One-point Improvement Research Articles

Treatment response in patients with clinical and supportive laboratory features of chronic inflammatory demyelinating polyneuropathy without demyelinative findings on nerve conduction studies: A retrospective study.

Not all patients with chronic inflammatory demyelinating polyneuropathy (CIDP) have evidence of demyelination on nerve conduction studies (NCS). Patients with "supportive" evidence of CIDP on cerebrospinal fluid (CSF), magnetic resonance imaging (MRI), ultrasound (US), or nerve biopsy but not on NCS, often receive immunomodulating therapy. We evaluated the treatment response of patients with clinical and supportive features of CIDP lacking NCS evidence of demyelination. Retrospective chart review was conducted on 232 patients who met CIDP clinical criteria and were treated with disease-modifying therapy. Patients included did not have NCS criteria of demyelination, but did have supportive CSF, MRI, or US findings consistent with CIDP. A positive treatment response was defined as at least a one-point improvement in the modified Rankin scale (mRS), or a four-point increase in the Medical Research Council sum score (MRCSS). Twenty patients met criteria: 17 of the 18 (94%) patients with CSF protein >45 mg/dL, 6 of the 14 (43%) with MRI lumbosacral root or plexus enhancement, and 4 of the 6 (67%) with enlarged proximal nerves on US. Eighteen patients received intravenous immunoglobulin, 10 corticosteroids, one plasma exchange, and six other immunomodulatory therapies. Twelve patients had a positive treatment response on the MRCSS or mRS. The presence of MRI lumbosacral root or plexus enhancement was associated with a positive treatment response. A trial of immunomodulating treatment should be considered for patients with clinical features of CIDP in the absence of NCS evidence of demyelination, particularly when there is MRI lumbosacral root or plexus enhancement.

A pragmatic randomised controlled trial of the effectiveness and cost-effectiveness of Well Parent Japan in routine care in Japan: The training and nurturing support for mothers (TRANSFORM) study.

Well Parent Japan (WPJ) is a new hybrid group parent training programme combining sessions to improve mothers' psychological well-being with a culturally adapted version of the New Forest Parenting Programme (NFPP). This study investigates the effectiveness and cost-effectiveness of WPJ against treatment as usual (TAU) within Japanese child mental health services. TRANSFORM was a pragmatic multi-site randomised controlled trial (RCT) with two parallel arms. Altogether 124 mothers of 6-12-year-old children with DSM-5 ADHD were randomised to WPJ (n = 65) or TAU (n = 59). Participants were assessed at baseline, post-treatment and three-month follow-up. The primary outcome was parent-domain stress following intervention. Secondary outcomes included maternal reports of child-domain stress, parenting practices, parenting efficacy, mood, family strain, child behaviour and impairment. Objective measures of the parent-child relationship were collected at baseline and post-treatment. Data analysis was intention to treat (ITT) with treatment effects quantified through analysis of covariance (ANCOVA) via multilevel modelling. An incremental cost-effectiveness ratio (ICER) assessed WPJ's cost-effectiveness. WPJ was superior to TAU in reducing parent-domain stress post-treatment (adjusted mean difference = 5.05, 95% CI 0.33 to 9.81, p = .036) and at follow-up (adjusted mean difference 4.82, 95% CI 0.09 to 9.55, p = .046). Significant WPJ intervention effects were also observed for parenting practices, parenting efficacy and family strain. WPJ and TAU were not significantly different post-intervention or at follow-up for the other secondary outcomes. The incremental cost of WPJ was 34,202 JPY (315.81 USD). The probability that WPJ is cost-effective is 74% at 10,000 JPY (USD 108.30) per one-point improvement in parenting stress, 92% at 20,000 JPY (216.60 USD). The programme was delivered with high fidelity and excellent retention. WPJ can be delivered in routine clinical care at modest cost with positive effects on self-reported well-being of the mothers, parenting practices and family coping. WPJ is a promising addition to psychosocial interventions for ADHD in Japan.

Do private rental tenants pay for energy efficiency?: The dynamics of green premiums and brown discounts

ABSTRACT The rental market, notably within the UK, is facing increased scrutiny with the tightening of regulation in relation to energy performance and the increases in energy costs and rental unaffordability. Whilst a sizeable volume of research has examined the pricing effects of EPCs and house prices, scrutiny of this relationship within the private rental sector remains more embryonic. This study, using 2,914 transactions for Northern Ireland, extends the traditional analysis beyond the conditional mean estimate by examining the quantiles of the relationship between EPCs and rental prices. The findings provide evidence of a rental premium of 0.2% for a one-point improvement in energy efficiency. In terms of EPC ratings, we find premiums for B- and C-rated dwellings of 8.2% and 2.4% and also discount effects for E, F and G-rated properties ranging between 3.9%-5.5%. The quantile findings exhibited a parabolic effect across the price distribution demonstrating the lowest and highest priced properties to comprise higher price premiums of 13% and 16% for B-rated dwellings, however more pronounced discount effects for F- and G-rated properties at the lowest and highest deciles. The findings provide evidence to help alleviate the split-incentive problem between landlords and tenants within the UK.

Implementation fidelity, student outcomes, and cost-effectiveness of train-the-trainer strategies for Masters-level therapists in urban schools: results from a cluster randomized trial

BackgroundLittle is known about the effectiveness and cost-effectiveness of train-the-trainer implementation strategies in supporting mental health evidence-based practices in schools, and about the optimal level of support needed for TT strategies.MethodsThe current study is part of a larger type 2 hybrid cluster randomized controlled trial. It compares two train-the-trainer strategies, Train-the-Trainer (TT) and Train-the-Trainer plus ongoing consultation for trainers (TT +) on the delivery of a group cognitive behavioral treatment protocol for anxiety disorders. Participants were 33 therapists, 29 supervisors, and 125 students who were at risk for anxiety disorders from 22 urban schools. Implementation outcomes were implementation fidelity and treatment dosage. Student outcomes were child- and parent-reported symptoms of anxiety, child-reported symptoms of depression, and teacher-reported academic engagement. We estimated the cost of implementing the intervention in each condition and examined the probability that a support strategy for supervisors (TT vs TT +) is a good value for varying values of willingness to pay.ResultsTherapists in the TT and TT + conditions obtained similarly high implementation fidelity and students in the conditions received similar treatment dosages. A mixed effects modeling approach for student outcomes revealed time effects for symptoms of anxiety and depression reported by students, and emotional disaffection reported by teachers. There were no condition or condition × times effects. For both conditions, the time effects indicated an improvement from pre-treatment to post-treatment in symptoms of anxiety and depression and academic emotional engagement. The average cost of therapist, supervisor, and consultant time required to implement the intervention in each condition was $1002 for TT and $1431 for TT + (p = 0.01). There was a greater than 80% chance that TT was a good value compared to TT + for all values of willingness to pay per one-point improvement in anxiety scores.ConclusionsA TT implementation approach consisting of a thorough initial training workshop for therapists and supervisors as well as ongoing supervision for therapists resulted in adequate levels of fidelity and student outcomes but at a lower cost, compared to the TT + condition that also included ongoing external expert consultation for supervisors.Trial registrationClinicalTrials.gov identifier: NCT02651402.

Is communication key in stroke rehabilitation and recovery? National linked stroke data study

ABSTRACT Background Information on the characteristics or long-term outcomes of people with communication support needs post-stroke is limited. We investigated associations between communication gains in rehabilitation and long-term outcomes (quality-of-life [EuroQOL-ED-3 L], mortality) by post-stroke communication support need status. Methods Retrospective cohort study using person-level linked data from the Australian Stroke Clinical Registry and the Australasian Rehabilitation Outcomes Centre (2014–2017). Communication support needs were assessed using the Functional Independence Measure™ comprehension and expression items recorded on admission indicated by scores one (total assistance) to five (standby prompting). Multivariable multilevel and Cox regression models were used to determine associations with long-term outcomes. Results Of 8,394 patients who received in-patient rehabilitation after stroke (42% female, median age 75.6 years), two-thirds had post-stroke communication support needs. Having aphasia (odds ratio [OR] 4.34, 95% CI 3.67–5.14), being aged ≥65 years (OR 1.21, 95% CI 1.08–1.36), greater stroke severity (unable to walk on admission; OR 1.48, 95% CI 1.32–1.68) and previous stroke (OR 1.25, 95% CI 1.11–1.41) were associated with increased likelihoods of having communication support needs. One-point improvement in FIM™ expression was associated with reduced likelihood of self-reporting problems related to mobility (OR 0.85, 95% CI: 0.80–0.90), self-care (OR 0.79, 95% CI: 0.74–0.86) or usual activities (OR 0.84, 95% CI: 0.75–0.94) at 90–180 days. Patients with communication support needs had greater mortality rates within one-year post-stroke (adjusted hazard ratio 1.99, 95% CI: 1.65–2.39). Conclusions Two-thirds of patients with stroke require communication support to participate in healthcare activities. Establishing communication-accessible stroke care environments is a priority.

Occupational Characteristics Associated with Professional Fulfillment and Burnout Among U.S. Physiatrists.

Multiple national studies suggest that, among physicians, physiatrists are at increased risk for occupational burnout. To identify characteristics of the work environment associated with professional fulfillment and burnout among U.S. physiatrists. Between May and December 2021, a mixed qualitative and quantitative approach was used to identify factors contributing to professional fulfillment and burnout in physiatrists. Online interviews, focus groups, and survey. Physiatrists in the AAPM&R Membership Masterfile. Burnout and professional fulfillment assessed using the Stanford Professional Fulfillment Index. Individual interviews with 21 physiatrists were conducted to identify domains that contributed to professional fulfillment followed by focus groups for further definition. Based on themes identified, scales were identified or developed to evaluate: control over schedule (6 items; Cronbach's alpha=0.86); integration of physiatry into patient care (3 items; Cronbach's alpha=0.71); personal-organizational values alignment (3 items; Cronbach's alpha=0.90); meaningfulness of physiatrist clinical work (6 items; Cronbach's alpha=0.90); teamwork and collaboration (3 items; Cronbach's alpha=0.89). Of 5760 physiatrists contacted in the subsequent national survey, 882 (15.4%) returned surveys (median age 52 years; 46.1% women). Overall, 42.6% (336 of 788) experienced burnout and 30.6% (244 of 798) had high levels of professional fulfillment. In multivariable analysis, each one-point improvement in control over schedule (odds ratio [OR]=1.96; 95% confidence interval [CI]=1.45-2.69), integration of physiatry into patient care (OR= 1.77; 95% CI=1.32-2.38), personal-organizational values alignment (OR=1.92; 95% CI=1.48-2.52), meaningfulness of physiatrist clinical work (OR=2.79; 95% CI=1.71-4.71) and teamwork and collaboration score (OR=2.11; 95% CI=1.48-3.03) was independently associated with higher likelihood of professional fulfillment. Control over schedule, optimal integration of physiatry into clinical care, personal-organizational values alignment, teamwork, and meaningfulness of physiatrist clinical work are strong and independent drivers of occupational well-being in U.S. physiatrists. Variation in these domains by practice setting and subspecialty suggests tailored approaches are needed to promote professional fulfillment and reduce burnout among U.S. physiatrists.

Political determinants of health: (re) examining the role of governance in reducing maternal mortality.

Given change in the universal developmental agenda and the quality of governance in the last two decades, this paper re-examines the relationship between governance, health expenditure and maternal mortality using panel data for 184 countries from 1996 to 2019. By employing the 'dynamic panel data regression model', the study reveals that a one-point improvement in the governance index decreases maternal mortality by 10-21%. We also find that good governance can better translate health expenditure into improved maternal health outcomes through effective allocation and equitable distribution of available resources. These results are robust to alternative instruments, alternative dependent variables (such as infant mortality rate and life expectancy), estimation by different governance dimensions and at the sub-national level. Additional findings using 'Quantile regression' estimates show that the quality of governance matters more than the health expenditure in countries with a higher level of maternal mortality. While the 'Path regression' analysis exhibits the specific direct and indirect mechanisms through which the causal inference operates between governance and maternal mortality.

Occupational Characteristics Associated With Professional Fulfillment and Burnout Among US Physiatrists.

Multiple national studies suggest that among physicians, physiatrists are at increased risk for occupational burnout. The aim of the study is to identify characteristics of the work environment associated with professional fulfillment and burnout among US physiatrists. Between May and December 2021, a mixed qualitative and quantitative approach was used to identify factors contributing to professional fulfillment and burnout in physiatrists. Online interviews, focus groups, and survey were conducted. The participants are physiatrists in the American Academy of Physical Medicine and Rehabilitation Membership Masterfile. Burnout and professional fulfillment were assessed using the Stanford Professional Fulfillment Index. Individual interviews with 21 physiatrists were conducted to identify domains that contributed to professional fulfillment followed by focus groups for further definition. Based on themes identified, scales were identified or developed to evaluate: control over schedule (6 items, Cronbach α = 0.86); integration of physiatry into patient care (3 items, Cronbach α = 0.71); personal-organizational values alignment (3 items, Cronbach α = 0.90); meaningfulness of physiatrist clinical work (6 items, Cronbach α = 0.90); teamwork and collaboration (3 items, Cronbach α = 0.89). Of 5760 physiatrists contacted in the subsequent national survey, 882 (15.4%) returned surveys (median age, 52 yrs; 46.1% women). Overall, 42.6% (336 of 788) experienced burnout and 30.6% (244 of 798) had high levels of professional fulfillment. In multivariable analysis, each one-point improvement in control over schedule (odds ratio = 1.96; 95% confidence interval = 1.45-2.69), integration of physiatry into patient care (odds ratio = 1.77; 95% confidence interval = 1.32-2.38), personal-organizational values alignment (odds ratio = 1.92; 95% confidence interval = 1.48-2.52), meaningfulness of physiatrist clinical work (odds ratio = 2.79; 95% confidence interval = 1.71-4.71), and teamwork and collaboration score (odds ratio = 2.11; 95% confidence interval = 1.48-3.03) was independently associated with higher likelihood of professional fulfillment. Control over schedule, optimal integration of physiatry into clinical care, personal-organizational values alignment, teamwork, and meaningfulness of physiatrist clinical work are strong and independent drivers of occupational well-being in US physiatrists. Variation in these domains by practice setting and subspecialty suggests that tailored approaches are needed to promote professional fulfillment and reduce burnout among US physiatrists.

Abstract WP158: Impact Of Atrial Fibrillation On Clinical Outcomes After Endovascular Thrombectomy: A Post-Hoc Analysis Of The Defuse-3 Trial

Introduction: Previous studies have failed to show an interaction between known atrial fibrillation (AF) and treatment effect of endovascular thrombectomy (EVT) performed within 6 hours of time last known well. However, it is not known if these findings apply to patients treated beyond 6 hours. The objective of the present study is to determine if a known diagnosis of AF exhibits effect modification on the association between treatment (EVT vs. medical therapy) and outcomes in patients >6 hours from time last known well. Methods: We performed a post hoc analysis of the DEFUSE-3 trial investigating the functional outcomes in study participants stratified by AF status. Our primary endpoint was functional outcome as measured by the modified Rankin Scale (mRS) score. We constructed an ordinal logistic regression model to determine the association between EVT/medical therapy and mRS in subgroups by AF status. Secondary endpoints include functional independence (mRS 0-2 vs. 3-6), final infarct volume, sICH, and mortality, examined via binary logistic or linear regression. We fit treatment modality*AF interaction terms. Results: Among 182 participants, 62 had AF (34 randomized to EVT) and 120 did not have AF (58 randomized to EVT). Patients with AF were older (median: 76.5 vs 66.5), presented with a higher NIHSS (median: 17 vs 16), and received IV tPA less frequently (4.8% vs. 12.5%). In patients with AF, the odds of a one-point improvement in mRS in EVT vs. medical therapy were 4.56 (95% CI: 1.79-12.17), while in patients without AF, the odds were 2.42 (95% CI: 1.27-4.67). We found no significant interaction between AF and EVT for the primary or secondary endpoints. Conclusion: Our study did not show a significant interaction between AF status and EVT, with the caveat that the study may be underpowered to detect such an effect. The trend for greater treatment effect should be evaluated in larger studies.

The Pain Clinic for Older People.

Multidisciplinary pain clinics have an established role in the management of persistent pain, but there is little evidence to support this approach in an older population. This study describes the characteristics and pain outcomes of patients attending a pain clinic designed exclusively for older people. A retrospective audit was performed of outcomes of the Pain Clinic for Older People (PCOP) in 2015-2019. Response to treatment was determined by change in Brief Pain Inventory (BPI) scores at initial attendance and after a treatment program. Clinically meaningful improvement was defined by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) consensus criteria of ≥30% improvement in average pain and one-point improvement in pain interference. Results were compared with the national benchmark collated by the electronic Persistent Pain Outcomes Collaboration (ePPOC), which reports the combined results from 67 participating Australian and New Zealand pain services. Patients attending the PCOP had a mean age of 80.5 years and had high rates of frailty (84%), cognitive impairment (30%), and multimorbidity. Significant reductions in BPI average pain and BPI pain interference scores were achieved. Clinically meaningful improvement in BPI average pain was achieved in 63% of patients attending the PCOP who were 65-74 years of age and in 46% of patients who were ≥75 years of age, which met the national benchmark set by ePPOC of 40% for both age groups. Clinically meaningful improvement in BPI pain interference was achieved in 69% of those attending the PCOP who were 65-74years of age and in 66% of those who were ≥75 years of age, comparable to the ePPOC benchmark of 71% and 65% for the respective age groups. PCOP clients achieved significant and meaningful improvements in their pain outcomes that satisfied the national benchmark. Advanced age, cognitive impairment, frailty and multimorbidity should not be regarded as barriers to benefit from a pain clinic specifically designed for older people.

A Prospective, Randomized, Double-Blind, Vehicle-Controlled Study Evaluating the Efficacy, Safety, and Patient Satisfaction of Tretinoin 0.05% Lotion for Chest Rejuvenation.

There is increasing interest in non-invasive options for chest rejuvenation with minimal to no downtime. Topical retinoids have long been used to correct photoaging due to their ability to promote epidermal hyperplasia, matrix metalloproteinase inhibition, collagen synthesis, and dispersion of melanin granules. Topical retinoid use is often limited by the ensuing irritation that occurs with initial use and resolves after about one month. Vehicle of delivery is a key factor to consider in order to minimize irritation and increase patient satisfaction. Micronized tretinoin 0.05% suspended in a polymer emulsion of hydrating ingredients (sodium hyaluronate, soluble collagen, and glycerin) is designed to aid in reducing irritation while ensuring uniform drug delivery. The primary objective of our study is to evaluate the safety, efficacy, and patient satisfaction of tretinoin 0.05% lotion for nonprocedural photorejuvenation of the chest. A total of 29 patients completed the trial, average age of 54.42 years (37-66 years old), Fitzpatrick II-IV skin types. Both the active and vehicle groups showed 30-40% improvement at day 180 according to the blinded evaluator mean percent improvement. Investigator global aesthetic improvement scale also trended towards improvement in both groups, with most patients exhibiting "improvement." Both the active and vehicle groups showed a significant change over time according to the nine-point photodamage and wrinkling scale, P<0.001 and P=0.007 (single factor ANOVA), respectively. The Fabi Bolton Wrinkle Scale also demonstrated improvement from screening to day 180; however, there was no statistical significance at any time point. At day 90, the active group had statistically significantly more erythema than the vehicle group (P<0.001), although both groups were only mild. At day 180, erythema decreased in both groups with the active group being similar to the vehicle group, 0.50±0.73 versus 0.09±0.30, respectively. Subjects in both the active and vehicle groups were equally satisfied at day 180, (2.38±1.15 in the active group versus 2.30±1.16 in the treatment group), with most subjects feeling "satisfied" with their results by day 180. This was also reflected in the subject global aesthetic improvement scale with most subjects noting noticeable improvement in the appearance of their chest from day 30 to day 180. Tretinoin 0.05% lotion delivered in a proprietary blend of hydrating ingredients offers a safe and efficacious option that has minimal downtime for patients seeking non-procedural photo-rejuvenation of the chest. The proprietary vehicle, containing hyaluronic acid, glycerin, and collagen, was crucial in minimizing irritation and producing at least a one-point improvement according to the 9 point photodamage scale and 30-40% improvement in photodamage as noted by the blinded evaluator percent improvement score in both the vehicle and active groups. J Drugs Dermatol. 2022;21(6):645-652. doi:10.36849/JDD.6658.

Calcium Hydroxyapatite Filler With Integral Lidocaine CaHA (+) for Soft Tissue Augmentation: Results from an Open-Label Multicenter Clinical Study.

Soft tissue augmentation with calcium hydroxylapatite (CaHA) is a versatile technique for line filling, skin tightening, lifting, contouring, and volumizing. The present study was designed to confirm safety and effectiveness of the product with lidocaine (CaHA (+)) in a holistic treatment of nasolabial folds (NLFs), marionette lines, and/or cheeks. A total of 207 subjects with moderate to severe facial volume deficit were treated with CaHA(+) in this open-label study. Effectiveness assessments included Merz Aesthetics Scales® (MAS), investigator- and subject-assessed Global Aesthetic Improvement Scales (iGAIS/sGAIS), and FACE-QTM questionnaires. Responder rates were defined as at least one-point improvement on MAS according to blinded rating. Safety was assessed through adverse event reporting. Primary endpoint was evaluated 12 weeks after last injection. Responder rates were 93.6%, 88.7%, and 81.9% in the NLFs, marionette lines, and cheeks, respectively, and were statistically significant above the pre-defined 60% threshold (P< 0.0001). Investigator- and subject-assessed GAIS were consistent and showed high rates of improvement throughout the study, with peak values of 98.0% at week 4 on iGAIS and 93.5% at 12 weeks after last injection on sGAIS. After 18 months, the majority of subjects (52.5%) still perceived improvement via sGAIS. Moreover, total FACE-Q scores demonstrated high subject satisfaction with treatment. All related treatment emergent adverse events were transient and expected injection-site reactions mostly of mild to moderate intensity. CaHA (+) has demonstrated safety and effectiveness in the treatment of NLFs, marionette lines, and cheek volume loss in real-life conditions up to 18 months. J Drugs Dermatol. 2022;21(5):481-487. doi:10.36849/JDD.6737.

Change in Cardiovascular Health Metrics and Risk for Proteinuria Development: Analysis of a Nationwide Population-Based Database

Introduction: Evidence is lacking regarding the association between cardiovascular health (CVH) metrics and the risk for proteinuria. Methods: We performed this observational cohort study including 865,087 participants (median age, 46 years, 60.7% men) with negative proteinuria at the initial health check-up, who underwent repeated health check-ups within 4 years. Ideal CVH metrics included nonsmoking, body mass index <25 kg/m², physical activity at goal, eating breakfast, blood pressure <120/80 mm Hg, fasting plasma glucose <100 mg/dL, and total cholesterol <200 mg/dL. The primary outcome was incident proteinuria, defined as ≥1 + on the urine dipstick test. Results: Participants were categorized as having low CVH metrics defined as having 0–2 ideal CVH metrics (n = 84,439), middle CVH metrics defined as having 3–4 ideal CVH metrics (n = 335,773), and high CVH metrics defined as having 5–7 ideal CVH metrics (n = 444,875). Compared with low CVH metrics, middle CVH metrics (odds ratio (OR): 0.61, 95% CI: 0.59–0.63) and high CVH metrics (OR: 0.45, 95% CI: 0.43–0.46) were associated with a lower risk of proteinuria. The OR of a one-point increase in the ideal number of CVH metrics was 0.83 (95% CI: 0.82–0.83). All CVH metrics components except for ideal total cholesterol were associated with a decreased risk of proteinuria. A one-point improvement in the number of ideal CVH metrics at 1 year after the initial health check-up was associated with a decreased incidence of proteinuria (OR: 0.90, 95% CI: 0.89–0.92). Conclusion: Not only maintaining better CVH metrics but also improving CVH metrics would prevent developing proteinuria in a general population.

An Economic Evaluation of Australia's Newborn Hearing Screening Program: A Within-Study Cost-Effectiveness Analysis.

Hearing loss is one of the most prevalent congenital disorders among children. Many countries have implemented universal newborn hearing screening (UNHS) for the early diagnosis and treatment of hearing loss. Despite widespread implementation, the value for money of UNHS is unclear due to lack of cost and outcomes data from rigorous study designs. The objective of this research is to conduct a within-study cost-effectiveness analysis of UNHS compared with targeted screening (targeting children with risk factors of hearing loss) from the Australian healthcare system perspective. This evaluation is the first economic evaluation to assess the cost-effectiveness of UNHS compared to targeted screening using real-world data from a natural experiment. The evaluation assumed the Australian healthcare system perspective and considered a time horizon of 5 years. Utilities were estimated using responses to the Health Utilities Index Mark III. Screening costs were estimated based on the Victorian Infant Hearing Screening Program. Ongoing costs were estimated based on administrative data, while external data sources were used to estimate costs related to hearing services. Missing data were handled using the multiple imputation method. Outcome measures included quality-adjusted life years (QALYs) and four language and communication-related outcomes: Peabody Picture Vocabulary Test, Wechsler Nonverbal Scale of Ability, Progressive Achievement Test, and comprehensive, expressive, and total language scores based on the Preschool Language Scale. On average, the UNHS cost an extra Australian dollar (A$)22,000 per diagnosed child and was associated with 0.45 more QALYs per diagnosed child compared with targeted screening to 5 years, resulting in an incremental cost-effectiveness ratio (ICER) of A$48,000 per QALY gained. The ICERs for language outcomes lay between A$3,900 (for expressive language score) and A$83,500 per one-point improvement in language score (for Wechsler Nonverbal Scale of Ability). UNHS had a 69% probability of being more cost-effective compared to targeted screening at a willingness to pay threshold of A$60,000 per QALY gained. ICERs were most sensitive to the screening costs. The evaluation demonstrated the usefulness of a within-study economic evaluation to understand the value for money of the UNHS program in the Australian context. Findings from this evaluation suggested that screening costs were the key driver of cost-effectiveness results. Most outcomes were not significantly different between UNHS and targeted screening groups. The ICER may be overestimated due to the short follow-up period. Further research is warranted to include long-term resource use and outcome data, late diagnosis, transition and remission between severity levels, and timing of diagnosis and treatment.

Effect of entecavir plus Ganshuang granule on fibrosis and cirrhosis in patients with chronic hepatitis B.

To investigate the effect of entecavir plus Ganshuang granule (, GSG) on advanced fibrosis and cirrhosis in patients with chronic hepatitis B virus infection. One hundred thirty-five patients were randomly assigned to one of two cohorts: GSG cohort (n = 69) or placebo cohort (n = 66). The GSG cohort received entecavir plus GSG and the placebo cohort received entecavir plus placebo for 48 weeks. Liver biopsy was performed at baseline and between weeks 44 and 48 during this placebo-controlled trial. We assessed histological improvement (greater than a two-point decrease using the Knodell in fl ammatory score and no worsening of the Ishak fibrosis score) and fibrosis regression (a decrease of at least one point in the Ishak fibrosis score). There were 95.7% of patients (66/69) in the GSG cohort and 66.7% (44/66) of patients in the placebo cohort who showed necroin fl ammation improvement. The mean reduction in the Knodell necroinflammatory score was 5.1 and 2.6, respectively. There were 89.9% (62/69) of patients in the GSG cohort and 31.8% (21/66) of patients in the placebo cohort who showed at least a one-point improvement in the Ishak fibrosis score. The mean reduction in the Ishak fibrosis score was 1.7 and 0.4, respectively. Patients with advanced fibrosis and cirrhosis caused by chronic hepatitis B showed more improvement in liver histology in a shorter time after treatment with entecavir plus GSG compared with entecavir plus placebo.

Chronic low-dose intravenous immunoglobulins as steroid-sparing therapy in myasthenia gravis

Intravenous immunoglobulin (IVIg) has been proven beneficial in myasthenic crisis, but their role as maintenance therapy is unclear. The aim of this study was to determine if maintenance therapy with low-dose IVIg improves clinical outcome and may be used as a steroid-sparing agent in myasthenia gravis (MG). We retrospectively reviewed charts of all MG patients treated with IVIg from January 2006 to December 2019. Long-term treatment response to IVIg was assessed by improvement in the Myasthenia Gravis Foundation of America (MGFA) clinical classification scale as primary end point, as well as the ability to reduce the time-weighted average required dose of prednisone as secondary end-point, in a follow-up period of 36months. 109 patients were treated with IVIg. The mean follow-up time was 34.03 ± 5.5months. Sixty-seven patients (61.4%) responded to therapy with at least one-point improvement of the MGFA scale. There was no statistical difference in demographic and clinical characteristics between IVIg responders and non-responders. The mean prednisone dose decreased significantly from 33.1 ± 14.5mg at baseline to 7.2 ± 7.8mg after 36months of IVIg treatment (P < 0.0001), with the greatest effect after 6months (33.1 ± 14.5mg Vs. 17.9 ± 11.7mg; P < 0.0001). In the follow-up period of 36months, most patients (92.5%) remained clinically and pharmacologically stable under chronic IVIg treatment. This retrospective study demonstrates that chronic low-dose IVIg treatment in patients with MG improves clinical outcomes and has a prolonged and significant steroid-sparing effect over a period of 3years.

Abstract P16: Alteplase Within 4.5 Hours via Telemedicine and In-Person for Central or Branch Retinal Artery Occlusion vs Medical Management

Introduction: Central or branch retinal artery occlusion (CRAO/BRAO) results in acute monocular vision loss. Only one prospective study of IV tPA use within 4.5 hours with a recent updated patient-level meta-analysis showed favorable visual outcomes but long-term visual outcomes were not reported. We evaluated the use of IV tPA within 4.5 hours for CRAO/BRAO vs medical management and assessed 90-day visual outcomes. Given the increasing use of telemedicine (TM), we also assessed the diagnostic accuracy of CRAO/BRAO evaluated via TM vs in-person. Methods: Data were retrospectively abstracted for CRAO/BRAO treated with IV tPA vs medical management within a large managed healthcare system. 90-day visual outcomes were reported as Low Vision (no light perception, light perception, hand motion, finger counting) and mean LogMAR, which was converted from Snellen, and classified as normal-mild impairment (LogMAR 0.4-0.5), moderate-severe impairment (LogMAR 0.6-1.3) and blind-low vision (LogMAR &gt;1.3). Visual outcomes were analyzed using the Wilcoxon rank-sum and signed-rank tests. Results: Between 2012-2019, 21 patients received IV tPA within 4.5 hours for presumed CRAO/BRAO vs 34 medically managed. One patient evaluated via TM and one patient evaluated in-person were misdiagnosed and excluded from analysis. Of those accurately diagnosed and treated with IV tPA, 15 were evaluated via TM and 4 in-person. At 90 days, intragroup analysis revealed at least a one-point improvement on the Low Vision scale (68% tPA, p= 0.007 vs 30% non-tPA, p=0.63) and the LogMAR scale (32% tPA, p=0.03 vs 12% non-tPA, p=0.38) with 26% of tPA patients having normal-mild impairment in vision vs 9% in non-tPA patients. Initial to 90-day vison on the Low Vision scale showed visual improvement in the tPA group (p=0.001) and a trend towards improvement on the LogMAR scale (p=0.07). Conclusions: Similar to a recent prospective study with patient level meta-analysis, we found that IV tPA within 4.5 hours for CRAO/BRAO may lead to improved visual outcomes at 90 days compared to medical management. Diagnostic accuracy of CRAO/BRAO was similar irrespective of method of being evaluated via TM or in-person. Our study was limited by small sample size and retrospective design.

108. IMPROVING RESIDENT EDUCATION IN THE NEONATAL INTENSIVE CARE UNIT

Background At the Medical University of South Carolina, the neonatal ICU is known for its high volume of patients. With such high volume, education often is not prioritized. Resident evaluations of the NICU rotation were reviewed from the previous year. Residents perceived education in the NICU as one of the weaknesses of this rotation. Aim Statement Our primary aim was to improve the quality of education as measured by surveys on a Likert scale. Our goal was a one-point improvement (on a 5-point scale) over a six-month period. Our secondary aim was to increase the total number of educational sessions per month in the NICU. Interventions Our interventions were implemented over three PDSA cycles. In the first cycle, we provided neonatology textbooks to residents, set iPhone calendar reminders for residents and fellows to complete weekly educational sessions and provided a checklist to track education. We continued those improvements for cycle 2, with the addition of weekly bedside education. For cycle 3, we added an expectation that each off-service fellow would provide one additional lecture per month. Measures The primary outcome was quality of resident education in the NICU. Residents completed surveys at the end of their rotation to evaluate the education they received. Also, the number of educational sessions per month were documented and a run chart was created. Results Our results showed that there was no change in the quality or quantity of the resident educational experience in the NICU. Regarding the 3 PDSA cycles, 20/22 (91%), 11/30 (37%), and 12/42 (29%) of goal educational activities were completed. Conclusions and Next Steps We surmise that the high clinical volume combined with limited time was the reason this initiative failed to produce change. In addition, we approached potential solutions to the lack of education from a resident and fellow driven perspective. We believe that when the responsibility for education is placed on the residents and fellows, patient care and documentation take precedent over creating educational opportunities. In hindsight, the project may have been more successful with more faculty involvement. The next step will be presenting our data to the MUSC NICU faculty and discussing further changes.

Internal Load Metrics In Division III Men's And Women's Soccer: The Significance Of Sleep Quality

Wearable technology is the number one fitness trend for 2019. Sleep quality (SQ), sleep duration, mood, stress, soreness, and fatigue have been associated with performance in sports through physiological and psychological mechanisms. Division III (DIII) schools are the biggest participant in NCAA. In terms of number of athletes, soccer is the second most popular sport in NCAA. PURPOSE: To investigate the relationship of SQ with sleep duration, mood, stress, soreness, and fatigue in a DIII men’s and women’s soccer team. METHODS: All 56 players agreed to participate (Mage=19.42, SD=1.09). Data were collected using readiness surveying based on the Titan 1+ sensor protocol. Subjective information on SQ, sleep duration, mood, stress, soreness, and fatigue was reported by each athlete before every practice and game. All data, but sleep (in hours), were quantified via a 0-10 visual analog scale (e.g., SQ: 0=Excellent, 10=Poor). In total, 200 assessments took place in pre- and in-season. The analysis consisted of Pearson correlations, t tests, and regression analysis in R. RESULTS: The correlations of SQ with the other variables were: sleep duration (r=-.43), mood (r =.70), stress (r =.62), soreness (r =.53), and fatigue (r =.83). There were no statistically differences between male and female athletes on any of the variables included in the analysis. Therefore, the data were analyzed in aggregate. The regressions were estimated to examine the expected increase in these outcomes for a one-point improvement in reported SQ (e.g., a one-point improvement in SQ is associated with an expected 0.98-point improvement in reported fatigue; p<.001). CONCLUSIONS: On average, the findings indicate a strong relationship between SQ and hours of sleep, mood, stress, fatigue, and soreness in this DIII soccer program. Therefore, there is preliminary evidence to support that all stakeholders may need to focus on SQ strategies (including sleep duration) as means to manipulate several internal load variables that affect performance in sports. Future studies should add external metrics (e.g., speed/sprint/impact metrics), investigate differences between practice and game-day data and Divisions, and collect information from larger samples. Possible limitations include convenience sample and self- reported data.

Treatment of Coronavirus Disease 2019 (COVID-19) Patients with Convalescent Plasma

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, has spread globally, and no proven treatments are available. Convalescent plasma therapy has been used with varying degrees of success to treat severe microbial infections for >100 years. Patients (n = 25) with severe and/or life-threatening COVID-19 disease were enrolled at the Houston Methodist hospitals from March 28, 2020, to April 14, 2020. Patients were transfused with convalescent plasma, obtained from donors with confirmed severe acute respiratory syndrome coronavirus 2 infection who had recovered. The primary study outcome was safety, and the secondary outcome was clinical status at day 14 after transfusion. Clinical improvement was assessed on the basis of a modified World Health Organization six-point ordinal scale and laboratory parameters. Viral genome sequencing was performed on donor and recipient strains. At day 7 after transfusion with convalescent plasma, nine patients had at least a one-point improvement in clinical scale, and seven of those were discharged. By day 14 after transfusion, 19 (76%) patients had at least a one-point improvement in clinical status, and 11 were discharged. No adverse events as a result of plasma transfusion were observed. Whole genome sequencing data did not identify a strain genotype-disease severity correlation. The data indicate that administration of convalescent plasma is a safe treatment option for those with severe COVID-19 disease.