Unlocking DOE potential by selecting the most appropriate design for rAAV optimization

Producing recombinant adeno-associated virus (rAAV) for gene therapy via triple transfection is an intricate process involving many cellular interactions. Each of the different elements encoded in the three required plasmids-pHelper, pRepCap, and pGOI-plays a distinct role, affecting different cellular pathways when producing rAAVs. The required expression balance emphasizes the critical need to fine-tune the concentration of all these different elements. The use of design of experiments (DOE) to find optimal ratios is a powerful method to streamline the process. However, the choice of the DOE method and design construction is crucial to avoid misleading results. In this work, we examined and compared four distinct DOE approaches: rotatable central composite design (RCCD), Box-Behnken design (BBD), face-centered central composite design (FCCD), and mixture design (MD). We compared the abilities of the different models to predict optimal ratios and interactions among the plasmids and the transfection reagent. Our findings revealed that blocking is essential to reduce the variability caused by uncontrolled random effects and that MD coupled with FCCD outperformed all other approaches, improving volumetric productivity 109-fold. These outcomes underscore the importance of selecting a model that can effectively account for the biological context, ultimately yielding superior results in optimizing rAAV production.

Unravelling risk selection in Spanish general government employee mutual funds: evidence from cancer hospitalizations in the public health network

Government employees in Spain are covered by public Mutual Funds that purchase a uniform basket of benefits, equal to the ones served to the general population, from private companies. Companies apply as private bidders for a fixed per capita premium hardly adjusted by age. Our hypothesis is that this premium does not cover risks, and companies have incentives for risk selection, which are more visible in high-cost patients. We focus on a particularly costly disease, cancer, whose prevalence is similar among government employees and the general population. We compare hospitalisations in the public hospitals of the government employees that have chosen public provision and the general population. We analysed a database of hospital discharges in the Valencian Community from 2010 to 2015 (3 million episodes). Using exact matching and logistic models, we find significant risk selection; thus, in hospitalised government employees, the likelihood for a solid metastatic carcinoma and non-metastatic cancer to appear in the registry is 31% higher than in the general population. Lymphoma shows the highest odds ratio of 2.64. We found quantitatively important effects. This research provides indirect evidence of risk selection within Spanish Mutual Funds for government employees, prompting action to reduce incentives for such a practice. More research is needed to figure out if what we have observed with cancer patients occurs in other conditions.

Impact of red blood cell transfusion and hemoglobin threshold on 1-year mortality among surgical sepsis survivors: A propensity score matching study

BACKGROUND

Despite the fact that red blood cell (RBC) transfusion is commonly applied in surgical intensive care unit (ICU), the effect of RBC transfusion on long-term outcomes remains undetermined. We aimed to explore the association between RBC transfusion and the long-term prognosis of surgical sepsis survivors.

METHODS

This retrospective study was conducted on adult sepsis patients admitted to a tertiary surgical ICU center in China. Patients were divided into transfusion and non-transfusion groups based on the presence of RBC transfusion. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW)were performed to balance the potential confounders.

RESULTS

A total of 1421 surgical sepsis survivors were enrolled, including 403 transfused patients and 1018 non-transfused patients. There was a significant difference in 1-year mortality between the two groups (23.1 ​% vs 12.7 ​%, HR: 1.539, 95 ​% confidence interval [CI]: 1.030-2.299, P ​< ​0.001). After PSM and IPTW, transfused patients still showed significantly increased 1-year mortality risks compared to non-transfused individuals (PSM: 23.6 ​% vs 15.9 ​%, HR 1.606, 95 ​% CI 1.036-2.488 ​P ​= ​0.034; IPTW: 20.1 ​% vs 12.9 ​%, HR 1.600, 95 ​% CI 1.040-2.462 ​P ​= ​0.032). Among patients with nadir hemoglobin below 70 ​g/L, 1-year mortality risks in both groups were similar (HR 1.461, 95 ​% CI 0.909-2.348, P ​= ​0.118). However, among patients with nadir hemoglobin above 70 ​g/L, RBC transfusion was correlated with increased 1-year mortality risk (HR 1.556, 95 ​% CI 1.020-2.374, P ​= ​0.040).

CONCLUSION

For surgical sepsis survivors, RBC transfusion during ICU stay was associated with increased 1-year mortality, especially when patients show hemoglobin levels above 70 ​g/L.

Association between prescription drugs and all-cause mortality risk in the UK population

Although most drugs currently approved are meant to treat specific diseases or symptoms, it has been hypothesized that some might bear a beneficial effect on lifespan in healthy older individuals, outside of their specific disease indication. Such drugs include, among others, metformin, SGLT2 inhibitors and rapamycin. Since 2006, the UK biobank has recorded prescription medication and mortality data for over 500'000 participants, aged between 40 and 70 years old. In this work, we examined the impact of the top 406 prescribed medications on overall mortality rates within the general population of the UK. As expected, most drugs were linked to a shorter lifespan, likely due to the life-limiting nature of the diseases they are prescribed to treat. Importantly, a few drugs were associated with increased lifespans, including notably Sildenafil, Atorvastatin, Naproxen and Estradiol. These retrospective results warrant further investigation in randomized controlled trials.

Impact of community-based multidomain preventive health program on healthcare utilisation among elderly persons in Singapore: a propensity score matched and difference-in-differences study

OBJECTIVES

Ageing populations present substantial challenges for healthcare systems. Community-based health worker (CHW) interventions for promoting healthy ageing and preventing/managing non-communicable diseases have gained considerable attention in recent years. This study aimed to assess the impacts of a multidomain preventive health initiative delivered by CHWs, specifically the 'My Health Map (MHM)' programme, on participants' health service utilisation using a propensity score matching methodology.

DESIGN, SETTING AND PARTICIPANTS

The multidomain MHM programme, which was implemented in Bukit Batok township, encompassed screenings, vaccinations, chronic disease management, counselling and socio-environmental interventions. Individuals, aged ≥40 years old, who received care at Ng Teng Fong General Hospital and were enrolled in the MHM programme constituted the intervention group. Outcomes of the intervention group were compared with a 1:1 propensity-matched comparison group at enrolment and 1-year follow-up. The outcome measures were emergency department (ED) utilisation and hospital admissions. Statistical evaluations were performed using χ2/non-parametric tests and difference-in-difference (DiD) estimation with a bias-adjusted generalised estimating equation (α=0.05).

RESULTS

A comparable comparison group was formed with no significant differences in baseline characteristics between groups. Data from a total of 299 MHM participants (mean age 70.7 (SD 9.6); 62.5% women) and 299 matched comparisons (mean age 72.1 (SD 16.6); 61.5% women) were appraised. DiD analysis indicated a significant reduction in ED attendance (-16.7%, p<0.001) and hospital admission (-18.4%, p<0.001) among intervention participants than the comparison participants.

CONCLUSIONS

The multidomain MHM programme proved effective in reducing ED attendances and hospital admissions in older adults. CHWs have the potential to serve as change agents in healthcare and should be systematically integrated into preventive health programmes.

New initiation of opioids, benzodiazepines and antipsychotics following hospitalization for COVID-19

BACKGROUND

Patients newly initiated on opioids (OP), benzodiazepines (BZD), and antipsychotics (AP) during hospitalization are often prescribed these on discharge. Implications of this practice on outcomes remains unexplored.

OBJECTIVE

To explore the prevalence and risk factors of new initiation of select OP, BZD and AP among patients requiring in-patient stays. Test the hypothesis that new prescriptions are associated with higher odds of readmission or death within 28 days of discharge.

DESIGN

Single center retrospective cohort study.

SETTING AND PARTICIPANTS

Patients admitted to a tertiary-level medical center with either a primary diagnosis of RT-PCR positive for COVID-19 or high index of clinical suspicion thereof.

INTERVENTION

None.

MAIN OUTCOME AND MEASURES

Exposure was the new initiation of select common OP, BZD, and AP which were continued on hospital discharge. Outcome was a composite of 28-day readmission or death following index admission. Multivariable logistic regression was used to assess patient mortality or readmission within 28 days of discharge associated with new prescriptions at discharge.

RESULTS

1319 patients were included in the analysis. 11.3% (149/1319) were discharged with a new prescription of select OP, BZD, or AP either alone or in combination. OP (110/149) were most prescribed followed by BZD (41/149) and AP (22/149). After adjusting for unbalanced confounders, new prescriptions (adjusted odds ratio: 2.44, 95% confidence interval: 1.42-4.12; p = .001) were associated with readmission or death within 28 days of discharge. One in nine patients admitted with a diagnosis of COVID-19 or high clinical suspicion thereof were discharged with a new prescription of either OP, BZD or AP. New prescriptions were associated with higher odds of 28-day readmission or death. Strengthening medication reconciliation processes focused on these classes may reduce avoidable harm.

Evaluation of dupilumab on the disease burden in children and adolescents with atopic dermatitis: A population-based cohort study

BACKGROUND

Dupilumab is the first and only biologic agent approved for the treatment of atopic dermatitis (AD) in pediatric patients aged from 6 months to 17 years. The study aimed to evaluate the impact of dupilumab on the occurrence of comorbidities in pediatric patients with AD.

METHODS

In this population-based cohort study, we utilized electronic health records from multiple healthcare organizations across the United States. Pediatric patients (<18 years of age) with a diagnosis of AD initiating dupilumab were propensity-score matched 1:1 to those initiating other systemic agents (azathioprine, cyclosporine, methotrexate, mycophenolate mofetil, or systemic corticosteroids). The primary outcomes were new-onset comorbidities emerging during the study period measured by the risk ratio (RR) and its confidence interval (CI). Subgroup analyses were stratified by age (0-5 years, 6-11 years, and 12-17 years), sex, and race.

RESULTS

A total of 3575 pediatric patients with AD treated with dupilumab were matched to 3575 patients treated with other systemic agents. The dupilumab cohort was associated with a lowered risk of new-onset atopic comorbidities (including asthma [RR, 0.72; 95% CI, 0.59-0.89] and allergic rhinitis [RR, 0.62; 95% CI, 0.52-0.74]), infections (e.g., skin and soft tissue infection [RR, 0.70; 95% CI, 0.63-0.76] and respiratory tract infection [RR = 0.56; 95% CI, 0.51-0.61]), psychiatric disorders (e.g., mood disorder [RR, 0.52; 95% CI, 0.39-0.70] and anxiety [RR, 0.57; 95% CI, 0.46-0.70], sleep disturbance [RR, 0.60; 95% CI, 0.47-0.77]), neurologic and developmental disorders (e.g., attention deficit hyperactivity disorder [RR, 0.54; 95% CI, 0.38-0.75]). Furthermore, the positive effects are found to be more pronounced in younger children (aged 0-5 years) with AD.

CONCLUSIONS

Treatment with dupilumab compared to systemic agents resulted in reductions in AD-related comorbidities in pediatric patients.

An app promoting weight gain prevention via healthy behaviours amongst young women with a family history of breast cancer: Acceptability and usability assessment

BACKGROUND

Breast cancer is the most frequent female malignancy in the UK. Around 20% of cases are linked to weight gain, excess weight and health behaviours. We designed a weight gain prevention, health behaviour intervention for young women at increased risk.

METHODS

The study comprised a single arm observational study over 2 months testing acceptability and usability of the intervention: online group welcome event, app and private Facebook group. Females aged 18-35 years at moderate or high risk of breast cancer (>17% lifetime risk) were recruited via invite letters and social media posts. The app included behaviour change techniques and education content. Online questionnaires were completed at baseline, as well as at 1 and 2 months. We also assessed feasibility of study procedures.

RESULTS

Both recruitment methods were successful. Thirty-five women were recruited, 26% via social media posts. Median age was 33 (interquartile range = 28.2-34.5) years, the majority (94.1%) were of White ethnicity. Thirty-four participants were included in the analyses, of which 94% downloaded the app. Median self-monitoring logs per participant during the study period was 10.0 (interquartile range = 4.8-28.8). App quality mean (SD) score was 3.7 (0.6) at 1 and 2 months (scale: 1-5). Eighty-nine per cent rated the app at average or above at 1 month and 75.0% at 2 months. Nineteen women (55.9%) joined the Facebook group and there were 61 comments and 83 reactions and votes from participants during the study period.

CONCLUSIONS

This first iteration of the app and intervention was well received and is suitable to progress to the next stage of refining and further testing.

Association Between Early Mobilization and Functional Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage: A Multicenter Retrospective Propensity Score-Matched Study

BACKGROUND

Early mobilization has been shown to promote functional recovery and prevent complications in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, the efficacy of early mobilization in patients with aSAH remains unclear. This study aimed to investigate the association between early mobilization and functional outcomes in patients with aSAH.

METHODS

This multicenter retrospective study was conducted in Japan and included patients with aSAH who received physical therapy with or without occupational therapy from April 2014 to March 2019. The primary outcome was the modified Rankin Scale (mRS) score, with a favorable functional outcome defined as an mRS score of 0-2 and an unfavorable outcome with an mRS score of 3-5. Patients initiating walking training within 14 days of aSAH onset were classified into the early mobilization group, whereas those initiating training after 14 days were classified into the delayed mobilization group. Propensity score matching analysis was performed to assess the association between early mobilization and favorable outcomes.

RESULTS

A total of 718 patients were screened, and 450 eligible patients were identified. Before matching, 229 patients (50.9%) were in the early mobilization group and 221 (49.1%) were in the delayed mobilization group. After matching, each group consisted of 122 patients, and the early mobilization group exhibited a higher proportion of favorable outcomes than did the delayed mobilization group (81.1% vs. 52.5%, risk difference 28.7%, 95% confidence interval 17.4-39.9, p < 0.001).

CONCLUSIONS

This multicenter retrospective study suggests that initiating walking training within 14 days of aSAH onset is associated with favorable outcomes.

The Impact of a Breast Cancer Risk Assessment on the Decision for Gender-Affirming Chest Masculinization Surgery in Transgender and Gender-Diverse Individuals: A Pilot Single-Arm Educational Intervention Trial

BACKGROUND

Persons assigned female or intersex at birth and identify as transgender and/or gender-diverse (TGD) may undergo gender-affirming chest masculinization surgery (GACMS); however, GACMS is not considered equivalent to risk-reducing mastectomies (RRM). This study aimed to estimate the prevalence of elevated breast cancer (BC) risk in TGD persons, compare self-perceived versus calculated risk, and determine how risk impacts the decision for GACMS versus RRM.

METHODS

A prospective single-arm pilot educational intervention trial was conducted in individuals assigned female or intersex at birth, age ≥ 18 years, considering GACMS, without a BC history or a known pathogenic variant. BC risk was calculated using the Tyrer-Cuzik (all) and Gail models (age ≥ 35 years). Elevated risk was defined as ≥ 17%.

RESULTS

Twenty-five (N = 25) participants were enrolled with a median age of 24.0 years (interquartile range, IQR 20.0-30.0 years). All were assigned female sex at birth, most (84%) were Non-Hispanic (NH)-White, 48% identified as transgender and 40% as nonbinary, and 52% had a first- and/or second-degree family member with BC. Thirteen (52%) had elevated risk (prevalence 95% confidence interval (CI) 31.3-72.2%). Median self-perceived risk was 12% versus 17.5% calculated risk (p = 0.60). Of the 13 with elevated risk, 5 (38.5%) underwent/are scheduled to undergo GACMS, 3 (23%) of whom underwent/are undergoing RRM.

CONCLUSIONS

Over half of the cohort had elevated risk, and most of those who moved forward with surgery chose to undergo RRM. A BC risk assessment should be performed for TGD persons considering GACMS. Future work is needed to examine BC incidence and collect patient-reported outcomes. Trial Registration Number ClinicalTrials.gov (No. NCT06239766).

Chronic Non-cancer Pain and Associated Risks of Incident Mild Cognitive Impairment and Alzheimer's Disease and Related Dementias in Middle-Aged and Older Adults

The goal of this study is to investigate the association between chronic non-cancer pain (CNCP) and mild cognitive impairment (MCI)/Alzheimer's disease and related dementias (ADRDs) development among adults aged ≥50 using administrative claims data from a national commercial health insurance company during 2007-2017. To reduce selection bias, propensity-score matching was applied to select comparable CNCP and non-CNCP patients. Time-dependent Cox proportional-hazards regressions were conducted to estimate the hazard ratios (HRs) of incident MCI/ADRDs. Of 170,900 patients with/without CNCP, 0.61% developed MCI and 2.33% had been diagnosed with ADRDs during the follow-up period. Controlling for potential confounders, CNCP patients had a 123% increase in MCI risk (HR = 2.23; 95% CI = 1.92-2.58) and a 44% increase in ADRDs risk (HR = 1.44; 95% CI = 1.34-1.54) relative to non-CNCP patients. CNCP is a risk factor for MCI/ADRDs. Promoting awareness and improving early CNCP diagnosis in middle-aged and older adults should be incorporated into cognitive impairment and dementia prevention.

Advancing high quality longitudinal data collection: Implications for the HEALthy Brain and Child Development (HBCD) Study design and recruitment

The HEALthy Brain and Child Development (HBCD) Study, a multi-site prospective longitudinal cohort study, will examine human brain, cognitive, behavioral, social, and emotional development beginning prenatally and planned through early childhood. The HBCD Study aims to reflect the sociodemographic diversity of pregnant individuals in the U.S. The study will also oversample individuals who use substances during pregnancy and enroll similar individuals who do not use to allow for generalizable inferences of the impact of prenatal substance use on trajectories of child development. Without probability sampling or a randomization-based design, the study requires innovation during enrollment, close monitoring of group differences, and rigorous evaluation of external and internal validity across the enrollment period. In this article, we discuss the HBCD Study recruitment and enrollment data collection processes and potential analytic strategies to account for sources of heterogeneity and potential bias. First, we introduce the adaptive design and enrollment monitoring indices to assess and enhance external and internal validity. Second, we describe the visit schedule for in-person and remote data collection where dyads are randomly assigned to visit windows based on a jittered design to optimize longitudinal trajectory estimation. Lastly, we provide an overview of analytic procedures planned for estimating trajectories.

Self-help groups and opioid use disorder treatment: An investigation using a machine learning-assisted robust causal inference framework

OBJECTIVES

This study investigates the impact of participation in self-help groups on treatment completion among individuals undergoing medication for opioid use disorder (MOUD) treatment. Given the suboptimal adherence and retention rates for MOUD, this research seeks to examine the association between treatment completion and patient-level factors. Specifically, we evaluated the causal relationship between self-help group participation and treatment completion for patients undergoing MOUD.

METHODS

We used the Substance Abuse and Mental Health Services Administration's (SAMHSA) Treatment Episode Data Set: Discharges (TEDS-D) from 2015 to 2019. The data are filtered by the patient's opioid use history, demographics, treatment modality, and other relevant information. In this observational study, machine learning models (Lasso Regression, Decision Trees, Random Forest, and XGBoost) were developed to predict treatment completion. Outcome Adaptive Elastic Net (OAENet) was used to select confounders and outcome predictors, and the robust McNemars test was used to evaluate the causal relationship between self-help group participation and MOUD treatment completion.

RESULTS

The machine-learning models showed a strong association between participation in self-help groups and treatment completion. Our causal analysis demonstrated an average treatment effect on treated (ATT) of 0.260 and a p-value < 0.0001 for the robust McNemars test.

CONCLUSIONS

Our study demonstrates the importance of participation in self-help groups for MOUD treatment recipients. We found that participation in MOUD along with self-help groups caused higher chances of treatment completion than MOUD alone. This suggests that policymakers should consider further integrating self-help groups into the treatment for OUD to improve the adherence and completion rate.

Large-scale meta-analyses and network analyses of neural substrates underlying human escalated aggression

Escalated aggression represents a frequent and severe form of violence, sometimes manifesting as antisocial behavior. Driven by the pressures of modern life, escalated aggression is of particular concern due to its rising prevalence and its destructive impact on both individual well-being and socioeconomic stability. However, a consistent neural circuitry underpinning it remains to be definitively identified. Here, we addressed this issue by comparing brain alterations between individuals with escalated aggression and those without such behavioral manifestations. We first conducted a meta-analysis to synthesize previous neuroimaging studies on functional and structural alterations of escalated aggression (325 experiments, 2997 foci, 16,529 subjects). Following-up network and functional decoding analyses were conducted to provide quantitative characterizations of the identified brain regions. Our results revealed that brain regions constantly involved in escalated aggression were localized in the subcortical network (amygdala and lateral orbitofrontal cortex) associated with emotion processing, the default mode network (dorsal medial prefrontal cortex and middle temporal gyrus) associated with mentalizing, and the salience network (anterior cingulate cortex and anterior insula) associated with cognitive control. These findings were further supported by additional meta-analyses on emotion processing, mentalizing, and cognitive control, all of which showed conjunction with the brain regions identified in the escalated aggression. Together, these findings advance the understanding of the risk biomarkers of escalated aggressive populations and refine theoretical models of human aggression.

Use of defibrotide in COVID-19 pneumonia: comparison of a phase II study and a matched real-world cohort control

The coronavirus disease 2019 (COVID-19) pandemic led to an unprecedented burden on healthcare systems around the world and a severe global socioeconomic crisis, with more than 750 million confirmed cases and at least 7 million deaths reported by December 31, 2023. The DEFI-VID19 study (clinicaltrials gov. Identifier: NCT04335201), a phase II, single-arm, multicenter, open-label trial was designed in mid-2020 to assess the safety and efficacy of defibrotide in treating patients with COVID-19 pneumonia. Defibrotide was administered at a dose of 25 mg/kg intravenously, divided into four daily doses over a planned 14-day period for patients with COVID-19 pneumonia receiving non-invasive ventilation. The primary endpoint was respiratory failure-free survival (RFFS). Overall survival (OS), the number of post-recovery days, and adverse events were the secondary endpoints. For comparison, a contemporaneous control cohort receiving standard of care only was retrospectively selected by applying the eligibility criteria of the DEFI-VID19 trial. To adjust for the imbalance between the two cohorts in terms of baseline variable distributions, an outcome regression analysis was conducted. In adjusted analysis, patients receiving defibrotide reported a trend towards higher RFFS (hazard ratio [HR]=0.71; 95% confidence interval [CI]: 0.34-1.29; P=0.138) and OS (HR=0.78; 95% CI: 0.33-1.53; P=0.248]) and showed a significantly increased number of post-recovery days (difference in means =3.61; 95% CI: 0.97-6.26; P=0.0037). Despite concomitant thromboprophylaxis with low molecular weight heparin, the safety profile of defibrotide proved to be favorable. Taken together, our findings suggest that defibrotide may represent a valuable addition to the COVID-19 therapeutic options.

Air pollution below US regulatory standards and cardiovascular diseases using a double negative control approach

Growing evidence suggests that long-term air pollution exposure is a risk factor for cardiovascular mortality and morbidity. However, few studies have investigated air pollution below current regulatory limits, and causal evidence is limited. We use a double negative control approach to examine the association between long-term exposure to air pollution at low concentration and cardiovascular hospitalizations among US Medicare beneficiaries aged ≥65 years between 2000 and 2016. The expected values of the negative outcome control (preceding-year hospitalizations) regressed on exposure and negative exposure control (subsequent-year exposure) are treated as a surrogate for omitted confounders. With analyses separately restricted to low-pollution areas (PM2.5 < 9 μg/m³, NO2 < 75.2 µg/m3 [40 ppb], warm-season O3 < 88.2 μg/m3 [45 ppb]), we observed positive associations of the three pollutants with hospitalization rates of stroke, heart failure, and atrial fibrillation and flutter. The associations generally persisted in demographic subgroups. Stricter national air quality standards should be considered.

Malnutrition defined by global leadership initiative on malnutrition criteria impedes home discharge in acute care hospital admissions

BACKGROUND & AIMS

Limited evidence exists on the association between malnutrition diagnosis using the Global Leadership Initiative on Malnutrition (GLIM) criteria in hospitalized acute care patients and their outcomes; several aspects still require clarification. This study aimed to evaluate the relationship between malnutrition, as defined by the GLIM criteria, at the time of acute hospital admission and discharge to home.

METHODS

This retrospective observational study was conducted at a hospital that provides acute care in Japan. Adult patients admitted between July 2023 and April 2024 were included in this study. The primary outcome was the number of patients discharged to home, with in-hospital mortality as the secondary outcome. To ensure the reliability of the cohort-wide results, background factors were adjusted using propensity score matching. The two groups were compared based on the presence or absence of malnutrition, as defined by the GLIM criteria at admission. Furthermore, multiple logistic regression analysis was conducted, with the outcome as the dependent variable and malnutrition, diagnosed using the GLIM criteria, as the explanatory variable, adjusting for covariates.

RESULTS

A total of 1007 patients were included in the final analysis, of whom 492 (49 %) were diagnosed without malnutrition, while 515 (51 %) were diagnosed with malnutrition according to the GLIM criteria. In the multivariate logistic regression analysis after matching, malnutrition defined by the GLIM criteria emerged as an independent factor associated with discharge to home (odds ratio [OR] = 0.37, 95 % confidence interval = 0.25-0.56, P < 0.001) when adjusting for age, sex, and various comorbidities. Among the GLIM sub-criteria, reduced muscle mass, reduced food intake or assimilation, and disease burden or inflammation were independently associated with discharge to home. Notably, disease burden/inflammation exhibited the lowest OR among the GLIM sub-criteria for discharge.

CONCLUSION

Malnutrition diagnosed using the GLIM criteria upon admission in patients admitted to a regional hospital providing acute care was associated with decreased rates of discharge to home and increased in-hospital mortality. Specifically, attention should be paid to the criteria for reduced muscle mass and disease burden or inflammation within the GLIM framework.

Consider or not consider: the unsolved question on the use of radioactive iodine for differentiated thyroid cancer with low to intermediate risk of recurrence

BACKGROUND

Surgery stands as the cornerstone treatment for differentiated thyroid cancer (DTC). After surgery, radioactive iodine (RAI) administration is primarily recommended for high-risk patients and commonly employed to address residual disease or mitigate the risk of recurrence. However, the optimal application of RAI in cases categorized as low to intermediate risk is still uncertain. This study aims to assess the indication of post-surgical RAI treatment specifically in patients diagnosed with DTC falling within the low to intermediate risk category for recurrent disease.

METHODS

retrospective analysis of consecutive patients with DTC falling within the low to intermediate risk category for recurrence and diagnosed between 2009-2015. Patients were categorized into either treated or untreated with RAI. Treatment effect was assessed by the inverse-probability weighted regression adjustment (IPWRA), by balancing the distribution of factors influencing outcome and treatment assignment.

RESULTS

after surgery, 328 patients (69.9%) were treated with RAI while 141 (30.1%) were left untreated. Across the entire cohort, 44 individuals (9.4%) displayed biochemical or structural disease after a median time of 17.5 months following diagnosis. Recurrent disease was more prevalent in patients who underwent RAI treatment compared to those untreated (12.5% vs 2.1%, respectively, p < 0.001). Factors independently associated with recurrent disease, identified through multivariate logistic regression analysis, included lymph node metastases (pN1) (OR = 4.07; 95% CI 1.84-8.97), male sex (OR = 2.71; 95% CI 1.31-5.59), tumor size (OR = 1.03; 95% CI 1.00-1.06), and microscopic extrathyroidal extension (OR = 2.36; 95% CI 1.15-4.81). IPWRA analysis revealed that the occurrence of recurrent disease was 9.6% (95% CI = 6.3-12.9) in RAI-treated patients and 15.9% (95% CI = 11.1-20.71) in untreated patients (p = 0.021). As a consequence, if all patients underwent RAI treatment, the estimated risk of recurrence would be reduced by 42% (RR = 0.58; 95% CI = 0.35-0.91, p = 0.018). The greatest benefit was observed in patients with 2 intermediate risk factors.

CONCLUSIONS

These results suggest that treatment with RAI in low to intermediate DTC can reduce the risk of recurrence in selected patients. However, definitive answers regarding whether to consider RAI therapy for this category of patients can only be attained through prospective clinical trials. Up to date these results recommend a meticulous assessment of tumor characteristics at diagnosis to guide the decision regarding RAI administration.

Comparison between OK-432 and Talc for pleurodesis in patients with persistent pulmonary air leak: a Japanese nationwide retrospective database study

OBJECTIVES

OK-432 (Picibanil®) and talc are used in patients with persistent pulmonary air leaks. However, it is unclear which of these two agents is more effective.

METHODS

This retrospective study used data from the Japanese Diagnosis Procedure Combination inpatient database. Patients with pneumothorax who underwent chemical pleurodesis between July 2010 and March 2022 were included in this study. The patients were categorized into two groups: the OK-432 and talc groups. The primary outcome measure was treatment failure, defined as a composite of requirement for additional surgical procedures, bronchoscopic interventions, or chemical pleurodesis. The secondary outcome measures were in-hospital mortality, length of hospital stay, 30-day readmission, and incidence of interstitial lung diseases after hospitalization. To compare the outcomes between the groups, 1:4 propensity score matching was conducted.

RESULTS

Among the 4179 eligible patients, 3551 and 628 patients underwent chemical pleurodesis using OK-432 and talc, respectively. Propensity score matching yielded 2508 and 627 patients who underwent chemical pleurodesis using OK-432 and talc within seven days of admission, respectively. The frequency of treatment failure in the talc group (37.5% vs. 31.4%; P = 0.006) was lower than that in the OK-432 group with no significant differences in other outcomes.

CONCLUSIONS

Medical professionals can consider talc as the initial pleurodesis agent for patients with persistent air leaks.

Prevalence and Incidence of Psoriatic Arthritis among Patients with Psoriasis and Risk Factors for Psoriatic Arthritis in Republic of Korea: A Nationwide Database Cohort Study

Population-based epidemiological studies on disease burden and risk factors for psoriatic arthritis (PsA) in patients with psoriasis (PsO) are limited, especially in Asian populations. Therefore, the aim was to determine the prevalence and incidence of PsA among PsO patients in Korea, and examine associated clinical factors. A cohort study was performed to determine the annual prevalence and incidence of PsA among PsO patients between 2008 and 2020 using nationwide claims data in Korea. Risk factors for PsA development were also examined using logistic regression among matched PsA cases and controls. An increasing trend in PsA prevalence per 1,000 patients was observed; prevalence was 6.17 (95% confidence interval [CI] 5.73-6.65) in 2008 and 19.03 (95% CI 18.39-19.70) in 2020. Similarly, the PsA incidence rate per 1,000 patient-years increased from 3.35 (95% CI 3.01-3.72) in 2008 to 5.01 (95% CI 4.68-5.36) in 2020. Patients with plaque PsO, moderate-to severe PsO, receiving oral systemic therapy or phototherapy, with a higher burden of comorbidities, and concomitant autoimmune diseases had a higher risk of PsA. The results provide insight into the burden of PsA among PsO patients in Korea and risk factors associated with developing PsA.

Adherence to cardiovascular medications and risk of cardiovascular disease in breast cancer patients: A causal inference approach in the Pathways Heart Study

PURPOSE

Women with breast cancer (BC) are at high risk of developing cardiovascular disease (CVD). We examined adherence to CVD medications and their association with major CVD events over 14 years of follow-up in the Pathways Heart Study, a prospective study of 4,776 stage I-III BC patients diagnosed from 2005-2013.

METHODS

Eligibility included being alive 6 months post-BC diagnosis, with dyslipidemia, hypertension, or diabetes at diagnosis along with ≥1 prior outpatient order or dispensing for a statin, anti-hypertensive, or diabetes medication, respectively, in the 30 months prior. Medication adherence was measured from pharmacy data to calculate cumulative average adherence (CAA). Incident heart failure (HF), ischemic heart disease (IHD), and stroke were determined via validated diagnosis and procedure codes. Working marginal structural models (MSM) fitted with inverse probability weighting evaluated the effect of adherence regimens on the hazards for each CVD event, while controlling for baseline and time-varying confounders. MSM parameterizations included: 1) CAA<100% versus CAA = 100% (ref), 2) CAA<80% versus CAA≥80% (ref) and 3) CAA<80% versus 80%≤CAA<100% versus CAA = 100%.

RESULTS

Poor statin adherence (CAA<80%) was associated with higher risk of composite CVD (HR = 2.54; 95% CI: 1.09, 5.94) versus CAA≥80%. Poor statin adherence was also associated with a higher risk of stroke (HR = 8.13; 95% CI: 2.03, 32.51) but not risk of IHD and HF. Further, compared with perfect adherence (CAA = 100%), good adherence (80%≤CAA<100%) was associated with lower risk (HR = 0.35; 95% CI: 0.13, 0.92) while poor adherence (CAA<80%) was associated with higher risk of composite CVD (HR = 2.45; 95% CI: 1.05, 5.70). Levels of adherence to anti-hypertensives and diabetes medications had mixed or null associations with risk of CVD.

CONCLUSIONS

Maintaining good adherence (≥80%) to statins after BC treatment is beneficial for cardiovascular health in patients with dyslipidemia. Future studies should determine factors associated with lower adherence to statins and ways to improve adherence.

Childhood PM2.5 exposure and upward mobility in the United States

Although it is well documented that exposure to fine particulate matter (PM2.5) increases the risk of several adverse health outcomes, less is known about its relationship with economic opportunity. Previous studies have relied on regression modeling, which implied strict assumptions regarding confounding adjustments and did not explore geographical heterogeneity. We obtained data for 63,165 US census tracts (86% of all census tracts in the United States) on absolute upward mobility (AUM) defined as the mean income rank in adulthood of children born to families in the 25th percentile of the national income distribution. We applied and compared several state-of-the-art confounding adjustment methods to estimate the overall and county-specific associations of childhood exposure to PM2.5 and AUM controlling for many census tract-level confounders. We estimate that census tracts with a 1 μg/m3 higher PM2.5 concentrations in 1982 are associated with a statistically significant 1.146% (95% CI: 0.834, 1.458) lower AUM in 2015, on average. We also showed evidence that this relationship varies spatially between counties, exhibiting a more pronounced negative relationship in the Midwest and the South.

Predictive Value of the D-Dimer-to-Fibrinogen Ratio for Acute Kidney Injury after Living-Donor Liver Transplantation: A Retrospective Observational Cohort Study Using Logistic Regression and Propensity Score Matching Analyses

Background/Objectives: Liver transplantation (LT) is typically performed as a surgery to treat end-stage liver disease (ESLD). Factors influencing acute kidney injury (AKI) post-living-donor LT (LDLT) have been identified; however, the potential role of the D-dimer-to-fibrinogen ratio (DFR) in predicting AKI remains unexplored. Therefore, we analyzed the relationship between DFR levels and the occurrence of AKI following LT. Methods: We retrospectively analyzed 648 recipients after 76 were excluded based on the exclusion criteria. Multivariate logistic regression and propensity score (PS) matching analyses were performed to evaluate the association between a high DFR (>1.05) and AKI. Results: After LDLT, AKI was observed in 148 patients (22.8%). A high DFR (>1.05) was independently associated with AKI. Multivariate logistic regression analysis showed that patients with a DFR above this threshold were four times more susceptible to AKI than those with a low DFR. A high DFR was also significantly associated with AKI in the propensity score-matched patients. Conclusions: Our findings suggest that incorporating preoperative DFR assessment into the management of patients undergoing LDLT could enhance the risk stratification for postoperative AKI.

The association of economic difficulties with social and health care costs of children-target trial emulation using complete birth cohort data in Finland

It is unclear how much costs economic difficulties in families with children incur to the health and social care sector. We examined the health and social service costs after families entered into, and transitioned out of, social assistance used as a proxy measure for economic difficulties. We analyzed register data on all Finnish children born in 1997 and used the non-randomized target trial framework. The two target trials of entry to economic difficulties (social assistance) and continued economic difficulties included 697 680 and 71 131 children-year observations, respectively, in total. Inverse probability treatment weighting techniques were used to make the comparison group similar to the treatment group in terms of health, socioeconomic and demographic-related pretreatment variables. Entry to social assistance use was associated with some 1511-2619€ (50% compared to the control group) higher cumulative health and social care costs of the children three years after their families transitioned to social assistance, compared to the group that did not enter to social assistance system. This difference was primarily attributed to higher social care costs. Continued social assistance use was associated with some 1007-2709€ (31%) higher costs compared to the comparison group that exited social assistance. These findings support an economic argument to prevent families from entering economic difficulties and to help those in such situations to transition out.

Is Seeing Believing? A Practitioner's Perspective on High-Dimensional Statistical Inference in Cancer Genomics Studies

Variable selection methods have been extensively developed for and applied to cancer genomics data to identify important omics features associated with complex disease traits, including cancer outcomes. However, the reliability and reproducibility of the findings are in question if valid inferential procedures are not available to quantify the uncertainty of the findings. In this article, we provide a gentle but systematic review of high-dimensional frequentist and Bayesian inferential tools under sparse models which can yield uncertainty quantification measures, including confidence (or Bayesian credible) intervals, p values and false discovery rates (FDR). Connections in high-dimensional inferences between the two realms have been fully exploited under the "unpenalized loss function + penalty term" formulation for regularization methods and the "likelihood function × shrinkage prior" framework for regularized Bayesian analysis. In particular, we advocate for robust Bayesian variable selection in cancer genomics studies due to its ability to accommodate disease heterogeneity in the form of heavy-tailed errors and structured sparsity while providing valid statistical inference. The numerical results show that robust Bayesian analysis incorporating exact sparsity has yielded not only superior estimation and identification results but also valid Bayesian credible intervals under nominal coverage probabilities compared with alternative methods, especially in the presence of heavy-tailed model errors and outliers.

Evaluating disparity of subjective cognitive decline between male veterans and non-veterans in the United States using propensity score matching estimation: A behavioral risk factor surveillance system survey cross-sectional study

Subjective cognitive decline (SCD) is one of the most important early onset symptoms of Alzheimer's Disease. Previous studies consistently reported that SCD is associated with quality of life, socio-economic factors, and related health comorbidities. However, the impact of veteran status on SCD has been little investigated. This study conducted a cross-sectional study to address disproportionate effects in subjective cognitive decline between veterans and non-veterans in the United States. Propensity score matching (PSM) was applied in this observational study to achieve covariate balancing and reduce selection bias, providing a more accurate estimate of the isolated effect of veteran status on SCD. Our study utilized 32,431 forty-five years or older non-institutionalized White, Black or African-American, and Hispanic or Latin-American male population from the 2019 Behavioral Risk Factor Surveillance System data. We first identified 10,685 paired PSM samples for the binary veteran status using the preselected covariates. Next, we performed a logistic regression for modeling the relationship between the veteran status and the SCD status using the PSM samples along with the covariates selected by a BIC-based stepwise selection. Our analyses revealed a statistically significant causal association between veteran status and SCD after PSM (odds ratio (OR): 1.16 and 95% confidence interval (CI): 1.06-1.27). We obtained a similar result before PSM with an OR of 1.20 and 95% CI of 1.10-1.31. When we focused on a minority group (Black or African-American males), we found a significantly increased veterans' risk of SCD, especially after propensity score matching (OR: 1.69, 95% CI: 1.16-2.45). We also found several factors such as employment status, difficulty dressing/walking/running errands, general health status, physical health status, unaffordability of medical costs, mental health status, and comorbid conditions including stroke, blindness, high cholesterol, and arthritis as statistically significantly associated with SCD (P-value < 0.05). Similar to post-traumatic stress disorder and traumatic brain injury, our study demonstrated a causal association between SCD and military-related activities in the United States, which has a disproportionate impact on the minority population. This study sets the groundwork to further research in this domain to diagnose neurological diseases early among veterans.

Telehealth vs In-Person Early Palliative Care for Patients With Advanced Lung Cancer: A Multisite Randomized Clinical Trial

Importance

Numerous studies show that early palliative care improves quality of life and other key outcomes in patients with advanced cancer and their caregivers, although most lack access to this evidence-based model of care.

Objective

To evaluate whether delivering early palliative care via secure video vs in-person visits has an equivalent effect on quality of life in patients with advanced non-small cell lung cancer (NSCLC).

Design, Setting, and Participants

Randomized, multisite, comparative effectiveness trial from June 14, 2018, to May 4, 2023, at 22 US cancer centers among 1250 patients within 12 weeks of diagnosis of advanced NSCLC and 548 caregivers.

Intervention

Participants were randomized to meet with a specialty-trained palliative care clinician every 4 weeks either via video visit or in person in the outpatient clinic from the time of enrollment and throughout the course of disease. The video visit group had an initial in-person visit to establish rapport, followed by subsequent virtual visits.

Main Outcomes and Measures

Equivalence of the effect of video visit vs in-person early palliative care on quality of life at week 24 per the Functional Assessment of Cancer Therapy-Lung questionnaire (equivalence margin of ±4 points; score range: 0-136, with higher scores indicating better quality of life). Participants completed study questionnaires at enrollment and at weeks 12, 24, 36, and 48.

Results

By 24 weeks, participants (mean age, 65.5 years; 54.0% women; 82.7% White) had a mean of 4.7 (video) and 4.9 (in-person) early palliative care encounters. Patient-reported quality-of-life scores were equivalent between groups (video mean, 99.7 vs in-person mean, 97.7; difference, 2.0 [90% CI, 0.1-3.9]; P = .04 for equivalence). Rate of caregiver participation in visits was lower for video vs in-person early palliative care (36.6% vs 49.7%; P < .001). Study groups did not differ in caregiver quality of life, patient coping, or patient and caregiver satisfaction with care, mood symptoms, or prognostic perceptions.

Conclusions and Relevance

The delivery of early palliative care virtually vs in person demonstrated equivalent effects on quality of life in patients with advanced NSCLC, underscoring the considerable potential for improving access to this evidence-based care model through telehealth delivery.

Trial Registration

ClinicalTrials.gov Identifier: NCT03375489.

Rental Housing Deposits and Health Care Use

Importance

Housing deposits and tenancy supports have become new Medicaid benefits in multiple states; however, evidence on impacts from these specific housing interventions is limited.

Objective

To evaluate the association of rental housing deposits and health care use among Medicaid beneficiaries receiving social needs case management as part of a Whole-Person Care (Medicaid 1115 waiver) pilot program in California.

Design, Setting, and Participants

This cohort study compared changes in health care use among a group of adults who received a housing deposit between October 2018 and December 2021 along with case management vs a matched comparison group who received case management only in Contra Costa County, California, a large county in the San Francisco Bay Area. All participants were enrolled in health and social needs case management based on elevated risk of acute care use. Data analysis took place from March 2023 to June 2024.

Exposure

Rental housing deposit funds that covered 1-time moving transition costs. Funds averaged $1750 per recipient.

Main Outcomes and Measures

Changes in hospitalizations, emergency department visits, primary care visits, specialty care visits, behavioral health visits, psychiatric emergency services, or detention intakes during the 6 months before vs 6 months after deposit receipt. Changes 12 months before and after deposit receipt were examined as a sensitivity analysis.

Results

Of 1690 case management participants, 845 received a housing deposit (362 [42.8%] <40 years old; 422 [49.9%] male) and 845 received case management only (367 [43.4%] <40 years old; 426 [50.4%] male). In adjusted analyses, deposit recipients had no statistically significant differential changes in health care use for any measure compared to participants who received case management alone. Twelve-month sensitivity analyses yielded consistent results.

Conclusions and Relevance

In this cohort study, compared to case management only, housing deposits with case management were not associated with short-term changes in health care use. There may be other unmeasured health benefits or downstream benefits from greater case management engagement. States considering housing deposits as an expanded Medicaid benefit may need to temper expectations about short-term health care use impacts.

The role of funding in the performance of Latin America's protected areas

Conservationists have long argued that inadequate funding for managing protected areas (PAs) jeopardizes their ability to achieve conservation goals. However, this claim has rarely been substantiated by quantitative evaluations. To address this, we examined the impact of funding on PA effectiveness both at the scale of 17 national PA systems across Latin America and within a PA system (Ecuador), for which we had precise historical financial data. Most PAs reduced deforestation between 2000 and 2010, demonstrating their crucial role in forest conservation. However, large deficits in funding considerably reduced the effectiveness of PAs in Ecuador (on average, a unit decrease in deficit leads to a 3.07% increase in effectiveness in avoiding deforestation). While differences in effectiveness between individual PAs in Ecuador were associated with funding deficits, national-level socioeconomic metrics (e.g., the Human Development Index) were the major factor when comparing PA system-level effectiveness among countries. This result suggests that while funding plays a major role in the performance of individual PAs, the quality of the socioeconomic context at the country level is critical for the overall performance of the PA systems. We, therefore, emphasize that maximizing the effectiveness of PAs requires a multilevel approach that includes better and more strategic resource allocation for individual PAs, combined with actions for strengthening the governance and institutions that regulate PA systems.

Breast Density Status Changes: Frequency, Sequence, and Practice Implications

OBJECTIVE

Changes in a patient's reported breast density status (dense vs nondense) trigger modifications in their cancer risk profile and supplemental screening recommendations. This study tracked the frequency and longitudinal sequence of breast density status changes among patients who received serial mammograms.

METHODS

This IRB-approved, HIPAA-compliant retrospective cohort study tracked breast density changes among patients who received at least 2 mammograms over an 8-year study period. BI-RADS density assessment categories A through D, visually determined at the time of screening, were abstracted from electronic medical records and dichotomized into either nondense (categories A or B) or dense (categories C or D) status. A sequence analysis of longitudinal changes in density status was performed using Microsoft SQL.

RESULTS

A total of 58 895 patients underwent 231 997 screening mammograms. Most patients maintained the same BI-RADS density category A through D (87.35% [51 444/58 895]) and density status (93.35% [54 978/58 859]) throughout the study period. Among patients whose density status changed, the majority (97% [3800/3917]) had either scattered or heterogeneously dense tissue, and over half (57% [2235/3917]) alternated between dense and nondense status multiple times.

CONCLUSION

Our results suggest that many cases of density status change may be attributable to intra- and interradiologist variability rather than to true underlying changes in density. These results lend support to consideration of automated density assessment because breast density status changes can significantly impact cancer risk assessment and supplemental screening recommendations.

Comparison of Weighting Methods to Understand Improved Outcomes Attributable to Public Health Nursing Interventions

BACKGROUND

The complex work of public health nurses (PHNs) specifically related to mental health assessment, intervention, and outcomes makes it difficult to quantify and evaluate the improvement in client outcomes attributable to their interventions.

OBJECTIVES

We examined heterogeneity across parents of infants served by PHNs receiving different interventions, compared the ability of traditional propensity scoring methods versus energy-balancing weight (EBW) techniques to adjust for the complex and stark differences in baseline characteristics among those receiving different interventions, and evaluated the causal effects of the quantity and variety of PHN interventions on client health and social outcomes.

METHODS

This retrospective study of 4,109 clients used existing Omaha System data generated during the routine documentation of PHN home visit data. We estimated the effects of intervention by computing and comparing weighted averages of the outcomes within the different treatment groups using two weighting methods: (a) inverse probability of treatment (propensity score) weighting and (b) EBWs.

RESULTS

Clients served by PHNs differed in baseline characteristics with clients with more signs/symptoms. Both weighting methods reduced heterogeneity in the sample. EBWs were more effective than inverse probability of treatment weighting in adjusting for multifaceted confounding and resulted in close balance of 105 baseline characteristics. Weighting the sample changed outcome patterns, especially when using EBWs. Clients who received more PHN interventions and a wider variety of them had improved knowledge, behavior, and status outcomes with no plateau over time, whereas the unweighted sample showed plateaus in outcomes over the course of home-visiting services.

DISCUSSION

Causal analysis of PHN-generated data demonstrated PHN intervention effectiveness for clients with mental health signs/symptoms. EBWs are a promising tool for evaluating the true causal effect of PHN home-visiting interventions.

Comparative effects of sodium-glucose cotransporter 2 inhibitors versus dipeptidyl peptidase-4 inhibitors on kidney function decline in Japanese individuals with type 2 diabetes

BACKGROUND

Limited direct comparative studies exist in terms of the effects of sodium-glucose cotransporter 2 inhibitors (SGLT2is) and dipeptidyl peptidase-4 inhibitors (DPP4is) on the kidney outcomes in Japanese individuals with type 2 diabetes.

METHODS

This retrospective cohort study included 561 Japanese adults with type 2 diabetes, who were newly prescribed either an SGLT2i or a DPP4i and had an eGFR ≥ 30 mL/min/1.73 m2. The cohort comprised 207 women and 354 men, with a mean (± standard deviation) age of 63 (± 12) years. The exposure and outcome were SGLT2i or DPP4i initiation and eGFR slope during the overall follow-up period, restricted to participants who were followed for ≥2 years. We adopted the on-treatment analysis. Analysis of covariance was used to compare the adjusted eGFR slope between the two groups, incorporating 10 variables at baseline.

RESULTS

During the median follow-up period of 3.4 years, least square mean (95% CI) eGFR slopes were -1.91 (-2.15, -1.67) and -1.12 (-1.58, -0.67) mL/min/1.73 m2/year in individuals treated with a DPP4i (n = 460) and an SGLT2i (n = 101), respectively, demonstrating statistical significance (p = 0.002). The robustness of this finding was strengthened by sensitivity analyses.

CONCLUSIONS

This study provides potential evidence of the superiority of SGLT2is over DPP4is in slowing kidney function decline in Japanese adults with type 2 diabetes and eGFR ≥ 30 mL/min/1.73 m2.

PATIENT RECRUITMENT USING ELECTRONIC HEALTH RECORDS UNDER SELECTION BIAS: A TWO-PHASE SAMPLING FRAMEWORK

Electronic health records (EHRs) are increasingly recognized as a cost-effective resource for patient recruitment in clinical research. However, how to optimally select a cohort from millions of individuals to answer a scientific question of interest remains unclear. Consider a study to estimate the mean or mean difference of an expensive outcome. Inexpensive auxiliary covariates predictive of the outcome may often be available in patients' health records, presenting an opportunity to recruit patients selectively, which may improve efficiency in downstream analyses. In this paper we propose a two-phase sampling design that leverages available information on auxiliary covariates in EHR data. A key challenge in using EHR data for multiphase sampling is the potential selection bias, because EHR data are not necessarily representative of the target population. Extending existing literature on two-phase sampling design, we derive an optimal two-phase sampling method that improves efficiency over random sampling while accounting for the potential selection bias in EHR data. We demonstrate the efficiency gain from our sampling design via simulation studies and an application evaluating the prevalence of hypertension among U.S. adults leveraging data from the Michigan Genomics Initiative, a longitudinal biorepository in Michigan Medicine.

Examining the causal effects of exposure to violence on crime among youth involved in the justice system: Experienced, witnessed, and experienced-witnessed violence

Previous studies on exposure to violence lack a nuanced understanding of the causal effects of different exposure types on offending behaviors. This study, drawing on Pathways to Desistance Study (PDS) data tracking 1354 adjudicated youths aged 14-18 over 7 years, explores the contemporaneous (cross-sectional), acute (after 1 year), enduring (after 3 years), and long-term (after 6 years) causal effects of violence exposure on property and violent offending. The sample, predominantly male (86%), consisted of White (20%), Black (42%), and other (38%) individuals. The generalized propensity score is used to match unbalanced covariates across multiple exposure types, namely noninvolved (n = 392), witnessed (n = 577), experienced (n = 31), and experienced-witnessed violence (n = 305). Results demonstrate the contemporaneous, acute, enduring, and long-term effects of violence exposure on both violent and property offending, with varying durations and strengths across exposure types. The most pronounced risk effects are immediate, diminishing over time and potentially reversing in the long term as youth transition into adulthood. Among exposure types, experienced-witnessed violence exhibits the most potent effects on offending, followed by witnessed violence and then experienced violence-a pattern consistent across the observed time points. Noteworthy is the finding that the impact of violence exposure is more pronounced for violent offending, diminishing more rapidly compared to the effects on property offending.

Adaptive designs in dermatology clinical trials: Current status and future perspectives

Current drug development strategies present many challenges that can impede drug approval by regulatory agencies. Alternative study models, such as adaptive trial designs, have recently sparked interest, as they provide a flexible and more efficient approach in conducting clinical trials. Adaptive trial designs offer several potential benefits over traditional randomized controlled trials, which include decrease in costs, reduced clinical development time and limiting exposure of patients to potentially ineffective treatments allowing completion of studies with fewer patients. This article explores the current use of adaptive trial designs in non-oncologic skin diseases and highlights the most common types of adaptive designs used in the field. We also review the operational challenges and statistical considerations associated with such designs and propose clinical development strategies to successfully implement adaptive designs. The article also proposes instances where adaptive trial designs are particularly beneficial, and other situations where they may not be very useful.

False Discovery Rate Control for Lesion-Symptom Mapping With Heterogeneous Data via Weighted p-Values

Lesion-symptom mapping studies provide insight into what areas of the brain are involved in different aspects of cognition. This is commonly done via behavioral testing in patients with a naturally occurring brain injury or lesions (e.g., strokes or brain tumors). This results in high-dimensional observational data where lesion status (present/absent) is nonuniformly distributed, with some voxels having lesions in very few (or no) subjects. In this situation, mass univariate hypothesis tests have severe power heterogeneity where many tests are known a priori to have little to no power. Recent advancements in multiple testing methodologies allow researchers to weigh hypotheses according to side information (e.g., information on power heterogeneity). In this paper, we propose the use of p-value weighting for voxel-based lesion-symptom mapping studies. The weights are created using the distribution of lesion status and spatial information to estimate different non-null prior probabilities for each hypothesis test through some common approaches. We provide a monotone minimum weight criterion, which requires minimum a priori power information. Our methods are demonstrated on dependent simulated data and an aphasia study investigating which regions of the brain are associated with the severity of language impairment among stroke survivors. The results demonstrate that the proposed methods have robust error control and can increase power. Further, we showcase how weights can be used to identify regions that are inconclusive due to lack of power.

The burden of allergic rhinitis is undermanaged in a large proportion of Chinese young adults from Singapore

Background

Allergic rhinitis (AR) is a nasal disorder characterized by the simultaneous manifestation of at least 2 out of 4 possible symptoms: rhinorrhea, nasal itching, nasal pruritus, and sneezing. Presently, among Chinese young adults from Singapore, we characterised AR phenotypes, established Total Nasal Symptom Score (TNSS) baselines, and examined the management of AR.

Methods

Participants completed an investigator-administered International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire and underwent a skin prick test (SPT). Individuals exhibiting sensitization during the SPT while having at least 2 rhinitis symptoms were identified as AR cases, then categorized into Allergic Rhinitis in Asthma (ARIA) classifications.

Results

There were 9323 subjects analyzed. AR prevalence was estimated at 35.4%. Rhinorrhea was perceived as the most severe (mean Nasal Symptom Score (mNSS) ± SD: 1.42 ± 0.74), while nasal pruritus was the least severe (mNSS ± SD: 1.24 ± 0.68). Among moderate-severe AR (68.1%), most were affected by either troublesome symptoms (27.7%) or sleep disturbances (18.4%). By ARIA classes, 26.6% were mild intermittent, 5.4% were mild persistent, 50.3% were moderate-severe intermittent, and 17.6% were moderate-severe persistent. The mean TNSS (mTNSS) of AR cases was 4.43 (SD = 2.49) and between AR classifications, the mTNSS was significantly different. Notably, a large proportion of AR cases remained undiagnosed (85.2%), untreated (72.5%), or both (65.4%); 19.8% self-medicated for AR.

Conclusions

There was a significant difference in TNSS of the AR phenotypes, and among phenotypes with a higher mTNSS, a large proportion remained untreated, undiagnosed, or both. The evidence indicates an existing burden of AR among Chinese young adults in Singapore which is notably undermanaged.

Incidence of Liver and Non-liver Cancers After Hepatitis C Virus Eradication: A Population-Based Cohort Study

BACKGROUND AND OBJECTIVES

Direct-acting antivirals (DAAs) offer a high rate of hepatitis C virus (HCV) eradication. However, concerns on the risk of cancer after HCV eradication remain. Our study aimed at quantifying the incidence of cancer in patients treated with anti-HCV therapies in Catalonia (Spain) and their matched controls.

METHODS

This was a population-based study using real-world data from the public healthcare system of Catalonia between 2012 and 2016. Propensity score matching was performed in patients with HCV infection treated with interferon-based therapy (IFN), sequential IFN and DAA (IFN+DAA), and DAA only (DAA) with concurrent controls. We estimated the annual incidence of overall cancer, hepatocellular carcinoma, and non-liver cancer of HCV-treated patients and their corresponding rate ratios.

RESULTS

The study included 11,656 HCV-treated patients and 49,545 controls. We found statistically significant increases in the rate of overall cancer for IFN+DAA-treated (rate ratio [RR] 1.77, 95% confidence interval [CI] 1.27-2.46) and DAA-treated patients (RR 1.90, 95% CI 1.66-2.19) and in the rate of HCC for IFN-treated (RR 1.50, 95% CI 1.02-2.22), IFN+DAA-treated (RR 3.89, 95% CI 2.26-6.69), and DAA-treated patients (RR 6.45, 95% CI 4.90-8.49) compared with their corresponding controls. Moreover, DAA-treated patients with cirrhosis showed an increased rate of overall cancer versus those without cirrhosis (RR 1.92, 95% CI 1.51-2.44).

CONCLUSIONS

Results showed that overall cancer and hepatocellular carcinoma incidence in Catalonia was significantly higher among HCV-treated patients compared with matched non-HCV-infected controls, and risks were higher in patients with cirrhosis. An increased awareness of the potential occurrence of uncommon malignant events and monitoring after HCV eradication therapy may benefit patients.

A Two-Step Framework for Validating Causal Effect Estimates

BACKGROUND

Comparing causal effect estimates obtained using observational data to those obtained from the gold standard (i.e., randomized controlled trials [RCTs]) helps assess the validity of these estimates. However, comparisons are challenging due to differences between observational data and RCT generated data. The unknown treatment assignment mechanism in the observational data and varying sampling mechanisms between the RCT and the observational data can lead to confounding and sampling bias, respectively.

AIMS

The objective of this study is to propose a two-step framework to validate causal effect estimates obtained from observational data by adjusting for both mechanisms.

MATERIALS AND METHODS

An estimator of causal effects related to the two mechanisms is constructed. A two-step framework for comparing causal effect estimates is derived from the estimator. An R package RCTrep is developed to implement the framework in practice.

RESULTS

A simulation study is conducted to show that using our framework observational data can produce causal effect estimates similar to those of an RCT. A real-world application of the framework to validate treatment effects of adjuvant chemotherapy obtained from registry data is demonstrated.

CONCLUSION

This  study constructs a framework for comparing causal effect estimates between observational data and RCT data, facilitating the assessment of the validity of causal effect estimates obtained from observational data.

Doubly robust calibration of prediction sets under covariate shift

Conformal prediction has received tremendous attention in recent years and has offered new solutions to problems in missing data and causal inference; yet these advances have not leveraged modern semi-parametric efficiency theory for more efficient uncertainty quantification. We consider the problem of obtaining well-calibrated prediction regions that can data adaptively account for a shift in the distribution of covariates between training and test data. Under a covariate shift assumption analogous to the standard missing at random assumption, we propose a general framework based on efficient influence functions to construct well-calibrated prediction regions for the unobserved outcome in the test sample without compromising coverage.

Overcoming Data Gaps in Life Course Epidemiology by Matching Across Cohorts

Life course epidemiology is hampered by the absence of large studies with exposures and outcomes measured at different life stages in the same individuals. We describe when the effect of an exposure ( A ) on an outcome ( Y ) in a target population is identifiable in a combined ("synthetic") cohort created by pooling an early-life cohort including measures of A with a late-life cohort including measures of Y . We enumerate causal assumptions needed for unbiased effect estimation in the synthetic cohort and illustrate by simulating target populations under four causal models. From each target population, we randomly sampled early- and late-life cohorts and created a synthetic cohort by matching individuals from the two cohorts based on mediators and confounders. We estimated the effect of A on Y in the synthetic cohort, varying matching variables, the match ratio, and the strength of association between matching variables and A . Finally, we compared bias in the synthetic cohort estimates when matching variables did not d-separate A and Y to the bias expected in the original cohort. When the set of matching variables includes all variables d-connecting exposure and outcome (i.e., variables blocking all backdoor and front-door pathways), the synthetic cohort yields unbiased effect estimates. Even when matching variables did not fully account for confounders, the synthetic cohort estimate was sometimes less biased than comparable estimates in the original cohort. Methods based on merging cohorts may hasten the evaluation of early- and mid-life determinants of late-life health but rely on available measures of both confounders and mediators.

Functional disability and receipt of informal care among Chinese adults living alone with cognitive impairment

BACKGROUND

Adults with cognitive impairment are prone to living alone in large numbers but receive relatively little attention. This study aimed to evaluate whether living alone with cognitive impairment was associated with a higher burden of functional disability but lack of informal care.

METHODS

982 observations of adults living alone with cognitive impairment and 50,695 observations of adults living with others and with normal cognition were identified from 4 waves (2011/2012, 2013, 2015, and 2018) of the China Health and Retirement Longitudinal Study (CHARLS). A matched comparator was selected using propensity score matching (1:2). Functional disability included disability in Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), and mobility. The time of receiving informal care was measured in monthly hours.

RESULTS

Adults living alone with cognitive impairment demonstrated significantly higher odds ratio of ADL disability (OR = 1.59, 95 % CI: 1.30, 1.95), IADL disability (OR = 1.19, 95 % CI: 1.00, 1.44), mobility disability (OR = 1.38, 95 % CI: 1.12, 1.70), but received fewer hours of informal care (β = -127.7 h per month, standard error = 25.83, P < 0.001), compared to the adults living with others and with normal cognition.

CONCLUSIONS

This study highlights the high burden of functional disability but low coverage of informal care among Chinese adults living alone with cognitive impairment and calls for more resources to be allocated to this vulnerable subpopulation to improve the functional health and to increase the provision of long-term care services.

Newton-Raphson Meets Sparsity: Sparse Learning Via a Novel Penalty and a Fast Solver

In machine learning and statistics, the penalized regression methods are the main tools for variable selection (or feature selection) in high-dimensional sparse data analysis. Due to the nonsmoothness of the associated thresholding operators of commonly used penalties such as the least absolute shrinkage and selection operator (LASSO), the smoothly clipped absolute deviation (SCAD), and the minimax concave penalty (MCP), the classical Newton-Raphson algorithm cannot be used. In this article, we propose a cubic Hermite interpolation penalty (CHIP) with a smoothing thresholding operator. Theoretically, we establish the nonasymptotic estimation error bounds for the global minimizer of the CHIP penalized high-dimensional linear regression. Moreover, we show that the estimated support coincides with the target support with a high probability. We derive the Karush-Kuhn-Tucker (KKT) condition for the CHIP penalized estimator and then develop a support detection-based Newton-Raphson (SDNR) algorithm to solve it. Simulation studies demonstrate that the proposed method performs well in a wide range of finite sample situations. We also illustrate the application of our method with a real data example.

Comparative effectiveness of bovine carotid artery xenograft and polytetrafluoroethylene in hemodialysis access revision

BACKGROUND

When hemodialysis arteriovenous accesses fail, autogenous options are often limited. Non-autogenous conduit choices include bovine carotid artery xenografts (BCAG) and expanded polytetrafluoroethylene (PTFE), yet their comparative effectiveness in hemodialysis access revision remains largely unknown.

METHODS

A cohort study was performed from a prospectively collected institutional database from August 2010 to July 2021. All patients undergoing an arteriovenous access revision with either BCAG or PTFE were followed for up to 3 years from their index access revision. Revision was defined as graft placement to address a specific problem of an existing arteriovenous access while maintaining one or more of the key components of the original access (e.g. inflow, outflow, and cannulation zone). Outcomes were measured starting at the date of the index revision procedure. The primary outcome was loss of secondary patency at 3 years. Secondary outcomes included loss of post-intervention primary patency, rates of recurrent interventions, and 30-day complications. Pooled logistic regression was used to estimate inverse probability weighted marginal structural models for the time-to-event outcomes of interest.

RESULTS

A total of 159 patients were included in the study, and 58% received access revision with BCAG. Common indications for revision included worn out cannulation zones (32%), thrombosis (18%), outflow augmentation (16%), and inflow augmentation (13%). Estimated risk of secondary patency loss at 3 years was lower in the BCAG group (8.6%, 3.9-15.1) compared to the PTFE group (24.8%, 12.4-38.7). Patients receiving BCAG experienced a 60% decreased relative risk of secondary patency loss at 3 years (risk ratio 0.40, 0.14-0.86). Recurrent interventions occurred at similar rates in the BCAG and PTFE groups, with 1.86 (1.31-2.43) and 1.60 (1.07-2.14) interventions at 1 year, respectively (hazard ratio 1.22, 0.74-1.96).

CONCLUSIONS

Under the conditions of this contemporary cohort study, use of BCAG in upper extremity hemodialysis access revision decreased access abandonment when compared to PTFE.

Seeing more than the Tip of the Iceberg: Approaches to Subthreshold Effects in Functional Magnetic Resonance Imaging of the Brain

Many functional magnetic resonance imaging (fMRI) studies and presurgical mapping applications rely on mass-univariate inference with subsequent multiple comparison correction. Statistical results are frequently visualized as thresholded statistical maps. This approach has inherent limitations including the risk of drawing overly-selective conclusions based only on selective results passing such thresholds. This article gives an overview of both established and newly emerging scientific approaches to supplement such conventional analyses by incorporating information about subthreshold effects with the aim to improve interpretation of findings or leverage a wider array of information. Topics covered include neuroimaging data visualization, p-value histogram analysis and the related Higher Criticism approach for detecting rare and weak effects. Further examples from multivariate analyses and dedicated Bayesian approaches are provided.

A comparison of PM2.5 exposure estimates from different estimation methods and their associations with cognitive testing and brain MRI outcomes

BACKGROUND

Reported associations between particulate matter with aerodynamic diameter ≤2.5 μm (PM2.5) and cognitive outcomes remain mixed. Differences in exposure estimation method may contribute to this heterogeneity.

OBJECTIVES

To assess agreement between PM2.5 exposure concentrations across 11 exposure estimation methods and to compare resulting associations between PM2.5 and cognitive or MRI outcomes.

METHODS

We used Visit 5 (2011-2013) cognitive testing and brain MRI data from the Atherosclerosis Risk in Communities (ARIC) Study. We derived address-linked average 2000-2007 PM2.5 exposure concentrations in areas immediately surrounding the four ARIC recruitment sites (Forsyth County, NC; Jackson, MS; suburbs of Minneapolis, MN; Washington County, MD) using 11 estimation methods. We assessed agreement between method-specific PM2.5 concentrations using descriptive statistics and plots, overall and by site. We used adjusted linear regression to estimate associations of method-specific PM2.5 exposure estimates with cognitive scores (n = 4678) and MRI outcomes (n = 1518) stratified by study site and combined site-specific estimates using meta-analyses to derive overall estimates. We explored the potential impact of unmeasured confounding by spatially patterned factors.

RESULTS

Exposure estimates from most methods had high agreement across sites, but low agreement within sites. Within-site exposure variation was limited for some methods. Consistently null findings for the PM2.5-cognitive outcome associations regardless of method precluded empirical conclusions about the potential impact of method on study findings in contexts where positive associations are observed. Not accounting for study site led to consistent, adverse associations, regardless of exposure estimation method, suggesting the potential for substantial bias due to residual confounding by spatially patterned factors.

DISCUSSION

PM2.5 estimation methods agreed across sites but not within sites. Choice of estimation method may impact findings when participants are concentrated in small geographic areas. Understanding unmeasured confounding by factors that are spatially patterned may be particularly important in studies of air pollution and cognitive or brain health.

Association between hydroxyethyl starch 130/0.4 administration during noncardiac surgery and postoperative acute kidney injury: A propensity score-matched analysis of a large cohort in China

STUDY OBJECTIVE

The use of hydroxyethyl starch 130/0.4 has been linked to renal injury in critically ill patients, but its impact on surgical patients remains uncertain.

DESIGN

A retrospective cohort study.

SETTING

This study was conducted at one tertiary care hospital in China.

PATIENTS

We evaluated the records of 51,926 Chinese adults who underwent noncardiac surgery from 2013 to 2022. Patients given a combination of hydroxyethyl starch 130/0.4 and crystalloids were propensity-matched at a 1: 1 ratio of baseline characteristics to patients given only crystalloids (11,725 pairs).

INTERVENTIONS

Eligible patients were divided into those given a combination of hydroxyethyl starch 130/0.4 and crystalloid during surgery and a reference crystalloid group consisting of patients who were not given any colloid.

MEASUREMENTS

The primary outcome was the incidence of acute kidney injury. Secondarily, acute kidney injury stage, need for renal replacement therapy, intensive care unit transfer rate, and duration of postoperative hospitalization were considered.

MAIN RESULTS

After matching, hydroxyethyl starch use [8.5 (IQR: 7.5-10.0) mL/kg] did not increase the incidence of acute kidney injury compared with that in the crystalloid group [2.0 vs. 2.2%, OR: 0.90 (0.74-1.08), P = 0.25]. Nor did hydroxyethyl starch use worsen acute kidney injury stage [OR 0.90 (0.75-1.08), P = 0.26]. No significant differences between the fluid groups were observed in renal replacement therapy [OR 0.60 (0.41-0.90), P = 0.02)] or intensive care unit transfers [OR 1.02 (0.95-1.09), P = 0.53] after Bonferroni correction. Even in a subset of patients at high risk of renal injury, hydroxyethyl starch use was not associated with worse outcomes.

CONCLUSIONS

Hydroxyethyl starch 130/0.4 use was not significantly associated with a greater incidence of postoperative acute kidney injury compared to receiving crystalloid solutions only.

Predicting Immediate Lordosis Restoration After Anterior Lumbar Interbody Fusion and the Effect of Posterior Column Osteotomies

OBJECTIVE

Anterior lumbar interbody fusion (ALIF) can be combined with posterior column osteotomies (PCOs) to maximize lordotic correction. This study compares radiographic changes in regional and segmental lordosis in patients undergoing ALIF with and without PCOs.

METHODS

Patients >18 years old who underwent ALIF at 1 or 2 segments at a single institution (January 2014-July 2020) were included. Preoperative and postoperative radiographic parameters were determined, and a propensity-matched analysis was performed.

RESULTS

Ninety-nine patients (53 [54%] men) underwent ALIF at 129 levels (mean [SD], 1.3 [0.46] levels; median [range] age, 61 [32-83] years). PCOs were performed in 13 (13%) patients at 19 (15%) segments. PCOs included 13 Schwab grade 1 and 6 grade 2 osteotomies. All measures, including lumbar lordosis, segmental lordosis, disc angle, and neural foramen height, increased significantly after surgery (P ≤ 0.003). In the propensity-matched analysis, PCO was associated with greater increases in lumbar lordosis (14.9° vs. 8.2°, P = 0.02), segmental lordosis (14.0° vs. 9.6°, P = 0.03), and disc angle (15.0° vs. 10.2°, P = 0.046). The change in disc angle more closely approximated the inherent lordosis of the cage when PCO was performed (94% vs. 62%, P = 0.004).

CONCLUSIONS

Performing PCOs and ALIFs significantly increased the radiographic correction of overall and segmental lordosis in the selected patient cohort. The disc angle achieved with ALIF without PCOs was approximately 60% of the cage lordosis. The addition of PCO allowed for greater segmental compression, enabling the disc angle to reach nearly 100% of the inherent interbody cage lordosis.

Externally Controlled Studies Using Real-World Data in Patients With Hematological Cancers: A Systematic Review

Importance

The use of real-world data (RWD) external control arms in prospective studies is increasing. The advantages, including the immediate availability of a control population, must be balanced with the requirements of meeting evidentiary standards.

Objective

To address the question of whether and to what extent the methods of RWD studies compare to standard methods used in randomized clinical trials.

Evidence Review

A systematic search across 4 electronic databases and Google Scholar was conducted from January 1, 2000, to October 23, 2023. Studies were included in the systematic review if they compared an intervention arm in a clinical trial to an RWD control arm in patients with hematological cancers and if they were published between 2000 and 2023.

Findings

Thirty-two prospective intervention studies incorporating external control data from RWD sources of patients with hematological cancers were identified. A total of 4306 patients from intervention arms and 10 594 from RWD control arms were included across all studies. Only 2 studies (6%) included prospectively collected RWD. The complete trial inclusion criteria were applied to the RWD cohort in 7 studies (22%). Four studies (13%) published the statistical analysis plan and prespecified use of RWD. A total of 23 studies (72%) applied matching algorithms for trial and RWD cohorts, including matching for demographic, disease, and/or therapy-related characteristics. The end point criteria were the same as the trial in 8 studies (25%). In contrast, 12 studies (38%) used different end points, and 12 (38%) did not provide an end point definition for the RWD. Twelve studies (38%) had a median follow-up difference of less than a year between arms. Eight studies (25%) reported toxic effect data for the trial arm, of which 5 studies reported toxic effect data for the RWD arm.

Conclusions and Relevance

In this systematic review, limitations were observed in the application of clinical trial eligibility criteria to RWD, statistical rigor and application of matching methods, the definition of end points, follow-up, and reporting of adverse events, which may challenge the conclusions reported in studies using RWD.