Urban diversity and epidemic resilience: The case of the COVID-19

New-generation antidiabetic medications and dementia risk in older adults with type 2 diabetes: A retrospective cohort study

BACKGROUND

New-generation antidiabetic medications may have therapeutic potential for dementia, beyond their glycemic effects. However, information from observational studies exploring the association between new-generation antidiabetic use and dementia risk is limited.

OBJECTIVES

To examine the association between new-generation antidiabetic medication use and dementia risk.

DESIGN

Retrospective cohort study using electronic health records of a large non-profit health maintenance organization.

PARTICIPANTS

84,798 dementia-free individuals aged ≥65y with type 2 diabetes.

MEASUREMENTS

Antidiabetic medication exposure was based on purchased prescriptions and was used as a time-varying variable. Exposure periods were defined as periods in which either dipeptidyl peptidase-4 inhibitors (DPP-4i), sodium-glucose cotransporter-2 inhibitors (SGLT-2i), or glucagon-like peptide-1 analogs (GLP-1a) or their combinations were used, otherwise unexposed. Dementia classification was based on the International Classification of Diseases, Ninth Revision codes or antidementia medication prescriptions. Cox regression models were fitted to quantify the association between antidiabetic medication use and incident dementia. Models were adjusted for 13 potential sources of confounding using inverse-probability weighting.

RESULTS

Among 84,798 individuals with a mean diabetes onset age of 66.4 ± 7.5 years, the median follow-up for dementia risk was 8.7 years (Q1-Q3: 5.4-12.8). Dementia was diagnosed in 11,642 (13.7%) individuals. New-generation medication use was associated with reduced dementia risk (HR = 0.69; 95% CI, 0.66-0.73) and by drug classes (DPP-4i, HR 0.67 [95% CI 0.63-0.71]; SGLT-2i, 0.63 [95% CI 0.56-0.70], GLP-1a, 0.61 [95% CI 0.54-0.69].

CONCLUSIONS

The results of this large-scale study suggest that new-generation antidiabetic medication use may be associated with lower dementia risk in older adults with T2D.

Breastfeeding Duration and Child Development

Importance

Detecting and addressing potentially modifiable factors associated with healthy development is key to optimizing a child's potential. When investigating the outcomes of child development, it is important to account for disparities in feeding practices and avoid confounding bias.

Objectives

To estimate the independent association between breastfeeding and attainment of developmental milestones or neurodevelopmental conditions.

Design, Setting, and Participants

This retrospective cohort study used data from a national network for routine child development surveillance in Israel linked with national social insurance financial entitlements for neurodevelopmental deficiencies. Participants were children born between January 2014 and December 2020 after at least 35 weeks' gestation without severe morbidity and with at least 1 follow-up surveillance visit at 2 to 3 years of age. Outcome data were collected in March 2023.

Exposures

Duration and exclusivity of breastfeeding in infancy.

Main Outcomes and Measures

The primary outcomes were delays in attainment of developmental milestones and diagnosis of prespecified neurodevelopmental conditions. Multivariable regression, matching, and within-family analyses were used to estimate adjusted odds ratios (AORs) after accounting for potential confounding factors related to the child (gestational age, birth weight, multiple gestation, and child order in the family) and mother (age, socioeconomic status, educational level, marital status, employment, nationality, and postpartum depression).

Results

Of 570 532 children (291 953 [51.2%] male), 20 642 (3.6%) were preterm, 38 499 (6.7%) were small for gestational age, and 297 571 (52.1%) were breastfed for at least 6 months (123 984 [41.7%] were exclusively breastfed). Children who were breastfed for at least 6 months exhibited fewer delays in attaining language and social or motor developmental milestones compared with children exposed to less than 6 months of breastfeeding (AOR, 0.73 [95% CI, 0.71-0.76] for exclusive breastfeeding; AOR, 0.86 [95% CI, 0.83-0.88] for nonexclusive breastfeeding). Among 37 704 sibling pairs, children who were breastfed for at least 6 months were less likely to demonstrate milestone attainment delays (OR, 0.91 [95% CI, 0.86-0.97]) or be diagnosed with neurodevelopmental conditions (OR, 0.73 [95% CI, 0.66-0.82]) compared with their sibling with less than 6 months of breastfeeding or no breastfeeding.

Conclusions and Relevance

In this cohort study, exclusive or longer duration of breastfeeding was associated with reduced odds of developmental delays and language or social neurodevelopmental conditions. These findings may guide parents, caregivers, and public health initiatives in promoting early child development.

Age-corrected development of preterm children: a population-based study

BACKGROUND

The standard practice to account for expected developmental lags in preterm children is calculating their age as if born on their expected delivery date. We aimed to assess the accuracy of standard age correction in a large and diverse population.

METHODS

Routine surveillance data was extracted from a national network of mother-child clinics covering over 70% of the Israeli population. We included children with no developmental delay at age 2 years old, to exclude chronic dysfunctions. For each milestone assessed before age 2 years old we calculated the age of 90% and 95% population-milestone attainment, and compared attainment age between term and preterm children, before and after age correction.

RESULTS

The study consisted of n = 656,986 and n = 52,662 term and preterm children respectively. Without age correction extensive gaps were observed in all domains, all degrees of prematurity and persisted throughout the first 2 years of life. With age correction most gaps were resolved among moderate/late preterm children, but not among extreme and very preterm, with residual gaps of at least 2 months for motor and 1 month for language-social development.

CONCLUSION

While standard age correction accounts for maturational delay in late/moderate preterm children, it may underestimate the maturational delay among very/ extremely preterm children.

IMPACT

Standard age correction is sufficient for late/moderate preterm children, and underestimates the maturational delay of extreme and very preterm children. Prior evidence on the accuracy of standard age correction across developmental domains and degrees of prematurity was limited to dated, small-scale data. Maturational delays persist throughout the first 2 years of life across all developmental domains and in all levels of prematurity. Developmental assessments without age correction may lead to unnecessary parental anxiety.

Increase Incidence and Prevalence of Eosinophilic Gastrointestinal Disorders in Israel During the Last Decade

BACKGROUND

Eosinophilic gastrointestinal disorders (EGIDs) are primary immune-mediated disorders, with significant morbidity and long-term sequelae. Temporal trends in incidence and prevalence are on the rise, but studies outside Europe and North America are sparse.

METHODS

Based on retrospective Electronic Medical Records (EMR) data, we studied a large population cohort during the years 2014-2021 of all patients diagnosed with EGIDs. Incidence rate and prevalence were calculated for each year during the study cohort stratified by disease location, age, and sex.

RESULTS

Between 2014 and 2021, among a population of 2.4 million persons, the incidence rate of EGIDs tripled from 2.51 (95% CI: 1.78-3.23) to 7.88 (95% CI: 6.75-9.01) per 100 000 person-years. Most (85.1%) were patients with eosinophilic esophagitis (EoE). The increased temporal trend was almost identical among all subgroups, including patients with EoE, patients with non-EoE EGIDs, and patients with EGIDs with esophageal involvement. The prevalence of EGIDs increased from 14.53 (95% CI: 12.80-16.26) to 51.43 (95% CI: 48.60-54.26) per 100 000 persons. In 2021, at the end of the study, the prevalence of EoE was 39.54 (95% CI: 37.05-42.02) per 100 000 persons, and the prevalence of non-EoE EGID was 11.89 (95% CI: 10.53-13.26) per 100 000 persons.

CONCLUSIONS

The incidence and prevalence of EGIDs in Israel have risen steeply during the last decade. The main contribution came from the increased incidence rate of patients with EoE. By the end of the surveillance period, the increased temporal trends did not reach a plateau.

Real-world effectiveness of sodium-glucose cotransporter-2 inhibitors on the progression of chronic kidney disease in patients without diabetes, with and without albuminuria

AIM

To examine the renal effects of sodium-glucose cotransporter-2 (SGLT2) inhibition among non-diabetic individuals with chronic kidney disease (CKD) in a real-world setting.

METHODS

We collected de-identified data on adults without diabetes and with an estimated glomerular filtration rate (eGFR) of 25-60 mL/min/1.73 m2, who initiated the SGLT2 inhibitors dapagliflozin or empagliflozin between September 2020 and November 2022 at Maccabi Healthcare Services, an Israeli health maintenance organization. We assessed the effects of SGLT2 inhibitors on renal function (changes in eGFR slope/time). Index date was defined as the date of the first dispensing of SGLT2 inhibitors. Annual baseline slope was calculated using all eGFR measurements during the 2 years prior to index date (median = 7 measurements), while annual follow-up slope was calculated from all evaluations during 90-900 days post index date, along with baseline measurement at index date (median = 6 measurements). Paired t tests were used to compare differences between baseline and follow-up annual slopes.

RESULTS

Of a total of 354 participants with CKD, without diabetes, who received SGLT2 inhibitors and were followed for a median of 527 days, the mean age was 72.8 ± 11.8 years, 26% were female, and 91% used renin-angiotensin system blockade. The mean eGFR was 45.4 ± 9.5 mL/min/1.73 m2. The mean body mass index was 29.1 ± 5.4 kg/m2. During the year before index date, 146 participants (41%) had a urinary albumin to creatinine ratio (UACR) <30 mg/g, 81 (23%) had a UACR of 30-300 mg/g, 74 (21%) had a UACR >300 mg/g, and 53 (15%) had no UACR evaluation. The mean eGFR slope over time was -5.6 ± 7.7 mL/min/1.73 m2 per year at baseline, which improved to -1.7 ± 6.8 mL/min/1.73 m2 per year after SGLT2 inhibitor administration (p <0.001). This effect was independent of UACR.

CONCLUSION

In a real-world study of primarily older non-diabetic adults with CKD, SGLT2 inhibition was associated with a slower rate of kidney function decline, regardless of baseline UACR level.

Youth Mental Health Outcomes up to Two Years After SARS-CoV-2 Infection Long-COVID or Long-Pandemic Syndrome: A Retrospective Cohort Study

PURPOSE

Youth mental distress has substantially increased during the COVID-19 pandemic. However, it is unclear if mental symptoms are directly related to SARS-CoV-2 infection or to social restrictions. We aimed to investigate mental health outcomes in infected versus uninfected adolescents, for up to two years after an index polymerase chain reaction (PCR) test.

METHODS

A retrospective cohort study, based on electronic health records from a large nationally representative Israeli health fund, among adolescents aged 12-17 years with a PCR test for SARS-CoV-2 between March 1, 2020 and March 1, 2021. Infected and uninfected individuals were matched by age, sex, test date, sector, and socioeconomic status. Cox regression was used to derive hazard ratios (HRs) for mental health outcomes within two years from PCR test for infected versus uninfected individuals, while accounting for pre-existing psychiatric history. External validation was performed on UK primary care data.

RESULTS

Among 146,067 PCR-tested adolescents, 24,009 were positive and 22,354 were matched with negative adolescents. SARS-CoV-2 infection was significantly associated with reduced risks for dispensation of antidepressants (HR 0.74, 95% confidence interval [CI] 0.66-0.83), diagnoses of anxiety (HR 0.82, 95% CI 0.71-0.95), depression (HR 0.65, 95% CI 0.53-0.80), and stress (HR 0.80, 95% CI 0.69-0.92). Similar results were obtained in the validation dataset.

DISCUSSION

This large, population-based study suggests that SARS-CoV-2 infection is not associated with elevated risk for mental distress in adolescents. Our findings highlight the importance of taking a holistic view on adolescents' mental health during the pandemic, with consideration of both SARS-CoV-2 infection and response measures.

Religious diversity and public health: Lessons from COVID-19

Scholars have identified a range of variables that predict public health compliance during COVID-19, including: psychological, institutional and situational variables as well as demographic characteristics, such as gender, location and age. In this paper, we argue that religious affiliation is also a clear predictor for compliance with public health guidelines. Based on a sample representative survey (N = 800) of Haredi Jews in Israel, we found that Haredi Jews mostly followed COVID-19 health regulations. Among the respondents who were non-compliant, however, we found large divergences which mostly reflected religious affiliation. While members of Lithuanian and Sephardi communities reported following guidelines, Hasidim, a more charismatic sub-group, were 12% and 14% more likely to flout public health guidelines than their Lithuanian and Sephardi counterparts, respectively. Despite this inner diversity, all Haredim were portrayed in Israeli media as one homogeneous group that was blamed for flouting public health guidelines and spreading COVID-19. Based on these findings, we argue for the importance of public health messaging that attends to diverse aspects of religious dogma, practice and observance by creating partnerships and sustainable relationships between different actors and stakeholders. In addition, we found that compliance was also shaped by knowledge about COVID-19 and public concern. Taking these findings together, health communication that acknowledges religious diversity while providing critical knowledge about the pandemic is key to developing and implementing community-focused interventions and public health programs. Practically, these insights help to improve pandemic governance as well as contributing theoretically to the study of public health relations and religion by highlighting how discourses around health vary and how differently positioned actors shape representations of responsiveness and health compliance.

Kidney function loss and albuminuria progression with GLP-1 receptor agonists versus basal insulin in patients with type 2 diabetes: real-world evidence

BACKGROUND

In clinical trials enrolling patients with type 2 diabetes (T2D) at high cardiovascular risk, many glucagon-like peptide-1 receptor agonists (GLP-1 RAs) improved albuminuria status and possibly mitigated kidney function loss. However, limited data are available regarding the effects of GLP-1 RAs on albuminuria status and kidney function in real-world settings, including populations with a lower baseline cardiovascular and kidney risk. We assessed the association of GLP-1 RAs initiation with long-term kidney outcomes in the Maccabi Healthcare Services database, Israel.

METHODS

Adults with T2D treated with  ≥ 2 glucose-lowering agents who initiated GLP-1 RAs or basal insulin from 2010 to 2019 were propensity-score matched (1:1) and followed until October 2021 (intention-to-treat [ITT]). In an as-treated (AT) analysis, follow-up was also censored at study-drug discontinuation or comparator-initiation. We assessed the risk of a composite kidney outcome, including confirmed  ≥ 40% eGFR loss or end-stage kidney disease, and the risk of new macroalbuminuria. Treatment-effect on eGFR slopes was assessed by fitting a linear regression model per patient, followed by a t-test to compare the slopes between the groups.

RESULTS

Each propensity-score matched group constituted 3424 patients, 45% women, 21% had a history of cardiovascular disease, and 13.9% were treated with sodium-glucose cotransporter-2 inhibitors at baseline. Mean eGFR was 90.6 mL/min/1.73 m² (SD 19.3) and median UACR was 14.6 mg/g [IQR 0.0-54.7]. Medians follow-up were 81.1 months (ITT) and 22.3 months (AT). The hazard-ratios [95% CI] of the composite kidney outcome with GLP-1 RAs versus basal insulin were 0.96 [0.82-1.11] (p = 0.566) and 0.71 [0.54-0.95] (p = 0.020) in the ITT and AT analyses, respectively. The respective HRs for first new macroalbuminuria were 0.87 [0.75-0.997] and 0.80 [0.64-0.995]. The use of GLP-1 RA was associated with a less steep eGFR slope compared with basal insulin in the AT analysis (mean annual between-group difference of 0.42 mL/min/1.73 m²/year [95%CI 0.11-0.73]; p = 0.008).

CONCLUSION

Initiation of GLP-1 RAs in a real-world setting is associated with a reduced risk of albuminuria progression and possible mitigation of kidney function loss in patients with T2D and mostly preserved kidney function.

Data-Driven Assessment of Adolescents' Mental Health During the COVID-19 Pandemic

OBJECTIVE

Adolescents' mental health was severely compromised during the COVID-19 pandemic. Longitudinal real-world studies on changes in the mental health of adolescents during the later phase of the pandemic are limited. We aimed to quantify the effect of COVID-19 pandemic on adolescents' mental health outcomes based on electronic health records.

METHOD

This was a retrospective cohort study using the computerized database of a 2.5 million members, state-mandated health organization in Israel. Rates of mental health diagnoses and psychiatric drug dispensations were measured among adolescents 12 to 17 years of age with and without pre-existing mental history, for the years 2017 to 2021. Relative risks were computed between the years, and interrupted time series (ITS) analyses evaluated changes in monthly incidence rates of psychiatric outcomes.

RESULTS

The average population size was 218,146 in 2021. During the COVID-19 period, a 36% increase was observed in the incidence of depression (95% CI = 25-47), 31% in anxiety (95% CI = 23-39), 20% in stress (95% CI = 13-27), 50% in eating disorders (95% CI = 35-67), 25% in antidepressant use (95% CI = 25-33), and 28% in antipsychotic use (95% CI = 18-40). A decreased rate of 26% (95% CI = 0.80-0.88) was observed in ADHD diagnoses. The increase of the examined outcomes was most prominent among youth without psychiatric history, female youth, general secular Jewish population, youth with medium-high socioeconomic status, and those 14 to 15 years of age. ITS analysis confirmed a significantly higher growth in the incidence of psychiatric outcomes during the COVID-19 period, compared to those in previous years.

CONCLUSION

This real-world study highlights the deterioration of adolescents' mental health during the COVID-19 pandemic and suggests that youth mental health should be considered during health policy decision making.

DIVERSITY & INCLUSION STATEMENT

We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. We actively worked to promote sex and gender balance in our author group. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work.

A general urban spreading pattern of COVID-19 and its underlying mechanism

Currently, the global situation of COVID-19 is aggravating, pressingly calling for efficient control and prevention measures. Understanding the spreading pattern of COVID-19 has been widely recognized as a vital step for implementing non-pharmaceutical measures. Previous studies explained the differences in contagion rates due to the urban socio-political measures, while fine-grained geographic urban spreading pattern still remains an open issue. Here, we fill this gap by leveraging the trajectory data of 197,808 smartphone users (including 17,808 anonymous confirmed cases) in nine cities in China. We find a general spreading pattern in all cities: the spatial distribution of confirmed cases follows a power-law-like model and the spreading centroid human mobility is time-invariant. Moreover, we reveal that long average traveling distance results in a high growth rate of spreading radius and wide spatial diffusion of confirmed cases in the fine-grained geographic model. With such insight, we adopt the Kendall model to simulate the urban spreading of COVID-19 which can well fit the real spreading process. Our results unveil the underlying mechanism behind the spatial-temporal urban evolution of COVID-19, and can be used to evaluate the performance of mobility restriction policies implemented by many governments and to estimate the evolving spreading situation of COVID-19.

Research on household emergency supplies storage from the theory of planned behavior and intention-behavior gap in the context of COVID-19

Introduction

In the context of COVID-19 epidemic, household-level emergency supplies are becoming a critical link in the national emergency response mechanism for public health emergencies. The main goal of this study is to analyze the forming process of household emergency supplies storage intention and behavior based on the theory of planned behavior.

Methods

A total of 486 valid questionnaires were obtained from China and analyzed using structural equation modeling.

Results

The study found that subjective norms and perceived behavioral control had a positive impact on residents' intention to store emergency supplies, while attitudes did not play a significant role. Community institutional trust and community network play significant moderating roles in the transformation from intentions to behaviors.

Discussion

This study explored the influencing factors of residents' household emergency supplies storage, and introduced community institutional trust and community network as moderating variables to analyze the process of transformation of residents' household emergency supplies storage intentions to behaviors from the perspective of community situation, and initially constructed a two-stage integration model including intention formation and behavior transformation. By analyzing the forming process of household emergency supplies behavior, this paper revealed the effective paths for the formation of household emergency supplies storage intention, and put forward policy suggestions from the government and community levels.

Long covid outcomes at one year after mild SARS-CoV-2 infection: nationwide cohort study

OBJECTIVES

To determine the clinical sequelae of long covid for a year after infection in patients with mild disease and to evaluate its association with age, sex, SARS-CoV-2 variants, and vaccination status.

DESIGN

Retrospective nationwide cohort study.

SETTING

Electronic medical records from an Israeli nationwide healthcare organisation.

POPULATION

1 913 234 Maccabi Healthcare Services members of all ages who did a polymerase chain reaction test for SARS-CoV-2 between 1 March 2020 and 1 October 2021.

MAIN OUTCOME MEASURES

Risk of an evidence based list of 70 reported long covid outcomes in unvaccinated patients infected with SARS-CoV-2 matched to uninfected people, adjusted for age and sex and stratified by SARS-CoV-2 variants, and risk in patients with a breakthrough SARS-CoV-2 infection compared with unvaccinated infected controls. Risks were compared using hazard ratios and risk differences per 10 000 patients measured during the early (30-180 days) and late (180-360 days) time periods after infection.

RESULTS

Covid-19 infection was significantly associated with increased risks in early and late periods for anosmia and dysgeusia (hazard ratio 4.59 (95% confidence interval 3.63 to 5.80), risk difference 19.6 (95% confidence interval 16.9 to 22.4) in early period; 2.96 (2.29 to 3.82), 11.0 (8.5 to 13.6) in late period), cognitive impairment (1.85 (1.58 to 2.17), 12.8, (9.6 to 16.1); 1.69 (1.45 to 1.96), 13.3 (9.4 to 17.3)), dyspnoea (1.79 (1.68 to 1.90), 85.7 (76.9 to 94.5); 1.30 (1.22 to 1.38), 35.4 (26.3 to 44.6)), weakness (1.78 (1.69 to 1.88), 108.5, 98.4 to 118.6; 1.30 (1.22 to 1.37), 50.2 (39.4 to 61.1)), and palpitations (1.49 (1.35 to 1.64), 22.1 (16.8 to 27.4); 1.16 (1.05 to 1.27), 8.3 (2.4 to 14.1)) and with significant but lower excess risk for streptococcal tonsillitis and dizziness. Hair loss, chest pain, cough, myalgia, and respiratory disorders were significantly increased only during the early phase. Male and female patients showed minor differences, and children had fewer outcomes than adults during the early phase of covid-19, which mostly resolved in the late period. Findings remained consistent across SARS-CoV-2 variants. Vaccinated patients with a breakthrough SARS-CoV-2 infection had a lower risk for dyspnoea and similar risk for other outcomes compared with unvaccinated infected patients.

CONCLUSIONS

This nationwide study suggests that patients with mild covid-19 are at risk for a small number of health outcomes, most of which are resolved within a year from diagnosis.

Cumulative damage for multi-type epidemics and an application to infectious diseases

A continuous time multivariate stochastic model is proposed for assessing the damage of a multi-type epidemic cause to a population as it unfolds. The instants when cases occur and the magnitude of their injure are random. Thus, we define a cumulative damage based on counting processes and a multivariate mark process. For a large population we approximate the behavior of this damage process by its asymptotic distribution. Also, we analyze the distribution of the stopping times when the numbers of cases caused by the epidemic attain levels beyond certain thresholds. We focus on introducing some tools for statistical inference on the parameters related with the epidemic. In this regard, we present a general hypothesis test for homogeneity in epidemics and apply it to data of Covid-19 in Chile.

Measuring the effects of Compactness/Sprawl on COVID 19 spread patterns at the neighborhood level

This study analyzes the compactness/sprawl index and its effects on the spread of COVID-19 in the neighborhoods of Ahvaz, Iran. Multiple Criteria Decision Making and GIS techniques were used to develop the index. Also, the effects of compactness/sprawl on COVID-19 were investigated using a regression model. It was found that when considering the number of COVID-19 cases per 1000 people, the compactness/sprawl index did not affect the spread of the disease. However, it had a low but significant effect if the raw number of cases was considered. Results also showed that the compactness index significantly affected the raw number of cases, with a coefficient of 0.291, indicating that more compact neighborhoods had more COVID-19 cases. This is unsurprising as more people live in compact areas and, therefore, the raw number of cases is also likely to be higher. In the absence of proper control measures, this could result in further contact between people, thereby, increasing the risk of virus spread. Overall, we found that compactness had a dual effect on the spread of COVID-19 in Ahvaz. We conclude that proper development and implementation of control measures in well-designed compact neighborhoods are essential for enhancing pandemic resilience.