Proximal vs Distal Approach of Ultrasound-guided Suprascapular Nerve Block for Patients With Adhesive Capsulitis of the Shoulder: Prospective Randomized Controlled Trial

ObjectivesTo evaluate the early clinical outcomes of ultrasound (US)-guided suprascapular nerve block (SSNB) using a proximal approach compared with a distal approach for outpatient treatment of adhesive capsulitis.DesignRandomized controlled trial.SettingOutpatient clinicParticipantsParticipants (N=47) with symptomatic adhesive capsulitis.InterventionsParticipants were randomly assigned to either US-guided SSNB using a proximal approach (n=23, proximal group) or a distal approach (n=24, distal group).Main Outcome MeasuresThe primary outcome measure was the visual analog scale (VAS) for pain at week 12. Secondary outcomes included the American Shoulder Elbow Surgeon’s (ASES) score, University California Los Angeles score, Short Form-36 mental and physical component summaries, and range of motion. All patients completed clinical follow-up at 2, 6, and 12 weeks after treatment. On US images, depth and insertion angle of needle during injection were measured.ResultsThe VAS significantly improved in both groups at week 12. After treatment, no significant differences were found in early clinical outcomes (weeks 2, 6, and 12) between groups (all P>.05), except that ASES at 2 weeks showed a significantly higher score in the distal group than in the proximal group (87.1±4.8 and 83.0±6.3, respectively; P=.014). The mean depth and insertion angle of needle was significantly lower (depth: 13.4±3.9 and 30.6±4.3 mm, respectively; P<.001; insertion angle: 19.6°±6.4° and 38.7°±5.8°; P<.001) in the proximal group than in the distal group.ConclusionsThis study demonstrated that proximal approach of US-guided SSNB provided favorable short-term outcomes of pain and functional improvement and that outcomes were comparable to those of the distal approach in adhesive capsulitis. The suprascapular nerve was located more superficially and easily identified in the proximal approach, suggesting that this method might improve the accuracy of injection.     

Outcome measurement in functional somatic syndromes: SF-36 summary scores and some scales were not valid

Objective

This study aimed to test the validity of the 36-item Short-Form Health Survey (SF-36) scales and summaries in patients with severe functional somatic syndromes (FSS), such as fibromyalgia and irritable bowel syndrome.

Study Design and Setting

One hundred twenty patients with severe FSS enrolled in a randomized controlled trial filled in the SF-36 questionnaire. We tested for data quality, central scaling assumptions, and agreement with the conceptual model.

Results

Most SF-36 scales were found to be valid; however, three scales (role physical, role emotional, and general health) did not satisfy predefined criteria for construct validity, internal consistency, or targeting to the sample. The correlations between SF-36 scales differed considerably from those reported in the general population. As a consequence, the SF-36 summaries, physical component summary (PCS) and mental component summary (MCS), did not accurately reflect their underlying scales and were negatively correlated (r = −0.46, 95% CI [−0.60 to −0.31]).

Conclusion

Although the SF-36 is a valuable instrument to assess perceived health in patients with severe FSS, there are problems with some of the scales and with the scoring procedure of the summaries. The SF-36 PCS may, therefore, not accurately measure the physical health status of these patients. Alternative summary measures are needed.     

Bayesian meta-analysis across genome-wide association studies of diverse phenotypes

Genome-wide association studies (GWAS) are a powerful tool for understanding the genetic basis of diseases and traits, but most studies have been conducted in isolation, with a focus on either a single or a set of closely related phenotypes. We describe MetABF, a simple Bayesian framework for performing integrative meta-analysis across multiple GWAS using summary statistics. The approach is applicable across a wide range of study designs and can increase the power by 50% compared with standard frequentist tests when only a subset of studies have a true effect. We demonstrate its utility in a meta-analysis of 20 diverse GWAS which were part of the Wellcome Trust Case Control Consortium 2. The novelty of the approach is its ability to explore, and assess the evidence for a range of possible true patterns of association across studies in a computationally efficient framework.     

Diagnostic utility of automated indirect immunofluorescence compared to manual indirect immunofluorescence for anti-nuclear antibodies in patients with systemic rheumatic diseases: A systematic review and meta-analysis

Objective

This study aimed to review and compare the analytical and clinical performance of automated indirect immunofluorescence (AIIF) and manual indirect immunofluorescence (MIIF) as anti-nuclear antibody screening assays for patients with systemic rheumatic diseases (SRDs), such as systemic lupus erythematosus (SLE) and systemic sclerosis (SSc).

Hospital discharge summary scorecard: a quality improvement tool used in a tertiary hospital general medicine service

We assessed the impact of completion and feedback of discharge summary scorecards on the quality of discharge summaries written by interns in a general medicine service of a tertiary hospital. The scorecards significantly improved summary quality in the first three rotations of the intern year and could be readily adopted by other units as a quality improvement intervention for optimizing clinical handover to primary care providers.     

Incidence and Outcomes of Pneumonia in Patients With Heart Failure

BackgroundThe incidence of pneumonia and subsequent outcomes has not been compared in patients with heart failure and reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF).ObjectivesThis study aimed to examine the rate and impact of pneumonia in the PARADIGM-HF (Prospective Comparison of Angiotensin Receptor-Neprilysin Inhibitor With Angiotensin Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure) and PARAGON-HF (Prospective Comparison of ARNI with ARB Global Outcomes in Heart Failure with Preserved Ejection Fraction) trials.MethodsThe authors analyzed the incidence of investigator-reported pneumonia and the rates of HF hospitalization, cardiovascular death, and all-cause death before and after the occurrence of pneumonia, and estimated risk after the first occurrence of pneumonia in unadjusted and adjusted analyses (the latter including N-terminal pro–B-type natriuretic peptide).ResultsIn PARADIGM-HF, 528 patients (6.3%) developed pneumonia after randomization, giving an incidence rate of 29 (95% CI: 27 to 32) per 1,000 patient-years. In PARAGON-HF, 510 patients (10.6%) developed pneumonia, giving an incidence rate of 39 (95% CI: 36 to 42) per 1,000 patient-years. The subsequent risk of all trial outcomes was elevated after the occurrence of pneumonia. In PARADIGM-HF, the adjusted hazard ratio (HR) for the risk of death from any cause was 4.34 (95% CI: 3.73 to 5.05). The corresponding adjusted HR in PARAGON-HF was 3.76 (95% CI: 3.09 to 4.58).ConclusionsThe incidence of pneumonia was high in patients with HF, especially HFpEF, at around 3 times the expected rate. A first episode of pneumonia was associated with 4-fold higher mortality. (Prospective Comparison of Angiotensin Receptor–Neprilysin Inhibitor With Angiotensin-Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure [PARADIGM-HF], NCT01035255; Prospective Comparison of ARNI [Angiotensin Receptor–Neprilysin Inhibitor] With ARB [Angiotensin Receptor Blocker] Global Outcomes in Heart Failure With Preserved Ejection Fraction [PARAGON-HF], NCT01920711)     

From the Cover: Estimating genetic nurture with summary statistics of multigenerational genome-wide association studies

Marginal effect estimates in genome-wide association studies (GWAS) are mixtures of direct and indirect genetic effects. Existing methods to dissect these effects require family-based, individual-level genetic, and phenotypic data with large samples, which is difficult to obtain in practice. Here, we propose a statistical framework to estimate direct and indirect genetic effects using summary statistics from GWAS conducted on own and offspring phenotypes. Applied to birth weight, our method showed nearly identical results with those obtained using individual-level data. We also decomposed direct and indirect genetic effects of educational attainment (EA), which showed distinct patterns of genetic correlations with 45 complex traits. The known genetic correlations between EA and higher height, lower body mass index, less-active smoking behavior, and better health outcomes were mostly explained by the indirect genetic component of EA. In contrast, the consistently identified genetic correlation of autism spectrum disorder (ASD) with higher EA resides in the direct genetic component. A polygenic transmission disequilibrium test showed a significant overtransmission of the direct component of EA from healthy parents to ASD probands. Taken together, we demonstrate that traditional GWAS approaches, in conjunction with offspring phenotypic data collection in existing cohorts, could greatly benefit studies on genetic nurture and shed important light on the interpretation of genetic associations for human complex traits.

Genome-wide association studies (GWAS) have been a great success in the past decade, identifying tens of thousands of associations for numerous complex human traits (1). The standard GWAS approach estimates the marginal association between each single-nucleotide polymorphism (SNP) and a phenotype while assuming that genetic and environmental factors additively affect the phenotype. Despite the simplicity, such an analytical strategy is computationally efficient and statistically robust. However, interpretation of GWAS associations remains a challenge, in part because most identified associations have weak effect sizes and are located in the noncoding regions of the genome (2, 3). Interpretation is especially challenging for behavioral traits since the role of each variant or gene in complex human behavior is difficult to disentangle. Nevertheless, biobank-scale GWAS of complex traits have produced polygenic scores (PGS) that aggregate the effects of many SNPs in the genome to provide robust prediction of trait values (4). These scores are widely used in social genomics research, although our understanding of the underlying mechanism is superficial and incomplete (5).Recent evidence from family-based studies suggested that a substantial fraction of genetic associations may be mediated by the family environment (6–16). In particular, parental genotypes could affect the family environment through the parents’ educational attainment (EA) (17), personalities (18, 19), behavior (20–24), and socioeconomic status (25), which could subsequently affect the offspring’s phenotypes (26). As a result, a person’s genotypes, which also reside in his or her biological parents, could associate with the person’s phenotype both directly (through inherited genetic variants) and indirectly (through parents and the family environment they create). Due to the correlation between parental and offspring genotypes, GWAS captures both the direct and indirect genetic effects in its estimates, which further complicates the interpretation of GWAS results (13). If the genetic nurture effect (i.e., parental genotypes affecting offspring phenotype) is present for a given trait, downstream analyses based on GWAS associations could be biased and misleading (6, 8, 27).It is thus crucial to decompose the direct and indirect genetic effects and understand how they jointly affect the phenotype. By leveraging large-scale trio cohorts and regressing the offspring phenotype on two sets of PGS calculated using transmitted and nontransmitted alleles in parents, Kong et al. (6) convincingly demonstrated the existence of genetic nurture effects for multiple traits. In particular, PGS of nontransmitted alleles in parents has an effect size that is about 30% of that by the standard PGS for EA. Using PGS, several other studies (7–12) also identified indirect genetic effects on various phenotypes. Existing methods to detect direct and indirect genetic effects, however, have limitations. First, they require individual-level genotype and phenotype data of a large number of parents–offspring trios or, in some cases, other types of rare samples [e.g., adopted individuals (11, 12)]. Although sample size in GWAS has been steadily increasing, number of trio samples with accessible individual-level data remains moderate even in large biobanks. Second, existing methods quantify genetic nurture using PGS which relies on large GWAS conducted on samples independent from the study. Even when such a GWAS exists, it remains challenging to interrogate the direct and indirect effects of each SNP using designs and data similar to the current GWAS practice, which is critical for functional follow-ups and out-of-sample prediction (13).Although a simple study design that regresses the phenotypes on both own and parental genotypes should provide estimates for direct and indirect genetic effects of each SNP, such a strategy is most likely underpowered given the limited sample size of trios in existing cohorts. Several recent studies have attempted to solve this challenging problem. Warrington et al. (28) used a structural equation model (SEM) approach to decompose direct genetic effects and indirect maternal effects on birth weight while assuming paternal effects to be 0. This approach only requires summary statistics from a standard GWAS on birth weight and a second GWAS based on maternal genotypes and offspring phenotypes, thus effectively expanding the available sample size. However, the SEM approach was too computationally demanding to be applied to the genome-wide scale, and a “weighted linear model” alternative could not account for sample overlap if individual-level data are unavailable. Another recent approach (14, 15) expands family genotype data by imputing the unobserved parental genotypes using data from other family members. However, this approach still requires a large sample of sibling or parent–offspring pairs. Further, when parental genotypes are imputed from sibling pairs, it is challenging to distinguish paternal and maternal autosomal genotypes. Thus, separate estimation of indirect maternal and paternal effects is unattainable.Here, we introduce DONUTS (decomposing nature and nurture using GWAS summary statistics), a statistical framework that can estimate direct and indirect genetic effects at the SNP level. It requires GWAS summary statistics as input, allows differential paternal and maternal effects, and accounts for GWAS sample overlap and assortative mating. DONUTS has low computational burden and can complete genome-wide analyses within seconds. Applied to birth weight, our method showed near-identical effect estimates compared to analyses (28) that leveraged individual-level data and improved SE and statistical power after accounting for sample overlap. We also applied our method to dissect the direct and indirect genetic effects of EA. Our results revealed distinct genetic correlations of the direct and indirect genetic components of EA with various traits and shed important light on the complex and heterogenous genetic architecture of EA. Followed up in three independent cohorts of autism spectrum disorder (ASD) proband–parent trios, we identified significant overtransmission of the direct component of EA from healthy parents to ASD probands but not to the healthy siblings.     

近5年我国护理证据总结类论文的方法学质量分析

目的:检索国内相关数据库,参考JBI循证卫生保健研究中心证据总结制作的核心要素,分析护理证据总结类论文的常见方法学问题,为证据总结的撰写和发表提供参考。方法:使用"证据总结"为检索词检索近5年中国知网、万方数据库、维普数据库中发表的证据总结类论文,将其共性问题进行归纳总结并探讨对应的处理策略。结果:经筛选后共纳入证据总结类论文78篇,其循证问题的提出、证据的检索、筛选、评价以及证据的分级和推荐强度的制定等方面均存在一些共性问题。结论:规范证据总结的报告方法将有利于临床科学决策。     

医疗器械相关压力性损伤预防的证据总结

目的 遴选并获取预防医疗器械相关压力性损伤的临床实践依据,并对相关证据进行总结.方法 针对医疗器械相关压力性损伤提出问题,检索国内外数据库相关文献,检索时限为建库至2019年10月.由2名研究者依据JBI循证卫生保健中心的文献评价标准和证据分级系统,对各类研究进行文献质量评价及证据级别评定,纳入符合质量标准的文献,并提取证据.结果 共纳入证据8篇,包括指南6篇、专家共识1篇、系统评价1篇.最终形成包括皮肤评估、皮肤清洁、医疗器械的安置与移动、合理使用敷料和教育培训5个方面的最佳证据.结论 本研究总结了预防医疗器械相关压力性损伤的临床实践依据,在临床应用证据时,建议评估相关医疗机构的就医环境、设备条件及医护人员应用证据时的促进及阻碍因素、患者意愿等因素,筛选调适后,进行有针对性的证据使用,以促进证据有效地向临床转化,为临床护理实践提供更多科学依据,从而提升护理质量.     

Bella and the white water rapids

Abstract

This article is an exploration of the feeling state engendered in the art psychotherapist when working with a child who had been emotionally and sexually abused. It attempts to discover the meaning of what happened in a therapy when no verbal or thinking interaction could initially take place. It describes the difficulty of finding a way to articulate the fragmented information available, both to bring to consciousness the snippets of memory presented, and to structure them into an organised story.

Thinking appeared to be what the child was desperate to avoid. It was far too painful for her, so anger and abuse were used as a defence. Noise was produced during therapy, so that the artwork, the games and in particular the experience of projective identification could not be thought about. The noise often led to the art psychotherapist being silenced and also unable to think.

Countertransference feelings were communicated, including shame, hatred, love and fear. These were explored to help find meaning, which led to understanding that the child needed to experience attachment to a constant and non-retaliatory Other. This made the experience of both merging and separation from the therapist an enabling space in which to find symbol and thought.