Small Sample Methods for Multilevel Modeling: A Colloquial Elucidation of REML and the Kenward-Roger Correction

Enabling analytical power calculations for multilevel models with autocorrelated errors through deriving and approximating the precision matrix

To unravel how within-person psychological processes fluctuate in daily life, and how these processes differ between persons, intensive longitudinal (IL) designs in which participants are repeatedly measured, have become popular. Commonly used statistical models for those designs are multilevel models with autocorrelated errors. Substantive hypotheses of interest are then typically investigated via statistical hypotheses tests for model parameters of interest. An important question in the design of such IL studies concerns the determination of the number of participants and the number of measurements per person needed to achieve sufficient statistical power for those statistical tests. Recent advances in computational methods and software have enabled the computation of statistical power using Monte Carlo simulations. However, this approach is computationally intensive and therefore quite restrictive. To ease power computations, we derive simple-to-use analytical formulas for multilevel models with AR(1) within-person errors. Analytic expressions for a model family are obtained via asymptotic approximations of all sample statistics in the precision matrix of the fixed effects. To validate this analytical approach to power computation, we compare it to the simulation-based approach via a series of Monte Carlo simulations. We find comparable performances making the analytic approach a useful tool for researchers that can drastically save them time and resources.

Model selection of GLMMs in the analysis of count data in single-case studies: A Monte Carlo simulation

Generalized linear mixed models (GLMMs) have great potential to deal with count data in single-case experimental designs (SCEDs). However, applied researchers have faced challenges in making various statistical decisions when using such advanced statistical techniques in their own research. This study focused on a critical issue by investigating the selection of an appropriate distribution to handle different types of count data in SCEDs due to overdispersion and/or zero-inflation. To achieve this, I proposed two model selection frameworks, one based on calculating information criteria (AIC and BIC) and another based on utilizing a multistage-model selection procedure. Four data scenarios were simulated including Poisson, negative binominal (NB), zero-inflated Poisson (ZIP), and zero-inflated negative binomial (ZINB). The same set of models (i.e., Poisson, NB, ZIP, and ZINB) were fitted for each scenario. In the simulation, I evaluated 10 model selection strategies within the two frameworks by assessing the model selection bias and its consequences on the accuracy of the treatment effect estimates and inferential statistics. Based on the simulation results and previous work, I provide recommendations regarding which model selection methods should be adopted in different scenarios. The implications, limitations, and future research directions are also discussed.

Suicide Ideation Among Transgender and Gender Diverse Adolescents: The Role of Parental Invalidation of Adolescents' Gender Identity

Transgender and gender diverse (TGD) youth experience chronic and acute stress associated with their gender identity contributing to their increased risk of suicide and suicide ideation (SI) compared to non-TGD peers. This study examined how invalidating and accepting gender-related experiences with a parent impact SI severity among TGD adolescents cross-sectionally and longitudinally, within-person. Participants were 15 TGD adolescents with past month SI recruited across community and clinical settings. Adolescents completed a baseline assessment of validated interviews and self-report measures on parental invalidation and SI severity. Over a 14-day follow-up period, adolescents reported instances of parental gender invalidation and acceptance, relative stress of those experiences, and SI severity multiple times/day via ecological momentary assessment (EMA). Bivariate associations of parental invalidation and acceptance with SI were examined at baseline, while multilevel models examined the relationship within-person over follow-up. Cross-sectionally, greater perceived invalidation and non-affirmation by their parents was associated with more severe SI. Over the follow up, instances of perceived parental invalidation were associated with passive SI within-person. Findings partially support the minority stress theory and social safety perspective by showing that perceived gender-invalidation from parents affects SI in TGD adolescents, both cross-sectionally and longitudinally. Further research is needed to identify specific emotional and cognitive factors, such as perceived stress, that contribute to the risk of SI among TGD youth and inform the development of targeted interventions for this vulnerable population.

Evaluating two small-sample corrections for fixed-effects standard errors and inferences in multilevel models with heteroscedastic, unbalanced, clustered data

Multilevel modeling (MLM) is commonly used in psychological research to model clustered data. However, data in applied research usually violate one of the essential assumptions of MLM-homogeneity of variance. While the fixed-effect estimates produced by the maximum likelihood method remain unbiased, the standard errors for the fixed effects are misestimated, resulting in inaccurate inferences and inflated or deflated type I error rates. To correct the bias in fixed effects standard errors and provide valid inferences, small-sample corrections such as the Kenward-Roger (KR) adjustment and the adjusted cluster-robust standard errors (CR-SEs) with the Satterthwaite approximation for t tests have been used. The current study compares KR with random slope (RS) models and the adjusted CR-SEs with ordinary least squares (OLS), random intercept (RI) and RS models to analyze small, heteroscedastic, clustered data using a Monte Carlo simulation. Results show the KR procedure with RS models has large biases and inflated type I error rates for between-cluster effects in the presence of level 2 heteroscedasticity. In contrast, the adjusted CR-SEs generally yield results with acceptable biases and maintain type I error rates close to the nominal level for all examined models. Thus, when the interest is only in within-cluster effect, any model with the adjusted CR-SEs could be used. However, when the interest is to make accurate inferences of the between-cluster effect, researchers should use the adjusted CR-SEs with RS to have higher power and guard against unmodeled heterogeneity. We reanalyzed an example in Snijders & Bosker (2012) to demonstrate the use of the adjusted CR-SEs with different models.

Examining fish scale biomineral from Atlantic salmon populations

Fish scale microchemistry can be used to make life-history inferences, although ecological studies examining scale composition are relatively rare. Salmon scales have an external layer of calcium phosphate hydroxyl apatite (HAP). The structure, hardness, and calcium content of this layer have been shown to vary within and between species. This variation may lead to misinterpretation of trace element profiles. This study uses backscatter scanning electron microscopy with electron dispersive spectrometry to compare scales from salmon populations and to present a more detailed analysis of scale HAP than was previously available. Our findings extend the range of salmon populations for which HAP Ca is available and confirm previous findings that the HAP Ca is relatively invariable within this species.

Impact of an Online Discussion Forum on Self-Guided Internet-Delivered Cognitive Behavioral Therapy for Public Safety Personnel: Randomized Trial

BACKGROUND

Internet-delivered cognitive behavioral therapy (ICBT) is an effective and accessible treatment for various mental health concerns. ICBT has shown promising treatment outcomes among public safety personnel (PSP), who experience high rates of mental health problems and face barriers to accessing other mental health services. Client engagement and clinical outcomes are better in ICBT with therapist guidance, but ICBT is easier to implement on a large scale when it is self-guided. Therefore, it is important to identify strategies to improve outcomes and engagement in self-guided ICBT and other self-guided digital mental health interventions. One such strategy is the use of online discussion forums to provide ICBT clients with opportunities for mutual social support. Self-guided interventions accompanied by online discussion forums have shown excellent treatment outcomes, but there is a need for research experimentally testing the impact of online discussion forums in ICBT.

OBJECTIVE

We aimed to evaluate a transdiagnostic, self-guided ICBT intervention tailored specifically for PSP (which had not previously been assessed), assess the impact of adding a therapist-moderated online discussion forum on outcomes, and analyze participants' feedback to inform future research and implementation efforts.

METHODS

In this randomized trial, we randomly assigned participating PSP (N=107) to access an 8-week transdiagnostic, self-guided ICBT course with or without a built-in online discussion forum. Enrollment and participation were entirely web-based. We assessed changes in depression, anxiety, and posttraumatic stress as well as several secondary outcome measures (eg, treatment engagement and satisfaction) using questionnaires at the pre-enrollment, 8-week postenrollment, and 20-week postenrollment time points. Mixed methods analyses included multilevel modeling and qualitative content analysis.

RESULTS

Participants engaged minimally with the forum, creating 9 posts. There were no differences in treatment outcomes between participants who were randomly assigned to access the forum (56/107, 52.3%) and those who were not (51/107, 47.7%). Across conditions, participants who reported clinically significant symptoms during enrollment showed large and statistically significant reductions in symptoms (P<.05 and d>0.97 in all cases). Participants also showed good treatment engagement and satisfaction, with 43% (46/107) of participants fully completing the intervention during the course of the study and 96% (79/82) indicating that the intervention was worth their time.

CONCLUSIONS

Previous research has shown excellent clinical outcomes for self-guided ICBT accompanied by discussion forums and good engagement with those forums. Although clinical outcomes in our study were excellent across conditions, engagement with the forum was poor, in contrast to previous research. We discuss several possible interpretations of this finding (eg, related to the population under study or the design of the forum). Our findings highlight a need for more research evaluating the impact of online discussion forums and other strategies for improving outcomes and engagement in self-guided ICBT and other digital mental health interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05145582; https://clinicaltrials.gov/study/NCT05145582.

A secondary analysis examining the performance of the State Optimism Measure (SOM) compared to the Life Orientation Test-Revised (LOT-R) in measuring optimism over time

Objective: Optimism is an important factor impacting health and human functioning. Originally conceptualized as a trait, increasing evidence indicates that optimism can change over time and could be an intervention target. Measures are needed that can capture changes in optimism.

Design: In this secondary analysis, we compared the performance of a newly developed state measure, the State Optimism Measure (SOM), to the widely used trait measure, the Life Orientation Test-Revised (LOT-R), in detecting changes over time during a disruptive life event: the onset of the COVID-19 pandemic in the United States.

Main Outcome Measures: Participants (n = 81) were nondaily smokers participating in a smoking cessation intervention, who completed the SOM and LOT-R before and after the initial COVID-19 outbreak.

Results: Optimism declined from pre- to post-COVID-19 outbreak, as assessed by both scales (LOT-R: p=.0147,gav=0.23; SOM: p<.0001,gav=0.56). The change detected was greater when measured by the SOM (p<.0001). Changes in optimism were correlated with concurrent changes in perceived stress, positive affect, and negative affect.

Conclusion: Our results suggest that the SOM has a greater sensitivity to detect within-person changes in optimism than the LOT-R and highlight the SOM's utility for longitudinal studies assessing changes in optimism.

Depressive symptoms of people living in areas with high exposure to environmental noise: a multilevel analysis

Exposure and damage caused by noise have been reported in many countries around the world. However, few nationwide studies explored the association of residential environmental noise with depressive symptoms, this study aims to examine this association. The Korean Community Health Survey at the individual-level and the Korean Environmental Noise Measurement Database at the regional-level were used. A total of 30,630 individuals were eligible for the analysis. Multilevel model framework was applied to account for the clustered structure of the regional-level data in which individual-level data containing demographic characteristics and health information were nested. As a result of the analysis, Individuals living in the highest environmental noise area had a 1.55 times higher likelihood of experiencing depressive symptoms than those living in the lowest environmental noise area (95% CI, 1.04-2.31). After stratified analysis according to depressive symptom severity, individuals residing in areas with the highest environmental noise exposure had significantly higher odds of mild (aOR, 1.46; 95% CI, 1.02-2.07) and moderate symptoms (aOR, 1.70; 95% CI, 1.00-2.91). In conclusion, the higher the residential environmental noise, the higher the possibility of mild-to-moderate depressive symptoms. Our findings suggest the need for continued attention to and management of noise pollution, which has the potential to adversely affect individual's mental health.

Patient-reported outcomes and experiences of migrants enrolled in a multidisciplinary HIV clinic with rapid, free, and onsite treatment dispensation: the 'ASAP' study

BACKGROUND

Scholars recommend providing migrants living with HIV (MLWH) with free treatment, rapidly, once linked to care to optimize their HIV-related experiences and health outcomes. Quantitative evaluations of patient-reported measures for MLWH in such models are necessary to explore the viability of these recommendations.

METHODS

Within a 96-week prospective cohort study at a multidisciplinary HIV clinic, participants received bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) for free and rapidly following care linkage. Eight patient-reported measures were administered at weeks 4, 24, and 48: (1) mMOS-SS to measure perceived social support; (2) IA-RSS to measure internalized stigma; (3) K6 to measure psychological distress; (4) PROMIS to measure self-efficacy with treatment taking; (5) G-MISS to measure perceived compliance with clinicians' treatment plans; (6) HIVTSQ to measure treatment satisfaction; (7) CARE to measure perceived provider empathy; and (8) PRPCC to measure perceived clinician cultural competence. Linear mixed modelling with bootstrapping was conducted to identify significant differences by sociodemographics and time.

RESULTS

Across weeks 4, 24, and 48, results suggest that MLWH enrolled in this study experienced moderate levels of social support; elevated levels of HIV-related stigma; moderate levels of distress; high self-efficacy with daily medication self-management; great compliance with clinicians' treatment plans; high treatment satisfaction; high perceived empathy; and high perceived cultural competence. Experience of social support (i.e., mMOS-SS scores) differed significantly by birth region. Experience of HIV-related stigma (i.e., IA-RSS scores) differed significantly by birth region, age, and language. Experience of distress (i.e., K6 scores) differed significantly by sexual orientation. Experience of treatment satisfaction (i.e., HIVTSQ scores) differed significantly by birth region and age. No significant differences were identified by time for any measure.

CONCLUSION

Overall, participants expressed positive experiences around treatment and care, alongside comparably lower perceptions of social support, internalized stigma, and distress, potentially underscoring a need to embed targeted, well-funded, and accessible mental health support within HIV care models.

Internet-based acceptance and commitment therapy for obsessive-compulsive symptoms: A randomized controlled trial

Subthreshold obsessive-compulsive symptoms (OCS) are associated with increased distress, help seeking behaviours, and functional problems, and may predict progression into further mental health problems. This study investigated the effectiveness of a four-module internet-based acceptance and commitment therapy (iACT) for adults with OCS compared to internet-based progressive relaxation training (iPRT). Eighty-nine adults with OCS participated in a single-blinded randomised controlled trial of iACT or iPRT. Self-report assessments of OCS, psychological flexibility, and quality of life, among others, were measured at baseline, post-treatment, and at three-month follow-up. Both iACT and iPRT showed large pre-post improvements in OCS (b = 6.32, p < 0.001, d = 0.8) and medium improvements in psychological flexibility (b = -0.38, p = 0.011, d = 0.47) and quality of life (b = -5.26, p = 0.008, d = 0.58), with no significant differences in effects between groups. All improvements were maintained at follow-up. There were no differences in attrition or adherence between groups. iACT was rated more favourably by participants at post-treatment, and there were some differences in qualitative feedback across groups. These findings suggest both iPRT and iACT may be helpful in improving mental health in adults with OCS, but that iACT may be more acceptable.

A life span perspective on competencies for a healthy, physically active lifestyle: Findings of a data pooling initiative with over 7000 individuals

Individuals are recommended to lead active lifestyles throughout the life course. The model of physical activity-related health competence (PAHCO) adopts a competence approach by integrating physical, cognitive, and motivational determinants for health-enhancing PA (movement competence, control competence, self-regulation competence). Drawing on a comprehensive dataset pooling, the goal of the present study was to model the idiosyncratic courses of 10 PAHCO indicators over the life span. We identified studies that empirically operationalized PAHCO, combining data of 7134 individuals (age range: 15-97 years; 61% female) from 18 different populations (prevention and rehabilitation sectors). We applied a stepwise multilevel analysis approach with disjunct sub-samples (n = 48) to examine linear and quadratic associations between age and PAHCO. Indicators of movement competence (i.e., manageability of endurance, strength, and balance demands; task-specific self-efficacy) congruently showed negative associations with age (0.054 ≤ R marg 2 ${R}_{\text{marg}}^{2}$  ≤ 0.211). However, parameters of control competence remained stable across the life span (-0.066 ≤ β ≤ 0.028). The three indicators of self-regulation competence revealed an inconsistent relationship with age, though uncovering positive associations for self-control (β = 0.106) and emotional attitude toward PA (β = 0.088). The associations of some indicators varied significantly across sub-samples. The results suggest differential analyses for associations between PAHCO and age. While the physically determined PAHCO indicators (movement competence) probably decline across the life span, the ability to ensure regularity of PA (self-regulation competence) or align PAs with an individual's health (control competence) appear to remain constant or improve with increasing age. The findings reinforce a de-stigmatizing approach for PA promotion practices with considerable space for aligning activities with health also in the elderly.

Neural correlates of emotion-label vs. emotion-laden word processing in late bilinguals: evidence from an ERP study

The brain processes underlying the distinction between emotion-label words (e.g. happy, sad) and emotion-laden words (e.g. successful, failed) remain inconclusive in bilingualism research. The present study aims to directly compare the processing of these two types of emotion words in both the first language (L1) and second language (L2) by recording event-related potentials (ERP) from late Chinese-English bilinguals during a lexical decision task. The results revealed that in the early word processing stages, the N170 emotion effect emerged only for L1 negative emotion-laden words and L2 negative emotion-label words. In addition, larger early posterior negativity (EPN) was elicited by emotion-laden words than emotion-label words in both L1 and L2. In the later processing stages, the N400 emotion effect was evident for L1 emotion words, excluding positive emotion-laden words, while it was absent in L2. Notably, L1 emotion words elicited enhanced N400 and attenuated late positive complex (LPC) compared to those in L2. Taken together, these findings confirmed the engagement of emotion, and highlighted the modulation of emotion word type and valence on word processing in both early and late processing stages. Different neural mechanisms between L1 and L2 in processing written emotion words were elucidated.

Comparative efficacy of various pharmacologic treatments for alcohol withdrawal syndrome: a systematic review and network meta-analysis

This study was to compare multiple classes of medications and medication combinations to find alternatives or additives for patients not applicable to benzodiazepines (BZDs). We performed a network meta-analysis to assess the comparative effect of 11 pharmacologic treatments in patients with alcohol withdrawal syndrome. Forty-one studies were included, comprising a total sample size of 4187 participants. The pooled results from the randomized controlled trials showed that there was no significant difference in the Clinical Institute Withdrawal Assessment-Alcohol, revised (CIWA-Ar) reduction with other medications or medication combinations compared to BZDs. Compared to BZDs, the mean difference in ICU length of stay of anticonvulsants + BZDs was -1.71 days (95% CI = -2.82, -0.59). Efficacy rankings from cohort studies showed that anticonvulsant + BZDs were superior to other treatments in reducing CIWA-Ar scores and reducing the length of stay in the ICU. Synthesis results from randomized controlled trials indicate that there are currently no data suggesting that other medications or medication combinations can fully replace BZDs. However, synthetic results from observational studies have shown that BZDs are effective in the context of adjuvant anticonvulsant therapy, particularly with early use of gabapentin in combination with BZDs in the treatment of alcohol withdrawal syndrome, which represents a promising treatment option.

Atypical Time to Contact Estimation in Young Adults with Autism Spectrum Disorder

Individuals with Autism Spectrum Disorder (ASD) present atypical sensory processing in the perception of moving stimuli and biological motion. The present study aims to explore the performance of young adults with ASD in a time to contact (TTC) estimation task involving social and non-social stimuli. TTC estimation involves extrapolating the trajectory of a moving target concealed by an occluder, based on the visible portion of its path, to predict the target's arrival time at a specific position. Sixteen participants with a diagnosis of level-1 ASD (M = 19.2 years, SE = 0.54 years; 3 F, 13 M) and sixteen participants with TD (M = 22.3 years, SE = 0.44 years; 3 F, 13 M) took part in the study and underwent a TTC estimation task. The task presented two object types (a car and a point-light walker), different object speeds, occluder lengths, motion directions and motion congruency. For the car object, a larger overestimation of TTC emerged for ASDs than for TDs, whereas no difference between ASDs and TDs emerged for the point-light walker. ASDs exhibited a larger TTC overestimation for the car object than for the point-light walker, whereas no difference between object types emerged for TDs. Our results indicated an atypical TTC estimation process in young adults with ASD. Given its importance in daily life, future studies should further explore this skill. Significant effects that emerged from the analysis are discussed.

Feasibility and Preliminary Efficacy of American Elderberry Juice for Improving Cognition and Inflammation in Patients with Mild Cognitive Impairment

Despite data showing that nutritional interventions high in antioxidant/anti-inflammatory properties (anthocyanin-rich foods, such as blueberries/elderberries) may decrease risk of memory loss and cognitive decline, evidence for such effects in mild cognitive impairment (MCI) is limited. This study examined preliminary effects of American elderberry (Sambucus nigra subsp. canadensis) juice on cognition and inflammatory markers in patients with MCI. In a randomized, double-blind, placebo-controlled trial, patients with MCI (n = 24, Mage = 76.33 ± 6.95) received American elderberry (n = 11) or placebo (n = 13) juice (5 mL orally 3 times a day) for 6 months. At baseline, 3 months, and 6 months, patients completed tasks measuring global cognition, verbal memory, language, visuospatial cognitive flexibility/problem solving, and memory. A subsample (n = 12, 7 elderberry/5 placebo) provided blood samples to measure serum inflammatory markers. Multilevel models examined effects of the condition (elderberry/placebo), time (baseline/3 months/6 months), and condition by time interactions on cognition/inflammation outcomes. Attrition rates for elderberry (18%) and placebo (15%) conditions were fairly low. The dosage compliance (elderberry-97%; placebo-97%) and completion of cognitive (elderberry-88%; placebo-87%) and blood-based (elderberry-100%; placebo-100%) assessments was high. Elderberry (not placebo) trended (p = 0.09) towards faster visuospatial problem solving performance from baseline to 6 months. For the elderberry condition, there were significant or significantly trending decreases over time across several markers of low-grade peripheral inflammation, including vasorin, prenylcysteine oxidase 1, and complement Factor D. Only one inflammatory marker showed an increase over time (alpha-2-macroglobin). In contrast, for the placebo, several inflammatory marker levels increased across time (L-lactate dehydrogenase B chain, complement Factor D), with one showing deceased levels over time (L-lactate dehydrogenase A chain). Daily elderberry juice consumption in patients with MCI is feasible and well tolerated and may provide some benefit to visuospatial cognitive flexibility. Preliminary findings suggest elderberry juice may reduce low-grade inflammation compared to a placebo-control. These promising findings support the need for larger, more definitive prospective studies with longer follow-ups to better understand mechanisms of action and the clinical utility of elderberries for potentially mitigating cognitive decline.

The Importance of Multiorgan Procurement in the Improvement of Residents' Open Surgical Skills

INTRODUCTION

The multiorgan procurement (MOP) represents a chance for the general surgery resident to learn the fundamental steps of open abdominal surgery. The objective of this study was to evaluate the impact of MOP on the residents' open surgical skills.

METHODS

Residents' surgical skills were assessed during a 6-month transplant rotation (October 2020-March 2021) using a modified Objective Structured Assessment of Technical Skills with the global rating scale. The surgeries were self-assessed by residents and tutors based on 9 specific steps (SS) and 4 general skills (GS). Each item was rated from 1 (poor) to 5 (excellent) with a maximum score of 45 points for SS and 20 for GS. A crossed-effects linear regression analysis was performed both to evaluate any associations between GS/SS scores and some prespecified covariates, and to study differences in the assessments performed by residents and tutors.

RESULTS

Residents actively participated in a total of 59 procurements. In general, there were no significant differences in SS/GS mean scorings between residents (n = 15) and tutors (n = 5). There was a significantly positive association between mean GS/SS scorings and the number of donor surgeries performed (at least 5). Comparing the evaluations of the tutors with the residents, this significance was retained only when scorings were assigned by the tutors.

CONCLUSIONS

MOP was shown to improve basic open surgical skills among residents. Awareness of the utility of a clinical rotation in transplant surgery should be raised also on an institutional level.

Long-Term Longitudinal Course of Cognitive and Motor Symptoms in Patients With Cerebral Small Vessel Disease

BACKGROUND AND OBJECTIVES

Patients with cerebral small vessel disease (SVD) show a heterogenous clinical course. The aim of the current study was to investigate the longitudinal course of cognitive and motor function in patients who developed parkinsonism, dementia, both, or none.

METHODS

Participants were from the Radboud University Nijmegen Diffusion Tensor and Magnetic Resonance Cohort study, a prospective cohort of patients with SVD. Parkinsonism and dementia were, respectively, diagnosed according to the UK Parkinson's Disease Society brain bank criteria and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria for major neurocognitive disorder. Linear and generalized linear mixed-effect analyses were used to study the longitudinal course of motor and cognitive tasks.

RESULTS

After a median follow-up of 12.8 years (interquartile range 10.2-15.3), 132 of 501 (26.3%) participants developed parkinsonism, dementia, or both. Years before diagnosis of these disorders, participants showed distinct clinical trajectories from those who developed none: Participant who developed parkinsonism had an annual percentage of 22% (95% CI 18%-27%) increase in motor part of the Unified Parkinson's Disease Rating Scale score. This was significantly higher than the 16% (95% CI 14%-18%) of controls, mainly because of a steep increase in bradykinesia and posture and gait disturbances. When they developed dementia as well, the increase in Timed Up and Go Test time of 0.73 seconds per year (95% CI 0.58-0.87) was significantly higher than the 0.20 seconds per year increase (95% CI 0.16-0.23) of controls. All groups, including the participants who developed parkinsonism without dementia, showed a faster decline in executive function compared with controls: Annual decline in Z-score was -0.07 (95% CI -0.10 to -0.05), -0.09 (95% CI -0.11 to -0.08), and -0.11 (95% CI -0.14 to -0.08) for participants who developed, respectively, parkinsonism, dementia, and both parkinsonism and dementia. These declines were all significantly faster than the annual decline in Z-score of 0.07 (95% CI -0.10 to -0.05) of controls.

DISCUSSION

A distinct pattern in deterioration of clinical markers is visible in patients with SVD, years before the diagnosis of parkinsonism and dementia. This knowledge aids early identification of patients with a high risk of developing these disorders.

The effect of emotional valence and font size on metacognition and memory

Predictions about memory involve the use of metacognition, and metacognition can rely on various cues. The present study investigated metacognition and recall performance when to-be-remembered words differed in font size and emotional valence, to determine what cues are utilised when making metacognitive judgments. Participants were presented with lists of words varying in font size (small and large) and emotional valence (negative and neutral) and were asked to remember as many words as possible for a later recall test while engaging in item-level metacognitive assessments. Specifically, after studying each word, participants either made only judgments of learning (JOLs, Experiment 1) or both JOLs and restudy judgments (Experiment 2). Across experiments, results revealed that while JOLs were sensitive to both font size and emotional valence, restudy judgments were mostly sensitive to emotional valence, and participants' metacognitive assessments mapped onto memory performance generally for emotional words. Additionally, we found that the effect of font size on metacognition and memory was robust to experience-based learning. Together, the current study extends our understanding of how emotion and font size affect metacognition (monitoring and control) and memory and suggests that when presented with multiple cues, certain diagnostic cues can be harnessed to mitigate metacognitive illusions.

Effects of social buffering on fear extinction in adolescent rats

Across social species, the presence of another individual can reduce stress reactions to adverse stimuli, a phenomenon known as social buffering. The present study investigated whether social buffering influences the expression and extinction of learned fear in adolescence, a developmental period of diminished fear inhibition and increased social interaction. Quality of maternal care and degree of social investigation were examined as factors that may influence social buffering. In adolescence, male rats were fear conditioned and then given extinction training either in the presence of a same-age rat or alone. Animals were then tested alone for extinction retention. In two experiments, the presence of a conspecific robustly reduced conditioned fear responses during extinction training. Interestingly, a persistent social buffering effect was observed when the extinction and conditioning contexts had prominent differences in features (Experiment 1), but not when these contexts were relatively similar (Experiment 2). Neither quality of maternal care nor degree of social investigation predicted the effects of social buffering. These findings suggest that social buffering robustly dampens fear responses during adolescence when a peer is present and this suppression can persist, in some instances, even when the peer is absent.

Longitudinal coupling of emotional wellbeing in parent-adolescent dyads: Evaluating the role of daily life positive affect socialization processes

This study evaluated the role of bidirectional micro- and macro- level positive affect-related processes in the longitudinal coupling of depressive symptoms in parent-adolescent dyads. Using a measurement-burst design, including dyadic experience sampling methods (ESM) and monthly follow-ups over one year, this work investigated associations between (1) parental depressive symptoms and anhedonia and parental daily-life enhancing and dampening responses to youth positive affect; (2) parental daily-life enhancing and dampening and trajectories of youth positive affect, negative affect, and depressive symptoms across one year; and (3) youth developmental trajectories and prospective parental daily-life enhancing and dampening, and parental depressive symptoms and anhedonia at one-year follow-up. Participants included 146 early adolescents (52.1% girls, 47.9% boys; Mage[SD] = 12.71[.86]) and 139 parents (78.7% mothers; Mage[SD] = 44.11[5.08]). Parental enhancing and dampening were measured using a dyadic ESM procedure at baseline and 12-months. Youth completed monthtly questionnaires assessing depressive symptoms and trait positive and negative affect across 12 months. Parents reported on depressive symptoms and anhedonia at baseline and 12-months. Results showed that parental anhedonia negatively related to parental daily-life enhancing, and youths' perceptions of their parents' enhancing and dampening reciprocally related to youth emotional development across one year, with downstream implications for parents' own symptoms of depression.

Therapeutic alliance in two forms of guided self-help for binge eating

The role of therapeutic alliance within psychological treatments for eating disorders (EDs), including those delivered remotely, is well established. However, few studies have investigated alliance in guided self-help, a widely recommended first-line treatment for EDs characterised by regular binge eating. Using data from a randomised controlled trial, the current study examined both facilitator and patient assessments of alliance within e-mail-assisted and face-to-face guided self-help and looked at associations between alliance, ED symptoms and ED-related impairment. One hundred thirteen patients and 11 facilitators completed measures of alliance during and following a course of guided self-help. Whilst ratings were reliable across patients and facilitators, alliance scores were higher both in the patient sample and in the face-to-face condition. Ratings of alliance showed no correlations with ED symptoms at post-treatment, and early alliance was not significantly associated with outcome, which could inform how early symptom change is encouraged in guided self-help.

Rapid ART initiation with bictegravir/emtricitabine/tenofovir alafenamide in individuals presenting with advanced HIV disease (Rainbow study)

BACKGROUND

A rapid ART initiation approach can be beneficial in people with advanced HIV disease, in consideration of their high morbidity and mortality. The aim of our study was to evaluate the feasibility, efficacy and safety of rapid ART start with BIC/FTC/TAF in this setting.

METHODS

Pilot, single-centre, single-arm, prospective, phase IV clinical trial conducted in a tertiary Italian hospital. Thirty ART-naïve people presenting with advanced HIV-1 diagnosis (defined as the presence of an AIDS-defining event and/or CD4 cell count <200 µL), were enrolled. Main exclusion criteria were active tuberculosis, cryptococcosis and pregnant/breastfeeding women. BIC/FTC/TAF was started within 7 days from HIV diagnosis. The primary endpoint was clinical or virologic failure (VF). Immunological parameters, safety, feasibility, neurocognitive performances and patient-reported outcomes were assessed as well.

RESULTS

Over the study period, 40 (34%) of 116 patients diagnosed with HIV infection at INMI Spallanzani had advanced disease, of whom 30 (26%) were enrolled. The proportion of participants with HIV-RNA <50 cp/mL was 9/30 (30%) at week (w) 4, 19/30 (63%) at w12, 24/30 (80%) at w24, 23/30 (77%) at w36 and 27/30 (90%) at w48. Two unconfirmed VF occurred. No ART discontinuation due to toxicity or VF was observed. No ART modification was performed based on the review of genotype and no mutations for the study drugs were detected. Mean CD4 cells count changed by 133 cells/μL at BL to 309 cells/μL at w 48 and 83% of participants had a CD4 > 200 cells/µL at w 48. Two participants developed IRIS and one was diagnosed with disseminated TB and needed an ART switch.

INTERPRETATIONS

Our results support the feasibility, efficacy and safety of BIC/FTC/TAF as a rapid ART strategy in patients with advanced HIV disease.

Examining the normality assumption of a design-comparable effect size in single-case designs

What Works Clearinghouse (WWC, 2022) recommends a design-comparable effect size (D-CES; i.e., gAB) to gauge an intervention in single-case experimental design (SCED) studies, or to synthesize findings in meta-analysis. So far, no research has examined gAB's performance under non-normal distributions. This study expanded Pustejovsky et al. (2014) to investigate the impact of data distributions, number of cases (m), number of measurements (N), within-case reliability or intra-class correlation (ρ), ratio of variance components (λ), and autocorrelation (ϕ) on gAB in multiple-baseline (MB) design. The performance of gAB was assessed by relative bias (RB), relative bias of variance (RBV), MSE, and coverage rate of 95% CIs (CR). Findings revealed that gAB was unbiased even under non-normal distributions. gAB's variance was generally overestimated, and its 95% CI was over-covered, especially when distributions were normal or nearly normal combined with small m and N. Large imprecision of gAB occurred when m was small and ρ was large. According to the ANOVA results, data distributions contributed to approximately 49% of variance in RB and 25% of variance in both RBV and CR. m and ρ each contributed to 34% of variance in MSE. We recommend gAB for MB studies and meta-analysis with N ≥ 16 and when either (1) data distributions are normal or nearly normal, m = 6, and ρ = 0.6 or 0.8, or (2) data distributions are mildly or moderately non-normal, m ≥ 4, and ρ = 0.2, 0.4, or 0.6. The paper concludes with a discussion of gAB's applicability and design-comparability, and sound reporting practices of ES indices.

Yoga Therapy as an Intervention to Improve Patient-Reported Outcomes Among Adults After Treatment for Cancer: Preliminary Findings From a Trial Using Single-Subject Experimental Design

BACKGROUND

Cancer is a chronic condition associated with a substantial symptom burden, which can impair recovery after treatment. Investigating interventions with potential to improve self-reported disease and/or treatment effects-known as patient-reported outcomes (PROs)-is paramount to inform cancer care. The objective of this study was to evaluate the effects of a yoga therapy (YT) intervention on key PROs (ie, cancer-related fatigue, anxiety, cognitive function, depression, stress, quality of life [QoL]) among adults after treatment for cancer.

METHODS

Data from 20 adults (Mage = 55.74 years, 85% female; Mtime since diagnosis = 2.83 years) who had completed treatment for cancer were analyzed for this study. In this single-subject exploratory experimental study, the YT intervention comprised a 1:1 YT session (ie, 1 participant with 1 yoga therapist) followed by 6 weekly small (ie, 2-3 participants) group YT sessions. Group sessions were facilitated by the same yoga therapist who delivered participants' 1:1 session to ensure an in-depth personalized approach. PROs were assessed before (ie, pre-intervention) and after the 1:1 YT session (ie, during the intervention), as well as after the last group YT session (ie, post-intervention). Hierarchical linear modeling was used to analyze the data.

RESULTS

Participants showed improvements in cancer-related fatigue, state anxiety, trait anxiety, perceived cognitive impairments, impacts of perceived cognitive impairments on QoL, and 1 dimension of QoL (ie, functional wellbeing) over time. Notably, cancer-related fatigue and state anxiety increased immediately after the 1:1 session, but showed greater improvements over time afterward (ie, during the intervention phase). No changes were observed for the remaining PROs.

CONCLUSION

Although results require confirmation in future trials, this study highlights the importance of continuing to investigate YT as an intervention to enhance important PROs (ie, cancer-related fatigue and state anxiety) after treatment for cancer. More research is needed to identify additional beneficial effects and factors that influence participants' responses to 1:1 and group YT (ie, moderators and mediators).

REGISTRATION NUMBER

ISRCTN64763228.

DATE OF REGISTRATION

December 12, 2021. This trial was registered retrospectively.

URL OF TRIAL REGISTRY RECORD

https://www.isrctn.com/ISRCTN64763228.

PUBLISHED PROTOCOL

Brunet, J., Wurz, A., Hussien, J., Pitman, A., Conte, E., Ennis, J. K., . . . & Seely, D. (2022). Exploring the Effects of Yoga Therapy on Heart Rate Variability and Patient-Reported Outcomes After Cancer Treatment: A Study Protocol. Integrative Cancer Therapies, 21, 15347354221075576.

Psychometric properties of sum scores and factor scores differ even when their correlation is 0.98: A response to Widaman and Revelle

Commentary in Widaman and Revelle (2022) argued that sum scoring is justified as long as unidimensionality holds because sum score reliability is defined. My response begins with a review of the literature supporting the perspective we adopted in the original article. I then conduct simulation studies to assess the psychometric properties of sum scores created using Widaman and Revelle's justification relative to scores created by the weighted factor score approach in the original article. In my simulations, I generate data where sum and factor scores are correlated at 0.96 or 0.98 because high factor-sum score correlations are often used to support the contention that sum and factor scores have interchangeable psychometric properties. I explore (a) correlations between estimated scores and true scores, (b) classification accuracy of sum and factor scores, and (c) reliability of sum and factor scores. Results show that factor scores have (a) higher correlations with true scores (Δ = 0.02-0.04), (b) higher sensitivity (Δ = 4-8 percentage points), and (c) higher reliability (Δ = 0.04-0.07). Factor score performance metrics also have less sampling variability in most conditions. Psychometric properties of sum scores-even when highly correlated with factor scores-remain less desirable than those of factor scores. Additional considerations like models with multiple factors and measurement invariance are also discussed. Essentially, even if accepting Widaman and Revelle's justification for sum scoring, it is uncertain whether researchers generally would want to sum score after fitting a factor analysis unless sum and factor scores correlate at (and not merely close to) 1.00.

Novel 3-arm wait-list controlled trial designs together with mixed-effects analysis improve precision of treatment effect estimators

Clinical trialists have long been searching for approaches to increase statistical power without increasing sample size. Conventional wait-list controlled (WLC) trials are limited to two trial arms and two or three repeated measurements per person. These features limit statistical power. Furthermore, their analysis is usually based on analysis of covariance or mixed effects modelling, with a focus on estimating treatment effect at one time-period after initiation of therapy. We propose two 3-arm WLC trial designs together with a mixed-effects analysis framework. The designs require three or four repeated measurements per person. The analytic framework defines up to three treatment effect estimands, representing the effects at one to three time-periods after initiation of therapy. The precision (inverse of variance) of the treatment effect estimators in the new and conventional trial designs are analytically derived and evaluated in simulations. The results are interpreted in the context of a cognitive training trial in older people. The proposed designs and analysis methods increase the precision level of treatment effect estimators as compared to conventional designs and analyses. Given a target level of statistical power, the proposed methods require a smaller number of participants per trial than the conventional methods, without necessarily increasing the number of measurements per trial. Furthermore, the proposed analytic framework sheds light on the treatment effects at different times after initiation of therapy, which is not usually considered in conventional WLC trial analysis. In situations that a WLC trial is appropriate, the 3-arm designs are useful alternatives to existing 2-arm designs.

Adolescent Social Communication Through Smartphones: Linguistic Features of Internalizing Symptoms and Daily Mood

The increasing use of smartphone technology by adolescents has led to unprecedented opportunities to identify early indicators of shifting mental health. This intensive longitudinal study examined the extent to which differences in mental health and daily mood are associated with digital social communication in adolescence. In a sample of 30 adolescents (ages 11-15 years), we analyzed 22,152 messages from social media, email, and texting across one month. Lower daily mood was associated with linguistic features reflecting self-focus and reduced temporal distance. Adolescents with lower daily mood tended to send fewer positive emotion words on a daily basis, and more total words on low mood days. Adolescents with lower daily mood and higher depression symptoms tended to use more future focus words. Dynamic linguistic features of digital social communication that relate to changes in mental states may represent a novel target for passive detection of risk and early intervention in adolescence.

Predicting Therapists' Intentions to Use Innovations: Comparing the Role of Individual, Organizational, and Innovation Characteristics

Theories emphasize the role of individual and organizational characteristics in implementation outcomes, yet research indicates that these characteristics account for only a small amount of variance in those outcomes. Innovation characteristics might be important proximal determinants of implementation outcomes but are infrequently examined in mental health services research. This study examined the relative variance explained by individual, organizational, and innovation characteristics on behavioral intentions, a central implementation outcome in implementation theories. Data were collected from 95 therapists and 28 supervisors who participated in a cluster randomized trial that tested the effectiveness of two clinical decision-making innovations. Multilevel models compared individual, organizational, and innovation characteristics as predictors of therapists' intentions to use the innovations. Subsequent mediational path analyses tested whether innovation characteristics mediated the effect of innovation type on intentions. Individual and organizational characteristics explained 29% of the variability in therapists' intentions. Approximately 75% of the variability in therapists' intentions was accounted for by innovation characteristics. Individual and organizational characteristics were not statistically significant predictors of intentions after controlling for innovation characteristics. The indirect effect of innovation type on intentions through therapists' beliefs was statistically significant (B = 0.410, 95% Bootstrapped CI = [0.071, 0.780]), but the direct effect of innovation type was not (B = 0.174, p = .365). Innovation characteristics are related to therapist intentions and might explain why some innovations are received more favorably than others. Future studies should explore the complex interrelationships between these beliefs alongside other individual or organizational characteristics.

Time matters less: Variance partitioning of return on equity for banks in Uganda

This study investigates variations in the return on equity (ROE) and its determinants within Ugandan banks from 2010 to 2020. Using a two-level hierarchical linear model (HLM), we analyze ROE variability at both time and bank levels, considering temporal effects and the impact of specific bank-level variables on ROE. Variance decomposition reveals that the variability in ROE is more attributable to bank-specific factors than to temporal ones, signifying that individual banks' practices have a more pronounced impact on performance than time-bound fluctuations. Our HLM results, marked by high intraclass correlation coefficients (ICC) that range between 64.4% and 85.8%, underscore the dominance of bank-level variables in accounting for ROE variations. Key determinants of ROE identified by the HLM analysis include inflation, policy uncertainty, assets, equity, profits, profit margin, asset turnover, equity multipliers, and non-performing loans. A primary takeaway from our findings is the potential for operational efficiency enhancements and judicious investment decisions to produce favorable shifts in ROE. For banking managers, this highlights the necessity for ongoing process refinement and meticulous investment scrutiny. We recommend that policymakers mull over incentives for these practices, possibly through regulatory concessions or guidelines endorsing efficient operational benchmarks.

The Hitchhiker's guide to longitudinal models: A primer on model selection for repeated-measures methods

Longitudinal data are becoming increasingly available in developmental neuroimaging. To maximize the promise of this wealth of information on how biology, behavior, and cognition change over time, there is a need to incorporate broad and rigorous training in longitudinal methods into the repertoire of developmental neuroscientists. Fortunately, these models have an incredibly rich tradition in the broader developmental sciences that we can draw from. Here, we provide a primer on longitudinal models, written in a beginner-friendly (and slightly irreverent) manner, with a particular focus on selecting among different modeling frameworks (e.g., multilevel versus latent curve models) to build the theoretical model of development a researcher wishes to test. Our aims are three-fold: (1) lay out a heuristic framework for longitudinal model selection, (2) build a repository of references that ground each model in its tradition of methodological development and practical implementation with a focus on connecting researchers to resources outside traditional neuroimaging journals, and (3) provide practical resources in the form of a codebook companion demonstrating how to fit these models. These resources together aim to enhance training for the next generation of developmental neuroscientists by providing a solid foundation for future forays into advanced modeling applications.

Asymmetric hearing thresholds are associated with hyperacusis in a large clinical population

Hyperacusis is a debilitating auditory condition whose characterization is largely qualitative and is typically based on small participant cohorts. Here, we characterize the hearing and demographic profiles of adults who reported hyperacusis upon audiological evaluation at a large medical center. Audiometric data from 626 adults (age 18-80 years) with documented hyperacusis were retrospectively extracted from medical records and compared to an age- and sex-matched reference group of patients from the same clinic who did not report hyperacusis. Patients with hyperacusis had lower (i.e., better) high-frequency hearing thresholds (2000-8000 Hz), but significantly larger interaural threshold asymmetries (250-8000 Hz) relative to the reference group. The probability of reporting hyperacusis was highest for normal, asymmetric, and notched audiometric configurations. Many patients reported unilateral hyperacusis symptoms, a history of noise exposure, and co-morbid tinnitus. The high prevalence of both overt and subclinical hearing asymmetries in the hyperacusis population suggests a central compensatory mechanism that is dominated by input from an intact or minimally damaged ear, and which may lead to perceptual hypersensitivity by overshooting baseline neural activity levels.

Multilevel analysis of matching behavior: A comparison of maximum likelihood and Bayesian estimation

While trying to infer laws of behavior, accounting for both within-subjects and between-subjects variance is often overlooked. It has been advocated recently to use multilevel modeling to analyze matching behavior. Using multilevel modeling within behavior analysis has its own challenges though. Adequate sample sizes are required (at both levels) for unbiased parameter estimates. The purpose of the current study is to compare parameter recovery and hypothesis rejection rates of maximum likelihood (ML) estimation and Bayesian estimation (BE) of multilevel models for matching behavior studies. Four factors were investigated through simulations: number of subjects, number of measurements by subject, sensitivity (slope), and variance of the random effect. Results showed that both ML estimation and BE with flat priors yielded acceptable statistical properties for intercept and slope fixed effects. The ML estimation procedure generally had less bias, lower RMSE, more power, and false-positive rates closer to the nominal rate. Thus, we recommend ML estimation over BE with uninformative priors, considering our results. The BE procedure requires more informative priors to be used in multilevel modeling of matching behavior, which will require further studies.

An Investigation of Factored Regression Missing Data Methods for Multilevel Models with Cross-Level Interactions

A growing body of literature has focused on missing data methods that factorize the joint distribution into a part representing the analysis model of interest and a part representing the distributions of the incomplete predictors. Relatively little is known about the utility of this method for multilevel models with interactive effects. This study presents a series of Monte Carlo computer simulations that investigates Bayesian and multiple imputation strategies based on factored regressions. When the model's distributional assumptions are satisfied, these methods generally produce nearly unbiased estimates and good coverage, with few exceptions. Severe misspecifications that arise from substantially non-normal distributions can introduce biased estimates and poor coverage. Follow-up simulations suggest that a Yeo-Johnson transformation can mitigate these biases. A real data example illustrates the methodology, and the paper suggests several avenues for future research.

Programming Levels and Speech Perception in Pediatric Cochlear Implant Recipients With Enlarged Vestibular Aqueduct or GJB2 Mutation

OBJECTIVE

To determine the relationship between hearing loss etiology, cochlear implant (CI) programming levels, and speech perception performance in a large clinical cohort of pediatric CI recipients.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary care hospitals.

PATIENTS

A total of 136 pediatric CI recipients (218 ears) were included in this study. All patients had diagnoses of either enlarged vestibular aqueduct (EVA) or GJB2 (Connexin-26) mutation confirmed via radiographic data and/or genetic reports. All patients received audiologic care at either Boston Children's Hospital or Massachusetts Eye and Ear in Boston, MA, between the years 1999 and 2020.

MAIN OUTCOME MEASURES

Electrode impedances and programming levels for each active electrode and speech perception scores were evaluated as a function of etiology (EVA or GJB2 mutation).

RESULTS

Children with EVA had significantly higher impedances and programming levels (thresholds and upper stimulation levels) than the children with GJB2 mutation. Speech perception scores did not differ as a function of etiology in this sample; rather, they were positively correlated with duration of CI experience (time since implantation).

CONCLUSIONS

Differences in electrode impedances and CI programming levels suggest that the electrode-neuron interface varies systematically as a function of hearing loss etiology in pediatric CI recipients with EVA and those with GJB2 mutation. Time with the CI was a better predictor of speech perception scores than etiology, suggesting that children can adapt to CI stimulation with experience.

Stimulus-specific random effects inflate false-positive classification accuracy in multivariate-voxel-pattern-analysis: A solution with generalized mixed-effects modelling

When conducting multivariate-voxel pattern analysis (MVPA), researchers typically compute the average accuracy for each subject and statistically test if the average accuracy is different from the chance level across subjects (by-subject analysis). We argue that this traditional by-subject analysis leads to inflated Type-1 error rates, regardless of the type of machine learning method used (e.g., support vector machine). This is because by-subject analysis does not consider the variance attributed to the idiosyncratic features of the stimuli that have a common influence on all subjects (i.e., the random stimulus effect). As a solution, we proposed the use of generalized linear mixed-effects modelling to evaluate average accuracy. This method only requires post-classification data (i.e., it does not consider the type of classification methods used) and is easily implemented in the analysis pipeline with common statistical software (SPSS, R, Python, etc.). Using both statistical simulation and real fMRI data analysis, we demonstrated that the traditional by-subject method indeed increases Type-1 error rates to a considerable degree, while generalized mixed-effects modelling that incorporates random stimulus effects can indeed maintain the nominal Type-1 error rates.

Perceived interpersonal competence as a predictor of clinical outcomes in a randomized controlled trial for social anxiety and employment

This study explored relationships among perceived interpersonal competence and demographic and work history variables in a randomized control trial for social anxiety disorder (SAD) that compared work-related group cognitive behavioral therapy plus vocational services (WCBT+VSAU) to vocational services only (VSAU-alone). Intervention effects of perceived interpersonal competence on treatment outcomes over 12 weeks were also examined. Data from 250 job seekers with SAD (59.2% Female; 40.8% Black/African American; 82.4% Non-Hispanic/non-Latino/a) were analyzed. We predicted negative relationships between perceived interpersonal competence and symptoms/impairment and that individuals with lower perceived interpersonal competence would benefit more quickly in WCBT+VSAU relative to VSAU-alone. Results indicated that perceived interpersonal competence did not vary by gender, race, ethnicity, homeless status, or employment history. There were no intervention effects of perceived interpersonal competence regarding social anxiety or overall functional impairment, but results supported negative relationships between perceived interpersonal competence and lower social anxiety and overall functional impairment in both conditions. Separately, perceived interpersonal competence moderated effects in the depression model such that there were faster declines in depression at lower perceived interpersonal competence levels in WCBT+VSAU, but not in VSAU-alone. Results indicate the value of attending to perceived interpersonal competence in interventions, which may result in mood benefits.

Efficacy of Cryoablation on Chronic Rhinitis Management: A Systematic Review and Meta-Analysis

BACKGROUND

ClariFix for posterior nasal nerve ablation has been approved for use since 2017, and this is the first study attempting to synthesize and assess the efficacy of this new device on the management of chronic rhinitis.

OBJECTIVE

The primary objective of this meta-analysis is to assess the efficacy of ClariFix in the symptomatic management of patients with chronic rhinitis. The main outcome measure is the mean difference in the reflective total nasal symptom score (rTNSS).

METHODS

A systematic search of Pubmed/Medline, Web of Science, and EBSCOhost was conducted from inception to May 2022. Peer-reviewed clinical trials reporting postcryotherapy rTNSS at both 1- and 3-month intervals for patients with chronic rhinitis were included. A random-effects model was utilized for meta-analysis. Study heterogeneity, bias, and overall quality were all assessed. The authors followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. The primary outcome measures included mean differences in rTNSS from baseline to both 1- and 3-month postoperative time points. Secondary measures included other questionnaires including the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ).

RESULTS

There were 5 studies that met the criteria (247 individuals). The pooled rTNSS mean difference from baseline to 1 and 3 months postoperatively was found to be -3.48 points (95% CI: -3.73 to -3.23, I² = 0.13). and -3.50 (95% CI: -3.71 to -3.29, I² = 0.00), respectively. The mean difference from baseline to 3 months postoperatively regarding the RQLQ was found to be -1.53 (95% CI: -1.74 to -1.31, I² = 0.00). The most common adverse effects included facial or surgical site pain (40.4%), followed by headache (18.2%), oral numbness (11.1%), and sinusitis (4.0%).

CONCLUSIONS

The findings of this systematic review suggest that cryoablation with Clarifix is an effective treatment modality for chronic rhinitis. However, higher-quality randomized controlled trials will need to be performed to affirm the findings of this study.

Real-World Intake of Dietary Sugars Is Associated with Reduced Cortisol Reactivity Following an Acute Physiological Stressor

There is increasing academic and clinical interest in understanding the nature of the relation between diet and response to stress exposure as a risk factor for mental illness. Cross-species evidence shows that conditions of chronic and acute stress increase the intake of, and preference for, caloric-dense palatable foods, a phenomenon thought to be explained by the mitigating effects of comfort foods on the activity of the stress-response network. It is largely unknown whether and how real-world dietary intake of saturated fat and sugars impacts stress responsivity in humans. Therefore, here we examined whether real-world dietary intake of saturated fat and sugars predicted salivary cortisol reactivity following an acute physiological stressor. Multilevel modelling of four salivary cortisol measures collected up to 65 min after the stressor on 54 participants (18-49 years old) were analyzed using a quadratic growth curve model. Sugar intake significantly predicted a weaker cortisol response following the Cold Pressor Test (CPT) controlling for BMI and gender, revealing an inhibitory effect of caloric-dense diets on cortisol reactivity to stress. As the consumption of sugar rose individuals had lower post-stressor cortisol levels, a smaller rate of increase in cortisol 20 and 35 min after the CPT, a lower cortisol peak, and an overall weaker quadratic effect. These observations add to a growing body of evidence reporting suppressive effects of high-energy foods on stress-associated glucocorticoids reactivity and are consistent with the comfort food hypothesis, where people are seen as motivated to eat palatable foods to alleviate the detrimental repercussions of stressor exposure.

Gratitude, affect balance, and stress buffering: A growth curve examination of cardiovascular responses to a laboratory stress task

Previous research has indicated that gratitude and affect-balance play key stress-buffering roles. However, to date there is limited research on the impact of gratitude and affect balance on cardiovascular recovery from acute psychological stress, and whether affect balance moderates the relationship between gratitude and cardiovascular reactions to acute psychological stress. In this study, 68 adults completed measures of state gratitude, positive and negative affect, and completed a laboratory-based cardiovascular stress-testing protocol. This incorporated a 20-minute acclimatization period, a 10-minute baseline, a 6-minute arithmetic stress task, and an 8-minute recovery period. Mixed-effects growth curve models were fit and the results indicated that state gratitude predicted lower systolic blood pressure responses throughout the stress-testing period. Affect balance was found to moderate the association between state gratitude and diastolic blood pressure responses to stress, amplifying the effects of state gratitude. These findings suggest that state gratitude has a unique stress-buffering effect on both reactions to and recovery from acute psychological stress.

Protocol for a systematic review and meta-analysis of minimal important differences for generic multiattribute utility instruments

INTRODUCTION

Generic multiattribute utility instruments (MAUIs) are efficient tools for determining and enumerating health-related quality of life. MAUIs accomplish this by generating health state utilities (HSUs) via algorithms. Minimal important differences (MIDs) assist with the interpretation of HSUs by estimating minimum changes that are clinically significant. The overall goal of the proposed systematic review and meta-analysis is the development of comprehensive guidelines for MID estimation.

METHODS AND ANALYSIS

This protocol defines a systematic review and meta-analysis of MIDs for generic MAUIs. The proposed research will involve a comprehensive investigation of 10 databases (EconLit, IDEAs database, INAHTA database, Medline, PsycINFO, Embase, Emcare, JBIEBP and CINAHL) from 1 June 2022 to 7 June 2022, and will be performed and reported in accordance with several validated guidelines, principally the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The quality of papers, considered for inclusion in the review, will be appraised using the COnsensus-based Standards for the selection of health Measurement INstruments, inter alia.Narrative analysis will involve identifying the characteristics of MIDs including methods of calculation, sources of heterogeneity, and validation. Meta-analysis will also be conducted. The descriptive element of meta-analysis will involve the generation of I² statistics and Galbraith plots of MID heterogeneity. Together with narrative analysis, this will allow sources of MID heterogeniety to be identified. A multilevel mixed model, estimated via restricted maximum likelihood estimation, will be constructed for the purposes of meta-regression. Meta-regression will attempt to enumerate the effects of sources of heterogeneity on MID estimates. Meta-analysis will be concluded with pooling of MIDs via a linear random-effects model.

ETHICS AND DISSEMINATION

Ethics approval is not required for this review, as it will aggregate data from published literature. Methods of dissemination will include publication in a peer-reviewed journal, as well as presentation at conferences and seminars.

PROSPERO REGISTRATION NUMBER

CRD42021261821.

Cognitive and behavioral effects of whole brain conventional or high dose rate (FLASH) proton irradiation in a neonatal Sprague Dawley rat model

Recent studies suggest that ultra-high dose rates of proton radiation (>40 Gy/s; FLASH) confer less toxicity to exposed healthy tissue and reduce cognitive decline compared with conventional radiation dose rates (~1 Gy/s), but further preclinical data are required to demonstrate this sparing effect. In this study, postnatal day 11 (P11) rats were treated with whole brain irradiation with protons at a total dose of 0, 5, or 8 Gy, comparing a conventional dose rate of 1 Gy/s vs. a FLASH dose rate of 100 Gy/s. Beginning on P64, rats were tested for locomotor activity, acoustic and tactile startle responses (ASR, TSR) with or without prepulses, novel object recognition (NOR; 4-object version), striatal dependent egocentric learning ([configuration A] Cincinnati water maze (CWM-A)), prefrontal dependent working memory (radial water maze (RWM)), hippocampal dependent spatial learning (Morris water maze (MWM)), amygdala dependent conditioned freezing, and the mirror image CWM [configuration B (CWM-B)]. All groups had deficits in the CWM-A procedure. Weight reductions, decreased center ambulation in the open-field, increased latency on day-1 of RWM, and deficits in CWM-B were observed in all irradiated groups, except the 5 Gy FLASH group. ASR and TSR were reduced in the 8 Gy FLASH group and day-2 latencies in the RWM were increased in the FLASH groups compared with controls. There were no effects on prepulse trials of ASR or TSR, NOR, MWM, or conditioned freezing. The results suggest striatal and prefrontal cortex are sensitive regions at P11 to proton irradiation, with reduced toxicity from FLASH at 5 Gy.

Face mask use during the COVID-19 pandemic: how risk perception, experience with COVID-19, and attitude towards government interact with country-wide policy stringency

BACKGROUND

During the 2020 COVID-19 pandemic, governments imposed numerous regulations to protect public health, particularly the (mandatory) use of face masks. However, the appropriateness and effectiveness of face mask regulations have been widely discussed, as is apparent from the divergent measures taken across and within countries over time, including mandating, recommending, and discouraging their use. In this study, we analyse how country-level policy stringency and individual-level predictors associate with face mask use during the early stages of the global COVID-19 pandemic.

METHOD

First, we study how (self and other-related) risk perception, (direct and indirect) experience with COVID-19, attitude towards government and policy stringency shape face mask use. Second, we study whether there is an interaction between policy stringency and the individual-level variables. We conduct multilevel analyses exploiting variation in face mask regulations across countries and using data from approximately 7000 students collected in the beginning of the pandemic (weeks 17 through 19, 2020).

RESULTS

We show that policy stringency is strongly positively associated with face mask use. We find a positive association between self-related risk perception and mask use, but no relationship of mask use with experience with COVID-19 and attitudes towards government. However, in the interaction analyses, we find that government trust and perceived clarity of communication moderate the link between stringency and mask use, with positive government perceptions relating to higher use in countries with regulations and to lower use in countries without regulations.

CONCLUSIONS

We highlight that those countries that aim for widespread use of face masks should set strict measures, stress self-related risks of COVID-19, and use clear communication.

Sleep Patterns and Affect Dynamics Among College Students During the COVID-19 Pandemic: Intensive Longitudinal Study

Background

Sleep disturbance is a transdiagnostic risk factor that is so prevalent among young adults that it is considered a public health epidemic, which has been exacerbated by the COVID-19 pandemic. Sleep may contribute to mental health via affect dynamics. Prior literature on the contribution of sleep to affect is largely based on correlational studies or experiments that do not generalize to the daily lives of young adults. Furthermore, the literature examining the associations between sleep variability and affect dynamics remains scant.

Objective

In an ecologically valid context, using an intensive longitudinal design, we aimed to assess the daily and long-term associations between sleep patterns and affect dynamics among young adults during the COVID-19 pandemic.

Methods

College student participants (N=20; female: 13/20, 65%) wore an Oura ring (Ōura Health Ltd) continuously for 3 months to measure sleep patterns, such as average and variability in total sleep time (TST), wake after sleep onset (WASO), sleep efficiency, and sleep onset latency (SOL), resulting in 1173 unique observations. We administered a daily ecological momentary assessment by using a mobile health app to evaluate positive affect (PA), negative affect (NA), and COVID-19 worry once per day.

Results

Participants with a higher sleep onset latency (b=−1.09, SE 0.36; P=.006) and TST (b=−0.15, SE 0.05; P=.008) on the prior day had lower PA on the next day. Further, higher average TST across the 3-month period predicted lower average PA (b=−0.36, SE 0.12; P=.009). TST variability predicted higher affect variability across all affect domains. Specifically, higher variability in TST was associated higher PA variability (b=0.09, SE 0.03; P=.007), higher negative affect variability (b=0.12, SE 0.05; P=.03), and higher COVID-19 worry variability (b=0.16, SE 0.07; P=.04).

Conclusions

Fluctuating sleep patterns are associated with affect dynamics at the daily and long-term scales. Low PA and affect variability may be potential pathways through which sleep has implications for mental health.

Fixed or random? On the reliability of mixed-effects models for a small number of levels in grouping variables

Biological data are often intrinsically hierarchical (e.g., species from different genera, plants within different mountain regions), which made mixed-effects models a common analysis tool in ecology and evolution because they can account for the non-independence. Many questions around their practical applications are solved but one is still debated: Should we treat a grouping variable with a low number of levels as a random or fixed effect? In such situations, the variance estimate of the random effect can be imprecise, but it is unknown if this affects statistical power and type I error rates of the fixed effects of interest. Here, we analyzed the consequences of treating a grouping variable with 2-8 levels as fixed or random effect in correctly specified and alternative models (under- or overparametrized models). We calculated type I error rates and statistical power for all-model specifications and quantified the influences of study design on these quantities. We found no influence of model choice on type I error rate and power on the population-level effect (slope) for random intercept-only models. However, with varying intercepts and slopes in the data-generating process, using a random slope and intercept model, and switching to a fixed-effects model, in case of a singular fit, avoids overconfidence in the results. Additionally, the number and difference between levels strongly influences power and type I error. We conclude that inferring the correct random-effect structure is of great importance to obtain correct type I error rates. We encourage to start with a mixed-effects model independent of the number of levels in the grouping variable and switch to a fixed-effects model only in case of a singular fit. With these recommendations, we allow for more informative choices about study design and data analysis and make ecological inference with mixed-effects models more robust for small number of levels.

Enhancing Daily Affect in Youth Experiencing High-Conflict Parental Divorce: A Multiple Baseline Trial of an Online Prevention Program

This study investigated the effects of a highly interactive, online cognitive-behavioral youth coping program: Children of Divorce-Coping with Divorce (CoD-CoD; Boring et al., 2015) on children exposed to high levels of interparental conflict (IPC). A multiple-baseline experimental design (N = 9) evaluated within-subject intervention effects on change in daily positive and negative affect before, during, and after the intervention (n_observations = 462). Participants were youth ages 11-16 who reported high exposure to IPC and whose parents had filed for divorce or parenting plan determinations in the prior year. A significant interaction effect indicated change in positive affect, but not negative affect, between the intervention and baseline phases. Positive affect linearly decreased during the baseline phase and flattened during the intervention phase. Results indicate that CoD-CoD was effective in interrupting a decline in youth-reported positive affect in a high-IPC sample, which may indicate a buffering effect against depression. Critical future directions include conducting large-scale randomized trials with children from high-IPC families to assess for whom the program is effective and assess long-term effects across a broad range of important outcomes.

Model Selection and Model Averaging for Mixed-Effects Models with Crossed Random Effects for Subjects and Items

A good deal of experimental research is characterized by the presence of random effects on subjects and items. A standard modeling approach that includes such sources of variability is the mixed-effects models (MEMs) with crossed random effects. However, under-parameterizing or over-parameterizing the random structure of MEMs bias the estimations of the Standard Errors (SEs) of fixed effects. In this simulation study, we examined two different but complementary perspectives: model selection with likelihood-ratio tests, AIC, and BIC; and model averaging with Akaike weights. Results showed that true model selection was constant across the different strategies examined (including ML and REML estimators). However, sample size and variance of random slopes were found to explain true model selection and SE bias of fixed effects. No relevant differences in SE bias were found for model selection and model averaging. Sample size and variance of random slopes interacted with the estimator to explain SE bias. Only the within-subjects effect showed significant underestimation of SEs with smaller number of items and larger item random slopes. SE bias was higher for ML than REML, but the variability of SE bias was the opposite. Such variability can be translated into high rates of unacceptable bias in many replications.

Incomplete recovery of bone strength and trabecular microarchitecture at the distal tibia 1 year after return from long duration spaceflight

Determining the extent of bone recovery after prolonged spaceflight is important for understanding risks to astronaut long-term skeletal health. We examined bone strength, density, and microarchitecture in seventeen astronauts (14 males; mean 47 years) using high-resolution peripheral quantitative computed tomography (HR-pQCT; 61 μm). We imaged the tibia and radius before spaceflight, at return to Earth, and after 6- and 12-months recovery and assessed biomarkers of bone turnover and exercise. Twelve months after flight, group median tibia bone strength (F.Load), total, cortical, and trabecular bone mineral density (BMD), trabecular bone volume fraction and thickness remained − 0.9% to − 2.1% reduced compared with pre-flight (p ≤ 0.001). Astronauts on longer missions (> 6-months) had poorer bone recovery. For example, F.Load recovered by 12-months post-flight in astronauts on shorter (< 6-months; − 0.4% median deficit) but not longer (− 3.9%) missions. Similar disparities were noted for total, trabecular, and cortical BMD. Altogether, nine of 17 astronauts did not fully recover tibia total BMD after 12-months. Astronauts with incomplete recovery had higher biomarkers of bone turnover compared with astronauts whose bone recovered. Study findings suggest incomplete recovery of bone strength, density, and trabecular microarchitecture at the weight-bearing tibia, commensurate with a decade or more of terrestrial age-related bone loss.

Exploring the impact of community-based choral participation on cognitive function and well-being for persons with dementia: evidence from the Voices in Motion project

OBJECTIVES

Music-based interventions are postulated to mitigate cognitive decline in individuals with dementia. However, the mechanisms underlying why music-based interventions facilitate cognitive benefits remain unknown. The present study examines whether a choral intervention can modulate patterns of cognitive change in persons with dementia and whether within-person variation in affect is associated with this change.

METHODS

Thirty-three older adults with dementia engaged weekly in the Voices in Motion (ViM) study consisting of 3 choral seasons spanning 18-months. Performance on the Mini-Mental State Examination (MMSE) and the Positive and Negative Affect Schedule was assessed monthly within each choral season using a longitudinal intensive repeated-measures design. Three-level multilevel models were employed to disaggregate between- and within-person effects across short- (month-to-month) and long-term (season-to-season) intervals.

RESULTS

ViM participants exhibited an annual MMSE decline of 1.8 units, notably less than the clinically meaningful 3.3 units indicated by non-intervention literature. Further, variability in negative affect shared a within-person time-varying association with MMSE performance; decreases in negative affect, relative to one's personal average, were linked to corresponding improvements in cognitive function.

CONCLUSION

Engagement in the ViM choral intervention may attenuate cognitive decline for persons with dementia via a reduction of psychological comorbidities such as elevated negative affect.

Stay-at-Home: The Impact of the COVID-19 Lockdown on Household Functioning and ART Adherence for People Living with HIV in Three Sub-districts of Cape Town, South Africa

In March 2020, the South African government imposed a lockdown to control COVID-19 transmission. Lockdown may affect people living with HIV's (PLWH) antiretroviral therapy (ART) adherence. Data from a cluster randomised control trial was collected from 152 PLWH in Cape Town sub-districts from October 2019-March 2020 when the lockdown halted collection. Subsequently, 83 PLWH were followed-up in June-July 2020. Random effects models were used to analyse: (1) changes between baseline and follow-up and (2) correlates of adherence during lockdown. At follow-up, there was an increase in the odds of being below the poverty line and the odds of experiencing violence decreased. Measures for well-being, household functioning, stigma and HIV competency improved. Violence, depression, food insecurity, and stigma were associated with poorer ART adherence; higher well-being scores were associated with better adherence. During lockdown, governments need to ensure financial support, access to (mental) health services, and services for those experiencing violence.Clinical Trial Number: Pan African Clinical Trial Registry, PACTR201906476052236. Registered on 24 June 2019.