12-month follow-up of intensive outpatient treatment for PTSD combining prolonged exposure therapy, EMDR and physical activity

BACKGROUND

Preliminary evidence shows promising treatment outcomes at short-term follow-up for intensive posttraumatic stress disorder (PTSD) treatment, but long-term follow-up studies are sparse. This study is a sequel to a previous pilot study and open trial, set out to investigate treatment outcomes at 12-month follow-up for outpatients completing an 8-day intensive treatment for PTSD.

METHODS

All patients were diagnosed with PTSD and had multiple previous psychotherapy attempts (M = 3.1). Patients were assessed at pre-treatment, post-treatment, 3- and 12-month follow-up. Of 35 treated patients, 32 (91.4%) attended the long-term follow-up assessment. The treatment programme combined prolonged exposure therapy, eye movement desensitization and reprocessing, and physical activity.

RESULTS

The effect sizes indicated large reductions in symptoms of PTSD, depression, anxiety, interpersonal problems, and well-being. Changes in functioning showed a small-medium effect. Results were stable across the follow-up period. The treatment response rates showed that 46-60% of patients achieved recovery with respect to PTSD symptoms, and that 44-48% no longer met diagnostic criteria for PTSD.

CONCLUSIONS

Time-limited and concentrated outpatient treatment for PTSD can yield large and enduring positive outcomes. Controlled trials are needed to establish relative efficacy.

TRIAL REGISTRATION

The study was registered in Current Research Information System In Norway (Cristin). Cristin-project-ID: 654,790. Date of registration: 18.03.2019.

Follow up after surgery for colorectal liver metastases: A systematic review

INTRODUCTION

Recurrence post hepatectomy for colorectal liver metastases (CRLM) occurs in 70 % of patients within two years. No established guidance on the method or intensity of follow-up currently exists. The aim of this systematic review was to summarise literature and determine whether it is possible to identify an optimal follow up regime. To this date there are no randomised prospective studies investigating this.

METHODS

A systematic review was performed according to PRISMA guidelines. Outcomes included general demographics, method, frequency and duration of follow up, survival and recurrence data. Quality assessment of the papers was performed.

RESULTS

Twenty-five articles published between 1994 and 2022 were included, including 9945 patients. CT was the most common imaging modality (n = 14) and CEA most common blood test (n = 11). Intensity of follow up was higher in the first two years post resection and only two papers continued follow up post 5 years resection. There was wide variation in outcome measures - Overall survival (OS) was most commonly reported. Nine papers reported OS ranging between 39 and 78.1 %.

CONCLUSIONS

There is wide variation in follow up methods and outcome reporting. There is no strong evidence to support intensive follow up, and the benefits of long term follow up are also unknown due to the lack of patient centred data. High quality, prospective studies should be the focus of future research as further retrospective data is unlikely to resolve uncertainties around optimal follow up.

Survival benefit of pediatric-based regimen for adults with acute lymphoblastic leukemia: A single-center retrospective cohort

INTRODUCTION

Improving survival of Acute Lymphoblastic Leukemia (ALL) in adult patients has been a challenge. Despite intensive chemotherapy treatment, overall survival is poor. However, several studies demonstrate that young adult patients have better survival when treated with pediatric-based intensive regimens. Considering these results, We decided to treat newly diagnosed ALL patients according to age and risk factors. The goal of this study was to describe the results of this intensive chemotherapy treatment approach for ALL adult patients diagnosed at our institution.

METHODS

Fifty-eight ALL patients, diagnosed from 2004 to 2013, were included in the analysis. Patients were assigned to either the St. Jude Total Therapy XIIIB high-risk arm (St Jude) or the CALGB 8811 (CALGB). The Kaplan-Meier survival curve was used for the survival analyses and the Cox proportional hazard regression, for multivariable analysis.

RESULTS

The overall survival was 22.9% at 10 years. The St. Jude improved survival, compared to the CALGB (p = 0.007), with 32.6% vs. 7.4% survival rate at 10 years. However, no survival benefit was found for patients younger than 20 years old (p = 0.32). The multivariable analysis demonstrated that undetectable minimal residual disease (MRD) and hematopoietic stem cell transplantation (HSCT) had beneficial impact on survival (p = 0.0007 and p = 0.004, respectively).

CONCLUSION

ALL is a disease of poor prognosis for adults. The joint effort to standardize treatment and seek solutions is the way to start improving this scenario.

Coping with Transitions: A Promising Intensive Outpatient DBT Program for Emerging Adults and Their Families

Emerging adulthood is a period of significant exploration, transformation, variability, and growth. Simultaneously, this developmental period presents unique challenges as emerging adults work to achieve developmental milestones including self-identity formation, the establishment of long-term intimate relationships, career advancement, and independence from parents. For those who are vulnerable, this period is also marked by the development of significant mental health problems and associated impairment, which prevents individuals from successfully reaching these developmental milestones. To address the various challenges unique to this developmental period, we created and implemented a multifaceted DBT treatment protocol to specifically address emotional dysregulation within emerging adults. The current study presents an evaluation of a novel, intensive, outpatient DBT program called System for Adult Growth and Emergence-Foundations (SAGE-F). We aim to first introduce the SAGE-F treatment protocol, and then to assess both its short and long-term therapeutic value. Participants enrolled in SAGE-F were administered a testing battery assessing symptom severity, functioning capacities, and coping strategies at intake, upon completion of the program 6-weeks later, and at 3-month follow-up. It was found participants who completed SAGE-F reported significant reductions in depression and anxiety symptoms, as well as non-suicidal self-injurious behaviors. Simultaneously, participants also reported improvements in their daily functioning and coping capacities. Follow-up assessments indicated therapeutic progress remained.

Extremity Fractures as the Most Common Missed Injuries: A Prospective Cohort in Intensive Care Unit Admitted Multiple Trauma Patients

Background

Although an intensive care unit (ICU) admission is a risk factor for missed injury, there has been some disagreement on whether missed injuries in trauma ICU patients have a longer length of stay (LOS). With this in mind, these patients' frequency of missed injuries and related factors were investigated.

Materials and methods

This was a prospective cohort study on multiple trauma injury patients in a tertiary referral trauma center's trauma intensive care unit (TICU) from March 2020 to March 2021. A tertiary survey was conducted in the TICU by attending physicians to find the types I and II missed injuries (any injury discovered after primary and secondary surveys during the hospital stay). A logistic regression model was designed for predictors of missed injuries in ICU-admitted multiple trauma patients.

Results

Out of 290 study participants, 1,430 injuries were found, and of those injuries, 74 cases (25.5%) had missed injuries. In other words, there were 103 missed injuries, resulting in a missed injury detection rate of 7.2%. The most frequently missed injuries (43.4%) were concluded as extremities fractures. The regression model showed that the patients with missed injuries are prone to longer TICU LOS [odds ratio (OR) = 1.15; p = 0.033], and cases who underwent a computed tomography (CT) scan are less likely to have missed injuries (OR = 0.04; p < 0.001). The abbreviated injury scale (AIS) range was 1-3 in missed injuries.

Conclusion

Our research underlines the importance of finding missed injuries and the necessity of CT scan to decrease them. In teaching centers, life-threatening injuries decrease with increasing visits and examination times. Although these missed injuries do not increase mortality, they cause longer TICU LOS and costs.

How to cite this article

Bahramian M, Shahbazi P, Hemmati N, Mohebzadeh P, Najafi A. Extremity Fractures as the Most Common Missed Injuries: A Prospective Cohort in Intensive Care Unit Admitted Multiple Trauma Patients. Indian J Crit Care Med 2023;27(3):201-204.

Impact of intensive follow-up of cardiac implantable electronic devices via remote monitoring: A pilot study

Background

The volume of remote monitoring (RM) data generates a significant workload and is generally dealt with by clinic staff during standard office hours, potentially delaying clinical action.

Objective

The purpose of this study was to determine the clinical efficiency and workflow of implementing intensive RM (IRM) in patients with cardiac implantable electronic device (CIED) when compared with standard RM (SRM).

Methods

From a cohort of >1500 remotely monitored devices, 70 patients were randomly selected to undergo IRM. For comparison, an equal number of matched patients were prospectively selected for SRM. Intensive follow-up occurred via automated vendor-neutral software with rapid alert processing by International Board of Heart Rhythm Examiners-certified device specialists. Standard follow-up was conducted by clinic staff during office hours via individual device vendor interfaces. Alerts were categorized on the basis of the level of acuity as actionable (red [high], yellow [moderate]), or green [not requiring action]).

Results

Over 9 months of follow-up, 922 remote transmissions were received; 339 (36.8%) were coded as actionable alerts (118 in IRM and 221 in SRM; P < .001). The median time from initial transmission to review was 6 hours (interquartile range [IQR] 1.8-16.8 hours) in the IRM group compared with 10.5 hours (IQR 6.0-32.2 hours) in the SRM group (P < .001). The median time from transmission to review of actionable alerts in the IRM group was 5.1 hours (IQR 2.3-8.9 hours) compared with 9.1 hours (IQR 6.7-32.5 hours) in the SRM group (P < .001).

Conclusion

Intensive and managed RM results in a significant reduction in time to review alerts and number of actionable alerts. Monitoring with enhanced alert adjudication is needed to facilitate device clinic efficiency and optimize patient care.

Study Registration

ACTRN12621001275853.

Efficacy and safety of intensive versus conventional glucose targets in people with type 2 diabetes: a systematic review and meta-analysis

OBJECTIVE

The aim of study is to re-evaluate the risk-benefits of intensive glycemic control in the context of multi-factorial intervention in adults with T2D.

METHODS

We searched Ovid MEDLINE, Embase, Cochrane, and CINHAL for randomized control trials comparing standard glucose targets to intensive glucose targets with pre-specified HbA_1clevels. Subgroup analysis was also performed to account for the inclusion of glucose only versus multi-factorial intervention trials. Results are reported as risk ratio (RR) and 95% confidence interval (CI).

RESULTS

Fifty-seven publications including 19 trials were included. Compared to conventional glycemic control, intensive glycemic control decreased the risk of non-fatal myocardial infarction (0.8, 0.7-0.91), macroalbuminuria (0.72, 0.5--0.87), microalbuminuria (0.67, 0.52-0.85), major amputation (0.6, 0.38-0.96), retinopathy (0.75 ,0.63-0.9), and nephropathy (0.78, 0.63-0.97). The risk of hypoglycemia increased with intensive glycemic control than conventional treatment (2.04, 1.34-3.1). No reduction in all-cause or cardiovascular mortality was observed. However, in the context of multifactorial intervention, intensive glucose control was associated with a significant reduction in all-cause mortality (0.74, 0.57-0.95).

CONCLUSION

Targeting HbA_1c levels should be individualized based on the clinical status, balancing risks and benefits and potential risk for developing these complications among people with T2D.

Intensive rTMS for treatment-resistant depression patients with suicidal ideation: An open-label study

The advantages of intensive repetitive transcranial magnetic stimulation (rTMS) protocol are in the possible acute effect of the stimulation and in the possible reduction in the time required to achieve remission in depression. Here, we investigated the antidepressant effects and antisuicidal effects of a more intensive rTMS protocol for treatment-resistant depression (TRD) patients with suicidal ideation. Thirty-one outpatients were included in this study, including 22 military veterans and 9 non- militaries. The rTMS treatment consisted of 25 sessions, each session lasting 30 min (60 trains of 50 pulsations, 110 % resting motor threshold intensity) for a total of 3000 pulse. The total amount of stimulation (750,000 pulses) applied by our rTMS protocol was equivalent to that of a 5-week standard rTMS protocol. We found a significant effect of time on the 17-item Hamilton Depression Rating Scale (HAMD-17) scores and the Sheehan Disability Scale (SDS) scores. There was no difference in change in the HAMD-17 scores and SDS scores between the military veteran group and the non-military group between baseline and the week 4 assessment time point. The response rate of depression was 64.52 %, and the remission rate of depression was 51.61 % at day 5. 48.39 % and 35.48 % at week 4, respectively. All patients (100 %) met response criteria of suicidal ideation, and the remission rate was 87.09 % at day 5. The response rate was 83.87 % %, and the remission rate was 77.42 % at week 4. The accelerated high-dose rTMS treatment was well tolerated by all patients. Our intensive rTMS protocol is preliminarily safe and feasible. The TRD patients with suicidal ideation could benefit from much shorter exposure to this protocol with more efficacy in comparison with conventional rTMS protocol. In addition, intensive rTMS offers a promising treatment for military veteran populations.

Intensive vs non-intensive statin pretreatment before percutaneous coronary intervention in Chinese patients: A meta-analysis of randomized controlled trials

BACKGROUND

The results of intensive statin pretreatment before percutaneous coronary intervention (PCI) is inconsistent between Chinese and Western populations, and there are no corresponding meta-analyses involving hard clinical endpoints in the available published literature.

AIM

To evaluate the efficacy and safety of high-dose statin loading before PCI in Chinese patients through a meta-analysis.

METHODS

Relevant studies were identified by searching the electronic databases of PubMed, Embase and Cochrane’s Library to December 2019. The outcomes included an assessment of major adverse cardiovascular event (MACE), non-fatal myocardial infarction (MI), cardiac death, target vessel revascularization (TVR), myalgia /myasthenia and abnormal alanine aminotransferase (ALT) in all enrolled patients. Random effect model and fixed effect model were applied to combine the data, which were further analyzed by χ² test and I² test. The main outcomes were then analyzed through the use of relative risks (RR) and its 95% confidence interval (95%CI).

RESULTS

Eleven studies involving 3123 individuals were included. Compared with patients receiving placebo or no statin treatment before surgery, intensive statin treatment was associated with a clear reduction of risk of MACE (RR = 0.44, 95%CI: 0.31-0.61, P < 0.00001). However, compared with the patients receiving moderate-intensity statin before surgery, no advantage to intensive statin treatment was seen (RR = 1.04, 95%CI: 0.82-1.31, P = 0.74). In addition, no significant difference was observed between intensive statin therapy and non-intensive statin therapy on the incidence of TVR (RR = 0.43, 95%CI: 0.18-1.02, P = 0.06) , myalgia /myasthenia (RR = 1.35, 95%CI: 0.30-5.95, P = 0.69) and abnormal alanine aminotransferase (RR = 1.47, 95%CI: 0.54-4.02, P = 0.45) except non-fatal MI (RR = 0.54, 95%CI: 0.33-0.88, P = 0.01).

CONCLUSION

Compared with placebo or no statin pretreatment, intensive statin before PCI displayed reduced incidence of MACE. However, there was no significant benefit between high and moderate-intensity statin. In addition, no significant difference was observed between intensive statin therapy and non-intensive statin therapy on the incidence of TVR, myalgia/myasthenia and abnormal alanine aminotransferase except non-fatal MI.

Effectiveness of a high-intensive trauma-focused, family-based therapy for youth exposed to family violence: study protocol for a randomized controlled trial

BACKGROUND

Family violence is a common problem with direct adverse effects on children as well as indirect effects through disruption of parenting and parent-child relationships. The complex interrelationships between family violence, parenting, and relationships make recovery from psychological responses difficult. In more than half of the families referred to mental health care after family violence, the violence continues. Also, the effect sizes of "golden standard" treatments are generally lower for complex trauma compared to other forms of trauma. In the treatment of complex trauma, trauma-focused therapies including cognitive restructuring and imaginal exposure are most effective, and intensifying therapy results in faster symptom reduction. Furthermore, there is promising evidence that adding a parental component to individual trauma treatment increases treatment success. In family-based intensive trauma treatment (FITT), these factors are addressed on an individual and family level in a short period of time to establish long-term effects on the reduction of trauma symptoms and recovery of security in the family. This randomized controlled multicentre study tests if FITT is an effective treatment for concurrent reduction of trauma symptoms of children, improvement of parenting functioning, and increasing emotional and physical security in children, through the improvement of parent-child relationships.

METHODS

The effectiveness of FITT will be tested by a RCT design. A total of 120 adolescents with a history of family violence and PTS symptoms will be randomized to (a) an intensive trauma treatment with a parent and systemic component (FITT), (b) an intensive trauma treatment without these components (ITT), and (c) treatment as usual (TAU, low-frequency trauma treatment with parent therapy and family sessions). Changes in children's trauma symptoms, child and parent functioning, and emotional and physical security in the family will be monitored before, during, after, and at 3 months follow-up.

DISCUSSION

Comparing these interventions with and without a high intensive frequency and parenting and family components can help to understand if and how these interventions work and can contribute to the ambition to recover from the impact of family violence and restore emotional and physical security for children and young people.

TRIAL REGISTRATION

Netherlands Trial Register Trial NL8592 . Registered on 4 May 2020.

The Fluency Trust Residential Course for young people who stutter: A pragmatic feasibility study

INTRODUCTION

A feasibility study of The Fluency Trust Residential Course (FTRC) for adolescents who stutter was conducted. The study aimed to measure key areas of a feasibility trial, for example, recruitment and retention, outcome measure completion, outcome measure reliability, and acceptability of the intervention to inform future research into the FTRC.

METHODS

Quantitative and qualitative methods were used. Participants were 23 adolescents (12-17 years), 23 parents and 2 Speech-Language Pathologists (SLPs) from the FTRC. Data collection included: outcome measure collection via a pre-test post-test quasi-experimental design (including two baseline measures), intervention fidelity checklists, semi-structured interviews with adolescents to explore acceptability of the intervention and semi-structured interviews with SLPs to explore their experiences of research participation and views on a future trial.

RESULTS

Recruitment, retention and outcome measure completion levels were all 100%. Intervention fidelity was 95% and there were no adverse events. Outcome measures showed good test- re-test reliability: Progress Questionnaire Child Intraclass Correlation Coefficient (ICC) = 0.87 (95% CI = 0.69-0.94 sig< 0.001) and Progress Questionnaire Parent ICC = 0.88 (95% CI = 0.70-0.95 sig< 0.001). Descriptive statistics showed that group medians and means of all outcome measures shifted in a positive direction between pre and post-tests (9 weeks follow-up). Twenty-five percent of young people showed changes on the Progress Questionnaire Child that were above the minimal important difference. Seventy-five percent of parents showed changes on the Progress Questionnaire Parent that were above the minimal important difference. Acceptability of the intervention by adolescents was high. SLPs reported participation was manageable and they were pleased to be part of the research.

CONCLUSION

Quantitative and qualitative data suggest that a future definitive trial of the FTRC is indicated after additional development work and feasibility testing. Recommendations for further research are included.

Intensive chemotherapy perturbs heart rate variability in children with cancer

OBJECTIVES

In children, cancer chemotherapy may impair the functioning of the cardiac autonomic nervous system. Moreover, it is not known whether there are any differences between intensive and maintenance phases of chemotherapy. Therefore, the aim of the current study was to assess autonomic nervous system activity using heart rate variability, in children receiving intensive or maintenance cancer chemotherapy.

METHODS

For that purpose, children who were healthy (healthy control, n = 30), receiving intensive chemotherapy (chemotherapy, n = 30), and receiving maintenance chemotherapy (maintenance, n = 25) were included in the study. Autonomic nervous system activity was measured by means of heart rate variability. Electrocardiogram recordings were used to calculate time- and frequency-domain heart rate variability parameters.

RESULTS

Time-domain parameters such as standard deviation of NN intervals and frequency-domain parameters such as total power were lower during the intensive chemotherapy but not during maintenance phase (standard deviation of NN intervals: 50±5, 33±3, and 48±3 ms, and total power: 2613±504, 1379±296 and 2295±264 ms², respectively for healthy control, chemotherapy and maintenance groups, P<0.001 for both standard deviation of NN intervals and total power).

DISCUSSION

The present results indicate that intensive chemotherapy perturbs the function of heart rate variability in children, with recovery during the maintenance phase. This suggests that intensive chemotherapy is likely to affect the autonomic nervous system but this effect does not appear to be permanent.

Effect of Intensive Blood Pressure Lowering on Incident Atrial Fibrillation: A Systematic Review and Meta-Analysis

The effect of intensive versus standard blood pressure (BP) lowering on the risk of atrial fibrillation (AF) is uncertain. Intensive BP lowering is associated with a lower risk of AF among patients with hypertension. We searched PubMed, EMBASE, and CENTRAL (inception to June 5, 2020) for randomized controlled trials evaluating the effect of intensive versus standard (target systolic BP < 140 mmHg) BP lowering on incident AF. We assessed heterogeneity using the I2 statistic then used fixed-effects meta-analysis models to report pooled treatment effects and 95% confidence intervals. We also tested for publication bias by three funnel plot-based methods. The quality of each study was assessed with the Cochrane Risk of Bias tool. We assessed 16 candidate studies for eligibility from 2,312 published articles, but only three randomized clinical trials were eligible for inclusion and included a combined 12,219 participants with hypertension: Cardio-Sis (Studio Italiano Sugli Effetti Cardiovascolari del Controllo della Pressione Arteriosa Sistolica), ACCORD-BP (Action to Control Cardiovascular Risk in Diabetes Blood Pressure trial), and SPRINT (Systolic Blood Pressure Intervention Trial). The target systolic BP in the intensive BP arm was <120 mmHg for participants in SPRINT and ACCORD-BP, but <130 mmHg for participants in Cardio-Sis. Participants randomized to intensive BP lowering had significantly lower risk of incident AF compared with those randomized to standard BP lowering (AF incidence 2.2% vs. 3.0%, respectively; pooled hazard ratio (95% confidence interval): 0.74 (0.59 - 0.93)). Intensive BP lowering is associated with a significantly lower risk of incident AF in patients with hypertension. These findings add to the current evidence supporting the benefits of intensive BP control.

Accelerated theta burst stimulation for the treatment of depression: A randomised controlled trial

INTRODUCTION

Theta burst pattern repetitive transcranial magnetic stimulation (TBS) is increasingly applied to treat depression. TBS's brevity is well-suited to application in accelerated schedules. Sizeable trials of accelerated TBS are lacking; and optimal TBS parameters such as stimulation intensity are not established.

METHODS

We conducted a three arm, single blind, randomised, controlled, multi-site trial comparing accelerated bilateral TBS applied at 80 % or 120 % of the resting motor threshold and left unilateral 10 Hz rTMS. 300 patients with treatment-resistant depression (TRD) were recruited. TBS arms applied 20 bilateral prefrontal TBS sessions over 10 days, while the rTMS arm applied 20 daily sessions of 10 Hz rTMS to the left prefrontal cortex over 4 weeks. Primary outcome was depression treatment response at week 4.

RESULTS

The overall treatment response rate was 43.7 % and the remission rate was 28.2 %. There were no significant differences for response (p = 0.180) or remission (p = 0.316) across the three groups. Response rates between accelerated bilateral TBS applied at sub- and supra-threshold intensities were not significantly different (p = 0.319). Linear mixed model analysis showed a significant effect of time (p < 0.01), but not rTMS type (p = 0.680).

CONCLUSION

This is the largest accelerated bilateral TBS study to date and provides evidence that it is effective and safe in treating TRD. The accelerated application of TBS was not associated with more rapid antidepressant effects. Bilateral sequential TBS did not have superior antidepressant effect to unilateral 10 Hz rTMS. There was no significant difference in antidepressant efficacy between sub- and supra-threshold accelerated bilateral TBS.

Clinical features and prognostic factors of intensive and non-intensive 1014 COVID-19 patients: an experience cohort from Alahsa, Saudi Arabia

BACKGROUND

COVID-19 is a worldwide pandemic and has placed significant demand for acute and critical care services on hospitals in many countries.

OBJECTIVES

To determine the predictors of severe COVID-19 disease requiring admission to an ICU by comparing patients who were ICU admitted to non-ICU groups.

METHODS

A cohort study was conducted for the laboratory-confirmed COVID-19 patients who were admitted to six Saudi Ministry of Health's hospitals in Alahsa, between March 1, 2020, and July 30, 2020, by reviewing patient's medical records retrospectively.

RESULTS

This cohort included 1014 patients with an overall mean age of 47.2 ± 19.3 years and 582 (57%) were males. A total of 205 (20%) of the hospitalized patients were admitted to the ICU. Hypertension, diabetes and obesity were the most common comorbidities in all study patients (27.2, 19.9, and 9%, respectively). The most prevalent symptoms were cough (47.7%), shortness of breath (35.7%) and fever (34.3%). Compared with non-ICU group, ICU patients had older age (p ≤ 0.0005) and comprised a higher proportion of the current smokers and had higher respiratory rates (p ≤ 0.0005), and more percentage of body temperatures in the range of 37.3-38.0 °C (p ≥ 0.0005); and had more comorbidities including diabetes (p ≤ 0.0005), hypertension (p ≥ 0.0005), obesity (p = 0.048), and sickle cell disease (p = 0.039). There were significant differences between the non-ICU and ICU groups for fever, shortness of breath, cough, fatigue, vomiting, dizziness; elevated white blood cells, neutrophils, alanine aminotransferase and alkaline aminotransferase, lactate dehydrogenase, and ferritin, and decreased hemoglobin; and proportion of abnormal bilateral chest CT images (p < 0.05). Significant differences were also found for multiple treatments (p < 0.05). ICU patients group had a much higher mortality rate than those with non-ICU admission (p ≤ 0.0005).

CONCLUSION

Identifying key clinical characteristics of COVID-19 that predict ICU admission and high mortality can be useful for frontline healthcare providers in making the right clinical decision under time-sensitive and resource-constricted environment.

Effect of in-bed cycling on acute muscle wasting in critically ill adults: A randomised clinical trial

PURPOSE

To examine whether in-bed cycling assists critically ill adults to reduce acute muscle wasting, improve function and improve quality of life following a period of critical illness.

MATERIALS AND METHODS

A single-centre, two-group, randomised controlled trial with blinded assessment of the primary outcome was conducted in a tertiary ICU. Critically ill patients expected to be mechanically ventilated for at least 48 h were randomised to 30 min daily in-bed cycling in addition to usual-care physiotherapy (n = 37) or usual-care physiotherapy (n = 37). The primary outcome was muscle atrophy of rectus femoris cross-sectional area (RF_CSA) measured by ultrasound at Day 10 following study enrolment. Secondary outcomes included manual muscle strength, handgrip strength, ICU mobility score, six-minute walk test distance and health-related quality of life up to six-months following hospital admission.

RESULTS

Analysis included the 72 participants (mean age, 56-years; male, 68%) who completed the study. There were no significant between-group differences in muscle atrophy of RF_CSA at Day 10 (mean difference 3.4, 95% CI -6.9% to 13.6%; p = .52), or for secondary outcomes (p-values ranged p = .11 to p = .95).

CONCLUSIONS AND RELEVANCE

In-bed cycling did not reduce muscle wasting in critically ill adults, but this study provides useful effect estimates for large-scale clinical trials.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12616000948493.

Time-intensive behavioural activation for depression: A multiple baseline study

BACKGROUND AND OBJECTIVES

Depression is the second leading cause of disability, worldwide, and increasing access to its effective/preferred treatment requires more attention. Behavioural activation and time-intensive treatment delivery both show promise in this regard, yet research into their combination is limited. This study aimed to investigate the feasibility, effectiveness, and acceptability of time-intensive behavioural activation (BA) for depression METHODS: Eight adults with major depressive disorder were recruited from three outpatient IAPT services in London. The study employed a single case experimental design with multiple baselines. All participants completed time-intensive BA, consisting of up to seven twice weekly sessions with daily prompting in-between and three optional booster sessions. Idiographic, standardised and process measures of depression symptomatology were collected.

RESULTS

Treatment recruitment and retention indicated that the intervention was feasible. Visual and statistical analyses showed that relative to baseline, 6 out of 8 participants made significant improvements in all idiographic symptoms of depression following the intervention. According to standardised measures of depression, four out of eight participants were considered treatment responders. Five participants completed follow-up measures and the majority of progress was maintained after the withdrawal of the intervention. The intervention was also considered highly acceptable by participants and therapists.

LIMITATIONS

Conclusions cannot be drawn about the generalizability or the long-term durability of the findings CONCLUSIONS: Overall this study provides new, but tentative evidence highlighting the potential of time-intensive BA as a feasible, effective and acceptable treatment for some adult outpatients with depression. The findings now warrant further, more rigorous evaluation of the treatment.

Liver transplantation for critically ill cirrhotic patients: Overview and pragmatic proposals

Liver transplantation for critically ill cirrhotic patients with acute deterioration of liver function associated with extrahepatic organ failures is controversial. While transplantation has been shown to be beneficial on an individual basis, the potentially poorer post-transplant outcome of these patients taken as a group can be held as an argument against allocating livers to them. Although this issue concerns only a minority of liver transplants, it calls into question the very heart of the allocation paradigms in place. Indeed, most allocation algorithms have been centered on prioritizing the sickest patients by using the model for end-stage liver disease score. This has led to allocating increasing numbers of livers to increasingly critically ill patients without setting objective or consensual limits on how sick patients can be when they receive an organ. Today, finding robust criteria to deem certain cirrhotic patients too sick to be transplanted seems urgent in order to ensure the fairness of our organ allocation protocols. This review starts by fleshing out the argument that finding such criteria is essential. It examines five types of difficulties that have hindered the progress of recent literature on this issue and identifies various strategies that could be followed to move forward on this topic, taking into account the recent discussion on acute on chronic liver failure. We move on to review the literature along four axes that could guide clinicians in their decision-making process regarding transplantation of critically ill cirrhotic patients.

Is the overall survival for older adults with AML finally improving?

Older adults with acute myeloid leukemia (AML) traditionally have very poor survival outcomes. Those who receive only supportive care have worse overall survival than those who undergo treatment, regardless of treatment type, and improvements in overall survival in the last several decades are largely attributable to the increasing decision to treat rather than offer only supportive care. However, there are a few newer agents that appear promising; these include CPX-351 (a liposomal product with cytarabine and daunorubicin), glasdegib (a selective Hedgehog signaling pathway inhibitor), and venetoclax (potent small molecule inhibitor of BCL2). A systematic review and meta-analysis is being completed to help clinicians optimize standard therapies for older AML patients.

Combination Therapy With Intensive Granulocyte and Monocyte Adsorptive Apheresis Plus Ustekinumab in Patients With Refractory Crohn's Disease

Ustekinumab is applied to induce clinical remission in patients with Crohn's disease. Granulocyte and monocyte absorptive apheresis depletes activated myeloid lineage leukocytes and has been applied for active Crohn's disease. This study retrospectively examined the efficacy and safety of combining intensive granulocyte and monocyte absorptive apheresis and ustekinumab for remission induction therapy in refractory Crohn's disease. Between June and September 2017, three consecutive cases (two females) with refractory Crohn's disease were treated with intensive granulocyte and monocyte absorptive apheresis plus ustekinumab. Crohn's disease activity index, and simple endoscopic score for Crohn's disease at baseline and 10 weeks were applied as treatment efficacy outcomes. In all three cases, at week 10, clinical remission was achieved, while simple endoscopic score for Crohn's disease reflected no improvement. Thus, combination therapy with intensive granulocyte and monocyte absorptive apheresis plus ustekinumab appeared to represent a safe and effective intervention for inducing clinical remission.

A systematic review of the public health risks of bioaerosols from intensive farming

BACKGROUND

Population growth, increasing food demands, and economic efficiency have been major driving forces behind farming intensification over recent decades. However, biological emissions (bioaerosols) from intensified livestock farming may have the potential to impact human health. Bioaerosols from intensive livestock farming have been reported to cause symptoms and/or illnesses in occupational-settings and there is concern about the potential health effects on people who live near the intensive farms. As well as adverse health effects, some potential beneficial effects have been attributed to farm exposures in early life. The aim of the study was to undertake a systematic review to evaluate potential for adverse health outcomes in populations living near intensive livestock farms.

MATERIAL AND METHODS

Two electronic databases (PubMed and Scopus) and bibliographies were searched for studies reporting associations between health outcomes and bioaerosol emissions related to intensive farming published between January 1960 and April 2017, including both occupational and community studies. Two authors independently assessed studies for inclusion and extracted data. Risk of bias was assessed using a customized score.

RESULTS

38 health studies met the inclusion criteria (21 occupational and 1 community study measured bioaerosol concentrations, 16 community studies using a proxy measure for exposure). The majority of occupational studies found a negative impact on respiratory health outcomes and increases in inflammatory biomarkers among farm workers exposed to bioaerosols. Studies investigating the health of communities living near intensive farms had mixed findings. All four studies of asthma in children found increased reported asthma prevalence among children living or attending schools near an intensive farm. Papers principally investigated respiratory and immune system outcomes.

CONCLUSIONS

The review indicated a potential impact of intensive farming on childhood respiratory health, based on a small number of studies using self-reported outcomes, but supported by findings from occupational studies. Further research is needed to measure and monitor exposure in community settings and relate this to objectively measured health outcomes.

Intensive versus standard lowering of blood pressure in the acute phase of intracranial haemorrhage: a systematic review and meta-analysis

The optimal target of blood pressure (BP) in the acute phase of intracranial haemorrhage (ICH) is still controversial. Our aim was to evaluate safety and efficacy of intensive BP lowering compared to standard BP treatment in ICH. We conducted a systematic review and meta-analysis of all available randomized controlled trials recruiting patients with elevated BP in acute spontaneous ICH to intensive or standard BP-lowering treatment. Our primary outcomes were 3-month mortality, disability (modified Rankin Scale 3-5) and combined death or disability. Secondary outcomes were early neurological deterioration at 24 h, substantial haematoma enlargement within 24-72 h and 3-month non-fatal serious adverse events. We included six studies for a total of 4385 patients (mean age 62 years, 62.3% men). No differences were detected between the two treatment groups in 3-month mortality (RR = 0.99, 95% CI 0.83-1.17), disability (RR = 0.96, 95% CI 0.89-1.03) and combined death and disability (RR = 0.97, 95% CI 0.90-1.03). The rate of patients with early neurological deterioration, substantial haematoma enlargement and non-fatal serious adverse events was similar in the two treatment groups (RR = 1.03, 95% CI 0.88-1.19, RR = 0.85, 95% CI 0.70-1.03, RR = 1.07, 95% CI 0.90-1.28, respectively). An intensive BP control in the acute phase of ICH is not beneficial and should not be recommended. Therefore, the systolic BP target of less than 140 mmHg that is now suggested by guidelines needs to be reconsidered.

Brief intensive CBT for pediatric OCD with E-therapy maintenance

Cognitive behaviour therapy (CBT), incorporating exposure and response prevention (ERP), has received strong empirical support for the treatment of paediatric OCD, and moreover, is considered the first line treatment of choice (Geller & March, 2012). However, despite the availability of effective treatments for this chronic and debilitating disorder, only a small proportion of youth receive these evidence-based approaches. The present study aimed to examine the effectiveness of an intensive ERP-based treatment for youth OCD, using a multiple baseline controlled design. Children and youth (N=10; aged 11-16 years) with a primary diagnosis of OCD were randomly assigned to a 1- or 2-week baseline monitoring condition followed by the intervention. The efficacy of the intensive treatment, involving 1 session psychoeducation, 2-sessions ERP plus e-therapy maintenance was examined across parent- child- and clinician-rated measures at post-treatment and 6-month follow-up. Overall, there were significant reductions across time on almost all measures (except self-report anxiety), and moreover, the majority of the sample (80%) were considered reliably improved, and meeting clinically significant change. At post-treatment, 60% were in remission of symptoms, and at 6-month follow-up this increased to 70%. These findings provide strong support for intensive, time-limited approaches to ERP-based CBT for children and youth with OCD.

Effect of an intensive metabolic control lifestyle intervention in type-2 diabetes patients

OBJECTIVE

To evaluate the effectiveness of an intensive lifestyle intervention on metabolic control in patients with type 2 diabetes.

METHODS

199 patients recently diagnosed with type 2 diabetes, with lack of metabolic control and overweight/obesity, were randomly assigned to intensive lifestyle intervention or collaborative educational program alone, with 6 months of follow-up. Intervention included 150min of physical activity a week to reduce body weight by 7%. Both groups received 16 sessions on behavior modification over the course of the 6 months. Measurements were taken at baseline, 3 and 6 months. Results were analyzed and compared.

RESULTS

Significant weight loss was achieved by both groups, with greater loss in the intervention group. Those with lower baseline A1c appeared to benefit more from the educational program than intensive intervention over time.

CONCLUSIONS

Both interventions produced positive if modest changes in metabolic control. These results suggest that, for weight loss and control of A1c, an intensive intervention may be more effective.

PRACTICE IMPLICATIONS

The current study demonstrates the value of a systematic application of behavior modification and self-care techniques in the treatment of type 2 diabetes. It demonstrates the importance of intensive, all-inclusive treatment, and of attention to individual concerns.

Intensive diabetes management and goal setting are key aspects of improving metabolic control in children and young people with type 1 diabetes mellitus

Diabetes control in children remains poor in spite of advances in treatment for last 10 years. The aim of this review was to look at various aspects of intensive therapy in the management of type 1 diabetes such as insulin regimes, role of target setting, psycho-educational approaches and self-management. To achieve good metabolic control, clear goal setting with adequate support for self-management are essential. Psycho-educational and behavioural interventions aimed at specific areas of management have shown significant improvement in quality of life and diabetes control.

Intensive HF-rTMS treatment in refractory medication-resistant unipolar depressed patients

BACKGROUND

Major depression is a worldwide severe mental health problem. Unfortunately, not all depressed patients respond to pharmacotherapy or psychotherapy, even when adhering to treatment guidelines. Even though current guidelines do not in particular advocate repetitive Transcranial Magnetic Stimulation (rTMS) in refractory treatment resistant depression (TRD), using more intensive stimulation parameters might hold promise as a valuable alternative.

OBJECTIVE

Consequently, in this randomized sham-controlled crossover study, we wanted to evaluate clinical outcome of intensive HF-rTMS treatment in TRD when applied to the left dorsolateral prefrontal cortex (DLPFC).

METHODS

After a 2-week antidepressant washout, 20 unipolar TRD patients, at least stage III, received 20 sham-controlled high-frequency (HF)-rTMS sessions, in a crossover design. Five daily suprathreshold HF-rTMS sessions were spread over four successive days delivering in total 31,200 stimuli.

RESULTS

Overall, the procedure resulted in immediate statistical significant decreases in depressive symptoms regardless of order/type of stimulation (real/sham), suggesting possible placebo responses. On the other hand, albeit only 35% (7/20) of the patients showed a 50% reduction of their initial Hamilton Depression rating score at the end of the two-week procedure, all these patients showed a prompt clinical response after real HF-rTMS treatment, not after sham. Furthermore, a shorter duration of the current depressive episode was a predictor for beneficial clinical outcome. Unresponsiveness to former ECT could be indicative for negative clinical outcome in these kinds of patients.

LIMITATIONS

Single center setup with relatively small sample size and no follow-up.

CONCLUSIONS

Our findings indicate that intensive HF-rTMS treatment might have the potential to result in fast clinical response when confronted with a refractory TRD patient.