Akaike's information criterion in generalized estimating equations

Assessment of HCC response to Yttrium-90 radioembolization with gadoxetate disodium MRI: correlation with histopathology

BACKGROUND AND AIMS

Transarterial ⁹⁰Y radioembolization (TARE) is increasingly being used for hepatocellular carcinoma (HCC) treatment. However, tumor response assessment after TARE may be challenging. We aimed to assess the diagnostic performance of gadoxetate disodium MRI for predicting complete pathologic necrosis (CPN) of HCC treated with TARE, using histopathology as the reference standard.

METHODS

This retrospective study included 48 patients (M/F: 36/12, mean age: 62 years) with HCC treated by TARE followed by surgery with gadoxetate disodium MRI within 90 days of surgery. Two radiologists evaluated tumor response using RECIST1.1, mRECIST, EASL, and LI-RADS-TR criteria and evaluated the percentage of necrosis on subtraction during late arterial, portal venous, and hepatobiliary phases (AP/PVP/HBP). Statistical analysis included inter-reader agreement, correlation between radiologic and pathologic percentage of necrosis, and prediction of CPN using logistic regression and ROC analyses.

RESULTS

Histopathology demonstrated 71 HCCs (2.8 ± 1.7 cm, range: 0.5-7.5 cm) including 42 with CPN, 22 with partial necrosis, and 7 without necrosis. EASL and percentage of tumor necrosis on subtraction at the AP/PVP were independent predictors of CPN (p = 0.02-0.03). Percentage of necrosis, mRECIST, EASL, and LI-RADS-TR had fair to good performance for diagnosing CPN (AUCs: 0.78 - 0.83), with a significant difference between subtraction and LI-RADS-TR for reader 2, and in specificity between subtraction and other criteria for both readers (p-range: 0.01-0.04). Radiologic percentage of necrosis was significantly correlated to histopathologic degree of tumor necrosis (r = 0.66 - 0.8, p < 0.001).

CONCLUSIONS

Percentage of tumor necrosis on subtraction and EASL criteria were significant independent predictors of CPN in HCC treated with TARE. Image subtraction should be considered for assessing HCC response to TARE when using MRI.

KEY POINTS

• Percentage of tumor necrosis on image subtraction and EASL criteria are significant independent predictors of complete pathologic necrosis in hepatocellular carcinoma treated with⁹⁰Y radioembolization. • Subtraction, mRECIST, EASL, and LI-RADS-TR have fair to good performance for diagnosing complete pathologic necrosis in hepatocellular carcinoma treated with⁹⁰Y radioembolization.

Analyzing differences between restricted mean survival time curves using pseudo-values

Hazard ratios are ubiquitously used in time to event analysis to quantify treatment effects. Although hazard ratios are invaluable for hypothesis testing, other measures of association, both relative and absolute, may be used to fully elucidate study results. Restricted mean survival time (RMST) differences between groups have been advocated as useful measures of association. Recent work focused on model-free estimates of the difference in restricted mean survival through follow-up times, instead of focusing on a single time horizon. The resulting curve can be used to quantify the association in time units with a simultaneous confidence band. In this work a model-based estimate of the curve is proposed using pseudo-values allowing for possible covariate adjustment. The method is easily implementable with available software and makes possible to compute a simultaneous confidence region for the curve. The pseudo-values regression using multiple restriction times is in good agreement with the estimates obtained by standard direct regression models fixing a single restriction time. Moreover, the proposed method is flexible enough to reproduce the results of the non-parametric approach when no covariates are considered. Examples where it is important to adjust for baseline covariates will be used to illustrate the different methods together with some simulations.

Provider-Referred Versus Self-Referred Emergency Department Visit After Urgent Care Center Visit

BACKGROUND

Urgent care centers (UCCs) provide an alternative to emergency departments (EDs) for low-acuity acute care, as they are convenient with shorter wait time, but little is known about the quality of care at UCCs.

OBJECTIVE

We described and determined the differences in characteristics of patients who were sent to the ED by UCC physicians (provider-referred) with those of patients who went to the ED on their own (self-referred) within 72 h of discharge after a UCC visit. Our primary objective was to investigate whether observation unit use or hospital admission rates were different between the two groups. Our secondary objective was to identify whether their follow-up ED visits were avoidable.

METHODS

We conducted this prospective cohort study between March 22, 2017 and September 30, 2018 in a closed health system. A total of 53,178 UCC visits resulted in 582 provider-referred and 263 self-referred ED visits. We compared the characteristics of the two groups and measured the outcomes of observation unit or hospital admissions.

RESULTS

Patients with self-referred ED visits were younger; mean (standard deviation) age was 47.9 (24.5) years. Provider-referred patients appeared to be significantly associated with observation unit or hospital admission (odds ratio [OR] 1.75; 95% confidence interval [CI] 1.24-2.46). Among the predictors for observation unit or hospital admission, consultation with a specialist in the ED was the strongest (adjusted OR 9.09; 95% CI 6.24-13.24); other significant predictors were Medicaid or no insurance.

CONCLUSIONS

We found that after an urgent care visit, patients who were sent to the ED by a UCC provider were not more likely than self-referred patients to be admitted to an observation unit or hospital from the ED. Significant predictors for observation unit or hospital admission after UCC discharge were specialist consultation and type of insurance.

Baseline Predictors of Longitudinal Changes in Symptom Severity and Quality of Life in Patients With Suspected Gastroparesis

BACKGROUND & AIMS

Whether gastric emptying tests predict longitudinal outcomes in patients with symptoms of gastroparesis is unclear. We aimed to determine whether baseline gastric emptying tests and gut motility parameters could impact longitudinal symptom(s) and quality of life (QOL) in a prospective, observational cohort study of patients with symptoms of gastroparesis.

METHODS

One hundred fifty patients with gastroparesis symptoms underwent simultaneous scintigraphy (GES) and wireless motility capsule (WMC) measurement of gastric emptying and other motility parameters. Patient Assessment of Upper Gastrointestinal Symptoms and Quality of Life were administered at baseline, and 3 and 6 months after testing. Multivariable generalized linear marginal models were fit to determine which baseline parameters predict longitudinal changes in symptoms and QOL.

RESULTS

Overall upper GI symptoms and QOL scores were moderate in severity at baseline and significantly improved over 6 months. Clinical variables, including female gender, harder stools by Bristol stool form score, and presence of functional dyspepsia (FD) by Rome III criteria, were predictive of more severe upper GI symptoms. Even after controlling for these clinical factors, delayed gastric emptying by GES or WMC was associated with worse symptom severity and QOL scores. Low gastric and elevated small bowel contractile parameters by WMC were also independently associated with more severe upper GI symptoms and worse QOL scores.

CONCLUSIONS

Baseline features, including demographic and clinical variables, delayed gastric emptying and abnormal gastrointestinal contractility, were independent predictors of more severe longitudinal symptoms and worse quality of life outcomes. These factors may help to risk stratify patients and guide treatment decisions. ClinicalTrials.gov no: NCT02022826.

The Influence of Visual-Manual Distractions on Anticipatory Driving

OBJECTIVE

The aim of this study is to investigate how anticipatory driving is influenced by distraction.

BACKGROUND

The anticipation of future events in traffic can allow potential gains in recognition and response times. Anticipatory actions (i.e., control actions in preparation for potential traffic changes) have been found to be more prevalent among experienced drivers in simulator studies when driving was the sole task. Despite the prevalence of visual-manual distractions and their negative effects on road safety, their influence on anticipatory driving has not yet been investigated beyond hazard anticipation.

METHODS

A simulator experiment was conducted with 16 experienced and 16 novice drivers. Half of the participants were provided with a self-paced visual-manual secondary task presented on a dashboard display.

RESULTS

More anticipatory actions were observed among experienced drivers; experienced drivers also exhibited more efficient visual scanning behaviors as indicated by higher glance rates toward and percent times looking at cues that facilitate the anticipation of upcoming events. Regardless of experience, those with the secondary task displayed reduced anticipatory actions and paid less attention toward anticipatory cues. However, experienced drivers had lower odds of exhibiting long glances toward the secondary task compared to novices. Further, the inclusion of glance duration on anticipatory cues increased the accuracy of a model predicting anticipatory actions based on on-road glance durations.

CONCLUSION

The results provide additional evidence to existing literature supporting the role of driving experience and distraction engagement in anticipatory driving.

APPLICATION

These findings can guide the design of in-vehicle systems and guide training programs to support anticipatory driving.

Course of screening-based depression in young adults with a long type 1 diabetes duration: Prevalence and transition probabilities - A cohort study

AIMS

To extend the current knowledge of the prevalence and course of screening-based depression (SBD) and its predictors in emerging adults with a long type 1 diabetes duration.

METHODS

A total of 487 young adults (64.7% women, mean age 24.0 years) who participated in a nationwide cohort study provided data on SBD (Patient Health Questionnaire (PHQ-9) score ≥ 10). We estimated the overall and age- and sex-specific prevalence of SBD, identified the associated covariates, and determined the transition probabilities between SBD states using adjusted first-order Markov transition models.

RESULTS

The prevalence of SBD was 17.7% in women and 7.0% in men. A total of 70.4% (95%-CI 57.4%; 80.8%) of the participants with SBD at the first screening still had SBD at the three-year follow-up. Of the subjects without SBD at baseline, 6.9% (4.9%; 9.8%) had SBD at follow-up. The main predictor of current SBD was previous SBD (OR 39.0 (15.4; 98.6)), followed by living in one's own or in a shared apartment vs. living with both parents (OR: 2.75 (1.03; 7.36)).

CONCLUSIONS

Using an innovative analytical approach, emerging adults with a long diabetes duration demonstrated a moderate rate of incident SBD but a high rate of persistent SBD.

Effects of Drought on Mortality in Macro Urban Areas of Brazil Between 2000 and 2019

A significant fraction of Brazil's population has been exposed to drought in recent years, a situation that is expected to worsen in frequency and intensity due to climate change. This constitutes a current key environmental health concern, especially in densely urban areas such as several big cities and suburbs. For the first time, a comprehensive assessment of the short-term drought effects on weekly non-external, circulatory, and respiratory mortality was conducted in 13 major Brazilian macro-urban areas across 2000-2019. We applied quasi-Poisson regression models adjusted by temperature to explore the association between drought (defined by the Standardized Precipitation-Evapotranspiration Index) and the different mortality causes by location, sex, and age groups. We next conducted multivariate meta-analytical models separated by cause and population groups to pool individual estimates. Impact measures were expressed as the attributable fractions among the exposed population, from the relative risks (RRs). Overall, a positive association between drought exposure and mortality was evidenced in the total population, with RRs varying from 1.003 [95% CI: 0.999-1.007] to 1.010 [0.996-1.025] for non-external mortality related to moderate and extreme drought conditions, from 1.002 [0.997-1.007] to 1.008 [0.991-1.026] for circulatory mortality, and from 1.004 [0.995-1.013] to 1.013 [0.983-1.044] for respiratory mortality. Females, children, and the elderly population were the most affected groups, for whom a robust positive association was found. The study also revealed high heterogeneity between locations. We suggest that policies and action plans should pay special attention to vulnerable populations to promote efficient measures to reduce vulnerability and risks associated with droughts.

Evaluating the Ability to Consent to Research: A Twenty-Year Track Record

Occasionally, the ability of prospective research participants to consent may be uncertain. Yet standardized capacity-assessment tools may not suffice to determine the ability to consent to a particular research protocol. This study consisted of a retrospective review of the outcomes of an alternative approach used by the Ability to Consent Assessment Team at the National Institutes of Health. Of 944 individuals evaluated over 20 years (1999-2019), 70.1% were determined to have capacity to consent to participate in research. Of those who lacked capacity to consent and were subsequently evaluated for their ability to assign a surrogate, 86.0% had the ability to do so. The findings demonstrate that establishing a task-specific approach for assessing the capacity of potential participants to consent to a variety of research protocols can facilitate safe and ethically justifiable inclusion of individuals whose ability to consent is initially uncertain.

Control charts for chronic disease surveillance: testing algorithm sensitivity to changes in data coding

Background

Algorithms used to identify disease cases in administrative health data may be sensitive to changes in the data over time. Control charts can be used to assess how variations in administrative health data impact the stability of estimated trends in incidence and prevalence for administrative data algorithms. We compared the stability of incidence and prevalence trends for multiple juvenile diabetes algorithms using observed-expected control charts.

Methods

Eighteen validated algorithms for juvenile diabetes were applied to administrative health data from Manitoba, Canada between 1975 and 2018. Trends in disease incidence and prevalence for each algorithm were modelled using negative binomial regression and generalized estimating equations; model-predicted case counts were plotted against observed counts. Control limits were set as predicted case count ±0.8*standard deviation. Differences in the frequency of out-of-control observations for each algorithm were assessed using McNemar’s test with Holm-Bonferroni adjustment.

Results

The proportion of out-of-control observations for incidence and prevalence ranged from 0.57 to 0.76 and 0.45 to 0.83, respectively. McNemar’s test revealed no difference in the frequency of out-of-control observations across algorithms. A sensitivity analysis with relaxed control limits (2*standard deviation) detected fewer out-of-control years (incidence 0.19 to 0.33; prevalence 0.07 to 0.52), but differences in stability across some algorithms for prevalence.

Conclusions

Our study using control charts to compare stability of trends in incidence and prevalence for juvenile diabetes algorithms found no differences for disease incidence. Differences were observed between select algorithms for disease prevalence when using wider control limits.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12328-w.

Clinical Parameters and Metabolomic Biomarkers That Predict Inhospital Outcomes in Patients With ST-Segment Elevated Myocardial Infarctions

Background

Postoperative risk stratification is challenging in patients with ST-segment elevation myocardial infarction (STEMI) who undergo percutaneous coronary intervention. This study aimed to characterize the metabolic fingerprints of patients with STEMI with different inhospital outcomes in the early stage of morbidity and to integrate the clinical baseline characteristics to develop a prognostic prediction model.

Methods

Plasma samples were collected retrospectively from two propensity score-matched STEMI cohorts from May 6, 2020 to April 20, 2021. Cohort 1 consisted of 48 survivors and 48 non-survivors. Cohort 2 included 48 patients with unstable angina pectoris, 48 patients with STEMI, and 48 age- and sex-matched healthy controls. Metabolic profiling was generated based on ultra-performance liquid chromatography and a mass spectrometry platform. The comprehensive metabolomic data analysis was performed using MetaboAnalyst version 5.0. The hub metabolite biomarkers integrated into the model were tested using multivariate linear support vector machine (SVM) algorithms and a generalized estimating equation (GEE) model. Their predictive capabilities were evaluated using areas under the curve (AUCs) of receiver operating characteristic curves.

Results

Metabonomic analysis from the two cohorts showed that patients with STEMI with different outcomes had significantly different clusters. Seven differentially expressed metabolites were identified as potential candidates for predicting inhospital outcomes based on the two cohorts, and their joint discriminative capabilities were robust using SVM (AUC = 0.998, 95% CI 0.983–1) and the univariate GEE model (AUC = 0.981, 95% CI 0.969–0.994). After integrating another six clinical variants, the predictive performance of the updated model improved further (AUC = 0.99, 95% CI 0.981–0.998).

Conclusion

A survival prediction model integrating seven metabolites from non-targeted metabonomics and six clinical indicators may generate a powerful early survival prediction model for patients with STEMI. The validation of internal and external cohorts is required.

Oxygen Consumption (VO2) and Surface Electromyography (sEMG) during Moderate-Strength Training Exercises

Oxygen consumption (VO₂) during strength training can be predicted through surface electromyography (sEMG) of local muscles. This research aimed to determine relations between VO₂ and sEMG of upper and lower body muscles to predict VO₂ from sEMG during moderate-intensity strength training exercises. Of the 12 participants recruited, 11 were divided into two groups: untrained (n = 5; with no training experience) and trained (n = 6; with 2 months of training experience). On different days, each individual completed six training sessions. Each participant performed training sessions consisting of three types of dumbbell exercises: shoulder press, deadlift, and squat, while wearing a mask for indirect calorimetric measurements of VO₂ using the Cortex Metalyzer 3B. sEMG measurements of the bilateral middle deltoid, lumbar erector spinae, quadriceps (rectus femoris), and hamstring (biceps femoris) muscles were recorded. The VO₂ was predicted from sEMG root mean square (RMS) values of the investigated muscles during the exercise period using generalized estimating equation (GEE) modeling. The predicted models for the three types of exercises for the untrained vs. trained groups were shoulder press [QIC = 102, * p = 0.000 vs. QIC = 82, * p = 0.000], deadlift [QIC = 172, * p = 0.000 vs. QIC = 320, * p = 0.026], and squat [QIC = 76, * p = 0.000 vs. QIC = 348, * p = 0.001], respectively. It was observed that untrained vs. trained groups predicted GEE models [quasi-likelihood under an independence model criterion (QIC) = 368, p = 0.330 vs. QIC = 837, p = 0.058], respectively. The study obtained significant VO₂ prediction models during shoulder press, deadlift, and squat exercises using the right and left middle deltoid, right and left lumbar erector spinae, left rectus femoris, and right and left biceps femoris sEMG RMS for the untrained and trained groups during moderate-intensity strength training exercises.

Internet solicitation linked to enhanced occupational health and safety outcomes among sex workers in Metro Vancouver, Canada 2010-2019

OBJECTIVES

Examine the independent association between online solicitation and sex workers' (SWs') occupational health and safety (OHS), particularly violence and work stress.

METHODS

Data were drawn from a cohort of women SWs (N=942, 2010-2019) in Vancouver, Canada. Analyses used descriptive statistics and bivariate and multivariable logistic and linear regression using generalised estimating equations (GEE); explanatory and confounder modelling approaches were used.

RESULTS

33.9% (n=319) of participants solicited online and 14.1% (n=133) primarily solicited online in the last 6 months in at least one study visit. In multivariable GEE analysis, factors associated with primarily soliciting online included younger age (adjusted OR (AOR) 0.95 per year older, 95% CI 0.93 to 0.97), sexual minority status (AOR 2.57, 95% CI 1.61 to 4.10), gender minority status (AOR 3.09, 95% CI 1.80 to 5.28), higher education (AOR 2.13, 95% CI 1.34 to 3.40), higher sex work income (AOR 1.03 per $100 weekly, 95% CI 1.01 to 1.06), being an im/migrant to Canada (AOR 2.40, 95% CI 1.26 to 4.58) and primarily servicing in informal indoor workspaces (AOR 3.47, 95% CI 2.32 to 5.20). In separate GEE confounder models, primarily soliciting online significantly (1) reduced odds of physical/sexual workplace violence (AOR 0.64, 95% CI 0.39 to 1.06) and (2) reduced work stress (β coefficient -0.93, 95% CI -1.59 to -0.26).

DISCUSSION/CONCLUSIONS

Younger workers, gender/sexual minorities, im/migrants and those in informal indoor spaces had higher odds of soliciting online. Confounder models indicate access to online solicitation methods may support enhanced OHS. Decriminalisation of sex work-including advertising via online platforms-remains necessary to support SWs' OHS.

Prehospital time for patients with acute cardiac complaints: A rural health disparity

OBJECTIVE

Delays in care for patients with acute cardiac complaints are associated with increased morbidity and mortality. The objective of this study was to quantify rural and urban differences in prehospital time intervals for patients with cardiac complaints.

METHODS

The ESO Data Collaborative dataset consisting of records from 1332 EMS agencies was queried for 9-1-1 encounters with acute cardiac problems among adults (age ≥ 18) from 1/1/2013-6/1/2018. Location was classified as rural or urban using the 2010 United States Census. The primary outcome was total prehospital time. Generalized estimating equations evaluated differences in the average times between rural and urban encounters while controlling for age, sex, race, transport mode, loaded mileage, and patient stability.

RESULTS

Among 428,054 encounters, the median age was 62 (IQR 50-75) years with 50.7% female, 75.3% white, and 10.3% rural. The median total prehospital, response, scene, and transport times were 37.0 (IQR 29.0-48.0), 6.0 (IQR 4.0-9.0), 16.0 (IQR 12.0-21.0), and 13.0 (IQR 8.0-21.0) minutes. Rural patients had an average total prehospital time that was 16.76 min (95%CI 15.15-18.38) longer than urban patients. After adjusting for covariates, average total time was 5.08 (95%CI 4.37-5.78) minutes longer for rural patients. Average response and transport time were 4.36 (95%CI 3.83-4.89) and 0.62 (95%CI 0.33-0.90) minutes longer for rural patients. Scene time was similar in rural and urban patients (0.09 min, 95%CI -0.15-0.33).

CONCLUSION

Rural patients with acute cardiac complaints experienced longer prehospital time than urban patients, even after accounting for other key variables, such as loaded mileage.

Cats and dogs: A mesopredator navigating risk and reward provisioned by an apex predator

Successfully perceiving risk and reward is fundamental to the fitness of an animal, and can be achieved through a variety of perception tactics. For example, mesopredators may "directly" perceive risk by visually observing apex predators, or may "indirectly" perceive risk by observing habitats used by predators. Direct assessments should more accurately characterize the arrangement of risk and reward; however, indirect assessments are used more frequently in studies concerning the response of GPS-marked animals to spatiotemporally variable sources of risk and reward. We investigated the response of a mesopredator to the presence of risk and reward created by an apex predator, where risk and reward likely vary in relative perceptibility (i.e., degree of being perceptible). First, we tested whether coyotes (Canis latrans) use direct or indirect assessments to navigate the presence of mountain lions (Puma concolor; risk) and kills made by mountain lions (reward) in an area where coyotes were a common prey item for mountain lions. Second, we assessed the behavioral response of coyotes to direct encounters with mountain lions. Third, we evaluated spatiotemporal use of carrion by coyotes at kills made by mountain lions. Indirect assessments generally outperformed direct assessments when integrating analyses into a unified framework; nevertheless, our ability to detect direct perception in navigating to mountain lion kills was likely restricted by scale and sampling limitations (e.g., collar fix rates, unsampled kill sites). Rather than responding to the risk of direct encounters with mountain lions, coyotes facilitated encounters by increasing their movement rate, and engaged in risky behavior by scavenging at mountain lion kills. Coyotes appear to mitigate risk by using indirect perception to avoid mountain lions. Our predator-predator interactions and insights are nuanced and counter to the conventional predator-prey systems that have generated much of the predation risk literature.

A comparison of statistical methods to predict the residual lifetime risk

Lifetime risk measures the cumulative risk for developing a disease over one's lifespan. Modeling the lifetime risk must account for left truncation, the competing risk of death, and inference at a fixed age. In addition, statistical methods to predict the lifetime risk should account for covariate-outcome associations that change with age. In this paper, we review and compare statistical methods to predict the lifetime risk. We first consider a generalized linear model for the lifetime risk using pseudo-observations of the Aalen-Johansen estimator at a fixed age, allowing for left truncation. We also consider modeling the subdistribution hazard with Fine-Gray and Royston-Parmar flexible parametric models in left truncated data with time-covariate interactions, and using these models to predict lifetime risk. In simulation studies, we found the pseudo-observation approach had the least bias, particularly in settings with crossing or converging cumulative incidence curves. We illustrate our method by modeling the lifetime risk of atrial fibrillation in the Framingham Heart Study. We provide technical guidance to replicate all analyses in R.

Intent to Be Vaccinated against COVID-19 in Victoria, Australia

BACKGROUND

High vaccine uptake requires strong public support, acceptance, and willingness.

METHODS

A longitudinal cohort study gathered survey data every four weeks between 1 October 2020 and 9 November 2021 in Victoria, Australia. Data were analysed for 686 participants aged 18 years and older.

RESULTS

Vaccine intention in our cohort increased from 60% in October 2020 to 99% in November 2021. Vaccine intention increased in all demographics, but longitudinal trends in vaccine intention differed by age, employment as a healthcare worker, presence of children in the household, and highest qualification attained. Acceptance of vaccine mandates increased from 50% in October 2020 to 71% in November 2021. Acceptance of vaccine mandates increased in all age groups except 18-25 years; acceptance also varied by gender and highest qualification attained. The main reasons for not intending to be vaccinated included safety concerns, including blood clots, and vaccine efficacy.

CONCLUSION

COVID-19 vaccination campaigns should be informed by understanding of the sociodemographic drivers of vaccine acceptance to enable socially and culturally relevant guidance and ensure equitable vaccine coverage. Vaccination policies should be applied judiciously to avoid polarisation.

Associations between refined athlete monitoring measures and individual match performance in professional Australian football

The purpose of this study was to assess relationships between measures of training load, training response and neuromuscular performance and changes in individual match performance in professional Australian football. Data were collected from 45 professional Australian footballers from one club during the 2019 competition season. External load was measured by GPS technology. Internal load was measured via session rate of perceived exertion (sRPE). Perceptual wellness was measured via pre-training questionnaires (1-5 Likert scale rating of soreness, sleep, fatigue, stress and motivation). Percentage of maximum speed was calculated relative to individual maximum recorded during preseason testing. Rolling derivative training load measures (7-day and 28-day) were calculated. Principal Component Analysis (PCA) identified eight uncorrelated components. PCA factor loadings were used to calculate summed variable covariates and single variables were chosen from components based on practicality and statistical contribution. Associations between covariates and performance were determined via linear Generalised Estimating Equations. Performance was assessed via Player Ratings from a commercial statistics company. Seven-day total distance, IMA event count and sRPE load showed significant positive relationships with performance (18-23% increase in performance z-score). No other covariates displayed significant associations with performance. Individual relative increases in training load within the 7-day period prior to a match may be beneficial for enhancing individual performance.

A Framework for Building Comprehensive Driver Profiles

Conventional approaches to modelling driver risk have incorporated measures such as driver gender, age, place of residence, vehicle model, and annual miles driven. However, in the last decade, research has shown that assessing a driver’s crash risk based on these variables does not go far enough—especially as advanced technology changes today’s vehicles, as well as the role and behavior of the driver. There is growing recognition that actual driver usage patterns and driving behavior, when it can be properly captured in modelling risk, offers higher accuracy and more individually tailored projections. However, several challenges make this difficult. These challenges include accessing the right types of data, dealing with high-dimensional data, and identifying the underlying structure of the variance in driving behavior. There is also the challenge of how to identify key variables for detecting and predicting risk, and how to combine them in predictive algorithms. This paper proposes a systematic feature extraction and selection framework for building Comprehensive Driver Profiles that serves as a foundation for driver behavior analysis and building whole driver profiles. Features are extracted from raw data using statistical feature extraction techniques, and a hybrid feature selection algorithm is used to select the best driver profile feature set based on outcomes of interest such as crash risk. It can give rise to individualized detection and prediction of risk, and can also be used to identify types of drivers who exhibit similar patterns of driving and vehicle/technology usage. The developed framework is applied to a naturalistic driving dataset—NEST, derived from the larger SHRP2 naturalistic driving study to illustrate the types of information about driver behavior that can be harnessed—as well as some of the important applications that can be derived from it.

Applications of operant demand to treatment selection I: Characterizing demand for evidence-based practices

Various treatment approaches have been determined efficacious for improving child behavior outcomes. Despite a variety of evidence-based options, consumers often disregard empirically supported treatments to pursue alternatives that lack empirical support, such as 'fad' therapies. The choice to pursue therapies lacking empirical support has been considered a 'gamble' on therapeutic outcomes and this form of risky choice has historically been explained using various cognitive heuristics and biases. This report translates quantitative analyses from the Operant Demand Framework to characterize how caregivers of children with behavioral issues consume treatment services. The Operant Demand Framework is presented, its utility for characterizing patterns of treatment consumption is discussed, and a preliminary application of cross-price analyses of demand is performed to illustrate how various factors jointly influence treatment-related choice. Results indicated that caregivers endorsing interest in receiving behavioral parent training regularly pursued pseudoscientific alternatives as a functional substitute for an established therapy, despite explicit language stating a lack of evidence. These findings question the presumption of rationality in models of treatment choice and degree to which scientific evidence influences the consumption of therapies. This report concludes with a discussion of Consumer Behavior Analysis and how quantitative analyses of behavior can be used to better understand factors that enhance or detract from the dissemination of evidence-based practices.

The effect of informal caregiving on physical health among non-migrants and Ethnic German Immigrants in Germany: a cohort analysis based on the GSOEP 2000-2018

BACKGROUND

The number of people in need of care in Germany has been rising since decades, which is related to an increasing need and relevance of informal caregiving. Likewise, the number of people with a migration background has been increasing. This study aims to analyse the impact of informal caregiving on physical health in comparative perspective for Ethnic German Immigrants (EGI) - the largest and oldest immigrant group in Germany - and non-migrant Germans (NMG).

METHODS

The sample was drawn from the years 2000-2018 of the German Socio-Economic Panel (n = 26,354). NMG (n = 24,634) and EGI (n = 1,720) were categorized into non-caregivers (n = 24,379) and caregivers (n = 1,975), where the latter were distinguished by 1) their caregiving status and history (current, former, and never caregiver) and 2) the number of years in the caregiver role. Generalized Estimating Equations were applied to examine main effects and the interaction effects of caregiving status and migration background for changes in physical health (n = 102,066 observations).

RESULTS

Adjusting for socioeconomic, household related, and individual characteristics, NMG and EGI had similar caregiving patterns and physical health. However, the interaction between migration background and caregiving revealed significantly higher declines in physical health for currently caregiving EGI. Sensitivity analyses indicated that particularly socioeconomic resources moderated this effect.

CONCLUSIONS

Findings suggest that caregiving is associated with declines in physical health, particularly in the long term and for EGI. This implies that care-related disadvantages accumulate over time and that the association of caregiving, health and associated determinants are culturally diverse and shaped by migration background. Both the health disadvantages of caregivers and EGI might be mitigated by a positive social and socioeconomic setting, which highlights the relevance of supporting structures and benefits for these subgroups.

Organizational Justice and Long-term Metabolic Trajectories: A 25-Year Follow-up of the Whitehall II Cohort

CONTEXT

Organizational justice has been linked to lower risk of several chronic conditions among employees, but less is known about the long-term mechanisms underlying this risk reduction.

OBJECTIVE

To assess whether self-reported organizational justice is associated with individual and composite long-term metabolic trajectories.

DESIGN

Twenty-five-year follow-up of the Whitehall II prospective cohort study.

SETTING

Middle-aged public servants from the United Kingdom.

PARTICIPANTS

Data on 8182 participants were used.

MAIN OUTCOME MEASURES

Levels of 11 anthropometric, glycemic, lipid, and blood pressure biomarkers were measured at 5 timepoints (1991-2013). We used generalized estimating equations and group-based trajectory modeling to investigate the relationship between organizational justice and biomarker trajectories.

RESULTS

High vs low organizational justice were associated with lower waist (-1.7 cm) and hip (-1 cm) circumference, body mass index (-0.6 kg/m2), triglycerides (-1.07 mmol/L), and fasting insulin (-1.08 µIU/mL) trajectories. Two latent metabolic trajectory clusters were identified: a high- and a low-risk cluster. High organizational justice (vs low) were associated with belonging to the low-risk cluster (pooled odds ratio = 1.47). The low-risk cluster demonstrated lower baseline levels of most biomarkers and better glycemic control, whereas the high-risk cluster showed higher baseline levels of most biomarkers, glycemic deterioration, but also greater improvements in lipid levels over time.

CONCLUSIONS

People with high organizational justice had more favorable long-term cardiometabolic biomarker patterns than those with low organizational justice, indicating a potential mechanism contributing to the lower risk of chronic diseases in the first group. Further intervention studies are warranted to determine whether improvement of organizational justice might improve long-term health.

Applications of operant demand to treatment selection II: Covariance of evidence strength and treatment consumption

Evidence-based practices (EBPs) are a critical component of effective and ethical service delivery. Clinicians in the behavioral sciences regularly advocate for the use of therapies and interventions based on the strength and breadth of scientific evidence. However, caregiver choices related to specific behavior therapies are seldom based solely on the degree (or the presence) of scientific evidence. This study applied methods from the Operant Demand Framework to characterize caregiver choices when concurrently available behavior therapies varied in terms of unit price and levels of evidence. Four Hypothetical Treatment Purchase Tasks were designed to evaluate how relative differences in scientific evidence between behavior therapies influenced the demand for, and substitutability of, EBPs. Results from 106 caregivers recruited from the Amazon Mechanical Turk platform indicated that low-, moderate-, and high-evidence treatment choices all functioned as substitutes for a high-evidence (i.e., well-established) behavior therapy. A main effect was observed for the level of evidence, whereby the strength of evidence appeared to moderate the degree to which respective treatments functioned as substitutes. These results extend the literature on the factors associated with treatment choices, and specifically, highlight how differences in the degree of scientific evidence influence choice when deciding between behavior therapies. These results are discussed in the context of more effectively advocating for the use of EBPs with mainstream and lay audiences.

Non-invasive preoperative imaging differential diagnosis of pineal region tumor: A novel developed and validated multiparametric MRI-based clinicoradiomic model

BACKGROUND

Preoperative differential diagnosis of pineal region tumor can greatly assist clinical decision-making and avoid economic costs and complications caused by unnecessary radiotherapy or invasive procedures. The present study was performed to pre-operatively distinguish pineal region germinoma and pinealoblastoma using a clinicoradiomic model by incorporating radiomic and clinical features.

METHODS

134 pineal region tumor patients (germinoma, 69; pinealoblastoma, 65) with complete clinic-radiological and histopathological data from Tiantan hospital were retrospectively reviewed and randomly assigned to training and validation sets. Radiomic features were extracted from MR images, then the elastic net and recursive feature elimination algorithms were applied to select radiomic features for constructing a fusion radiomic model. Subsequently, multivariable logistic regression analysis was used to select the clinical features, and a clinicoradiomic model incorporating the fusion radiomic model and selected clinical features was constructed for individual predictions. The calibration, discriminating capacity, and clinical usefulness were also evaluated.

RESULTS

Seven significant radiomic features were selected to construct a fusion radiomic model that achieved an area under the curve (AUC) value of 0.920 and 0.880 in the training and validation sets, respectively. A clinicoradiomic model that incorporated the radiomic model and four selected clinical features was constructed and showed good discrimination and calibration, with an AUC of 0.950 in the training set and 0.940 in the validation set. The analysis of the decision curve showed that the radiomic model and clinicoradiomic model were clinically useful for patients with pineal region tumor.

CONCLUSIONS

Our clinicoradiomic model showed great performance and high sensitivity in the differential diagnosis of germinoma and pinealoblastoma, and could contribute to non-invasive development of individualized diagnosis and treatment of patients with pineal region tumor.

Longitudinal relationship of particulate matter and metabolic control and severe hypoglycaemia in children and adolescents with type 1 diabetes

BACKGROUND

Evidence for the metabolic impact of long-term exposure to air pollution on diabetes is lacking. We investigated the association of particulate matter <10 μm (PM₁₀) and <2.5 μm (PM_2.5) with yearly averages of HbA1c, daily insulin dose (IU/kg) and rates of severe hypoglycaemia in type 1 diabetes (T1D).

METHODS

We studied data of 44,383 individuals with T1D < 21 years which were documented in 377 German centres within the diabetes prospective follow-up registry (DPV) between 2009 and 2018. Outcomes were aggregated by year and by patient. PM₁₀-and PM_2.5-yearly averages prior to the respective treatment year were linked to individuals via the five-digit postcode areas of residency. Repeated measures linear and negative binomial regression were used to study the association between PM-quartiles (Q1 lowest, Q4 highest concentration) and yearly averages of HbA1c, daily insulin dose and rates of severe hypoglycaemia (confounders: sex, time-dependent age, age at diabetes onset, time-dependent type of treatment, migratory background, degree of urbanisation and socioeconomic index of deprivation).

RESULTS

Adjusted mean HbA1c increased with PM₁₀ (Q1: 7.96% [95%-CI: 7.95-7.98], Q4: 8.03% [8.02-8.05], p-value<0.001) and with PM_2.5 (Q1: 7.97% [7.95-7.99], Q4: 8.02% [8.01-8.04], p < 0.001). Changes in daily insulin dose were inversely related to PM (PM₁₀ and PM_2.5: Q1 0.85 IU/kg [0.84-0.85], Q4: 0.83 IU/kg [0.82-0.83], p < 0.001). Adjusted rates of severe hypoglycaemia increased with PM-quartile groups (PM₁₀ Q1:11.2 events/100 PY [10.9-11.5], PM₁₀ Q4: 15.3 [14.9-15.7], p < 0.001; PM_2.5 Q1: 9.9 events/100 PY [9.6-10.2], PM_2.5 Q4: 14.2 [13.9-14.6], p < 0.001).

DISCUSSION

Air pollution was associated with higher HbA1c levels and increased risk of severe hypoglycaemia in people with T1D, consequently indicating a higher risk of diabetes complications. Further studies are needed to explore causal pathways of the observed associations.

Association of school absence and exclusion with recorded neurodevelopmental disorders, mental disorders, or self-harm: a nationwide, retrospective, electronic cohort study of children and young people in Wales, UK

BACKGROUND

Poor attendance at school, whether due to absenteeism or exclusion, leads to multiple social, educational, and lifelong socioeconomic disadvantages. We aimed to measure the association between a broad range of diagnosed neurodevelopmental and mental disorders and recorded self-harm by the age of 24 years and school attendance and exclusion.

METHODS

In this nationwide, retrospective, electronic cohort study, we drew a cohort from the Welsh Demographic Service Dataset, which included individuals aged 7-16 years (16 years being the school leaving age in the UK) enrolled in state-funded schools in Wales in the academic years 2012/13-2015/16 (between Sept 1, 2012, and Aug 31, 2016). Using the Adolescent Mental Health Data Platform, we linked attendance and exclusion data to national demographic and primary and secondary health-care datasets. We identified all pupils with a recorded diagnosis of neurodevelopmental disorders (ADHD and autism spectrum disorder [ASD]), learning difficulties, conduct disorder, depression, anxiety, eating disorders, alcohol or drugs misuse, bipolar disorder, schizophrenia, other psychotic disorders, or recorded self-harm (our explanatory variables) before the age of 24 years. Outcomes were school absence and exclusion. Generalised estimating equations with exchangeable correlation structures using binomial distribution with the logit link function were used to calculate odds ratios (OR) for absenteeism and exclusion, adjusting for sex, age, and deprivation.

FINDINGS

School attendance, school exclusion, and health-care data were available for 414 637 pupils (201 789 [48·7%] girls and 212 848 [51·3%] boys; mean age 10·5 years [SD 3·8] on Sept 1, 2012; ethnicity data were not available). Individuals with a record of a neurodevelopmental disorder, mental disorder, or self-harm were more likely to be absent or excluded in any school year than were those without a record. Unadjusted ORs for absences ranged from 2·1 (95% CI 2·0-2·2) for those with neurodevelopmental disorders to 6·6 (4·9-8·3) for those with bipolar disorder. Adjusted ORs (aORs) for absences ranged from 2·0 (1·9-2·1) for those with neurodevelopmental disorders to 5·5 (4·2-7·2) for those with bipolar disorder. Unadjusted ORs for exclusion ranged from 1·7 (1·3-2·2) for those with eating disorders to 22·7 (20·8-24·7) for those with a record of drugs misuse. aORs for exclusion ranged from 1·8 (1·5-2·0) for those with learning difficulties to 11·0 (10·0-12·1) for those with a record of drugs misuse.

INTERPRETATION

Children and young people up to the age of 24 years with a record of a neurodevelopmental or mental disorder or self-harm before the age of 24 years were more likely to miss school than those without a record. Exclusion or persistent absence are potential indicators of current or future poor mental health that are routinely collected and could be used to target assessment and early intervention. Integrated school-based and health-care strategies to support young peoples' engagement with school life are required.

FUNDING

The Medical Research Council, MQ Mental Health Research, and the Economic and Social Research Council.

TRANSLATION

For the Welsh translation of the abstract see Supplementary Materials section.

Patient-Reported Outcomes Following Total Thyroidectomy for Graves' Disease

Background: Graves' disease accounts for ∼80% of all cases of hyperthyroidism and is associated with significant morbidity and decreased quality of life. Understanding the association of total thyroidectomy with patient-reported quality-of-life and thyroid-specific symptoms is critical to shared decision-making and high-quality care. We estimate the change in patient-reported outcomes (PROs) before and after surgery for patients with Graves' disease to inform the expectations of patients and their physicians. Methods: PROs using the MD Anderson Symptom Inventory (MDASI) validated questionnaire were collected prospectively from adult patients with Graves' disease from January 1, 2015, to November 20, 2020, on a longitudinal basis. Survey responses were categorized as before surgery (≤120 days), short term after surgery (<30 days; ST), and long term after surgery (≥30 days; LT). Negative binomial regression was used to estimate the association of select covariates with PROs. Results: Eighty-five patients with Graves' disease were included. The majority were female (83.5%); 47.1% were non-Hispanic white and 35.3% were non-Hispanic black. The median thyrotropin (TSH) value before surgery was 0.05, which increased to 0.82 in ST and 1.57 in LT. In bivariate analysis, the Total Symptom Burden Score, a composite of all patient-reported burden, significantly reduced shortly after surgery (before surgery mean of 56.88 vs. ST 39.60, p < 0.001), demonstrating improvement in PROs. Furthermore, both the Thyroid Symptoms Score, including patient-reported thermoregulation, palpitations, and dysphagia, and the Quality-of-Life Symptom Score improved in ST and LT (thyroid symptoms, before surgery 13.88 vs. ST 8.62 and LT 7.29; quality of life, before surgery 16.16 vs. ST 9.14 and LT 10.04, all p < 0.05). After multivariate adjustment, the patient-reported burden in the Thyroid Symptom Score and the Quality-of-Life Symptom Score exhibited reduction in ST (thyroid symptoms, rate ratio [RR] 0.55, confidence interval [CI]: 0.42-0.72; quality of life, RR 0.57, CI: 0.40-0.81) and LT (thyroid symptoms, RR 0.59, CI: 0.44-0.79; quality of Life, RR 0.43, CI: 0.28-0.65). Conclusions: Quality of life and thyroid-specific symptoms of Graves' patients improved significantly from their baseline before surgery to both shortly after and longer after surgery. This work can be used to guide clinicians and patients with Graves' disease on the expected outcomes following total thyroidectomy.

Regression Modeling of Individual-Patient Correlated Discrete Outcomes with Applications to Cancer Pain Ratings

Purpose:

To formulate and demonstrate methods for regression modeling of probabilities and dispersions for individual-patient longitudinal outcomes taking on discrete numeric values.

Methods:

Three alternatives for modeling of outcome probabilities are considered. Multinomial probabilities are based on different intercepts and slopes for probabilities of different outcome values. Ordinal probabilities are based on different intercepts and the same slope for probabilities of different outcome values. Censored Poisson probabilities are based on the same intercept and slope for probabilities of different outcome values. Parameters are estimated with extended linear mixed modeling maximizing a likelihood-like function based on the multivariate normal density that accounts for within-patient correlation. Formulas are provided for gradient vectors and Hessian matrices for estimating model parameters. The likelihood-like function is also used to compute cross-validation scores for alternative models and to control an adaptive modeling process for identifying possibly nonlinear functional relationships in predictors for probabilities and dispersions. Example analyses are provided of daily pain ratings for a cancer patient over a period of 97 days.

Results:

The censored Poisson approach is preferable for modeling these data, and presumably other data sets of this kind, because it generates a competitive model with fewer parameters in less time than the other two approaches. The generated probabilities for this model are distinctly nonlinear in time while the dispersions are distinctly non-constant over time, demonstrating the need for adaptive modeling of such data. The analyses also address the dependence of these daily pain ratings on time and the daily numbers of pain flares. Probabilities and dispersions change differently over time for different numbers of pain flares.

Conclusions:

Adaptive modeling of daily pain ratings for individual cancer patients is an effective way to identify nonlinear relationships in time as well as in other predictors such as the number of pain flares.

The effect of oil palm-dominated landscapes on the home range and distribution of a generalist species, the Asian water monitor

The Asian water monitor lizard, Varanus salvator, is one of the largest predators in Southeast Asia which persists in human-dominated landscapes and, as such, is a suitable model to understand the behavioral plasticity of generalists in anthropogenic landscapes. We used Local Convex Hull with adaptive algorithm to estimate the home range size of 14 GPS-tagged individuals, followed by a MAXENT approach and community prey composition to understand the habitat preferences within the landscape. We estimated larger home ranges in forest than in oil palm plantations, as well as a larger diversity and abundance of mammals. Core home ranges were always linked to water bodies. However, the use of underproductive oil palm, freshwater swamp forest, and degraded forest by monitor lizards were higher than other kind of vegetation. This suitable habitat is proportionally larger in forest (73.7%) than in oil palm plantations (39.6%). Generalized estimation equation models showed that, while full home range size was negatively associated with the abundance of mammals, core areas depicted a positive association with mammal abundance, as well as with the proportion of suitable habitat within the home range. Besides having smaller home ranges in oil palm plantations, our findings suggest that limited suitable habitat availability forces the Asian water monitor lizard's population to establish only one or very few core areas. Contrastingly, under the protection of forest, they have more core areas, widely dispersed within larger home ranges. We conclude that regardless the plasticity of the species, human-dominated landscapes are altering natural patterns of home range establishment in the monitor lizard's population, creating a potential ecological trap where conditions may not remain favorable for them in the long run. A deeper understanding of the ecological implications on the species and the prey community is advisable.

Affective Responses to Both Climbing and Nordic Walking Exercise Are Associated With Intermediate-Term Increases in Physical Activity in Patients With Anxiety and Posttraumatic Stress Disorder - A Randomized Longitudinal Controlled Clinical Pilot Trial

BACKGROUND

Exercise programs have shown anxiolytic effects in psychiatric patients. Adherence to exercise programs and subsequent long-term lifestyle change is influenced by acute affective responses of the exercise programs. This research aimed to assess acute affective responses of two different exercise modalities compared to a non-exercise control program and its effects on persisting physical activity behavior change.

METHODS

Sixty-six outpatients diagnosed with an anxiety disorder or posttraumatic stress disorder were randomly allocated to one of three groups in a randomized longitudinal controlled clinical pilot trial: climbing (n = 26), nordic walking (n = 19), social contact control (n = 21). Affective responses were assessed pre, during, and post activity. General physical activity behavior was recorded prior to participation in the program, post program, and at follow-ups three and six months after the program.

RESULTS

Multilevel modeling analyzes of 1,066 individual data points revealed increases in affective valence in the exercise sessions compared to the social contact sessions. State anxiety decreased in the climbing group compared to the social contact group. Physical activity behavior was increased immediately following the program as well as at six months follow-up in both exercise groups. A larger increase in affective valence during and after the sessions was associated with higher physical activity post program.

CONCLUSIONS

Climbing and conventional nordic walking exercise sessions revealed positive affective changes in outpatients indicating therapeutic potential of both modalities for acute emotion regulation. In accordance with theoretical models of human behavior change, it was judged that the experience of a more pleasant affective state following the exercise sessions induced more persisting effects on physical activity behavior after the exercise programs.

TRIAL REGISTRATION

https://www.clinicaltrials.gov/ct2/show/NCT03758599, identifier: NCT03758599.

Young adults in motor vehicle collisions in Norway: user safety errors observed in majority of cases with severe or fatal injuries

PURPOSE

We performed a multidisciplinary investigation of young adults involved in motor vehicle collisions (MVCs) to elucidate injury mechanisms and the role of passive safety equipment such as seat belts and airbags.

METHODS

MVCs resulting in death or serious injuries to the driver or passengers aged 16-24 years in southeastern Norway during 2013-2016 were investigated upon informed consent. We assessed the crash scene, the motor vehicle (MV) interior and exterior, and analyzed data from medical records, forensic autopsies and reports from police and civil road authorities.

RESULTS

This study included 229 young adult occupants involved in 212 MVCs. The Maximum Abbreviated Injury Scale (MAIS) score was ≥2 in 111 occupants, of which 22 were fatalities. In 59% (65/111) of the cases with MAIS score ≥2 injuries, safety errors and occupant protection inadequacies were considered to have contributed to the injury outcome. Common errors were seatbelt non-use and misuse, carrying insecure luggage, and the seat back being too reclined. MAIS score ≥2 head/neck injuries were observed in side impacts despite correct seatbelt use, related to older MVs lacking side airbag curtains. The independent risk factors for MAIS score ≥2 injuries included not using a seatbelt, driving under the influence of alcohol or drugs, nighttime driving, side impacts, heavy collision partner, and MV deformation.

CONCLUSION

User safety errors (not using a seatbelt, seatbelt misuse, excessive seat-back reclining, and insecure cargo) and a lack of occupant protection in older MVs resulted in young adults sustaining severe or fatal injuries in MVCs.

Weighted Bayesian Poisson Regression for The Number of Children Ever Born per Woman in Bangladesh

Number of children ever born to women of reproductive age forms a core component of fertility and is vital to the population dynamics in any country. Using Bangladesh Multiple Indicator Cluster Survey 2019 data, we fitted a novel weighted Bayesian Poisson regression model to identify multi-level individual, household, regional and societal factors of the number of children ever born among married women of reproductive age in Bangladesh. We explored the robustness of our results using multiple prior distributions, and presented the Metropolis algorithm for posterior realizations. The method is compared with regular Bayesian Poisson regression model using a Weighted Bayesian Information Criterion. Factors identified emphasize the need to revisit and strengthen the existing fertility-reduction programs and policies in Bangladesh.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44199-022-00044-2.

MRI-based peritumoral radiomics analysis for preoperative prediction of lymph node metastasis in early-stage cervical cancer: A multi-center study

PURPOSE

To evaluate intra- and preitumoral radiomics on the contrast-enhanced T1-weighted (CE-T1) and T2-weighted (T2W) MRI for predicting the LNM, and develop a nomogram for potential clinical uses.

METHODS

We enrolled 169 cervical cancer cases who underwent CE-T1 and T2W MR scans from two hospitals between Dec. 2015 and Sep. 2021. Intra- and peritumoral features were extracted separately and selected by the least absolute shrinkage and selection operator (LASSO) regression. Radiomics signatures were built using the selected features from different regions. Clinical parameters were evaluated by statistical analysis. The nomogram was developed combining the multi-regional radiomics signature and the most predictive clinical parameters.

RESULTS

Five radiomics features were finally selected from the peritumoral regions with 1 and 3 mm distances in the CE-T1 and T2W MRI, respectively. The nomogram incorporating multi-regional combined radiomics signature, MR-reported LN status and tumor diameter achieved the highest AUCs in the training (nomogram vs. combined radiomics signature vs. clinical model, 0.891 vs. 0.830 vs. 0.812), internal validation (nomogram vs. combined radiomics signature vs. clinical model, 0.863 vs. 0.853 vs. 0.816) and external validation (nomogram vs. combined radiomics signature vs. clinical model, 0.804 vs. 0.701 vs. 0.787) cohort. DCA suggested good clinical usefulness of our developed models.

CONCLUSION

The current work suggested clinical potential for intra- and peritumoral radiomics with multi-modal MRI for preoperative predicting LNM.

Repeated measures discriminant analysis using multivariate generalized estimation equations

Discriminant analysis procedures that assume parsimonious covariance and/or means structures have been proposed for distinguishing between two or more populations in multivariate repeated measures designs. However, these procedures rely on the assumptions of multivariate normality which is not tenable in multivariate repeated measures designs which are characterized by binary, ordinal, or mixed types of response distributions. This study investigates the accuracy of repeated measures discriminant analysis (RMDA) based on the multivariate generalized estimating equations (GEE) framework for classification in multivariate repeated measures designs with the same or different types of responses repeatedly measured over time. Monte Carlo methods were used to compare the accuracy of RMDA procedures based on GEE, and RMDA based on maximum likelihood estimators (MLE) under diverse simulation conditions, which included number of repeated measure occasions, number of responses, sample size, correlation structures, and type of response distribution. RMDA based on GEE exhibited higher average classification accuracy than RMDA based on MLE especially in multivariate non-normal distributions. Three repeatedly measured responses namely severity of epilepsy, current number of anti-epileptic drugs, and parent-reported quality of life in children with epilepsy were used to demonstrate the application of these procedures.

Tidal volumes and pressures delivered by the NeoPuff T-piece resuscitator during resuscitation of term newborns

AIM

T-piece resuscitators are commonly used for respiratory support during newborn resuscitation. This study aimed to describe delivered pressures and tidal volumes when resuscitating term newborns immediately after birth, using the NeoPuff T-piece resuscitator.

METHOD

Observational study from June 2019 through March 2021 at Stavanger University Hospital, Norway, including term newborns ventilated with a T-piece resuscitator after birth, with consent to participate. Ventilation parameters of the first 100 inflations from each newborn were recorded by respiration monitors and divided into an early (inflation 1-20) and a late (inflation 21-100) phase.

RESULTS

Of the 7730 newborns born, 232 term newborns received positive pressure ventilation. Of these, 129 newborns were included. In the early and the late phase, the median (interquartile range) peak inflating pressure was 30 (28-31) and 30 (27-31) mbar, and tidal volume was 4.5 (1.6-7.8) and 5.7 (2.2-9.8) ml/kg, respectively. Increased inflation times were associated with an increase in volume before plateauing at an inflation time of 0.41 s in the early phase and 0.50 s in the late phase. Inflation rates exceeding 32 per minute in the early phase and 41 per minute in the late phase were associated with lower tidal volumes.

CONCLUSION

There was a substantial variation in tidal volumes despite a relatively stable peak inflating pressure. Delivered tidal volumes were at the lower end of the recommended range. Our results indicate that an inflation time of approximately 0.5 s and rates around 30-40 per minute are associated with the highest delivered tidal volumes.

Mindfulness meditation training effects on quality of life, immune function and glutathione metabolism in service healthy female teachers: A randomized pilot clinical trial

BACKGROUND

Despite the crucial role of educators in encourage students' academic learning, addressing educator stress inside the classroom remains a significant challenge in the educational context. Mindfulness Meditation training (MM) has been recommended as an environmental enrichment strategy in schools to help teachers cope with stress and cultivating a state of awareness in daily life. Although studies have shown that MM can improve immune system dynamics the biological mechanism underlying glutathione metabolism in a healthy human is unclear.

OBJECTIVE

The purpose of this study was to determine whether MM training benefits psychological and behavioral response, immunological functions and glutathione metabolism in service healthy female teachers from public schools.

METHODS

We randomly assigned 76 teachers to an 8-week Mindfulness-Based Health Program for Educators (MBHPEduca) or Neuroscience for Education program (Neuro-Educa; active control group). Using the quality of life as our primary outcome, perceived stress, negative affectivity, and resilience as our secondary outcome, and pro-inflammatory cytokines and glutathione levels as our third outcome at baseline and post-intervention that occurred in public schools. Blood samples were collected for the measurement of three proinflammatory markers, including interleukin-1β (IL-1β), interleukin-6 (IL-6), and interleukin-8 (IL-8) and three GSH metabolism, including Cysteine (Cys), Homocysteine (HCys) and GSH were conducted at pre-and post-intervention, with selfreported assessments over time. Treatment effects were analyzed using generalized estimating equations (GEE) with to intention to treat.

RESULTS

We observed statistically significant improvements to the MBHP-Educa group compared to active control in perceived stress, resilience, positive and negative affect, and quality of life after 8-weeks MM (p ​< ​0.0001). Further, the MBHP-Educa group exhibited lower circulating IL-6 production accompanied by high circulating GSH, and Cys (p ​< ​0.0001). Additional analyses indicated that enhancing quality of life through mindfulness meditation training was mediated by reducing perceived stress and serum levels of IL- 6 and increasing resilience and teachers 'plasma GSH levels.

CONCLUSIONS

The present study is a pilot trial with low-power and provides preliminary evidence that mindfulness meditation training help teachers to cope with stress in the school environment with an impact on the quality of life, immune function, and glutathione metabolism.

Attentional control may be modifiable with Mindfulness-Based Cognitive Therapy to Prevent Suicide

OBJECTIVE

To test whether Mindfulness-Based Cognitive Therapy to Prevent Suicide (MBCT-S) is associated with improvement in attentional control, an objective marker of suicide attempt.

METHOD

In the context of a randomized clinical trial targeting suicide risk in Veterans, computerized Stroop and emotion Stroop (E-Stroop) tasks were administered 3 times over 6-months follow-up to 135 high suicide risk Veterans. Seventy were randomized to receive MBCT-S in addition to enhanced treatment as usual (eTAU), and 65 were randomized to eTAU only. E-Stroop word types included positively- and negatively-valenced emotion, suicide, and combat-related words. Interference scores and mixed effects linear regression analyses were used.

RESULTS

Veterans receiving MBCT-S showed a more favorable trajectory of attentional control over time, as indicated by performance on two E-Stroop tasks. Combat-stress interference scores improved over time among Veterans in MBCT-S. Interference processing time for negative affective words deteriorated over time among Veterans receiving eTAU only.

CONCLUSIONS

MBCT-S may effectively target attentional control, and in particular reduce processing time during affective interference, in high suicide risk Veterans. Future studies to replicate these findings are warranted.

Regional and sociodemographic differences in average BMI among US children in the ECHO program

OBJECTIVE

The aim of this study was to describe the association of individual-level characteristics (sex, race/ethnicity, birth weight, maternal education) with child BMI within each US Census region and variation in child BMI by region.

METHODS

This study used pooled data from 25 prospective cohort studies. Region of residence (Northeast, Midwest, South, West) was based on residential zip codes. Age- and sex-specific BMI z scores were the outcome.

RESULTS

The final sample included 14,313 children with 85,428 BMI measurements, 49% female and 51% non-Hispanic White. Males had a lower average BMI z score compared with females in the Midwest (β = -0.12, 95% CI: -0.19 to -0.05) and West (β = -0.12, 95% CI: -0.20 to -0.04). Compared with non-Hispanic White children, BMI z score was generally higher among children who were Hispanic and Black but not across all regions. Compared with the Northeast, average BMI z score was significantly higher in the Midwest (β = 0.09, 95% CI: 0.05 to 0.14) and lower in the South (β = -0.12, 95% CI: -0.16 to -0.08) and West (β = -0.14, 95% CI: -0.19 to -0.09) after adjustment for age, sex, race/ethnicity, and birth weight.

CONCLUSIONS

Region of residence was associated with child BMI z scores, even after adjustment for sociodemographic characteristics. Understanding regional influences can inform targeted efforts to mitigate BMI-related disparities among children.

Compensatory Connections? Living Alone, Loneliness, and the Buffering Role of Social Connection among older American and European Adults

OBJECTIVE

The growth of solo living has important implications for the rising "loneliness epidemic" among older adults. This study considered whether two forms of social connectedness-extra-household core discussion networks and social participation-buffer the loneliness associated with living alone.

METHOD

Our study used data from two surveys (National Social Life, Health, and Aging Project; Survey of Health, Ageing and Retirement in Europe) encompassing 20 developed Western countries in 2009/2010 and 2015/2016 (n = 110,817). Harmonizing measures across data sets, we estimated survey-specific and pooled longitudinal regression models with interaction terms.

RESULTS

High levels of social connectedness only moderately buffered the loneliness associated with living alone in later life. Findings were largely consistent across regions of Europe and the United States, though the buffering patterns were most robustly identified for widowed solo dwellers.

DISCUSSION

Extra-household connections are partial compensators, but do not seem to fully replace the ready companionship afforded by residential co-presence in later life. Future research is needed to understand whether the efficacy of compensatory connections differs by gender, race/ethnicity, and across more diverse global regions.

Impact of Oropharyngeal Administration of Colostrum in Preterm Newborns' Oral Microbiome

The initial colonization of the human microbiota is of paramount importance. In this context, the oropharyngeal administration of colostrum is a safe, viable, and well-tolerated practice even by the smallest preterm infants. Therefore, this study evaluated the effects of oropharyngeal administration of colostrum on the establishment of preterm infants' oral microbiota. A longitudinal observational study was carried out with 20 premature neonates, divided into two groups: one receiving the protocol (Oropharyngeal Administration of Colostrum; OAC) and the other one receiving Standard Caare (SC). Saliva samples were collected from the newborns weekly during the study period (from the day of birth until the 21st day of life) for analysis of oral microbiota through 16S rRNA gene sequencing. We observed that the colonization of the oral microbiota of preterm newborns preseanted a higher relative abundance of Staphylococcus on the 7th day of life, mainly in the OAC group. Additionally, an increased abundance of Bifidobacterium and Bacteroides was observed in the OAC group at the first week of life. Regarding alpha and beta diversity, time was a key factor in the oral modulation of both groups, showing how dynamic this environment is in early life.

The epidemiology of soil-transmitted helminth infections in children up to 8 years of age: Findings from an Ecuadorian birth cohort

Background

There are few prospective longitudinal studies of soil-transmitted helminth (STH) infections during early childhood. We studied the epidemiology of and risk factors for soil-transmitted helminth infections from birth to 8 years of age in tropical Ecuador.

Methods

2,404 newborns were followed to 8 years of age with periodic stool sample collections. Stool samples were collected also from household members at the time of the child’s birth and examined by microscopy. Data on social, environmental, and demographic characteristics were collected by maternal questionnaire. Associations between potential risk factors and STH infections were estimated using generalized estimated equations applied to longitudinal binary outcomes for presence or absence of infections at collection times.

Results

Of 2,404 children, 1,120 (46.6%) were infected with at least one STH infection during the first 8 years of life. The risk of A. lumbricoides (16.2%) was greatest at 3 years, while risks of any STH (25.1%) and T. trichiura (16.5%) peaked at 5 years. Factors significantly associated with any STH infection in multivariable analyses included age, day-care (OR 1.34, 95% CI 1.03–1.73), maternal Afro-Ecuadorian ethnicity (non-Afro vs. Afro, OR 0.55, 95% CI 0.43–0.70) and lower educational level (secondary vs. illiterate, OR 0.31, 95% CI 0.22–0.45)), household overcrowding (OR 1.53, 95% CI 1.21–1.94)), having a latrine rather than a water closet (WC vs. latrine, OR 0.77, 95% CI 0.62–0.95)), and STH infections among household members (OR 2.03, 95% CI 1.59–2.58)). T. trichiura was more associated with poverty (high vs. low socioeconomic status, OR, 0.63, 95% CI 0.40–0.99)] and presence of infected siblings in the household (OR 3.42, 95% CI 2.24–5.22).

Conclusion

STH infections, principally with A. lumbricoides and T. trichiura, peaked between 3 and 5 years in this cohort of children in tropical Ecuador. STH infections among household members were an important determinant of infection risk and could be targeted for control and elimination strategies.

Soil-transmitted helminths (STH) cause significant morbidity among children in low and middle-income countries (LMICs). We followed a birth cohort to 8 years of age in a rural area of coastal Ecuador and showed almost half acquired STH infections during childhood. The dominant STH parasites in this setting in children were Ascaris lumbricoides and Trichuris trichiura and infections peaked in frequency between 3 and 5 years of age. Risk of infection during childhood was associated with markers of marginalisation (Afro-Ecuadorian ethnicity and low educational level), household poverty (overcrowding and poor sanitation), and STH infections among other household members. There was evidence of a reduction in STH infection risk across all ages in study households over the calendar time course of this longitudinal study in parallel with improvements in living conditions, a period of economic growth, and increased government support for those living in extreme poverty. Our data indicate that targeting anthelmintic treatment at members of STH-infected households is likely to reduce the risk of infection in young children.

Antibodies to neurofilament light as potential biomarkers in multiple sclerosis

Background and objective

The concentration of neurofilament light (NfL) protein in cerebrospinal fluid (CSF) and blood is widely considered as a quantitative measure of neuro-axonal injury. Immune reactivity to NfL released into extracellular fluids induces specific autoantibody response. We investigated the levels and avidity of antibodies to NfL in patients with multiple sclerosis (MS) treated with disease-modifying therapies (DMTs) and their correlation with disease worsening and NfL protein concentration.

Methods

We conducted a prospective longitudinal study in 246 patients with MS (125 DMT-treated and 121 untreated at baseline). Serum levels of NfL antibodies, antibody avidity and immune complexes were determined by ELISA. NfL protein was measured using the Simoa platform. Clinical variables were tested for their association with the measured parameters in multivariate generalised estimating equation models.

Results

Multivariate analysis showed that levels of NfL antibodies were higher in progressive MS compared with clinically isolated syndrome (CIS)/relapsing remitting multiple sclerosis (RRMS) (p=0.010). Anti-NfL levels drop with increasing disability score (Expanded Disability Status Scale (EDSS)) (p=0.002), although conversely, were significantly elevated in CIS/RRMS after a recent EDSS increase (p=0.012). Patients receiving DMTs showed decreased levels of anti-NfL (p=0.008), high-avidity antibodies (p=0.017) and immune-complexes compared with untreated CIS/RRMS. Patients with MS switching to natalizumab showed lower levels of anti-NfL but higher immune complexes compared with healthy controls (p=0.0071). A weak association was observed between the levels of NfL protein and NfL antibodies.

Conclusions

These results support the potential usefulness of quantifying antibody response to NfL as potential markers of progression and treatment response in MS and need to be considered when interpreting peripheral blood NfL levels.

The gain in keratinized gingiva using apically positioned flap during implant placement with and without ridge augmentation: A comparative prospective study

OBJECTIVES

To evaluate whether ridge augmentation (RA) affects the gain in keratinized gingiva (KG) in implant surgery using a full-thickness apically positioned flap (fAPF).

MATERIAL AND METHODS

We conducted a prospective study from April 2017 to April 2019 recording patient- and implant-related factors. The subjects underwent fAPF during implant placement and were divided two groups: Group A, one-stage surgical protocol without RA; Group B, two-stage surgical protocol with RA. The initial width of KG and the width of KG at 1 week, 3 weeks, 3 months, and 6 months after surgery and baseline were measured using a paper ruler. Multivariable generalized estimating equation (GEE) models were estimated to evaluate RA effects on the gain in KG, the shrinkage amount of KG, and shrinkage ratio of KG after fAPF.

RESULTS

Seventy-nine participants with 203 implants were included. The baseline values of KG were 1.68 mm in Group A and 0.82 mm in Group B (p < 0.001). The results of the multivariable GEE demonstrated that the gain in KG, the shrinkage amount of KG, and the shrinkage ratio of KG showed no significant difference in groups (p > 0.05). The gain in KG was 1.92 ± 1.67 mm in Group A, 1.48 ± 1.36 mm in Group B. The total shrinkage amount and the shrinkage ratio of KG were 1.87 mm and 42.43%, respectively.

CONCLUSIONS

A fAPF is a reliable technique that enables significant increase in KG regardless of RA in implant surgery.

CDC Guideline For Opioid Prescribing Associated With Reduced Dispensing To Certain Patients With Chronic Pain

The Centers for Disease Control and Prevention's 2016 Guideline for Prescribing Opioids for Chronic Pain aimed to reduce unsafe opioid prescribing. It is unknown whether the guideline influenced prescribing in the target population: patients with chronic, noncancer pain, who may be at particular risk for opioid-related harms. To study this question, we used 2014-18 data from a commercial claims database to examine associations between the release of the guideline and opioid dispensing in a national cohort of more than 450,000 patients with four common chronic pain diagnoses. We also examined whether any reductions associated with the guideline were larger for diagnoses for which there existed stronger expert consensus against opioid prescribing. Overall, the guideline was associated with substantial reductions in dispensing opioids, including a reduction in patients' rate of receiving at least one opioid prescription by approximately 20 percentage points by December 2018 compared with the counterfactual, no-guideline scenario. However, the reductions in dispensing did not vary by the strength of expert consensus against opioid prescribing. These findings suggest that although voluntary guidelines can drive changes in prescribing, questions remain about how clinicians are tailoring opioid reductions to best benefit patients.