 4.7% were Asian, 11.8% were Black, 13.8% were Latino/Hispanic, and 69.7% were White. The estimated percentages of people with low income were 28.2%, 46.1%, 51.5%, and 23.9% among Asian, Black, Latino/Hispanic, and White individuals, respectively. Black individuals with low income had the highest estimated prevalence of poor or fair health status (29.1% [95% CI, 26.5%-31.7%] in 1999 and 24.9% [95% CI, 21.8%-28.3%] in 2018), while White individuals with middle and high income had the lowest (6.4% [95% CI, 5.9%-6.8%] in 1999 and 6.3% [95% CI, 5.8%-6.7%] in 2018). Black individuals had a significantly higher estimated prevalence of poor or fair health status than White individuals in 1999, regardless of income strata (P < .001 for the overall and low-income groups; P = .03 for middle and high-income group). From 1999 to 2018, racial and ethnic gaps in poor or fair health status did not change significantly, with or without income stratification, except for a significant decrease in the difference between White and Black individuals with low income (-6.7 percentage points [95% CI, -11.3 to -2.0]; P = .005); the difference in 2018 was no longer statistically significant (P = .13). Black and White individuals had the highest levels of self-reported functional limitations, which increased significantly among all groups over time. There were significant reductions in the racial and ethnic differences in some self-reported measures of health care access, but not affordability, with and without income stratification.

CONCLUSIONS AND RELEVANCE

In a serial cross-sectional survey study of US adults from 1999 to 2018, racial and ethnic differences in self-reported health status, access, and affordability improved in some subgroups, but largely persisted.