Abdominal and general adiposity are independently associated with mortality, but there is no consensus on how best to assess abdominal adiposity. We compared the ability of alternative waist indices to complement body mass index (BMI) when assessing all-cause mortality. We used data from 352,985 participants in the European Prospective Investigation into Cancer and Nutrition (EPIC) and Cox proportional hazards models adjusted for other risk factors. During a mean follow-up of 16.1 years, 38,178 participants died. Combining in one model BMI and a strongly correlated waist index altered the association patterns with mortality, to a predominantly negative association for BMI and a stronger positive association for the waist index, while combining BMI with the uncorrelated A Body Shape Index (ABSI) preserved the association patterns. Sex-specific cohort-wide quartiles of waist indices correlated with BMI could not separate high-risk from low-risk individuals within underweight (BMI < 18.5 kg/m 2) or obese (BMI ≥ 30 kg/m 2) categories, while the highest quartile of ABSI separated 18-39% of the individuals within each BMI category, which had 22-55% higher risk of death. In conclusion, only a waist index independent of BMI by design, such as ABSI, complements BMI and enables efficient risk stratification, which could facilitate personalisation of screening, treatment and monitoring.

Background: Patient response burden is often raised as a human subject concern in consideration of the length or complexity of patient-reported outcome (PRO) instruments used in oncology. Objectives: To quantify patient response burden and identify its predictive factors. Methods: Data were collected presurgically during a prospective trial that used a comprehensive symptom and healthrelated quality-of-life (HRQOL) PRO assessment. A subset of patients also completed HRQOL interviews. Response burden was captured using an internally developed six-item instrument. Demographic and clinical characteristics as well as HRQOL scores were examined as potential predictors using hierarchical regression. Response burden was used to predict participant dropout at the first follow-up interval. Results: A total of 275 patients (mean age 67.5 years; 23.6% female) completed surveys (n ¼ 126) or surveys in addition to interviews (n ¼ 149). Patients experienced low response burden (mean 12.19 ± 11.65). Repetitive questions were identified by 60 patients (21.8%), whereas 31.6% indicated that additional information should be gathered; 35 patients (12.7%) identified repetitive questions and expressed a desire for additional items. Low self-reported cognitive function was a significant predictor of higher response burden (b ¼ À0.20; t(270) ¼ À3.38; P ¼ 0.01; model-adjusted R 2 ¼ 0.04). Response burden was not a significant predictor of study dropout. Conclusions: Despite completing a large battery of PRO measures and interviews, patients reported minimal response burden, with nearly one-third expressing that more questions should have been asked. Patients with lower cognitive function are more likely to report higher response burden when completing PRO measures. Further examination of patient characteristics related to response burden may reveal useful pathways for tailoring patient-centered interventions.

IntroductionExtended half-life factor products have reduced annualized bleeding rates in hemophilia patients. The impact of extended half-life versus conventional factor products on hemophilia caregiver burden has not been investigated. This study aimed to evaluate caregiver burden in extended half-life versus conventional factor products for hemophilia A and B.MethodsThis cross-sectional web-based study of caregivers of people with hemophilia A or B was recruited from a panel research company and by word of mouth. Participants completed the Hemophilia Caregiver Impact measure, the PedsQL Family Impact Module (PedsQL), and the Work Productivity and Activity Impairment Questionnaire (WPAI). We also collected demographic, insurance coverage, and medical information related to the hemophilia patient(s). Burden differences were assessed using linear regression and matched cohort analyses.ResultsThe sample (n = 448) included 49 people who were caring for people on extended half-life factor products. Worse caregiver burden was associated with more infusions per week and more bleeds in the past 6 months. Regression analyses suggested that caring for someone who is on a extended half-life factor product is associated with lower emotional impact (β = − 0.11, p < 0.05, Adjusted R2 = 0.06), and shows a trend association with lower practical impact (β = − 0.09, p < 0.10, Adjusted R2 = 0.05). The matched cohort analysis also revealed that people on extended half-life factor product had lower Emotional Impact and Practical Impact scores (t = − 2.95 and − 2.94, respectively, p < 0.05 in both cases). No differences were detected on the PedsQL or the WPAI.ConclusionThe reduced required frequency of factor product infusions of extended half-life factor products appears to reduce the emotional distress and practical burden of caregiving. Future work should evaluate the longitudinal impact.

BACKGROUND CONTEXT: Underlying cognitive factors have been found to influence patients' symptom experience. Current evidence suggests that concomitant changes in appraisal must be taken into account to accurately interpret change as measured by standard spine patientreported outcomes (PROs). PURPOSE: To investigate changes in patients' minimally important differences (MID) over recovery from spinal surgery; whether and how cognitive appraisal processes are implicated in the change trajectories. STUDY DESIGN/SETTING: Longitudinal cohort study with up to 12 months follow-up. PATIENT SAMPLE: Surgical patients (n = 167) with a diagnosis of disc herniation or spinal stenosis. OUTCOME MEASURES: Standard spine patient-reported PROs were used (Rand-36, Oswestry Disability Index, Numerical Rating Scale for pain, PROMIS Pain Impact). METHODS: This study was funded by the Feldberg Chair in Spinal Research, Sunnybrook Health Sciences Centre and the authors have no conflicts of interest. MID used an anchor technique and was computed by global assessment of change (GAC) grouping. Participants were binned into groups based on their GAC response patterns at all time points: Consistently better post-surgery, consistently worse post-surgery, and bouncers, whose GAC ratings fluctuate (ie, better-then-worsethen-better; or vice versa). Individuals' longitudinal quality of life (QOL) and appraisal slope scores were computed. QOL-appraisal slopes' correlations were computed by GAC group. Fisher's Z transformation tested the hypothesis that GAC groups differed in the QOL-appraisal relationship over time. RESULTS: Moderate to large changes are recognized as clinically important in the early stages of recovery (ie, 6 weeks post-surgery), and over time smaller and smaller changes become important. The three pattern groups emphasized and deemphasized different standards of comparison over time, with the Better group emphasizing personal goals and the Worse and Bouncers deemphasizing doctors' input. These group differences translated to differential relationships between PRO change and appraisal changes over time. CONCLUSIONS: The MID reflects increasingly subtle change over time in PROs. Appraisal may influence how patients experience the same (MID) change over time, with better outcomes associated with emphasizing long-term goals. PRO change seems to be driven by different standards of FDA device/drug status: Not applicable.

The BAI provides a practical, short tool for evaluating appraisal in a wide range of assessment situations. Future research might utilize the BAI in longitudinal research aimed at detecting response-shift effects over time, and in clinical settings to improve patient-provider communication about concerns related to health, health care, or QOL.