According to Cohen’s effect size, weather conditions may affect the scores for PROMs and, indirectly, health-related outcomes via influencing the relative humidity and weather-related conditions. The findings suggest avoiding PROMs’ collection in certain conditions if the odds of outcome-based underperformance are to be minimized. This would ensure a balance between costs for PROMs’ collection and data availability.One of the next frontiers in medical research, particularly in orthopaedic surgery, is personalized treatment outcome prediction. In personalized medicine, treatment choices are adjusted for the patient based on the individual’s and their disease’s distinct features. A high-value and patient-centered health care system requires evaluating results that integrate the patient’s viewpoint. Patient-reported outcome measures (PROMs) are widely used to shed light on patients’ perceptions of their health status after an intervention by using validated questionnaires. The aim of this study is to examine whether meteorological or light (night vs. day) conditions affect PROM scores and hence indirectly affect health-related outcomes. We collected scores for PROMs from questionnaires completed by patients (N = 2326) who had undergone hip and knee interventions between June 2017 and May 2020 at the IRCCS Orthopaedic Institute Galeazzi (IOG), Milan, Italy. Nearest neighbour propensity score (PS) matching was applied to ensure the similarity of the groups tested under the different weather-related conditions. The exposure PS was derived through logistic regression. The data were analysed using statistical tests (Student’s  One of the next frontiers in medical research, particularly in orthopaedic surgery, is personalized treatment outcome prediction . In persPatients may have diverse clinical outcomes while having the same diagnoses, and their reactions to identical medication regimens are often highly variable. Unfortunately, many of these reactions are not easily predictable . On the As is well known, patient-related outcome measures (PROMs) are codified perceptions of patients regarding their health status post-treatment that are collected using validated questionnaires ,6,7,8. TIdeally, only the medical intervention and treatment adherence should affect treatment outcomes, including PROMs, and not other conditions. The latter include the time of day or year when the patient is clinically evaluated or questioned about his/her health status, the patient’s mood at the time of observation or questioning, and external factors, such as light  or weather conditions. The independence of outcome measures from contextual conditions is the main assumption behind the actual realization of value-based healthcare.Value-based healthcare is a model of healthcare delivery that relies on reliable assessments of the outcome of a procedure to reimburse it either integrally or partially based on the degree to which the expected outcome is achieved ,11. AccoSome potential effects of light conditions and the circadian cycle on perceived outcomes have also been documented in the literature. In one study, light conditions contributed to worse visual acuity, as perceived by patients with phakic presbyopia . In anotTo our knowledge, no studies have attempted to investigate the relationship between weather conditions and PROMs. Therefore, the purpose of this study is to determine whether meteorological or light conditions influence PROMs. The IRCCS Orthopaedic Institute Galeazzi (IOG) in Milan, Italy, is a large teaching hospital that specializes in the diagnosis and treatment of musculoskeletal problems. Nearly 5000 surgeries are conducted at the IOG each year, the majority of which are arthroplasties (hip and knee prosthetic surgery) and spine-related procedures. All patients admitted to the IOG are encouraged to engage in the PROM collection program, and most patients volunteer to participate either via phone or online, filling in questionnaires on a regular basis, usually 12, 24 and 36 months post-surgery. In this study, we used data collected by the IOG to shed light on whether meteorological or light (night vs. day) conditions affect the scores for PROMs and hence indirectly affect healthcare outcomes.The study group comprised patients admitted to the IOG between June 2017 and May 2020. To minimize potential biases such as those observed in , where whttps://www.ilmeteo.it/ (accessed on 8 July 2020); https://www.3bmeteo.com/ (accessed on 8 July 2020)). We retrieved the meteorological data associated with the questionnaires for the 3-month and 6-month PROMs. In the analysis, we used the 3-month meteorological data for the 3-month scores and 3-month improvements of the chosen PROMs, and the 6-month meteorological data for the 6-month scores and 6-month improvements of the chosen PROMs. The Heat Index (HI) was computed based on temperature (>27 °C) and humidity (>40%). We computed the HI based on the formula reported in [Meteorological data  were extracted from online sources  and humidity, in this study, we included two other groups of meteorological variables: the clear weather conditions versus a group comprising a number of other weather conditions . We represented the other conditions under different levels of granularity . Moreover, we stratified the data according to whether the interview was performed during the daylight hours or at night.Homogeneous groups in terms of patients’ age, pre-operative scores, gender, categories related to the operating area such as hip and knee, and mode of completing the questionnaire, specifically with or without the presence of the operator , were cPropensity score matching is a statistical approach used with observational data that aims to determine the validity of concluding that there is a probable causal relationship between treatment or intervention and an outcome(s) of interest. Once the propensity score is computed , the NN algorithm is employed to find the most similar instance of the opposite group by exploiting a 1 to 1 approach: taking the minority group into account, the undersampling procedure was applied to the majority groups, and for each instance of the minority group, the most similar instances from the other batch were sampled. Specifically, the Propensity Score-Matching Python (PsmPy) framework  was emplThe exposure PS was derived through a logistic regression model, which included the following covariates: age; gender and pre-operative status, as assessed by visual analogue scale (VAS) and Short Form 12 (SF12) physical and mental health scores ; operating area; and mode of completing the questionnaires.t-test, considering the null hypothesis of no significant difference between two groups of patients at the 95% confidence level (CI). For all hypotheses tested, two-tailed p values of <0.05 were considered significant. If the data did not meet the t-test’s assumption of normality, the Mann–Whitney U test, which requires no such assumption, was applied. For each hypothesis analysed, p-value adjustment (Holm–Bonferroni correction) was performed based on the 6 tests for each hypothesis group. The correction was applied within each hypothesis because each sample group differs from other hypothesis-testing groups [To detect a significant difference between the groups mentioned above, a hypothesis-testing procedure was applied to the data. We applied the Student’s g groups  due to td was used and applied to identify differences between the compared groups [As a measure of effect size, Cohen’s d groups . We usedNegative values of these two variables indicate worsening of health conditions instead of improvement for the SF12 MentalScores and PhysicalScores. Negative values of these two variables indicate improvement of health conditions for the VAS total Score.Descriptive statistics of the study population are shown in p-values for the 3-month outcomes, and p-values for the 6-month outcomes. Below, we report the most significant results for the hypothesis tests performed. t-test was conducted to compare the improvement at 3 months regarding the SF12 PhysicalScores of the two groups. The t-test normality assumptions were met for both periods. We found a significant difference in the improvement at 3 months regarding the SF12 PhysicalScores under humidity conditions below the 75th quantile  when compared to humidity conditions greater than the 75th quantile . Moreover, an independent-samples t-test was conducted to compare the improvement at 3 months in the SF12 MentalScores in the two groups. The T-test normality assumptions were met for both periods. We found a significant difference in the SF12 MentalScores under humidity conditions below the 75th quantile  when compared to humidity conditions greater than the 75th quantile .At 3 months, an independent-samples p = 0.011). Finally, for the 3-month outcomes, there was a significant difference in the SF12 MentalScores regarding the relative humidity below the 75th quantile  versus relative humidity greater than the 75th quantile .According to the results of the Mann−Whitney U test comparing the SF12 PhysicalScores of the group under humidity conditions below the 75th quantile and the group under humidity conditions greater than the 75th quantile 3 months post-surgery, there was a significant difference in the SF12 PhysicalScores regarding the relative humidity below the 75th quantile  versus the relative humidity greater than the 75th quantile . At 3 months, an independent-samples t-test was conducted to compare the improvement at 3 months with respect to the SF12 MentalScores of the two groups. The t-test normality assumptions were met for both periods. We found a significant difference in the improvement at 3 months regarding the SF12 MentalScores for clear weather-related conditions  when compared to other weather-related conditions .According to the results of the Mann−Whitney U test comparing the SF12 MentalScores of the clear and other weather-related conditions groups 3 months post-surgery, there was a significant difference in the SF12 MentalScores for clear weather-related conditions  versus other weather-related conditions  to identify potential differences in the reporting of outcome measures. Collecting data on patient-reported outcomes allows researchers to capture patients’ perspectives on treatment outcomes . HoweverAs shown by our results, we found no statistically significant differences in the 3-month VAS total Score and in the 3-month SF12 MentalScores and PhysicalScores of the patients who completed the questionnaires under the higher boundaries for each of the risk thresholds chosen for HI conditions, i.e., greater than 27 °C, 32 °C, and 41 °C . MoreoveLikewise, as can be seen in All other weather conditions  worsened the perceived health status between the pre- and post-operative phases, with the exception of clear weather conditions. Indeed, we found a statistically significant difference in the improvement at 3 months in the SF12 MentalScores and at 3 months post-surgery in the SF12 MentalScores under other weather conditions . NotablyIn In light of our findings, PROMs should not be recorded under relative humidity conditions over the cut-off threshold of the 75th quantile, nor under inclement weather-related conditions . In contrast, lower relative humidity conditions (below 75th quantile) have positive impacts on the reporting of PROMs; similarly, clear weather conditions favourably affected patients’ perceptions of their mental health status 3 months post-surgery.d = 0.13) and at 3 months post-surgery (d = 0.16) for clear and sunny weather-related conditions. Based on the Holm–Bonferroni correction, we found that the effect of clear weather conditions on the reporting of post-operative scores was still statistically significant (p adj = 0.006). In short, clear and sunny weather affect the absolute outcome measures more than the improvement, indicating that this weather affects more subjects who were not in relatively worse conditions before surgery.Regarding the effect of clear and sunny weather with respect to other weather conditions, the effect size (computed in terms of Cohen’s d) was greater (and not irrelevant) in terms of the post-operative scores alone than in the case of the improvement  . We deted = 0.28) and 3 months post-operation (d = 0.23). Likewise, a moderate effect for the difference between the pre- and post-operative SF12 MentalScores after 3 months (d = 0.18) and 3 months post-operation (d = 0.24) was detected. Interestingly, we found that the effects of the less uncomfortable humidity conditions were still statistically significant with respect to the difference between the pre- and post-operative SF12 PhysicalScores after 3 months (p adj = 0.015) and 3 months post-operation (p adj = 0.044), as well as in terms of the improvement at 3 months in the SF12 MentalScores (p adj = 0.006). This finding seems to confirm the effect of the relative humidity conditions (below 75th quantile) on patients’ perceived health-related status.Moreover, with regard to the relative humidity conditions below the cut-off threshold of the 75th quantile with respect to greater relative humidity conditions (higher than the 75th quantile), we found a moderate effect for the difference between the pre- and post-operative SF12 PhysicalScores after 3 months . Although the effect size was small, the corresponding effects should not be overlooked in terms of their impact on reimbursement procedures and value-based health care policy making. Second, we did not consider the baseline weather conditions . However, we conjecture that doing so could only have an impact on the pre- and post-operative difference, or improvement, wherein the results are less relevant and significant.In this study, we aimed to shed light on the potential influence of weather conditions on the scores for PROMs of patients admitted to the IOG, Milan, Italy. As shown by our results, meteorological variables can lead to the worsening of patient-reported scores in terms of both the improvement at 3 months and 3 months post-surgery. Our findings also showed that relative humidity (<75th quantile) and clear weather-related conditions may have an impact on the scores for PROMs reported by patients 3 months post-surgery. In relation to humidity, relative humidity (>75th quantile) decreased the reported SF12 PhysicalScores and MentalScore. With respect to weather-related conditions, clear weather-related conditions appeared to positively influence the perceived mental health outcomes 3 months post-surgery and the difference between the scores for the PROMs 3 months post-surgery and those obtained pre-surgery. In contrast, relative humidity and weather-related conditions did not affect the 6-month outcomes.According to Cohen’s effect size, weather conditions may affect scores for PROMs. Thus, they may indirectly affect health-related outcomes via effects on relative humidity and weather-related conditions. In fact, a small but significant effect size has been observed for weather conditions other than clear and sunny weather with respect to worsening outcomes. A similarly significant but even stronger effect size has been observed in terms of the SF PhysicalScores and MentalScores improvement at 3 months and 3 months post-surgery in lower relative humidity conditions (below the 75th quantile) rather than relative humidity conditions over the cut-off threshold (greater than the 75th quantile). These findings may suggest avoiding PROM collection in certain conditions if the odds of outcome-based underperformance must be minimized. Based on the findings of this study, we conclude that weather-related conditions may affect health-related outcomes. Relative humidity may influence patients’ perceptions of their physical and mental health status 3 months post-surgery and their improvement at 3 months. Clear weather conditions may positively influence perceived mental health outcomes 3 months post-surgery. Although the IOG collects data up to 36 months after surgery, we concentrated on PROM scores collected at 3 and 6 months post-surgery because we lacked sufficient data for longer follow-up periods. To confirm these findings, further research should focus on patients’ health-related perceptions after periods longer than 6 months post-surgery.


The role of working alliance remains unclear for many forms of internet-based interventions (IBIs), a set of effective psychotherapy alternatives that do not require synchronous interactions between patients and therapists.This study examined the conceptual invariance, trajectories, and outcome associations of working alliance across an unguided IBI and guided IBIs that incorporated clinician support through asynchronous text messaging or video messaging.Adults with high education attainment (n=145) with subclinical levels of anxiety, stress, or depressive symptoms were randomized to 1 of 3 treatment conditions for 7 weeks. All participants received treatments from MyCompass, an unguided IBI using cognitive behavior therapy. Participants in condition 2 and 3 received supplemental, asynchronous clinician support through text and video, respectively. Working alliance with the IBIs was measured weekly using select items from the 12-item version of the Agnew Relationship Measure. Symptom and functional outcomes were assessed at baseline, at the end of treatment, and 1-month follow-up.Working alliance with the IBIs was conceptually invariant across the 3 conditions. Working alliance followed a quadratic pattern of change over time for all conditions and declined significantly only in the text-support condition. After controlling for baseline symptoms, higher baseline levels of working alliance predicted less depression and less functional impairment at follow-up, whereas faster increases in working alliance predicted less worry at the end of treatment and at follow-up, all of which only occurred in the video-support condition.Working alliance with the IBIs was generally established in the initial sessions. Although working alliance is conceptually invariant across IBIs with or without clinician support, the associations between working alliance and treatment outcomes among IBIs may differ depending on clinician involvement and the modalities of support.ClinicalTrials.gov NCT05122429; https://clinicaltrials.gov/ct2/show/NCT05122429 Working alliance is often conceptualized as a tripartite construct comprising agreement on therapeutic tasks and goals, as well as the bond between patients and therapists . It has Technology innovations have offered alternative options such as internet-based interventions (IBIs), which provide accessible mental health services that do not require synchronous communication. An unguided IBI, which is characterized by the delivery of a web-based therapeutic program with no support from clinicians, is an example of such interventions. Many unguided IBIs, also known as self-help programs, are based on cognitive behavior therapy (CBT) principles and involve components of psychoeducation, behavioral and cognitive practice, homework, and tracking-related activities for important variables  ,5. In coPrevious studies have focused on understanding the level, trajectories, and outcome associations of working alliance in IBIs. A high level of working alliance has been reported by patients across guided IBIs with varying degrees of clinician involvement and different communication modalities ,9, as wetherapist with the word program in items to refer to the relationship with therapeutic programs and clinicians together). The potential differences of working alliance in various IBI contexts remained unexamined in most cases . Theceptions  providesIn addition to the potential differences in working alliance between guided and unguided interventions, the nature of working alliance may also vary for guided IBIs with different communication modalities. Clinician support can be delivered through video-based messages or text messages, both of which may have unique impacts on the development of working alliance. For example, video-based support is hypothesized to better facilitate the development of working alliance than text-based support because it allows for visual messages with facial expressions that facilitate nonverbal communication and relational bonding . By contThe literature on working alliance in face-to-face psychotherapy has consistently suggested that not only the levels but also the trajectories of working alliance matter. For example, studies show that varying trajectories of rupture repair–related patterns of working alliance in face-to-face therapy are differentially related to therapy progress , suggestr=0.20 (95% CI 0.14-0.26) for the associations. It also noted that there was no difference between clinician communication modalities  or between interventions with or without self-help components . However, no comparisons of working alliance and treatment outcome associations between unguided and guided programs were included in the study. Furthermore, the meta-analysis found significant higher associations between working alliance and treatment outcomes when working alliance was measured at the end of treatment rather than during the early phase of treatment, which indicated that the working alliance trajectories may influence the associations between working alliance and treatment outcomes. In light of these results, our third study aim was to examine the associations between treatment outcomes and trajectories of working alliance in both unguided and guided IBIs.Many studies have examined the associations between working alliance and treatment outcomes, but the field has not yet reached a consensus regarding this relationship in the context of IBIs. Several systematic reviews suggest mixed relationships between working alliance and treatment outcomes assessed at the end of treatment ,9,11 andIn summary, there were 3 key aims of this study. First, we examined the measurement invariance of working alliance across 3 conditions of CBT-based IBIs . We hypothesized that working alliance would be conceptually equivalent across the 3 conditions. Second, we examined the trajectories of working alliance over the course of the brief treatments in the 3 conditions. We expected to see increases in working alliance over time for all conditions. Finally, we examined the associations between working alliance trajectories and treatment outcomes  across the 3 conditions. We hypothesized that higher working alliance would predict better treatment outcomes in all 3 conditions.MyCompass without additional clinician support. Condition 2 was the G-IBI-Text condition in which participants used the same self-help IBI (MyCompass) and received additional asynchronous text-based support from a clinician. Condition 3 was the G-IBI-Video condition in which participants used the same self-help IBI (MyCompass) and received additional asynchronous video-based support from a clinician.We conducted secondary data analysis of a randomized controlled trial of a 7-week internet-based psychological intervention. The original study was a 3-arm randomized controlled trial that was designed to approximate treatment situations for treatment-seeking adults in stressful occupations and with no resources for real-time communications . Condition 1 was the U-IBI condition in which participants used an unguided, self-help IBI called The study design and protocol were approved by the Stony Brook University Institutional Review Board (903034).MyCompass program is a self-help IBI designed and shown to improve mild to moderate symptoms of depression, anxiety, and stress [MyCompass program also includes homework tasks for each module as well as functions such as mood and symptom tracking, feedback from the program on patient performance, and psychoeducation .The d stress . The proMyCompass during the 7-week treatment period. Participants in the U-IBI condition received automated email reminders to encourage them to use the program, track their symptoms, examine patterns and triggers related to changes in their mood and behaviors, and practice the skills they learned in real-world situations. No clinician support was provided in this condition.Participants in all 3 conditions were asked to complete at least two modules of their choice on MyCompass or to try a MyCompass module that was relevant to a stressor identified by the participant in a previous message to the clinician. Clinicians were instructed not to introduce skills or concepts not covered by the MyCompass program. Participants could respond to their clinician or initiate contact with them at any time during the 7-week study but were informed that clinicians would only respond to messages during specified business hours. Clinicians were encouraged to use their own words rather than prefabricated responses to communicate with their patients.Each participant in the G-IBI-Text condition was assigned to a clinician for additional, asynchronous text-based support. All clinicians (n=10) had master’s or higher-level degrees and were trained and supervised weekly by 2 licensed psychologists (BM and AG). The clinicians initiated 1 weekly message through text at a prescheduled time to provide general support and positive reinforcement for program participation. This text-based contact typically involved encouraging participants to log on to video message and communicated with participants through asynchronous video messages. Participants could initiate contact with clinicians or respond to clinicians by sending video messages on a communication platform that was specifically designed to receive asynchronous video messages for this study. As in the G-IBI-Text condition, clinicians in the G-IBI-Video condition were instructed not to introduce skills or concepts not covered by the MyCompass program.The experience of participants in the G-IBI-Video condition was similar to that of participants in the G-IBI-Text condition, except that the clinicians initiated a weekly Adults with high education attainment who sought treatment for subclinical levels of anxiety, depression, and stress were selected in the original study. The inclusion criteria were as follows: (1) aged ≥18 years; (2) English speaking; (3) enrolled in, or completed, a graduate-level education in science, technology, engineering, or math domains; (4) having a score of ≥5 on the depression subscale, ≥4 on the anxiety subscale, or ≥8 on the stress subscale of the 21-item version of the Depression, Anxiety, and Stress Scale .The exclusion criteria were as follows: (1) active suicidal ideation in the past month, (2) any history of suicide attempt within the past 5 years, (3) having a diagnosis of psychotic disorder or bipolar disorder, (4) alcohol or substance dependency in the past 6 months, (5) serious medical problems , (6) pregnancy, (7) current participation in psychotherapy, and (8) having recently started a new psychoactive medication . The Mini International Neuropsychiatric Interview  was usedMyCompass program and the study web-based portal.Eligible participants completed a baseline assessment consisting of in-person or over-the-telephone clinical assessment and web-based questionnaires administered through Qualtrics. After this baseline assessment, participants were randomly assigned to a condition based on a pregenerated random assignment table—the procedure was weighted to favor assignment to the U-IBI condition. Participants in all 3 conditions received access to the A total of 300 individuals completed screening forms to indicate interest in the study between May 2018 and September 2018. Of the 300 individuals screened, 155 (51.7%) were excluded for the following reasons: they did not meet the inclusion criteria , were no longer interested when contacted by the research team , or met an exclusion criterion . Subsequently, of the 300 people screened, 145 (48.3%) were enrolled into the trial. These 145 participants were randomized to the U-IBI condition , the G-IBI-Text condition , or the G-IBI-Video condition , of heterosexual orientation , and identified as White  and non-Hispanic . The average age was 30 (SD 8.21) years. In total, 96.6% (140/145) of the participants were college graduates, with 59.3% (86/145) having at least a master’s degree. The proportion of participants identifying as Hispanic was lower in the G-IBI-Text condition than in the other 2 treatment conditions; otherwise, no demographic differences in sex, age, sexual orientation, race, ethnicity, or education attainment were noted across the 3 conditions (refer to clinician to program or app in items [clinician seems bored or impatient with me” is modified to “the program seems bored or impatient with me”). Therefore, to enhance the measure’s content validity across the treatment conditions, this study only included items that were assessed by experts’ and users’ consensus in previous qualitative studies as relevant for IBIs [strongly disagree to 7=strongly agree). The ARM-12 items were administered after each week of the intervention, starting from the first week and ending in the seventh week.In total, 4 items that were adapted from the Agnew Relationship Measure, 12-item version (ARM-12) were used to examine working alliance across the treatment conditions . The ARMin items . Such alfor IBIs . The 4 iχ22=1.2 and χ22=1.3, respectively; comparative fit index=1.00, Tucker-Lewis Index=1.00, and root mean squared error of approximation (RMSEA)=0.00 in models at week 1 and at the end of treatment), suggesting that a single common factor of the working alliance underlay the 4 items.The Cronbach α values were .78 and .91 for the 4 items assessed at week 1 and at the end of treatment, respectively. We also examined factorial validity in confirmatory factor analysis for a single common factor of these 4 items at baseline and at the end of treatment, given the previous finding of a core working alliance factor for short versions of the ARM . The sinThe Patient Health Questionnaire-9 (PHQ-9) , Penn StMultigroup confirmatory factor analysis and multigroup longitudinal structural equation modeling were used to assess the conceptual invariance, trajectories, and treatment outcome associations across treatment conditions. Data were modeled with Mplus  . Full inConfirmatory factor analysis was used to evaluate measurement invariance and determine whether working alliance was conceptually comparable across the 3 IBI conditions. In the multigroup invariance analyses, baseline models with no constraints requiring equality among the groups were compared with various invariance models to determine the best modeling fit to the data . We usedResults section), we fit a series of univariate latent growth curve models to identify the appropriate change pattern of working alliance for the entire sample. Data were modeled with multiple types of trajectories, including (1) a no-change, intercept-only model where we only estimated means and variance for all measurement points without a slope; this model indicates no change in working alliance over time; (2) a linear change model where we estimated both intercept and slope for the trajectories; this model indicates that working alliance changes in a linear fashion over time; (3) a latent basis model, where an intercept and a slope were estimated but the loading on the slope was not based on the temporal time and is freely estimated; this model indicates that working alliance may change at a nonlinear rate with time; and (4) a quadratic model where we estimated the intercept, a linear slope, and a quadratic slope; this model indicates that working alliance may change in a quadratic pattern. We used the model fit indices to determine the best-fitting model that depicted the trajectories of working alliance among the aforementioned models.Once we determined that working alliance was conceptually invariant , we created alternative models in which the 3 conditions may not be equal  and compared the model fit between alternative models and the fully constrained model. The following parameters (if they existed in the best-fitting model) were loosened to be uniquely estimated in each group one at a time: mean of intercept, mean of linear slope, quadratic slope, mean of autoregressive coefficient (if it existed), variance of intercept, variance of linear slope, variance of quadratic slope, and residual variance. In case of model misspecifications, the cause of misspecification was examined through modification indices. Model modifications were used with caution and applied only if supported by possible theoretical explanations. If any of the alternative models yielded better model fit than the fully constrained model, it indicated differences in the trajectories of working alliance across treatment conditions.We examined whether the trajectories of working alliance contributed to treatment outcomes in each condition by examining whether the intercept  or the change rates  of the working alliance would predict treatment outcomes on depression (PHQ-9), worry (PSWQ), and social functioning impairment (SDS). We did so by including each outcome and the associations between each outcome and the intercept and slope of working alliance in the best-fitting multigroup structural equation modeling models that were identified from the previous step. We ran separate models for each outcome and controlled for the baseline level of each treatment outcome measure in each model.The levels of working alliance based on the selected items of ARM-12 for week 1 to week 7 are presented in P=.56 and P=.05 in scalar invariance models for week 1 and for week 7, respectively). This suggests that the selected 4 items of the ARM-12 had measurement invariance across treatment groups, indicating that it is appropriate to compare scores across conditions to detect differences on the latent construct of working alliance.The model fit indices for configural, metric, and scalar invariance models for the selected working alliance items at week 1 and week 7 are presented in The model fit indices for latent curve models are presented in This quadratic model for all groups was then used as the baseline model in the multigroup modeling comparison to examine whether there were any group differences in trajectories. We compared this model with alternative models where we allowed 1 parameter to be different at a time. We identified the best-fitting model based on the chi-square difference test, acceptable model fit indices , and the lowest Akaike information criterion and Bayesian information criterion. The best-fitting model allowed the linear slope to be different in the G-IBI-Text condition but not in the other 2 conditions. In addition, the best-fitting model allowed the residual variance to be different in the G-IBI-Text condition. This indicated that for the best-fitting model, there was a significantly different linear change rate in the G-IBI-Text condition compared with the other 2 conditions.P=.04) compared with the nonsignificant linear slope for the other 2 conditions . This indicates that the working alliance followed a different quadratic pattern in the G-IBI-Text condition compared with the other 2 conditions, in that there was a significant linear decrease only in the G-IBI-Text condition and no significant linear change in working alliance for the U-IBI or G-IBI-Video conditions.The estimations for the parameters are presented in We examined how the intercept  and the linear slope  of the working alliance trajectories predicted each treatment outcome  at the end of treatment and at 1-month follow-up after controlling for each treatment outcome variable at baseline separately. The model fit indices are presented in P=.04 for both models) such that a higher initial level of working alliance predicted lower depression and lower functional impairment for the participants at 1-month follow-up after controlling for their baseline levels of depression or functional impairment. In addition, for the G-IBI-Video condition, the linear slope of working alliance negatively predicted worry (PSWQ) at the end of treatment and at 1-month follow-up , which means that a faster increase of working alliance over time would predict less worry at the end of treatment and at 1-month follow-up, after controlling for baseline levels of worry.After controlling for baseline severity, the associations between treatment outcomes and working alliance seemed to vary across conditions. In the G-IBI-Video condition, the intercept of working alliance significantly predicted depression (PHQ-9) and functioning impairment (SDS) negatively at 1-month follow-up (P=.049) in the U-IBI condition. However, this significant effect disappeared at 1-month follow-up.By contrast, neither the intercept nor the linear slope of working alliance was associated with any treatment outcomes at either time points for the U-IBI condition or the G-IBI-Text condition, with 1 exception: the linear slope of working alliance was negatively associated with worry (PSWQ) at the end of the treatment  condition.The results indicated that participants’ ratings of their working alliance with the IBIs were conceptually invariant across the U-IBI condition and the asynchronous G-IBI-Text and G-IBI-Video conditions. This result was consistent with our hypothesis, supporting the equivalence of the underlying construct of working alliance for IBIs and allowed for further between-group comparisons across conditions. A growing number of studies ,40 have We hypothesized that working alliance would increase over time but found that working alliance followed a quadratic pattern and remained relatively stable in the U-IBI and the G-IBI-Video conditions while displaying significant deterioration in the G-IBI-Text condition. This indicated that working alliance with the IBIs may have been established quickly in the initial weeks. The stable, quadratic pattern of working alliance also corresponds to patterns reported in the literature on face-to-face therapy, suggesting that these patterns may not be unique to IBIs .Nonetheless, the linear decrease in working alliance in the G-IBI-Text condition was surprising. Although deteriorating patterns have been documented in previous studies examining the development of working alliance over the course of face-to-face interventions , this trOur results indicated that working alliance mattered in the G-IBI-Video condition. After controlling for baseline levels of symptoms, higher initial levels of working alliance predicted lower depressive symptoms and less functional impairment at 1-month follow-up. In addition, greater increases in working alliance over time predicted lower worry at the end of treatment and at 1-month follow-up. These results are consistent with the extensive literature on face-to-face therapy  as well By contrast, working alliance was not consistently associated with treatment outcomes in the U-IBI or the G-IBI-Text conditions. These findings were unexpected, although not completely inconsistent with previous studies that did not find significant relationships between CBT-based IBIs and working alliance -45. It iMyCompass program delivered in this study is a 7-week intervention. The brief duration of the interventions may have interfered with participants’ ability to display more complex trajectories of working alliance, which may have been observed in longer interventions. Fourth, this study focused on using CBT-based IBIs to treat subclinical levels of depression, anxiety, and stress; therefore, the findings may not be generalizable to other IBIs using different theoretical frameworks or targeting other symptoms. In addition, this study selected 3 treatment outcomes that were moderately to highly correlated to each other. Future studies should select treatment outcome measures to reduce multicollinearity and examine whether the predictions of working alliance on treatment outcomes may differ depending on the outcome variables.The study’s findings should be considered in light of the following limitations. First, our sample was composed of individuals with high educational achievement, which may limit the generalizability of these findings. Future research should attempt to replicate these findings with a sample representative of the general clinical population. Second, working alliance in IBIs may be particularly important for individuals with more moderate to severe levels of psychopathology; hence, future studies should examine whether the associations between working alliance and treatment outcomes among IBIs may vary depending on clinical populations. Third, the Future studies should also examine the potential mediators through which the initial level or the change rate of working alliance may affect treatment outcomes. For example, it is possible that an initial high level of working alliance would help the patient to use IBIs more frequently or complete the homework more often, which may result in greater symptom reduction. Finally, the study is limited to assessing working alliance with IBIs; future studies are needed to understand similarities and differences between working alliance with only clinicians and working alliance with IBIs.This study examined the conceptual equivalence, trajectories, and outcome associations of working alliance in a randomized controlled trial with 3 conditions, including unguided IBIs as well as guided IBIs with text-based and video-based support. We found conceptual equivalence of working alliance with the IBIs across the 3 conditions. Our results also revealed a quadratic pattern of working alliance over time in the U-IBI and G-IBI-Video conditions, but a deterioration pattern was revealed in the G-IBI-Text condition. Higher initial-level and faster increases of working alliance in the G-IBI-Video condition predicted lower mental health symptoms and functional impairment at the end of treatment and 1-month follow-up compared with the other 2 conditions. Working alliance was also not consistently associated with treatment outcomes in the U-IBI or G-IBI-Text conditions. Our results suggested that despite similar conceptual interpretation and trajectories, the function of working alliance may differ among IBIs with varying degrees and types of clinician support for high-functioning populations with subclinical levels of distress.


The debate around optimal target dose for first-line antidepressants (ADs) is still ongoing. Along this line, therapeutic drug monitoring (TDM) represents one of the most promising tools to improve clinical outcome. Nevertheless, a few data exist regarding the concentration-effect relationship of first-line ADs which limits TDM implementation in routine clinical practice. We conducted the first patient-level concentration-response mega-analysis including data acquired by us previously and explored the concentration dependency of first-line AD (206 subjects). Further, new data on mirtazapine are reported (18 subjects). Hamilton Depression Rating Scale-21 administered at baseline, at month 1 and month 3 was used as the measure of efficacy to assess antidepressant response (AR). When pooling all four first-line ADs together, normalized plasma levels and AR significantly fit a bell-shaped quadratic function with a progressive increase of AR up to around the upper normalized limit of the therapeutic reference range with a decrease of AR at higher serum levels. Our results complement the available evidence on the issue and the recent insights gained from dose-response studies. A concentration-dependent clinical efficacy, such as previously demonstrated for tricyclic compounds, also emerge for first-line ADs. Our study supports a role for TDM as a tool to optimize AD treatment to obtain maximum benefit. First-line antidepressants (ADs), such as selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs) and noradrenergic and specific serotonergic antidepressant (NaSSA), are extensively prescribed worldwide in clinical practice and represent the first pharmacological option in major depressive disorder (MDD). Despite their unquestioned efficacy, dose-response correlational studies repeatedly failed to identify a dose effect until recent years , with mixed initial results when considering AD pharmacotherapy specifically. TDM is supposed to play a role as an aid to clinicians in defining an appropriate AD prescription, based on the assumption that clinical efficacy correlates better to drug plasma levels than doses . HoweverOn the contrary, for first-line ADs, despite specific therapeutic ranges having been established, there is no evidence to support routine TDM, with the only exception of citalopram , or justTo fill this gap, we aimed at examining plasma levels of first-line ADs. To fully cover all major first-line AD classes, we first present our preliminary results exploring the association between a NaSSA (mirtazapine) and antidepressant response (AR) in a small sample of MDD outpatients in a naturalistic setting. Then, we conducted a posthoc patient-level mega-analysis comprising all our previous works concerning three different AD classes  investigating the concentration-response relationship of first-line AD.Subjects were selected from outpatients who met DSM-5 criteria for MDD in the Psychiatric Unit of Bolzano during the period 2018-2019. Inclusion criteria were a diagnosis of current major depressive episode according to DSM V criteria , with a Hamilton Depression Rating Scale-21 items (HAMD-21) score greater than or equal to 14 . Exclusiet al., 2019; We then conducted a mega-analysis pooling individual-level data from all our previous studies. Mega-analyses in fact, when feasible, combining raw data into a larger, single sample allow retention of more detailed information and avoid several within-study assumptions than other designs  , where 0 ng/ml represents the lower limit of the ideal therapeutic reference range and 100 the upper one, respectively. Plasma levels of all four examined ADs show linear pharmacokinetics at therapeutic ranges  and at month 3 . We repeat the analysis excluding two patients who showed extremely low plasma levels less than or equal to 8 ng/ml, likely for lack of compliance . Despite the lack of statistical significance throughout the entire follow-up period due to the lack of statistical power, the preliminary results show a promising pattern especially considering the small sample involved , but interestingly we found no significant correlation with sex  or ethnicity.Normalized plasma levels show high interindividual variability (mean 32.63 ± 57.45 ng/ml) and were positively correlated with age  and at month 1 .Finally, we found a significant positive correlation between plasma levels and AR both at the end of the follow-up period at month 3  and stratifying for variables with a known potential for interaction in the association between plasma levels and response.P = 0.001, r = 0.31) and 3 months .Within the recommended therapeutic range, we still found a positive correlation between plasma levels and AR both at 1 month  and at 3 months .Stratifying per age, we found for ages greater than 65 years a similar positive correlation at 1 month (a + (PL − PL2), relative to other possible models, including the logistic one, explained a higher percentage of variance both at month 1  and at month 3 . Repeating the analysis, considering concentrations within the 0-200 ng/ml range, gives similar results Furthermore, we tested which model best describes the relationship between plasma levels and AR. We found that the quadratic function AR = n = 18) which is significantly smaller than the others.The aim of the present study was to investigate a possible drug-response relationship for first-line AD to clarify the usefulness of TDM for AD treatment optimization. It stands out in many regards: it focuses on TDM and concentration-response relationship eliminating the bias due to the high PK interindividual variability of dose-response studies; it is based on pooled patient-level data; homogeneous data were all collected from a real-world and monocentric naturalistic setting showing comparable sample size between drugs with the exception of the mirtazapine . Interestingly, a positive correlation emerges between plasma concentrations and age, highlighting the importance of TDM especially in the elderly, where no reliable strategy to calculate a proper dose exists. A better description of the wide PK interindividual variability caused by the CYP450 system is provided in our previous studies , 2021. HWe confirmed our previous observations on the lack of efficacy for concentrations below the lower reference range threshold . This has extensively been observed in the literature considering the pharmacodynamic properties of first-line ADs which require a minimum percentage of enzyme/receptor blockage to provide any clinical efficacy . The current APA guidelines  would be better described by two logistic concentration-response combined, an ascending one up to the optimal concentration and a descending one likely due to the adverse effects of higher concentrations . PsychomSecond, as already outlined in our previous works, the outpatient setting did not guarantee medication compliance or the concomitant assumption of other drugs/foods and/or lifestyles that are known to potentially cause significant plasma level fluctuations. A way to minimize the impact of such variables on the results would have been to allow for multiple measurements across the follow-up period, at least in cases of a subsequent drug prescription, to control for potential interactions. Moreover, the lack of complete information on the smoking habit of each patient recruited in the previous studies represents an important limitation taking into account the well-known influence of CYP1A2 in the metabolism of some of the ADs included in the pooled analysis (Third, the current upper limit of the therapeutic reference ranges reflects the lack of further therapeutic improvement due to adverse effects, which only indirectly corresponds to a decreased clinical response (Lastly, because we do not observe a significant correlation between age, sex, ethnicity and AR in our sample, probably because of the relatively small sample size, no multiple regression has been therefore performed. Nonetheless, as they are known interaction factors in explaining the relationship between plasma levels and AR, their effects should not be discarded (In conclusion, our mega-analysis showed a clear-cut concentration-response relationship up to the upper limit of the therapeutic reference range. A known concentration-effect relationship has been previously demonstrated for TCA but not for first-line AD, which has limited the implementation of TDM in clinical practice. The numerous reasons for failing to demonstrate concentration-response relationships, a notorious shortcoming of clinical trials in psychiatry, have been discussed in detail elsewhere along with suggestions to avoid the respective pitfalls  There isThere are no conflicts of interest.


Noise in mode-locked lasers has been a central issue for dual-comb metrological applications. In this work, we investigate the laser intensity noise on dual-comb absolute ranging precision. Two different dual-comb schemes based on linear optical sampling (LOS) and nonlinear asynchronous optical sampling (ASOPS) have been constructed. In the LOS scheme, the ranging precision deteriorates with the increase in laser relative intensity noise (RIN). This effect can be corrected by implementing a balanced photo-detection (BPD). In the ASOPS scheme, the experiment shows that the conversion from laser RIN to dual-comb ranging precision is negligible, making a balanced detection unnecessary for ranging precision improvement. The different manners of RIN’s impact on absolute ranging precision are attributed to the distinct cross-correlation signal patterns and the underlying time-of-flight (TOF) extraction algorithms. Mode-locked lasers generate equidistant discrete optical pulse trains with ultrashort pulse duration and are taken as one of the most suitable generators for optical frequency combs (OFCs) . OFCs baThe absolute ranging capability based on OFCs can be further improved by adopting a dual-comb configuration ,31,32,33To further improve the dual-comb absolute distance measurement performance, the impact of different laser parameters has been investigated . High prIn this paper, we investigate the impact of laser intensity noise on dual-comb TOF distance measurement precision for both linear optical sampling (LOS) and nonlinear asynchronous optical sampling (ASOPS). In the LOS scheme, a pair of phase-locked nonlinear amplifier loop mirror (NALM) mode-locked fiber lasers are used. The interferometric beat notes between the target/reference reflected pulses and the LO are digitalized and the following Hilbert transforming algorithm is used to extract TOF. Triple outputs of the signal laser with different intensity noise ,40 have In order to study the impact of laser intensity noise on the absolute ranging based on LOS, we built an all-polarization-maintaining  erbium-doped fiber laser mode-locked by a nonlinear amplifier loop mirror with triple outputs and a similarly structured LO laser. The schematics of the triple-output signal laser and LO laser are shown in A high-reflective mirror mounted on a piezoelectric transducer (PZT) is used instead of the optical fiber mirror as the reflection arm of the LO laser to achieve phase locking. To obtain environmentally stable output characteristics, the SL adopts an all-PM fiber configuration, and no active control of the cavity length is applied. The differential repetition rate between the two lasers is stabilized by an external radio frequency (RF) signal source and the phase-locking scheme is shown in The relative intensity noise of each port of the triple-output signal laser is characterized using the measurement setup shown in A set of distance values measured within ~0.5 s from port 3 is shown in When the avalanche photodetector is used for detection, with the increase in laser output intensity noise, the ranging standard deviation of measurement using different outputs increases with the RIN of the output. Using ports 1, 2 and 3 for absolute ranging, the precision is 26.08393 μm, 31.60821 μm and 36.21884 μm, respectively, within the acquisition time of ~0.5 s. The balanced photodetector can be used to eliminate the impact of RIN on ranging precision. In the same acquisition time, the ranging precision using each port is 10.13781 μm, 9.10924 μm and 11.14095 μm, much smaller compared with a single photodetector. Note that, in our past work , we demoThe optical power level of the triple-output SL laser used in the above experiments cannot directly meet the requirements of the ASOPS principle. It is also better not to add an external EDFA, which may introduce more intensity noise. Therefore, we studied the impact of laser RIN on the dual-comb ranging precision based on nonlinear ASOPS in an independent experiment.The experimental setup is illustrated in The measurement principle based on nonlinear ASOPS is shown in The reference mirror and the objective mirror are also fixed at a short distance. The combined beam is directed into the OC, where the reference and target pulses are all optically sampled by the much shorter LO pulses. The OC signal is received by an avalanche photodetector. The output voltage signal from the photodetector is digitized and stored by a digitizer . The timing of the reference and target retro-reflected pulses is determined by the peak of the OC signal.The Allan deviation of the distance measurement with different averaging times at a fixed target mirror position ~0.7 m away is shown by the red trace in The BOC configuration is shown in The measurement result is shown by the blue trace in In conclusion, this paper studies the impact of laser intensity noise on the dual-comb absolute ranging precision. For LOS, a triple-output mode-locked laser with different RIN levels acts as the signal laser. It is phase-locked with an LO such that the differential repetition rate is fixed. In a dual-comb ranging experiment, ranging precision deteriorates with increasing output laser RIN level, and the obtained ranging precision is 26.1 μm, 31.6 μm and 36.2 μm in the presence of RIN levels of 0.020%, 0.023%, 0.026%, respectively. By using balanced detection, the ranging precision in each port reaches 10.1 μm, 9.1 μm and 11.1 μm, respectively, improved significantly compared with a single photodetector. While, for ASOPS, there is no significant difference in measurement precision based on OC and BOC (7 μm Allan deviation without time averaging) even when free-running dual-comb sources are used. The difference between LOS and ASOPS lies in the TOF extraction algorithm. For LOS, laser intensity noise may distort interferometric beat notes and even fail the Hilbert transform algorithm, which is necessary to separate the envelope and the interferometric fringes. Therefore, balanced detection is beneficial to measurement precision improvement. While, for ASOPS, the nonlinear optical cross-correlation process technically avoids the optical fringes and makes the following TOF acquisition (either by center-of-gravity or zero-crossing determination) straightforward. The slight distortion of the signal caused by laser RIN hardly affects the single measurement precision and the BOC method is not necessary. This study provides a new avenue towards precision optimization in various dual-comb absolute ranging systems.


BackgroundFixed orthodontic appliances on tooth surfaces, such as brackets and bands, complicate oral hygiene and increase plaque accumulation, contributing to gingivitis, periodontitis, and tooth decay. While manual toothbrushes are an essential part of oral hygiene, there is little clinical evidence to demonstrate how effective manual toothbrushes with novel designs are at removing plaque from orthodontic patients. This study aims to evaluate three types of manual toothbrushes , and orthodontic type (O-TB)) for their efficacy in plaque removal among patients undergoing fixed orthodontic treatment.MethodologyThe study followed the Consolidated Standards of Reporting Trials (CONSORT) guidelines. It was a three-treatment, three-period, examiner-blinded crossover clinical trial conducted with a single brushing exercise. Twenty-four subjects were randomized to one of three different bristle designs . The primary outcome measure was the difference (baseline minus post-brushing) in plaque scores assessed using the Turesky-Modified Quigley-Hein Plaque Index during each study period.ResultsOf the 27 subjects enrolled in the study, 24 met the inclusion criteria and completed all three periods of the study. The mean age was 19.58 ± 1.55 years, with a range of 18-23 years. The differences between treatments in plaque score reduction after brushing were statistically significant . The treatment differences were statistically significant , favoring the C-TB toothbrush and the O-TB over the Pulsar design. On the contrary, the difference between the O-TB and C-TB types was not statistically significant.ConclusionsC-TB and O-TB remove significantly more plaque than Pulsar toothbrushes after a single brushing exercise. Nevertheless, the C-TB tested in this study was more effective in removing dental plaque than the O-TB in patients wearing fixed orthodontic appliances. Considering the limitations of this study, additional research is required before evidence-based advice concerning the relative performance of the Pulsar toothbrushes in fixed orthodontic patients can be proven. Dental biofilm contributes to the initiation and development of dental caries and periodontitis . The impMechanical plaque control with a regular toothbrush and fluoridated toothpaste plays a fundamental role in oral hygiene for primary prevention and is the most widespread means of controlling plaque at home and a primary preventive strategy for periodontitis -7. DentaTM) that pivot independently (designed to penetrate deep between teeth) and a battery-powered gentle pulse action (designed to lift food and plaque) . In. In31]. All participants between 18 and 25 years old, in good general and oral health, and wearing fully bonded fixed orthodontic appliances with a minimum of 25 natural teeth with facial and lingual scorable surfaces without any oral lesions or periodontal pockets of 3 mm or loss of attachment/recession of 2 mm were included in the study. The participants were also instructed to postpone elective dentistry, including prophylaxis, until the study was completed and to avoid participating in any other oral care studies while it was still ongoing.The exclusion criteria were evidence of mucogingival problems, smoking, pregnancy, five or more carious lesions requiring restorative treatment, or wearing fixed or removable prosthesis. Participation in any other elective dental procedure, including prophylaxis, during the study period or the presence of any disease or condition that would interfere with the study procedures were additional grounds for exclusion.The orthodontic residents approached all eligible patients attending the Orthodontic Clinic at the Dental Centre, Ministry of National Guard - Health Affairs, and gave them written study material. Only after getting their written informed consent were they included in the study.Sample size estimationThe sample size was determined based on the previous plaque removal data from a similarly designed crossover study . A samplThree different bristle designs of commercially available toothbrushes  were used. The orthodontic brush used was the Oral-B Pro-Expert Clinic Line Orthodontic Manual Toothbrush, and the conventional brush was the Oral-B Pro Gum Care Manual Brush. The third Pulsar brush was an Oral-B Pro-Expert Battery Operated Manual Toothbrush. All brushes were adult brushes with soft brush heads Figure .Randomization The study subjects were randomly assigned to one of the three treatment sequences determined by a computer-generated plan prepared before the study  with 24 participants in each treatment sequence. The distribution and allocation of toothbrushes were carried out by an investigator who was blind to the data collection process. To conceal allocations, sequentially numbered, opaque, sealed envelopes containing pre-prepared treatment allocation cards were used. The participants were recalled four times  with a wash-out period of one week between each visit.Participants were instructed not to brush or floss their teeth or use a mouth rinse for 24 hours before each appointment, as well as not to eat, drink, or smoke for four hours before each appointment. Two blinded evaluators evaluated and scored the plaque. The intraclass correlation (ICC) was used to calculate the interexaminer reliability for plaque scoring.The patients were interviewed on day 1 and relevant information was gathered about their demography, oral hygiene habits, and dental clinical examination, including recording the number of teeth.On the first day, all patients were given verbal and written instructions on how to utilize the assigned toothbrush with the modified Bass method. The toothbrush is positioned at the gum line at a 45° angle and is moved in short, vibratory strokes along the dental arches as well until all of the tooth surfaces that are accessible have been brushed. During each appointment, the patient used the designated toothbrush and standard fluoride toothpaste to brush their teeth for two minutes (30 seconds for each quadrant). After brushing, the participants were asked to rinse their mouths once lightly with water.A red disclosing solution was used to disclose the plaque during each visit to gather baseline information. Plaque assessments were performed by two periodontists who were blinded to the treatment (type of brush) method using the Turesky Modified Quigley-Hein Plaque Index. The scores were re-evaluated by the same examiners independently after brushing and swishing with disclosing solution again. The examiners received prior training with the method.The same procedure was repeated during subsequent appointments using the other toothbrushes that were randomly assigned to each participant. The same procedure was followed for all three periods. In Period 3, the participant accountability was documented.Table Outcomes (primary and secondary) and any changes after trial commencementThe plaque scores were averaged for each participant to obtain a single whole-mouth average score at baseline and another whole-mouth average score following brushing. The outcome was the difference (baseline minus post-brushing) in the average scores calculated for each participant during each treatment period.Throughout the study, all serious adverse events (AEs) were included in appropriate case reports, and all self-reported non-serious oral AEs were also recorded. Whole-body AE was recorded only if it could be related to the use of the device.BlindingBlinding of the patients was not possible. Plaque assessments were performed by two periodontists who were blinded to the treatment groups.Statistical analysesDescriptive statistics were used to summarize the sample characteristics and baseline dental measurements. Means and standard deviations (SD) were calculated for the three groups at baseline and after brushing. To analyze the effect of the type of toothbrush on the plaque, a mixed-effects linear model was used to account for the repeated measurements that yield period, sequence, intrapatient, and interpatient variability.The difference in scores (baseline minus post-brushing) as average scores were calculated for each participant, for each period, and analyzed for treatment group differences using a mixed model analysis for repeated measures. The factors in the model were subject (random effect), period, treatment, carryover, and baseline whole-mouth average score as the covariate. If the carryover was not significant at the 10% level, it was deleted from the final statistical model. The ICC measured the degree of consistency or reliability between the two examiners for the average pre-brushing and post-brushing scores.NCSS software® (version 20) was used for data entry and analysis . P-valueParticipant flowThe 24 participants enrolled in the trial were randomized to one of the three treatment sequences. In total, 27 participants were included in the study. Three participants refused to comply with the visits Figure .Baseline dataThe patient characteristics and baseline plaque scores are summarized in Table Outcome, estimation, precision, and subgroup analysesThe F-test for the treatment was nearly significant  at the 0.05 level. There appeared to be no period effect  and no carryover effect. The treatment differences were statistically significant between the C-TB and Pulsar brush groups  favoring the C-TB over the Pulsar brush and between the O-TB and cross-action (p = 0.004) toothbrush favoring the O-TB over the Pulsar brush. However, the difference between the O-TB and C-TB types was not statistically significant (p = 0.063)  and post-brushing . These results showed a high degree of consistency or reliability between the two examiners. No serious AEs were observed.This study investigated the effects of three different manual toothbrushes  on plaque removal when using the modified Bass method of brushing in orthodontic patients. A significant effect in plaque score was found favoring both the flat trim C-TB and the O-TB compared to the Pulsar toothbrushes. Surprisingly, the difference in plaque score was not significant between the O-TB and C-TB in patients with fixed orthodontic appliances. However, a greater plaque reduction in terms of mean difference was seen for the C-TB compared to the O-TB Figure .One of the several tools that have been developed for proper oral hygiene maintenance in orthodontic patients includes the specially designed orthodontic manual toothbrush with a unique design of V-shaped grooves along its bristles on the long axis of the toothbrush head. The V-groove nylon bristles gradually shorten, increasing the contact area of the central bracket area, and the long, soft filaments function around the area of the bracket wing. This improves the contact surface between the toothbrush bristles and the orthodontic appliance and improves the hygiene of the patient wearing the fixed orthodontic appliance . ConflicAccording to a recent meta-analysis, gingival bleeding is not modified by the O-TB, but major plaque removal of the O-TB by 1.72  was validated . HoweverTM) that pivot independently (designed to penetrate deep between teeth) and a battery-powered gentle pulse action (lifting food particles and plaque). However, Our findings contradict the findings of previous studies [On the other hand, studies have reported clinically significant plaque reductions with the Pulsar brush on intact teeth -21. Some studies -21 in thStudy strengthsA key strength of our study is its single-use, three-period, crossover design evaluating whole-mouth plaque removal and treatment sequences including washout phases between study periods. This is an ideal model for the estimation of the period, carryover, and treatment effects. The use of a crossover design has several advantages, including a smaller number of participants required for the study and confounding factors within the participants, such as age, gender, and hand skills. In addition, the effects are measured in the same person. Another strength is that we used two examiners compared with the literature reporting only one examiner. In addition, our study was a short-term, single-use trial. The short-term nature of trials is useful for controlling confounding variables, for example, participant compliance. We also standardized our methodology by adhering to the modified Bass technique, which is recommended by many orthodontists for manual brushes . Two minStudy limitationsA major limitation of the study was that the treatments tested were performed as a single exercise; hence, long-term effects could not be assessed. It was not possible to report any AEs associated with prolonged toothbrush use. Well-designed randomized controlled trials are needed to compare the short and long-term effects of different manual toothbrushes. A slightly <90% power in the analyses could be a reason why we did not observe significant differences between the C-TB and the O-TB groups, although the mean difference for the C-TB was much higher compared to the O-TB Figure . AlthougThe results of this cross-over randomized controlled trial demonstrated that the Pulsar toothbrushes are not as effective as the C-TB and O-TB in removing dental plaque in participants with fixed orthodontic appliances. This indicates that even though the Pulsar designs appear to work better in intact teeth ,21, indiWithin the limitations of this study, the C-TB and O-TB removed significantly more plaque after a single brushing than the Pulsar toothbrush. Nevertheless, the C-TB tested in this study was more effective in removing dental plaque than the O-TB in patients wearing fixed orthodontic appliances. Considering the limitations of this study, additional research is required before evidence-based advice concerning the relative performance of the Pulsar toothbrushes in fixed orthodontic patients can be proven.


Metadynamics calculations of large chemical systems with ab initio methods are computationallyprohibitive due to the extensive sampling required to simulate the large degrees of freedomin these systems. To address this computational bottleneck, we utilized a GPU-enhanced densityfunctional tight binding (DFTB) approach on a massively parallelized cloud computing platform toefficiently calculate the thermodynamics and metadynamics of biochemical systems. To first validateour approach, we calculated the free-energy surfaces of alanine dipeptide and showed that ourGPU-enhanced DFTB calculations qualitatively agree with computationally-intensive hybrid DFTbenchmarks, whereas classical force fields give significant errors. Most importantly, we show thatour GPU-accelerated DFTB calculations are significantly faster than previous approaches by up totwo orders of magnitude. To further extend our GPU-enhanced DFTB approach, we also carriedout a 10 ns metadynamics simulation of remdesivir, which is prohibitively out of reach for routineDFT-based metadynamics calculations. We find that the free-energy surfaces of remdesivir obtainedfrom DFTB and classical force fields differ significantly, where the latter overestimates the internalenergy contribution of high free-energy states. Taken together, our benchmark tests, analyses, andextensions to large biochemical systems highlight the use of GPU-enhanced DFTB simulations forefficiently predicting the free-energy surfaces/thermodynamics of large biochemical systems. Molecular dynamics (MD) simulations are used to study a wide range of dynamic atomistic effects, including free energetics of chemical processes ,2,3, proWhen coupled with metadynamics, classical force field simulations of large systems can be used to estimate the structure and thermodynamics of relatively complex chemicals and materials. However, classical force fields can be inaccurate  and failIn a previous work , we deveT is the kinetic energy of the electrons, We briefly discuss the DFTB formalism in this section since it is used extensively to calculate free-energy surfaces/thermodynamics of biochemical systems in this study. Specifically, we used the third-order expansion of the Kohn–Sham (KS) DFT energy around a reference density, which is commonly referred to as DFTB3. To derive the DFTB3 total energy, the DFT total energy expression  is choseTo obtain the expression of the DFTB3 total energy, a Taylor series expansion of Equation  around tEquation  and invoThe second, third, and fourth summations in Equation  run overEquation  is a sumgiven by :3)Hμν0=Hμν0=EBS,given by : (4)−12▽otential .Based on the form of Equation , only tweraction . The thi charges ,37. The olecules . Similarquations :(5)∑νMcνThe DFTB Hamiltonian, Equation  is givenquation , Equation  flowchart [Algorithm 1: The tridiagonal Divide-And-Conquer algorithm.The Divide-And-Conquer algorithm scales as O(n3) , where nlowchart .Algoritt is constructed from the sum of Gaussian “hills” [W is the initial height of the bias potential, T are the Boltzmann constant and temperature, respectively), ith CV in the set, s, of collective variables. The first exponential term in Equation (Metadynamics is an accelerated sampling method that can be used to explore the free-energy landscape of a system as a function of collective variables (CVs) . Within  “hills” :13)VBFiBlimtThe free energy, potential energy, and entropy landscapes of ADP and remdesivir were calculated using the GROMACS  and DFTBAll-atom molecular dynamics simulations for the remdesivir molecule were performed with the Amber ff19SB force field  and geneAMBER 20 . The welAMBER 20  simulatiA structural assessment of remdesivir was performed using metadynamics simulations, which determined the conformational preferences of the dihedral angles in the main scaffold. Gaussian hills with an initial height of 1.2 kJ molhe Lincs ,58 methohe Lincs  softwarehe Lincs  was emplAll DFTB calculations in this study utilized high-performance computing hardware (40 Intel Xeon Platinum 8168 CPUs and 8 NVIDIA Volta V100 GPUs) executed on virtual machines (VMs) from Microsoft Azure cloud computing resources. Using the high-performance computing container maker (HPCCM) , an openermostat . Metadynermostat  patched ermostat . All of as-based  python sTo evaluate the computational speedup gained from our heterogeneous CPU+GPU DFTB metadynamics calculations, we benchmarked the timings for carrying out eight SCC iterations of the first MD step on protease (PDB ID: 6LU7), which consists of 5029 atoms. To assess the efficiency and accuracy of our DFTB-based metadynamics calculations, we first performed a benchmark analysis with alanine dipeptide (ADP). In the scientific literature, ADP is frequently used as the archetypal system to evaluate the performance of various enhanced sampling methods, including, for example, the extended harmonic superposition approach , replicaIn contrast with the classical force field results, the FESs obtained with DFT-PBE0 and DFTB3  have the in Ref. , where tA is the free energy, U is the internal energy, T is the temperature, and S is the entropy. The internal energy contribution to the FES was calculated using the local average of the internal energy computed during the MD simulations on a To understand the origin of the FES differences, we further investigated the contribution of internal energy and entropy to the free energy in the MD simulations. The change in free energy is given byessential for obtaining an accurate description of large peptides, especially for folding and unfolding processes. In particular, our DFTB3 calculations for the FES/PES qualitatively agree with computationally intensive DFT-PBE0 benchmarks, whereas classical force fields give significant errors.The entropic contributions to the free energy also exhibit significant differences . The clant claim  that then is the matrix dimension), increasing the system size twice would incur an eight-fold increase in computational cost. Therefore, a system size of ≈80 atoms is well within the capabilities of our GPU-enhanced DFTB approach , which cannot be easily obtained with DFT-based metadynamics.Most importantly, the computational effort/time for our DFTB calculations is significantly less than that of full DFT . As reported in a previous study by de Pablo et al. , the DFTWith our GPU-enhanced DFTB approach validated against the high-level DFT-PBE0 ADP benchmarks, we then proceeded with metadynamics calculations of remdesivir as a proof-of-concept example of a system that is impractical to calculate with full DFT. Remdesivir has garnered recent attention in treating various ailments ,79,80 anAs mentioned previously, converged metadynamics calculations with full DFT on large chemical systems such as remdesivir are impractical. More specifically, previous DFT-PBE0 metadynamics calculations on the 22-atom ADP molecule required 4.5 continuous weeks of computing time [Before calculating the FES, we examined the convergence of our DFTB WT-MetaD simulations by calculating the free energy as a function of time. In general, when a metadynamics simulation is converged, the resulting FES profiles are similar within a constant offset. ce field a and DFTce field b approacThere are clear differences between the DFTB3 and classical force field predictions for the FES. The most discernible difference is near the maximum at Similar to our analysis on ADP, we investigated the origin of the FES differences by computing the contribution of internal energy and entropy for remdesivir. In summary, our results emphasize the importance of including quantum effects for accurately probing the metadynamics of remdesivir. In particular, our DFTB3 and Amber classical field calculations give qualitatively different predictions for the remdesivir FES. To estimate the accuracy of these two computational approaches, we carried out benchmark tests showing that the DFTB3 results are much more consistent with full DFT than the Amber classical force field. The resulting errors in the Amber classical force field manifest themselves in the FES by overestimating the internal energy contribution, particularly in the high free-energy remdesivir configurations. Taken together, our results show that our GPU-enhanced DFTB approach is a promising approach for accurately calculating the long-term metadynamics of remdesivir, which cannot be easily carried out with full DFT calculations.In conclusion, we have extended our GPU-enhanced DFTB approach to enable efficient simulations of long-term metadynamics calculations of complex biochemical systems. Carrying out metadynamics calculations on these large biochemical systems is a natural extension of our GPU-enhanced DFTB approach because the diagonalization of the Hamiltonian matrix is performed several times during a single MD trajectory, which can be accelerated with massively parallelized GPUs. To enable these large simulations, we also carried out these calculations on Microsoft’s Azure cloud platform to demonstrate the viability of cloud computing resources for quantum simulations.After testing the performance of our GPU-DFTB approach on various hardware configurations for optimal performance, we verified the accuracy of our computational approach by calculating the free-energy surfaces of alanine dipeptide, which is a standard reference system for evaluating the performance/accuracy of enhanced sampling methods. In contrast to classical force fields, which give qualitatively different results than DFT-PBE0 benchmarks, we found that our GPU-enhanced DFTB calculations are in good agreement  with the computationally intensive DFT-PBE0 benchmarks. To further extend our GPU-enhanced DFTB approach, we also carried out a 10 ns metadynamics simulation of remdesivir, which is prohibitively out of reach for routine DFT-based metadynamics calculations. To the best of our knowledge, this is the first time that a quantum-based FES has been calculated for remdesivir for a relatively long sampling time of 10 ns. We found the free-energy surfaces obtained from classical and DFTB3 calculations differ signifcantly. Compared to DFTB3, the classical force field overestimates the internal energy contribution of high free-energy states in remdesivir, which produces dissimilar transition pathways that connect different minima on the free-energy surface. Taken together, our calculations and benchmark studies indicate that GPU-enhanced DFTB metadynamics is a promising technique for sampling the long-term thermodynamics of biochemical systems that require more accuracy than classical force fields but cannot be easily calculated with full DFT methods.


This study was conducted with the intension of providing a more detailed view about the dynamics of COVID-19 pandemic. To this aim, characteristics, implemented public health measures, and health outcome of COVID-19 patients during five consecutive waves of the disease were assessed.This study was a population-based cross-sectional analysis of data on adult patients who were diagnosed with COVID-19 during five waves of the disease in Iran. Chi-squared test, One-way ANOVA, and Logistic Regression analysis were applied. A detailed literature review on implemented public health policies was performed by studying published documents and official websites responsible for conveying information about COVID-19.Data on 328,410 adult patients was analyzed. Main findings indicated that the probability of dying with COVID-19 has increased as the pandemic wore on, showing its highest odd during the third wave  and has gradually decreased during the next two waves. The same pattern was observed in the proportion of patients requiring ICU admission (P < 0.001). First wave presented mainly with respiratory symptoms, gastrointestinal complaints were added during the second wave, neurological manifestations with peripheral involvement replaced the gastrointestinal complaints during the third wave, and central nervous system manifestations were added during the fourth and fifth waves. A significant difference in mean age of patients was revealed between the five waves (P < 0.001). Moreover, results showed a significant difference between men and women infected with COVID-19, with men having higher rates of the disease at the beginning. However, as the pandemic progressed the proportion of women gradually increased, and ultimately more women were diagnosed with COVID-19 during the fifth wave. Our observations pointed to the probability that complete lockdowns were the key measures that helped to mitigate the virus spread during the first twenty months of the pandemic in the country.A changing pattern in demographic characteristics, clinical manifestations, and severity of the disease has been revealed as the pandemic unfolded. Reviewing COVID-19-related public health interventions highlighted the importance of immunization and early implementation of restrictive measures as effective strategies for reducing the acute burden of the disease. The ongoing pandemic of COVID-19 (coronavirus disease 2019) has now affected almost every region around the globe and continues to impact lives in all societies. Its causative pathogen, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), was first detected in China in late 2019, but has spread rapidly ever since causing significant burden of morbidity and mortality worldwide .However, different countries presented different COVID-19 epidemics. Iran was one of the first countries hit by the virus, with the COVID-19 outbreak being reported initially in late February 2020. Like many other countries, massive public health measures have been imposed across the country since the beginning of the epidemic to contain the spread of the virus . HoweverUntil now, incredible insight has been gained on COVID-19, but it has been mainly dominated by studies offering an overall view of the pandemic –10. Yet,, 2020. The fourth wave began on March 31, 2021, during which an average of 929 cases were reported daily. The province managed to come out of it on May 29, 2021, however shortly after, on June 22 the country entered its fifth wave with the average daily count of 5825. The wave came to an end on December 18, 2021, after several weeks of declining numbers of new cases followed by a plateau.This study was a population-based cross-sectional analysis of data on adult patients who were diagnosed with COVID-19 during the five waves of the disease in Tehran, Iran. With over 13 million residents, Tehran is the most populated province of Iran and an important epicentre for COVID-19 outbreaks in the country . AccordiThe province-wide data on all patients aged 18 years or older infected with COVID-19 during the five consecutive waves of the epidemic were extracted from the registry database of Coronavirus Control Operations Headquarter in Tehran. Of note, as of late February 2020, all health care facilities visiting suspected, probable, and confirmed cases of COVID-19 patients (defined bases on WHO case definition guideline) in the province, had to use the COVID-19 online registry, where a standard online form with required and optional fields were directly filled during the visits by health care professionals . In thisThe qualitative information including the implemented public health policies intended for virus containment were retrieved from the country’s official governmental sources  and a detailed catalogue of recommended and administered government policies related to COVID-19 which was available from the Coronavirus Control Operations Headquarter in Tehran.2 sat %) on admission, polymerase chain reaction (PCR) test result on admission, chest CT findings on admission, intensive care unit (ICU) admission, health outcome, and the epidemiological waves.Variables used included age, sex, history of underlying diseases , clinical presentations on admission , blood oxygen saturation level , with significance level of α < 0.05.Shahid Beheshti University of Medical Sciences Ethics Committee approved the study with a waiver of informed consent (Reference number: IR.SBMU.MSP.REC.1400.316). Data were de-identified prior to analysis. All methods were performed in accordance with the Declaration of Helsinki guidelines and regulations. = 1993.7, P < 0.001). Post hoc comparisons using the Scheffe test showed significant difference between mean age of patients among all comparisons (P < 0.001) except for difference between wave 2 and wave 4 which was insignificant (P = 0.23). Table In total, data on 328,410 patients  who were diagnosed with COVID-19 during five consecutive waves of the disease in Tehran were analysed. The mean age of patients was 53.5 ± 17.26 years . The one-way ANOVA revealed a significant difference in the mean age of patients between the groups  as well as social gathering limits of 15 person indoor . HoweverThis study is a population-based cross-sectional analysis of data on 328,410 adult patients who were diagnosed with COVID-19 during five consecutive waves of the disease in Tehran. Main findings indicated that the probability of dying with COVID-19 has increased as the pandemic wore on, showing its highest odd during the third wave and has gradually decreased during the next two waves. The same pattern was observed in the proportion of patients requiring ICU admission. Overall, the first wave presented mainly with respiratory symptoms, and gastrointestinal complaints were added during the second wave. During the third wave, neurological manifestations with peripheral involvement replaced the gastrointestinal complaints, and central nervous system manifestations were added during the next two waves. With respect to containment public health policies, adopting complete or targeted lockdowns were the key measures that helped to mitigate the virus spread in Iran.Our findings revealed that more severe cases have been reported during the third wave, compared to the other waves. After adjusting for age, sex, and underlying diseases in the logistic regression analysis, the odds of dying with COVID-19 has increased during the first three waves but has significantly decreased during the next two waves. The same pattern was seen in South Korea, Australia, and France which were experiencing their second wave of COVID-19 during the same period when Iran was in its third wave, suggesting that as of early August, a more virulent and fatal variant of the virus was circulating in most countries around the globe –19. A reMoreover, this study found changes in the patterns of COVID-19 symptoms as the epidemic evolved in the country. Overall, few studies have evaluated the changes in the COVID-19 presentation during the different pandemic waves, but the overall changing pattern of the symptoms have been previously reported , 27. ThiOur results revealed a demographic shift towards more younger people and more women being affected by the illness as the epidemic progressed, which was aligned with reports on changing demographics of the pandemic from other countries –34. The Iran is among the few countries with five waves of the disease in its COVID-19 epidemiological curve causing the government to take a wide range of public health measures in their response to outbreaks. Throughout the pandemic, a descending trend in new case counts was observed each time a complete lockdown was adopted. This observation points to the probability that complete lockdowns were the key measures that helped to mitigate the virus spread and to initiate the descending phase of the epidemiological curve. Though our finding lends support to previous reports in the literature, the association should be interpreted with caution since it could be affected by different interfering factors –38. OverFinally, our research had few potential limitations. First, this study was a retrospective analysis of existing data which has restricted our analyses to available information. Future studies evaluating the effects of respiratory supports and other approved therapies on the health outcome of SARS-CoV-2 infected patients are recommended. Second, COVID-19 waves have occurred in different periods, hence there could be different confounding factors which could influence the health outcome of patients in different stages including use of therapies associated with improved health outcomes over time, proportion of vaccinated or previously infected individuals, changes in population behaviours, exhaustion of healthcare workforce, and strains on health system resources containing ICU or total bed capacity. Third, since the government had rolled out several public health interventions simultaneously during the peaks, detangling the impact of each intervention was challenging. And fourth, given the large sample size even small differences might become detectable, however, that statistical significance may not always imply something practically meaningful. Despite these drawbacks, by using a large provincial representative study population and a high-quality data set, collected by trained health care personnel based on a standardized reporting form, we were able to provide a reliable picture of the COVID-19 epidemic in the country allowing more confident extension of inferences to the target population. Moreover, consulting with authorities directly involved in COVID-19 related public policy making, enabled us to provide a more in-depth review of the implemented strategies.This study revealed a changing pattern in clinical manifestations and severity of COVID-19 pandemic during the five consecutive waves of the disease in Iran during 2020 and 2021. COVID-19 related public health interventions have also been reviewed, indicating the importance of population-wide COVID-19 immunization coverage and early implementation of infection control measures as effective strategies of virus containment.