Clinical Significance of Background Parenchymal Enhancement in Breast Cancer Risk Stratification

BACKGROUND

Background parenchymal enhancement (BPE) is an established breast cancer risk factor. However, the relationship between BPE levels and breast cancer risk stratification remains unclear.

PURPOSE

To evaluate the clinical relationship between BPE levels and breast cancer risk with covariate adjustments for age, ethnicity, and hormonal status.

STUDY TYPE

Retrospective.

POPULATION

954 screening breast MRI datasets representing 721 women divided into four cohorts: women with pathogenic germline breast cancer (BRCA) mutations (Group 1, N = 211), women with non-BRCA germline mutations (Group 2, N = 60), women without high-risk germline mutations but with a lifetime breast cancer risk of ≥20% using the Tyrer-Cuzick model (Group 3, N = 362), and women with <20% lifetime risk (Group 4, N = 88).

FIELD STRENGTH/SEQUENCE

3 T/axial non-fat-saturated T1, short tau inversion recovery, fat-saturated pre-contrast, and post-contrast T1-weighted images.

ASSESSMENT

Data on age, body mass index, ethnicity, menopausal status, genetic predisposition, and hormonal therapy use were collected. BPE levels were evaluated by two breast fellowship-trained radiologists independently in accordance with BI-RADS, with a third breast fellowship-trained radiologist resolving any discordance.

STATISTICAL TESTS

Propensity score matching (PSM) was utilized to adjust covariates, including age, ethnicity, menopausal status, hormonal treatments, and prior bilateral oophorectomy. The Mann-Whitney U test, chi-squared test, and univariate and multiple logistic regression analysis were performed, with an odds ratio (OR) and corresponding 95% confidence interval. Weighted Kappa statistic was used to assess inter-reader variation. A P value <0.05 indicated a significant result.

RESULTS

In the assessment of BPE, there was substantial agreement between the two interpreting radiologists (κ = 0.74). Patient demographics were not significantly different between patient groups after PSM. The BPE of Group 1 was significantly lower than that of Group 4 and Group 3 among premenopausal women. In estimating the BPE level, the OR of gene mutations was 0.35.

DATA CONCLUSION

Adjusting for potential confounders, the BPE level of premenopausal women with BRCA mutations was significantly lower than that of non-high-risk women.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY: Stage 3.

The contribution of audiobook use on the mental health of older adults: the mediating effects of social adaptation

Objectives: This study aims to examine the association between audiobook use and the mental health of older adults.

Methods: Data were from the 2018 China Longitudinal Aging Social Survey(CLASS 2018). The study utilized multiple linear regression to examine the association between audiobook use and the mental health of older adults. Robustness and heterogeneity analyses were conducted to validate the findings. Mediation analysis was employed to assess the mediating role of social adaptation in the relationship between audiobook use and mental health.

Results: The study revealed a significant positive association between audiobook use and the mental health of older adults. Further mediation analysis indicated that social adaptation played a mediating role in this relationship.

Conclusion: These findings underscore the potential of audiobooks as a valuable tool for promoting the mental health of older individuals. The research emphasizes the significance of integrating audiobook interventions into strategies aimed at enhancing the mental health of the older adults.

Understanding the association between intimate partner violence and sexually transmitted infections among women in India: a propensity score matching approach

BACKGROUND

Intimate partner violence (IPV) against women can significantly impact their overall health. While numerous studies in developing nations highlight the association between IPV and sexually transmitted infections (STIs), the evidence available within the Indian context remains limited. Therefore, this study aims to fill this knowledge gap by investigating the relationship between exposure to different forms of IPV and the occurrence of STIs, using a quasi-experimental approach.

METHODS

The study used a sample of 63 851 women aged 15-49 years from the latest National Family Health Survey-5. Propensity score matching (PSM) was employed to assess the 'treatment effect' from exposure to IPV (physical, emotional or sexual) in the past 12 months on STIs.

RESULTS

About 12.2% of women (95% CI: 11.7% to 12.8%) reported symptoms of STIs at the time of the survey. Approximately 31.9% (95% CI: 31.2% to 32.7%) of women reported experiencing at least one form of IPV-either physical, emotional or sexual IPV. Of all forms of IPV, physical IPV was the most prevalent, reported by 28.6%, followed by emotional IPV (13.2%) and sexual IPV (5.7%). Women who experienced any form of IPV-whether physical, sexual or emotional-reported a higher prevalence of STIs (17.8%) as compared with those who did not experience any IPV (9.5%). The findings from the PSM analysis indicated that among the three forms of IPV, the impact of sexual IPV on STIs was the most pronounced. The average treatment effect on the treated from exposure to sexual IPV on STIs was 0.15 (95% CI 0.13 to 0.17).

CONCLUSION

This study provides evidence of a significant association between IPV and STIs among women in India and underscores the urgent need for intensified efforts and interventions to address both IPV and STIs, to improve the overall health and well-being of women in India.

Covariate Balancing Methods for Randomized Controlled Trials Are Not Adversarially Robust

The first step toward investigating the effectiveness of a treatment via a randomized trial is to split the population into control and treatment groups then compare the average response of the treatment group receiving the treatment to the control group receiving the placebo. To ensure that the difference between the two groups is caused only by the treatment, it is crucial that the control and the treatment groups have similar statistics. Indeed, the validity and reliability of a trial are determined by the similarity of two groups' statistics. Covariate balancing methods increase the similarity between the distributions of the two groups' covariates. However, often in practice, there are not enough samples to accurately estimate the groups' covariate distributions. In this article, we empirically show that covariate balancing with the standardized means difference (SMD) covariate balancing measure, as well as Pocock and Simon's sequential treatment assignment method, are susceptible to worst case treatment assignments. Worst case treatment assignments are those admitted by the covariate balance measure, but result in highest possible ATE estimation errors. We developed an adversarial attack to find adversarial treatment assignment for any given trial. Then, we provide an index to measure how close the given trial is to the worst case. To this end, we provide an optimization-based algorithm, namely adversarial treatment assignment in treatment effect trials (ATASTREET), to find the adversarial treatment assignments.

Impact of glaucoma medications on subsequent Schlemm's canal surgery outcome: Cox proportional hazard model and propensity score-matched analysis

PURPOSE

The impact of various preoperative glaucoma medications on Schlemm's canal surgery outcomes remains unclear. This study aimed to investigate the impact of preoperative glaucoma medications on the postoperative 1-year outcomes of μTLO.

METHODS

We analyzed the medical records of 218 patients who underwent their first μTLO to investigate the 1-year postoperative outcomes. Cox proportional hazard regression analysis was performed with surgical failure as the dependent variable and each type of preoperative medication as the independent variable. We also compared the 1-year outcomes of μTLO between users and non-users of specific medications using propensity score matching. Surgical success was defined as a postoperative intraocular pressure ranging from 5 to 21 mmHg, a ≥20% reduction in IOP from baseline, and no additional glaucoma surgery within 1 year postoperatively.

RESULTS

The Cox proportional hazard analysis showed that all drugs that do not increase the conventional outflow exhibited hazard ratios greater than 1.0, and the preoperative use of β-blockers and oral CAI was a significant surgical risk factor (hazard ratio: 2.65 and 2.45, p = 0.04 and <0.001). In the propensity score matching analysis, success rates at 1 year postoperatively were 55/85, 54/79, 60/73, and 40/76% for users/non-users of β-blockers, topical CAIs, an alpha-2 adrenergic agonist, and an oral CAI, respectively. Kaplan-Meier survival curves in these comparisons also demonstrated that preoperative β-blockers and oral CAI use were significant surgical risks (p = 0.01, <0.001).

CONCLUSION

Our study suggests that preoperative medications that do not involve conventional pathway outflow have a detrimental effect on subsequent Schlemm's canal surgery outcomes.

Glucose metabolism and autonomic function in healthy individuals and patients with type 2 diabetes mellitus at rest and during exercise

Autonomic dysfunction is a common complication of type 2 diabetes mellitus (T2DM). However, the character of dysfunction varies in different reports. Differences in measurement methodology and complications might have influenced the inconsistent results. We sought to evaluate comprehensively the relationship between abnormal glucose metabolism and autonomic function at rest and the response to exercise in healthy individuals and T2DM patients. We hypothesized that both sympathetic and parasympathetic indices would decrease with the progression of abnormal glucose metabolism in individuals with few complications related to high sympathetic tone. Twenty healthy individuals and 11 T2DM patients without clinically evident cardiovascular disease other than controlled hypertension were examined. Resting muscle sympathetic nerve activity (MSNA), heart rate variability, spontaneous cardiovagal baroreflex sensitivity (CBRS), sympathetic baroreflex sensitivity and the MSNA response to handgrip exercise were measured. Resting MSNA was lower in patients with T2DM than in healthy control subjects (P = 0.011). Resting MSNA was negatively correlated with haemoglobin A1c in all subjects (R = -0.45, P = 0.024). The parasympathetic components of heart rate variability and CBRS were negatively correlated with glycaemic/insulin indices in all subjects and even in the control group only (all, P < 0.05). In all subjects, the MSNA response to exercise was positively correlated with fasting blood glucose (R = 0.69, P < 0.001). Resting sympathetic activity and parasympathetic modulation of heart rate were decreased in relationship to abnormal glucose metabolism. Meanwhile, the sympathetic responses to handgrip were preserved in diabetics. The responses were correlated with glucose/insulin parameters throughout diabetic and control subjects. These results suggest the importance of a comprehensive assessment of autonomic function in T2DM.

Safety and efficacy of a new high-dose regimen of panobinostat, gemcitabine, busulfan, and melphalan for 1st or 2nd salvage ASCT for refractory/relapsed or high-risk myeloma: Matched-pair comparisons with concurrent control cohorts

Improvement of autologous stem-cell transplantation (ASCT) for myeloma is needed. Building on our prior work, we prospectively evaluated panobinostat and gemcitabine/busulfan/melphalan (GemBuMel) with ASCT in this population. Patients aged 18-65 years with relapsed/refractory or high-risk myeloma and adequate end-organ function were eligible. Treatment included panobinostat (20 mg/day, days -9 to -2) and GemBuMel (days -8 to -2). Patients were enrolled in 1st (ASCT-1) or 2nd ASCT (ASCT-2) cohorts. We compared their outcomes with all our other concurrent ASCT patients who met eligibility criteria but received melphalan or BuMel off study, matched for age, prior therapy lines, high-risk cytogenetics, and response at ASCT. We enrolled 80 patients, 48 and 32 in the ASCT-1 and ASCT-2 cohorts, respectively; in these two cohorts, high-risk cytogenetics were noted in 33 and 15 patients, respectively; unresponsive disease in 12 and 11 patients, respectively, after a median of 2 and 3 therapy lines, respectively. Transplant-related mortality (TRM) occurred in two ASCT-2 patients. One-year PFS rates were 69% (ASCT-1) and 72% (ASCT-2); 1-year OS rates were 79% (ASCT-1) and 84% (ASCT-2). Minimal residual disease negativity improved after ASCT-1 (8.5%-23%, p < .0001) and ASCT-2 (34%-55%, p = .02), which correlated with improved outcomes. Trial patients and controls (N = 371) had similar TRM and post-ASCT maintenance. Trial patients had better PFS after either a 1st (p = .02) or a 2nd ASCT (p = .04) than matched-paired control patients. In conclusion, panobinostat/GemBuMel is effective for relapsed/refractory or high-risk myeloma patients, with better PFS than concurrent matched controls receiving melphalan or BuMel.

BUILDing an Early Advantage: An Examination of the Role of Strategic Interventions in Developing First-Year Undergraduate Students' Science Identity

The federal government and a number of nonprofit, non-governmental agencies have invested heavily in programs designed to provide research opportunities, financial support, and mentorship to undergraduates in science-related fields. These efforts are aimed at supporting students' matriculation in science majors and into science-related careers. This study used a quasi-experimental design to examine whether college students who participate in a federally sponsored intervention program develop significantly stronger science identities in their first year of college compared to their peers who do not participate in the intervention. Results suggest intervention participants develop significantly stronger science identities compared to their counterparts in the control group, but these benefits are somewhat mitigated after controls for mentoring enter the model.

Periodontitis and postoperative inflammation in gastric cancer patients: Propensity score analysis

OBJECTIVE

The objective of this study was to clarify the association between preoperative periodontitis and postoperative systemic inflammation in patients with gastric cancer.

SUBJECTS AND METHODS

This retrospective cohort study analyzed data from 140 gastric cancer patients who underwent surgery at Hiroshima University Hospital between May 2019 and May 2022. Periodontal inflamed surface area (PISA) scores were determined to assess periodontitis severity using modified Nesse's methods. Propensity score matching was used to compare patients with high and low PISA scores (> or < the median PISA score of 92.4, respectively). Propensity scores were calculated using a logistic regression model, based on 17 clinical parameters: age, sex, smoking, alcohol consumption, hypertension, diabetes, dyslipidemia, cardiovascular disease, stroke, clinical stage, surgical procedure, surgical approach, neoadjuvant chemotherapy, surgery duration, blood loss during surgery, remaining teeth, and denture use.

RESULTS

Thirty-seven patients were propensity-score-matched. Participants with high PISA scores had a higher incidence of surgical site infection (10.5%) than those with low PISA scores (5.3%). Moreover, participants with high PISA scores had significantly higher C-reactive protein levels on postoperative days 1 than those with low PISA scores.

CONCLUSION

Preoperative periodontitis may determine the level of postoperative systemic inflammation in patients with gastric cancer.

Does improving basic public health services promote household consumption of rural migrant workers? Evidence from China

Background

Transforming rural migrant workers' consumption potential into a consumption booster requires ensuring their equal rights as urban residents. The adequate access to Basic Public Health Services (BPHS) help effectively tackle rural migrant workers' health challenges and promote the well-being of this vulnerable population. Assessing the welfare effects of BPHS through a consumption perspective offers valuable insights and provides policy implications for enhancing the equity of BPHS and achieving common prosperity.

Methods

Utilizing the household-level data from China Migrants Dynamic Survey 2017 (CMDS 2017), this study comprehensively evaluated the effects of BPHS on rural migrant workers' household consumption by combining the methods of OLS, PSM, and IV.

Results

The enhancement of BPHS promotes rural migrant workers' household consumption even after considering endogeneity problems. Mechanism analysis indicates that BPHS imposes its positive effects on rural migrant workers through improving health literacy and increasing citizenization willingness. Furthermore, we identified heterogeneous effects across individual and household characteristics of rural migrant workers, and their flow patterns.

Conclusion

Our analysis indicates that BPHS plays a greater role in promoting household consumption of socially vulnerable groups, such as trans-provincial migration, rural migrant workers in old generations, and with lower-level income. Overall, these results suggest that the welfare effects of BPHS are inclusive in China.

Optimizing treatment allocation in randomized clinical trials by leveraging baseline covariates

We consider the problem of optimizing treatment allocation for statistical efficiency in randomized clinical trials. Optimal allocation has been studied previously for simple treatment effect estimators such as the sample mean difference, which are not fully efficient in the presence of baseline covariates. More efficient estimators can be obtained by incorporating covariate information, and modern machine learning methods make it increasingly feasible to approach full efficiency. Accordingly, we derive the optimal allocation ratio by maximizing the design efficiency of a randomized trial, assuming that an efficient estimator will be used for analysis. We then expand the scope of optimization by considering covariate-dependent randomization (CDR), which has some flavor of an observational study but provides the same level of scientific rigor as a standard randomized trial. We describe treatment effect estimators that are consistent, asymptotically normal, and (nearly) efficient under CDR, and derive the optimal propensity score by maximizing the design efficiency of a CDR trial (under the assumption that an efficient estimator will be used for analysis). Our optimality results translate into optimal designs that improve upon standard practice. Real-world examples and simulation results demonstrate that the proposed designs can produce substantial efficiency improvements in realistic settings.

Impact of nonmalignant ascites on outcomes of open inguinal hernia repair in the USA

PURPOSE

Studies on inguinal hernia repair in patients with ascites are limited, small, and inconsistent, exacerbating a challenging clinical dilemma for surgeons. To fill this gap in the literature, this retrospective cohort study used a national US database to examine the impact of ascites on the outcomes of open inguinal herniorrhaphy.

METHODS

Patients who underwent open inguinal herniorrhaphy between 2005 and 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Two groups were defined by the presence or absence of nonmalignant preoperative ascites. Ascites patients were propensity matched 1:10 with non-ascites patients. Surgical outcomes at 30 days for the matched groups, stratified by electiveness of procedure, were compared, with the primary end points of mortality and the NSQIP composite outcome "serious complication".

RESULTS

The study included 682 patients with ascites. Compared to matched controls, those with ascites had significantly increased odds of mortality (OR 3.3, 95% CI 1.5-7.0) after elective repair, but not after nonelective repair. Ascites was associated with increased odds of serious complication after both elective (OR 1.7, 1.2-2.3) and nonelective (OR 2.0, 1.3-3.0) surgery. Among ascites patients, age ≥ 65 years was associated with increased mortality (risk-adjusted OR 3.8, 1.2-14.4) and serious complication (OR 2.2, 1.2-3.9).

CONCLUSION

In this largest study to date on patients with ascites undergoing open inguinal herniorrhaphy, ascites increased the odds of mortality after elective repair and of serious complication after elective and nonelective repair. Age ≥ 65 was a risk factor for poor outcome. Inguinal herniorrhaphy is fraught with complications in this population.

Efficient algorithms for building representative matched pairs with enhanced generalizability

Many recent efforts center on assessing the ability of real-world evidence (RWE) generated from non-randomized, observational data to produce results compatible with those from randomized controlled trials (RCTs). One noticeable endeavor is the RCT DUPLICATE initiative. To better reconcile findings from an observational study and an RCT, or two observational studies based on different databases, it is desirable to eliminate differences between study populations. We outline an efficient, network-flow-based statistical matching algorithm that designs well-matched pairs from observational data that resemble the covariate distributions of a target population, for instance, the target-RCT-eligible population in the RCT DUPLICATE initiative studies or a generic population of scientific interest. We demonstrate the usefulness of the method by revisiting the inconsistency regarding a cardioprotective effect of the hormone replacement therapy (HRT) in the Women's Health Initiative (WHI) clinical trial and corresponding observational study. We found that the discrepancy between the trial and observational study persisted in a design that adjusted for the difference in study populations' cardiovascular risk profile, but seemed to disappear in a study design that further adjusted for the difference in HRT initiation age and previous estrogen-plus-progestin use. The proposed method is integrated into the R package match2C.

Intensive Versus Traditional Cardiac Rehabilitation: Mortality and Cardiovascular Outcomes in a 2016-2020 Retrospective Medicare Cohort

BACKGROUND

Traditional cardiac rehabilitation (CR) improves cardiovascular outcomes and reduces mortality, but less is known about the relative benefit of intensive CR (ICR) which incorporates greater lifestyle education through 72 sessions (versus 36 in CR). Our objective was to determine whether ICR is associated with a mortality and cardiovascular benefit compared with CR.

METHODS

Retrospective cohort study of Medicare Fee-For-Service beneficiaries in a 100% sample, claims data set. Qualifying events were captured from May 1, 2016 to December 31, 2019 and ICR/CR utilization captured from May 1, 2016 to December 31, 2020. Among patients attending at least 1 day of either CR or ICR, Cox proportional hazards models using a 1 to 5 propensity score match were used to compare utilization and the association of ICR versus CR participation with (1) all-cause mortality and (2) cardiovascular-related hospitalizations or nonfatal cardiac events. Dose-response was assessed by the number of days attended.

RESULTS

From 2016 to 2019, 1 277 358 unique patients met at least one qualifying indication for ICR/CR from 2016 to 2019. Of these, 262 579 (20.6%) and 4452 (0.4%) attended at least one session of CR or ICR, respectively (mean [SD] age, 73.2 [7.8] years; 32.3% female). In the matched sample, including 26 659 total patients (median, 2.4-year follow-up), ICR was associated with 12% lower all-cause mortality (multivariable adjusted hazard ratio, 0.88 [95% CI, 0.78-0.99]; P=0.036) compared with CR but no significant difference for cardiovascular-related hospitalization or nonfatal cardiac events. The mortality benefit was seen for both ICR and CR per day strata, with each modality demonstrating a clear dose-response benefit.

CONCLUSIONS

ICR is associated with lower mortality than traditional CR among Medicare beneficiaries but no difference in cardiovascular-related hospitalization or nonfatal cardiac events. Moreover, ICR and CR demonstrate a dose-response relationship for mortality. Additional studies are needed to confirm these observations and to better understand the mechanisms by which ICR may lead to a reduction in mortality.

Postoperative norepinephrine versus dopamine in patients undergoing noncardiac surgery: a propensity-matched analysis using a nationwide intensive care database

BACKGROUND

Choosing catecholamines, such as norepinephrine and dopamine, for perioperative blood pressure control is essential for anesthesiologists and intensivists. However, studies specific to noncardiac surgery are limited. Therefore, we aimed to evaluate the effects of postoperative norepinephrine and dopamine on clinical outcomes in adult noncardiac surgery patients by analyzing a nationwide intensive care patient database.

METHODS

The Japanese Intensive care PAtient Database (JIPAD) was used for this multicenter retrospective study. Adult patients in the JIPAD who received norepinephrine or dopamine within 24 h after noncardiac surgery in 2018-2020 were included. We compared the norepinephrine and dopamine groups using a one-to-one propensity score matching analysis. The primary outcome was in-hospital mortality. Secondary outcomes were intensive care unit (ICU) mortality, hospital length of stay, and ICU length of stay.

RESULTS

A total of 6,236 eligible patients from 69 ICUs were allocated to the norepinephrine (n = 4,652) or dopamine (n = 1,584) group. Propensity score matching was used to create a matched cohort of 1,230 pairs. No differences in the in-hospital mortality was found between the two propensity score matched groups (risk difference: 0.41%, 95% CI [-1.15, 1.96], P = 0.608). Among the secondary outcomes, only the ICU length of stay was significantly shorter in the norepinephrine group than in the dopamine group (median length: 3 vs. 4 days, respectively; P < 0.001).

CONCLUSIONS

In adult patients after noncardiac surgery, norepinephrine was not associated with decreased mortality but was associated with a shorter ICU length of stay than dopamine.

Neurodevelopmental outcomes in children after prenatal marijuana exposure

BACKGROUND

The effect of prenatal marijuana exposure (PME) on child neurodevelopment remains poorly understood. Prior studies have demonstrated inconsistent results.

OBJECTIVES

This study evaluated the association between PME and neuropsychological test scores in late childhood and early adulthood, accounting for a wide range of parental characteristics.

METHODS

This study evaluated participants from the Raine Study, a cohort of 2868 children born between 1989 and 1992. Children whose mothers provided information on marijuana use during pregnancy were included. The primary outcome was the Clinical Evaluation of Language Fundamentals (CELF) at age 10. Secondary outcomes included the Peabody Picture Vocabulary Test (PPVT), Child Behaviour Checklist (CBCL), McCarron Assessment of Neuromuscular Development (MAND), Coloured Progressive Matrices (CPM), Symbol Digit Modality Test (SDMT) and Autism Spectrum Quotient (AQ) scores. Exposed and unexposed children were matched by propensity score using optimal full matching. Missing covariate data were imputed using multiple imputation. Inverse probability of censoring weighting (IPCW) was used to adjust for missing outcome data. Linear regression within matched sets, adjusted by IPCW, evaluated score differences between exposed and unexposed children. As a secondary analysis, modified Poisson regression, adjusted by match weights and IPCW, evaluated the risk of clinical deficit in each outcome following PME.

RESULTS

Of the 2804 children in this cohort, 285 (10.2%) had PME. After optimal full matching and IPCW, exposed children scored similarly on CELF Total (-0.33 points, 95% confidence interval [CI] -4.71, 4.05), Receptive (+0.65 points, 95% CI -4.08, 5.38) or Expressive (-0.53 points, 95% CI -5.07, 4.02). PME was not associated with secondary outcomes or risks of clinical deficit in any neuropsychological assessments.

CONCLUSIONS

After adjusting for sociodemographic and clinical covariates, PME was not associated with worse neuropsychological test scores at age 10 or autistic traits at 19-20.

Determining the effect of one decade on fitness of elite Austrian youth soccer players using propensity score matching

Current trends in attacking strategies and increases in external workload have led to a need for fast and well-conditioned athletes in modern soccer. More recently, progressions in speed, coordination, power and endurance were found over a decade in elite Austrian youth players. However, possible confounders such as relative age, maturation, learning effects, and academy philosophy may have influenced these changes. The present study aimed to determine the decade effect on fitness under statistical control of players' exact age, height, body mass, test location as well as total number of pretests and time interval between test and pretest. Players annually completed a battery of anthropometric, general and soccer-specific fitness tests. MANCOVA was calculated to identify the overall impacts of the covariates on fitness. To balance the covariates of initially 2,530 "former" (2002 to 2005) and 2,611 "recent" (2012 to 2015) players, 1:1 nearest neighbor propensity score (PS) matching was used, resulting in 587 U13, 573 U14, 475 U15, 325 U16, 262 U17, and 129 U18 matched pairs. The decade effect on fitness was assessed by independent t-tests and Cohen's d separately at each age group. Superior performances of recent players were found for linear sprint across all age categories (d = 0.154-0.476) as well as for agility (d = 0.125-0.340) and change-of-direction speed (d = 0.172-0.466) in U15 to U18. Reaction speed increased in U13 (d = 0.288) and U15 (d = 0.310). Flexibility reduced over the decade in all age categories (d = -0.151 to -0.589) and upper-limb power decreased (d = -0.278 to -0.347) in U13 and U14. Balancing the covariate distribution via PS matching generally confirmed previous findings, with fitness decade effects reflecting the athletic needs for modern soccer. Since fitness performance changed over time, reference values should be periodically updated. Coaches favor both physical and cognitive fast players nowadays. Thus, training should target all aspects of speed, without disregarding flexibility, upper-limb power and other preventive strategies that keep the players on the pitch.

Causal effect estimation for multivariate continuous treatments

Causal inference is widely used in various fields, such as biology, psychology, and economics, etc. In observational studies, balancing the covariates is an important step in estimating the causal effect. This study extends the one-dimensional entropy balancing method to multiple dimensions to balance the covariates. Both parametric and nonparametric methods are proposed to estimate the causal effect of multivariate continuous treatments and theoretical properties of the two estimations are provided. Furthermore, the simulation results show that the proposed method is better than other methods in various cases. Finally, the proposed method is applied to analyze the impact of the duration and frequency of smoking on medical expenditure. The results from the parametric method indicate that the frequency of smoking increases medical expenditure while the duration of smoking does not. The results from the nonparametric method indicate that there is a short-term downward trend and then a long-term upward trend as the duration and frequency of smoking increase.

Model-Selection Inference for Causal Impact of Clusters and Collaboration on MSMEs in India

Do firms benefit more from agglomeration-based spillovers than the technical know-how obtained through inter-firm collaboration? Quantifying the relative value of the industrial policy of cluster development vis-à-vis firm's internal decision of collaboration can be valuable for policy-makers and entrepreneurs. I observe the universe of Indian MSMEs inside an industrial cluster (Treatment Group 1), those in collaboration for technical know-how (Treatment Group 2) and those outside clusters with no collaboration (Control Group). Conventional econometric methods to identify the treatment effects would suffer from selection bias and misspecification of the model. I use two data-driven, model-selection methods, developed by (Belloni, A., Chernozhukov, V., and Hansen, C. (2013). Inference on treatment e ects after selection among high-dimensional controls. Review of Economic Studies, 81(2):608 650.) and (Chernozhukov, V., Hansen, C., and Spindler, M. (2015). Post selection and post regulariza- tion inference in linear models with many controls and instruments. American Economic Review, 105(5):486 490.), to estimate the causal impact of the treatments on GVA of firms. The results suggest that ATE of cluster and collaboration is nearly equal at 30%. I conclude by offering policy implications.

Anticoagulant Treatment Adherence and Persistence in German Patients with Atrial Fibrillation

INTRODUCTION

Treatment adherence and persistence impact the effectiveness of edoxaban for the prevention of thromboembolism in patients with atrial fibrillation (AF). The objective of this analysis was to assess adherence and persistence of edoxaban vs. other non-vitamin K antagonist oral anticoagulants (NOACs) and vitamin K antagonists (VKAs).

METHODS

Utilizing a German claims database, adults with AF with the first pharmacy claim identified for edoxaban, apixaban, dabigatran, rivaroxaban, or VKAs from January 2013 to December 2017 were included in a propensity score-matched analysis. The first pharmacy claim was the index claim. Adherence (i.e., proportion of days covered [PDC]) and persistence (proportion of patients who continued therapy) were compared between edoxaban and other therapies. Patients receiving once-daily (QD) vs. twice-daily (BID) NOAC were also analyzed.

RESULTS

Overall, 21,038 patients were included (1236 edoxaban, 6053 apixaban, 1306 dabigatran, 7013 rivaroxaban, and 5430 VKA). After matching, baseline characteristics were well balanced across cohorts. Adherence was significantly higher for edoxaban vs. apixaban, dabigatran, and VKAs (all P < 0.0001). Significantly more edoxaban patients continued therapy vs. rivaroxaban (P = 0.0153), dabigatran (P < 0.0001), and VKAs (P < 0.0001). Time to discontinuation was significantly longer for edoxaban vs. dabigatran, rivaroxaban, and VKAs (all P < 0.0001). More patients receiving NOACs QD had a PDC ≥ 0.8 compared with those receiving NOACs BID (65.3 vs. 49.6%, respectively; P < 0.05); persistence rates were comparable between QD and BID groups.

CONCLUSIONS

Patients with AF receiving edoxaban had significantly higher adherence and persistence compared with those receiving VKAs. This trend was also seen in NOAC QD regimens vs. NOAC BID regimens for adherence. These results provide insight into how adherence and persistence may contribute to the effectiveness of edoxaban for stroke prevention in patients with AF in Germany.

Assessment of Corticosteroid Therapy and Death or Disability According to Pretreatment Risk of Death or Bronchopulmonary Dysplasia in Extremely Preterm Infants

Importance

Meta-analyses suggest that corticosteroids may be associated with increased survival without cerebral palsy in infants at high risk of bronchopulmonary dysplasia (BPD) but are associated with adverse neurologic outcomes in low-risk infants. Whether this association exists in contemporary practice is uncertain because most randomized clinical trials administered corticosteroids earlier and at higher doses than currently recommended.

Objective

To evaluate whether the pretreatment risk of death or grade 2 or 3 BPD at 36 weeks' postmenstrual age modified the association between postnatal corticosteroid therapy and death or disability at 2 years' corrected age in extremely preterm infants.

Design, Setting, and Participants

This cohort study analyzed data on 482 matched pairs of infants from 45 participating US hospitals in the National Institute of Child Health and Human Development Neonatal Research Network Generic Database (GDB). Infants were included in the cohort if they were born at less than 27 weeks' gestation between April 1, 2011, and March 31, 2017; survived the first 7 postnatal days; and had 2-year death or developmental follow-up data collected between January 2013 and December 2019. Corticosteroid-treated infants were propensity score matched with untreated controls. Data were analyzed from September 1, 2019, to November 30, 2022.

Exposure

Systemic corticosteroid therapy to prevent BPD that was initiated between day 8 and day 42 after birth.

Main Outcomes and Measures

The primary outcome was death or moderate to severe neurodevelopmental impairment at 2 years' corrected age. The secondary outcome was death or moderate to severe cerebral palsy at 2 years' corrected age.

Results

A total of 482 matched pairs of infants (mean [SD] gestational age, 24.1 [1.1] weeks]; 270 males [56.0%]) were included from 656 corticosteroid-treated infants and 2796 potential controls. Most treated infants (363 [75.3%]) received dexamethasone. The risk of death or disability associated with corticosteroid therapy was inversely associated with the estimated pretreatment probability of death or grade 2 or 3 BPD. The risk difference for death or neurodevelopmental impairment associated with corticosteroids decreased by 2.7% (95% CI, 1.9%-3.5%) for each 10% increase in the pretreatment risk of death or grade 2 or 3 BPD. This risk transitioned from estimated net harm to benefit when the pretreatment risk of death or grade 2 or 3 BPD exceeded 53% (95% CI, 44%-61%). For death or cerebral palsy, the risk difference decreased by 3.6% (95% CI, 2.9%-4.4%) for each 10% increase in the risk of death or grade 2 or 3 BPD and transitioned from estimated net harm to benefit at a pretreatment risk of 40% (95% CI, 33%-46%).

Conclusions and Relevance

Results of this study suggested that corticosteroids were associated with a reduced risk of death or disability in infants at moderate to high pretreatment risk of death or grade 2 or 3 BPD but with possible harm in infants at lower risk.

Cream skimming and discrimination in access to medical care: A field experiment

This study measures the differences in access to healthcare for female patients in France in three medical specialties (dentistry, gynecology and psychiatry) according to two criteria: the African ethnicity of the patient and the benefit of having means-tested health insurance coverage. To this purpose, we conducted a nationally representative field experiment on more than 1500 physicians. We do not find substantial discrimination against the patient of African origin. However, the results indicate that patients with means-tested health insurance coverage are less likely to get an appointment. Differentiating between two types of coverage, we show that the lesser-known coverage (ACS) is more penalized than the other (CMU-C) as poor knowledge of the program increases the physician's expectation of additional administrative tasks and is an important element to explain cream-skimming. We also find that, for physicians who are free to set their fees, the opportunity cost of accepting a means-tested patient increases the penalty. Finally, the results suggest that enrollment in OPTAM, the controlled pricing practice option that incentivizes physicians to accept means-tested patients, reduces cream-skimming.

A Payer-Provider Partnership for Endocrine Targeted Automatic eConsults: Implementation and Early Impact on Diabetes and Cost Outcomes

In the United States, many individuals with diabetes mellitus (DM) do not achieve treatment goals despite the availability of effective interventions. Provider clinical inertia is one cause of these unfavorable outcomes. Targeted automatic eConsults (TACos) are an emerging technology-based intervention with potential to address clinical inertia in primary care (PC). TACos prospectively identify at-risk patients and use unsolicited specialist recommendations to prompt treatment intensification. Through a payer-provider collaboration, a TACos intervention was piloted for adults with uncontrolled DM (HbA1c >8%) to understand impact on DM clinical inertia and outcomes. Clinical inertia was assessed by measuring whether a PC provider implemented recommended therapeutic changes. Six-month changes in HbA1c and health care costs per member per month were evaluated using an observational matched design and intention-to-treat (ITT) analysis. The analysis included 196 individuals who received a TACos between February 2021 and August 2021 (ITT group) matched to 392 controls based on clinical and demographic criteria. TACos recommendations were implemented 65% of the time. Median percent change in HbA1c was significantly greater for the ITT group versus controls (-10.9% vs. -10.2%; P = 0.0359). Median total costs were 7.9% lower in the ITT group (P = 0.0900). A per protocol analysis was done to examine effects between ITT group individuals with an implemented TACos recommendation (n = 126) and controls. Median percent change in HbA1c was significantly greater (-19.5% vs. -10.2%; P < 0.0001), but there was no difference in total costs (-7.9%; P = 0.1753). TACos may feasibly address clinical inertia in PC and improve HbA1c for uncontrolled DM.

Effects of menthol use and transitions in use on short-term and long-term cessation from cigarettes among US smokers

OBJECTIVES

To estimate the effect of menthol use and transitions in use (switching to or from menthol) on short-term and long-term cessation from cigarette smoking and whether this differed across demographic groups (age, sex, race).

METHODS

We compared the probability of 30+ day and 12-month abstinence from cigarette smoking by menthol use status using two cohorts of US adult cigarette smokers who attempted to quit smoking in the Population Assessment of Tobacco and Health (wave 1 to wave 3 and wave 2 to wave 4; n=5759), inverse probability of treatment weighting and adjusted risk ratios (aRRs).

RESULTS

Using menthol (vs non-menthol) prior to a quit attempt decreased the probability of 30+ day abstinence by 28% (aRR=0.78; 95% CI 0.67 to 0.91) and the probability of 12-month abstinence by 53% (aRR=0.65; 95% CI 0.47 to 0.88). Additionally, switching from menthol (vs maintaining menthol use) increased the probability of 30+ day abstinence by 58% (aRR=1.58; 95% CI 1.00 to 2.50) and the probability of 12-month abstinence by 97% (aRR=1.86; 95% CI 0.92 to 3.74). Switching to menthol (vs maintaining non-menthol use) was associated with a lower probability of 30+ day (aRR=0.70; 95% CI 0.42 to 1.16) and 12-month abstinence (aRR=0.64; 95% CI 0.30 to 1.36), but these associations were imprecise. The effects of menthol use on impaired quitting were slightly larger for non-Hispanic Black smokers, but not different for other demographic groups.

CONCLUSION

These results demonstrate that menthol impaired menthol smokers' attempts to quit smoking but switching from menthol improved success. This suggests that removing menthol may improve menthol smokers' success during quit attempts.

Consequences of early thyroid ultrasound on subsequent tests, morbidity and costs: an explorative analysis of routine health data from German ambulatory care

OBJECTIVES

This study aims to evaluate whether the use of thyroid ultrasound (US) early in the work-up of suspected thyroid disorders triggers cascade effects of medical procedures and to analyse effects on morbidity, healthcare usage and costs.

STUDY DESIGN

Retrospective analysis of claims data from ambulatory care (2012-2017).

SETTING

Primary care in Bavaria, Germany, 13 million inhabitants.

PARTICIPANTS

Patients having received a thyroid stimulating hormone (TSH) test were allocated to (1) observation group: TSH test followed by an early US within 28 days or (2) control group: TSH test, but no early US. Propensity score matching was used adjusting for socio-demographic characteristics, morbidity and symptom diagnosis (N=41 065 per group after matching).

PRIMARY AND SECONDARY OUTCOME MEASURES

Using cluster analysis, groups were identified regarding frequency of follow-up TSH tests and/or US and compared.

RESULTS

Four subgroups were identified: cluster 1: 22.8% of patients, mean (M)=1.6 TSH tests; cluster 2: 16.6% of patients, M=4.7 TSH tests; cluster 3: 54.4% of patients, M=3.3 TSH tests, 1.8 US; cluster 4: 6.2% of patients, M=10.9 TSH tests, 3.9 US. Overall, reasons that explain the tests could rarely be found. An early US was mostly found in clusters 3 and 4 (83.2% and 76.1%, respectively, were part of the observation group). In cluster 4 there were more women, thyroid-specific morbidity and costs were higher and the early US was more likely to be performed by specialists in nuclear medicine or radiologists.

CONCLUSION

Presumably unnecessary tests in the field of suspected thyroid diseases seem to be frequent, contributing to cascades effects. Neither German nor international guidelines provide clear recommendations for or against US screening. Therefore, guidelines on when to apply US and when not are urgently needed.

A latent class model to multiply impute missing treatment indicators in observational studies when inferences of the treatment effect are made using propensity score matching

Analysts often estimate treatment effects in observational studies using propensity score matching techniques. When there are missing covariate values, analysts can multiply impute the missing data to create m completed data sets. Analysts can then estimate propensity scores on each of the completed data sets, and use these to estimate treatment effects. However, there has been relatively little attention on developing imputation models to deal with the additional problem of missing treatment indicators, perhaps due to the consequences of generating implausible imputations. However, simply ignoring the missing treatment values, akin to a complete case analysis, could also lead to problems when estimating treatment effects. We propose a latent class model to multiply impute missing treatment indicators. We illustrate its performance through simulations and with data taken from a study on determinants of children's cognitive development. This approach is seen to obtain treatment effect estimates closer to the true treatment effect than when employing conventional imputation procedures as well as compared to a complete case analysis.

Short-term effect of colorectal cancer on income: analysis of an Italian cohort

INTRODUCTION

The ability to return to work after a cancer diagnosis is a key aspect of cancer survivorship and quality of life. Studies have reported a significant risk of income loss for cancer survivors; however, there is limited evidence of the Italian context.

METHODS

The Work Histories Italian Panel (WHIP)-Salute database was used to select a cohort of incident cases of colorectal cancer (CRC) among workers in the private sector, based on hospital discharges. A propensity score matching was used to find a balanced control group for several confounders. Ordinary least square and logistic regressions were used to estimate the effect of a CRC diagnosis on annual income and the probability of switching from a full-time contract to a part-time one considering 3 years after the diagnosis.

RESULTS

Overall, we identified 925 CRC incident cases from 2006 until 2012. Our results confirm a statistically significant reduction in survivors' income compared with controls. This reduction was greater in the first year and then tend to decrease, with an average income loss over 3 years of about €12 000. Stratified analyses by sex and position confirmed the overall trend while indicating a strong effect modification. Regarding the switching from full-time to part-time employment, the results were never significant.

CONCLUSION

Income loss does not seem to be related to an increase in part-time contracts, but rather to survivors' reduced work capacity following the invasive treatments. Further research is needed to investigate the complex dynamics behind this association.

Comparative Effectiveness of Left Atrial Appendage Occlusion Versus Oral Anticoagulation by Sex

BACKGROUND

The comparative real-world outcomes of older patients with atrial fibrillation (AF) treated with anticoagulation compared with left atrial appendage occlusion (LAAO) may be different from those in clinical trials because of differences in anticoagulation strategies and patient demographics, including a greater proportion of women. We sought to compare real-world outcomes between older patients with AF treated with anticoagulation and those treated with LAAO by sex.

METHODS

Using Medicare claims data from 2015 to 2019, we identified LAAO-eligible beneficiaries and divided them into sex subgroups. Patients receiving LAAO were matched 1:1 to those receiving anticoagulation alone through propensity score matching. The risks of mortality, stroke or systemic embolism, and bleeding were compared between matched groups with adjustment for potential confounding characteristics in Cox proportional hazards models.

RESULTS

Among women, 4085 LAAO recipients were matched 1:1 to those receiving anticoagulation; among men, 5378 LAAO recipients were similarly matched. LAAO was associated with a significant reduction in the risk of mortality for women and men (hazard ratio [HR], 0.509 [95% CI, 0.447-0.580]; and HR, 0.541 [95% CI, 0.487-0.601], respectively; P<0.0001), with a similar finding for stroke or systemic embolism (HR, 0.655 [95% CI, 0.555-0.772]; and HR, 0.649 [95% CI, 0.552-0.762], respectively; P<0.0001). Bleeding risk was significantly greater in LAAO recipients early after implantation but lower after the 6-week periprocedural period for women and men (HR, 0.772 [95% CI, 0.676-0.882]; and HR, 0.881 [95% CI, 0.784-0.989], respectively; P<0.05).

CONCLUSIONS

In a real-world population of older Medicare beneficiaries with AF, compared with anticoagulation, LAAO was associated with a reduction in the risk of death, stroke, and long-term bleeding among women and men. These findings should be incorporated into shared decision-making with patients considering strategies for reduction in AF-related stroke.

Hurdles and signposts on the road to virtual control groups-A case study illustrating the influence of anesthesia protocols on electrolyte levels in rats

Introduction: Virtual Control Groups (VCGs) represent the concept of using historical control data from legacy animal studies to replace concurrent control group (CCG) animals. Based on the data curation and sharing activities of the Innovative Medicine Initiatives project eTRANSAFE (enhancing TRANSlational SAFEty Assessment through Integrative Knowledge Management) the ViCoG working group was established with the objectives of i) collecting suitable historical control data sets from preclinical toxicity studies, ii) evaluating statistical methodologies for building adequate and regulatory acceptable VCGs from historical control data, and iii) sharing those control-group data across multiple pharmaceutical companies. During the qualification process of VCGs a particular focus was put on the identification of hidden confounders in the data sets, which might impair the adequate matching of VCGs with the CCG. Methods: During our analyses we identified such a hidden confounder, namely, the choice of the anesthetic procedure used in animal experiments before blood withdrawal. Anesthesia using CO₂ may elevate the levels of some electrolytes such as calcium in blood, while the use of isoflurane is known to lower these values. Identification of such hidden confounders is particularly important if the underlying experimental information (e.g., on the anesthetic procedure) is not routinely recorded in the standard raw data files, such as SEND (Standard for Exchange of Non-clinical Data). We therefore analyzed how the replacement of CCGs with VCGs would affect the reproducibility of treatment-related findings regarding electrolyte values (potassium, calcium, sodium, and phosphate). The analyses were performed using a legacy rat systemic toxicity study consisting of a control and three treatment groups conducted according to pertinent OECD guidelines. In the report of this study treatment-related hypercalcemia was reported. The rats in this study were anesthetized with isoflurane. Results: Replacing the CCGs with VCGs derived from studies comprising both anesthetics resulted in a shift of control electrolyte parameters. Instead of the originally reported hypercalcemia the use of VCG led to fallacious conclusions of no observed effect or hypocalcemia. Discussion: Our study highlights the importance of a rigorous statistical analysis including the detection and elimination of hidden confounders prior to the implementation of the VCG concept.

In sight, in mind: Spatial proximity to protest sites and changes in peoples' political attitudes

Occupying public spaces can be an effective tactic for conveying a semantic message of protest and gaining wider support; however, it may also severely disrupt the everyday lives of non-participants and causes a backfire. Therefore, it remains unclear whether and how the occupy movements have shifted political attitudes among the general public. Bringing a social-spatial perspective to the case of the Occupy Central Movement (OCM) in Hong Kong, this study investigates how the attitudinal impact of occupation has varied according to people's spatial proximity to the protest sites. Using two waves of individual-level panel data collected right before and after the OCM and detailed geo-information on the respondents' home addresses and the occupied areas, we apply a difference-in-differences (DIDs) design to identify the causal link between space and attitudes. In addition, propensity score matching (PSM) methods are used to ensure the comparability of nearby and faraway residents. The results show that after the OCM, residents living near the occupied areas not only maintained their support for the pro-democracy camp but also became more liberal as compared to faraway residents. This phenomenon can be explained by the "on-site" effect, which suggests that the direct exposure to protestors' solidarity and the repressive actions of authorities arouse bystanders' sympathy for the protestors and support for their political cause. Such influence appears to be long-lasting and can be evidenced by the local election results after the protest.

Nursing homes and mortality in Europe: Uncertain causality

The current health crisis has particularly affected the elderly population. Nursing homes have unfortunately experienced a relatively large number of deaths. On the basis of this observation and working with European data (from SHARE), we want to check whether nursing homes were lending themselves to excess mortality even before the pandemic. Controlling for a number of important characteristics of the elderly population in and outside nursing homes, we conjecture that the difference in mortality between those two samples is to be attributed to the way nursing homes are designed and organized. Using matching methods, we observe excess mortality in Sweden, Belgium, Germany, Switzerland, Czech Republic and Estonia but not in the Netherlands, Denmark, Austria, France, Luxembourg, Italy and Spain. This raises the question of the organization and management of these nursing homes, but also of their design and financing.

Effects of electroconvulsive therapy on the use of anxiolytics and sleep medications: a propensity score-matched analysis

AIM

We investigated the association of electroconvulsive therapy (ECT) with anxiolytic and sleep medication use in patients with major depressive disorder (MDD) and schizophrenia (SZ).

METHODS

This nationwide observational study analyzed data from 3483 MDD inpatients and 6663 SZ inpatients. Patients with MDD and SZ were classified into those who underwent ECT during hospitalization and those who did not. A propensity score-matching method was performed to adjust for preadmission characteristics and clinical information, which were expected bias between the two groups. Rates of anxiolytic and sleep medication use at discharge were compared in the matched sample.

RESULTS

500 MDD patients were assigned to both groups. In the matched MDD sample, the rate of anxiolytic and sleep medication use at discharge was significantly lower in the ECT group than in the non-ECT group (64.9% vs. 75.8%, P = 1.7 × 10^-4 ). In the ECT group, the rate of anxiolytic and sleep medication use at discharge was significantly lower than that prior to admission (64.9% vs. 73.2%, P = 1.2 × 10^-14 ). 390 SZ patients were allocated. In the matched SZ sample, the ECT group was not significantly different from the non-ECT group in the rate of anxiolytics and sleep medications use at discharge (61.3% vs. 68.2%, P = 4.3 × 10^-2 ). In the ECT group, the rate of anxiolytics and sleep medications use at discharge was significantly lower than that before admission (61.3% vs. 70.5%, P = 4.4 × 10^-4 ), although this was not the primary outcome.

CONCLUSION

Reduction of anxiolytic and sleep medication use may be considered positively when ECT is indicated for treatment of MDD.

Effectiveness of early colonoscopy in patients with colonic diverticular hemorrhage: A single-center retrospective cohort study

BACKGROUND

Current guidelines recommend colonoscopy within 24 h for acute lower gastrointestinal bleeding; however, the evidence in support for colonic diverticular hemorrhage (CDH) indications remains insufficient.

AIM

To investigate the effectiveness of early colonoscopy on the length of hospital stay for CDH patients.

METHODS

We conducted a single-center retrospective cohort study. Patients who underwent colonoscopy within 24 h of presentation (early group) were compared with those who underwent colonoscopy beyond 24 h of presentation (elective group). The primary outcome was the length of hospital stay, and secondary outcomes were the identification of stigmata of recent hemorrhage (SRH), rebleeding, red blood cell transfusion more than 4 units, and interventional radiology and abdominal surgery after colonoscopy.

RESULTS

We identified 574 CDH cases. Patients were divided into the early (n = 328) and elective (n = 226) groups. After propensity score matching, 191 pairs were generated. The length of hospital stay did not significantly differ between the two groups (early group vs elective group; median, 7 vs 8 d; P = 0.10). The early group had a significantly high identification of SRH (risk difference, 11.6%; 95%CI: 2.7 to 20.3; P = 0.02). No significant differences were found in the rebleeding (risk difference, 4.7%; 95%CI: -4.1 to 13.5; P = 0.35), red blood cell transfusion more than 4 units (risk difference, 1.6%; 95%CI: -7.5 to 10.6; P = 0.82), and interventional radiology and abdominal surgery rate after colonoscopy (risk difference, 0.5%; 95%CI: -2.2 to 3.2; P = 1.00).

CONCLUSION

Early colonoscopy within 24 h, on arrival for CDH, could not improve the length of hospital stay.

Implementation of systematic safety checklists in a neurocritical care unit: a quality improvement study

BACKGROUND AND OBJECTIVES

Structured and systematised checklists have been shown to prevent complications and improve patient care. We evaluated the implementation of systematic safety checklists in our neurocritical care unit (NCCU) and assessed its effect on patient outcomes.

DESIGN/METHODS

This quality improvement project followed a Plan-Do-Study-Act (PDSA) methodology. A checklist for medication reconciliation, thromboembolic prophylaxis, glycaemic control, daily spontaneous awakening, breathing trial, diet, catheter/lines duration monitoring and antibiotics de-escalation was implemented during daily patient rounds. Main outcomes included the rate of new infections, mortality and NCCU-length of stay (LOS). Intervened patients were compared with historical controls after propensity score and Euclidean distance matching to balance baseline covariates.

RESULTS

After several PDSA iterations, we applied checklists to 411 patients; the overall average age was 61.34 (17.39). The main reason for admission included tumour resection (31.39%), ischaemic stroke (26.76%) and intracerebral haemorrhage (10.95%); the mean Sequential Organ Failure Assessment (SOFA) score was 2.58 (2.68). At the end of the study, the checklist compliance rate throughout the full NCCU stays reached 97.11%. After controlling for SOFA score, age, sex and primary admitting diagnosis, the implementation of systematic checklists significantly correlated with a reduced LOS (ß=-0.15, 95% CI -0.24 to -0.06), reduced rate of any new infections (OR 0.59, 95% CI 0.40 to 0.87) and reduced urinary tract infections (UTIs) (OR 0.23, 95% CI 0.09 to 0.55). Propensity score and Euclidean distance matching yielded 382 and 338 pairs with excellent covariate balance. After matching, outcomes remained significant.

DISCUSSION

The implementation of safety checklists in the NCCU proved feasible, easy to incorporate into the NCCU workflow, and a helpful tool to improve adherence to practice guidelines and quality of care measurements. Furthermore, our intervention resulted in a reduced NCCU-LOS, rate of new infections and rate of UTIs compared with propensity score and Euclidean distance matched historical controls.

Finger Tapping Test for Assessing the Risk of Mild Cognitive Impairment

AIM

A testing method for early diagnosis of Mild cognitive dementia (MCI) that can be easily applied in clinical practice was investigated in this study. We examined whether MCI risk can be determined through finger movements.

METHODS

Between 2013 and 2020, 1097 individuals were screened. After applying propensity-score matching to adjust for variability between the groups, 173 individuals each in the mild cognitive impairment and control groups were selected. Thereafter, differences between groups in mean values of parameters extracted from finger tap movements were determined using unpaired t-test and effect size. Furthermore, area under the curve, sensitivity, and specificity were calculated from the receiver operating characteristic curve for parameters with significant difference.

RESULTS

A significant difference was observed, especially in the number of taps in the MCI group compared with that in the control group (p < .001; 95% CI, -12.7 to -8.8; r = 0.51). A cut-off value of 30 taps was applied (sensitivity, 0.77; specificity, 0.67; AUC, 0.79). Significant differences were also observed in rhythm-related parameters.

CONCLUSIONS

These parameters might be useful for capturing MCI risk. Finger taps are easily measured and may be suitable for screening large populations. This tool might be used as a supplemental method to increase the sensitivity of traditional cognitive tests.

Effectiveness of early colonoscopy in patients with colonic diverticular hemorrhage: Nationwide inpatient analysis in Japan

OBJECTIVES

Current guidelines recommend colonoscopy within 24 h for acute lower gastrointestinal bleeding; however, the evidence in support for colonic diverticular hemorrhage (CDH) indications remains insufficient. We use a nationwide database to investigate the effectiveness of early colonoscopy for CDH.

METHODS

We conducted a retrospective cohort study using the Japanese Diagnosis Procedure Combination inpatient database and identified patients who were admitted for CDH from 2010 to 2017. Patients who underwent colonoscopy on the same day of admission (early group) were compared with those who underwent colonoscopy on the next day of admission (elective group). The primary outcome was in-hospital mortality, and secondary outcomes were length of hospital stay, total hospitalization cost, fasting period, and the prevalence of re-colonoscopy, interventional radiology or abdominal surgery. Propensity score matching was used to adjust for confounders.

RESULTS

We identified 74,569 eligible patients. Patients were divided into the early (n = 46,759) and elective (n = 27,810) groups. After propensity score matching, 27,696 pairs were generated. In-hospital mortality did not significantly differ between the two groups (0.49% in the early group vs. 0.41% in the elective group; risk difference 0.08%; 95% confidence interval -0.02 to 0.19; P = 0.14). The early group had a significantly longer length of hospital stay, higher total hospitalization cost, longer fasting period, and higher prevalence of re-colonoscopy and abdominal surgery.

CONCLUSIONS

The effectiveness of early colonoscopy conducted on the same day of admission for CDH could not be confirmed. Early colonoscopy may not result in favorable outcomes in CDH patients.

Positive Demand Spillover of Popular App Adoption: Implications for Platform Owners’ Management of Complements

As platform owners interact with end users and complementors, their demand-side characteristics and performance affect the overall value creation of ecosystems. This research investigated how the emergence of popular complements on a mobile communication platform impacts the usage of other complements by the platform’s end users and how platform owners can benefit from such demand spillovers. Using individual user-level app usage data, we empirically demonstrated how the presence of a popular app alters the demand structure of a platform through changes in the usage of other apps operating within it. The findings reveal that popular app adoption by users increases the app usage, excluding the usage of popular apps, only within the platform offering a popular app, supporting the existence of positive spillovers from popular complement adoption on a platform. Such positive within-platform spillovers occur through the increased usage of both existing and new apps, with stronger positive spillovers for new apps. These findings imply that platform owners can reap benefits by coordinating the launch of new complements and the promotion of less-known counterparts to end users with the emergence of a popular app. All these results shed light on how platform owners can manage their complements and create value from popular complements.

Analysis of Voluntary Environmental Behavior and Innovation Quality of Chinese Textile Enterprises Based on Grounded Theory and Propensity Score Matching

At a new stage of “carbon peak” and “carbon neutral,” we need to strengthen the internal impetus of institutions and policies to promote ecological civilization construction. The initiative implementation of voluntary environmental behavior (VEB) is an effective way for enterprises to achieve high quality sustainable development. The VEB of enterprises include but are not limited to compliance with voluntary environmental regulations (VER). Different from the existing literature on enterprise VER, most of which are just the verification of ISO14001, the study conducts a comprehensive exploratory research on the theoretical framework of what is driving the VEB of Chinese textile enterprises. First, based on grounded theory, the paper coded the hand-collected environmental text information of Chinese listed textile enterprises from 2004 to 2018 and constructed a complete theoretical analysis framework from motivation to performance evaluation of enterprise VEB. Second, PSM method is taken to verify the conceptual model. As a result, we find the following: (1) in addition to ISO14001, the textile enterprises involve many industry-specific VER. (2) The VEB and VER of Chinese textile enterprises promote each other. (3) Either following VER or implementing VEB can effectively increase the innovation input and then actively improve the innovation quality of Chinese textile enterprises. In this way, the conclusion not only provides analysis ideas for future empirical research, but also offers practical suggestions to Chinese textile enterprises and policy makers for environmental management.

Abbreviated Screening MRI for Women with a History of Breast Cancer: Comparison with Full-Protocol Breast MRI

Background Few studies have compared abbreviated breast MRI with full-protocol MRI in women with a personal history of breast cancer (PHBC), and they have not adjusted for confounding variables. Purpose To compare abbreviated breast MRI with full-protocol MRI in women with PHBC by using propensity score matching to adjust for confounding variables. Materials and Methods In this single-center retrospective study, women with PHBC who underwent full-protocol MRI (January 2008-August 2017) or abbreviated MRI (September 2017-April 2019) were identified. With use of a propensity score-matched cohort, screening performances were compared between the two MRI groups with the McNemar test or a propensity score-adjusted generalized estimating equation. The coprimary analyses were sensitivity and specificity. The secondary analyses were the cancer detection rate, interval cancer rate, positive predictive value for biopsies performed (PPV3), and Breast Imaging Reporting and Data System (BI-RADS) category 3 short-term follow-up rate. Results There were 726 women allocated to each MRI group (mean age ± SD, 50 years ± 8 for both groups). Abbreviated MRI and full-protocol MRI showed comparable sensitivity (15 of 15 cancers [100%; 95% CI: 78, 100] vs nine of 13 cancers [69%; 95% CI: 39, 91], respectively; P = .17). Abbreviated MRI showed higher specificity than full-protocol MRI (660 of 711 examinations [93%; 95% CI: 91, 95] vs 612 of 713 examinations [86%; 95% CI: 83, 88], respectively; P < .001). The cancer detection rate (21 vs 12 per 1000 examinations), interval cancer rate (0 vs five per 1000 examinations), and PPV3 (61% [14 of 23 examinations] vs 41% [nine of 22 examinations]) were comparable (all P < .05). The BI-RADS category 3 short-term follow-up rate of abbreviated MRI was less than half that of full-protocol MRI (5% [36 of 726 examinations] vs 12% [84 of 726 examinations], respectively; P < .001). Ninety-three percent (14 of 15) of cancers detected at abbreviated MRI were node-negative T1-invasive cancers (n = 6) or ductal carcinoma in situ (n = 8). Conclusion Abbreviated breast MRI showed comparable sensitivity and superior specificity to full-protocol MRI in breast cancer detection in women with a personal history of breast cancer. © RSNA, 2022 Online supplemental material is available for this article.

Potential long-term effect of tumor necrosis factor inhibitors on dementia risk: A propensity score matched retrospective cohort study in US veterans

INTRODUCTION

Tumor necrosis factor (TNF) inhibitors are widely used to treat rheumatoid arthritis (RA) and their potential to retard Alzheimer's disease (AD) progression has been reported. However, their long-term effects on the dementia/AD risk remain unknown.

METHODS

A propensity scored matched retrospective cohort study was conducted among 40,207 patients with RA within the US Veterans Affairs health-care system from 2000 to 2020.

RESULTS

A total of 2510 patients with RA prescribed TNF inhibitors were 1:2 matched to control patients. TNF inhibitor use was associated with reduced dementia risk (hazard ratio [HR]: 0.64, 95% confidence interval [CI]: 0.52-0.80), which was consistent as the study period increased from 5 to 20 years after RA diagnosis. TNF inhibitor use also showed a long-term effect in reducing the risk of AD (HR: 0.57, 95% CI: 0.39-0.83) during the 20 years of follow-up.

CONCLUSION

TNF inhibitor use is associated with lower long-term risk of dementia/AD among US veterans with RA.

Equivariance Allows Handling Multiple Nuisance Variables When Analyzing Pooled Neuroimaging Datasets

Pooling multiple neuroimaging datasets across institutions often enables improvements in statistical power when evaluating associations (e.g., between risk factors and disease outcomes) that may otherwise be too weak to detect. When there is only a single source of variability (e.g., different scanners), domain adaptation and matching the distributions of representations may suffice in many scenarios. But in the presence of more than one nuisance variable which concurrently influence the measurements, pooling datasets poses unique challenges, e.g., variations in the data can come from both the acquisition method as well as the demographics of participants (gender, age). Invariant representation learning, by itself, is ill-suited to fully model the data generation process. In this paper, we show how bringing recent results on equivariant representation learning (for studying symmetries in neural networks) instantiated on structured spaces together with simple use of classical results on causal inference provides an effective practical solution. In particular, we demonstrate how our model allows dealing with more than one nuisance variable under some assumptions and can enable analysis of pooled scientific datasets in scenarios that would otherwise entail removing a large portion of the samples. Our code is available on https://github.com/vsingh-group/DatasetPooling.

Inpatient hospitalisation and mortality rate trends from 2004 to 2014 in the USA: a propensity score-matched case-control study of hyperkalaemia

OBJECTIVE

To study the trends of hyperkalaemia in USA inpatient hospitalisation records with heart failure (HF), chronic kidney disease (CKD), acute kidney injury (AKI) and/or type II diabetes mellitus (T2DM) from 2004 to 2014 with respect to prevalence and inpatient mortality.

DESIGN

Observational cross-sectional and propensity score-matched case-control study.

SETTING

The National Inpatient Sample (representing up to 97% of inpatient hospital discharge records in the USA) from 2004 to 2014 PARTICIPANTS: 120 513 483 (±2 312 391) adult inpatient hospitalisation records with HF, CKD/end-stage renal disease (ESRD), AKI and/or T2DM.

EXPOSURE

Hyperkalaemia, defined as the presence of an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code of '276.7' in any of the first 15 diagnostic codes.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcomes of interest are the annual rates of hyperkalaemia prevalence and inpatient mortality.

RESULTS

Among 120 513 483 (±2 312 391) adult inpatient hospitalisations with HF, CKD/ESRD, AKI and/or T2DM, we found a 28.9% relative increase of hyperkalaemia prevalence from 4.94% in 2004 to 6.37% in 2014 (p<0.001). Hyperkalaemia was associated with an average of 4 percentage points higher rate of inpatient mortality (1.71 post-matching, p<0.0001). Inpatient mortality rates decreased from 11.49%±0.17% to 6.43%±0.08% and 9.67%±0.13% to 5.05%±0.07% for matched cases with and without hyperkalaemia, respectively (p<0.001).

CONCLUSIONS

Hyperkalaemia prevalence increased over time and was associated with greater inpatient mortality, even after accounting for presentation characteristics. We detected a decreasing trend in inpatient mortality risk, regardless of hyperkalaemia presence.

Relationships between muscle sympathetic nerve activity and novel indices of arterial stiffness using single oscillometric cuff in patients with hypertension

The arterial velocity pulse index (AVI) and arterial pressure-volume index (API) have been proposed as new arterial stiffness indices that can be measured using an oscillometric cuff. Sympathetic nerve activity (SNA) contributes to arterial stiffness via increasing vascular smooth muscle tone. However, the associations between SNA and the AVI or API are not understood. The purpose of this study was to evaluate the relationships between muscle sympathetic nerve activity (MSNA) and the AVI or API in healthy individuals and patients with hypertension (HT). Forty healthy individuals (40.1 ± 15.2 years, 8 females) (healthy group) and 40 patients with HT (60.2 ± 13.6, 18 females) (HT group) were included in this study. The AVI, API, MSNA, beat-by-beat blood pressure, and heart rate were recorded simultaneously. The AVI and API were higher in the HT group than in the healthy group (AVI, 26.1 ± 7.6 vs. 16.5 ± 4.0, p < 0.001; API, 31.2 ± 8.6 vs. 25.5 ± 7.2, p = 0.002). MSNA in the HT group was also higher than in the healthy group (p < 0.001). MSNA was correlated with the AVI, but not with the API, in both the healthy group (R = 0.52, p = 0.001) and HT group (R = 0.57, p < 0.001). MSNA was independently correlated with the AVI in multivariate analysis (ß = 0.34, p = 0.001). In conclusion, AVI, obtained by a simple and less user-dependent method, was related to the MSNA in healthy individuals and patients with HT.

The impact of the first announced state of emergency owing to coronavirus disease-2019 on stress and blood pressure levels among patients with type 2 diabetes mellitus in Japan

Aims/Introduction

After the first coronavirus disease 2019 state of emergency announcement, there was an increase in stress that might have affected the self‐management of patients with type 2 diabetes mellitus. This study identified the changes in clinical findings and stress among patients with type 2 diabetes mellitus, and investigated the characteristics of patients who experienced an increase in blood pressure (BP) after the announcement.

Materials and Methods

Retrospectively, we scrutinized 310 patients with type 2 diabetes mellitus who were treated by the Sagamihara Physicians Association. After the announcement, 164 and 146 patients showed an increase (ΔBP >0 group) and decrease in BP (ΔBP ≤0 group), respectively. The propensity score matching method was used to compare the differences in clinical findings and stress‐related questionnaire responses between the two groups.

Results

After the announcement, 47% of patients experienced an increase in daily stress. Furthermore, 17% and 36% reported worsening dietary intake and a decrease in exercise, respectively. More patients reported that their dietary and salt intake had worsened in the ΔBP >0 group than in the ΔBP ≤0 group (9% vs 20%, P = 0.02, and 3% vs 10%, P = 0.04, respectively). Additionally, both systolic and diastolic BP measured in the office were significantly increased (P = 0.02 and P = 0.03, respectively); however, systolic BP measured at home significantly decreased (P = 0.01). The total stress scores were higher in the ΔBP >0 group than in the ΔBP ≤0 group (0.05 ± 2.61 and 0.93 ± 2.70, respectively, P = 0.03).

Conclusions

An increase in stress and, particularly, worsening dietary and salt intake were noted among patients with type 2 diabetes mellitus who experienced an increase in BP after the state of emergency announcement.

A comparison of local therapy alone with local plus systemic therapy for stage I pT1aN0M0 HER2+ breast cancer: A National Cancer Database analysis

BACKGROUND

Small invasive breast cancers (BCs) with tumor sizes ≤5 mm (T1a) are associated with an excellent prognosis without systemic therapy. Although HER2 overexpression (HER2+) is associated with a higher risk of recurrence and poorer clinical outcomes, in the absence of HER2 directed therapy, it remains unclear whether adjuvant systemic therapy is necessary in node-negative patients diagnosed with HER2+ invasive BCs ≤5 mm (pT1aN0M0).

METHODS

The National Cancer Database was searched to identify patients diagnosed with HER2+ pT1aN0M0 BCs from 2004 to 2017. The cohort was stratified by treatment status: local therapy alone or local plus adjuvant systemic therapy. A 1:1 propensity match was performed. Overall survival (OS) was analyzed using stratified multivariable Cox proportional hazards regression analyses.

RESULTS

Of the 8948 patients found, 4026 (45.0%) underwent surgery alone, and 4922 (55.0%) received surgery plus systemic therapy. Patients with either moderately differentiated (odds ratio [OR], 2.053; P < .001) or poorly/undifferentiated tumors (OR, 3.780; P < .001) or with the presence of lymphovascular invasion (OR, 3.351; P < .001) were more likely to have received systemic therapy. Propensity matching generated 1162 pairs of patients who were hormone receptor positive (HR+) and 748 pairs who were hormone receptor negative (HR-). Propensity matching effectively reduced selection bias between study groups. In the matched cohort, the addition of systemic therapy was not associated with superior OS (hazard ratio for HR+, 1.613; P = .107, and hazard ratio for HR- 1.319; P = .369) compared with patients who received local therapy alone.

CONCLUSIONS

In pT1aN0M0 HER2+ BC, the addition of adjuvant systemic therapy after surgical excision was not associated with improved OS compared with local therapy alone.

Emerald ash borer intensifies harvest regimes on private land

Invasive forest insects have significant direct impacts on forest ecosystems and they are also generating new risks, uncertainties, and opportunities for forest landowners. The growing prevalence and inexorable spread of invasive insects across the United States, combined with the fact that the majority of the nation's forests are controlled by thousands of autonomous private landowners, raises an important question: To what extent will private landowners alter their harvest practices in response to insect invasions? Using a quasi-experimental design, we conducted a causal analysis to investigate the influence of the highly impactful emerald ash borer (EAB) on (1) annual probability of harvest; (2) intensity of harvest; and (3) diameter of harvested trees, for both ash and non-ash species on private land throughout the Midwest and mid-Atlantic regions of the United States. We found that EAB detection had a negative impact on annual harvest probability and a positive impact on harvest intensity, resulting in a net increase in harvested biomass. Furthermore, our estimates suggest that EAB detection will influence private landowners to harvest greater quantities of ash, relative to non-ash species. We also found that harvested trees in EAB-infested areas had smaller diameters, on average, compared with those unaffected by EAB. These results can help policymakers, forest managers, and extension programs to anticipate and better advise landowners and managers about their options and the associated outcomes for forests.

Eudaimonic and Hedonic Psychological Well-Being among Parents of Children with Cancer before and during the COVID-19 Pandemic: A Comparative Cross-Sectional Study

The main aim of this study was to analyze the eudaimonic and hedonic well-being of parents of children with cancer by considering the role of a global stressor—the COVID-19 pandemic. One group of parents was assessed during the COVID-19 pandemic, and the other was assessed before it occurred. It was hypothesized that there may be a cumulative effect of stress, with parents expressing lower well-being during the pandemic due to the accumulation of stress related to their child’s illness and the pandemic. In total, 310 parents participated in the study. Following propensity score matching, 111 pairs were established. The results of the comparative analyses did not support the hypothesis, as the groups did not differ significantly in their reported levels of either eudaimonic (F (1.93) = 0.11, p = 0.75, η_p²= 0.001) or hedonic well-being (F (1.100) = 0.02, p = 0.89, η_p² = 0.0001). These findings showed a limited effect of the COVID-19 pandemic on the well-being of parents of children with cancer. The oncological disease of a child is likely to be the central and the strongest factor for the parents, meaning that an additional, global stressor does not cause deeper exacerbation of their well-being.