Intervention Decisions Research Articles

Modeling Low Muscle Mass Screening in Hemodialysis Patients

Introduction: Computed tomography (CT) can accurately measure muscle mass, which is necessary for diagnosing sarcopenia, even in dialysis patients. However, CT-based screening for such patients is challenging, especially considering the availability of equipment within dialysis facilities. We therefore aimed to develop a bedside prediction model for low muscle mass, defined by the psoas muscle mass index (PMI) from CT measurement. Methods: Hemodialysis patients (n = 619) who had undergone abdominal CT screening were divided into the development (n = 441) and validation (n = 178) groups. PMI was manually measured using abdominal CT images to diagnose low muscle mass by two independent investigators. The development group’s data were used to create a logistic regression model using 42 items extracted from clinical information as predictive variables; variables were selected using the stepwise method. External validity was examined using the validation group’s data, and the area under the curve (AUC), sensitivity, and specificity were calculated. Results: Of all subjects, 226 (37%) were diagnosed with low muscle mass using PMI. A predictive model for low muscle mass was calculated using ten variables: each grip strength, sex, height, dry weight, primary cause of end-stage renal disease, diastolic blood pressure at start of session, pre-dialysis potassium and albumin level, and dialysis water removal in a session. The development group’s adjusted AUC, sensitivity, and specificity were 0.81, 60%, and 87%, respectively. The validation group’s adjusted AUC, sensitivity, and specificity were 0.73, 64%, and 82%, respectively. Discussion/Conclusion: Our results facilitate skeletal muscle screening in hemodialysis patients, assisting in sarcopenia prophylaxis and intervention decisions.

Clinical and temporal characterization of COVID-19 subgroups using patient vector embeddings of electronic health records.

To identify and characterize clinical subgroups of hospitalized Coronavirus Disease 2019 (COVID-19) patients. Electronic health records of hospitalized COVID-19 patients at NewYork-Presbyterian/Columbia University Irving Medical Center were temporally sequenced and transformed into patient vector representations using Paragraph Vector models. K-means clustering was performed to identify subgroups. A diverse cohort of 11313 patients with COVID-19 and hospitalizations between March 2, 2020 and December 1, 2021 were identified; median [IQR] age: 61.2 [40.3-74.3]; 51.5% female. Twenty subgroups of hospitalized COVID-19 patients, labeled by increasing severity, were characterized by their demographics, conditions, outcomes, and severity (mild-moderate/severe/critical). Subgroup temporal patterns were characterized by the durations in each subgroup, transitions between subgroups, and the complete paths throughout the course of hospitalization. Several subgroups had mild-moderate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections but were hospitalized for underlying conditions (pregnancy, cardiovascular disease [CVD], etc.). Subgroup 7 included solid organ transplant recipients who mostly developed mild-moderate or severe disease. Subgroup 9 had a history of type-2 diabetes, kidney and CVD, and suffered the highest rates of heart failure (45.2%) and end-stage renal disease (80.6%). Subgroup 13 was the oldest (median: 82.7 years) and had mixed severity but high mortality (33.3%). Subgroup 17 had critical disease and the highest mortality (64.6%), with age (median: 68.1 years) being the only notable risk factor. Subgroups 18-20 had critical disease with high complication rates and long hospitalizations (median: 40+ days). All subgroups are detailed in the full text. A chord diagram depicts the most common transitions, and paths with the highest prevalence, longest hospitalizations, lowest and highest mortalities are presented. Understanding these subgroups and their pathways may aid clinicians in their decisions for better management and earlier intervention for patients.

Use of polar coordinates for improving the measurement of resistant cross-sections of existing timber elements combining laser scanner and drilling resistance tests

Historic timber structures typically have elements with irregular cross-sections often with decayed segments, making of extreme importance to have proper methods to obtain the resistant cross-section. Knowing as accurately as possible the measurements of the resistant section of these beams is fundamental for the structural safety analysis. Small changes on the size and geometry of the resistant cross-section may be fundamental in an intervention decision process. In this work an algorithm was created that allows to obtain the geometry of the resistant section of existing timber beams by use of data obtained by laser scanning of the external apparent sections combined with drilling resistance tests. The algorithm is based on polar coordinates and proved to obtain more reliable resistant cross-sections than those obtained solely by common practice using drilling resistant tests. The developed algorithm was calibrated with a laboratory beam and subsequently applied and validated in a case study.

Shared decision-making and planning end-of-life care for patients with end-stage kidney disease: a protocol for developing and testing a complex intervention

BackgroundInternationally, it has been stressed that advance care planning integrated within kidney services can lead to more patients being involved in decisions for end-of-life care. In Denmark, there is no systematic approach to advance care planning and end-of-life care interventions within kidney services. A shared decision-making intervention for planning end-of-life care may support more effective treatment management between patients with end-stage kidney disease, their relatives and the health professionals. The purpose of this research is to find evidence to design a shared decision-making intervention and test its acceptability to patients with end-stage kidney disease, their relatives, and health professionals in Danish kidney services.MethodsThis research project will be conducted from November 2020 to November 2023 and is structured according to the UK Medical Research Council framework for complex intervention design and evaluation research. The development phase research includes mixed method surveys. First, a systematic literature review synthesising primary empirical evidence of patient-involvement interventions for patients with end-stage kidney disease making end-of-life care decisions will be conducted. Second, interview methods will be carried out with patients with end-stage kidney disease, relatives, and health professionals to identify experiences of involvement in decision-making and decisional needs when planning end-of-life care. Findings will inform the co-design of the shared decision-making intervention using an iterative process with our multiple-stakeholder steering committee. A pilot test across five kidney units assessing if the shared decision-making intervention is acceptable and feasible to patients, relatives, and health professionals providing services to support delivery of care in kidney services.DiscussionThis research will provide evidence informing the content and design of a shared decision-making intervention supporting patient-professional planning of end-of-life care for patients with end-stage kidney disease, and assessing its acceptability and feasibility when integrated within Danish kidney units. This research is the first step to innovating the involvement of patients in end-of-life care planning with kidney professionals.

How Might Indices of Happiness Inform Early Intervention Research and Decision Making?

ObjectivesThe child-caregiver relationship is the foundation for which intervention occurs. Therefore, the acceptability of the intervention should be considered for both parties. Indices of happiness (IOH) have shown to be effective in assessing social validity and providing insight to improving interventions to promote better quality of life. However, to date, there is limited attention to the integration of IOH in very early caregiver-led intervention. The purpose of this study is to explore how researchers and clinicians might collect direct data on IOH to assess the acceptability of an intervention.MethodsParticipants in this study included 4 children, ages 19–26 months old, identified as “at-risk” for autism, and their caregivers. Caregiver-led intervention focused on pairing, play, and following the child’s lead. IOH data was collected on both child and caregiver using 10 s partial-interval recording. Data analysis from the intervention is presented using three different approaches: pre/post-analysis on an individual level, pre/post-analysis on a dyad level, and during intervention as a primary dependent variable.ResultsVariations were seen in levels of happiness, both on an individual level and dyad level. IOH for caregivers increased in relation as their fidelity increased but child IOH decreased as they acquired the targeted skill.ConclusionsDirect observation of happiness data is likely to provide valuable insight into participants perception of an intervention. And retrospective analysis may be a valuable tool for reflection and guidance and planning of future interventions.

OA18 A rare presentation of Polyarteritis Nodosa

OA18 A rare presentation of Polyarteritis Nodosa

Physicians’ Knowledge, Attitude and Practice toward Ethical and Medical Issues of Palliative Care in Suez Canal University Hospital

Palliative care (PC) includes a varied range of medical and ethical aspects that should be considered. The role of physicians in PC is crucial so this work explores physicians' knowledge, attitude and practice toward PC in Suez Canal University hospital in Egypt. A questionnaire survey investigating physician's knowledge, attitude and practice in PC in 30 questions besides their personal and professional data. Nearly 31% of participants received education in PC. Only 5.5% realised that PC should be introduced to patients at all health-care levels. Most participants (70.9%) were not aware about the WHO three-step analgesic ladder. About 57.7% and 43.6% of participants preferred informing terminal patients about their diagnosis and prognosis, respectively. More than half of participants (58.6%) agreed that the medical intervention decision is the patient's right and 63.2% agreed that do not resuscitate choice is the patient or his family right if he is incompetent. Participants who do not have advance care plans discussions with their terminal patients represented 53.6%. This study indicated lack of knowledge and insufficient professionalism during management of terminal patients regarding some medical and ethical issues of PC. Formal education and training are urgently needed to improve the holistic vision and practice of PC in Egypt.

Comprehensive geriatric assessment: Valuation and patient preferences in older Japanese adults with cancer.

Current guidelines recommend a comprehensive geriatric assessment (CGA) for the management of older adults with cancer. We evaluated the effect of CGA conducted by a geriatric oncology service (GOS) on the management of older adults with cancer. We also queried patients about their perceptions of the value of this process. This was a prospective quality assessment study of 498 consecutive older adults with cancer who were referred to the GOS from May 2020 through December 2021. Treating physicians requested a consultation and the GOS conducted a CGA and assessed patient preferences. The GOS provided recommendations on cancer treatment and geriatric interventions. Patient perspectives on the consultation were evaluated using collaboRATE and modified Patient Assessment of Care for Chronic Conditions (PACIC) subscales. A 10-item frailty index based on a CGA (FI-CGA-10) [Oncologist, 26, e1751 (2021)] in the 498 patients showed that 19% of patients were fit, 40% pre-frail, and 41% frail. Prior to CGA the intent of the proposed cancer treatment was curative in 56% (n=280), life-extending in 40% (n=201), and palliative in 3.4% (n=17). After a CGA consultation, a cancer treatment decision was changed in 45% of patients. The intent of treatment after the CGA consultation was curative in 45%, life-extending in 34%, and palliative in 21%. At least one referral to relevant disciplines was recommended for 88% of patients and was implemented in 43%. As part of the GOS consultation educational support was provided to 97% of patients. Based on the collaboRATE and PACIC tools, patients perceived the GOS consultation positively and helpful for facilitating shared decision-making and patient-centered care. Our institutional experience demonstrated the valuable effect of the CGA consultation on oncologic decision-making and geriatric interventions in a patient-centered manner.

Risk model of hepatocellular carcinoma based on cuproptosis-related genes.

Background: Owing to the heterogeneity displayed by hepatocellular carcinoma (HCC) and the complexity of tumor microenvironment (TME), it is noted that the long-term effectiveness of the cancer therapy poses a severe clinical challenge. Hence, it is essential to categorize and alter the treatment intervention decisions for these tumors. Materials and methods: “ConsensusClusterPlus” tool was used for developing a secure molecular classification system that was based on the cuproptosis-linked gene expression. Furthermore, all clinical properties, pathway characteristics, genomic changes, and immune characteristics of different cell types involved in the immune pathways were also assessed. Univariate Cox regression and the least absolute shrinkage and selection operator (Lasso) analyses were used for designing the prognostic risk model associated with cuproptosis. Results: Three cuproptosis-linked subtypes (clust1, clust2, and clust3) were detected. Out of these, Clust3 showed the worst prognosis, followed by clust2, while Clust1 showed the best prognosis. Three subtypes had significantly different enrichment in pathways related to Tricarboxylic Acid (TCA) cycle, cell cycle, and cell senescence (p < 0.01). The clust3 subtype with poor prognosis had a low “ImmuneScore” and low immune cell infiltration, and the three subtypes had significant differences in the antigen processing and presentation pathway of the macrophages. Clust1 had a low TIDE score and was sensitive to immunotherapy. Then, according to the prognosis-related genes of cuproptosis, a prognosis risk model related to cuproptosis was constructed, containing seven genes (KIF2C, PTTG1, CENPM, CDC20, CYP2C9, SFN, and CFHR3). “High” group had a higher TIDE score compared to the TIDE score value shown by the “Low” group, which benefited less from immunotherapy, whereas the “High” group patients were more sensitive to the conventional drugs. Finally, the prognosis risk model related to cuproptosis was combined with clinical pathological characteristics to further improve the prognostic model and survival prediction. Conclusion: Three new molecular subgroups based on cuproptosis-linked genes were revealed, and a cuproptosis-related prognostic risk model comprising seven genes was established in this study, which could assist in predicting the prognosis and identifying the patients benefit from immunotherapy.

How to deal with nonsevere stenoses in coronary artery bypass grafting - a critical perspective on competitive flow and surgical precision.

For invasive treatment of coronary artery disease (CAD), we assess anatomical complexity, analyse surgical risk and make heart-team decisions for percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). With PCI, treating flow-relevant lesions is recommended, and reintervention easily treats disease progression. For CABG, some stenoses may only be borderline or nonsevere despite a clear surgical indication. As reoperations are not easy, the question on how to address these lesions has been around from the start, but has never satisfactorily been answered. With a new mechanistic perspective, we had suggested that infarct-prevention by surgical collateralization is the main prognostic mechanism of CABG in chronic coronary syndrome. Importantly, the majority of infarctions arise from nonsevere coronary lesions. Thus, surgical collateralization may be a valid treatment option for nonsevere lesions, but graft patency moves more into focus here, because graft patency directly correlates with the severity of coronary stenoses. In addition, CABG may even accelerate native disease progression. We here review the evidence for and against grafting nonsevere CAD lesions, suggesting that patency of grafts (to moderate lesions) may be improved by increasing surgical precision. In addition, we must improve our ability to predict future myocardial infarctions.

Monitoring osteoarthritis: A simple mathematical model

Osteoarthritis (OA) is a kind of joint inflammation which can be ascribed to the age, obesity, gender, depression, genetic predisposition, and cyclic or heavy cartilage loading. There is no definitive treatment for OA; hence, as far as possible the best practical resort is the prevention. We herein propose a simple mathematical model that receives the age, obesity, gender,and overloading by considering the impact of cartilage self-repair and predicts the cartilage damage. Python programming language using Numpy library was used for modeling and solver module. Assuming body mass index (BMI) > 27, we assumed that with the damage to cartilage increases by 6.5% with an increase of each BMI unit, whereas for a BMI <27 the cartilage damage can be ignored. The model predicted that the critical damge occurs is between ages of 44 and 64. In this timeframe, damage to the cartilage increases by 10%, which is roughly in line with the clinical data. Moreover, the impact of gender on the cartilage damage is not pronounced. The proposed simple mathematical model helps physiotherapists to privide themselves with a possibility of a timely rough prediction of the cartilage damage and probably making smarter decisions for invasive interventions.

Enrolling people of color to evaluate a practice intervention: lessons from the shared decision-making for atrial fibrillation (SDM4AFib) trial

BackgroundTrial recruitment of Black, indigenous, and people of color (BIPOC) is key for interventions that interact with socioeconomic factors and cultural norms, preferences, and values. We report on our experience enrolling BIPOC participants into a multicenter trial of a shared decision-making intervention about anticoagulation to prevent strokes, in patients with atrial fibrillation (AF).MethodsWe enrolled patients with AF and their clinicians in 5 healthcare systems (three academic medical centers, an urban/suburban community medical center, and a safety-net inner-city medical center) located in three states (Minnesota, Alabama, and Mississippi) in the United States. Clinical encounters were randomized to usual care with or without a shared decision-making tool about anticoagulation.AnalysisWe analyzed BIPOC patient enrollment by site, categorized reasons for non-enrollment, and examined how enrollment of BIPOC patients was promoted across sites.ResultsOf 2247 patients assessed, 922 were enrolled of which 147 (16%) were BIPOC patients. Eligible Black participants were significantly less likely (p < .001) to enroll (102, 11%) than trial-eligible White participants (185, 15%). The enrollment rate of BIPOC patients varied by site. The inclusion and prioritization of clinical practices that care for more BIPOC patients contributed to a higher enrollment rate into the trial. Specific efforts to reach BIPOC clinic attendees and prioritize their enrollment had lower yield.ConclusionsBest practices to optimize the enrollment of BIPOC participants into trials that examined complex and culturally sensitive interventions remain to be developed. This study suggests a high yield from enrolling BIPOC patients from practices that prioritize their care.Trial registrationClinicalTrials.gov (NCT02905032).

Paramedic use of the Physician Order for Life-Sustaining Treatment (POLST) for medical intervention and transportation decisions

BackgroundPhysician Order for Life-Sustaining Treatment forms (POLST) exist in some format in all 50 states. The objective of this study is to determine paramedic interpretation and application of the California POLST for medical intervention and transportation decisions.MethodsThis study used a prospective, convenience sample of California Bay Area paramedics who reviewed six fictional scenarios of patients and accompanying mock POLST forms. Based on the clinical case and POLST, paramedics identified medical interventions that were appropriate (i.e. non-invasive positive pressure airway) as well as transportation decisions (i.e. non-transport to the hospital against medical advice). EMS provider confidence in their POLST interpretation was also assessed.ResultsThere were 118 paramedic participants with a mean of 13.3 years of EMS experience that completed the survey. Paramedics routinely identified the selected medical intervention on a patients POLST correctly as either comfort focused, selective or full treatment (113-118;96%-100%). For many clinical scenarios, particularly when a patient’s POLST indicated comfort focused treatment, paramedics chose to use online medical oversight through base physician contact (68-73;58%-62%). In one case, a POLST indicated “transport to hospital only if comfort needs cannot be met in current location”, 13 (14%) paramedics elected to transport the patient anyway and 51 (43%) chose “Non-transport, Against Medical Advice”. The majority of paramedics agreed or strongly agreed that they knew how to use a POLST to decide which medical interventions to provide (106;90%) and how to transport a patient (74;67%). However, after completing the cases, similar proportions of paramedics agreed (42;36%), disagreed (43;36%) or were neutral (30;25%) when asked if they find the POLST confusing.ConclusionThe POLST is a powerful tool for paramedics when caring patients with serious illness. Although paramedics are confident in their ability to use a POLST to decide appropriate medical interventions, many still find the POLST confusing particularly when making transportation decisions. Some paramedics rely on online medical oversight to provide guidance in challenging situations. Authors recommend further research of EMS POLST utilization and goal concordant care, dedicated paramedic POLST education, specific EMS hospice and palliative care protocols and better nomenclature for non-transport in order to improve care for patients with serious illness.

Comparing the diagnostic accuracy of modified RIPASA and MASS in patients diagnosed with acute appendicitis in Suez Canal University Hospital Emergency Department: a cross-sectional study

IntroductionAcute appendicitis is the most common surgical condition presented in emergency departments globally. It is also the most common cause of abdominal pain treated surgically, with a lifetime risk of 7%. Recent studies show MASS to be easy, simple and cheap diagnostic tool for supporting the diagnosis of acute appendicitis.The modified RIPASA scoring system includes more parameters than MASS and the latter did not contain certain parameters. These parameters are shown to add to the accuracy of modified RIPASA over MASS especially in Asian population.Aim of this studyThe aim of the study was to improve the diagnosis of acute appendicitis in order to lower the negative appendectomy rates.Patients & methodsThis is cross sectional study, the study included 40 patients presented to the emergency department at Suez Canal University hospital with abdominal pain and suspected clinically as acute appendicitis. Then the decision of surgical intervention was made by surgeons, who were blinded for our study, based on their clinical judgment. Then both scores were calculated for all patients and other clinical data were obtained from patients after accepting being included in our study with an informed consent.After operations, the operating theatre records were obtained and cases pathological investigation of the appendices was done. Then the sensitivity, specificity, positive and negative predictive values were calculated and so the diagnostic accuracy for both scoring systems.ResultsClinically, all the patients were suffering acute right iliac fossa tenderness (100%), rebound tenderness (90%), and nausea/ vomiting (70%). Only 45% had elevated White blood count and 55% had negative urine analysis.Histopathological analysis of appendices of the studied patients showed that 40% of the patients had suppurative appendicitis, one quarter of them had catarrhal appendicitis and only 20% had complicated perforated appendicitis. Meanwhile, about 15% had normal (negative) appendix. Modified RIPASA showed a good discriminative ability in our study where the area under the curve for modified RIPASA was 0.902 (95% CI: 0.798 – 1.00) (p = 0.002). Moreover, a value of 8.5 or higher was found to be the best cut-off point to predict acute appendicitis among patient suspected clinically as acute appendicitis with sensitivity = 70.6%, specificity = 100%, positive predictive value of 100%, and negative predictive value of 37.5% and 75% accuracy.The best cut-off score to diagnose acute appendicitis in our sample based on MASS was fixed at 5.5, where the sensitivity of the MASS reached 47.1%, with specificity of 33.3%, positive predictive value of 80%, negative predictive value of 10% and accuracy 45%.ConclusionThe modified RIPASA score is the best diagnostic scoring system for acute appendicitis if compared to the modified Alvarado score, with the former achieving significantly higher sensitivity and diagnostic accuracy. Modified RIPASA was concluded to be a more applicable and useful score. Negative appendicectomy rates can also be avoided by using modified RIPASA score.

Cerebral abscess as a neurosurgical emergency in Eisenmenger syndrome: illustrative case.

Eisenmenger syndrome caused by severe pulmonary arterial hypertension in congenital heart disease can cause multisystemic involvement and is a risk factor for development of cerebral abscess. Cerebral abscess, if not detected and treated in a timely manner, can present as acute neurosurgical emergency. The authors reported a case of cerebral abscess in a patient with Eisenmenger syndrome. The patient presented with acute neurological deterioration with mass effect and cerebral infarcts and received emergency neurosurgical intervention. A further literature search was done to identify prior reported cases of cerebral abscess with Eisenmenger syndrome. Patients with Eisenmenger syndrome have compromised cardiorespiratory status, and decision for neurosurgical intervention should be given careful consideration. Multidisciplinary team management along with preoperative optimization of the patient should be used.

Could Purposefully Engineered Native Grassland Gardens Enhance Urban Insect Biodiversity?

Progress is required in response to how cities can support greater biodiversity. This calls for more research on how landscape designers can actively shape urban ecologies to deliver context-specific empirical bases for green space intervention decisions. Design experiments offer opportunities for implemented projects within real-world settings to serve as learning sites. This paper explores preliminary ecological outcomes from a multidisciplinary team on whether purposefully engineered native grassland gardens provide more habitat functions for insects than mainstream gardens in the City of Tshwane, South Africa. Six different sites were sampled: two recently installed native grassland garden interventions (young native), two contemporary non-native control gardens (young non-native) on the same premises and of the same ages as the interventions, one remnant of a more pristine native grassland reference area (old native), and one long-established, non-native reference garden (old non-native). Plant and insect diversity were sampled over one year. The short-term findings suggest that higher plant beta diversity (species turnover indicating heterogeneity in a site) supports greater insect richness and evenness in richness. Garden size, age, and connectivity were not clear factors mediating urban habitat enhancement. Based on the preliminary results, the researchers recommend high native grassland species composition and diversity, avoiding individual species dominance, but increasing beta diversity and functional types when selecting garden plants for urban insect biodiversity conservation in grassland biomes.

Machine Learning Prediction of Hypoglycemia and Hyperglycemia From Electronic Health Records: Algorithm Development and Validation.

BackgroundAcute blood glucose (BG) decompensations (hypoglycemia and hyperglycemia) represent a frequent and significant risk for inpatients and adversely affect patient outcomes and safety. The increasing need for BG management in inpatients poses a high demand on clinical staff and health care systems in addition.ObjectiveThis study aimed to generate a broadly applicable multiclass classification model for predicting BG decompensation events from patients’ electronic health records to indicate where adjustments in patient monitoring and therapeutic interventions are required. This should allow for taking proactive measures before BG levels are derailed.MethodsA retrospective cohort study was conducted on patients who were hospitalized at a tertiary hospital in Bern, Switzerland. Using patient details and routine data from electronic health records, a multiclass prediction model for BG decompensation events (<3.9 mmol/L [hypoglycemia] or >10, >13.9, or >16.7 mmol/L [representing different degrees of hyperglycemia]) was generated based on a second-level ensemble of gradient-boosted binary trees.ResultsA total of 63,579 hospital admissions of 38,250 patients were included in this study. The multiclass prediction model reached specificities of 93.7%, 98.9%, and 93.9% and sensitivities of 67.1%, 59%, and 63.6% for the main categories of interest, which were nondecompensated cases, hypoglycemia, or hyperglycemia, respectively. The median prediction horizon was 7 hours and 4 hours for hypoglycemia and hyperglycemia, respectively.ConclusionsElectronic health records have the potential to reliably predict all types of BG decompensation. Readily available patient details and routine laboratory data can support the decisions for proactive interventions and thus help to reduce the detrimental health effects of hypoglycemia and hyperglycemia.

Predictive Scoring for Recurrent Patellar Instability After a First-time Patellar Dislocation.

Patellofemoral instability is a common acute knee injury seen in the pediatric population. First-time patellar dislocations usually undergo conservative management, but ~15% to 80% of patients experience recurrent instability. This study aims to develop a prediction model using radiographic parameters of the patellofemoral joint seen on computed tomography scans in different degrees of knee flexion, to determine the risk of recurrence after the first episode of patellofemoral instability. A 12-year retrospective case-control study was performed. All patients in a single institution aged 18 years or younger who had a computed tomography patellar tracking scan performed for patellar instability were included. Predictors included in the score were determined through backward logistic regression and compared using receiver operating characteristic curve analysis. This study revealed that recurrent dislocation in first-time patellofemoral dislocation could be accurately predicted using the prediction score that consisted of age, tibial tubercle-trochlear groove distance and congruence angle at 10- and 20-degree flexion. The sensitivity of the score was 100% and specificity was 73.3%. Three diagnostic zones were identified and used to categorize patients into low-, intermediate-, and high-probability groups. This study presented a scoring system that incorporated radiographic knee kinematics in the risk assessment for recurrent patellofemoral instability for patient stratification. The scoring system could guide the decision for early surgical intervention after the first-episode patellofemoral dislocation for patients at high risk of recurrent patellofemoral dislocation.

Effectiveness and cost-effectiveness of an intervention to improve Initial Medication Adherence to treatments for cardiovascular diseases and diabetes in primary care: study protocol for a pragmatic cluster randomised controlled trial and economic model (the IMA-cRCT study)

BackgroundBetween 2 and 43% of patients who receive a new prescription in PC do not initiate their treatments. Non-initiation is associated with poorer clinical outcomes, more sick leave and higher costs to the healthcare system. Existing evidence suggests that shared decision-making positively impacts medication initiation. The IMA-cRCT assesses the effectiveness of the IMA intervention in improving adherence and clinical parameters compared to usual care in patients with a new treatment for cardiovascular disease and diabetes prescribed in PC, and its cost-effectiveness, through a cRCT and economic modelling.MethodsThe IMA intervention is a shared decision-making intervention based on the Theoretical Model of Non-initiation. A cRCT will be conducted in 24 PC teams in Catalonia (Spain), randomly assigned to the intervention group (1:1), and community pharmacies in the catchment areas of the intervention PC teams. Healthcare professionals in the intervention group will apply the intervention to all patients who receive a new prescription for cardiovascular disease or diabetes treatment (no other prescription from the same pharmacological group in the previous 6 months). All the study variables will be collected from real-world databases for the 12 months before and after receiving a new prescription. Effectiveness analyses will assess impact on initiation, secondary adherence, cardiovascular risk, clinical parameters and cardiovascular events. Cost-effectiveness analyses will be conducted as part of the cRCT from a healthcare and societal perspective in terms of extra cost per cardiovascular risk reduction and improved adherence; all analyses will be clustered. Economic models will be built to assess the long-term cost-effectiveness of the IMA intervention, in terms of extra cost for gains in QALY and life expectancy, using clinical trial data and data from previous studies.DiscussionThe IMA-cRCT represents an innovative approach to the design and evaluation of behavioural interventions that use the principles of complex interventions, pragmatic trials and implementation research. This study will provide evidence on the IMA intervention and on a new methodology for developing and evaluating complex interventions. The results of the study will be disseminated among stakeholders to facilitate its transferability to clinical practice.Trial registrationClinicalTrials.gov, NCT05026775. Registered 30th August 2021.

Impact of mobility based network on COVID-19 spread

ABSTRACT COVID-19 has had a strong impact on this world. With the spreading of the virus and the implementation of various mitigation measures, the pandemic has indubitably upended our way of living. Research indicates that mobility is one of the key reasons of the spread. The purpose of this paper is to provide a suitable mobility measure based on intra-county and inter-county movements on the spreading of COVID-19 in the United States. Deviating from the extant research, which measures mobility by the average distance people travel, we operationalise mobility by the number of trips made. We further weigh them based on the current caseload, as the spread will not only depend on how many people are moving but also the proportion of infectious people within them. We also distinguish such trips based on their origin and destination, as that may help in taking appropriate policy decisions for intervention.