Revisiting the Table 2 fallacy: A motivating example examining preeclampsia and preterm birth

Trajectory of Cardiometabolic Disease-Related Hospitalizations Before and After Dementia Diagnosis: A Matched Cohort Study

OBJECTIVES

Dementia is associated with increased health care use; however, the timing of hospitalizations in relation to the development of dementia remains unclear. Cardiometabolic diseases (CMDs) including type 2 diabetes, heart disease, and stroke often co-occur with dementia, but the impact of dementia on hospitalizations related to CMDs remains unknown. We aimed to map the trajectory of CMD-related hospitalization before and after dementia diagnosis and to further identify factors of CMD-related hospitalization.

DESIGN

Matched cohort study.

SETTING AND PARTICIPANTS

Within the Swedish Twin Registry, 1657 participants aged ≥65 years (58.8% women) with incident dementia were matched with 1657 dementia-free participants using propensity scores.

METHODS

Participants were followed for up to 20 years to detect CMD-related hospitalizations. Dementia and CMD-related hospitalizations (both planned and unplanned) were identified from medical records. Potential related factors included age, sex, education, marital status, smoking, drinking, physical activity, body mass index, and hypertension. Data were analyzed using Poisson regression and generalized estimating equation models.

RESULTS

Compared with the control patients, the incidence of CMD-related hospitalization among people with dementia started to increase from 4 years before [incidence rate ratio (IRR), 1.25; 95% CI, 1.00-1.57], and started to decrease 3 years after, the diagnosis (IRR, 0.74; 95% CI, 0.58-0.94). People with dementia had a greater number of CMD-related hospitalizations (IRR, 1.19; 95% CI, 1.04-1.36) and longer cumulative length of stay (IRR, 1.27; 95% CI, 1.04-1.56) in the 5 years before dementia diagnosis, but these rates decreased after the diagnosis. Male sex, smoking, obesity, and hypertension were associated with further increases in CMD-related hospitalization among people with dementia.

CONCLUSIONS AND IMPLICATIONS

Patterns of CMD-related hospitalization change over the course of dementia development. Our findings suggest that the health care burden increases even before the diagnosis of dementia, and CMD-related hospitalization may be an early sign of the future onset of dementia.

Characterization of Cannabis users and products and the experience of negative mental emotions following Cannabis use

There is a potential link between cannabis and mental disorders. Cannabis exposure involves in many cases negative mental emotions, which are unpleasant sensations or thoughts. Whereas mild cases of negative mental emotions inflict patient's quality of life, more severe cases lead to therapy discontinuations, or even hospitalizations and death. This study characterizes cannabis users who experienced negative mental emotions after cannabis exposure. The Releaf App database was utilized to evaluate the association between personal and cannabis use characteristics on reporting a negative mental emotion during cannabis exposure. This global mobile lets individuals track real-time cannabis experience use with cannabinoid-based products, containing data points such as gender, age, reasons for use, product type, cannabis composition, and feelings and emotions experienced after cannabis use. Multivariable logistic regression models were constructed, adjusting for potential confounders such as gender and previous experience with cannabis use. The study population comprised 4,435 users, and 34,279 sessions were collected from various countries, mainly from North America, and included in the primary analysis. Reporting on negative mental emotions was associated with users in the age group of 18-30 years. Using cannabis for a mental purpose was associated with a small increase in reporting on negative mental emotions (OR = 1.10, 95%CI [1.03-1.19]). Oral products were associated with reporting on negative mental emotions. THC-dominant products were associated with reporting negative mental emotions compared to balanced products (OR = 1.21, 95%CI [1.06-1.38]). This study suggests that some characteristics of cannabis use, such as young age and oral consumption are associated with negative mental emotions. Further studies should examine the interface between cannabis consumption, characteristics of consumers, and negative emotional experience or even long-term mental disorders.

Differences in Factors Associated With Preterm and Term Stillbirth: A Secondary Cohort Analysis of the DESiGN Trial

OBJECTIVE

To identify whether maternal and pregnancy characteristics associated with stillbirth differ between preterm and term stillbirth.

DESIGN

Secondary cohort analysis of the DESiGN RCT.

SETTING

Thirteen UK maternity units.

POPULATION

Singleton pregnant women and their babies.

METHODS

Multiple logistic regression was used to assess whether the 12 factors explored were associated with stillbirth. Interaction tests assessed for a difference in these associations between the preterm and term periods.

MAIN OUTCOME MEASURE

Stillbirth stratified by preterm (<37+0 weeks') and term (37+0-42+6 weeks') births.

RESULTS

A total of 195 344 pregnancies were included. Six hundred and sixty-seven were stillborn (3.4 per 1000 births), of which 431 (65%) were preterm. Significant interactions were observed for maternal age, ethnicity, IMD, BMI, parity, smoking, PAPP-A, gestational hypertension, pre-eclampsia and gestational diabetes but not for chronic hypertension and pre-existing diabetes. Stronger associations with term stillbirth were observed in women with obesity compared to BMI 18.5-24.9 kg/m2 (BMI 30.0-34.9 kg/m2 term adjusted OR 2.1 [95% CI 1.4-3.0] vs. preterm aOR 1.1 [0.8-1.7]; BMI ≥ 35.0 kg/m2 term aOR 2.2 [1.4-3.4] vs. preterm aOR 1.5 [1.2-1.8]; p-interaction < 0.01), nulliparity compared to parity 1 (term aOR 1.7 [1.1-2.7] vs. preterm aOR 1.2 [0.9-1.6]; p-interaction < 0.01) and Asian ethnicity compared with White (p-interaction < 0.01). A weaker or lack of association with term, compared to preterm, stillbirth was observed for older maternal age, smoking and pre-eclampsia.

CONCLUSION

Differences in association exist between mothers experiencing preterm and term stillbirth. These differences could contribute to design of timely surveillance and interventions to further mitigate the risk of stillbirth.

Maternal social deprivation and preterm birth: The PreCARE cohort study

BACKGROUND

Maternal exposure to unfavourable social conditions is associated with a higher rate of perinatal complications, such as placental vascular pathologies. A higher risk of preterm birth (PTB) has also been reported, and variations across studies and settings suggest that different patterns may be involved in this association.

OBJECTIVE

To assess the association between maternal social deprivation and PTB (overall and by phenotype).

METHODS

We analysed 9365 patients included in the PreCARE cohort study. Four dimensions (social isolation, insecure housing, no income from work and absence of standard health insurance) defined maternal social deprivation (exposure). They were considered separately and combined into a social deprivation index (SDI). The associations between social deprivation and PTB <37 weeks (primary outcome) were analysed with univariable and multivariable log-binomial models (adjusted for maternal age, parity, education level and birthplace). Then we used multinomial analysis to examine the association with preterm birth phenotypes (secondary outcome): spontaneous labour, preterm prelabour rupture of membranes (PPROM) and placental vascular pathologies.

RESULTS

In all, 66.3%, 17.8%, 8.9% and 7.0% of patients had an SDI of 0, 1, 2 and 3, respectively. Social isolation affected 4.5% of the patients, insecure housing 15.5%, no income from work 15.6% and no standard health insurance 22.4%. Preterm birth complicated 7.0% of pregnancies (39.8% spontaneous labour, 28.3% PPROM, 21.8% placental vascular pathologies and 10.1% other phenotypes). Neither the univariable nor multivariable analyses found any association between social deprivation and the risk of preterm birth overall (SDI 1 versus 0: aRR 1.02, 95% confidence interval [CI] 0.83, 1.26; 2 versus 0: aRR 1.05, 95% CI 0.80, 1.38; 3 versus 0: aRR 0.92, 95% CI 0.66, 1.29) or its different phenotypes.

CONCLUSIONS

In the French PreCARE cohort, we observed no association between markers of social deprivation and the risk of preterm birth, regardless of phenotype.

Evaluation of Physiological Variables Determining Time-to-Mortality after Stroke-Associated Pneumonia

INTRODUCTION

Stroke-associated pneumonia (SAP) frequently complicates stroke and is associated with significant mortality. Clinicians often use physiological variables within the National Early Warning Score (NEWS) when diagnosing and prescribing antibiotics for SAP, but little is known of its association with mortality. We investigated the relationship of the NEWS 2 score and its components (respiratory rate, heart rate, temperature, oxygen requirement, oxygen saturation, and alertness level) prior to antibiotic initiation, with time-to-mortality in SAP.

METHODS

We included patients with SAP (n = 389) from a single hyperacute stroke unit. Diagnosis of SAP was made if pneumonia occurred within 7 days of hospital admission. Kaplan-Meier survival curves were generated to assess NEWS 2 parameters influencing survival at pre-defined time periods (1 year and 5 years). The association of these parameters on time-to-mortality were analysed using multivariable Cox-regression models to account for a set of pre-specified potential confounders.

RESULTS

The median age was 80 years (71-87 years) and median NIHSS was 7 (IQR 4-17). Mortality within 1 year was 52.4% and 65.8% within 5 years. In the multivariable analyses, time-to-mortality was independently associated with respiratory rate (heart rate [HR] 1.04, 95% confidence intervals [CI] 1.01-1.08, p = 0.009) and total NEWS 2 score (HR 1.13, 95% CI 1.06-1.21, p < 0.001).

CONCLUSIONS

In patients with SAP, higher respiratory rate and total NEWS 2 score prior to antibiotic initiation were independently associated with time-to-mortality. Further studies are warranted to identify potential opportunities for intervention and ultimately guide treatment to improve outcomes in SAP patients.

Risk factors and recurrence of hyperemesis gravidarum: A population-based record linkage cohort study

INTRODUCTION

There are limited contemporary population-based studies on the risk factors for hyperemesis gravidarum (HG), a severe type of nausea and vomiting in pregnancy. This study aimed to determine the prevalence and trend of HG over time, identify risk factors for any and multiple HG health service visits during pregnancy, and investigate HG recurrence across pregnancies.

MATERIAL AND METHODS

This population-based record linkage cohort study featured births in New South Wales, Australia from 2010 to 2019. Hospital and emergency data collections were used to identify health service visits for HG using relevant diagnosis codes and were linked to the corresponding pregnancy on the birth data set. Outcomes included any HG and multiple HG visits during pregnancy, and HG recurrence across pregnancies. Annual HG prevalence was calculated, and negative binomial regression was used to examine standardized prevalence trends. Risk factors for any HG and multiple HG visits within a pregnancy were examined using Robust Poisson models with generalized estimating equations and Prentice-Williams-Peterson Gap Time models, respectively. Rates and risk of recurrence were calculated for women with a second and third pregnancy.

RESULTS

Of the 955 107 pregnancies, 21 702 (2.3%) were classified as HG. There was an average annual increase of 6.8% (95% CI 5.3-8.3) in HG prevalence. Younger maternal age, multiple pregnancies, and selected preexisting conditions were associated with an increased risk of HG, with the strongest factor being HG in any previous pregnancy (risk ratio 8.92, 99% CI 8.43-9.44). Hyperemesis gravidarum recurrence at the second (28.9%) and third (54.7%) pregnancies was high.

CONCLUSIONS

Hyperemesis gravidarum history is the strongest risk factor for HG, which has implications for counseling and care that women receive around pregnancy.

Prevalence of alcohol use by gender and HIV status in rural Uganda

BACKGROUND

Alcohol use is a major contributor to mortality and morbidity worldwide. Uganda has a high level of alcohol use per capita. Compared to men, women are less likely to consume alcohol globally; however, women who drink have increased risks for co-occurring conditions, including depression, intimate partner violence, and HIV. This study assessed the prevalence of alcohol use and correlates of harmful alcohol use by gender and HIV status in rural Uganda.

METHODS

We used cross-sectional data from a study among women and men aged 15-59 residing in rural, central Uganda and accepting home-based HIV testing (Nov 2017 to Dec 2020). We estimated the prevalence of levels of alcohol use (categorized as no alcohol use (score 0), low (score 1-3 for men; 1-2 for women), medium (score 4-5 for men; 3-5 for women), high (score 6-7), and very-high (score 8-12) use with the AUDIT-C), stratified by gender and HIV status. We assessed correlates of harmful alcohol use using multivariable logistic regression models for women and men.

RESULTS

Among 18,460 participants, 67% (95% CI: 66-67%) reported no alcohol use, 16% (95% CI: 16-17%) reported low, 5% (95% CI: 4.8-5%) reported medium, 5% (95% CI: 4-5%) reported high, and 3% (95% CI: 2.8-3) reported very high alcohol use. Compared to women, men were more likely to report alcohol use (Chi-squared p-value<0.0001). People diagnosed with HIV (both newly diagnosed and previously aware of their status prior to home-based HIV testing) were more likely to report low, medium, high, and very high alcohol use compared to those who were HIV negative (Chi-squared p-value<0.0001). Among women, those who were newly diagnosed were more likely report alcohol use, compared to those who were HIV negative. In multivariable models, being newly diagnosed with HIV (compared to HIV negative) increased the odds of harmful alcohol use among women, but not men.

CONCLUSION

While alcohol use was higher among men and people living with HIV, being newly diagnosed with HIV had a stronger relationship with harmful alcohol use among women than men. More research is needed to understand how alcohol use may increase the risks of HIV acquisition among women and to identify gender-responsive services to address harmful alcohol use and increase access to HIV testing and linkage to care for women who use harmful levels of alcohol.

Lifestyle and psychosocial associations with cognition at the cusp of midlife using twins and siblings

INTRODUCTION

This study investigates the relationship between cognitive functioning and 59 modifiable and intrinsic factors at the cusp of midlife.

METHODS

We analyzed data from 1221 participants in the Colorado Adoption/Twin Study of Lifespan behavioral development and cognitive aging (CATSLife; Mage = 33.20, %Female = 52.74). We assessed the impact of 59 factors on cognitive functioning using regularized regression and co-twin control models, controlling for earlier-life cognitive functioning and gray matter volume.

RESULTS

Eight robust factors were identified, including education attainment, cognitive complexity, purpose-in-life, and smoking status. Twins reporting higher levels of cognitive complexity and purpose-in-life showed better cognitive performance than their cotwin, while smoking was negatively associated. Using meta-analytically derived effect size threshold, we additionally identified that twins experiencing more financial difficulty tend to perform less well compared with their cotwin.

DISCUSSION

The findings highlight the early midlife link between cognitive functioning and lifestyle/psychological factors, beyond prior cognitive performance, brain status, genetic and familial confounders. Our results further highlight the potential of established adulthood as a crucial window for dementia prevention interventions targeting lifestyle and psychosocial factors.

Highlights

Cog complexity(+), purpose-in-life(+) were associated with cognition in early midlife.Smoking(-) was also associated with cognition in early midlife.Results were consistent controlling for genetic and environmental confounds.Association between EA and cognition might be mostly genetic and familial confounded.

Housing conditions and risk of incident COPD: a Danish cohort study, 2000-2018

BACKGROUND

More knowledge is needed on the risk of developing chronic obstructive pulmonary disease (COPD) associated with housing conditions and indoor environment based on cohort studies with a long follow-up time.

OBJECTIVE

To examine the association between housing conditions and indoor environment and the risk of developing COPD.

METHODS

In this cohort study, we followed 11,590 individuals aged ≥ 30 years free of COPD at baseline. Information on incident COPD and housing conditions and indoor environment was obtained from the Danish national registers and the Danish Health and Morbidity Survey year 2000. Poisson regression of incidence rates (IRs) were used to estimate incidence rate ratios (IRRs) of COPD.

RESULTS

The overall IR of COPD was 8.6 per 1,000 person-years. Individuals living outside the biggest cities vs. living in the biggest cities (≥ 50,000) had a lower risk of COPD (200-4,999; IRR 0.77 (95% CI 0.65-0.90). Individuals living in semi-detached houses had a higher risk compared to individuals living in detached houses (IRR 1.29 (95% CI 1.07-1.55)). Likewise, individuals living in rented homes had a higher risk (IRR 1.47 (95% CI 1.27-1.70)) compared to individuals living in owned homes. The IR of COPD was 17% higher among individuals living in dwellings build > 1982 compared with individuals living in older dwellings (< 1962), not statistically significant though (IRR 0.83 (95% CI 0.68-1.03)). Likewise, the IR of COPD was 15% higher among individuals living in the densest households compared with individuals living in the least dense households, not statistically significant though (IRR 1.15 (95% CI 0.92-1.45)). This was primary seen among smokers. There was no difference in risk among individuals with different perceived indoor environments. Overall, similar patterns were seen when stratified by smoking status with exception of perceived indoor environment, where opposite patterns were seen for smokers and never smokers.

CONCLUSION

Individuals living in semi-detached houses or rented homes had a higher risk of developing COPD compared to individuals living in detached or owned homes. Individuals living in cities with < 50.000 residents had a lower risk of COPD compared to individuals living in cities with ≥ 50.000 residents.

Transportability Without Positivity: A Synthesis of Statistical and Simulation Modeling

Studies designed to estimate the effect of an action in a randomized or observational setting often do not represent a random sample of the desired target population. Instead, estimates from that study can be transported to the target population. However, transportability methods generally rely on a positivity assumption, such that all relevant covariate patterns in the target population are also observed in the study sample. Strict eligibility criteria, particularly in the context of randomized trials, may lead to violations of this assumption. Two common approaches to address positivity violations are restricting the target population and restricting the relevant covariate set. As neither of these restrictions is ideal, we instead propose a synthesis of statistical and simulation models to address positivity violations. We propose corresponding g-computation and inverse probability weighting estimators. The restriction and synthesis approaches to addressing positivity violations are contrasted with a simulation experiment and an illustrative example in the context of sexually transmitted infection testing uptake. In both cases, the proposed synthesis approach accurately addressed the original research question when paired with a thoughtfully selected simulation model. Neither of the restriction approaches was able to accurately address the motivating question. As public health decisions must often be made with imperfect target population information, model synthesis is a viable approach given a combination of empirical data and external information based on the best available knowledge.

Exploring contextual effects of post-migration housing environment on mental health of asylum seekers and refugees: A cross-sectional, population-based, multi-level analysis in a German federal state

Asylum seekers and refugees (ASR) in Germany are dispersed quasi-randomly to state-provided, collective accommodation centres. We aimed to analyse contextual effects of post-migration housing environment on their mental health. We drew a balanced random sample of 54 from 1 938 accommodation centres with 70 634 ASR in Germany's 3rd largest federal state. Individual-level data on depression and anxiety as well as sociodemographic- and asylum-related covariates, were collected and linked to contextual geo-referenced data on housing environment ('Small-area Housing Environment Deterioration' index, number of residents, remoteness, urbanity, and German Index of Multiple Deprivation). We fitted two-level random-intercept models to exploratively estimate adjusted contextual effects. Of 411 surveyed participants, 45.53% and 44.83%, respectively, reported symptoms of depression or anxiety. 52.8% lived in centres with highest deterioration, 46.2% in centres with > = 50 residents, 76.9% in urban, and 56% in deprived districts. 7.4% of centres were remote. We found statistically significant clustering in reporting anxiety on the level of accommodation centres. The model resulted in an intraclass correlation of 0.16 which translated into a median odds ratio of 2.10 for the accommodation-level effects. No significant clustering was found for symptoms of depression. The highest degree of deterioration, large accommodation size, remoteness, and district urbanity showed higher, but statistically not significant, odds for reporting anxiety or depression. District deprivation demonstrated higher odds for anxiety and lower odds for depression yet remained statistically insignificant for both. Evidence for contextual effects of housing environment on mental health of ASR could not be established but residual confounding by length of stay in the accommodation centre cannot be ruled out. Confirmatory analyses with prior power calculations are needed to complement these exploratory estimates.

Previous High-Intensity Breastfeeding Lowers the Risk of an Abnormal Fasting Glucose in a Subsequent Pregnancy Oral Glucose Tolerance Test

Breastfeeding is associated with reduced lifetime cardiometabolic risk, but little is known regarding the metabolic benefit in a subsequent pregnancy. The primary aim of this study was to investigate the association between breastfeeding duration and intensity and next pregnancy oral glucose tolerance test (OGTT) results. A retrospective cohort study was conducted from March 2020 to October 2022. All multiparous women who met inclusion criteria and gave birth during the study period were eligible for inclusion. Analysis was stratified by risk for gestational diabetes (GDM). High GDM risk criteria included previous GDM and BMI > 35 kg/m2. The association between breastfeeding duration and high-intensity breastfeeding (HIBF) and subsequent pregnancy OGTT were assessed with multivariate logistic models adjusted for statistically and clinically relevant covariables. There were 5374 multiparous participants who met the inclusion criteria for analysis. Of these, 61.7% had previously breastfed for >6 months, and 43.4% were at high risk for GDM. HIBF was associated with 47% reduced odds of an abnormal fasting glucose in a subsequent pregnancy OGTT (aOR 0.53; 95%CI 0.38-0.75; p < 0.01). There was no association between HIBF and other glucose results on the OGTT. Women who smoked were least likely to breastfeed at high intensity (aOR 0.31; 95%CI 0.21-0.47; p < 0.01). South Asian women had 65% higher odds of HIBF than women who identified as White/European (aOR 1.65; 1.36-2.00; p < 0.01). This study highlights the importance of exclusive breastfeeding to potentially reduce the prevalence of GDM and may also translate into long-term reduction of cardiometabolic risk.

Voxel-based analysis: Roadmap for clinical translation

Voxel-based analysis (VBA) allows the full, 3-dimensional, dose distribution to be considered in radiotherapy outcome analysis. This provides new insights into anatomical variability of pathophysiology and radiosensitivity by removing the need for a priori definition of organs assumed to drive the dose response associated with patient outcomes. This approach may offer powerful biological insights demonstrating the heterogeneity of the radiobiology across tissues and potential associations of the radiotherapy dose with further factors. As this methodological approach becomes established, consideration needs to be given to translating VBA results to clinical implementation for patient benefit. Here, we present a comprehensive roadmap for VBA clinical translation. Technical validation needs to demonstrate robustness to methodology, where clinical validation must show generalisability to external datasets and link to a plausible pathophysiological hypothesis. Finally, clinical utility requires demonstration of potential benefit for patients in order for successful translation to be feasible. For each step on the roadmap, key considerations are discussed and recommendations provided for best practice.

Prevalence and incidence of tuberculosis infection among healthcare workers in chest diseases hospitals, Bangladesh: Putting infection control into context

BACKGROUND

Healthcare workers (HCWs) are at increased risk of tuberculosis infection (TBI). We estimated the prevalence and incidence of TBI and risk factors among HCWs in Bangladeshi hospitals to target TB infection prevention and control (IPC) interventions.

METHODS

During 2013-2016, we conducted a longitudinal study among HCWs in four chest disease hospitals. At baseline, we administered a questionnaire on sociodemographic and occupational factors for TB, tuberculin skin tests (TST) in all hospitals, and QuantiFERON ®-TB Gold in-Tube (QFT-GIT) tests in one hospital. We assessed factors associated with baseline TST positivity (induration ≥10mm), TST conversion (induration increase ≥10mm from baseline), baseline QFT-GIT positivity (interferon-gamma ≥0.35 IU/mL), and QFT-GIT conversion (interferon-gamma <0.35 IU/mL to ≥0.35 IU/mL). We included factors with a biologically plausible relationship with TBI identified in prior studies or having an association (p = <0.20) in the bivariate analyses with TST positivity or QFT-GIT positivity in multivariable generalized linear models. The Kaplan-Meier was used to estimate the cumulative TBI incidence rate per 100 person-years.

RESULTS

Of the 758 HCWs invited, 732 (97%) consented to participate and 731 completed the one-step TST, 40% had a positive TST result, and 48% had a positive QFT-GIT result. In multivariable models, HCWs years of service 11-20 years had 2.1 (95% CI: 1.5-3.0) times higher odds of being TST-positive and 1.6 (95% CI 1.1-2.5) times higher odds of QFT-GIT-positivity at baseline compared with those working ≤10 years. HCWs working 11-20 years in pulmonary TB ward had 2.0 (95% CI: 1.4-2.9) times higher odds of TST positivity, and those >20 years had 2.5 (95% CI: 1.3-4.9) times higher odds of QFT-GIT-positivity at baseline compared with those working <10 years. TBI incidence was 4.8/100 person-years by TST and 4.2/100 person-years by QFT-GIT. Females had 8.5 (95% CI: 1.5-49.5) times higher odds of TST conversion than males.

CONCLUSIONS

Prevalent TST and QFT-GIT positivity was associated with an increased number of years working as a healthcare worker and in pulmonary TB wards. The incidence of TBI among HCWs suggests ongoing TB exposure in these facilities and an urgent need for improved TB IPC in chest disease hospitals in Bangladesh.

Socio-ecological Barriers to Viral Suppression Among Transgender Women Living with HIV in San Francisco and Los Angeles, California

Troubling disparities in viral suppression persist among transgender (trans) women living with HIV in the US. We utilized baseline data from a randomized controlled trial of a behavioral intervention among trans women living with HIV in San Francisco and Los Angeles, to identify the socio-ecological correlates of biologically confirmed viral suppression (< 200 HIV-1 RNA copies/mL). Among 253 participants, the mean age was 43 (SD = 11), 46% identified as Black or African American and 35% were virally non-suppressed. In adjusted Poisson regression models, the following barriers to viral suppression were identified: injection drug use [adjusted risk ratio (aRR) 0.78, 95% CI 0.65-0.93, Z = - 2.64, p = 0.008], methamphetamine use (aRR 0.65, 95% CI 0.51-0.83, Z = - 3.45, p = 0.001), amphetamine use (aRR 0.62, 95% CI 0.44-0.87, Z = - 2.75, p = 0.006), homelessness (aRR 0.79, 95% CI 0.63-0.98, Z = - 2.06, p = 0.039), and sex work (aRR 0.60, 95% CI 0.41-0.86, Z = - 2.77, p = 0.009). These findings underscore the importance of interventions that address the socio-ecological barriers to viral suppression among trans women in urban settings.

Are trajectories of depressive symptoms during the first half of drug-sensitive pulmonary tuberculosis treatment associated with loss to follow-up? A secondary analysis of longitudinal data

OBJECTIVE

The objective of this study was to identify trajectories of depressive symptoms (DSs) during the first half of drug-sensitive pulmonary tuberculosis (PTB) treatment and examine their association with loss to follow-up (LTFU) in the second half.

DESIGN

This study involved a secondary analysis of longitudinal data to identify potential trajectories of DS and their relationship with LTFU.

SETTING

The study was conducted in first and second-level health centres located in San Juan de Lurigancho, Lima, Peru.

PARTICIPANTS

Anonymised data from 265 individuals, including monthly measures of DSs from diagnosis to the completion of treatment, initiation of treatment for multidrug resistant TB, LTFU or death, were collected.

RESULTS

Three trajectories were identified: 'declining', 'growth' and 'high'. These trajectories were observed in 182 (68.7%), 53 (20%) and 30 (11.3%) of the 265 individuals, respectively, during the first half of PTB treatment. Compared with those with a 'declining' trajectory, individuals with a 'growth' trajectory had a higher likelihood of experiencing LTFU during the second half of PTB treatment, after controlling for sociodemographic factors and at least weekly alcohol use (OR 3.9; 95% CI 1.09 to 13.97, p=0.036).

CONCLUSIONS

The findings suggest that a trajectory of increasing DSs during the first half of PTB treatment is associated with a higher risk of LTFU during the second half.

The role of geography and distance on physician follow-up after a first hospitalization with a diagnosis of a schizophrenia spectrum disorder: A retrospective population-based cohort study in Ontario, Canada

BACKGROUND

Timely follow-up after hospitalization for a schizophrenia spectrum disorder (SSD) is an important quality indicator. We examined the proportion of individuals who received physician follow-up within 7 and 30 days post-discharge by health region and estimated the effect of distance between a person's residence and discharging hospital on follow-up.

METHODS

We created a retrospective population-based cohort of incident hospitalizations with a discharge diagnosis of a SSD between 01/01/2012 and 30/03/2019. The proportion of follow-up with a psychiatrist and family physician within 7 and 30 days were calculated for each region. The effect of distance between a person's residence and discharging hospital on follow-up was estimated using adjusted multilevel logistic regression models.

RESULTS

We identified 6,382 incident hospitalizations for a SSD. Only 14.2% and 49.2% of people received follow-up care with a psychiatrist within 7 and 30 days of discharge, respectively, and these proportions varied between regions. Although distance from hospital was not associated with follow-up within 7 days of discharge, increasing distance was associated with lower odds of follow-up with a psychiatrist within 30 days.

CONCLUSION

Post-discharge follow-up is poor across the province. Geospatial factors may impact post-discharge care and should be considered in further evaluation of quality of care.

The role of targeted temperature management in 30-day hospital readmissions in cardiac arrest survivors: A national population-based study

Background

Targeted temperature management (TTM) implementation following resuscitation from cardiac arrest is controversial. Although prior studies have shown that TTM improves neurological outcomes and mortality, less is known about the rates or causes of readmission in cardiac arrest survivors within 30 days. We aimed to determine whether the implementation of TTM improves all-cause 30-day unplanned readmission rates in cardiac arrest survivors.

Methods

Using the Nationwide Readmissions Database, we identified 353,379 adult cardiac arrest index hospitalizations and discharges using the International Classification of Diseases, 9th and 10th codes. The primary outcome was 30-day all-cause unplanned readmissions following cardiac arrest discharge. Secondary outcomes included 30-day readmission rates and reasons, including impacts on other organ systems.

Results

Of 353,379 discharges for cardiac arrest with 30-day readmission, 9,898 (2.80%) received TTM during index hospitalization. TTM implementation was associated with lower 30-day all-cause unplanned readmission rates versus non-recipients (6.30% vs. 9.30%, p < 0.001). During index hospitalization, receiving TTM was also associated with higher rates of AKI (41.12% vs. 37.62%, p < 0.001) and AHF (20.13% vs. 17.30%, p < 0.001). We identified an association between lower rates of 30-day readmission for AKI (18.34% vs. 27.48%, p < 0.05) and trend toward lower AHF readmissions (11.32% vs. 17.97%, p = 0.05) among TTM recipients.

Conclusions

Our study highlights a possible negative association between TTM and unplanned 30-day readmission in cardiac arrest survivors, thereby potentially reducing the impact and burden of increased short-term readmission in these patients. Future randomized studies are warranted to optimize TTM use during post-arrest care.

Humidity's Role in Heat-Related Health Outcomes: A Heated Debate

BACKGROUND

As atmospheric greenhouse gas concentrations continue to rise, temperature and humidity will increase further, causing potentially dire increases in human heat stress. On physiological and biophysical grounds, exposure to higher levels of humidity should worsen heat stress by decreasing sweat evaporation. However, population-scale epidemiological studies of heat exposure and response often do not detect associations between high levels of humidity and heat-related mortality or morbidity. These divergent, disciplinary views regarding the role of humidity in heat-related health risks limit confidence in selecting which interventions are effective in reducing health impacts and in projecting future heat-related health risks.

OBJECTIVES

Via our multidisciplinary perspective we seek to a) reconcile the competing realities concerning the role of humidity in heat-related health impacts and b) help ensure robust projections of heat-related health risks with climate change. These objectives are critical pathways to identify and communicate effective approaches to cope with present and future heat challenges.

DISCUSSION

We hypothesize six key reasons epidemiological studies have found little impact of humidity on heat-health outcomes: a) At high temperatures, there may be limited influence of humidity on the health conditions that cause most heat-related deaths (i.e., cardiovascular collapse); b) epidemiological data sets have limited spatial extent, a bias toward extratropical (i.e., cooler and less humid), high-income nations, and tend to exist in places where temporal variations in temperature and humidity are positively correlated; c) analyses focus on older, vulnerable populations with sweating, and thus evaporative, impairments that may be further aggravated by dehydration; d) extremely high levels of temperature and humidity (seldom seen in the historical record) are necessary for humidity to substantially impact heat strain of sedentary individuals; e) relationships between temperature and humidity are improperly considered when interpreting epidemiological model results; and f) sub-daily meteorological phenomena, such as rain, occur at high temperatures and humidity, and may bias epidemiological studies based on daily data. Future research must robustly test these hypotheses to advance methods for more accurate incorporation of humidity in estimating heat-related health outcomes under present and projected future climates. https://doi.org/10.1289/EHP11807.

Mechanisms linking gender-based violence to worse HIV treatment and care outcomes among women in the United States

OBJECTIVE

To test whether substance use mediates the associations between gender-based violence (GBV) and suboptimal adherence to antiretroviral therapy (ART), and GBV and poor engagement in care, among women living with HIV (WLHIV) in the United States (US).

DESIGN

We analyzed longitudinal data collected among 1717 WLHIV in the Women's Interagency HIV Study (WIHS).

METHODS

From 2013 to 2017, WLHIV completed semi-annual assessments on GBV, substance use, and HIV treatment and care. Adjusted multilevel logistic regression models were built to estimate the impact of GBV on; suboptimal (<95%) adherence and at least one missed HIV care appointment without rescheduling in the past 6 months. Mediation analyses were performed to test whether heavy drinking and illicit drug use mediated the associations between GBV and the two HIV outcomes.

RESULTS

The mean age was 47 (standard deviation = 9), 5% reported experiencing GBV, 17% reported suboptimal adherence and 15% reported at least one missed appointment in the past 6 months. Women who experienced GBV had a significantly higher odds of suboptimal adherence [adjusted odds ratio (aOR) = 1.99; 95% confidence interval (CI) = 1.40-2.83] and missed appointments (aOR = 1.92, 95% CI = 1.32-2.33). Heavy drinking and illicit drug use mediated 36 and 73% of the association between GBV and suboptimal adherence and 29 and 65% of the association between GBV and missed appointments, respectively.

CONCLUSIONS

Substance use is an underlying mechanism through which GBV affects outcomes along the HIV care continuum among WLHIV in the US. To optimize HIV treatment and care among women, interventions should address the combined epidemics of substance use, violence, and HIV.

Risk factors for neonatal encephalopathy in late preterm and term singleton births in a large California birth cohort

OBJECTIVE

The objective was to investigate maternal and pregnancy characteristics associated with neonatal encephalopathy (NE).

STUDY DESIGN

We queried an administrative birth cohort from California between 2011 and 2017 to determine the association between each factor and NE with and without hypothermia treatment.

RESULTS

From 3 million infants born at 35 or more weeks of gestation, 6,857 cases of NE were identified (2.3 per 1000 births), 888 (13%) received therapeutic hypothermia. Risk factors for NE were stronger among cases receiving hypothermia therapy. Substance-related diagnosis, preexisting diabetes, preeclampsia, and any maternal infection were associated with a two-fold increase in risk. Maternal overweight/obesity, nulliparity, advanced maternal age, depression, gestational diabetes or hypertension, and short or long gestations also predicted NE. Young maternal age, Asian race and Hispanic ethnicity, and cannabis-related diagnosis lowered risk of NE.

CONCLUSIONS

By disseminating these results, we encourage further interrogation of these perinatal factors.

Female reproductive factors and risk of joint replacement arthroplasty of the knee and hip due to osteoarthritis in postmenopausal women: a nationwide cohort study of 1.13 million women

OBJECTIVES

Previous studies of the relationships between female reproductive factors and osteoarthritis (OA) have shown conflicting results. In this study, we aimed to explore the relationships between reproductive factors and joint replacement arthroplasty of the knee (TKRA) and hip (THRA) in a large nationwide population-based cohort of postmenopausal Korean women.

METHODS

We included 1,134,680 subjects who participated in national health examinations in 2009 in the study. The study outcomes were incident THRA or TKRA due to severe hip or knee OA. The relationships between reproductive factors and THRA or TKRA were evaluated using a multivariable-adjusted proportional hazards model.

RESULTS

During a mean follow-up duration of 8.2 years, 1,610 incident THRA cases and 60,670 incident TKRA cases were observed. Later age at menarche, longer breastfeeding, HRT and OC use were associated with increased risk of TKRA for severe knee OA, while later age at menopause and longer reproductive span were associated with decreased risk. With regard to THRA for severe hip OA, later menarche, longer breastfeeding, HRT more than 5 years, and OC use more than 1 year were associated with higher risk. The associations between reproductive factors and severe OA were more pronounced in underweight and younger subjects.

CONCLUSION

We found that shorter estrogen exposure was associated with higher risk of TKRA due to severe knee OA, and such associations were more pronounced in underweight and younger subjects. The association between shorter estrogen exposure and THRA was not robust.

A scoping review of Table 2 fallacy in the oral health literature

BACKGROUND

Coined by Westreich and Greenland in 2013, Table 2 fallacy refers to the practice of reporting estimates of the primary exposure and adjustment covariates derived from a single model on the same table. This study seeks to describe the extent to which Table 2 fallacy is present in the oral health literature and provide recommendations on presenting findings from multivariable-adjusted models and/or interpretation of adjustment covariate estimates that are not the primary exposure.

METHODS

We conducted a scoping review in PubMed and Scopus of human observational studies published in 4 oral health journals (JDR-CTR, CDOE, JPHD, BMC Oral Health) starting in 2013 until the end of 2018. The resulting articles were exported into Excel and were either included or excluded for full-text review based on six criteria. After categorizing the articles, we exported and summarized the results in SAS.

RESULTS

A total of 1358 articles were initially screened of which 937 articles were excluded based on title or abstract for being animal studies, systematic reviews or meta-analysis, prediction models or descriptive studies. The remaining 421 articles were eligible for full text reviewed of which, 189 (45%) committed Table 2 fallacy. The prevalence of table 2 fallacy appears high in the oral health literature.

CONCLUSIONS

The problem of presenting multiple effect estimates derived from a single model in the same table is that it inadvertently encourages the reader to interpret all estimates the same way, often as total effects. Implications and recommendations are discussed.

Vaccination assessments using the Demographic and Health Survey, 2005-2018: a scoping review

OBJECTIVE

To characterise studies which have used Demographic and Health Survey (DHS) datasets to evaluate vaccination status.

DESIGN

Scoping review.

DATA SOURCES

Electronic databases including PubMed, EBSCOhost and POPLINE, from 2005 to 2018.

STUDY SELECTION

All English studies with vaccination status as the outcome and the use of DHS data.

DATA EXTRACTION

Studies were selected using a predetermined list of eligibility criteria and data were extracted independently by two authors. Data related to the study population, the outcome of interest (vaccination) and commonly seen predictors were extracted.

RESULTS

A total of 125 articles were identified for inclusion in the review. The number of countries covered by individual studies varied widely (1-86), with the most published papers using data from India, Nigeria, Pakistan and Ethiopia. Many different definitions of full vaccination were used although the majority used a traditional schedule recommended in the WHO's Expanded Programme on Immunisation. We found studies analysed a wide variety of predictors, but the most common were maternal education, wealth, urbanicity and child's sex. Most commonly reported predictors had consistent relationships with the vaccination outcome, outside of sibling composition.

CONCLUSIONS

Researchers make frequent use of the DHS dataset to describe vaccination patterns within one or more countries. A clearer idea of past use of DHS can inform the development of more rigorous studies in the future. Researchers should carefully consider whether a variable needs to be included in the multivariable model, or if there are mediating relationships across predictor variables.

Perceived barriers to pre-exposure prophylaxis use among HIV-negative men who have sex with men in Tijuana, Mexico: A latent class analysis

BACKGROUND

Given the slow uptake of PrEP among cisgender men who have sex with men (MSM) in high-income countries, efforts to roll-out PrEP in low- and middle-income countries (LMIC) should address barriers to PrEP use to facilitate its more rapid uptake. To inform PrEP programs in LMIC, we examined patterns of perceived barriers to PrEP use among HIV-negative MSM in Tijuana, Mexico.

METHODS

From 03/2016-09/2017, 364 MSM completed interviewer-administered surveys assessing perceived barriers to PrEP use across 4 domains: PrEP attribute, individual, interpersonal, and structural. Latent class analysis was performed to identify distinct classes with respect to perceived barriers to PrEP use. Multinomial logistic regression was used to identify factors associated with class membership.

RESULTS

We identified three classes characterized by (1) high levels of perceived barriers across domains (12%), (2) low levels of perceived barriers across domains (43%), and (3) perceived PrEP attribute barriers (i.e., side-effects and cost) (45%). Membership in the high level of perceived barriers class (vs. the low level of perceived barriers class) was positively associated with having a history of incarceration (AOR: 2.44; 95% CI: 1.04, 5.73) and negatively associated with more social support (AOR: 0.99; 95% CI: 0.98, 1.00). Membership in the perceived PrEP attribute barriers class was positively associated with having seen a healthcare provider in the past year (AOR: 2.78; 95% CI: 1.41, 5.45) and negatively associated with having any HIV-positive or status unknown partners (AOR: 0.56; 95% CI: 0.31, 1.01).

CONCLUSIONS

Since most participants were in either the low level of perceived barriers class or the perceived PrEP attribute barriers class, future PrEP uptake may be high among MSM in Tijuana. However, these findings suggest that achieving sufficient PrEP uptake and adherence among MSM in Tijuana may require a range of comprehensive HIV prevention interventions.

Vaginal washing and lubrication among female sex workers in the Mexico-US border region: implications for the development of vaginal PrEP for HIV prevention

Background

To assess the potential acceptability and inform the development of behaviorally-congruent vaginal douche- or gel-based HIV pre-exposure prophylaxis (PrEP) products, we examined vaginal washing and lubrication practices among female sex workers (FSWs) in Tijuana and Ciudad Juarez, two northern Mexico cities bordering the United States (US).

Methods

Two hundred and ninety-five HIV-negative FSWs (145 Tijuana; 150 Ciudad Juarez) enrolled in a behavioral HIV prevention intervention trial completed surveys assessing vaginal washing and lubrication practices, as well as motivators and barriers to performing each practice. Logistic regression was used to identify potential predictors of each practice in the past month.

Results

In the past month, vaginal washing was performed by 56 and 22% of FSWs in Tijuana and Ciudad Juarez (p <  0.0001), respectively, while vaginal lubrication was performed by 64 and 45% of FSWs in Tijuana and Ciudad Juarez (p = 0.001), respectively. Vaginal washing was positively associated with living in Tijuana (adjusted odds ratio [AOR] = 4.35, 95% confidence interval [CI]: 2.60–7.30), older age (AOR = 1.04 per year, 95% CI: 1.01–1.06), and vaginal lubrication (AOR = 2.99, 95% CI: 1.67–5.35), while it was negatively associated with being born in the same state as the study site (AOR = 0.50, 95% CI: 0.31–0.82), earning a monthly income ≥3500 pesos (AOR = 0.53, 95% CI: 0.28–1.00), and hazardous alcohol consumption (AOR = 0.56, 95% CI: 0.33–0.95). Vaginal lubrication was positively associated with living in Tijuana (AOR = 2.21, 95% CI: 1.37–3.54) and vaginal washing (AOR = 2.91, 95% CI: 1.64–5.18), while it was negatively associated with being born in the same state as the study site (AOR = 0.47, 95% CI: 0.29–0.75).

Conclusions

The moderate and high prevalence of vaginal washing and lubrication, respectively, suggest behaviorally-congruent, multi-purpose, vaginal douche- and gel-based PrEP products that simultaneously address FSWs’ needs and prevent HIV infection may be acceptable to many FSWs along the Mexico-US border. Future product development and implementation should also consider the link between vaginal washing and lubrication to ensure existing practices do not undermine vaginal PrEP product effectiveness.

Trial registration

ClincialTrials.gov (NCT02447484).

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5946-z) contains supplementary material, which is available to authorized users.