Effect modification, interaction and mediation: an overview of theoretical insights for clinical investigators

Socioeconomic status, alcohol use and the role of social support and neighbourhood environment among individuals meeting criteria for a mental health problem: a cross-sectional study

PURPOSE

Indicators of socioeconomic status (SES), such as education and occupational grade, are known to be associated with alcohol use but this has not been examined among individuals with a mental health problem. This study developed latent classes of SES, their associations with alcohol use, and examined the indirect effect via social support and neighbourhood environment.

METHODS

A secondary analysis of the 2014 Adult Psychiatric Morbidity Survey was conducted among participants with a mental health problem (N = 1,436). SES classes were determined using a range of indicators. Alcohol use was measured using the Alcohol Use Disorder Identification Test. Social support and neighbourhood neighbourhood environment were measured using validated questionnaires. A latent class analysis was conducted to develop SES classes. Multinomial logistic regression examined associations of SES and alcohol use. Structural equation models tested indirect effects via social support and neighbourhood environment.

RESULTS

A four-class model of SES was best-fitting; "economically inactive,GCSE-level and lower educated,social renters", "intermediate/routine occupation,GCSE-level educated,mixed owner/renters", "retired, no formal education,homeowners", and "professional occupation,degree-level educated,homeowners". Compared to "professional occupation,degree-level educated, homeowners", SES classes were more likely to be non-drinkers; odds were highest for "economically inactive,GCSE-level and lower educated,social renters" (OR = 4.96,95%CI 3.10-7.93). "Retired, no formal education,homeowners" were less likely to be hazardous drinkers (OR = 0.35,95%CI 0.20-0.59). Associations between "economically inactive,GCSE-level and lower educated,social renters" and "retired, no formal education,homeowners" and non- and harmful drinking via social support and neighbourhood environment were significant.

CONCLUSIONS

In contrast to the alcohol harms paradox, among individuals with a mental health problem, lower SES groups were more likely to be non-drinkers while no associations with harmful drinking were found. There is also a need to examine the alcohol harms paradox in the context of the area in which they live.

Exploration of the regional effects of colchicine in the LoDoCo2 trial

BACKGROUND

The Low Dose Colchicine 2 (LoDoCo2) trial randomized 5,522 patients with chronic coronary disease to colchicine 0.5mg daily or placebo in a 1:1 ratio and demonstrated the cardiovascular benefits of colchicine. In the trial, which was conducted in Australia and The Netherlands, a prespecified subgroup analysis suggested a difference in magnitude of treatment effect of colchicine by region (Australia: HR 0.51; 95% CI 0.39-0.67 vs The Netherlands: HR 0.92; 95% CI 0.71-1.20). The aim of this study was to explore possible explanations for the apparent difference in magnitude of treatment effect of colchicine by region in the LoDoCo2 trial.

METHODS

The analysis explored potential determinants of variations in the magnitude of effectiveness of colchicine treatment across the regions. This included investigating differences in investigational product, clinical characteristics, concurrent medical therapies and the duration of follow-up using a range of statistical techniques, including sub-group, landmark and effect modification analyses.

RESULTS

No differences were found in the colchicine product used in each region. Despite minor differences observed in baseline clinical characteristics and concomitant therapies, the effect modifier analyses demonstrated that these factors did not explain the difference in magnitude of treatment effect of colchicine by region. Randomization in Australia began more than 2 years before The Netherlands, with shorter duration of follow-up in The Netherlands compared to Australia. In a landmark analysis, over the period when more than 90% of patients in each region had been followed, the effects of colchicine were similar (Australia hazard ratio [HR] 0.58; 95% CI 0.34-0.97 vs The Netherlands HR 0.67; 95% CI 0.47-0.96).

CONCLUSIONS

After examining several plausible explanations for the observed differences in the magnitude of treatment effect of colchicine between regions in the LoDoCo2 trial could be due to the differences in duration of follow-up but a substantial portion of the differences remain unexplained.

CLINICAL TRIAL REGISTRATION

https://www.anzctr.org.au/ACTRN12614000093684.

Influence of study characteristics on harm estimates from randomised controlled trials in patients with inflammatory arthritis receiving biological or synthetic antirheumatic drugs: a meta-epidemiological study

OBJECTIVE

To examine the association between study characteristics and the harms reported in randomised controlled trials (RCTs) on biological and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) in patients with inflammatory arthritis (IA).

METHODS

We searched MEDLINE for all Cochrane reviews and for systematic reviews published since April 2015. RCTs were eligible if they included patients with IA receiving b/tsDMARD, compared with any comparator arm. Harms were evaluated based on number of withdrawals due to adverse events (WDdtAEs), total withdrawals (WDs), serious adverse events (SAEs) and deaths. Data were extracted for 48 trial/patient characteristics and meta-regression analyses were performed to relate the relative risk ratio (RRR) of harms to the trial characteristics.

RESULTS

A total of 284 trials (from 245 reviews) with 97 607 patients were included, contributing 490 comparisons for the primary analysis. Overall, the relative risk of WDdtAEs was lower when trials used active comparators (RRR, 0.74 (95% CI 0.58 to 0.94)) and higher when requiring raised inflammatory markers at enrolment (RRR, 1.25 (1.01 to 1.55)). Our meta-regression analyses suggested that trials with eligibility criteria for minimum tender/swollen joint count and maximum disease duration decreased the risk of WDs, while previous b/tsDMARDs use at the time of enrolment increased the risk of SAEs.

CONCLUSIONS

Most study characteristics do not affect the reported harm measures. However, a trend was observed where trials selecting patients with higher baseline disease activity found a higher risk ratio of WDdtAEs and SAEs, but also a lower risk of WDs, compared with trials not selecting patients with a high disease activity.

PROSPERO REGISTRATION NUMBER

CRD42020171124.

A Systematic Review on the Impact of Plant-Based Milk Consumption on Growth and Nutrition in Children and Adolescents

BACKGROUND

Children are increasingly consuming plant-based milks, yet the impact on their growth and nutrition is unclear.

OBJECTIVE

This systematic review aimed to summarize the available evidence on the impact of plant-based milk consumption on growth and nutrition in children and adolescents.

METHODS

MEDLINE, Embase (Excerpta Medica Database), EBM Reviews - Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature, Child Development and Adolescent Studies, and Scopus were comprehensively searched from 2000 to 2024 to identify studies evaluating the growth and nutritional effects of plant-based milk consumption in children aged 1-18 y. Two reviewers independently screened full-text articles, assessed their quality, and extracted data.

RESULTS

A total of 6 studies were identified: 3 cross-sectional studies, 1 prospective cohort study, and 2 clinical trials (total n = 15,815). Observational studies found that consumption of plant-based milk was associated with lower childhood body mass index (BMI), height, and serum vitamin D concentrations compared with cow milk. No association was found between soy milk consumption and BMI in adolescent girls. Low-quality clinical trials showed minimal effects on growth, and 1 study found that adolescent girls with low calcium intake who consumed fortified soy milk had higher bone density compared with those who did not consume soy milk.

CONCLUSIONS

Available evidence suggests that children who consume plant-based milk may have lower BMI, height, and micronutrient intake compared with those who consume cow milk, whereas fortified soy milk may support bone health in adolescents who do not drink cow milk. Longitudinal studies and randomized controlled trials are needed to determine whether these associations persist over time, differ between children and adolescents or among those who consume soy milk, and to understand the potential underlying mechanisms. This trial was registered at PROSPERO as CRD42022367269.

From conceptualising to modelling structural determinants and interventions in HIV transmission dynamics models: a scoping review and methodological framework for evidence-based analyses

BACKGROUND

Including structural determinants (e.g. criminalisation, stigma, inequitable gender norms) in dynamic HIV transmission models is important to help quantify their population-level impacts and guide implementation of effective interventions that reduce the burden of HIV and inequalities thereof. However, evidence-based modelling of structural determinants is challenging partly due to a limited understanding of their causal pathways and few empirical estimates of their effects on HIV acquisition and transmission.

METHODS

We conducted a scoping review of dynamic HIV transmission modelling studies that evaluated the impacts of structural determinants, published up to August 28, 2023, using Ovid Embase and Medline online databases. We appraised studies on how models represented exposure to structural determinants and causal pathways. Building on this, we developed a new methodological framework and recommendations to support the incorporation of structural determinants in transmission dynamics models and their analyses. We discuss the data and analyses that could strengthen the evidence used to inform these models.

RESULTS

We identified 17 HIV modelling studies that represented structural determinants and/or interventions, including incarceration of people who inject drugs (number of studies [n] = 5), violence against women (n = 3), HIV stigma (n = 1), and housing instability (n = 1), among others (n = 7). Most studies (n = 10) modelled exposures dynamically. Almost half (8/17 studies) represented multiple exposure histories (e.g. current, recent, non-recent exposure). Structural determinants were often assumed to influence HIV indirectly by influencing mediators such as contact patterns, condom use, and antiretroviral therapy use. However, causal pathways' assumptions were sometimes simple, with few mediators explicitly represented in the model, and largely based on cross-sectional associations. Although most studies calibrated models using HIV epidemiological data, less than half (7/17) also fitted or cross-validated to data on the prevalence, frequency, or effects of exposure to structural determinants.

CONCLUSIONS

Mathematical models can play a crucial role in elucidating the population-level impacts of structural determinants and interventions on HIV. We recommend the next generation of models reflect exposure to structural determinants dynamically and mechanistically, and reproduce the key causal pathways, based on longitudinal evidence of links between structural determinants, mediators, and HIV. This would improve the validity and usefulness of predictions of the impacts of structural determinants and interventions.

The impact of comorbidity burden on cardiac arrest mortality: A population-based cohort study

AIM

Patients experiencing cardiac arrest are often burdened with comorbidities that increase mortality. This study examined the impact of comorbidity burden on cardiac arrest mortality by quantifying biological interaction.

METHODS

Nationwide population-based Danish cohort study of adult patients hospitalized for cardiac arrest during 1996-2021 and 5:1 matched comparisons from the general population (matched on age, sex, calendar year, and all Charlson Comorbidity Index comorbidities). Mortality rates and hazard ratios for the association between cardiac arrest and mortality was calculated according to comorbidity burden (none, low, moderate, severe). Biological interaction was examined by calculating interaction contrasts (difference in rate differences).

RESULTS

For no comorbidity burden, the 30-day mortality rate per 1,000 person-years was 18,110 in the cardiac arrest cohort and 24 in the comparison cohort (hazard ratio = 1,435). For low comorbidity burden, the 30-day mortality rate increased to 20,272 in the cardiac arrest cohort and 41 in the comparison cohort (hazard ratio = 504). The corresponding interaction contrast of 2,145 indicated that 11% of the mortality rate in patients with cardiac arrest and low comorbidity burden was explained by interaction between the two. This percentage increased to 20% for moderate and to 28% for severe comorbidity burden. Within 31-365-day follow-up, the percentage of the mortality rate explained by interaction was 28% for low, 38% for moderate, and 41% for severe comorbidity burden. The interaction effect was present for both out-of-hospital and in-hospital cardiac arrest.

CONCLUSIONS

Comorbidity burden interacted with cardiac arrest to increase mortality beyond that explained by their separate effects.

Fish oil supplementation modifies the associations between genetically predicted and observed concentrations of blood lipids: a cross-sectional gene-diet interaction study in UK Biobank

BACKGROUND

Dyslipidemia is a well-known risk factor for cardiovascular disease, the leading cause of mortality worldwide. Although habitual intake of fish oil is associated with cardioprotective effects through triglyceride reduction, the interactions of fish oil with the genetic predisposition to dysregulated lipids remain elusive.

OBJECTIVES

We examined whether fish oil supplementation modifies the association between genetically predicted and observed concentrations of total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides.

METHODS

A total of 441,985 participants with complete genetic and phenotypic data from the UK Biobank were included. Polygenic scores (PGS) of the 4 lipids were calculated in participants of diverse ancestries. For each lipid, multivariable linear regression models were used to assess if fish oil supplementation modified the association between PGS and the observed circulating concentration, with adjustment for relevant covariates.

RESULTS

Fish oil supplementation attenuates the associations between genetically predicted and observed circulating concentrations of total cholesterol, LDL cholesterol, and triglycerides while accentuating the corresponding association for HDL cholesterol among 424,090 participants of European ancestry. Consistent significant findings were obtained using PGS calculated based on multiple genome-wide association studies or alternative PGS methods. For triglycerides, each standard deviation (SD) increment in PGS is associated with 0.254 [95% confidence interval (CI): 0.248, 0.259] SD increase in the observed concentration among European-ancestry participants who reported fish oil usage. In contrast, a stronger association was observed in nonusers (0.267; 95% CI: 0.263, 0.270). Consistently, we showed that fish oil significantly attenuates the association between genetically predicted and observed concentrations of triglycerides in African-ancestry participants.

CONCLUSIONS

Fish oil supplementation attenuates the association between genetically predicted and observed circulating concentrations of total cholesterol, LDL cholesterol, and triglycerides while accentuating the corresponding association for HDL cholesterol in individuals of European ancestry. Further research is needed to understand the clinical implications of these findings.

Predictive Models for Long Term Survival of AML Patients Treated with Venetoclax and Azacitidine or 7+3 Based on Post Treatment Events and Responses: Retrospective Cohort Study

BACKGROUND

The treatment of acute myeloid leukemia (AML) in older or unfit patients typically involves a regimen of venetoclax plus azacitidine (ven/aza). Toxicity and treatment responses are highly variable following treatment initiation and clinical decision-making continually evolves in response to these as treatment progresses. To improve clinical decision support (CDS) following treatment initiation, predictive models based on evolving and dynamic toxicities, disease responses, and other features should be developed.

OBJECTIVE

This study aims to generate machine learning (ML)-based predictive models that incorporate individual predictors of overall survival (OS) for patients with AML, based on clinical events occurring after the initiation of ven/aza or 7+3 regimen.

METHODS

Data from 221 patients with AML, who received either the ven/aza (n=101 patients) or 7+3 regimen (n=120 patients) as their initial induction therapy, were retrospectively analyzed. We performed stratified univariate and multivariate analyses to quantify the association between toxicities, hospital events, and short-term disease responses and OS for the 7+3 and ven/aza subgroups separately. We compared the estimates of confounders to assess potential effect modifications by treatment. 17 ML-based predictive models were developed. The optimal predictive models were selected based on their predictability and discriminability using cross-validation. Uncertainty in the estimation was assessed through bootstrapping.

RESULTS

The cumulative incidence of posttreatment toxicities varies between the ven/aza and 7+3 regimen. A variety of laboratory features and clinical events during the first 30 days were differentially associated with OS for the two treatments. An initial transfer to intensive care unit (ICU) worsened OS for 7+3 patients (aHR 1.18, 95% CI 1.10-1.28), while ICU readmission adversely affected OS for those on ven/aza (aHR 1.24, 95% CI 1.12-1.37). At the initial follow-up, achieving a morphologic leukemia free state (MLFS) did not affect OS for ven/aza (aHR 0.99, 95% CI 0.94-1.05), but worsened OS following 7+3 (aHR 1.16, 95% CI 1.01-1.31) compared to that of complete remission (CR). Having blasts over 5% at the initial follow-up negatively impacted OS for both 7+3 (P<.001) and ven/aza (P<.001) treated patients. A best response of CR and CR with incomplete recovery (CRi) was superior to MLFS and refractory disease after ven/aza (P<.001), whereas for 7+3, CR was superior to CRi, MLFS, and refractory disease (P<.001), indicating unequal outcomes. Treatment-specific predictive models, trained on 120 7+3 and 101 ven/aza patients using over 114 features, achieved survival AUCs over 0.70.

CONCLUSIONS

Our findings indicate that toxicities, clinical events, and responses evolve differently in patients receiving ven/aza compared with that of 7+3 regimen. ML-based predictive models were shown to be a feasible strategy for CDS in both forms of AML treatment. If validated with larger and more diverse data sets, these findings could offer valuable insights for developing AML-CDS tools that leverage posttreatment clinical data.

Fibrinogen inhibits sonic hedgehog signaling and impairs neonatal cerebellar development after blood-brain barrier disruption

Cerebellar injury in preterm infants with central nervous system (CNS) hemorrhage results in lasting neurological deficits and an increased risk of autism. The impact of blood-induced pathways on cerebellar development remains largely unknown, so no specific treatments have been developed to counteract the harmful effects of blood after neurovascular damage in preterm infants. Here, we show that fibrinogen, a blood-clotting protein, plays a central role in impairing neonatal cerebellar development. Longitudinal MRI of preterm infants revealed that cerebellar bleeds were the most critical factor associated with poor cerebellar growth. Using inflammatory and hemorrhagic mouse models of neonatal cerebellar injury, we found that fibrinogen increased innate immune activation and impeded neurogenesis in the developing cerebellum. Fibrinogen inhibited sonic hedgehog (SHH) signaling, the main mitogenic pathway in cerebellar granule neuron progenitors (CGNPs), and was sufficient to disrupt cerebellar growth. Genetic fibrinogen depletion attenuated neuroinflammation, promoted CGNP proliferation, and preserved normal cerebellar development after neurovascular damage. Our findings suggest that fibrinogen alters the balance of SHH signaling in the neurovascular niche and may serve as a therapeutic target to mitigate developmental brain injury after CNS hemorrhage.

Heat exposure induced risks of preterm birth mediated by maternal hypertension

Heat exposure is associated with an increased risk of preterm birth (PTB), with previous work suggesting that maternal blood pressure may play a role in these associations. Here we conducted a cohort study of 197,080 singleton live births across 8 provinces in China from 2015 to 2018. The study first estimated the associations between heat exposure, maternal hypertension and clinical subtypes of PTB, and then quantified the role of maternal hypertension in heat and PTB using mediation analyses. We show that heat exposure (>85th, 90th and 95th percentiles of local temperature distributions) spanning from conception to the 20th gestational week was associated with a 15-21% increase in PTB, and a 20-22% increase in medically indicated PTB. Heat exposure is likely to increase the risk of maternal hypertension and elevated blood pressure. Maternal hypertension mediated 15.7% and 33.9% of the effects of heat exposure (>90th percentile) on PTB and medically indicated PTB, respectively. Based on this large-population study, we found that exposure to heat in early pregnancy can increase the risk of maternal hypertension, thereby affecting the incidence of PTB.

Common mistakes in biostatistics

Biostatistics plays a pivotal role in developing, interpreting and drawing conclusions from clinical, biological and epidemiological data. However, the improper application of statistical methods can lead to erroneous conclusions and misinterpretations. This paper provides a comprehensive examination of the most frequent mistakes encountered in the biostatistical analysis process. We identified and elucidated 10 common errors in biostatistical analysis. These include using the wrong metric to describe data, misinterpreting P-values, misinterpreting the 95% confidence interval, misinterpreting the hazard ratio as an index of prognostic accuracy, ignoring the sample size calculation, misinterpreting analysis by strata in randomized clinical trials, confusing correlation and causation, misunderstanding confounders and mediators, inadequately codifying variables during the data collection, and bias arising when group membership is attributed on the basis of future exposure in retrospective studies. We discuss the implications of these errors and propose some practical strategies to mitigate their impact. By raising awareness of these pitfalls, this paper aims to enhance the rigor and reproducibility of biostatistical analyses, thereby fostering more robust and reliable biomedical research findings.

Change on the Revised Hearing Handicap Inventory and associated factors: results from a longitudinal cohort study

OBJECTIVE

Describe how the Revised Hearing Handicap Inventory (RHHI) changes over time and determine associated factors.

DESIGN

Data were from a community-based cohort study. Linear regression models were used to estimate mean baseline and final RHHI scores and change (final minus baseline score). Logistic regression models were used to determine factors associated with substantial RHHI change, defined as ±6 points. Factors included baseline age, sex, race, hearing aid use, and baseline pure-tone average (PTA; 0.5, 1.0, 2.0, 4.0 kHz, worse ear).

STUDY SAMPLE

This study included 583 participants (mean age: 66.4 [SD 9.1] years; 59.9% female; 14.2% Minority race) with a mean follow-up time of 7.6 (SD 4.9) years.

RESULTS

Baseline and final RHHI scores were 7.9 and 9.2 points, corresponding to an average 1.3-point increase in hearing difficulty over time. Most participants (65.4%) did not show substantial RHHI change, whereas 21.4% and 13.2% experienced substantial increase and decrease, respectively. In separate multivariable models, PTA and hearing aid use were associated with substantial increase in hearing difficulty, and PTA was associated with substantial decrease.

CONCLUSIONS

The average RHHI change was relatively small. Hearing aid use and PTA were associated with RHHI change.

Human immune and metabolic biomarker levels, and stress-biomarker associations, differ by season: Implications for biomedical health research

Although seasonal changes in physiology are well documented, little is known about how human immune and metabolic markers vary across seasons, and no studies have examined how stress → health biomarker associations differ across the year. To investigate these issues, we analyzed data from 2118 participants of the Midlife in the United States (MIDUS) study to determine whether there were differences in (a) levels of 19 immune and metabolic markers, and (b) the association between perceived stress and each biomarker across the year. Results of component-wide boosted generalized additive models revealed seasonal patterning for most biomarkers, with immune proteins generally peaking when days were shorter. Moreover, whereas levels of hemoglobin A1C rose from late fall to spring, triglycerides were elevated in the summer and fall, and high-density lipoprotein decreased steadily from January to December. Urinary cortisol and cortisone exhibited opposite patterns, peaking at the beginning and end of the year, respectively. Most critically, we found that the effects of perceived stress on 18 of the 19 health biomarkers assessed varied by month of measurement. In some cases, these differences involved the magnitude of the stress → biomarker association but, in other cases, it was the direction of the effect that changed. Studies that do not account for month of biomarker assessment may thus yield misleading or unreproducible results.

Increased risk of preterm birth due to heat exposure during pregnancy: Exploring the mechanism of fetal physiology

BACKGROUND

Heat exposure during pregnancy can increase the risk of preterm birth (PTB) through a range of potential mechanisms including pregnancy complications, hormone secretion and infections. However, current research mainly focuses on the effect of heat exposure on pathophysiological pathways of pregnant women, but ignore that maternal heat exposure can also cause physiological changes to the fetus, which will affect the risk of PTB.

OBJECTIVE

In this study, we aimed to explore the mediating role of fetal heart rate (FHR) in the relationship between maternal heat exposure and PTB incidence.

METHODS

We assigned heat exposure to a multi-center birth cohort in China during 2015-2018, which included all 162,407 singleton live births with several times FHR measurements during the second and third trimesters. We examined the associations between heat exposure, FHR and PTB in the entire pregnancy, each trimester and the last gestational month. The inverse odds ratio-weighted approach applied to the Cox regression was used to identify the mediation effect of heat exposure on PTB and its clinical subtypes via FHR.

FINDINGS

Exposure to heat significantly increased the risk of PTB during the third trimester and the entire pregnancy, hazard ratios and 95 % CIs were 1.266 (1.161, 1.379) and 1.328 (1.218, 1.447). Heat exposure during the third trimester and entire pregnancy increased FHR in the third trimester by 0.24 bpm and 0.14 bpm. The proportion of heat exposure mediated by FHR elevation on PTB and its subtype ranged from 3.68 % to 24.06 %, with the significant mediation effect found for both medically indicated PTB and spontaneous PTB.

CONCLUSIONS

This study suggests that heat exposure during pregnancy has an important impact on fetal health, and FHR, as a surrogate marker of fetal physiology, may mediate the increased risk of PTB caused by extreme heat. Monitoring and managing physiological changes in the fetus would constitute a promising avenue to reduce adverse birth outcomes associated with maternal heat exposure.

Mediators of the Association Between Socioeconomic Status and Survival After Out-of-Hospital Cardiac Arrest: A Systematic Review

Low socioeconomic status (SES) is associated with poor outcomes after out-of-hospital cardiac arrest (OHCA). Patient characteristics, care processes, and other contextual factors may mediate the association between SES and survival after OHCA. Interventions that target these mediating factors may reduce disparities in OHCA outcomes across the socioeconomic spectrum. This systematic review identified and quantified mediators of the SES-survival after OHCA association. Electronic databases (MEDLINE, Embase, PubMed, Web of Science) and grey literature sources were searched from inception to July or August 2023. Observational studies of OHCA patients that conducted mediation analyses to evaluate potential mediators of the association between SES (defined by income, education, occupation, or a composite index) and survival outcomes were included. A total of 10 studies were included in this review. Income (n = 9), education (n = 4), occupation (n = 1), and composite indices (n = 1) were used to define SES. The proportion of OHCA cases that had bystander involvement, presented with an initial shockable rhythm, and survived to hospital discharge or 30 days increased with higher SES. Common mediators of the SES-survival association that were evaluated included initial rhythm (n = 6), emergency medical services response time (n = 5), and bystander cardiopulmonary resuscitation (n = 4). Initial rhythm was the most important mediator of this association, with a median percent excess risk explained of 37.4% (range 28.6%-40.0%; n = 5; 1 study reported no mediation) and mediation proportion of 41.8% (n = 1). To mitigate socioeconomic disparities in outcomes after OHCA, interventions should target potentially modifiable mediators, such as initial rhythm, which may involve improving bystander awareness of OHCA and the need for prompt resuscitation.

Cluster analysis identifies novel real-world lung disease-pulmonary hypertension subphenotypes: implications for treatment response

Background

Clinical trials repurposing pulmonary arterial hypertension (PAH) therapies to patients with lung disease- or hypoxia-pulmonary hypertension (PH) (classified as World Health Organization Group 3 PH) have failed to show a consistent benefit. However, Group 3 PH clinical heterogeneity suggests robust phenotyping may inform detection of treatment-responsive subgroups. We hypothesised that cluster analysis would identify subphenotypes with differential responses to oral PAH therapy.

Methods

Two k-means analyses were performed on a national cohort of US veterans with Group 3 PH; an inclusive model (I) of all treated patients (n=196) and a haemodynamic model (H) limited to patients with right heart catheterisations (n=112). The primary outcome was organ failure or all-cause mortality by cluster. An exploratory analysis evaluated within-cluster treatment effects.

Results

Three distinct clusters of Group 3 PH patients were identified. In the inclusive model (C1I n=43, 21.9%; C2I n=102, 52.0%; C3I n=51, 26.0%), lung disease and spirometry drove cluster assignment. By contrast, in the haemodynamic model (C1H n=44, 39.3%; C2H n=43, 38.4%; C3H n=25, 22.3%), right heart catheterisation data surpassed the importance of lung disease and spirometry. In the haemodynamic model, compared to C3H, C1H experienced the greatest hazard for respiratory failure or death (HR 6.1, 95% CI 3.2-11.8). In an exploratory analysis, cluster determined treatment response (p=0.006). Conclusions regarding within-cluster treatment responses were limited by significant differences between select variables in the treated and untreated groups.

Conclusions

Cluster analysis identifies novel real-world subphenotypes of Group 3 PH patients with distinct clinical trajectories. Future studies may consider this methodological approach to identify subgroups of heterogeneous patients that may be responsive to existing pulmonary vasodilatory therapies.

Impact of patient attributes on the relationship between hearing handicap and readiness to pursue audiologic rehabilitation

OBJECTIVE

This study explored whether select patient attributes were significant predictors of readiness to pursue hearing aids (HAs) and estimated the impacts of hearing aid self-efficacy (HASE) and emotional states, on the relationship between perceived hearing handicap and readiness to pursue HAs.

DESIGN & STUDY SAMPLE

Sixty-two adults with self-reported hearing difficulties and no previous experience with HAs self-reported their hearing handicap, HASE, personality, emotional states in varying contexts, and readiness to pursue HAs.

RESULTS

Individuals with greater hearing handicap and who had experienced hearing loss for a shorter duration were more ready to pursue HAs. Having higher HASE, more positive emotional states in "Social" situations, higher scores for the Agreeableness, and having lower Conscientiousness personality trait scores also independently predicted readiness. Neither HASE nor reported emotional states had a significant impact on the relationship between perceived hearing handicap and readiness to pursue HAs.

CONCLUSIONS

Certain patient characteristics independently motivate people towards or away from pursuing HAs. However, it remains unclear whether targeted modification of these attributes would directly facilitate behaviour change. Future research should further explore these questions to facilitate a more individualised audiologic rehabilitation.

Self-reported periodontitis association with impaired smell and taste: A multicenter survey

OBJECTIVES

To investigate the association between self-reported periodontitis and the senses of taste and smell among employees of one Danish and two American universities.

MATERIALS AND METHODS

Data were collected through a digital survey. A total of 1239 individuals from Aarhus University - Denmark, the University of Iowa, and the University of Florida - USA were included. Self-reported periodontitis was the exposure. The perceived senses of taste and smell were the outcomes and were measured through a visual analog scale (VAS). Self-perceived halitosis was the mediator. Confounders were age, sex, income, education, xerostomia, COVID-19, smoking, body mass index, and diabetes. The total effect was decomposed into direct and indirect using a counterfactual approach.

RESULTS

The total effect of periodontitis on an impaired sense of taste was OR 1.56 (95% CI [1.02, 2.09]), of which 23% was mediated by halitosis (OR 1.13; 95% CI [1.03, 1.22]). Additionally, individuals with self-reported periodontitis had a 53% higher chance of having impaired smell (OR 1.53; 95% CI [1.00, 2.04]), with halitosis mediating 21% of the total effect (OR 1.11; 95% CI [1.02, 1.20]).

CONCLUSION

Our findings suggest that periodontitis is associated with distorted senses of taste and smell. Additionally, this association appears to be mediated by halitosis.

Associations between Rat Infestations and Mental Health Vary by Gender, Race, and Income in Chicago

Rats are an understudied stressor for people in urban environments around the world but the effects may not be distributed equally among residents. In this study, we examined associations between residential rat sightings and mental health in Chicago, where rat complaints are the highest of any American city. We examined how this relationship varied by frequency of rat sightings, race, ethnicity, income, home ownership, and gender and explored potential psychosocial pathways (e.g., feelings about the home) between rat sightings and mental distress. We conducted a randomized household survey along an income gradient in 2021 and asked about depressive symptoms in the past week (i.e., Center for Epidemiologic Studies Depression scale), frequency of rat sightings in/around the home, perceptions of rats, neighborhood conditions, and socio-demographic characteristics. We used logistic regression to assess relationships among these variables for our entire sample and for specific demographics using stratified models. Respondents (n = 589; 409 complete cases) who saw rats in/around the home daily/almost daily had 5.5 times higher odds of reporting high depressive symptoms relative to respondents who saw rats less frequently after accounting for socio-demographics and neighborhood conditions. This relationship was significant for men and respondents with lower incomes or race or ethnicity other than white. Our results show that rat infestations should be considered a threat to mental health among urban residents. Increased mental health support for residents living in rat-infested housing may improve public health in cities.

Emotional Exhaustion in Healthcare Workers: Moving Beyond Coping Skills to Improve Organizational Conditions

OBJECTIVE

Emotional exhaustion (EE)-the first stage of burnout-is related to preventable work environment exposures. We examined the understudied impact of organizational support for safety (OSS) and safety hazards (SH) on EE in a mixed licensed and unlicensed population of healthcare workers (HCWs).

METHODS

A work environment exposures survey was conducted in five US public healthcare facilities in 2018-2019. A total of 1059 questionnaires were collected from a predominantly female population of mixed HCWs.

RESULTS

Mean EE scores were higher among women, direct care workers, and younger subjects. In linear regression models, EE was positively associated with SH, emotional labor, psychological demands, physical demands, job strain, assault, and negative acts, while OSS was negatively associated. Safety hazard s both mediated and moderated the relationship between OSS and EE.

CONCLUSIONS

When perception of SH is high, OSS has less impact on reducing EE, suggesting a need to effectively put safety policies to practice for improving EE in HCWS.

Associating Liver Enzymes and Their Interactions with Metabolic Syndrome Prevalence in a Japanese Working Population

Background: Serum gamma-glutamyltransferase (γ-GT), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) levels often increase in metabolic diseases. Objective: This study was conducted to determine which liver enzymes are strongly associated with metabolic syndrome (MetS), how they interact to produce different probability estimates, and what cutoff levels should be used to guide clinical decision-making. Methods: The researchers examined the insurance-based medical checkup data of 293,610 employees ≥35 years years of age, who underwent medical checkups between April 1, 2016, and March 31, 2017. Liver enzyme levels were grouped into quartiles. The association and interaction of liver enzymes with MetS were examined using logistic regression, and receiver operating characteristic (ROC) analyses were used to determine the optimal cutoff values for each liver enzyme in detecting the prevalence of MetS. Results: High levels of γ-GT and ALT were more strongly associated with MetS than AST. At various levels, the tested liver enzymes were found interactive, and associated with the likelihood of MetS prevalence. ROC analysis underscored the significance of all liver enzymes in predicting the development of MetS. The cutoff values for each liver enzyme were determined. Conclusion: This findings of this study directly support the identification of MetS risks within the population, prioritize prevention strategies, and potentially inform policy formulation.

Household cooking fuel and gallbladder cancer risk: a multi-centre case-control study in India

PURPOSE

Gallbladder cancers (GBC), unique to certain geographical regions, are lethal digestive tract cancers, disproportionately affecting women, with limited information on risk factors.

METHODS

We evaluated the association between household cooking fuel and GBC risk in a hospital-based case-control study conducted in the North-East and East Indian states of Assam and Bihar. We explored the potential mediation by diet, fire-vents, 'daily exposure duration' and parity (among women). We recruited biopsy-confirmed GBC (n = 214) men and women aged 30-69 years between 2019 and 2021, and controls frequency-matched by age, sex and region (n = 166). Information about cooking fuel, lifestyle, personal and family history, female reproductive factors, socio-demographics, and anthropometrics was collected. We tested associations using multivariable logistic regression analyses.

RESULTS

All participants (73.4% women) were categorised based on predominant cooking fuel use. Group-1: LPG (Liquefied Petroleum Gas) users in the previous 20 years and above without concurrent biomass use (26.15%); Group-2: LPG users in the previous 20 years and above with concurrent secondary biomass use (15.9%); Group-3: Biomass users for ≥ 20 years (57.95%). Compared to group-1, accounting for confounders, GBC risk was higher in group-2 [OR: 2.02; 95% CI: 1.00-4.07] and group-3 [OR: 2.01; 95% CI: 1.08-3.73] (p-trend:0.020). These associations strengthened among women that attenuated with high daily consumption of fruits-vegetables but not with fire-vents, 'daily exposure duration' or parity.

CONCLUSION

Biomass burning was associated with a high-risk for GBC and should be considered as a modifiable risk factor for GBC. Clean cooking fuel can potentially mitigate, and a healthy diet can partially reduce the risk among women.

Posttraumatic Stress Disorder Symptoms and Incarceration: The Impact on Sexual Risk-Taking, Sexually Transmitted Infections, and Depression Among Black Sexual Minority Men in HIV Prevention Trials Network (HPTN) 061

Black men and people belonging to sexual minority groups are disproportionately impacted by criminal legal involvement and sexually transmitted infections (STIs). Traumatic experiences are often associated with later criminal legal involvement, depression symptoms, sexual risk behavior, and STIs. Research on the joint influence of trauma and incarceration on STI risk among racial and/or sexual minority people is limited. This study tested the association between post-traumatic stress disorder (PTSD) symptoms and incarceration on sexual risk behavior and STI among Black sexual minority men, a population that may be at higher risk for contracting STIs. Using data from the HIV Prevention Trials Network 061 Study, a longitudinal study of adult Black sexual minority men in six U.S. cities (N = 855), we tested associations between past six-month incarceration and subsequent sexual risk behavior, STI, and depression symptoms, for those with and without pre-incarceration PTSD symptoms. PTSD symptoms were elevated among participants who reported Hispanic ethnicity, having sex with both men and women, and previous incarceration. Although there were not significant differences between recent incarceration and sexual risk for those with and without PTSD, incarceration was linked to some sexual risk behaviors regardless of PTSD symptoms. Among people with PTSD symptoms, there was a higher prevalence of sexual risk and depression symptoms, regardless of incarceration. These findings suggest a potentially compounding influence of PTSD symptoms and incarceration on sexual risk and infection among Black sexual minority men.

Mediation of metabolic syndrome in the association between long-term exposure to particulate matter and incident cardiovascular disease: Evidence from a population-based cohort in Chengdu

BACKGROUND

Particulate matter (PM) exposure has been linked with cardiovascular disease (CVD) and metabolic syndrome (MetS), the latter characterized by concurrent multiple metabolic disorders. As a result, the mechanisms assumption from PM to CVD through MetS have emerged, thus requiring further epidemiological evidence. This cohort study aimed to assess whether MetS mediates the associations of PM with CVD risk.

METHODS

This study included 14,195 participants from the Chengdu cohort of the China Multi-Ethnic Cohort (CMEC) study in 2018. The primary outcome of incident CVD diagnoses was identified using matched hospital records from the Health Information Center of Sichuan Province. Residence-specific levels of PM with aerodynamic diameters of ≤ 1 µm (PM1), ≤ 2.5 µm (PM2.5), and ≤ 10 µm (PM10) were estimated by spatiotemporal models. Causal mediation analyses were applied to evaluate the indirect effect of MetS.

RESULTS

Increased exposure levels to PM were significantly associated with MetS and CVD. Mediation analyses indicated that the associations between PM exposure and CVD were mediated by MetS, with the proportion of multiple mediations being 19.3%, 12.1%, and 13.5% for PM1, PM2.5, and PM10, respectively. Further moderated mediation analyses suggested that male, overweight individuals, alcohol drinkers, and those suffering from indoor air pollution may experience more significant adverse effects from PM exposure on CVD via MetS than others.

CONCLUSIONS

Our findings suggest that MetS partially mediates the association between long-term exposure to PM and CVD. These mediation effects appear to be amplified by demographic characteristics and unhealthy lifestyles.

Identifying disparities in suicidal thoughts and behaviors among US adolescents during the COVID-19 pandemic

BACKGROUND

Suicidal thoughts and behaviors (STBs) became more common among racial and ethnic minorities and sexual and gender minorities (SGM) during the COVID-19 pandemic relative to White and non-SGM adolescents. This study examines associations between pandemic-related stressors and STBs among a nationally representative sample of adolescents to identify vulnerable subpopulations.

METHODS

We analyzed data from 6769 high school students using the 2021 Adolescent Behaviors and Experiences Survey. Pandemic-related stressors were assessed via seven items related to negative experiences (e.g., parent job loss; food insecurity) during the COVID-19 pandemic. Logistic regression analyses estimated the association between pandemic-related stressors and four outcomes: (1) sadness/hopelessness; (2) suicidal ideation; (3) suicide planning; and (4) recent suicide attempt (i.e., past 12 months). Interactions were modeled by sex, race/ethnicity, and sexual identity.

RESULTS

A greater number of pandemic-related stressors was associated with higher odds for sadness and hopelessness (aOR: 1.55; 95% CI:1.44-1.67), suicidal ideation (aOR: 1.48; 95% CI:1.39-1.57), suicide planning (aOR:1.47; 95% CI: 1.36-1.59), and recent suicide attempt (aOR: 1.64; 95% CI:1.42-1.88). Pandemic-related stressors were also more strongly associated with some types of STBs in males (relative to females) and SGM females (relative to heterosexual females).

CONCLUSION

Study findings indicate that pandemic-related stressors are associated with STBs within the US adolescent population, particularly among male and SGM female adolescents. Researchers are encouraged to use this knowledge to ensure nationwide suicide prevention efforts adequately address inequities in suicide risk.

Trial arm outcome variance difference after dropout as an indicator of missing-not-at-random bias in randomized controlled trials

Randomized controlled trials (RCTs) are vulnerable to bias from missing data. When outcomes are missing not at random (MNAR), estimates from complete case analysis (CCA) and multiple imputation (MI) may be biased. There is no statistical test for distinguishing between outcomes missing at random (MAR) and MNAR. Current strategies rely on comparing dropout proportions and covariate distributions, and using auxiliary information to assess the likelihood of dropout being associated with the outcome. We propose using the observed variance difference across trial arms as a tool for assessing the risk of dropout being MNAR in RCTs with continuous outcomes. In an RCT, at randomization, the distributions of all covariates should be equal in the populations randomized to the intervention and control arms. Under the assumption of homogeneous treatment effects and homoskedastic outcome errors, the variance of the outcome will also be equal in the two populations over the course of follow-up. We show that under MAR dropout, the observed outcome variances, conditional on the variables included in the model, are equal across trial arms, whereas MNAR dropout may result in unequal variances. Consequently, unequal observed conditional trial arm variances are an indicator of MNAR dropout and possible bias of the estimated treatment effect. Heterogeneous treatment effects or heteroskedastic outcome errors are another potential cause of observing different outcome variances. We show that for longitudinal data, we can isolate the effect of MNAR outcome-dependent dropout by considering the variance difference at baseline in the same set of patients who are observed at final follow-up. We illustrate our method in simulation for CCA and MI, and in applications using individual-level data and summary data.

Occupational Etiology of Oropharyngeal Cancer: A Literature Review

While abundant evidence exists linking alcohol, tobacco, and HPV infection to a carcinogenic impact on the oropharynx, the contribution of inhalational workplace hazards remains ill-defined. We aim to determine whether the literature reveals occupational environments at a higher-than-average risk of developing oropharyngeal cancer (OPC) and summarize the available data. To identify studies assessing the relationship between occupational exposure and risk of OPC, a search of the literature through the PubMed-NCBI database was carried out and, ultimately, 15 original articles meeting eligibility criteria were selected. Only original articles in English focusing on the association between occupational exposure and risk or death of specifically OPC were included. The available data are supportive of a potentially increased risk of OPC in waiters, cooks and stewards, artistic workers, poultry and meat workers, mechanics, and World Trade Center responders exposed to dust. However, the available literature on occupation-related OPC is limited. To identify occupational categories at risk, large cohorts with long follow-ups are needed. Identification of causal associations with occupation-related factors would require dose-response analyses adequately adjusted for confounders.

Using mediators to understand effect modification and interaction

Effect modification and interaction are key concepts within epidemiologic research. They refer to situations where the magnitude and/or direction of the causal effect of some exposure variable on an outcome depends on the level of a second variable (effect modification) or on the effect of a second variable (interaction). Interest in case of effect modification is primarily in one exposure variable, with its effects varying across subgroups, whereas primary interest in case of interaction is in the interplay of effects of two exposure variables. Distinctions between the concepts of effect modification and interaction are subtle. The goal of this article is to clarify these distinctions by using the concept of mediation, which focuses on elucidating mechanisms of causal effects.

Association between childhood adversities and premature and potentially avoidable mortality in adulthood: a population-based study

BACKGROUND

The association of childhood adversities with mortality has rarely been explored, and even less studied is the question of whether any excess mortality may be potentially preventable. This study examined the association between specific childhood adversities and premature and potentially avoidable mortality (PPAM) in adulthood in a representative sample of the general population. Also, we examined whether the associations were potentially mediated by various adult socioeconomic, psychosocial, and behavioral factors.

METHODS

The study used data from the National Population Health Survey (NPHS-1994) linked to the Canadian Vital Statistics Database (CVSD 1994-2014) available from Statistics Canada. The NPHS interview retrospectively assessed childhood exposure to prolonged hospitalization, parental divorce, prolonged parental unemployment, prolonged trauma, parental problematic substance use, physical abuse, and being sent away from home for doing something wrong. An existing definition of PPAM, consisting of causes of death considered preventable or treatable before age 75, was used. Competing cause survival models were used to examine the associations of specific childhood adversities with PPAM in adulthood among respondents aged 18 to 74 years (rounded n = 11,035).

RESULTS

During the 20-year follow-up, 5.4% of the sample died prematurely of a cause that was considered potentially avoidable. Childhood adversities had a differential effect on mortality. Physical abuse (age-adjusted sub-hazard ratio; SHR 1.44; 95% CI 1.03, 2.00) and being sent away from home (age-adjusted SHR 2.26; 95% CI 1.43,3.57) were significantly associated with PPAM. The associations were attenuated when adjusted for adulthood factors, namely smoking, poor perceived health, depression, low perceived social support, and low income, consistent with possible mediating effects. Other adversities under study were not associated with PPAM.

CONCLUSION

The findings imply that the psychological sequelae of childhood physical abuse and being sent away from home and subsequent uptake of adverse health behavior may lead to increased risk of potentially avoidable mortality. The potential mediators identified offer directions for future research to perform causal mediation analyses with suitable data and identify interventions aimed at preventing premature mortality due to potentially avoidable causes. Other forms of adversities, mostly related to household dysfunction, may not be determinants of the distal health outcome of mortality.

Green-blue space exposure changes and impact on individual-level well-being and mental health: a population-wide dynamic longitudinal panel study with linked survey data

Background

Cross-sectional evidence suggests that living near green and blue spaces benefits mental health; longitudinal evidence is limited.

Objectives

To quantify the impact of changes in green and blue spaces on common mental health disorders, well-being and health service use.

Design

A retrospective, dynamic longitudinal panel study.

Setting

Wales, UK.

Participants

An e-cohort comprising 99,682,902 observations of 2,801,483 adults (≥ 16 years) registered with a general practice in Wales (2008-2019). A 5312-strong 'National Survey for Wales (NSW) subgroup' was surveyed on well-being and visits to green and blue spaces.

Main outcome measures

Common mental health disorders, general practice records; subjective well-being, Warwick-Edinburgh Mental Well-being Scale.

Data sources

Common mental health disorder and use of general practice services were extracted quarterly from the Welsh Longitudinal General Practice Dataset. Annual ambient greenness exposure, enhanced vegetation index and access to green and blue spaces (2018) from planning and satellite data. Data were linked within the Secure Anonymised Information Linkage Databank.

Methods

Multilevel regression models examined associations between exposure to green and blue spaces and common mental health disorders and use of general practice. For the National Survey for Wales subgroup, generalised linear models examined associations between exposure to green and blue spaces and subjective well-being and common mental health disorders.

Results and conclusions

Our longitudinal analyses found no evidence that changes in green and blue spaces through time impacted on common mental health disorders. However, time-aggregated exposure to green and blue spaces contrasting differences between people were associated with subsequent common mental health disorders. Similarly, our cross-sectional findings add to growing evidence that residential green and blue spaces and visits are associated with well-being benefits: Greater ambient greenness (+ 1 enhanced vegetation index) was associated with lower likelihood of subsequently seeking care for a common mental health disorder [adjusted odds ratio (AOR) 0.80, 95% confidence interval, (CI) 0.80 to 0.81] and with well-being with a U-shaped relationship [Warwick-Edinburgh Mental Well-being Scale; enhanced vegetation index beta (adjusted) -10.15, 95% CI -17.13 to -3.17; EVI2 beta (quadratic term; adj.) 12.49, 95% CI 3.02 to 21.97]. Those who used green and blue spaces for leisure reported better well-being, with diminishing extra benefit with increasing time (Warwick-Edinburgh Mental Well-being Scale: time outdoors (hours) beta 0.88, 95% CI 0.53 to 1.24, time outdoors2 beta -0.06, 95% CI -0.11 to -0.01) and had 4% lower odds of seeking help for common mental health disorders (AOR 0.96, 95% CI 0.93 to 0.99). Those in urban areas benefited most from greater access to green and blue spaces (AOR 0.89, 95% CI 0.89 to 0.89). Those in material deprivation benefited most from leisure time outdoors (until approximately four hours per week; Warwick-Edinburgh Mental Well-being Scale: time outdoors × in material deprivation: 1.41, 95% CI 0.39 to 2.43; time outdoors2 × in material deprivation -0.18, 95% CI -0.33 to -0.04) although well-being remained generally lower.

Limitations

Longitudinal analyses were restricted by high baseline levels and limited temporal variation in ambient greenness in Wales. Changes in access to green and blue spaces could not be captured annually due to technical issues with national-level planning datasets.

Future work

Further analyses could investigate mental health impacts in population subgroups potentially most sensitive to local changes in access to specific types of green and blue spaces. Deriving green and blue spaces changes from planning data is needed to overcome temporal uncertainties.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (Project number 16/07/07) and will be published in full in Public Health Research; Vol. 11, No. 10. Sarah Rodgers is part-funded by the NIHR Applied Research Collaboration North West Coast.

Tobacco Smoking and Pack-Years Are Associated With Frailty Among People With HIV

BACKGROUND

Tobacco smoking increases frailty risk among the general population and is common among people with HIV (PWH) who experience higher rates of frailty at younger ages than the general population.

METHODS

We identified 8608 PWH across 6 Centers for AIDS Research Network of Integrated Clinical Systems sites who completed ≥2 patient-reported outcome assessments, including a frailty phenotype measuring unintentional weight loss, poor mobility, fatigue, and inactivity, and scored 0-4. Smoking was measured as baseline pack-years and time-updated never, former, or current use with cigarettes/day. We used Cox models to associate smoking with risk of incident frailty (score ≥3) and deterioration (frailty score increase by ≥2 points), adjusted for demographics, antiretroviral medication, and time-updated CD4 count.

RESULTS

The mean follow-up of PWH was 5.3 years (median: 5.0), the mean age at baseline was 45 years, 15% were female, and 52% were non-White. At baseline, 60% reported current or former smoking. Current (HR: 1.79; 95% confidence interval: 1.54 to 2.08) and former (HR: 1.31; 95% confidence interval: 1.12 to 1.53) smoking were associated with higher incident frailty risk, as were higher pack-years. Current smoking (among younger PWH) and pack-years, but not former smoking, were associated with higher risk of deterioration.

CONCLUSIONS

Among PWH, smoking status and duration are associated with incident and worsening frailty.

Fish oil supplementation modifies the genetic potential for blood lipids

Background

Dyslipidemia is a well-known risk factor for cardiovascular disease, which has been the leading cause of mortality worldwide. Although habitual intake of fish oil has been implicated in offering cardioprotective effects through triglyceride reduction, the interactions of fish oil with the genetic predisposition to dysregulated lipids remain elusive.

Objectives

We examined whether fish oil supplementation can modify the genetic potential for the circulating levels of four lipids, including total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides.

Methods

A total of 441,985 participants with complete genetic and phenotypic data from the UK Biobank were included in our study. Polygenic scores (PGS) were calculated in participants of diverse ancestries. Multivariable linear regression models were used to assess associations with adjustment for relevant risk factors.

Results

Fish oil supplementation mitigated genetic susceptibility to elevated levels of total cholesterol, LDL-C, and triglycerides, while amplifying genetic potential for increased HDL-C among 424,090 participants of European ancestry P interaction < 0.05 . Consistent significant findings were obtained using PGS calculated based on multiple genome-wide association studies or alternative PGS methods. We also showed that fish oil significantly attenuated genetic predisposition to high triglycerides in African-ancestry participants.

Conclusions

Fish oil supplementation attenuated the genetic susceptibility to elevated blood levels of total cholesterol, LDL-C, and triglycerides, while accentuating genetic potential for higher HDL-C. These results suggest that fish oil may have a beneficial impact on modifying genome-wide genetic effects on elevated lipid levels in the general population.

The effects of social determinants of health on acquired immune deficiency syndrome in a low-income population of Brazil: a retrospective cohort study of 28.3 million individuals

Background

Social determinants of health (SDH) include factors such as income, education, and race, that could significantly affect the human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS). Studies on the effects of SDH on HIV/AIDS are limited, and do not yet provide a systematic understanding of how the various SDH act on important indicators of HIV/AIDS progression. We aimed to evaluate the effects of SDH on AIDS morbidity and mortality.

Methods

A retrospective cohort of 28.3 million individuals was evaluated over a 9-year period (from 2007 to 2015). Multivariable Poisson regression, with a hierarchical approach, was used to estimate the effects of SDH-at the individual and familial level-on AIDS incidence, mortality, and case-fatality rates.

Findings

A total of 28,318,532 individuals, representing the low-income Brazilian population, were assessed, who had a mean age of 36.18 (SD: 16.96) years, 52.69% (14,920,049) were female, 57.52% (15,360,569) were pardos, 34.13% (9,113,222) were white/Asian, 7.77% (2,075,977) were black, and 0.58% (154,146) were indigenous. Specific socioeconomic, household, and geographic factors were significantly associated with AIDS-related outcomes. Less wealth was strongly associated with a higher AIDS incidence (rate ratios-RR: 1.55; 95% confidence interval-CI: 1.43-1.68) and mortality (RR: 1.99; 95% CI: 1.70-2.34). Lower educational attainment was also greatly associated with higher AIDS incidence (RR: 1.46; 95% CI: 1.26-1.68), mortality (RR: 2.76; 95% CI: 1.99-3.82) and case-fatality rates (RR: 2.30; 95% CI: 1.31-4.01). Being black was associated with a higher AIDS incidence (RR: 1.53; 95% CI: 1.45-1.61), mortality (RR: 1.69; 95% CI: 1.57-1.83) and case-fatality rates (RR: 1.16; 95% CI: 1.03-1.32). Overall, also considering the other SDH, individuals experiencing greater levels of socioeconomic deprivation were, by far, more likely to acquire AIDS, and to die from it.

Interpretation

In the population studied, SDH related to poverty and social vulnerability are strongly associated with a higher burden of HIV/AIDS, most notably less wealth, illiteracy, and being black. In the absence of relevant social protection policies, the current worldwide increase in poverty and inequalities-due to the consequences of the COVID-19 pandemic, and the effects of war in the Ukraine-could reverse progress made in the fight against HIV/AIDS in low- and middle-income countries (LMIC).

Funding

National Institute of Allergy and Infectious Diseases (NAIDS), National Institutes of Health (NIH), US Grant Number: 1R01AI152938.

The Relation Between Obesity and Mortality in Postcardiotomy Venoarterial Membrane Oxygenation

BACKGROUND

Obesity is an important health problem in cardiac surgery and among patients requiring postcardiotomy venoarterial extracorporeal membrane oxygenation (V-A ECMO). Still, whether these patients are at risk for unfavorable outcomes after postcardiotomy V-A ECMO remains unclear. The current study evaluated the association between body mass index (BMI) and in-hospital outcomes in this setting.

METHODS

The Post-cardiotomy Extracorporeal Life Support (PELS-1) study is an international, multicenter study. Patients requiring postcardiotomy V-A ECMO in 36 centers from 16 countries between 2000 and 2020 were included. Patients were divided in 6 BMI categories (underweight, normal weight, overweight, class I, class II, and class III obesity) according to international recommendations. Primary outcome was in-hospital mortality, and secondary outcomes included major adverse events. Mixed logistic regression models were applied to evaluate associations between BMI and mortality.

RESULTS

The study cohort included 2046 patients (median age, 65 years; 838 women [41.0%]). In-hospital mortality was 60.3%, without statistically significant differences among BMI classes for in-hospital mortality (P = .225) or major adverse events (P = .126). The crude association between BMI and in-hospital mortality was not statistically significant after adjustment for comorbidities and intraoperative variables (class I: odds ratio [OR], 1.21; 95% CI, 0.88-1.65; class II: OR, 1.45; 95% CI, 0.86-2.45; class III: OR, 1.43; 95% CI, 0.62-3.33), which was confirmed in multiple sensitivity analyses.

CONCLUSIONS

BMI is not associated to in-hospital outcomes after adjustment for confounders in patients undergoing postcardiotomy V-A ECMO. Therefore, BMI itself should not be incorporated in the risk stratification for postcardiotomy V-A ECMO.

Age-related changes in plasma biomarkers and their association with mortality in COVID-19

BACKGROUND

Coronavirus disease 2019 (COVID-19)-induced mortality occurs predominantly in older patients. Several immunomodulating therapies seem less beneficial in these patients. The biological substrate behind these observations is unknown. The aim of this study was to obtain insight into the association between ageing, the host response and mortality in patients with COVID-19.

METHODS

We determined 43 biomarkers reflective of alterations in four pathophysiological domains: endothelial cell and coagulation activation, inflammation and organ damage, and cytokine and chemokine release. We used mediation analysis to associate ageing-driven alterations in the host response with 30-day mortality. Biomarkers associated with both ageing and mortality were validated in an intensive care unit and external cohort.

RESULTS

464 general ward patients with COVID-19 were stratified according to age decades. Increasing age was an independent risk factor for 30-day mortality. Ageing was associated with alterations in each of the host response domains, characterised by greater activation of the endothelium and coagulation system and stronger elevation of inflammation and organ damage markers, which was independent of an increase in age-related comorbidities. Soluble tumour necrosis factor receptor 1, soluble triggering receptor expressed on myeloid cells 1 and soluble thrombomodulin showed the strongest correlation with ageing and explained part of the ageing-driven increase in 30-day mortality (proportion mediated: 13.0%, 12.9% and 12.6%, respectively).

CONCLUSIONS

Ageing is associated with a strong and broad modification of the host response to COVID-19, and specific immune changes likely contribute to increased mortality in older patients. These results may provide insight into potential age-specific immunomodulatory targets in COVID-19.

Racial differences in COVID-19 severity associated with history of substance use disorders and overdose: Findings from multi-site electronic health records in New York City

Substance use disorders (SUD) are associated with increased risk of worse COVID-19 outcomes. Likewise, racial/ethnic minority patients experience greater risk of severe COVID-19 disease compared to white patients. Providers should understand the role of race and ethnicity as an effect modifier on COVID-19 severity among individuals with SUD. This retrospective cohort study assessed patient race/ethnicity as an effect modifier of the risk of severe COVID-19 disease among patients with histories of SUD and overdose. We used merged electronic health record data from 116,471 adult patients with a COVID-19 encounter between March 2020 and February 2021 across five healthcare systems in New York City. Exposures were patient histories of SUD and overdose. Outcomes were risk of COVID-19 hospitalization and subsequent COVID-19-related ventilation, acute kidney failure, sepsis, and mortality. Risk factors included patient age, sex, and race/ethnicity, as well as medical comorbidities associated with COVID-19 severity. We tested for interaction between SUD and patient race/ethnicity on COVID-19 outcomes. Findings showed that Non-Hispanic Black, Hispanic/Latino, and Asian/Pacific Islander patients experienced a higher prevalence of all adverse COVID-19 outcomes compared to non-Hispanic white patients. Past-year alcohol (OR 1.24 [1.01-1.53]) and opioid use disorders (OR 1.91 [1.46-2.49]), as well as overdose history (OR 4.45 [3.62-5.46]), were predictive of COVID-19 mortality, as well as other adverse COVID-19 outcomes. Among patients with SUD, significant differences in outcome risk were detected between patients of different race/ethnicity groups. Findings indicate that providers should consider multiple dimensions of vulnerability to adequately manage COVID-19 disease among populations with SUDs.

First-line opioid agonist treatment as prevention against assisting others in initiating injection drug use: A longitudinal cohort study of people who inject drugs in Vancouver, Canada

Background

Among people who inject drugs, frequent injecting and experiencing withdrawal are associated with facilitating others' first injections. As these factors may reflect an underlying substance use disorder, we investigated whether first-line oral opioid agonist treatment (OAT; methadone or buprenorphine/naloxone) reduces the likelihood that people who inject drugs help others initiate injecting.

Methods

We used questionnaire data from semi-annual visits between December 2014-May 2018 on 334 people who inject drugs with frequent non-medical opioid use in Vancouver, Canada. We estimated the effect of current first-line OAT on subsequent injection initiation assistance provision (i.e., helped someone initiate injecting in the following six months) using inverse-probability-weighted estimation of repeated measures marginal structural models to reduce confounding and informative censoring by time-fixed and time-varying covariates.

Results

By follow-up visit, 54-64% of participants reported current first-line OAT whereas 3.4-6.9% provided subsequent injection initiation assistance. Per the primary weighted estimate (n = 1114 person-visits), participants currently on first-line OAT (versus no OAT) were 50% less likely, on average, to subsequently help someone initiate injecting (relative risk [RR]=0.50, 95% CI=0.23-1.11). First-line OAT was associated with reduced risk of subsequent injection initiation assistance provision in participants who, at baseline, injected opioids less than daily (RR=0.15, 95% CI=0.05-0.44) but not in those who injected opioids daily (RR=0.86, 95% CI=0.35-2.11).

Conclusions

First-line OAT seemingly reduces the short-term likelihood that people who inject drugs facilitate first injections. However, the extent of this potential effect remains uncertain due to imprecise estimation and observed heterogeneity by baseline opioid injecting frequency.

Order Set Usage is Associated With Lower Hospital Mortality in Patients With Sepsis

The Surviving Sepsis Campaign recommends standard operating procedures for patients with sepsis. Real-world evidence about sepsis order set implementation is limited.

OBJECTIVES

To estimate the effect of sepsis order set usage on hospital mortality.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Fifty-four acute care hospitals in the United States from December 1, 2020 to November 30, 2022 involving 104,662 patients hospitalized for sepsis.

MAIN OUTCOMES AND MEASURES

Hospital mortality.

RESULTS

The sepsis order set was used in 58,091 (55.5%) patients with sepsis. Initial mean sequential organ failure assessment score was 0.3 lower in patients for whom the order set was used than in those for whom it was not used (2.9 sd [2.8] vs 3.2 [3.1], p < 0.01). In bivariate analysis, hospital mortality was 6.3% lower in patients for whom the sepsis order set was used (9.7% vs 16.0%, p < 0.01), median time from emergency department triage to antibiotics was 54 minutes less (125 interquartile range [IQR, 68-221] vs 179 [98-379], p < 0.01), and median total time hypotensive was 2.1 hours less (5.5 IQR [2.0-15.0] vs 7.6 [2.5-21.8], p < 0.01) and septic shock was 3.2% less common (22.0% vs 25.4%, p < 0.01). Order set use was associated with 1.1 fewer median days of hospitalization (4.9 [2.8-9.0] vs 6.0 [3.2-12.1], p < 0.01), and 6.6% more patients discharged to home (61.4% vs 54.8%, p < 0.01). In the multivariable model, sepsis order set use was independently associated with lower hospital mortality (odds ratio 0.70; 95% CI, 0.66-0.73).

CONCLUSIONS AND RELEVANCE

In a cohort of patients hospitalized with sepsis, order set use was independently associated with lower hospital mortality. Order sets can impact large-scale quality improvement efforts.

Associations between pregnancy glucose measurements and risk of preterm birth: a retrospective cohort study of commercially insured women in the United States from 2003 to 2021

PURPOSE

To investigate associations between glucose measurements during pregnancy and risk of preterm birth (PTB).

METHODS

Retrospective cohort study of commercially insured women with singleton live births in the United States from 2003 to 2021 using longitudinal medical claims, socioeconomic data, and eight glucose results from different fasting and post-load tests performed between 24 and 28 weeks of gestation for gestational diabetes screening. Risk ratios of PTB (<37 weeks) were estimated via Poisson regression for z-standardized glucose measures. Non-linear relationships for continuous glucose measures were examined via generalized additive models.

RESULTS

Elevations in all eight glucose measures were associated with increased risk (adjusted risk ratio point estimates: 1.05-1.19) of PTB for 196,377 women with non-fasting 50-g glucose challenge test (one glucose result), 31,522 women with complete 100-g, 3-hour fasting oral glucose tolerance test (OGTT) results (four glucose results), and 10,978 women with complete 75-g, 2-hour fasting OGTT results (three glucose results). Associations were consistent after adjusting for and stratifying by sociodemographic and clinical factors. Substantial non-linear relationships (U-, J-, and S-shaped) were observed between several glucose measurements and PTB.

CONCLUSIONS

Elevations in various glucose measures were linearly and non-linearly associated with increased PTB risk, even before diagnostic thresholds for gestational diabetes.

Association of Early Sports Participation With Sedentary Behavior in Community-Dwelling Adults-The Role of Sociodemographic Factors in a Retrospective Epidemiological Study

BACKGROUND

The role of sociodemographic factors in the association between early sports participation (ESP) and sedentary behavior is unclear. We analyzed the association of ESP with sedentary behavior and identified the influence of sociodemographic factors in adulthood.

METHODS

A sample of 264 community-dwelling adults was randomly assessed (42.6 [17.0] y old, 57.6% women). Sociodemographic factors (age, gender, and socioeconomic status) and ESP (retrospectively) were assessed by questionnaire. Sedentary behavior was measured by accelerometer and self-reported for domains identification. The association between ESP and sedentary behavior domains and sociodemographic factors was analyzed by Poisson regression and presented in prevalence ratio (PR). Sociodemographic factors were separately included as covariates to identify their role in the main association analysis.

RESULTS

The ESP prevalence was 56.4% (n = 149). ESP participants included a higher proportion of men (59.7% vs 20.0%), had a lower age (36.8 [15.3] vs 50.8 [15.9]), and included a smaller proportion of individuals with low socioeconomic status (24.8% vs 43.5%) compared with those without ESP. The ESP was inversely associated with older age (PR = 0.58, P < .001 for middle aged; PR = 0.34, P < .001 for older participants), female gender (PR = 0.79, P < .001), low socioeconomic status (PR = 0.63, P = .036), and TV watching (PR = 0.67, P = .011). ESP was associated with driving (PR = 1.50, P = .028), office/paper work (PR = 1.63, P = .012), and using a cellphone (PR = 1.60, P = .009). The age was the main confounding factor of association between ESP and sedentary behavior, followed by socioeconomic status. No mediation role was identified.

CONCLUSION

The ESP was associated with mentally active behavior domains and inversely associated with mentally passive sedentary behavior domains, but this association was majorly affected by sociodemographic factors, mainly by age.

Mechanical power and 30-day mortality in mechanically ventilated, critically ill patients with and without Coronavirus Disease-2019: a hospital registry study

BACKGROUND

Previous studies linked a high intensity of ventilation, measured as mechanical power, to mortality in patients suffering from "classic" ARDS. By contrast, mechanically ventilated patients with a diagnosis of COVID-19 may present with intact pulmonary mechanics while undergoing mechanical ventilation for longer periods of time. We investigated whether an association between higher mechanical power and mortality is modified by a diagnosis of COVID-19.

METHODS

This retrospective study included critically ill, adult patients who were mechanically ventilated for at least 24 h between March 2020 and December 2021 at a tertiary healthcare facility in Boston, Massachusetts. The primary exposure was median mechanical power during the first 24 h of mechanical ventilation, calculated using a previously validated formula. The primary outcome was 30-day mortality. As co-primary analysis, we investigated whether a diagnosis of COVID-19 modified the primary association. We further investigated the association between mechanical power and days being alive and ventilator free and effect modification of this by a diagnosis of COVID-19. Multivariable logistic regression, effect modification and negative binomial regression analyses adjusted for baseline patient characteristics, severity of disease and in-hospital factors, were applied.

RESULTS

1,737 mechanically ventilated patients were included, 411 (23.7%) suffered from COVID-19. 509 (29.3%) died within 30 days. The median mechanical power during the first 24 h of ventilation was 19.3 [14.6-24.0] J/min in patients with and 13.2 [10.2-18.0] J/min in patients without COVID-19. A higher mechanical power was associated with 30-day mortality (OR_adj 1.26 per 1-SD, 7.1J/min increase; 95% CI 1.09-1.46; p = 0.002). Effect modification and interaction analysis did not support that this association was modified by a diagnosis of COVID-19 (95% CI, 0.81-1.38; p-for-interaction = 0.68). A higher mechanical power was associated with a lower number of days alive and ventilator free until day 28 (IRR_adj 0.83 per 7.1 J/min increase; 95% CI 0.75-0.91; p < 0.001, adjusted risk difference - 2.7 days per 7.1J/min increase; 95% CI - 4.1 to - 1.3).

CONCLUSION

A higher mechanical power is associated with elevated 30-day mortality. While patients with COVID-19 received mechanical ventilation with higher mechanical power, this association was independent of a concomitant diagnosis of COVID-19.

Do imaging findings modify the effect of non-surgical treatment in patients with knee and hip osteoarthritis? A systematic literature review

OBJECTIVES

To review the available evidence on diagnostic imaging findings in knee and hip osteoarthritis (OA) as treatment effect modifiers in non-surgical OA interventions.

METHODS

MEDLINE, Embase and The Cochrane Central Register of Controlled Trials were searched from the earliest records published to 22 March 2022. Studies in knee and hip OA reporting subgroup analyses in randomised controlled trials with imaging findings as potential treatment effect modifiers were included. Studies were critically appraised using the Cochrane risk of bias tool and a subgroup analysis quality assessment.

RESULTS

Of 10 014 titles and abstracts screened, eight studies met the inclusion criteria, six on knee OA and two on hip OA. The studies investigated effect modifiers in exercise therapy, intra-articular injections and unloading shoes. Imaging findings assessed as potential treatment effect modifiers were radiographic OA severity, hip effusion (ultrasound), bone marrow lesions and meniscal pathology (MRI). Two studies fulfilled the methodological quality criteria for assessing effect modification. One reported that radiographic knee OA severity modified the effect of unloading shoes on walking pain. Those with more severe radiographic knee OA had a greater response to shoe inserts. One reported no interaction between radiographic OA severity or joint effusion and the effect of intraarticular injections of corticosteroid or hyaluronic acid in hip OA, indicating no difference in response in people with greater hip joint effusion or radiographic OA severity compared with those with less severe joint disease.

CONCLUSION

Overall, methodological limitations and very few studies do not permit conclusions on diagnostic imaging findings as effect modifiers in non-surgical interventions in knee and hip OA.Radiographic severity of knee OA potentially modifies the effect of unloading shoes.

PROSPERO REGISTRATION NUMBER

CRD42020181934.

Association between urinary polycyclic aromatic hydrocarbon metabolites and diabetes mellitus among the US population: a cross-sectional study

BACKGROUND

The primary aim of this study is to examine the association between urinary polycyclic aromatic hydrocarbons (PAHs) and diabetes mellitus (DM) among the US population.

METHODS

We used data from the National Health and Nutritional Examination Survey 2003-16, which is a nationally representative population-based survey of the US non-institutionalized population. Logistic regression analysis was performed to evaluate the association between urinary PAHs and the prevalence of DM using odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

The study sample including 13 792 individuals ≥18 y of age. The average ages of the three PAH tertiles were 42.56±19.67, 42.21±19.51 and 43.39±17.99 y. An increased risk of DM was found with increased odds for the second (OR 1.56 [95% CI 1.36 to 1.79]) and third tertile (OR 1.79 [95% CI 1.55 to 2.06)] of urinary PAH as compared with the first tertile. Similarly, higher chances of DM were observed in the second (men: OR 1.42 [95% CI 1.18 to 1.71]; women: OR 1.76 [95% CI 1.44 to 2.14]) and third tertile (men: OR 1.69 [95% CI 1.38 to 2.08]; women: OR 1.79 [95% CI 1.46 to 2.19]) of urinary PAHs as compared with the first tertile in both men and women.

CONCLUSIONS

A population-based cross-sectional study found a positive association between urinary PAHs and DM in the US population.

Obesity and adverse childhood experiences in relation to stress during the COVID-19 pandemic: an analysis of the Canadian Longitudinal Study on Aging

BACKGROUND

People with obesity are at increased risk of chronic stress, and this may have been exacerbated during the COVID-19 pandemic. Adverse childhood experiences (ACE) are also associated with both obesity and stress, and may modify risk of stress among people with obesity. The objectives of this study were to evaluate the associations between obesity, ACEs, and stress during the pandemic, and to determine if the association between obesity and stress was modified by ACEs.

METHODS

A longitudinal study was conducted among adults aged 50-96 years (n = 23,972) from the Canadian Longitudinal Study on Aging (CLSA) COVID-19 Study. Obesity and ACEs were collected pre-pandemic (2015-2018), and stress was measured at COVID-19 Exit Survey (Sept-Dec 2020). We used logistic, Poisson, and negative binomial regression to estimate relative risks (RRs) and 95% confidence intervals (CIs) for the associations between obesity, ACEs, and stress outcomes during the pandemic. Interaction by ACEs was evaluated on the additive and multiplicative scales.

RESULTS

People with obesity were more likely to experience an increase in overall stressors (class III obesity vs. healthy weight RR = 1.19; 95% CI: 1.12-1.27) as well as increased health related stressors (class III obesity vs. healthy weight RR: 1.25; 95% CI: 1.12-1.39) but did not perceive the consequences of the pandemic as negative. ACEs were also associated an increase in overall stressors (4-8 ACEs vs. none RR = 1.38; 95% CI: 1.33-1.44) and being more likely to perceive the pandemic as negative (4-8 ACEs vs. none RR = 1.32; 95% CI: 1.19-1.47). The association between obesity and stress was not modified by ACEs.

CONCLUSIONS

Increased stress during the first year of the COVID-19 pandemic was observed among people with obesity or ACEs. The long-term outcomes of stress during the pandemic need to be determined.

Interaction analyses: Enhancing understanding of chronic low back pain

BACKGROUND

Chronic low back pain (CLBP) is complex. Statistical examination of influences of exposures (e.g. characteristics) upon outcomes (e.g. pain) facilitates understanding of complexity and personalized care. Psychological factors may be associated with higher disability following exercise in CLBP. Examining interactions of psychological variables with exercise on disability might further understanding of CLBP.

OBJECTIVES

Secondary analysis of data from a CLBP cohort evaluating interactions between psychological variables and exercise on disability.

DESIGN

Longitudinal cohort study.

METHOD

Variables from a published prognostic model for disability: disability (baseline/one-year follow-up), psychological principal component scores (principal component score two (PC2) - Fear-avoidance beliefs, pain catastrophizing, pain self-efficacy; principal component score three (PC3) - thought suppression, behavioral endurance), exercise (during follow-up), forward-bending time, punishing significant other responses. Differences between exercisers and non-exercisers were assessed using Chi-Squared/Mann-Whitney tests. Multivariable linear regression models for follow-up disability included a term examining interaction between principal component scores and exercise.

RESULTS

Exercisers had significantly different scores for PC2 (p = .02) and PC3 (p = .03), lower baseline (p = .005) and follow-up pain intensity (p < .001), follow-up disability (p < .001) and faster forward-bend times (p = .014). There was no significant interaction between exercise and PC2 (p = .92) or PC3 (p = .75).

CONCLUSIONS

This study showed no interaction between psychological factors and exercise on disability at follow-up. These findings suggest that the disability outcome of people with CLBP who undertake exercise as an intervention does not differ from those who do not undertake exercise, irrespective of their baseline psychological status.

Combined Effects of Diabetes and Education on Decline of Cognitive Performance in the Older Population: The Survey of Health, Ageing, and Retirement in Europe

AIMS

Diabetes management requires cognitive abilities. Unfortunately, diabetes is a risk factor for cognitive decline. However, the effects of diabetes in persons with reduced cognitive reserves are unclear. We aimed to examine whether the effects of diabetes and education on cognitive skills simply add up or deviate from simple additivity.

METHODS

We used data from waves 1 to 7 (except wave 3) of the Survey of Health, Ageing, and Retirement in Europe (SHARE) collected between 2004 and 2017. SHARE includes 140,000 persons aged ≥50 years from 28 European countries and Israel. Diabetes was assessed by self-report and education was coded according to the International Standard Classification of Education levels. Verbal fluency, immediate, and delayed memory were assessed using standard tests. Interaction between diabetes and education was estimated from interaction contrasts and from interaction terms in adjusted regression models.

RESULTS

At baseline, cognitive performance declined in the order "no diabetes/high education" > "diabetes/high education" > "no diabetes/low education" > "diabetes/low education" for all three tests - e.g., the first group named 21.4 ± 7.2, the fourth group 14.6 ± 6.1 animals in a minute in the test of verbal fluency. Interaction contrasts and regression coefficients of interaction terms were close to zero, showing that the effects of diabetes and education on cognitive performance added up without interaction both in cross-sectional and longitudinal analyses.

CONCLUSION

We have observed no interaction between education and diabetes on cognitive skills. Yet, people with diabetes and low education showed poor cognitive performance and should receive particular support in managing diabetes.

Causal inference in medical records and complementary systems pharmacology for metformin drug repurposing towards dementia

Metformin, a diabetes drug with anti-aging cellular responses, has complex actions that may alter dementia onset. Mixed results are emerging from prior observational studies. To address this complexity, we deploy a causal inference approach accounting for the competing risk of death in emulated clinical trials using two distinct electronic health record systems. In intention-to-treat analyses, metformin use associates with lower hazard of all-cause mortality and lower cause-specific hazard of dementia onset, after accounting for prolonged survival, relative to sulfonylureas. In parallel systems pharmacology studies, the expression of two AD-related proteins, APOE and SPP1, was suppressed by pharmacologic concentrations of metformin in differentiated human neural cells, relative to a sulfonylurea. Together, our findings suggest that metformin might reduce the risk of dementia in diabetes patients through mechanisms beyond glycemic control, and that SPP1 is a candidate biomarker for metformin's action in the brain.

Impact of belatacept and tacrolimus on cytomegalovirus viral load control and relapse in moderate and high-risk cytomegalovirus serostatus kidney transplant recipients

BACKGROUND

Belatacept improves long-term graft survival, but control of some primary viral infections may be impaired. We evaluated the impact of belatacept and tacrolimus on cytomegalovirus (CMV) viral control, remission and relapse in CMV high-risk and moderate-risk recipients.

METHODS

Using a multistate Markov model, we evaluated viral load state transitions of 173 kidney transplant recipients with at least one episode of viremia within 1 year after transplant: state 1, undetectable/low viral load; state 2, moderate viremia; and state 3, severe viremia.

RESULTS

Among high-risk recipients, belatacept-treated recipients exhibited a significantly higher probability of entering moderate viremia (.36; 95% CI = .31, .41) than tacrolimus-treated recipients (.20; 95% CI = .13, .29). The expected number of days in viremic states differed. High-risk belatacept-treated recipients persisted in moderate viremia for significantly longer (128 days, 95% CI = 110, 146) than did tacrolimus-treated recipients (70.0 days, 95% CI = 45.2, 100) and showed a trend of shorter duration in low/undetectable viral load state (172 days, 95% CI = 148, 195) than did tacrolimus-treated recipients (239 days, 95% CI = 195, 277). Moderate-risk recipients showed better viral load control and with no differences by immunosuppression.

CONCLUSION

High-risk belatacept-treated recipients showed defects in sustaining viral control relative to tacrolimus-treated recipients. Avoidance of initial use belatacept in high-risk recipients or development of modified management protocols should be considered.

The association between nonpharmacological interventions and quality of life in children with attention deficit hyperactivity disorder: A systematic review

BACKGROUND

Attention deficit hyperactivity disorder is a common psychiatric disorder with a worldwide prevalence of about five percent among children and adolescents. This disorder affects most aspects of their lives e.g., academic performance and social relations, and their overall quality of life is reduced compared to healthy peers. The majority of children with ADHD are treated with medication that potentially has an insufficient effect and/or frequently occurring side effects.

OBJECTIVES

To enable nurses and other health care professionals to guide children with ADHD and their families in their choices of treatment, based on the best available literature on the association between nonpharmacological interventions and quality of life.

DATA SOURCES

A literature search was performed in the databases CENTRAL, Embase, PubMed, CINAHL, and PsycINFO. Seven randomized controlled trials were included in this systematic review. They examined the use of polyunsaturated fatty acids, physical activity, psychoeducation, cognitive therapy, cognitive training, hippotherapy, and behavioral therapy.

CONCLUSIONS

The study of behavioral therapy in the form of a sleep intervention detected an improvement in quality of life which was statistically significant compared to the control group.

IMPLICATIONS FOR PRACTICE

Children with ADHD and a sleep disorder may gain improvement in their quality of life from a sleep intervention.

Cross-sectional and longitudinal relationships between urinary 1-bromopropane metabolite and pulmonary function and underlying role of oxidative damage among urban adults in the Wuhan-Zhuhai cohort in China

1-bromopropane is a US Environmental Protection Agency-identified significant hazardous air pollutant with concerned adverse respiratory effect. We aimed to investigate the relationship between 1-bromopropane exposure and pulmonary function and the underlying role of oxidative damage, which all remain unknown. Pulmonary function and urinary biomarkers of 1-bromopropane exposure (N-Acetyl-S-(n-propyl)-L-cysteine, BPMA) and oxidative damage to DNA (8-hydroxy-deoxyguanosine, 8-OHdG) and lipid (8-iso-prostaglandin-F2α, 8-iso-PGF2α) were measured for 3259 Chinese urban adults from the Wuhan-Zhuhai cohort. The cross-sectional relationship of BPMA with pulmonary function and the joint relationship of BPMA and 8-OHdG or 8-iso-PGF2α with pulmonary function were investigated by linear mixed models. The mediating roles of 8-OHdG and 8-iso-PGF2α were evaluated by mediation analysis. Additionally, a panel of 138 subjects was randomly convened from the same cohort to evaluate the stability of BPMA repeatedly measured in urine samples collected over consecutive three days and intervals of one, two, and three years, and to estimate the longitudinal relationship of BPMA with pulmonary function change in three years. We found each 3-fold increase in BPMA was cross-sectionally related to FVC and FEV₁ reductions by 29.88-mL and 25.67-mL, respectively (all P < 0.05). Joint relationship of BPMA and 8-OHdG rather than 8-iso-PGF2α with reduced pulmonary function was observed. Moreover, 8-OHdG significantly mediated 9.44% of the BPMA-related FVC reduction. Findings from the panel revealed a fair to excellent stability (intraclass correlation coefficient: 0.43-0.79) of BPMA in repeated urines collected over a period of three years. Besides, BPMA was longitudinally related to pulmonary function reduction in three years: compared with subjects with persistently low BPMA level, those with persistently high BPMA level had 79.08-mL/year and 49.80-mL/year declines in FVC and FEV₁, respectively (all P < 0.05). Conclusively, 1-bromopropane exposure might impair pulmonary function of urban adult population, and oxidative DNA damage might be a potential mechanism underlying 1-bromopropane impairing pulmonary function especially FVC.