Akaike's information criterion in generalized estimating equations

Surveillance Outcomes by Imaging Methods in the First 5 Years After Breast Cancer Surgery

OBJECTIVE

To compare the outcomes of imaging methods (mammography alone, ultrasound [US] alone, mammography combined with US, and magnetic resonance imaging [MRI]-based examination) for surveillance during the first 5 years after breast cancer surgery.

MATERIALS AND METHODS

This retrospective cohort study analyzed the medical records of patients who underwent breast cancer surgery at a single institution between January 2011 and December 2015. Imaging surveillance was performed at 6-month or 1-year intervals during the first 5 years.

RESULTS

A total of 6371 women (median age, 49 years; age range, 20-90 years) underwent 28199 mammograms, 42759 US, and 2619 MRI examinations. Of 172 second breast cancer diagnoses, 19 (11.0%) were interval cancers. Mammography combined with US demonstrated higher cancer detection rate (CDR) compared to mammography alone (odds ratios [OR] = 3.31, 95% confidence interval [CI]: 1.52-8.96, P = 0.009) and US alone (OR = 2.80, 95% CI: 1.71-4.65, P < 0.001), whereas there was no statistical significance when compared with MRI-based examinations (OR = 0.89, 95% CI: 0.49-1.74, P > 0.999). A statistically significant interaction was observed between the mammographic breast density (MBD) and CDR of the imaging methods (P for interaction = 0.003).

CONCLUSION

The CDR of surveillance mammography combined with US was comparable with that of MRI-based examinations in an intensive surveillance setting. Considering the significant interaction between MBD and the CDR, a tailored approach for surveillance based on breast density is warranted.

The impact of bluetongue serotype 3 on cattle mortality, abortions and premature births in the Netherlands in the first year of the epidemic

In September 2023, bluetongue virus serotype 3 (BTV-3) was identified among sheep and cattle in the Netherlands. Severe clinical signs and increased mortality were reported in sheep and cattle. The aim of this study was to quantify the impact of BTV-3 on mortality, abortions and premature births in cattle in the Netherlands in 2023. Data were available from 1 January 2020-31 December 2023 and were aggregated at herd-month level. Cattle herds were assigned a BTV-3 status for each herd-month: 1) herds that notified clinical signs of BTV-3, 2) herds that did not notify clinical signs but were located in BTV-3 infected areas or 3) herds that were located in BTV-3 free areas (all areas without BTV-3 notifications). Multivariable population-averaged generalized estimating equations models were used to quantify the association between the BTV-3 epidemic and cattle mortality, abortions and premature births. The results showed that from September 2023 until the end of 2023, perinatal calf mortality increased 1.11 (95 % CI:1.06-1.16) and 1.07 (95 % CI: 1.05-1.09) times, in dairy herds with a notified BTV-3 outbreak and in other dairy herds located in outbreak areas, respectively. Premature birth may be one of the explanations of increased calf mortality, as suggested by an odds ratio of 1.39 (95 % CI: 1.26-1.54) for premature births in dairy herds with a notified BTV-3 outbreak compared to dairy herds in BTV-3 free areas. The odds of abortions in infected dairy herds was 1.1 (95 %CI: 1.02-1.20) times higher compared to non-infected herds. Mortality in cattle aged 1-2 years and older than 2 years increased 2.25 (95 %CI: 1.97-2.58) and 1.71 (95 % CI: 1.62-1.81) times respectively, in infected dairy herds. In dairy herds without notification located in BTV-3 infected areas, mortality increased by 1.17 (95 %CI: 1.07-1.27) and 1.22 (95 % CI: 1.19-1.25) times respectively, compared to herds in BTV-3 free areas. In addition, suckler cow herds, beef cattle herds and small scale non-dairy cattle herds with a notified BTV-3 outbreak showed a significantly increased mortality during the BTV-3 epidemic compared to herds in BTV-3 free areas. In conclusion, BTV-3 infections markedly increased abortions, mortality and premature births in cattle herds.

The changing impact of the active job openings-to-applicants ratio (AJOAR) on ambulance dispatches during deflation: A longitudinal ecological study

BACKGROUND

Frequent ambulance dispatches is a common challenge in developed countries. Several factors have been identified as contributing to increase in dispatches, but no stipulation has explained the particular shift observed in Japan since 1995. This study examined ambulance dispatches in view of changes in a macroeconomic indicator.

METHODS

This longitudinal ecological study covered all annual ambulance dispatch incidents in Japan between 1980 and 2021 (42 years). The regression model comprised the active job openings-to-applicants ratio during deflation, the active job openings-to-applicants ratio during inflation, aging population trend, and mean ambient temperature, with the Japanese total population as an offset variable.

RESULTS

There were a total of 177,042,244 ambulance dispatches during the study period. The active job openings-to-applicants ratio during deflation showed statistical significance in the regression analysis (generalized estimation equations estimate: 0.165, 95% confidence interval: 0.087 to 0.243) whereas the active job openings-to-applicants ratio during inflation did not (0.019, -0.021 to 0.059).

CONCLUSION

The active job openings-to-applicants ratio during deflationary periods was associated with increased ambulance dispatches.

Durability of the moderate-to-heavy intensity transition can be predicted using readily available markers of physiological decoupling

PURPOSE

To assess relationships between heart rate (HR), ventilation (̇ V ˙ E), and respiratory frequency (FR) decoupling and durability of the first ventilatory threshold (VT1), and the strength of practical models to predict power output at VT1 during prolonged exercise.

METHODS

Durability of VT1 was assessed via measurements of power output at VT1 before and after ~ 2.5-h of initially moderate-intensity cycling in 51 trained cyclists, as part of four studies published elsewhere. In 12 of those participants, power output at VT1 was assessed every hour until task failure. For every assessment of power output at VT1, HR, FR, and V ˙ ̇E was measured at fixed power outputs, and thus decoupling of these variables with power output was determined. Bivariate repeated-measures correlations (rrm) between decoupling and durability of VT1 were assessed. Multivariable models were created to predict power output at VT1 during prolonged exercise using generalised estimating equations.

RESULTS

Negative correlations were observed between exercise-induced change in power output at VT1 and HR (rrm = -0.76, P < 0.001) and FR (rrm = -0.40, P = 0.013) decoupling, but not V ˙ ̇E decoupling (rrm = -0.25, P = 0.136). The final prediction model, containing baseline VT1 and peak oxygen uptake, FR decoupling, and an interaction between HR decoupling and exercise duration, effectively predicted real-time VT1 (mean absolute error, ~ 7.2 W; R2, 0.95).

CONCLUSION

HR and/or FR decoupling during controlled training sessions may be a practically useful durability assessment. Our prediction models may be an effective means of improving within-session intensity regulation and training load monitoring.

Diatom-dinoflagellate dynamics in marine ranching ecosystems under seasonal shifts and interannual climatic conditions

Global climate events like the El Niño-Southern Oscillation (ENSO) significantly influence ecological dynamics in coastal ecosystems, particularly engineered ones. The health of primary producers such as diatoms and dinoflagellates are vital for engineered ecosystem balance, and understanding their dynamics is essential for effective conservation strategies. This study utilizes long-term monitoring data from 2003 to 2022, employing generalized additive models (GAM) to analyze the spatio-temporal variations of diatom and dinoflagellate abundance in Haizhou Bay, with a focus on the impacts of interannual climate events. The results showed that diatom abundance peaked in October, with significantly lower values in May, indicating strong seasonal variation (P<0.01). In contrast, dinoflagellate abundance was highest in October and showed less pronounced seasonal differences. Interannually, diatom abundance was highest in 2017 and 2020, while dinoflagellates peaked in 2016 and 2012. Diatoms exhibited a shifting spatial distribution, concentrating in the central and eastern areas during different seasons, while dinoflagellates showed relatively uniform distributions initially, later concentrating in central and northern regions. The spatial patterns were influenced by both seasonal changes and ENSO events. The GAM analysis revealed that diatom abundance was significantly affected by temperature and nutrient availability across different seasons. Under strong El Niño conditions, diatom abundance increased, while dinoflagellate populations remained stable, indicating a competitive advantage for diatoms during these periods. Conversely, dinoflagellate abundance showed no significant variation across interannual events. Our findings underscore the importance of resource availability in shaping phytoplankton communities. Changes in diatoms and dinoflagellate abundance are key indicators of health and stress within the marine ranching ecosystem. This research supports effective management strategies and highlights the need for adaptive practices to enhance coastal engineered ecosystem resilience amid climate change.

Heroes in Red: Traumatic Event Exposure Linked to Reduced Wellbeing Among a Cohort of U.S. Ski Patrollers

IntroductionSki patrollers face unique occupational risks and may be exposed to traumatic events. This study aimed to determine the relationship between traumatic event exposures and wellbeing among a cohort of U.S. ski patrollers.MethodsA non-experimental, descriptive, longitudinal design was followed to complete a pilot study. An online survey was employed with repeated measures (1, 2, & 3 months). Participants were conveniently sampled from one ski resort in the Western United States. This study was informed by the stress continuum model.ResultsA total of 29 participants completed at least one follow-up survey and were included as the analytic sample. Participants were primarily White (n = 27, 93.10%), non-Hispanic or Latino (n = 27, 93.10%), and male (n = 19, 65.52%), aged 39.07 on average. Three-quarters of participants reported exposure to traumatic events at Survey 1 (n = 22, 75.86%), and the frequency ranged from 1 to 20 events. Increased frequency of traumatic events by each one event was significantly related to decreased wellbeing levels over 3 months (β = -0.0253, p < .0001, 95% CI: [-0.0364, -0.0141]), after controlling for age, sex, race, ethnicity, marital status, and working hours. When included as an interaction term, resilience was found to buffer the negative effect of traumatic event exposure on wellbeing (β = -0.0068, p < .0001, 95% CI: [-0.0099, -0.0038]).ConclusionsFindings underscore the need for additional research to identify the most effective ways to support the wellbeing and resilience of ski patrollers.

FLAIR-based radiomics signature from brain-tumor interface for early prediction of response to EGFR-TKI therapy in NSCLC patients with brain metastasis

Objectives

Evaluating response to epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitors (TKIs) is crucial in non-small cell lung cancer (NSCLC) patients with brain metastases (BM). To explore values of multi-sequence MRI in early assessing response to EGFR-TKIs in non-small cell lung cancer (NSCLC) patients with BM.

Approach

A primary cohort of 133 patients (January 2018 to March 2024) from center one and an external cohort of 52 patients (May 2017 to December 2022) from center two were established. Radiomics features were extracted from 4 mm brain-tumor interface (BTI) and whole BM region across T1-weighted contrast enhanced (T1CE) and T2-weighted (T2W) and T2 fluid-attenuated inversion recovery (T2-FLAIR) MRI sequences. The most relevant features were selected using the U test and least absolute shrinkage and selection operator (LASSO) method to develop the multi-sequence models based on BTI (RS-BTI-COM) and BM (RS-BM-COM). By integrating RS-BTI-COM with peritumoral edema volume (VPE), the combined model was built using logistic regression. Model performance was evaluated using the area under the ROC curve (AUC), sensitivity (SEN), specificity (SPE) and accuracy (ACC).

Main Results

The constructed RS-BTI-COM demonstrated a higher association with early response to EGFR-TKI therapy than RS-BM-COM. The combined RS-BTIplusVPE, incorporating BTI-based radiomics features and VPE, exhibited the highest AUCs (0.843-0.938), SPE (0.808-0.905) and ACC (0.712-0.875) in the training, internal validation, and external validation cohort, respectively.

Significance

The study developed a validated non-invasive model (RS-BTIplusVPE) based on integrating BTI-based radiomics features and VPE, which showed improved prediction of EGFR-TKI response in NSCLC patients with BM compared to tumor-focused models.

The association of residential greenery with noise annoyance depends on transport source and environmental context: Insights from the large-scale NORAH study

A growing body of literature highlights residential greenery (green vegetation in general and/or greenspaces) as a means to reduce negative health effects of transportation noise. A recent study using the Swiss nation-wide SiRENE survey data revealed that residential greenery was associated with reduced road traffic and railway noise annoyance, but increased aircraft noise annoyance. While the findings on road traffic and railway noise annoyance were expected, those on aircraft noise annoyance were unexpected. The aim of the current study therefore was to test the generalizability of the latter findings with data from the cross-sectional German NORAH study, which covers four major German airport regions with records of 26,607 individual participants. We complemented the NORAH data set with the metric "normalized difference vegetation index (NDVI)" for greenery and a metric for public greenspaces, and reanalyzed the associations of annoyance with residential greenery and noise exposure. Overall, we found road traffic noise annoyance to decrease with increasing greenery for day-evening-night-levels (Lden) of up to around 60 dB, but to increase at higher Lden. For aircraft noise annoyance, in contrast, the opposite was true, with a turning point at around 55 dB Lden. For railway noise, no consistent trend was observed. Our results thus confirm the findings from the SiRENE survey for road traffic and aircraft noise annoyance, except that residential greenery was found to be a moderator. Our study also shows that whether and how residential greenery is associated with noise annoyance depends on the noise source, noise level and environmental context.

Effects of an integrated social-art intervention on cognitive and psychosocial outcomes among older adults with mild cognitive impairment in nursing homes: a mixed methods study

BACKGROUND

The rising prevalence of mild cognitive impairment (MCI) among older adults in nursing homes necessitates effective interventions to slow the progression to dementia. Integrated social-art interventions have shown promise in enhancing cognitive function and reducing social isolation. This study aimed to evaluate the effects of such an intervention on cognitive and psychosocial outcomes in older adults with MCI.

METHODS

An explanatory sequential mixed-methods study was conducted, comprising a cluster randomized controlled trial (RCT) and a descriptive qualitative study. Four nursing homes in two districts of a city in southeastern China were randomly assigned (1:1) to either the intervention or the control group. The intervention group received a 14-week, 28-session integrated social-art program structured around theme-based group activities, while the control group received usual care, including assistance with daily living activities, basic medical care, recreational activities, and environmental cleaning. Quantitative outcomes were measured at baseline (T0), immediately post-intervention (T1), and at 24-week follow-up (T2), with global cognitive function as the primary outcome, and specific cognitive functions, psychosocial indicators, functional abilities, and quality of life as secondary outcomes. Qualitative interviews were conducted post-intervention to explore the reasons underlying the observed variations in efficacy.

RESULTS

Eighty older adults with MCI (median age 86.50 years) participated, with an average attendance rate of 86.25% in the intervention group. Intention-to-treat analyses revealed a significant improvement in global cognitive function at T1 in the intervention group compared to the control group (β = 2.85; 95%CI [1.27, 4.44], P < 0.001); however, this effect was not sustained at T2. No significant improvements were observed in psychosocial indicators, functional abilities, or quality of life (P > 0.05). Qualitative findings indicated that structured, sequential tasks and professional guidance contributed to short-term cognitive gains, whereas age-related health issues and limited ongoing engagement impeded the durability of these benefits.

CONCLUSIONS

The 14-week integrated social-art intervention appears feasible and may promote short-term cognitive activation in institutionalized older adults with MCI, though its benefits were not sustained at follow-up. Future research should investigate strategies for maintaining cognitive improvements and explore modifications to enhance broader clinical outcomes in this vulnerable population.

TRIAL REGISTRATION

The trial was prospectively registered at the Chinese Clinical Trials Registry with the registration number ChiCTR2200061681 on 30 June 2022.

Does inclusion of neighborhood variables improve clinical risk prediction for advanced prostate cancer in Black and White men?

INTRODUCTION

Black men are diagnosed with high-grade prostate cancer (PCa; Gleason sum ≥7) at greater rates than White men. This persistent disparity has led to mortality rates among Black men that are twice the rate of White men. Risk prediction tools can aid clinical decision making for PCa screening, biopsy, and treatment. However, research has not integrated neighborhood-level risk factors that are associated with rates of high-grade PCa. This study sought to determine whether inclusion of neighborhood-level variables can improve prediction of high-grade PCa over the existing Prostate Cancer Prevention Trial (PCPT) calculator.

METHODS

Existing PCa cases from 2005 to 2017 were ascertained from urology, radiation, and medical oncology clinics at Fox Chase Cancer Center/Temple University Health System (FCCC/TUHS). Existing databases from patient medical records, biosamples, pathology, and neighborhood data from the U.S. census were linked via geocodes. Informed by prior studies that selected social environmental variables, a series of logistic regression models were completed to predict the probability of high-grade PCa on prespecified sets of variables from the PCPT.

RESULTS

Our best fitting, multilevel model included PCPT variables (i.e., PSA, digital rectal exam, age, race, prior biopsy, family history) as well as insurance status, neighborhood-level poverty, residence in a high risk PCa cluster, and % of Employed Men in Protective Service Occupations. However, the AUC for this model (0.673) was only marginally improved from the initial model of only PCPT variables (0.671). Further, in separate analyses by race (White, Black) the % of Employed Men in Protective Service Occupations was only significant among White men.

DISCUSSION

Study findings demonstrate the potential for neighborhood variables to enhance current risk prediction models and identify interaction effects revealing differences across subgroups, such as race. The lack of significant associations between neighborhood variables and Black men highlight the complexity of systemic racism and neighborhood-level variables on PCa outcomes.

Wellbeing and quality of life among parents of individuals with Fontan physiology

PURPOSE

To examine global and health-related quality of life (QOL) among parents of individuals with Fontan physiology and determine associations with sociodemographic, parent and child-related health, psychological, and relational factors.

METHODS

Parents participating in the Australian and New Zealand Fontan Registry (ANZFR) QOL Study (N = 151, Parent Mean age = 47.9 ± 10.2 years, age range: 31.6-79.6 years, 66% women; child Mean age = 16.3 ± 8.8, age range: 6.9-48.7 years, 40% female) completed a series of validated measures. Health-related QOL was assessed using the PedsQL 4.0 Core Generic Scales for adults and global QOL was assessed using a visual analogue scale (0-10).

RESULTS

Most parents (81%) reported good global QOL (≥ 6), consistent with broader population trends. Nearly one-third of parents (28%) reported at-risk health-related QOL (based on total PedsQL scores) with physical functioning most affected (44%). Psychological factors, including psychological stress and sense of coherence, emerged as the strongest correlates of global and health-related QOL, explaining an additional 16 to 30% of the variance (using marginal R2). Final models explained 35 and 57% and of the variance in global and health-related QOL, respectively (marginal R2). Relational factors, including perceived social support and family functioning contributed minimally when analyzed alongside psychological variables.

CONCLUSION

While parents of individuals with Fontan physiology report good global QOL, challenges in health-related QOL exist. We identified key psychological, sociodemographic, and health-related factors associated with parental QOL outcomes. These data may aid early identification of physical and psychosocial difficulties and guide targeted health resource allocation for this population.

The effect of depression on antiretroviral drug non-adherence among women living with HIV in Gondar health facilities, northwest Ethiopia: a prospective cohort study

Background

Globally, depression has been recognized as one of the risk factors for poorer outcomes in human immunodeficiency virus (HIV)- affected populations including women living with HIV (WLWHIV). Additionally, depression continues to be a barrier to antiretroviral therapy (ART) adherence. In African countries, including Ethiopia, depression often goes undetected and untreated for extended periods, leading to prolonged health outcomes. Factors such as the lack of awareness about depression and its impact on ART adherence contribute to its poor management. Understanding depression's role in ART is crucial for generating evidence to improve individuals' functionality and treatment outcomes. This study aimed to examine the effects of depression on ART non-adherence among WLWHIV in Ethiopia.

Methods

A prospective cohort study was conducted with data collected from 627 study participants who were on stable ART regimens at baseline, 3 months, and 6 months. Depression, the primary exposure variable, was measured using the Patient Health Questionnaire (PHQ-9). Antiretroviral adherence, the dependent variable, was assessed using the Simplified Medication Adherence Questionnaire (SMAQ). Generalized estimating equations (GEEs) were used to examine the association between HIV- related stigma, social support, depression, and ART non-adherence.

Results

The response rates of the study participants in the 2nd and 3rd phases were 99.7% and 94.4%, respectively, with a mean age of 42.27 years (SD ± 10.51). Depressed WLWHIV had a 2.19 times higher incidence of ART non-adherence compared to non-depressed WLWHIV. In panel data analysis, depression, poor social support, and HIV- related stigma were positively associated with ART non-adherence, with adjusted odds ratios of 1.97 [95% confidence interval (CI) (1.35, 2.87)], 2.15 [95% CI (1.05, 4.38)], and 1.56, [95% CI (1.09, 2.25)] respectively.

Conclusion

Depression, poor social support, and HIV- related stigma in women living with HIV were associated with ART non-adherence. Addressing these modifiable barriers could significantly enhance ART adherence in these populations.

Household tobacco expenditure and associated characteristics during substantial regular tobacco tax increases: analysis from a nationally representative longitudinal study in Australia from 2006 to 2022

OBJECTIVE

We investigated household tobacco expenditure by socioeconomic status and examined the associated factors in Australia from 2006 to 2022, incorporating a period of substantial regular tobacco tax increases (2010-2020).  METHODS: We conducted a repeated cross-sectional analysis of household data from the Household, Income, and Labour Dynamics in Australia survey to examine differences in household tobacco expenditure by Socio-Economic Indexes for Areas (SEIFA). Descriptive analyses were performed for all households and those with any tobacco expenditure, with dollar values adjusted for inflation to 2022. Linear regression with generalised estimating equations (GEE) assessed associations between different individual-level factors and household tobacco expenditure.

RESULTS

Between 2006 and 2022, smoking prevalence decreased by 5.6% points. Overall average annual household tobacco expenditure decreased by $7.8 ($980.5 to $972.7), while households that purchased tobacco increased spending by $1092.2 ($3839.5 to $4931.7). In 2022, households in the most disadvantaged areas allocated more than double the proportion of their disposable income to tobacco (6.3%) compared with households in the most advantaged areas (2.7%). GEE analysis showed a dose-response relationship between SEIFA category and household tobacco expenditure, with the most disadvantaged households spending an additional $245.5 (95% CI: $193.7-$297.2) compared with the most advantaged households. The additional tobacco-related expenditure for people who currently smoked compared with those who never smoked was $1500.5 (95% CI: $1424-$1577).

CONCLUSION

Disadvantaged households allocated more of their income to tobacco and spent more on tobacco overall than advantaged households, reflecting higher smoking prevalence. Additional non-price-related measures are needed to address these inequities.

Sterile but Sexy: Assessing the Mating Competitiveness of Irradiated Bagrada hilaris Males for the Development of a Sterile Insect Technique

Bagrada hilaris (known as painted bug) is a pest native to India, Southeast Asia, and middle and central Africa and was reported as invasive in the southwestern USA, Hawaii, Mexico, South America, and two Mediterranean islands. The feeding activity results in extensive damage to economically important Brassicaceae crops. Among sustainable alternatives to synthetic pesticides, the Sterile Insect Technique (SIT) is considered a promising strategy because it relies on the release of competitive sterile males that can reduce the pest reproduction. In this study, the efficacy of different doses of gamma irradiation (60, 80, and 100 Gy) was evaluated to identify the treatment that would ensure high sterility without compromising the competitiveness of the treated males. Observational tests showed that the doses of 60 Gy and 80 Gy showed no difference in mating times compared to non-irradiated males, in contrast to 100 Gy. Thus, 80 Gy was identified as the most promising dose. For further investigation, tests were conducted under choice and no-choice conditions at 80 Gy for three days. The results showed that irradiated males had a comprehensive higher mating rate than non-irradiated males, and under choice conditions, they were often preferred by females, confirming that SIT has potential as an environment-friendly method for controlling B. hilaris.

Transition to retirement impact on food consumption frequency: results from a longitudinal analysis within the Survey of Health, Ageing and Retirement in Europe (SHARE)

OBJECTIVES

It has been suggested that major life course transitions, such as retirement, can greatly impact lifestyles. However, the evidence is scant and inconclusive, especially with reference to the effects on dietary habits. We investigated the long-term effects of retirement on the frequency of food consumption using data from the Survey of Health, Ageing, and Retirement in Europe (SHARE).

DESIGN AND PARTICIPANTS

We used data from a SHARE-based cohort, including European individuals from 28 countries aged 50 and older who were employed at baseline and retired during follow-up time (2004-2020).

MEASUREMENTS

Dietary habits were assessed through self-reported frequencies of consumption for fruit and vegetables, dairy products, meat and fish, legumes and eggs. A dietary score (dichotomised as ≥5 or <5) was also estimated. Generalised estimating equation models calculated relative risks (RR) of daily (for fruit, vegetables and dairy products) and 3-6 times per week (for meat, fish, legumes and eggs) consumptions before and after retirement, adjusting for selected variables.

RESULTS

The cohort included 8,998 individuals with a mean follow-up time of 9 years. Baseline daily consumption frequencies were 73.7% for fruit and vegetables and 65.9% for dairy products, while 3-6 times per week frequencies were 39.8% for meat and fish and 26.1% for legumes and eggs. An increase in 3-6 times a week consumption of meat and fish (RR 1.07, 95% CI 1.01-1.13) and legumes and eggs (RR 1.09, 95% CI 1.01-1.17) was observed 10 or more years post-retirement. Daily consumption of fruit and vegetables, and dairy products remained stable. The RR of a dietary score ≥5 post-retirement was 1.11 (95% CI 1.06-1.16, 10 or more years after).

CONCLUSIONS

Retirement positively appears to influence overall dietary habits, particularly by improving the consumption frequency of protein-rich foods, while the stability in fruit, vegetables, and dairy consumption suggests that well-established habits persist despite life transitions.

Prognostic significance of different lymph node staging systems in patients with resectable, node-positive, stage III, non-small cell lung cancer: Identifying the optimal classification for enhanced prognostic stratification

PURPOSE

The traditional N staging system fails to adequately stratify the prognostic heterogeneity in patients with resectable node-positive, stage III, non-small cell lung cancer, particularly in those undergoing postoperative radiotherapy. The purpose of this study was to determine the optimal nodal status classification strategy: the traditional N classification, the positive lymph nodes-based classification, or the lymph node ratio-based classification. Furthermore, we aimed to identify the population that would benefit the most from postoperative radiotherapy using the best classification strategy.

METHODS

We analysed data from 5028 patients with resectable node-positive, stage III, non-small cell lung cancer sourced from the Surveillance, Epidemiology, and End Results (SEER) database. Various lymph node staging systems, including traditional N staging, classification based on the number of positive lymph nodes, and classification based on the lymph node ratio, were incorporated into the prognostic prediction model. Survival outcomes were evaluated using lung cancer-specific survival and Kaplan-Meier analysis.

RESULTS

The lymph node ratio classification model demonstrated the highest prognostic prediction performance, with the highest C-index, area under the curve, and the lowest Akaike information criterion, followed by the positive lymph nodes classification model and the traditional N staging model. Prognostic stratification analysis based on different lymph node staging systems indicated that a lymph node ratio greater than 0.28 and more than three positive lymph nodes were associated with a high-risk prognosis. Furthermore, postoperative radiotherapy significantly improved lung cancer-specific survival in overall resectable node-positive, stage III, non-small cell lung cancer (P<0.05). Notably, survival curve analysis revealed the most pronounced differences in lung cancer-specific survival between the groups receiving postoperative radiotherapy or not in the high-risk prognosis group, particularly among those with a lymph node ratio greater than 0.28, and more than three positive lymph nodes, and lastly the traditional N staging model.

CONCLUSION

In patients with resectable node-positive, stage III, non-small cell lung cancer, classification according to the lymph node ratio, followed by the positive lymph nodes, may offer superior prognostic prediction capabilities compared to the traditional N staging in addressing prognostic heterogeneity. Additionally, identifying a high-risk prognosis with a lymph node ratio greater than 0.28 appears to be the most effective criterion for selecting candidates who would benefit from postoperative radiotherapy.

DCE-MRI radiomics of primary breast lesions combined with ipsilateral axillary lymph nodes for predicting efficacy of NAT

BACKGROUND

This study aimed to assess the predictive value of radiomic analysis derived from primary lesions and ipsilateral axillary suspicious lymph nodes (SLN) on dynamic contrast-enhanced MRI (DCE-MRI) for evaluating the response to neoadjuvant therapy (NAT) in early high-risk and advanced breast cancer (BC) patients.

METHODS

A retrospective analysis was conducted on 222 BC patients (192 from Center I and 30 from Center II) who underwent NAT. Radiomic features were extracted from the primary lesion (intra- and peritumoral regions) and ipsilateral axillary SLN to develop radiomic signatures (RS-primary, RS-SLN). An integrated signature (RS-Com) combined features from both regions. Feature selection was performed using correlation analysis, the Mann-Whitney U test, and least absolute shrinkage and selection operator (LASSO) regression. A diagnostic nomogram was constructed by integrating RS-Com with key clinical factors. Model performance was evaluated using receiver operating characteristic (ROC) and decision curve analysis (DCA).

RESULTS

RS-Com demonstrated superior predictive performance compared to RS-primary and RS-SLN alone. The DeLong test confirmed that axillary SLNs provide supplementary information to the primary lesion. Among clinical factors, N staging and HER2 status were significant contributors. The nomogram, integrating RS-Com, N staging, and HER2 status, achieved the highest performance in the training (AUC: 0.926), validation (AUC: 0.868), and test (AUC: 0.839) cohorts, outperforming both the clinical models and RS-Com alone.

CONCLUSION

Radiomic features from axillary SLNs offer valuable supplementary information for predicting NAT response in BC patients. The proposed nomogram, incorporating radiomics and clinical factors, provides a robust tool for individualized treatment planning.

A path forward on online misinformation mitigation based on current user behavior

Social media misinformation has become a serious societal problem, and recent research has focused on developing effective ways to counter its harmful impacts. This work investigates user-level countermeasures, or how individuals who see the misinformation respond to it directly, possibly to help stop its spread in their online communities. Using a registered report design, we conducted an online survey of 1010 American social media users who use social media at least once weekly. Participants were asked how they respond and think others should respond to misinformation they unintentionally post or see posted by others, and how their responses differ depending on their relationship with the person who posted that misinformation. Overall, the results revealed a difference between respondents' beliefs and actions: participants reported expecting others to exert more effort when responding to misinformation than the level of effort they themselves reported. Additionally, on average, participants were more likely to say they intervened when misinformation was posted by someone close to them rather than by an acquaintance or a stranger. Understanding current behavioral patterns and public opinion can inform efforts to elicit public participation in countering misinformation and increase the effectiveness of platform-level countermeasures.Protocol registration: The stage 1 protocol for this Registered Report was accepted in principle on March 13th, 2024. The protocol, as accepted by the journal, can be found at: https://figshare.com/s/683b1e7c2f2bad96f604 .

Conventional Cardiopulmonary Resuscitation Versus Extracorporeal Membrane Oxygenation-Assisted CPR in Children: A Retrospective Analysis of Outcomes and Factors Associated with Conversion from the Former to the Latter

BACKGROUND/OBJECTIVES

Conventional cardiopulmonary resuscitation (CCPR) has been the foundational resuscitation approach for decades. Where CCPR is unsuccessful, extracorporeal membrane oxygenation-assisted CPR (ECPR) may improve outcomes. Predicting failure of CCPR and immediate need for ECPR is difficult, and data are lacking. In this retrospective analysis, we analysed both factors that are associated with conversion from CCPR to ECPR and survival outcomes for each event.

METHODS

Patients having a CPR event that occurred in the PICU between 2016 and 2022 were included. Pre-CPR-event clinical and laboratory data were collected. We recorded whether CPR was converted to ECPR and documented patient outcomes.

RESULTS

201 CPR events occurred in 164 children, with 45 events converted from CCPR to ECPR. Time to ROSC or time to ECMO flow was (median [IQR]) 2 (1.5) min for CCPR events and 37 (21.60) min for ECPR events. The maximum pre-CPR-event lactate values were 1.8 mmol/L for CCPR and 4.5 mmol/L for ECPR events. Respiratory arrest preceded 35.3% of CCPR and 4.4% of ECPR events. PICU mortality was 27.8% for CCPR and 50% for ECPR events. Most deaths occurred because of withdrawal of life-sustaining treatments. In a multivariable analysis, cardiac surgical diagnosis, pre-CPR-event lactate, as well as duration of CPR were associated with conversion from CCPR to ECPR.

CONCLUSIONS

Our study demonstrates that pre-CPR-event lactate concentrations and duration of arrest should alert clinicians to a high likelihood of needing ECPR, while a preceding respiratory arrest may indicate a low likelihood. Mortality post CCPR is significant, mainly due to overall illness severity rather than the consequences of the CPR event.

Continuity of care in a pandemic: an observational study in GP-centred healthcare in Germany

BACKGROUND

Continuity of care (COC) refers to the sustained quality of healthcare over time and is a central element of effective general practice. High levels of COC have been associated with improved health outcomes, including reduced risks of hospitalisation. Previous research demonstrated that participation in Germany's "general practitioner-centred healthcare" (GPCHC) programme, designed to strengthen general practice care, led to higher COC. Furthermore, higher COC was independently linked to decreased risks of hospitalisations, including rehospitalisations and avoidable admissions. This study aimed to investigate whether the benefits of COC for GPCHC patients persisted in 2020, the first year of the COVID-19 pandemic, compared with 2019, the year preceding the pandemic.

METHODS

An observational study was conducted in Germany using data from a health insurance database. The study included two patient cohorts: those enrolled in the GPCHC programme (n=1 049 910) and those not enrolled in GPCHC (n=537 759) for both 2019 and 2020. The analysis compared three measures of COC-Usual Provider Index, Herfindahl Index and Sequential Continuity Index-adjusted for patient characteristics. Longitudinal multivariable regression models were employed to evaluate differences between the cohorts and assess the impact of the COVID-19 pandemic on COC outcomes.

RESULTS

For GPCHC patients, COC in general practice was relevantly and significantly higher with respect to the three COC measures in 2019. We could observe the same advantage for GPCHC patients in 2020. Interestingly, for the SCI index, indicating the fraction of sequential encounter pairs at which the same provider is seen, we could observe that COC was even more advantageous for GPCHC patients in 2020 in comparison to 2019. Finally, we could observe that higher COC in 2019 was independently associated with decreased healthcare utilisation of the inpatient care sector in 2020.

CONCLUSIONS

In a pandemic period in which healthcare is faced with new challenges, both for patients and healthcare providers, GPCHC was still associated with higher COC. The GPCHC programme and its contents are obviously better up to the requirements of the COC even in such a situation of pandemic-induced discontinuity.

A Novel Method to Predict Carbohydrate and Energy Expenditure During Endurance Exercise Using Measures of Training Load

BACKGROUND

Sports nutrition guidelines recommend carbohydrate (CHO) intake be individualized to the athlete and modulated according to changes in training load. However, there are limited methods to assess CHO utilization during training sessions.

OBJECTIVES

We aimed to (1) quantify bivariate relationships between both CHO and overall energy expenditure (EE) during exercise and commonly used, non-invasive measures of training load across sessions of varying duration and intensity and (2) build and evaluate prediction models to estimate CHO utilization and EE with the same training load measures and easily quantified individual factors.

METHODS

This study was undertaken in two parts: a primary study, where participants performed four different laboratory-based cycle training sessions, and a validation study where different participants performed a single laboratory-based training session using one of three exercise modalities (cycling, running, or kayaking). The primary study included 15 cyclists (five female; maximal oxygen consumption [ V ˙ O2max], 51.9 ± 7.2 mL/kg/min), the validation study included 21 cyclists (seven female; V ˙ O2max 53.5 ± 11.0 mL/kg/min), 20 runners (six female; V ˙ O2max 57.5 ± 7.2 mL/kg/min), and 18 kayakers (five female; V ˙ O2max 45.6 ± 4.8 mL/kg/min). Training sessions were quantified using six training load metrics: two using heart rate, three using power, and one using perceived exertion. Carbohydrate use and EE were determined separately for aerobic (gas exchange) and anaerobic (net lactate accumulation, body mass, and O2 lactate equivalent method) energy systems and summed. Repeated-measures correlations were used to examine relationships between training load and both CHO utilization and EE. General estimating equations were used to model CHO utilization and EE, using training load alongside measures of fitness and sex. Models were built in the primary study and tested in the validation study. Model performance is reported as the coefficient of determination (R2) and mean absolute error, with measures of calibration used for model evaluation and for sport-specific model re-calibration.

RESULTS

Very-large to near-perfect within-subject correlations (r = 0.76-0.96) were evident between all training load metrics and both CHO utilization and EE. In the primary study, all models explained a large amount of variance (R2 = 0.77-0.96) and displayed good accuracy (mean absolute error; CHO = 16-21 g [10-14%], EE = 53-82 kcal [7-11%]). In the validation study, the mean absolute error ranged from 16-50 g [15-45%] for CHO models to 53-182 kcal [9-31%] for EE models. The calibrated mean absolute error ranged from 9-20 g [8-18%] for CHO models to 36-72 kcal [6-12%] for EE models.

CONCLUSIONS

At the individual level, there are strong linear relationships between all measures of training load and both CHO utilization and EE during cycling. When combined with other measures of fitness, EE and CHO utilization during cycling can be estimated accurately. These models can be applied in running and kayaking when used with a calibration adjustment.

Alternative Formulations of Job Strain and Sleep Disturbances: A Longitudinal Study in the United States

BACKGROUND

Sleep disturbances are a major public health concern in the United States, leading to adverse health outcomes. In the working population, job strain has been identified as an important risk factor for sleep disturbances, but evidence from the United States remained limited. This study aimed to examine longitudinal associations between job strain and sleep disturbances in the United States, with a focus on the alternative formulations of job strain.

METHODS

A total of 1721 participants were drawn from two waves of the Midlife in the United States (MIDUS) study, with an average 9-year follow-up period. Job strain was measured using Karasek's Job-Demand-Control model and operationalized in six formulations: standard quadrant, simplified quadrant, linear, quotient, logarithm quotient, and quartile based on quotient. Generalized Estimating Equations were used to estimate longitudinal associations of alternative formulations of job strain at baseline with sleep disturbances across follow-up. Corrected Quasi-likelihood Information Criterion (QICu) was used to assess the goodness of fit.

RESULTS

All approaches showed that higher job strain at baseline was significantly associated with an increase in sleep disturbances across follow-up. QICu scores indicated that continuous Demand-Control formulations (linear, quotient, logarithm quotient) had better model performance of 4602.66, 4604.28, and 4601.99, respectively. The logarithm quotient showed the best fit.

CONCLUSIONS

Our findings imply the importance of early workplace interventions in reducing job strain to improve sleep hygiene. They further show that the continuous formulations quantifying job strain were more consistent and robust, which provides suggestions for future workplace health research in the United States.

Incentivizing adherence to pre-exposure prophylaxis for HIV prevention: a randomized pilot trial among male sex workers in Mexico

Low adherence to preventative medications against life-long health conditions is a major contributor to global morbidity and mortality. We implemented a pilot randomized controlled trial in Mexico to measure the extent to which conditional economic incentives help male sex workers increase their adherence to pre-exposure prophylaxis (PrEP) for HIV prevention. We followed n = 110 male sex workers over 6 months. At each quarterly visit (at months 0, 3, and 6), all workers received a $10 transport reimbursement, a free 3-month PrEP supply, and completed socio-behavioral surveys. The primary outcome was an objective biomarker of medication adherence based on tenofovir (TFV) drug concentration levels in hair collected at each visit. Individuals randomized to the intervention received incentives based on a grading system as a function of PrEP adherence: those with high (> 0.043 ng/mg TFV concentration), medium (0.011 to 0.042 ng/mg), or low (< 0.011 ng/mg) adherence received $20, $10, or $0, respectively. Six-month pooled effects of incentives on PrEP adherence were analyzed using population-averaged gamma generalized estimating equation models. We estimated heterogeneous treatment effects by sex worker characteristics. The incentive intervention led to a 28.7% increase in hair antiretroviral concentration levels over 6 months consistent with increased PrEP adherence (p = 0.05). The effect of incentives on PrEP adherence was greater for male sex workers who were street-based (vs. internet) workers (p < 0.10). These pilot findings suggest that modest conditional economic incentives could be effective, at scale, for improving PrEP adherence among male sex workers, and should be tested in larger implementation trials. ClinicalTrials.gov Identifier: NCT03674983.

Knowledge of Medical Interpretation Rights Among Individuals With Non-English Language Preference: A Cross-Sectional Study

OBJECTIVES

We aimed to identify demographic, acculturation, and health care factors associated with self-reported knowledge of the right to medical interpretation among individuals with non-English language preference (NELP) in California.

BACKGROUND

NELP is a significant social determinant of health contributing to adverse health outcomes through barriers in communication, limited health literacy, and biases in care delivery. The ability of patients with NELP to self-advocate for interpreter services is crucial yet hindered by various factors, including a lack of knowledge about their rights.

METHODS

This cross-sectional study used pooled data from the California Health Interview Survey from 2012 to 2021. Subjects were 12,219 adults with NELP, representing 2,516,157 individuals in California. The primary outcome was self-reported knowledge of the right to medical interpretation. Covariates included demographic, acculturation, and health care factors.

RESULTS

Of the participants, 28.6% were unaware of their rights to interpretation. Married females had higher odds of knowledge, while recent immigrants (≤5 y in the United States), those with mixed language households, no doctor visits in the past year, no insurance, and self-reported poorer health had lower odds. Sociodemographic factors like age, race, ethnicity, education, and geography showed no significant association.

CONCLUSIONS

Nearly one-third of individuals with NELP lack awareness of their right to medical interpretation. Factors such as recent immigration, poor health, and limited health care contact are significant barriers. In addition to system and policy level changes, interventions targeting these vulnerable groups are needed to improve health equity and empower patients to use interpreter services.

Variable selection in modelling clustered data via within-cluster resampling

In many biomedical applications, there is a need to build risk-adjustment models based on clustered data. However, methods for variable selection that are applicable to clustered discrete data settings with a large number of candidate variables and potentially large cluster sizes are lacking. We develop a new variable selection approach that combines within-cluster resampling techniques with penalized likelihood methods to select variables for high-dimensional clustered data. We derive an upper bound on the expected number of falsely selected variables, demonstrate the oracle properties of the proposed method, and evaluate the finite sample performance of the method through extensive simulations. We illustrate the proposed approach using a colon surgical site infection data set consisting of 39,468 individuals from 149 hospitals to build risk-adjustment models that account for both the main effects of various risk factors and their two-way interactions.

Traumatic Encephalopathy Syndrome: Head Impact Exposure and Blood Biomarkers in Professional Combat Athletes

OBJECTIVE

This study aimed to (1) determine whether there was an association between a diagnosis of traumatic encephalopathy syndrome (TES) and changes in three specific serum biomarkers, and (2) determine head impact exposure thresholds among both TES+ and TES- groups.

SETTING

Data were collected from Cleveland Clinic's Professional Athletes Brain Health Study (PABHS).

PARTICIPANTS

This study included 192 professional combat athletes, 35 years of age and older. Athletes must be actively fighting or retired with a minimum of 10 professional fights over their careers.

DESIGN/INTERVENTION

This was a retrospective observational study of the PABHS longitudinal cohort.

MAIN MEASURES

The generalized linear model with the generalized estimating equation for repeated measurements was used to compare various biomarkers between both active and retired TES- and TES+ groups.

RESULTS

The odds ratio for TES diagnosis was 5.44 (95% CI = 2.48, 11.94; P < .0001) among active fighters and 10.75 (95% CI = 3.52, 32.85; P < .0001) among retired fighters, indicating the odds for a TES diagnosis were over 5 times greater for active fighters with every fight completed at or beyond 30 professional fights. Retired fighters had 10 times greater odds of TES diagnosis with every fight completed at or beyond 15 professional fights. Likewise, the odds of a TES diagnosis were 2.0% (95% CI = 0.3, 3.1; P = 0.0039) greater with each pg/mL increase of glial fibrillary acidic protein (GFAP). No relationship was observed between a TES diagnosis and neurofilament light chain or P-tau231.

CONCLUSION

This study provides preliminary evidence that progressively elevated levels of the GFAP blood biomarker increase the odds of a TES diagnosis among retired professional fighters. Further evaluation is required to improve clarity and understanding of the relationship between progressive changes in the GFAP blood biomarker and a TES diagnosis, specifically evaluating the duration of chronicity and exposure thresholds.

A rapid decline in gender bias relates to changes in subsistence practices over demographic changes in a formerly matrilineal community

This research examines dynamics of kinship systems, emphasizing changes in gender-biased inheritance and social interaction within a formerly matrilineal community. Using demographic data over 70-year of lifespan from 17 Tibetan villages, we observe a significant shift within the predominantly matrilineal inheritance structure: a once-prevalent preference for females in older cohorts has now gone in recent generations. We explore two possible explanations: that this is driven by changes in subsistence system or by changes in sibling configuration. Our investigation reveals that a change from agriculture to non-traditional economy with more market integration marks a pivot from matrilineal to non-unilineal inheritance systems. Moreover, results from economic games conducted in two distinct survey periods (2015 and 2021) indicate that high donations for females in 2015 have become unbiased in 2021. These findings provide concrete evidence of shifts in gender preference both at the level of familial resource allocation and broader societal interactions.

Comparative Feeding and Defecation Behaviors of Trypanosoma cruzi-Infected and Uninfected Triatomines (Hemiptera: Reduviidae) from the Americas

Triatomines are vectors of Trypanosoma cruzi (Kinetoplastida: Trypanosomatidae), the agent of Chagas disease. Stercorarian transmission occurs when infectious parasites are passed in insect feces to vertebrates through the biting wound or mucosa. Defecating on hosts during or shortly after blood feeding is, therefore, critical for transmission, and delayed triatomine defecation behavior has been posited to contribute to a low incidence of human Chagas disease in the U.S. We allowed nymphal T. cruzi-infected and uninfected Triatoma gerstaeckeri (Stål, 1859) and Triatoma sanguisuga (LeConte, 1855) to interact with restrained guinea pigs and measured insect feeding and defecation events; South American Rhodnius prolixus (Stål, 1859; Latin America) served as a comparison group. In 148 trials, 40.0% of insects fed, of which 71.2% defecated. Compared to R. prolixus, T. gerstaeckeri had >9 times higher odds of feeding, and T. sanguisuga fed longer. Observations of defecation while feeding occurred across all three species. The post-feeding defecation interval (PFDI) of R. prolixus was significantly shorter (4.54 ± 2.46 min) than that of T. gerstaeckeri (9.75 ± 2.52 min) and T. sanguisuga (20.69 ± 8.98 min). Furthermore, the PFDI was shorter for TcI-infected insects compared to uninfected insects. Triatoma gerstaeckeri and T. sanguisuga are capable of stercorarian transmission, although the calculated metrics suggest they are less efficient vectors than R. prolixus.

Full title: prevalence and risk factors of overweight in Beijing infants basing generalized estimating equation: a longitudinal study

BACKGROUND

The prevalence of childhood overweight and obesity in China has been rapidly increasing in recent years. The purposes of this study were to investigate the prevalence of infant overweight in Beijing and to explore the influencing factors using a generalized estimating equation (GEE) model.

METHODS

This is a birth cohort study from January 2022 to December 2022 in Beijing, involving 2,008 newborns from local residents. Four times of follow-up visits were conducted at 2, 5, 8, and 12 months of age for physical measurements and health information collection. Multiple exposures were considered, including demographic characteristics of infants, maternal pregnancy information, feeding pattern and outdoor activities of infants. The GEE model was utilized to identify influencing factors for infant overweight while adjusting for potential confounders.

RESULTS

The prevalence of overweight for 2-, 5-, 8-, and 12-month-old infants were 14.4%, 21.6%, 24.4%, and 24.2%, respectively. Among the influencing factors, irregular exercise during pregnancy (OR = 1.190, P = 0.045), mixed feeding or artificial feeding (non-exclusive breastfeeding) (OR = 1.233, P = 0.025), high birth weight (OR = 1.468, P < 0.001), and high pre-pregnancy body mass index (BMI) (OR = 2.113, P = 0.005) were positively correlated with infant overweight. Conversely, weight gain ≤ 15.0 kg during pregnancy (OR = 0.778, P = 0.016), high birth length (OR = 0.990, P = 0.003), and longer duration of outdoor activity for infants (OR = 0.764, P < 0.001) were negatively correlated with infant overweight.

CONCLUSIONS

Our findings suggest certain factors are associated with infant overweight risk. Further research is required before making causal inferences and formulating preventive strategies for infant overweight.

Noninvasive Radiomics Approach Predicts Dopamine Agonists Treatment Response in Patients with Prolactinoma: A Multicenter Study

RATIONALE AND OBJECTIVES

The first-line treatment for prolactinoma is drug therapy with dopamine agonists (DAs). However, some patients with resistance to DA treatment should prioritize surgical treatment. Therefore, it is crucial to accurately identify the drug treatment response of prolactinoma before treatment. The present study was performed to determine the DA treatment response of prolactinoma using a clinical radiomic model that incorporated radiomic and clinical features before treatment.

MATERIALS AND METHODS

In total, 255 patients diagnosed with prolactinoma were retrospectively divided to training and validation sets. An elastic net algorithm was used to screen the radiomic features, and a fusion radiomic model was established. A clinical radiomic model was then constructed to integrate the fusion radiomic model and the most important clinical features through multivariate logistic regression analysis for individual prediction. The calibration, discrimination, and clinical applicability of the established models were evaluated. 60 patients with prolactinoma from other centers were used to validate the performance of the constructed model.

RESULTS

The fusion radiomic model was constructed from three significant radiomic features, and the area under the curve in the training set and validation set was 0.930 and 0.910, respectively. The clinical radiomic model was constructed using the radiomic model and three clinical features. The model exhibited good recognition and calibration abilities as evidenced by its area under the curve of 0.96, 0.92, and 0.92 in the training, validation, and external multicenter validation set, respectively. Analysis of the decision curve showed that the fusion radiomic model and clinical radiomic model had good clinical application value for DA treatment response prediction in patients with prolactinoma.

CONCLUSION

Our clinical radiomic model demonstrated high sensitivity and excellent performance in predicting DA treatment response in prolactinoma. This model holds promise for the noninvasive development of individualized diagnosis and treatment strategies for patients with prolactinoma.

On GEE for Mean-Variance-Correlation Models: Variance Estimation and Model Selection

Generalized estimating equations (GEE) are of great importance in analyzing clustered data without full specification of multivariate distributions. A recent approach by Luo and Pan jointly models the mean, variance, and correlation coefficients of clustered data through three sets of regressions. We note that it represents a specific case of the more general estimating equations proposed by Yan and Fine which further allow the variance to depend on the mean through a variance function. In certain scenarios, the proposed variance estimators for the variance and correlation parameters in Luo and Pan may face challenges due to the subtle dependence induced by the nested structure of the estimating equations. We characterize specific model settings where their variance estimation approach may encounter limitations and illustrate how the variance estimators in Yan and Fine can correctly account for such dependencies. In addition, we introduce a novel model selection criterion that enables the simultaneous selection of the mean-scale-correlation model. The sandwich variance estimator and the proposed model selection criterion are tested by several simulation studies and real data analysis, which validate its effectiveness in variance estimation and model selection. Our work also extends the R package geepack with the flexibility to apply different working covariance matrices for the variance and correlation structures.

Group cohesion and alliance predict cognitive-behavioral group treatment outcomes for youth with anxiety disorders

Knowledge about how to enhance group cognitive behavioral therapy (GCBT) outcomes is needed. In a randomized controlled effectiveness trial, we examined group cohesion (the bond between group members) and the alliance (the client-clinician bond) as predictors of GCBT outcomes. The sample was 88 youth (M age 11.7 years, SD = 2.1; 54.5% girls; 90.7% White) with anxiety disorders. Observers rated group cohesion and alliance in 32 sessions from 16 groups. We examined early group cohesion and alliance (r = .50, p < .001) and group cohesion and alliance change from early to late in treatment in relation to outcomes using generalized estimation equations accounting for nesting within groups (ICCs .31 to .55). The outcomes were diagnostic recovery, clinical severity, and parent- and youth-reported anxiety symptoms, each at post-treatment, 12-months, and 4-years follow-up. There were more significant associations with 4-years follow-up than earlier outcomes. Clinical severity and parent-reported anxiety symptoms were more frequently predicted than diagnostic recovery. Clinician- and parent-reported outcomes were far more frequently significantly predicted by cohesion and alliance than youth-rated outcomes. We conclude that group cohesion and alliance are related but distinct variables, both associated with some GCBT outcomes for as long as 4 years after treatment.

Prevalence, Determinants, and Trends in the Experience and Perpetration of Intimate Partner Violence Among a Cohort of Gay, Bisexual, and Other Men Who Have Sex with Men in Montréal, Toronto, and Vancouver, Canada (2017-2022)

Purpose: Longitudinal data on the experience and perpetration of intimate partner violence (IPV) among gay, bisexual, and other men who have sex with men (GBM) are limited. We estimated the prevalence of past 6-month (P6M) physical and/or sexual IPV (hereafter IPV) experience and perpetration, identified their determinants, and assessed temporal trends, including the impact of the coronavirus disease (COVID)-19 pandemic. Methods: We used data from the Engage Cohort Study (2017-2022) of GBM recruited using respondent-driven sampling in Montréal, Toronto, and Vancouver. Adjusted prevalence ratios (aPRs) for determinants and self-reported P6M IPV were estimated using generalized estimating equations, accounting for attrition (inverse probability of censoring weights) and relevant covariates. Longitudinal trends of IPV were also assessed. Results: Between 2017 and 2022, 1455 partnered GBM (median age 32 years, 82% gay, and 71% White) had at least one follow-up visit. At baseline, 31% of participants experienced IPV in their lifetime and 17% reported ever perpetrating IPV. During follow-up, IPV experience was more common (6%, 95% confidence interval [CI]: 5%-7%) than perpetration (4%, 95% CI: 3%-5%). Factors associated with P6M IPV experience included prior IPV experience (aPR: 2.68, 95% CI: 1.76-4.08), lower education (aPR: 2.31, 95% CI: 1.32-4.04), and substance use (injection aPR: 5.05, 95% CI: 2.54-10.05, non-injection aPR: 1.68, 95% CI: 1.00-2.82). Similar factors were associated with IPV perpetration. IPV was stable over time; periods of COVID-19 restrictions were not associated with IPV changes in this cohort. Conclusion: Prevalence of IPV was high among GBM. Determinants related to marginalization were associated with an increased risk of IPV. Interventions should address these determinants to reduce IPV and improve health.

Association between a large change between the minimum and maximum monthly values of solar insolation and a history of suicide attempts in bipolar I disorder

BACKGROUND

The rate of suicide attempts by patients with bipolar disorder is high. In addition to patient and country specific factors, environmental factors may contribute to suicidal behavior. Sunlight has multiple diverse impacts on human physiology and behavior. Solar insolation is defined as the electromagnetic energy from the sun striking a surface area on earth. We previously found that a large change in solar insolation between the minimum and maximum monthly values was associated with an increased risk of suicide attempts in patients with bipolar I disorder.

METHODS

The association between solar insolation and a history of suicide attempts in bipolar disorder was again investigated using an international database with 15% more data and more sites at diverse locations and countries.

RESULTS

Data were available from 5641 patients with bipolar I disorder living at a wide range of latitudes in 41 countries in both hemispheres. A large change in solar insolation between the minimum and maximum monthly values was associated with a history of suicide attempts in patients with bipolar I disorder, a replication of our prior analysis. The estimated model also associated state sponsored religion in the onset country, female gender, a history of alcohol or substance abuse, and being part of a younger birth cohort with a history of suicide attempts.

CONCLUSIONS

A large change between the minimum and maximum monthly values of solar insolation was associated with a history of suicide attempts in bipolar I disorder, replicating our prior research. Physicians should be aware that daylight has wide ranging physiological and psychiatric impacts, and that living with large changes in solar insolation may be associated with an increased suicide risk.

Quantification of household food waste in Greece to establish the 2021 national baseline and methodological implications

The aim of this study was to present the national-level quantification of household food waste in Greece for 2021, in alignment with the legal framework of the European Union (EU) for measuring and reporting food waste. An online diary survey was conducted in spring 2021, utilizing pre-tested semi-structured food waste logs. Descriptive statistics were employed to analyze food waste levels and generalized estimating equations (GEE) were performed to assess the influence of diary duration on food waste levels. The final representative sample consisted of 1,133 households. At the national level, the average per-capita annual total food waste generation rate was 86.5 ± 64.5 kg. The predominant share of food waste (47 %) was inedible plant-derived parts, reflecting underlying consumption patterns, whereas 40 % was once-edible food parts. Particularly, vegetables, fruits, and bakery products were the most discarded once-edible food items. Moreover, no statistically significant difference was found between food waste levels across the diary entries, with reporting periods varying from one day to one week. This study marks the first implementation of the EU legislation for household food waste measurement and reporting in Greece. Moreover, the study results indicate that the utilization of diaries with shorter reporting periods than one week, with a sufficiently large sample, may be an appropriate method for measuring nationwide levels, enhancing compliance while mitigating social desirability bias and reducing attrition. Future research should delve into the behaviors driving food waste, motives for prevention in different geographic and cultural contexts, and optimal diary reporting durations.

Interactions between blood lead (Pb) concentration, oxidative stress, cellular immune response and reproductive status in livestock from a mining area

Chronic exposure to lead (Pb) in livestock grazing in abandoned mining areas affects animal welfare and productivity, as well as represents a significant food safety risk. Here, we evaluate the physiological effects of Pb exposure in goats maintained under extensive farming conditions in a non-remediated mining area. We monitored blood, fecal, and milk Pb levels in two groups of goats, pregnant (n = 17) and lactating (n = 24), kept in different enclosures with high soil Pb concentrations (geometric means of 270 and 143 μg/g, respectively) in Sierra Madrona mining district (Spain). We also studied the influence of Pb exposure on the ability to mount a cellular immune response, and on oxidative stress and biochemical biomarkers measured in blood. Blood Pb concentration was higher in pregnant than in lactating goats, but this difference was not observed in fecal Pb concentration. Pb levels in feces and milk concentrations were correlated with those measured in blood, with 11% of milk samples showing Pb concentrations above the maximum level (ML) for Pb in raw milk established by the EU (0.02 μg/g wet weight). Animals with increased blood Pb levels showed reduced concentrations of retinol in plasma, but these Pb levels did not affect the cellular immune response. The stimulation of the cellular immune response in lactating goats was associated with an increase in blood Pb and calcium levels. The reproductive status and age of goats significantly affected several oxidative stress, antioxidants and plasma biochemistry variables. Goats grazing on soils contaminated by past Pb mining activities may be susceptible to detrimental health effects mediated by retinol deficiency. In view of the detected transfer of Pb through milk, special attention should be paid to the food safety of derived products (i.e. cheese).

Exploring the value of arterial spin labeling and six diffusion MRI models in differentiating solid benign and malignant renal tumors

OBJECTIVE

To explore the value of three-dimensional arterial spin labeling (ASL) and six diffusion magnetic resonance imaging (MRI) models in differentiating solid benign and malignant renal tumors.

METHODS

This retrospective study included 89 patients with renal tumors. All patients underwent ASL and ZOOMit diffusion-weighted imaging (DWI) examinations and were divided into three groups: clear cell renal cell carcinoma (ccRCC), non-ccRCC, and benign renal tumors (BRT). The mean and peak renal blood flow (RBFmean and RBFpeak) from ASL and fourteen diffusion parameters from mono-exponential DWI (Mono_DWI), intravoxel incoherent motion (IVIM), diffusion kurtosis imaging (DKI), stretched exponential model (SEM), fractional order calculus (FROC), and continuous-time random-walk (CTRW) model were analyzed. Binary logistic regression was used to determine the optimal parameter combinations. The diagnostic performance of various MRI-derived parameters and their combinations was compared.

RESULTS

Among the six diffusion models, the SEM model achieved the highest performance in differentiating ccRCC from non-ccRCC (area under the receiver operating characteristic curve [AUC] 0.880) and from BRT (AUC 0.891). IVIM model achieved the highest AUC (0.818) in differentiating non-ccRCC from BRT. Among all the MRI-derived parameters, RBFpeak combined with DKI_MK yielded the highest AUC (0.970) in differentiating ccRCC from non-ccRCC, and the combination of RBFpeak, SEM_DDC, and FROC_μ yielded the highest AUC (0.992) for differentiating ccRCC from BRT.

CONCLUSION

ASL and all diffusion models showed similar diagnostic performance in differentiating ccRCC from non-ccRCC or BRT, while the IVIM model performed better in distinguishing non-ccRCC from BRT. Combining ASL with diffusion models can provide additional value in predicting ccRCC.

RELEVANCE STATEMENT

Considering the increasing detection rate of incidental renal masses, accurate discrimination of benign and malignant renal tumors is crucial for decision-making. Combining ASL with diffusion MRI models offers a promising solution to this clinical issue.

KEY POINTS

All assessed models were effective for differentiating ccRCC from non-ccRCC or BRT. ASL and all diffusion models showed similar performance in differentiating ccRCC from non-ccRCC or BRT. Combining ASL with diffusion models significantly improved diagnostic efficacy in predicting ccRCC. IVIM model could better differentiate non-ccRCC from BRT.

Online Mindfulness-Based Intervention (eMBI) in management of dyspnea in patients with interstitial lung disease: A randomized clinical trial

RATIONALE

Dyspnea and cough are frequent symptoms in ILD patients. The management of these symptoms is challenging, and evidence-based therapies are lacking.

OBJECTIVES

To evaluate the effect of an online Mindfulness-Based Intervention (eMBI) on reducing dyspnea in patients affected by different ILDs.

METHODS

This study was a prospective, open-label, controlled trial that included patients ≥18 years and a modified Medical Research Council (mMRC) dyspnea scale score of ≥ 1. Patients were randomized into either the eMBI or the control group (CG) for 8 weeks. The primary outcome was the change in the dyspnea mMRC scale. The Leicester Cough Questionnaire (LCQ), King's Brief Interstitial Lung Disease (K-BILD) questionnaire, and Depression, Anxiety, and Stress Scale (DASS-21) were performed before and after the eight weeks. All analyses were conducted on an intention-to-treat basis. The study was registered at the Brazilian Registry of Clinical Trials (ReBEC), RBR-3s4mf9y.

RESULTS

24 patients in the eMBI and 25 in the CG completed the intervention. In the eMBI group, compared to the control group, there was a greater proportion of patients with a reduction in dyspnea according to the mMRC scale score (48.9 % versus, 15.4 %, p = 0.001). There was no significant difference between the groups in the LCQ (p = 0.666), or in the K-BILD (p = 0.108), depression (p = 0.08), or anxiety (p = 0.869 or stress (p = 0.789). No moderate or severe adverse events were observed in either group.

CONCLUSIONS

Eight weeks eMBI is a potentially viable and safe approach, that can help manage dyspnea in ILD patients.

A longitudinal pre-post study: An evaluation of the Department of the Air Force bundled occupational fall prevention efforts

INTRODUCTION

Fall injuries are the second leading cause of traumatic injury and death for all US workers and are a leading injury concern for the Department of the Air Force (DAF). Bundled interventions can improve the likelihood of injury reduction, especially in large, heterogeneous working populations. In 2013, the DAF implemented the "Air Force Fall Prevention Focus," a bundled intervention of prevention efforts designed to reduce occupational fall injury events among DAF members. The purpose of this study is to describe the burden and risk factors associated with fall injuries and evaluate the effectiveness of the Fall Prevention Focus in reducing the burden of fall injuries.

METHODS

The National Institute for Occupational Safety and Health (NIOSH) partnered with the US Air Force Safety Center (AFSEC) to examine the impact of the Fall Prevention Focus as a bundled intervention. Injury events included a narrative description of the injury event, demographics, work environment, job tasks, and other structured details. Descriptive statistics and pre-post longitudinal modeling were used to evaluate changes in fall injury rates.

RESULTS

The Fall Prevention Focus Implementation (2013-2018) resulted in an annual 10.4% (95% confidence interval [CI]: 8.5%, 12.2%) reduction, and a 6-year cumulative 48.3% (95% CI: 41.4%, 54.3%) reduction in fall injury event rates by 2018.

DISCUSSION

Safety in the DAF involves a comprehensive approach. Documenting the impact of the Fall Prevention Focus may help translate these findings to improve fall prevention efforts in other sectors of the military and high fall-risk industries in the private sector, such as construction.

Tushirikiane-4-Uthabiti (Supporting Each Other For Resilience): study protocol of a mental health, HIV self-testing and livelihoods randomised controlled trial for advancing HIV prevention outcomes among urban refugee youth in Kampala, Uganda

INTRODUCTION

Research with urban refugee youth in Uganda has documented co-occurring social (e.g., poverty) and health (e.g., depression) disparities associated with HIV vulnerabilities. Benefits of HIV self-testing (HIVST) in increasing HIV testing uptake among youth are well established, yet limited interventions have examined if combining HIVST with mental health promotion, or with mental health promotion alongside poverty reduction, is associated with greater improvements in HIV prevention and testing outcomes.

METHODS AND ANALYSIS

The aim is to evaluate the effectiveness of: (1) HIVST alone (standard of care); (2) mobile health (mHealth) and graphic medicine (comic) programme for mental health alongside HIVST; and (3) the combination of HIVST, a livelihoods programme, and mHealth mental health programme, in advancing the primary outcome of HIV testing uptake and secondary outcomes (HIV status knowledge, linkage to confirmatory testing and HIV care, HIV knowledge, consistent condom use, condom use self-efficacy, sexual risk) with urban refugee youth in Kampala, Uganda. A three-arm randomised controlled trial will be implemented from 8 April 2024 to 31 October 2024 with youth across five informal settlements in Kampala, grouped into three sites based on proximity, and randomised in a 1:1:1 design. Approximately 330 participants (110 per arm) are enrolled and data collection will occur at three time points (baseline enrolment, 3-month follow-up and 6-month follow-up).

ETHICS AND DISSEMINATION

The study received ethical approval from the University of Toronto (#37496), Mildmay Uganda Research Ethics Committee (#MUREC-2021-41) and Uganda National Council for Science & Technology (#SS1021ES). The trial is registered at ClinicalTrials.gov (NCT06270160). Study findings will produce new knowledge of the impacts of a mental health programme, and a combined mental health and livelihoods programme, on improving HIV prevention outcomes among urban refugee youth in Kampala. Findings will be shared in peer-reviewed publications, conference presentations and in community dissemination.

TRIAL REGISTRATION NUMBER

NCT06270160 (date of registration: 13 February 2024).

TRIAL SPONSOR

Dr. Carmen Logie, carmen.logie@utoronto.ca.

Impact of the active job openings-to-applicants ratio on the number of ambulance dispatches in Japan, 2003-2021: a longitudinal ecological study

OBJECTIVE

To examine the contribution of the active job openings-to-applicants ratio, a macroeconomic indicator, to the number of ambulance dispatches.

DESIGN

Longitudinal ecological study.

SETTING

Japan, between January 2003 and December 2021.

PARTICIPANTS

All ambulance dispatches.

PRIMARY AND SECONDARY OUTCOME MEASURES

The contribution of the active job openings-to-applicants ratio in a month, adjusted by the number of older people, mean temperature and total population, to the number of ambulance dispatches in that specific month was examined and the primary model was compared to the conventional model considering only the older population, mean temperature, and total population.

RESULTS

There were 108 724 969 ambulance dispatches during this period. The active job openings-to-applicants ratio was significantly associated with the number of ambulance dispatches (the increase rate of monthly ambulance dispatches for 1% rise in the active job openings-to-applicants ratio, 1.00082; 95% CI 1.00052 to 1.00112). Additionally, the primary model effectively demonstrated better fitness to the actual trend than the conventional model (the quasi-likelihood under the independence model criteria were -2 626 817 720 and -2 626 775 185, respectively).

CONCLUSIONS

The number of ambulance dispatches was correlated with the active job openings-to-applicants ratio. Macroeconomic perspectives may be needed to address the issue of increasing ambulance dispatches.

Influence of Antibiotic Exposure Intensity on the Risk of Clostridioides difficile Infection

BACKGROUND

Antibiotics are a strong risk factor for Clostridioides difficile infection (CDI), and CDI incidence is often measured as an important outcome metric for antimicrobial stewardship interventions aiming to reduce antibiotic use. However, risk of CDI from antibiotics varies by agent and dependent on the intensity (ie, spectrum and duration) of antibiotic therapy. Thus, the impact of stewardship interventions on CDI incidence is variable, and understanding this risk requires a more granular measure of intensity of therapy than traditionally used measures like days of therapy (DOT).

METHODS

We performed a retrospective cohort study to measure the independent association between intensity of antibiotic therapy, as measured by the antibiotic spectrum index (ASI), and hospital-associated CDI (HA-CDI) at a large academic medical center between January 2018 and March 2020. We constructed a marginal Poisson regression model to generate adjusted relative risks for a unit increase in ASI per antibiotic day.

RESULTS

We included 35 457 inpatient encounters in our cohort. Sixty-eight percent of patients received at least 1 antibiotic. We identified 128 HA-CDI cases, which corresponds to an incidence rate of 4.1 cases per 10 000 patient-days. After adjusting for known confounders, each additional unit increase in ASI per antibiotic day was associated with 1.09 times the risk of HA-CDI (relative risk = 1.09; 95% CI: 1.06-1.13).

CONCLUSIONS

The ASI was strongly associated with HA-CDI and could be a useful tool in evaluating the impact of antibiotic stewardship on HA-CDI rates, providing more granular information than the more commonly used DOT.

Influencing factors of effective lens position in patients with Marfan syndrome and ectopia lentis

AIMS

The aim of this study was to analyse the effective lens position (ELP) in patients with Marfan syndrome (MFS) and ectopia lentis (EL).

METHODS

Patients with MFS undergoing lens removal and primary intraocular lens (IOL) implantation were enrolled in the study. The back-calculated ELP was obtained with the vergence formula and compared with the theoretical ELPs. The back-calculated ELP and ELP error were evaluated among demographic and biometric parameters, including axial length (AL), corneal curvature radius (CCR) and white-to-white (WTW).

RESULTS

A total of 292 eyes from 200 patients were included. The back-calculated ELP was lower in patients undergoing scleral-fixated IOL than those receiving in-the-bag IOL implantation (4.54 (IQR 3.65-5.20) mm vs 4.98 (IQR 4.56-5.67) mm, p<0.001). The theoretical ELP of the SRK/T formula exhibited the highest accuracy, with no difference from the back-calculated ELP in patients undergoing in-the-bag IOL implantation (5.11 (IQR 4.83-5.65) mm vs 4.98 (IQR 4.56-5.67) mm, p=0.209). The ELP errors demonstrated significant correlations with refraction prediction error (PE): a 1 mm ELP error led to PE of 2.42D (AL<22 mm), 1.47D (22 mm≤AL<26 mm) and 0.54D (AL≥26 mm). Multivariate analysis revealed significant correlations of ELP with AL (b=0.43, p<0.001), CCR (b=-0.85, p<0.001) and WTW (b=0.41, p=0.004).

CONCLUSION

This study provides novel insights into the origin of PE in patients with MFS and EL and potentially refines existing formulas.

The novel developed and validated multiparametric MRI-based fusion radiomic and clinicoradiomic models predict the postoperative progression of primary skull base chordoma

Local progression of primary skull base chordoma (PSBC) is a sign of treatment failure. Predicting the postoperative progression of PSBC can aid in the development of individualized treatment plans to improve patients' progression-free survival (PFS) after surgery. This study aimed to develop a multiparametric MRI-based fusion radiomic model (FRM) and clinicoradiomic model (CRM) via radiomic and clinical analysis and to explore their validity in predicting postoperative progression in PSBC patients before surgery. In this retrospective study, a total of 129 patients with PSBC from our institution, including 57 patients with progression, were enrolled and randomized to the training set (TS) or the validation set (VS) at a 2:1 ratio. Radiomic features were extracted and dimensionally reduced from 3.0 T/axial T2-weighted imaging (T2WI), T1-weighted imaging (T1WI) and contrast-enhanced T1-weighted imaging (CE-T1WI) sequences for each patient, and the features were used for radiomic analysis. Univariate and multivariate Cox regression analyses were used to screen for key clinical factors. We constructed models on the basis of multivariate logistic regression analysis. Receiver operating characteristic (ROC) curve, calibration curve, and decision curve analyses were performed to evaluate the performance of the clinical model (CM), FRM and CRM. Through analysis, we found that blood supply was the only significantly different clinical factor in the CM. For the FRM, the area under the receiver operating characteristic curve (AUC) of the TS was 0.925, and the calibration curves were consistent across the TS. In the CRM, the AUC of the TS was 0.929, the calibration curve analysis was consistent for both the TS and the VS, and the DCA showed that the net benefit was greater at a threshold probability of > 0% for both the TS and the VS. Our proposed FRM can help clinicians better predict PSBC progression preoperatively, and the use of the CRM can lead to the development of more appropriate protocols to improve patients' PFS after surgery.

Can human brain connectivity explain verbal working memory?

The ability of humans to store spoken words in verbal working memory and build extensive vocabularies is believed to stem from evolutionary changes in cortical connectivity across primate species. However, the underlying neurobiological mechanisms remain unclear. Why can humans acquire vast vocabularies, while non-human primates cannot? This study addresses this question using brain-constrained neural networks that realize between-species differences in cortical connectivity. It investigates how these structural differences support the formation of neural representations for spoken words and the emergence of verbal working memory, crucial for human vocabulary building. We develop comparative models of frontotemporal and occipital cortices, reflecting human and non-human primate neuroanatomy. Using meanfield and spiking neural networks, we simulate auditory word recognition and examine verbal working memory function. The "human models", characterized by denser inter-area connectivity in core language areas, produced larger cell assemblies than the "monkey models", with specific topographies reflecting semantic properties of the represented words. Crucially, longer-lasting reverberant neural activity was observed in human versus monkey architectures, compatible with robust verbal working memory, a necessary condition for vocabulary building. Our findings offer insights into the structural basis of human-specific symbol learning and verbal working memory, shedding light on humans' unique capacity for large vocabulary acquisition.

Using Multilevel Models and Generalized Estimating Equation Models to Account for Clustering in Neurology Clinical Research

In clinical and health services research, clustered data (also known as data with a multilevel or hierarchical structure) are frequently encountered. For example, patients may be clustered or nested within hospitals. Understanding when data have a multilevel structure is important because clustering of individuals can induce a homogeneity in outcomes within clusters, so that, even after adjusting for measured covariates, outcomes for 2 individuals in the same cluster are more likely to be similar than outcomes for 2 individuals from different clusters. Using conventional statistical regression models to analyze clustered data can result in incorrect conclusions being drawn. In particular, estimated CIs may be artificially narrow, and significance levels may be artificially low. As a result, one may conclude that there is a statistically significant association when there is none. To avoid this problem, investigators should ensure that their analyses use techniques that account for clustering of data. Generalized linear models estimated using generalized estimating equation (GEE) methods and multilevel regression models (also known as hierarchical regression models, mixed-effects models, or random-effects models) are two such techniques. We provide an introduction to clustered or multilevel data and describe how GEE models or multilevel models can be used for the analysis of multilevel data.

Association between preterm birth and economic and educational outcomes in adulthood: A population-based matched cohort study

BACKGROUND AND OBJECTIVES

Preterm birth (PTB) affects ~10% of births worldwide; however, most literature focused on short-term clinical outcomes, with much less focus on long-term socioeconomic outcomes after PTB. We examined associations between PTB and individuals' income, employment, and educational outcomes during early adulthood.

METHODS

We conducted a population-level matched cohort study including all live births in Canada between 1990 and 1996, followed until 2018. Outcomes included Employment income per year in 2018 CAD and employment between ages 18 and 28 years, postsecondary education enrollment (18-22 years), and maximum educational attainment at age 22-27 years. Mean differences and risk ratios (RR) and differences (RD) were estimated using generalized estimating equation regression models for economic outcomes and multinomial logistic regression models for educational outcomes.

RESULTS

Of 2.4 million births, 7% were born preterm (0.3%, 0.6%, 0.8%, and 5.4% born extremely preterm (24-27 weeks), very preterm (28-31 weeks), moderately preterm (32-33 weeks), and late preterm (34-36 weeks) respectively). After matching on baseline characteristics (e.g., sex, province of birth, and parental demographics) and adjusting for age and period effects, preterm-born individuals, on average, had $958 CAD less employment income per year (95% CI: $854-$1062), 6% lower income per year, than term-born individuals, and were 2.13% less likely to be employed (1.98-2.29%). PTB was also negatively associated with university enrollment (RR 0.93 (0.91-0.94) and graduation with a university degree (RR 0.95 (0.94-0.97)). Mean income differences for those born 24-27 weeks were -$5,463 CAD per year (17% lower), and adjusted RR were 0.55 for university enrollment and graduation.

CONCLUSION

In this population-based study, preterm birth was associated with lower economic and educational achievements at least until the late twenties. The associations were stronger with decreasing GA at birth. Policymakers, clinicians, and parents should be aware that the socioeconomic impact of PTB is not limited to the early neonatal period but extends into adulthood.

Temporal and spatial variation patterns of chlorophyll a in marine ranching under global interannual events

Marine ecosystems are facing numerous environmental challenges due to global climate change. In response to these challenges, the establishment and growth of marine ranching has emerged as a pivotal solution. Chlorophyll a concentration (Chla) is recognized as a valuable indicator for the ecological assessment of marine ranching. This study focused on the spatiotemporal distribution of Chla and its response to environmental factors according to the dataset in the marine ranching area of Haizhou Bay (Lianyungang, Jiangsu, China) from 2003 to 2022. The results showed that Chla had a significant cycle of summer > spring > autumn and was distributed evenly in the central area of the marine ranching. During interannual changes, Chla patches were centered in the central region during 2014, 2015, and 2016. The Chla patches predominantly focused on the eastern area in 2018-2019, shifting to the western area in 2020-2021. The generalized additive model (GAM) indicated that salinity, depth, temperature, biological oxygen demand (BOD5) and SiO3--Si were the main environmental factors affecting Chla during spring, summer and autumn. However, during El Niño events, salinity, depth, temperature, BOD5 and transparency became the main environmental factors. We concluded that salinity, depth and temperature consistently played a crucial role in determining Chla under various climate conditions, and SiO3--Si and transparency will no longer be an environmental factor limiting Chla. In addition, The effect of interannual variability on upwelling and vertical mixing of water layers may potentially alter the spatial distribution pattern of Chla. These findings can offer ideas into predicting the variation of Chla in marine ranching under global interannual events in the future. Furthermore, this can contribute to the comprehensive assessment of ecological benefits and the in-depth construction of marine ranching. Ultimately, it can provide essential data and scientific references for offshore ecological environment assessment and ecosystem restoration.

Risk factors for the introduction of Salmonella spp. serogroups B and D into Dutch dairy herds

Salmonella spp. infections in animals are a concern due to their zoonotic nature, welfare effects and economic impact on the livestock industry. To enable targeted surveillance, it is important to identify risk factors for the introduction of Salmonella spp. in a herd. Since 2009, Dutch dairy processors require herds delivering milk to their plants to participate in a Salmonella programme. In this programme, bulk milk is tested three times a year (i.e. test rounds) by ELISA on presence of antibodies against Salmonella spp. serogroups B and D. Based on these bulk milk results we identified newly infected herds, and aimed to identify associated risk factors. Effects of putative risk factors for becoming newly infected were studied using a multivariable population average logistic regression (PA-GEE) model with binomial distribution. Per test round in 2019-2021, 0.85-4.10 % of the Dutch dairy herds at risk became newly infected, with large regional differences. Several risk factors for becoming newly infected in the context of the low herd-level prevalence were identified. The most evident risk factors that were identified were having at least one infected or recently recovered dairy herd within 500 m (OR = 2.67), on-farm presence of pigs (OR = 1.63), introduction of more than 2 cattle from other herds in the previous 12 months (OR = 1.17), being in an area with a relative soil moisture of >0.54 % (OR = 1.31), being located in an area with a high water surface area (>2 %; OR = 1.14) and a larger herd size (OR = 1.65). These results indicate that, in addition to introduction of cattle, local transmission plays an important role in the between-herd transmission of Salmonella spp. Information on risk factors for becoming newly infected based on regularly collected data, can be used to improve surveillance and to implement targeted control measures against salmonellosis.

Normative Values and Anthropometric Prediction Models for Lean Mass and Fat Mass in the Northeastern Thai Population

Background: Data on reference values for lean mass (LM) and fat mass (FM) in the Southeast Asian populations are currently lacking. Therefore, we aimed to estimate the normative values and generate anthropometric prediction models for LM and FM in the Thai population. Methods: Consecutive community-dwelling individuals aged 20-90 years were recruited from Srinagarind Hospital, Khon Kaen, Thailand, between 2010 and 2015. LM and FM were measured using dual energy X-ray absorptiometry. Age and sex stratified percentile of LM and FM were presented. Anthropometric prediction models for LM and FM were developed by using linear regression to generate competing models. Results: A total of 832 individuals (334 males and 498 females) were included in the study. The mean ± SD age, LM, and FM were 50.0 ± 16.2 years, 38.9 ± 8.0 kg, and 15.5 ± 7.7 kg, respectively. LM decreased with age from 49.4 kg in 20-29 years group to 42.3 kg in ≥70 years group in male and 34.6 kg in 30-39 years group to 30.8 kg in ≥70 years group in females. FM has an inverse U-shaped association with age, which peaked at 11.9 kg in 60-69 years group in males and 20.7 kg in 50-59 years group in females. Among the various anthropometric models, the models incorporating age, sex, weight, and height were considered the best fit for predicting both LM and FM. Conclusion: In the Thai population, peak LM was reached during early adulthood and decline with age, whereas FM showed an inverse U-shaped association with age. The prediction models incorporating age, sex, weight, and height were proposed as practical tools for assessing LM and FM in clinical practice.