Akaike's information criterion in generalized estimating equations

Geographically weighted accelerated failure time model for spatial survival data: application to ovarian cancer survival data in New Jersey

BACKGROUND

In large multiregional cohort studies, survival data is often collected at small geographical levels (such as counties) and aggregated at larger levels, leading to correlated patterns that are associated with location. Traditional studies typically analyze such data globally or locally by region, often neglecting the spatial information inherent in the data, which can introduce bias in effect estimates and potentially reduce statistical power.

METHOD

We propose a Geographically Weighted Accelerated Failure Time Model for spatial survival data to investigate spatial heterogeneity. We establish a weighting scheme and bandwidth selection based on quasi-likelihood information criteria. Theoretical properties of the proposed estimators are thoroughly examined. To demonstrate the efficacy of the model in various scenarios, we conduct a simulation study with different sample sizes and adherence to the proportional hazards assumption or not. Additionally, we apply the proposed method to analyze ovarian cancer survival data from the Surveillance, Epidemiology, and End Results cancer registry in the state of New Jersey.

RESULTS

Our simulation results indicate that the proposed model exhibits superior performance in terms of four measurements compared to existing methods, including the geographically weighted Cox model, when the proportional hazards assumption is violated. Furthermore, in scenarios where the sample size per location is 20-25, the simulation data failed to fit the local model, while our proposed model still demonstrates satisfactory performance. In the empirical study, we identify clear spatial variations in the effects of all three covariates.

CONCLUSION

Our proposed model offers a novel approach to exploring spatial heterogeneity of survival data compared to global and local models, providing an alternative to geographically weighted Cox regression when the proportional hazards assumption is not met. It addresses the issue of certain counties' survival data being unable to fit the model due to limited samples, particularly in the context of rare diseases.

Predictors of moderate-to-severe side-effects following COVID-19 mRNA booster vaccination: a prospective cohort study among primary health care providers in Belgium

BACKGROUND

COVID-19 vaccine effectiveness declines months after vaccination. Therefore, it is likely that during the next few years, people may be repeatedly offered a booster vaccine to enhance humoral immunity levels. A growing number of people are questioning whether the benefits of a booster vaccine outweigh the side-effects.

OBJECTIVE

This study aims (1) to identify the most frequently reported side-effects after different doses of COVID-19 mRNA vaccines, (2) and the longest lasting symptoms; and (3) to predict the likelihood of having moderate-to-severe side-effects after a booster COVID-19 mRNA vaccine given individual- and vaccine-specific characteristics.

DESIGN, SETTING, AND PARTICIPANTS

Secondary analysis of a prospective cohort study in primary health care providers (PHCPs) in Belgium conducted between December 2020 and December 2021, and in February-March 2023.

METHODS

In nine subsequent surveys over a period of 2 years vaccine dose-number and side-effects after COVID-19 vaccines were collected. A Generalized Estimation Equations approach on the data of the first and second booster dose was used to investigate the probability of having moderate-to-severe side-effects after mRNA booster vaccination. Predictive performance of a binary classifier was assessed by looking at discrimination (i.e., quantified in terms of the area under the receiver operating characteristic curve). The final prediction model was validated using data with regard to the third booster by assessing misclassification rate, sensitivity and specificity.

RESULTS

In total, 11% of the PHCPs had moderate-to-severe side-effects after their booster COVID-19 mRNA vaccine. The most common side-effects of COVID-19 mRNA doses included fatigue, local pain at the injection site, general pains, and headache. These side-effects typically lasted for a median of 1 to 2 days. The final model included five predictors: sex, alcohol consumption, history of moderate-to-severe side-effects after any previous dose, recent COVID-19 infection, and the booster dose-number (first, second). Having experienced moderate-to-severe side-effects after any previous dose was the strongest predictor of moderate-to-severe side-effects following an mRNA vaccine booster, with an odds ratio (OR) of 3.64 (95% CI: 2.80-4.75). The OR for female sex was 1.49 (95% CI: 1.21-1.84) implying that females have a higher odds of moderate-to-severe side-effects following booster vaccination. The differences in effect for booster dose-number, alcohol consumption and recent COVID-19 infection was not significant.

CONCLUSION AND RELEVANCE

COVID-19 mRNA booster vaccination implies a low prevalence of moderate-to-severe side-effects among PHCPs, with a short median duration of symptoms if any. The strongest predictors are a history of moderate-to-severe side-effects after any previous dose and being female. These reassuring findings can help addressing concerns about booster vaccination and encourage their uptake.

TRIAL REGISTRATION

NCT04779424 (registration date: 2021-02-22).

Trends in Veteran hospitalizations and associated readmissions and emergency department visits during the MISSION Act era

OBJECTIVE

To examine changes in hospitalization trends and healthcare utilization among Veterans following Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act implementation.

DATA SOURCES AND STUDY SETTING

VA Corporate Data Warehouse and Centers for Medicare and Medicaid Services datasets.

STUDY DESIGN

Retrospective cohort study to compare 7- and 30-day rates for unplanned readmission and emergency department visits following index hospital stays based on payor type (VHA facility stay, VA-funded stay in community facility [CC], or Medicare-funded community stay [CMS]). Segmented regression models were used to compare payors and estimate changes in outcome levels and slopes following MISSION Act implementation.

DATA COLLECTION/EXTRACTION METHODS

Veterans with active VA primary care utilization and ≥1 acute hospitalization between January 1, 2016 and December 31, 2021.

PRINCIPAL FINDINGS

Monthly index stays increased for all payors until MISSION Act implementation, when VHA and CMS admissions declined while CC admissions accelerated and overtook VHA admissions. In December 2021, CC admissions accounted for 54% of index admissions, up from 25% in January 2016. From adjusted models, just prior to implementation (May 2019), Veterans with CC admissions had 47% greater risk of 7-day readmission (risk ratio [RR]: 1.47, 95% confidence interval [CI]: 1.43, 1.51) and 20% greater risk of 30-day readmission (RR: 1.20, 95% CI: 1.19, 1.22) compared with those with VHA admissions; both effects persisted post-implementation. Pre-implementation CC admissions were also associated with higher 7- and 30-day ED visits, but both risks were substantially lower by study termination (RR: 0.90, 95% CI: 0.88, 0.91) and (RR: 0.89, 95% CI: 0.87, 0.90), respectively.

CONCLUSIONS

MISSION Act implementation was associated with substantial shifts in treatment site and federal payor for Veteran hospitalizations. Post-implementation readmission risk was estimated to be higher for those with CC and CMS index admissions, while post-implementation risk of ED utilization following CC admissions was estimated to be lower compared with VHA index admissions. Reasons for this divergence require further investigation.

Factors associated with weight gain in pre- and post-menopausal women receiving adjuvant endocrine therapy for breast cancer

PURPOSE

Weight gain after breast cancer poses health risks. We aimed to identify factors associated with weight gain during adjuvant endocrine therapy (AET).

METHODS

Women initiating AET enrolled in a prospective cohort. Participants completed FACT-ES plus PROMIS pain interference, depression, anxiety, fatigue, sleep disturbance and physical function measures at baseline, 3, 6, 12, 24, 36, 48 and 60 months. Treatment-emergent symptoms were defined as changes in scores in the direction indicative of worsening symptoms that exceeded the minimal important difference at 3 and/or 6 months compared to baseline. We used logistic regression to evaluate associations of clinicodemographic features and treatment-emergent symptoms with clinically significant weight gain over 60 months (defined as ≥ 5% compared to baseline) in pre- and post-menopausal participants.

RESULTS

Of 309 participants, 99 (32%) were pre-menopausal. The 60 months cumulative incidence of clinically significant weight gain was greater in pre- than post-menopausal participants (67% vs 43%, p < 0.001). Among pre-menopausal participants, treatment-emergent pain interference (OR 2.49), aromatase inhibitor receipt (OR 2.8), mastectomy, (OR 2.06) and White race (OR 7.13) were associated with weight gain. Among post-menopausal participants, treatment-emergent endocrine symptoms (OR 2.86), higher stage (OR 2.25) and White race (OR 2.29) were associated with weight gain while treatment-emergent physical function decline (OR 0.30) was associated with lower likelihood of weight gain.

CONCLUSIONS

Weight gain during AET is common, especially for pre-menopausal women. Clinicodemographic features and early treatment-emergent symptoms may identify at risk individuals.

IMPLICATIONS FOR CANCER SURVIVORS

Patients at risk for weight gain can be identified early during AET.

CLINICAL TRIALS

GOV IDENTIFIER

NCT01937052, registered September 3, 2013.

Analysis of Cerebral Spinal Fluid Drainage and Intracranial Pressure Peaks in Patients with Subarachnoid Hemorrhage

BACKGROUND

After aneurysmal subarachnoid hemorrhage (aSAH), elevated intracranial pressure (ICP) due to disrupted cerebrospinal fluid (CSF) dynamics is a critical concern. An external ventricular drainage (EVD) is commonly employed for management; however, optimal strategies remain debated. The randomized controlled Earlydrain trial showed that an additional prophylactic lumbar drainage (LD) after aneurysm treatment improves neurological outcome. We performed a post hoc investigation on the impact of drainage volumes and critical ICP values on patient outcomes after aSAH.

METHODS

Using raw patient data from Earlydrain, we analyzed CSF drainage amounts and ICP measurements in the first 8 days after aSAH. Outcomes were the occurrence of secondary infarctions and the score on the modified Rankin scale after 6 months, dichotomized in values of 0-2 as favorable and 3-6 as unfavorable. Repeated measurements were considered with generalized estimation equations.

RESULTS

Earlydrain recruited 287 patients, of whom 221 received an EVD and 140 received an LD. Higher EVD volumes showed a trend to more secondary infarctions (p = 0.09), whereas higher LD volumes were associated with less secondary infarctions (p = 0.009). The mean total CSF drainage was 1052 ± 659 mL and did not differ concerning infarction and neurological outcome. Maximum ICP values were higher in patients with poor outcomes but not related to drainage volumes via EVD. After adjustment for aSAH severity and total CSF drainage, higher LD volume was linked to favorable outcome (per 100 mL: odds ratio 0.61 (95% confidence interval 0.39-0.95), p = 0.03), whereas higher EVD amounts were associated with unfavorable outcome (per 100 mL: odds ratio 1.63 (95% confidence interval 1.05-2.54), p = 0.03).

CONCLUSIONS

Findings indicate that effects of CSF drainage via EVD and LD differ. Higher amounts and higher proportions of LD volumes were associated with better outcomes, suggesting a potential quantity-dependent protective effect. Optimizing LD volume and mitigating ICP spikes may be a strategy to improve patient outcomes after aSAH.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01258257.

Supportive periodontal care with or without subgingival instrumentation: Microbiological results of a 2-year randomized clinical trial

AIM

To compare the subgingival microbiota of patients receiving supportive periodontal care (SPC) with and without subgingival instrumentation, over 2 years.

MATERIALS AND METHODS

This study was a randomized clinical trial that included 62 participants (50.97 ± 9.26 years old; 40 females) who completed non-surgical periodontal therapy. Participants were randomly assigned to receive oral prophylaxis with oral hygiene instructions alone (test) or in combination with subgingival instrumentation (control) during SPC. Pooled subgingival biofilm samples were obtained from four sites per patient at SPC baseline and at 3, 6, 12, 18, and 24 months. Real-time polymerase chain reaction was used for absolute quantification of Eubacteria and the target bacteria Porphyromonas gingivalis, Tannerella forsythia, and Treponema denticola. Data were analysed using generalized estimating equations, taking into consideration the clustering of observations within individuals.

RESULTS

No significant differences were found between the experimental groups regarding the mean counts of Eubacteria and target bacteria, as well as the periodontal parameters at the sampled sites. Although significant variability in bacterial counts was present during SPC, all counts after 2 years were not statistically different from those at baseline. Bacterial counts were associated with the presence of plaque, bleeding on probing, mean probing depth ≥3 mm, and follow-up period.

CONCLUSIONS

SPC with or without subgingival instrumentation can result in comparable subgingival microbiological outcomes.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov: NCT01598155 (https://clinicaltrials.gov/study/NCT01598155?intr=supragingival%20control&rank=4#study-record-dates).

Repetitive head impacts among professional fighters: a pilot study evaluating Traumatic Encephalopathy Syndrome and postural balance

OBJECTIVES

Clinical criteria for Traumatic Encephalopathy Syndrome (ccTES) were developed for research purposes to reflect the clinical symptoms of Chronic Traumatic Encephalopathy (CTE). The aims of this study were to 1) determine whether there was an association between the research diagnosis of TES and impaired postural balance among retired professional fighters, and 2) determine repetitive head impacts (RHI) exposure thresholds among both TES positive and TES negative groups in retired professional fighters when evaluating for balance impairment.

METHODS

This was a pilot study evaluating postural balance among participants of the Professional Athletes Brain Health Study (PABHS). Among the cohort, 57 retired professional fighters met the criteria for inclusion in this study. A generalized linear model with generalized estimating equations was used to compare various balance measures longitudinally between fighters with and without TES.

RESULTS

A significant association was observed between a TES diagnosis and worsening performance on double-leg balance assessments when stratifying by RHI exposure thresholds. Additionally, elevated exposure to RHI was significantly associated with increased odds of developing TES; The odds for TES diagnosis were 563% (95% CI = 113, 1963; p-value = 0.0011) greater among athletes with 32 or more professional fights compared to athletes with less than 32 fights when stratifying by balance measures. Likewise, the odds for TES diagnosis were 43% (95% CI = 10, 102; p-value = 0.0439) greater with worsening double leg stance balance in athletes exposed to 32 or more fights.

CONCLUSION

This pilot study provides preliminary evidence of a relationship between declining postural balance and a TES diagnosis among retired professional fighters with elevated RHI exposure. Further research exploring more complex assessments such as the Functional Gait Assessment may be of benefit to improve clinical understanding of the relationship between TES, RHI, and balance.

Radiomics of multi-parametric MRI for the prediction of lung metastasis in soft-tissue sarcoma: a feasibility study

PURPOSE

To investigate the value of multi-parametric MRI-based radiomics for preoperative prediction of lung metastases from soft tissue sarcoma (STS).

METHODS

In total, 122 patients with clinicopathologically confirmed STS who underwent pretreatment T1-weighted contrast-enhanced (T1-CE) and T2-weighted fat-suppressed (T2FS) MRI scans were enrolled between Jul. 2017 and Mar. 2021. Radiomics signatures were established by calculating and selecting radiomics features from the two sequences. Clinical independent predictors were evaluated by statistical analysis. The radiomics nomogram was constructed from margin and radiomics features by multivariable logistic regression. Finally, the study used receiver operating characteristic (ROC) and calibration curves to evaluate performance of radiomics models. Decision curve analyses (DCA) were performed to evaluate clinical usefulness of the models.

RESULTS

The margin was considered as an independent predictor (p < 0.05). A total of 4 MRI features were selected and used to develop the radiomics signature. By incorporating the margin and radiomics signature, the developed nomogram showed the best prediction performance in the training (AUCs, margin vs. radiomics signature vs. nomogram, 0.609 vs. 0.909 vs. 0.910) and validation (AUCs, margin vs. radiomics signature vs. nomogram, 0.666 vs. 0.841 vs. 0.894) cohorts. DCA indicated potential usefulness of the nomogram model.

CONCLUSIONS

This feasibility study evaluated predictive values of multi-parametric MRI for the prediction of lung metastasis, and proposed a nomogram model to potentially facilitate the individualized treatment decision-making for STSs.

Improved Prediction of Epidermal Growth Factor Receptor Status by Combined Radiomics of Primary Nonsmall-Cell Lung Cancer and Distant Metastasis

OBJECTIVES

This study aimed to investigate radiomics based on primary nonsmall-cell lung cancer (NSCLC) and distant metastases to predict epidermal growth factor receptor (EGFR) mutation status.

METHODS

A total of 290 patients (mean age, 58.21 ± 9.28) diagnosed with brain (BM, n = 150) or spinal bone metastasis (SM, n = 140) from primary NSCLC were enrolled as a primary cohort. An external validation cohort, consisting of 69 patients (mean age, 59.87 ± 7.23; BM, n = 36; SM, n = 33), was enrolled from another center. Thoracic computed tomography-based features were extracted from the primary tumor and peritumoral area and selected using the least absolute shrinkage and selection operator regression to build a radiomic signature (RS-primary). Contrast-enhanced magnetic resonance imaging-based features were calculated and selected from the BM and SM to build RS-BM and RS-SM, respectively. The RS-BM-Com and RS-SM-Com were developed by integrating the most important features from the primary tumor, BM, and SM.

RESULTS

Six computed tomography-based features showed high association with EGFR mutation status: 3 from intratumoral and 3 from peritumoral areas. By combination of features from primary tumor and metastases, the developed RS-BM-Com and RS-SM-Com performed well with areas under curve in the training (RS-BM-Com vs RS-BM, 0.936 vs 0.885, P = 0.177; RS-SM-Com vs RS-SM, 0.929 vs 0.843, P = 0.003), internal validation (RS-BM-Com vs RS-BM, 0.920 vs 0.858, P = 0.492; RS-SM-Com vs RS-SM, 0.896 vs 0.859, P = 0.379), and external validation (RS-BM-Com vs RS-BM, 0.882 vs 0.805, P = 0.263; RS-SM-Com vs RS-SM, 0.865 vs 0.816, P = 0.312) cohorts.

CONCLUSIONS

This study indicates that the accuracy of detecting EGFR mutations significantly enhanced in the presence of metastases in primary NSCLC. The established radiomic signatures from this approach may be useful as new predictors for patients with distant metastases.

Habitat-Based Radiomics for Predicting EGFR Mutations in Exon 19 and 21 From Brain Metastasis

RATIONALE AND OBJECTIVES

To explore and externally validate habitat-based radiomics for preoperative prediction of epidermal growth factor receptor (EGFR) mutations in exon 19 and 21 from MRI imaging of non-small cell lung cancer (NSCLC)-originated brain metastasis (BM).

METHODS

A total of 170, 62 and 61 patients from center 1, center 2 and center 3, respectively were included. All patients underwent contrast-enhanced T1-weighted (T1CE) and T2-weighted (T2W) MRI scans. Radiomics features were extracted from the tumor active (TA) and peritumoral edema (PE) regions in each MRI slice. The most important features were selected by the least absolute shrinkage and selection operator regression to develop radiomics signatures based on TA (RS-TA), PE (RS-PE) and their combination (RS-Com). Receiver operating characteristic (ROC) curve analysis was performed to access performance of radiomics models for both internal and external validation cohorts.

RESULTS

10, four and six most predictive features were identified to be strongly associated with the EGFR mutation status, exon 19 and exon 21, respectively. The RSs derived from the PE region outperformed those from the TA region for predicting the EGFR mutation, exon 19 and exon 21. The RS-Coms generated the highest performance in the primary training (AUCs, RS-EGFR-Com vs. RS-exon 19-Com vs. RS-exon 21-Com, 0.955 vs. 0.946 vs. 0.928), internal validation (AUCs, RS-EGFR-Com vs. RS-exon 19-Com vs. RS-exon 21-Com, 0.879 vs. 0.819 vs. 0.882), external validation 1 (AUCs, RS-EGFR-Com vs. RS-exon 19-Com vs. RS-exon 21-Com, 0.830 vs. 0.825 vs. 0.822), and external validation 2 (AUCs, RS-EGFR-Com vs. RS-exon 19-Com vs. RS-exon 21-Com, 0.812 vs. 0.818 vs. 0.800) cohort.

CONCLUSION

The developed habitat-based radiomics model can be used to accurately predict the EGFR mutation subtypes, which may potentially guide personalized treatments for NSCLC patients with BM.

Cognitive subtypes in youth at clinical high risk for psychosis

Introduction

Schizophrenia is a mental health condition that severely impacts well-being. Cognitive impairment is among its core features, often presenting well before the onset of overt psychosis, underscoring a critical need to study it in the psychosis proneness (clinical high risk; CHR) stage, to maximize the benefits of interventions and to improve clinical outcomes. However, given the heterogeneity of cognitive impairment in this population, a one-size-fits-all approach to therapeutic interventions would likely be insufficient. Thus, identifying cognitive subtypes in this population is crucial for tailored and successful therapeutic interventions. Here we identify, validate, and characterize cognitive subtypes in large CHR samples and delineate their baseline and longitudinal cognitive and functional trajectories.

Methods

Using machine learning, we performed cluster analysis on cognitive measures in a large sample of CHR youth (n = 764), and demographically comparable controls (HC; n = 280) from the North American Prodrome Longitudinal Study (NAPLS) 2, and independently validated our findings with an equally large sample (NAPLS 3; n = 628 CHR, 84 HC). By utilizing several statistical approaches, we compared the clusters on cognition and functioning at baseline, and over 24 months of followup. We further delineate the conversion status within those clusters.

Results

Two main cognitive clusters were identified, "impaired" and "intact" across all cognitive domains in CHR compared to HC. Baseline differences between the cognitively intact cluster and HC were found in the verbal abilities and attention and working memory domains. Longitudinally, those in the cognitively impaired cluster group demonstrated an overall floor effect and did not deteriorate further over time. However, a "catch up" trajectory was observed in the attention and working memory domain. This group had higher instances of conversion overall, with these converters having significantly more non-affective psychotic disorder diagnosis versus bipolar disorder, than those with intact cognition. In the cognitively intact group, we observed differences in trajectory based on conversion status, where those who start with intact cognition and later convert demonstrate a sharp decline in attention and functioning. Functioning was significantly better in the cognitively intact than in the impaired group at baseline. Most of the cognitive trajectories demonstrate a positive relationship with functional ones.

Conclusion

Our findings provide evidence for intact and impaired cognitive subtypes in youth at CHR, independent of conversion status. They further indicate that attention and working memory are important to distinguish between the CHR with intact cognition and controls. The cognitively intact CHR group becomes less attentive after conversion, while the cognitively impaired one demonstrates a catch up trajectory on both attention and working memory. Overall, early evaluation, covering several cognitive domains, is crucial for identifying trajectories of improvement and deterioration for the purpose of tailoring intervention for improving outcomes in individuals at CHR for psychosis.

Study protocol: a mixed-methods study of the implementation of doula care to address racial health equity in six state Medicaid programs

BACKGROUND

Racial inequities in severe maternal morbidity (SMM) and mortality constitute a public health crisis in the United States. Doula care, defined as care from birth workers who provide culturally appropriate, non-clinical support during pregnancy and postpartum, has been proposed as an intervention to help disrupt obstetric racism as a driver of adverse pregnancy outcomes in Black and other birthing persons of colour. Many state Medicaid programs are implementing doula programs to address the continued increase in SMM and mortality. Medicaid programs are poised to play a major role in addressing the needs of these populations with the goal of closing the racial gaps in SMM and mortality. This study will investigate the most effective ways that Medicaid programs can implement doula care to improve racial health equity.

METHODS

We describe the protocol for a mixed-methods study to understand how variation in implementation of doula programs in Medicaid may affect racial equity in pregnancy and postpartum health. Primary study outcomes include SMM, person-reported measures of respectful obstetric care, and receipt of evidence-based care for chronic conditions that are the primary causes of postpartum mortality (cardiovascular, mental health, and substance use conditions). Our research team includes doulas, university-based investigators, and Medicaid participants from six sites (Kentucky, Maryland, Michigan, Pennsylvania, South Carolina and Virginia) in the Medicaid Outcomes Distributed Research Network (MODRN). Study data will include policy analysis of doula program implementation, longitudinal data from a cohort of doulas, cross-sectional data from Medicaid beneficiaries, and Medicaid healthcare administrative data. Qualitative analysis will examine doula and beneficiary experiences with healthcare systems and Medicaid policies. Quantitative analyses (stratified by race groups) will use matching techniques to estimate the impact of using doula care on postpartum health outcomes, and will use time-series analyses to estimate the average treatment effect of doula programs on population postpartum health outcomes.

DISCUSSION

Findings will facilitate learning opportunities among Medicaid programs, doulas and Medicaid beneficiaries. Ultimately, we seek to understand the implementation and integration of doula care programs into Medicaid and how these processes may affect racial health equity. Study registration The study is registered with the Open Science Foundation ( https://doi.org/10.17605/OSF.IO/NXZUF ).

Nativity Disparities in Colorectal Cancer Screening Among Hispanics in the United States

Hispanics in the United States (U.S.) have previously exhibited lower guideline-concordant colorectal cancer (CRC) screening uptake than non-Hispanic (NH) Whites, with disparities accentuated in foreign-born Hispanics, however it is unclear whether nativity-related CRC screening disparities have changed in the last two decades and whether these disparities are attenuated after adjusting for socioeconomic and demographic characteristics. We evaluated CRC screening adherence in foreign- and U.S.-born Hispanics compared to U.S.-born NH Whites. We used 2019 National Health Interview Survey data to compare the prevalence of up-to-date CRC screening per the 2019 U.S. Preventive Services Task Force recommendations among Hispanic nativity subgroups (i.e., foreign- and U.S.-born) and U.S.-born NH Whites using unadjusted and adjusted weighted log-linked binomial regression. Foreign- and U.S.-born Hispanics had a significantly lower unadjusted prevalence of up-to-date screening than U.S.-born NH Whites (47.18% and 64.18% versus 70.70%; p < 0.0001 and p = 0.0109, respectively). After adjusting for socioeconomic and demographic differences, the prevalence of up-to-date screening was lower in foreign-born Hispanics compared to U.S.-born NH Whites [adjusted prevalence ratio 0.80 (95% confidence interval 0.70-0.91)]; however, no statistically significant difference was observed between U.S.-born Hispanics and NH Whites. Our results suggest a low screening uptake in foreign-born Hispanics independent of socioeconomic and demographic differences. Future interventions should target foreign-born Hispanics to address disparities and promote early detection and prevention of CRC regardless of socioeconomic factors.

A longitudinal analysis of COVID-19 prevention strategies implemented among US K-12 public schools during the 2021-2022 school year

PURPOSE

Examine how school-based COVID-19 prevention strategy implementation varied over time, including by local characteristics.

METHODS

School administrators (n = 335) from a nationally representative sample of K-12 public schools completed four surveys assessing COVID-19 prevention strategies at two-month intervals between October 2021 and June 2022. We calculated weighted prevalence estimates by survey wave. Generalized estimating equations (GEE) were used to model longitudinal changes in strategy implementation, accounting for school and county covariates.

RESULTS

Opening doors/windows, daily cleaning, and diagnostic testing were reported by ≥ 50 % of schools at each survey wave. Several strategies were consistently implemented across the 2021-2022 school year (i.e., daily cleaning, opening doors and windows, diagnostic testing) while other strategies increased initially and then declined (i.e., contact tracing, screening testing, on-campus vaccination) or declined consistently throughout the school year (i.e., mask requirement, classroom distancing, quarantine). Although longitudinal changes in strategy implementation did not vary by school characteristics, strategy implementation varied by urban-rural classification and school level throughout the school year.

CONCLUSIONS

Strategies that were consistently implemented throughout the school year were also reported by a majority of schools, speaking toward their feasibility for school-based infection control and prevention and potential utility in future public health emergencies.

Suicide attempts of friends and family during adolescence and long-term suicidal ideation and attempts: Findings from the 25-year Add Health study

BACKGROUND

Suicide is a significant global public health concern. However, previous studies have predominantly focused on individual-level risk factors. Against this backdrop, microsystem suicide propinquity, which encompasses suicidal thoughts and behaviors (STB) within families and peer groups, is significant in elucidating the development and perpetuation of STB in adolescents.

METHODS

This study utilized data from the National Longitudinal Study of Adolescent to Adult Health (Add Health, 1994-2018). Adolescents who reported instances of suicide attempts among their friends and family members during Wave 1 were selected (N = 4826). Generalized estimation equations (GEE) and structural equation models (SEM) were employed.

RESULTS

GEE analyses indicated that individuals with friends who had attempted suicide exhibited higher risks for suicidal ideation (OR [95 % CI] = 2.57 [2.13, 3.11]) and suicide attempts (OR [95 % CI] = 2.47 [1.78, 3.42]). Also, individuals with family members who had attempted suicide exhibited higher risks for suicidal ideation (OR [95 % CI] = 2.37 [1.62, 3.46]) and attempts (OR [95 % CI] = 2.27 [1.17, 4.41]). However, friends' and family members' suicide attempts failed to show significant interactive effect. Besides, SEM analyses indicated that friends' and family members' suicide attempts were associated with one's long-term suicidal ideation and attempts via depressive symptoms.

CONCLUSION

Suicide attempts of friends and family during adolescence were long-term risk factors for suicidal ideation and attempts from adolescence to young adulthood. Moreover, depressive symptoms served as long-term mechanisms in these associations.

Impacts of information quantity and display formats on driving behaviors in a connected vehicle environment

The emerging connected vehicle (CV) technologies facilitate the development of integrated advanced driver assistance systems (ADASs), with which various functions are coordinated in a comprehensive framework. However, challenges arise in enabling drivers to perceive important information with minimal distractions when multiple messages are simultaneously provided by integrated ADASs. To this end, this study introduces three types of human-machine interfaces (HMIs) for an integrated ADAS: 1) three messages using a visual display only, 2) four messages using a visual display only, and 3) three messages using visual plus auditory displays. Meanwhile, the differences in driving performance across three HMI types are examined to investigate the impacts of information quantity and display formats on driving behaviors. Additionally, variations in drivers' responses to the three HMI types are examined. Driving behaviors of 51 drivers with respect to three HMI types are investigated in eight field testing scenarios. These scenarios include warnings for rear-end collision, lateral collision, forward collision, lane-change, and curve speed, as well as notifications for emergency events downstream, the specified speed limit, and car-following behaviors. Results indicate that, compared to a visual display only, presenting three messages through visual and auditory displays enhances driving performance in four typical scenarios. Compared to the presentation of three messages, a visual display offering four messages improves driving performance in rear-end collision warning scenarios but diminishes the performance in lane-change scenarios. Additionally, the relationship between information quantity and display formats shown on HMIs and driving performance can be moderated by drivers' gender, occupation, driving experience, annual driving distance, and safety attitudes. Findings are indicative to designers in automotive industries in developing HMIs for future CVs.

Postoperative stroke in acute type A aortic dissection: incidence, outcomes, and perioperative risk factors

BACKGROUND

Despite advances in surgical techniques, the incidence of stroke following acute type A aortic dissection (ATAAD) repair remains markedly high, with substantial immediate and long-term adverse outcomes such as elevated mortality, extended hospital stays, and persistent neurological impairments. The complexity of managing ATAAD extends beyond the operation itself, highlighting a crucial gap in research concerning modifiable preoperative patient conditions and perioperative anesthetic management strategies.

OBJECTIVES

This investigation aimed to elucidate the incidence, consequences, and perioperative determinants of stroke following surgical intervention for acute type A aortic dissection (ATAAD).

METHODS

In a multicenter retrospective analysis, 516 ATAAD surgery patients were evaluated. The data included demographic information, clinical profiles, surgical modalities, and outcomes. The primary endpoint was postoperative stroke incidence, with hospital mortality and other complications serving as secondary endpoints.

RESULTS

Postoperative stroke occurred in 13.6% of patients (70 out of 516) and was associated with significant extension of the ICU (median 10 vs. 5 days, P < 0.001) and hospital stay (median 18 vs. 12 days, P < 0.001). The following key independent stroke risk factors were identified: modified Frailty Index (mFI) ≥ 4 (odds ratio [OR]: 4.18, 95% confidence interval [CI]: 1.24-14.1, P = 0.021), common carotid artery malperfusion (OR: 3.76, 95% CI: 1.23-11.44, P = 0.02), pre-cardiopulmonary bypass (CPB) hypotension (mean arterial pressure ≤ 50 mmHg; OR: 2.17, 95% CI: 1.06-4.44, P = 0.035), ≥ 20% intraoperative decrease in cerebral regional oxygen saturation (rSO2) (OR: 1.93, 95% CI: 1.02-3.64, P = 0.042), and post-CPB vasoactive-inotropic score (VIS) ≥ 10 (OR: 2.24, 95% CI: 1.21-4.14, P = 0.01).

CONCLUSIONS

Postoperative stroke significantly increases ICU and hospital durations in ATAAD surgery patients. These findings highlight the critical need to identify and mitigate major risks, such as high mFI, common carotid artery malperfusion, pre-CPB hypotension, significant cerebral rSO2 reductions, and elevated post-CPB VIS, to improve outcomes and reduce stroke prevalence.

TRIAL REGISTRATION

Thai Clinical Trials Registry (TCTR20230615002). Date registered on June 15, 2023. Retrospectively registered.

Sperm whale demographics in the Gulf of Alaska and Bering Sea/Aleutian Islands: An overlooked female habitat

Sperm whales exhibit sexual dimorphism and sex-specific latitudinal segregation. Females and their young form social groups and are usually found in temperate and tropical latitudes, while males forage at higher latitudes. Historical whaling data and rare sightings of social groups in high latitude regions of the North Pacific, such as the Gulf of Alaska (GOA) and Bering Sea/Aleutian Islands (BSAI), suggest a more complex distribution than previously understood. Sperm whales are the most sighted and recorded cetacean in marine mammal surveys in these regions but capturing their demographic composition and habitat use has proven challenging. This study detects sperm whale presence using passive acoustic data from seven sites in the GOA and BSAI from 2010 to 2019. Differences in click characteristics between males and females (i.e., inter-click and inter-pulse interval) was used as a proxy for animal size/sex to derive time series of animal detections. Generalized additive models with generalized estimation equations demonstrate how spatiotemporal patterns differ between the sexes. Social groups were present at all recording sites with the largest relative proportion at two seamount sites in the GOA and an island site in the BSAI. We found that the seasonal patterns of presence varied for the sexes and between the sites. Male presence was highest in the summer and lowest in the winter, conversely, social group peak presence was in the winter for the BSAI and in the spring for the GOA region, with the lowest presence in the summer months. This study demonstrates that social groups are not restricted to lower latitudes and capture their present-day habitat use in the North Pacific. It highlights that sperm whale distribution is more complex than accounted for in management protocol and underscores the need for improved understanding of sperm whale demographic composition to better understand the impacts of increasing anthropogenic threats, particularly climate change.

Pursuit and escape drive fine-scale movement variation during migration in a temperate alpine ungulate

Climate change reduces snowpack, advances snowmelt phenology, drives summer warming, alters growing season precipitation regimes, and consequently modifies vegetation phenology in mountain systems. Elevational migrants track spatial variation in seasonal plant growth by moving between ranges at different elevations during spring, so climate-driven vegetation change may disrupt historic benefits of migration. Elevational migrants can furthermore cope with short-term environmental variability by undertaking brief vertical movements to refugia when sudden adverse conditions arise. We uncover drivers of fine-scale vertical movement variation during upland migration in an endangered alpine specialist, Sierra Nevada bighorn sheep (Ovis canadensis sierrae) using a 20-year study of GPS collar data collected from 311 unique individuals. We used integrated step-selection analysis to determine factors that promote vertical movements and drive selection of destinations following vertical movements. Our results reveal that relatively high temperatures consistently drive uphill movements, while precipitation likely drives downhill movements. Furthermore, bighorn select destinations at their peak annual biomass and maximal time since snowmelt. These results indicate that although Sierra Nevada bighorn sheep seek out foraging opportunities related to landscape phenology, they compensate for short-term environmental stressors by undertaking brief up- and downslope vertical movements. Migrants may therefore be impacted by future warming and increased storm frequency or intensity, with shifts in annual migration timing, and fine-scale vertical movement responses to environmental variability.

Rates, Risk Factors, and Progression of Diabetic Retinopathy in Children with Type 1 Diabetes: A 15-Year Retrospective Study from a Regional Center in New Zealand

Aims

Diabetic retinopathy (DR) is the primary microvascular complication associated with diabetes. Evidence on DR prevalence among children in New Zealand is scarce. We examined DR rates and associated risk factors in youth with type 1 diabetes (T1D) aged <16 years receiving care from a regional diabetes service in January 2006-December 2020.

Materials and Methods

DR diagnosis followed the International Society for Pediatric and Adolescent Diabetes guidelines. The study included 646 participants; mean age (±SD) at T1D diagnosis was 7.4 ± 3.6 years, 47% were female, and 69% identified as NZ Europeans.

Results

The initial DR screening occurred at a mean age of 12.6 ± 2.4 years and 5.2 ± 2.2 years after T1D diagnosis. At the first DR screen, 23.5% of participants (152/646) were diagnosed with DR: 69.1% (105/152) with minimal, 30.3% (46/152) with mild, and one moderate case (0.7%). Older age at diagnosis (p=0.029) and longer diabetes duration (p=0.015) were predictors of DR at first screen. Patients with at least one positive DR screen had a higher average HbA1c at their first screen (+2.6 mmol/mol; p=0.042). Overall, 55.6% (359/646) of patients had a positive DR screen, whose worst grade was mostly either minimal (58.2%) or mild (40.7%) DR, with only three moderate cases (0.8%) and one severe (0.3%). Children diagnosed with T1D before age 10 were 72% more likely to have DR than older children (p < 0.0001), and DR risk was 32% and 41% higher among Pacific children than NZ European (p=0.008) and Māori (p=0.014) children. Lastly, the only predictor of DR at discharge from paediatric services was HbA1c at the first screen (p < 0.0001).

Conclusions

In this regional cohort of children with T1D, there was a high rate of low-grade DR overall and at first retinal screen, with an increasing rate until transfer to adult services. Our findings underscore the importance of ongoing DR screening, reducing glycaemic levels, and supporting vulnerable high-risk groups.

Magnesium enhances aurintricarboxylic acid's inhibitory action on the plasma membrane Ca2+-ATPase

Our research aimed to elucidate the mechanism by which aurintricarboxylic acid (ATA) inhibits plasma membrane Ca2+-ATPase (PMCA), a crucial enzyme responsible for calcium transport. Given the pivotal role of PMCA in cellular calcium homeostasis, understanding how it is inhibited by ATA holds significant implications for potentially regulating physiopathological cellular processes in which this pump is involved. Our experimental findings revealed that ATA employs multiple modes of action to inhibit PMCA activity, which are influenced by ATP but also by the presence of calcium and magnesium ions. Specifically, magnesium appears to enhance this inhibitory effect. Our experimental and in-silico results suggest that, unlike those reported in other proteins, ATA complexed with magnesium (ATA·Mg) is the molecule that inhibits PMCA. In summary, our study presents a novel perspective and establishes a solid foundation for future research efforts aimed at the development of new pharmacological molecules both for PMCA and other proteins.

Early impact of a new food store intervention on health-related outcomes

This study investigated the early impact of a community-based food intervention, the Good Food Junction (GFJ), a full-service grocery store (September 2012 - January 2016) in a former food desert in Saskatoon, Canada. The hypothesis tested was that frequent shopping at the GFJ improved food security and selected health-related outcomes among shoppers, and the impact was moderated by socioeconomic factors. Longitudinal data were collected from 156 GFJ shoppers, on three occasions: 12-, 18-, and 24-months post-opening. Participants were grouped into three categories based on the frequency of shopping at the GFJ: low, moderate, and high. A generalized estimating equations approach was used for model building; moderating effects were tested. Participants were predominantly female, Indigenous, low-income, and had high school or some post-secondary education. The GFJ use was associated with household food security (OR for high and moderate frequency shoppers reporting less than a high school education were 1.81 and 1.06, respectively), and mental health (OR for high and moderate frequency shoppers reporting high income were 2.82 and 0.87, respectively) exhibiting a dose-response relationship, and indicated that these outcomes were significantly moderated by participants' socioeconomic factors. Shopping at the GFJ had a positive effect on food security and mental health, but to varying levels for those with low incomes, with less than high school or high school or better levels of education.

Reducing intersectional stigma among transgender women in Brazil to promote uptake of HIV testing and PrEP: study protocol for a randomised controlled trial of Manas por Manas

INTRODUCTION

Globally, transgender ('trans') women experience extreme social and economic marginalisation due to intersectional stigma, defined as the confluence of stigma that results from the intersection of social identities and positions among those who are oppressed multiple times. Among trans women, gender-based stigma intersects with social positions such as engagement in sex work and substance use, as well as race-based stigma to generate a social context of vulnerability and increased risk of HIV acquisition. In Brazil, trans women are the 'most at-risk' group for HIV, with 55 times higher estimated odds of HIV infection than the general population; further, uptake of HIV testing and pre-exposure prophylaxis (PrEP) among trans women is significantly lower than other at-risk groups. Through extensive formative work, we developed Manas por Manas, a multilevel intervention using HIV prevention strategies with demonstrated feasibility and acceptability by trans women in Brazil, to address intersectional stigma and increase engagement in the HIV prevention continuum.

METHODS AND ANALYSIS

We are conducting a two-arm randomised wait-list controlled trial of the intervention's efficacy in São Paulo, Brazil, to improve uptake of HIV testing and PrEP among transgender women (N=400). The primary outcomes are changes in HIV testing (self-testing and clinic based), changes in PrEP uptake and changes in PrEP persistence at baseline and follow-up assessment for 12 months at 3-month intervals.

ETHICS AND DISSEMINATION

This study was approved by University of California, San Francisco Institutional Review Board (15-17910) and Comissão Nacional de Ética em Pesquisa (Research Ethics National Commission, CAAE: 25215219.8.0000.5479) in Brazil. Participants provided informed consent before enrolment. We are committed to collaboration with National Institutes of Health officials, other researchers, and health and social services communities for rapid dissemination of data and sharing of materials. The results will be published in peer-reviewed academic journals and scientific presentations.

TRIAL REGISTRATION NUMBER

NCT03081559.

Cardiac interoception in the museum: A novel measure of experience

Interoception is the perception of the body's internal signals in response to various external and internal stimuli. The present study uses a novel method adapted from the CARdiac Elevation Detection Task to examine cardiac interoception objectively and subjectively in a unique context-in the presence of art. Self-report questionnaires were used to measure subjective interoceptive awareness, subjective interoceptive accuracy, and aesthetic appreciation. For objective interoceptive accuracy and sensibility, a wearable device (Shimmer) measured heart rate (HR) and connected to a mobile application to prompt two questions: "Is your heart beating faster than usual?" and "How confident are you in your previous response?" Participants explored an art gallery for 40 minutes while the Shimmer measured their HR and randomly prompted them to answer the questions. Using a Generalized Estimating Equation model, interoceptive sensibility was not found to predict the odds of submitting a correct response. It was also found that art does not improve participants' perceptions of their HR. Finally, there was no relation between aesthetic appreciation and subjective or objective cardiac interoception. Despite lack of statistical significance, the current study's method presents an improved method by examining interoceptive accuracy in the moment under ecological conditions. To date, findings and methods used in interoception are inconsistent or flawed; the value in the current study lies in the development and demonstration of a method to examine how the environment influences the body and self-awareness across a wide variety of contexts, thereby offering a possible standardized measure of interoception for investigators to adopt.

Juvenile social play predicts adult reproductive success in male bottlenose dolphins

For over a century, the evolution of animal play has sparked scientific curiosity. The prevalence of social play in juvenile mammals suggests that play is a beneficial behavior, potentially contributing to individual fitness. Yet evidence from wild animals supporting the long-hypothesized link between juvenile social play, adult behavior, and fitness remains limited. In Western Australia, adult male bottlenose dolphins (Tursiops aduncus) form multilevel alliances that are crucial for their reproductive success. A key adult mating behavior involves allied males using joint action to herd individual females. Juveniles of both sexes invest significant time in play that resembles adult herding-taking turns in mature male (actor) and female (receiver) roles. Using a 32-y dataset of individual-level association patterns, paternity success, and behavioral observations, we show that juvenile males with stronger social bonds are significantly more likely to engage in joint action when play-herding in actor roles. Juvenile males also monopolized the actor role and produced an adult male herding vocalization ("pops") when playing with females. Notably, males who spent more time playing in the actor role as juveniles achieved more paternities as adults. These findings not only reveal that play behavior provides male dolphins with mating skill practice years before they sexually mature but also demonstrate in a wild animal population that juvenile social play predicts adult reproductive success.

Incidence of Health Facility Switching and Associations With HIV Viral Rebound Among Persons on Antiretroviral Therapy in Uganda: A Population-based Study

BACKGROUND

A substantial proportion of persons on antiretroviral therapy (ART) considered lost to follow-up have actually transferred their human immunodeficiency virus (HIV) care to other facilities. However, the relationship between facility switching and virologic outcomes, including viral rebound, is poorly understood.

METHODS

We used data from 40 communities (2015-2020) in the Rakai Community Cohort Study to estimate incidence of facility switching and viral rebound. Persons aged 15-49 years with serologically confirmed HIV who self-reported ART use and contributed ≥1 follow-up visit were included. Facility switching and virologic outcomes were assessed between 2 consecutive study visits (ie, index and follow-up visits, interval of approximately 18 months). Those who reported different HIV treatment facilities between index and follow-up study visits were classified as having switched facilities. Virologic outcomes included viral rebound among individuals initially suppressed (<200 copies/mL). Multivariable Poisson regression was used to estimate associations between facility switching and viral rebound.

RESULTS

Overall, 2257 persons who self-reported ART use (median age, 35 years; 65% female, 92% initially suppressed) contributed 3335 visit-pairs and 5959 person-years to the analysis. Facility switching was common (4.8 per 100 person-years; 95% confidence interval [CI], 4.2-5.5) and most pronounced in persons aged <30 years and fishing community residents. Among persons suppressed at their index visit (n = 2076), incidence of viral rebound was more than twice as high in persons who switched facilities (adjusted incidence rate ratio = 2.27; 95% CI, 1.16-4.45).

CONCLUSIONS

Facility switching was common and associated with viral rebound among persons initially suppressed. Investments in more agile, person-centered models for mobile clients are needed to address system inefficiencies and bottlenecks that can disrupt HIV care continuity.

Factors in COVID-19 vaccine uptake in five racial/ethnic Colorado communities: A report from the Colorado CEAL project

PURPOSE

To understand motivators, concerns, and factors associated with COVID-19 vaccine initiation for adults in five racial/ethnic communities across Colorado.

METHODS

Community-based data collectors surveyed participants from five Colorado communities (urban and rural Latina/o/x, urban Black, rural African American immigrant, and urban American Indian) about vaccine attitudes, intentions, and uptake from September to December 2021. Bivariate and multivariable logistic regression models were used to examine factors associated with the primary outcome of COVID-19 vaccine "initiation."

RESULTS

Most participants (71.1%) reported having initiated COVID-19 vaccination; vaccine series completion was 65.1%. Both motivators and concerns about COVID-19 vaccines were prevalent. Vaccine hesitancy (OR: 0.41, 95% CI:0.32-0.53; p < .001) and low perceptions of COVID-19 vaccination social norms (OR: 0.48, 95% CI:0.27-0.84; p = .01) were associated with vaccine initiation.

CONCLUSION

Despite the limitation of a moderate sample size, our findings support the need for further interventions to increase vaccination against COVID-19 by reducing vaccine hesitancy and improving perceived social norms of vaccination in underserved Colorado communities.

IMPLICATIONS

To improve trust in vaccines and promote vaccine uptake, community messaging should be tailored to vaccination motivators and concerns and demonstrate COVID-19 vaccination as the community default.

Preterm Birth, Family Income, and Intergenerational Income Mobility

Importance

Preterm birth (PTB) has been associated with lower income in adulthood, but associations with intergenerational income mobility and the role of family socioeconomic status (SES) as modifying factor are unclear.

Objectives

To assess whether the association between PTB and income differs according to family SES at birth and to assess the association between PTB and intergenerational income mobility.

Design, Setting, and Participants

This study comprised a matched cohort of live births in Canada between January 1, 1990, and December 31, 1996, with follow-up until December 31, 2018. Statistical analysis was performed between May 2023 and March 2024.

Exposure

Preterm birth, defined as birth between 24 and 37 weeks' gestational age (with gestational age subcategories of 34-36, 32-33, 28-31, and 24-27 weeks) vs early and full term births (gestational age, 37-41 weeks).

Main Outcomes and Measures

Associations between PTB and annual adulthood income in 2018 Canadian dollars were assessed overall (current exhange rate: $1 = CAD $1.37) and stratified by family income quintiles, using generalized estimating equation regression models. Associations between PTB and percentile rank change (ie, difference between the rank of individuals and their parents in the income distribution within their respective generations) and upward or downward mobility (based on income quintile) were assessed using linear and multinomial logistic regressions, respectively.

Results

Of 1.6 million included births (51.1% boys and 48.9% girls), 6.9% infants were born preterm (5.4% born at 34-36 weeks, 0.7% born at 32-33 weeks, 0.5% born at 28-31 weeks, and 0.2% born at 24-27 weeks). After matching on baseline characteristics (eg, sex, province of birth, and parental demographics) and adjusting for age and period effects, PTB was associated with lower annual income (mean difference, CAD -$687 [95% CI, -$788 to -$586]; 3% lower per year), and the differences were greater among those belonging to families in the lowest family SES quintile (mean difference, CAD -$807 [95% CI, -$998 to -$617]; 5% lower per year). Preterm birth was also associated with lower upward mobility and higher downward mobility, particularly for those born earlier than 31 weeks' gestational age (24-27 weeks: mean difference in percentile rank change, -8.7 percentile points [95% CI, -10.5 to -6.8 percentile points]).

Conclusions and Relevance

In this population-based matched cohort study, PTB was associated with lower adulthood income, lower upward social mobility, and higher downward mobility, with greater differences among those belonging to economically disadvantaged families. Interventions to optimize socioeconomic outcomes of preterm-born individuals would need to define target population considering SES.

Patterns of Opioid Prescriptions in the Veterans Health Administration for Patients With Chronic Low-Back Pain After the Onset of the COVID-19 Pandemic: A Retrospective Cohort Analysis

The COVID-19 pandemic led to severe disruptions in health care and a relaxation of rules surrounding opioid prescribing-changes which led to concerns about increased reliance on opioids for chronic pain and a resurgence of opioid-related harms. Although some studies found that opioid prescriptions increased in the first 6 months of the pandemic, we know little about the longer-term effects of the pandemic on opioid prescriptions. Further, despite the prevalence of pain in veterans, we know little about patterns of opioid prescriptions in the Veterans Health Administration (VA) associated with the pandemic. Using a retrospective cohort of VA patients with chronic low-back pain, we examined the proportion of patients with an opioid prescription and mean morphine milligram equivalents over a 3-year period-1 year prior to and 2 years after the pandemic's onset. Analyses revealed that both measures fell during the entire observation period. The largest decrease in the odds of filling an opioid prescription occurred in the first quarter of the pandemic, but this downward trend continued throughout the observation period, albeit at a slower pace. Clinically meaningful differences in opioid prescriptions and dose over time did not emerge based on patient race or rurality; however, differences emerged between female and male veterans, with decreases in opioid prescriptions slowing more markedly for women after the pandemic onset. These findings suggest that the pandemic was not associated with short- or long-term increases in opioid prescriptions or doses in the VA. PERSPECTIVE: This article examines opioid prescribing over a 3-year period-1 year prior to and 2 years after the onset of the COVID-19 pandemic-for VA patients with chronic low-back pain. Results indicate that, despite disruptions to health care, opioid prescriptions and doses decreased over the entire observation period.

Penalized weighted smoothed quantile regression for high-dimensional longitudinal data

Quantile regression, known as a robust alternative to linear regression, has been widely used in statistical modeling and inference. In this paper, we propose a penalized weighted convolution-type smoothed method for variable selection and robust parameter estimation of the quantile regression with high dimensional longitudinal data. The proposed method utilizes a twice-differentiable and smoothed loss function instead of the check function in quantile regression without penalty, and can select the important covariates consistently using the efficient gradient-based iterative algorithms when the dimension of covariates is larger than the sample size. Moreover, the proposed method can circumvent the influence of outliers in the response variable and/or the covariates. To incorporate the correlation within each subject and enhance the accuracy of the parameter estimation, a two-step weighted estimation method is also established. Furthermore, we prove the oracle properties of the proposed method under some regularity conditions. Finally, the performance of the proposed method is demonstrated by simulation studies and two real examples.

Economic Burden of Acute Gastroenteritis among Members of Integrated Healthcare Delivery System, United States, 2014-2016

We conducted a large surveillance study among members of an integrated healthcare delivery system in Pacific Northwest of the United States to estimate medical costs attributable to medically attended acute gastroenteritis (MAAGE) on the day care was sought and during 30-day follow-up. We used multivariable regression to compare costs of MAAGE and non-MAAGE cases matched on age, gender, and index time. Differences accounted for confounders, including race, ethnicity, and history of chronic underlying conditions. Analyses included 73,140 MAAGE episodes from adults and 18,617 from children who were Kaiser Permanente Northwest members during 2014-2016. Total costs were higher for MAAGE cases relative to non-MAAGE comparators as were costs on the day care was sought and costs during follow-up. Costs of MAAGE are substantial relative to the cost of usual-care medical services, and much of the burden accrues during short-term follow-up.

Characterization of Demographical Histologic Diversity in Small Renal Masses With the Clear Cell Likelihood Score

OBJECTIVE

This study aimed to develop a diagnostic model to estimate the distribution of small renal mass (SRM; ≤4 cm) histologic subtypes for patients with different demographic backgrounds and clear cell likelihood score (ccLS) designations.

MATERIALS AND METHODS

A bi-institution retrospective cohort study was conducted where 347 patients (366 SRMs) underwent magnetic resonance imaging and received a ccLS before pathologic confirmation between June 2016 and November 2021. Age, sex, race, ethnicity, socioeconomic status, body mass index (BMI), and the ccLS were tabulated. The socioeconomic status for each patient was determined using the Area Deprivation Index associated with their residential address. The magnetic resonance imaging-derived ccLS assists in the characterization of SRMs by providing a likelihood of clear cell renal cell carcinoma (ccRCC). Pathological subtypes were grouped into four categories (ccRCC, papillary renal cell carcinoma, other renal cell carcinomas, or benign). Generalized estimating equations were used to estimate probabilities of the pathological subtypes across different patient subgroups.

RESULTS

Race and ethnicity, BMI, and ccLS were significant predictors of histology (all P < 0.001). Obese (BMI, ≥30 kg/m 2 ) Hispanic patients with ccLS of ≥4 had the highest estimated rate of ccRCC (97.1%), and normal-weight (BMI, <25 kg/m 2 ) non-Hispanic Black patients with ccLS ≤2 had the lowest (0.2%). The highest estimated rates of papillary renal cell carcinoma were found in overweight (BMI, 25-30 kg/m 2 ) non-Hispanic Black patients with ccLS ≤2 (92.3%), and the lowest, in obese Hispanic patients with ccLS ≥4 (<0.1%).

CONCLUSIONS

Patient race, ethnicity, BMI, and ccLS offer synergistic information to estimate the probabilities of SRM histologic subtypes.

The association between loneliness with health service use and quality of life among informal carers in Australia

OBJECTIVE

The demanding nature of caregiving and limited social support can lead to informal carers experiencing loneliness, which can impact their well-being and overall health service use (HSU). The study aims to examine the association between loneliness with HSU and Health state utility values among informal carers in Australia.

METHODS

Data were derived from three waves (2009, 2013, and 2017) of the nationally representative longitudinal Household Income and Labour Dynamics of Australia (HILDA) survey, focusing on adult informal carers. Outcome measures included visits to the General Practitioner, the number of hospital admissions, and the SF-6D score. Generalized Estimating Equations (GEE) analysis was conducted to explore the associations between loneliness and HSU, as well as loneliness and utility values (based on SF-6D) while adjusting for age, sex, education, marital status, income, and physical/mental health conditions.

RESULTS

After controlling for covariates, lonely carers reported lower utility values (IRR = 0.91, 95%CI [0.89, 0.93], p < 0.001) compared to non-lonely carers. Lonely carers reported a higher number of GP visits (IRR = 1.18, 95% CI [1.04, 1.36], p < 0.05) as well as a higher likelihood of visiting specialists (AOR = 1.31, p = 0.046) and hospital doctors (AOR = 1.42, p = 0.013) compared to the non-lonely carers.

CONCLUSIONS

The findings of this study highlight the relationship between loneliness on both healthcare utilization and carers' overall well-being. Addressing loneliness through targeted interventions and social support systems can help improve health outcomes and potentially reduce the overall healthcare costs among informal carers in Australia.

New Equations for the Estimation of the Age of the Formation of the Harris Lines

Harris Lines (HLs) are transverse, sclerotic lines that can be visualized by X-ray imaging and that occur in long bones, most commonly in the tibia and femur. HLs are associated with disrupted bone mineralization during endochondral ossification, affecting the normal growth process. The etiology of HLs is debated, with some claims linking their presence to detrimental factors such as inflammation, malnutrition, alcohol abuse, and diseases. The age at which HLs form can be estimated based on their location, which allows for a retrospective assessment of the individual's health status during childhood or youth. The current study is concerned with providing new equations to estimate the age of Harris Line occurrences using a simple calculating tool. Bone growth curves were derived based on a dataset provided by Byers in 1991 using non-linear estimation. The best model was chosen with the Akaike Information Criterion. New and old methods were compared through Bland-Altman plots. As a result, we managed to produce reliable, well-fitted growth curves, concordant with previous methods.

Provider-to-provider telehealth for sepsis patients in a cohort of rural emergency departments

BACKGROUND

Telehealth has been proposed as one strategy to improve the quality of time-sensitive sepsis care in rural emergency departments (EDs). The purpose of this study was to measure the association between telehealth-supplemented ED (tele-ED) care, health care costs, and clinical outcomes among patients with sepsis in rural EDs.

METHODS

Cohort study using Medicare fee-for-service claims data for beneficiaries treated for sepsis in rural EDs between February 1, 2017, and September 30, 2019. Our primary hospital-level analysis used multivariable generalized estimating equations to measure the association between treatment in a tele-ED-capable hospital and 30-day total costs of care. In our supporting secondary analysis, we conducted a propensity-matched analysis of patients who used tele-ED with matched controls from non-tele-ED-capable hospitals. Our primary outcome was total health care payments among index hospitalized patients between the index ED visit and 30 days after hospital discharge, and our secondary outcomes included hospital mortality, hospital length of stay, 90-day mortality, 28-day hospital-free days, and 30-day inpatient readmissions.

RESULTS

In our primary analysis, sepsis patients in tele-ED-capable hospitals had 6.7% higher (95% confidence interval [CI] 2.1%-11.5%) total health care costs compared to those in non-tele-ED-capable hospitals. In our propensity-matched patient-level analysis, total health care costs were 23% higher (95% CI 16.5%-30.4%) in tele-ED cases than matched non-tele-ED controls. Clinical outcomes were similar.

CONCLUSIONS

Tele-ED capability in a mature rural tele-ED network was not associated with decreased health care costs or improved clinical outcomes. Future work is needed to reduce rural-urban sepsis care disparities and formalize systems of regionalized care.

Factors associated with the outcome of root canal treatment-A cohort study conducted in a private practice

AIM

To investigate the association of various pre-, intra- and post-operative factors on root canal treatment outcome.

METHODOLOGY

In this cohort study, primary or secondary root canal treatment of mature permanent teeth was performed by a single endodontist in a private practice over 13 years, and followed 1-4 years after treatment. Treatment details and clinical and radiographic data were collected. The proportion of successfully treated teeth and roots based on strict radiographic (periapical index (PAI) ≤2) and clinical criteria (absence of pain, swelling or sinus tract) was estimated. To evaluate joint associations of prognostic factors and treatment success probability, 44 pre, intra- and post-operative factors were investigated using bivariate associations, and a multiple logistic regression model was fitted using Generalized Estimating Equations.

RESULTS

1259 teeth (2445 roots, 3149 canals) were assessed with a recall rate of 91%. The proportion of successfully treated teeth was 79.9% [95% confidence interval 77.7-82.1]. Eleven prognostic factors were identified that significantly reduced the odds ratio (OR) for treatment success at tooth level. Six were preoperative: injury history (OR = 0.05[0.01-0.24]), root PAI (OR = 0.29[0.20-0.42], 0.21[0.13-0.34] and 0.22[0.12-0.42] for PAI = 3, 4 and 5, respectively, against PAI = 1), lesion diameter (OR = 0.30[0.21-0.43] and 0.24[0.16-0.37] for diameters of 1-5 mm and ≥6 mm, respectively, against no lesion), tooth type (OR = 0.51[0.27-0.97] and OR = 0.45[0.24-0.83] for premolars and molars, respectively, against incisors or canines), tenderness to periapical palpation (OR = 0.64[0.43-0.94]) and two canals per root (OR = 0.67[0.54-0.83]). Four factors were intraoperative: root filling of unsatisfactory quality (OR = 0.18[0.08-0.40]) or extending beyond or shorter than 2 mm from the apex (OR = 0.44[0.26-0.75] and 0.62[0.40-0.97] respectively), resin sealer (OR = 0.58[0.39-0.87] against bioceramic sealer) and single visit treatment (OR = 0.40[0.21-0.75] against multiple visits). One factor was post-operative: defective coronal restoration (OR = 0.35[0.21-0.56]).

CONCLUSION

The following factors were associated with unsuccessful root canal treatment: (i) history of injury, apical periodontitis with increased severity (larger lesion, higher PAI, tenderness to periapical palpation), or complicated anatomic conditions (premolar or molar, two canals in a single root); (ii) technically suboptimal root filling (of unsatisfactory quality or not ending within 2 mm of radiographic apex) performed in a single-visit, or use of resin sealer instead of novel bioceramic sealer; (iii) suboptimal quality coronal restoration.

Novel insights into the pathogenesis of thyroid eye disease through ferroptosis-related gene signature and immune infiltration analysis

Thyroid eye disease (TED) has brought great physical and mental trauma to patients worldwide. Although a few potential signaling pathways have been reported, knowledge of TED remains limited. Our objective is to explore the fundamental mechanism of TED and identify potential therapeutic targets using diverse approaches. To perform a range of bioinformatic analyses, such as identifying differentially expressed genes (DEGs), conducting enrichment analysis, establishing nomograms, analyzing weighted gene correlation network analysis (WGCNA), and studying immune infiltration, the datasets GSE58331, GSE105149, and GSE9340 were integrated. Further validation was conducted using qPCR, western blot, and immunohistochemistry techniques. Eleven ferroptosis-related DEGs derived from the lacrimal gland were originally screened. Their high diagnostic value was proven, and diagnostic prediction nomogram models with high accuracy and robustness were established by using machine learning. A total of 15 hub gene-related DEGs were identified by WGCNA. Through CIBERSORTx, we uncovered five immune cells highly correlated with TED and found several special associations between these immune cells and the above DEGs. Furthermore, EGR2 from the thyroid sample was revealed to be closely negatively correlated with most DEGs from the lacrimal gland. High expression of APOD, COPB2, MYH11, and MYCN, as well as CD4/CD8 T cells and B cells, was verified in the periorbital adipose tissues of TED patients. To summarize, we discovered a new gene signature associated with ferroptosis that has a critical impact on the development of TED and provides valuable insights into immune infiltration. These findings might highlight the new direction and therapeutic strategies of TED.

Project CHARIOT: study protocol for a hybrid type 1 effectiveness-implementation study of comprehensive tele-harm reduction for engagement of people who inject drugs in HIV prevention services

BACKGROUND

People who inject drugs (PWID) remain a high priority population under the federal Ending the HIV Epidemic initiative with 11% of new HIV infections attributable to injection drug use. There is a critical need for innovative, efficacious, scalable, and community-driven models of healthcare in non-stigmatizing settings for PWID. We seek to test a Comprehensive-TeleHarm Reduction (C-THR) intervention for HIV prevention services delivered via a syringe services program (SSP).

METHODS

The CHARIOT trial is a hybrid type I effectiveness-implementation study using a parallel two-arm randomized controlled trial design. Participants (i.e., PWID; n = 350) will be recruited from a syringe services program (SSP) in Miami, Florida. Participants will be randomized to receive either C-THR or non-SSP clinic referral and patient navigation. The objectives are: (1) to determine if the C-THR intervention increases engagement in HIV prevention (i.e., HIV pre-exposure prophylaxis; PrEP or medications for opioid use disorder; MOUD) compared to non-SSP clinic referral and patient navigation, (2) to examine the long-term effectiveness and cost-effectiveness of the C-THR intervention, and (3) to assess the barriers and facilitators to implementation and sustainment of the C-THR intervention. The co-primary outcomes are PrEP or MOUD engagement across follow-up at 3, 6, 9 and 12 months. For PrEP, engagement is confirmed by tenofovir on dried blood spot or cabotegravir injection within the previous 8 weeks. For MOUD, engagement is defined as screening positive for norbuprenorphine or methadone on urine drug screen; or naltrexone or buprenorphine injection within the previous 4 weeks. Secondary outcomes include PrEP adherence, engagement in HCV treatment and sustained virologic response, and treatment of sexually transmitted infections. The short and long term cost-effectiveness analyses and mixed-methods implementation evaluation will provide compelling data on the sustainability and possible impact of C-THR on comprehensive HIV prevention delivered via SSPs.

DISCUSSION

The CHARIOT trial will be the first to our knowledge to test the efficacy of an innovative, peer-led telehealth intervention with PWID at risk for HIV delivered via an SSP. This innovative healthcare model seeks to transform the way PWID access care by bypassing the traditional healthcare system, reducing multi-level barriers to care, and meeting PWID where they are.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05897099. Trial registry name: Comprehensive HIV and Harm Prevention Via Telehealth (CHARIOT). Registration date: 06/12/2023.

Derivation and validation of a risk-stratification model for patients with probable or proven COVID-19 in EDs: the revised HOME-CoV score

BACKGROUND

The HOME-CoV (Hospitalisation or Outpatient ManagEment of patients with SARS-CoV-2 infection) score is a validated list of uniquely clinical criteria indicating which patients with probable or proven COVID-19 can be treated at home. The aim of this study was to optimise the score to improve its ability to discriminate between patients who do and do not need admission.

METHODS

A revised HOME-CoV score was derived using data from a previous prospective multicentre study which evaluated the original Home-CoV score. Patients with proven or probable COVID-19 attending 34 EDs in France, Monaco and Belgium between April and May 2020 were included. The population was split into a derivation and validation sample corresponding to the observational and interventional phases of the original study. The main outcome was non-invasive or invasive ventilation or all-cause death within 7 days following inclusion. Two threshold values were defined using a sensitivity of >0.9 and a specificity of >0.9 to identify low-risk and high-risk patients, respectively. The revised HOME-CoV score was then validated by retrospectively applying it to patients in the same EDs with proven or probable COVID-19 during the interventional phase. The revised HOME-CoV score was also tested against original HOME-CoV, qCSI, qSOFA, CRB65 and SMART-COP in this validation cohort.

RESULTS

There were 1696 patients in the derivation cohort, of whom 65 (3.8%) required non-invasive ventilation or mechanical ventilation or died within 7 days and 1304 patients in the validation cohort, of whom 22 (1.7%) had a progression of illness. The revised score included seven clinical criteria. The area under the curve (AUC) was 87.6 (95% CI 84.7 to 90.6). The cut-offs to define low-risk and high-risk patients were <2 and >3, respectively. In the validation cohort, the AUC was 85.8 (95% CI 80.6 to 91.0). A score of <2 qualified 73% of patients as low risk with a sensitivity of 0.77 (0.55-0.92) and a negative predictive value of 0.99 (0.99-1.00).

CONCLUSION

The revised HOME-CoV score, which does not require laboratory testing, may allow accurate risk stratification and safely qualify a significant proportion of patients with probable or proven COVID-19 for home treatment.

Hedonic property values and water quality: A meta-analysis of commodity, market, and methodological choices

This study quantitatively reviews the hedonic literature examining surface water quality to assess how attributes of the commodity, housing market, and methodological choices lead to variation in the significance and expected sign of the estimated property value effects (i.e., elasticities). We conduct a meta-analysis of 29 studies with 290 unique estimates, published or released between 1985 and 2017, and find evidence based on probit meta-regression models that some of the definitions and decisions made in primary studies do influence the estimated relationship between water quality and home prices. Our most robust evidence suggests that methodological choices (e.g., accounting for spatial dependence, or if the water quality measure was based on something other than in situ measurement) have a critical role in determining the likelihood of finding a significant and theoretically expected result; and perhaps most importantly, it is not always selections that reflect best practices that lead to this finding. This study can help identify potential concerns with data and modeling choices in the collective hedonic literature focused on water quality.

Physiological changes in captive elephants in northern Thailand as a result of the COVID-19 tourism ban-stress biomarkers

The international travel ban instituted by the Thai government in March 2020 in response to the COVID-19 pandemic greatly affected how tourist camp elephants were managed, with reductions in exercise opportunities, longer chaining hours, and diminished food provisioning. This study was conducted to determine how those changes affected health and welfare biomarkers in individual elephants over the 2 years of the countrywide lockdown (April 2020-April 2022). Blood and fecal samples were collected from 58 elephants at six camps (monthly in Year 1, quarterly in Year 2) and analyzed for stress biomarkers - fecal glucocorticoid metabolites (fGCM), serum oxidative stress [malondialdehyde (MDA) and 8-hydroxy-2'-deoxyguanosine (8-OHdG)], and stress leukograms. Overall, fGCM concentrations increased within the first few months and remained higher than pre-COVID levels, as did the H/L ratio, a measure affected by cortisol. Serum 8-OHdG, an indicator of DNA oxidative damage, also increased over time, while monocytosis and lymphopenia further suggested alterations in immune function as a result of stress. By contrast, another marker of oxidative stress, serum MDA, declined, possibly in response to reduced roughage and supplement intake. A notable finding was a seasonal pattern of fGCM that was significantly different from previous studies. Whereas higher fGCM during the rainy season were observed in this study, previously, concentrations were highest during the winter, high tourist season. Thus, ironically, both the presence and absence of tourists have been associated with increased fGCM concentrations, albeit for different reasons. Camp management factors negatively affecting stress outcomes included shorter chain lengths, longer chain hours, lack of exercise, and reduced roughage and supplements. Overall, it was clear that camps struggled to maintain adequate care for elephants during the COVID-19 pandemic, highlighting the importance of tourist income and need for contingency plans to cope with potential future disruptions to tourism.

Antimicrobial resistance in Escherichia coli isolated from pigs and associations with aggregated antimicrobial usage in Ireland: A herd-level exploration

AIMS

Antimicrobial resistance (AMR) is of significant global concern and is a major One Health issue. There is evidence to suggest that increased antimicrobial usage (AMU) can be associated with AMR patterns, and therefore, there have been efforts to reduce AMU in anticipation of reducing AMR emergence risk. The aim of this study was to investigate whether there were any associations between AMU and AMR patterns of commensal Escherichia coli isolated from pig herds in Ireland.

METHODS AND RESULTS

Data on AMR from a panel of antimicrobials (AMDs) were gathered as part of national surveillance activities. These data were associated with reported usage of AMDs, on a year-quarter basis, measured in mg/kg at a herd-level using generalized estimating equation regression analysis. Associations were tested with AMR presence or multi-drug resistance (MDR; ≥3 classes) profiles and total AMU during the contemporaneous quarter and previous quarter, respectively. Furthermore, individual and AMD class-based associations were tested. The final dataset contained 218 observations (herd-quarter usage and AMR resistance profile) from 122 herds during 2019-2021. Apparent resistance prevalence varied according to AMD type, with the highest mean prevalence found with tetracycline at 51.57% (95% CI: 45.06%-58.09%). There were significant associations between a herd obtaining a positive AMR result for any AMDs and the overall levels of AMU during the year-quarter. Furthermore, there were significant positive associations between MDR and total AMU. At the compound level, chloramphenicol resistance was significantly associated with increased usage of trimethoprim/sulfadiazine and chlortetracycline, respectively (p < 0.010). Tetracycline resistance was associated with increased use of chlortetracycline (p = 0.008). At the antimicrobial class level, there was a significant positive relationship between the usage of phenicol and the probability of a resistance for chloramphenicol (p = 0.026) and between the usage of tetracycline and tetracycline resistance probability (p = 0.018).

CONCLUSIONS

Our data provide evidence of associations between overall AMU and AMR or MDR risk at the herd-quarter level. There was also evidence of associations between specific AMDs and patterns of resistance. Associations varied depending on whether time lags in usage were modelled or how usage was modelled (e.g. dichotomized or continuous). Associations with rarely used AMDs (e.g. critically important AMDs) were precluded due to a lack of statistical power. Continued monitoring of both AMU and AMR is crucial to assess the impacts of policy changes aimed at reducing AMU.

Intra- and Peritumoral Based Radiomics for Assessment of Lymphovascular Invasion in Invasive Breast Cancer

BACKGROUND

Radiomics has been applied for assessing lymphovascular invasion (LVI) in patients with breast cancer. However, associations between features from peritumoral regions and the LVI status were not investigated.

PURPOSE

To investigate the value of intra- and peritumoral radiomics for assessing LVI, and to develop a nomogram to assist in making treatment decisions.

STUDY TYPE

Retrospective.

POPULATION

Three hundred and sixteen patients were enrolled from two centers and divided into training (N = 165), internal validation (N = 83), and external validation (N = 68) cohorts.

FIELD STRENGTH/SEQUENCE

1.5 T and 3.0 T/dynamic contrast-enhanced (DCE) and diffusion-weighted imaging (DWI).

ASSESSMENT

Radiomics features were extracted and selected based on intra- and peritumoral breast regions in two magnetic resonance imaging (MRI) sequences to create the multiparametric MRI combined radiomics signature (RS-DCE plus DWI). The clinical model was built with MRI-axillary lymph nodes (MRI ALN), MRI-reported peritumoral edema (MPE), and apparent diffusion coefficient (ADC). The nomogram was constructed with RS-DCE plus DWI, MRI ALN, MPE, and ADC.

STATISTICAL TESTS

Intra- and interclass correlation coefficient analysis, Mann-Whitney U test, and least absolute shrinkage and selection operator regression were used for feature selection. Receiver operating characteristic and decision curve analyses were applied to compare performance of the RS-DCE plus DWI, clinical model, and nomogram.

RESULTS

A total of 10 features were found to be associated with LVI, 3 from intra- and 7 from peritumoral areas. The nomogram showed good performance in the training (AUCs, nomogram vs. clinical model vs. RS-DCE plus DWI, 0.884 vs. 0.695 vs. 0.870), internal validation (AUCs, nomogram vs. clinical model vs. RS-DCE plus DWI, 0.813 vs. 0.695 vs. 0.794), and external validation (AUCs, nomogram vs. clinical model vs. RS-DCE plus DWI, 0.862 vs. 0.601 vs. 0.849) cohorts.

DATA CONCLUSION

The constructed preoperative nomogram might effectively assess LVI.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY: Stage 2.

Temporal dynamics and drivers of durable HIV viral load suppression and persistent high- and low-level viraemia during Universal Test and Treat scale-up in Uganda: a population-based study

INTRODUCTION

Population-level data on durable HIV viral load suppression (VLS) following the implementation of Universal Test and Treat (UTT) in Africa are limited. We assessed trends in durable VLS and viraemia among persons living with HIV in 40 Ugandan communities during the UTT scale-up.

METHODS

In 2015-2020, we measured VLS (<200 RNA copies/ml) among participants in the Rakai Community Cohort Study, a longitudinal population-based HIV surveillance cohort in southern Uganda. Persons with unsuppressed viral loads were characterized as having low-level (200-999 copies/ml) or high-level (≥1000 copies/ml) viraemia. Individual virologic outcomes were assessed over two consecutive RCCS survey visits (i.e. visit-pairs; ∼18-month visit intervals) and classified as durable VLS (<200 copies/ml at both visits), new/renewed VLS (<200 copies/ml at follow-up only), viral rebound (<200 copies/ml at initial visit only) or persistent viraemia (≥200 copies/ml at both visits). Population prevalence of each outcome was assessed over calendar time. Community-level prevalence and individual-level predictors of persistent high-level viraemia were also assessed using multivariable Poisson regression with generalized estimating equations.

RESULTS

Overall, 3080 participants contributed 4604 visit-pairs over three survey rounds. Most visit-pairs (72.4%) exhibited durable VLS, with few (2.5%) experiencing viral rebound. Among those with any viraemia at the initial visit (23.5%, n = 1083), 46.9% remained viraemic through follow-up, 91.3% of which was high-level viraemia. One-fifth (20.8%) of visit-pairs exhibiting persistent high-level viraemia self-reported antiretroviral therapy (ART) use for ≥12 months. Prevalence of persistent high-level viraemia varied substantially across communities and was significantly elevated among young persons aged 15-29 years (vs. 40- to 49-year-olds; adjusted risk ratio [adjRR] = 2.96; 95% confidence interval [95% CI]: 2.21-3.96), males (vs. females; adjRR = 2.40, 95% CI: 1.87-3.07), persons reporting inconsistent condom use with non-marital/casual partners (vs. persons with marital/permanent partners only; adjRR = 1.38, 95% CI: 1.10-1.74) and persons reporting hazardous alcohol use (adjRR = 1.09, 95% CI: 1.03-1.16). The prevalence of persistent high-level viraemia was highest among males <30 years (32.0%).

CONCLUSIONS

Following universal ART provision, most persons living with HIV in south-central Uganda are durably suppressed. Among persons exhibiting any viraemia, nearly half exhibited high-level viraemia for ≥12 months and reported higher-risk behaviours associated with onward HIV transmission. Intensified efforts linking individuals to HIV treatment services could accelerate momentum towards HIV epidemic control.

Prevalence, correlates, and quality-of-life outcomes of major or persistent pain among women living with HIV in Metro Vancouver, Canada

While women living with HIV (WLWH) are twice as likely to report severe or undertreated chronic pain compared to men, little is known about pain among WLWH. Our goal was to characterize the correlates of pain as well as its impact on quality-of-life outcomes among women enrolled in the Sexual Health and HIV/AIDS Women's Longitudinal Needs Assessment (SHAWNA), an open longitudinal study of WLWH accessing care in Metro Vancouver, Canada. We conducted logistic regression analyses to identify associations between self-reported major or persistent pain with sociostructural and psychosocial correlates and with quality-of-life outcomes. Data are presented as adjusted odds ratios (aORs) with 95% confidence intervals. Among 335 participants, 77.3% reported pain at ≥ 1 study visit, with 46.3% experiencing any undiagnosed pain and 53.1% managing pain with criminalized drugs. In multivariable analysis, age (aOR 1.04[1.03-1.06] per year increase), food and housing insecurity (aOR 1.54[1.08-2.19]), depression diagnosis (aOR 1.34[1.03-1.75]), suicidality (aOR 1.71[1.21-2.42]), and non-daily, non-injection opioid use (aOR 1.53[1.07-2.17]) were associated with higher odds of pain. Daily non-injection opioid use (aOR 0.46[0.22-0.96]) and health services access (aOR 0.63[0.44-0.91]) were associated with lower odds of pain. In separate multivariable confounder models, pain was associated with reduced odds of good self-rated health (aOR 0.64[0.48-0.84] and increased odds of health interference with social activities (aOR 2.21[1.63-2.99]) and general function (aOR 3.24[2.54-4.13]). In conclusion, most WLWH in our study reported major or persistent pain. Pain was commonly undiagnosed and associated with lower quality of life. We identified structural and psychosocial factors associated with pain in WLWH, emphasizing the need for low-barrier, trauma-informed, and harm reduction-based interventions.

Shared decision-making and client-reported dose satisfaction in a longitudinal cohort receiving injectable opioid agonist treatment (iOAT)

BACKGROUND

Across different types of oral Opioid Agonist Treatment for people with Opioid Use Disorder, receiving a dose that meets their needs is associated with better outcomes. Evidence also shows patients are more likely to receive an "adequate dose" when their prescribers are involving them in decision making. Neither of these findings have been studied in the context of injectable Opioid Agonist Treatment, which is the purpose of this study.

METHODS

This study was a retrospective analysis of an 18-month prospective longitudinal cohort study of 131 people receiving injectable Opioid Agonist Treatment. In the 18-month study, observations were collected every two months for one year, and then once more at 18 months. At 6 months, participants were asked whether their dose was satisfactory to them (outcome variable). Generalized Estimating Equations were used, to account for multiple observations from each participant. The final multivariate model was built using a stepwise approach.

RESULTS

Five hundred forty-five participant-observations were included in the analysis. Participant-observations were grouped by "dose is satisfactory" and "wants higher dose". From unadjusted analyses, participants were less likely to report being satisfied with their dose if they: were Indigenous, had worse psychological or physical health problems, had ever attempted suicide, were younger when they first injected any drug, were a current smoker, felt troubled by drug problems, gave their medication a lower "drug liking" score, and felt that their doctor was not including them in decisions the way they wanted to be. In the final multivariate model, all previously significant associations except for "current smoker" and "troubled by drug problems" were no longer significant after the addition of the "drug liking" score.

CONCLUSIONS

Patients in injectable Opioid Agonist Treatment who are not satisfied with their dose are more likely to: be troubled by drug problems, be a current smoker, and report liking their medication less than dose-satisfied patients. Prescribers' practicing shared decision-making can help patients achieve dose-satisfaction and possibly alleviate troubles from drug problems. Additionally, receiving a satisfactory dose may be dependent on patients being able to access an opioid agonist medication (and formulation) that they like.

Entheseal changes and activity patterns in southern African hunter-gatherer/herders from the Holocene

OBJECTIVES

Activity patterns and lifeways in southern African hunter-gatherer/herders (sAHGH) during the Holocene were dynamic, with subsistence activities and mobility varying through space and time. In this study, spatial and temporal variations in entheseal changes (ECs) are assessed as physical activity markers in sAHGH from the Holocene.

METHODS

The Coimbra method was used to assess fibrocartilaginous ECs in the upper and lower limbs of 118 sAHGH from the Holocene. Descriptive statistics and generalized estimating equations were used to explore the association between ECs, sex, age, ecological biomes, and temporality.

RESULTS

A total of 118 individuals were sampled, comprising 67 males, and 42 females, mostly from the fynbos (59/118), forest (30/118) and succulent karoo biomes (16/118). ECs were identified in 94% of the sample. Interobserver scoring suggests our findings are likely to underrepresent the extent of EC score differences in sAHGH. Findings indicate a complex pattern of physical activity in sAHGH with differences attributable to regional ecology rather than age or sex. More prominent ECs were identified in individuals from the forest biome, relative to the fynbos and succulent karoo biomes. These were consistent with resource search and processing costs, and terrain differences in these ecozones. ECs were only detected temporally relative to the infiltration of pastoralism (at 2000 BP) when the data were stratified by ecological biome.

DISCUSSION

This study provides evidence that regional ecology plays a central role in driving activity patterns regardless of social or cultural organization. Ecological biomes provide a gradient along which the temporal impact of resource limitations on human biology, activity patterns and sociocultural behaviors can be studied.

Statistical modeling of diffusive CO2 emissions before the creation of the SINOP hydroelectric reservoir, Brazil

Abstract Several discussions have arisen about energy from hydroelectric plants being considered clean energy and its reservoirs have been investigated due to the large emission of greenhouse gases (GHG), such as carbon dioxide, methane, and nitrous oxide. The present work shows a statistical study of the diffusive CO2 emissions before the formation of the reservoir of the hydroelectric power plant (HPP) of SINOP, Brazil. The association between emissions collected at the surface (water-air) and at the bottom of the reservoir (sediment-water) was investigated during four data collection campaigns, carried out from November 2017 to September 2018. This study aims to compare the effect of reservoir depth on the diffusive flow of CO2 at 34 collection points. The variable depth analyzed was defined from points collected on the surface and bottom of the reservoir. The objective is to detect whether different periods of time and whether the depth of the reservoir have a direct impact on the behavior of diffusive CO2 emissions. As the measurements of the observational unit are repeatedly observed, there is a multilevel structure, individuals are independent of each other, but there is an intra-individual correlation. Considering this data configuration, an estimation of generalized equations (GEE) was performed, which is a technique that estimates the intra-individual correlation matrix and thus produces estimates for the parameters of the generalized regression models (Generalized Regression Models – GLM) that are not biased. The study showed that the average diffusive CO2 emissions are higher on the reservoir surface. The study also found that, on average, there are more emissions during the rainy season in the region than during the dry season.

Ct-based subregional radiomics using hand-crafted and deep learning features for prediction of therapeutic response to anti-PD1 therapy in NSCLC

PURPOSE

To develop and externally validate subregional radiomics for predicting therapeutic response to anti-PD1 therapy in non-small-cell lung cancer (NSCLC).

METHODS

Sixty-six patients from center 1 served as training and internal validation cohorts. Thirty patients from center 2 and thirty patients from center 3 served as external validation 1 and external validation 2 cohorts, respectively. The lesions identified on CT scans were subdivided into two phenotypically consistent subregions by automatic clustering on the patient-level and population-level (denoted as marginal S1 and inner S2). Handcrafted and deep learning-based features were extracted separately from the entire tumor region and subregions, then selected using the intraclass correlation coefficient and least absolute shrinkage and selection operator regression (LASSO). Radiomics signatures (RSs) were built integrating the selected features and correlation coefficients using a logistic regression method. Area under the receiver operating characteristic (ROC) curve (AUC) was calculated to assess the RSs.

RESULTS

RSs derived from S1 outperformed those from S2 and the whole tumor region for both handcrafted and deep learning features. The Fusion-RS incorporating the two feature types achieved the best prediction performance in training (AUC = 0.947, 95 % Confidence Interval [CI] 0.905-0.989, SPE = 0.895, SEN = 0.878), internal validation (AUC = 0.875, 95 % CI: 0.782-0.969, SPE = 0.724, SEN = 0.952), external validation 1 (AUC = 0.836, 95 % CI: 0.694-0.977, SPE = 1.000, SEN = 0.533) and external validation 2 (AUC = 0.783, 95 % CI: 0.613-0.953, SPE = 0.765, SEN = 0.692) cohorts.

CONCLUSIONS

Subregional radiomics analysis can be useful for predicting therapeutic response to anti-PD1 therapy. The developed Fusion-RS may be considered as a potential non-invasive tool for individual treatment managements.

Physiological changes in captive elephants in Northern Thailand as a result of the COVID-19 tourism ban - muscle, liver, metabolic function, and body condition

The international travel ban initiated in March 2020 due to the COVID-19 pandemic greatly affected how captive elephants were managed in Thailand. A lack of tourists and associated income meant elephants were chained longer with reduced food provisions, had fewer mahouts, and limited exercise like riding, which likely affected health and welfare. Fifty-eight elephants from six tourist camps were assigned a body condition score (BCS) and blood samples were collected monthly for 2 years during the travel ban to measure: (1) muscle enzymes [creatine kinase (CK), aspartate aminotransferase (AST)]; (2) liver enzymes [aspartate aminotransferase (AST), alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT)]; (3) lipids [total cholesterol (TC), triglycerides (TG), low (LDL) and high (HDL) density lipoproteins]; and metabolic function [glucose, insulin, fructosamine]. Serum CK concentrations were lower at the end of the study, possibly due to no tourist activities like riding. Changes in liver function included increased AST and ALP, also possibly due to physical inactivity. Feeding less bananas and sugar cane was associated with fewer elephants in the obese category and lower TG concentrations. However, increases in glucose, insulin and fructosamine were observed as local people returned to feed elephants after lifting travel restrictions. In sum, changes in several health biomarkers were observed in association with restricted activities and food resources. Camps need better plans to meet the health and welfare needs of elephants during any future disruptions to the tourism industry, although reduced feeding of sweet treats appeared to have positive effects on body condition and metabolic function.