Uncovering Survivorship Bias in Longitudinal Mental Health Surveys During the COVID-19 Pandemic.

AIMS: Markedly elevated adverse mental health symptoms were widely observed early in the coronavirus disease 2019 (COVID-19) pandemic. Unlike the U.S., where cross-sectional data indicate anxiety and depression symptoms have remained elevated, such symptoms reportedly declined in the U.K., according to analysis of repeated measures from a largescale longitudinal study. However, nearly 40% of U.K. respondents (those who did not complete multiple follow-up surveys) were excluded from analysis, suggesting that survivorship bias might partially explain this discrepancy. We therefore sought to assess survivorship bias among participants in our longitudinal survey study as part of The COVID-19 Outbreak Public Evaluation (COPE) Initiative. METHODS: Survivorship bias was assessed 4,039 U.S. respondents who completed surveys including the assessment of mental health as part of The COPE Initiative in April 2020 and were invited to complete follow-up surveys. Participants completed validated screening instruments for symptoms of anxiety, depression, and insomnia. Survivorship bias was assessed for (1) demographic differences in follow-up survey participation, (2) differences in initial adverse mental health symptom prevalences adjusted for demographic factors, and (3) differences in follow-up survey participation based on mental health experiences adjusted for demographic factors. RESULTS: Adjusting for demographics, individuals who completed only one or two out of four surveys had higher prevalences of anxiety and depression symptoms in April 2020 (e.g., one-survey versus four-survey, anxiety symptoms, adjusted prevalence ratio [aPR]: 1.30, 95% confidence interval [CI]: 1.08-1.55, P=0.0045; depression symptoms, aPR: 1.43, 95% CI: 1.17-1.75, P=0.00052). Moreover, individuals who experienced incident anxiety or depression symptoms had higher odds of not completing follow-up surveys (adjusted odds ratio [aOR]: 1.68, 95% CI: 1.22-2.31, P=0.0015, aOR: 1.56, 95% CI: 1.15-2.12, P=0.0046, respectively). CONCLUSIONS: Our findings revealed significant survivorship bias among longitudinal survey respondents, indicating that restricting analytic samples to only respondents who provide repeated assessments in longitudinal survey studies could lead to overly optimistic interpretations of mental health trends over time. Cross-sectional or planned missing data designs may provide more accurate estimates of population-level adverse mental health symptom prevalences than longitudinal surveys.

The SSRI citalopram increases the sensitivity of the human circadian system to light in an acute dose.

RATIONALE: Disturbances of the circadian system are common in depression. Though they typically subside when depression is treated with antidepressants, the mechanism by which this occurs is unknown. Despite being the most commonly prescribed class of antidepressants, the effect of selective serotonin reuptake inhibitors (SSRIs) on the human circadian clock is not well understood. OBJECTIVE: To examine the effect of the SSRI citalopram (30 mg) on the sensitivity of the human circadian system to light. METHODS: This study used a double-blind, placebo-controlled, within-subjects, crossover design. Participants completed two melatonin suppression assessments in room level light (~ 100 lx), taking either a single dose of citalopram 30 mg or a placebo at the beginning of each light exposure. Melatonin suppression was calculated by comparing placebo and citalopram light exposure conditions to a dim light baseline. RESULTS: A 47% increase in melatonin suppression was observed after administration of an acute dose of citalopram, with all participants showing more suppression after citalopram administration (large effect, d = 1.54). Further, melatonin onset occurred later under normal room light with citalopram compared to placebo. CONCLUSIONS: Increased sensitivity of the circadian system to light could assist in explaining some of the inter-individual variability in antidepressant treatment responses, as it is likely to assist in recovery in some patients, while causing further disruption for others.

The Eastbourne Trauma Assisted Discharge Scheme (TADS) Reduces Length of Stay in Hip Fracture Patients.

UNLABELLED: PURPOSE OF THE STUDY The aim of this prospective study; The Trauma Assisted Discharge Scheme (TADS), was to set up a new model of postoperative care for patients following a fractured hip, addressing the need for efficiency, cost effectiveness and meeting local demand. MATERIAL AND METHODS All patients with hip fractures between December 2010 and December 2011, meeting the TADS inclusion criteria were enrolled in the study. Innovative use of staff within existing budgets helped create a TAD team who with the use of defined patient goals and a link nurse provided a seamless transition from acute to community services. RESULTS One hundred and sixteen patients followed the TADS pathway; the majority aged 80-89 years and independent prior to falling. A total of 35 patients underwent dynamic hip screw fixation; 55 hemiarthroplasty, 11 total hip replacement and 11 cannulated screw fixation. The average length of in-hospital stay was 8.6 nights. The TADS reduced the average length of stay by 4.78 days. CONCLUSION TADS has the potential to be used as a model of care in other specialities and is easily transferable to the wider NHS. KEY WORDS: continuous quality improvement, quality improvement, surgery, cost-effectiveness, ambulatory care.

Osteochondral Fractures of the Knee in Skeletally Immature Patients: Short-Term Results of Operative Fixation using Omnitech Screws.

PURPOSE OF THE STUDY: Retrospective case series looking at the use of Omnitech compression screws for the management of osteochondral fractures in skeletally immature patients. MATERIAL AND METHODS: Nine patients with a mean age of 14 were included in the study with a mean follow up of 26 months. RESULTS: The average KOOS, IKDC and Tegner Lysholm Scores were 86.7, 90.34 and 96.1 respectively. CONCLUSION: The use of Omnitech screws in the acute setting for skeletally immature patients shows excellent short-term outcomes.

Osteochondral fractures of the knee in skeletally immature patients: short term results of operative fixation using Omnitech screws.

PURPOSE: Osteochondral fractures in skeletally immature patients are rare. A retrospective case series is reported looking at the use of Omnitech compression screws for these injuries. METHOD: Nine patients with a mean age of 14 were included in the study with a mean follow up of 26 months. RESULTS: The average KOOS, IKDC and Tegner Lysholm Scores were 86.7, 90.34 and 96.1 respectively. CONCLUSION: The use of Omnitech screws in the acute setting for skeletally immature patients shows excellent short-term outcomes.

Colonic transit in the empty colon after defunctioning ileostomy: do we really know what happens?

BACKGROUND: There is disagreement amongst surgeons about the use of oral mechanical bowel preparation (MBP) prior to low anterior resection with diverting ileostomy. Colonic transit in the early post-operative period is an important factor in determining the role of MBP, as propagation of any stool remaining in the defunctioned colon may exacerbate morbidity in the event of anastomotic leak. We studied colonic transit time in the first 7 days following low anterior resection with diverting ileostomy. METHODS: We conducted a prospective observational study of patients with rectal cancer undergoing elective low anterior resection with diverting ileostomy in a tertiary colorectal unit. Twenty radio-opaque markers were inserted into the caecum via the distal limb of the loop ileostomy at surgery. Plain abdominal radiographs were taken on post-operative days 1, 3 and 5. The primary endpoint was passage of the markers to the neorectum. Data were collected on treatment, return of gastrointestinal function and complications. RESULTS: Twenty-two patients (mean age 68.5 years; 18 males) participated in the study. In 20 patients, all markers remained in the right colon on day 7. Three markers were present in the left colon in one patient, and eight markers were present in the neorectum in another patient, on the seventh day. CONCLUSIONS: Colonic transit may be abolished by the presence of diverting ileostomy. It should now be established whether clearance of the left colon alone, using enemas, is sufficient for patients undergoing low anterior resection, thus avoiding the morbidity associated with oral MBP.

Mutations seen among patients with pheochromocytoma and paraganglioma at a referral center from India.

Determining the mutational status of susceptibility genes including RET, VHL, SDHx (SDHB, SDHC, SDHD) among patients with pheochromocytoma/paraganglioma (PCC/PGL) is gaining importance. These genes have not been systematically characterized among patients with PCC/PGL from India. The aim of the work was to screen the most frequently mutated genes among patients with PCC/PGL to determine the frequency and spectrum of mutations seen in this region. Fifty patients with PCC/PGL treated at our tertiary care hospital between January 2010 and June 2012 were screened for mutations in susceptibility genes using an algorithmic approach. Thirty-two percent (16/50) of patients were found to be positive for mutations including mutations among RET (n=4), VHL (n=6), SDHB (n=3), and SDHD (n=3) genes. None of these patients were positive for SDHC mutations. A significant association was found between young patients with bilateral tumors and VHL mutations (p=0.002). Two of the 3 patients with extra-adrenal SDHB associated tumors, had unique mutations, viz., c.436delT (exon 5) and c.788_857del (exon 8), one of which was malignant. High frequency of mutations seen among patients in this study emphasizes the need to consider mutational analysis among Indian patients with PCC/PGL.

Disturbances in melatonin secretion and circadian sleep-wake regulation in Parkinson disease.

OBJECTIVE: Using salivary dim light melatonin onset (DLMO) and actigraphy, our study sought to determine if Parkinson disease (PD) patients demonstrate circadian disturbance compared to healthy controls. Additionally, our study investigated if circadian disturbances represent a disease-related process or may be attributed to dopaminergic therapy. METHODS: Twenty-nine patients with PD were divided into unmedicated and medicated groups and were compared to 27 healthy controls. All participants underwent neurologic assessment and 14 days of actigraphy to establish habitual sleep-onset time (HSO). DLMO time and area under the melatonin curve (AUC) were calculated from salivary melatonin sampling. The phase angle of entrainment was calculated by subtracting DLMO from HSO. Overnight polysomnography (PSG) was performed to determine sleep architecture. RESULTS: DLMO and HSO were not different across the groups. However, the phase angle of entrainment was more than twice as long in the medicated PD group compared to the unmedicated PD group (U = 35.5; P = .002) and was more than 50% longer than controls (U = 130.0; P = .021). The medicated PD group showed more than double the melatonin AUC compared to the unmedicated group (U = 31; P = 0.001) and controls (U = 87; P = .001). There was no difference in these measures comparing unmedicated PD and controls. CONCLUSIONS: In PD dopaminergic treatment profoundly increases the secretion of melatonin. Our study reported no difference in circadian phase and HSO between groups. However, PD patients treated with dopaminergic therapy unexpectedly showed a delayed sleep onset relative to DLMO, suggesting dopaminergic therapy in PD results in an uncoupling of circadian and sleep regulation.

Hours of work and rest in the rail industry.

Currently, the National Transport Commission is considering four options to form the regulatory framework for rail safety within Australia with respect to fatigue. While the National Transport Commission currently recommends no limitations around hours of work or rest, we provide evidence which suggests regulatory frameworks should incorporate a traditional hours of service regulation over more flexible policies. Our review highlights: Shift durations >12 h are associated with a doubling of risk for accident and injury. Fatigue builds cumulatively with each successive shift where rest in between is inadequate (<12 h). A regulatory framework for fatigue management within the rail industry should prescribe limits on hours of work and rest, including maximum shift duration and successive number of shifts. Appropriately, validated biomathematical models and technologies may be used as a part of a fatigue management system, to augment the protection afforded by limits on hours of work and rest. A comprehensive sleep disorder screening and management programme should form an essential component of any regulatory framework.

Primary total hip replacement with a Furlong fully hydroxyapatite-coated titanium alloy femoral component: Results at a minimum follow-up of 20 years.

We present the extended follow-up (≥ 20 years) of a series of fully hydroxyapatite-coated femoral components used in 72 primary total hip replacements (THRs). Earlier results of this cohort have been previously published. All procedures were performed between 1986 and 1991. The series involved 45 women and 15 men with 12 bilateral procedures. Their mean age at the time of surgery was 60 years (46 to 80) and the mean duration of follow-up was 22.5 years (20 to 25). At final follow-up, the mean Merle d'Aubigné and Postel hip scores were 5.5 (4.5 to 6), 3.8 (3.5 to 5) and 3.3 (3.0 to 5.0) for pain, mobility and function, respectively. Of the patients 92% were very satisfied at the time of final follow-up. There were seven revisions: six of the acetabular component for aseptic loosening and one of both the stem and the acetabular component for loosening due to deep infection. The survival of this prosthesis at 22.5 years with revision for any reason as the endpoint was 91.7% (95% confidence interval (CI) 84 to 99). Survival with aseptic loosening of the stem as the endpoint was 100% (95% CI 90 to 100). This prosthesis provides pain relief in the long term. Survival of this component is comparable to the best results for primary THR with any means of fixation.

The modified tibial tubercle osteotomy for anterior knee pain due to chondromalacia patellae in adults: A five-year prospective study.

OBJECTIVES: To assess the effectiveness of a modified tibial tubercle osteotomy as a treatment for arthroscopically diagnosed chondromalacia patellae. METHODS: A total of 47 consecutive patients (51 knees) with arthroscopically proven chondromalacia, who had failed conservative management, underwent a modified Fulkerson tibial tubercle osteotomy. The mean age was 34.4 years (19.6 to 52.2). Pre-operatively, none of the patients exhibited signs of patellar maltracking or instability in association with their anterior knee pain. The minimum follow-up for the study was five years (mean 72.6 months (62 to 118)), with only one patient lost to follow-up. RESULTS: A total of 50 knees were reviewed. At final follow-up, the Kujala knee score improved from 39.2 (12 to 63) pre-operatively to 57.7 (16 to 89) post-operatively (p < 0.001). The visual analogue pain score improved from 7.8 (4 to 10) pre-operatively to 5.0 (0 to 10) post-operatively. Overall patient satisfaction with good or excellent results was 72%. Patients with the lowest pre-operative Kujala score benefitted the most. Older patients benefited less than younger ones. The outcome was independent of the grade of chondromalacia. Six patients required screw removal. There were no major complications. CONCLUSIONS: We conclude that this modification of the Fulkerson procedure is a safe and useful operation to treat anterior knee pain in well aligned patellofemoral joints due to chondromalacia patellae in adults, when conservative measures have failed.

An examination of Australian general practitioners' knowledge, attitudes and practices in relation to sleep disorders.

BACKGROUND: Sleep disorders represent an under-recognised public health problem and are reported to be under-diagnosed in general practices. AIMS: To examine general practitioners' (GPs) attitude, knowledge and practice behaviour and identify barriers to detection, diagnosis and treatment of sleep disorders encountered in the Australian primary care setting. METHOD: Using mixed methods, quantitative data from the Dartmouth Sleep Knowledge Questionnaire (DSKQ) were analysed using MS Excel 2007. Qualitative data were obtained from one focus group and eight interviews. Data were thematically analysed. RESULTS: 15 GPs participated; seven in a focus group and eight in interviews. Scores from DSKQ suggest gaps in GPs' knowledge. Qualitative analysis revealed that patients frequently presented with sleep disorders underpinned by mental health disorders. GPs agreed that prescribing pharmacological interventions was undesirable and behavioural interventions were preferred. Barriers included limited training for GPs, lack of resources, patient expectations and willingness to engage in lifestyle changes, and consultation time constraints. DISCUSSION: Greater flexibility to investigate sleep related problems within the standard consultation and improved access to educational activities could assist GPs. Patient factors, such as adherence to management strategies, are paramount to successful management of sleep disorders; however, these obstacles to clinical practice may be difficult to overcome. CONCLUSION: Providing education for GPs about sleep disorders, greater flexibility within consultations may improve patient care and patient engagement in management strategies may assist, yet a critical success factor in disease management includes patient engagement in management strategies.

The role of patient factors and implant position in squeaking of ceramic-on-ceramic total hip replacements.

We investigated factors that were thought to be associated with an increased incidence of squeaking of ceramic-on-ceramic total hip replacements. Between June 1997 and December 2008 the three senior authors implanted 2406 primary total hip replacements with a ceramic-on-ceramic bearing surface. The mean follow-up was 10.6 years. The diagnosis was primary osteoarthritis in each case, and no patient had undergone previous surgery to the hip. We identified 74 squeaking hips (73 patients) giving an incidence of 3.1% at a mean follow-up of 9.5 years (4.1 to 13.3). Taller, heavier and younger patients were significantly more likely to have hips that squeaked. Squeaking hips had a significantly higher range of post-operative internal (p = 0.001) and external rotation (p = 0.003) compared with silent hips. Patients with squeaking hips had significantly higher activity levels (p = 0.009). A squeaking hip was not associated with a significant difference in patient satisfaction (p = 0.24) or Harris hip score (p = 0.34). Four implant position factors enabled good prediction of squeaking. These were high acetabular component inclination, high femoral offset, lateralisation of the hip centre and either high or low acetabular component anteversion. This is the largest study to date to examine patient factors and implant position factors that predispose to squeaking of a ceramic-on-ceramic hip. The results suggest that factors which increase the mechanical forces across the hip joint and factors which increase the risk of neck-to-rim impingement, and therefore edge-loading, are those that predispose to squeaking.

Sleep disturbance and melatonin levels following traumatic brain injury.

OBJECTIVES: Sleep disturbances commonly follow traumatic brain injury (TBI) and contribute to ongoing disability. However, there are no conclusive findings regarding specific changes to sleep quality and sleep architecture measured using polysomnography. Possible causes of the sleep disturbances include disruption of circadian regulation of sleep-wakefulness, psychological distress, and a neuronal response to injury. We investigated sleep-wake disturbances and their underlying mechanisms in a TBI patient sample. METHODS: This was an observational study comparing 23 patients with TBI (429.7 +/- 287.6 days post injury) and 23 age- and gender-matched healthy volunteers on polysomnographic sleep measures, salivary dim light melatonin onset (DLMO) time, and self-reported sleep quality, anxiety, and depression. RESULTS: Patients with TBI reported higher anxiety and depressive symptoms and sleep disturbance than controls. Patients with TBI showed decreased sleep efficiency (SE) and increased wake after sleep onset (WASO). Although no significant group differences were found in sleep architecture, when anxiety and depression scores were controlled, patients with TBI showed higher amount of slow wave sleep. No differences in self-reported sleep timing or salivary DLMO time were found. However, patients with TBI showed significantly lower levels of evening melatonin production. Melatonin level was significantly correlated with REM sleep but not SE or WASO. CONCLUSIONS: Reduced evening melatonin production may indicate disruption to circadian regulation of melatonin synthesis. The results suggest that there are at least 2 factors contributing to sleep disturbances in patients with traumatic brain injury. We propose that elevated depression is associated with reduced sleep quality, and increased slow wave sleep is attributed to the effects of mechanical brain damage.

Long-term results of a hydroxyapatite-coated femoral component in total hip replacement: a 15- to 21-year follow-up study.

Between 1986 and 1991 we implanted 331 consecutive Furlong hydroxyapatite-coated femoral components of a total hip replacement in 291 patients. A cemented acetabular prosthesis was used in 217 hips and a hydroxyapatite-coated component in 114. We describe the long-term clinical and radiological survival of the femoral component at a mean follow-up of 17.5 years (15 to 21). Only two patients (0.68%) were lost to follow-up. With revision of the femoral component for any reason as the endpoint, the survival at a mean of 17 years was 97.4% (95% confidence interval 94.1 to 99.5), and with revision for aseptic loosening as the endpoint it was 100%. The survival at a maximum of 21 years with revision of the femoral component for any reason as the endpoint was 97.4% (95% confidence interval 81.0 or 99.5). These results compare favourably with the best long-term results of cemented or uncemented femoral components used in total hip replacement.

The effect of traumatic brain injury on the timing of sleep.

While there have been single case reports of the development of circadian rhythm sleep disorders, most commonly delayed sleep phase syndrome following traumatic brain injury (TBI), to our knowledge there have been no group investigations of changes to sleep timing in this population. The aim of the present study was to investigate sleep timing following TBI using the dim light melatonin onset (DLMO) as a marker of circadian phase and the Morningness-Eveningness Questionnaire (MEQ) as a measure of sleep-wake behavior. A sleep-wake diary was also completed. It was hypothesized that the timing of DLMO would be delayed and that there would be a greater tendency toward eveningness on the MEQ in a post-acute TBI group (n=10) compared to a gender and age matched control group. Participants were recruited at routine outpatient review appointments (TBI) and from the general population (control) as part of a larger study. They attended the sleep laboratory where questionnaires were completed, some retrospectively, and saliva melatonin samples were collected half-hourly according to a standard protocol. The results show that the TBI and control groups reported similar habitual sleep times and this was reflected on the MEQ. There was, however, significant variability in the TBI group's change from the pre-injury to the current MEQ score. The timing of melatonin onset was not different between the groups. While subtle changes (advances or delays) in this small sample may have cancelled each other out,. the present study does not provide conclusive objective evidence of shift in circadian timing of sleep following TBI. Furthermore, although participants did report sleep timing changes, it is concluded that the MEQ may not be suitable for use with this cognitively impaired clinical group.

Lessons about sleepiness and driving from the Selby rail disaster case: R v Gary Neil Hart.

In April 2003, near the town of Selby in North Yorkshire, England, a motor vehicle went off the road to cause a train collision, killing 10 and injuring more than 70 people. The driver of the vehicle, Gary Neil Hart, had allegedly fallen asleep while driving, and was charged and subsequently convicted of causing death by dangerous driving. Evidence from an expert witness was led by the prosecution to establish that Hart had in fact fallen asleep, and that prior to falling asleep, he knew (or ought to have known) that he was at risk of falling asleep but nevertheless continued to drive. The issue of whether and to what extent individuals are aware that they are about to fall asleep has significant implications for criminal prosecutions. Generally, the definition of a criminal offense includes a mental element such as intent or knowledge. Therefore, it is imperative that issues such as whether in every individual there is forewarning of sleep and the degree to which individuals are able to self-assess their ability to continue driving under conditions of extreme sleepiness must be resolved. Sleepiness is now regarded as the largest identifiable and preventable cause of accidents in all modes of transportation. Litigation for such accidents is likely to increase, and therefore it is of great importance that further research be undertaken to examine the process of falling asleep, especially the subjective experiences immediately preceding sleep.

Hydrocortisone dose and postoperative diabetes insipidus in patients undergoing transsphenoidal pituitary surgery: a prospective randomized controlled study.

We report the results of a prospective randomized controlled trial, which looked at the incidence of postoperative diabetes insipidus (DI) following the use of three different hydrocortisone protocols, and the results of a study, on the incidence of DI and cortisol response in patients not given hydrocortisone. In study 1, 114 patients with pituitary macroadenoma were randomized into three groups: conventional dose (inj. hydrocortisone 100 mg IV 6-hourly for 3 days); intermediate dose (inj. hydrocortisone 100 mg IV 6-hourly on day 1, 100 mg IV 8-hourly on day 2, and 100 mg IV 12-hourly on day 3); low dose protocol (inj. hydrocortisone 25 mg IV 6-hourly on day 1, 25 mg IV 8-hourly on day 2 and 25 mg IV 12-hourly on day 3). Radical excision was achieved in 92 patients. The incidence of DI with the conventional dose was 52%, intermediate dose, 36% and low dose, 24% (p = 0.025). Study 2 included 16 consecutive patients with Hardy's grade A & B pituitary adenoma. These patients were randomized to receive (Group I) or not receive (Group II) hydrocortisone. Patients in Group II demonstrated normal cortisol response intraoperatively and no patient developed features of hypocortisolism; the incidence of DI in this group was 14%. The low dose hydrocortisone protocol reduced the incidence of DI by 46% when compared with the conventional dose hydrocortisone protocol. In patients with grade A and B tumour with normal preoperative cortisol levels, the use of perioperative hydrocortisone can be avoided.

Midgut volvulus in an adult.

We report a case of duodenal malrotation that presented in adulthood as midgut volvulus. On colour Doppler ultrasound, findings of a clockwise rotation of the superior mesenteric vein around the superior mesenteric artery (whirlpool sign) and a distinctive 'whirl'-like pattern resulting from an encircling of loops of the bowel around the SMA on CT is diagnostic of midgut volvulus.