An application of a pattern-mixture model with multiple imputation for the analysis of longitudinal trials with protocol deviations

The FACT-GP5 as a global tolerability measure: responsiveness and robustness to missing assessments

PURPOSE

The Functional Assessment of Cancer Therapy item (FACT-GP5) has the potential to provide an understanding of global treatment tolerability from the patient perspective. Longitudinal evaluations of the FACT-GP5 and challenges posed by data missing-not-at-random (MNAR) have not been explored. Robustness of the FACT-GP5 to missing data assumptions and the responsiveness of the FACT-GP5 to key side-effects are evaluated.

METHODS

In a randomized, double-blind study (NCT00065325), postmenopausal women (n = 618) with hormone receptor-positive (HR+), advanced breast cancer received either fulvestrant or exemestane and completed FACT measures monthly for seven months. Cumulative link mixed models (CLMM) were fit to evaluate: (1) the trajectory of the FACT-GP5 and (2) the responsiveness of the FACT-GP5 to CTCAE grade, Eastern Cooperative Oncology Group (ECOG) Performance Status scale, and key side-effects from the FACT. Sensitivity analyses of the missing-at-random (MAR) assumption were conducted.

RESULTS

Odds of reporting worse side-effect bother increased over time. There were positive within-person relationships between level of side-effect bother (FACT-GP5) and severity of other FACT items, as well as ECOG performance status and Common Terminology Criteria for Adverse Events (CTCAE) grade. The number of missing FACT-GP5 assessments impacted the trajectory of the FACT-GP5 but did not impact the relationships between the FACT-GP5 and other items (except for nausea [FACT-GP2]).

CONCLUSIONS

Results support the responsiveness of the FACT-GP5. Generally speaking, the responsiveness of the FACT-GP5 is robust to missing assessments. Missingness should be considered, however, when evaluating change over time of the FACT-GP5.

TRIAL REGISTRATION

NCT00065325.

TRIAL REGISTRATION YEAR

2003.

Assessing the hazard of death, cardiac tamponade, and pericardial constriction among HIV and tuberculosis pericarditis patients using the extended Cox-hazard model: Intervention study

Background and Aims

Tuberculous (TB) pericarditis (TBP), a TB of the heart, is linked to significant morbidity and mortality rates. Administering glucocorticoid therapy to individuals with TBP might enhance overall results and lower the likelihood of fatality. However, the actual clinical effectiveness of supplementary glucocorticoids remains uncertain. This study specifically evaluated the effects of prednisolone, prednisolone-antiretroviral therapy (ART) interaction, and other potential risk factors in reducing the hazard of the composite outcome, death, cardiac tamponade, and constriction, among TBP and human immunodeficiency virus (HIV) patients.

Methods

The data used in this study were obtained from the investigation of the Management of Pericarditis trial, a multicentre international randomized double-blind placebo-controlled 2 × 2 factorial study that investigated the effects of two TB treatments, prednisolone and Mycobacterium indicus pranii  immunotherapy in patients with TBP in Africa. This study used a sample size of 587 TBP and HIV-positive patients randomized into prednisolone and its corresponding placebo arm. We used the extended Cox-proportional hazard model to evaluate the effects of the covariates on the hazard of the survival outcomes. Models fitting and parameter estimation were carried out using R version 4.3.1.

Results

Prednisolone reduces the hazard of composite outcome (hazrad ratio [HR] = 0.32, 95% confidence interval [CI] = 0.19 , 0.54 , p < 0.001), cardiac tamponade (HR = 0.14, 95% CI = 0.05, 0.42, p < 0.001) and constriction (HR = 0.81, 95% CI = 0.41, 1.61, p = 0.55). However, prednisolone increases the hazard of death (HR = 1.58, 95% CI = 1.11, 2.24, p = 0.01). Consistent usage of ART reduces the hazard of composite outcome, death, and constriction but insignificantly increased the hazard of cardiac tamponade.

Conclusion

The study offers valuable insights into how prednisolone impact the hazard of different outcomes in patients with TBP and HIV. The findings hold potential clinical significance, particularly in guiding treatment decisions and devising strategies to enhance outcomes in this specific patient group. However, there are concerns about prednisolone potentially increasing the risk of death due to HIV-related death.

Assessing body mass index stages, individual diabetes and hypertension history effects on the risk of developing hypertension among Ghanaians: A cross-sectional study

Background and Aims

This study aimed to understand the relationship between body mass index (BMI), diabetes and hypertension history, and other risk of hypertension among Ghanaians.

Methods

The BMI data are categorized according to the World Health Organization (WHO) definition. The data were obtained from the WHO Study on global AGEing and adult health (WHO SAGE) Ghana Wave 2. Descriptive statistics were used to summarize the variables, and the association between these variables and hypertension was assessed using the χ². Multivariable logistic regression was used to examine the relationship between hypertension and different BMI levels and other variables.

Results

Obesity class II individuals have about a 4-fold higher risk of developing hypertension compared to underweight individuals. Obesity class III, class I, and preobesity individuals have approximately a 3-fold higher risk. Normal weight is associated with increased hypertension risk. Both males and females show a significant increase in hypertension risk across all BMI categories. History of hypertension is linked to a 2.2-fold increased risk. Diabetes history is associated with hypertension when considering other factors. Elevated hypertension risk is observed among married, divorced, and widowed males then never married males. Only widowed females showed an increased risk. Older age significantly increases hypertension risk, particularly in females. Vegetable servings reduce hypertension risk, while fruit servings are associated with an increased risk. Vigorous exercise increases hypertension risk, particularly in females.

Conclusion

Regular check-ups are recommended for married, divorced, and widowed males, focusing on blood pressure (BP) levels. Regular exercise from young age helps lower BP in later years. Individuals with a history of hypertension should follow BP control measures. Encouraging the consumption of the right combination of vegetables and fruits can help lower BP. Female tobacco smoking should be strongly discouraged due to a 54% increased risk of developing hypertension.

Mixed effects logistic regression analysis of blood pressure among Ghanaians and associated risk factors

Blood pressure (BP) control is a global health issue with an increase in BP beyond the normal BP leading to different stages of hypertension in humans and hence the need to identify risk factors of BP for efficient and effective control. Multiple BP measurement have proven to provide BP readings close to the true BP status of the individual. In this study, we used multiple BP measurement data on 3809 Ghanaians to determine risk factors associated with BP. The data were obtained from World Health Organization study on Global AGEing and Adult Health. We defined high blood pressure (HBP) as [Formula: see text] 130/80 mmHg or normal as [Formula: see text] 130/80 mmHg. We provide summary statistics and also used the Chi-Square test to assess significance of association between HBP versus risk factors of HBP. The aim of this study is to identify risk factors of BP using the mixed effects logistic regression model. Data were analyzed using R version 4.2.2. The results showed that the risk of high blood pressure (HBP) decreases across the three measurement periods. There is reduced risk (OR = 0.274, 95% CI = 0.2008, 0.405) of HBP among male participants relative to female participants. The risk (OR = 2.771, 95% CI = 1.8658, 4.1145) of HBP increased by 2.771-folds among those who are 60 years and above relative to those below the age of 60 years. Those whose work involves/requires vigorous exercise has 1.631-fold increase in the risk (OR = 1.631, 95% CI = 1.1151, 2.3854) of HBP relative to those whose work does not involve vigorous exercise. There is approximately 5-folds increased in the risk (OR = 4.896, 95% CI = 1.9535, 12.2268) of among those who have ever been diagnosed with diabetes. The results also revealed high risk (OR = 1.649, 95%CI = 1.1108, 2.4486) of HBP among those who have formal education. The risk (OR = 1.009, 95% CI = 1.0044, 1.0137) of HBP increases with increasing weight and a reduced risk (OR = 0.996, 95% CI = 0.9921, 0.9993) of HBP with increasing height. We found that sad experience, either mild, moderate or severe, is associated with a reduced risk of HBP. Those who have vegetable servings at least 2 cups per day have increased risk of HBP and those who have fruits servings at least 2 cups per day is associated with a reduced risk of HBP, however this is not statistically significant. To achieve success in BP control, programs should be designed with the aim of reducing weight, educate those with formal eduction on issues relating to HBP. Those whose work requires vigorous exercise are recommended to have regular check-ups to ensure that pressure build-up in the lungs is cleared. SBP is lower for women at young age but continue to increase after menopause as their BP increase becomes salt-sensitive. Hence there is need to give more attention to menopausal women so as to improve BP. Both young and old individuals are recommended to practice regular exercise since this has shown to reduce risk of being overweight or becoming diabetic and reduces the risk of HBP at yong age and old age. Also, to improve blood pressure control, programs for management of blood pressure or hypertension should focus more short stature individuals since such people are more likely to experience HBP.

A Randomized Controlled Trial of a Smartphone-Based Well-Being Training in Public School System Employees During the COVID-19 Pandemic

While the extraordinary pressures of the COVID-19 pandemic on student mental health have received considerable attention, less attention has been placed on educator well-being. School system employees play a vital role in society, and teacher levels of well-being are associated with the educational outcomes of young people. We extend extant research on the prevalence and correlates of educator distress during the pandemic by reporting on a pragmatic randomized wait-list controlled trial (N=662; 64% teachers) of an innovative mental health promotion strategy implemented during the pandemic; a free four-week smartphone-based meditation app designed to train key constituents of well-being (Healthy Minds Program; HMP). Following our preregistered analysis plan and consistent with hypotheses, assignment to the HMP predicted significantly larger reductions in psychological distress, our primary outcome, at post-intervention (Cohen's d=-0.52, 95% confidence interval [-0.68, -0.37], p<.001) and at the three-month follow-up (d=-0.33 [-0.48, -0.18], p<.001). Also consistent with hypotheses, we observed similar indications of immediate and sustained benefit following the HMP on all six preregistered secondary outcomes selected to tap skills targeted in the app (e.g., perseverative thinking, social connection, well-being; absolute ds=0.19-0.42, all ps<.031 corrected except mindful action at follow-up). We found no evidence for elevated adverse events and the HMP was equally effective among participants with elevated baseline anxiety and depressive symptoms. These data suggest that the HMP may be an effective and scalable approach to supporting the mental health and well-being of teachers and other school system employees, with implications for employee retention and performance, and student outcomes.

Integrating mindfulness and connection practices into preservice teacher education results in durable automatic race bias reductions

Automatic race bias, which is the tendency to associate positive attributes more quickly with White as compared to Black faces, reflects enculturation processes linked to inequitable teaching behaviors. In sample of undergraduate preservice teachers (N = 88), we examined whether a novel mindfulness and connection practice intervention without anti-bias content incorporated into undergraduate teacher education would result in reduced automatic race bias favoring White faces. Random assignment to the intervention predicted significantly reduced race preference for White child faces immediately after the intervention. These significant reductions persisted at the 6-month follow-up, which are the most durable reductions in automatic race bias reported to date in adults. Data from semi-structured interviews indicated that the intervention enhanced self-awareness and self-regulation while reducing automatic responding among preservice teachers. These qualities are instrumental to adaptive teaching and putative mechanisms for reducing automatic race bias. The potential value of integrating mindfulness and connection practices into undergraduate preservice teacher education is discussed.

Frequentist and Bayesian Regression Approaches for Determining Risk Factors of Child Mortality in Ghana

Background

Child mortality is a global health problem. The United Nations' 2018 report on levels and trends on child mortality indicated that under-five mortality is one of the major public health problems in Ghana with a rate of 60 deaths per 1000 live births. To further mitigate this problem, it is important to identify the drivers of under-five mortality in order to achieve the United Nations SDG Goal 3 target 2.

Methods

In this study, we investigated the effects of some selected risk factors on child mortality using data from the 2014 Ghana Demographic Health Survey. We modelled the relationship between child mortality and the risk factors using a logistic regression model under the frequentist and Bayesian frameworks. We used the Metropolis-Hastings Algorithm to simulate parameter estimates from the posterior distributions, and statistical analyses were carried out using STATA version 14.1.

Results

Results from the frequentist framework are in line with those from the Bayesian framework. The results showed an increased risk of death among children who were delivered through caesarean and reduced relative odds of death among children whose sizes are average or large at birth and whose mothers have formal education.

Conclusions

There is a need for improved health facilities for better health-care for mothers and children. Education should, among other things, emphasise on the need for mothers to go for regular check-ups during antinatal and postnatal periods for improved mother and child health.

Factors That Determine the Likelihood of Giving Birth to the First Child within 10 Months after Marriage

Background

One of the major aims of marriage is to procreate or give birth to a child. Childbirth is so crucial in marriage that it often determines the happiness of the couple. Too much delay in childbirth after marriage or the likelihood that one cannot give birth after marriage can lead to divorce. However, causes of delay in childbirth are often difficult to detect by both the Gynaecologist and the couple involved. This makes proposing solutions to issues related to childbirth usually unsuccessful.

Methods

It is against this background that we conducted this study to identify factors that determine childbirth within 10 months or after 10 months of marriage (birth length) among women in Ghana. This was achieved by using a logistic regression model for the dichotomous birth length variable, adjusting for risk factors/predictors of birth length. The data used for the study were obtained from the 2014 Ghana Demographic and Health Survey, consisting 6,525 complete cases with 18 predictor variables. Statistical analyses were carried out using STATA version 14.1.

Results

The results show that respondents who have ever terminated pregnancy are more likely (OR = 0.178, 95%CI = 0.044, 0.312) to deliver after 10 months, wives whose husbands have higher education are less likely (OR = ‐0.162, 95%CI = ‐0.236, ‐0.088) to give birth after 10 months of marriage, wives who reported that beating is justified if she goes out without her husband's notice are more likely (OR = 0.466, 95%CI = 0.305, 0.628) to give birth after 10 months, wives who reported that beating is justified if she neglects the child are more likely (OR = ‐0.305, 95%CI = ‐0.461, ‐0.149) to give birth within 10 months, and wives who reported that beating is justified when she argues with her husband are less likely (OR = ‐0.301, 95%CI = ‐0.451, ‐0.152) to give birth after 10 months of marriage. Every unit increase in the age of the respondent at marriage increases the likelihood of giving birth after 10 months of marriage, and a unit increase in the age of the respondent at first sex decreases the likelihood of giving birth after 10 months in marriage.

Conclusions

For conception within 1 month of marriage, wives and husbands should/are encouraged to have frequent sex, any negative social behaviour or policies must be discouraged, experts' advice on contraceptive use must be sought, and women are encouraged to desist from termination of pregnancy at any time of their life. Husbands should openly express their desire and love for their children since this increases the likelihood of wives' desire to give birth. This leads to frequent sex, which then reduces conception time, and hence childbirth within the shortest possible time.

Sensitivity analysis for the generalized shared-parameter model framework

In this paper, we assess the effect of tuberculosis pericarditis treatment (prednisolone) on CD4 count changes over time and draw inferences in the presence of missing data. We accounted for the missing data and performed sensitivity analyses to assess robustness of inferences, from a model that assumes that the data are missing at random, to models that assume that the data are not missing at random. Our sensitivity approaches are within the shared-parameter model framework. We implemented the approach by Creemers and colleagues to the CD4 count data and performed simulation studies to evaluate the performance of this approach. We also assessed the influence of potentially influential subjects, on parameter estimates, via the global influence approach. Our results revealed that inferences from missing at random analysis model are robust to not missing at random models and influential subjects did not overturn the study conclusions about prednisolone effect and missing data mechanism. Prednisolone was found to have no significant effect on CD4 count changes over time and also did not interact with anti-retroviral therapy. The simulation studies produced unbiased estimates of prednisolone effect with lower mean square errors and coverage probabilities approximately equal the nominal coverage probability.