Fast 5-minute shoulder MRI protocol with accelerated TSE-sequences and deep learning image reconstruction for the assessment of shoulder pain at 1.5 and 3 Tesla

Purpose

The objective of this study was to implement a 5-minute MRI protocol for the shoulder in routine clinical practice consisting of accelerated 2D turbo spin echo (TSE) sequences with deep learning (DL) reconstruction at 1.5 and 3 Tesla, and to compare the image quality and diagnostic performance to that of a standard 2D TSE protocol.

Methods

Patients undergoing shoulder MRI between October 2020 and June 2021 were prospectively enrolled. Each patient underwent two MRI examinations: first a standard, fully sampled TSE (TSES) protocol reconstructed with a standard reconstruction followed by a second fast, prospectively undersampled TSE protocol with a conventional parallel imaging undersampling pattern reconstructed with a DL reconstruction (TSEDL). Image quality and visualization of anatomic structures as well as diagnostic performance with respect to shoulder lesions were assessed using a 5-point Likert-scale (5 = best). Interchangeability analysis, Wilcoxon signed-rank test and kappa statistics were performed to compare the two protocols.

Results

A total of 30 participants was included (mean age 50±15 years; 15 men). Overall image quality was evaluated to be superior in TSEDL versus TSES (p<0.001). Noise and edge sharpness were evaluated to be significantly superior in TSEDL versus TSES (noise: p<0.001, edge sharpness: p<0.05). No difference was found concerning qualitative diagnostic confidence, assessability of anatomical structures (p>0.05), and quantitative diagnostic performance for shoulder lesions when comparing the two sequences.

Conclusions

A fast 5-minute TSEDL MRI protocol of the shoulder is feasible in routine clinical practice at 1.5 and 3 T, with interchangeable results concerning the diagnostic performance, allowing a reduction in scan time of more than 50% compared to the standard TSES protocol.

Scoring the EQ-HWB-S: can we do it without value sets? A non-parametric item response theory analysis

BACKGROUND

Only one pilot value set (UK) is currently available for the EQ Health and Wellbeing Instrument short version (EQ-HWB-S). As an alternative to preference-weighted scoring, we examined whether a level summary score (LSS) is appropriate for the EQ-HWB-S using Mokken scaling analyses.

METHODS

Data from patients, carers and the general population collected during the developmental phase of the EQ-HWB-S in Australia, US and UK were used, noting 3 of 9 items have since undergone revision. EQ-HWB-S data fit was examined using R package Mokken scaling's monotone homogeneity model, utilizing the automated item selection procedure (AISP) as well as Loevinger's scaling coefficients for items and the scale (HS). Manifest monotonicity was assessed by examining whether the cumulative probability for responses at or above each response level did not decrease across the summary score.

RESULTS

EQ-HWB-S data were available for 3340 respondents: US = 903, Australia = 514 and UK = 1923. Mean age was 50 ± 18 and 1841 (55%) were female. AISP placed all 9 items of the EQ-HWB-S on a single scale when the lower bound was set to < 0.448. Strong scalability (HS = 0.561) was found for the EQ-HWB-S as a single scale. Stronger scales were formed by separating the psychosocial items (n = 6, HS = 0.683) and physical sensation items (n = 3, HS = 0.713). No violations of monotonicity were found except for the items mobility and daily activities for the subgroups with long-term conditions and UK subjects, respectively.

DISCUSSION

As EQ-HWB-S items formed a strong scale and subscales based on Mokken analysis, LSS is a promising weighting-free approach to scoring.

Danger Zones of the Gluteal Anatomy: Improving the Safety Profile of the Gluteal Fat Grafting

INTRODUCTION

Knowledge of the vascular anatomy is critical to performing safe gluteal surgery. To date, only the course of the main blood vessels within the muscles has been outlined. These findings are based on MRI and CTA images that do not conform to a topographically standardized and normalized probability distribution.

OBJECTIVES

The aim of this study was to develop a three-dimensional mapping of the gluteal zones of high vascular density in relation to anatomical landmarks.

MATERIALS AND METHODS

This single-center retrospective cohort analysis comprised all consecutive patients who underwent cone-beam computed tomography (CBCT) scans between January 2016 and October 2021. The location of blood vessels in the gluteal region was allometrically normalized in relation to anatomical landmarks. Moreover, the caliber and area of the blood vessels were assessed.

RESULTS

CBCT scans of 32 patients with an average age of 64 ± 12 years (range 34-87 years) were included. Fifty-three percent were female. The median [IQR] caliber of the intramuscular gluteal vessels was 1.47 [1.15-1.88] mm, significantly greater than that of the subcutaneous vessels 1.09 [0.72-1.44] mm (p < 0.001). Vascular density was higher intramuscularly, as 4.5% of the area of the muscle was occupied by blood vessels, as opposed to 0.3% in the adipose tissue.

CONCLUSION

The analysis of the CBCT scans showed a higher vascular density and larger vessels intramuscularly. We, therefore, recommend the injection of autologous fat merely to the subcutaneous plane.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Prospective study of complications and sequelae of glucocorticoid therapy in ANCA-associated vasculitis

OBJECTIVE

Glucocorticoids (GC) are a cornerstone in treating antineutrophil cytoplasmic antibodies-associated vasculitides (AAV), however, they add to morbidity and mortality. To date, GC toxicity in AAV has rarely been systematically investigated.

METHODS

Patients with a confirmed AAV were included in this monocentric prospective study. GC toxicity was assessed by structured interviews, clinical examination and electronic medical record analysis. The Glucocorticoid Toxicity Index (GTI) consisting of the Aggregate Improvement Score (GTI-AIS) and the Cumulative Worsening Score (GTI-CWS) was assessed at two time points (t1 baseline, t2 6 months later). We used regression analyses to assess the relationship between GTI and GC exposure, toxicity, and disease activity, and a receiver operating characteristic analysis to calculate a GC threshold dose beyond which toxicity is expected to occur.

RESULTS

We included 138 patients with AAV. The median cumulative GC dose was 9014.0 mg. The most frequent adverse events were skin atrophy, osteoporosis and myopathy. GC exposure and toxicity were significantly correlated (p<0.001). GTI-AIS was significantly higher in active disease compared with patients in remission (p<0.001). GTI-CWS scored significantly higher in long-standing diseases (p=0.013) with high cumulative GC doses (p=0.003). Patients with a cumulative GC dose of 935 mg or more showed an 80% likelihood for a clinically meaningful change in GTI scoring.

CONCLUSION

The GTI is capable of capturing GC toxicity in AAV and identifies patients at increased risk for GC side effects. Our data support efforts to limit GC exposure in patients with AAV.

Occupational health literacy and work ability: a moderation analysis including interpersonal and organizational factors in healthy organizations

Introduction

Healthy organizations approach to occupational safety and health should holistically include individual, interpersonal, and organizational levels. There is an empirical research gap in considering different levels in organizations for health promotion in the context of maximizing work ability. This study aims to investigate the association of (1) occupational health literacy (on an individual level), (2) health-oriented leadership (interpersonal level), (3) participation possibilities in health, and (4) values of health in companies (both organizational levels) on work ability. Additionally, we examined the potentially moderating role of health-oriented leadership, participation possibilities in health, and values of health between occupational health literacy and work ability.

Methods

Cross-sectional data were obtained from 828 employers and employees in small and medium-sized enterprises. Self-report measures included occupational health literacy, health-oriented leadership, work ability, participation possibilities in health at work, and values of health in the company. Occupational health literacy comprises two factors: a knowledge-/skill-based approach to occupational health and a willingness/responsibility for occupational health. Participation possibilities in health are measured regarding participatory opportunities and co-creation of health at work. Values of health in the company capture the importance of health in the workplace and the scope for improving employees' health. Data were analyzed using latent regression and latent moderation analyses controlling for age, gender, and educational level.

Results

Occupational health literacy (knowledge-/skill-based), health-oriented leadership, participation possibilities in health, and values of health in companies showed positive associations with work ability. Health-oriented leadership on an interpersonal level was found to moderate the positive relationship between (knowledge-/skill-based) occupational health literacy and work ability. Participation possibilities in health on an organizational level acted as a moderator on the relationship between both occupational health literacy factors and work ability.

Discussion

Individual, interpersonal, and organizational factors play important roles in maintaining work ability in healthy organizations. This study highlights the importance of promoting occupational health literacy among employees and leaders, creating a healthy workplace through health-oriented leadership, and providing participatory opportunities for co-creation in health promotion at work. Future research should further explore these factors' roles in different industries and contexts and how they may be addressed effectively in tailored workplace interventions.

Enhanced Recovery After Surgery (ERAS) Pathways for Aesthetic Breast Surgery: A Prospective Cohort Study on Patient-Reported Outcomes

BACKGROUND

Patients' expectations of an anticipated timeline of recovery and fear of anesthesia in aesthetic breast surgery have not been studied.

OBJECTIVE

This study aims to assess patient anxiety, expectations, and satisfaction after Enhanced Recovery after Surgery (ERAS) pathways for aesthetic breast surgery and the progress of postoperative recovery.

MATERIALS AND METHODS

All consecutive patients who underwent aesthetic breast surgery between April 2021 and August 2022 were included in this single-center prospective cohort study. The ERAS protocol consists of more than 20 individual measures in the pre-, intra-, and postoperative period. Epidemiological data, expectations, and recovery were systematically assessed with standardized self-assessment questionnaires, including the International Pain Outcome Questionnaire (IPO), the BREAST-Q or BODY-Q, and data collection forms.

RESULTS

In total, 48 patients with a median of 30 years of age were included. Patients returned to most daily activities within 5 days. Eighty-eight percent of patients were able to accomplish daily activities sooner than expected. The time of return to normal daily activities was similar across all procedure types. There was no statistically significant difference regarding postoperative satisfaction between patients who recovered slower (12%) and patients who recovered as fast or faster (88%) than anticipated (p=0.180). Patients reporting fear of anesthesia in the form of conscious sedation significantly diminished from 17 to 4% postoperatively (p<0.001).

CONCLUSION

Enhanced Recovery after Surgery (ERAS) pathways for aesthetic breast surgery are associated with rapid recovery and high patient satisfaction. This survey study provides valuable insight into patients' concerns and perspectives that may be implemented in patient education and consultations to improve patient satisfaction following aesthetic treatments.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Definitions of Abnormal Breast Size and Asymmetry: A Cohort Study of 400 Women

BACKGROUND

Macromastia, micromastia and breast asymmetry have an impact on health and quality of life. However, there is scarce information addressing breast size and asymmetry frequency distribution in reference populations.

OBJECTIVE

The current study aims to identify factors that influence breast size and symmetry and classifies abnormal breast sizes and breast asymmetries in an adult German population.

METHODS

Breast base dimensions, breast volume, symmetry, and other breast anthropometric parameters of 400 German female patients were determined in a retrospective review of the MRI archives at our institution. Professional medical MRI-segmentation software was used for volume measurement.

RESULTS

A total of 400 Patients were retrospectively enrolled. The patients had a mean age of 50 ± 12 years (min: 24; max: 82), mean BMI of 25.0 ± 5.0 (min: 14.7, max: 45.6), and a mean total breast volume of 976 ml (right: 973 ml, min: 64, max: 4777; left: 979 ml, min: 55, max: 4670). The strongest correlation of breast volume was observed with BMI (r = 0.834, p < 0.001), followed by breast base width (r = 0.799, p < 0.001). Smaller breasts have higher breast volume asymmetry ratios (r = - 0.124, p < 0.014). For a BMI between 18.5 and 24.9 kg/m2, micromastia is defined by breast volumes below 250 ml (5th percentile) and macromastia by volumes above 1250 ml (95th percentile). Abnormal breast volume asymmetry (< 5th and > 95th percentile) is equivalent to an absolute difference of approximately 25% relative to the smallest side (bidirectional asymmetry ratio 5th percentile - 19%; 95th percentile 26%).

CONCLUSION

This study provides normative data of German women, as well as selected size-for-BMI percentiles and asymmetry ratio percentiles. The normative data may help to establish transparent and objective coverage criteria for health insurances.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The effect of buzzy®, DistrACTION® cards on reducing pediatric pain and fear during blood collection in the rheumatology polyclinic: A randomized controlled trial

PURPOSE

The aim of this study was to compare the effectiveness of Buzzy® and DistrACTION® Cards in reducing children's pain and fear while taking venous blood samples.

METHODS

This research was designed as a randomized controlled experimental study. The study population consisted of children aged 6-12 years admitted to the Pediatric Rheumatology Diseases Polyclinic in a Faculty of Medicine in Germany. The sample of the study consisted of 96 children (Buzzy® = 32, DistrACTION® Cards = 32, control = 32) who met the patient selection criteria and agreed to participate in the study. The data were obtained using a Child and Family Information Form, the Children Fear Scale (CFS), and the Faces Pain Scale-Revised (FPS-R). The data were evaluated using the Pearson chi-square test, Kruskal-Wallis test, One-way ANOVA test with Bonferroni correction, and Fisher-Freeman-Halton.

FINDINGS

In the study, the average age of the children was 9.21 ± 2.15 years. The Buzzy® group had the lowest pain and procedural fear scores (self-report = 0.88 ± 1.13, 0.31 ± 0.47; parent report = 0.75 ± 0.98, 0.34 ± 0.48, and researcher report = 0.81 ± 1.00, 0.31 ± 0.54, respectively) than the DC, and control groups.

CONCLUSIONS

The Buzzy® method was effective in reducing venipuncture pain and fear in children.

PRACTICE IMPLICATIONS

Nurses can use the Buzzy® methods to help reduce venipuncture pain and fear in children. The clinical trial registration number is NCT05560074. (https://clinicaltrials.gov/ct2/show/study/NCT05560074).

Quantification of Facial Fat Compartment Variations: A Three-Dimensional Morphometric Analysis of the Cheek

BACKGROUND

Cheek contour is a main determinant of facial attractiveness. The aim of this study was to evaluate the relationship between age, sex, and body mass index (BMI) and cheek fat volume in a large cohort to better understand and treat facial aging.

METHODS

The authors performed a retrospective review of the archives of the Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen. Epidemiologic data and medical history were assessed. Cheek superficial and deep fat compartment volumes were measured on magnetic resonance images. Statistical analyses were performed using SPSS and SAS statistical software.

RESULTS

A total of 87 patients with a mean age of 46 years (range, 18 to 81 years) were included. The superficial and deep fat compartment volumes of the cheek increased with BMI ( P < 0.001 and P = 0.005), but there was no significant relationship between age and volume. The ratio of superficial versus deep fat did not change with age. No significant difference of the superficial or deep fat compartments was found between men and women in a regression analysis ( P = 0.931 and P = 0.057).

CONCLUSIONS

Cheek fat volume measurements on magnetic resonance imaging scans using reconstruction software suggest that the fat volume of the cheek increases with BMI but does not change significantly with age. Further studies are needed to elucidate the role of age-related changes of bone structures or sagging of the fat compartments.

Quantification of Breast Volume According to age and BMI: A Three-Dimensional MRI Analysis of 400 Women

OBJECTIVE

Breast size alteration is the most common aesthetic surgical procedure worldwide. This study aimed to assess the correlation between breast volume and BMI or age.

MATERIALS AND METHODS

The analyses were conducted utilizing 400 patients selected by a retrospective review of the archives at our institution. Epidemiological data and medical history were assessed. Adjusting for the age and BMI of patient from previously described cohorts, we calculated mean breast volumes per side and differences from the upper and lower percentiles to the mean volumes.

RESULTS

The patients had a median BMI of 23.5 (range: 14.7-45.6) and a median age of 51 (range: 24-82). The average total breast volume increased strongly with BMI (r=0.834, p<0.01) and moderately with age (r=0.305, p<0.01). Within a BMI range of 18-24, breast volumes in the 8th and 18th percentile differ on average by about 50 ml. One BMI unit increase in women with breast sizes in the 10th percentile accounts for a breast volume difference of about 30 ml.

CONCLUSION

BMI strongly correlates with breast size. To achieve natural results, preoperative consultation and planning of aesthetic and reconstructive breast surgery must recognize BMI as a major determinant of average breast size.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Predicting complicated appendicitis is possible without the use of sectional imaging-presenting the NoCtApp score

PURPOSE

Appendicitis is among the most common acute conditions treated by general surgery. While uncomplicated appendicitis (UA) can be treated delayed or even non-operatively, complicated appendicitis (CA) is a serious condition with possible long-term morbidity that should be managed with urgent appendectomy. Distinguishing both conditions is usually done with computed tomography. The goal of this study was to develop a model to reliably predict CA with widespread available clinical and laboratory parameters and without the use of sectional imaging.

METHODS

Data from 1132 consecutive patients treated for appendicitis between 2014 and 2021 at a tertiary care hospital were used for analyses. Based on year of treatment, the data was divided into training (n = 696) and validation (n = 436) samples. Using the development sample, candidate predictors for CA-patient age, gender, body mass index (BMI), American Society of Anesthesiologist (ASA) score, duration of symptoms, white blood count (WBC), total bilirubin and C-reactive protein (CRP) on admission and free fluid on ultrasound-were first investigated using univariate logistic regression models and then included in a multivariate model. The final development model was tested on the validation sample.

RESULTS

In the univariate analysis age, BMI, ASA score, symptom duration, WBC, bilirubin, CRP, and free fluid each were statistically significant predictors of CA (each p < 0.001) while gender was not (p = 0.199). In the multivariate analysis BMI and bilirubin were not predictive and therefore not included in the final development model which was built from 696 patients. The final development model was significant (x2 = 304.075, p < 0.001) with a sensitivity of 61.7% and a specificity of 92.1%. The positive predictive value (PPV) was 80.4% with a negative predictive value (NPV) of 82.0%. The receiver operator characteristic of the final model had an area under the curve of 0.861 (95% confidence interval 0.830-0.891, p < 0.001. We simplified this model to create the NoCtApp score. Patients with a point value of ≤ 2 had a NPV 95.8% for correctly ruling out CA.

CONCLUSIONS

Correctly identifying CA is helpful for optimizing patient treatment when they are diagnosed with appendicitis. Our logistic regression model can aid in correctly distinguishing UA and CA even without utilizing computed tomography.

Treatment of Acute Mesenteric Ischemia: Individual Challenges for Interventional Radiologists and Abdominal Surgeons

Background: Acute mesenteric ischemia (AMI) is a life-threatening condition resulting from occlusion of the mesenteric arterial vessels. AMI requires immediate treatment with revascularization of the occluded vessels. Purpose: to evaluate the technical success, clinical outcomes and survival of patients receiving endovascular treatment for AMI followed by surgery. Material and Methods: A search of our institution’s database for AMI revealed 149 potential patients between 08/2016 and 08/2021, of which 91 were excluded due to incomplete clinical data, insufficient imaging or missing follow-up laparoscopy. The final cohort included 58 consecutive patients [(median age 73.5 years [range: 43−96 years], 55% female), median BMI 26.2 kg/m2 (range:16.0−39.2 kg/m2)]. Periinterventional imaging regarding the cause of AMI (acute-embolic or acute-on-chronic) was evaluated by two radiologists in consensus. The extent of AMI and the degree of technical success was graded according to a modified TICI (Thrombolysis in Cerebral Infarction scale) score (TICI-AMI) classification (0: no perfusion; 1: minimal; 2a < 50% filling; 2b > 50%; 2c: near complete or slow; 3: complete). Lab data and clinical data were collected, including the results of follow-up laparoscopy. Non-parametric statistics were used. Results: All interventions were considered technically successful. The most common causes of AMI were emboli (51.7%) and acute-on-chronic thrombotic occlusions (37.9%). Initial imaging showed a TICI-AMI score of 0, 1 or 2a in 87.9% (n = 51) of patients. Post-therapeutic TICI-AMI scores improved significantly with 87.9% of patients grade 2b and better. Median lactate levels reduced from 2.7 (IQR 2.0−3.7) mg/dL (1−18) to 1.45 (IQR 0.99−1.90). Intestinal ischemia was documented in 79.1% of cases with resection of the infarcted intestinal loops. In total, 22/58 (37.9%) patients died during the first 30 days after intervention and surgery. According to CIRSE criteria, we did not observe any SAE scores of grade 2 or higher. Conclusions: AMI is a serious disease with high lethality within the first 30 days despite optimal treatment. However, interventional revascularization before surgery with resection of the infarcted bowel can save two out of three of critically ill patients.

Enhanced Recovery After Aesthetic Breast Surgery Under Sedation, Intercostal Block and Tumescent Anaesthesia: A Prospective Cohort Study of the Early Postoperative Phase

BACKGROUND

Comfort and recovery are major concerns of patients seeking aesthetic surgery. This study aimed to assess postoperative pain and recovery after outpatient breast surgery under sedation, intercostal block, and local anaesthesia.

METHODS

This prospective cohort study included all consecutive patients who underwent aesthetic breast surgery between April 2021 and August 2022. Epidemiological data, anaesthesia, pain, and patients' satisfaction were systematically assessed with standardized self-assessment questionnaires.

RESULTS

Altogether, 48 patients [median (IQR) age: 30 (36-25)] were included. The most frequent surgery was mastopexy. 69% of surgeries involved additional procedures. The mean intercostal block and local anaesthesia time was 15 min. Patients received a median (IQR) of 19 (34-2) mg/kg lidocaine and 2.3 (2.5-2.0) mg/kg ropivacaine. The median (IQR) consumption of propofol and alfentanil was, respectively, 4.89 (5.48-4.26) mg/kg/h and 0.27 (0.39-0.19) µg/kg/min. No conversion to general anaesthesia or unplanned hospital admission occurred. Patients were discharged after a median (IQR) of 2:40 (3:43-1:58) hours. Within the first 24 postoperative hours, 17% required once an antiemetic medication and 38% an opioid. Patients were very satisfied with the anaesthesia and 90% of the patients had not wished more analgesia in the first 24 h.

CONCLUSIONS

Aesthetic breast surgery under sedation, intercostal block, and tumescent anaesthesia can safely be performed as an ambulatory procedure and is associated with minimal intra- and postoperative opioid consumption and high patient satisfaction. These data may be used to inform patients and clinicians and improve the overall quality of care.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Corrigendum: Methylene blue dosing strategies in critically ill adults with shock-A retrospective cohort study

[This corrects the article DOI: 10.3389/fmed.2022.1014276.].

Methylene blue dosing strategies in critically ill adults with shock-A retrospective cohort study

Background

Shock increases mortality in the critically ill and the mainstay of therapy is the administration of vasopressor agents to achieve hemodynamic targets. In the past, studies have found that the NO-pathway antagonist methylene blue improves hemodynamics. However, the optimal dosing strategy remains elusive. Therefore, we investigated the hemodynamic and ICU outcome parameters of three different dosing strategies for methylene blue.

Methods

We performed a retrospective cohort study of patients in shock treated with methylene blue. Shock was defined as norepinephrine dose >0.1 μg/kg/min and serum lactate level >2 mmol/l at the start of methylene blue administration. Different demographic variables, ICU treatment, and outcome parameters were evaluated. To compare the differences in the administration of vasopressors or inotropes, the vasoactive inotropic score (VIS) was calculated at different time points after starting the administration of methylene blue. Response to methylene blue or mortality at 28 days were assessed.

Results

262 patients from July 2014 to October 2019 received methylene blue. 209 patients met the inclusion criteria. Three different dosing strategies were identified: bolus injection followed by continuous infusion (n = 111), bolus injection only (no continuous infusion; n = 59) or continuous infusion only (no bolus prior; n = 39). The groups did not differ in demographics, ICU scoring system, or comorbidities. In all groups, VIS decreased over time, indicating improved hemodynamics. Cardiogenic shock and higher doses of norepinephrine increased the chance of responding to methylene blue, while bolus only decreased the chance of responding to methylene blue treatment. 28-day mortality increased with higher SAPSII scores and higher serum lactate levels, while bolus injection followed by continuous infusion decreased 28-day mortality. No severe side effects were noted.

Conclusion

In this cohort, methylene blue as a bolus injection followed by continuous infusion was associated with a reduced 28-day mortality in patients with shock. Prospective studies are needed to systematically evaluate the role of methylene blue in the treatment of shock.

What difference does multiple imputation make in longitudinal modeling of EQ-5D-5L data? Empirical analyses of simulated and observed missing data patterns

Purpose

Although multiple imputation is the state-of-the-art method for managing missing data, mixed models without multiple imputation may be equally valid for longitudinal data. Additionally, it is not clear whether missing values in multi-item instruments should be imputed at item or score-level. We therefore explored the differences in analyzing the scores of a health-related quality of life questionnaire (EQ-5D-5L) using four approaches in two empirical datasets.

Methods

We used simulated (GR dataset) and observed missingness patterns (ABCD dataset) in EQ-5D-5L scores to investigate the following approaches: approach-1) mixed models using respondents with complete cases, approach-2) mixed models using all available data, approach-3) mixed models after multiple imputation of the EQ-5D-5L scores, and approach-4) mixed models after multiple imputation of EQ-5D 5L items.

Results

Approach-1 yielded the highest estimates of all approaches (ABCD, GR), increasingly overestimating the EQ-5D-5L score with higher percentages of missing data (GR). Approach-4 produced the lowest scores at follow-up evaluations (ABCD, GR). Standard errors (0.006–0.008) and mean squared errors (0.032–0.035) increased with increasing percentages of simulated missing GR data. Approaches 2 and 3 showed similar results (both datasets).

Conclusion

Complete cases analyses overestimated the scores and mixed models after multiple imputation by items yielded the lowest scores. As there was no loss of accuracy, mixed models without multiple imputation, when baseline covariates are complete, might be the most parsimonious choice to deal with missing data. However, multiple imputation may be needed when baseline covariates are missing and/or more than two timepoints are considered.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-021-03037-3.

Association of Three-Dimensional Mesh-Derived Right Ventricular Strain with Short-Term Outcomes in Patients Undergoing Cardiac Surgery

BACKGROUND

Three-dimensional (3D) right ventricular (RV) strain analysis is not routinely performed perioperatively. Although 3D RV strain adds incrementally to outcome prediction in various cardiac diseases, its role in the perioperative setting is not sufficiently understood. The aim of this study was to investigate the association between 3D RV strain measured on RV meshes created from 3D transesophageal echocardiographic data and short-term outcomes among patients undergoing cardiac surgery.

METHODS

A total of 496 patients undergoing cardiac surgery who underwent intraoperative 3D transesophageal echocardiography (under general anesthesia, before sternotomy) were retrospectively selected, and RV meshes were generated using commercially available speckle-tracking software. Custom-made software automatically quantified longitudinal and circumferential RV strains on the mesh surfaces. Echocardiographic and clinical parameters were entered into logistic regression models to determine their associations with the primary (in-hospital death or need for extracorporeal life support) and secondary (postoperative ventilation > 48 hours) end points.

RESULTS

Mesh-derived RV strain analysis was feasible in 94% of patients and revealed distinct regional patterns with basal-apical gradients for both longitudinal and circumferential strain. Thirty-seven patients (7.6%) reached the primary end point, and 118 patients (23.8%) reached the secondary end point. In a multivariable logistic regression model, serum lactate (P < .01), an emergency indication for surgery (P < .01), tricuspid regurgitation (P < .001), and mesh-derived RV global longitudinal strain (RV-GLS; P < .01) were independently associated with the primary end point, while established measures of RV function (3D RV ejection fraction, fractional area change, tricuspid annular plane systolic excursion) and left ventricular (LV) function (3D-derived LV ejection fraction and LV-GLS) were not independently associated. Hematocrit (P < .01), serum lactate (P < .001), pulmonary hypertension (P = .04), tricuspid regurgitation (P < .01), emergency procedures (P = .02), LV-GLS (P = .02), and RV-GLS (P < .001) were associated with the secondary end point.

CONCLUSIONS

RV-GLS measured on RV meshes derived from 3D transesophageal echocardiography was independently associated with short-term outcomes in patients undergoing cardiac surgery and might be helpful for identifying patients at risk for adverse postoperative events.

Predictors of COVID-19 in an outpatient fever clinic

BACKGROUND

The objective of this study was to identify clinical risk factors for COVID-19 in a German outpatient fever clinic that allow distinction of SARS-CoV-2 infected patients from other patients with flu-like symptoms.

METHODS

This is a retrospective, single-centre cohort study. Patients were included visiting the fever clinic from 4th of April 2020 to 15th of May 2020. Symptoms, comorbidities, and socio-demographic factors were recorded in a standardized fashion. Multivariate logistic regression was used to identify risk factors of COVID-19, on the bases of those a model discrimination was assessed using area under the receiver operation curves (AUROC).

RESULTS

The final analysis included 930 patients, of which 74 (8%) had COVID-19. Anosmia (OR 10.71; CI 6.07-18.9) and ageusia (OR 9.3; CI 5.36-16.12) were strongly associated with COVID-19. High-risk exposure (OR 12.20; CI 6.80-21.90), especially in the same household (OR 4.14; CI 1.28-13.33), was also correlated; the more household members, especially with flu-like symptoms, the higher the risk of COVID-19. Working in an essential workplace was also associated with COVID-19 (OR 2.35; CI 1.40-3.96), whereas smoking was inversely correlated (OR 0.19; CI 0.08-0.44). A model that considered risk factors like anosmia, ageusia, concomitant of symptomatic household members and smoking well discriminated COVID-19 patients from other patients with flu-like symptoms (AUROC 0.84).

CONCLUSIONS

We report a set of four readily available clinical parameters that allow the identification of high-risk individuals of COVID-19. Our study will not replace molecular testing but will help guide containment efforts while waiting for test results.

Combining EQ-5D-5L items into a level summary score: demonstrating feasibility using non-parametric item response theory using an international dataset

Background

The EQ-5D-5L is a well-established health questionnaire that estimates health utilities by applying preference-based weights. Limited work has been done to examine alternative scoring approaches when utility weights are unavailable or inapplicable. We examined whether the Mokken scaling approach can elucidate 1) if the level summary score is appropriate for the EQ-5D-5L and 2) an interpretation of such a score.

Methods

The R package “mokken” was used to assess monotonicity (scaling coefficients H, automated item selection procedure) and manifest invariant item ordering (MIIO: paired item response functions [IRF], H^T). We used a rich dataset (the Multiple Instrument Comparison, MIC) which includes EQ-5D-5L data from six Western countries.

Results

While all EQ-5D-5L items demonstrated monotonicity, the anxiety/depression (AD) item had weak scalability (H_i = 0.377). Without AD, scalability improved from H_s = 0.559 to H_s = 0.714. MIIO revealed that the 5 items can be ordered, and the ordering is moderately accurate in the MIC data (H^T = 0.463). Excluding AD, H^T improves to 0.743. Results were largely consistent across disease and country subgroups.

Discussion

The 5 items of the EQ-5D-5L form a moderate to strong Mokken scale, enabling persons to be ordered using the level summary score. Item ordering suggests that the lower range of the score represents mainly problems with pain and anxiety/depression, the mid-range indicates additional problems with mobility and usual activities, and middle to higher range of scores reveals additional limitations with self-care. Scalability and item ordering are even stronger when the anxiety/depression item is not included in the scale.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-021-02922-1.

Translation and adaptation of the German version of the Veterans Rand-36/12 Item Health Survey

BACKGROUND

The translated and culturally adapted German version of the Veterans Rand 36 Items Health Survey (VR-36), and its short form, the VR-12 counterpart, were validated in a German sample of orthopedic (n = 399) and psychosomatic (n = 292) inpatient rehabilitation patients.

METHODS

The instruments were analyzed regarding their acceptance, distributional properties, validity, responsiveness and ability to discriminate between groups by age, sex and clinically specific groups. Eligible study participants completed the VR-36 (n = 169) and the VR-12 (n = 177). They also completed validated patient-reported outcome measures (PROs) including the Euroqol-5 Dimensions 5 Level (EQ-5D-5L); Depression, Anxiety and Stress Scale (DASS); Hannover Functional Abilities Questionnaire (HFAQ); and CDC Healthy Days. The VR-12 and the VR-36 were compared to the reference instruments MOS Short Form-12 Items Health Survey (SF-12) version 1.0 and MOS Short Form-36 Items Health Survey (SF-36) version 1.0, using percent of completed items, distributional properties, correlation patterns, distribution measures of known groups validity, and effect size measures.

RESULTS

Item non-response varied between 1.8%/1.1% (SFVR-36/RESF-36) and 6.5%/8.6% (GHVR-36/GHSF-36). PCS was normally distributed (Kolmogorov-Smirnov tests: p > 0.05) with means, standard deviations and ranges very similar between SF-36 (37.5 ± 11.7 [13.8-66.1]) and VR-36 (38.5 ± 10.1 [11.7-67.8]), SF-12 (36.9 ± 10.9 [15.5-61.6]) and VR-12 (36.2 ± 11.5 [12.7-59.3]). MCS was not normally distributed with slightly differing means and ranges between the instruments (MCSVR-36: 36.2 ± 14.2 [12.9-66.6], MCSSF-36: 39.0 ± 15.6 [2.0-73.2], MCSVR-12: 37.2 ± 13.8 [8.4-70.2], MCSSF-12: 39.0 ± 12.3 [17.6-65.4]). Construct validity was established by comparing correlation patterns of the MCSVR and PCSVR with measures of physical and mental health. For both PCSVR and MCSVR there were moderate (≥ 0.3) to high (≥ 0.5) correlations with convergent (PCSVR: 0.55-0.76, MCSVR: 0.60-0.78) and small correlations (< 0.1) with divergent (PCSVR: < 0.12, MCSVR: < 0.16) self-report measures. Known-groups validity was demonstrated for both VR-12 and VR-36 (MCS and PCS) via comparisons of distribution parameters with significant higher mean PCS and MCS scores in both VR instruments found in younger patients with fewer sick days in the last year and a shorter duration of rehabilitation.

CONCLUSIONS

The psychometric analysis confirmed that the German VR is a valid and reliable instrument for use in orthopedic and psychosomatic rehabilitation. Yet further research is needed to evaluate its usefulness in other populations.

Testing for SARS-CoV-2 seroprevalence: experiences of a tertiary eye centre

INTRODUCTION

The actual prevalence of a SARS-CoV-2 infection and the individual assessment of being or having been infected may differ. Facing the great uncertainty-especially at the beginning of the pandemic-and the possibility of asymptomatic or mildly symptomatic, subclinical infections, we evaluate the experience of SARS-CoV-2 antibody screening at a tertiary clinical setting.

METHODS AND ANALYSIS

All employees of a tertiary eye centre and a research institute of ophthalmology were offered antibody testing in May 2020, using a sequential combination of different validated assays/antigens and point-of-care (POC) testing for a subset (NCT04446338). Before taking blood, a systematic inquiry into past symptoms, known contacts and a subjective self-assessment was documented. The correlations between serostatus, patient contacts and demographic characteristics were analysed. Different tests were compared by Kappa statistics.

RESULTS

Among 318 participants, SARS-CoV-2 antibodies were detected in 9 employees. Chemiluminescence assays (chemiluminescence immunoassay and electrochemiluminescence) showed superior specificity and high reproducibility, compared with ELISA and POC results.In contrast to the low seropositivity (2.8%) of healthcare workers, higher than that of the other departments of the hospital, a large proportion mistakenly assumed that they might have already been infected. Antiviral antibody titres increased and remained on a plateau for at least 3 months.

CONCLUSIONS

The great demand and acceptance confirmed the benefit of highly sensitive testing methods in the early phase of the pandemic. The coincidence of low seroprevalence and anxious employees may have contributed to internalising the need of hygiene measures.

Psychometric properties of the EQ-5D-5L: a systematic review of the literature

PURPOSE

Although the EQ-5D has a long history of use in a wide range of populations, the newer five-level version (EQ-5D-5L) has not yet had such extensive experience. This systematic review summarizes the available published scientific evidence on the psychometric properties of the EQ-5D-5L.

METHODS

Pre-determined key words and exclusion criteria were used to systematically search publications from 2011 to 2019. Information on study characteristics and psychometric properties were extracted: specifically, EQ-5D-5L distribution (including ceiling and floor), missing values, reliability (test-retest), validity (convergent, known-groups, discriminate) and responsiveness (distribution, anchor-based). EQ-5D-5L index value means, ceiling and correlation coefficients (convergent validity) were pooled across the studies using random-effects models.

RESULTS

Of the 889 identified publications, 99 were included for review, representing 32 countries. Musculoskeletal/orthopedic problems and cancer (n = 8 each) were most often studied. Most papers found missing values (17 of 17 papers) and floor effects (43 of 48 papers) to be unproblematic. While the index was found to be reliable (9 of 9 papers), individual dimensions exhibited instability over time. Index values and dimensions demonstrated moderate to strong correlations with global health measures, other multi-attribute utility instruments, physical/functional health, pain, activities of daily living, and clinical/biological measures. The instrument was not correlated with life satisfaction and cognition/communication measures. Responsiveness was addressed by 15 studies, finding moderate effect sizes when confined to studied subgroups with improvements in health.

CONCLUSIONS

The EQ-5D-5L exhibits excellent psychometric properties across a broad range of populations, conditions and settings. Rigorous exploration of its responsiveness is needed.

Forecasting tuberculosis using diabetes-related google trends data

Online activity-based data can be used to aid infectious disease forecasting. Our aim was to exploit the converging nature of the tuberculosis (TB) and diabetes epidemics to forecast TB case numbers. Thus, we extended TB prediction models based on traditional data with diabetes-related Google searches. We obtained data on the weekly case numbers of TB in Germany from June 8^th, 2014, to May 5^th, 2019. Internet search data were obtained from a Google Trends (GTD) search for 'diabetes' to the corresponding interval. A seasonal autoregressive moving average (SARIMA) model (0,1,1) (1,0,0) [52] was selected to describe the weekly TB case numbers with and without GTD as an external regressor. We cross-validated the SARIMA models to obtain the root mean squared errors (RMSE). We repeated this procedure with autoregressive feed-forward neural network (NNAR) models using 5-fold cross-validation. To simulate a data-poor surveillance setting, we also tested traditional and GTD-extended models against a hold-out dataset using a decreased 52-week-long period with missing values for training. Cross-validation resulted in an RMSE of 20.83 for the traditional model and 18.56 for the GTD-extended model. Cross-validation of the NNAR models showed a mean RMSE of 19.49 for the traditional model and 18.99 for the GTD-extended model. When we tested the models trained on a decreased dataset with missing values, the GTD-extended models achieved significantly better prediction than the traditional models (p < 0.001). The GTD-extended models outperformed the traditional models in all assessed model evaluation parameters. Using online activity-based data regarding diabetes can improve TB forecasting, but further validation is warranted.

Exploring the Internal Structure of the EQ-5D Using Non-Preference-Based Methods

BACKGROUND

When the EuroQol EQ-5D is applied in settings other than resource allocation, a non-preference-based score may be more appropriate than societal, preference-weighted utility. To develop a psychometric score for the EQ-5D, its structural relationship, ie, how the 5 items/dimensions interrelate, must be understood to inform appropriate methods of summarizing the instrument.

OBJECTIVES

To explore psychometrically derived approaches of elucidating the 5-level EQ-5D (EQ-5D-5L) item structure.

METHODS

Three measurement models were assessed. All 5 items were modeled as reflective indicators using confirmatory factor analysis. EQ-5D-5L items were conceptualized as formative indicators, and other health scales (eg, the short form 36 health survey) were conceptualized as reflective indicators in Multiple Indicators Multiple Causes models (external MIMIC). The EQ-5D-5L items were modeled as a combination of formative and reflective indicators in internal MIMIC models. Results across 9 data sets from various countries and patient groups were examined to determine their robustness.

RESULTS

All items loaded well (0.63-0.96) in the confirmatory factor analysis except for anxiety/depression (0.20-0.66, excluding 1 outlier). The model fit statistics of the external MIMIC models were poor, and the coefficients of the Self-Care dimension were small. The internal MIMIC model with Mobility, Pain/Discomfort, and Anxiety/Depression as formative indicators and Self-Care and Usual Activities as reflective indicators fit best. The model results of the Spanish valuation data set were outliers.

CONCLUSIONS

Although there were some variations in results across subgroups, the relationship between the items remained robust. The evidence calls for testing of formative/reflective combination approaches to summarize the EQ-5D-5L.

[The efficacy of cognitive behavioral therapy in insomnic patients with or without comorbidities: a pilot study]

Objectives: To evaluate the effectiveness of cognitive behavior therapy for insomnia (CBT-i) in chronic insomnia patients in terms of the improvements of psychological and sleep diary parameters. Methods: Patients who met the diagnostic criteria of chronic insomnia, were divided into primary group or comorbid group. Both groups received standard CBT-i interventions. Psychological scales and sleep diaries were used to evaluate participants' severity of insomnia and psychological conditions related to insomnia at four time points: before intervention (baseline), immediate after intervention, 4 weeks and 16 weeks after intervention. Results: Both groups achieved significant improvements after intervention on psychological measurements and sleep diary parameters. Such improvements were maintained at 4-week and 16-week follow-ups. The sleep diary data indicated that by the end of the intervention, there were significant differences on sleep onset latency (51.72 min to 10.53 min in primary group, P<0.01; 59.26 min to 15.67min in comorbid group, P<0.01) and sleep efficiency (71% to 95% in primary group, P<0.01; 68% to 90% in comorbid group, P<0.01). There were differences on sleep onset latency (10.00 min vs. 13.93 min, P<0.05), total sleep time (355.71 min vs. 327.85 min, P<0.05) and sleep efficiency (95% vs. 91%, P<0.01) in primary group and comorbid group respectively. No differences were found on wake after sleep onset in the two groups. Conclusions: Chronic insomnia patients with or without comorbidities both have improvements after CBT-i. Sleep diary parameters rather than psychological measurements are different in two groups. Thus, CBT-i is an effective non-pharmaceutical therapy inpatients with chronic insomnia.

A Systematic Review of Studies Comparing the Measurement Properties of the Three-Level and Five-Level Versions of the EQ-5D

BACKGROUND

Since the introduction of the five-level version of the EQ-5D (5L), many studies have comparatively investigated the measurement properties of the original three-level version (3L) with the 5L version.

OBJECTIVE

The aim of this study was to consolidate the available evidence on the performance of both instruments.

METHODS

A systematic literature search of studies in the English and German languages was conducted (2007-January 2018) using the PubMed, EMBASE, and PsycINFO (EBSCO) databases, as well as the EuroQol Research Foundation website. Data were extracted and assessed on missing values, distributional properties, informativity indices (Shannon's H' and J'), inconsistencies, responsiveness, and test-retest reliability.

RESULTS

Twenty-four studies were included in the review. Missing values and floor effects (percentage reporting the worst health state) were found to be negligible for both 3L and 5L (< 5%). From 18 studies, inconsistencies ranged from 0 to 10.6%, although they were generally well below 5%, with 9 studies reporting the most inconsistencies for Usual Activities (mean percentage 4.1%). Shannon's indices were always higher for 5L than for 3L, and all but three studies reported lower ceiling effects ('11111') for 5L than for 3L. There is mixed and insufficient evidence on responsiveness and test-retest reliability, although results on index values showed better performance for 5L on test-retest reliability.

CONCLUSION

Overall, studies showed similar or better measurement properties of the 5L compared with the 3L, and evidence indicated moderately better distributional parameters and substantial improvement in informativity for the 5L compared with the 3L. Insufficient evidence on responsiveness and test-retest reliability implies further research is needed.

Oral anticoagulation use by patients with atrial fibrillation in Germany

Atrial fibrillation (AF) is the most common significant cardiac rhythm disorder. Oral anticoagulation (OAC) is recommended by guidelines in the presence of a moderate to high risk of stroke. Based on an analysis of claims-based data, the aim of this contribution is to quantify the stroke-risk dependent OAC utilisation profile of German AF patients as well as the possible causes and the associated clinical outcomes of OAC under-use. Our data set was derived from two large mandatory German medical insurance funds. Risk stratification of patients was based on the CHADS2-score and the CHA2DS2-VASc-score. Two different scenarios were constructed to deal with factors potentially disfavouring OAC use. Causes of OAC under-use and its clinical consequences were analysed using multivariate analysis. Observation year was 2008. A total of 183,448 AF patients met the inclusion criteria. This represents an AF prevalence of 2.21%. The average CHADS2-score was 2.8 (CHA2DS2-VASc-score: 4.3). On between 40.5 and 48.7% of the observed patient-days, there was no antithrombotic protection by OAC, other anticoagulants or aspirin. Older female patients with a high number of comorbidities had a higher risk of OAC under-use. Patients who had already experienced a thromboembolic event had a lower risk of OAC under-use. In the observation year, 3,367 patients experienced a stroke (incidence rate 1.8%). In our multi-level Poisson random effects estimate, OAC use decreases the stroke rate by almost 80% (IRR 0.236). In conclusion, OAC under-use is widespread in the German market. It is associated with severe clinical consequences.

Differences in EQ-5D-3L health state valuations among patients with musculoskeletal diseases, health care professionals and healthy volunteers

BACKGROUND

Results from existing studies indicate that different respondent groups' health state valuations in cost-utility analyses are not equivalent.

OBJECTIVES

The objectives in our study were to analyse differences in health state valuations among three respondent groups in the context of medical rehabilitation in Germany.

METHODS

Using the time trade-off (TTO) technique, valuations of EQ-5D-3L health states were obtained from patients with musculoskeletal diseases, healthy volunteers and health care professionals. We used linear mixed models to predict TTO utilities and specified and tested interaction effects.

RESULTS

We identified statistically significant (p < 0.05) differences among the three groups in six out of 42 health states. On average, patients' TTO values were somewhat higher compared with other respondent groups. Most of these differences occurred in severe health states. Mean differences and mean absolute differences were 0.02 and 0.14 for patients vs healthy volunteers and 0.06 and 0.14 for patients vs health care professionals. Furthermore, significant effects among respondents were observed for seven of the 22 possible interactions describing differences between respondent groups. Coefficients associated with significant interaction effects ranged from 0.08 to 0.18 (absolute values).

CONCLUSION

The results of our study suggest that TTO valuations of health states differ depending on the specific respondent group from which valuations are obtained. On average, these differences were small. However, researchers and decision makers should remain aware of these differences when interpreting incremental cost-utility assessments.

Overweight and dental caries: the association among German children

OBJECTIVES

The aim of this study was to determine the relationship between iso-body mass index (iso-BMI) and both dental caries status and caries increment among German school children.

METHODS

Six hundred and ninety-four students (age range 9-12 years, mean 10.34 ± 0.56, 48% females) were recruited from the fifth grade of 18 primary schools. Weight, height, and oral health data number of decayed, missing and filled teeth (DMFT) as well as parent/legal guardian questionnaire (measuring SES) were collected during school dental examination at baseline and after one and a half-year follow-up. The body mass index (BMI) was calculated using the international classification system for childhood overweight and obesity (iso-BMI). Statistical analyses were performed using Poisson regression models.

RESULTS

Iso-BMI was significantly associated with dental caries prevalence and severity in the permanent dentition (P = 0.039). Low-normal weight children had a lower mean DMFT (0.56) than did overweight/obese children (0.70). In addition, a border-line significant association was found between overweight/obese children and caries increment (P = 0.055).

CONCLUSION

Although iso-BMI was associated with dental caries prevalence and severity, the association between caries increment and iso-BMI did not reach a statistical significance. Overweight/obese children however acquired more additional carious lesions during the follow-up period than children with low-normal weight.

Measuring changes in health over time using the EQ-5D 3L and 5L: a head-to-head comparison of measurement properties and sensitivity to change in a German inpatient rehabilitation sample

PURPOSE

To compare measurement properties and sensitivity to change of the standard version of the EQ-5D (3L) with a newly developed 5-level version (5L) in a multicenter sample of German rehabilitation inpatients (n = 230).

METHODS

Rehabilitation patients (n = 114 orthopedic, n = 54 psychosomatic, n = 62 rheumatic) were asked to complete both versions of the EQ-5D and several other questionnaires at the beginning of, the end of and 3 month after inpatient rehabilitation. 3L and 5L were compared regarding missing values, ceiling effects, redistribution properties, informativity and sensitivity to change.

RESULTS

There were nearly no missing values in both questionnaires. Ceiling effects were 1.6 % points to 16.4 % points lower on average for the 5L. For psychosomatic patients, ceiling effects for 5L were as high as in the general German population. Absolute informativity (mean 5L: 1.76, 3L: 1.06) and relative informativity (5L: 0.76, 3L: 0.67) were both higher for 5L. 5L could better detect both positive and negative health changes in most dimensions and patient samples. Overall, patients made better use of the response levels of the 5L. Average proportion of inconsistent responses between 3L and 5L was 6.1 %.

CONCLUSIONS

Cross-sectionally and longitudinally, 5L was associated with an improved ability to detect health changes over time, reduced ceiling effects, and improved discriminatory power. Overall, these findings were in line with previous study outcomes, although differing in magnitude. Since the sample size is moderate and generalizability of the reported results is unclear, further comparisons in other patient populations will be informative and should be encouraged.

Systematic literature review and validity evaluation of the Expanded Disability Status Scale (EDSS) and the Multiple Sclerosis Functional Composite (MSFC) in patients with multiple sclerosis

BACKGROUND

There are a number of instruments that describe severity and progression of multiple sclerosis and they are increasingly used as endpoints to assess the effectiveness of therapeutic interventions. We examined to what extent the psychometric properties of two accepted instruments--EDSS and MSFC--meet methodological standards and the value they have in clinical trials.

METHODS

We conducted a systematic literature search in relevant databases [MEDLINE (PubMed), ISI Web of Science, EMBASE, PsycINFO & PSYNDEX, CINAHL] yielding 3,860 results. Relevant full-text publications were identified using abstract and then full-text reviews, and the literature was reviewed.

RESULTS

For evaluation of psychometric properties (validity, reliability, sensitivity of change) of EDSS and MSFC, 120 relevant full-text publications were identified, 54 of them assessed the EDSS, 26 the MSFC and 40 included both instruments. The EDSS has some documented weaknesses in reliability and sensitivity to change. The main limitations of the MSFC are learning effects and the z-scores method used to calculate the total score. However, the methodological criterion of validity applies sufficiently for both instruments.For use in clinical studies, we found the EDSS to be preferred as a primary and secondary outcome measure in recent studies (50 EDSS, 9 MSFC).

CONCLUSIONS

Recognizing their strengths and weaknesses, both EDSS and MSFC are suitable to detect the effectiveness of clinical interventions and to monitor disease progression. Almost all publications identify the EDSS as the most widely used tool to measure disease outcomes in clinical trials. Despite some limitations, both instruments are accepted as endpoints and neither are discussed as surrogate parameters in identified publications. A great advantage of the EDSS is its international acceptance (e.g. by EMA) as a primary endpoint in clinical trials and its broad use in trials, enabling cross-study comparisons.

L-Carnitine-supplementation in advanced pancreatic cancer (CARPAN)--a randomized multicentre trial

Background

Cachexia, a >10% loss of body-weight, is one factor determining the poor prognosis of pancreatic cancer. Deficiency of L-Carnitine has been proposed to cause cancer cachexia.

Findings

We screened 152 and enrolled 72 patients suffering from advanced pancreatic cancer in a prospective, multi-centre, placebo-controlled, randomized and double-blinded trial to receive oral L-Carnitine (4 g) or placebo for 12 weeks. At entry patients reported a mean weight loss of 12 ± 2,5 (SEM) kg. During treatment body-mass-index increased by 3,4 ± 1,4% under L-Carnitine and decreased (−1,5 ± 1,4%) in controls (p < 0,05). Moreover, nutritional status (body cell mass, body fat) and quality-of-life parameters improved under L-Carnitine. There was a trend towards an increased overall survival in the L-Carnitine group (median 519 ± 50 d versus 399 ± 43 d, not significant) and towards a reduced hospital-stay (36 ± 4d versus 41 ± 9d,n.s.).

Conclusion

While these data are preliminary and need confirmation they indicate that patients with pancreatic cancer may have a clinically relevant benefit from the inexpensive and well tolerated oral supplementation of L-Carnitine.

Interim scoring for the EQ-5D-5L: mapping the EQ-5D-5L to EQ-5D-3L value sets

BACKGROUND

A five-level version of the EuroQol five-dimensional (EQ-5D) descriptive system (EQ-5D-5L) has been developed, but value sets based on preferences directly elicited from representative general population samples are not yet available. The objective of this study was to develop values sets for the EQ-5D-5L by means of a mapping ("crosswalk") approach to the currently available three-level version of the EQ-5D (EQ-5D-3L) values sets.

METHODS

The EQ-5D-3L and EQ-5D-5L descriptive systems were coadministered to respondents with conditions of varying severity to ensure a broad range of levels of health across EQ-5D questionnaire dimensions. We explored four models to generate value sets for the EQ-5D-5L: linear regression, nonparametric statistics, ordered logistic regression, and item-response theory. Criteria for the preferred model included theoretical background, statistical fit, predictive power, and parsimony.

RESULTS

A total of 3691 respondents were included. All models had similar fit statistics. Predictive power was slightly better for the nonparametric and ordered logistic regression models. In considering all criteria, the nonparametric model was selected as most suitable for generating values for the EQ-5D-5L.

CONCLUSIONS

The nonparametric model was preferred for its simplicity while performing similarly to the other models. Being independent of the value set that is used, it can be applied to transform any EQ-5D-3L value set into EQ-5D-5L index values. Strengths of this approach include compatibility with three-level value sets. A limitation of any crosswalk is that the range of index values is restricted to the range of the EQ-5D-3L value sets.

Self-perceived quality of life predicts mortality risk better than a multi-biomarker panel, but the combination of both does best

Background

Associations between measures of subjective health and mortality risk have previously been shown. We assessed the impact and comparative predictive performance of a multi-biomarker panel on this association.

Methods

Data from 4,261 individuals aged 20-79 years recruited for the population-based Study of Health in Pomerania was used. During an average 9.7 year follow-up, 456 deaths (10.7%) occurred. Subjective health was assessed by SF-12 derived physical (PCS-12) and mental component summaries (MCS-12), and a single-item self-rated health (SRH) question. We implemented Cox proportional-hazards regression models to investigate the association of subjective health with mortality and to assess the impact of a combination of 10 biomarkers on this association. Variable selection procedures were used to identify a parsimonious set of subjective health measures and biomarkers, whose predictive ability was compared using receiver operating characteristic (ROC) curves, C-statistics, and reclassification methods.

Results

In age- and gender-adjusted Cox models, poor SRH (hazard ratio (HR), 2.07; 95% CI, 1.34-3.20) and low PCS-12 scores (lowest vs. highest quartile: HR, 1.75; 95% CI, 1.31-2.33) were significantly associated with increased risk of all-cause mortality; an association independent of various covariates and biomarkers. Furthermore, selected subjective health measures yielded a significantly higher C-statistic (0.883) compared to the selected biomarker panel (0.872), whereas a combined assessment showed the highest C-statistic (0.887) with a highly significant integrated discrimination improvement of 1.5% (p < 0.01).

Conclusion

Adding biomarker information did not affect the association of subjective health measures with mortality, but significantly improved risk stratification. Thus, a combined assessment of self-reported subjective health and measured biomarkers may be useful to identify high-risk individuals for intensified monitoring.

Methods for increasing nitrile biotransformation into amides using Mesorhizobium sp

Nitriles are potential soil pollutants from industrial wastewater. There has been increased demand for efficient process for nitrile degradation process. Nitrile hydratase (NHase) has been extensively used in the production of acrylamide and treatment of organocyanide contaminated industrial effluents. The NHase of Mesorhizobium sp., isolated from polyacrylonitrile activated sludge from fiber manufacturing wastewater treatment systems was studied in the whole bacterial cells. Different chemicals were added to observe the variation in the percentage of acrylonitrile converted into acrylamide. The result indicated that cobalt ions were the NHase cofactor and could increase the NHase activity. The addition of propionaldehyde, or butyraldehyde could enhance the acrylonitrile conversion rate. Therefore, acrylamide could be accumulated effectively and the percentage of acrylonitrile converted into acrylamide increased. Propionaldehyde was the most effective NHase activator. The percentage of acrylonitrile converted into acrylamide was nearly 100% at 3.8 h when propionaldehyde was added at about 207.4 mg/l. The addition of benzaldehyde was unable to increase the percentage of acrylonitrile converted into acrylamide. EDTA and acrylamide showed no effect on NHase activity. However, 0.1 mg/l of Ag2SO4 would slightly inhibit NHase activity, producing an acrylonitrile conversion rate of 492.9 mg/l with 54.9% converted at 29.1 h. The ability of the acrylonitrile biotransformation was completely inhibited if the Ag2SO4 concentration was above 0.5 mg/l.

Titanium(IV) chloride and quaternary ammonium salt promoted Baylis-Hillman reaction

The Baylis-Hillman reaction of aldehydes with alpha,beta-unsaturated ketones can be drastically affected by the reaction temperature and Lewis bases. When the reaction was carried out at -78 degrees C using catalytic amounts of quaternary ammonium salts (R4N+X-, X = Cl, Br, I) as Lewis bases, in the presence of titanium(IV) chloride, the chlorinated aldol adduct 1 was obtained as the major product. Quaternary ammonium bromides and iodides (R4N+X-, X = Br, I) have higher catalytic activity than corresponding chlorides (R4N+Cl-). Quaternary ammonium fluorides (R4N+F-) do not have activity at all. The amounts of Lewis acid and quaternary ammonium salts used affect the reaction rate and product. A plausible reaction mechanism is proposed. If the reaction was carried out at room temperature (about 20 degrees C) in the presence of titanium(IV) chloride and quaternary ammonium salts (R4N+X-, X = Cl, Br, I), the elimination product 3, derived from 1, was formed as the major product.

[Electrophoretic migration behavior of deoxyribonucleic acid fragments in three polymer solution concentration regions]

The theory of polymer coils shrinking in semi-dilute solution has recently been developed on polymer solution. The polymer solution from coils shrinking concentration Cs to uniform entangled concentt concentration C+ has been defined as semi-dilute solution. We experimentally investigated the electrophoretic migration behavior of 100 bp deoxyribonucleic acid (DNA) Ladder in hydroxypropyl methyl cellulose (HPMC) concentration ranging from 1.25 g/L to 16.06 g/L. The friction force mobility mu f is used to express the friction force that DNA will encounter in capillary electrophoresis. Our results indicate the division of polymer solution into three regions depending on the relationship of mu f and HPMC concentration and Ferguson plot. Resolutions of 200 bp/300 bp and 700 bp/800 bp show semi-dilute polymer solution suits large fragments and small fragments DNA separation respectively. the results confirm that the current polymer theory is valid under actual CE condition.

Myoglobin clearance during continuous veno-venous hemofiltration with or without dialysis

The management of acute myoglobinuric renal failure, the major complication of rhabdomyolysis, continues to be a treatment dilemma for the clinician as limited therapeutic options are available. Previously, we have demonstrated that continuous arteriovenous hemofiltration (CAVH) is an effective technique for removing myoglobin in an animal model. In the present study, swine were administered four grams of equine myoglobin intravenously and underwent the continuous veno-venous hemofiltration (CVVH) procedure for six hours each. Animals were studied in each of the following groups: CVVH at a pump rate 100 ml/minute, CVVH at a pump rate 200 ml/minute and CVVH at a pump rate 100 ml/minute plus dialysis at a dialysate flow rate of one Liter/h. Once the filtering process was initiated there was a rapid and sustained production of ultrafiltrate in all groups. The amount of myoglobin excreted in the ultrafiltrate over the six-hour filtering period was 688, 948 and 570 mg which corresponded to 17, 24 and 14 percent of the administered dose, respectively, for the three treatments. In comparison to previous CAVH experiments, CVVH removed more circulating myoglobin and the addition of the dialysis component did not appear to improve removal. Based on these findings, it appears that the CVVH hemofiltration system is a viable option for the removal of systemic myoglobin.

[Evaluation of rapid colon preparation by oral intake of dulcolax for colorectal surgery]

The optimal result of colorectal surgery is best achieved by adequate preoperative colon preparation, which should be simple, safe, rapid, and thoroughly clean with little or no discomfort at all for patients. Conventional mechanical preparation, though effective, is time-consuming and unpleasant for patients, therefore new methods have been frequently presented in recent literature to meet the above ideal. A prospective and randomized study was conducted to evaluate preoperative colon preparation in elective, nonobstructive colorectal surgery. Group I included 32 patients who received three-day diet control and enema, while group II included 42 patients who received one-day diet control and oral dulcolax. Both groups were given systemic antibiotics. The result favored group II because of its significantly less abdominal fullness, but the electrolyte change and bacteriologic study revealed no significant difference between two groups. Neither did they exhibit variance in the adequacy of bowel cleansing (81.3% in group I vs 81% in group II). It is therefore suggested that, without enema and with less abdominal fullness, oral dulcolax should be encouraged for colon preparation in colorectal surgery.

One-stage operation for obstructing carcinomas of the left colon and rectum

A consecutive series of 28 patients with acutely obstructing carcinomas of the left colon and rectum were encountered during the last three years. Two patients treated by loop colostomy only were excluded from the study. Fifteen patients received a one-stage operation of immediate resection and primary anastomosis without proximal colostomy. The remaining 11 patients were treated by a conventional staged operation. The operative mortality and complications were similar in both groups. The duration of hospital stay in the former was half of that in the latter. Of nine patients treated by subtotal or total colectomy with primary anastomosis, the average number of bowel movements three months after surgery was 1.8 per day. Intraoperative colonic irrigation was performed in five patients of the one-stage group and permitted a safe primary anastomosis. The immediate results of the one-stage operation were surprisingly good. The authors propose it as the treatment of choice for the majority of patients with obstructing carcinomas of the left colon and rectum.