Akaike's information criterion in generalized estimating equations

Volar Plate Fixation Versus Cast Immobilization in Acceptably Reduced Intra-Articular Distal Radial Fractures: A Randomized Controlled Trial

BACKGROUND

The evidence for the treatment of acceptably reduced intra-articular distal radial fractures remains inconclusive. We therefore compared the functional outcomes of cast immobilization (nonoperative) and volar plate fixation (operative) for patients with these fractures.

METHODS

This multicenter randomized controlled trial enrolled patients between 18 and 75 years old with an acceptably reduced intra-articular distal radial fracture. Patients were randomized to nonoperative treatment or to operative treatment. The primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE) score after 12 months. Secondary outcome measures were the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; the Short Form-36 (SF-36) questionnaire; a visual analog scale for pain; range of motion; grip strength; radiographic parameters; and complications. Analyses followed the intention-to-treat principle.

RESULTS

A total of 96 patients were randomized, and 90 (46 in the nonoperative group and 44 in the operative group) were included in the analysis. Patients treated in the operative group had significantly better functional outcomes measured with the PRWE at 6 weeks, 3 months, 6 months, and 1 year. Additionally, a 28% rate of subsequent surgery was identified in the nonoperative group.

CONCLUSIONS

Adult patients with an acceptably reduced intra-articular distal radial fracture have better functional outcomes for 12 months when treated operatively instead of nonoperatively. We therefore recommend surgical treatment for patients with these fractures.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Association of chiropractic integration in an Ontario community health centre with prescription opioid use for chronic non-cancer pain: a mixed methods study protocol

INTRODUCTION

Emerging evidence from a number of primary care centres suggests that integration of chiropractic services into chronic pain management is associated with improved clinical outcomes and high patient satisfaction as well as with reductions in physician visits, specialist referrals use of advanced imaging and prescribing of analgesics. However, formal assessments of the integration of chiropractic services into primary care settings are sparse, and the impact of such integration on prescription opioid use in chronic pain management remains uncertain. To help address this knowledge gap, we will conduct a mixed methods health service evaluation of an integrated chiropractic back pain programme in an urban community health centre in Ontario, Canada. This centre provides services to vulnerable populations with high unemployment rates, multiple comorbidities and musculoskeletal disorders that are commonly managed with prescription opioids.

METHODS AND ANALYSIS

We will use a sequential explanatory mixed methods design, which consists of a quantitative phase followed by a qualitative phase. In the quantitative phase, we will conduct a retrospective chart review and evaluate whether receipt of chiropractic services is associated with reduced opioid use among patients already prescribed opioid therapy for chronic pain. We will measure opioid prescriptions (ie, opioid fills, number of refills and dosages) by reviewing electronic medical records of recipients and non-recipients of chiropractic services between 1 January 2014 and 31 December 2020 and use multivariable regression analysis to examine the association. In the qualitative phase, we will conduct in-depth, one-on-one interviews of patients and their general practitioners to explore perceptions of chiropractic integration and its impact on opioid use.

ETHICS AND DISSEMINATION

This study was approved by the Hamilton Integrated Research Ethics Board at McMaster University (approval number 2021-10930). The results will be disseminated via peer-reviewed publications, conference presentations and in-person or webinar presentations to community members and healthcare professionals.

The effect of person, treatment and prescriber characteristics on retention in opioid agonist treatment: a 15-year retrospective cohort study

BACKGROUND AND AIMS

There is limited evidence on the relationship between retention in opioid agonist treatment for opioid dependence and characteristics of treatment prescribers. This study estimated retention in buprenorphine and methadone treatment and its relationship with person, treatment and prescriber characteristics.

DESIGN

Retrospective longitudinal study.

SETTING

New South Wales, Australia.

PARTICIPANTS

People entering the opioid agonist treatment programme for the first time between August 2001 and December 2015.

MEASUREMENTS

Time in opioid agonist treatment (primary outcome) was modelled using a generalized estimating equation model to estimate associations with person, treatment and prescriber characteristics.

FINDINGS

The impact of medication type on opioid agonist treatment retention reduced over time; the risk of leaving treatment when on buprenorphine compared with methadone was higher among those who entered treatment earlier [e.g. 2001-03: odds ratio (OR) = 1.59, 95% confidence interval (CI) = 1.45-1.75] and lowest among those who entered most recently (2013-15: OR = 1.23, 95% CI = 1.11-1.36). In adjusted analyses, risk of leaving was reduced among people whose prescriber had longer tenure of prescribing (e.g. 3 versus 8 years: OR = 0.94, 95% CI = 0.93-0.95) compared with prescribers with shorter tenure. Aboriginal and Torres Strait Islander people, being of younger age, past-year psychosis disorder and having been convicted of more criminal charges in the year prior to treatment entry were associated with increased risk of leaving treatment.

CONCLUSION

In New South Wales, Australia, retention in buprenorphine treatment for opioid dependence, compared with methadone, has improved over time since its introduction in 2001. Opioid agonist treatment retention is affected not only by characteristics of the person and his or her treatment, but also of the prescriber, with those of longer prescribing tenure associated with increased retention of people in opioid agonist treatment.

An Intervention by and for Transgender Women Living With HIV: Study Protocol for a Two-Arm Randomized Controlled Trial Testing the Efficacy of “Healthy Divas” to Improve HIV Care Outcomes

Introduction: Transgender women (assigned “male” at birth but who do not identify as male) are disproportionately impacted by HIV and experience unique barriers and facilitators to HIV care engagement. In formative work, we identified culturally specific and modifiable barriers to HIV treatment engagement among transgender women living with HIV (TWH), including prioritizing transition-related healthcare over HIV treatment, avoiding HIV care settings due to gender-related and HIV stigma, concerns about potential drug interactions with hormones, and inadequate social support. Grounded in the investigators' Models of Gender Affirmation and Health Care Empowerment, we developed the Healthy Divas intervention to optimize engagement in HIV care among TWH at risk for treatment failure and consequential morbidity, mortality, and onward transmission of HIV.

Methods and Analysis: We conducted a 2-arm randomized controlled trial (RCT) of the intervention's efficacy in Los Angeles and San Francisco to improve engagement in care among TWH (N = 278). The primary outcome was virologic control indicated by undetectable HIV-1 level (undetectability = < 20 copies/mL), 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 Western Institutional Review Board (20181370). Participants provided informed consent before enrolment in the study. 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. We will make our results available to researchers interested in transgender health to avoid unintentional duplication of research, as well as to others in health and social services communities, including HIV clinics, LGBT community-based organizations, and AIDS service organizations.

Clinical Trial Registration:Clinicaltrials.gov, identifier NCT03081559.

Preoperative Cerebrospinal Fluid Cortisol and the Risk of Postoperative Delirium: A Prospective Study of Older Hip Fracture Patients

BACKGROUND

Ageing, depression, and neurodegenerative disease are common risk factors for delirium in the elderly. These risk factors are associated with dysregulation of the hypothalamic-pituitary-adrenal axis, resulting in higher levels of cortisol under normal and stressed conditions and a slower return to baseline.

OBJECTIVES

We investigated whether elevated preoperative cerebrospinal fluid (CSF) cortisol levels are associated with the onset of postoperative delirium.

METHODS

In a prospective cohort study CSF samples were collected after cannulation for the introduction of spinal anesthesia of 75 patients aged 75 years and older admitted for surgical repair of acute hip fracture. Delirium was assessed with the confusion assessment method (CAM) and the Delirium Rating Scale-Revised-98 (DRS-R98). Because the CAM and DRS-R98 were available for time of admission and 5 postoperative days, we used generalized estimating equations and linear mixed modeling to examine the association between preoperative CSF cortisol levels and the onset of postoperative delirium.

RESULTS

Mean age was 83.5 (SD 5.06) years, and prefracture cognitive decline was present in one-third of the patients (24 [33%]). Postoperative delirium developed in 27 (36%) patients. We found no association between preoperative CSF cortisol levels and onset or severity of postoperative delirium.

CONCLUSIONS

These findings do not support the hypothesis that higher preoperative CSF cortisol levels are associated with the onset of postoperative delirium in elderly hip fracture patients.

Temporal scale of habitat selection for large carnivores: Balancing energetics, risk and finding prey

When navigating heterogeneous landscapes, large carnivores must balance trade-offs between multiple goals, including minimizing energetic expenditure, maintaining access to hunting opportunities and avoiding potential risk from humans. The relative importance of these goals in driving carnivore movement likely changes across temporal scales, but our understanding of these dynamics remains limited. Here we quantified how drivers of movement and habitat selection changed with temporal grain for two large carnivore species living in human-dominated landscapes, providing insights into commonalities in carnivore movement strategies across regions. We used high-resolution GPS collar data and integrated step selection analyses to model movement and habitat selection for African lions Panthera leo in Laikipia, Kenya and pumas Puma concolor in the Santa Cruz Mountains of California across eight temporal grains, ranging from 5 min to 12 hr. Analyses considered landscape covariates that are related to energetics, resource acquisition and anthropogenic risk. For both species, topographic slope, which strongly influences energetic expenditure, drove habitat selection and movement patterns over fine temporal grains but was less important at longer temporal grains. In contrast, avoiding anthropogenic risk during the day, when risk was highest, was consistently important across grains, but the degree to which carnivores relaxed this avoidance at night was strongest for longer term movements. Lions and pumas modified their movement behaviour differently in response to anthropogenic features: lions sped up while near humans at fine temporal grains, while pumas slowed down in more developed areas at coarse temporal grains. Finally, pumas experienced a trade-off between energetically efficient movement and avoiding anthropogenic risk. Temporal grain is an important methodological consideration in habitat selection analyses, as drivers of both movement and habitat selection changed across temporal grain. Additionally, grain-dependent patterns can reflect meaningful behavioural processes, including how fitness-relevant goals influence behaviour over different periods of time. In applying multi-scale analysis to fine-resolution data, we showed that two large carnivore species in very different human-dominated landscapes balanced competing energetic and safety demands in largely similar ways. These commonalities suggest general strategies of landscape use across large carnivore species.

What Drives Outpatient Care Costs in Kenya? An Analysis With Generalized Estimating Equations

Objective: This study aimed to identify the factors associated with outpatient expenses incurred by households in Kenya.

Background: The problem of outpatient healthcare expenses incurred by citizens in countries with limited resources has received little attention. Thus, this study aimed to determine the predictors of household spending on outpatient expenses in Kenya.

Method: We conducted a cross-sectional analysis on households in Kenya using data from the 2018 Kenya Household Health Expenditure and Utilization Survey. We applied the generalized estimating equations method to determine the best subset of predictors of outpatient care cost.

Findings: The best predictors of outpatient care expenses in Kenya are age, wealth index, and education level of the household head.

Conclusions: There were no differences regarding age in the mean spending on outpatient care. Moreover, we found that the cost of outpatient care changes with age in a sinusoidal manner. We observed that rich households spent more on outpatient care, mostly owing to their financial ability. Households whose heads reported primary or secondary school education level spent less on outpatient costs than households headed by those who never went to school.

Robust approach for variable selection with high dimensional longitudinal data analysis

This article proposes a new robust smooth-threshold estimating equation to select important variables and automatically estimate parameters for high dimensional longitudinal data. A novel working correlation matrix is proposed to capture correlations within the same subject. The proposed procedure works well when the number of covariates p n increases as the number of subjects n increases. The proposed estimates are competitive with the estimates obtained with the true correlation structure, especially when the data are contaminated. Moreover, the proposed method is robust against outliers in the response variables and/or covariates. Furthermore, the oracle properties for robust smooth-threshold estimating equations under "large n, diverging p n " are established under some regularity conditions. Extensive simulation studies and a yeast cell cycle data are used to evaluate the performance of the proposed method, and results show that the proposed method is competitive with existing robust variable selection procedures.

Association between Thyroid Function and Heart Rate Monitored by Wearable Devices in Patients with Hypothyroidism

BACKGROUND

Heart rate (HR) monitored by a wearable device (WD) has demonstrated its clinical feasibility for thyrotoxicosis subjects. However, the association of HR monitored by wearables with hypothyroidism has not been examined. We assessed the association between serum thyroid hormone concentration and three WD-HR parameters in hypothyroid subjects.

METHODS

Forty-four subjects scheduled for radioactive iodine therapy (RAI Tx) after thyroid cancer surgery were included. Thirty subjects were prepared for RAI Tx by thyroid hormone withdrawal (hypothyroidism group) and 14 subjects by recombinant human thyrotropin (control group). Three WD-HR parameters were calculated from the HR data collected during rest, during sleep, and from 2:00 AM to 6:00 AM, respectively. We analyzed the changes in conventionally measured resting HR (On-site rHR) and WDHR parameters relative to thyroid hormone levels.

RESULTS

Serum free thyroxine (T4) levels, On-site rHR, and WD-HR parameters were lower in the hypothyroid group than in the control group at the time of RAI Tx. WD-HR parameters also reflected minute changes in free T4 levels. A decrease in On-site rHR and WD-HR parameters by one standard deviation (On-site rHR, approximately 12 bpm; WD-HR parameters, approximately 8 bpm) was associated with a 0.2 ng/dL decrease in free T4 levels (P<0.01) and a 2-fold increase of the odds ratio of hypothyroidism (P<0.01). WD-HR parameters displayed a better goodness-of-fit measure (lower quasi-information criterion value) than On-site rHR in predicting the hypothyroidism.

CONCLUSION

This study identified WD-HR parameters as informative and easy-to-measure biomarkers to predict hypothyroidism.

Conventional oxygen therapy versus CPAP as a ceiling of care in ward-based patients with COVID-19: a multi-centre cohort evaluation

BACKGROUND

Continuous positive airway pressure (CPAP) therapy is commonly used for respiratory failure due to severe COVID-19 pneumonitis, including in patients deemed not likely to benefit from invasive mechanical ventilation (nIMV). Little evidence exists demonstrating superiority over conventional oxygen therapy, whilst ward-level delivery of CPAP presents practical challenges. We sought to compare clinical outcomes of oxygen therapy versus CPAP therapy in patients with COVID-19 who were nIMV.

METHODS

This retrospective multi-centre cohort evaluation included patients diagnosed with COVID-19 who were nIMV, had a treatment escalation plan of ward-level care and clinical frailty scale ≤ 6. Recruitment occurred during the first two waves of the UK COVID-19 pandemic in 2020; from 1st March to May 31st, and from 1st September to 31st December. Patients given CPAP were compared to patients receiving oxygen therapy that required FiO2 ≥0.4 for more than 12 hours at hospitals not providing ward-level CPAP. Logistic regression modelling was performed to compare 30-day mortality between treatment groups, accounting for important confounders and within-hospital clustering.

FINDINGS

Seven hospitals provided data for 479 patients during the UK COVID-19 pandemic in 2020. Overall 30-day mortality was 75.6% in the oxygen group (186/246 patients) and 77.7% in the CPAP group (181/233 patients). A lack of evidence for a treatment effect persisted in the adjusted model (adjusted odds ratio 0.84 95% CI 0.57-1.23, p=0.37). 49.8% of patients receiving CPAP-therapy (118/237) chose to discontinue it.

INTERPRETATION

No survival difference was found between using oxygen alone or CPAP to treat patients with severe COVID-19 who were nIMV. A high patient-initiated discontinuation rate for CPAP suggests a significant treatment burden. Further reflection is warranted on the current treatment guidance and widespread application of CPAP in this setting.

FUNDING

L Pearmain is supported by the MRC (MR/R00191X/1). TW Felton is supported by the NIHR Manchester Biomedical Research Centre.

Estimation of age at onset of linear enamel hypoplasia. New calculation tool, description and comparison of current methods

Enamel Hypoplasia (EH) is known to be a useful indicator for wide range of detrimental factors in early childhood in past populations, such as nutritional disturbances, mechanical trauma, disease, metabolic, and/or genetic disorders. EH may be divided into three categories: pits, grooves, and lines, where the last two are referred to as "Linear Enamel Hypoplasia" (LEH). The regularity of enamel formation allows retrospective determination of the age of LEH formation. The current article reviews and compares the best-known methods used to estimate age at LEH formation and provides a new computational tool. Growth curves for canines and incisors were developed based on tooth growth tables by previous authors. Optimal models were selected using the Akaike Information Criterion. A Microsoft Excel spreadsheet was created to calculate age at LEH formation using the most common methods. All method results were compared with an archaeological sample (44 teeth of 18 individuals from an early modern cemetery from Wrocław, Poland) and a theoretical model. The results of the methods were compared pairwise with Bland-Altman plots. The current article provides a quick and easy-to-use tool for analyzing LEH chronology and comparing the results of different methods. As shown by the Bland-Altman plots, most methods provide approximately consistent results for LEHs formed at around 2-3 years of age. However, LEHs formed particularly early or late are more prone to discrepancies between different methods. Comparison of the age at LEH formation obtained by different methods should be done carefully - and the new LEH calculation tool with optimized equations provided in this publication can facilitate this process.

Risk Factors for Salmonella Contamination of Whole Chicken Carcasses following Changes in U.S. Regulatory Oversight

ABSTRACT

Salmonella is a common cause of foodborne illness in the United States and often is linked to chicken products. Salmonella contamination has been associated with meat processing facility characteristics, such as the number of employees (i.e., hazard analysis critical control point [HACCP]-based definition of size). The risk factors for Salmonella contamination in U.S. poultry have not been evaluated since implementation of the New Poultry Inspection System (NPIS) in 2014. The goal of this study was to determine whether risk factors for Salmonella contamination changed after implementation of the NPIS. Presence or absence of Salmonella in whole chicken carcasses was modeled using microbiological testing data collected from 203 poultry processing establishments by the U.S. Department of Agriculture Food Safety and Inspection Service between May 2015 and December 2019. A model was fit using generalized estimating equations for weekly presence or absence of Salmonella, and production volume, geographic location, and season were included as potential covariates among other establishment demographics. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated from the marginal model. Of the 40,497 analyzable samples, 1,725 (4.26%) were positive for Salmonella. Odds of contamination was lower among establishments slaughtering ≥10,000,000 birds per year (OR = 0.466; 95% CI, [0.307, 0.710]) and establishments producing ready-to-eat finished products (OR = 0.498; 95% CI, [0.298, 0.833]) and higher among establishments historically (previous 84 days) noncompliant with HACCP regulations (OR = 1.249; 95% CI, [1.071, 1.456]). Contamination also significantly varied by season and geographic region, with higher odds of contamination during summer and outside the MidEast Central region. These results support continuation of targeted food safety policies and initiatives promoting pathogen reduction by establishments with smaller volumes and those noncompliant with HACCP regulations.

HIGHLIGHTS

The costs of bipolar disorder in the United Kingdom

OBJECTIVES

To estimate the individual cost and population-level economic burden of Bipolar Disorder (BD), and explore the impact of clinical and sociodemographic factors on costs in the United Kingdom.

METHODS

Annual UK health care, social care and societal cost data were collected from a prospective cohort of 91 BD patients using digital monitoring of symptoms. Costs (in £) were calculated for the year of resource use collection (2010-2011) and main results inflated to year 2018-2019. A Generalized Estimating Equation framework was used to investigate individual factors influencing costs. An economic burden estimate was derived by multiplying the mean annual cost per patient with literature-based population prevalence.

RESULTS

The average annual cost of BD per patient was £12,617 (SE = ±£1085) or £14,938 (SE = ±£1281) at 2018-2019 prices with 68% of the total costs attributed to lost productivity and informal care, 31% to health care costs, 1% to private out-of-pocket expenses, and 0.5% to social care costs. A unit increase in average levels of depressive or manic symptoms were associated with 7% and 11% higher societal costs, respectively. The estimated annual prevalence of BD in the United Kingdom was 0.8% resulting in a population-level economic burden estimate of £5.1 billion for 2010-2011 or £6.43 billion for 2018-2019.

CONCLUSIONS

BD is a disease of substantial costs in the United Kingdom with the majority of the economic burden falling outside the health care system in the form of productivity losses and informal care. These costs highly correlate with patient outcomes highlighting further needs for improved treatment efforts into functionality.

Midden site selection in Dorcas gazelle: Larger is not always better

Dorcas gazelles are believed to use middens to mark their territories and transmit information. Given the commitment to maintaining a midden, it is believed that middens are not placed randomly. We examined how the habitat (tree height and maximum canopy) and anthropogenic disturbance (camel and human presence) influenced the selection of midden sites by Dorcas gazelles in South Sinai, Egypt. Our results showed that Dorcas gazelles did not place middens at larger trees, while favoring relatively smaller trees and shrubs where the anthropogenic disturbance and perceived hunting risk are less. Our results, in light of the previous findings, suggest that selection of midden sites is species context-dependent behavior. In areas with less anthropogenic disturbance and hunting, Dorcas gazelles have been shown to select the largest trees of the same species as midden sites. In contract, in our study site with high anthropogenic disturbance and no protection from hunting, gazelles did not utilize the presumably optimum landmarks for midden sites. Our study showed that Dorcas gazelles instead utilized smaller trees and some shrubs that are less conspicuous and presumably less effective as advertisement sites, but safer.

Penalized joint generalized estimating equations for longitudinal binary data

In statistical research, variable selection and feature extraction are a typical issue. Variable selection in linear models has been fully developed, while it has received relatively little attention for longitudinal data. Since a longitudinal study involves within-subject correlations, the likelihood function of discrete longitudinal responses generally cannot be expressed in analytically closed form, and standard variable selection methods cannot be directly applied. As an alternative, the penalized generalized estimating equation (PGEE) is helpful but very likely results in incorrect variable selection if the working correlation matrix is misspecified. In many circumstances, the within-subject correlations are of interest and need to be modeled together with the mean. For longitudinal binary data, it becomes more challenging because the within-subject correlation coefficients have the so-called Fréchet-Hoeffding upper bound. In this paper, we proposed smoothly clipped absolute deviation (SCAD)-based and least absolute shrinkage and selection operator (LASSO)-based penalized joint generalized estimating equation (PJGEE) methods to simultaneously model the mean and correlations for longitudinal binary data, together with variable selection in the mean model. The estimated correlation coefficients satisfy the upper bound constraints. Simulation studies under different scenarios are made to assess the performance of the proposed method. Compared to existing PGEE methods that specify a working correlation matrix for longitudinal binary data, the proposed PJGEE method works much better in terms of variable selection consistency and parameter estimation accuracy. A real data set on Clinical Global Impression is analyzed for illustration.

Prevalence and correlates of having sexual and reproductive health priorities met by HIV providers among women living with HIV in a Canadian setting

OBJECTIVE

To: (1) describe the prevalence of key reproductive health outcomes (e.g., pregnancy, unintended pregnancy; abortion); and (2) examine social-structural correlates, including HIV stigma, of having key sexual and reproductive health (SRH) priorities met by participants' primary HIV provider, among women living with HIV.

METHODS

Data were drawn from a longitudinal community-based open cohort (SHAWNA) of women living with HIV. The associations between social-structural factors and two outcomes representing having SRH priorities met by HIV providers ('being comfortable discussing sexual health [SH] and/or getting a Papanicolaou test' and 'being comfortable discussing reproductive health [RH] and/or pregnancy needs') were analyzed using bivariate and multivariable logistic regression models with generalized estimating equations for repeated measures over time. Adjusted odds ratios (AOR) and 95% confidence intervals [95% CIs] are reported.

RESULTS

Of 314 participants, 77.1% reported having SH priorities met while 64.7% reported having RH priorities met by their primary HIV provider at baseline. In multivariable analysis, having SH priorities met was inversely associated with: sexual minority identity (AOR: 0.59, 95% CI: 0.37-0.94), gender minority identity (AOR: 0.52, 95% CI: 0.29-0.95) and recent verbal or physical violence related to HIV status (AOR: 0.55, 95% CI: 0.31-0.97) and positively associated with recently accessing women-centred services (Oak Tree Clinic) (AOR: 4.25, 95% CI: 2.20-8.23). Having RH priorities met was inversely associated with: sexual minority identity (AOR: 0.56, 95% CI: 0.40-0.79), gender minority identity (AOR: 0.45, 95% CI: 0.25-0.81) and being born in Canada (AOR: 0.29, 95% CI: 0.15-0.56) and positively associated with recently accessing women-centred services (AOR: 1.81, 95% CI: 1.29-2.53) and a history of pregnancy (AOR: 2.25, 95% CI: 1.47-3.44).

CONCLUSION

Our findings suggest that there remain unmet priorities for safe SRH care and practice among women living with HIV, and in particular, for women living with HIV with sexual and/or gender minority identity and those who experience enacted HIV stigma. HIV providers should create safe, non-judgmental environments to facilitate discussions on SRH. These environments should be affirming of all sexual orientations and gender identities, culturally safe, culturally humble and use trauma-informed approaches.

Nasopharyngeal Codetection of H. influenzae and S. pneumoniae and Respiratory Syncytial Virus Disease Outcomes in Children

BACKGROUND

The role of nasopharyngeal bacteria on RSV disease has been underestimated. We measured the frequency and quantitative detection of potentially pathogenic bacteria in the upper respiratory tract of infants with RSV infection over seven respiratory seasons, and their impact on clinical outcomes.

METHODS

Children <2 years old with mild (outpatients; n=115) or severe (inpatients; n=566) RSV infection, and matched healthy controls (n=161) were prospectively enrolled. Nasopharyngeal samples were obtained for RSV, S. pneumoniae, S. aureus, M. catarrhalis, and H. influenzae detection and quantitation by PCR. Multivariable models were constructed to identify variables predictive of severe disease.

RESULTS

S. pneumoniae, H. influenzae, and M. catarrhalis, but not S. aureus, were detected more frequently in RSV-infected children (84%) than healthy controls (46%; p<0.001). Detection of S. pneumoniae and/or H. influenzae was associated with fever, more frequent antibiotic treatment, worse radiologic findings, and higher neutrophil counts (p<0.01). In adjusted analyses S. pneumoniae/H. influenzae co-detection was associated with greater odds (OR; 95% CI) of hospitalization (2.25 [1.07-4.74), higher disease severity scores (1.93 [1.14-3.26]), prolonged oxygen administration (2.23 [1.01-4.91]), and longer hospitalization (2.53 [1.33-4.79]).

CONCLUSIONS

Nasopharyngeal co-detection of S. pneumoniae and H. influenzae in infants with RSV infection is associated with increased disease severity.

Some Generalized Estimating Equations Models Based on Causality Tests for Investigation of The Economic Growth of The Country Groups

In this study, investigation of the economic growth of the Organization for Economic Cooperation and Development (OECD) countries and the countries in different income groups in the World Data Bank is conducted by using causality analyses and Generalized Estimating Equations (GEEs) which is an extension of Generalized Linear Models (GLMs). Eight different macro-economic, energy and environmental variables such as the gross domestic product (GDP) (current US$), CO2 emission (metric tons per capita), electric power consumption (kWh per capita), energy use (kg of oil equivalent per capita), imports of goods and services (% of GDP), exports of goods and services (% of GDP), foreign direct investment (FDI) and population growth rate (annual %) have been used. These countries have been categorized according to their OECD memberships and income groups. The causes of the economic growth of these countries belonging to their OECD memberships and income groups have been determined by using the Toda-Yamamoto causality test. Furthermore, various GEE models have been established for the economic growth of these countries belonging to their OECD membership and income groups in the aspect of the above variables. These various GEE models for the investigation of the economic growth of these countries have been compared to examine the contribution of the causality analyses to the statistical model establishment. As a result of this study, the highlight is found as the use of causally-related variables in the causality-based GEE models is much more appropriate than in the non-causality based GEE models for determining the economic growth profiles of these countries.

Olfaction-Related Factors Affecting Chemosensory Dream Content in a Sleep Laboratory

Mental activity in sleep often involves visual and auditory content. Chemosensory (olfactory and gustatory) experiences are less common and underexplored. The aim of the study was to identify olfaction-related factors that may affect the occurrence of chemosensory dream content. Specifically, we investigated the effects of all-night exposure to an ambient odour, participants' appraisal of their current olfactory environment, their general propensity to notice odours and act on them (i.e., odour awareness), and their olfactory acuity. Sixty pre-screened healthy young adults underwent olfactory assessment, completed a measure of odour awareness, and spent three nights in weekly intervals in a sleep laboratory. The purpose of the first visit was to adapt to the experimental setting. On the second visit, half of them were exposed to the smell of vanillin or thioglycolic acid and the other half to an odourless control condition. On the third visit, they received control or stimulation in a balanced order. On each visit, data were collected twice: once from the first rapid eye movement (REM) stage that occurred after 3 a.m., and then shortly before getting up, usually from a non-REM stage. Participants were asked to report the presence of sensory dream content and to assess their current olfactory environment. Neither exposure, nor participants' assessments of the ambient odour, or olfactory acuity affected reports of chemosensory dream content but they were more frequent in individuals with greater odour awareness. This finding may have implications for treatment when such experiences become unwanted or bothersome.

The Effects of Age, Biological Maturation and Sex on the Development of Executive Functions in Adolescents

The development of executive functions (EF) has been widely investigated and is associated with various domains of expertise, such as academic achievement and sports performance. Multiple factors are assumed to influence the development of EF, among them biological maturation. Currently the effect of biological maturation on EF performance is largely unexplored, in contrast to other domains like physical development or sports performance. Therefore, this study aimed (a) to explore the effect of chronological age on EF performance and (b) to investigate to what extent age-related changes found in EF are affected by biological maturation on both sexes. To this end, EF performance and degree of maturity, indexed by percentage of predicted adult height (%PAH), of 90 adolescents (11-16 years old, 54% males) were measured on three occasions in a time frame of 12 months. A Generalized Estimating Equation (GEE) approach was used to examine the association between chronological age and %PAH and the weighted sum scores for each EF component (i.e., inhibition, planning, working memory, shifting). All models were run separately for both sexes. The males' results indicated that EF performance improved with age and degree of maturity on all four components. Interaction effects between age and %PAH on inhibition showed that at a younger age, males with a higher %PAH had a lower chance of performing well on inhibition, whereas at later ages, males with a higher %PAH had a higher chance to have a good inhibition performance. For working memory, it seems that there is no maturity effect at a younger age, while at later ages, a disadvantage for later maturing peers compared to on-time and earlier maturing male adolescents emerged. Females showed slightly different results. Here, age positively influenced EF performance, whereas maturity only influenced inhibition. Interaction effects emerged for working memory only, with opposite results from the males. At younger ages, females with lower %PAH values seem to be scoring higher, whereas at later ages, no maturity effect is observed. This study is one of the first to investigate the effect of biological maturation on EF performance, and shows that distinct components of EF are influenced by maturational status, although the effects are different in both sexes. Further research is warranted to unravel the implications for maturation-driven effects on EF that might significantly affect domains of human functioning like academic achievement and social development.

Early Evaluation of an Ultra-Portable X-ray System for Tuberculosis Active Case Finding

X-ray screening is an important tool in tuberculosis (TB) prevention and care, but access has historically been restricted by its immobile nature. As recent advancements have improved the portability of modern X-ray systems, this study represents an early evaluation of the safety, image quality and yield of using an ultra-portable X-ray system for active case finding (ACF). We reported operational and radiological performance characteristics and compared image quality between the ultra-portable and two reference systems. Image quality was rated by three human readers and by an artificial intelligence (AI) software. We deployed the ultra-portable X-ray alongside the reference system for community-based ACF and described TB care cascades for each system. The ultra-portable system operated within advertised specifications and radiologic tolerances, except on X-ray capture capacity, which was 58% lower than the reported maximum of 100 exposures per charge. The mean image quality rating from radiologists for the ultra-portable system was significantly lower than the reference (3.71 vs. 3.99, p < 0.001). However, we detected no significant differences in TB abnormality scores using the AI software (p = 0.571), nor in any of the steps along the TB care cascade during our ACF campaign. Despite some shortcomings, ultra-portable X-ray systems have significant potential to improve case detection and equitable access to high-quality TB care.

Mapping Workplace Neighborhood Mobility Among Sex Workers in an Urban Canadian Setting: Results of a Community-Based Spatial Epidemiological Study From 2010-2016

Mobility among sex workers has been linked not only to improved economic and social opportunities, but also to concerns regarding displacement, criminalization, and violence. In 2014, new "end-demand" legislation criminalized new aspects of sex work in Canada (e.g., third-party advertising, purchasing) while leaving the sale of sex legal. Utilizing data from a longitudinal community-based cohort of women sex workers in Metro Vancouver (An Evaluation of Sex Workers Health Access [AESHA], 2010-2016), we used kernel density mapping to understand and identify geographic patterns of workplace neighborhood mobility (i.e., changing the primary neighborhood in which one worked in the last 6 months); multivariable logistic regression using generalized estimating equations was also used to model contextual (policing, violence, and safety) and individual correlates of workplace mobility among sex workers over the 6-year period, including potential changes in mobility patterns pre- and post-end-demand criminalization. A total of 543 sex workers were included in analyses, contributing 2,199 observations. A total of 402 (74.0%) experienced workplace neighborhood mobility during the study period. Neighborhood mobility was negatively correlated with age (adjusted odds ratio [AOR] = 0.98/year older, 95% confidence interval [CI] = [0.97, 0.99]) and positively correlated with homelessness (AOR = 1.43, 95% CI = [1.12, 1.82]), identifying as a gender/sexual minority (AOR = 1.31, 95% CI = [1.04, 1.70]), and servicing clients primarily outdoors (vs. informal indoor or in-call venues; AOR = 1.48, 95% CI = [1.21, 1.81]); police harassment (AOR = 1.19, 95% CI = [0.96, 1.48], p = .11) and changing one's neighborhood of work due to safety concerns (AOR = 1.37, 95% CI = [0.94, 2.00], p = .09) were both marginally correlated. Steps to promote safer working conditions for marginalized women in urban environments remain urgently needed, including shifts away from criminalized enforcement toward community-led initiatives and promoting access to safer indoor workspaces.

Variations in seasonal solar insolation are associated with a history of suicide attempts in bipolar I disorder

Background

Bipolar disorder is associated with circadian disruption and a high risk of suicidal behavior. In a previous exploratory study of patients with bipolar I disorder, we found that a history of suicide attempts was associated with differences between winter and summer levels of solar insolation. The purpose of this study was to confirm this finding using international data from 42% more collection sites and 25% more countries.

Methods

Data analyzed were from 71 prior and new collection sites in 40 countries at a wide range of latitudes. The analysis included 4876 patients with bipolar I disorder, 45% more data than previously analyzed. Of the patients, 1496 (30.7%) had a history of suicide attempt. Solar insolation data, the amount of the sun’s electromagnetic energy striking the surface of the earth, was obtained for each onset location (479 locations in 64 countries).

Results

This analysis confirmed the results of the exploratory study with the same best model and slightly better statistical significance. There was a significant inverse association between a history of suicide attempts and the ratio of mean winter insolation to mean summer insolation (mean winter insolation/mean summer insolation). This ratio is largest near the equator which has little change in solar insolation over the year, and smallest near the poles where the winter insolation is very small compared to the summer insolation. Other variables in the model associated with an increased risk of suicide attempts were a history of alcohol or substance abuse, female gender, and younger birth cohort. The winter/summer insolation ratio was also replaced with the ratio of minimum mean monthly insolation to the maximum mean monthly insolation to accommodate insolation patterns in the tropics, and nearly identical results were found. All estimated coefficients were significant at p < 0.01.

Conclusion

A large change in solar insolation, both between winter and summer and between the minimum and maximum monthly values, may increase the risk of suicide attempts in bipolar I disorder. With frequent circadian rhythm dysfunction and suicidal behavior in bipolar disorder, greater understanding of the optimal roles of daylight and electric lighting in circadian entrainment is needed.

Bans on Cellphone Use While Driving and Traffic Fatalities in the United States

BACKGROUND

As of January 2020, 18 of 50 US states comprehensively banned almost all handheld cellphone use while driving, 3 states and the District of Columbia banned calling and texting, 27 states banned texting on a handheld cellphone, and 2 states had no general cellphone ban for all drivers. However, it remains unknown whether these bans were associated with fewer traffic deaths and whether comprehensive handheld bans are more effective than isolated calling or texting bans. We evaluated whether cellphone bans were associated with fewer driver, non-driver, and total fatalities nationally.

METHODS

We conducted a longitudinal panel analysis of traffic fatality rates by state, year, and quarter. Population-based rate ratios and 95% CIs were estimated comparing state-quarters with and without cellphone bans.

RESULTS

From 1999 through 2016, 616,289 persons including 344,003 drivers died in passenger vehicle crashes in the United States. Relative to no ban, comprehensive handheld bans were associated with lower driver fatality rates (adjusted rate ratio aRR = 0.93, 95% CI = 0.90, 0.97) but not for non-driver fatalities (aRR = 1.01, 95% CI = 0.95, 1.07) or total fatalities (aRR = 0.98, 95% CI = 0.94, 1.01). We found no differences in driver fatalities for calling-only bans (aRR = 1.00, 95% CI = 0.97, 1.03), texting-only bans (aRR = 1.02, 95% CI = 0.99, 1.05), texting plus phone-manipulating bans (aRR = 0.99, 95% CI = 0.93, 1.04), or calling and texting bans (aRR = 0.98, 95% CI = 0.88, 1.09).

CONCLUSIONS

Comprehensive handheld bans were associated with fewer driver fatalities.

Dynamic selection for forage quality and quantity in response to phenology and insects in an Arctic ungulate

Spatiotemporal variation in forage is a primary driver of ungulate behavior, yet little is known about the nutritional components they select, and how selection varies across the growing season with changes in forage quality and quantity. We addressed these uncertainties in barren-ground caribou (Rangifer tarandus), which experience their most important foraging opportunities during the short Arctic summer. Recent declines in Arctic caribou populations have raised concerns about the influence of climate change on summer foraging opportunities, given shifting vegetation conditions and insect harassment, and their potential effects on caribou body condition and demography. We examined Arctic caribou selection of summer forage by pairing locations from females in the Central Arctic Herd of Alaska with spatiotemporal predictions of biomass, digestible nitrogen (DN), and digestible energy (DE). We then assessed selection for these nutritional components across the growing season at landscape and patch scales, and determined whether foraging opportunities were constrained by insect harassment. During early summer, at the landscape scale, caribou selected for intermediate biomass and high DN and DE, following expectations of the forage maturation hypothesis. At the patch scale, however, caribou selected for high values of all forage components, particularly DN, suggesting that protein may be limiting. During late summer, after DN declined below the threshold for protein gain, caribou exhibited a switch at both spatial scales, selecting for higher biomass, likely enabling mass and fat deposition. Mosquito activity strongly altered caribou selection of forage and increased their movement rates, while oestrid fly activity had little influence. Our results demonstrate that early and late summer periods afford Arctic caribou distinct foraging opportunities, as they prioritize quality earlier in the summer and quantity later. Climate change may further constrain caribou access to DN as earlier, warmer Arctic summers may be associated with reduced DN and increased mosquito harassment.

Comparative construct validity of three presenteeism instruments in workers with musculoskeletal complaints: a prospective cohort study

OBJECTIVES

To compare the construct validity of three presenteeism instruments, using health and economic outcomes as external references, among working persons reporting musculoskeletal complaints.

METHODS

Data from the prospective Study on Transitions in Employment, Ability and Motivation were used. Presenteeism measurement comprised a global rating of work-ability, and two instruments indicating at-work productivity, and was assessed yearly over 6 years of follow-up. Longitudinal associations between measures of health and subsequent presenteeism, and between presenteeism and subsequent days of sick leave were assessed using generalised estimating equation models. The effect of groups of contextual factors (socio-demographic, lifestyle, personal and work-related factors) was investigated by assessing the change in explained variability.

RESULTS

In total, 4523 persons were analysed. The association between physical health and work-ability was stronger than both at-work productivity measures; 10 points increase in physical health (0-100, higher is better) was associated with 0.79 points (95% CI 0.75 to 0.84) better work-ability (0-10, higher is better) in the subsequent year. Besides, work-ability best predicted sick leave; one point higher work-ability was associated with 4 days less sick leave (95% CI -5.09 to -3.63) the subsequent year. Personal factors improved model fit for models on health and work-ability, but conflicting results were seen for both at-work productivity instruments.

CONCLUSION

Work-ability showed higher construct validity against health and economic outcomes as compared to at-work productivity, which shows that work-ability is different to productivity (losses). Personal factors are especially relevant when interpreting the relation between health and work-ability or self-reported quantity of work.

Relationships between animal management and habitat characteristics with two potential indicators of welfare for bottlenose dolphins under professional care

Accredited zoos and aquariums continually strive to ensure high levels of animal welfare for the animals under their professional care. Best management practices include conducting research to better understand factors that lead to optimal welfare and then turning findings into practice. The current study is part of the larger Cetacean Welfare Study or more formally, "Towards understanding the welfare of cetaceans in zoos and aquariums." Facilities participating in the study were accredited by the Alliance of Marine Mammal Parks and Aquariums and/or the Association of Zoos and Aquariums. Animal management factors and habitat characteristics were examined in relation to two potential indicators of welfare for common (Tursiops truncatus) and Indo-Pacific (Tursiops aduncus) bottlenose dolphins. Specifically, we examined environmental enrichment, animal training, and habitat characteristics that were significantly related to behavioral diversity and route tracing, a form of stereotypic behavior. Behavior was recorded from 47 animals at 25 facilities around the world. Overall, the rate of route tracing behavior observed during the study was very low and few animal management factors or habitat characteristics were found to be related to this behavior. One factor, enrichment diversity, had a significant positive relationship with route tracing and an inverse relationship with behavioral diversity. This finding may be a product of a response mounted by animal care specialists to the behavior as opposed to a cause. Animals that engaged in this behavior were likely provided more diverse enrichment in attempts to ameliorate the stereotypic behavior. However, multiple factors were found to significantly relate to behavioral diversity, a potential positive indicator of welfare for bottlenose dolphins. Dolphins that were trained on a predictable schedule had higher behavioral diversity than those on a semi-predictable schedule. There was a positive significant relationship between behavioral diversity and the number of habitats to which an animal had access, and a significant inverse relationship with the maximum depth of the habitat. Finally, animals that were split into groups and reunited or rotated between subgroups had higher behavioral diversity than animals managed in the same group. Information gained from the current study suggested that animal management techniques may be more important in ensuring good welfare for bottlenose dolphins than focusing on habitat size.

Assessment of animal management and habitat characteristics associated with social behavior in bottlenose dolphins across zoological facilities

Bottlenose dolphins are a behaviorally complex, social species that display a variety of social behaviors. Because of this, it is important for zoological facilities to strive to ensure animals display species-appropriate levels of social behavior. The current study is part of the multi-institutional study entitled "Towards understanding the welfare of cetaceans in zoos and aquariums" commonly referred to as the Cetacean Welfare Study. All participating facilities were accredited by the Alliance of Marine Mammal Parks and Aquariums and/or the Association of Zoos and Aquariums. Behavioral data were collected on 47 bottlenose dolphins representing two subspecies, Tursiops truncatus and Tursiops aduncus, at 25 facilities. The social behaviors of group related activity (group active) as well as interacting with conspecifics (interact with conspecific) were examined for their relationships to both animal management factors and habitat characteristics. The behavioral state of group active and the rate of interact with conspecific were both positively related to the frequency of receiving new forms of environmental enrichment. Both were inversely related to the random scheduling of environmental enrichment. Additional results suggested interact with conspecific was inversely related with daytime spatial experience and that males displayed group active more than females. Overall, the results suggested that animal management techniques such as the type and timing of enrichment may be more important to enhance social behavior than habitat characteristics or the size of the habitat. Information gained from this study can help facilities with bottlenose dolphins manage their enrichment programs in relation to social behaviors.

Impact of changing reimbursement criteria on the use of fluoroquinolones in Belgium

Objectives

The criteria for the reimbursement of fluoroquinolones changed in Belgium on 1 May 2018. This study aims to quantify the difference in fluoroquinolone use after this change, and to assess the timing and persistence of this effect, both in terms of total reimbursed fluoroquinolone use and its relative proportion.

Methods

Longitudinal reimbursement data on fluoroquinolone use in the Belgian community from January 2017 to November 2018 were analysed to identify a change in reimbursed fluoroquinolone use expressed in DDD per 1000 inhabitants per day (DID), using a set of non-linear mixed models including change-points. In addition, longitudinal data on the relative proportion of prescribed fluoroquinolones from January 2017 to December 2018 were analysed to identify a change in the relative proportion of prescribed fluoroquinolones using generalized estimation equations including change-points.

Results

Fluoroquinolone use dropped significantly immediately after the change in reimbursement criteria, from 2.21 DID (95% CI: 2.03–2.38) to 0.52 DID (95% CI: 0.48–0.56) and from 9.14% (95% CI: 8.75%–9.56%) to 6.52% (95% CI: 6.04%–7.04%). The observed decrease in fluoroquinolone use persisted over time.

Conclusions

While fluoroquinolone use was still above the target of 5% after the change in reimbursement criteria, its implementation helped to lower fluoroquinolone use in Belgium.

Patterns of allergic sensitization and factors associated with emergence of sensitization in the rural tropics early in the life course: findings of an Ecuadorian birth cohort

Introduction

There are limited data on emergence of allergic sensitization (or atopy) during childhood in tropical regions.

Methods

We followed a birth cohort of 2404 newborns to 8 years in tropical Ecuador and collected: risk factor data by maternal questionnaires periodically from birth; atopy was measured by skin prick test reactivity (SPT) to aeroallergens in parents, and aeroallergens and food allergens in children at 2, 3, 5, and 8 years; and stool samples for soil-transmitted helminths (STH) from children periodically to 8 years and from parents and household members at the time of recruitment of cohort children. Data on risk factors were measured either at birth or repeatedly (time-varying) from birth to 8 years. Longitudinal repeated-measures analyses were done using generalized estimating equations to estimate an the age-dependent risk of positive SPT (SPT+) to any allergen or mite during early childhood to school age.

Results

SPT+ to any allergen was present in 29.0% of fathers and 24.8% of mothers, and in cohort children increased with age, initially to mite but later to cockroach, reaching 14.8% to any allergen (10.7% mite and 5.3% cockroach) at 8 years. Maternal SPT+, particularly presence of polysensitization (OR 2.04, 95% CI 1.49-2.77) significantly increased the risk of SPT+ during childhood, while household overcrowding at birth decreased the risk (OR 0.84, 95% CI 0.72-0.98). For mite sensitization, maternal polysensitization increased (OR 2.14, 95% CI 1.40-3.27) but rural residence (OR 0.69, 95% CI 0.50-0.94) and birth order (3^rd -4^th vs. 1^st - 2^nd: OR 0.71, 95% CI 0.52-0.98) decreased the risk. Time-varying exposures to agricultural activities (OR 0.77, 95% CI 0.60-0.98) and STH parasites (OR 0.70, 95% CI 0.64-0.91) during childhood decreased while anthelmintics increased the childhood risk (OR 1.47, 95% CI 1.05-2.05) of mite sensitization.

Conclusion

Our data showed the emergence of allergic sensitization, primarily to mite and cockroach allergens, during childhood in tropical Ecuador. A role for both antenatal and postnatal factors acting as potential determinants of SPT+ emergence was observed.

Effect of a self-care educational intervention to improve self-care adherence among patients with chronic heart failure: a clustered randomized controlled trial in Northwest Ethiopia

BACKGROUND

As the burden of cardiovascular disease increases in sub-Saharan Africa, there is a growing need for low-cost interventions to mitigate its impact. Providing self-care health education to patients with chronic heart failure (CHF) is recommended as an intervention to prevent complications, improve quality of life, and reduce financial burdens on fragile health systems. However, little is known about health education's effectiveness at improving CHF self-management adherence in sub-Saharan Africa. Therefore the present study aimed to assess the effectiveness of an educational intervention to improve self-care adherence among patients with CHF at Debre Markos and Felege Hiwot Referral Hospitals in Northwest Ethiopia.

METHODS

To address this gap, we adapted a health education intervention based on social cognitive theory comprising of intensive four-day training and, one-day follow-up sessions offered every four months. Patients also received illustrated educational leaflets. We then conducted a clustered randomized control trial of the intervention with 186 randomly-selected patients at Debre Markos and Felege Hiwot referral hospitals. We collected self-reported data on self-care behavior before each educational session. We analyzed these data using a generalized estimating equations model to identify health education's effect on a validated 8-item self-care adherence scale.

RESULTS

Self-care adherence scores were balanced at baseline. After the intervention, patients in the intervention group (n = 88) had higher adherence scores than those in the control group (n = 98). This difference was statistically significant (β = 4.15, p < 0.05) and increased with each round of education. Other factors significantly associated with adherence scores were being single (β = - 0.25, p < 0.05), taking aspirin (β = 0.76, p < 0.05), and having a history of hospitalization (β = 0.91, p < 0.05).

CONCLUSIONS

We find that self-care education significantly improved self-care adherence scores among CHF patients. This suggests that policymakers should consider incorporating self-care education into CHF management.

TRIAL REGISTRATION NUMBER

PACTR201908812642231.

How social learning amplifies moral outrage expression in online social networks

Moral outrage shapes fundamental aspects of social life and is now widespread in online social networks. Here, we show how social learning processes amplify online moral outrage expressions over time. In two preregistered observational studies on Twitter (7331 users and 12.7 million total tweets) and two preregistered behavioral experiments (N = 240), we find that positive social feedback for outrage expressions increases the likelihood of future outrage expressions, consistent with principles of reinforcement learning. In addition, users conform their outrage expressions to the expressive norms of their social networks, suggesting norm learning also guides online outrage expressions. Norm learning overshadows reinforcement learning when normative information is readily observable: in ideologically extreme networks, where outrage expression is more common, users are less sensitive to social feedback when deciding whether to express outrage. Our findings highlight how platform design interacts with human learning mechanisms to affect moral discourse in digital public spaces.

Parent stress and coping trajectories in Hispanic and non-Hispanic families of children at risk of autism spectrum disorder

LAY ABSTRACT

Little is known about parent experiences throughout the diagnostic process for autism or how these parent experiences may help explain the disparities that exist between Hispanic and non-Hispanic families in time-to-diagnosis among children identified as at risk for autism. The current study examined trajectories of parenting stress, coping, and perceived family impact over time, throughout the autism diagnostic process among Hispanic and non-Hispanic families. Hispanic families reported lower levels of parenting stress, coping, and negative family impact across time. Further, there were differences in the change in use of coping and the amount of negative family impact reported between Hispanic and non-Hispanic parents over time. These differences shed light on the unique experiences and strengths of Hispanic families demonstrate. Interventions that leverage those strengths and focus on education, empowerment, and resilience might be particularly beneficial for Hispanic families and may also better inform work to increase resilience.

MRI-based radiomics analysis for predicting the EGFR mutation based on thoracic spinal metastases in lung adenocarcinoma patients

PURPOSE

This study aims to develop and evaluate multi-parametric MRI-based radiomics for preoperative identification of epidermal growth factor receptor (EGFR) mutation, which is important in treatment planning for patients with thoracic spinal metastases from primary lung adenocarcinoma.

METHODS

A total of 110 patients were enrolled between January 2016 and March 2019 as a primary cohort. A time-independent validation cohort was conducted containing 52 patients consecutively enrolled from July 2019 to April 2021. The patients were pathologically diagnosed with thoracic spinal metastases from primary lung adenocarcinoma; all underwent T1-weighted (T1W), T2-weighted (T2W), and T2-weighted fat-suppressed (T2FS) MRI scans of the thoracic spinal. Handcrafted and deep learning-based features were extracted and selected from each MRI modality, and used to build the radiomics signature. Various machine learning classifiers were developed and compared. A clinical-radiomics nomogram integrating the combined rad signature and the most important clinical factor was constructed with receiver operating characteristic (ROC), calibration, and decision curves analysis (DCA) to evaluate the prediction performance.

RESULTS

The combined radiomics signature derived from the joint of three modalities can effectively classify EGFR mutation and EGFR wild-type patients, with an area under the ROC curve (AUC) of 0.886 (95% confidence interval [CI]: 0.826-0.947, SEN =0.935, SPE =0.688) in the training group and 0.803 (95% CI: 0.682-0.924, SEN = 0.700, SPE = 0.818) in the time-independent validation group. The nomogram incorporating the combined radiomics signature and smoking status achieved the best prediction performance in the training (AUC = 0.888, 95% CI: 0.849-0.958, SEN = 0.839, SPE = 0.792) and time-independent validation (AUC = 0.821, 95% CI: 0.692-0.929, SEN = 0.667, SPE = 0.909) cohorts. The DCA confirmed potential clinical usefulness of our nomogram.

CONCLUSION

Our study demonstrated the potential of multi-parametric MRI-based radiomics on preoperatively predicting the EGFR mutation. The proposed nomogram model can be considered as a new biomarker to guide the selection of individual treatment strategies for patients with thoracic spinal metastases from primary lung adenocarcinoma.

Gender diversity and financial performance in an emerging economy: empirical evidencefrom India

Purpose

This paper aims to examine the impact of gender diversity both at operational and leadership levels on the financial performance of firms in India.

Design/methodology/approach

The study is based on a panel data set of 100 large Indian corporate firms. This study uses the Blau index and Shannon index to compute gender diversity. First, this paper uses system generalized method of moments model to deal with the potential endogeneity issue in the association between gender diversity and firm performance. Second, to unveil heterogeneity in such a relationship, the study applies panel data quantile regression model. Finally, the study adopts a generalized estimating equation model to investigate such relationships for group affiliated and standalone firms.

Findings

This study finds a significant positive impact of workforce gender diversity and board gender diversity on the financial performance of firms. Further, the results of the quantile regression model indicate that the impact of gender diversity (workforce and board) on firm performance is more pronounced at higher quantiles of the conditional distribution of firm performance. However, the study fails to extricate any significant impact of audit committee gender diversity on firm performance. Finally, the study also finds a significant positive impact of gender diversity at both workforce and board level for a group affiliated, as well as standalone firms.

Originality/value

The present study makes a novel contribution to the extant literature on the association between gender diversity and financial performance of firms by examining such diversity at both operational and leadership levels in the context of an emerging country such as India that captures the complex realities pertaining to gender issues. Further, the study contributes to the empirical literature regarding the heterogeneous impact of gender diversity on firm performance in the Indian context.

A new GEE method to account for heteroscedasticity using asymmetric least-square regressions

Generalized estimating equations ( G E E ) are widely used to analyze longitudinal data; however, they are not appropriate for heteroscedastic data, because they only estimate regressor effects on the mean response - and therefore do not account for data heterogeneity. Here, we combine the G E E with the asymmetric least squares (expectile) regression to derive a new class of estimators, which we call generalized expectile estimating equations ( G E E E ) . The G E E E model estimates regressor effects on the expectiles of the response distribution, which provides a detailed view of regressor effects on the entire response distribution. In addition to capturing data heteroscedasticity, the GEEE extends the various working correlation structures to account for within-subject dependence. We derive the asymptotic properties of the G E E E estimators and propose a robust estimator of its covariance matrix for inference (see our R package, github.com/AmBarry/expectgee). Our simulations show that the GEEE estimator is non-biased and efficient, and our real data analysis shows it captures heteroscedasticity.

Albumin use in bleeding cardiac surgical patients and associated patient outcomes

PURPOSE

Albumin solution is a colloid used for resuscitation in cardiac surgical patients, but it is unclear if it offers advantages over crystalloids. We examined current clinical practice across 11 cardiac surgical centres and the association of albumin with outcomes in a cohort of bleeding cardiac surgical patients.

METHODS

This was a post hoc analysis of data from the Effect of Fibrinogen Concentrate vs Cryoprecipitate on Blood Component Transfusion After Cardiac Surgery (FIBRES) trial. Multivariable regression models adjusted for demographic and surgical characteristics were used to examine predictors of early albumin administration (within the initial 24 perioperative hours), late albumin administration (from 24 hr to seven days after cardiopulmonary bypass), and the association of albumin use with 28-day acute kidney injury, mortality, and length of hospital and intensive care unit (ICU) stay.

RESULTS

Of the 735 patients included, 525 (71%) received albumin, ranging from 4.8% to 97.4% of patients across institutions, with 475 (64.6%) receiving albumin early (5% or 25% solution). In the adjusted models, female sex and preoperative hospital admission were associated with early use, while heart failure, female sex, bleeding severity, older age, and prior albumin use were predictors of later administration. Early albumin use was not associated with differences in acute kidney injury (adjusted odds ratio [aOR] 1.77; 95% confidence interval [CI], 0.96 to 3.27; P = 0.07), mortality (aOR 1.66; 95% CI, 0.99 to 2.78; P = 0.05), or length of ICU stay (P = 0.11) or hospital stay (P = 0.67).

CONCLUSIONS

Albumin use is common but highly variable within and across sites. Albumin use was not associated with improved outcomes. High quality randomized controlled trials should clarify its role in cardiac surgical patients.

The relationship between common mental disorders and incident diabetes among participants in the Kerala Diabetes Prevention Program (K-DPP)

This study aims to describe the prevalence of depression and anxiety among a population sample of people at high risk for type 2 diabetes in Kerala, India, and examine the relationship between depressive symptoms, anxiety, and incident Type 2 Diabetes Mellitus (T2DM) over a two-year period. We used data from the Kerala Diabetes Prevention Program, a cluster-randomized controlled trial for diabetes prevention among 1007 high-risk individuals. The prevalence of depression and anxiety were estimated using the 9-item Patient Health Questionnaire and the Generalized Anxiety Disorder 7-item scale, respectively. We calculated proportions for depression and anxiety and performed generalized estimating equations (GEE) to examine the relationship between baseline mental health status and incident T2DM. The prevalence of depression and anxiety at baseline were 7.5% and 5.5%, respectively. Compared with those reporting none/low symptoms, the odds ratio for incident diabetes was 1.07 (95% CI 0.54–2.12) for participants with moderate to severe depression and 0.73 (95% CI 0.23–2.28) for participants with moderate to severe anxiety, after adjusting for potential confounders. Our findings suggest that the prevalence of depression and anxiety were higher than those previously reported in the general population in India. However, among this sample of community-based adults at high risk of developing T2DM, the presence of moderate to severe depression and/or anxiety symptoms was not significantly associated with the risk of developing T2DM.

Trial registration: Australia and New Zealand Clinical Trials Registry ACTRN12611000262909. Registered 10 March 2011.

Factors Associated with Health-Related Quality of Life in Psoriatic Arthritis Patients: A Longitudinal Analysis

INTRODUCTION

Psoriatic arthritis (PsA) is considered a multifaceted disease, with patients reporting low health-related quality of life (HRQoL). Data on disease burden are substantial and there exists a need for properly designed studies to learn more about the evolution of HRQoL in this condition. This study aims to identify factors associated to HRQoL evolution in PsA patients followed-up in a real-world setting in Spain.

METHODS

We conducted a retrospective longitudinal observational study including incident patients from the rheumatology outpatient clinic of Hospital Clínico San Carlos (Madrid, Spain), diagnosed for the first time of PsA, defined as having received any ICD9/ICD10 diagnosis code of PsA, from 2007 to 2016, and followed-up until loss of follow-up, death, or November 2017. The influence of demographic and clinical variables in baseline HRQoL [assessed with the Rosser Classification Index (RCI)] was analyzed using bivariable and multivariable generalized linear models. The influence of those variables and of treatment-related factors in repeated measures of HRQoL was analyzed using bivariable and multivariable generalized estimating equations (GEE) models nested by patient.

RESULTS

Two hundred and thirty patients were included in the analysis, with 3384 registered visits. At baseline, older age, a previous diagnosis of obesity, and the presence of enthesitis were significantly associated with worse HRQoL. During follow-up, using an exchangeable working correlation structure, the presence of enthesitis was also associated with worse HRQoL, coefficient (95% CI) - 0.006 (- 0.01 to - 0.002), p = 1.00E-03; conversely, treatment with methotrexate or antimalarials was associated with better HRQoL with 0.007 (0.001-0.014), p = 0.020 and 0.003 (0.001-0.005), p = 3.00E-03, respectively.

CONCLUSIONS

Musculoskeletal manifestations and comorbidities exert a deleterious effect in HRQoL of PsA patients. Therefore, the optimal management of this condition needs to also address these manifestations in order to try to restore the QoL of these patients.

Landscape transformations produce favorable roosting conditions for turkey vultures and black vultures

Recent increases in turkey vulture (Cathartes aura) and black vulture (Coragyps atratus) populations in North America have been attributed in part to their success adapting to human-modified landscapes. However, the capacity for such landscapes to generate favorable roosting conditions for these species has not been thoroughly investigated. We assessed the role of anthropogenic and natural landscape elements on roosting habitat selection of 11 black and 7 turkey vultures in coastal South Carolina, USA using a GPS satellite transmitter dataset derived from previous research. Our dataset spanned 2006–2012 and contained data from 7916 nights of roosting. Landscape fragmentation, as measured by land cover richness, influenced roosting probability for both species in all seasons, showing either a positive relationship or peaking at intermediate values. Roosting probability of turkey vultures was maximized at intermediate road densities in three of four seasons, and black vultures showed a positive relationship with roads in fall, but no relationship throughout the rest of the year. Roosting probability of both species declined with increasing high density urban cover throughout most of the year. We suggest that landscape transformations lead to favorable roosting conditions for turkey vultures and black vultures, which has likely contributed to their recent proliferations across much of the Western Hemisphere.