Evaluation of Allied Healthcare in Patients Recovering from Covid-19: Study Protocol and Baseline Data of a National Prospective Cohort Study

Objective

To report the study protocol and baseline characteristics of a prospective cohort study to evaluate longitudinal recovery trajectories of patients recovering from COVID-19 who have visited a primary care allied health professional.

Design

Report of the protocol and baseline characteristics for a prospective cohort study with a mixed-methods approach.

Patients

Patients recovering from COVID-19 treated by primary care dietitians, exercise therapists, occupational therapists, physical therapists and/or speech and language therapists in the Netherlands.

Methods

The prospective study will measure primary outcome domains: participation, health-related quality of life, fatigue, physical functioning, and costs, at baseline, 3, 6, 9 and 12 months. Interviews, on the patients’ experiences with allied healthcare, will be held with a subsample of patients and allied health professionals.

Results

The cohort comprises 1,451 patients (57% female, mean age 49 (standard deviation 13) years). Preliminary results for the study cohort show that 974 (67%) of the participants reported mild/moderate severity symptoms during the infection period and patients reported severe restrictions in activities of daily living compared with previous research in other patient populations. Both quantitative and qualitative, will provide insight into the recovery of patients who are treated by allied health professionals.

Conclusion

In conclusion, this will be the first comprehensive study to longitudinally evaluate the recovery trajectories and related costs of patients recovering from COVID-19 who are treated by allied health professionals in the Netherlands. This study will provide evidence for the optimal strategy to treat patients recovering from COVID-19 infection, including which patients benefit, and to what extent, from treatment, and which factors might impact their recovery course over time. The preliminary results of this study demonstrated the severity of restrictions and complaints at the start of therapy are substantial.

OP0090 EFFICACY OF SUBCUTANEOUS TANEZUMAB FOR THE TREATMENT OF CHRONIC LOW BACK PAIN: AN ANALYSIS OF BRIEF PAIN INVENTORY-SHORT FORM SCORES FROM A 56-WEEK, RANDOMIZED, PLACEBO- AND TRAMADOL-CONTROLLED, PHASE 3 TRIAL

Background:

Tanezumab, a monoclonal antibody against nerve growth factor, was recently evaluated in an 80 week placebo and tramadol-controlled trial in patients with chronic low back pain (CLBP) and a history of inadequate response to standard-of-care analgesics (NSAIDs, opioids, etc). Primary endpoint was change in Low Back Pain Intensity (LBPI) at week 16 vs placebo. Key secondary endpoints were the proportion of patients with ≥50% improvement in LBPI at week 16, change in Roland Morris Disability Questionnaire score at week 16, and change in LBPI at week 2 (all vs placebo). Tanezumab 10mg met the primary and all key secondary endpoints. Tanezumab 5mg did not meet the primary endpoint, but improved 2 of 3 key secondary endpoints. Due to the primary endpoint result and the statistical gate-keeping approach to control for multiple comparisons, a conclusion of superiority over placebo could not be made for the 5mg dose.

Objectives:

To further characterize tanezumab’s effects on pain and function in this trial through analysis of Brief Pain Inventory-short form (BPI-sf) scores.

Methods:

Patients received placebo (n=406), subcutaneous (SC) tanezumab 5mg (every 8 weeks; n=407), SC tanezumab 10mg (every 8 weeks; n=407) or oral tramadol prolonged-release (100-300mg/day; n=605). Pre-specified secondary endpoints included BPI-sf worst pain, average pain, the overall pain interference index, and selected individual domains of the index (general activity, walking ability, sleep, and normal work). Least squares (LS) mean (standard error [SE]) changes from baseline in BPI-sf scores were compared between groups (unadjusted for multiplicity) at week 16 using an analysis of covariance model. Scores range from 0-10 with higher scores indicating greater pain severity or functional impairment.

Results:

LS mean (SE) differences from placebo for worst pain were -0.52 (0.19) for tanezumab 5mg (p≤0.01), -0.54 (0.19) for tanezumab 10mg (≤0.01), and -0.24 (0.17) for tramadol (p=0.17). LS mean (SE) differences from placebo for average pain were -0.37 (0.18) for tanezumab 5mg (p=0.04), -0.46 (0.18) for tanezumab 10mg (≤0.01), and -0.17 (0.16) for tramadol (p=0.29). LS mean (SE) differences from placebo for the pain interference index were -0.41 (0.18) for tanezumab 5mg (p=0.03), -0.58 (0.18) for tanezumab 10mg (≤0.01), and -0.15 (0.17) for tramadol (p=0.39). Effects of tanezumab were not statistically different (p>0.05) from tramadol for worst pain, average pain, and the pain interference index, with exception of the pain interference index for tanezumab 10mg (p=0.01). Mean dose of tramadol was 203mg/day at week 16.

Tanezumab 10mg significantly (p<0.05) improved individual domains of the pain interference index (general activity, walking ability, sleep, and normal work) vs placebo and vs tramadol. Tanezumab 5mg significantly (p<0.05) improved pain interference with general activity and normal work vs placebo, and sleep vs placebo and vs tramadol. No statistical differences in any domain was observed for tramadol vs placebo.

Conclusion:

Tanezumab 5mg and 10mg significantly improved worst pain, average pain, and overall pain interference index scores vs placebo in patients with CLBP. Tanezumab 10mg also significantly improved the overall pain interference index vs tramadol. Tanezumab 5mg significantly improved most individual domains of the pain interference index vs placebo, while tanezumab 10mg significantly improved all domains assessed vs placebo and vs tramadol.

Disclosure of Interests:

John Markman Consultant of: Consultant: Trigemina, Editas Medicine, and Plasma Surgical; Advisory board: Clexio Biosciences, Flexion Therapeutics, Quark Pharmaceuticals, Quartet Medicine, Collegium Pharmaceutical, Purdue Pharma, Biogen, Novartis, Aptinyx, Nektar, Allergan, Grünenthal, Eli Lilly and Company, Depomed, Janssen Pharmaceuticals, Teva Pharmaceutical Industries, KemPharm, Abbott Laboratories, Plasma Surgical, Chromocell, Convergence Pharmaceuticals, Inspirion, Pfizer, Sanofi, Daiichi Sankyo, and Trevena; Data safety monitoring boards for Novartis and Allergan, Serge Perrot Consultant of: Grunenthal, Pfizer, Lilly, MSD, Sanofi, Menarini, Seiji Ohtori: None declared, Thomas Schnitzer Consultant of: Pfizer, Lilly, AstraZeneca, GSK, Said Beydoun Grant/research support from: Argenx, Catalyst Pharma, Mallinckrodt, Pfizer, UCB, Consultant of: Alexion, Akcea, Alnylam, CSL, Takeda, Mitsubishi Tanabe, Speakers bureau: Alexion, Akcea, Alnylam, CSL, Takeda, Mitsubishi Tanabe, Lars Viktrup Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Ruoyong Yang Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Candace Bramson Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Christine West Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Ken Verburg Shareholder of: Pfizer Inc, Employee of: Pfizer Inc

A framework for analysing nitrification inhibition: A case study on 3,4-dimethylpyrazole phosphate (DMPP)

Nitrification inhibitors show great potential to reduce nitrogen losses from agricultural systems and to improve nitrogen use efficiency. The most recently developed nitrification inhibitor 3,4-dimethylpyrazole phosphate (DMPP) is gaining popularity due to its benefits relative to other compounds. However, the behaviour of DMPP and its effect on nitrification in soils has been characterised using inconsistent and confusing terminology. Many studies have used the term half-life to describe the persistence of DMPP but used different experimental methods to derive it leading to highly variable results. We assessed how different methodologies in experiments may have contributed to the variability in the results using a framework that describes the behaviour of DMPP and its effect on nitrification in terms of: persistence, bioactivity and longevity. We show that deriving the persistence of DMPP using ¹⁴C labelling techniques is challenging because it requires consideration of other ¹⁴C pools in the soil. We also describe the limitations of soil inorganic nitrogen measurements to characterise the bioactivity and longevity of the inhibitory effect on nitrification. We conclude by proposing experiments that can facilitate the evaluation of the benefits of DMPP across broader scales. While this study focused on DMPP, the concepts presented here are equally relevant to other nitrification inhibitors.

Lucerne in crop rotations on the Riverine Plains. 3. Model evaluation and simulation analyses

The use of a lucerne phase in crop rotations can reduce water lost as drainage past the root zone under dryland agriculture in southern Australia. During the lucerne phase the perenniality of lucerne and its deep rooting ability allow extraction of soil water from below the root zone of annual crops and the creation of a soil water storage buffer against deep water loss. The longevity of the soil water storage buffer depends on rainfall patterns, management of the crops and summer fallows, as well as the magnitude of the buffer created during the lucerne phase. Results from a previously reported field experiment in north-eastern Victoria (average annual rainfall 600 mm) suggested that a 2-year lucerne phase could be insufficient to prevent drainage under subsequent crops for more than 1 year. Computer simulations were used to explore the implications of climatic variability on the creation and refilling of the soil water storage buffer. After first testing that the simulations described the experimental data satisfactorily, they were then used to extend the results and conclusions of the field experiment. These showed that the outcome of the experimental evaluation was affected by the climatic conditions experienced during the experiment and that a lucerne phase duration of 2 years was not appreciably less effective than a 3-year lucerne phase in reducing drainage past 1.8 m (the depth evaluated in the experiment). This conclusion was, however, sensitive to the depth at which drainage was evaluated and also depended on management factors such as the timing of lucerne removal and weed control during the summer fallows. For example, when drainage was evaluated to the maximum depth of lucerne rooting (3.6 m), lucerne was removed in December rather than April, and weeds were permitted, a third year of lucerne allowed a longer cropping phase without refilling of the profile in 47% of years. As a general recommendation a 3-year lucerne phase might, therefore, be an appropriate option for maximising the prevention of drainage. The large variability in the longevity of the soil water storage buffer (from 3 to > 45 months) and its sensitivity to management suggest, however, that it may be more beneficial to link phase changes to local assessment of the status of soil water storage buffer.

An evaluation of the tactical use of lucerne phase farming to reduce deep drainage

Lucerne phase farming has been suggested as a way of reducing deep drainage in the cereal belt of southern Australia. It is based on the concept that lucerne (Medicago sativa L.), a perennial pasture with a deep root system, creates a soil water storage buffer below the root zone of the annual crops, which gradually refills during the subsequent cropping phase, temporarily reducing the risk of deep drainage. The rate of refilling is variable because it is affected by the amount and distribution of rainfall as well as management of the crop and the summer fallow. There is, therefore, uncertainty about the optimum phase durations that will maximise the effect of the lucerne phase. Computer simulations were applied to evaluate the use of a soil water measurement below the root zone of annual crops to schedule the phase changes, referred to as tactical phase farming. The results confirmed that phase farming reduced average annual deep drainage significantly, but at the cost of lower average annual gross margin. In most cases, tactical phase farming improved the trade-off between deep drainage and gross margin relative to fixed duration phases; for a given amount of average annual deep drainage the average annual gross margin was larger, and for a given gross margin the drainage was smaller. The benefits of tactical phase systems were greatest in soils with a large available water-holding capacity and when the variability of the refilling rate was large. Overall, however, the benefits of the tactical approach relative to fixed phase systems were small.

Comorbid depressive disorder increases vulnerability to the 35% carbon dioxide (CO2) challenge in panic disorder patients

BACKGROUND

The hypothesis of this study was that panic disorder patients with a comorbid depressive disorder would be less vulnerable to the 35% CO2 panic provocation challenge than panic disorder patients without a comorbid depressive disorder. This hypothesis was based on findings from ventilatory response studies in depressive patients.

METHODS

Twelve panic disorder patients with and 23 panic disorder patients without a comorbid depressive disorder were challenged.

RESULTS

Panic disorder patients with a comorbid depressive disorder scored significantly higher on ratings of subjective anxiety and panic symptoms induced by the challenge.

CONCLUSIONS

A comorbid depressive disorder appeared to increase the vulnerability of panic disorder patients to this panic provocation.

LIMITATION

We did find significant differences, but these differences did not confirm the original hypothesis.

CLINICAL RELEVANCE

Our results support clinical data that show that a comorbid depressive disorder correlates with an increased severity of panic disorder.

Reliability of the 35% carbon dioxide panic provocation challenge

The objective of this study was to determine the test-retest reliability of the 35% carbon dioxide (CO2) panic provocation challenge. Thirty patients with panic disorder were included in this study. Twenty-four patients were challenged twice, with 1 week between the two challenges. Six patients dropped out after the first test. The 35% CO2 challenge appeared to have a good test-retest reliability; both on induced subjective anxiety, measured on a Visual Analogue Scale for Anxiety (VAS-A), and induced panic symptoms, measured with a Panic Symptom List. Assessing the state of anxiety immediately after the challenge gave the most reliable results. Calculating increase in anxiety from the pre- and post-scores on the VAS-A rendered less reliable scores. This study completes a series of studies in which the criteria for an ideal model of panic are tested for the 35% CO2 challenge. Apart from an absolute specificity for panic disorder, the challenge meets these criteria.

Alprazolam premedication and 35% carbon dioxide vulnerability in panic patients

A group of 20 patients who met the DSM-III-R criteria for panic disorder with or without agoraphobia underwent a 35% carbon dioxide (CO2) challenge after either 1 mg alprazolam or placebo in a double-blind, randomized, cross-over design. Despite the anxiolytic potential of alprazolam, it produced no significant effects on CO2-induced anxiety and panic symptomatology when compared to placebo.

Fluvoxamine attenuates panic induced by 35% CO2 challenge

BACKGROUND

The authors investigated whether 6 weeks of treatment with fluvoxamine would decrease the anxiogenic response to the 35% CO2 challenge in 11 patients with DSM-III-R panic disorder with agoraphobia.

METHOD

The patients underwent a 35% CO2 challenge at baseline and again after 6 weeks of fluvoxamine treatment.

RESULTS

The anxiogenic effect of CO2 was significantly (p < .05) reduced during fluvoxamine treatment.

CONCLUSION

The results suggest a relationship between the anxiogenic effect of CO2 and the therapeutic effect of fluvoxamine.

Discrimination between panic disorder and generalized anxiety disorder by 35% carbon dioxide challenge

OBJECTIVE

The authors' goal was to determine whether 35% carbon dioxide (CO2) challenge would discriminate between patients with panic disorder and patients with other anxiety disorders.

METHOD

Nine patients with panic disorder and nine with generalized anxiety disorder underwent the 35% CO2 challenge.

RESULTS

Patients with panic disorder experienced a significantly stronger increase in subjective anxiety than patients with generalized anxiety disorder. However, increases in panic symptom scores were high in both groups.

CONCLUSIONS

These results suggest that a large increase in subjective anxiety due to the CO2 challenge is specific for patients with panic disorder but that an increase in panic symptoms is not.

Respiratory disorders as a possible predisposing factor for panic disorder

150 consecutive anxiety patients completed a specially designed questionnaire which asked for the occurrence of respiratory and other somatic disorders before the onset of their anxiety disorder. The sample was divided into 82 panic disorder patients and 68 other anxiety patients serving as controls. Panic disorder patients had a significantly higher prevalence of respiratory diseases before the onset of their anxiety disorder than controls (42.7 vs. 16.2%). This higher prevalence was mainly due to a higher prevalence of bronchitis (26.8 vs. 8.8%). Differences in numbers of respiratory disorders mentioned appeared not to result from a tendency to hypochondria.

Yohimbine premedication and 35% CO2 vulnerability in healthy volunteers

A group of 20 healthy volunteers underwent a 35% carbon dioxide/65% oxygen air-placebo controlled challenge test twice, premedicated 1 h before with either 20 mg yohimbine or placebo, following a double-blind randomized crossover design. Contrary to expectation the anxiety response to carbon dioxide was not higher when premedicated with yohimbine compared to premedication with placebo. Possible implications of this finding are discussed, with reference to general chemical models of panic.