Standards of care and determinants of women's satisfaction with delivery services in Nepal: a multi-perspective analysis using data from a health facility-based survey.

BACKGROUND: Compliance with standards of care is required for sustained improvement in the quality of delivery services. It thus represents a key challenge to improving maternal survival and meeting the Sustainable Development Goal (SDG) target of reducing the maternal mortality ratio to 70 deaths per 100,000 live births. This study examines the extent to which normal low-risk health facility deliveries in Nepal meet the standards of quality of care and assesses the effect of the standards of quality of care and various contextual factors on women's satisfaction with the services they receive. METHODS: Drawing on the 2021 Nepal Health Facility Survey, the sample comprised 320 women who used health facilities for normal, low-risk delivery services. A weighted one-sample t-test was applied to examine the proportion of deliveries meeting the eight standards of care. Women's overall satisfaction level was computed from seven satisfaction variables measured on a Likert scale, using principal component analysis. The composite measure was then dichotomized. Binary logistic regression was used to analyze the determinants of women's satisfaction with delivery care services. RESULTS: Deliveries complying with the eight standards of care and its 53 indicators varied widely; output indicators were more frequently met than input indicators. Of the eight standards of care, the "functional referral system" performed highest (92.0%), while "competent, motivated human resources" performed the least (52.4%). Women who were attended by a provider when they called for support (AOR: 5.29; CI: 1.18, 23.64), who delivered in health facilities that displayed health statistics (AOR 3.16; CI: 1.87, 5.33), who experienced caring behaviors from providers (AOR: 2.59; CI: 1.06, 6.30) and who enjoyed audio-visual privacy (AOR 2.13; CI: 1.04, 4.38) had higher satisfaction levels compared to their counterparts. The implementation of the Maternity Incentive Scheme and presence of a maternal waiting room in health facilities, however, were associated with lower satisfaction levels. CONCLUSIONS: Nepal performed moderately well in meeting the standards of care for normal, low-risk deliveries. To meet the SDG target Nepal must accelerate progress. It needs to focus on people-centered quality improvement to routinely assess the standards of care, mobilize available resources, improve coordination among the three tiers of government, and implement high-impact programs.

Emergency obstetric and newborn care signal functions: The situation in health facilities in Nepal between 2015 and 2021.

Expanding access to facility-based delivery services and improving the functionality of emergency obstetric and neonatal care (EmONC) are important strategies toward achieving a maternal mortality ratio of 70 deaths per 100,000 live births by 2030. In this study the researchers assess signal functions at designated facilities in Nepal, using Nepal Health Facility Survey data for 2015 and 2021. The functionality of basic and comprehensive EmONC sites was low, declining over the six-year period. Lack of progress may partly be attributed to the COVID-19 pandemic. Nepal needs to expand EmONC sites strategically, strengthen referral systems, improve service readiness, and periodically assess service quality.

Changes in health facility readiness for obstetric and neonatal care services in Nepal: an analysis of cross-sectional health facility survey data in 2015 and 2021.

BACKGROUND: Nepal is committed to achieving the Sustainable Development Goal (SDG) 2030 target 3.1 of reducing the maternal mortality ratio to 70 deaths per 100,000 live births. Along with increasing access to health facility (HF)-based delivery services, improving HF readiness is critically important. The majority of births in Nepal are normal low-risk births and most of them take place in public HFs, as does the majority of maternal deaths. This study aims to assess changes in HF readiness in Nepal between 2015 and 2021, notably, if HF readiness for providing high-quality services for normal low-risk deliveries improved; if the functionality of basic emergency obstetric and neonatal care (BEmONC) services increased; and if infection prevention and control improved. METHODS: Cross-sectional data from two nationally representative HF-based surveys in 2015 and 2021 were analyzed. This included 457 HFs in 2015 and 804 HFs in 2021, providing normal low-risk delivery services. Indices for HF readiness for normal low-risk delivery services, BEmONC service functionality, and infection prevention and control were computed. Independent sample T-test was used to measure changes over time. The results were stratified by public versus private HFs. RESULTS: Despite a statistically significant increase in the overall HF readiness index for normal low-risk delivery services, from 37.9% in 2015 to 43.7%, in 2021, HF readiness in 2021 remained inadequate. The availability of trained providers, essential medicines for mothers, and basic equipment and supplies was high, while that of essential medicines for newborns was moderate; availability of delivery care guidelines was low. BEmONC service functionality did not improve and remained below five percent facility coverage at both time points. In private HFs, readiness for good quality obstetrical care was higher than in public HFs at both time points. The infection prevention and control index improved over time; however, facility coverage in 2021 remained below ten percent. CONCLUSIONS: The slow progress and sub-optimal readiness for normal, low-risk deliveries and infection prevention and control, along with declining and low BEmONC service functionality in 2021 is reflective of poor quality of care and provides some proximate explanation for the moderately high maternal mortality and the stagnation of neonatal mortality in Nepal. To reach the SDG 2030 target of reducing maternal deaths, Nepal must hasten its efforts to strengthen supply chain systems to enhance the availability and utilization of essential medicines, equipment, and supplies, along with guidelines, to bolster the human resource capacity, and to implement mechanisms to monitor quality of care. In general, the capacity of local governments to deliver basic healthcare services needs to be increased.

Stellate Ganglion Block and Intraarterial Spasmolysis in Patients with Cerebral Vasospasm: A Retrospective Cohort Study.

BACKGROUND: In patients with symptomatic cerebral vasospasm (CV) following aneurysmal subarachnoid hemorrhage who do not respond to medical therapy, urgent treatment escalation has been suggested to be beneficial for brain tissue at risk. In our routine clinical care setting, we implemented stellate ganglion block (SGB) as a rescue therapy with subsequent escalation to intraarterial spasmolysis (IAS) with milrinone for refractory CV. METHODS: In this retrospective analysis from 2012 to 2021, patients with CV following aneurysmal subarachnoid hemorrhage who received an SGB or IAS were identified. Patients were assessed through neurological examination and transcranial Doppler. Rescue therapy was performed in patients with mean cerebral blood flow velocity (CBFV) ≥ 120 cm/s and persistent neurological deterioration/intubation under induced hypertension. Patients were reassessed after therapy and the following day. The Glasgow Outcome Scale was assessed at discharge and 6-month follow-up. RESULTS: A total of 82 patients (mean age 50.16 years) with 184 areas treated with SGB and/or IAS met the inclusion criteria; 109 nonaffected areas were extracted as controls. The mean CBFV decrease in the middle cerebral artery on the following day was - 30.1 (± 45.2) cm/s with SGB and - 31.5 (± 45.2) cm/s with IAS. Mixed linear regression proved the significance of the treatment categories; other fixed effects (sex, age, aneurysm treatment modality [clipping or coiling], World Federation of Neurological Surgeons score, and Fisher score) were insignificant. In logistic regression, the presence of cerebral infarction on imaging before discharge from the intensive care unit (34/82) was significantly associated with unfavorable outcomes (Glasgow Outcome Scale ≤ 3) at follow-up. CONCLUSIONS: Stellate ganglion block and IAS decreased CBFV the following 24 h in patients with CV. We suggest SGB alone for patients with mild symptomatic CV (CBFV < 180 cm/s), while subsequent escalation to IAS proved to be beneficial in patients with refractory CV and severe CBFV elevation (CBFV ≥ 180 cm/s).

[Quality of Life and Return to Work Following Rehabilitation - Results of the icfPROreha Study]. / Lebensqualität und Arbeitsfähigkeit nach unfallchirurgischer Rehabilitation ­ Ergebnisse der icfPROreha-Studie.

BACKGROUND: Not only the severity of an injury, but also bio-psycho-social factors affect health-related quality of life and participation in social life after severe musculoskeletal injuries. METHODS: Multicentre prospective longitudinal study with follow-up up to 78 weeks after discharge from inpatient trauma rehabilitation. Data were collected using a comprehensive assessment tool. Quality of life was assessed using the EQ-5D-5L, return to work by patients' self-reports and routine data of health insurances. Analyses of the association between quality of life and return to work, change over time in quality of life compared to the general German population and multivariate analyses to predict quality of life were conducted. RESULT: Of 612 study participants (444 men (72.5%); M=48.5 years; SD 12.0), 502 (82.0%) returned to work 78 weeks after discharge from inpatient rehabilitation. Quality of life improved during rehabilitation treatment from 50.18 to 64.50 (mean of visual analogue scale of EQ-5D-5L) and slightly to 69.38 78 weeks after discharge from inpatient trauma rehabilitation. EQ-5D index was below the values of the general population. In total, 18 factors were selected to predict quality of life 78 weeks after discharge from inpatient trauma rehabilitation. Among others, pain at rest and suspected anxiety disorder at admission had a very strong effect on quality of life. Contextual factors such as therapies after acute care and self-efficacy also had an effect on quality of life 78 weeks after discharge from inpatient rehabilitation. CONCLUSION: Bio-psycho-social factors affect long-term quality of life of patients with musculoskeletal injuries. Already at the time of discharge from acute treatment and even more at the beginning of inpatient rehabilitation, decisions can be made in order to achieve the best possible quality of life for those affected.

ICF-based prediction of return to work after trauma rehabilitation: Results of the icfPROreha study in patients with severe musculoskeletal injuries.

Background: Physical aspects such as the type and severity of an injury are not the only factors contributing to whether or not a person can return to work (RTW) after a serious injury. A more comprehensive, biopsychosocial approach is needed to understand the complexity of RTW fully. The study aims to identify predictors of RTW 78 weeks after discharge from initial inpatient trauma rehabilitation in patients with severe musculoskeletal injuries using a biopsychosocial perspective. Methods: This is a prospective multicenter longitudinal study with a follow-up of up to 78 weeks after discharge from trauma rehabilitation. Data on potential predictors were collected at admission to rehabilitation using a comprehensive assessment tool. The status of RTW (yes vs. no) was assessed 78 weeks after discharge from rehabilitation. The data were randomly divided into a training and a validation data set in a ratio of 9:1. On the training data, we performed bivariate and multiple logistic regression analyses on the association of RTW and potential predictors. The final logit model was selected via stepwise variable selection based on the Akaike information criterion. The final model was validated for the training and the validation data. Results: Data from 761 patients (n = 561 male, 73.7%; mean age: 47.5 years, SD 12.3), primarily suffering from severe injuries to large joints and complex fractures of the large tubular bones, could be considered for analyses. At 78 weeks after discharge, 618 patients (81.2%) had returned to work. Eleven predictors remained in the final logit model: general health, current state of health, sensation of pain, limitations and restrictions in activities and participation (disability), professional sector, ongoing legal disputes, financial concerns (assets), personality traits, life satisfaction preaccident, attitude to life, and demand for pension claim. A predicted probability for RTW based on the multiple logistic regression model of 76.3% was revealed as the optimal cut-off score based on the ROC curve. Conclusion: A holistic biopsychosocial approach is needed to address RTW and strengthen person-centered treatment and rehabilitation. Patients at risk for no RTW in the long term can already be identified at the onset of rehabilitation.

Evaluating the Effectiveness of a One-Week Multimodal Prevention Program for Slowing down and Stress Reduction Performed in a German Health Resort: Results of a Randomized Controlled Trial.

BACKGROUND: Effective concepts are required to overcome the negative impact of daily stressful overwhelming. We investigated the effectiveness of a 1-week multimodal program for stress reduction. METHODS: We performed a randomized controlled trial including adults with above-average stress level. The intervention consisted of health coaching, relaxation, physical activity, and balneotherapeutic elements. Individuals were randomized either to the intervention group (IG) or to one of the two control groups B and C. The main outcome was change in stress (Perceived Stress Questionnaire [PSQ], Screening Scale of Chronic Stress of the Trier Inventory for Chronic Stress [TICS-SSCS]) at 6 months post intervention; further outcomes were well-being (World Health Organization 5-Item Well-Being Index [WHO-5]) and health status (EuroQol visual analog scale [EQ-5D VAS]). Data were collected pre/post intervention as well as after 1, 3, and 6 months. RESULTS: Data of 96 individuals (mean age 48.0 years, 74% female) were available for analyses. The IG improved overtime with -13.45 points for the PSQ and -6.44 points for the TICS-SSCS after 6 months. At 6-month follow-up the IG did not significantly differ from group B (PSQ: p = 0.2332; TICS-SSCS: p = 0.0805) or group C (PSQ: p = 0.0950; TICS-SSCS: p = 0.0607) when controlling for baseline (ANCOVA). Compared to group C, ANCOVA revealed significant differences in WHO-5 (p = 0.0292) and EQ-5D VAS (p = 0.0177) post intervention. At the 3- and 6-month follow-up and compared to group B, no substantial differences could be found for WHO-5 and EQ-5D VAS. CONCLUSION: The results indicate that even a short-term multimodal program for stress reduction appears to set a positive trend towards less perceived and chronic stress.

Physical Activity during COVID-19 in German Adults: Analyses in the COVID-19 Snapshot Monitoring Study (COSMO).

The novel coronavirus (COVID-19) and the resulting outbreak response measures in Germany and worldwide led to severe limitations in everyday life. This affected all sorts of daily activities and the possibility for physical activity (PA), which represents a major coping strategy against stress. The objective of this study was to analyse PA in German adults during a total lockdown phase including school closures in April 2020 in certain subgroups and in relation to other coping strategies. Data from the COVID-19 Snapshot Monitoring (COSMO) survey, an online cross-sectional study with 1034 participants between 18 and 74 years, were utilised (14/15 April 2020). In addition to descriptive analyses, the odds of performing PA according to the World Health Organization (WHO) recommendations for adults (at least 2.5 h/week of at least moderate intensity) were analysed by univariate and multivariate logistic regression analyses. In total, 440 (42.6%) participants fulfilled this criterion. Participants with children <6 years were less likely to meet the WHO recommendation (OR = 0.51; 95% CI: 0.33-0.78), while those with a higher level of education, good coping behaviour, regular alcohol consumption, and being satisfied with life were more likely to meet the WHO recommendation. In conclusion, PA intervention strategies tailored to specific vulnerable subgroups such as individuals with low educational background and parents with young children are needed in future pandemic response.

A Multimodal Stress-Prevention Program Supplemented by Telephone-Coaching Sessions to Reduce Perceived Stress among German Farmers: Results from a Randomized Controlled Trial.

This study compared the effectiveness of a 12-day stress-prevention program (SGS) supplemented by individualized, structured, four-session telephone-coaching to that of an SGS without telephone-coaching in entrepreneurs from the green professions presenting with increased stress levels. All participants went through the SGS before being randomized either to the telephone-coaching group (TC) or to the control group without telephone-coaching (noTC). SGS included four key therapeutic elements: stress-management intervention, relaxation, physical exercise, and balneotherapy. The primary outcome was the current degree of subjectively experienced stress assessed with the Perceived Stress Questionnaire (PSQ) at a 9-month follow-up. Secondary outcomes included burnout symptoms, well-being, health status, sleep disorders, expectation of self-efficacy, depression, anxiety, ability to work, pain, and days of sick leave. Assessments were conducted at baseline, 12 days (end of program), and 1 (start telephone-coaching), 3, 6 (end of telephone-coaching), and 9 months. Data from 103 adults (TC = 51; noTC = 52), mostly fulltime farmers, were available for analysis (mean age: 55.3; 49.1% female). Participants experienced significant immediate improvement in all outcome measurements, which declined somewhat during the first three months after the end of SGS and then remained stable for at least another six months. While within-group changes from baseline to 9 months showed significant improvements at medium to large effect sizes for all target variables (PSQ-total, TC: -13.38 (±14.98); 95%-CI: (-17.68; -9.07); noTC: -11.09 (±14.15); 95%-CI: (-15.11; -7.07)), no statistically significant differences were found between the groups at any time and for any target variable (between-group ANCOVA for PSQ-total at 9 months, parameter estimator for the group: -1.58; 95%-CI: (-7.29; 4.13)). The stress-prevention program SGS is a feasible, effective, and practical way to reduce perceived stress and improve participants' resources. Four subsequent telephone-coaching sessions do not seem to contribute to a further improvement in the results.

Factors Predicting Response to the Recovery-Oriented Cognitive Behavioural Workshop for Persons Diagnosed with Schizophrenia.

A recovery-oriented, cognitive behavioural workshop for service users diagnosed with schizophrenia was developed, implemented and evaluated in a pilot study. Further analysis is required regarding factors which contribute to better treatment response, as this will provide useful information for workshop adaptation. Secondary multilevel model analyses were performed to determine whether workshop and booster session attendance, as well as sociodemographic variables such as gender, age, education, and duration of illness, predicted workshop responsiveness. Results showed that completers had lower responsiveness to the workshop in terms of confidence and hope, whereas those who attended an online booster session demonstrated better responsiveness as to psychosocial functioning. Longer duration of illness and older age generally predicted lower intervention responsiveness. In conclusion, adaptations utilising more booster sessions and accommodating older participants with longer duration of illness are required, as is further workshop evaluation in a randomised controlled study.

Reliability, usability and applicability of the ICD-11 beta draft focusing on hand injuries and diseases: results from German field testing.

OBJECTIVE: To test the interrater reliability when using the codes of the 11th revision of the International Classification of Diseases (ICD)-11 beta draft as well as ICD-10 and to explore the usability of the ICD-11 beta draft and the applicability of ICD-11's Supplementary section for functioning assessment in hand injuries and diseases. DESIGN: We conducted a validation study of the ICD-11 beta draft complemented by a single-centre study to collect clinical routine data on functioning. SETTING: German hand surgery clinics. PARTICIPANTS: Twenty-three physicians coded real-life cases containing diagnostic information on hand injuries and diseases. Additionally, clinical information of 100 patients was coded by 6 physicians and a nurse using ICD-11's Supplementary section for functioning assessment. MAIN OUTCOME MEASURES: Physicians coded 210 cases using the ICD-11 beta draft and ICD-10. Krippendorff's alpha was calculated. Clinical routine data was coded using 38 functioning categories. RESULTS: Interrater reliability (Krippendorff's alpha) of 0.67 for ICD-11 coding and 0.71 for ICD-10 coding was obtained, indicating substantial agreement. However, physicians reported a high proportion of problems with ICD-11 coding and slightly fewer problems with ICD-10 coding. The collected data on functioning could be mapped to ICD-11's Supplementary section for functioning assessment. For some data, however, only unspecific codes were available. CONCLUSIONS: Interrater reliability of ICD-10 and ICD-11 was satisfactory. Training material for ICD-11 is needed to further improve reliability and usability. Future users of ICD-11 should be encouraged to use the Supplementary section for functioning assessment to shed light on the problems patients experience in everyday life.

[Validation of the ICD-11 beta draft in hand surgery]. / Validierung der ICD-11 Betaversion im Bereich Handchirurgie.

BACKGROUND: The practice of hand surgery is characterised by the surgical and conservative treatment of patients with a broad range of single and multiple hand injuries, many of them complex, as well as hand diseases. Thus far, the coding of especially complex hand injuries using the International Statistical Classification of Diseases and Related Health Problems, 10th revision (German Modification) (ICD-10-GM) has often been a challenge for the persons responsible for coding. To ensure an exact, unambiguous and reliable coding of patient cases, the mapping of these cases in the 11th revision of the ICD is an inevitable requirement. The aim of this study was to examine the representation of hand injuries and diseases in the ICD-11 beta draft. METHODS: We performed a case-oriented validation study. Based on real-life patient cases, we developed two types of case scenarios (short diagnostic statements: "lines", and more comprehensive case descriptions: "cases"), which were coded using the ICD-11 beta draft. To gain insight into participants' experiences with the coding process, additional telephone interviews were carried out. RESULTS: Twenty-three hand surgeons from nine participating institutions coded a total of 315 case scenarios using the ICD-11 beta draft - 210 lines and 105 cases. An inter-rater reliability (Krippendorff's alpha) of 0.67 for both lines and cases indicated substantial agreement between the coding physicians. Study participants reported difficulties with coding in approximately one third of case scenarios (lines: 27 % and cases: 35 %). Nine physicians additionally took part in telephone interviews. Problems with coding using the ICD-11 beta draft as well as specific suggestions for changes were collected, verified by a working group and complemented by further proposals. CONCLUSION: The results of this study entailed important adaptations of the ICD-11 in the field of hand surgery and will in future enable an unambiguous and specific coding of hand injuries and diseases, especially multiple injuries. The obtained inter-rater reliability for the ICD-11 beta draft is satisfactory. Specific problems as well as proposals for changes supported the finalisation of the ICD-11.

Development and Evaluation of a Recovery-Oriented Cognitive Behavioural Workshop for People Diagnosed with Schizophrenia.

BACKGROUND: There is a need to develop culturally adapted interventions that support the personal recovery and real-world functioning of people diagnosed with schizophrenia. AIMS: This study reports on the development and evaluation of a culturally adapted, recovery-oriented, cognitive behavioural workshop for service users with schizophrenia. METHOD: The feasibility and acceptability were assessed, as were changes over time in personal recovery and psychosocial functioning (primary outcomes) along with psychopathology and health-related behaviours (secondary outcomes), using multi-level modelling. It was also assessed whether personal recovery predicts psychosocial functioning. RESULTS: The workshop was feasible and was received favourably. Participants improved over time regarding confidence and hope, feeling less dominated by symptoms, psychosocial functioning, and psychopathology. Personal recovery predicted decreased psychosocial difficulties. CONCLUSIONS: The workshop is a promising intervention. It shows potential in terms of both improving personal recovery as well as real-life functioning of people diagnosed with schizophrenia. Further workshop evaluation in a randomized controlled study is required.

Development and Evaluation of Digital Game-Based Training for Managers to Promote Employee Mental Health and Reduce Mental Illness Stigma at Work: Quasi-Experimental Study of Program Effectiveness.

BACKGROUND: To counteract the negative impact of mental health problems on business, organizations are increasingly investing in mental health intervention measures. However, those services are often underused, which, to a great extent, can be attributed to fear of stigmatization. Nevertheless, so far only a few workplace interventions have specifically targeted stigma, and evidence on their effectiveness is limited. OBJECTIVE: The objective of this study was to develop and evaluate a digital game-based training program for managers to promote employee mental health and reduce mental illness stigma at work. METHODS: We describe the empirical development of Leadership Training in Mental Health Promotion (LMHP), a digital game-based training program for leaders. A 1-group pre-post design and a 3-month follow-up were used for training evaluation. We applied multilevel growth models to investigate change over time in the dependent variables knowledge, attitudes, self-efficacy, and intentions to promote employee mental health in 48 managers of a global enterprise in the United Kingdom. Participants were mainly male (44/48, 92%) and ranged in age from 32 to 58 (mean 46.0, SD 7.2) years. RESULTS: We found a positive impact of the Web-based training program on managers' knowledge of mental health and mental illness (P<.001), on attitudes toward people with mental health problems (P<.01), and on their self-efficacy to deal with mental health situations at work (P<.001), with the exception of intentions to promote employee mental health, which was initially high. CONCLUSIONS: Results provide first evidence of the effectiveness of LMHP to positively affect managers' skills to promote employee mental health at work. Furthermore, the high rate of participation in LMHP (48/54, 89%) supports the use of digital game-based interventions to increase user engagement and user experience in mental health programs at work.

Examination of the Applicability of the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire to Patients with Hand Injuries and Diseases Using Rasch Analysis.

BACKGROUND: The Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire is the most commonly applied patient-reported outcome measure used to assess disability and functioning in clinical research and practice for patients with injuries and diseases of the upper extremities. The objective of this study was to assess whether the DASH is a valid and reliable questionnaire to measure disability and functioning in patients with hand injuries and diseases using Rasch analysis. METHODS: We performed a psychometric study using data derived from two multicentre studies carried out to develop the International Classification of Functioning, Disability and Health (ICF) Core Sets for Hand Conditions. We analysed the data of 417 patients recruited in a clinical setting and suffering from hand injuries (e.g. finger fracture, flexor tendon injury) or diseases (e.g. carpal tunnel syndrome, rhizarthrosis). We examined whether the DASH fulfilled the assumptions for its use as a measure by applying a partial credit model and testing for differential item functioning for sex and age. RESULTS: Bifactor analysis revealed problems with the underlying latent trait of functioning and disability. Rasch analysis raised further issues, including disordered thresholds for eight items and misfit in nine items. One item showed Differential Item Functioning for sex. CONCLUSION: The study reveals that some DASH items do not fit the underlying trait that the DASH aims to measure. Further studies using Rasch analysis are needed to compare our findings with results of studies involving other target groups (e.g. patients with injuries of the upper arm and shoulder).

De novo donor-specific anti-HLA antibodies after kidney transplantation are associated with impaired graft outcome independently of their C1q-binding ability.

Many aspects of post-transplant monitoring of donor-specific (DSA) and non-donor-specific (nDSA) anti-HLA antibodies on renal allograft survival are still unclear. Differentiating them by their ability to bind C1q may offer a better risk assessment. We retrospectively investigated the clinical relevance of de novo C1q-binding anti-HLA antibodies on graft outcome in 611 renal transplant recipients. Acute rejection (AR), renal function, and graft survival were assessed within a mean follow-up of 6.66 years. Post-transplant 6.5% patients developed de novo DSA and 11.5% de novo nDSA. DSA (60.0%; P < 0.0001) but not nDSA (34.1%, P = 0.4788) increased rate of AR as compared with controls (27.4%). C1q-binding anti-HLA antibodies did not alter rate of AR in both groups. Renal function was only significantly diminished in patients with DSAC1q+ . However, DSA significantly impaired 5-year graft survival (65.2%; P < 0.0001) in comparison with nDSA (86.7%; P = 0.0054) and controls (90.7%). While graft survival did not differ between DSAC1q- and DSAC1q+ recipients, 5-year allograft survival was reduced in nDSAC1q+ (80.9%) versus nDSAC1q- (90.7%, P = 0.0251). De novo DSA independently of their ability to bind C1q are associated with diminished graft survival.

The Effectiveness of a Stress Reduction and Burnout Prevention Program.

BACKGROUND: Chronic psychological distress appears to have increased in recent years, mainly among the working population. The data available indicate that mental and behavioral disorders, including burnout syndrome, represent not only a personal problem for those afflicted, but also a serious public health issue. This study aimed at evaluating the effects of an outpatient burnout prevention program in a mono-center health resort setting. METHODS: Adults experiencing an above-average level of stress and thus being at an increased risk of burnout were randomized either to the intervention group (IG) or the waiting control group (WG). The 3-week program included stress management intervention, relaxation, physical exercise and moor applications. The primary outcome was change in perceived stress (PSQ) at 6 months post-intervention. Secondary outcomes included burnout symptoms, well-being, health status, psychological symptoms, back pain, and number of sick days. Participants were examined at baseline, post-intervention (3 weeks) and after 1, 3 and 6 months. RESULTS: Data from 88 adults (IG=43; WG=45) were available for (per protocol) analysis (mean age: 50.85; 76.1% female). Participants in the IG experienced significant immediate improvement in all outcome measures, which declined somewhat during the first three months post-intervention and then remained stable for at least another three months. Those in the WG did not experience substantial change across time. For the 109 randomized persons, results for PSQ were confirmed in an intention-to-treat analysis with missing values replaced by last observation carried forward (between-group ANCOVA for PSQScore at 6 months, parameter estimator for the group: -20.57; 95% CI: [-26.09; -15.04]). Large effect sizes (Cohen's d for PSQ: 1.09-1.72) indicate the superiority of the intervention. CONCLUSION: The program proved to be effective in reducing perceived stress, emotional exhaustion and other targets. Future research should examine the long-term impact of the program and the effect of occasional refresher training.

The PaArticular Scales - A new outcome measure to quantify the impact of joint contractures on activities and participation in individuals in geriatric care: Development and Rasch analysis.

BACKGROUND: Joint contractures are frequent conditions in individuals in geriatric care settings and are associated with activity limitations and participation restrictions. As such, relevant intervention programs should address these aspects, and the effectiveness of such programs should be determined by assessing improvement in activities and participation. However, no patient-centred and psychometrically sound outcome measures for this purpose are available so far. OBJECTIVES: The objectives of this study were to develop and to validate a new outcome measure, the PaArticular Scales, to quantify activities and participation in older individuals with joint contractures. Specific aims were (A) to operationalize the content of an International Classification of Functioning, Disability and Health-based standard set towards meaningful questions and to combine them to a questionnaire and (B) to assess the psychometric properties of the developed questionnaire, in detail to evaluate test-retest reliability, objectivity, internal consistency reliability and criterion validity. DESIGN: Operationalization was reached by an expert consensus conference and a subsequent expert Delphi survey. Psychometric properties were assessed in a cross-sectional study. SETTINGS: Nursing homes, geriatric rehabilitation facilities. PARTICIPANTS: 23 experts (nurses, physicians, physical and occupational therapists) participated in the consensus conference and the Delphi survey. A total of 191 individuals with joint contractures (as confirmed by physician, nurse or physical therapist) between 65 and 102 years, living in nursing homes or as patients in geriatric rehabilitation were enrolled in the cross-sectional study. METHODS: Rasch Partial Credit Modelling. RESULTS: The consensus conference and Delphi survey resulted in a questionnaire with 86 items of the International Classification of Functioning, Disability and Health. Test-retest-reliability among those was acceptable (Cohen's weighted kappa: 0.779). The Rasch analysis revealed two independent interval-scaled scales with 24 items for the Activities scale and 11 items for the Participation scale with high internal consistency reliability. Cronbach's alpha was 0.96 for the Activities scale and 0.92 for the Participation scale. Criterion validity was -0.40 and -0.30 for the Activities scale and for the Participation scale, respectively. CONCLUSIONS: The PaArticular Scales, a new patient-centred and psychometric sound outcome measures to comprehensively assess the impact of joint contractures in geriatric care, are available now. These developed scales will serve as primary outcomes in a scheduled evaluation of a complex intervention to improve participation and quality of life in nursing home residents with joint contractures.

Development of a metric for tracking and comparing population health based on the minimal generic set of domains of functioning and health.

BACKGROUND: The following minimal set of valid health domains for tracking the health of both clinical and general populations has recently been proposed: 1) energy and drive functions, 2) emotional functions, 3) sensation of pain, 4) carrying out daily routine, 5) walking and moving around, and 6) remunerative employment. This study investigates whether these domains can be integrated into a sound psychometric measure to adequately assess, compare, and monitor the health of populations. METHODS: Data from waves 3 and 4 of the English Longitudinal Study of Ageing (ELSA) were analysed (N = 9779 and 11,050). From ELSA, 12 items operationalizing the six domains of the minimal generic set were identified. The Partial Credit Model (PCM) was applied to create a health metric based on these items. The Item Response Theory (IRT) model assumptions of unidimensionality, local independence, and monotonicity were evaluated, and Differential Item Functioning (DIF) was examined for sex and age groups. The psychometric properties of: 1) internal consistency reliability, 2) construct validity, and 3) sensitivity to change were evaluated to establish the final health metric. RESULTS: IRT model assumptions were found to be fulfilled. None of the items showed DIF by sex or age group. The final health metric demonstrated sound psychometric properties. CONCLUSIONS: The health metric developed in this study - based on the domains of the minimal generic set - proved useful for a wide range of health comparisons, especially for different groups of persons, and both cross-sectionally and over time. Monitoring health over time provides especially useful information for health care providers and health policymakers and both in clinical settings and the general population. The developed health metric offers a wide range of applications, including comparisons of levels of health among different groups in the general population, clinical populations, and even populations within and across different countries.