Flares after hydroxychloroquine reduction or discontinuation: results from the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort

ObjectivesTo evaluate systemic lupus erythematosus (SLE) flares following hydroxychloroquine (HCQ) reduction or discontinuation versus HCQ maintenance.MethodsWe analysed prospective data from the Systemic Lupus International Collaborating Clinics (SLICC) cohort, enrolled from 33 sites within 15 months of SLE diagnosis and followed annually (1999–2019). We evaluated person-time contributed while on the initial HCQ dose (‘maintenance’), comparing this with person-time contributed after a first dose reduction, and after a first HCQ discontinuation. We estimated time to first flare, defined as either subsequent need for therapy augmentation, increase of ≥4 points in the SLE Disease Activity Index-2000, or hospitalisation for SLE. We estimated adjusted HRs (aHRs) with 95% CIs associated with reducing/discontinuing HCQ (vs maintenance). We also conducted separate multivariable hazard regressions in each HCQ subcohort to identify factors associated with flare.ResultsWe studied 1460 (90% female) patients initiating HCQ. aHRs for first SLE flare were 1.20 (95% CI 1.04 to 1.38) and 1.56 (95% CI 1.31 to 1.86) for the HCQ reduction and discontinuation groups, respectively, versus HCQ maintenance. Patients with low educational level were at particular risk of flaring after HCQ discontinuation (aHR 1.43, 95% CI 1.09 to 1.87). Prednisone use at time-zero was associated with over 1.5-fold increase in flare risk in all HCQ subcohorts.ConclusionsSLE flare risk was higher after HCQ taper/discontinuation versus HCQ maintenance. Decisions to maintain, reduce or stop HCQ may affect specific subgroups differently, including those on prednisone and/or with low education. Further study of special groups (eg, seniors) may be helpful.

Prevalence of Long COVID symptoms in Bangladesh: a prospective Inception Cohort Study of COVID-19 survivors

BackgroundThe objective of this study was to identify the prevalence of long COVID symptoms in a large cohort of people living with and affected by long COVID and identify any potential associated risk factors.MethodsA prospective survey was undertaken of an inception cohort of confirmed people living with and affected by long COVID (aged 18–87 years). 14392 participants were recruited from 24 testing facilities across Bangladesh between June and November 2020. All participants had a previously confirmed positive COVID-19 diagnosis, and reported persistent symptoms and difficulties in performing daily activities. Participants who consented were contacted by face-to-face interview, and were interviewed regarding long COVID, and restriction of activities of daily living using post COVID-19 functional status scale. Cardiorespiratory parameters measured at rest (heart rate, systolic blood pressure, diastolic blood pressure, oxygen saturation levels, maximal oxygen consumption, inspiratory and expiratory lung volume) were also measured.ResultsAmong 2198 participants, the prevalence of long COVID symptoms at 12 weeks was 16.1%. Overall, eight long COVID symptoms were identified and in descending order of prominence are: fatigue, pain, dyspnoea, cough, anosmia, appetite loss, headache and chest pain. People living with and affected by long COVID experienced between 1 and 8 long COVID symptoms with an overall duration period of 21.8±5.2 weeks. Structural equation modelling predicted the length of long COVID to be related to younger age, female gender, rural residence, prior functional limitation and smoking.ConclusionIn this cohort, at 31 weeks post diagnosis, the prevalence of long COVID symptoms was 16.1%. The risk factors identified for presence and longer length of long COVID symptoms warrant further research and consideration to support public health initiatives.

OXYGEN MANAGEMENT IN NEW ZEALAND AND AUSTRALIAN INTENSIVE CARE UNITS: A KNOWLEDGE TRANSLATION STUDY

<p><b>Background: Knowledge translation literature shows a delay between publication and uptake of research findings into clinical practice. There is uncertainty about whether this delay exists in the intensive care unit (ICU) context and whether participation in research influences changes in clinical practice. Knowing whether ICU participation in research increases the likelihood of research findings being incorporated into clinical care is important to funders, researchers and patients.</b></p> <p>Aim: To investigate the effects of participating in the Intensive Care Unit Randomised Trial Comparing Two Approaches to Oxygen therapy (ICU-ROX) randomised controlled trial on attitudes and practices in relation to ICU oxygen therapy.</p> <p>Methods: The research question was examined using three different methods: a survey, an inception cohort study, and a retrospective cohort study. The practitioner attitudes survey and inception cohort study were conducted before ICU-ROX started, after ICU-ROX finished but before the results were known, and, finally, after publication of the ICU-ROX results. The retrospective cohort study (using the Australian and New Zealand ICU adult patient database) compared data from 48 weeks before and 48 weeks after publication of the ICU-ROX trial.</p> <p>Results: Practitioner attitudes survey: Responses were received from 112 specialist doctors and 153 ICU nurses from 11 ICU-ROX and 11 non-ICU-ROX sites. Before the ICU-ROX trial was conducted, respondents from ICU-ROX trial sites and those from non-ICU-ROX trial sites were similarly likely to indicate they would use a fraction of inspired oxygen (FIO2) of 0.21, in a ventilated patient with peripheral oxygen saturations (SpO2) of 91-96%. However, after participation in the ICU-ROX trial, and before the trial results were known, ICU-ROX trial site respondents were significantly more likely than their non-ICU-ROX trial site counterparts to state they would use an FIO2 of 0.21 in a patient with an SpO2 of 91-96%. The differences in all patient admission categories, except the ‘other ICU patients’ category, persisted after the ICU-ROX trial was published. Nurses were generally less likely to report they would use an FIO2 of 0.21 in a ventilated patient than doctors. Following ICU-ROX publication, 41.1% of the doctors compared to 13.6% of the nurses knew the ICU-ROX results (P<0.001), and 53.1% and 5.4%, respectively, reported having read the publication (P<0.001).</p> <p>Inception cohort study: Data were analysed from 650 patients from 11 ICU-ROX and 11 non-ICU-ROX sites. ICU-ROX site patients spent 8.2% of the time ventilated at FIO2 of 0.21, before ICU-ROX started, 7.7% after their participation in the ICU-ROX trial and 7.1% of the time after ICU-ROX publication, a change over time was not statistically significant. For the non-ICU-ROX site patients, time spent ventilated at FIO2 of 0.21 was 0.9% before ICU-ROX, 2.4% after ICU-ROX was conducted and 3.3% after publication. This change for non-ICU-ROX site patients after ICU-ROX publication was statistically significant (relative rate 3.63; 95% CI 1.39 to 9.47, P=0.01).</p> <p>Retrospective cohort study: The FIO2 from the arterial blood gas associated with the worst Acute Physiology and Chronic Health Evaluation III-J score in the first 24 hours of admission to ICU was analysed for 51,498 pre-publication admissions and 47,523 post-publication admissions from 15 ICU-ROX sites and 188 non-ICU-ROX sites. Although the average FIO2 values varied considerably from week to week, there was a statistically significant reduction in the average FIO2 over time in ICU-ROX sites (P=0.01) but not in non-ICU-ROX sites (P=0.49).</p> <p>Conclusion: Differences between attitudes of practitioners in relation to oxygen in ICU-ROX sites compared with non-ICU-ROX sites changed over time (before and after the ICU-ROX trial, and after publication of the results). Differences in oxygen therapy practice changes for ICU-ROX versus non-ICU-ROX sites shown in the inception cohort study and retrospective cohort study were small, and are unlikely to be clinically important. These studies did not demonstrate a consistent effect of participation in ICU-ROX on knowledge translation.</p>

Oxygen management in New Zealand and Australian intensive care units: A knowledge translation study

<p><b>Background: Knowledge translation literature shows a delay between publication and uptake of research findings into clinical practice. There is uncertainty about whether this delay exists in the intensive care unit (ICU) context and whether participation in research influences changes in clinical practice. Knowing whether ICU participation in research increases the likelihood of research findings being incorporated into clinical care is important to funders, researchers and patients.</b></p> <p>Aim: To investigate the effects of participating in the Intensive Care Unit Randomised Trial Comparing Two Approaches to Oxygen therapy (ICU-ROX) randomised controlled trial on attitudes and practices in relation to ICU oxygen therapy.</p> <p>Methods: The research question was examined using three different methods: a survey, an inception cohort study, and a retrospective cohort study. The practitioner attitudes survey and inception cohort study were conducted before ICU-ROX started, after ICU-ROX finished but before the results were known, and, finally, after publication of the ICU-ROX results. The retrospective cohort study (using the Australian and New Zealand ICU adult patient database) compared data from 48 weeks before and 48 weeks after publication of the ICU-ROX trial.</p> <p>Results: Practitioner attitudes survey: Responses were received from 112 specialist doctors and 153 ICU nurses from 11 ICU-ROX and 11 non-ICU-ROX sites. Before the ICU-ROX trial was conducted, respondents from ICU-ROX trial sites and those from non-ICU-ROX trial sites were similarly likely to indicate they would use a fraction of inspired oxygen (FIO2) of 0.21, in a ventilated patient with peripheral oxygen saturations (SpO2) of 91-96%. However, after participation in the ICU-ROX trial, and before the trial results were known, ICU-ROX trial site respondents were significantly more likely than their non-ICU-ROX trial site counterparts to state they would use an FIO2 of 0.21 in a patient with an SpO2 of 91-96%. The differences in all patient admission categories, except the ‘other ICU patients’ category, persisted after the ICU-ROX trial was published. Nurses were generally less likely to report they would use an FIO2 of 0.21 in a ventilated patient than doctors. Following ICU-ROX publication, 41.1% of the doctors compared to 13.6% of the nurses knew the ICU-ROX results (P<0.001), and 53.1% and 5.4%, respectively, reported having read the publication (P<0.001).</p> <p>Inception cohort study: Data were analysed from 650 patients from 11 ICU-ROX and 11 non-ICU-ROX sites. ICU-ROX site patients spent 8.2% of the time ventilated at FIO2 of 0.21, before ICU-ROX started, 7.7% after their participation in the ICU-ROX trial and 7.1% of the time after ICU-ROX publication, a change over time was not statistically significant. For the non-ICU-ROX site patients, time spent ventilated at FIO2 of 0.21 was 0.9% before ICU-ROX, 2.4% after ICU-ROX was conducted and 3.3% after publication. This change for non-ICU-ROX site patients after ICU-ROX publication was statistically significant (relative rate 3.63; 95% CI 1.39 to 9.47, P=0.01).</p> <p>Retrospective cohort study: The FIO2 from the arterial blood gas associated with the worst Acute Physiology and Chronic Health Evaluation III-J score in the first 24 hours of admission to ICU was analysed for 51,498 pre-publication admissions and 47,523 post-publication admissions from 15 ICU-ROX sites and 188 non-ICU-ROX sites. Although the average FIO2 values varied considerably from week to week, there was a statistically significant reduction in the average FIO2 over time in ICU-ROX sites (P=0.01) but not in non-ICU-ROX sites (P=0.49).</p> <p>Conclusion: Differences between attitudes of practitioners in relation to oxygen in ICU-ROX sites compared with non-ICU-ROX sites changed over time (before and after the ICU-ROX trial, and after publication of the results). Differences in oxygen therapy practice changes for ICU-ROX versus non-ICU-ROX sites shown in the inception cohort study and retrospective cohort study were small, and are unlikely to be clinically important. These studies did not demonstrate a consistent effect of participation in ICU-ROX on knowledge translation.</p>

Oxygen management in New Zealand and Australian intensive care units: A knowledge translation study

<p><b>Background: Knowledge translation literature shows a delay between publication and uptake of research findings into clinical practice. There is uncertainty about whether this delay exists in the intensive care unit (ICU) context and whether participation in research influences changes in clinical practice. Knowing whether ICU participation in research increases the likelihood of research findings being incorporated into clinical care is important to funders, researchers and patients.</b></p> <p>Aim: To investigate the effects of participating in the Intensive Care Unit Randomised Trial Comparing Two Approaches to Oxygen therapy (ICU-ROX) randomised controlled trial on attitudes and practices in relation to ICU oxygen therapy.</p> <p>Methods: The research question was examined using three different methods: a survey, an inception cohort study, and a retrospective cohort study. The practitioner attitudes survey and inception cohort study were conducted before ICU-ROX started, after ICU-ROX finished but before the results were known, and, finally, after publication of the ICU-ROX results. The retrospective cohort study (using the Australian and New Zealand ICU adult patient database) compared data from 48 weeks before and 48 weeks after publication of the ICU-ROX trial.</p> <p>Results: Practitioner attitudes survey: Responses were received from 112 specialist doctors and 153 ICU nurses from 11 ICU-ROX and 11 non-ICU-ROX sites. Before the ICU-ROX trial was conducted, respondents from ICU-ROX trial sites and those from non-ICU-ROX trial sites were similarly likely to indicate they would use a fraction of inspired oxygen (FIO2) of 0.21, in a ventilated patient with peripheral oxygen saturations (SpO2) of 91-96%. However, after participation in the ICU-ROX trial, and before the trial results were known, ICU-ROX trial site respondents were significantly more likely than their non-ICU-ROX trial site counterparts to state they would use an FIO2 of 0.21 in a patient with an SpO2 of 91-96%. The differences in all patient admission categories, except the ‘other ICU patients’ category, persisted after the ICU-ROX trial was published. Nurses were generally less likely to report they would use an FIO2 of 0.21 in a ventilated patient than doctors. Following ICU-ROX publication, 41.1% of the doctors compared to 13.6% of the nurses knew the ICU-ROX results (P<0.001), and 53.1% and 5.4%, respectively, reported having read the publication (P<0.001).</p> <p>Inception cohort study: Data were analysed from 650 patients from 11 ICU-ROX and 11 non-ICU-ROX sites. ICU-ROX site patients spent 8.2% of the time ventilated at FIO2 of 0.21, before ICU-ROX started, 7.7% after their participation in the ICU-ROX trial and 7.1% of the time after ICU-ROX publication, a change over time was not statistically significant. For the non-ICU-ROX site patients, time spent ventilated at FIO2 of 0.21 was 0.9% before ICU-ROX, 2.4% after ICU-ROX was conducted and 3.3% after publication. This change for non-ICU-ROX site patients after ICU-ROX publication was statistically significant (relative rate 3.63; 95% CI 1.39 to 9.47, P=0.01).</p> <p>Retrospective cohort study: The FIO2 from the arterial blood gas associated with the worst Acute Physiology and Chronic Health Evaluation III-J score in the first 24 hours of admission to ICU was analysed for 51,498 pre-publication admissions and 47,523 post-publication admissions from 15 ICU-ROX sites and 188 non-ICU-ROX sites. Although the average FIO2 values varied considerably from week to week, there was a statistically significant reduction in the average FIO2 over time in ICU-ROX sites (P=0.01) but not in non-ICU-ROX sites (P=0.49).</p> <p>Conclusion: Differences between attitudes of practitioners in relation to oxygen in ICU-ROX sites compared with non-ICU-ROX sites changed over time (before and after the ICU-ROX trial, and after publication of the results). Differences in oxygen therapy practice changes for ICU-ROX versus non-ICU-ROX sites shown in the inception cohort study and retrospective cohort study were small, and are unlikely to be clinically important. These studies did not demonstrate a consistent effect of participation in ICU-ROX on knowledge translation.</p>

Comparison of physical and psychological health outcomes for motorcyclists and other road users after land transport crashes: an inception cohort study

Background Serious injuries and fatalities among vulnerable road users on two wheeled motorised vehicles have increased across Australia and internationally in the past decade yet fallen for motor vehicle occupants. Almost half of all reported motorcycle injury crashes cause serious injury or death, nearly double that of motor vehicle police-reported crashes. This study explores associations with sociodemographic and pre-injury health characteristics and health outcomes after a road traffic injury; aiming to compare motorcyclists with other road users and inform recovery care. Methods An inception cohort study recruited 1854 individuals aged > 17 years, injured following land-transport crashes in New South Wales, Australia (July 2013–November 2016). Interviews conducted at baseline, 6-and 12-months post-injury elicited demographic, socioeconomic, and self-reported health conditions. Results Primary analysis involved 1854 participants who were recruited at baseline as three distinct road user groups; 628 (33.9%) motorcyclists, 927 (50%) vehicle occupants and 299 (16.1%) bicyclists. At baseline, injury patterns differed significantly between road user groups; motorcyclists were more than twice as likely to sustain lower extremity injury (p < 0.001); to have more severe injury severity scores (p < 0.001) and longer hospital stays versus vs vehicle occupants and bicyclists (< 0.001) across these measures. Injured motorcyclists were predominantly male (88.1%, p < 0.001), were younger on average (38 years) than bicyclists (41.5 years), had lower income and education levels, and poorer pre-injury physical health than other road user groups. Despite these differences, at 12 months post-injury motorcyclists had better physical health (SF12-PCS 2.07 (0.77, 3.36), p = 0.002) and reported lower pain scores (− 0.51 (− 0.83, − 0.2), p < 0.001) than vehicle occupants. Motorcyclists displayed less evidence of psychological distress than vehicle occupants, but more than bicyclists across several measures used. Conclusions Road user types differ in important characteristics, including pre-injury health status and recovery after injury. As vulnerable road users experiencing transport crash and considering their higher initial injury severity, the degree of recovery among motorcyclists compared with other user types is remarkable and unexplained. Health and recovery outcomes after land-transport crashes is least favourable among vehicle occupants despite their higher levels of protection in a crash. This information is valuable for targeting early intervention strategies by road user type during the post-crash care phase, to improve long-term recovery.