Improvements In Relevant Outcomes Research Articles

PSAT357 Preventing Progression of Ophthalmopathy Using a 'Block-Replace' Treatment Strategy in Labile Graves’ Disease

Abstract Introduction Graves’ disease is an autoimmune disorder that most commonly causes hyperthyroidism. Pathogenesis usually involves the stimulation of TSH receptors by antibodies, but in rare cases can alternate between hyper- and hypothyroidism. In this case report, we describe a patient who had labile thyroid function with persistent ophthalmopathy, requiring a temporizing "block and replace" strategy for treatment. Case Description A 53-year-old woman with a history of GERD and fibroids presented to her primary care physician with a month-long history of hand and leg tremors, weakness, heat intolerance, palpitations and worsened anxiety. She also developed eye irritation and enlargement. Thyromegaly was noted on examination. Thyroid function tests showed that TSH was <0.01 (0.45-5.33 uIU/mL) and Free T4 was 2.48 (0.61-1.12 ng/dL). TRab was 21.2 (<1.75 IU/L). Thyroid ultrasound revealed heterogeneous enlargement with increased vascularity representing thyroiditis. CT orbit revealed mild bilateral ocular proptosis with normal extraocular muscle. She was diagnosed with Graves’ disease complicated by ophthalmopathy and she was started on methimazole and metoprolol. Repeat labs six weeks later improved to TSH of 0.01 and total T4 of 6.5 (4.50-11.70 ug/dL). Unfortunately, follow up labs 2 months later revealed overt hypothyroidism, with TSH of 134 with total T4 0.9. Methimazole and metoprolol were discontinued and 75mcg of levothyroxine was started. One month later, TSH was suppressed again to 0.11 and Total T4 was 17.8, so methimazole was again added with the intent of suppressing hyperthyroidism while simultaneously replacing levothyroxine to avoid hypothyroidism. Given the difficulty of maintaining a euthyroid state and ongoing symptomatic ophthalmopathy, she eventually underwent total thyroidectomy and started levothyroxine post operatively. Pathology of the thyroid gland was consistent with Graves’ disease. Discussion Graves’ disease is typically treated with anti-thyroid medical therapy (thioamides such as methimazole), which is titrated to a euthyroid state. In our case, the patient's thyroid function varied widely on methimazole, potentially representing variable stimulating and blocking functions of TRab. As periods of hypothyroidism can worsen ophthalmopathy, a "block and replace" treatment strategy was adopted, which involves a thioamide and levothyroxine concurrently to achieve a biochemically euthyroid state. While a Cochrane review has suggested there is no improvement in relevant outcomes using this approach, it was useful in our case as a bridge to surgical management1.

Does age matter? Initial treatment goals of older adults with major depression in outpatient cognitive behavioural therapy.

Personal treatment goals (PTG) are important means to tailor psychotherapy to the needs of the patient, leading to increased engagement and greater improvement in relevant outcomes. According to lifespan developmental research, motivational goals in old age differ from goals of younger people, with management of losses rather than growth becoming more prevalent. However, this study is the first to systematically investigate age-specific differences in PTGs. We used routine data from patients with major depression assessed at the beginning of outpatient cognitive behavioural therapy. Initial high-priority PTGs were assessed using the Bern Inventory of Treatment Goals (BIT-C). Older patients (≥60 years, n = 52) were matched to younger patients (<60 years, n = 52) with regard to severity of depression, number of comorbidities, gender and level of education. Using a mixed method approach, high-priority PTGs of both age groups were focused most strongly on reducing depressive symptoms and, subsequently, anxiety. At the same time, older patients focused more strongly on PTGs related to well-being and functioning, while younger patients' emphasis was on personal growth. Furthermore, better coping with the ageing process and physical losses emerged as important PTGs for some older patients. Initial PTG themes are specific to diagnosis, but also seem to differ in regard to age. Thus, it is important to develop age-sensitive measures that allow appropriate and efficient tailoring of psychotherapy to meet older patients' needs and preferences.

Treatment of central disorders of hypersomnolence: an American Academy of Sleep Medicine clinical practice guideline.

This guideline establishes clinical practice recommendations for the treatment of central disorders of hypersomnolence in adults and children. The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine to develop recommendations and assign strengths to each recommendation, based on a systematic review of the literature and an assessment of the evidence using the GRADE process. The task force provided a summary of the relevant literature and the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations that support the recommendations. The AASM Board of Directors approved the final recommendations. The following recommendations are intended to guide clinicians in choosing a specific treatment for central disorders of hypersomnolence in adults and children. Each recommendation statement is assigned a strength ("strong" or "conditional"). A "strong" recommendation (ie, "We recommend…") is one that clinicians should follow under most circumstances. A "conditional" recommendation (ie, "We suggest…") is one that requires that the clinician use clinical knowledge and experience and strongly consider the individual patient's values and preferences to determine the best course of action. Under each disorder, strong recommendations are listed in alphabetical order followed by the conditional recommendations in alphabetical order. The section on adult patients with hypersomnia because of medical conditions is categorized based on the clinical and pathological subtypes identified in ICSD-3. The interventions in all the recommendation statements were compared to no treatment. We recommend that clinicians use modafinil for the treatment of narcolepsy in adults. (STRONG). We recommend that clinicians use pitolisant for the treatment of narcolepsy in adults. (STRONG). We recommend that clinicians use sodium oxybate for the treatment of narcolepsy in adults. (STRONG). We recommend that clinicians use solriamfetol for the treatment of narcolepsy in adults. (STRONG). We suggest that clinicians use armodafinil for the treatment of narcolepsy in adults. (CONDITIONAL). We suggest that clinicians use dextroamphetamine for the treatment of narcolepsy in adults. (CONDITIONAL). We suggest that clinicians use methylphenidate for the treatment of narcolepsy in adults. (CONDITIONAL). We recommend that clinicians use modafinil for the treatment of idiopathic hypersomnia in adults. (STRONG). We suggest that clinicians use clarithromycin for the treatment of idiopathic hypersomnia in adults. (CONDITIONAL). We suggest that clinicians use methylphenidate for the treatment of idiopathic hypersomnia in adults. (CONDITIONAL). We suggest that clinicians use pitolisant for the treatment of idiopathic hypersomnia in adults. (CONDITIONAL). We suggest that clinicians use sodium oxybate for the treatment of idiopathic hypersomnia in adults. (CONDITIONAL). We suggest that clinicians use lithium for the treatment of Kleine-Levin syndrome in adults. (CONDITIONAL). We suggest that clinicians use armodafinil for the treatment of hypersomnia secondary to dementia with Lewy bodies in adults. (CONDITIONAL). We suggest that clinicians use modafinil for the treatment of hypersomnia secondary to Parkinson's disease in adults. (CONDITIONAL). We suggest that clinicians use sodium oxybate for the treatment of hypersomnia secondary to Parkinson's disease in adults. (CONDITIONAL). We suggest that clinicians use armodafinil for the treatment of hypersomnia secondary to traumatic brain injury in adults. (CONDITIONAL). We suggest that clinicians use modafinil for the treatment of hypersomnia secondary to traumatic brain injury in adults. (CONDITIONAL). We suggest that clinicians use modafinil for the treatment of hypersomnia secondary to myotonic dystrophy in adults. (CONDITIONAL). We suggest that clinicians use modafinil for the treatment of hypersomnia secondary to multiple sclerosis in adults. (CONDITIONAL). We suggest that clinicians use modafinil for the treatment of narcolepsy in pediatric patients. (CONDITIONAL). We suggest that clinicians use sodium oxybate for the treatment of narcolepsy in pediatric patients. (CONDITIONAL). Maski K, Trotti LM, Kotagal S, et al. Treatment of central disorders of hypersomnolence: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021;17(9):1881-1893.

Community-care unit model of residential mental health rehabilitation services in Queensland, Australia: predicting outcomes of consumers 1-year post discharge.

Community care units (CCUs) are a model of residential psychiatric rehabilitation aiming to improve the independence and community functioning of people with severe and persistent mental illness. This study examined factors predicting improvement in outcomes among CCU consumers. Hierarchical regression using data from a retrospective cohort (N = 501) of all consumers admitted to five CCUs in Queensland, Australia between 2005 and 2014. The primary outcome was changed in mental health and social functioning (Health of the Nation Outcome Scale). Secondary outcomes were disability (Life Skills Profile-16), service use, accommodation instability, and involuntary treatment. Potential predictors covered service, consumer, and treatment characteristics. Group-level and individualised change were assessed between the year pre-admission and post-discharge. Where relevant and available, the reliable and clinically significant (RCS) change was assessed by comparison with a normative sample. Group-level analyses showed statistically significant improvements in mental health and social functioning, and reductions in psychiatry-related bed-days, emergency department (ED) presentations and involuntary treatment. There were no significant changes in disability or accommodation instability. A total of 54.7% of consumers demonstrated reliable improvement in mental health and social functioning, and 43.0% showed RCS improvement. The majority (60.6%) showed a reliable improvement in psychiatry-related bed-use; a minority demonstrated reliable improvement in ED presentations (12.5%). Significant predictors of improvement included variables related to the CCU care (e.g. episode duration), consumer characteristics (e.g. primary diagnosis) and treatment variables (e.g. psychiatry-related bed-days pre-admission). Higher baseline impairment in mental health and social functioning (β = 1.12) and longer episodes of CCU care (β = 1.03) increased the likelihood of RCS improvement in mental health and social functioning. CCU care was followed by reliable improvements in relevant outcomes for many consumers. Consumers with poorer mental health and social functioning, and a longer episode of CCU care were more likely to make RCS improvements in mental health and social functioning.

A systematic review of strategies to increase access to health services among children in low and middle income countries

BackgroundUniversal Health Coverage is widely endorsed as the pivotal goal in global health, however substantial barriers to accessing health services for children in low and middle-income countries (LMIC) exist. Failure to access healthcare is an important contributor to child mortality in these settings. Barriers to access have been widely studied, however effective interventions to overcome barriers and increase access to services for children are less well documented.MethodsWe conducted a systematic review of effectiveness of interventions aimed at increasing access to health services for children aged 5 years and below in LMIC. Four databases (EMBASE, Global Health, MEDLINE, and PSYCINFO) were searched in January 2016. Studies were included if they evaluated interventions that aimed to increase: health care utilisation; immunisation uptake; and compliance with medication or referral. Randomised controlled trials and non-randomised controlled study designs were included in the review. A narrative approach was used to synthesise results.ResultsFifty seven studies were included in the review. Approximately half of studies (49%) were conducted in sub-Saharan Africa. Most studies were randomised controlled trials (n = 44; 77%) with the remaining studies employing non-randomised designs. Very few studies were judged as high quality. Studies evaluated a diverse range of interventions and various outcomes. Supply side interventions included: delivery of services at or closer to home and service level improvements (eg. integration of services). Demand side interventions included: educational programmes, text messages, and financial or other incentives. Interventions that delivered services at or closer to home and text messages were in general associated with a significant improvement in relevant outcomes. A consistent pattern was not noted for the remaining studies.ConclusionsThis review fills a gap in the literature by providing evidence of the range and effectiveness of interventions that can be used to increase access for children aged ≤5 years in LMIC. It highlights some intervention areas that seem to show encouraging trends including text message reminders and delivery of services at or close to home. However, given the methodological limitations found in existing studies, the results of this review must be interpreted with caution.Systematic review registrationPROSPERO CRD420160334200

A Pilot Study of Self-Management-based Nutrition and Physical Activity Intervention in Cancer Survivors

ABSTRACTExercise and a healthy diet are beneficial after cancer, but are not uniformly adopted by cancer survivors. This study reports on the feasibility, acceptability, and effectiveness of a self-management-based nutrition and exercise intervention for Australian cancer survivors. Adult survivors (n = 25) during curative chemotherapy (stratum 1[S1]; n = 11) or post-treatment (stratum 2 [S2]; n = 14) were recruited prospectively from a single center. The Flinders Living Well Self-Management Program™ (FLW Program) was utilized to establish patient-led nutrition and exercise goals and develop a tailored 12-wk intervention plan. Fortnightly reviews occurred with assessments at baseline, 6 and 12 wk. A recruitment and retention rate of 38% and 84% were observed. Both strata maintained total skeletal muscle mass. Small reductions in body mass index, hip circumference, and percentage body fat, and small increases in hand grip strength and exercise capacity among subjects in both strata were observed. No significant differences were observed between strata; however, significant increases in exercise capacity and global health status for S2 were observed from baseline to 12 wk. FLW Program is a feasible mode of delivering nutrition and exercise intervention to cancer survivors and it appears that there are no barriers to implementing this program early during chemotherapy. Hence, the additive effect of gains achieved over a longer duration is promising and this should be explored in randomized controlled trials adequately powered to observe clinically and statistically significant improvements in relevant outcomes.