Akaike's information criterion in generalized estimating equations

Patient Characteristics and Clinical Process Predictors of Patients Leaving Without Being Seen from the Emergency Department

INTRODUCTION

Delays in patient flow in the emergency department (ED) result in patients leaving without being seen (LWBS). This compromises patient experience and quality of care. Our primary goal was to develop a predictive model by evaluating associations between patients LWBS and ED process measures and patient characteristics.

METHODS

This was a cross-sectional study in a 95,000 annual visit adult ED comparing patients LWBS, with controls. Data were drawn from four seasonally adjusted four-week periods (30,679 total visits). Process measures included 1) arrivals per hour; 2) "door-to-provider" time; and the numbers of 3) patients in the waiting room; 4) boarding ED patients waiting for an inpatient bed; 5) providers and nurses (RN); and 6) patients per RN. Patient characteristics collected included 1) age; 2) gender; 3) race/ethnicity; 4) arrival mode (walk-in or via emergency medical services [EMS]); and 5) acuity based on Emergency Severity Index (ESI). Univariable analyses included t-tests and Pearson's chi-square tests. We split the data randomly into derivation and validation cohorts. We used backward selection to develop the final derivation model, and factors with a p-value ≤ 0.05 were retained. Estimates were applied to the validation cohort and measures of discrimination (receiver operating characteristic) and model fit were assessed.

RESULTS

In the final model, the odds of LWBS increased with the number of patients in the waiting room (odds ratio [OR] 1.05; 95% confidence interval [CI], 1.03 to 1.06); number of boarding patients (OR 1.02; 95% CI, 1.01 to 1.03); arrival rate (OR 1.04; 95% CI, 1.02 to 1.05) and longer "door-to-provider" times (test of linear trend in the adjusted OR was p = 0.002). Patient characteristics associated with LWBS included younger age (OR 0.98; 95% CI, 0.98 to 0.99), and lower acuity (higher ESI category) (OR 2.01; 95% CI, 1.84 to 2.20). Arrival by EMS was inversely associated with LWBS (OR 0.29; 0.23 to 0.36). The area under the curve for the final model in the validation cohort was 0.85 (95% CI, 0.84 to 0.86). There was good agreement between the observed and predicted risk.

CONCLUSION

Arrival rate, "door-to-provider time," and the numbers of patients in the waiting room and ED boarders are all associated with patients LWBS.

Disentangling Social-Genetic From Rearing-Environment Effects for Alcohol Use Disorder Using Swedish National Data

Investigations of social-genetic effects, whereby a social partner's genotype affects another's outcomes, can be confounded by the influence of the social partner's rearing environment. We used marital information on more than 300,000 couples from Swedish national data to disentangle social-genetic from rearing-environment effects for alcohol use disorder (AUD). Using observational and extended-family designs, we found that (a) marriage to a spouse with a predisposition toward AUD (as indexed by a parental history of AUD) increased risk for developing AUD; (b) this increased risk was not explained by socioeconomic status, the spouse's AUD status, or contact with the spouse's parents; and (c) this increased risk reflected the psychological consequences of the spouse having grown up with an AUD-affected parent (i.e., a rearing-environment effect) rather than a social-genetic effect. Findings illustrate that a spouse's rearing-environment exposures may confer risk for AUD.

Associations Between School Characteristics and Classroom Radon Concentrations in Utah's Public Schools: A Project Completed by University Environmental Health Students

Radon (²²²Rn), a radioactive gas, is the second leading cause of lung cancer deaths in the U.S. Classroom radon concentrations in public schools in our target area had never been measured or had not been measured in many years. We had university students, primarily enrolled in environmental health courses, measure radon concentrations in 2289 classrooms in 66 of Utah’s public schools and identify school characteristics associated with classroom radon concentrations. The geometric mean (GM) classroom radon concentration was 31.39 (95% confidence interval (CI): 27.16, 36.28) Bq/m³ (GM: 0.85; 95% CI: 0.72, 0.98 pCi/L). Thirty-seven (2%) classrooms in 13 (20%) schools had radon concentrations at or above the U.S. Environmental Protection Agency’s (EPA) recommended action level of 148 Bq/m³ (4.0 pCi/L). Number of classrooms had a u-shaped association with classroom radon concentrations. The year the heating, ventilation, and air conditioning (HVAC) system was installed was inversely associated with having classroom radon concentrations at or above the EPA’s recommended action level. Number of classrooms and number of students had u-shaped associations with having classroom radon concentrations at or above the EPA’s recommended action level. Classroom radon concentrations decreased when schools’ HVAC systems were on. Replacing HVAC systems and turning/keeping them on may be effective radon mitigation strategies to prevent radon-associated lung cancer, especially for small and large schools.

The Impact of Dedicated Cardiac Intensive Care Units on Outcomes in Pediatric Cardiac Surgery: A Virtual Pediatric Systems Database Analysis

Care of children undergoing cardiac surgery occurs in dedicated cardiac intensive care units (CICU) or mixed intensive care units. In this article, we analyzed data from Virtual Pediatric Systems (VPS, LLC) database (2009-2014) for children < 18 years of age undergoing cardiac surgery, classified according to Society of Thoracic Surgery-European Association of Cardiothoracic Surgery (STS-EACTS) risk category. We had 25,052 (52%) patients in 53 mixed units (mortality rate, 2.99%), and 22,762 (48%) patients in 19 dedicated CICUs (mortality rate, 2.62%). There was a direct relationship between STS-EACTS risk category and death rate in both units. By multivariable logistic and linear regression, there was no difference in mortality between mixed unit and CICU death rates within STS-EACTS risk categories. We found no difference in outcomes for children undergoing cardiac surgery based on the unit type (dedicated CICU or mixed unit).

Modifiable Risk Factors for Poor Cognitive Function in Former American-Style Football Players: Findings from the Harvard Football Players Health Study

Recent attention to consequences of head trauma among former professional American-style football players has increased the likelihood that former players and their healthcare providers attribute neurocognitive effects to these exposures. In addition to head trauma, however, many potentially modifiable risk factors are associated with cognitive impairment. We examined the association of self-reported risk factors for cognitive impairment (e.g., cardiovascular health, sleep, pain, depression, anxiety, smoking, physical impairment, and physical activity) with cognition-related quality of life, measured by the Quality of Life in Neurological Disorders, Applied Cognition-General Concerns (Neuro-QOL) among 3803 former National Football League (NFL) players. We examined the prevalence of risk factors among men who had experienced a high number of concussion symptoms during playing years, comparing men with good current cognition-related QOL, the "healthy concussed," to men with poor cognition-related QOL, the "unhealthy concussed." Physical functioning, pain, depression, and anxiety were very strongly associated with poor cognitive-related QOL (risk ratio range, 2.21-2.70, p < 0.0001 for all). Short sleep duration and low physical activity were also strongly associated (RR = 1.69 and 1.57, respectively, p < 0.0001 for both). The largest differences between healthy and unhealthy concussed were in chronic pain (72.0% vs. 21.2%), depressive symptoms (50.3% vs. 6.3%), anxiety symptoms (53.4% vs. 11.6%), and physical impairment (52.4% vs. 12.5%). Substantial differences also existed in prevalence of sleep apnea, short sleep duration, high-intensity exercise, weight training, high blood pressure, and body mass index ≥35 kg/m² (all differences >10 percentage points). We identified cognitive risk factors, including chronic pain, mood problems, sleep problems, obesity, and lack of exercise, that were commonly present in former football players with cognition-related impairment. Better treatment for these factors may reduce cognitive problems in this population.

Linkage between Particulate Matter Properties and Lung Function in Schoolchildren: A Panel Study in Southern China

While several scientific studies have linked PM_2.5 to decreased lung function, there is still some degree of uncertainty regarding which particulate physicochemical properties are most harmful. We followed a panel of 57 healthy schoolchildren (857 person-days) to investigate the associations between a wide variety of PM_2.5 and lung function in Heshan, China in 2016 for three periods. We monitored the daily concentrations of mass, chemical composition, size, number, surface area, and volume of particulate mixture. Associations of lung function with various particle metrics were estimated using generalized estimating equations and unconstrained distributed lag models. Random forest model was used to compare the relative importance of exposure metrics. Immediate (lag 0) associations of PM_2.5 and carbonaceous aerosols with reduced FEV₁ and MMEF, and accumulation-mode particles with FEV₁ were found. Slightly delayed (lag 1, 2) effects on PEF were particularly prominent for Aitken-mode particles. Possible cumulative (lags 0-2) effects of PM_2.5 and carbonaceous aerosols on PEF and Aitken-mode particles on FEV₁, MMEF, and PEF were observed. This study provides comprehensive evidence that the physicochemical properties of particulate mixtures are associated with reduced lung function in children. Organic carbon (OC) may be an important risk factor for the decreased lung function related to PM exposure.

Tutorial on Biostatistics: Longitudinal Analysis of Correlated Continuous Eye Data

PURPOSE

To describe and demonstrate methods for analyzing longitudinal correlated eye data with a continuous outcome measure.

METHODS

We described fixed effects, mixed effects and generalized estimating equations (GEE) models, applied them to data from the Complications of Age-Related Macular Degeneration Prevention Trial (CAPT) and the Age-Related Eye Disease Study (AREDS). In CAPT (N = 1052), we assessed the effect of eye-specific laser treatment on change in visual acuity (VA). In the AREDS study, we evaluated effects of systemic supplement treatment among 1463 participants with AMD category 3.

RESULTS

In CAPT, the inter-eye correlations (0.33 to 0.53) and longitudinal correlations (0.31 to 0.88) varied. There was a small treatment effect on VA change (approximately one letter) at 24 months for all three models (p = .009 to 0.02). Model fit was better with the mixed effects model than the fixed effects model (p < .001). In AREDS, there was no significant treatment effect in all models (p > .55). Current smokers had a significantly greater VA decline than non-current smokers in the fixed effects model (p = .04) and the mixed effects model with random intercept (p = .0003), but marginally significant in the mixed effects model with random intercept and slope (p = .08), and GEE models (p = .054 to 0.07). The model fit was better with the fixed effects model than the mixed effects model (p < .0001).

CONCLUSION

Longitudinal models using the eye as the unit of analysis can be implemented using available statistical software to account for both inter-eye and longitudinal correlations. Goodness-of-fit statistics may guide the selection of the most appropriate model.

Effects of Bladder Cancer on UK Healthcare Costs and Patient Health-Related Quality of Life: Evidence From the BOXIT Trial

BACKGROUND

Limited evidence exists regarding the cost and health-related quality of life (HRQoL) effects of non-muscle-invasive bladder cancer (NMIBC) recurrence and progression to muscle-invasive bladder cancer (MIBC). We examined these effects using evidence from a recent randomized control trial.

MATERIAL AND METHODS

The costs and HRQoL associated with bladder cancer were assessed using data from the BOXIT trial (bladder COX-2 inhibition trial; n = 472). The cost and HRQoL effects from clinical events were estimated using generalized estimating equations. The costs were derived from the recorded resource usage and UK unit costs. HRQoL was assessed using the EQ-5D-3L and reported UK preference tariffs. The events were categorized using the TMN classification.

RESULTS

Cases of grade 3 recurrence and progression were associated with statistically significant HRQoL decrements (-0.08; 95% confidence interval [CI], -0.13 to -0.03; and -0.10; 95% CI, -0.17 to -0.03, respectively). The 3-year average cost per NMIBC patient was estimated at £8735 (95% CI, 8325-9145). Cases of grade 1, 2, and 3 recurrence were associated with annual cost effects of £1218 (95% CI, 403-2033), £1677 (95% CI, 920-2433), and £3957 (95% CI, 2332-5583), respectively. Progression to MIBC was associated with an average increase in costs of £5407 (95% CI, 2663-8152).

CONCLUSION

Evidence from the BOXIT trial suggests that patients with NMIBC will both experience decrements in HRQoL and incur significant costs, especially in the event of a grade 3 recurrence or a progression to MIBC.

Perinatal risk factors of symptomatic preterm patent ductus arteriosus and secondary ligation

BACKGROUND

There has been conflicting evidence for the association between antenatal factors and the development of symptomatic patent ductus arteriosus (PDA) or failure of pharmacologic treatment, especially for maternal pregnancy-induced hypertension (PIH) or chorioamnionitis. We assessed the perinatal risk factors of symptomatic PDA in preterm infants and those of secondary ligation in infants with pharmacologic treatment for symptomatic PDA using a national cohort.

METHODS

A total of 2961 infants with 22-29 weeks of gestation with symptomatic PDA or no PDA were included from the Korean Neonatal Network database. To identify significant perinatal risk factors associated with symptomatic PDA or secondary ligation, all perinatal factors were included in the univariate and multivariate generalized estimating equation analysis and final model was selected using backward elimination method based on Quasi-likelihood Information Criterion.

RESULTS

Lower gestational age (GA), female gender, maternal PIH and surfactant use were significant risk factors of symptomatic PDA. Antenatal corticosteroid use decreased the risk of symptomatic PDA. For secondary ligation, lower GA and cesarean section were significant risk factors. Adjusted odds ratio (aOR) of PIH as a risk factor of symptomatic PDA was 1.56 [95% confidence interval 1.17-2.08]. In the subgroup analysis according to the GA, lower GA, female gender, multiple pregnancy, maternal PIH and surfactant use increased the risk of symptomatic PDA, and histologic chorioamnionitis and antenatal corticosteroid use decreased the risk of symptomatic PDA only in GA 26-29 weeks group.

CONCLUSION

Lower GA increased the risk of symptomatic PDA and secondary ligation. Maternal PIH and surfactant use increased the risk of symptomatic PDA; however, antenatal corticosteroid use decreased it. Close observation of the clinical symptoms of PDA is needed in preterm infants with maternal PIH.

Are medical comorbidities contributing to the use of opioid analgesics in patients with knee osteoarthritis?

BACKGROUND

Although opioid analgesics are not generally recommended for treatment of knee osteoarthritis (OA), they are frequently used. We sought to determine the association between medical comorbidities and self-reported opioid analgesic use in these patients.

METHODS

This cross-sectional study recruited patients referred to two provincial hip and knee clinics in Alberta, Canada for consideration of total knee arthroplasty. Standardized questionnaires assessed demographic (age, gender, income, education, social support, smoking status) and clinical (pain, function, total number of troublesome joints) characteristics, comorbid medical conditions, and non-surgical OA management participants had ever used or were currently using. Multivariable Poisson regression with robust estimate of the standard errors assessed the association between comorbid medical conditions and current opioid use, controlling for potential confounders.

RESULTS

2,127 patients were included: mean age 65.4 (SD 9.1) years and 59.2% female. Currently used treatments for knee OA were: 57.6% exercise and/or physiotherapy, 61.1% NSAIDs, and 29.8% opioid analgesics. In multivariable regression, controlling for potential confounders, comorbid hypertension (RR 1.18, 95% CI 1.02-1.37), gastrointestinal disease (RR 1.31, 95% CI 1.07-1.60), depressed mood (RR 1.25, 95% CI 1.05-1.48) and a higher number of troublesome joints (RR 1.04 per joint, 95% CI 1.00-1.09) were associated with opioid use, with no association found with having ever used recommended non-opioid pharmacological or non-pharmacological treatments.

CONCLUSIONS

In a large cohort of patients with knee OA, of 12 comorbidities assessed, comorbid hypertension, gastrointestinal disease, and depressed mood were associated with current use of opioid analgesics, in addition to total burden of troublesome joints. Improved guidance on the management of painful OA in the setting of common comorbidities is warranted.

C hlamydia trachomatis during pregnancy and childhood asthma-related morbidity: a population-based prospective cohort

INTRODUCTION

Chlamydia trachomatis is the most commonly reported sexually transmitted disease and although infection during pregnancy is associated with neonatal complications, long-term respiratory consequences are unknown. We aimed to determine whether C. trachomatis infection during pregnancy is associated with asthma-related symptoms across childhood METHODS: This study among 2475 children and their mothers was embedded in a population-based prospective cohort study. Maternal urine samples were tested for C. trachomatis infection during pregnancy. Questionnaires provided information on childhood physician-attended lower respiratory tract infections and wheezing, and current asthma at age 10 years. Lung function was measured by spirometry at age 10 years.

RESULTS

The prevalence of C. trachomatis infection during pregnancy was 3.2% (78 out of 2475). C. trachomatis infection during pregnancy was not associated with lower respiratory tract infections until age 6 years, but was associated with a higher odds of wheezing in children until age 10 years (OR 1.50 (95% CI 1.10-2.03)). C. trachomatis infection during pregnancy was associated with an increased odds of asthma (OR 2.29 (95% CI 1.02-5.13)), and with a lower forced expiratory volume in 1 s/forced vital capacity and forced expiratory flow at 75% of forced vital capacity (z-score difference -0.28 (95% CI -0.52- -0.04) and -0.24 (95% CI -0.46- -0.01), respectively) in children at age 10 years. The observed associations were only partly explained by mode of delivery, gestational age at birth or birthweight.

CONCLUSIONS

C. trachomatis infection during pregnancy is associated with increased odds of wheezing, asthma and impaired lung function. The causality of the observed associations and potential underlying mechanisms need to be explored.

Reinforcement Learning during Adolescence in Rats

The most dynamic period of postnatal brain development occurs during adolescence, the period between childhood and adulthood. Neuroimaging studies have observed morphologic and functional changes during adolescence, and it is believed that these changes serve to improve the functions of circuits that underlie decision-making. Direct evidence in support of this hypothesis, however, has been limited because most preclinical decision-making paradigms are not readily translated to humans. Here, we developed a reversal-learning protocol for the rapid assessment of adaptive choice behavior in dynamic environments in rats as young as postnatal day 30. A computational framework was used to elucidate the reinforcement-learning mechanisms that change in adolescence and into adulthood. Using a cross-sectional and longitudinal design, we provide the first evidence that value-based choice behavior in a reversal-learning task improves during adolescence in male and female Long-Evans rats and demonstrate that the increase in reversal performance is due to alterations in value updating for positive outcomes. Furthermore, we report that reversal-learning trajectories in adolescence reliably predicted reversal performance in adulthood. This novel behavioral protocol provides a unique platform for conducting biological and systems-level analyses of the neurodevelopmental mechanisms of decision-making.SIGNIFICANCE STATEMENT The neurodevelopmental adaptations that occur during adolescence are hypothesized to underlie age-related improvements in decision-making, but evidence to support this hypothesis has been limited. Here, we describe a novel behavioral protocol for rapidly assessing adaptive choice behavior in adolescent rats with a reversal-learning paradigm. Using a computational approach, we demonstrate that age-related changes in reversal-learning performance in male and female Long-Evans rats are linked to specific reinforcement-learning mechanisms and are predictive of reversal-learning performance in adulthood. Our behavioral protocol provides a unique platform for elucidating key components of adolescent brain function.

Risks to pedestrians in traffic systems with unfamiliar driving rules: a virtual reality approach

In this study, a virtual-reality (VR) pedestrian simulation method was used to evaluate the risks to pedestrians crossing streets in a traffic system with driving rules that were unfamiliar to them. Pedestrians from mainland China (which has a right-side driving (RD) system) and Hong Kong (which has a left-side driving (LD) system) were studied. Significant differences were observed between pedestrians from the different locations in terms of the direction in which the pedestrians habitually first looked before crossing. When exposed to an unfamiliar driving rule (i.e., traffic coming from an inconsistent direction in terms of participants' habitual driving system), the odds of participants from mainland China making an error in their looking behavior were 2.93 times those when exposed to a familiar driving rule. Road markings and traffic sound did not improve these participants' looking behavior. The results also show a negative correlation between inattentive looking behavior and time to collision (significant at the 1% level), as these errors lead to a shorter time to collision and increased the risk to pedestrians. The results of this study confirmed the risks for pedestrians traveling to places with unfamiliar driving rules and confirmed the existence of habitual looking behavior, and therefore provide evidence of the need for future studies to improve this problem. These may help decision makers take the risks of pedestrians from different driving rules into consideration in future traffic policymaking or traffic-facility improvements. The use of a VR simulation-based approach in this study provided a safe and controllable way to trial interventions and potential improvements without risking injury to participants, and thus may also be used for similar future studies.

Do Athlete Monitoring Tools Improve a Coach's Understanding of Performance Change?

PURPOSE

To assess a coach's subjective assessment of their athletes' performances and whether the use of athlete-monitoring tools could improve on the coach's prediction to identify performance changes.

METHODS

Eight highly trained swimmers (7 male and 1 female, age 21.6 [2.0] y) recorded perceived fatigue, total quality recovery, and heart-rate variability over a 9-month period. Prior to each race of the swimmers' main 2 events, the coach (n = 1) was presented with their previous race results and asked to predict their race time. All race results (n = 93) with aligning coach's predictions were recorded and classified as a dichotomous outcome (0 = no change; 1 = performance decrement or improvement [change +/- > or < smallest meaningful change]). A generalized estimating equation was used to assess the coach's accuracy and the contribution of monitoring variables to the model fit. The probability from generalized estimating equation models was assessed with receiver operating characteristic curves to identify the model's accuracy from the area under the curve analysis.

RESULTS

The coach's predictions had the highest diagnostic accuracy to identify both decrements (area under the curve: 0.93; 95% confidence interval, 0.88-0.99) and improvements (area under the curve: 0.89; 95% confidence interval, 0.83-0.96) in performance.

CONCLUSIONS

These findings highlight the high accuracy of a coach's subjective assessment of performance. Furthermore, the findings provide a future benchmark for athlete-monitoring systems to be able to improve on a coach's existing understanding of swimming performance.

Feasibility as a mechanism for model identification and validation

As new technologies permit the generation of hitherto unprecedented volumes of data (e.g. genome-wide association study data), researchers struggle to keep up with the added complexity and time commitment required for its analysis. For this reason, model selection commonly relies on machine learning and data-reduction techniques, which tend to afford models with obscure interpretations. Even in cases with straightforward explanatory variables, the so-called 'best' model produced by a given model-selection technique may fail to capture information of vital importance to the domain-specific questions at hand. Herein we propose a new concept for model selection, feasibility, for use in identifying multiple models that are in some sense optimal and may unite to provide a wider range of information relevant to the topic of interest, including (but not limited to) interaction terms. We further provide an R package and associated Shiny Applications for use in identifying or validating feasible models, the performance of which we demonstrate on both simulated and real-life data.

Statistical Challenges in Development of Prognostic Models in Diffuse Large B-Cell Lymphoma: Comparison Between Existing Models - A Systematic Review

Background and Aim

Based on advances in the diagnosis, classification, and management of diffuse large B-cell lymphoma (DLBCL), a number of new prognostic models have been proposed. The aim of this study was to review and compare different prognostic models of DLBCL based on the statistical methods used to evaluate the performance of each model, as well as to analyze the possible limitations of the methods.

Methods and Results

A literature search identified 46 articles that proposed 55 different prognostic models for DLBCL by combining different clinical, laboratory, and other parameters of prognostic significance. In addition, six studies used nomograms, which avoid risk categorization, to create prognostic models. Only a minority of studies assessed discrimination and/or calibration to compare existing models built upon different statistical methods in the process of development of a new prognostic model. All models based on nomograms reported the c-index as a measure of discrimination. There was no uniform evaluation of the performance in other prognostic models. We compared these models of DLBCL by calculating differences and ratios of 3-year overall survival probabilities between the high- and the low-risk groups. We found that the highest and lowest ratio between low- and high-risk groups was 6 and 1.31, respectively, while the difference between these groups was 18.9% and 100%, respectively. However, these studies had limited duration of follow-up and the number of patients ranged from 71 to 335.

Conclusion

There is no universal statistical instrument that could facilitate a comparison of prognostic models in DLBCL. However, when developing a prognostic model, it is recommended to report its discrimination and calibration in order to facilitate comparisons between different models. Furthermore, prognostic models based on nomograms are becoming more appealing owing to individualized disease-related risk estimations. However, they have not been validated yet in other study populations.

Prognostic value of log odds of positive lymph nodes in patients with resectable oral squamous cell carcinoma

OBJECTIVES

Log odds of positive lymph nodes (LODDS) was reported to be significantly associated with prognosis in several malignant tumors. However, few are the studies on the correlation between LODDS and overall survival (OS) in patients with oral squamous cell carcinoma (OSCC).

MATERIALS AND METHODS

A retrospective study including 233 patients with OSCC during 2009 to 2013 was conducted. We probed the correlation between clinicopathological factor, LODDS, lymph node ratio (LNR), pN and OS. The potential prognostic factor and the independent factor were calculated using univariate analysis and multivariate analysis respectively. The goodness of fit and the discriminability was analyzed with Somer's D value, Nagelkerke R2 index, and Akaike information criterion (AIC). Kaplan-Meier survival curve of OS was contrasted by log-rank test in LODDS, LNR and pN, respectively.

RESULTS

According to the X-tile, the cut-off values are -1.491 and -0.763 for LODDS, 0.024 and 0.133 for LNR. LODDS, LNR and pN were significantly correlated with OS by univariate analysis (P < 0.001). Multivariate analysis demonstrated LODDS, LNR and pN as an independent prognostic factors for OS (P < 0.01). Compared with pN and LNR models, LODDS showed the strongest predictive power. LODDS was superior to LNR and pN in predicting outcomes in patients with no positive lymph nodes and inadequate neck dissection.

CONCLUSION

LODDS would be incorporated into future N classification, which may be conducive to discern the prognosis of OSCC and make a decision of adjuvant therapy in clinical practice.

Maternal Betamethasone for Prevention of Respiratory Distress Syndrome in Neonates: Population Pharmacokinetic and Pharmacodynamic Approach

Despite antenatal corticosteroids therapy, respiratory distress syndrome (RDS) is still a leading cause of neonatal morbidity and mortality in premature newborns. To date, the relationship between in utero fetal drug exposure and occurrence of RDS remains poorly evaluated. This study aims to describe the pharmacokinetics of betamethasone in pregnant women and to evaluate the transplacental drug transfer and administration scheme for the prevention of RDS. Pregnant women > 27 weeks' gestation and who received at least a single dose of betamethasone for prevention of RDS were enrolled. Maternal, cord blood, and amniotic fluid betamethasone time-courses were analyzed using the Monolix software. A total of 220 maternal blood, 56 cord blood, and 26 amniotic fluid samples were described by a two-compartment model with two effect compartments linked by rate transfer constants. Apparent clearances and volumes of distribution parameters were allometrically scaled for a 70 kg third trimester pregnant woman. The impact of a twin pregnancy was found to increase maternal clearance by 28%. Using a fetal-to-mother exposure ratio, the median (95% confidence interval (CI)) transplacental transfer of betamethasone was estimated to 35% (95% CI 0.11-0.67). After adjustment for gestational age and twin pregnancy, RDS was found to be associated to the time spent in utero below quantifiable concentrations (i.e., < 1 ng/mL): odds ratio of 1.10 (95% CI 1.01-1.19) per day increase (P < 0.05). Trying to take into account both efficacy and safety, we simulated different dosing schemes in order to maintain a maximum of fetuses above 1 ng/mL without exceeding the total standard dose.

Workflow Differences Affect Data Accuracy in Oncologic EHRs: A First Step Toward Detangling the Diagnosis Data Babel

PURPOSE

Diagnosis (DX) information is key to clinical data reuse, yet accessible structured DX data often lack accuracy. Previous research hints at workflow differences in cancer DX entry, but their link to clinical data quality is unclear. We hypothesized that there is a statistically significant relationship between workflow-describing variables and DX data quality.

METHODS

We extracted DX data from encounter and order tables within our electronic health records (EHRs) for a cohort of patients with confirmed brain neoplasms. We built and optimized logistic regressions to predict the odds of fully accurate (ie, correct neoplasm type and anatomic site), inaccurate, and suboptimal (ie, vague) DX entry across clinical workflows. We selected our variables based on correlation strength of each outcome variable.

RESULTS

Both workflow and personnel variables were predictive of DX data quality. For example, a DX entered in departments other than oncology had up to 2.89 times higher odds of being accurate (P < .0001) compared with an oncology department; an outpatient care location had up to 98% fewer odds of being inaccurate (P < .0001), but had 458 times higher odds of being suboptimal (P < .0001) compared with main campus, including the cancer center; and a DX recoded by a physician assistant had 85% fewer odds of being suboptimal (P = .005) compared with those entered by physicians.

CONCLUSION

These results suggest that differences across clinical workflows and the clinical personnel producing EHR data affect clinical data quality. They also suggest that the need for specific structured DX data recording varies across clinical workflows and may be dependent on clinical information needs. Clinicians and researchers reusing oncologic data should consider such heterogeneity when conducting secondary analyses of EHR data.

Non-invasive and real-time proliferative activity estimation based on a quantitative radiomics approach for patients with acromegaly: a multicenter study

BACKGROUND

Proliferative activity prediction is important for determining individual treatment strategies for patients with acromegaly, and tumor proliferative activity is usually measured by the expression of Ki-67.

OBJECTIVE

This study aimed to assess the value of a magnetic resonance imaging (MRI)-based radiomics approach in predicting the Ki-67 index of acromegaly patients.

METHODS

A total of 138 patients with acromegaly were retrospectively reviewed and randomly assigned to primary and validation cohorts. Radiomics features were extracted from MR images, and then the elastic net and recursive feature elimination algorithms were applied to determine critical radiomics features for constructing a radiomics signature. Subsequently, multivariable logistic regression analysis was used to select the most informative clinical features, and a radiomics nomogram incorporating a radiomics signature and selected clinical features was constructed for individual predictions. Twenty-five acromegaly patients were enrolled for multicenter model validation.

RESULTS

Seventeen radiomics features were selected to construct a radiomics signature that achieved an area under the curve (AUC) value of 0.96 and 0.89 in the primary cohort and the validation cohort, respectively. A radiomics nomogram that incorporated the radiomics signature and eight selected clinical features was constructed and showed good discrimination and calibration, with an AUC of 0.94 in the primary cohort and 0.91 in the validation cohort. The radiomics signature in the multicenter validation achieved an accuracy of 88.2%. The analysis of the decision curve showed that the radiomics signature and radiomics nomogram were clinically useful for patients with acromegaly.

CONCLUSIONS

The radiomics signature developed in this study could aid neurosurgeons in predicting the Ki-67 index of patients with acromegaly and could contribute to non-invasive measurement of proliferative activity, affecting individual treatment strategies.

Syntactic Complexity as a Linguistic Marker to Differentiate Mild Cognitive Impairment From Normal Aging

Purpose In this study, we sought to identify critical linguistic markers that can differentiate sentence processing of individuals with mild cognitive impairment (MCI) from the sentence processing of normal-aging populations by manipulating sentences' linguistic complexity. We investigated whether passive sentences, as linguistically complex structures, can serve as linguistic markers that can contribute to diagnoses that distinguish MCI from normal aging. Method In total, 52 participants, including 26 adults with amnestic MCI and 26 cognitively unimpaired adults, participated in the study. All participants were native speakers of Korean. We administered the two subsets of active and passive conditions using a sentence-picture paradigm with semantically reversible sentences to both groups. Results A mixed-effects model using PROC NLMIXED demonstrated that the MCI group exhibited differentially greater difficulty in processing passive than active sentences compared to the normal-aging group. A logistic regression fitted with the PROC LOGISTIC model identified the sum of the passive sentences, with age and education effects as the best models to distinguish individuals with MCI from the normal-aging group. Conclusion Sentence comprehension deficits emerged in the MCI stage when the syntactic complexity was increased. Furthermore, a passive structure was the best predictor for efficiently distinguishing the MCI group from the normal-aging group. These results are clinically and theoretically important, given that linguistic complexity can serve as a critical behavioral marker in the detection of early symptoms associated with linguistic-cognitive decline.

Flash Flood Forecasting in São Paulo Using a Binary Logistic Regression Model

This study presents a flash flood forecasting model that uses a binary logistic regression method to determine the occurrence of flash flood events in different watersheds in the city of São Paulo, Brazil. This study is based on two years (2015–2016) of rain estimates from a dual-polarization S-band Doppler weather radar (SPOL) and flood locations observed by the Climate Emergency Management Center (CGE) of São Paulo City Hall. The logistic regression model is based on daily accumulated precipitation, a maximum precipitation rate, and daily rainfall duration. The model presented a probability of detection (POD) of 46% (71%) on average for flood events (conditional), while, for events without flash flood, it reached 98% probability. Despite the low averaged POD for flash flood occurrence, the model demonstrated a good performance for watersheds located in the east of the city near the Tietê River and in the southeast with probabilities above 50%.

Labor market exit around retirement age in Sweden and trajectories of psychotropic drugs in a context of downsizing

Background

A maintained psychological wellbeing is important in order to continue working longer and remain active into older age. However, little is known about impact of different organizational factors, such as downsizing, on the mental health of older workers exiting the labor market. The aim in this study was to investigate trajectories of purchases of psychotropic drugs in relation to labor market exit later in life in a context with and without downsizing.

Method

People living in Sweden, born 1941–1951, exiting paid work via unemployment, sickness absence/disability pension, or old-age pension were followed from 2005 to 2013 regarding purchases of psychotropic drugs. Individuals employed at a workplace closing down or downsizing with ≥18% between two subsequent years were compared to employees exiting from workplaces without downsizing or workplace closure. Generalized estimating equations was applied to derive trajectories of annual prevalence of purchased antidepressants, sedatives and anxiolytics from 4 years before to 4 years after a labour market exit.

Results

During the period around the exit, old-age retirees experiencing a downsizing/workplace closure did not decrease their purchases of sedatives (OR 1.01 95% CI 0.95–1.07) while the unexposed decreased their purchases during this period (OR 0.95 95% CI 0.92–0.98). Similar differences concerning sedatives and antidepressants between exposed and unexposed were seen for those exiting via sickness absence or disability pension. Furthermore, a significant difference in purchases of anxiolytics was observed between those exposed to downsizing (OR 1.10 95% CI 0.97–1.24) and the unexposed (OR 0.98 95% CI 0.91–1.06) exiting via old-age retirement during the time before the exit.

Conclusion

Downsizing or workplace closure, although weakly, was associated with higher prevalence of psychotropic drugs certain years around the labor market exit. The results support the idea that involuntary labor market exit in mature adulthood may negatively affect the development of mental health.

Persuasive Appeals Predict Credibility Judgments of Phishing Messages

Two studies examined effects of using persuasive appeals in phishing messages on judgments of credibility. Participants were tasked with reading a combination of legitimate and phishing e-mails to determine whether each message was legitimate or a scam. In both Study 1 and Study 2, when phishing messages included more appeals to authority and likability, phishing susceptibility increased. However, as the number of fear and urgency appeals in the message increased, phishing susceptibility decreased, as it was easier for participants to detect the phishing attempt. Contrary to prediction, perceived source likability did not mediate the relationship between appeal type and credibility judgments. Results highlight the importance of authority appeals on credibility, describe relationships between appeal type and phishing susceptibility, and offer strategies for users to defend against online deception.

Prevalence, Incidence, and Risk Factors for Overall, Physical, and Cognitive Independence Among Those From Exceptionally Long-Lived Families: The Long Life Family Study

BACKGROUND

The Long Life Family Study (LLFS) enrolled families exhibiting exceptional longevity. The goal of this article was to determine the prevalence and predictors of remaining independent after 7 years in the oldest generation.

METHODS

We examined 7-year change in physical (free of activities of daily living difficulty), cognitive (Mini-Mental State Examination score ≥ 24), and overall independence (physically/cognitively independent) in adults aged 90.3 ± 6.3 from LLFS's oldest generation. Potential predictors (n = 28) of remaining independent included demographics, diseases, biomarkers, anthropometrics, and physical and cognitive performance tasks and were determined using generalized estimating equations (α: p < .05). This was a discovery/exploratory analysis, so no multiple testing correction was employed and the results require independent replication.

RESULTS

At baseline (n = 1442), 67.3%, 83.8%, and 79.7% were overall, physically, and cognitively independent, respectively. After 7 years, 66% died, 7.5% were lost to follow-up, and the prevalence of overall independence decreased to 59.1% in survivors (-8.2%, 95% confidence interval: -14.1%, 2.2%). Of those with baseline independence, 156/226 (69.0%) remained independent. Predictors of remaining physically independent included younger age, better Short Physical Performance Battery score and lung function, smaller waist circumference, and lower soluble receptor for advanced glycation end-product levels (p < .05). Predictors of remaining cognitively independent included no cancer history, better Digit Symbol Substitution Test performance, and higher body weight (p < .05).

CONCLUSIONS

The prevalence of independence decreased by only 8.2% after 7 years, demonstrating the close correspondence between disability and mortality. Further, despite a mean baseline age of 90 years, a large proportion of survivors remained independent, suggesting this exceptional subgroup may harbor protective mechanisms.

The Chemistry and Kinetics of Polyethylene Pyrolysis: A Process to Produce Fuels and Chemicals

The annual global production of plastics reached 335 million metric tons in 2016. Most waste plastics are landfilled or enter the natural environment in an uncontrolled manner. Pyrolysis can convert waste plastics, such as polyethylene (PE), to smaller hydrocarbons that can be used as fuels or chemicals. In this work, pyrolysis of PE was studied by thermogravimetric analysis (TGA) and in a fluidized-bed reactor. A kinetic model based on two parallel first-order random-scission steps was developed on the basis of the TGA results. PE was pyrolyzed in a fluidized-bed reactor over the temperature range of 500-600 °C and at residence times of 12.4-20.4 s. The yield of gas-phase products increased from 8.2 to 56.8 wt %, and the yield of liquid-phase products decreased from 81.2 to 28.5 wt % as the temperature increased from 500 to 600 °C. Detailed analysis of the gas- and liquid-phase products revealed their potential as precursors for production of fuels and chemicals. Gas-phase products included hydrogen, C₁ -C₄ paraffins, C₂ -C₄ olefins, and 1,3-butadiene. The major liquid-phase products were mono-olefins and cycloalkanes/alkadienes with smaller amounts of n-paraffins, isoparaffins, and aromatics. The carbon-number distribution of the fluidized-bed pyrolysis products suggested contributions of nonrandom reactions of random-scission fragments at low conversion.

A novel id-iri score: development and internal validation of the multivariable community acquired sepsis clinical risk prediction model

We aimed to develop a scoring system for predicting in-hospital mortality of community-acquired (CA) sepsis patients. This was a prospective, observational multicenter study performed to analyze CA sepsis among adult patients through ID-IRI (Infectious Diseases International Research Initiative) at 32 centers in 10 countries between December 1, 2015, and May 15, 2016. After baseline evaluation, we used univariate analysis at the second and logistic regression analysis at the third phase. In this prospective observational study, data of 373 cases with CA sepsis or septic shock were submitted from 32 referral centers in 10 countries. The median age was 68 (51-77) years, and 174 (46,6%) of the patients were females. The median hospitalization time of the patients was 15 (10-21) days. Overall mortality rate due to CA sepsis was 17.7% (n = 66). The possible predictors which have strong correlation and the variables that cause collinearity are acute oliguria, altered consciousness, persistent hypotension, fever, serum creatinine, age, and serum total protein. CAS (%) is a new scoring system and works in accordance with the parameters in third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). The system has yielded successful results in terms of predicting mortality in CA sepsis patients.

Effort-based decision making varies by smoking status

RATIONALE

A reduced willingness to perform effort based on the magnitude and probability of potential rewards has been associated with diminished dopamine function and may be relevant to chronic drug use.

OBJECTIVES

Here, we investigated the influence of smoking status on effort-based decisions. We hypothesized that smokers would make fewer high-effort selections than ex-smokers and never-smokers.

METHODS

Current smokers (n = 25), ex-smokers (≥ 1 year quit, n = 23), and never-smokers (n = 19) completed the Effort Expenditure for Rewards Task in which participants select between low-effort and high-effort options to receive monetary rewards at varying levels of reward magnitude, probability and expected value.

RESULTS

Overall, participants selected more high-effort options as potential reward magnitude and expected value increased. Smokers did not make fewer high-effort selections overall, but smokers were less sensitive to the changes in magnitude, probability, and expected value compared to never-smokers. Smokers were also less sensitive to the changes in probability and expected value, but not magnitude, compared to ex-smokers. Among smokers and ex-smokers, less nicotine dependence was associated with an increased likelihood of high-effort selections.

CONCLUSIONS

These results demonstrate the relevance of smoking status to effort-based decisions and suggest that smokers have diminished sensitivity to nondrug reward value. Among ex-smokers, greater pre-existing sensitivity to reward value may have been conducive to smoking cessation, or sensitivity was improved by smoking cessation. Future prospective studies can investigate whether effort-related decision making is predictive of smoking initiation or cessation success.

IMPLICATIONS

Willingness to perform effort to achieve a goal and sensitivity to changes in reward value are important aspects of motivation. These results showed that smokers have decreased sensitivity to changes in effort-related reward probability and expected value compared to ex-smokers and never-smokers. Potentially, improved sensitivity to rewards among ex-smokers may be a cause or consequence of smoking cessation. These findings may help explain why some smokers are able to achieve long-term abstinence.

Low risks for spiritual highs: Risk-taking behaviours and the protective benefits of spiritual health among Saskatchewan adolescents

Objectives

Adolescent risk-taking behaviours, such as substance use and early sexual activity, can adversely impact physical health and psychosocial development. A connection to spiritual health may buffer against the negative health impacts of several risk-taking behaviours. The aim of this study was to determine if higher spiritual health was associated with lower risk-taking behaviours among school-attending adolescents in Saskatchewan, Canada.

Methods

A representative sample of 4,751 adolescents in the Canadian province of Saskatchewan completed the Health Behaviour of School-aged Children (HBSC) questionnaire during the 2014 to 2015 school year. The main risk-taking behavioural outcomes were self-reported: smoking; alcohol; and cannabis use; as well as sexual intercourse. The main exposures related to spiritual health included four factors: connectedness to (1) one’s self; (2) others; (3) nature; and (4) notions of the transcendent. Multivariable logistic regression analyses were used to test for associations between exposures and outcome measures.

Results

The sample was balanced across gender, primarily Caucasian (71%), and primarily ages 11 to 15 years (48%). Adolescents indicated a high prevalence of spiritual health. Across all adjusted models, the results demonstrated that adolescents who value the various components of spiritual health showed a decreased likelihood of engaging in cigarette smoking, alcohol and marijuana use, and sexual intercourse.

Conclusion

The findings indicate the potential for spiritual health to be considered as the basis for public- and community-health interventions, pending further evidence from experimental studies.

Female need for paternal care shapes variation in extra-pair paternity in a cooperative breeder

Socially monogamous females regularly mate with males outside the pair bond. The prevailing explanation for this behavior is that females gain genetic benefits resulting from increased fitness of extra-pair offspring. Furthermore, because of the risk of reduced paternal care in response to cuckoldry, females are expected to seek extra-pair copulations when they can rear offspring with little help from their social partner (“constrained female” hypothesis). We tested these hypotheses and analyzed variation in paternal care in the Afrotropical, facultative cooperative breeding placid greenbul (Phyllastrephus placidus). Overall, approximately 50% of the offspring resulted from extra-pair (and extra-group) mating. Identified extra-pair males were in most cases neighboring dominant males, yet never within-group subordinates. As predicted by the constrained female hypothesis, the occurrence of extra-pair paternity (EPP) increased with the number of cooperative helpers (and not with total group size). However, dominant males did not adjust their food provisioning rates in response to EPP. Although extra-pair males were more strongly related to the dominant female and less heterozygous than the latter’s social mate, this did not result in more inbred extra-pair offspring, likely because identified extra-pair males were not representative of the extra-pair male population. While earlier studies on EPP mainly focused on male genetic quality, results from this study provide evidence that female’s social context may affect extra-pair strategies too.

Topographic analysis of macular choriocapillaris flow deficits in diabetic retinopathy using swept-source optical coherence tomography angiography

Background

The purpose of this study was to investigate the association between diabetic retinopathy (DR) severity and macular choriocapillaris (CC) flow deficit percentage (FD %) in different macular regions using swept-source optical coherence tomography angiography (SS-OCTA).

Methods

Diabetic patients with SS-OCTA images were graded by severity and retrospectively assessed. CC FD % was calculated in four different regions of the OCTA image: inner, middle, outer, and full-field region. The generalized estimating equations (GEE) approach for clustered eye data was used to determine effect size and significance of age and disease severity on FD % for each region.

Results

160 eyes from 90 total diabetic patients met inclusion criteria. Out of 90 patients, 33 had no DR, 17 had mild nonproliferative DR (NPDR), 8 had moderate NPDR, 10 had severe NPDR and 22 had proliferative DR. Age and DR severity had a significant positive association with FD % for each region studied with a greater effect in the two centermost regions. The increase in flow deficit percentage per year of age by region was: inner 0.12 (p < 0.001), middle 0.09 (p < 0.001), outer 0.05 (p < 0.001, full-field 0.06 (p < 0.001). The increase in flow deficit percentage per increase in diabetic retinopathy severity stage by region was: inner 0.65 (p < 0.0087), middle 0.56 (p < 0.0012), outer 0.33 (p < 0.045), full-field 0.36 (p < 0.018).

Conclusions

Topographic analysis of the CC FD % in diabetic eyes suggests that CC flow impairment corresponds to DR severity, with all studied regions of the CC significantly affected. There was greater regional impairment due to age and disease severity in the inner and middle regions.

Longitudinal associations between depressive symptoms and clinical factors in ankylosing spondylitis patients: analysis from an observational cohort

OBJECTIVES

Although cross-sectional studies have shown that ankylosing spondylitis-specific factors correlate with depressive symptom severity, the association of these factors over time is unresolved. We examined the demographic and clinical factors associated with longitudinal depressive symptom severity in AS patients.

METHODS

We analyzed sociodemographic, clinical, behavioral and medication data from 991 patients from the Prospective Study of Outcomes in Ankylosing spondylitis cohort, and measured depression severity with the Center for Epidemiological Studies Depression (CES-D) Scale administered at approximately 6-month visit intervals. Multivariable longitudinal negative binomial regression models were conducted using generalized estimating equation modeling to assess the demographic, clinical, and medication-related factors associated with depression severity by CES-D scores over time.

RESULTS

The median baseline CES-D score (possible range 0-60) was 10.0 (interquartile range = 5, 17). In longitudinal multivariable analyses, higher CES-D scores were associated with longitudinal smoking, greater functional impairment, greater disease activity, self-reported depression, and poor global health scores. Marital status (e.g., being married) was associated with lower CES-D. Adjusted mean CES-D scores in our model decreased over time, with a significant interaction between time and gender observed.

CONCLUSION

This study identified longitudinal clinical factors such as greater disease activity, greater functional impairment, and poor global health to be associated with longitudinal depression severity. These factors are potentially modifiable and may help manage depressive symptoms in AS.

Single versus Multiple Dose Ivermectin Regimen in Onchocerciasis-Infected Persons with Epilepsy Treated with Phenobarbital: A Randomized Clinical Trial in the Democratic Republic of Congo

BACKGROUND

There is anecdotal evidence that ivermectin may decrease seizure frequency in Onchocerca volvulus-infected persons with epilepsy (PWE).

METHODS

In October 2017, a 12-month clinical trial was initiated in rural Democratic Republic of Congo. PWE with onchocerciasis-associated epilepsy experiencing ≥2 seizures/month were randomly allocated to receive, over a one-year period, ivermectin once or thrice (group 1), while other onchocerciasis-infected PWE (OIPWE) were randomized to ivermectin twice or thrice (group 2). All participants also received anti-epileptic drugs. Data was analyzed using multiple logistic regression.

RESULTS

We enrolled 197 participants. In an intent-to-treat analysis (data from group 1 and 2 combined), seizure freedom was more likely among OIPWE treated with ivermectin thrice (OR: 5.087, 95% CI: 1.378-19.749; p = 0.018) and twice (OR: 2.471, 95% CI: 0.944-6.769; p = 0.075) than in those treated once. Similarly, >50% seizure reduction was more likely among those treated with ivermectin twice (OR: 4.469, 95% CI: 1.250-16.620) and thrice (OR: 2.693, 95% CI: 1.077-6.998). Absence of microfilariae during the last 4 months increased the odds of seizure freedom (p = 0.027).

CONCLUSIONS

Increasing the number of ivermectin treatments was found to suppress both microfilarial density and seizure frequency in OIPWE, suggesting that O. volvulus infection plays an etiological role in causing seizures.

Changes in Health Insurance Coverage Over Time by Immigration Status Among US Older Adults, 1992-2016

IMPORTANCE

Disparities in health insurance coverage by immigration status are well documented; however, there are few data comparing long-term changes in insurance coverage between immigrant and nonimmigrant adults as they age into older adulthood.

OBJECTIVE

To compare longitudinal changes in insurance coverage over 24 years of follow-up between recent immigrant, early immigrant, and nonimmigrant adults in the US.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used data from the nationally representative Health and Retirement Study. Data were collected biennially from 1992 to 2016. The population included community-dwelling US adults born between 1931 and 1941 and aged 51 to 61 years at baseline. Statistical analysis was performed from February 3, 2017, to January 10, 2020.

EXPOSURES

Participants were categorized as nonimmigrants (born in the US), early immigrants (immigrated to the US before the age of 18 years), and recent immigrants (immigrated to the US from the age of 18 years onward).

MAIN OUTCOMES AND MEASURES

Self-reported data on public, employer, long-term care, and other private insurance were used to define any insurance coverage. Longitudinal changes in insurance coverage were examined over time by immigration status using generalized estimating equations accounting for inverse probability of attrition weights. The association between immigration status and continuous insurance coverage was also evaluated.

RESULTS

A total of 9691 participants were included (mean [SD] age, 56.0 [3.2] years; 5111 [52.6%] female). Nonimmigrants composed 90% (n = 8649) of the cohort; early immigrants, 2% (n = 201); and recent immigrants, 8% (n = 841). Insurance coverage increased from 68%, 83%, and 86% of recent immigrant, early immigrant, and nonimmigrant older adults, respectively, in 1992 to 97%, 100%, and 99% in 2016. After accounting for selective attrition, recent immigrants were 15% less likely than nonimmigrants to have any insurance at baseline (risk ratio, 0.85; 95% CI, 0.82-0.88), driven by lower rates of private insurance. However, disparities in insurance decreased incrementally over time and were eliminated, such that insurance coverage rates were similar between groups as participants attained Medicare age eligibility. Furthermore, recent immigrants were less likely than nonimmigrants to be continuously insured (risk ratio, 0.89; 95% CI, 0.85-0.94).

CONCLUSIONS AND RELEVANCE

Among community-dwelling adults who were not age eligible for Medicare, recent immigrants had lower rates of health insurance, but this disparity was eliminated over the 24-year follow-up period because of uptake of public insurance among all participants. Future studies should evaluate policies and health care reforms aimed at reducing disparities among vulnerable populations such as recent immigrants who are not age eligible for Medicare.

Health Impacts of Early Complementary Food Introduction Between Formula-fed and Breastfed Infants

BACKGROUND

Global health agencies agree that infants should not be fed complementary foods before 4 to 6 months of age. However, given the World Health Organization (WHO) definition of complementary food as "anything other than breast milk," little is known about the relative risks of formula compared with other complementary foods on infant health. This article aims to fill this gap in the literature, by assessing how differences in the timing of the introduction of nonformula complementary food between breastfed and formula-fed infants impacts infant health.

METHODS

Eight health outcomes by complementary food introduction, breast-feeding, formula feeding, and mixed feeding (breastfed and formula-fed) were predicted using logistic regression with generalized estimating equations on the newborn through 6-month waves of the Infant Feeding Practices Study II (IFPS-II).

RESULTS

Complementary foods increased the likelihood for all health risks measured. Given greater prevalence of early complementary food introduction among formula-fed infants, most health differences between breast-feeding groups shift to nonsignificance in full models, with the exception of higher rates of hard stool and cough/wheeze among formula-fed and mixed-fed infants but lower rates of diarrhea (LO = -0.577; 95% confidence interval [CI] = -1.074 to 0.080) and runny nose or cold (LO = -3.19; 95% CI = -0.552 to -0.086) for mixed-fed than breastfed infants.

CONCLUSIONS

Our results confirm health benefits of exclusive breast-feeding and that the introduction of complementary foods before 4 to 6 months poses a greater risk to infant health than does formula. Greater attention to the early introduction of complementary foods is needed in research and clinical practice.

The effects of Chile's 2005 traffic law reform and in-country socioeconomic differences on road traffic deaths among children aged 0-14 years: A 12-year interrupted time series analysis

OBJECTIVES

This study assessed the effect of Chile's 2005 traffic law reform (TLR) on the rates of road traffic deaths (RTD) in children aged 0-14 years, adjusting for socioeconomic differences among the regions of the country.

METHODS

Free-access sources of official and national information provided the data for every year of the study period (2002-2013) and for each of the country's 13 upper administrative divisions with respect to RTD in child pedestrians and RTD in child passengers (dependent variables), and the following control variables: the number of road traffic tickets processed, investment in road infrastructure, poverty, income inequality, insufficient education, unemployment, population aged 0-14 years, and prevalence of alcohol consumption in the general population. Interrupted time series analyses (level and slope change impact model), using generalized estimating equation methods, were conducted to assess the impact of the TLR (independent variable) on the dependents variables.

RESULTS

There was a significant interaction between time and Chile's 2005 TLR for a reduction in child pedestrians (incidence rate ratio [IRR] 0.87, 95% confidence interval [CI] 0.79-0.96) and passengers RTD (IRR for interaction 0.80, 95% CI 0.67-0.96) trends. In addition, in child pedestrians, RTD rates were affected by poverty (IRR 1.04, 95% CI 1.02-1.05), income inequality (IRR 1.02, 95% CI 1.00-1.04), and unemployment (IRR 0.94, 95% CI 0.90-0.98), whereas in the case of child passengers, poverty (IRR 1.05, 95% CI 1.01-1.08) and income inequality (IRR 0.93, 95% CI 0.91-0.95) were significant.

CONCLUSIONS

Large-scale legislative actions can be effective road safety measures if they are aimed at promoting behavioral change in developing countries, improving the safety of children on the road. Additionally, regional socioeconomic differences are associated with higher RTD rates in this population, making this an argument in favor of road safety policies that consider these inequalities. The number of road traffic tickets processed and the investment in road infrastructure were not significant.

Interdisciplinary Sport Research Can Better Predict Competition Performance, Identify Individual Differences, and Quantify Task Representation

Sport performance consists of interacting individual, task and environmental constraints, but research has used a monodisciplinary, rather than an interdisciplinary approach to understand performance. This study used Australian football (AF) as the exemplar sport to investigate the value of an interdisciplinary approach to understand sport performance. Through this, it was also possible to quantify individual differences and representative task design. Fifty-nine semi-professional Australian footballers participated. Based upon accessibility, combinations of these players completed physiological (3 × 1 km trial) and perceptual-cognitive-motor (small-sided game, SSG) tests, with coach rating of psychological skill (mental toughness coach, MTC). Univariate monodisciplinary models indicated that all tests predicted disposal efficiency; 3 × 1 km trial (p = 0.047), SSG (p = 0.001), and MTC (p = 0.035), but only the SSG predicted coaches' vote (p = 0.003). A multivariate interdisciplinary model indicated that SSG and MTC tests predicted disposal efficiency with a better model fit than the corresponding univariate model. The interdisciplinary model formulated an equation that could identify individual differences in disposal efficiency. In addition, the interdisciplinary model showed that the higher representative SSG test contributed a greater magnitude to the prediction of competition performance, than the lower representative MTC rating. Overall, this study demonstrates that a more comprehensive understanding of sport performance, individual differences, and representative tasks, can be obtained through an interdisciplinary approach.

Association Between Surgical Trainee Daytime Sleepiness and Intraoperative Technical Skill When Performing Septoplasty

Importance

Daytime sleepiness in surgical trainees can impair intraoperative technical skill and thus affect their learning and pose a risk to patient safety.

Objective

To determine the association between daytime sleepiness of surgeons in residency and fellowship training and their intraoperative technical skill during septoplasty.

Design, Setting, and Participants

This prospective cohort study included 19 surgical trainees in otolaryngology-head and neck surgery programs at 2 academic institutions (Johns Hopkins University School of Medicine and MedStar Georgetown University Hospital). The physicians were recruited from June 13, 2016, to April 20, 2018. The analysis includes data that were captured between June 27, 2016, and April 20, 2018.

Main Outcomes and Measures

Attending physician and surgical trainee self-rated intraoperative technical skill using the Septoplasty Global Assessment Tool (SGAT) and visual analog scales. Daytime sleepiness reported by surgical trainees was measured using the Epworth Sleepiness Scale (ESS).

Results

Of 19 surgical trainees, 17 resident physicians (9 female [53%]) and 2 facial plastic surgery fellowship physicians (1 female and 1 male) performed a median of 3.00 septoplasty procedures (range, 1-9 procedures) under supervision by an attending physician. Of the 19 surgical trainees, 10 (53%) were aged 25 to 30 years and 9 (47%) were 31 years or older. The mean ESS score overall was 6.74 (95% CI, 5.96-7.52), and this score did not differ between female and male trainees. The mean ESS score was 7.57 (95% CI, 6.58-8.56) in trainees aged 25 to 30 years and 5.44 (95% CI, 4.32-6.57) in trainees aged 31 years or older. In regression models adjusted for sex, age, postgraduate year, and technical complexity of the procedure, there was a statistically significant inverse association between ESS scores and attending physician-rated technical skill for both SGAT (-0.41; 95% CI, -0.55 to -0.27; P < .001) and the visual analog scale (-0.75; 95% CI, -1.40 to -0.07; P = .03). The association between ESS scores and technical skill was not statistically significant for trainee self-rated SGAT (0.04; 95% CI, -0.17 to 0.24; P = .73) and the self-rated visual analog scale (0.19; 95% CI, -0.79 to 1.2; P = .70).

Conclusions and Relevance

The findings suggest that daytime sleepiness of surgical trainees is inversely associated with attending physician-rated intraoperative technical skill when performing septoplasty. Thus, surgical trainees' ability to learn technical skill in the operating room may be influenced by their daytime sleepiness.

Level of Evidence

NA.

Depressive symptoms and cannabis use in a placebo-controlled trial of N-Acetylcysteine for adult cannabis use disorder

RATIONALE

Depression is common among individuals with cannabis use disorder (CUD), particularly individuals who present to CUD treatment. Treatments that consider this comorbidity are essential.

OBJECTIVES

The goal of this secondary analysis was to examine whether N-acetylcysteine (NAC) reduced depressive symptoms among adults (age 18-50) with CUD (N = 302) and whether the effect of NAC on cannabis cessation varied as a result of baseline levels of depression. Bidirectional associations between cannabis use amount and depression were also examined.

METHODS

Data for this secondary analysis were from a National Drug Abuse Treatment Clinical Trials Network (NIDA CTN) multi-site clinical trial for CUD. Adults with CUD (N = 302) were randomized to receive 2400 mg of NAC daily or matched placebo for 12 weeks. All participants received abstinence-based contingency management. Cannabis quantity was measured by self-report, and weekly urinary cannabinoid levels (11-nor-9-carboxy-Δ9-tetrahydrocannabinol) confirmed abstinence. Depressive symptoms were measured by the Hospital Anxiety and Depression Scale.

RESULTS

Depressive symptoms did not differ between the NAC and placebo groups during treatment. There was no significant interaction between treatment and baseline depression predicting cannabis abstinence during treatment. Higher baseline depression was associated with decreased abstinence throughout treatment and a significant gender interaction suggested that this may be particularly true for females. Cross-lagged panel models suggested that depressive symptoms preceded increased cannabis use amounts (in grams) during the subsequent month. The reverse pathway was not significant (i.e., greater cannabis use preceding depressive symptoms).

CONCLUSIONS

Results from this study suggest that depression may be a risk factor for poor CUD treatment outcome and therefore should be addressed in the context of treatment. However, results do not support the use of NAC to concurrently treat co-occurring depressive symptoms and CUD in adults.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT01675661.

Internalized HIV-Related Stigma and Breast Health Beliefs Among African-American Women Receiving Care for HIV in the USA

OBJECTIVES

African-American women suffer disproportionately from HIV, breast cancer, and other illnesses. Little is known about the relationship between internalized HIV-related stigma and health beliefs related to other illnesses, including breast cancer. Our study examined (1) the relationship between internalized HIV-related stigma and breast health beliefs over time and (2) the moderating effects of participating in a stigma reduction intervention and/or social support.

METHODS

Data from 239 African-American women receiving care for HIV in Chicago, IL, or Birmingham, AL, enrolled in the Unity randomized controlled trial, were used in this secondary analysis. Threat of breast cancer was measured in terms of perceived susceptibility, fear, and adverse consequences as well as an overall perceived threat of breast cancer. We used multivariate models with generalized estimating equations to examine the relationship between internalized HIV-related stigma and breast health beliefs across three time points (baseline, immediately post-workshop, and at 12-month follow-up) and to examine if the study arm (HIV stigma reduction vs. breast cancer education) or social support moderated the relationship.

RESULTS

Internalized HIV-related stigma was associated with greater overall perceived threat (p < 0.001), susceptibility (p = 0.03), fear (p < 0.001), and perceived adverse consequences (p < 0.001) of breast cancer. These associations remained consistent across study arms and across all levels of social support.

CONCLUSIONS

Future studies that examine co-morbid health conditions among African-American women living with HIV should consider the impact of HIV-related stigma on attitudes and beliefs related to co-morbid conditions.

Multimodal Percutaneous Thermal Ablation of Small Hepatocellular Carcinoma: Predictive Factors of Recurrence and Survival in Western Patients

BACKGROUND

To identify the predictive factors of recurrence and survival in an unselected population of Western patients who underwent multimodal percutaneous thermal ablation (PTA) for small Hepatocellular Carcinomas (HCCs).

METHODS

January 2015-June 2019: data on multimodal PTA for <3 cm HCC were extracted from a prospective database. Local tumor progression (LTP), intrahepatic distant recurrence (IDR), time-to-LTP, time-to-IDR, recurrence-free (RFS) and overall (OS) survival were evaluated.

RESULTS

238 patients underwent 317 PTA sessions to treat 412 HCCs. During follow-up (median: 27.1 months), 47.1% patients had IDR and 18.5% died. LTP occurred after 13.3% of PTA. Tumor size (OR = 1.108, p < 0.001; hazard ratio (HR) = 1.075, p = 0.002) and ultrasound guidance (OR = 0.294, p = 0.017; HR = 0.429, p = 0.009) independently predicted LTP and time-to-LTP, respectively. Alpha fetoprotein (AFP) > 100 ng/mL (OR = 3.027, p = 0.037) and tumor size (OR = 1.06, p = 0.001) independently predicted IDR. Multinodular HCC (HR = 2.67, p < 0.001), treatment-naïve patient (HR = 0.507, p = 0.002) and AFP > 100 ng/mL (HR = 2.767, p = 0.014) independently predicted time-to-IDR. RFS was independently predicted by multinodular HCC (HR = 2.144, p = 0.001), treatment naivety (HR = 0.546, p = 0.004) and AFP > 100 ng/mL (HR = 2.437, p = 0.013). The American Society of Anesthesiologists (ASA) score > 2 (HR = 4.273, p = 0.011), AFP (HR = 1.002, p < 0.001), multinodular HCC (HR = 3.939, p = 0.003) and steatotic HCC (HR = 1.81 × 10-16, p < 0.001) independently predicted OS.

CONCLUSIONS

IDR was associated with tumor aggressiveness, suggesting a metastatic mechanism. Besides AFP association with LTP, IDR, RFS and OS, treatment-naïve patients had longer RFS, and multi-nodularity was associated with shorter RFS and OS. Steatotic HCC, identified on pre-treatment MRI, independently predicted longer OS, and needs to be further explored.

Variable selection via penalized generalized estimating equations for a marginal survival model

Clustered and multivariate survival times, such as times to recurrent events, commonly arise in biomedical and health research, and marginal survival models are often used to model such data. When a large number of predictors are available, variable selection is always an important issue when modeling such data with a survival model. We consider a Cox's proportional hazards model for a marginal survival model. Under the sparsity assumption, we propose a penalized generalized estimating equation approach to select important variables and to estimate regression coefficients simultaneously in the marginal model. The proposed method explicitly models the correlation structure within clusters or correlated variables by using a prespecified working correlation matrix. The asymptotic properties of the estimators from the penalized generalized estimating equations are established and the number of candidate covariates is allowed to increase in the same order as the number of clusters does. We evaluate the performance of the proposed method through a simulation study and analyze two real datasets for the application.

A Single-Arm, Multicenter Validation Study of Prostate Cancer Localization and Aggressiveness With a Quantitative Multiparametric Magnetic Resonance Imaging Approach

OBJECTIVES

The aims of this study were to assess the discriminative performance of quantitative multiparametric magnetic resonance imaging (mpMRI) between prostate cancer and noncancer tissues and between tumor grade groups (GGs) in a multicenter, single-vendor study, and to investigate to what extent site-specific differences affect variations in mpMRI parameters.

MATERIALS AND METHODS

Fifty patients with biopsy-proven prostate cancer from 5 institutions underwent a standardized preoperative mpMRI protocol. Based on the evaluation of whole-mount histopathology sections, regions of interest were placed on axial T2-weighed MRI scans in cancer and noncancer peripheral zone (PZ) and transition zone (TZ) tissue. Regions of interest were transferred to functional parameter maps, and quantitative parameters were extracted. Across-center variations in noncancer tissues, differences between tissues, and the relation to cancer grade groups were assessed using linear mixed-effects models and receiver operating characteristic analyses.

RESULTS

Variations in quantitative parameters were low across institutes (mean [maximum] proportion of total variance in PZ and TZ, 4% [14%] and 8% [46%], respectively). Cancer and noncancer tissues were best separated using the diffusion-weighted imaging-derived apparent diffusion coefficient, both in PZ and TZ (mean [95% confidence interval] areas under the receiver operating characteristic curve [AUCs]; 0.93 [0.89-0.96] and 0.86 [0.75-0.94]), followed by MR spectroscopic imaging and dynamic contrast-enhanced-derived parameters. Parameters from all imaging methods correlated significantly with tumor grade group in PZ tumors. In discriminating GG1 PZ tumors from higher GGs, the highest AUC was obtained with apparent diffusion coefficient (0.74 [0.57-0.90], P < 0.001). The best separation of GG1-2 from GG3-5 PZ tumors was with a logistic regression model of a combination of functional parameters (mean AUC, 0.89 [0.78-0.98]).

CONCLUSIONS

Standardized data acquisition and postprocessing protocols in prostate mpMRI at 3 T produce equivalent quantitative results across patients from multiple institutions and achieve similar discrimination between cancer and noncancer tissues and cancer grade groups as in previously reported single-center studies.