A meta-analysis of vascular access outcomes in hemodialysis patients aged 75 years or older

BACKGROUND

Several existing guidelines advocate the access creation without any specific recommendations for those patients over 75 years of age. The aim of this meta-analysis is to compare the outcomes of different vascular access procedures in the sub-group of elderly ESRD patients ⩾75 years of age.

METHODS

A literature search was performed using the MEDLINE and SCOPUS electronic databases. The analysis focused on studies with subgroups of elderly patients ⩾75 years of age with different vascular access procedures, and compared the failure rates of autologous versus prosthetic vascular access. Articles comparing patency rates of distal (forearm) versus proximal upper arm AVFs were also investigated.

RESULTS

Twelve relevant studies were identified and included in the meta-analysis. The pooled results revealed a statistically significant unassisted (primary) failure rate at 24 months in favor of autologous AVFs [odds ratio (OR): 0.56, 95% CI: 0.38-0.83, p = 0.003]. A secondary analysis revealed significantly higher 12 months unassisted (primary) and secondary failure rates of forearm AVFs compared with proximal upper arm AVFs (OR: 2.14, 95% CI: 1.53-2.97, p < 0.00001 and OR: 1.76, 95% CI: 1.12-2.78, p < 0.01 respectively).

CONCLUSION

An increased risk of failure of prosthetic vascular access procedures was found compared with autologous AVFs in patients ⩾75 years of age. Elderly patients ⩾75 years should not be excluded from creation of an autologous access, with proximal upper arm AVFs having better patency rates.

Growth differentiation factor-15 as a negative predictor for microvascular obstruction in ST-segment elevation myocardial infarction after primary percutaneous coronary intervention

Growth differentiation factor-15 (GDF-15) is an anti-inflammatory cytokine with cardioprotective effects, but circulating GDF-15 concentration predicts adverse cardiovascular outcomes in clinical settings. Microvascular obstruction (MVO) formation contributed to poor prognosis in patients with ST-segment elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (pPCI). We aimed to investigate GDF-15 concentration in relation to cardiac magnetic resonance (CMR)-derived MVO in STEMI patients after pPCI, which might help better understand the role of GDF-15 in STEMI. GDF-15 levels at 6 h after pPCI and MVO extent at day 5 ± 2 after pPCI were measured in 74 STEMI patients (mean age 60.3 ± 12.8 years, 86.5% men). The adjusted association of GDF-15 with MVO was analyzed with MVO treated as a categorized variable (extensive MVO, defined as MVO extent ≥ 2.6% of left ventricular (LV)) and a continuous variable (MVO mass, % of LV), respectively, in multivariate logistic and linear regression models. 41.9% of the patients developed extensive MVO after pPCI. In multivariate analysis, the odds ratio (95% confidential interval (CI)) of each standard deviation (SD) increase in GDF-15 for developing extensive MVO was 0.46 (0.21, 0.82), p = 0.02). Consistently, when MVO was used a continuous variable, each SD increase in GDF-15 was associated with a substantially lower MVO mass (β - 0.42, standard error 0.19, p = 0.03). GDF-15 was a negative predictor for MVO in STEMI patients after pPCI. The observation was consistent with results from experiment studies, suggesting a potential protective effect of GDF-15 against cardiac injury.

Complaint management system and patient satisfaction in grassroots hospitals

Primary healthcare institutions face limitations in medical resources, leading to concerns from patients and their families regarding the quality of medical services, resulting in complaints against these institutions. This study aims to analyze the causes of complaints and implement improvement measures to enhance the service quality of primary healthcare institutions, increase satisfaction among patients and their families, and reduce the number of complaints. Relevant data were collected, and verified complaints were categorized based on departments, administrative office, and category. Pearson Chi-square test, Spearman correlation analysis, as well as univariate logistic regression were employed to analyze factors influencing patient satisfaction. A complaint-handling process was established, and regulations pertaining to complaints were formulated. Pearson Chi-square test results indicated a significant correlation between satisfaction and departments (P = .016) and administrative office (P = .022). Spearman correlation analysis revealed a significant correlation between satisfaction and departments (ρ = 0.157, P = .017) and administrative office (ρ = 0.151, P = .021). Univariate logistic regression analysis demonstrated a significant correlation between satisfaction and other related complaints in administrative office (OR = 3.321, 95% CI = 1.196-9.218, P = .021). Complaints related to departments and administrative offices are significantly correlated with satisfaction. After the implementation of a complaint management system in primary healthcare institutions, there is a notable improvement in service quality, enhanced patient experience, increased satisfaction, and a reduction in hospital complaints.

Bilingual translations of intensifiers in Dong-A Ilbo's news about China: A corpus-based discourse analysis approach

Drawing on the framework of Ideological Square Model, this paper carries out a corpus-based analysis of the ways in which group relations and the image of China are re-shaped in the English translation (ET) and the Chinese translation (CT) of Korean news discourse about China with intensifiers as an entry of inquiry. The results show that (1) There is a statistically significant difference regarding faithfulness between the ET and the CT of intensifiers (χ2 = 38.11>3.84, p<0.05), with the ET having more translation shifts. Additionally, the Chi-square test of a 3x3 contingency table (T = 49.77>5.99, P<0.05) indicates that there is a difference between the distribution of translation shifts at the 3 levels between ET and CT. (2) The ET of Korean news about China aligns more closely with van Dijk's ideological square model, while CT violates. It is argued that South Korean media have ideological factors to consider when it comes to Chinese readers accepting CT. (3) There is an alteration of the ideological square model in the target texts. The results indicate that in the translation of a target language, the translation propensity for relevant topics of the target country in which the language is spoken obeys the rules of "Us", the ingroup, but not "them", the outgroup.

Permutation Tests for Assessing Potential Non-Linear Associations between Treatment Use and Multivariate Clinical Outcomes

In many psychometric applications, the relationship between the mean of an outcome and a quantitative covariate is too complex to be described by simple parametric functions; instead, flexible nonlinear relationships can be incorporated using penalized splines. Penalized splines can be conveniently represented as a linear mixed effects model (LMM), where the coefficients of the spline basis functions are random effects. The LMM representation of penalized splines makes the extension to multivariate outcomes relatively straightforward. In the LMM, no effect of the quantitative covariate on the outcome corresponds to the null hypothesis that a fixed effect and a variance component are both zero. Under the null, the usual asymptotic chi-square distribution of the likelihood ratio test for the variance component does not hold. Therefore, we propose three permutation tests for the likelihood ratio test statistic: one based on permuting the quantitative covariate, the other two based on permuting residuals. We compare via simulation the Type I error rate and power of the three permutation tests obtained from joint models for multiple outcomes, as well as a commonly used parametric test. The tests are illustrated using data from a stimulant use disorder psychosocial clinical trial.

Long-Term Outcomes of Coronary Artery Bypass Grafting Using an Internal Thoracic Artery versus a Radial Artery as a Second Arterial Graft

PURPOSE

To compare the outcomes of left circumflex artery (LCx) revascularization using an internal thoracic artery (ITA) or radial artery (RA) as the second arterial graft.

METHODS

Patients who underwent primary isolated coronary artery bypass grafting with left anterior descending artery revascularization using an ITA and LCx revascularization using another bilateral ITA (BITA group) or an RA (ITA-RA group) were included. All-cause mortality (primary endpoint), cardiac death, major adverse cardiac events, in-hospital death, and deep sternal wound infection (secondary endpoints) were evaluated.

RESULTS

Among 790 patients (BITA, n = 548 (69%); ITA-RA, n = 242 (31%)), no significant difference in all-cause mortality between the groups was observed (hazard ratio (HR): 0.87; 95% confidence interval (CI): 0.67-1.12; p = 0.27) during follow-up (mean, 10 years). Multivariate analysis revealed that the BITA group exhibited significantly lower rates of long-term all-cause mortality (HR: 0.63; 95% CI: 0.48-0.84; p = 0.01). In the propensity-matched cohort (n = 480, 240 pairs), significantly fewer all-cause deaths occurred in the BITA group (HR: 0.66; 95% CI 0.47-0.93; p = 0.02). There were no significant differences in secondary outcomes.

CONCLUSIONS

When used as second grafts for LCx revascularization, ITA grafts may surpass RA grafts in reducing all-cause mortality 10 years postoperatively.

The characteristics of counterattacks in the Spanish league (La Liga) in 2021-2022

BACKGROUND

Current studies on counterattacks are limited despite the fact that it is one of the most effective ways to score in soccer. The aim of the study was to investigate the characteristics of counterattacks in the Spanish league (La Liga) for the year 2021-2022.

METHODS

The sample used in the study were 2631 counterattacks collected from a total of 380 games. The variables used were: 1) the space which the counterattack had started; 2) the number of players who participated; 3) the number of defending players; 4) the duration of the counterattack; 5) the touches to complete the counterattack; 6) the formation of both teams; 7) the way that counterattack was completed (final action); 8) the minute that the counterattack took place; and 9) which team had a home advantage. The results were analyzed using the Chi-square test. The level of significance was defined at P<0.05.

RESULTS

Firstly, it appeared that most counterattacks began from the axis of the defensive zone lasting 6-15 seconds. There were 3-4 attackers participating against 4-6 defenders, using 5-9 touches. In addition, most of them took place in the 46-60 minute of the game and were completed in a shot.

CONCLUSIONS

The study can help coaches and analysts to understand the characteristics of the counterattacks and adapt their training in a way to make their teams more effective, both in the attacking and defending phase.

Variations and thicknesses of anterior belly of the digastric muscle: an ultrasonographic study

PURPOSE

This study aims to evaluate the anatomy and anatomical variations of the anterior belly of the digastric muscle.

METHODS

Hundred and fifty one ultrasonographic images of the digastric muscle pairs were evaluated in Near East University Faculty of Dentistry Department of Dentomaxillofacial Radiology. Morphological variations were recorded using the classification of the digastric muscle into 12 types by Kim et al. For the analysis, the Mann-Whitney U test and Chi-square test were used, and for the correlational analysis, Spearman's rho test was applied. P < 0.05 was considered statistically significant in all tests.

RESULTS

Seventy female and 81 male patients aged 19-60 years were evaluated. Type 1 digastric muscle was observed in 145 of 151 patients, Type 2 in 3 patients, and Type 7 in 3 patients. The thicknesses of the right and left digastric muscles were measured, and a statistically significant difference was observed between the groups when the genders were compared. It was observed that both right and left digastric muscle thicknesses were higher in males than females. There was a statistically significant positive high correlation between right and left digastric muscle thicknesses (p = 0.000; r = 0.736). No statistically significant difference was found between genders (p = 0.596) in terms of anatomical variations.

CONCLUSION

Considering that the variations of the digastric muscle may have a clinical significance role, the normal anatomy and variations of this muscle should be well known by maxillofacial surgeons and radiologists.

Endodontic Procedural Errors and Associated Factors among Undergraduate Dental Students: A Cross-sectional Study

AIMS AND BACKGROUND

To assess the procedural errors committed by undergraduate students at RAK College of Dental Sciences, during root canal treatments and the factors associated with these errors.

MATERIALS AND METHODS

In this cross-sectional study, 180 self-administered questionnaires were distributed, each comprising 26 questions, among 4th and 5th-year students. Participants were requested to report their endodontic mishaps based on feedback from their supervisors. The questionnaire assessed the frequency and types of procedural errors, considering patient, operator, and tooth-related factors. Data were collected tabulated and analyzed using the Chi-square test.

RESULTS

A total of 124 root canal-treated teeth exhibiting iatrogenic errors done by students were assessed. Out of which, 53% were performed by 5th-year students, and 69% were conducted by female operators. About 62% of errors occurred in the upper teeth and 68% in the posterior teeth. The most prevalent errors during the rubber dam isolation step were soft tissue trauma (21%) and isolation leakage (20%), significantly associated with limited mouth opening, excessive salivation, and tooth malalignment (p < 0.05). Apical blockage (15%) emerged as the most frequent error during instrumentation phase, showing a significant association with canal dimension and curvature (p < 0.05). For access cavity and obturation phases, under-extended cavity (9%), and under-extended filling (11%) were the most reported errors, respectively.

CONCLUSION

Tooth isolation emerges as a particularly challenging aspect for dental students, particularly when dealing with patients exhibiting limited mouth opening and excessive salivation.

CLINICAL SIGNIFICANCE

Clinical instructors should caution the undergraduates about the heightened risk of endodontic procedural errors when dealing with patients exhibiting limited mouth opening, excessive salivation, tooth misalignment, and narrow canals. Addressing these challenges is crucial for enhancing the proficiency of undergraduate students in performing successful root canal treatments. How to cite this article: Elsayed MA, Islam MS, Saleh DR, et al. Endodontic Procedural Errors and Associated Factors among Undergraduate Dental Students: A Cross-sectional Study. J Contemp Dent Pract 2023;24(12):998-1007.

Effect of couple-based health education on male-partners knowledge and attitude towards maternity waiting homes in rural Ethiopia: a cluster-randomized trial

This cluster-randomized controlled trial examined the effect of couple-based health education on male partners' knowledge and attitude towards maternity waiting homes (MWH) in rural Ethiopia. Sixteen clusters and 320 couples were randomly assigned to intervention group (receiving group health education, home visits and print health messages alongside usual care) or control group (receiving usual care). The Chi-square test was used to estimate statistical differences, and the difference-in-differences model was used to estimate the effect of the intervention. The generalized linear regression model was used to determine the odds of outcomes between the groups. Statistical significance was set at p < 0.05, with a 95% CI. There were no significant differences in baseline characteristics between the control and intervention groups. The net effect of the intervention on improving knowledge about MWHs, and attitude towards MWHs were 35.6% and 36.2%, respectively. The participants in the intervention group were 5.5 times more likely to have good knowledge about MWH (AOR 5.55, 95% CI 3.37-9.14) and 5.6 times more likely to have a favorable attitude towards MWH (AOR 5.61, 95% CI 3.45-9.10) compared to their counterparts. Health education provided to couples significantly improved male partners' knowledge and attitude towards MWHs in rural Ethiopia.Trial registration: ClinicalTrials.gov Identifier: NCT05015023.

Researcher degrees of freedom in statistical software contribute to unreliable results: A comparison of nonparametric analyses conducted in SPSS, SAS, Stata, and R

Researcher degrees of freedom can affect the results of hypothesis tests and consequently, the conclusions drawn from the data. Previous research has documented variability in accuracy, speed, and documentation of output across various statistical software packages. In the current investigation, we conducted Pearson's chi-square test of independence, Spearman's rank-ordered correlation, Kruskal-Wallis one-way analysis of variance, Wilcoxon Mann-Whitney U rank-sum tests, and Wilcoxon signed-rank tests, along with estimates of skewness and kurtosis, on large, medium, and small samples of real and simulated data in SPSS, SAS, Stata, and R and compared the results with those obtained through hand calculation using the raw computational formulas. Multiple inconsistencies were found in the results produced between statistical packages due to algorithmic variation, computational error, and statistical output. The most notable inconsistencies were due to algorithmic variations in the computation of Pearson's chi-square test conducted on 2 × 2 tables, where differences in p-values reported by different software packages ranged from .005 to .162, largely as a function of sample size. We discuss how such inconsistencies may influence the conclusions drawn from the results of statistical analyses depending on the statistical software used, and we urge researchers to analyze their data across multiple packages to check for inconsistencies and report details regarding the statistical procedure used for data analysis.

Secondary post-tonsillectomy haemorrhage: is there evidence of diurnal and monthly variation in haemorrhage rates?

BACKGROUND

Anecdotally, secondary post-tonsillectomy haemorrhage tends to occur out-of-hours. This study sought to establish whether there is a link between haemorrhage and time of day, and examined correlations with month and with monthly temperature.

METHODS

Data were obtained for patients in our hospital undergoing surgical arrest of secondary post-tonsillectomy haemorrhage between January 2002 and December 2020. Haemorrhage timing was categorised into daytime (07:00-18:00), evening (18:00-22:00) and overnight (22:00-07:00). The chi-square test was used to assess diurnal and monthly variation in haemorrhage rates (p < 0.05). Pearson's correlation test was used to analyse monthly haemorrhage rates and average monthly temperature.

RESULTS

Fifty per cent of patients suffered post-tonsillectomy haemorrhage overnight and 28.1 per cent haemorrhaged in the evening, representing a significant difference (p = 0.018). The highest rate of haemorrhage was in July (2.96 per cent), which was statistically significant (p = 0.0024). There was a positive correlation between average monthly temperature and haemorrhage rate (Pearson's correlation = 0.478, p = 0.116004), although this was not significant.

CONCLUSION

Most post-tonsillectomy haemorrhages occur out-of-hours (78.1 per cent), which could be conveyed during the consent process. The haemorrhage rate is lower in winter, which may influence planned operating theatre scheduling.

Malignancy-related mir-210, mir-373 and let-7 levels are affected in iron deficiency anemia

Background

Hypoxia is the hallmark of iron deficiency anemia (IDA) and in hypoxic environment, significant changes are observed in malignancy-related microRNAs (miRNA). Our aim is to examine whether there is any difference in the levels of miR-210, miR-373 and let-7, which are directly related to malignancies in patients with IDA.

Methods

Thirty-five female patients with IDA between the ages of 18-65 and 10 healthy controls were included in the study. Patients who received oral iron therapy, who had inflammatory disease, and who were pregnant were excluded from the study. Student t Test was used for comparing variables with normal distribution in two independent groups, and Mann-Whitney U Test was used for variables without normal distribution. Comparison of categorical data was made using the chi-square test.

Results

The mean hemoglobin and ferritin level were 10,78±0,93 and 6.28±5,76 respectively. Plasma miR-210 expression were found as -7.27±2.23 and -6.15±0,88 in IDA and control group respectively (p = 0.022). Plasma miRNA-373 were -7.36±2,58 and -6,96±1,93 and let-7 expression were 2.14±2,15 and 3,57±2,21 in IDA and control group. (p = 0.65 and p = 0.20, respectively).

Conclusions

Plasma miR-210 expression was significantly up-regulated and miR-373 and let-7 expression was down-regulated, though insignificantly, in IDA group.

Ball Screens in the Men's 2019 Basketball World Cup

BACKGROUND

The objective of this research was to analyse the effectiveness and search for successful patterns in ball screens in the men's 2019 Basketball World Cup.

METHODS

The sample consisted of 515 ball screens obtained in critical moments. LINCE software was used as a registration instrument by means of an observational instrument designed ad hoc. A descriptive analysis and chi-square tests (χ2) were performed with SPSS 25.0 and a T-patterns analysis with Theme 5 software.

RESULTS

The results indicate that the criteria that have the most influence on this type of action are the result of the team executing the screen (winning, losing or tying), the type of offense and the defence used on the ball screen. The most representative patterns of success tend to take place between 9-16 s of possession, with the screeners being inside players and the screened players being outside players, and it is performed in the upper areas of the court against an individual type of defence and ending with the screened player advancing towards the basket or passing to an open teammate.

CONCLUSIONS

The data obtained will enable the coaching staff to train ball screens in accordance with specific game situations.

The relative age effect in top 100 elite female tennis players in 2007-2016

The Relative Age Effect (RAE) has been the subject of many studies, but few have focused on professional athletes in individual sports. The aim of this study was to verify the existence of the RAE among elite senior female tennis players (top 100 players) in the WTA Rankings (n = 1000) in the years 2007-2016. The analysis was performed among top 100, resp. top 10 female tennis players, among players in 4 age subgroups and among left-handed (LH) and right-handed (RH) players. The existence of the RAE was assessed with the use of chi-square test (goodness of fit). More than half of top 100 players were born in first semester: both in individual years (53.0-63.0%) and in the whole observed period (58.4%). Significant RAE (ES medium) was observed in top 100 female players only in 2012 and 2016; significant RAE (ES small) was detected in the period of 2007-2016. Among the top 10 players, significant RAE (ES medium) was demonstrated during the whole period. No significant RAE (ES medium) was detected in the 17-18y subgroups, significant in 19-24y and 25-30y (ES small) as well as in 31-36y (ES medium). Although significant RAE was observed in the subgroups of LH and RH female players, ES was large only in the LH. The results contribute to the expansion of the knowledge about the reduction of the RAE existence in adulthood among coaches, athletes and tennis officials.

Racial and ethnic disparities in 3-year outcomes following infrainguinal bypass for chronic limb-threatening ischemia

OBJECTIVE

Black and Hispanic patients have had higher rates of chronic limb-threatening ischemia (CLTI) and experienced worse perioperative outcomes after lower extremity bypass compared with White patients. The underlying reasons for these disparities have remained unclear, and data on 3-year outcomes are limited. Therefore, we examined the differences in 3-year outcomes after open infrainguinal bypass for CLTI stratified by race/ethnicity and explored the potential factors contributing to these differences.

METHODS

We identified all CLTI patients who had undergone primary open infrainguinal bypass in the Vascular Quality Initiative registry from 2003 to 2017 with linkage to Medicare claims through 2018 for the 3-year outcomes. Our primary outcomes were the 3-year rates of major amputation, reintervention, and mortality. We also recorded the 30-day major adverse limb events (MALE) defined as major amputation or reintervention. We used Kaplan-Meier estimation methods and multivariable Cox regression analyses to evaluate the outcomes stratified by race/ethnicity and identify contributing factors.

RESULTS

Of the 7108 patients with CLTI, 5599 (79%) were non-Hispanic White, 1053 (15%) were Black, 48 (1%) were Asian, and 408 (6%) were Hispanic patients. Compared with White patients, Black patients had higher rates of 3-year major amputation (Black vs White, 32% vs 19%; hazard ratio [HR], 1.9; 95% confidence interval [CI], 1.7-2.2), reintervention (Black vs White, 61% vs 57%; HR, 1.2; 95% CI, 1.1-1.3), and 30-day MALE (Black vs White, 8.1% vs 4.9%; HR, 1.3; 95% CI, 1.2-1.4) but lower mortality (Black vs White, 38% vs 42%; HR, 0.9; 95% CI, 0.8-0.99). Hispanic patients also experienced higher rates of amputation (Hispanic vs White, 27% vs 19%; HR, 1.6; 95% CI, 1.3-2.0), reintervention (Hispanic vs White, 70% vs 57%; HR, 1.4; 95% CI, 1.2-1.6), and MALE (Hispanic vs White, 8.7% vs 4.9%; HR, 1.5; 95% CI, 1.3-1.7. However, mortality was similar between the two groups (Hispanic vs White, 38% vs 42%; HR, 0.88; 95% CI, 0.76-1.0). The low number of Asian patients prevented a meaningful assessment of amputation (Asian vs White, 20% vs 19%; HR, 0.93; 95% CI, 0.44-2.0), reintervention (Asian vs White, 55% vs 57%; HR, 0.79; 95% CI, 0.51-1.2), MALE (Asian vs White, 8.5% vs 4.9%; HR, 0.71; 95% CI, 0.46-1.1), or mortality (Asian vs White, 36% vs 42%; HR, 0.83; 95% CI, 0.52-1.3). In the adjusted analyses, the association of Black race and Hispanic ethnicity with amputation and reintervention was explained by differences in the demographic characteristics (ie, age, sex) and baseline comorbidities (ie, tobacco use, diabetes, renal disease).

CONCLUSIONS

Compared with White patients, Black and Hispanic patients had higher 3-year major amputation and reintervention rates. However, mortality was lower for Black patients than for the White patients and similar between Hispanic and White patients. Disparities in amputation and reintervention were partly attributable to differences in demographic characteristics and the higher prevalence of comorbidities in Black and Hispanic patients with CLTI. Future work is necessary to determine whether interventions to improve access to care and reduce the burden of comorbidities in these populations will confer limb salvage benefits.

Surgical site infection after open lower extremity revascularization associated with doubled rate of major limb amputation

OBJECTIVE

Surgical site infection (SSI) after open lower extremity revascularization is a relatively common complication associated with increased hospital stays, graft infection, and in severe cases, graft loss. Although the short-term effects of SSI can be significant, it has not been considered a complication that increases major limb amputation. The purpose of this study was to determine the association of SSI with outcomes in patients undergoing surgical revascularization for peripheral arterial disease.

METHODS

We analyzed nationwide Vascular Quality Initiative (VQI) data from the infrainguinal bypass module from 2003 to 2017. The cohort included adults who underwent open lower extremity bypass for symptomatic peripheral arterial disease and had at least one follow-up record. Weighted Kaplan-Meier curves and Cox proportional hazards regression were used to assess the association between SSI and 1-year mortality and major limb amputation. Inverse-probability of treatment weights were used to account for differences in demographics and patient characteristics and allow for 'adjusted' Kaplan-Meier curves.

RESULTS

The analysis included 21,639 patients, and 1155 (5%) had a reported SSI within 30 days of surgery. Patients with SSI were more likely be obese (41% vs 30%), but there were no other clinically relevant differences between demographics, comorbidities, and bypass details. After weighting, patients with SSI were almost twice as likely to undergo major amputation by 6 months (hazard ratio, 1.84; 95% confidence interval, 1.07-3.17). The association with SSI and increased amputation rates persisted at 1 year. The association of SSI on amputation was no different based on preoperative Rutherford class (P = .91). The association between SSI and 1-year mortality rate was not statistically significant (hazard ratio, 1.15; 95% confidence interval, 0.91-1.46).

CONCLUSIONS

SSI is more common in obese patients, and patients who develop an SSI are observed to have a significantly increased rate of limb amputation after open lower extremity revascularization.

Blind estimation of sound coloration in rooms using chi-square distributions of damping constants

Depending on the room type and various other assumptions, the damping distribution of a room will follow a specific "reference distribution," i.e., any deviation from the distribution should indicate sound coloration. In this paper, sound coloration will be caused by the acoustic feedback when operating sound reinforcement systems at relatively high gain settings. A sound reinforcement system based on measured impulse responses as well as an "emulated" system are studied using two speech and two music samples with system gains ranging from low to just before instability. Using one microphone placed in the audience area, blind estimation of sound coloration is achieved by computing decay times of non-harmonic components in the time-frequency domain. The results show that the computed damping distributions agree well with the chi-square distributions at low system gains. As the system gain increases, the distributions are shifted toward lower damping constants, and their shapes deviate more and more from the reference distribution, thus, giving a clear indication of sound coloration. The suggested objective measures show that deviations from the reference damping distribution can be detected at substantially lower system gains compared to results of related listening tests where audible coloration is evaluated.

Evaluation of Zygomaticosphenoidal Angle in Patients With Unilateral Zygomaticomaxillary Complex Fracture

ABSTRACT

This study aimed to assess the zygomaticosphenoidal (ZS) angle in patients with reducted unilateral zygomatico-maxillary complex (ZMC) fracture and compare it with the normal control group. This study was performed on CT images of 60 cases and 60 controls with a mean age of 35.1 ± 14.6. The ZS angle was measured on axial images containing the equator of the eyeball. Moreover, the mean absolute difference value and asymmetry index were calculated. Chi-square test, independent-sample t test, 1-way ANOVA, paired-sample t test, and ROC curve analysis were applied. The mean ZS angle in the control group was 46.6° ± 3.5°. Considering laterality, the mean of ZS was not significant in the control group. However, after reduction of unilateral ZMC fracture, there was a significant difference between the mean ZS angle in right and left sides. The mean absolute difference between right and left ZS angles was significantly higher in the case group. A threshold number of 0.9° is established in the mean absolute difference value which is the difference between the right and left ZS angles in an individual for detecting asymmetry. The ZS angle can be a useful anatomical aid to guide surgeons in achieving facial symmetry in ZMC fractures.

The association between 2,4-D and serum testosterone levels: NHANES 2013-2014

BACKGROUND

Previous studies have investigated associations between herbicides such as 2,4-Dichlorophenoxyacetic acid (2,4-D) and dyshormonogenesis, specifically low testosterone, in human, rodent, and cell models, but results have been conflicting and inconclusive.

METHODS

Using data from a cross-sectional study of 456 adult men in the 2013-2014 NHANES survey cycle, we examined the relationship between urinary concentrations of 2,4-D and serum testosterone levels.

RESULTS

Multivariable regression models adjusting for potential confounders revealed a significant, negative association between urinary 2,4-D and mean serum testosterone among U.S. adult males (β =  - 11.4 ng/dL, p = 0.02). Multivariable logistic regression models using a cutoff defining abnormally low testosterone (i.e., serum testosterone < 300 ng/dL) revealed no significant associations between 2,4-D and the odds of low testosterone.

CONCLUSION

These findings expand on previous literature implicating a role for 2,4-D in the etiology of low testosterone and dyshormonogenesis. Future studies are warranted to corroborate these findings, determine clinical significance, and to investigate the proposed potential biological mechanisms underlying this association.

Risk factors for gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs): a three-centric case-control study

PURPOSE

Risk factors for sporadic GEP-NENs are still not well defined. To identify the main clinical risk factors represents the aim of this study performed by three Italian referral centers for NENs.

METHODS

We performed a retrospective case-control study including 148 consecutive sporadic GEP-NENs and 210 age- and sex-matched controls. We collected data on clinical features, cancer family history and other potential risk factors.

RESULTS

Mean age was 58.3 ± 15.8 years; 50% males, primary site was pancreas (50.7%), followed by ileum (22.3%). The 62.8% and 29.1% of cases were G1 and G2, respectively; the 40% had locally advanced or metastatic disease at diagnosis. Independent risk factors for GEP-NENs were: family history of non-neuroendocrine GEP cancer (OR 2.16, 95% CI 1.31-3.55, p = 0.003), type 2 diabetes mellitus (T2DM) (OR 2.5, 95% CI 1.39-4.51, p = 0.002) and obesity (OR 1.88, 95% CI 1.18-2.99, p = 0.007). In the T2DM subjects, metformin use was a protective factor (OR 0.28, 95% CI 0.08-0.93, p = 0.049). T2DM was also associated with a more advanced (OR 2.39, 95% CI 1.05-5.46, p = 0.035) and progressive disease (OR 2.47, 95% CI 1.08-5.34, p = 0.03). Stratifying cases by primary site, independent risk factors for pancreatic NENs were T2DM (OR 2.57, 95% CI 1.28-5.15, p = 0.008) and obesity (OR 1.98, 95% CI 1.11-3.52, p = 0.020), while for intestinal NENs family history of non-neuroendocrine GEP cancer (OR 2.46, 95% CI 1.38-4.38, p = 0.003) and obesity (OR 1.90, 95% CI 1.08-3.33, p = 0.026).

CONCLUSION

This study reinforces a role for family history of non-neuroendocrine GEP cancer, T2DM and obesity as independent risk factors for GEP-NENs and suggests a role of metformin as a protective factor in T2DM subjects. If confirmed, these findings could have a significant impact on prevention strategies for GEP-NENs.

Frequency of the Statistical Methods and Relation with Acceptance Period in Archives of Iranian Medicine Articles: A Review from 2015-2019

BACKGROUND

Statistical methods (SM) are a ubiquitous tool in research. This study aimed to review SM used in original article published in the Archives of Iranian Medicine (AIM) and assess their effect on article acceptance period.

METHODS

The original articles published in the period 2015-2019 from volumes 18 to 22 and issues 1 to 12 of the AIM were reviewed and six items such as SM, study design, statistical population, sample size, software and acceptance period were extracted. Mean (SD), frequency (percentage) and multiple response analysis (MRA) were used for description. The Kruskal-Wallis test and Spearman correlation coefficient were used for data analysis in SPSS 26 with significance level at 5%.

RESULTS

During the study period, 423 original articles were reviewed. The statistical population in most of them was patients (38.8% and 164 articles), and most studies (51.5% and 218 articles) had a sample size of less than 500 people. The study design in most of the articles was analytical-observational (55.1% and 233 articles), and 79.7% (337 articles) used SPSS for data analysis. The median (IQR) acceptance period was 194 (134.25). MRA results showed that the highest rate of use of SM was related to descriptive statistics (277 articles, 30.3%) and Chi square test (130 articles, 14.2%). In the last two years, the acceptance period had a declining trend. There was no significant relation between mentioned variables and acceptance period (P>0.05).

CONCLUSION

Contrary to the researchers' misconceptions, the acceptance period was not affected by SM, study design, statistical population, sample size, or type of software.

Sex differences in esophageal cancer overall and by histological subtype

Esophageal cancer is the seventh most common type of cancer in the world, the sixth leading cause of cancer-related death and its incidence is expected to rise 140% in the world in a period of 10 years until 2025. The overall incidence is higher in males, while data about prognosis and survival are not well established yet. The goal of this study was to carry out a comprehensive analysis of differences between sexes and other covariates in patients diagnosed with primary esophageal cancer. Data from 2005 to 2020 were obtained from the University Hospitals (UH) Seidman Cancer Center and from 2005 to 2018 from SEER. Patients were categorized according to histological subtype and divided according to sex. Pearson Chi-square test was used to compare variables of interest by sex and the influence of sex on survival was assessed by Kaplan Meier, log rank tests and Cox proportional hazards regression models. A total of 1205 patients were used for analysis. Sex differences in all types were found for age at diagnosis, histology, smoking status and prescriptions of NSAIDs and in SCC for age at diagnosis and alcoholism. Survival analysis didn't showed differences between males and females on univariable and multivariable models. Males have a higher incidence of Esophageal Cancer and its two main subtypes but none of the comprehensive set of variables analyzed showed to be strongly or unique correlated with this sex difference in incidence nor are they associated with a sex difference in survival.

Smoothed Quantiles for χ2 Type Test Statistics with Applications

Chi-square type test statistics are widely used in assessing the goodness-of-fit of a theoretical model. The exact distributions of such statistics can be quite different from the nominal chi-square distribution due to violation of conditions encountered with real data. In such instances, the bootstrap or Monte Carlo methodology might be used to approximate the distribution of the statistic. However, the sample quantile may be a poor estimate of the population counterpart when either the sample size is small or the number of different values of the replicated statistic is limited. Using statistical learning, this article develops a method that yields more accurate quantiles for chi-square type test statistics. Formulas for smoothing the quantiles of chi-square type statistics are obtained. Combined with the bootstrap methodology, the smoothed quantiles are further used to conduct equivalence testing in mean and covariance structure analysis. Two real data examples illustrate the applications of the developed formulas in quantifying the size of model misspecification under equivalence testing. The idea developed in the article can also be used to develop formulas for smoothing the quantiles of other types of test statistics or parameter estimates.

Deep phenotyping of Alzheimer's disease leveraging electronic medical records identifies sex-specific clinical associations

Alzheimer's Disease (AD) is a neurodegenerative disorder that is still not fully understood. Sex modifies AD vulnerability, but the reasons for this are largely unknown. We utilize two independent electronic medical record (EMR) systems across 44,288 patients to perform deep clinical phenotyping and network analysis to gain insight into clinical characteristics and sex-specific clinical associations in AD. Embeddings and network representation of patient diagnoses demonstrate greater comorbidity interactions in AD in comparison to matched controls. Enrichment analysis identifies multiple known and new diagnostic, medication, and lab result associations across the whole cohort and in a sex-stratified analysis. With this data-driven method of phenotyping, we can represent AD complexity and generate hypotheses of clinical factors that can be followed-up for further diagnostic and predictive analyses, mechanistic understanding, or drug repurposing and therapeutic approaches.

Incidence of liver- and non-liver-related outcomes in patients with HCV-cirrhosis after SVR

BACKGROUND & AIMS

As the long-term benefits of a sustained virological response (SVR) in HCV-related cirrhosis following direct-acting antiviral (DAA) treatment remain undefined, we assessed the incidence and predictors of liver-related events (LREs), non-liver-related events (NLREs) and mortality in DAA-treated patients with cirrhosis.

METHODS

Consecutive patients with cirrhosis and SVR were enrolled in a longitudinal, single-center study, and divided into 3 cohorts: Cohort A (Child-Pugh A without a previous LRE), Cohort B (Child-Pugh B or Child-Pugh A with prior non-hepatocellular carcinoma [HCC] LREs), Cohort C (previous HCC).

RESULTS

A total of 636 patients with cirrhosis (median 65 years-old, 58% males, 89% Child-Pugh A) were followed for 51 (8-68) months (Cohort A n = 480, Cohort B n = 89, Cohort C n = 67). The 5-year estimated cumulative incidences of LREs were 10.4% in Cohort A vs. 32.0% in Cohort B (HCC 7.7% vs. 19.7%; ascites 1.4% vs. 8.6%; variceal bleeding 1.3% vs. 7.8%; encephalopathy 0 vs. 2.5%) vs. 71% in Cohort C (HCC only) (p <0.0001). The corresponding figures for NLREs were 11.7% in Cohort A vs. 17.9% in Cohort B vs. 17.5% in Cohort C (p = 0.32). The 5-year estimated probabilities of liver-related vs. non-liver-related deaths were 0.5% vs. 4.5% in Cohort A, 16.2% vs. 8.8% in Cohort B and 12.1% vs. 7.7% in Cohort C. The all-cause mortality rate in Cohort A was similar to the rate expected for the general population stratified by age, sex and calendar year according to the Human Mortality Database, while it was significantly higher in Cohort B.

CONCLUSIONS

Patients with cirrhosis and an SVR on DAAs face risks of liver-related and non-liver-related events and mortality; however, their incidence is strongly influenced by pre-DAA patient history.

LAY SUMMARY

In this large single-center study enrolling patients with hepatitis C virus (HCV)-related cirrhosis cured by direct-acting antivirals, pre-treatment liver disease history strongly influenced long-term outcomes. In patients with HCV-related cirrhosis, hepatocellular carcinoma was the most frequent liver-related complication after viral cure. Due to improved long-term outcomes, patients with cirrhosis after HCV cure are exposed to a significant proportion of non-liver-related events.

Dentistry during COVID-19: patients' knowledge and satisfaction toward health protocols COVID-19 during dental treatment

BACKGROUND

Coronavirus disease 2019 (COVID-19) as an infectious disease primarily spreading through droplet infection in dental treatment. Patient satisfaction is an indicator of healthcare quality service. Quality of healthcare service and patient satisfaction has been affected by the COVID‑19 pandemic. This study aims to assess the knowledge and satisfaction toward health protocols COVID-19 during dental treatment among dental patients.

METHODS

An institutional-based cross-sectional study was conducted on 270 dental patients using a self‑designed questionnaire consisting of knowledge and satisfaction about health protocols COVID-19 during dental treatment through a random sampling technique. Data were imported to SPSS version 21 for analysis. Descriptive and analytical statistics were used to identify the factors associated with their knowledge and satisfaction. A p value < 0.05 was considered statistical significance.

RESULTS

Totally, 270 dental patients with mean age of 37.6 ± 6.7 years participated in the study. The mean knowledge score was 36.7 ± 3.5, as considerable number of participants were unaware about the risk associated with dental treatment as well as restrictions imposed on dental procedures. About 18% of participants experienced one or other form of dental complaints during the lockdown period. The overall level of patient satisfaction was 44.6%.

CONCLUSION

It can be concluded that, public knowledge is to be improved about risk of virus transmission that can be related with dental treatment and also people should be encouraged to use virtual facilities, such as teledentistry, so that no dental emergencies is left untreated during the pandemic time. In addition, the level of satisfaction was in a medium level for dental patients in the study area. Specifically, we deduced from the results that social/physical distancing measures are one of the mechanisms to decrease the fear of exposure to the COVID-19.

Cross-Camera External Validation for Artificial Intelligence Software in Diagnosis of Diabetic Retinopathy

AIMS

To investigate the applicability of deep learning image assessment software VeriSee DR to different color fundus cameras for the screening of diabetic retinopathy (DR).

METHODS

Color fundus images of diabetes patients taken with three different nonmydriatic fundus cameras, including 477 Topcon TRC-NW400, 459 Topcon TRC-NW8 series, and 471 Kowa nonmyd 8 series that were judged as "gradable" by one ophthalmologist were enrolled for validation. VeriSee DR was then used for the diagnosis of referable DR according to the International Clinical Diabetic Retinopathy Disease Severity Scale. Gradability, sensitivity, and specificity were calculated for each camera model.

RESULTS

All images (100%) from the three camera models were gradable for VeriSee DR. The sensitivity for diagnosing referable DR in the TRC-NW400, TRC-NW8, and non-myd 8 series was 89.3%, 94.6%, and 95.7%, respectively, while the specificity was 94.2%, 90.4%, and 89.3%, respectively. Neither the sensitivity nor the specificity differed significantly between these camera models and the original camera model used for VeriSee DR development (p = 0.40, p = 0.065, respectively).

CONCLUSIONS

VeriSee DR was applicable to a variety of color fundus cameras with 100% agreement with ophthalmologists in terms of gradability and good sensitivity and specificity for the diagnosis of referable DR.

The Association of Kidney Function Monitoring Adherence and Estimated Glomerular Filtration Rate Changes Among Patients At-Risk for Chronic Kidney Disease

BACKGROUND

Kidney Disease: Improving Global Outcome in 2012 has provided recommendations to prevent CKD progression by monitoring kidney function periodically according to the CKD stage and the clinician's adherence to these guidelines is important. This is the first study on the relationship between adherence to monitoring renal function and changes in estimated glomerular filtration rate (eGFR) in patients at risk for CKD in Indonesia.

METHODS

This study was a comparative observational study with a cross-sectional approach. Research subjects were electronic medical record data from the Hasan Sadikin General Hospital information system (SIRS) data collected with the SQL Server Report Builder and "HCLAB" applications on patients at risk for CKD at the Hasan Sadikin General Hospital's Outpatient Clinic from January 2018 to March 2020. The patients' data were taken by the total sampling technique and then processed with the Chi-Square test.

RESULTS

From 376 subjects, the results showed that poor adherence in renal function monitoring would increase the risk of decreasing eGFR by 1.51 times compared to good monitoring adherence (PR 1.51 95% CI (1.172 - 1.935); p-value 0.007). The eGFR changes were significant (p-value 0.002) with mean 10.84 ml/min/1.73m2 (95% CI: 4.17 - 17.50).

CONCLUSION

The study demonstrated that poor renal function monitoring adherence had an association with a decrease in eGFR in a group of patients at risk for CKD.

A Retrospective, Epidemiological Review of Type 2 Diabetes Mellitus in a Military Population

OBJECTIVE

Examine incidence rates of Type 2 Diabetes Mellitus (T2DM) in a military population over a tenyear period and whether demographic characteristics differ within the same population.

METHODS

Diagnostic data and demographic variables from 23,821 active duty service members between 2006 and 2015 were analyzed from the Defense Medical Epidemiological Database.

RESULTS

The incidence rates of new onset cases ranged from .22 (per 1,000 service members) in 2015 to a high of 1.46 (per 1,000 service members) in 2006 for T2DM without complications and .00 (per 1,000 service members) in 2007 to a high of .29 (per 1,000 service members) in 2015 for T2DM with complications. The one-sample chi-square test showed the observed, and expected frequencies differed significantly for all demographic variables tested.

CONCLUSIONS

Although there was a significant increase in the diagnosis of T2DM with complications in 2015, the overall downtrend is similar to that of the general US population. Older age and higher rank were more likely to be associated with the diagnosis of T2DM with and without complications, again suggestive of similar trends with the general US population. Continued efforts towards early diagnosis and treatment of these service members are needed to address this problem regarding military readiness.

Subjective prosthodontic treatment need, tooth loss and associated factors among dental patients in Dar es salaam, Tanzania

Background

A full complement of teeth has been shown to be a prerequisite for a healthy masticatory system and satisfactory function and having tooth loss can be undesirable.

Objective

To determine the subjective prosthodontic treatment need, tooth loss and associated factors among patients attending dental clinics in Dar-es-salaam, Tanzania.

Methods

This cross-sectional study was conducted among subjects with tooth loss aged 18 years and above attending public dental clinics in Dar-es-Salaam, Tanzania. A questionnaire and clinical examination were used to obtain data. Chi-Square test and logistic regression analyses were performed and a p-value of ≤0.05 was considered to be statistically significant.

Results

Majority of the 402 participants were aged 18–34 years (52.2%), females (64.9%) and with primary level of education or less (52.2%). Subjective prosthodontic treatment need was indicated by more than half of the participants 54.2%) and those who lost 4 or more teeth and those who lost teeth upper anterior had higher odds of expressing subjective treatment need (OR=2.6; CI=1.5–4.3 & OR=4.9; CI=2.2–10.8 respectively).

Conclusions

This study highlights that having four or more missing teeth and having tooth loss in the anterior location of the upper jaw were significant contributing factors in expressing patient's subjective prosthodontic treatment need.

Genetic variations of CYP2R1 (rs10741657) in Bangladeshi adults with low serum 25(OH)D level-A pilot study

Background

Some studies revealed that despite having sufficient sun exposure and dietary supply, the level of serum 25(OH)D in Bangladeshi adults is lower than its normal range. Genetic pattern of an individual is also an essential factor that regulates the level of serum 25(OH)D. However, the genetic variations of CYP2R1 (rs10741657) and their association with low serum 25(OH)D level in Bangladeshi adults are yet to be explored.

Objective

This study was conducted to determine the frequency of variants of rs10741657 of CYP2R1 gene and its association with low serum 25(OH)D level among Bangladeshi adults.

Method

This pilot study was conducted among thirty individuals with low serum 25(OH)D level as the study population and ten subjects with sufficient serum 25(OH)D level as controls based on the inclusion and exclusion criteria. Genetic analysis of rs10741657 of CYP2R1 including primer designing, DNA extraction, PCR of target region with purification and Sanger sequencing of the PCR products were done accordingly. For statistical analysis, One-way ANOVA followed by LSD test, Freeman-Halton extension of Fisher’s exact test, Chi-square test (χ²) test and unpaired student t-test were performed.

Results

In this study, genetic variants of CYP2R1 (rs10741657) among the study population were genotype GG (63.30%), GA (30%) and AA (6.7%). Minor allele frequency of the study population was 0.217. The association between GG and GA genotypes of CYP2R1 (rs10741657) with low serum 25(OH)D level among the study population was found and it was statistically significant. Statistically significant differences were also observed between the genotypes and alleles of the study population and controls.

Conclusions

The presence of ‘GG’ and ‘GA’ genotypes of rs1041657 in CYP2R1 gene is associated with low serum 25(OH)D level among Bangladeshi adults in this pilot study.

Forecasting mergers and acquisitions failure based on partial-sigmoid neural network and feature selection

Traditional forecasting methods in mergers and acquisitions (M&A) data have two limitations that significantly reduce forecasting accuracy: (1) the imbalance of data, that is, the failure cases of M&A are far fewer than the successful cases (82%/18% of our sample), and (2) both the bidder and the target of the merger have numerous descriptive features, making it difficult to choose which ones to forecast. This study proposes a neural network using partial-sigmoid (i.e., partial-sigmoid neural network [PSNN]) as the activation function of the output layer and compares three feature selection methods, namely, chi-square (chi2) test, information gain and gradient boosting decision tree (GBDT). Experimental results prove that our PSNN (improved up to 0.37 precision, 0.49 recall, 0.41 G-Mean and 0.23 F1-measure) and feature selection (improved 1.83%-13.16% accuracy) method can effectively improve the adverse effects of the defects of the above two merger data on forecasting. Scholars who studied the forecast of merger failure have overlooked three important features: assets of the previous year, market value and capital expenditure. The chi2 test feature selection method is the best among the three feature selection methods.

Prevalence of migraine in adults with celiac disease: A case control cross-sectional study

AIM

Celiac disease (CD) is an immune-mediated disorder with various manifestations. The aim of this study was to evaluate the prevalence of gastrointestinal (GI) and extra-intestinal symptoms of celiac patients, especially migraine, and compare it with healthy individuals.

METHODS

We compared 1000 celiac subjects (CS) registered at our celiac center with the control group for headache-based on International Classification of Headache Disorders, third edition criteria and their GI symptoms. Besides, CS with migraine and non-migrainous headache were compared in terms of GI symptoms and accompanied conditions.

RESULTS

Headache was more common in CS than controls (34% vs 27% respectively, P value<0.001) and more prevalent in females (71.9% in females vs 28% in males, P value = 0.004). Moreover, the prevalence of migraine in CS was higher than controls (20.7 vs 11.9% respectively, P value<0.001). Furthermore, migraine was more prevalent in females with CD (80% in females vs 19% in males, P value = 0.033), and often without aura (76%). Abdominal pain (76.9%, P value = 0.025), diarrhea (54.9%, P value = 0.002), and constipation (42.9%, P value = 0.011) were the most common GI symptoms in CS with headache and more prevalent in CS with migraine. Conversely, type 1 diabetes mellitus was less common in CS with migraine than in CS with non-migrainous headache. (P value = 0.001). On multivariate logistic regression analysis, female sex (OR 1.50, 95%CI 1.22-1.83, P value < 0.001), and CD (OR 1.36, 95%CI 1.12-1.65, P value = 0.002) were independent predictors of headache, whereas age more than 60 years (OR 0.70, 95%CI 0.50-0.97, P value = 0.032) had a protective effect.

CONCLUSION

Headache especially migraine is more prevalent in CS than healthy controls. In addition, abdominal pain, diarrhea, and constipation are more common in CS with migraine than in CS with non-migrainous headaches. Therefore, evaluation of CD in patients with migraine and these simultaneous GI symptoms seems reasonable.

Risk factors for early childhood disability in Bangladesh: Evidence from Multiple Indicator Cluster Survey 2019

INTRODUCTION

Early childhood is a vital part of human life because most of the brain developments occur in this particular period. Early childhood disability is a significant global public health burden, which can negatively impact the children's quality of life and their overall productivity. It is also a major social and economic problem in Bangladesh. Therefore, it is very important to understand the associated factors for early childhood disability, which may help disability prevention, better management and policy formulation. The main objective of this study is to investigate the child, family, and community-level factors associated with early childhood disability in Bangladesh.

METHODS

A cross sectional nationally representative data was derived from Multiple Indicator Cluster Survey (MICS), 2019. A total of 14,072 Bangladeshi children under five years of age were selected for this study. Various types of statistical analysis (simple, bivariate, multivariable) were performed. To assess the bivariate relationship between chosen categorical variables (independent) and early childhood disability (dependent), a chi-square test was used. The multivariable ordinal logistic regression was used to find out the association of disability with child, family, and community-level factors.

RESULTS

The results show that 2.0% of the children have at least one disability and 0.8% have more disabilities. Several factors namely not attending in early childhood education [Odds Ratio (OR) = 0.65; 95% confidence interval (CI) = 0.13-1.17 Ρ = 0.01], having mother's functional difficulty (OR = 1.23; 95% (CI) = 0.58-1.88 Ρ <0.001), unhappy mother's life (OR = 0.85; 95% CI = 0.30-1.39 Ρ <0.001), parents without internet access (OR = 0.68; 95% CI = 0.06-1.29 Ρ = 0.03) and parents using mobile phone (OR = 0.52; 95% CI = 0.09-0.95 Ρ = 0.02) were found to be important for early childhood disability in Bangladesh.

CONCLUSION

Early childhood disability is still neglected in Bangladesh and further epidemiological studies are recommended. The findings of this study may help policy makers and relevant stakeholders to develop interventions for reducing the overall burden of early childhood disability.

Evidence of Stability in Patient-Reported Global Health During the COVID-19 Pandemic

OBJECTIVES

Measures of health-related quality of life (HRQOL) are collected throughout healthcare systems and used in clinical, economic, and outcomes studies to direct patient-centered care and inform health policy. Studies have demonstrated increases in stressors unique to the COVID-19 pandemic, however, their effect on HRQOL is unknown. Our study aimed to assess the change in self-reported global health during the pandemic for patients receiving care in a large healthcare system compared with 1 year earlier.

METHODS

An observational cross-sectional study of 2 periods was conducted including adult patients who had a healthcare appointment and completed the Patient-Reported Outcomes Measurement Information System Global Health (PROMIS GH) as standard care during the COVID-19 pandemic and a year earlier. The effect of time on PROMIS global mental health (GMH) and global physical health (GPH) was evaluated through multiple statistical methods.

RESULTS

There were 38 037 patients (mean age 56.1 ± 16.6 years; 61% female; 87% white) who completed the PROMIS GH during the pandemic (August 2020) and 33 080 (age 56.7 ± 16.5 years; 61% female; 86% white) who had completed it 1 year earlier (August 2019). GMH was significantly worse, whereas GPH was similar during the pandemic compared with a year earlier (adjusted estimate [standard error]: -1.21 (0.08) and 0.11 (0.08) T-score points, respectively).

CONCLUSIONS

Our study found modest, nonclinically meaningful decreases in GMH and similar GPH during the COVID-19 pandemic compared with a year earlier in patients cared for in a large healthcare system. Nevertheless, healthcare systems are likely seeing a biased sample of patients during these times. Findings from our study have implications for the interpretation of HRQOL during this pandemic.

Does insulin resistance trigger thyroid nodule?

The relationship between insulin resistance and thyroid nodules is not clearly understood. The purpose of this study is to investigate the relationship between insülin resistance and thyroid nodules in non-diabetic patients. 410 patients who applied to the Internal Medicine outpatient clinic from June 2018 to July 2019 were reviewed retrospectively. A total of 216 non-diabetic patients were divided into two groups. The relationship of 105 patients with thyroid nodules and 110 patients without thyroid nodules with insulin resistance was investigated. Homeostasis model assessment of insulin resistance value, serum triglycerides and total cholesterol level, and the ratio of women were higher in the group with thyroid nodules (p < 0.05). There was a positive and significant relationship between homeostasis model assessment of insulin resistance value and thyroid nodules (r + 0.29, p < 0.05). In non-diabetic thyroid nodule patients, a significant relationship was detected between nodule formation and insulin resistance. However, these data must be confirmed by other studies in the future.

Effect of regional cooperative rescue systems based on chest pain centers for patients with acute myocardial infarction in a first-tier city in China

Given the increasing burden of acute myocardial infarction (AMI) in China, regional cooperative rescue systems have been constructed based on chest pain centers (CPCs). This study evaluated the effects of these regional cooperative rescue systems on reperfusion time and prognosis of AMI patients. This study included 1937 AMI patients, divided into two groups according to the date of admission, group A (July 2017-June 2018) and group B (July 2018-June 2019). Reperfusion time, the fatality rate for any cause during hospitalization, and the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) in the 6 months following discharge were compared between the two groups. The proportion of patients treated within the guideline goals for first medical contact to balloon (FMC-to-B) time showed improvement from 40.7% in group A to 50.4% in group B (P = 0.005). The fatality rate for any cause (5.5% vs. 8.0%, P = 0.026) during hospitalization was lower in the B group compared to the A group. Multivariate logistic regression analysis revealed that the fatality rate for any cause (OR 0.614, 95% CI 0.411-0.918, P = 0.017) was significantly lower in group B compared with group A. No significant differences were detected between the two groups for the incidence of MACCE and death for any cause at 6 months using the log-rank test and multivariate Cox regression analysis. The improvement of regional cooperative rescue systems shortened system delays and reduced in-hospital deaths. Although the system has resulted in some substantial improvements, additional improvement is needed.

Efficacy of topical capsaicin for cannabinoid hyperemesis syndrome in a pediatric and adult emergency department

INTRODUCTION

Cannabinoid hyperemesis syndrome (CHS) is a clinical diagnosis characterized by symptoms of recurrent nausea, vomiting, and severe abdominal pain in the setting of chronic cannabis use. Symptoms of CHS are frequently unresponsive to standard antiemetic therapy. Topical capsaicin applied to the abdomen has been cited as a potential effective agent for CHS however robust evidence is lacking.

METHODS

This was a single-center retrospective cohort study to evaluate the efficacy of topical capsaicin in pediatric and adult patients presenting to the emergency department (ED) with suspected or confirmed CHS. The primary outcome assessed was if utilization of capsaicin for CHS resulted in more patients achieving an "efficacious" result, defined as only requiring ≤1 rescue medication for symptom relief after receiving capsaicin or after administration of the first agent in patients who did not receive capsaicin during their ED course. Secondary outcomes included total ED length of stay, time to discharge after administration of the reference agent (RA), proportion of patients requiring admission, total number of medication doses given for symptom relief, change in pain score and episodes of emesis, and proportion of patients returning to the ED within 24 h for the same complaint. Additional analyses were also performed to explore patient characteristics that may be predictive of capsaicin efficacy.

RESULTS

201 patients were included in the final analysis of which 25 were <21 years old and seen in the pediatric ED. A greater proportion of patients in the capsaicin group achieved the primary outcome of efficacy as compared to patients who did not receive capsaicin (55% vs 21%, p < 0.001, unadjusted OR 1.44 [95% CI 0.586-0.820]). There were no differences in secondary outcomes except for time to discharge after administration of the RA which was shorter in the capsaicin group (3.72 vs 6.11 h, p = 0.001).

CONCLUSION

Significantly more patients in the capsaicin group experienced efficacy compared to patients who did not. Time to discharge after administration of the reference agent was shorter for those who received capsaicin compared to patients who did not. Administration of capsaicin did not influence patients' total number of medications received or total ED length of stay. Future research is needed to determine capsaicin's efficacy when utilized earlier in therapy, ideally upon initial diagnosis of CHS, and before additional adjunct medications are administered.

Prevalence of Malaria and Associated Knowledge, Attitude, and Practice among Suspected Patients in Bahir Dar Zuria District, Northwest Ethiopia

BACKGROUND

Control and prevention activities have brought substantial decline of malaria incidence in the last two decades in Ethiopia. However, lack of local data on the disease transmission and community knowledge, attitude, and practice about malaria are thought to reverse the trend of malaria in certain areas. Therefore, assessment of the prevalence and community awareness towards malaria plays pivotal role for the success of malaria control and prevention.

OBJECTIVE

To assess malaria prevalence and knowledge, attitude, and practice about malaria among febrile patients in Bahir Dar Zuria district, Northwest Ethiopia.

METHODS

A facility based crosssectional study was conducted from January to March 2020 among 149 febrile patients attending selected health centers in Bahir Dar Zuria district. Data about knowledge, attitude, and practice about malaria were collected using semistructured questionnaire. Blood sample from each participant was tested for Plasmodium species through malaria rapid diagnostic tests and blood film microscopy. Data were analyzed using statistical software for social sciences version 20.

RESULTS

Among 149 participants, 22 (14.8%) were positive for Plasmodium infection at least by one diagnostic methods. Prevalence of P. falciparum and P. vivax was 3.4% and 10.1%, respectively, while that of mixed infection was 1.3%. From the total study participants, 29.5% have good knowledge, 77.2% have positive attitude, and 34.9% have good practice towards malaria. Statistically significant associations were observed on knowledge with age group (X 2 = 10.377, P = 0.035), educational level (X 2 = 15.075, P = 0.001), family size (X 2 = 7.601, P = 0.022), attitude level and practice level. Participants with family size < 5 were 6.841 (95% CI: 2.570-18.206, P ≤ 0.001) times more likely to have negative attitude as compared to those with family size ≥ 5.

CONCLUSIONS

Prevalence of malaria in the study area was relatively high. Study participants had encouraging attitude; however, their knowledge and practice towards malaria were poor. Therefore, the existing malaria control activities should be supplemented with continuous health educations, aware the community, and ensure participation in the control and prevention activities.

Epidemiology of Acute Kidney Injury After Neonatal Cardiac Surgery: A Report From the Multicenter Neonatal and Pediatric Heart and Renal Outcomes Network

OBJECTIVES

Cardiac surgery-associated acute kidney injury occurs commonly following congenital heart surgery and is associated with adverse outcomes. This study represents the first multicenter study of neonatal cardiac surgery-associated acute kidney injury. We aimed to describe the epidemiology, including perioperative predictors and associated outcomes of this important complication.

DESIGN

This Neonatal and Pediatric Heart and Renal Outcomes Network study is a multicenter, retrospective cohort study of consecutive neonates less than 30 days. Neonatal modification of The Kidney Disease Improving Global Outcomes criteria was used. Associations between cardiac surgery-associated acute kidney injury stage and outcomes (mortality, length of stay, and duration of mechanical ventilation) were assessed through multivariable regression.

SETTING

Twenty-two hospitals participating in Pediatric Cardiac Critical Care Consortium.

PATIENTS

Twenty-two-thousand forty neonates who underwent major cardiac surgery from September 2015 to January 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Cardiac surgery-associated acute kidney injury occurred in 1,207 patients (53.8%); 983 of 1,657 in cardiopulmonary bypass patients (59.3%) and 224 of 583 in noncardiopulmonary bypass patients (38.4%). Seven-hundred two (31.3%) had maximum stage 1, 302 (13.5%) stage 2, 203 (9.1%) stage 3; prevalence of cardiac surgery-associated acute kidney injury peaked on postoperative day 1. Cardiac surgery-associated acute kidney injury rates varied greatly (27-86%) across institutions. Preoperative enteral feeding (odds ratio = 0.68; 0.52-0.9) and open sternum (odds ratio = 0.76; 0.61-0.96) were associated with less cardiac surgery-associated acute kidney injury; cardiopulmonary bypass was associated with increased cardiac surgery-associated acute kidney injury (odds ratio = 1.53; 1.01-2.32). Duration of cardiopulmonary bypass was not associated with cardiac surgery-associated acute kidney injury in the cardiopulmonary bypass cohort. Stage 3 cardiac surgery-associated acute kidney injury was independently associated with hospital mortality (odds ratio = 2.44; 1.3-4.61). No cardiac surgery-associated acute kidney injury stage was associated with duration of mechanical ventilation or length of stay.

CONCLUSIONS

Cardiac surgery-associated acute kidney injury occurs frequently after neonatal cardiac surgery in both cardiopulmonary bypass and noncardiopulmonary bypass patients. Rates vary significantly across hospitals. Only stage 3 cardiac surgery-associated acute kidney injury is associated with mortality. Cardiac surgery-associated acute kidney injury was not associated with any other outcomes. Kidney Disease Improving Global Outcomes criteria may not precisely define a clinically meaningful renal injury phenotype in this population.

Comparison of the sixth, seventh, and eighth editions of the American Joint Committee on Cancer Tumor-Node-Metastasis staging system for gastric cancer: A single institution experience

In 2018, the eighth edition of the American Joint Committee on Cancer Tumor-Node-Metastasis classification and staging system was implemented. Few reports were made comparing the performance of different editions of the American Joint Committee on Cancer (AJCC) system. Therefore, this study aimed to examine the prognostic predictability from the sixth to the eighth editions of the AJCC staging system for gastric cancer.A total of 414 patients with gastric cancer who underwent surgery at Changhua Christian Hospital from January 2007 to December 2017 were enrolled in the study. To identify the prognostic factors for gastric cancer death, univariate and multivariate analyses were performed. The homogeneity and discrimination abilities of the sixth to eighth editions of the staging system were compared using the likelihood ratio chi-square test, linear trend chi-square test, and Akaike information criterion.The sixth edition of the staging system had the lowest Akaike information criterion value, suggesting a better prognostic stratification than other editions. From the result of the likelihood ratio chi-square test, the T and N staging systems of the seventh and eighth editions had better homogeneity and discriminatory ability than the sixth edition. The eighth edition had better prognostic performance in patients at stage III compared with the seventh edition.The AJCC seventh and eighth editions had improved prognostic predictability of the T and N factors compared with the sixth edition. However, the overall staging performance of the eighth edition is not superior compared to the sixth edition. Further studies with larger sample size should be conducted to compare the performance of different editions of the AJCC staging system for different ethnic populations.

Limiting Acute Kidney Injury Progression In Sepsis: Study Protocol and Trial Simulation

OBJECTIVES

To describe study design considerations and to simulate a trial of biomarker-guided sepsis management aimed to reduce acute kidney injury (acute kidney injury). Tissue inhibitor of metalloproteinases-2 and insulin-like growth factor-binding protein 7, urinary biomarkers of cell-cycle arrest, and indicators of kidney stress can detect acute kidney injury before clinical manifestations. We sought to determine the event rates for acute kidney injury as a function of serial measurements of urinary (tissue inhibitor of metalloproteinases-2)•(insulin-like growth factor-binding protein 7) in patients at risk of sepsis-associated acute kidney injury, so that an escalating series of kidney-sparing sepsis bundles based on international guidelines could be applied.

DESIGN

We described the study protocol of "Limiting acute kidney injury Progression In Sepsis," a phase 4, multicenter, adaptive, randomized controlled trial. We performed simulations to estimate the rates for the trial's primary endpoint using patient-level data from two previous studies (Sapphire and Protocolized Care for Early Septic Shock).

SETTING

Academic and community ICUs.

PATIENTS

Critically ill patients with sepsis or septic shock, without evidence of stage 2/3 acute kidney injury at enrollment.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Our primary endpoint is progression of two or more stages of acute kidney injury, death, or dialysis within 72 hours after enrollment. In the Sapphire simulation, 45 of 203 patients (22%) with sepsis met the endpoint. In Protocolized Care for Early Septic Shock, 144 of 607 patients (24%) with septic shock met the endpoint. In both simulations, (tissue inhibitor of metalloproteinases-2)•(insulin-like growth factor-binding protein 7) patterns, suggested by Limiting acute kidney injury Progression In Sepsis protocol, stratified the risk for the endpoint from 6% (three negative tests) to 41% (for patients eligible for the highest level of kidney-sparing sepsis bundle) in Sapphire, and 14% (two negative tests) to 46% (for the highest level of kidney-sparing sepsis bundle) in Protocolized Care for Early Septic Shock.

CONCLUSIONS

Findings of our Limiting acute kidney injury Progression In Sepsis trial simulation confirmed that (tissue inhibitor of metalloproteinases-2)•(insulin-like growth factor-binding protein 7) could identify patients with different rates of progression to moderate/severe acute kidney injury, death, or dialysis in 72 hours. The Limiting acute kidney injury Progression In Sepsis protocol algorithm is therefore feasible in terms of identifying suitably high-risk individuals for kidney-sparing sepsis bundle.

Efficacy of erzhu jiedu recipe on hepatitis B cirrhosis with hyperalphafetoproteinemia: A randomized, double-blind, placebo-controlled clinical trial

BACKGROUND

Hepatitis B cirrhosis with hyperalphafetoproteinemia is the intermediate stage of liver cirrhosis progressing to hepatocellular carcinoma (HCC), there is no effective way to treat precancerous lesions of liver in modern medicine. In recent decades, clinical and experimental evidence shows that Chinese medicine (CM) has a certain beneficial effect on Hepatitis B Cirrhosis. Therefore, this trial aims to evaluate the efficacy and safety of a CM erzhu jiedu recipe (EZJDR) for the treatment of Hepatitis B Cirrhosis with Hyperalphafetoproteinemia.

METHODS

We designed a randomized, double blind, placebo-controlled clinical trial. A total of 72 patients of Hepatitis B Cirrhosis with hyperalphafetoproteinemia were randomized in 2 parallel groups. Patients in the control group received placebo granules similar to the EZJDR. In the EZJDR group, patients received EZJDR twice a day, after meals, for 48 weeks. The primary efficacy measures were changes in serum alpha-fetoprotein (AFP) and alpha-fetoprotein alloplasm (AFP-L3); The secondary indicators of efficacy are changes in liver function indicators, HBV-DNA level; Liver stiffness measurement (LSM); Hepatic portal vein diameter; T lymphocyte subgroup indexes during treatment. All data will be recorded in case report forms and analyzed by Statistical Analysis System software. Adverse events will also be evaluated.

RESULTS

The results showed that EZJDR can significantly inhibit the levels of AFP and AFP-L3 in patients with hepatitis B cirrhosis and hyperalphafetoproteinemia and have good security.

ETHICS AND DISSEMINATION

The study protocol was approved by the Medical Ethics Committee of Shuguang Hospital, affiliated with University of Traditional Chinese Medicine, Shanghai (NO.2018-579-08-01).

TRIAL REGISTRATION

This trial was registered on Chinese Clinical Trial Center (NO.ChiCTR1800017165).

A cross-sectional analysis of diagnosis and management of chronic obstructive pulmonary disease in people living with HIV: Opportunities for improvement

Chronic obstructive pulmonary disease (COPD) is common in people living with HIV (PLWH). We sought to evaluate the appropriateness of COPD diagnosis and management in PLWH, comparing results to HIV-uninfected persons.We conducted a cross-sectional analysis of Veterans enrolled in the Examinations of HIV-Associated Lung Emphysema study, in which all participants underwent spirometry at enrollment and reported respiratory symptoms on self-completed surveys. Primary outcomes were misdiagnosis and under-diagnosis of COPD, and the frequency and appropriateness of inhaler prescriptions. Misdiagnosis was defined as having an International Classification of Diseases (ICD)-9 diagnosis of COPD without spirometric airflow limitation (post-bronchodilator forced expiratory volume in 1-second [FEV1]/Forced vital capacity [FVC] < 0.7). Under-diagnosis was defined as having spirometry-defined COPD without a prior ICD-9 diagnosis.The analytic cohort included 183 PLWH and 152 HIV-uninfected participants. Of 25 PLWH with an ICD-9 diagnosis of COPD, 56% were misdiagnosed. Of 38 PLWH with spirometry-defined COPD, 71% were under-diagnosed. In PLWH under-diagnosed with COPD, 85% reported respiratory symptoms. Among PLWH with an ICD-9 COPD diagnosis as well as in those with spirometry-defined COPD, long-acting inhalers, particularly long-acting bronchodilators (both beta-agonists and muscarinic antagonists) were prescribed infrequently even in symptomatic individuals. Inhaled corticosteroids were the most frequently prescribed long-acting inhaler in PLWH (28%). Results were overall similar amongst the HIV-uninfected.COPD was frequently misdiagnosed and under-diagnosed in PLWH, similar to uninfected-veterans. Among PLWH with COPD and a likely indication for therapy, long-acting inhalers were prescribed infrequently, particularly guideline-concordant, first-line long-acting bronchodilators. Although not a first-line controller therapy for COPD, inhaled corticosteroids were prescribed more often.

Mortality associated with stopping statins in the oldest-old - with and without ischemic heart disease

The association between stopping statins and 1-year mortality in the general population of the oldest-old - with or without ischemic heart disease (IHD) - has been studied herein for the first time.This was a retrospective study. Included were all consecutive patients (n = 369) aged 80 years or more (mean age 87.8 years) hospitalized in a single Geriatrics department during 1 year. The study group included 140 patients in whom statins were stopped upon admission (statin stoppers). The control group included 229 patients who did not use statins in the first place (statin non-users). All-cause 1-year mortality rates were studied in both groups following propensity score matching and in IHD patients separately.Overall, 110 (29.8%) patients died during the year following admission: 38 (27.1%) statin stoppers and 72 (31.4%) statin non-users (P = .498). Cox regression analysis showed no association between stopping statins and 1-year mortality in the crude analysis (hazard ratio [HR] 0.976, 95% confidence interval [CI] 0.651-1.463, P = .907) and following propensity score matching (HR 1.067, 95%CI 0.674-1.689, P = .782). Among 108 IHD patients, 38 (35.2%) patients died during the year following admission: 18 (27.7%) statin stoppers and 20 (46.5%) statin non-users (P = .059). Cox regression analysis showed a nearly significant association between stopping statins (rather than not using statins) in IHD patients and lower 1-year mortality (HR 0.524, 95%CI 0.259-1.060, P = .072).Hence, stopping statins in the general population of the oldest-old - with or without IHD - is possibly safe. Future studies including the oldest-old statin continuers are warranted to confirm this observation.

Gastric emptying of preoperative carbohydrate in elderly assessed using gastric ultrasonography: A randomized controlled study

BACKGROUND

Preoperative carbohydrate loading enhances postoperative recovery and reduces patient discomfort. However, gastric emptying of liquids can be delayed in elderly populations. Therefore, this study aimed to evaluate the gastric emptying of 400 mL of a carbohydrate drink ingested 2 hours before surgery in elderly patients.

METHODS

In this prospective, randomized controlled study, patients aged >65 years were allocated to either fast from midnight (nil per os [NPO] group, n = 29) or drink 400 mL of a carbohydrate drink 2 hours before surgery (carbohydrate group, n = 29). The gastric antrum was assessed using ultrasonography in the supine position, followed by the right lateral decubitus (RLD) position. The gastric antrum was graded as grade 0 (fluid not seen in both positions), grade 1 (fluid only seen in the RLD position), and grade 2 (fluid seen in both positions). The gastric antral cross-sectional area (CSA) and aspirated residual gastric volume were measured.

RESULTS

In 58 patients, the incidence of grade 2 stomach was 13.8% in NPO group and 17.2% in carbohydrate group (P = .790). The gastric antral CSA in the supine position was larger in carbohydrate group than in NPO group (4.42 [3.72-5.18] cm2 vs 5.31 [4.35-6.92] cm2, P = .018). The gastric antral CSA in the RLD position was not different in NPO and carbohydrate groups (P = .120). There was no difference in gastric volume (2 [0-7.5] vs 3 [0-13.4], P = .331) in NPO group versus carbohydrate group.

CONCLUSION

The incidence of grade 2 stomach was not different between NPO group and carbohydrate group in elderly patients.

The characteristics of and responses to the two COVID-19 outbreak waves in Hebei Province of China, January 2020 to February 2021

Hebei Province was affected by two coronavirus disease 2019 (COVID-19) outbreak waves during the period 22 January 2020 through 27 February 2020 (wave 1) and 2 January 2021 through 14 February 2021 (wave 2). To evaluate and compare the epidemiological characteristics, containment delay, cluster events and social activity, as well as non-pharmaceutical interventions of the two COVID-19 outbreak waves, we examined real-time update information on all COVID-19-confirmed cases from a publicly available database. Wave 1 was closely linked with the COVID-19 pandemic in Wuhan, whereas wave 2 was triggered, to a certain extent, by the increasing social activities such as weddings, multi-household gatherings and church events during the slack agricultural period. In wave 2, the epidemic spread undetected in the rural areas, and people living in the rural areas had a higher incidence rate than those living in the urban areas (5.3 vs. 22.0 per 1 000 000). Furthermore, Rt was greater than 1 in the early stage of the two outbreak waves, and decreased substantially after massive non-pharmaceutical interventions were implemented. In China's 'new-normal' situation, development of targeted and effective intervention remains key for COVID-19 control in consideration of the potential threat of new coronavirus strains.

Factors associated with kindergarten teachers' willingness to continue working

The turnover rate among kindergarten teachers in advanced countries is extremely high. As such, there is an urgent need to determine the reasons for this turnover and to identify ways to prevent it. The current study investigates the individual and environmental factors that impact kindergarten teachers' willingness to continue working.A total of 600 kindergarten teachers in Japan participated in this study. Participants responded to questionnaires regarding their willingness to continue working, mental health, work engagement, and the availability of social support. Multiple logistic regression analysis was used to analyze participants' data, with willingness to continue working for 5 or more years as the dependent variable. Additionally, Spearman rank correlation was used to examine the correlations between factors associated with willingness to continue working.Factors such as older age, living with a spouse, caring for younger children (up to 2 years old) at work, good mental health, and higher work engagement were significantly associated with teachers' higher willingness to continue working. Factors such as marriage, health and family problems, overtime work, issues with workplace childcare, and education policy, working time/day problems, human relations, and difficulties taking care of children were correlated with teachers' lack of willingness to continue working.The findings of this cross-sectional study suggest that welfare benefits and individual support systems could be key elements to encourage kindergarten teachers to continue working and could lead to their improved job satisfaction and mental health. Balanced work conditions and workers' high agreement with their workplace's overall childcare or educational policies may lead to lower turnover. Some programs - such as relationship counselling - could have a positive impact on teachers' mental health and job satisfaction.