Standard Program Research Articles

Predictors of treatment response trajectories to cognitive behavioral therapy for chronic fatigue syndrome: A cohort study

BackgroundThe response to cognitive behavioral therapy (CBT) for chronic fatigue syndrome (CFS) varies greatly between patients, but predictors of treatment success remain to be elucidated. We aimed to identify patient subgroups based on fatigue trajectory during CBT, identify pre-treatment predictors of subgroup membership, and disentangle the direction of predictor – outcome relationships over time. Methods297 individuals with CFS were enrolled in a standardized CBT program consisting of 17 sessions, with session timing variable between participants. Self-reported levels of fatigue, depressive, anxiety, and somatic symptoms, perceived stress, and positive affect were collected pre-treatment, and after 3, 10, and 15 sessions. Latent Class Growth Analysis (LCGA) was used to identify subgroups based on fatigue trajectories and baseline predictors of group membership. Cross-lagged structural equation models were used to disentangle predictor-outcome relationships. ResultsLCGA identified four fatigue trajectory subgroups, which were labelled as “no improvement” (23 %), “weak improvement” (45 %), “moderate improvement” (23 %), and “strong improvement” (9 %) classes. Higher pre-treatment levels of depressive, anxiety, and somatic symptoms, stress, and lower levels of positive affect predicted membership of the “no improvement” subgroup. Reductions in anxiety preceded reductions in fatigue, while the depressive symptoms – fatigue relationship was bidirectional. ConclusionsOn a group level, there were statistically significant reductions in fatigue after 15 sessions of CBT, with important individual differences in treatment response. Higher pre-treatment levels of anxious, depressive, and somatic symptoms and perceived stress are predictors of lack of response, with reductions in anxiety and stress preceding improvements in fatigue.

Protocol for a Cluster Randomized Controlled Trial to Reduce Susceptibility to Tobacco Use Among School Going Adolescents in a South-Indian District—(Project TEACH)

Background: Adolescents are susceptible to using tobacco because of early exposure to tobacco through family members, easy access, or peer pressure. School-based educational programs are crucial for raising awareness of the harms of tobacco, thus preventing its uptake among adolescents. Studies conducted recently have recognized the need to bring change and reinforce ongoing school-based anti-tobacco education programs. Our study protocol aims to evaluate the effectiveness of a revised school-based anti-tobacco education on susceptibility to tobacco use among school-going adolescents. Method: Project TEACH (Tobacco Education and Awareness for Creating Healthier Adolescents) is an educational intervention that will comprise an animated video on the effects of tobacco on physical and mental health, along with dispelling myths about tobacco, which will be delivered along with a standard education program. The control group will only receive the standard school-based anti-tobacco education program. It will be conducted among students between 6th to 10th grade, with a sample size of 3,310 students. Results: Bivariate relations between the main socio-demographic characteristics and susceptibility to tobacco use will be tested using Pearson or Spearman’s correlation coefficients. For multivariable analyses, the binary logistic regression analysis is used to establish a risk model to correlate the socio-demographic factors with susceptibility to tobacco use and awareness of the harms of tobacco. Conclusion: Project TEACH aims to provide a sustainable school-based anti-tobacco education intervention. It will help test the effectiveness of the revised intervention, which could be incorporated into the current school education program being conducted in the district.

Encouraging creativity in standardized postgraduate programs with PPW

Encouraging creativity in standardized postgraduate programs with PPW

Potential preservative mechanisms of cardiac rehabilitation pathways on endothelial function in coronary heart disease.

Cardiac rehabilitation, a comprehensive exercise-based lifestyle and medical management, is effective in decreasing morbidity and improving life quality in patients with coronary heart disease. Endothelial function, an irreplaceable indicator in coronary heart disease progression, is measured by various methods in traditional cardiac rehabilitation pathways, including medicinal treatment, aerobic training, and smoking cessation. Nevertheless, studies on the effect of some emerging cardiac rehabilitation programs on endothelial function are limited. This article briefly reviewed the endothelium-beneficial effects of different cardiac rehabilitation pathways, including exercise training, lifestyle modification and psychological intervention in patients with coronary heart disease, and related experimental models, and summarized both uncovered and potential cellular and molecular mechanisms of the beneficial roles of various cardiac rehabilitation pathways on endothelial function. In exercise training and some lifestyle interventions, the enhanced bioavailability of nitric oxide, increased circulating endothelial progenitor cells (EPCs), and decreased oxidative stress are major contributors to preventing endothelial dysfunction in coronary heart disease. Moreover, the preservation of endothelial-dependent hyperpolarizing factors and inflammatory suppression play roles. On the one hand, to develop more endothelium-protective rehabilitation methods in coronary heart disease, adequately designed and sized randomized multicenter clinical trials should be advanced using standardized cardiac rehabilitation programs and existing assessment methods. On the other hand, additional studies using suitable experimental models are warranted to elucidate the relationship between some new interventions and endothelial protection in both macro- and microvasculature.

Optimal resource allocation for rapid convergence to stable healthy state in epidemic spreading models

The networked Susceptible-Infected-Susceptible (SIS) model has been widely investigated as a model for the spread of epidemics within networked systems. In networks with SIS dynamics and unstable healthy states, a critical question is how to distribute compensatory curing resources (with constrained total cost) among individuals, ensuring that the network converges to a healthy state as fast as possible. This paper introduces a novel approach to this problem by developing an algorithm for the optimal allocation of compensatory curing resources required by agents in a given network. This solution approach has been made possible by reformulating the original convergence rate optimization problem and an additional constraint guaranteeing a minimum convergence rate as a standard semidefinite programming problem. The applicability of the proposed algorithm to arbitrary undirected topologies and other variations of the SIS model, including the one with a weighted cost function, has been demonstrated. In the case of symmetry preserving curing and infection rates, it has been shown that the problem over a given network with a symmetric topology can be reduced to a smaller network with each orbit acting as a node. Additionally, for networks with one or two orbits, the problem has been addressed analytically, and several examples have been included. Based on two different scenarios inspired by the SARS outbreak in Hong Kong and the COVID-19 outbreak in the USA, it is shown that the algorithm's optimal results outperform the uniform distribution of additional curing resources. The paper also explores how optimal performance metrics change with the given upper limit on the total amount of additional curing resources.

Efficacy of continuous passive motion compared to physiotherapy in rehabilitation after total knee replacement: a prospective randomized controlled non-inferiority trial.

Successful total knee replacement (TKR) heavily depends on postoperative rehabilitation. This study aims to investigate the efficacy of continuous passive motion (CPM) partially replacing group physiotherapy in an inpatient rehabilitation setting in order to contribute to the lack of physiotherapists in patients' care. Adult patients after TKR were included. A prospective randomized controlled two-center trial was conducted across inpatient rehabilitation facilities in Germany. Participants were randomly assigned to CPM or group physiotherapy. In addition, all participants received the same standard rehabilitation program. Primary outcome was the Staffelstein Score, and secondary outcome measures included Oxford Knee Score, range of motion (ROM), pain, and return to work. Non-inferiority margin for Staffelstein Score was set at ±5% of maximum scores based on previous collected data. Results indicate no significant differences between CPM and physiotherapy groups in the Staffelstein Score (CPM: 94 ± 10 points; group physiotherapy: 92 ± 10 points; P > 0.05), ROM, or pain management at discharge from rehabilitation facility. This study underscores the potential of CPM as a valuable component of TKR rehabilitation, providing comparable outcomes to traditional physiotherapy. However, individualized physiotherapy remains integral to optimizing long-term success. Future research should explore extended follow-up periods and diverse patient populations to further elucidate CPM's role in TKR rehabilitation.

Fast heuristics for the time‐constrained immobile server problem

AbstractWe propose easy‐to‐implement heuristics for time‐constrained applications of a problem referred to in the literature as the facility location problem with immobile servers, stochastic demand, and congestion, the service system design problem, or the immobile server problem (ISP). The problem is typically posed as one of allocating capacity to a set of M/M/1 queues to which customers with stochastic demand are assigned with the objective of minimizing a cost function composed of a fixed capacity‐acquisition cost, a variable customer‐assignment cost, and an expected‐waiting‐time cost. The expected‐waiting‐time cost results in a nonlinear term in the objective function of the standard binary programming formulation of the problem. Thus, the solution approaches proposed in the literature are either sophisticated linearization or relaxation schemes, or metaheuristics. In this study, we demonstrate that an ensemble of straightforward, greedy heuristics can rapidly find high‐quality solutions. In addition to filling a gap in the literature on ISP heuristics, new stopping criteria for an existing cutting plane algorithm are proposed and tested, and a new mixed‐integer linear model requiring no iterating algorithm is developed. In many cases, our heuristic approach finds solutions of the same or better quality than those found by exact methods implemented with expensive, state‐of‐the‐art mathematical programming software, in particular a commercial nonlinear mixed‐integer linear programming solver, given a five‐minute time limit.

Biennial aerial application of Bacillus thuringiensis Berliner var. kurstaki is the most cost-effective approach of protection against spruce budworm (Choristoneura fumiferana [Clemens])

Key messageAerial application of Bacillus thuringiensis Berliner var. kurstaki (Btk) every second year to stands of white spruce (Picea glauca (Moench)Voss.), black spruce (Picea mariana Mill.) and balsam fir (Abies balsamea (L.) Mill.) is the most cost-effective spraying scenario for reducing the impact of spruce budworm (Choristoneura fumiferana Clemens) on wood production, providing a similar level of forest protection, but at lower cost, to the standard scenario currently used in which 50% of current year’s foliage is protected every year.ContextInsect outbreaks can have significant effects on forest productivity and various formulations of Bacillus thuringiensis Berliner var. kurstaki (Btk) are used to reduce their damage. In the Province of Québec, Canada, control programs aim to protect at least 50% of current-year foliage to limit tree mortality, but little information exists on the long-term cost-effectiveness of such programs.AimsOur goal was to evaluate the benefit/cost ratio and the efficacy of different Btk protection scenarios in reducing coniferous tree mortality and growth losses over a 11-year period. We hypothesized that less-intensive protection approaches (Btk applications every 2 or 3 years) may provide similar levels of protection but with higher cost-effectiveness ratios than the standard program currently used in Quebec.MethodsIn 2007, we established nineteen 100-ha experimental units in Quebec’s Côte-Nord region to determine the efficacy and cost-effectiveness of different Btk spraying scenarios for reducing tree mortality and volume losses in coniferous stands dominated by mature balsam fir trees (Abies balsamea (L.) Mill., with white spruce (Picea glauca (Moench) Voss.) and black spruce (P. mariana Mill.) as companion species. Tree mortality was monitored annually in three circular plots of 400 m2 within each experimental unit. Growth losses were evaluated using stem analyses.ResultsMortality was much higher in balsam fir than in black spruce and white spruce (respectively 74.4%, 13.8% and 5.9% in untreated stands) in all protection scenarios. The application of Btk every 2 years reduced balsam fir mortality to a level similar to the standard scenario (10.3% vs 7.15%, respectively) at a much lower cost. Growth losses have also been reduced but not to the same extent as in the standard scenario.ConclusionSpraying Btk every 2 years provides effective protection to balsam fir and is the most cost-effective scenario. A less intensive use of Btk would mitigate impact on non-target lepidoptera and allow protecting other areas, such as habitat of the woodland caribou, a threatened species which avoids disturbed areas.

Preserving and promoting national cultural identity for students majoring in the University of Greenwich Vietnam’s Graphic and Digital Design in an international University environment

In terms of development and integration of globalization, Vietnam has many qualities of international universities with international standard training programs, which prestigious educational accreditation organizations have recognized. Students have the opportunity to study entirely in English and in an advanced learning environment, which is a great advantage for learners in accessing international education. Research on Preserving and promoting national cultural identity for students majoring in the University of Greenwich Vietnam’s Graphic and Digital Design in an international University environment aims to emphasize the importance of national cultural identity in development, current globalization integration, especially for students studying international training programs that do not have specific subjects on national history and cultural traditions. From there, the topic proposes a number of solutions to raise learners' awareness of preserving and promoting national cultural identity in future professional activities. The research used analysis, synthesis, and interdisciplinary methods such as cultural studies, ethnology, and fine arts. This paper aims to contribute to the study of solutions to preserve national cultural identity in the context of today's international integration

6848 Improvement Of Free Thyroxine Measurement Quality Through The CDC Clinical Standardization Programs

Abstract Disclosure: A. Ribera: None. N. Vazquez: None. S. Knoblock: None. O. Sugahara: None. T. Buchannan: None. L. Collins: None. D. Spector: None. L. Zhang: None. U. Danilenko: None. H.W. Vesper: None. Thyroid function tests are among the most requested tests in patient care, and reliability of these measurements are crucial for appropriate diagnosis and management of thyroid disorders. In response to concerns from the clinical and research community about the quality of thyroid function tests, the CDC Clinical Standardization Programs (CSP) has created the hormone standardization (HoSt) program for free thyroxine (FT4) in partnership with the International Federation for Clinical Chemistry and Laboratory Medicine (IFCC). As a first step, CDC CSP has completed an interlaboratory comparison study of commercial immunoassays (IA) and lab-developed tests (LDT) to determine the current agreement among assays. Participants received 40 blinded, high quality individual donor serum samples with FT4 reference values assigned by the CDC FT4 reference measurement procedure (RMP). FT4 concentrations ranged between 11-32 pmol/L. Samples were analyzed in duplicate over 2 days and results were compared to the CDC FT4 RMP. To assess the potential impact of standardizing measurements to the CDC HoSt FT4 program, reported results were normalized to the CDC RMP results (recalibrated in silico using linear regression). Mean percent bias to the reference value was evaluated pre- and post-recalibration. In addition, inter-assay agreement of classification (assignment of hypo-, eu- or hyperthyroid status according to FT4 reference intervals) were assessed pre- and post-recalibration using the assay-specific and CDC RMP reference intervals, respectively. A total of 19 methods participated, consisting of 15 IA and 4 LDT. All participants showed a negative mean bias to the RMP, with IA showing a higher magnitude of bias (average: -20.7 ± 0.9%) than LDT (average: -4.7 ± 1.1%). Of the 40 samples measured, only 53% were classified uniformly by all 19 participants. Post-recalibration, mean percent bias improved profoundly (IA average: 0.0 ± 0.8%, LDT average: 0.1 ± 1.1%), and classification agreement improved by 33% to 86% of samples with consistent classification. The CDC CSP interlaboratory comparison among FT4 assays highlights the critical need for measurement standardization to improve accuracy of FT4 measurements and increase consistency in result interpretation. This study demonstrates that it is possible to develop common FT4 reference intervals via measurement standardization, which would allow for universal evidence-based clinical guidelines to be used in patient care. Presentation: 6/3/2024

6651 A Traceable Clinical Free Thyroxine Assay Based on Equilibrium Dialysis ID-LC/MS/MS

Abstract Disclosure: D. Spector: None. L. Zhang: None. A. Ribera: None. A. Doty: None. C. Tse: None. O. Sugahara: None. N. Vazquez: None. U. Danilenko: None. H.W. Vesper: None. Accurate diagnosis and effective treatment of thyroid diseases rely on reliable thyroid function tests. Serum free thyroxine (FT4) immunoassays (IAs) are most commonly used for FT4 measurements in clinical practice. However, FT4 IAs have not been standardized with large variations between different assay platforms. A reference measurement procedure (RMP) for FT4 based on well-defined equilibrium dialysis (ED) of serum has been established for CDC standardization program to support the standardization of clinical assays for patient care. In the current study, we aim to develop a routine clinical FT4 assay based on ED-LC/MS/MS that is traceable to the RMP. ED-LC/MS/MS analysis was performed using a commercially available micro-ED plate. FT4 in dialysate was extracted with a 96-well C18 SPE plate. FT4 in the samples was quantitated by using LC/MS/MS in positive ion mode. The assay was calibrated with the certified primary reference material. By using RMP as a reference, we compared the analysis of 40 single donor sera between the ED-LC/MS/MS assay and FT4 IA on Roche e401platform. ED-LC/MS/MS assay could resolve T4, T3, reverse triiodothyronine (rT3), and other interferences in the samples with C18 chromatography in 4 min. The linear range of the routine FT4 assay was from 0.5-100 pg/mL covering clinically relevant FT4 concentrations including hypo-, hyperthyroid patient samples. The intra and inter-run CV% of the assay in 20 days was 3.72 and 5.25%, respectively. The effect of minor changes to the method conditions was studied. It was determined that serum/buffer ratios from 1:1 to 1:2 in the ED inserts, speeds of shaker for ED, and ED incubation time, did not influence the FT4 measurement. However, elevated ED temperature at 38°C could result in a more than 10% increase in FT4 values. A microplate format for the procedures of ED and SPE is amiable to the application of an automation system which significantly improves the throughput of the procedure. Method comparison showed good agreement between ED-LC/MS/MS assay and RMP in Deming regression analysis with a slope close to 1, while there was significant bias of IA from RMP. ED-LC/MS/MS assay was also applied for pregnancy serum samples with minimal difference on the FT4 measurement from RMP. We have developed a routine clinical FT4 assay that is traceable to RMP. The accuracy, precision, and sensitivity of the assay are suitable for high-throughput FT4 measurements in clinical laboratories and large epidemiologic studies. We demonstrate that the developed method can provide accurate FT4 measurements in patients including pregnant women. Presentation: 6/3/2024

8551 Comparability of Free Testosterone Measurements

Abstract Disclosure: H. Zhou: None. O. Sugahara: None. U. Danilenko: None. H.W. Vesper: None. Assessment of free testosterone (FT) has been recommended as a biomarker for diagnosis and management of hypogonadism and female hyperandrogenism. Reliable laboratory measurements are essential for properly diagnosing and treating these diseases. FT is currently measured using direct commercial immunoassays, assays using equilibrium dialysis (ED) or other separation techniques, or estimated by calculating free testosterone (cFT) using different formulas based on the levels of total testosterone and sex hormone binding globulin (SHBG). There are concerns about the accuracy and reliability of current methods that may negatively impact correct detection, treatment, and prevention in patient care. CDC’s Clinical Standardization Programs (CDC CSP) has developed an accurate, high throughput method using ED coupled with isotope dilution ultra-high-performance liquid chromatography tandem mass spectrometry (ED-UHPLC-MS/MS). The ED step uses an internationally recognized procedure and is performed in a custom designed dialyzer system that allows maintaining equal ratio of sample-to-buffer volume. The method uses certified pure primary reference material (National Measurement Institute-M914) as calibrator. The method has a limit of detection of 0.6 pg/mL, with an accuracy of ±5%, and precision less than 10% CV. The measurement range is 2 – 2000 pg/mL. The analytical performance of this method as well as other FT methods used in patient care was assessed using single-donor serum samples. The evaluated methods included two commercially available platforms utilizing Chemiluminescence Immunoassay or radioimmunoassay techniques, as well as six laboratory-developed assays using ED-LC-MS/MS. The results of the interlaboratory comparison study will help assessing the current level of agreement among FT assays, to identify potential factors causing differences among assays, and to assist with developing materials to improve the agreement among assays. Presentation: 6/1/2024

A-038 Interlaboratory Comparison of Parathyroid Hormone Analytical Results Across Clinical Assays from 8 Manufacturers - Steps Towards Standardization

Abstract Background Parathyroid hormone (PTH) is an 84 amino acid peptide produced by the parathyroid gland and is a key biomarker used for the diagnosis and treatment of Chronic Kidney Disease-Mineral and Bone Disorder, as well as hypo- and hyperparathyroidism. PTH clinical assays were previously reported to exhibit significant inter-assay measurement variability, which limits the utility of PTH as a diagnostic biomarker and can result in the misclassification of patients. Thus, there is a need for PTH clinical assay standardization to improve clinical assay measurement agreement. The Centers for Disease Control and Prevention’s Clinical Standardization Program (CDC-CSP) will launch a PTH standardization program, which is in support of and coordinated with the IFCC Committee on Bone Metabolism. In preparation, the CDC-CSP conducted an Inter-Laboratory Comparison Study to evaluate the current status of PTH inter-assay variability and to investigate potential sources of variability. Methods Eight PTH assay manufacturer’s laboratories measured PTH in 42 deidentified, fresh-frozen single donor serum samples in duplicate over 2 independent runs. Sample PTH concentrations ranged from 1.3 - 324 pg/mL, based on initial screening values. Five manufacturers submitted data for 2 different assays, resulting in PTH measurements from 13 assays total. Data were submitted to the CDC CSP for analysis. Results Assay precision was <5% for 10/13 measurement procedures (MP) assessed and 3 MPs exhibited precisions between 5 - 18%. Assay-specific PTH measurements demonstrated good linear correlation compared to the all-assay mean concentration. Interestingly, inter-assay variability increased with increasing PTH concentrations, with individual sample standard deviations increasing from 2.9 - 123, with a mean SD of 24.1 and individual sample CVs increasing from 18.9 - 44.5%, with a mean CV of 24.2%. Conclusions This study provides new insights into PTH inter-assay variability and assay performance for assays commonly used in the clinical setting. The findings of this PTH Interlaboratory Comparison Study establish a baseline for PTH inter-assay variability and will guide future PTH standardization efforts.

A-338 Assessing the Technical and Analytical Performance of Point of Care Testing Devices for Blood Lipids Measurements

Abstract Background Cardiovascular diseases (CVDs) are the leading cause of death worldwide, causing over 17 million deaths each year. According to the World Health Organization (WHO), 85% of CVD deaths are due to heart disease and strokes, and over 75% occur in low- and middle-income countries (LMICs). Early detection and treatment are key to preventing consequences of CVD. Point-of-care testing (POCT) devices require minimal laboratory infrastructure and can be used to screen hard-to-reach populations for CVD risk. These devices are increasingly used in traditional care settings including hospitals and primary healthcare, and in non-traditional settings such as pharmacies. Although POCT devices offer fast and convenient testing, the analytical performance of these devices must produce accurate and reliable results, and have technical suitability for use. Several POCT devices for total cholesterol (TC) and other blood lipids are commercially available, however, the operational and analytical performance of these devices is not fully known. Methods Eight POCT devices for blood lipids were used in this study. For the technical assessment, a checklist was developed and applied, outlining the operational functionality and environmental conditions of the devices. Some relevant technical parameters in this checklist included requirements for temperature/humidity and power/voltage, storage conditions, and assay/test time. The analytical performance was assessed for parameters, such as accuracy and imprecision, using paired whole blood and serum donor samples for TC. In addition, these analytical parameters were assessed for serum High Density Lipoprotein-cholesterol (HDL-c) and Low Density Lipoprotein-cholesterol (LDL-c) samples on seven POCT devices. All samples were representative of a clinically relevant concentration range for TC, HDL-c, and LDL-c. Accuracy was compared to reference values obtained by the CDC reference measurement procedures. Results The mean bias for TC ranged among devices from -8.17% to 11.99% for whole blood and -7.89% to 7.02% for serum, respectively. The mean imprecision for TC in whole blood ranged from 1.94% to 11.63%, and in serum from 1.72% to 12.70%. The mean bias for serum HDL-c samples ranged from -7.33% to 17.36%, and for serum LDL-c samples from -20.92% to 5.04%. The mean imprecision for serum HDL-c samples ranged from 2.39% to 24.27% and for serum LDL-c samples ranged from 3.14% to 18.33%. For three of the eight devices, about 25% of the whole blood measurements and 50% of the serum measurements were reported outside of the measurement range and not included in the assessment. Comparing these non-reports with the reference values of these samples indicate that all of the reference values for whole blood and about 80% of the reference values for serum were actually within the measurement range of the device. Conclusions The technical assessment was helpful in building screening capacity in areas with limited laboratory infrastructure. The analytical assessment indicates notable differences in accuracy and precision for lipids measured in whole blood and serum, with serum measurements being more likely within performance requirements used by CDC's standardization programs. Additional studies to assess other devices and/or analytes, and future work to assist manufacturers improve the analytical performance of POCT devices are needed.

Work stress and competency among radiology residents: the mediating effect of resilience.

Competency of health professionals stands as a fundamental element in ensuring the quality of care. Notably, work stress and resilience are found to be associated with competency of health professionals. However, the role of resilience between work stress and competency remains unexplored. This study aims to investigate competency, work stress and resilience of radiology residents, and to examine the mediating effect of resilience. A cross-sectional survey was conducted among 3,666 radiology residents from 31 provinces of China in 2021. The diagnostic radiology milestones were used to measure the competency. Results of work stress and resilience were derived from self-reports and assessment of the Connor Davidson Resilience Scale (CD-RISC) respectively. To examine the association between work stress, resilience, and competency, Spearman correlation analysis and hierarchical linear regression were employed. The mediating effect of resilience was tested by bootstrapping analysis. Descriptive statistics show that the average score (mean ± SD) of work stress, competency and resilience among radiology residents were 1.55 ± 1.53 (range from 0 to 6), 28.14 ± 13 (range from 0 to 81) and 5.97 ± 1.92 (range from 0 to 8), respectively. Work stress was negatively associated with competency (β = -0.51, p < 0.001) and resilience (-0.57, p < 0.001). In particular, resilience mediated the relationship between work stress and competence, and the total mediating effect was -0.49 (= - 0.57 * 0.86), accounting for 49.06% of the total effect. Work stress is a significant contributor to competence among radiology residents. Resilience significantly mediated the association. This study highlights incorporating resilience training courses into the standardized residency training program to reduce intensive work stress and promote competency of radiology residents.

A-075 Comparability of Free Testosterone Measurements- Results of the Interlaboratory Study

Abstract Background Assessment of free testosterone (FT) has been recommended as a biomarker for diagnosis and management of hypogonadism and female hyperandrogenism. Reliable laboratory measurements are essential for correctly diagnosing and treating these diseases. FT is currently measured using direct commercial immunoassays, assays employing equilibrium dialysis (ED) or other separation techniques, or it is estimated by calculating free testosterone (cFT). There are concerns about the accuracy and reliability of current methods that may impact patient care. To obtain more information about variability of FT measurements used in patient care, CDC’s Clinical Standardization Programs (CDC CSP) conducted an interlaboratory comparison study. Methods CDC CSP developed an accurate, automated method using ED coupled with isotope dilution ultra-high-performance liquid chromatography tandem mass spectrometry (ED-UHPLC-MS/MS). The ED step follows an internationally recognized procedure. The method is calibrated with primary reference material (National Measurement Institute-M914) and was used to assign target values to sera used in the study. The FT concentrations ranged from 3 to 339 pg/mL. In the interlaboratory comparison study single-donor serum samples were provided to participants operating FT methods used in patient care. The participating methods included commercially available platforms utilizing Chemiluminescence Immunoassay or radioimmunoassay techniques, as well as laboratory-developed assays using ED-LC-MS/MS. Results Preliminary findings of the CSP interlaboratory comparison study found large variability among participating assays. The agreement among IA and among ED-LC-MS/MS assays was close. However, FT concentrations obtained by IAs were in average 6 times lower compared to the ED-LC-MS/MS methods. Results estimated using the Vermeulen equation overestimated FT in average by 15% compared to the ED-LC-MS/MS methods and by over 6 times compared to IAs. Conclusions Large variability is observed between FT laboratory developed tests (LDTs) and IAs. As both LDTs and IAs are used in patient care, standardization of FT measurements to assure better patient care is needed. CDC CSP is addressing the need by developing highly accurate and precise FT method and conducting an interlaboratory comparison studies that can aid with improvement of the agreement among assays and identifying potential factors causing differences among assays.

B-138 A Harmonization Program Leading to Improved Accuracy and Precision of Hemoglobin A1c (HbA1c) Testing: A Six-Year Multi-Site, Multi-Instrument Review and Comparison

Abstract Background Across four global laboratory locations in North America, Europe, and Asia a quality control system was implemented in the measurement of Hemoglobin A1c (HbA1c). The intent was to improve accuracy and reduce imprecision, both being independent contributors to total analytical performance. Methods Quality control (QC) data, created during routine clinical operations, was used for this analysis. Analysis of QC data evaluated bias and precision separately and provided the ability to predict and monitor performance. The in-process harmonization program indicated a change in instrumentation was needed to meet and maintain a more stringent analytical error profile. The instrumentation change allowed for a before and after comparison across platforms. Results Use of a harmonized quality control system allowed for the visualization of the role bias and precision play in measurements. Improved performance was confirmed using native matrix samples tested routinely from participation in the National Glycohemoglobin Standardization Program. Independently assessing bias and precision highlighted the cumulative and offsetting effects that challenge quality assessment and risk mitigation. Bias appeared to have both a transient and systematic nature. The transient bias contributed to the overall normal distributive property of the quality data. In contrast, the systematic accumulation of bias appeared to occur slowly, over multiple reagent and calibration cycles. The accumulation of bias occurred in the direction of the assay drift. While precision commonly consumes the largest amount of analytical error within an instrument, the dual (negative and positive) nature of bias similarly affects the harmonization of an instrument group. Conclusions Changing the way data is viewed to include assessments of bias improved performance and aided in the identification of opportunities to reduce analytical variances that results in inter- and intra-individual variation. Harmonization of instruments should include methods to assess and describe bias, independent of precision.

Are there unique facets of therapeutic alliance for users of digital mental health interventions? An examination with the eHealth Therapeutic Alliance Inventory

Therapeutic alliance (TA) is a well-established predictor of clinical outcomes in traditional psychotherapy. However, its association with outcomes in eHealth interventions has been inconsistent, which might be due to the absence of measurements specifically designed to capture TA in eHealth settings. The eHealth Therapeutic Alliance Inventory (ETAI) incorporates conventional as well as unique eHealth TA subscales, enabling to examine the contribution of new facets of TA beyond traditional concepts. This study investigates the predictive contribution of eHealth TA subscales compared to conventional TA subscales on clinical outcomes and evaluates the concurrent criterion validity of the ETAI. The study was conducted within the framework of a randomized controlled trial involving a 10-week digital parent training program aimed at addressing child disruptive behaviors. Parents were randomly assigned to either an enhanced-quality or a standard-quality program. Parents from 68 families completed the ETAI at five weeks' post-program initiation and at the post-intervention phase. The primary outcome was the improvement in child behavior, measured by the Eyberg Child Behavior Inventory. Positive Pearson correlations were found between all ETAI subscales covering unique eHealth TA aspects, measured at the 5-week time-point, and improvement in child behavior at post-intervention (rs ≥ 0.23, ps < 0.03). The conventional TA subscale showed no significant Pearson correlation with improvement in child behavior. When examining the unique contributions of ETAI-subscales to explain the improvement in child behavior, only ETAI-Perceived Emotional Investment subscale was found to have a unique contribution (β = 0.29, p = 0.019). In addition, scores on most ETAI subscales were significantly higher among parents using the enhanced-quality program compared with the standard program (Cohen's ds > 0.48), reinforcing ETAI's criterion validity. The development of TA scales that incorporates unique eHealth TA subscales show initial promise in predicting outcomes. Further research is needed to better understand how different factors of eHealth TA relate to clinical outcomes across diverse clinical targets and programs.

A multi-site prospective controlled pilot evaluation of Cardiac College for Women in the cardiac rehabilitation setting

ObjectiveTo test the limited efficacy of women-focused educational materials within supervised cardiac rehabilitation (CR) for the first time when compared to standard co-educational CR. MethodsA multi-site, prospective, pilot study with blinded outcome assessment was conducted at two Canadian CR programs. At intake, participants selected women-only CR with women-focused education (12 weeks) or a standard co-educational program (16 weeks). Both were comprehensive programs, with one education session/week. Outcomes were disease-related knowledge, functional capacity, quality of life, and heart-health behaviours. ResultsOf 114 women approached, 62 (54.4 %) consented. Forty elected the women-only CR program. Pre-CR medication adherence was high. Participants attended approximately 60 % of sessions; 55 (88.7 %) were retained at follow-up. Significant improvements in knowledge, quality of life, and functional capacity were observed in both groups (all p < .05). With adjustment for pre-CR scores, participants in women-only CR exhibited significantly greater improvements in knowledge (p < .05) and adherence to the Mediterranean diet (p = .04) post-program compared to control participants. ConclusionResults support of the utility of this women-focused education in the CR setting. Practice implicationsIntegrating women-focused education in CR can enhance health outcomes and address specific needs of female patients.

Pension funds with longevity risk: an optimal portfolio insurance approach

We present a unified framework designed to provide an optimal investment strategy for members of a defined contribution pension plan. Our model guarantees a minimum retirement savings level, expressed as a target annuity, by assuming uncertainty in interest rates, labor income, and mortality during the accumulation phase. To protect the accumulated retirement capital against both investment and longevity risks, the present value of the guaranteed lifetime annuity is regarded as the baseline wealth to hold upon reaching the retirement date, while a purpose-oriented proportion portfolio strategy is employed to invest the residual wealth. By applying standard dynamic programming techniques, we determine a closed-form solution to the stochastic control problem with the objective of maximizing the expected utility of the final surplus, defined as the difference between the accumulated wealth and the target annuity value. The theoretical findings are bolstered by a comprehensive numerical analysis, designed to assess the impact of longevity on investment policies, highlighting the suitability of our proposal in managing defined contribution schemes.