Robust integration of secondary outcomes information into primary outcome analysis in the presence of missing data

In clinical and observational studies, secondary outcomes are frequently collected alongside the primary outcome for each subject, yet their potential to improve the analysis efficiency remains underutilized. Moreover, missing data, commonly encountered in practice, can introduce bias to estimates if not appropriately addressed. This article presents an innovative approach that enhances the empirical likelihood-based information borrowing method by integrating missing-data techniques, ensuring robust data integration. We introduce a plug-in inverse probability weighting estimator to handle missingness in the primary analysis, demonstrating its equivalence to the standard joint estimator under mild conditions. To address potential bias from missing secondary outcomes, we propose a uniform mapping strategy, imputing incomplete secondary outcomes into a unified space. Extensive simulations highlight the effectiveness of our method, showing consistent, efficient, and robust estimators under various scenarios involving missing data and/or misspecified secondary models. Finally, we apply our proposal to the Uniform Data Set from the National Alzheimer's Coordinating Center, exemplifying its practical application.

Acute Kidney Injury, Systemic Inflammation and Long-term Cognitive Function: ASSESS-AKI

BACKGROUND

Cognitive dysfunction is a well-known complication of chronic kidney disease, but it is less known whether cognitive decline occurs in survivors after acute kidney injury (AKI). We hypothesized that an episode of AKI is associated with poorer cognitive function, mediated, at least in part, by persistent systemic inflammation.

METHODS

ASSESS-AKI enrolled patients surviving three months after hospitalization with and without AKI matched based on demographics, comorbidities, and baseline kidney function. A subset underwent cognitive testing using the modified mini-mental status examination (3MS) at 3, 12, and 36 months. We examined the association of AKI with 3MS scores using mixed linear models and assessed the proportion of risk mediated by systemic inflammatory biomarkers.

RESULTS

Among 1538 participants in ASSESS-AKI, 1420 (92%) completed the 3MS assessment at 3 months and had a corresponding matched participant. Participants with AKI had lower 3MS scores at three years (difference -1.1 (95% CI: -2.0, -0.3) P=0.009) compared to participants without AKI. A higher proportion of AKI participants had a clinically meaningful (≥ 5 point) reduction in 3MS scores at three years compared to participants without AKI (14% vs. 10%, P=0.04). In mediation analyses, plasma soluble tumor necrosis factor receptor-1 (sTNFR-1) at three months after AKI mediated 35% (P=0.02) of the AKI related risk for 3MS scores at three years.

CONCLUSIONS

AKI was associated with lower 3MS scores and sTNFR-1 concentrations appeared to mediate a significant proportion of the risk of long-term cognitive impairment. Further work is needed to determine if AKI is causal or a marker for cognitive impairment.

A Retrospective Cohort Study That Examined the Impact of Cannabis Consumption on Long-Term Kidney Outcomes

Background: Cannabis consumption for recreational and medical use is increasing worldwide. However, the long-term effects on kidney health and disease are largely unknown. Materials and Methods: Post hoc analysis of cannabis use as a risk factor for kidney disease was performed using data from the Assessment, Serial Evaluation, and Subsequent Sequelae of Acute Kidney Injury (ASSESS-AKI) study that enrolled hospitalized adults with and without acute kidney injury from four U.S. centers during 2009-2015. Associations between self-reported cannabis consumption and the categorical and continuous outcomes were determined using multivariable Cox regression and linear mixed models, respectively. Results: Over a mean follow-up of 4.5±1.8 years, 94 participants without chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR] >60 mL/min/1.73 m2) who consumed cannabis had similar rates of annual eGFR decline versus 889 nonconsumers (mean difference=-0.02 mL/min/1.73 m2/year, p=0.9) and incident CKD (≥25% reduction in eGFR compared with the 3-month post-hospitalization measured eGFR and achieving CKD stage 3 or higher) (adjusted hazard ratio [aHR]=1.2; 95% confidence interval [CI]=0.7-2.0). Nineteen participants with CKD (eGFR <60 mL/min/1.73 m2) who consumed cannabis had more rapid eGFR decline versus 597 nonconsumers (mean difference=-1.3 mL/min/1.73 m2/year; p=0.02) that was not independently associated with an increased risk of CKD progression (≥50% reduction in eGFR compared with the 3-month post-hospitalization eGFR, reaching CKD stage 5, or receiving kidney replacement therapy) (aHR=1.6; 95% CI=0.7-3.5). Cannabis consumption was not associated with the rate of change in urine albumin to creatinine ratio (UACR) over time among those with (p=0.7) or without CKD (p=0.4). Conclusions: Cannabis consumption did not adversely affect the kidney function of participants without CKD but was associated with a faster annual eGFR decline among participants with CKD. Cannabis consumption was not associated with changes in UACR over time, incident CKD, or progressive CKD regardless of baseline kidney function. Additional research is needed to investigate the kidney endocannabinoid system and the impact of cannabis use on kidney disease outcomes.

The Epidemiology of Berry Consumption and Association of Berry Consumption with Diet Quality and Cardiometabolic Risk Factors in United States Adults: The National Health and Nutrition Examination Survey, 2003-2018

BACKGROUND

Berries are rich in important nutrients and bioactive compounds, which could potentially contribute to maintenance of normal lipid and glucose profiles.

OBJECTIVE

We reported the epidemiology of berry consumption and examined associations of berry consumption with diet quality [measured by Healthy Eating Index (HEI-2015)] and levels of cardiometabolic risk factors, including body mass index (BMI), waist circumference (WC), systolic blood pressure (SBP), diastolic blood pressure, total cholesterol, high-density lipoprotein cholesterol (HDL cholesterol), glycated hemoglobin, and fasting biomarkers: triglycerides, low-density lipoprotein cholesterol (LDL cholesterol), glucose, insulin, and homeostasis model assessment of insulin resistance (HOMA-IR).

METHODS

We evaluated 33,082 adults (aged ≥20 y) using two 24-h diet recalls from National Health and Nutrition Examination Survey (2003-2018). Multivariable linear regression models were applied to examine the associations of total and individual berry intake with diet quality and cardiometabolic risk factors using appropriate sample weights.

RESULTS

Approximately 25 % of the United States adults consumed berries (0.08 ± 0.003 cup-equivalents/d), representing ∼10 % of the daily mean total fruit intake. Among berry consumers, the mean intake of strawberries (0.31 ± 0.01 cup-equivalents) was higher than for other berries. Berry consumers had a significantly higher HEI-2015 score than nonconsumers (mean HEI-2015 score = 58.8 compared with 52.3, P < 0.0001). Berry consumers had significantly lower concentrations of cardiometabolic indices than nonconsumers, including BMI, WC, SBP, total cholesterol, LDL cholesterol, triglycerides, fasting insulin, HOMA-IR, and higher mean HDL cholesterol, after adjusting for sociodemographic, lifestyle, and dietary confounders (all P < 0.05).

CONCLUSIONS

United States adult berry consumers had a higher diet quality and lower concentrations of cardiometabolic risk factors, suggesting a favorable role for berries in diets and cardiometabolic disease prevention in United States adult population.

Re-Analyses of 8 Historical Trials in Cardiovascular Medicine Assessing Multimorbidity Burden and Its Association with Treatment Response

OBJECTIVE

The purpose of this study was to examine the multimorbidity burden of clinical trial participants and assess its association with treatment response.

METHODS

We conducted a reanalysis of patient level data. There were 29,954 participants from 8 clinical trials containing 11 comparisons between an intervention and control condition. Patients were classified by Charlson Comorbidity Index (CCI) score. The primary outcomes were the primary study endpoints as originally specified for each trial. A Cox model that included the CCI score groups, the randomized group, and their interaction, was used to compare the primary outcome between randomized groups. The interaction term between randomized group and comorbidity index allowed the treatment effect to differ by level of comorbidity index and comprised the primary effect of interest. Hazard ratios and risk differences were reported for all comparisons.

RESULTS

The mean CCI scores of trial populations ranged from 2.1 to 3.9 points, and the percentage of patients with scores ≥5 from 3% to 39%. Tests of interaction terms in models yielded P values ≤ .10 for 4/11 comparisons and ≤ .05 for 2/11 comparisons. In 3 additional comparisons, potentially important treatment variation on an absolute scale was observed despite interaction tests with P values > .10 on the relative scale.

CONCLUSIONS

These trials were mainly composed of patient populations with CCI scores ≤4. Despite this, biologically plausible treatment interactions were commonly suggested. These results are hypothesis generating; confirmation of results would require larger studies or studies targeted specifically toward patients with higher levels of multimorbidity.

Association of Long COVID with mental health disorders: a retrospective cohort study using real-world data from the USA

OBJECTIVES

Mental health disorders (MHD) rank third for US adult hospitalisations. Given the substantial prevalence of 'Long COVID' in SARS-CoV-2 survivors, this study aims to assess its association with increased MHD risk using extensive real-world data.

DESIGN

A retrospective cohort study with propensity score matching was conducted. We used the International Classification of Diseases, 10th Revision codes to identify individuals with Long COVID status and COVID-19 histories. Multivariable stratified Cox proportional hazards regression analysis was conducted to determine the association of Long COVID status with MHD.

SETTING

Data were sourced from the TriNetX database, spanning records from 1 October 2021 to 16 April 2023.

PARTICIPANTS

Two distinct cohorts were established: one comprising individuals diagnosed with Long COVID and another comprising individuals with no history of Long COVID or COVID-19. At the start of the study, none of the participants had a recorded MHD.

PRIMARY AND SECONDARY OUTCOME MEASURES

The main outcome of interest was a composite diagnosis of MHD. Secondary outcomes were individual mental health conditions.

RESULTS

The study included 43 060 control participants without Long COVID and 4306 Long COVID participants, demonstrating well-balanced distribution across all covariates. After adjusting for 4 demographic factors and 10 comorbidities, Long COVID was associated with MHD (adjusted HR, aHR 2.60; 95% CI 2.37 to 2.85). In subgroup analysis, Long COVID was associated with major depression disorder (aHR 3.36; 95% CI 2.82 to 4.00) and generalised anxiety disorder (aHR 3.44; 95% CI 2.99 to 3.96).

CONCLUSIONS

In this retrospective large real-world cohort study, Long COVID was associated with an increased risk of incident MHD. The MHD impact is significant considering the vast number of patients with Long COVID. Enhanced MHD screening among COVID-19 survivors should be a priority.

Exploring Quality of Life Experiences and Concerns of Black Breast Cancer Survivors: a Narrative Approach

Black breast cancer survivors (BCS) in comparison with White BCS are more likely to experience suboptimal quality of life (QoL). QoL is a multi-dimensional concept that focuses on different aspects of well-being (e.g., emotional well-being). There is limited evidence on the perspectives and experiences of QoL (e.g., the influence of breast cancer on QoL) and the QoL concerns (e.g., negative perceptions of body appearance) among Black BCS. The purpose of this study was to explore the QoL experiences and QoL concerns of Black BCS. Primary data was collected in semi-structured interviews and analyzed using a thematic analysis. A narrative approach (detailed stories or life experiences of a small group of people) was used to better understand the research topic among the target group. Ferrell's Conceptual Framework on QoL in Breast Cancer was used to guide the development of the interview questions, codes, and themes. There were 10 Black BCS, averaging 58 years of age. Two coders achieved a moderate level of agreement (i.e., Kappa) of 0.77. Five major themes were identified: defining QoL (what QoL means to them), behavioral changes (e.g., altering behaviors due to cancer), phases of cancer (e.g., breast cancer diagnosis), QoL experiences and factors affecting QoL, and impactful statements from cancer survivors (other meaningful information shared by the participants). The survivors reported multiple QoL concerns and body image issues. The study findings warrant cancer education interventions or programs to address the relevant survivorship issues of Black BCS.

Exercise training improves serum biomarkers of liver fibroinflammation in patients with metabolic dysfunction-associated steatohepatitis

BACKGROUND AND AIMS

Exercise training is recommended for all patients with metabolic dysfunction-associated steatotic liver disease and may reverse liver fibrosis. Whether exercise training improves liver fibrosis without body weight loss remains controversial. We further investigated this relationship using serum biomarkers of liver fibroinflammation in a post hoc analysis of an exercise trial where patients did not lose significant body weight.

METHODS

In the NASHFit trial, patients with metabolic dysfunction-associated steatohepatitis were randomized to receive either moderate-intensity aerobic exercise training or standard clinical care for 20 weeks. Mediterranean-informed dietary counselling was provided to each group. Change in serum biomarkers was measured and compared between the two groups.

RESULTS

Exercise training led to improvement in serum biomarkers of liver fibroinflammation, including (1) ≥17 IU/L reduction in alanine aminotransferase (ALT) in 53% of individuals in the exercise training group compared to 13% in the standard clinical care group (p < 0.001; mean reduction 24% vs. 10% respectively) and (2) improvement in CK18 (-61 vs. +71 ng/mL, p = 0.040). ALT improvement ≥17 IU/L was correlated with ≥30% relative reduction in magnetic resonance imaging-measured liver fat and PNPLA3 genotype.

CONCLUSION

Exercise training improves multiple serum biomarkers of liver fibroinflammation at clinically significant thresholds of response without body weight loss. This study provides further evidence that exercise training should be viewed as a weight-neutral intervention for which response to intervention can be readily monitored with widely available non-invasive biomarkers that can be applied at the population level.

Consumption of Berries and Flavonoids in Relation to Mortality in NHANES, 1999-2014

BACKGROUND

Berries are foods that are abundant in nutrients, especially flavonoids, that promote good health; however, the effects of total berries on mortality are not well characterized.

OBJECTIVES

We evaluated whether intakes of total berries and specific berry types including blueberries, strawberries, cranberries, flavonoids, and subclasses of flavonoids (anthocyanidins, flavonols, flavones, flavanones, flavan-3-ols, and isoflavones) in relation to mortality risk in United States adults.

METHODS

A nationally representative sample of the United States adult population was obtained using data from the 1994-2014 NHANES (n = 37,232). Intake of berries was estimated using 24-h food recalls (1999-2014), and flavonoids intake was calculated using the matched USDA's expanded flavonoid database. Mortality outcomes based on 8 y of follow-up were obtained using linked death certificates.

RESULTS

Compared with nonconsumers, the multivariable-adjusted hazard ratio for all-cause mortality was 0.79 [95% confidence intervals (CI): 0.7, 0.89] for any berry consumption, 0.86 (0.75, 0.99) for strawberry consumption 0.79 (0.66, 0.95) for blueberries, and 0.69 (0.51, 0.93) for cranberries. Compared with the lower median of intake, risk of all-cause mortality for greater intake was 0.85 (0.74, 0.97) for total flavonoids, 0.85 (0.76, 0.95) for anthocyanidins, 0.9 (0.82, 0.99) for flavan-3-ols, 0.89 (0.79, 0.9) for flavanols, and 0.89 (0.8, 0.99) for flavones. There was a dose-response relationship between intakes of total flavonoids, anthocyanidins, and flavones and lower all-cause mortality risks (Ptrend < 0.05). Risk for cardiometabolic mortality was 0.75 (0.58, 0.98) for berry consumers and 0.49 (0.25, 0.98) for cranberry consumers. For respiratory disease mortality, risk was 0.41 (0.2, 0.86), compared with blueberry nonconsumers.

CONCLUSION

Higher intakes of berries and flavonoids were associated with a lower overall mortality risk in adult Americans. Few adults regularly consume berries, indicating that increased intake of berries and flavonoid-rich foods may be beneficial to health.

Berry Consumption in Relation to Allostatic Load in US Adults: The National Health and Nutrition Examination Survey, 2003-2010

INTRODUCTION

Berries are a rich source of antioxidant polyphenols and other nutrients that are associated with good health. Allostatic load (AL) is an aggregate measure of chronic stress-induced physiological dysregulations across cardiovascular, metabolic, autonomic, and immune systems; the extent of these dysregulations, collectively or in each system, can be characterized by a composite score or a domain score assessed by integrated biomarkers. It was hypothesized that the anti-inflammatory and other effects of berries lower AL. The association was determined between berry consumption and AL composite and domain scores in the 2003-2010 National Health and Nutrition Examination Survey (NHANES).

METHODS

Berry intake was measured using two 24 h dietary recalls collected from US adults in the 2003-2010 NHANES (n = 7684). The association with AL and its specific domains was examined using population weight-adjusted multivariable linear regression.

RESULTS

The mean AL composite scores for consumers of any berries (11.9), strawberries (11.6), and blueberries (11.6), respectively, were significantly lower than nonconsumers (12.3), after fully adjusting for sociodemographic, lifestyle, and dietary confounders. A significant dose-response relationship was determined between greater consumption of total berries, strawberries, and blueberries and lower mean AL composite scores (p-trend < 0.05, for all). Consistently, mean cardiovascular and metabolic domain scores remained significantly lower in the consumers of total berries (mean cardiovascular domain score: 4.73 versus 4.97 for nonconsumers; mean metabolic domain score: 2.97 versus 3.1), strawberries (4.73 versus 4.95; 2.99 versus 3.1), and blueberries (4.6 versus 4.95; 2.92 versus 3.11). Berry consumers also had significantly lower mean AL immune scores (1.52 versus 1.56) and lower mean AL autonomic scores (2.49 versus 2.57) than nonconsumers (initial sample: n = 15,620).

CONCLUSIONS

The current study indicates that consumption of berries lowers the AL composite scores and potentially reduces stress-related disease risks in the US adult population.

Evaluating the relationship between physical activity and quality of life in a racially diverse sample of breast cancer survivors

PURPOSE

Physical activity (PA) has been shown to improve quality of life (QoL) in predominantly White cancer survivors. Very few studies have examined the association between PA and QoL among Black breast cancer survivors (BCS). We investigated the association between PA and multiple QoL domains and the effects of race on the proposed association in a racially diverse group of BCS.

METHODS

This was an exploratory study using secondary data from a completed 12-month randomized controlled  trial (RCT). Mixed effects models were tested on a subset of participants in the control and exercise groups of the RCT. The primary outcomes were changes in the QoL domains (baseline to 12 months post baseline).

RESULTS

There were 173 participants included in this analysis, averaging 59 years of age; about 33% of the participants were Black women. There were no significant differences in the QoL outcomes between the control and exercise groups at 12 months post baseline. Race was not a significant moderator. Exercise improved emotional/mental wellbeing and body image as it relates to social barriers at 12 months post baseline in Black and White BCS, but the changes in these outcomes were only statistically significant in White BCS (p < 0.05).

CONCLUSIONS

Results show that exercise can improve multiple QoL domains over time in Black BCS. However, the significance of the effect on QoL was isolated to White BCS. The small sample size in Black women could constrain the statistical significance of observed effects. Future studies are warranted to assess associations between exercise and QoL in larger samples of Black women.

Association of pancreatitis with risk of diabetes: analysis of real-world data

Introduction

Diabetes is a major cause of disease burden with considerable public health significance. While the pancreas plays a significant role in glucose homeostasis, the association between pancreatitis and new onset diabetes is not well understood. The purpose of this study was to examine that association using large real-world data.

Materials and methods

Utilizing the IBM® MarketScan® commercial claims database from 2016 to 2019, pancreatitis and diabetes regardless of diagnostic category, were identified using International Classification of Diseases, Tenth Revision [ICD-10] codes. We then performed descriptive analyses characterizing non-pancreatitis (NP), acute pancreatitis (AP), and chronic pancreatitis (CP) cohort subjects. Stratified Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CI) of diabetes across the three clinical categories.

Results

In total, 310,962 individuals were included in the analysis. During 503,274 person-years of follow-up, we identified 15,951 incident diabetes cases. While men and women had higher incidence rates of CP and AP-related diabetes, the rates were significantly greater in men and highest among individuals with CP (91.6 per 1000 persons-years (PY)) followed by AP (75.9 per 1000-PY) as compared to those with NP (27.8 per 1000-PY). After adjustment for diabetes risk factors, relative to the NP group, the HR for future diabetes was 2.59 (95% CI: 2.45-2.74) (P<0.001) for the CP group, and 2.39 (95% CI: 2.30-2.48) (P<0.001) for the AP group.

Conclusion

Pancreatitis was associated with a high risk of diabetes independent of demographic, lifestyle, and comorbid conditions.

Berry Consumption and Sleep in the Adult US General Population: Results from the National Health and Nutrition Examination Survey 2005-2018

INTRODUCTION

Poor sleep is associated with numerous adverse health outcomes. Berries are rich in micronutrients and antioxidants that may improve sleep quality and duration. We determined the association of berry consumption and sleep duration and sleep difficulty among adult participants in NHANES.

METHODS

We analyzed the diet of US adults aged ≥ 20 y using two non-consecutive 24 h recalls from the National Health and Nutrition Examination Survey 2005 to 2018 (N = 29,217). Poor sleep quality was measured by sleep duration (short sleep duration: <7 h), long sleep (≥9 h), and reported sleep difficulty. The relative risk of poor sleep outcomes for berry consumers vs. nonconsumers was modelled using population weight-adjusted multivariable general logistic regression.

RESULTS

About 46% of participants reported inadequate sleep duration, and 27% reported sleep difficulties. Twenty-two percent reported consuming berries. Berry consumers had a 10-17% decreased risk of short sleep. The findings were consistent for specific berry types including strawberries and blueberries (p < 0.05). No significant associations with long sleep were found for total berries and any berry types. A decreased risk of sleep difficulties was found to be linked to blackberry consumption (adjusted OR = 0.63, 95% CI: 0.40-0.97; p = 0.036) but not for other berries.

CONCLUSIONS

US adult berry consumers had a decreased risk of reporting short sleep compared to nonconsumers. Berries are underconsumed foods in the US adult population, and increased berry consumption may improve sleep quality.

The ASSESS-AKI Study found urinary epidermal growth factor is associated with reduced risk of major adverse kidney events

Biomarkers of tubular function such as epidermal growth factor (EGF) may improve prognostication of participants at highest risk for chronic kidney disease (CKD) after hospitalization. To examine this, we measured urinary EGF (uEGF) from samples collected in the Assessment, Serial Evaluation, and Subsequent Sequelae of Acute Kidney Injury (ASSESS-AKI) Study, a multi-center, prospective, observational cohort of hospitalized participants with and without AKI. Cox proportional hazards regression was used to investigate the association of uEGF/Cr at hospitalization, three months post-discharge, and the change between these time points with major adverse kidney events (MAKE): CKD incidence, progression, or development of kidney failure. Clinical findings were paired with mechanistic studies comparing relative Egf expression in mouse models of kidney atrophy or repair after ischemia-reperfusion injury. MAKE was observed in 20% of 1,509 participants over 4.3 years of follow-up. Each 2-fold higher level of uEGF/Cr at three months was associated with decreased risk of MAKE (adjusted hazards ratio 0.46, 95% confidence interval: 0.39-0.55). Participants with the highest increase in uEGF/Cr from hospitalization to three-month follow-up had a lower risk of MAKE (adjusted hazards ratio 0.52; 95% confidence interval: 0.36-0.74) compared to those with the least change in uEGF/Cr. A model using uEGF/Cr at three months combined with clinical variables yielded moderate discrimination for MAKE (area under the curve 0.73; 95% confidence interval: 0.69-0.77) and strong discrimination for kidney failure at four years (area under the curve 0.96; 95% confidence interval: 0.92-1.00). Accelerated restoration of Egf expression in mice was seen in the model of adaptive repair after injury, compared to a model of progressive atrophy. Thus, urinary EGF/Cr may be a biomarker of distal tubular health, with higher concentrations and increased uEGF/Cr post-discharge independently associated with reduced risk of MAKE in hospitalized patients.

Human Immunodeficiency Virus (HIV) Treatment With Antiretroviral Therapy Mitigates the High Risk of Mental Health Disorders Associated With HIV Infection in the US Population

Background

Whether treatment of human immunodeficiency virus (HIV) with antiretroviral therapy (ART) is associated with lower risk of mental health disorders (MHDs) among people with HIV (PWH) remains unknown. We aim to determine the association between HIV and MHDs and whether ART alters the risk of MHDs among PWH in the US adult population.

Methods

We conducted a real-world study using the Merative MarketScan claims database (2016-2020), identifying individuals with HIV (diagnosed using International Classification of Diseases, Tenth Revision, Clinical Modification codes) and those without HIV. A multivariable stratified Cox proportional hazard regression model was conducted to examine the association of HIV treatment status with MHDs, adjusting for potential confounders. Additionally, we sought to determine the effect modification of ART on the relationship between living with HIV and MHDs.

Results

A total of 313 539 individuals, with a mean age of 44.2 (standard deviation, 11.4) years, predominantly males (81.2%), residing in the South region of the US (50.9%) were included in the present analysis. During 671 880 person-years of follow-up, 46 235 incident MHD cases occurred. In the multivariable Cox proportional hazard model, living with HIV was associated with higher risk of incident MHDs. Relative to those without HIV, the adjusted hazard ratio was 1.85 (95% confidence interval [CI], 1.79-1.92; P < .001) for those with HIV on treatment, and 2.70 (95% CI, 2.59-2.82; P < .001) for those with HIV without any treatment. Stronger associations between HIV and MHDs were observed in men relative to women, among those aged 18-34 years relative to those aged 55-63 years, and among those with no overweight/obesity relative to obese individuals (Pinteraction < .001 for all).

Conclusions

HIV was associated with an increased risk of developing MHDs. However, HIV treatment mitigated the risk.

REAP-2: An interactive quantitative tool for robust and efficient dose-response curve estimation

REAP-2 is an interactive dose-response curve estimation tool for Robust and Efficient Assessment of drug Potency. It provides user-friendly dose-response curve estimation for in vitro studies and conducts statistical testing for model comparisons with a redesigned user interface. We also make a major update of the underlying estimation method with penalized beta regression, which demonstrates great reliability and accuracy in dose estimation and uncertainty quantification. In this note, we describe the method and implementation of REAP-2 with a highlight on potency estimation and drug comparison.

Efficacy of Infrared Vein Visualization versus Standard Technique for Peripheral Venous Cannulation in Infant and Toddler Populations: A Randomized Study

Establishing intravenous (IV) access in younger patient populations via the traditional cannulation technique for procedures requiring anesthesia is often challenging. Infrared (IR) vein visualization is a modality that aids venous cannulation; however, few reports of this technique exist in the infant and toddler population. The primary aim of this study was to compare the efficacy of IR vein visualization to the standard cannulation technique for obtaining peripheral IV access in infant and toddler populations. Following Institutional Review Board (IRB) approval and written informed consent, children were randomly assigned to either a standard cannulation technique group or an IR vein visualization device group for venous cannulation. The primary outcome variable was the success rate of IV cannulation, and the secondary variables were the total number of attempts and the time to successful cannulation. No difference was noted between either group for first-attempt success rate (standard versus IR: 61.25% vs. 54.4%; p = 0.4) or time to establish IV cannulation (standard versus IR: median [interquartile range], 40 s [24-120] vs. 53 s [26-106]; p = 0.55). The anesthesiologist's grading of the anticipated difficulty of IV cannulation was a significant predictor of cannulation success (p = 0.0016). Our study demonstrated no significant benefit in utilizing the IR vein visualization device in terms of the overall success rate, number of attempts, and time to establish successful IV cannulation when compared to the standard technique. However, in difficult IV access situations, this device proved to be a valuable rescue adjunct.

Demonstrating the Value of Routine Anesthesiologist Involvement in Acute Stroke Care: A Retrospective Chart Review

INTRODUCTION

The value of routine involvement of anesthesiologists during endovascular thrombectomy (EVT) for acute ischemic stroke has not been clearly demonstrated. At some institutions, anesthesiologists are involved only as needed, while at other institutions, anesthesiologists are involved from the beginning for every EVT.

METHODS

We retrospectively analyzed the workflow, intraprocedural variables and complications, and outcomes in acute ischemic stroke patients undergoing EVT at a comprehensive stroke center after implementation of routine involvement of an anesthesia team and compared this cohort with patients who received care from sedation-trained nurses working under the supervision of neurointerventionalists with the involvement of anesthesiologists on an as-needed basis.

RESULTS

Routine involvement of anesthesiologists was associated with improved workflow performance measures, including decreased median door-to-arterial puncture time (68 min; interquartile range (IQR), 15.5-94.5 min vs. 81 min; IQR, 53-104 min; P =0.001), in-room to arterial puncture time (11 min; IQR, 8-14 min vs. 15 min; IQR, 9-21 min; P <0.0001), and procedure time (51 min; IQR, 40-64 min vs. 60 min; IQR, 40-88.5 min; P =0.007). It was also associated with a nonsignificant trend towards lower rates of desaturation events (8.2% vs. 3.4%; P =0.082) and lower rates of conversion to general anesthesia (1.7% vs. 0%; P =0.160). Ninety-day modified Rankin scores were similar regardless of provider type.

CONCLUSION

Implementation of routine involvement of an anesthesia team during EVT was not associated with improved outcomes but was associated with improved efficiency and greater adherence to guidelines-based physiological parameters, supporting the routine involvement of anesthesiologists during EVT.

Statins exposure and acute pancreatitis: a retrospective cohort study using a large national insurance database

OBJECTIVES

The association between the use of statins and the incidence of acute pancreatitis (AP) has yielded inconsistent findings. While statins have been implicated as an aetiology for drug-induced pancreatitis, more recent studies have found statin use is associated with a reduced risk of pancreatitis. We sought to examine the association between the use of any statin medications and the risk of AP using large real-world data.

DESIGN

All data were collected retrospectively, but individuals were prospectively followed forward in time to determine the outcome of interest using International Classification of Diseases, 10th Revision, Clinical Modification codes indicating a diagnosis of AP. A stratified Cox proportional hazards regression model was conducted to examine the association of statins use with AP.

SETTINGS

Merative MarketScan claims database 2017-2020.

PARTICIPANTS

Individuals who filled any statin prescriptions with at least 80% proportion of days covered between 1 January 2017 and 31 December 2017 and were continuously enrolled in the database from 2016 to 2020. We also identified non-users of statins and constructed multiple strata of individuals based on the 14 confounders of interest.

RESULTS

Among 1 695 914 individuals, 226 314 had filled their statins prescription during the study period. Unadjusted incidence rates of AP generally showed higher rates among statins users. The unadjusted incidence rate and 95% CI per 1000 person-years of follow-up was 0.63 (95% CI: 0.61 to 0.66) for non-statin users, versus 0.92 (95% CI: 0.86 to 0.98) for statins users. However, a stratified Cox proportional hazards regression analysis yielded a HR of 0.92 (95% CI: 0.84 to 1.01) for statins users, indicating no difference between the two groups.

CONCLUSIONS

In this large real-world analysis, use of statins was not associated with a higher risk of AP in this US healthcare setting.

Trends and predictors of nutritional deficiencies after bariatric surgeries: analysis of real-world data

BACKGROUND

Bariatric surgery (BS) can lead to postoperative nutritional deficiencies (NDs) due to restrictive and malabsorptive mechanisms, but there is limited literature quantifying NDs' prevalence over time and their predictors among patients undergoing BS.

OBJECTIVE

To characterize time trends and predictors of postoperative NDs.

SETTING

This retrospective cohort study used the U.S. IBM MarketScan commercial claims database (2005-2019) to include adults who underwent BS with continuous enrollment.

METHODS

BS included Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), adjustable gastric band (AGB), and biliopancreatic diversion with duodenal switch. NDs included protein malnutrition, deficiencies in vitamins D and B12, and anemia that may be related to NDs. Logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of NDs across BS types after adjusting for other patient factors.

RESULTS

Within 83,635 patients (mean age [SD], 44.5 [9.5] yr; 78% female patients), 38.7%, 32.9%, and 28% underwent RYGB, SG, and AGB, respectively. Age-adjusted prevalence of any NDs within 1, 2, and 3 years after BS ranged from 23%, 34%, and 42%, respectively (in 2006) to 44%, 54%, and 61%, respectively (in 2016). Relative to the AGB group, the adjusted OR of any 3-year postoperative NDs was 3.00 (95% CI, 2.89-3.11) for the RYGB group and 2.42 (95% CI, 2.33-2.51) for the SG group.

CONCLUSIONS

RYGB and SG were associated with 2.4- to 3.0-fold odds of developing 3-year postoperative NDs compared with AGB, independent of baseline ND status. Pre- and postoperative nutritional assessments are recommended for all patients undergoing BS to optimize postoperative outcomes.

Integrated Analysis of Blood and Urine Biomarkers to Identify Acute Kidney Injury Subphenotypes and Associations With Long-term Outcomes

RATIONALE & OBJECTIVE

Acute kidney injury (AKI) is a heterogeneous clinical syndrome with varying causes, pathophysiology, and outcomes. We incorporated plasma and urine biomarker measurements to identify AKI subgroups (subphenotypes) more tightly linked to underlying pathophysiology and long-term clinical outcomes.

STUDY DESIGN

Multicenter cohort study.

SETTING & PARTICIPANTS

769 hospitalized adults with AKI matched with 769 without AKI, enrolled from December 2009 to February 2015 in the ASSESS-AKI Study.

PREDICTORS

29 clinical, plasma, and urinary biomarker parameters used to identify AKI subphenotypes.

OUTCOME

Composite of major adverse kidney events (MAKE) with a median follow-up period of 4.7 years.

ANALYTICAL APPROACH

Latent class analysis (LCA) and k-means clustering were applied to 29 clinical, plasma, and urinary biomarker parameters. Associations between AKI subphenotypes and MAKE were analyzed using Kaplan-Meier curves and Cox proportional hazard models.

RESULTS

Among 769 AKI patients both LCA and k-means identified 2 distinct AKI subphenotypes (classes 1 and 2). The long-term risk for MAKE was higher with class 2 (adjusted HR, 1.41 [95% CI, 1.08-1.84]; P=0.01) compared with class 1, adjusting for demographics, hospital level factors, and KDIGO stage of AKI. The higher risk of MAKE among class 2 was explained by a higher risk of long-term chronic kidney disease progression and dialysis. The top variables that were different between classes 1 and 2 included plasma and urinary biomarkers of inflammation and epithelial cell injury; serum creatinine ranked 20th out of the 29 variables for differentiating classes.

LIMITATIONS

A replication cohort with simultaneously collected blood and urine sampling in hospitalized adults with AKI and long-term outcomes was unavailable.

CONCLUSIONS

We identify 2 molecularly distinct AKI subphenotypes with differing risk of long-term outcomes, independent of the current criteria to risk stratify AKI. Future identification of AKI subphenotypes may facilitate linking therapies to underlying pathophysiology to prevent long-term sequalae after AKI.

PLAIN-LANGUAGE SUMMARY

Acute kidney injury (AKI) occurs commonly in hospitalized patients and is associated with high morbidity and mortality. The AKI definition lumps many different types of AKI together, but subgroups of AKI may be more tightly linked to the underlying biology and clinical outcomes. We used 29 different clinical, blood, and urinary biomarkers and applied 2 different statistical algorithms to identify AKI subtypes and their association with long-term outcomes. Both clustering algorithms identified 2 AKI subtypes with different risk of chronic kidney disease, independent of the serum creatinine concentrations (the current gold standard to determine severity of AKI). Identification of AKI subtypes may facilitate linking therapies to underlying biology to prevent long-term consequences after AKI.

Tackling dynamic prediction of death in patients with recurrent cardiovascular events

In the field of cardiovascular disease, recurrent events such as stroke or myocardial infarction (MI) are often encountered, leading to an increase in the risk of death. Accurately evaluating the prognosis of patients and dynamically predicting the risk of death by considering the historical recurrent events can improve medical decisions and lead to better health care outcomes. Recently proposed joint modeling approaches within the Bayesian framework have inspired the development of a dynamic prediction tool, which can be applied for subject-level prediction of death with implementation in software packages. The prediction model incorporates subject heterogeneity with subject-level random effects that account for unobserved time-invariant factors and an extra copula function capturing the part caused by unmeasured time-dependent factors. Thereafter, given the prespecified landmark timet ' $$ {t}^{\prime } $$ , the survival probability for a prediction horizon time of interestt $$ t $$ can be estimated for each individual. The prediction accuracy is assessed by time-dependent receiving operating characteristic curve and the area under the curve and the Brier score with calibration plots is compared to traditional joint frailty models. Finally, the tool is applied to patients with multiple attacks of stroke or MI in the Cardiovascular Health study and the Atherosclerosis Risk in Communities study for illustration.

Associations of small vessel disease and acute symptomatic seizures in ischemic stroke patients

BACKGROUND AND PURPOSE

Cerebral microbleeds (CMBs), markers of small vessel disease are frequent in ischemic stroke, yet the association with acute symptomatic seizures (ASS) has not been well characterized.

METHODS

A retrospective cohort of hospitalized patients with anterior circulation ischemic stroke. The association of CMBs with acute symptomatic seizures was assessed using a logistic regression model and causal mediation analysis.

RESULTS

Of 381 patients, 17 developed seizures. Compared with patients without CMBs, those with CMBs had a three-fold higher unadjusted odds of seizures (unadjusted OR: 3.84, 95% 1.16-12.71, p = 0.027). After adjusting for confounders such as stroke severity, cortical infarct location, and hemorrhagic transformation, the association between CMBs and ASS was attenuated (adjusted OR: 3.11, 95%CI: 0.74-11.03, p = 0.09). The association was not mediated by stroke severity.

CONCLUSION

In this cohort of hospitalized patients with anterior circulation ischemic stroke, CMBs were more likely to be found in patients with ASS than those without ASS, an association that was attenuated when accounting for stroke severity, cortical infarct location, and hemorrhagic transformation. Evaluation of the long-term risk of seizures associated with CMBs and other markers of small vessel disease is warranted.

Genome-wide Association Study for AKI

Key Points

Two genetic variants in the DISP1-TLR5 gene locus were associated with risk of AKI. DISP1 and TLR5 were differentially regulated in kidney biopsy tissue from patients with AKI compared with no AKI.

Background

Although common genetic risks for CKD are well established, genetic factors influencing risk for AKI in hospitalized patients are poorly understood.

Methods

We conducted a genome-wide association study in 1369 participants in the Assessment, Serial Evaluation, and Subsequent Sequelae of AKI Study; a multiethnic population of hospitalized participants with and without AKI matched on demographics, comorbidities, and kidney function before hospitalization. We then completed functional annotation of top-performing variants for AKI using single-cell RNA sequencing data from kidney biopsies in 12 patients with AKI and 18 healthy living donors from the Kidney Precision Medicine Project.

Results

No genome-wide significant associations with AKI risk were found in Assessment, Serial Evaluation, and Subsequent Sequelae of AKI (P < 5×10 −8 ). The top two variants with the strongest association with AKI mapped to the dispatched resistance-nodulation-division (RND) transporter family member 1 (DISP1) gene and toll-like receptor 5 (TLR5) gene locus, rs17538288 (odds ratio, 1.55; 95% confidence interval, 1.32 to 182; P = 9.47×10 −8 ) and rs7546189 (odds ratio, 1.53; 95% confidence interval, 1.30 to 1.81; P = 4.60×10 −7 ). In comparison with kidney tissue from healthy living donors, kidney biopsies in patients with AKI showed differential DISP1 expression in proximal tubular epithelial cells (adjusted P = 3.9× 10−2) and thick ascending limb of the loop of Henle (adjusted P = 8.7× 10−3) and differential TLR5 gene expression in thick ascending limb of the loop of Henle (adjusted P = 4.9× 10−30).

Conclusions

AKI is a heterogeneous clinical syndrome with various underlying risk factors, etiologies, and pathophysiology that may limit the identification of genetic variants. Although no variants reached genome-wide significance, we report two variants in the intergenic region between DISP1 and TLR5 , suggesting this region as a novel risk for AKI susceptibility.

Short-term and intermediate-term fine particulate air pollution are synergistically associated with habitual sleep variability in adolescents - A cross-sectional study

BACKGROUND

Both air pollution and poor sleep have been associated with increased risk of cardiovascular diseases. However, the association between air pollution and sleep health, especially among adolescents, is rarely investigated.

METHODS

To investigate the association between fine particulate (PM_2.5) air pollution and habitual sleep patterns, we analyzed data obtained from 246 adolescents who participated in the Penn State Child Cohort follow-up examination. We collected their individual-level 24-h (short-term) PM_2.5 concentration by using a portable monitor. We estimated their residential-level PM_2.5 concentration during the 60-day period prior to the examination (intermediate-term) using a kriging approach. Actigraphy was used to measure participants' sleep durations for seven consecutive nights. Habitual sleep duration (HSD) and sleep variability (HSV) were calculated as the mean and SD of the seven-night sleep duration. Multivariable-adjusted linear regression models were used to assess the association between PM_2.5 exposures and HSD/HSV. An interaction between short-term and intermediate-term PM_2.5 was created to explore their synergistic associations with HSD/HSV.

RESULTS

Elevated short-term and intermediate-term PM_2.5 exposure were significantly (p < 0.05) associated with higher HSV, but not HSD. Specifically, the mean (95% CI) increase in HSV associated with 1 SD higher 24-h (26.3 μg/m³) and 60-day average (2.2 μg/m³) PM_2.5 were 14.6 (9.4, 14.8) and 4.9 (0.5, 9.2) minutes, respectively. In addition, there was a synergistic interaction (p = 0.08) between short-term and intermediate-term PM_2.5 exposure on HSV, indicative that the association between intermediate-term PM_2.5 and HSV became stronger as short-term PM_2.5 increases, and vice versa.

CONCLUSION

Short-term individual-level and intermediate-term residential-level PM_2.5 exposures are adversely and synergistically associated with increased sleep variability, an indicator of instability of sleep quantity, in adolescents. Through such an association with sleep pattern, PM_2.5 air pollution may increase long-term cardiometabolic risks.

Factors associated with pediatric febrile illnesses in 27 countries of Sub-Saharan Africa

BACKGROUND

Evidence on the relative importance of various factors associated with febrile illness in children and their heterogeneity across countries can inform the prevention, identification, and management of communicable diseases in resource-limited countries. The objective of the study is to assess the relative significance of factors associated with childhood febrile illness in 27 sub-Saharan African countries.

METHODS

This cross-sectional study of 298,327 children aged 0 to 59 months assessed the strengths of associations of 18 factors with childhood fevers, using Demographic and Health Surveys (2010-2018) from 27 sub-Saharan African countries. A total of 7 child level factors (i.e., respiratory illness, diarrhea, breastfeeding initiation; vitamin A supplements; child's age; full vaccination; sex), 5 maternal factors (maternal education; maternal unemployment; antenatal care; maternal age, and maternal marriage status) and 6 household factors (household wealth; water source; indoor pollution, stool disposal; family planning needs and rural residence) were assessed. Febrile illness was defined as the presence of fever in 2 weeks preceding the survey.

RESULTS

Among the 298,327 children aged 0 to 59 months included in the analysis, the weighted prevalence of fever was 22.65% (95% CI, 22.31%-22.91%). In the pooled sample, respiratory illness was the strongest factor associated with fever in children (adjusted odds ratio [aOR], 5.46; 95% CI, 5.26-5.67; P < .0001), followed by diarrhea (aOR, 2.96; 95% CI, 2.85-3.08; P < .0001), poorest households (aOR, 1.33; 95% CI,1.23-1.44; P < .0001), lack of maternal education (aOR, 1.25; 95% CI, 1.10-1.41; P < .0001), and delayed breastfeeding (aOR, 1.18; 95% CI, 1.14-1.22; P < .0001. Febrile illnesses were more prevalent in children older than >6 months compared to those 6 months and younger. Unsafe water, unsafe stool disposal, and indoor pollution were not associated with child fever in the pooled analysis but had a large country-level heterogeneity.

CONCLUSIONS

Major causes of fevers in sub-Saharan Africa could be attributed to respiratory infections and possibly viral infections, which should not be treated by antimalarial drugs or antibiotics. Point-of-care diagnostics are needed to identify the pathogenic causes of respiratory infections to guide the clinical management of fevers in limited-resource countries.

Joint Modeling of Clinical and Biomarker Data in Acute Kidney Injury Defines Unique Subphenotypes with Differing Outcomes

BACKGROUND

AKI is a heterogeneous syndrome. Current subphenotyping approaches have only used limited laboratory data to understand a much more complex condition.

METHODS

We focused on patients with AKI from the Assessment, Serial Evaluation, and Subsequent Sequelae in AKI (ASSESS-AKI). We used hierarchical clustering with Ward linkage on biomarkers of inflammation, injury, and repair/health. We then evaluated clinical differences between subphenotypes and examined their associations with cardiorenal events and death using Cox proportional hazard models.

RESULTS

We included 748 patients with AKI: 543 (73%) of them had AKI stage 1, 112 (15%) had AKI stage 2, and 93 (12%) had AKI stage 3. The mean age (±SD) was 64 (13) years; 508 (68%) were men; and the median follow-up was 4.7 (Q1: 2.9, Q3: 5.7) years. Patients with AKI subphenotype 1 ( N =181) had the highest kidney injury molecule (KIM-1) and troponin T levels. Subphenotype 2 ( N =250) had the highest levels of uromodulin. AKI subphenotype 3 ( N =159) comprised patients with markedly high pro-brain natriuretic peptide and plasma tumor necrosis factor receptor-1 and -2 and low concentrations of KIM-1 and neutrophil gelatinase-associated lipocalin. Finally, patients with subphenotype 4 ( N =158) predominantly had sepsis-AKI and the highest levels of vascular/kidney inflammation (YKL-40, MCP-1) and injury (neutrophil gelatinase-associated lipocalin, KIM-1). AKI subphenotypes 3 and 4 were independently associated with a higher risk of death compared with subphenotype 2 and had adjusted hazard ratios of 2.9 (95% confidence interval, 1.8 to 4.6) and 1.6 (95% confidence interval, 1.01 to 2.6, P = 0.04), respectively. Subphenotype 3 was also independently associated with a three-fold risk of CKD and cardiovascular events.

CONCLUSIONS

We discovered four AKI subphenotypes with differing clinical features and biomarker profiles that are associated with longitudinal clinical outcomes.

The association between proton pump inhibitor use and risk of post-hospitalization acute kidney injury: a multicenter prospective matched cohort study

BACKGROUND

Proton Pump Inhibitors (PPI) are among the most commonly used drugs to treat acid-related gastrointestinal disorders in the USA. Although PPI use has been linked to acute interstitial nephritis, the side effects of post-hospitalization acute kidney injury (AKI) and the progression of kidney disease still are controversial. We conducted a matched cohort study to examine the associations between PPI use and the side effects, especially in post-hospitalization AKI.

METHODS

We investigated 340 participants from the multicenter, prospective, matched-cohort ASSESS-AKI study, which enrolled participants from December 2009 to February 2015. After the baseline index hospitalization, follow-up visits were conducted every six months, and included a collection of self-reported PPI use by participants. Post-hospitalization AKI was defined as the percentage increase from the nadir to peak inpatient SCr value was ≥ 50% and/or absolute increase ≥ 0.3 mg/dL in peak inpatient serum creatinine compared with baseline outpatient serum creatinine. We applied a zero-inflated negative binomial regression model to test the relationship between PPI use and post-hospitalization AKI. Stratified Cox proportional hazards regression models also were conducted to examine the association between PPI use and the risk of progression of kidney disease.

RESULTS

After controlling for demographic variables, baseline co-morbidities and drug use histories, there was no statistically significant association between PPI use and risk of post-hospitalization AKI (risk ratio [RR], 0.91; 95% CI, 0.38 to 1.45). Stratified by AKI status at baseline, no significant relationships were confirmed between PPI use and the risk of recurrent AKI (RR, 0.85; 95% CI, 0.11 to 1.56) or incidence of AKI (RR, 1.01; 95% CI, 0.27 to 1.76). Similar non-significant results also were observed in the association between PPI use and the risk of progression of kidney diseases (Hazard Ratio [HR], 1.49; 95% CI, 0.51 to 4.36).

CONCLUSION

PPI use after the index hospitalization was not a significant risk factor for post-hospitalization AKI and progression of kidney diseases, regardless of the AKI status of participants at baseline.

Longitudinal biomarkers and kidney disease progression after acute kidney injury

BACKGROUNDLongitudinal investigations of murine acute kidney injury (AKI) suggest that injury and inflammation may persist long after the initial insult. However, the evolution of these processes and their prognostic values are unknown in patients with AKI.METHODSIn a prospective cohort of 656 participants hospitalized with AKI, we measured 7 urine and 2 plasma biomarkers of kidney injury, inflammation, and tubular health at multiple time points from the diagnosis to 12 months after AKI. We used linear mixed-effect models to estimate biomarker changes over time, and we used Cox proportional hazard regressions to determine their associations with a composite outcome of chronic kidney disease (CKD) incidence and progression. We compared the gene expression kinetics of biomarkers in murine models of repair and atrophy after ischemic reperfusion injury (IRI).RESULTSAfter 4.3 years, 106 and 52 participants developed incident CKD and CKD progression, respectively. Each SD increase in the change of urine KIM-1, MCP-1, and plasma TNFR1 from baseline to 12 months was associated with 2- to 3-fold increased risk for CKD, while the increase in urine uromodulin was associated with 40% reduced risk for CKD. The trajectories of these biological processes were associated with progression to kidney atrophy in mice after IRI.CONCLUSIONSustained tissue injury and inflammation, and slower restoration of tubular health, are associated with higher risk of kidney disease progression. Further investigation into these ongoing biological processes may help researchers understand and prevent the AKI-to-CKD transition.FUNDINGNIH and NIDDK (grants U01DK082223, U01DK082185, U01DK082192, U01DK082183, R01DK098233, R01DK101507, R01DK114014, K23DK100468, R03DK111881, K01DK120783, and R01DK093771).

Mobile health lifestyle intervention program leads to clinically significant loss of body weight in patients with NASH

BACKGROUND AIMS

Lifestyle intervention remains the foundation of clinical care for patients with NASH; however, most patients are unsuccessful in enacting sustained behavioral change. There remains a clear unmet need to develop lifestyle intervention programs to support weight loss. Mobile health (mHealth) programs offer promise to address this need, yet their efficacy remains unexplored.

APPROACH RESULTS

We conducted a 16-week randomized controlled clinical trial involving adults with NASH. Patients were randomly assigned (1:1 ratio) to receive Noom Weight (NW), a mHealth lifestyle intervention program, or standard clinical care. The primary end point was a change in body weight. Secondary end points included feasibility (weekly app engagement), acceptability (>50% approached enrolled), and safety. Of 51 patients approached, 40 (78%) were randomly assigned (20 NW and 20 standard clinical care). NW significantly decreased body weight when compared to standard clinical care (-5.5 kg vs. -0.3 kg, p = 0.008; -5.4% vs. -0.4%, p = 0.004). More NW subjects achieved a clinically significant weight loss of ≥5% body weight (45% vs. 15%, p = 0.038). No adverse events occurred, and the majority (70%) of subjects in the NW arm met the feasibility criteria.

CONCLUSIONS

This clinical trial demonstrated that NW is not only feasible, acceptable, and safe but also highly efficacious because this mHealth lifestyle intervention program led to significantly greater body weight loss than standard clinical care. Future large-scale studies are required to validate these findings with more representative samples and to determine if mHealth lifestyle intervention programs can lead to sustained, long-term weight loss in patients with NASH.

Serum Fibroblast Growth Factor 21 Is Markedly Decreased following Exercise Training in Patients with Biopsy-Proven Nonalcoholic Steatohepatitis

BACKGROUND AND AIMS

Exercise remains a key component of nonalcoholic fatty liver disease (NAFLD) treatment. However, mechanisms underpinning the improvements in NAFLD seen with exercise are unclear. Exercise improved liver fat and serum biomarkers of liver fibrosis in the NASHFit trial. We investigated exercise's mechanism of benefit by conducting a post hoc analysis of these data to determine the relationship between serum fibroblast growth factor (FGF) 21, which is implicated in NAFLD development, and exercise.

METHODS

In the 20 wk NASHFit trial, patients with nonalcoholic steatohepatitis (NASH) were randomized to receive moderate-intensity aerobic exercise training or standard clinical care. Mediterranean-informed dietary counseling was provided to each group. Change in serum FGF21 was measured after an overnight fast.

RESULTS

There was a significant improvement in serum FGF21 with exercise training compared to standard clinical care (p = 0.037) with serum FGF21 reducing by 22% (-243.4 +/-349 ng/mL) with exercise vs. a 34% increase (+88.4 ng/mL +/-350.3 ng/mL) with standard clinical care. There was a large inverse association between change in serum FGF21 and change in cardiorespiratory fitness (VO2peak) (r = -0.62, 95% CI -0.88 to -0.05, p = 0.031), and on multivariable analysis, change in VO2peak remained independently associated with change in FGF21 (β = -44.5, 95% CI -83.8 to -5.11, p = 0.031).

CONCLUSIONS

Serum FGF21 is markedly decreased in response to aerobic exercise training, offering a novel mechanism to explain the observed reduction in liver fat and improvement in serum biomarkers of liver fibrosis in patients with NASH who do exercise.

Physical Activity and Risk of Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Physical activity offers promise to protect against multiple non-hepatic primary cancers. We performed a systematic review to quantify the association between physical activity and hepatocellular carcinoma (HCC) risk.

METHODS

We searched the Cochrane Library, Embase, Medline and trial registries through December 2020 for studies that measured physical activity levels in adults at risk for HCC. The primary outcome was HCC. Subgroup analysis was performed limiting to vigorous physical activity. Proportions and random-effects odds ratios (OR) with corresponding 95% confidence intervals (CI) were calculated.

RESULTS

Seven studies met inclusion criteria, comprising 777,662 subjects (median age 55 years; 55% female). Greater amounts of physical activity were associated with less HCC (OR 0.65, 95% CI 0.45-0.95, p = 0.03) compared to lower amounts. Vigorous physical activity was associated with even less HCC (OR 0.62, 95% CI 0.49-0.79, p < 0.01).

CONCLUSIONS

This meta-analysis demonstrates that greater amounts of physical activity are associated with lower odds of HCC. These results support the use of regular physical activity as an effective way to prevent HCC and provide helpful data to support a for future exercise-based interventional study to better define the optimal exercise prescription for patients at risk for primary liver cancer.

Optimal Duration of Systemic Corticosteroids in Coronavirus Disease 2019 Treatment: A Systematic Review and Meta-analysis

Background

Corticosteroids confer a survival benefit in individuals hospitalized with coronavirus disease 2019 (COVID-19) who require oxygen. This meta-analysis seeks to determine the duration of corticosteroids needed to optimize this mortality benefit.

Methods

Electronic databases were searched to 9 March 2022, for studies reporting corticosteroid versus no corticosteroid treatment in hospitalized COVID-19 patients. We estimated the effect of corticosteroids on mortality by random-effects meta-analyses. Subgroup analyses and meta-analyses were conducted to assess the optimal duration of corticosteroid treatment while adjusting for the severity of disease, age, duration of symptoms, and proportion of control group given steroids.

Results

We identified 27 eligible studies consisting of 13 404 hospitalized COVID-19 patients. Seven randomized controlled trials and 20 observational studies were included in the meta-analysis of mortality, which suggested a protective association with corticosteroid therapy (risk ratio [RR], 0.71 [95% confidence interval {CI}, .58-.87]). Pooled analysis of 18 studies showed the greatest survival benefit for a treatment duration up to 6 days (RR, 0.54 [95% CI, .39-.74]). Survival benefit was 0.65 (95% CI, .51-.83) up to 7 days, and no additional survival benefit was observed beyond 7 days of treatment (RR, 0.64 [95% CI, .44-.93]). The survival benefit was not confounded by severity of disease, age, duration of symptoms, or proportion of control group given steroids.

Conclusions

In this meta-analysis, optimal duration of corticosteroid treatment for hospitalized COVID-19 patients was up to 6 days, with no additional survival benefit with >7 days of treatment.

Abstract P249: Moderate-to-Severe Depression Symptoms Are Associated With Poorly Controlled Glucose Levels in Persons With Type 2 Diabetes Mellitus

Objective: To investigate whether the severity of depression symptoms is associated with poor long-term control of plasma glucose levels in individuals with type 2 diabetes.

Methods: Electronic health record [EHR] data of 2842 individuals with mental illness enrolled in the Penn State Clinical Assessment and Rating Evaluation System [PCARES] registry were used. Demographics, body mass index [BMI], baseline type 2 diabetes mellitus [T2DM] status and all available glucose labs were extracted from the EHR. The nine-item patient health questionnaire [PHQ-9] was used to determine baseline depression symptoms. PHQ-9 scores greater than/equal to 10 indicated moderate-to-severe depression symptoms, whereas scores less than 10 indicated none-to-mild depression symptoms. While the baseline glucose measurement had to be within ± 90 days of the baseline PHQ-9 date, longitudinal glucose measurements had to be on or after this date and within one year of the second follow-up glucose lab test date. Each glucose lab test had to be within one year of the preceding lab test. There were 917 individuals that met the criteria for baseline and follow-up glucose measurements and contributed to the effective study sample. Linear mixed-effects models were used to assess the association between baseline depression and changes in glucose levels, with a focus on persons with baseline diabetes. Results are reported as beta-coefficients (standard errors [SE]) and P -values.

Results: The study sample included 917 individuals, with 65% females (596 of 917) and 85% (780 of 917) Non-Hispanic Caucasians. The mean (SD) age, PHQ-9 score, BMI, and glucose were 47.7 (16.9) years, 12.0 (7.1), 31.6 (8.6) Kg/m 2, and 115.9 (48.8) mg/dl, respectively. At baseline, 62.0% had moderate-to-severe depression (569 of 917), and 37.1% of persons had T2DM (341 of 917). Among individuals without T2DM, there was no association between the severity of depression symptoms and follow-up glucose levels with a beta (SE) of 1.1 (1.1) and P =0.32. Among persons with T2DM (N=341), there was an average increase in glucose levels by 2.8 (2.1) mg/dl, P =0.17, per year of follow-up. When stratified by the severity of depression symptoms, individuals with moderate-to-severe depression symptoms had a significant increase in glucose levels at 6.2 (2.7) mg/dl, P =0.02, per year of follow-up, indicative of poor control of blood glucose levels. Whereas, among persons with none-to-mild depression symptoms, blood glucose levels showed a non-significant decline at 2.6 (3.4) mg/dl, P =0.45, per year of follow-up.

Conclusions: In this clinic-based sample of persons with mental illness, moderate-to-severe depression symptoms were associated with significantly increasing blood glucose levels among persons with co-morbid T2DM. Our findings underscore integrated physical and mental healthcare services and routine depression screening among persons with diabetes.

Cardiovascular disease burden is associated with worsened depression symptoms in the U.S. general population

BACKGROUND

Cardiovascular disease (CVD) and depression are the leading causes of disability in the U.S. Using five cycles (2009-2018) of the U.S. National Health and Nutrition Examination Survey, we examined the cross-sectional association between CVD risk factor burden and depression severity in nonpregnant adults with no history of CVD events.

METHODS

With at least 3000 participants per cycle, the overall N was 18,175. CVD risk factors were ascertained through self-report, lab tests, or medications. The sum of hypertension, diabetes, dyslipidemia, and current smoking represented a CVD risk score variable (range: 0-4). Depression severity was assessed using scores on the 9-item patient health questionnaire: 0-9 (none-mild) and 10-27 (moderate-to-severe). Logistic regression models were performed to investigate the association between CVD risk score categories and moderate-to-severe depression. Cycle-specific odds ratios (OR) were meta-analyzed to obtain a pooled OR (95 % CI) (Q-statistic p > 0.05).

RESULTS

Compared to participants with no CVD risk factors, participants with risk scores of 1, 2, 3, and 4, had 1.28 (0.92-1.77), 2.18 (1.62-2.94), 2.53 (1.86-3.49), 2.97 (1.67-5.31) times higher odds of moderate-to-severe depression, respectively, after adjusting for socio-demographics and antidepressant use (linear trend p < 0.0001). This relationship persisted after additionally adjusting for lifestyle variables.

LIMITATIONS

NHANES data is cross-sectional and self-reported, thus preventing causal assessments and leading to potential recall bias.

CONCLUSIONS

Among U.S. adults, CVD risk factor burden was associated with worsened depression symptoms. Integrated mental and physical healthcare services could improve risk stratification among persons with CVD and depression, possibly reducing long-term disability and healthcare costs.

Plasma Soluble Tumor Necrosis Factor Receptor Concentrations and Clinical Events After Hospitalization: Findings From the ASSESS-AKI and ARID Studies

RATIONALE & OBJECTIVE

The role of plasma soluble tumor necrosis factor receptor 1 (sTNFR1) and sTNFR2 in the prognosis of clinical events after hospitalization with or without acute kidney injury (AKI) is unknown.

STUDY DESIGN

Prospective cohort.

SETTING & PARTICIPANTS

Hospital survivors from the ASSESS-AKI (Assessment, Serial Evaluation, and Subsequent Sequelae of Acute Kidney Injury) and ARID (AKI Risk in Derby) studies with and without AKI during the index hospitalization who had baseline serum samples for biomarker measurements.

PREDICTORS

We measured sTNFR1 and sTNFR2 from plasma samples obtained 3 months after discharge.

OUTCOMES

The associations of biomarkers with longitudinal kidney disease incidence and progression, heart failure, and death were evaluated.

ANALYTICAL APPROACH

Cox proportional hazard models.

RESULTS

Among 1,474 participants with plasma biomarker measurements, 19% had kidney disease progression, 14% had later heart failure, and 21% died during a median follow-up of 4.4 years. For the kidney outcome, the adjusted HRs (AHRs) per doubling in concentration were 2.9 (95% CI, 2.2-3.9) for sTNFR1 and 1.9 (95% CI, 1.5-2.5) for sTNFR2. AKI during the index hospitalization did not modify the association between biomarkers and kidney events. For heart failure, the AHRs per doubling in concentration were 1.9 (95% CI, 1.4-2.5) for sTNFR1 and 1.5 (95% CI, 1.2-2.0) for sTNFR2. For mortality, the AHRs were 3.3 (95% CI, 2.5-4.3) for sTNFR1 and 2.5 (95% CI, 2.0-3.1) for sTNFR2. The findings in ARID were qualitatively similar in terms of the magnitude of association between biomarkers and outcomes.

LIMITATIONS

Different biomarker platforms and AKI definitions; limited generalizability to other ethnic groups.

CONCLUSIONS

Plasma sTNFR1 and sTNFR2 measured 3 months after hospital discharge were independently associated with clinical events regardless of AKI status during the index admission. sTNFR1 and sTNFR2 may assist with the risk stratification of patients during follow-up.

Gun violence in United States during the second year of the COVID-19 pandemic

Objective

In the first year of the COVID-19 pandemic, gun violence (GV) rates in the United States (US) rose by 30%. We estimate the relative risk of GV in the US in the second year compared to the first year of the pandemic, in time and space.

Methods

Daily police reports of gun-related injuries and deaths in the 50 states and the District of Columbia from March 1, 2020, to February 28, 2022, were obtained from the GV Archive. Generalized linear mixed-effects models in the form of Poisson regression analyses were utilized to estimate state-specific rates of GV.

Results

Nationally, GV rates during the second year of the pandemic (March 1, 2021, through February 28, 2022) remained the same as that of the first year (March 1, 2020, through February 28, 2021) (Intensity Ratio = 0.996; 95% CI 0.98, 1.01; p = 0.53). Nevertheless, hotspots of GV were identified. Nine (18%) states registered a significantly higher risk of GV during the second year of the pandemic compared to the same period in the first year. In 10 (20%) states, the risk of GV during the second year of the pandemic was significantly lower compared to the same period in the first year.

Conclusion

GV risk in the US is heterogeneous. It continues to be a public health crisis, with 18% of the states demonstrating significantly higher GV rates during the second year of the COVID-19 pandemic compared to the same timeframe 1 year prior.

Factors associated with pregnancy termination in women of childbearing age in 36 low-and middle-income countries

Lack of access to safe, affordable, timely and adequate pregnancy termination care, and the stigma associated with abortion in low-middle income countries (LMICs), pose a serious risk to women's physical and mental well-being throughout the lifespan. Factors associated with pregnancy termination and their heterogeneity across countries in LMICs previously have not been thoroughly investigated. We aim to determine the relative significance of factors associated with pregnancy termination in LMICs and its variation across countries. Analysis of cross-sectional nationally representative household surveys carried out in 36 LMICs from 2010 through 2018. The weighted population-based sample consisted of 1,236,330 women of childbearing aged 15-49 years from the Demographic and Health Surveys. The outcome of interest was self-report of having ever had a pregnancy terminated. We used multivariable logistic regression models to identify factors associated with pregnancy termination. The average pooled weighted prevalence of pregnancy termination in the present study was 13.3% (95% CI: 13.2%-13.4%), ranging from a low of 7.8 (95% CI: 7.2, 8.4%) in Namibia to 33.4% (95% CI: 32.0, 34.7%) in Pakistan. Being married showed the strongest association with pregnancy termination (adjusted OR, 2.94; 95% CI, 2.84-3.05; P < 0.001) compared to unmarried women. Women who had more than four children had higher odds of pregnancy termination (adjusted OR, 2.45; 95% CI, 2.33-2.56; P < 0.001). Moreover, increased age and having primary and secondary levels of education were associated with higher odds of pregnancy termination compared to no education. In this study, married women, having one or more living children, those of older age, and those with at least primary level of education were associated with pregnancy termination in these 36 LMICs. The findings highlighted the need of targeted public health intervention to reduce unintended pregnancies and unsafe abortions.

Urine eosinophil-derived neurotoxin: A potential marker of activity in select eosinophilic disorders

BACKGROUND

Biomarkers of eosinophilic disease activity, especially in the context of novel therapies that reduce blood eosinophil counts, are an unmet need. Absolute eosinophil count (AEC) does not accurately reflect tissue eosinophilia or eosinophil activation. Therefore, the aims of this study were to compare the reliability of plasma and urine eosinophil major basic protein 1, eosinophil cationic protein, eosinophil-derived neurotoxin (EDN), and eosinophil peroxidase measurement and to evaluate the usefulness of eosinophil granule protein (EGP) measurement for the assessment of disease activity in patients with eosinophil-associated diseases treated with mepolizumab, benralizumab, or dexpramipexole.

METHODS

Eosinophil granule protein concentrations were measured in serum, plasma, and urine from healthy volunteers and patients with hypereosinophilic syndrome (HES), eosinophilic granulomatosis with polyangiitis (EGPA), and eosinophilic asthma using a multiplex assay.

RESULTS

Urine EGP concentrations remained stable, whereas serum and plasma EGP concentrations increased significantly with delayed processing. Plasma (p) EDN, but not urine (u) EDN, concentration correlated with AEC and negatively correlated with prednisone dose. Both pEDN and uEDN decreased significantly following treatment of HES patients with benralizumab and EGPA patients with mepolizumab. uEDN appeared to increase with clinical relapse in both patient groups.

CONCLUSIONS

Measurement of EGP in urine is noninvasive and unaffected by cellular lysis. Although plasma and urine EDN concentrations showed a similar pattern following benralizumab and mepolizumab treatment, the lack of correlation between AEC or prednisone dose and uEDN concentrations suggests that measurement of uEDN may provide a potential biomarker of disease activity in patients with HES and EGPA.

Dietary Methionine and Total Sulfur Amino Acid Restriction in Healthy Adults

OBJECTIVES

Dietary restriction of methionine (Met) and cysteine (Cys) delays the aging process and aging-related diseases, improves glucose and fat metabolism and reduces oxidative stress in numerous laboratory animal models. Little is known regarding the effects of sulfur amino acid restriction in humans. Thus, our objectives were to determine the impact of feeding diets restricted in Met alone (MetR) or in both Met and Cys (total sulfur amino acids, SAAR) to healthy adults on relevant biomarkers of cardiometabolic disease risk.

DESIGN

A controlled feeding study.

SETTING AND PARTICIPANTS

We included 20 healthy adults (11 females/9 males) assigned to MetR or SAAR diet groups consisting of three 4-wk feeding periods: Control period; low level restriction period (70% MetR or 50% SAAR); and high level restriction period (90% MetR or 65% SAAR) separated by 3-4-wk washout periods.

RESULTS

No adverse effects were associated with either diet and level of restriction and compliance was high in all subjects. SAAR was associated with significant reductions in body weight and plasma levels of total cholesterol, LDL, uric acid, leptin, and insulin, BUN, and IGF-1, and increases in body temperature and plasma FGF-21 after 4 weeks (P<0.05). Fewer changes occurred with MetR including significant reductions in BUN, uric acid and 8-isoprostane and an increase in FGF-21 after 4 weeks (P<0.05). In the 65% SAAR group, plasma Met and Cys levels were significantly reduced by 15% and 13% respectively (P<0.05).

CONCLUSION

These results suggest that many of the short-term beneficial effects of SAAR observed in animal models are translatable to humans and support further clinical development of this intervention.

1172. Factors Associated With Febrile illnesses in Children in 27 Countries of Sub-Saharan Africa

Background

Evidence on the relative importance of various factors associated with febrile illness in children and their heterogeneity across countries can inform the prevention, identification, and management of communicable diseases in resource-limited countries.

Heatmap of odds ratios.

Country-Specific Odds Ratios for 18 Factors Associated With Febrile illness From Multivariable Adjusted Models.

Methods

This cross-sectional study of 298 327 children aged 0 to 59 months assessed the strengths of associations of 18 factors with childhood fevers, using Demographic and Health Surveys (2010-2018) from 27 sub-Saharan African countries. A total of 7 direct factors (i.e., respiratory illness, diarrhea, breastfeeding initiation; vitamin A supplements; child's age; full vaccination; sex) and 11 indirect factors (household wealth; maternal education; maternal unemployment, water source; indoor pollution, stool disposal; antenatal care; family planning needs; maternal age, rural residence, and maternal marriage status) were assessed. Febrile illness was defined as the presence of fever in 2 weeks preceding the survey.

Results

Among the 298 327 children aged 0 to 59 months included in the analysis, the weighted prevalence of fever was 22.65% (95% CI, 22.31%-22.91%). In the pooled sample, respiratory illness was the strongest factor associated with fever in children (adjusted odds ratio [aOR], 5.46; 95% CI, 5.26-5.67; P &lt; .0001), followed by diarrhea (aOR, 2.96; 95% CI, 2.85-3.08; P &lt; .0001), poorest household wealth (aOR, 1.33; 95% CI,1.23-1.44; P &lt; .0001), lack of maternal education (aOR, 1.25; 95% CI, 1.10-1.41; P &lt; .0001), and delayed breastfeeding (aOR, 1.18; 95% CI, 1.14-1.22; P &lt; .0001. Febrile illnesses were more prevalent in older children &gt;6 months than those 6 months and younger.

Conclusion

In this study, respiratory illness, diarrhea, and socioeconomic conditions were the strongest factors associated with fevers in children of sub-Saharan Africa. Major causes of fevers in sub-Saharan Africa may mostly be attributed to respiratory infections and possibly viral—that may not be treated by antimalarial or antibiotics. Point of care diagnostics are needed to identify the pathogenic causes of respiratory infections to guide the clinical management of fevers in limited-resource countries.

Disclosures

All Authors: No reported disclosures.

Association of COVID-19 with diabetes: a systematic review and meta-analysis

Emerging evidence suggests that coronavirus disease-2019 (COVID-19) may lead to a wide range of post-acute sequelae outcomes, including new onset of diabetes. The aim of this meta-analysis was to estimate the incidence of newly diagnosed diabetes in survivors of COVID-19. We searched MEDLINE, Scopus, Cochrane Central Register of Controlled Trials and the World Health Organization Global Literature on Coronavirus Disease and clinical trial registries for studies reporting the association of COVID-19 and diabetes. Search dates were December 2019-October 16, 2022. Two investigators independently assessed studies for inclusion. Risk of bias was assessed using the Newcastle-Ottawa Scale. We estimated the effect of COVID-19 on incident diabetes by random-effects meta-analyses using the generic inverse variance method. We identified 8 eligible studies consisting of 4,270,747 COVID-19 patients and 43,203,759 controls. Median age was 43 years (interquartile range, IQR 35-49), and 50% were female. COVID-19 was associated with a 66% higher risk of incident diabetes (risk ratio, 1.66; 95% CI 1.38; 2.00). The risk was not modified by age, sex, or study quality. The median risk of bias assessment was 7. In this systematic review and meta-analysis, COVID-19 was associated with higher risk for developing new onset diabetes among survivors. Active monitoring of glucose dysregulation after recovery from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is warranted.

Clinical Decision Support for Glycemic Management Reduces Hospital Length of Stay

OBJECTIVE

Dysglycemia influences hospital outcomes and resource utilization. Clinical decision support (CDS) holds promise for optimizing care by overcoming management barriers. This study assessed the impact on hospital length of stay (LOS) of an alert-based CDS tool in the electronic medical record that detected dysglycemia or inappropriate insulin use, coined as gaps in care (GIC).

RESEARCH DESIGN AND METHODS

Using a 12-month interrupted time series among hospitalized persons aged ≥18 years, our CDS tool identified GIC and, when active, provided recommendations. We compared LOS during 6-month-long active and inactive periods using linear models for repeated measures, multiple comparison adjustment, and mediation analysis.

RESULTS

Among 4,788 admissions with GIC, average LOS was shorter during the tool's active periods. LOS reductions occurred for all admissions with GIC (-5.7 h, P = 0.057), diabetes and hyperglycemia (-6.4 h, P = 0.054), stress hyperglycemia (-31.0 h, P = 0.054), patients admitted to medical services (-8.4 h, P = 0.039), and recurrent hypoglycemia (-29.1 h, P = 0.074). Subgroup analysis showed significantly shorter LOS in recurrent hypoglycemia with three events (-82.3 h, P = 0.006) and nonsignificant in two (-5.2 h, P = 0.655) and four or more (-14.8 h, P = 0.746). Among 22,395 admissions with GIC (4,788, 21%) and without GIC (17,607, 79%), LOS reduction during the active period was 1.8 h (P = 0.053). When recommendations were provided, the active tool indirectly and significantly contributed to shortening LOS through its influence on GIC events during admissions with at least one GIC (P = 0.027), diabetes and hyperglycemia (P = 0.028), and medical services (P = 0.019).

CONCLUSIONS

Use of the alert-based CDS tool to address inpatient management of dysglycemia contributed to reducing LOS, which may reduce costs and improve patient well-being.

Comparing two advance care planning conversation activities to motivate advance directive completion in underserved communities across the USA: The Project Talk Trial study protocol for a cluster, randomized controlled trial

BACKGROUND

Advance care planning (ACP) is a process involving conversations between patients, loved ones, and healthcare providers that consider patient preferences for the types of medical therapies received at the end of life. Underserved populations, including Black, Hispanic, rural, and low-income communities are less likely to engage in ACP than other communities, a health inequity that results in lower-quality care and reduced hospice utilization. The purpose of this trial is to compare efficacy of two interventions intended to motivate ACP (particularly advance directive completion) for those living in underserved communities.

METHODS

This 3-armed cluster, randomized controlled mixed methods design is being conducted in 75 community venues in underserved communities across the USA. The goal of the trial is to compare the efficacy of two interventions at motivating ACP. Arm 1 uses an end-of-life conversation game (Hello); Arm 2 uses a nationally utilized workshop format for ACP conversations (The Conversation Project); and Arm 3 uses an attention control game (TableTopics). Events are held in partnership with 75 local community-based host organizations and will involve 1500 participants (n=20 per event). The primary outcome is completion of a visually verified advance directive at 6 months post-event. Primary analyses compare efficacy of each intervention to each other and the control arm. Secondary mixed methods outcomes include (a) other ACP behaviors and engagement; (b) communication quality; (c) impact of sociocultural environment on ACP (via qualitative interviews); and (d) implementation and sustainability. Subgroup analyses examine outcomes for Black, Hispanic, and rural groups in particular.

DISCUSSION

This trial will add to the evidence base behind various conversational ACP interventions, examine potential mechanisms of action for such interventions, and provide qualitative data to better understand the sociocultural environment of how community-based ACP interventions are experienced by underserved populations. Results will also provide important data for future researchers to learn whether visual verification of advance directives is necessary or whether reliance on self-reported outcomes is of comparable value. Data from this study will inform ways to effectively motivate underserved communities to participate in advance care planning.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04612738. Registered on October 12, 2020. All information from the WHO Trial Registration Data Set can be found within the protocol.

Acute Impact of Fine Particulate Air Pollution on Cardiac Arrhythmias in a Population‐Based Sample of Adolescents: The Penn State Child Cohort

Background

Fine particulate (fine particles with aerodynamic diameters ≤2.5 μm [PM 2.5 ]) exposure has been associated with a risk of cardiac arrhythmias in adults. However, the association between PM 2.5 exposure and cardiac arrhythmias in adolescents remains unclear.

Methods and Results

To investigate the association and time course between PM 2.5 exposure with cardiac arrhythmias in adolescents, we analyzed the data collected from 322 adolescents who participated in the PSCC (Penn State Child Cohort) follow‐up examination. We obtained individual‐level 24‐hour PM 2.5 concentrations with a nephelometer. Concurrent with the PM 2.5 measure, we obtained 24‐hour ECG data using a Holter monitor, from which cardiac arrhythmias, including premature atrial contractions and premature ventricular contractions (PVCs), were identified. PM 2.5 concentration and numbers of premature atrial contractions/PVCs were summarized into 30‐minute‐based segments. Polynomial distributed lag models within a framework of a negative binomial model were used to assess the effect of PM 2.5 concentration on numbers of premature atrial contractions and PVCs. PM 2.5 exposure was associated with an acute increase in number of PVCs. Specifically, a 10 μg/m 3 increase in PM 2.5 concentration was associated with a 2% (95% CI, 0.4%–3.3%) increase in PVC counts 0.5 to 1.0, 1.0 to 1.5, and 1.5 to 2.0 hours after the exposure. Cumulatively, a 10 μg/m 3 increment in PM 2.5 was associated with a 5% (95% CI, 1%–10%) increase in PVC counts within 2 hours after exposure. PM 2.5 concentration was not associated with premature atrial contraction.

Conclusions

PM 2.5 exposure was associated with an acute increased number of ventricular arrhythmias in a population‐based sample of adolescents. The time course of the effect of PM 2.5 on ventricular arrhythmia is within 2 hours after exposure.

Prevalence and determinants of meeting minimum dietary diversity among children aged 6-23 months in three sub-Saharan African Countries: The Demographic and Health Surveys, 2019-2020

Background

Dietary diversity is an indicator of nutritional adequacy, which plays a significant role in child growth and development. Lack of adequate nutrition is associated with suboptimal brain development, lower school performance, and increased risk of mortality and chronic diseases. We aimed to determine the prevalence and determinants of meeting minimum dietary diversity (MDD), defined as consuming at least five out of eight basic food groups in the previous 24-h in three sub-Saharan African countries.

Methods

A weighted population-based cross-sectional study was conducted using the most recent Demographic and Health Surveys (DHS). MDD data were available between 2019 and 2020 for three sub-Saharan African countries (Gambia, Liberia, and Rwanda). The study population included 5,832 children aged 6-23 months. A multivariable logistic regression model was developed to identify independent factors associated with meeting MDD.

Results

Overall, the weighted prevalence of children who met the MDD was 23.2% (95% CI: 21.7-24.8%), ranging from 8.6% in Liberia to 34.4% in Rwanda. Independent factors associated with meeting MDD were: age of the child (OR) = 1.96, 95% CI: 1.61, 2.39 for 12-17 months vs. 6-11 months], mothers from highest households' wealth status (OR = 1.86, 95% CI: 1.45-2.39) compared with the lowest, and mothers with secondary/higher education (OR = 1.69, 95% CI: 1.35-2.12) compared with those with no education. Mothers who were employed, had access to a radio, and those who visited a healthcare facility in the last 12 months were more likely to meet the MDD. There was no significant association between the child's sex and the odds of fulfilling the MDD.

Conclusions

There is substantial heterogeneity in the prevalence of MDD in these three sub-Saharan African countries. Lack of food availability or affordability may play a significant role in the low prevalence of MDD. The present analysis suggests that policies that will effectively increase the prevalence of meeting MDD should target poor households with appropriate materials or financial assistance and mothers with lower literacy. Public health interventions working with sectors such as education and radio stations to promote health education about the benefits of diverse diets is a critical step toward improving MDD in sub-Saharan Africa and preventing undernutrition.

Robust and Efficient Assessment of Potency (REAP) as a quantitative tool for dose-response curve estimation

The median-effect equation has been widely used to describe the dose-response relationship and identify compounds that activate or inhibit specific disease targets in contemporary drug discovery. However, the experimental data often contain extreme responses, which may significantly impair the estimation accuracy and impede valid quantitative assessment in the standard estimation procedure. To improve the quantitative estimation of the dose-response relationship, we introduce a novel approach based on robust beta regression. Substantive simulation studies under various scenarios demonstrate solid evidence that the proposed approach consistently provides robust estimation for the median-effect equation, particularly when there are extreme outcome observations. Moreover, simulation studies illustrate that the proposed approach also provides a narrower confidence interval, suggesting a higher power in statistical testing. Finally, to efficiently and conveniently perform common lab data analyses, we develop a freely accessible web-based analytic tool to facilitate the quantitative implementation of the proposed approach for the scientific community.

Association of human papillomavirus vaccination with cervical cancer screening: A systematic review and meta-analysis

INTRODUCTION

Prophylactic vaccination and routine screening are effective at preventing most cases of cervical cancer. Globally, cervical cancer is the fourth most frequently diagnosed cancer among women. The aim of this study was to investigate the association between human papillomavirus virus (HPV) vaccination (1, 2, or 3 doses) and cervical cancer screening.

METHODS

PubMed (MEDLINE), Scopus, Web of Science, and Cochrane Library electronic databases were systematically searched from July 1, 2006, up to September 30, 2021. We pooled estimates using random-effects models. Heterogeneity between studies was quantified using Cochran Q test and I2 statistics. In total, 12 studies involving 2.4 million individuals were included in the meta-analysis.

RESULTS

In the adjusted estimates, uptake of HPV vaccination was associated with increased cervical cancer screening (pooled relative risk [RR]: 1.35; 95% confidence interval [CI]: 1.21, 1.50; n = 12). Between-study heterogeneity was large (I2 = 99%). Compared to unvaccinated, those who received 3 doses of HPV vaccine had the highest uptake of cervical cancer screening (RR: 1.85; 95% CI: 1.58, 2.17), followed by those who received 2 doses (RR: 1.34; 95% CI: 1.21, 1.47). No statistically significant association with screening was found for those who received a single dose of the HPV vaccine.

CONCLUSION

In this meta-analysis, uptake of HPV vaccination was associated with higher cervical cancer screening. It is plausible that vaccinated individuals are more likely to engage in preventive health behaviors. Healthcare providers should remind patients to continue with routine screening for cervical cancer regardless of their HPV vaccine status since vaccination does not protect against all HPV types.

Communication Quality Analysis: A user-friendly observational measure of patient-clinician communication

Communication Quality Analysis (CQA) is a rigorous transcript-based coding method for assessing clinical communication quality. We compared the resource-intensive transcript-based version with a streamlined real-time version of the method with respect to feasibility, validity, reliability, and association with traditional measures of communication quality. Simulated conversations between 108 trainees and 12 standardized patients were assessed by 7 coders using the two versions of CQA (transcript and real-time). Participants also completed two traditional communication quality assessment measures. Real-time CQA was feasible and yielded fair to excellent reliability, with some caveats that can be addressed in future work. CQA ratings were moderately correlated with traditional measures of communication quality, suggesting that CQA captures different aspects of communication quality than do traditional measures. Finally, CQA did not exhibit the ceiling effects observed in the traditional measures of communication quality. We conclude that real-time CQA is a user-friendly method for assessing communication quality that has the potential for broad application in training, research, and intervention contexts and may offer improvements to traditional, self-rated communication measures.

Design and Rationale for the Use of Magnetic Resonance Imaging Biomarkers to Predict Diabetes After Acute Pancreatitis in the Diabetes RElated to Acute Pancreatitis and Its Mechanisms Study: From the Type 1 Diabetes in Acute Pancreatitis Consortium

ABSTRACT

This core component of the Diabetes RElated to Acute pancreatitis and its Mechanisms (DREAM) study will examine the hypothesis that advanced magnetic resonance imaging (MRI) techniques can reflect underlying pathophysiologic changes and provide imaging biomarkers that predict diabetes mellitus (DM) after acute pancreatitis (AP). A subset of participants in the DREAM study will enroll and undergo serial MRI examinations using a specific research protocol. The aim of the study is to differentiate at-risk individuals from those who remain euglycemic by identifying parenchymal features after AP. Performing longitudinal MRI will enable us to observe and understand the natural history of post-AP DM. We will compare MRI parameters obtained by interrogating tissue properties in euglycemic, prediabetic, and incident diabetes subjects and correlate them with metabolic, genetic, and immunological phenotypes. Differentiating imaging parameters will be combined to develop a quantitative composite risk score. This composite risk score will potentially have the ability to monitor the risk of DM in clinical practice or trials. We will use artificial intelligence, specifically deep learning, algorithms to optimize the predictive ability of MRI. In addition to the research MRI, the DREAM study will also correlate clinical computed tomography and MRI scans with DM development.