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Background | The Delphi technique is a structured approach to group communication process developed by the RAND Corporation in the 1950s to obtain more reliable opinion from knowledgeable individuals [Despite the “fixed” components that are its hallmark, Delphi studies show great variability in their implementation. Over the years, many reviewers have criticized and attempted to overcome the lack of guidance compromising the validity of Delphi outputs [However, the choice of assessment procedure to quantify the opinion of panel members is a key methodological aspect of the Delphi technique that has remained unexplored to date. In this regard, rating and ranking are the most commonly used [Most of the empirical literature to date comparing rating and ranking is in the field of value systems measurement in psychology [ | PMC10436639 | ||
Methods | PMC10436639 | |||
Study design and population | cardiovascular diseases | CARDIOVASCULAR DISEASES | A randomized controlled parallel group trial design embedded in an online Delphi study was used to conduct this research. The Delphi study aimed to identify the top organizational priorities shared by patients and clinicians regarding the management of cardiovascular diseases and risk factors in primary care settings. The main results of the study have been published elsewhere [Participants were regular primary care patients, formally trained patient partners experienced in the mobilization of their experiential knowledge, and primary care clinicians. Regular patients and clinicians were recruited opportunistically from seven family medicine group settings operating in metropolitan, suburban, and remote areas in the province of Quebec (Canada), by using posters in waiting rooms and staff rooms, and flyers distributed during on-site visits and lunch conferences. Patient partners rostered in Université de Montréal’s Patient Collaboration and Partnership branch [ | PMC10436639 |
Sample size | This nested trial was opportunistic in nature and statistical hypothesis testing should be viewed as exploratory. The sample size was determined by the number of participants in the Delphi study, which aimed to recruit 40 participants roughly balanced between patients and clinicians. Assuming a 15% loss to follow-up, this sample size allowed for two subpanels of 17 participants each (the rating and ranking study groups), which was equal to the median number of panelists found in a systematic review of Delphi studies published in healthcare [ | PMC10436639 | ||
Ethical considerations | The study was performed in accordance with the ethical standards of the Declaration of Helsinki [ | PMC10436639 | ||
e-Delphi process | The Delphi process took place entirely online on the SurveyMonkey platform. The number of rounds was predetermined at three to minimize attrition and because this was deemed sufficient to identify the prioritization of items [ | PMC10436639 | ||
Randomization | BLIND | After round 1, participants were randomly allocated 1:1 to a rating or ranking assessment procedure for the remainder of the Delphi process, which proceeded independently in the study groups. Stratified permuted block randomization was performed without involvement of the researchers by the CHUM Center for the Integration and Analysis of Medical Data (CITADEL), with strata based on panelists’ gender (female, male) and status (clinic patient, faculty patient partner, clinician) to balance the study groups. Participants’ anonymity was maintained throughout the study and panelists were unaware of the experiment. While it was not possible to blind participants to their assigned assessment procedures because of the nature of the interventions, they were kept unaware of the study hypotheses, and there were no interactions between participants allocated to different groups or with the study team. The assessors who evaluated the outcomes were aware of the participant allocation, but they could not influence the classification of panelists’ responses. All quantitative assessments and analyses were conducted without requiring subjective interpretation. | PMC10436639 | |
Rating and ranking procedures | During the second and third rounds, panelists were sent the questionnaire version that made use of their assigned assessment mode to appraise the items. Aside from specific instructions regarding each assessment procedure and related survey design questions, the content of both versions of the survey questionnaires was identical. In the second-round questionnaires, items were assessed within their thematic list on separate pages. To prevent order effects, the lists and items within each list were presented in random order to each panelist. Rating panelists used a 7-point unipolar scale ranging from 1 “not at all” to 7 “extremely” important. Numeric and verbal labels were added for each response category to reduce measurement error and increase reliability and validity [During the final round, panelists received structured statistical and qualitative feedback from their study group including, for each item: the person’s score, the group’s median rating or ranking, the interquartile range (IQR), and a summary of positive and negative reasons formulated. They were asked to reappraise only a subset of them to keep their focus on potential top priorities. This subset was produced independently in the two study arms. In the rating group, it included items scored 6 or 7 by at least two-thirds of panelists. In the ranking group, it included items ranked in the top half of their list by at least two-thirds of panelists. These criteria seemed sufficiently comparable as the items had been freely elicited as important from the outset, and we anticipated that most ratings would lie between 4 and 7. This time around, the items were presented on a single list in descending order of importance, as recommended by Delphi methodologists [ | PMC10436639 | ||
Trial outcomes and statistical analyses | SECONDARY | The main outcome of this trial was the level of agreement on the top organizational items between the two study groups after round 3. This was assessed by examining the overlap between the most important items in each group and by calculating Krippendorff’s alpha coefficient on the aggregate rank order of items in the two groups. Krippendorff’s alpha is a reliability measure that has been proposed as the standard reliability statistic due to its flexibility and advantages over other known reliability coefficients [The secondary outcomes were as follow: (1) time to complete round two and round three questionnaires, measured separately, and (2) self-reported ease or difficulty with the assessment task, measured by the Single Ease Question (SEQ) administered immediately after the final assessment of items. The SEQ is a standard user metric in the form of a 7-point rating scale (from 1 “very difficult” to 7 “very easy”) that is simple, quick, and has proven to perform as well or better than more complicated measures of task difficulty [ | PMC10436639 | |
Agreement on top priorities | groupsAbbreviations | The subset of items reassessed in the final round coincidentally included 16 items in each study group (Table Prioritization of top items in the study groupsAbbreviations in braces refer to item themes ( | PMC10436639 | |
Discussion | PMC10436639 | |||
Main findings | In this randomized trial, we found moderately high reliability between the prioritization of top items in a rating arm and a ranking arm at the end of a Delphi process (Krippendorff alpha = 0.811, 95% CI = 0.669–0.920). Krippendorff states that it is customary to require alpha ≥ 0.8 to ensure that the data under consideration are similarly interpretable by different coders and that ≥ 0.667 is the lower limit where tentative conclusions are acceptable [Contrary to common practice in Delphi, we did not define a consensus threshold to compare the final outputs of our experimental groups. Rather, we viewed the prioritization of top items as providing a fairer comparison between rating and ranking. Had we done so, it is likely that the final set of items in the ranking group would have included fewer items than in the rating group, as ranking prohibits ties. This is apparent in the results of the third round (Additional file This study also found that the ranking task was significantly more difficult. The 9-min mean difference to complete the third-round questionnaire in favor of the rating group failed to achieve statistical significance ( | PMC10436639 | ||
Strengths and limitations | heterogenous | The main strength of this study was the stratified random allocation of panelists to the rating or ranking study groups. This ensured both groups would be heterogenous and balanced in terms of clinical and experiential expertise as well as other potential confounders. Our Delphi panels also reflected the importance of acknowledging patients as equal partners with professionals in health systems improvement, a notion that is increasingly recognized [This study also had some limitations. Firstly, although our panel sizes were consistent with recommendations for Delphi studies incorporating the sharing of arguments [ | PMC10436639 | |
Conclusions | bipolar | In this randomized trial, the use of a rating or ranking procedure led to a modestly similar prioritization of items in a Delphi survey with 30 panelists. We found that both experimental groups identified the same highest priorities but also that discrepancies became increasingly frequent when moving away from the most favored items. The ranking task was perceived as significantly more difficult. Time to complete the study questionnaires showed no statistically significant difference. The embedded trial design was restricted by the requirements of the main Delphi study. Our study should be replicated with a larger number of participants and with variations in the ranking and rating procedures (e.g., ranking within larger lists and rating with smaller, larger or bipolar scales). When determining how to assess items in future Delphi surveys, investigators may favor rating unless they specifically seek to avoid potential ceiling effects. | PMC10436639 | |
Acknowledgements | We would like to thank the Delphi panelists who participated in the study, Marie-Pascale Pomey for helpful guidance during the Delphi process, and Jocelyne Gagné for the administrative support provided. We also acknowledge the two reviewers and the editor for their insightful comments which allowed us to improve the manuscript. | PMC10436639 | ||
Authors’ contributions | CDG | CDG and JK conceived the study. CDG was responsible for the acquisition, analysis, and interpretation of data and wrote the original draft of the manuscript. JK contributed to the interpretation of data and revised the manuscript draft. All authors read and approved the final manuscript. | PMC10436639 | |
Funding | This work was supported by the Fonds de Recherche du Québec – Santé [award number 36266] and the Dr. Sadok Besrour Chair in Family Medicine. The funders had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the manuscript; and in the decision to submit the article for publication. | PMC10436639 | ||
Availability of data and materials | The dataset generated and/or analyzed during the current study is available in the Figshare repository, | PMC10436639 | ||
Declarations | PMC10436639 | |||
Ethics approval and consent to participate | All participants provided online consent to participate in the study after reviewing the information and consent form. The study was approved by the University of Montreal Hospital Research Centre’s research ethics committee (project number 17.305). | PMC10436639 | ||
Consent for publication | Not applicable. | PMC10436639 | ||
Competing interests | The authors declare that they have no competing interests. | PMC10436639 | ||
References | PMC10436639 | |||
Introduction | obesity | OBESITY, INSULIN RESISTANCE | Edited by: Claire Joanne Stocker, Aston University, United KingdomReviewed by: Sahar Foshati, Shiraz University of Medical Sciences, Iran; Maryam Ekramzadeh, Harbor-UCLA Medical Center, United StatesThis study investigated the effects of 12 weeks of high-intensity functional training (HIFT) combined with spinach-derived thylakoid supplementation on some selected Adipokines and insulin resistance in males with obesity. | PMC10422041 |
Method | ± | Sixty-eight participants (mean age: 27.6 ± 8.4 yrs.; mean height: 168.4 ± 2.6 cm; mean weight: 95.7 ± 3.8 kg, mean BMI: 32.6 ± 2.6 kg/m | PMC10422041 | |
Results | There were significant interactions (p<0.001 for all) between exercise and time for adiponectin (ES:0.48), leptin (ES:0.46), resistin (ES:0.3), omentin (ES:0.65), vaspin (ES:0.46), visfatin (ES:0.62), apelin (ES:0.42), RBP4 (ES:0.63), chemrin (0.36) and semaphorin3c (ES: 0.5). Plasma levels of semaphorin3c were significantly correlated (p<0.05) with body weight (r= 0.57), BMI (r= 0.43), FFM (r= -0.612), FAT (r= 0.768), VO | PMC10422041 | ||
Discussion | obesity | OBESITY, INSULIN RESISTANCE | Our findings indicate that 12 weeks of HIFT supplemented with spinach-derived thylakoid reduced levels of leptin, resistin, vaspin, visfatin, apelin, RBP4, chemrin, semaphorin3c and insulin resistance while increasing adiponectin and omentin levels in men with obesity. | PMC10422041 |
Introduction | Obesity, obesity | OBESITY, OBESITY, OBESE, RECRUITMENT, INSULIN RESISTANCE, METABOLIC DISORDERS | Obesity is a chronic condition with increased global prevalence (High-intensity functional training (HIFT) is a newly described exercise training program that emphasizes functional, multi-joint movements, that can be prescribed for individuals with all fitness levels, and causes greater muscle recruitment compared to traditional exercise training (Despite the positive effects of different types of exercise training including HIFT, and the benefits of herbal supplements such as thylakoid-rich spinach extracts in managing obesity and combating its related metabolic disorders, there is limited information on HIFT alone or in combination with spinach-derived thylakoid ingestion on obesity and adipose tissue secreted adipokines. We hypothesized that HIFT supplemented with ingestion of spinach-derived thylakoid can amplify the effects of HIFT on obesity and circulating adipokines. This study aimed investigated the effects of 12 weeks of HIFT with or without spinach-derived thylakoid supplementation on the levels selected adipokines, insulin resistance and lipid profile in obese men. | PMC10422041 |
Materials and methods | ± | RECRUITMENT | The study had an initial recruitment of 100 male volunteers, of which 32 were ineligible and leaving 68 participants in the study (mean age: 27.6 ± 8.4 yrs.; mean height: 168.4 ± 2.6 cm; mean weight: 95.7 ± 3.8 kg, mean BMI: 32.6 ± 2.6 kg/m | PMC10422041 |
Experimental design | TG | The participants were familiarized with all study procedures one week prior to the start of the training programs. Height, weight, and body composition were measured for each of the participants, who were then randomly assigned into one of the four equally sized groups (17 per each): Control group (CG), Supplement group (SG), Training group (TG), and Training + supplement group (TSG). During the study, 8 participants from different groups withdrew from the study for medical reasons, employment related difficulties or lack of interest in continued participation, leaving 15 participants per group. Each group received instructions on performing the training protocols during the third session when body composition variables and VO | PMC10422041 | |
Body composition and cardio-respiratory fitness assessments | Body weights and heights were measured using a calibrated scale (Seca, Germany) and stadiometer (Seca, Germany), respectively, and were used to calculate body mass index (BMI) (kg/m | PMC10422041 | ||
Preparation of spinach thylakoids and placebo | Fresh baby spinach leaves (Spinacia oleracea) were used to prepare of thylakoid membranes according to previously registered protocols (Powder samples were packed in identical sachets with each sachet containing 5 g of thylakoid or 5 g of cornstarch powder. The contents of the sachets were dissolved in a glass of water and consumed by participants 30 min before lunch. Packages were coded and distributed monthly by a third person who was not involved in any other aspects of the study. A supplement consumption chart, which was provided to remind participants to consume their daily supplements, was returned at each visit to ensure compliance. Participants also received daily text messages and weekly phone call reminders to consume the supplements. The participants were asked to return the remaining sachets at each visit to allow monitoring of; compliance. Adherence was deemed acceptable when ≥80% of the supplements were consumed. | PMC10422041 | ||
Training protocols | Participants completed 36 sessions in the HIFT program that lasted up to 60 min per session. The CrossFit program was used and HIFT sessions were led by a CrossFit trainer where the first two sessions were structured as an introduction to common movements used in HIFT (e.g., squats, deadlift, press, jerks, barbell, dumbbell, and medicine ball cleans, pull-ups, kettlebell swings, among others) with no additional workouts on days 1 and 2. Starting on day 3, each HIFT class consisted of 10–15 min of stretching and warm up, 10–20 min of instruction and practicing techniques and movements, and 5–30 min for the workout of the day that was performed at vigorous intensity and relative individual levels of ability and fitness. Workout modalities included aerobic (e.g., running, jumping rope), body weight (e.g., pull-ups, squats), and weightlifting (e.g., front squats, kettlebell swings) exercises that were constantly varied using the CrossFit training template ( | PMC10422041 | ||
Nutrient intake and dietary analysis | Three-day food records (two weekdays and one weekend day) were obtained before and after the study to assess changes in habitual dietary intake over time (Nutritional intake in the four study groups.CG, Control group; SG, Supplement group; TG, Training group; TSG, Training supplement group. *Indicates significant differences compared to pre-study values (p<0.05). | PMC10422041 | ||
Blood markers | INSULIN RESISTANCE, BLOOD, INSULIN RESISTANCE | All tests were performed between 8-10 am under standard conditions of temperature and humidity. Fasting blood samples were taken from the right arm between 12 hours and 72 hours before the first exercise session and 72 hours after the last session. Blood samples were transferred to EDTA-containing tubes, centrifuged for 10 minutes at 3000 rpm, and stored at -70°C. Plasma glucose levels were measured with a colorimetric enzymatic kit (Parsazmun, Tehran, Iran) with a sensitivity of 5 mg/dl. Insulin resistance was assessed using the homeostasis model assessment of insulin resistance (HOMA) using the formula: HOMA-IR= 22.5 μmol/fasting plasma insulin X fasting plasma glucose. Plasma resistin was measured with an ELISA kit (Biovendor, Czech Republic, catalogue number RD191016100, sensitivity: 0.012 ng/ml, intra-CV = 5.9%, inter-CV = 7.6%). Plasma leptin was measured with an ELISA kit (Biovendor, Czech Republic, catalogue number: RD191001100, sensitivity: 0.2 ng/ml, intra-CV = 5.9%, inter-CV = 5.6). Plasma adiponectin was measured with an ELISA kit (Biovendor, Czech Republic, catalogue number: RD19502310, sensitivity: 26 ng/ml, intra-CV = 4.9%, inter-CV = 6.7%). Plasma visfatin was measured with an ELISA kit (Cusabio, China, catalogue number: CSB-E08940h, sensitivity: 0.156 ng/mL, intra-CV = <8%, inter-CV = <10%). Plasma vaspin was measured with an ELISA kit (Biovendor, Czech Republic, catalogue number: RD191097200R, sensitivity: 0.01 ng/ml, intra-CV = 7.6%, inter-CV = 7.7%). Plasma RBP-4 was measured with an ELISA kit (R&D Systems, USA, catalogue number: DRB400, sensitivity: 0.628 ng/mL, intra-CV = 7%, inter-CV = 8.6%). Plasma apelin was measured with an ELISA kit (Phoenix Pharmaceuticals, USA, catalogue number: EK-057-23, sensitivity: 0.07 ng/ml, intra-CV = <10%, inter-CV = <15%). Plasma omentin-1 was measured with an ELISA kit (Biovendor, Czech Republic, catalogue number: RD191100200R, sensitivity: 0.5 ng/ml, intra-CV = 3.7%, inter-CV = 4.6%). Plasma chemerin was determined using a commercially available ELISA kit (Biovendor, Czech, intra-assay coefficient of 5.1%). The plasma levels of semaphorin 3C (MBS037239, MBS2883689, MyBioSource, San Diego, USA) was measured with a commercially available ELISA kit. Insulin levels were measured with an ELISA kit (Demeditec, Germany, with a sensitivity of 1 ng/ml and between, within-coefficients of variation of 5.1% and 8.4% respectively. Glucose levels were measured with a colorimetric enzymatic kit (Parsazmun, Tehran, Iran, with a sensitivity of 5 mmol/l). Insulin resistance (IR) was calculated from the ratio of insulin to glucose (I0/G0) and the HOMA-IR index [HOMA-IR = fasting insulin (mU/L) × glucose (mmol/L)/22.5] ( | PMC10422041 | |
Statistical analysis | PMC10422041 | |||
Results | Measurements of nutritional intake variables are presented in Measurements of body composition and cardio-respiratory fitness variables are presented in Mean ( ± SD) and effect sizes of logical anthropomorphic levels in the all groups.CG, Control group; SG, Supplement group; TG, Training group; TSG, Training supplement group, BMI, Body mass index, FFM, Fat-free mass.Baseline levels of adiponectin, leptin, resistin, omentin, vaspin, visfatin, apelin, RBP4, chemrin, and semaphorin3c were not different between the study groups (p>0.05), although there were interactions between group and time for these variables (p<0.05, ES range: 0.3- 0.7) Mean ( ± SD) and effect sizes of adipokines levels in the all groups.CG, Control group; SG, Supplement group; TG, Training group; TSG, Training supplement group.
Correlation analysis matrix for Adipokines.**Correlation is significant at the 0.01 level (1-tailed).Correlation analysis semaphorin 3C with anthropomorphic markers.**Correlation is significant at the 0.01 level (1-tailed).
| PMC10422041 | ||
Discussion | Obesity, inflammation, hunger sensations, respiratory and musculoskeletal systems, satiety, weight loss, HIT | OBESITY, OBESE, INFLAMMATION, DISORDERS, INSULIN RESISTANCE, OXIDATIVE STRESS, TYPE 2 DIABETES, INFLAMMATORY DISEASE, ENDOTHELIAL DYSFUNCTION | The main findings of our study were that 12 weeks HIFT and spinach-derived thylakoid alone or combined improved the adipokine profiles and insulin resistance in obese men, which was greater in the TSG group, representing the synergistic effect of spinach-derived thylakoid ingestion with HIFT. Obesity is an inflammatory disease (Semaphorins are extracellular signaling proteins consisting of eight classes (Sema 1-8) that play a critical role in the development and maintenance of various organs and tissues, including cardiovascular, immune, endocrine, hepatic, renal, respiratory and musculoskeletal systems (Although exercise caused modest changes in the semaphorin 3C levels in our study, the reductions in circulation levels of semaphorin 3C we observed can be attributed to decreases in adipose tissue as a major source for secretion of this adipokines. The expression of semaphorin 3C correlates with weight change, and WAT expression decreased after weight loss through bariatric surgery, while semaphorin 3C can contribute to insulin resistance and type 2 diabetes (We report that 12 weeks HIFT reduced levels of leptin, resistin, vaspin, visfatin, RBP4, chemerin and increased levels of adiponectin (apelin, and omentin) levels. Leptin and resistin are inflammatory cytokines involved in the development of insulin resistance, whose levels increase with body fat mass (Exercise intensity modulates improvements in inflammation, as shown by our findings that HIFT improved the modulation of inflammation. Although there is little information on the effects of HIFT on adipokine profiles, but related to this is that high-intensity exercise training (HIT) caused more reductions in inflammation and endothelial dysfunction compared to low intensity exercise training (LIT) in obese adolescents (Another finding of our study is that spinach-derived thylakoid supplementation alone or in combination with HIFT modulates adipokine levels in obese men, and that consuming spinach-derived thylakoid amplified the anti-inflammatory effects of HIFT function. Thylakoids can lead to positive outcomes in overweight and obesity and their related disorders by inducing satiety and suppression of hunger sensations, lowering body fat and weight, enhancing glucose homeostasis, reducing serum lipids, attenuating oxidative stress and inflammation, and reducing the absorption of dietary fat and carbohydrate (Thylakoids can decrease fat mass primarily by delaying fat digestion in the intestine, and is associated with increased release of the satiety hormone cholecystokinin (CCK), causing inhibition of gastric emptying and lowering the distension of the stomach, and stimulating the release of satiety molecules such as serotonin (Our study shows that HIFT and thylakoids improve lipid profiles and increases VODespite these findings, there is limited information on the mechanisms of spinach-derived thylakoid combined with exercise training in improving health outcomes. | PMC10422041 |
Study limitations | RECRUITMENT | Our study has several limitations. Firstly, we did not identify the mechanisms by which bioactive components of spinach-derived thylakoid can improve adipokines levels. Second, our study cannot be generalized as females were not included in patient recruitment. The third is that we did not measure levels of chlorophyll and other thylakoid components. | PMC10422041 | |
Conclusions | FM | INSULIN RESISTANCE, OBESE | Our study provides novel information on the beneficial effects of a combination of spinach-derived thylakoid supplementation with HIFT in the management of adipokines in obese males. Our data suggests that nondrug strategies such as spinach- derived thylakoid supplementation with HIFT can have protective effects on adipokines, glucose homeostasis parameters (insulin, glucose and insulin resistance); and body composition variables (weight, FM and FFM). | PMC10422041 |
Data availability statement | The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. | PMC10422041 | ||
Ethics statement | The studies involving human participants were reviewed and approved by The Research and Ethics Committee of the Islamic Azad University approved all procedures of this study (Ethics code: IR-IAU1400-46). All procedures were performed according to the latest revision of the Declaration of Helsinki. The patients/participants provided their written informed consent to participate in this study. | PMC10422041 | ||
Author contributions | All authors contributed equally to data collection. They read and approved the submission of the final version of the manuscript. | PMC10422041 | ||
Acknowledgments | The authors thank all the volunteers for their enthusiastic participation in this study. | PMC10422041 | ||
Conflict of interest | The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. | PMC10422041 | ||
Publisher’s note | All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. | PMC10422041 | ||
References | PMC10422041 | |||
Background | Inadequate bowel preparation, adenoma | ADENOMA | Inadequate bowel preparation for colonoscopy remains an issue resulting in lower adenoma detection rates and increased cost. We assessed the efficacy, safety and tolerability of high-dose bowel preparations in subjects who previously had an inadequate colonoscopy preparation. | PMC10173556 |
Methods | inadequate colon | We performed a multi-step prospective trial of high-dose bowel preparations with subjects assigned to the dose higher than their previous inadequate preparation. Step 1: 1.5 times the standard-dose of polyethylene glycol 3350 (PEG, 459 g) and Gatorade; and Step 2: 2.0 times the standard-dose of PEG (612 g) and Gatorade, both were given as extended split-dose preparations. 69 outpatients consumed their preparation before a morning colonoscopy. The primary endpoint was colon cleanliness assessed by the Chicago bowel preparation scale (BPS). Safety was assessed by comparing a baseline basic metabolic panel (BMP) to a post-cleansing BMP. Patients with no history of inadequate colon cleansing who consumed standard doses of PEG (306 g to 357 g) and Gatorade were used as a comparison group. Tolerability of the bowel preparation was assessed using a subject-questionnaire. | PMC10173556 | |
Results | When compared to controls consuming standard-dose bowel preparations, subjects consuming high-dose preparations had no statistically significant difference in colon cleanliness as measured by the modified or total Chicago BPS scores or differences in tolerability. Baseline and post-cleaning BMPs were not significantly different other than the BUN falling ( | PMC10173556 | ||
Supplementary Information | The online version contains supplementary material available at 10.1186/s12876-023-02663-0. | PMC10173556 | ||
Keywords | PMC10173556 | |||
Background | Inadequate bowel, constipation | An adequate bowel preparation for colonoscopy is necessary to visualize the mucosa and safely reach the cecum. Inadequate bowel cleansing remains an issue for up to 20% of those undergoing a colonoscopy [A high percentage of those who had a previous inadequate preparation for colonoscopy have a subsequent inadequate preparation. A retrospective study [Two studies [In the United States, pure PEG-3350 powder is sold over-the-counter by the gram in sachets (packages) of 17 g or bottles ranging in size from 119 to 765 g for use as a laxative with a recommended dose of 17 g. PEG-3350 with electrolytes is sold by prescription for cleansing the colon for colonoscopy and is rarely used for constipation. In other parts of the world, PEG-4000 is sold as a laxative but there has never been a comparison of the osmotic effect of PEG-3350 vs. PEG-4000 when used a laxative in humans [A number of studies [Since 2008, our clinic almost exclusively used moderate (306 g to 357 g) doses of PEG in 1.9 l (64 oz) of Gatorade as our standard colonoscopy preparations. For those whose previous preparations were almost adequate, we use 374 g of PEG and Gatorade given as a split-dose. For those whose previous preparations were fair or poor, we use high doses (459 g to 612 g) of PEG and Gatorade with a dose chosen that was higher than the previous failed dose and given as a split dose over an extended period of time. This extended high-dose cleansing protocol seemed to have a high efficacy and be well tolerated.This prospective study reports the efficacy of a multi-step escalating high-dose extended cleansing protocol for those whose previous colon preparations were inadequate. The primary objectives of this study were to examine the efficacy and safety of high-dose PEG and Gatorade preparations for a morning colonoscopy. Secondary objectives of this study were to examine tolerability and patient acceptance of high-dose bowel preparations. | PMC10173556 | |
Methods | PMC10173556 | |||
Study design and oversight | high-dose bowel, P., NCT02661750 | RECRUITMENT | The protocol was approved by the AMITA Institutional Review Board (AMITA 2015-0004-02, ClinicalTrials.gov NCT02661750 first registered January 22, 2016). The trial was designed by the authors with no outside input. All authors contributed to the study conception and design, material preparation, data collection and analysis. The first draft of the manuscript was written by David P. Gerard and all authors commented on each version of the manuscript. All authors read and approved the final manuscript. AMITA waived the fee for the Institutional Review Board. All other expenses associated with this study were paid for by the authors. Subjects received no financial reward and paid for their own preparations.The study was prospective and non-blinded. All patients in our clinic who previously had an inadequate colonoscopy preparation with less than 90% of the mucosa seen and scheduled a subsequent colonoscopy between January 2016 and December 2020 where invited to participate. All colonoscopies were performed by one of 2 gastroenterologists (DPG, MWR) between 8 a.m. to noon in the endoscopy labs at our office or two community hospitals.Subjects were outpatients undergoing elective colonoscopy, at least 18 years of age and not pregnant. Each subject signed an informed consent document.Subjects were assigned to receive a high-dose (459 g or 612 g) PEG and Gatorade bowel preparation solution dosed as shown in the upper half of Table Three-step high-dose bowel preparation protocol (top) with the contents of the bowel preparations obtained from the package inserts (below) compared to 4 L SF PEG-ELS (NuLYTELY) and our standard preparation of 306 g PEG in 64 oz of GatoradePoorly Absorbed mOsm is estimated by adding the number of mOsms of Phosphate plus 2.2 multiplied by the mOsm of PEG [L indicates liters; mOsm, milliosmoles. SF, sulfate free; ELS, electrolyte solution; PEG, polyethylene glycol-3350All patients were instructed to omit fruits and vegetables with seeds or foods that are high in fiber from their diet for 3 days-prior to their colonoscopy and to consume a clear liquid diet starting the day-prior (our standard dietary instructions for all patients undergoing colonoscopy). The patient instructions for the bowel preparations are provided in Additional file The study was designed to include a total of up to 100 subjects, but recruitment would terminate after 5 years if at least 50 subjects had enrolled. A subject was allowed to withdraw from the study until the day-prior to their colonoscopy. Beginning the day-prior to the colonoscopy, all subjects were evaluated on an intention-to-treat basis no matter what bowel preparation they actually used. Subjects could be switched to another bowel cleaning regimen chosen by the physician on-call if they could not tolerate the one assigned to them.
A physician (DPG) was responsible for monitoring the data for any adverse outcomes. | PMC10173556 |
Measurements | A questionnaire was filled out by each subject immediately before the colonoscopy is provided in Additional file A questionnaire was filled out by the gastroenterologist immediately after the colonoscopy rating the cleanliness of the bowel preparation and is provided in Additional file A primary endpoint of this study (Table The Chicago Bowel Preparation Scale [Secondary end points of the study were the tolerance of high-dose bowel preparations determined from the subject questionnaire, cleanliness of the colon on the Boston Preparation Scale [400 subjects from arm 2 (357 g of PEG and Gatorade given the day-prior) and arm 3 (306 g of PEG and Gatorade given as a split-dose) of a previous colon cleansing study [Before the study began, each participating gastroenterologist watched a video (domweb.bumc.bu.edu/bowelprep/instruction.php) as a calibration exercise for both the Chicago BPS and Boston BPS with the results discussed among the authors. | PMC10173556 | ||
Data analysis | Continuous variables were compared using Student’s t-test (unpaired, two-tailed). Categoric variables with 2 outcomes were compared using the Fisher's exact test (two-tailed). Categoric variables with more than 2 outcomes were compared using Pearson’s Chi-squared test (non-directional). | PMC10173556 | ||
Power calculation | A power calculation was performed as part of the study design process | PMC10173556 | ||
Results | PMC10173556 | |||
Discussion | polyps, renal insufficiency | RECRUITMENT, RENAL INSUFFICIENCY, HYPOTONIC | Our prospective, non-blinded study of high doses of PEG (459 g to 612 g) and Gatorade given as part of a multi-step escalating extended cleansing protocol is the first to report the efficacy, tolerance and safety of any high-dose preparation for subjects whose colons were inadequately cleansed for a previous colonoscopy.Compared to historical control subjects who had no history of inadequate preparations who consumed standard doses of PEG (306 g to 357 g) and Gatorade, subjects had no significant difference in the colon cleanliness as measured by any of the bowel preparation scales including: (1) the Chicago BPS total score [Our definition of adequate cleansing (seeing 95% of the colonic mucosa after cleaning maneuvers) is better defined and sets a higher threshold than many other bowel preparation studies making our findings even more clinically relevant. It is important to note that the quality of the preparations was not just adequate but outstanding. All 10 subjects who used a Step 2 preparation (2.0 times the standard-dose of PEG) had perfect scores on the modified Chicago BPS and Boston BPS. Of the 59 subjects who used a Step 1 preparation (1.5 times the standard-dose of PEG): (1) 51 (86.4%) were not felt to require a higher dose of their bowel cleansing solutions for their next colonoscopy; and (2) 8 were felt to require a Step 2 preparation for their next colonoscopy including 5 (8.5%) who required extensive cleaning maneuvers to make their preparations adequate and 3 (4.3%) had inadequate preparations despite the cleaning maneuvers. Compared to historical controls, subjects had significantly more perfect Chicago BPS total scores of 36 (colons that needed no washing to visualize the mucosa).Another primary end point of this study was the safety of high doses of bowel cleansing preparations. The doses of PEG used as part of our Step 1 (459 g) and Step 2 (612 g) preparations are 1.5 to 2 times higher than our standard moderate split-dose of (306 g) PEG and Gatorade and 1.9 to 2.6 times higher than low doses (238 g to 255 g) of PEG and Gatorade. Unlike PEG-ELS, Gatorade is a hypotonic electrolyte solution (Table When the baseline BMPs were compared to the BMPs drawn as the IV was started and after subjects had consumed their preparation (Table Secondary endpoints of this study were tolerability and patient acceptance of high-dose bowel preparations. Including historical controls allowed us to compare the tolerance of high-dose preparations compared to standard dose preparations. The study preparations were well tolerated by all measures with subjects able to consume 98.9% of their high-dose cleansing solutions which was not significantly different than controls who consumed standard doses. Compared to controls, subjects had no significant increase in side effects, were just as willing to use the same preparation again for future colonoscopies, did not find the liquid more difficult to drink than their previous preparation, but did find the overall preparation more difficult.In order to understand the clinical relevance of studies such as this one that look at difficult to cleanse colons, it is necessary to understand the efficacy of the failed preparations and how selective the criteria were for inclusion. If the failed preparations were only 80% efficacious, then switching those with inadequate preparations to a standard preparation that is 98% efficacious would be expected to cleanse 90% of colons adequately (assuming the same patients would fail both preparations). Studies enrolling patients with a single prior borderline inadequate preparation would not be as informative as studies that enrolled subjects with multiple prior poor preparations.Two previous studies [In our study, 18 of 79 (22.8%) previous inadequate preparations (excluding the unknown ones) were given as a split-dose which might suggest that they were not highly efficacious. 85.5% of subjects had their last inadequate preparations in our clinic with all these colonoscopies performed since 2008. Since 2008, we have enrolled our patients in a series of 3 bowel preparation studies that documented the efficacy of the preparations we used during those eras. Before 2008, 4 L sulfate-free PEG-ELS given the day-prior was our standard preparation with a demonstrated efficacy of 94.5% [Our subjects were a very select group with very difficult to cleanse colons because: (1) most had already failed highly efficacious preparations; (2) over the past 12 years, patients with previous preparations that were borderline inadequate received 374 g of PEG and Gatorade given as a split-dose which seemed to work well and those who were successful with this preparation were ineligible to enroll in this study; and (3) 27.1% of subjects had 2 to 4 previous inadequate preparations.Subjects were significantly older than controls which was expected since they required a previous inadequate colonoscopy preparation to qualify for the study. Compared to controls, subjects were less likely to be undergoing a screening examination and more likely to have polyps found which suggests that a higher risk, more motivated group of patients chose to have a subsequent colonoscopy after an inadequate preparation.This study did not address the safety and efficacy of a Step 3 bowel preparation (2.5 times the standard-dose of PEG) since no subjects requiring this very high-dose preparation were seen during the recruitment period. Before this study began, we used protocols similar to Step 3 for a few patients who received PEG-ELS and MagCitrate. To date, we have not encountered a patient who had an inadequate Step 2 preparation (2.0 times the standard-dose of PEG). All our subjects used PEG and Gatorade as their bowel cleansing solutions; therefore, this study does not address the safety and efficacy of high doses of other bowel cleansing solutions.There were some limitations to this study. (1) The study was not a randomized trial and subjects might be more careful to follow any cleansing protocol after a previous inadequate preparation. (2) Only 7 patients with renal insufficiency were enrolled. (3) The study was not blinded. (4) Historical controls were used. | PMC10173556 |
Conclusions | inadequate bowel | Step 1 (1.5 times the standard-dose of PEG) and Step 2 (2.0 times the standard-dose of PEG) preparations from our multi-step escalating high-dose extended cleansing protocol using PEG and Gatorade were highly efficacious, safe, well tolerated and well accepted by subjects whose previous colon preparations were inadequate.
This is the first prospective study looking at high-dose bowel preparation solutions for patients who previously had an inadequate bowel preparations for colonoscopy. Bowel preparation solutions have been sold in fixed-dose packages with a "one-size-fit-all" dosing approach for the past 40 years. With this study, we continue to show how the flexible dosing of PEG and Gatorade allows the needs of a diverse patient population to be met. Patients willing to consume a split-dose preparation do well with 306 g of PEG, patients who want a day-prior preparation require 357 g of PEG and we have observed patients with a history of a borderline inadequate preparation doing well with 374 g of PEG given as a spit-dose. Now we report 459 g of PEG given as an extended split-dose preparation works well for those who failed standard dose preparations and 612 g of PEG works well for those who failed 1.5 times the standard preparation. | PMC10173556 | |
Acknowledgements | The authors thank our office personnel: Karina, Joanne, Elena, Maria, Jackie, Robin and Terri; the Hinsdale Hospital GI lab nurses. The authors thank Russell D Cohen, MD for reviewing a draft version of this paper. | PMC10173556 | ||
Author contributions | DG: study concept and design; data entry; analysis and interpretation of data; drafting of the manuscript; critical revision of the manuscript for important intellectual content; statistical analysis. SG: study concept and design; data entry; analysis and interpretation of data; drafting of the manuscript; critical revision of the manuscript for important intellectual content; statistical analysis. MWR: study concept and design; acquisition of data; analysis and interpretation of data; critical revision of the manuscript for important intellectual content. All authors read and approved the final manuscript. | PMC10173556 | ||
Funding | None. AMITA waived the fee for the Institutional Review Board. All other expenses associated with this study were paid for by the authors. Subjects received no financial reward and paid for their own preparations. | PMC10173556 | ||
Availability of data and materials | All data generated or analyzed during this study are included in this published article as an EXCEL file in Additional file | PMC10173556 | ||
Declarations | PMC10173556 | |||
Ethics approval and consent to participate | Approved by the AMITA Institutional Review Board (AMITA 2015-0004-02). All methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from all subjects. | PMC10173556 | ||
Consent for publication | Not applicable. | PMC10173556 | ||
Competing interests | The authors declare no competing interests. | PMC10173556 | ||
References | PMC10173556 | |||
Objectives | SSI, pilon fractures | SURGICAL SITE INFECTION | In this study, we try to investigate the risk factors of postoperative surgical site infection (SSI) in closed pilon fractures and establish a nomogram prediction model. | PMC10408134 |
Methods | pilon fracture, Pilon fracture | From January 2012 to June 2021, 516 closed pilon fracture patients were included in this study. Of these, 387 patients were randomly assigned to the training group and 129 patients were assigned to the validation group (3:1). By univariate and multivariate Cox analysis, we identified independent risk factors for postoperative SSI after Pilon fracture. We established a nomogram model and used receiver operating characteristic (ROC) and calibration chart to evaluate its discriminant and calibration. | PMC10408134 | |
Results | SSI, fracture | SSI occurred in 71 patients in the training group and 23 patients in the validation group. Ultimately, age, preoperative blood sugar, operative time, Tscherne classification and fracture classification were identified as independent risk factors for SSI. The AUC values for SSI of the training and validation group were 0.898 and 0.880, and the P value of the Hosmer–Lemeshow test was 0.125. We established a nomogram prediction model based on age, preoperative blood sugar, operative time, Tscherne classification and fracture classification. | PMC10408134 | |
Conclusion | pilon fracture | Our nomogram model had good discrimination and calibration power, so it could be used to predict SSI risk in patients with pilon fracture. | PMC10408134 | |
Keywords | PMC10408134 | |||
Introduction | pilon fractures, infection, SSI, fractures, comminution [Postoperative infection, injuries | INFECTION, SURGICAL SITE INFECTION | In 1911, French radiologist Etienne Destot first described pilon fractures as injuries to the distal tibia's articular weight-bearing surface [In the AO/OTA classification of long bone fractures, pilon fractures are classified as extra-articular (43A), partially articular (43B), and intra-articular (43C), and are further subdivided according to the degree of comminution [Postoperative infection is often catastrophic, and there is even a risk of amputation [In this study, we try to investigate the risk factors for postoperative surgical site infection (SSI) in closed pilon fractures and establish a nomogram prediction model. To provide a reference for the prevention and treatment of high-risk infection patients in the future. | PMC10408134 |
Materials and methods | PMC10408134 | |||
Inclusion and exclusion criteria | pilon fractures, wire or external fixation, fracture, pilon fracture, trimalleolar ankle fracture, Trauma | PATHOLOGICAL FRACTURE | This study was approved by the Ethics Committee of our Institute (NO. 2021-K-241-01) in accordance with the guiding principles of the Declaration of Helsinki. All electronic medical records and image data were anonymised and personal identifiers were completely removed.Patients who underwent surgical treatment for pilon fractures in our hospital from January 2012 to June 2021 were included in this retrospective study. The inclusion criteria were: (1) age ≥ 18 years; (2) the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 43 pilon fracture; (3) closed fracture; (4) underwent open reduction and internal fixation (ORIF); (5) complete clinical data. Exclusion criteria were as follows: (1) open fracture; (2) pathological fracture; (3) tibia shaft fracture; (4) trimalleolar ankle fracture; (5) conservative treatment; (6) kirschner wire or external fixation. Finally, a total of 516 pilon fracture patients were enrolled in our study. | PMC10408134 |
Risk factors and outcome measures | pilon fractures, Polytrauma, trauma, infection, tissue damage, Fractures | INFECTION, DISEASE, SURGICAL SITE INFECTION | Demographic information including, age, gender, hemoglobin, serum albumin, c-reactive protein (CRP), blood platelet, leukocyte, preoperative blood sugar, waiting time for surgery, current smoking status and drinking status were extracted from the medical records. Among the causes of injury were falling from height, traffic accident, hit by heavy object and other. Polytrauma was defined as trauma to more than one of the following systems: musculoskeletal, abdominal, cardiothoracic, urogenital, vascular, and central nervous systems. Fractures were classified as extra-articular (43A), partially articular (43B), and intra-articular (43C) according to the AO/OTA system [A staged approach was used for pilon fractures with severe soft tissue damage, first with external fixation of the tibia and/or restoration of fibula length, and then with delayed tibial open reduction and internal fixation after soft tissue improvement. We defined surgical site infection as any infection that occured at the surgical incision site or deep tissue within 30 days of surgery (within one year of implant used) according to the U.S. Centers for Disease Control and Prevention (CDC) [ | PMC10408134 |
Statistical analysis | Patients were randomly divided into a training group and a validation group (3:1). The data from the training group were used to search for independent risk factors to establish nomogram model. Data from the validation group were used to evaluate the prediction effectiveness of the nomogram model. Measurement data are expressed as mean ± standard deviation, and count data are expressed as n (%). In the training group, univariate analysis using Mann–Whitney U and Chisquared tests as appropriate was performed to assess the association between different variables and SSI. Multivariate analysis of variables with Discrimination of dichotomous result was most often evaluated by calculating the area under the curve (AUC) of the receiver operating characteristic (ROC) curve. Generally, an AUC between 0.5 and 0.7 indicates low accuracy, 0.70–0.9 is considered acceptable, and AUC > 0.9 means that the model has excellent discriminative power [ | PMC10408134 | ||
Results | pilon fracture, pneumonia, fracture | REGRESSION, PNEUMONIA | From January 2012 to June 2021, 516 pilon fracture patients who underwent open reduction and internal fixation were included in this study. Of these, 387 patients were randomly assigned to the training group and 129 patients were assigned to the validation group (3:1). The baseline data of the training group and the validation group were analyzed, and there was no significant difference between the two groups (Table Baseline characteristicsData are presented as the mean and the standard deviation with the range in parenthesis or expressed as the number with the percentage in parenthesis. *P-value, differences between patients with pneumonia and controlIn univariate analyses of the training group, the significant risk factors were age, preoperative blood sugar, Tscherne classification, fracture classification, operative time and surgical approach (Multivariable logistic regression of predictors for SSIData are presented as the odds ratio with the confidence interval in parenthesis. OR, odds ratio; CI, confidence intervalThen, we built a nomogram to predict SSI, including five independent risk factors based on multivariate logistic regression analysis (Fig. The nomogram predictive model for SSI. To use the nomogram, the points corresponding to each prediction variable were obtained, then the sum of the points was calculated as the total score, and the predicted risk corresponding to the total score was the probability of SSIThe validation of the model was based on discrimination and calibration. We plotted the ROC curve of the predictive model and calculated the AUC value. The AUC values for SSI of the training and validation group were 0.898 and 0.880 respectively, proving that this nomogram model had good discriminative power (Fig. ROC curves for validating the discrimination of the nomogram predictive model (training group AUC = 0.898, validation group AUC = 0880)Calibration plot of the nomogram for the probability of SSI | PMC10408134 |
Discussion | pilon fractures, fracture, infection, SSI, pilon fracture, injuries, diabetes | INFECTION, DIABETES | Ruedi and Allgower first published their surgical technique and early follow-up results for the treatment of pilon fractures in 1968, a key shift in treatment [In our research, 71 (18.35%) patients in the training group developed SSI and 23 (17.83%) patients in the validation group developed SSI. Previous studies have shown similar deep infection rates [The relationship between diabetes and SSI in pilon fractures remains unclear. Some articles reported that diabetes was not associated with deep infection in pilon fractures [Operating time is a well-established risk factor for SSI and may be a marker of technical difficulties, more extensive soft tissue dissection, and prolonged wound exposure, all of which contribute to an increased incidence of SSI. Our results demonstrated that patients with prolonged operative time were more likely to develop SSI. Ren et al. believed that operative time longer than 150 min was associated with an increased risk of SSI following surgical fixation of pilon fractures [Previous studies have shown that open fracture was associated with deep infection after pilon fractures, but there are few reports of closed soft tissue injuries associated with infection [To our knowledge, our article was the first study on risk factors and predictive model for SSI in closed pilon fracture patients. However, our work had some limitations. First, this study was a single-center retrospective study, and the sample size of the selected cases was relatively small. Second, the baseline characteristic data were not truly homogenous and there was bias. Third, for the validation of the predictive model we used internal data, not external data. | PMC10408134 |
Acknowledgements | The authors gratefully acknowledge all individuals who participated in this study. | PMC10408134 | ||
Author contributions | CK, JZ and GX contributed to the idea and design. GX, XD and JZ contributed to the data acquisition and analysis. CK and JZ contributed to the manuscript writing and revision. All authors contributed to data acquisition and analysis and to manuscript writing and revision, and agreed to all aspects of the work. | PMC10408134 | ||
Funding | This research was supported by Wenzhou Basic Scientific Research project funding (Nos. Y20210421, Y20220820). | PMC10408134 | ||
Availability of data and materials | The data used to support the findings of this study are available from the corresponding author upon request. Patient data comes from our hospital's medical records follow-up database, transparent and available. | PMC10408134 | ||
Declarations | PMC10408134 | |||
Ethics approval and consent for publications | This study followed the guidelines of the “Declaration of Helsinki” and was approved by the ethics committee of our hospital (The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China, NO.2021-K-241-01). All data is analyzed anonymously, and personal identifiers are completely deleted. | PMC10408134 | ||
Informed consent | All the participants have given informed consent for the present study. | PMC10408134 | ||
Competing interests | The authors declare no competing interests. | PMC10408134 | ||
References | PMC10408134 | |||
Background | For years it has been stated that the need for prevention and rehabilitation is not always identified early enough. Although many individuals have regular contact with a general practitioner (GP), this access path for applying for a prevention or rehabilitation service has not been fully exploited. The important role of GPs in supporting the intention to apply is highlighted in the research. This study aims to evaluate the effectiveness of the “check-up 45 + ” to support GPs both in identifying the need for prevention and rehabilitation services and in submitting applications. | PMC10116757 | ||
Methods | The study is designed as a two-arm, pragmatic 1:1 randomised controlled study (RCT), which will be conducted in about 20 general practices in the German states of Berlin and Brandenburg. Patients (Primary outcome is the proportion of applications for prevention or rehabilitation services financed by the German Pension Insurance. Administrative data will be provided for this purpose. Secondary outcomes include the proportion of approved applications and completed services. In addition, the proportion of persons with a need for prevention or rehabilitation according to the “check-up 45 + ” will be examined. Semi-structured interviews will be conducted and content-analysed to determine the practicability and acceptance of the “check-up 45 + ” by the relevant stakeholders. | PMC10116757 | ||
Discussion | Prevention and rehabilitation need is insufficiently identified and addressed so far. This study will determine the effectiveness of the “check-up 45 + ” in primary care. | PMC10116757 | ||
Trial registration | German Clinical Trials Register (DRKS00028303, 03.03.2022). | PMC10116757 | ||
Supplementary Information | The online version contains supplementary material available at 10.1186/s12913-023-09392-w. | PMC10116757 | ||
Keywords | Open Access funding enabled and organized by Projekt DEAL. | PMC10116757 | ||
Background | PMC10116757 | |||
Maintaining employability | Due to later retirement age and the increasing lack of qualified personnel, the importance of maintaining or restoring the work ability of older employees is increasing [ | PMC10116757 | ||
Needs, application procedure and barriers | A central function of the German Pension Insurance is to promote and maintain the work ability of insured persons by financing rehabilitation measures in specialized rehabilitation facilities with a usual duration of three to four weeks. Furthermore, the German Pension Insurance is to provide prevention services for insured persons with initial health impairments. These prevention services include about three to five full-time days in specialized health care provision (usually rehabilitation facilities) and three to six months extra-occupational group services. Both prevention and rehabilitation services require an application by the insured person to the German Pension Insurance. The prevention application can be filled out online by the patient in a few minutes. The application for rehabilitation is more time-consuming and includes extensive application documents that must be filled out by the patient and physician. Within the study, the application procedure will be simplified by providing the necessary forms, reducing the number of forms required and replacing the doctor’s medical report with a short form.The German Federal law to strengthen prevention and rehabilitation in working life ( | PMC10116757 |
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