Five myths about variable selection

Characteristics of teeth and patients receiving root canal treatment in National Dental PBRN practices: Comparison between Endodontist and general dentist practices

PURPOSE

To describe and compare patient and tooth characteristics determined prior to treatment among those receiving root canal treatment (RCT) from general dentists (GD) versus endodontists within the National Dental Practice-Based Research (PBRN) Network.

METHODS

This National Dental PBRN study involved 153 practitioners (104 GDs and 49 endodontists) who used a consecutive enrollment strategy to enroll patients. Practitioners recorded details about pre-operative tooth characteristics. Prior to RCT, patients provided data about their socio-demographic, medication use, temporomandibular disorder (TMD), and psycho-social characteristics. We describe the overall prevalence of these characteristics and compare them by provider type.

RESULTS

1,723 patients were enrolled; 788 by GDs and 935 by endodontists. Endodontists treated higher proportions of female, non-Hispanic white, better-educated patients, patients from the Midwest and Southwest regions, and molar teeth compared to GDs. GDs saw a higher proportion of patients from the Northeast region and whose teeth had a probing depth of 5 mm or more. All of these characteristics were independently and significantly (at p <.05) associated with provider type. Endodontists were more likely than GDs to see patients with TMD symptoms in bivariate comparisons, but their patient groups were similar with regard to treatment outcome expectation, dental fear, depression, and anxiety.

CONCLUSION

Significant differences exist between endodontists and GDs in patient demographics, tooth characteristics, and treatment patterns, with endodontists treating more molars, female, non-Hispanic white, and educated patients, while GDs manage more cases involving antibiotics use and teeth with deep probing depths, highlighting variations in referral patterns and treatment accessibility.

Association between hospitalised childhood pneumonia and follow-up chest radiographs in high-risk populations: a secondary analysis of a multicentre randomised controlled trial

OBJECTIVE

As children hospitalised with community-acquired pneumonia (CAP) are at risk of persistent chest radiograph (CXR) abnormalities and respiratory sequelae, we investigated factors associated with incomplete CXR resolution at 4 weeks and 12 months post-discharge in children from populations at high-risk of chronic lung disease.

DESIGN

Secondary analysis-multicentre, placebo-controlled, randomised controlled trial.

SETTINGS AND PATIENTS

324 children aged 3 months to ≤5 years hospitalised with radiographic-confirmed CAP were enrolled from seven hospitals in Australia, New Zealand and Malaysia. After 1-3 days of intravenous antibiotics, then 3 days of oral amoxicillin-clavulanate, they were randomised to extended (13-14 days) or standard (5-6 days) courses of antibiotics.

INTERVENTION

CXRs were performed at admission, 4 weeks, and 12 months post-discharge and reviewed in a blinded manner.

MAIN OUTCOME MEASURES

Radiographic changes of pneumonia at 4 weeks and 12 months post-discharge compared with admission CXRs.

RESULTS

Among children with interpretable CXRs, incomplete resolution was seen in 42/253 (17%) at 4 weeks, and 29/212 (14%) at 12 months. Characteristics at admission associated with incomplete CXR resolution at 4 weeks were previous pneumonia hospitalisation (adjusted odds ratio [ORadj])=6.46, 95% confidence interval [CI] 2.21 to 18.85) and increasing age (ORadj=0.60 per-year, 95% CI 0.38 to 0.94). Continuing respiratory symptoms/signs at 4 weeks post-discharge was also associated with incomplete resolution (OR=5.63, 95% CI 2.38 to 13.32). At 12 months, previous pneumonia hospitalisation was associated with persistent incomplete CXR resolution (OR=4.03, 95 % CI 1.25 to 13.02).

CONCLUSION

In high-risk settings, younger age, those with previous pneumonia hospitalisation, or ongoing respiratory symptoms/signs 4 weeks post-discharge from hospitalised CAP may be associated with incomplete CXR resolution. Consequently, follow-up imaging and monitoring may be warranted in these children.

Not small men: Sex-specific determinants of cortisol reactivity to psychosocial stress following trauma

Trauma impacts a vast percentage of the global population, with women disproportionally affected by trauma-related disorders-a disparity not explained by exposure alone. Identifying mechanisms associated with this inequity is critical to advancing preventative and responsive treatment. Blunted cortisol reactivity to psychosocial stress represents one possible mechanism, though the influence of sex and specific dimensions of trauma on this condition are underinvestigated. This study examined the roles of sex, developmental timing of trauma, trauma subtype, and subjective trauma impact on cortisol reactivity. Adults (N = 59, n = 37 female) participated in the Trier Social Stress Test, completed trauma measures, and provided salivary cortisol samples. Multiple regression analyses were performed to investigate correlates of blunted cortisol reactivity in the full sample and in sex-disaggregated data to account for unique endocrinological milieus. Women who endorsed childhood trauma demonstrated blunted cortisol reactivity, B = -8.72, p = .004, f 2 = .39; notably, this association held only when participants endorsed the childhood traumatic event as their most stressful lifetime event. Considering the lack of clarity regarding the conditions under which blunted cortisol reactivity develops, these findings provide insight into factors that may confer risk for these psychophysiological changes. The observed salience of sex-disaggregated analysis has important implications for future research. Despite decades of study, the pathways linking trauma, cortisol dysregulation, and pathology remain elusive; accounting for sex differences may contribute to resolving this quandary. Unraveling these mechanisms could inform prospective risk assessment, prevention efforts, and focused clinical trials.

Do Single-Nucleotide Polymorphisms Affect Pain Intensity and Sufentanil Analgesia After Pediatric Scoliosis Correction Surgery?

Pain management in children remains a challenge. Postoperative pain assessment, which currently relies on behavioral and subjective scales, could be enhanced by the identification of single nucleotide polymorphisms effect on pain thresholds and opioid metabolism. This study explores the impact of nine SNPs-rs1799971, rs4680, rs4633, rs6269, rs4818 (with catechol-o-methyltransferase haplotypes), rs7832704, rs1801253, and rs1045642-on postoperative pain intensity, opioid requirements, coanalgesic use, C-reactive protein levels, and post-anesthesia care unit length of stay. This study involved 42 pediatric patients undergoing scoliosis correction surgery with postoperative sufentanil infusion. The genotyping was performed using real-time PCR with peripheral blood samples. Patients with the rs1801253 ADRB1 GG genotype showed significantly lower 24 h NRS pain ratings (p = 0.032) and lower sufentanil infusion rates at the level of statistical tendency (p = 0.093). Patients with the rs1205 CRP CT genotype had a shorter PACU length of stay (p = 0.012). In contrast, those with the rs1045642 ABCB1 GG genotype had a longer PACU stay by 0.72 h (p = 0.046). No significant associations were found for OPRM1 rs1799971, COMT, or ENPP2 SNPs. ADRB1 rs1801253may be a novel SNP indicating higher postoperative pain risk, while rs1205 CRP and rs1045642 ABCB1 could predict increased care requirements in PACUs. The ADRB1 rs1801253 SNP may also predict opioid demand. These results suggest SNPs should be considered in acute pain assessment.

Insights into Molecular Profiles, Resistance Patterns, and Virulence Traits of Staphylococci from Companion Dogs in Angola

Staphylococci are prevalent in dogs' microbiota, with commensal strains being able to exhibit resistance and virulence traits, complicating secondary infection management. As antimicrobial resistance is a global threat, particularly in middle-income countries like Angola, surveillance of resistant bacteria is crucial. We analyzed the prevalence, antimicrobial resistance, and virulence profiles of staphylococci from dogs in Angola. Isolates were identified using VITEK® 2 Compact (bioMérieux© SA, Marcy l'Etoile, France), and their genetic diversity was assessed via PCR fingerprinting. Isolates' susceptibility to relevant antimicrobials was determined by disk diffusion, and their virulence profiles were evaluated using plaque assays. The relationship between antibiotic resistance and animal-related factors was also assessed by statistical analysis. Isolates were identified as Mammaliicoccus sciuri (former Staphylococcus sciuri, 38%), Staphylococcus xylosus (30%), Staphylococcus equorum (13%), Mammaliicoccus vitulinus (former Staphylococcus vitulinus, 7%), Mammaliicoccus lentus (former Staphylococcus lentus, 5%), Staphylococcus aureus (2%), and Staphylococcus spp. (5%). Of these, 86% were resistant to at least one of the antimicrobials tested, and 30% were classified as multidrug-resistant, being more common in females, dogs with clinical signs of disease, and vaccinated animals. Moreover, 93% of the isolates were able to produce biofilm, 46% could produce lecithinase and gelatinase, and 23% could produce hemolysins. Companion dogs from Angola can carry resistant staphylococci able to express several virulence factors, potentially representing a One Health risk.

Hepatitis B vaccine coverage in health care students: a cross-sectional study in Vietnam

Hepatitis B virus (HBV) remains a significant global health concern, with healthcare students being at elevated risk of infection during their internships in healthcare settings. This study aimed to determine the percentage of healthcare students vaccinated against hepatitis B and the factors associated with vaccination status. A cross-sectional study was conducted among healthcare students at the University of Medicine and Pharmacy at Ho Chi Minh City in Vietnam between February and May 2023 using a self-reported questionnaire. Participants were selected through stratified and random sampling. A multivariable analysis logistic regression was performed to determine the association between several factors with vaccination status. A total of 225 participants took part in the study. We found that 89.8% of the participants had received at least one dose of the HBV vaccine, while 63.3% had completed the entire vaccine schedule. Students with sufficient knowledge of HBV were 2.68 times more likely to be vaccinated (p <  0.05), while those practicing effective HBV prevention had 8.79 times higher vaccination rates (p <  0.001) compared to others. The rate of HBV vaccination among healthcare students remains suboptimal. Targeted health education that addresses knowledge gaps, enhances motivation, tackles vaccination barriers, and emphasizes preventive measures before internships could substantially improve vaccination coverage in this group.

Mediating effect of social support in the relationship of symptom burden and fear of disease progression in stroke patients

AIMS

To investigate the current status and influencing factors of fear of disease progression in stroke patients, and to analyze the mediating effect of social support between symptom burden and the fear of disease progression.

METHODS

A cross-sectional study recruited 235 stroke patients in a convenience sample from the neurology department of a tertiary hospital in China. The general information questionnaire, social support rating scale, stroke symptom experience scale, and fear of progression questionnaire short form were utilized for the survey. This study adheres to STROBE reporting guidelines.

RESULTS

The fear of disease progression score in stroke patients was 29.11 (6.72). Results from the multivariable analysis indicated that patients without a family history of stroke (β = -0.09, 95 % CI (-2.37, -0.15)), elderly patients (≥ 65) (β = -0.26, 95 % CI (-4.88, -2.32)), hypertensive patients (β = 0.10, 95 % CI (0.40, 2.63)), and patients with balanced budgets (β = -0.13, 95 % CI (-3.58, -0.28)) exhibited lower levels of fear of disease progression. Unemployment (β = 0.21, 95 % CI (1.72, 4.54)), patients experiencing heavy symptom burden (β = 0.56, 95 % CI (4.86, 6.67)), and those with low social support (β = -0.28, 95 % CI (-0.42, -0.22)) had a higher level of fear of disease progression. Social support (β = 0.14, 95 % CI (0.08, 0.20)) mediated the correlation between symptom burden and fear of disease progression.

CONCLUSIONS

Stroke patients have moderate to low levels of fear of disease progression. Nursing staff should provide more social support to patients with heavier symptom burdens to reduce their fear of disease progression.

IMPACT

Healthcare providers and caregivers can reduce the fear of disease progression in stroke patients with high symptom burden by increasing their level of social support. This study can help promote the mental health of stroke patients.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Health-Related Quality of Life in Long-Term Survivors of Non-Hodgkin Lymphoma: A French Population-Based Study

Background/Objectives: Non-Hodgkin lymphoma (NHL) represents 63% of all hematological malignancies in France, with diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma (FL) being the two most frequent forms. With the improvement of therapeutics, the issue of health-related quality of life (HRQoL) is becoming increasingly crucial for these patients. The aim was to compare HRQoL of NHL survivors with that of the general French population and to identify factors associated with HRQoL in NHL survivors. Methods: We conducted a population-based study among living patients from three registries of hematological malignancies, using standardized questionnaires, including the SF-12, in September 2023. The data collected were compared to those of a normative general French cohort. Results: In total, 493 patients completed the study questionnaires, yielding a response rate of 36%. The median time since diagnosis was 8 years (IQR 6-10) These NHL survivors reported lower HRQoL compared to the general French population, except in terms of bodily pain (p < 0.01). Each one-year increase in the time since diagnosis was associated with an increase in social functioning (p = 0.009). Men had better general health (p = 0.01) and less bodily pain (p = 0.007) than women. Higher income was associated with better HRQoL (p < 0.01). Underweight or obesity were associated with poorer physical functioning (p = 0.008). The presence of comorbidities, socioeconomic deprivation, anxiety, and depression were associated with poorer HRQoL (p < 0.01). Conclusions: This study provides valuable information of HRQoL values for comparison in further follow-up studies and proposes measures that could be implemented to improve the HRQoL of NHL survivors.

Environmental Factors Increasing the Risk of Poor Posture in Dental Hygiene Students

PURPOSE/OBJECTIVES

This study examined the relationship between environmental factors (e.g., working position, patient position, and scaling instruments) and poor posture in dental hygiene students.

METHODS

A longitudinal cohort study was conducted from 2017 to 2019 to observe dental hygiene students' clinical rotation performance at two undergraduate universities. Samples of video observations (n = 1487) of dental hygiene students performing scaling activities during oral care sessions were evaluated using the Rapid Upper Limb Assessment (RULA). Descriptive analysis and exploratory prediction modeling were performed to assess clinical environmental factors that predicted higher risks of developing WMSDs.

RESULTS

RULA scores (mean = 4.8, median = 5, range = 2-7) indicate dental hygiene students are at high risk of developing upper extremity MSDs. The type of scaling instrument, clock positioning relative to the patient, and sitting versus standing had statistically significant associations (p < 0.001) with the RULA outcome. In univariate analyses, clock positions 7 and 8 were the worst, having an increased risk of poor RULA outcomes (scores 5-7) by nearly nine times over working in clock position 12 (odds ratio [OR] 9.11, 95% CI 5.48-15.60). Multivariate predictive modeling indicated that the riskiest combination of factors is using a manual scaling instrument (OR 1.67, 95% CI 1.28-2.18), standing (OR 1.42, 95% CI 1.03-1.96), and working clock positions 7 and 8 (OR 8.4, 95% CI 5.02-14.50).

CONCLUSIONS

There is a need to consider the combined contribution of multiple environmental factors on working positions to optimize ergonomic training during dental hygiene and protect emerging dental health professionals from the negative health impacts of prolonged awkward postures.

Nutritional assessment using subjective global assessment identifies energy malnutrition and predicts mortality in patients with liver cirrhosis

This study aimed to evaluate whether the subjective global assessment (SGA) could effectively predict energy malnutrition, as assessed by indirect calorimetry, and mortality in hospitalized patients with cirrhosis. Energy malnutrition was defined by a nonprotein respiratory quotient (npRQ) < 0.85 using an indirect calorimetry. The usefulness of the SGA in identifying energy malnutrition and predicting mortality was assessed by the logistic regression and Cox proportional hazards models, respectively. Out of the 230 patients analyzed, 43% were found to have energy malnutrition. The distribution of SGA classifications was 54% for SGA-A, 32% for SGA-B, and 14% for SGA-C. Multivariable analysis indicated that both SGA-B (odds ratio, 3.59; 95% confidence interval [CI], 1.59-8.10) and SGA-C (odds ratio, 19.70; 95% CI, 3.46-112.00), along with free fatty acids (FFA), were independently linked to energy malnutrition. Regarding mortality, 125 patients (54%) died over a median follow-up period of 2.8 years. After adjustment, SGA-B (hazard ratio, 1.81; 95% CI, 1.08-3.03) and SGA-C (hazard ratio, 3.35; 95% CI, 1.28-8.76) were predictors of mortality in cirrhosis patients, while energy malnutrition and FFA were not. The SGA is a valuable tool for identifying energy malnutrition and predicting mortality in patients with cirrhosis.

AttributeRank: An Algorithm for Attribute Ranking in Clinical Variable Selection

BACKGROUND

Risk difference is a valuable measure of association in epidemiology and healthcare which has the potential to be used in medical and clinical variable selection.

OBJECTIVE

In this study, an attribute ranking algorithm, called AttributeRank, was developed to facilitate variable selection from clinical data sets.

METHODS

The algorithm computes the risk difference between a predictor and the response variable to determine the level of importance of a predictor. The performance of the algorithm was compared with some existing variable selection algorithms using five clinical data sets on neonatal birthweight, bacterial survival after treatment, myocardial infarction, breast cancer, and diabetes.

RESULTS

The variable subsets selected by AttributeRank yielded the highest average classification accuracy across the data sets, compared to Fisher score, Pearson's correlation, variable importance function, and Chi-Square.

CONCLUSION

AttributeRank proved to be more valuable in attribute ranking of clinical data sets compared to the existing algorithms and should be implemented in a user-friendly application in future research.

Comparison of Random Forest and Stepwise Regression for Variable Selection Using Low Prevalence Predictors: A case Study in Paediatric Sepsis

INTRODUCTION

Variable selection is a common technique to identify the most predictive variables from a pool of candidate predictors. Low prevalence predictors (LPPs) are frequently found in clinical data, yet few studies have explored their impact on model performance during variable selection. This study compared the Random Forest (RF) algorithm and stepwise regression (SWR) for variable selection using data from a paediatric sepsis screening tool, where 18 out of 32 predictors had a prevalence < 10%.

METHODS

Variable selection using RF was compared to forward and backward SWR. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC), and the variables retained. Additionally, a simulation study assessed how increasing the prevalence of the predictors impacted the variable selection results.

RESULTS

The best fitting RF and SWR models retained were 22, and 17 predictors, respectively, with 14 and 10 predictors having a prevalence < 10%. Both the RF and SWR models had similar predictive performance (RF: AUC [95% Confidence Interval] 0.79 [0.77, 0.81], LR: 0.80 [0.78, 0.82]). The simulation study revealed differences for both RF and SWR models in variable importance rankings and predictor selection with increasing prevalence thresholds, particularly for moderately and strongly associated predictors.

DISCUSSION

The RF algorithm retained a number of very low prevalence predictors compared to SWR. However, the predictive performance of both models were comparable, demonstrating that when applied correctly and the number of candidate predictors is small, both methods are suitable for variable selection when using low prevalence predictors.

Financial crisis and its association with parental stress and children's mental health in Lebanon

BACKGROUND

Lebanon has experienced a series of devastating crises that continue to have significant adverse effects on the mental health of parents and their children, especially those who are unemployed, burdened with debt or financial difficulties, and have pre-existing mental health conditions. Accordingly, this study aimed to assess the effect of financial insecurities on parents in Lebanon amid the multiple crises, and the impact of parents' mental health on their children's emotional and behavioral wellbeing.

METHODS

A cross-sectional study including 589 parents in Lebanon was performed using convenience sampling of parents of any gender with children aged 4 to 18 from the five Lebanese governorates. The study collected the sociodemographic data of the participants and incorporated supplementary measures such as the Parental Stress Scale (PSS), Pediatric Symptom Checklist (PSC), and the InCharge Financial Distress/Financial Well-Being (IFDFW) scale. Statistical tests included bivariate analysis, ANOVA test, linear regression, and mediation analyses.

RESULTS

A total of 589 parents, primarily mothers, participated in this study. Most children were males in elementary school. Bivariate analyses revealed that parents with non-Lebanese nationality, primary education, employment, or children in technical schools reported significantly higher PSS and PSC scores. Negative correlations were observed between the IFDFW scale and both PSS (r=-0.200, p < 0.001) and PSC scores (r=-0.086, p = 0.038), indicating lower stress and symptoms with improved financial well-being. Multivariable analysis showed that higher PSC scores, age, complementary education, and Lebanese nationality were associated with increased parental stress, while unemployment, lower age, and higher IFDFW were associated with reduced stress. Similarly, higher PSC scores were linked to increased parental stress, age, non-Lebanese nationality, and IFDFW, whereas university education, higher GPA, and residence outside Beirut/Mount Lebanon were associated with reduced PSC scores. Mediation analysis indicated that parental stress fully mediated the relationship between IFDFW and PSC scores, underscoring the impact of financial well-being on a child's psychological symptoms via parental stress.

CONCLUSIONS

The study revealed significant financial distress and low financial well-being among participants amid Lebanon's economic crisis, with a notable mediated association between financial well-being, parental stress, and child mental health symptoms. Parental stress was heightened among those with lower education levels, non-Lebanese nationality, and employment in low-wage jobs, with children from these families exhibiting elevated mental health symptoms. Additionally, regional factors and socioeconomic status played a role, as children in urbanized areas and technical schools reported higher distress. Targeted interventions are urgently recommended to alleviate financial and emotional burdens on families and ensure improved mental well-being for both parents and children.

Retrospective cohort study based on the MIMIC-IV database: analysis of factors influencing all-cause mortality at 30 days, 90 days, 1 year, and 3 years in patients with different types of stroke

Objective

This study aims to evaluate key factors influencing the short-term and long-term prognosis of stroke patients, with a particular focus on variables such as body weight, hemoglobin, electrolytes, kidney function, organ function scores, and comorbidities. Stroke poses a significant global health burden, and understanding its prognostic factors is crucial for clinical management.

Methods

This is a retrospective cohort study based on data from the MIMIC-IV database, including stroke patients from 2010 to 2020. A total of 5,110 patients aged 18 and older were included in the study. The exposure variables included body weight and hemoglobin levels, while the outcome variables were the 30-day, 90-day, 1-year, and 3-year mortality risks. Covariates included electrolyte levels, kidney function, organ function scores, and comorbidities. Random forest and gradient boosting tree models were employed for data analysis to assess mortality risk.

Results

Kaplan-Meier survival analysis showed that ischemic stroke patients had the highest 30-day mortality rate at 8.5%, with only 20% 1-year survival. Traumatic subarachnoid hemorrhage patients had the best prognosis, with a 1-year survival rate of 60%. Multivariable Cox regression analysis revealed that each 1-point increase in the Charlson Comorbidity Index raised the 1-year and 3-year mortality risks by 1.39 times (95% CI: 1.10-1.56) and 1.44 times, respectively. Each 1-point increase in the SOFA score increased the 30-day, 90-day, 1-year, and 3-year mortality risks by 2.11 times, 2.03 times, and 1.84 times, respectively. Additionally, lower hemoglobin levels were significantly associated with increased mortality, with 30-day, 90-day, and 1-year mortality risks increasing by 3.33 times, 3.34 times, and 4.16 times, respectively (p < 0.005). Age ≥ 71 years, longer hospital stays, and organ dysfunction were also significant factors affecting mortality.

Conclusion

This study highlights the critical role of stroke type, comorbidity index, SOFA score, hemoglobin levels, and length of hospital stay in stroke prognosis. These findings provide valuable insights for clinical risk assessment and the development of individualized treatment strategies, which may improve the management and outcomes of stroke patients. The predictive model constructed effectively assesses mortality risks in stroke patients, offering support for future clinical practice.

Predictors of outcome in patients with cerebral palsy following selective dorsal rhizotomy

BACKGROUND

To identify outcome predictors of selective dorsal rhizotomy (SDR) in children with spastic cerebral palsy (CP) using logistic regression models.

METHODS

A retrospective single-center study was conducted on children with spastic CP who had undergone SDR. Two outcomes were defined, one representing children not improving in motor function and spasticity and one representing children improving in motor function two years after surgery. Baseline variables were chosen based on established regressors and clinical considerations and tested for being predictors using multivariate logistic regression.

RESULTS

We included 96 patients (mean age [SD] 6y 9 m [2y 5 m], range 2y to 17y) in the study. Significant predictors of non-improvement in motor function and spasticity two years after SDR were higher age at surgery and higher preoperative Gross Motor Function Measure-88 (GMFM-88) score. Significant predictors of motor function improvement after SDR were lower preoperative Modified Ashworth Scale (MAS) scores, higher preoperative passive range of motion (pROM) and lower age at surgery.

CONCLUSIONS

For the first time, pROM and preoperative spasticity were identified as predictors of SDR outcome. We confirmed motor function and age as predictors. These variables will be useful for future patient selection. Adjusting for the GMFM-88's ceiling effect, children with higher motor function can still profit significantly from SDR.

HLA evolutionary divergence effect on bacterial infection risk in cirrhotic liver transplant candidates

Bacterial infections are common in cirrhosis patients, increasing the risk of decompensation and death. The impact of HLA evolutionary divergence (HED) on infection risk hasn't been studied in humans before. We conducted a retrospective study on cirrhosis patients awaiting liver transplantation (LT) from January 2019 to February 2022, examining class I and II-HED effects on bacterial infections and cirrhosis decompensation. We included 269 cirrhosis patients. Among them, 98 experienced 153 bacterial infections. Multivariable analysis after variable selection revealed that higher class II-HED was linked to fewer bacterial infections (p = 0.034), while class I-HED showed no effect (p = 0.074). Independent risk factors for bacterial infections included invasive procedures (p < 0.001), ICU hospitalization (p < 0.001), recent antibiotic treatment (p = 0.046), rifaximin use (p = 0.043), and cirrhosis decompensation (p = 0.002). Neither class I nor II-HED affected decompensation risk. This pioneering study shows that high class II-HED levels may protect against bacterial infections in cirrhosis patients awaiting LT, suggesting an immunological mechanism at play.

Healthy lifestyle factors and male perpetration of intimate partner violence: a cross-sectional study in Mwanza, Tanzania

BACKGROUND

In Tanzania, nearly half of ever-married women have experienced some form of intimate partner violence (IPV), yet little knowledge of IPV from the male perspective exists.

OBJECTIVE

To explore the role of essential healthy lifestyle factors, diet, sleep, and exercise, and their potential role in IPV perpetration.

METHODS

A cross-sectional survey was conducted with 1,002 young men (ages 18-24), 754 of which were in an intimate relationship in the previous year. The study took place in Mwanza, Tanzania and used multivariable logistic regression models to explore associations between male perpetration of IPV and diet, sleep, and exercise.

RESULTS

Six types of IPV perpetration were investigated separately and the prevalence of controlling behaviours (79.4%), economic abuse (30.6%), emotional abuse (47.3%), physical violence (16.4%), sexual violence (23.3%), and combined physical and/or sexual violence (32.1%) were obtained. Regular exercise demonstrated a protective effect for economic abuse perpetration; the chance of mildly active individuals perpetrating economic abuse was 38% less than their inactive counterparts (p = 0.003). Associations with sleep were varied and did not show a clear directional relationship. Diet, defined as poor food variety, was positively associated with every IPV type except physical violence and was significant in sexual violence perpetration (aOR:1.57, 95%CI:1.21-2.05).

CONCLUSIONS

The results from this study indicate that considering healthy lifestyle behaviours - diet, sleep, and exercise - in the design of intervention programmes may be beneficial in reducing IPV perpetration in Tanzania, and that they should be considered alongside previously established evidence-based risk factors.

Smac/DIABLO protein acts as an independent prognostic factor in oral squamous cell carcinoma

Oral squamous cell carcinoma (OSCC) poses significant health risks with increasing incidence and mortality rates. In this context, there is an urgent need to explore novel biomarkers to enhance therapeutic strategies and improve survival. Understanding apoptotic evasion in cancer pathogenesis, this pioneering study aims to investigate the correlation between a pro-apoptotic protein Smac/DIABLO and patient prognosis within the OSCC cohort. Immunohistochemistry (IHC) was employed to analyze Smac/DIABLO protein expression and correlate with clinicopathological and prognostic factors during a long-term follow-up. Smac/DIABLO low expression was associated with worse overall survival (OS), relapse-free survival (RFS), disease-specific survival (DSS), and an increase in risk of lymph node metastasis (LNM) in univariate analyses. Furthermore, multivariate analyses confirmed Smac/DIABLO as an independent prognostic factor, predicting poorer OS [Hazard Ratio (HR) = 3.6 (95% CI 1.7-7.6), p < 0.001], RFS [HR = 2.9 (95% CI 1.4-5.6), p = 0.003], DSS [HR = 6.7 (95% CI 2.7-16.7), p < 0.001], and increased likelihood of LNM [Odds Ratio (OR) = 4.8 (95% CI 1.4-15.9), p = 0.011]. Patients with positive Smac/DIABLO expression exhibited three times higher survival probability. Low proapoptotic protein Smac/DIABLO expression significantly influences prognostic predictions and strongly correlates with poor OSCC outcomes. Future studies involving Smac-mimetic drugs in OSCC are needed to evaluate their pro-apoptotic potential in cancer cells.

Perceived Training Needs of the Informal Caregivers of Older Adults: A Cross-Sectional Study

BACKGROUND

Due to the enormous caregiving burden faced by informal caregivers, providing appropriate skills training has become an important supporting strategy in many countries/regions. Understanding caregivers' training needs is instrumental in designing effective training intervention programs, which are expected to reduce the caregiving burden of informal caregivers and avoid the health deterioration associated with caregiving. This paper aims to explore the potential training needs of informal caregivers in Shanghai, and to identify the factors associated with these perceived training needs.

METHODS

A total of 196 eligible informal caregivers participated in this survey. A multivariate analysis was conducted to explore the factors associated with informal caregivers' perceived training needs.

RESULTS

86.7% (N = 170) of the caregivers reported at least one need for targeted training activity, and 62.7% (N = 123) of them identified two or more training needs. The top three activities requiring training included the following: self-care skills; safety supervision; and functional rehabilitation. The factors associated with various training needs included the health status of the care recipient, complementary caregiving support, caregiving stress, and the personal attributes of the informal caregiver. The technical skills training needs were more related to the care recipients' health status (e.g., dependency level, disease progression) and formal care support resources. Conversely, the intangible skills training needs were more sensitive to caregiver attributes (e.g., gender, age, and education level).

CONCLUSIONS

A personalized training strategy and early-stage intervention program are critical to providing effective support to informal caregivers. The potential implications are to raise awareness of the importance of skills training for informal caregivers, and to inform the implementation of effective training strategies for improving the quality of informal care and the well-being of informal caregivers in China.

Dropout in a Longitudinal Survey of Amazon Mechanical Turk Workers With Low Back Pain: Observational Study

BACKGROUND

Surveys of internet panels such as Amazon's Mechanical Turk (MTurk) are common in health research. Nonresponse in longitudinal studies can limit inferences about change over time.

OBJECTIVE

This study aimed to (1) describe the patterns of survey responses and nonresponse among MTurk members with back pain, (2) identify factors associated with survey response over time, (3) assess the impact of nonresponse on sample characteristics, and (4) assess how well inverse probability weighting can account for differences in sample composition.

METHODS

We surveyed adult MTurk workers who identified as having back pain. We report participation trends over 3 survey waves and use stepwise logistic regression to identify factors related to survey participation in successive waves.

RESULTS

A total of 1678 adults participated in wave 1. Of those, 983 (59%) participated in wave 2 and 703 (42%) in wave 3. Participants who did not drop out took less time to complete previous surveys (30 min vs 35 min in wave 1, P<.001; 24 min vs 26 min in wave 2, P=.02) and reported having fewer health conditions (5.88 vs 6.6, P<.001). In multivariate models predicting responding at wave 2, lower odds of participation were associated with more time to complete the baseline survey (odds ratio [OR] 0.98, 95% CI 0.97-0.99), being Hispanic (compared with non-Hispanic, OR 0.69, 95% CI 0.49-0.96), having a bachelor's degree as their terminal degree (compared with all other levels of education, OR 0.58, 95% CI 0.46-0.73), having more pain interference and intensity (OR 0.75, 95% CI 0.64-0.89), and having more health conditions. In contrast, older respondents (older than 45 years age compared with 18-24 years age) were more likely to respond to the wave 2 survey (OR 2.63 and 3.79, respectively) and those whose marital status was divorced (OR 1.81) and separated (OR 1.77) were also more likely to respond to the wave 2 survey. Weighted analysis showed slight differences in sample demographics and conditions and larger differences in pain assessments, particularly for those who responded to wave 2.

CONCLUSIONS

Longitudinal studies on MTurk have large, differential dropouts between waves. This study provided information about the individuals more likely to drop out over time, which can help researchers prepare for future surveys.

Practice in bronchiolitis management in Polish hospitals-a multicenter retrospective cohort study

Bronchiolitis is one of the main reasons for the hospitalization of young children. Based on updated recommendations, only supportive therapy is recommended for treatment. In Poland, many children that are hospitalized with bronchiolitis undergo a treatment that is not supported by current research. The study aimed to assess clinicians' adherence to the guidelines. This was a multicenter retrospective study of hospitalized infants with bronchiolitis; a cohort study design was utilized. Data were collected in four Pediatric Departments in Poland. All infants aged less than 24 months that had been hospitalized for their first and subsequent episodes of acute bronchiolitis from January 1, 2021, to December 31, 2022, were included. The exclusion criterion was an age over 24 months. A total of 629 infants with a median age of 8.5 months were included in this study. The medical interventions and treatments varied between the four hospitals. Laboratory blood tests were run for almost all children (99.5%), and the percentage of children for which a chest X-ray was performed ranged from 1.3% to 44%. The other measures were the use of intravenous hydration (51.3%-93.3%), use of hypertonic saline nebulization (1.3%-43.6%), use of normal saline nebulization (10%-95.1%), use of oxygen (7.3%-42%), use of beta-mimetics (19.1%-89.4%), use of nebulized steroids (8%-76.9%), use of systemic steroids (0.9%-42%), use of nebulized adrenaline (0%-8.1%), and use of antibiotics (12%-21.8%).

CONCLUSIONS

In total, 70% of infants who were hospitalized in four hospitals in Poland underwent examinations and treatment methods that are not supported by current guidelines and evidence-based research. This study shows that non-recommended medications are overused in bronchiolitis treatment, and there is a need to take action to implement the guidelines into healthcare providers' work.

WHAT IS KNOWN

• Bronchiolitis is a lower respiratory tract viral infection and is one of the main reasons for hospitalization among young children. • Only supportive therapy is recommended in the guidelines. • Bronchodilators, nebulized adrenaline, nebulized or systemic steroids, and antibiotics are not recommended.

WHAT IS NEW

• Non-recommended medications are overused in bronchiolitis treatment in Poland. • Up to 70% of hospitalized children in the studied centers underwent treatment that is not supported by guidelines.

Donor Time to Death and Kidney Transplant Outcomes in the Setting of a 3-Hour Minimum Wait Policy

Importance

Lengthening waiting lists for organ transplant mandates the development of strategies to expand the deceased donor pool. Due to concerns regarding organ viability, most organ donation organizations internationally wait no longer than 1 to 2 hours for potential donation after circulatory death (DCD), possibly underutilizing an important organ source; UK policy mandates a minimum 3-hour wait time.

Objective

To assess whether time to death (TTD) from withdrawal of life-sustaining treatment (WLST) is associated with kidney transplant outcomes.

Design, Setting, and Participants

This population-based cohort study used data from the prospectively maintained UK Transplant Registry from all 23 UK kidney transplant centers from January 1, 2013, to December 31, 2021; follow-up was until the date of data extraction (October 2023). Participants comprised 7183 adult recipients of DCD kidney-alone transplants.

Exposure

Duration of TTD, defined as time from WLST to donor mechanical asystole.

Main Outcomes and Measures

Primary outcome was 12-month estimated glomerular filtration rate (eGFR; for the main eGFR model, variables with significant right skew [histogram visual assessment] were analyzed on the log2 scale), with secondary outcomes of delayed graft function and graft survival (censored at death or 5 years).

Results

This study included 7183 kidney transplant recipients (median age, 56 years [IQR, 47-64 years]; 4666 men [65.0%]). Median donor age was 55 years (IQR, 44-63 years). Median TTD was 15 minutes (range, 0-407 minutes), with 885 kidneys transplanted from donors with TTD over 1 hour and 303 kidneys transplanted from donors with TTD over 2 hours. Donor TTD was not associated with recipient 12-month eGFR on adjusted linear regression (change per doubling of TTD, -0.25; 95% CI, -0.68 to 0.19; P = .27), nor with delayed graft function (adjusted odds ratio, 1.01; 95% CI, 0.97-1.06; P = .65) or graft survival (adjusted hazard ratio, 1.00; 95% CI, 0.95-1.07; P = .92). These findings were confirmed with restricted cubic spline models (assessing nonlinear associations) and tests of interaction (including normothermic regional perfusion). In contrast, donor asystolic time, cold ischemic time, and reperfusion time were independently associated with outcomes. Compared with a theoretical 1-hour maximum wait time, the UK policy (minimum 3-hour wait time) has been associated with 885 extra DCD transplants compared with 6298 transplants (14.1% increase).

Conclusions and Relevance

In this cohort study of DCD kidney recipients, donor TTD was not associated with posttransplant outcomes, in contrast to subsequent ischemic times. Altering international transplant practice to mandate minimum 3-hour donor wait times could substantially increase numbers of kidney transplants performed without prejudicing outcomes.

Development and internal validation of a simple clinical score for the estimation of the probability of deep vein thrombosis in outpatient emergency department patients

Background

Wells score comprises subjective elements, making physicians reluctant to use Wells score or cause them to use it incorrectly.

Objectives

To develop and internally validate a prediction score that is objective and simple for evaluating suspected deep vein thrombosis (DVT), with a safety comparable with that of Wells score.

Methods

We performed a post hoc analysis using data from the Ri-Schedule study (NCT02486445) involving suspected DVT patients at Østfold Hospital's Emergency Department, Norway (2015-2018). Candidate variables were identified through bootstrapping technique, with a confirmed DVT diagnosis as the outcome variable. Sensitivity, specificity, negative predictive value (NPV), and positive predictive values (PPV) were estimated and compared with the 2-tier Wells score.

Results

Among 1312 patients (median age, 64 years [IQR, 52-73]; 55% women), 19.9% were diagnosed with DVT. Exploration of 30 variables identified tenderness along deep veins and previous venous thromboembolism as significant predictors (selection frequency >60% in 1000 bootstrapping samples). The derived score categorized 450 patients with 0 items as unlikely to have DVT, of whom 8.0% were diagnosed with DVT, compared with 8.2% in DVT unlikely category according to Wells score. Compared with Wells score, the derived score demonstrated sensitivity of 86.2 (95% CI, 81.4-90.2) vs 80.1 (95% CI, 74.7-84.8), specificity of 39.4 (95% CI, 36.4-42.4) vs 55.3 (95% CI, 52.2-58.3), NPV of 92.0 (95% CI, 89.4-94.0) vs 91.8 (95% CI, 89.7-93.5), and PPV of 26.1 (95% CI, 24.8-27.5) vs 30.8 (95% CI, 28.9-32.8). When incorporating D-dimer cutoff of <0.5 µg/mL, the derived score had sensitivity of 99.6 (95% CI, 97.9-99.9), specificity of 16.1 (95% CI, 13.1-18.4), NPV of 99.4 (95% CI, 96.0-99.9), and PPV of 22.8 (95% CI, 22.3-23.3).

Conclusion

The derived DVT score, with 2 objective variables, had a comparable safety with that of the Wells score. However, an external validation is mandated prior to clinical use.

Work Systems Factors Associated With Burnout in Sonographers Working in the United States and Canada

Objective

Burnout in sonographers is a prevalent and complex professional hazard associated with poorer quality of work life, productivity, and patient outcomes. This study aimed to understand the prevalence of and work systems factors associated with burnout among a large sample of sonographers.

Materials and Methods

Research study registry participants (n=3659) were invited to complete a follow-up survey about personal and work environment factors, including work hours, break time, coworker and supervisor support, and job satisfaction, overall health, and sleep quality. The Copenhagen Burnout Inventory assessed personal, work-related, and client burnout. Simple and multiple linear regressions were used to identify work systems factors associated with burnout.

Results

Of 1389 respondents, over half reported moderate-to-severe personal and work-related burnout, while one-quarter reported moderate-to-severe client burnout. Higher work-related burnout was associated with younger age, working in the Western U.S., working full-time work, taking fewer weekly break hours, poorer overall health and sleep quality, and lower supervisor support and job satisfaction. Client burnout was associated with poorer sleep quality and lower job satisfaction.

Conclusion

Burnout was prevalent in a large sample of sonographers. Multilevel work systems factors are associated with burnout, suggesting collaboration among sonographers, administrators, and organizations is needed to address burnout.

Comparison of two modeling approaches for the identification of predictors of complications in children with cerebral palsy following spine surgery

BACKGROUND

Children with non-ambulatory cerebral palsy (CP) frequently develop progressive neuromuscular scoliosis and require surgical intervention. Due to their comorbidities, they are at high risk for developing peri- and post-operative complications. The objectives of this study were to compare stepwise and LASSO variable selection techniques for consistency in identifying predictors when modelling these post-operative complications and to identify potential predictors of respiratory complications and infections following spine surgery among children with CP.

METHODS

In this retrospective cohort study, a large administrative claims database was queried to identify children who met the following criteria: 1) ≤ 25 years old, 2) diagnosis of CP, 3) underwent surgery during the study period, 4) had ≥ 12-months pre-operative, and 5) ≥ 3-months post-operative continuous health plan enrollment. Outcome measures included the development of a post-operative respiratory complication (e.g., pneumonia, aspiration pneumonia, atelectasis, pleural effusion, pneumothorax, pulmonary edema) or an infection (e.g., surgical site infection, urinary tract infection, meningitis, peritonitis, sepsis, or septicemia) within 3 months of surgery. Codes were used to identify CP, surgical procedures, medical comorbidities and the development of post-operative respiratory complications and infections. Two approaches to variable selection, stepwise and LASSO, were compared to determine which potential predictors of respiratory complications and infection development would be identified using each approach.

RESULTS

The sample included 220 children. During the 3-month follow-up, 21.8% (n = 48) developed a respiratory complication and 12.7% (n = 28) developed an infection. The prevalence of 11 variables including age, sex and 9 comorbidities were initially considered to be potential predictors based on the intended outcome of interest. Model discrimination utilizing LASSO for variable selection was slightly improved over the stepwise regression approach. LASSO resulted in retention of additional comorbidities that may have meaningful associations to consider for future studies, including gastrointestinal issues, bladder dysfunction, epilepsy, anemia and coagulation deficiency.

CONCLUSIONS

Potential predictors of the development of post-operative complications were identified in this study and while identified predictors were similar using stepwise and LASSO regression approaches, model discrimination was slightly improved with LASSO. Findings will be used to inform future research processes determining which variables to consider for developing risk prediction models.

Longitudinal assessment of health-related quality of life after SARS-CoV-2 infection and the associations with clinical and social characteristics in a general practice population

BACKGROUND

We aimed to investigate the longitudinal impact of COVID-19 and the effects of clinical and psychosocial factors, accounting for post-COVID conditions (PCC), on the mental and physical aspect of health-related quality of life (HRQoL) of patients diagnosed with COVID-19.

METHODS

Data from the Nivel Corona Cohort were used, which includes individuals with an established SARS-CoV-2 infection that received four questionnaires over a year's time with questions regarding HRQoL (SF-12), symptoms and social characteristics. PCC was determined based on questionnaire data. Data on medical history and healthcare utilization were obtained from electronic health records from general practice. A repeated measures linear mixed model was used to explore associations between clinical and social characteristics, and the course of mental and physical HRQoL after a SARS-CoV-2 infection, taking PCC into account.

RESULTS

One hundred fifty-eight individuals of whom it was possible to determine whether they had PCC or not were included in this study. Seventy-six (48.1%) developed PCC, which was associated with a persistent reduction in both physical and mental HRQoL. Hospitalization during the acute phase of the infection had a negative impact on the physical HRQoL, which decreased over time. Females, people older than 53, and those with increased resilience and mental HRQoL before infection were more likely to report a more positive mental HRQoL over time.

CONCLUSION

The negative association PCC has with both mental and physical HRQoL for at least six months, calls for more research to support patients with PCC.

Vitamin D deficiency stratifies the risk of covert and overt hepatic encephalopathy in patients with cirrhosis: A retrospective cohort study

BACKGROUNDS & AIMS

This study aimed to investigate the association between vitamin D deficiency and covert hepatic encephalopathy (CHE), overt hepatic encephalopathy (OHE) occurrence, and mortality in patients with cirrhosis.

METHODS

This retrospective study reviewed 679 patients with cirrhosis. Vitamin D deficiency was defined as serum 25-hydorxyvitamin D (25-OHD) levels < 20 ng/mL. The associations between 25-OHD and CHE, OHE occurrence, and mortality were assessed using logistic regression, Fine-Gray competing risk regression, and Cox proportional hazards regression models, respectively.

RESULTS

Of 428 eligible patients, 75% had vitamin D deficiency and 23% had CHE. The prevalence of CHE was higher in patients with vitamin D deficiency than in those without vitamin D deficiency (28% vs. 13%, p = 0.002). During the median follow-up period of 2.3 years, 14% of the patients developed OHE and 27% died. Patients with vitamin D deficiency had a higher incidence of OHE (p = 0.002) and mortality (p = 0.006) than those without vitamin D deficiency. After adjustment for potential covariates, multivariate analyses showed that 25-OHE was associated with CHE (odds ratio, 0.95; 95% confidence interval [CI], 0.91-0.99; p = 0.023), OHE occurrence (sub-distribution hazard ratio, 0.92; 95% CI, 0.86-0.98; p = 0.013) and mortality (hazard ratio, 0.96; 95% CI, 0.93-0.99; p = 0.020) in patients with cirrhosis.

CONCLUSIONS

Vitamin D deficiency is highly prevalent and is associated with CHE, OHE, and mortality in patients with cirrhosis. Evaluation of vitamin D is essential to predict the outcomes of patients with cirrhosis.

Prevalence and prognostic value of zinc and selenium deficiency in advanced chronic liver disease

BACKGROUND AND AIMS

Zinc and selenium are essential trace elements involved in important (patho)physiological processes. The prevalence and prognostic implications of zinc and selenium deficiency in patients with advanced chronic liver disease (ACLD) remain unknown.

METHODS

We determined serum zinc and selenium concentrations in 309 patients with ACLD undergoing hepatic venous pressure gradient (HVPG) measurement between 2019 and 2022. We evaluated the prevalence of zinc/selenium deficiency and assessed its association with severity of ACLD and liver-related events (LRE, i.e. first/further hepatic decompensation/liver-related death).

RESULTS

Among 309 ACLD patients (median: age: 57 [IQR: 50-64], MELD: 11 [IQR: 9-16], HVPG: 17 [IQR: 11-20]), 73% (227) and 63% (195) were deficient in zinc and selenium, respectively. Decompensated (dACLD) patients showed significantly lower serum zinc (median: 48 [IQR: 38-59] vs. compensated, cACLD: 65 [IQR: 54-78], p < 0.001) and selenium levels (median: 4.9 [IQR 4.0-6.2] vs. cACLD: 6.1 [IQR 5.1-7.3], p < 0.001). Significant correlations of zinc/selenium levels were found with MELD (zinc: ρ = -0.498, p < 0.001; selenium: ρ = -0.295, p < 0.001), HVPG (zinc: ρ = -0.400, p < 0.001; selenium: ρ = -0.157, p = 0.006) and liver disease-driving mechanisms (IL6, bile-acid homeostasis). On multivariable analysis, low zinc/selenium levels, age and MELD remained independently associated with LRE.

CONCLUSION

Zinc and selenium deficiencies are common in ACLD patients especially with higher MELD and HVPG. Low zinc and selenium levels independently predicted hepatic decompensation and liver-related death. The effect of zinc/selenium supplementation in ACLD should be investigated in future trials.

Effect of smoking on the diagnostic results and complication rates of percutaneous transthoracic needle biopsy

OBJECTIVE

To investigate the association of smoking with the outcomes of percutaneous transthoracic needle biopsy (PTNB).

METHODS

In total, 4668 PTNBs for pulmonary lesions were retrospectively identified. The associations of smoking status (never, former, current smokers) and smoking intensity (≤ 20, 21-40, > 40 pack-years) with diagnostic results (malignancy, non-diagnostic pathologies, and false-negative results in non-diagnostic pathologies) and complications (pneumothorax and hemoptysis) were assessed using multivariable logistic regression analysis.

RESULTS

Among the 4668 PTNBs (median age of the patients, 66 years [interquartile range, 58-74]; 2715 men), malignancies, non-diagnostic pathologies, and specific benign pathologies were identified in 3054 (65.4%), 1282 (27.5%), and 332 PTNBs (7.1%), respectively. False-negative results for malignancy occurred in 20.5% (236/1153) of non-diagnostic pathologies with decidable reference standards. Current smoking was associated with malignancy (adjusted odds ratio [OR], 1.31; 95% confidence interval [CI]: 1.02-1.69; p = 0.03) and false-negative results (OR, 2.64; 95% CI: 1.32-5.28; p = 0.006), while heavy smoking (> 40 pack-years) was associated with non-diagnostic pathologies (OR, 1.69; 95% CI: 1.19-2.40; p = 0.003) and false-negative results (OR, 2.12; 95% CI: 1.17-3.92; p = 0.02). Pneumothorax and hemoptysis occurred in 21.8% (1018/4668) and 10.6% (495/4668) of PTNBs, respectively. Heavy smoking was associated with pneumothorax (OR, 1.33; 95% CI: 1.01-1.74; p = 0.04), while heavy smoking (OR, 0.64; 95% CI: 0.40-0.99; p = 0.048) and current smoking (OR, 0.64; 95% CI: 0.42-0.96; p = 0.04) were inversely associated with hemoptysis.

CONCLUSION

Smoking history was associated with the outcomes of PTNBs. Current and heavy smoking increased false-negative results and changed the complication rates of PTNBs.

CLINICAL RELEVANCE STATEMENT

Smoking status and intensity were independently associated with the outcomes of PTNBs. Non-diagnostic pathologies should be interpreted cautiously in current or heavy smokers. A patient's smoking history should be ascertained before PTNB to predict and manage complications.

KEY POINTS

• Smoking status and intensity might independently contribute to the diagnostic results and complications of PTNBs. • Current and heavy smoking (> 40 pack-years) were independently associated with the outcomes of PTNBs. • Operators need to recognize the association between smoking history and the outcomes of PTNBs.

Risk factors associated with the intensity of COVID-19 outbreaks in Canadian community settings: a retrospective analysis of outbreak-level surveillance data

BACKGROUND

The severity of COVID-19 outbreaks is disproportionate across settings (e.g., long-term care facilities (LTCF), schools) across Canada. Few studies have examined factors associated with outbreak severity to inform prevention and response. Our study objective was to assess how outbreak severity, as measured using outbreak intensity and defined as number of outbreak-associated cases divided by outbreak duration, differed by setting and factors known to influence SARS-CoV-2 transmission.

METHODS

We described outbreak intensity trends in 2021 using data from the Canadian COVID-19 Outbreak Surveillance System from seven provinces/territories, representing 93% of the Canadian population. A negative binomial fixed-effects model was used to assess for associations between the outcome, outbreak intensity, and characteristics of outbreaks: setting type, median age of cases, number at risk, and vaccination coverage of at least 1 dose. Also included were variables previously reported to influence SARS-CoV-2 transmission: stringency of non-pharmaceutical interventions (NPI) and the predominant SARS-CoV-2 variant detected by surveillance.

RESULTS

The longest outbreaks occurred in LTCF (mean = 25.4 days) and correctional facilities (mean = 20.6 days) which also reported the largest outbreaks (mean = 29.6 cases per outbreak). Model results indicated that outbreak intensity was highest in correctional facilities. Relative to correctional facilities (referent), the second highest adjusted intensity ratio was in childcare centres (intensity ratio = 0.58 [95% CI: 0.51-0.66]), followed by LTCF (0.56 [95% CI: 0.51-0.66]). Schools had the lowest adjusted intensity ratio (0.46 [95% CI: 0.40-0.53]) despite having the highest proportion of outbreaks (37.5%). An increase in outbreak intensity was associated with increases in median age, the number at risk, and stringency of NPI. Greater vaccination coverage with at least 1 dose was associated with reduced outbreak intensity.

CONCLUSION

Descriptive and multivariable model results indicated that in Canada during 2021, outbreak intensity was greatest in closed congregate living facilities: correctional facilities and LTCF. Findings from this study support the importance of vaccination in reducing outbreak intensity when vaccines are effective against infection with circulating variants, which is especially important for closed congregate living facilities where NPIs are more challenging to implement.

Subsidence Rates Associated With Porous 3D-Printed Versus Solid Titanium Cages in Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVE

To determine whether 3D-printed porous titanium (3DPT) interbody cages offer any clinical or radiographic advantage over standard solid titanium (ST) interbody cages in transforaminal lumbar interbody fusions (TLIF).

METHODS

A consecutive series of adult patients undergoing one- or two-level TLIF with either 3DPT or ST "banana" cages were analyzed for patient reported outcome measures (PROMs), radiographic complications, and clinical complications. Exclusion criteria included clinical or radiographic follow-up less than 1 year.

RESULTS

The final cohort included 90 ST interbody levels from 74 patients, and 73 3DPT interbody levels from 50 patients for a total of 124 patients. Baseline demographic variables and comorbidity rates were similar between groups (P > .05). Subsidence of any grade occurred more frequently in the ST group compared with the 3DPT group (24.4% vs 5.5%, respectively, P = .001). Further, the ST group was more likely to have higher grades of subsidence than the 3DPT group (P = .009). All PROMs improved similarly after surgery and revision rates did not differ between groups (both P > .05). On multivariate analysis, significant positive correlators with increasing subsidence grade included greater age (P = .015), greater body mass index (P = .043), osteoporosis/osteopenia (P < .027), and ST cage type (P = .019).

CONCLUSIONS

When considering interbody material for TLIF, both ST and 3DPT cages performed well; however, 3DPT cages were associated with lower rates of subsidence. The clinical relevance of these findings deserves further randomized, prospective investigation.

Long-Term Survival Outcomes After Minimally Invasive Surgery for Ileal Neuroendocrine Tumors

BACKGROUND

Ileal neuroendocrine tumors (i-NETs) are characterized by their multifocality and bulky mesenteric mass. Having shown that minimally invasive surgery (MIS) utilizing a hand-access port device has favorable short-term outcomes and achieves the goals of surgery for i-NETs, we sought to analyze long-term survival outcomes of MIS.

METHODS

One hundred and sixty-eight patients who underwent resection of primary i-NETs at a single institution between January 2007 and February 2023 were retrospectively studied. Patients were categorized into the MIS or open surgery cohorts on an intention-to-treat basis. Open surgery was selected mainly based on the need for hepatectomy or bulky mesenteric mass resection. Overall survival was analyzed using log-rank tests with propensity score matching (PSM) and Cox proportional hazards regression. PSM was performed to reduce standardized mean differences of the variables to <0.2.

RESULTS

Overall, 129 (77%) patients underwent MIS and 39 (23%) underwent open surgery. Twenty-seven MIS patients were converted to an open procedure. The median follow-up time was 49 months (interquartile range 23-87 months). In the PSM cohorts, overall survival did not differ significantly between the MIS and open surgery cohorts {median 99 months (95% confidence interval [CI] 91-not applicable [NA]) vs. 103 months (95% CI 86-NA), p = 0.77; hazard ratio 0.87 (95% CI 0.33-2.2), p = 0.77}.

CONCLUSIONS

MIS is an alternative to open surgery for i-NETs, achieving similar short- and long-term oncological outcomes. Bulky mesenteric mass and a plan for concurrent liver resection are potential criteria for open surgery.

Limitations of Separating Athletes into High or Low-Risk Groups based on a Cut-Off. A Clinical Commentary

Background

Athlete injury risk assessment and management is an important, yet challenging task for sport and exercise medicine professionals. A common approach to injury risk screening is to stratify athletes into risk groups based on their performance on a test relative to a cut-off threshold. However, one potential reason for ineffective injury prevention efforts is the over-reliance on identifying these 'at-risk' groups using arbitrary cut-offs for these tests and measures. The purpose of this commentary is to discuss the conceptual and technical issues related to the use of a cut-off in both research and clinical practice.

Clinical Question

How can we better assess and interpret clinical tests or measures to enable a more effective injury risk assessment in athletes?

Key Results

Cut-offs typically lack strong biologic plausibility to support them; and are typically derived in a data-driven manner and thus not generalizable to other samples. When a cut-off is used in analyses, information is lost, leading to potentially misleading results and less accurate injury risk prediction. Dichotomizing a continuous variable using a cut-off should be avoided. Using continuous variables on its original scale is advantageous because information is not discarded, outcome prediction accuracy is not lost, and personalized medicine can be facilitated.

Clinical Application

Researchers and clinicians are encouraged to analyze and interpret the results of tests and measures using continuous variables and avoid relying on singular cut-offs to guide decisions. Injury risk can be predicted more accurately when using continuous variables in their natural form. A more accurate risk prediction will facilitate personalized approaches to injury risk mitigation and may lead to a decline in injury rates.

Level of Evidence

5.

Prediction models for postoperative pulmonary complications in intensive care unit patients after noncardiac thoracic surgery

BACKGROUND

Postoperative pulmonary complication (PPC) is a leading cause of mortality and poor outcomes in postoperative patients. No studies have enrolled intensive care unit (ICU) patients after noncardiac thoracic surgery, and effective prediction models for PPC have not been developed. This study aimed to explore the incidence and risk factors and construct prediction models for PPC in these patients.

METHODS

This study retrospectively recruited patients admitted to the ICU after noncardiac thoracic surgery at West China Hospital, Sichuan University, from July 2019 to December 2022. The patients were randomly divided into a development cohort and a validation cohort at a 70% versus 30% ratio. The preoperative, intraoperative and postoperative variables during the ICU stay were compared. Univariate and multivariate logistic regression analyses were applied to identify candidate predictors, establish prediction models, and compare the accuracy of the models with that of reported risk models.

RESULTS

A total of 475 ICU patients were enrolled after noncardiac thoracic surgery (median age, 58; 72% male). At least one PPC occurred in 171 patients (36.0%), and the most common PPC was pneumonia (153/475, 32.21%). PPC significantly increased the duration of mechanical ventilation (p < 0.001), length of ICU stay (p < 0.001), length of hospital stay (LOS) (p < 0.001), and rate of reintubation (p = 0.047) in ICU patients. Seven risk factors were identified, and then the prediction nomograms for PPC were constructed. At ICU admission, the area under the curve (AUC) was 0.766, with a sensitivity of 0.71 and specificity of 0.60; after extubation, the AUC was 0.841, with a sensitivity of 0.75 and specificity of 0.83. The models showed robust discrimination in both the development cohort and the validation cohort, and they were well calibrated and more accurate than reported risk models.

CONCLUSIONS

ICU patients who underwent noncardiac thoracic surgery were at high risk of developing PPCs. Prediction nomograms were constructed and they were more accurate than reported risk models, with excellent sensitivity and specificity. Moreover, these findings could help assess individual PPC risk and enhance postoperative management of patients.

Psychosocial Trauma History Negatively Impacts Liver Transplant Access in Women with Chronic Liver Disease

Introduction

Few studies have evaluated the impact of psychological trauma (mental, emotional, or physical) on liver transplant (LT) candidacy and outcomes.

Methods

We performed a single center retrospective analysis of patients who completed routine LT evaluation between October 2017 and June 2021. We identified the prevalence of psychological trauma history in men and women LT candidates and evaluated the association between trauma history and LT access. The primary outcome measure was listing for LT.

Results

A total of 463 patients completed LT evaluation, of which 17% (n = 79) reported a history of trauma: 49 of 159 women and 30 of 304 men. Trauma history was significantly more common in women than in men (31% vs. 10%, p < 0.001). Women with trauma history were less likely to be listed for LT (80% vs. 93%, p = 0.016). Women with trauma history were also more likely to be removed from the LT waitlist (26% vs. 12%, p = 0.045); this persists when excluding patients removed for transfer to another center or for medical improvement (22% vs. 7%, p = 0.020). In contrast, listing for LT (87% vs. 86%, p = 0.973) and waitlist removal (12% vs. 10%, p = 0.766) did not differ in men with and without trauma history. In those that received a LT (n = 107), post-LT relapse, rejection, readmissions, and death did not differ in patients with (n=13)and without (n=94) trauma history.

Conclusions

Trauma history is associated with reduced access to LT in women but not men with chronic liver disease. Further studies are needed to understand the impact of psychological trauma on LT access and post-LT outcomes.

A meta-analysis of the relationship between milk protein production and absorbed amino acids and digested energy in dairy cattle

Milk protein production is the largest draw on AA supplies for lactating dairy cattle. Prior NRC predictions of milk protein production have been absorbed protein (MP)-based and used a first-limiting nutrient concept to integrate the effects of energy and protein, which yielded poor accuracy and precision (root mean squared error [RMSE] >21%). Using a meta-data set gathered, various alternative equation forms considering MP, absorbed total EAA, absorbed individual EAA, and digested energy (DE) supplies as additive drivers of production were evaluated, and all were found to be superior in statistical performance to the first limitation approach (RMSE = 14%-15%). Inclusion of DE intake and a quadratic term for MP or absorbed EAA supplies were found to be necessary to achieve intercept estimates (nonproductive protein use) that were similar to the factorial estimates of the National Academies of Sciences, Engineering, and Medicine (2021). The partial linear slope for MP was found to be 0.409, which is consistent with the observed slope bias of -0.34 g/g when a slope of 0.67 was used for MP efficiency in a first-limiting nutrient system. Replacement of MP with the supplies of individual absorbed EAA expressed in grams per day and a common quadratic across the EAA resulted in unbiased predictions with improved statistical performance as compared with MP-based models. Based on Akaike's information criterion and biological consistency, the best equations included absorbed His, Ile, Lys, Met, Thr, the NEAA, and individual DE intakes from fatty acids, NDF, residual OM, and starch. Several also contained a term for absorbed Leu. These equations generally had RMSE of 14.3% and a concordance correlation of 0.76. Based on the common quadratic and individual linear terms, milk protein response plateaus were predicted at approximately 320 g/d of absorbed His, Ile, and Lys; 395 g/d of absorbed Thr; 550 g/d of absorbed Met; and 70 g/d of absorbed Leu. Therefore, responses to each except Leu are almost linear throughout the normal in vivo range. De-aggregation of the quadratic term and parsing to individual absorbed EAA resulted in nonbiological estimates for several EAA indicating over-parameterization. Expression of the EAA as g/100 g total absorbed EAA or as ratios of DE intake and using linear and quadratic terms for each EAA resulted in similar statistical performance, but the solutions had identifiability problems and several nonbiological parameter estimates. The use of ratios also introduced nonlinearity in the independent variables which violates linear regression assumptions. Further screening of the global model using absorbed EAA expressed as grams per day with a common quadratic using an all-models approach, and exhaustive cross-evaluation indicated the parameter estimates for BW, all 4 DE terms, His, Ile, Lys, Met, and the common quadratic term were stable, whereas estimates for Leu and Thr were known with less certainty. Use of independent and additive terms and a quadratic expression in the equation results in variable efficiencies of conversion. The additivity also provides partial substitution among the nutrients. Both of these prevent establishment of fixed nutrient requirements in support of milk protein production.

Homozygous MTHFR C667T carriers ≤45 years old develop central retinal vein occlusion five years earlier than wild type

PURPOSE

To assess age at 1st central retinal vein occlusion (CRVO) in carriers ≤ 45 years old of the methylenetetrahydrofolate reductase (MTHFR) C667T genotype compared to heterozygous and wild type, and to identify predictors of age at CRVO.

METHODS

Retrospective cohort study consisting of 18 MTHFR TT, 23 MTHFR TC and 28 MTHFR CC participants; information regarding age, sex, age at CRVO, history of dyslipidaemia, hypertension, smoking and plasma HC measured by immunoassay were collected.

RESULTS

Age at CRVO was lower in MTHFR TT than MTHFR TC and CC (32 ± 6 vs 38 ± 5 vs 37 ± 6 years, respectively, p = 0.005); plasma HC was higher in MTHFR TT than in the other genotypes [14.4 (10.8, 19.6) vs 10.4 ((8.6,12.5) vs 8.5 ((7.5,9.8) μmol/l, p = 0.0002). Smoking (cigarettes/day) independently predicted age at CRVO (p = 0.039) and plasma HC (p = 0.005); smoking status (yes/no) predicted ischemic CRVO (p = 0.01) that was more common in the MTHFR TT group (p = 0.006).

CONCLUSIONS

Carriers of the MTHFR TT genotype ≤ 45 years old develop their 1st CRVO on average 5 years earlier than the MTHFR CC genotype; smoking contributes to the prematurity and severity of CRVO in MTHFR TT carriers.

Delay to surgery beyond 12 hours is associated with increased hip fracture mortality

PURPOSE

Time to surgery from admission is one of the few variables known to influence outcome after a hip fracture. We reviewed our hip fracture database to determine correlation between delays to surgery and mortality in our elderly hip fracture population.

METHODS

Data on all hip fracture patients admitted to a large district hospital were prospectively collected between January 1989 and August 2021. Time of the injury, time of admission and time of surgery were recorded. Patients over 60 years old with a hip fracture requiring operative management were included. Patients with pathological fractures, those managed conservatively, and patients delayed for medical reasons were excluded. Surgical timing categories were divided into; under 12 h, 12-24 h, 24-72 h and over 72 h.

RESULTS

Time from admission to surgery was recorded for 10,659 patients, of these time of fall was available for 10,346 patients. Mean age was 82.2 years (sd 8.39) for the cohort and 30 day mortality was 6.20%. Odds of 30-day mortality was 1.43 (CI 1.057-1.988, p = 0.025) for delay to surgery from admission of over 12 h compared to under 12 h. Odds ratios for 30-day mortality were not significant at any other time threshold. The odds of 30-day mortality for delay to surgery from time of fall were 1.550 (CI 1.026-2.459, p = 0.048) at the 12 h threshold.

CONCLUSION

This is the largest prospective study to date in elderly patients with hip fractures demonstrating a statistically significant increase in 30-day mortality with a delay to surgery over 12 h.

Small effects of olfactory identification and discrimination on global cognitive and executive performance over 1 year in aging people without a history of age-related cognitive impairment

Olfactory and cognitive performance share neural correlates profoundly affected by physiological aging. However, whether odor identification and discrimination scores predict global cognitive status and executive function in healthy older people with intact cognition is unclear. Therefore, in the present study, we set out to elucidate these links in a convenience sample of 204 independently living, cognitively intact healthy Czech adults aged 77.4 ± 8.7 (61-97 years) over two waves of data collection (one-year interval). We used the Czech versions of the Montreal Cognitive Assessment (MoCA) to evaluate global cognition, and the Prague Stroop Test (PST), Trail Making Test (TMT), and several verbal fluency (VF) tests to assess executive function. As a subsidiary aim, we aimed to examine the contribution of olfactory performance towards achieving a MoCA score above vs. below the published cut-off value. We found that the MoCA scores exhibited moderate associations with both odor identification and discrimination. Furthermore, odor identification significantly predicted PST C and C/D scores. Odor discrimination significantly predicted PST C/D, TMT B/A, and standardized composite VF scores. Our findings demonstrate that olfaction, on the one hand, and global cognition and executive function, on the other, are related even in healthy older people.

Mortality among HIV-Positive and HIV-Negative People Who Inject Drugs in Mizoram, Northeast India: A Repeated Cross-Sectional Study (2007-2021)

Background: HIV and drug overdose continue to be the leading causes of death among people who inject drugs (PWID). Mizoram, a small state in the northeast of India, has the highest prevalence of HIV in India and a high HIV prevalence among PWID. Objective: To estimate the mortality among HIV-positive and HIV-negative PWID and to describe its associated factors. Methods: Cross-sectional datasets from the 2007-2021 Mizoram State AIDS Control Society (MSACS) data comprising 14626 PWID were analyzed. Logistic regression analysis was conducted to examine the factors associated with mortality among HIV-negative and HIV-positive PWID after adjusting for potential confounding factors. Results: Mortality among HIV-negative PWID declined by 59% between 2007 and 2021. The mortality rate among HIV-positive PWID also declined by 41% between 2007 and 2021. The multiple logistic regression analysis revealed that being divorced/separated/widowed (AOR = 1.41, 95% CI 1.03-1.94) remained positively associated with mortality among HIV-positive PWID. Mortality among HIV-negative PWID remained positively associated with ages of 24-34 years (AOR = 1.54, 95% CI 1.29-1.84) and above 35 years (AOR = 2.08, 95% CI 1.52-2.86), being divorced/separated/widowed (AOR = 1.28, 95% CI 1.02-1.61), and the sharing of needles/syringes (AOR = 1.28, 95% CI 1.34-2.00). Mortality among HIV-negative PWID was negatively associated with being married (AOR = 0.72, 95% CI 0.57-0.90), being employed (AOR = 0.77, 95% CI 0.64-0.94), and having a monthly income. Conclusions: The mortality rate among HIV-negative and HIV-positive PWID declined significantly between 2007 and 2021 in Mizoram. To further reduce mortality among PWID, interventions should target those sharing needles/syringes, those above 24 years of age, and unmarried participants.

The Hidden Hunger among Nepalese Non-Pregnant Women Aged 15-49 Years: The Role of Individual, Household, and Community-Level Factors

Micronutrient deficiencies remain a public health burden among non-pregnant women in developing countries, including Nepal. Hence, this study examined micronutrient deficiencies among non-pregnant Nepalese women aged 15-49 using the 2016 Nepal National Micronutrient Status Survey (NNMSS). Data for 2143 non-pregnant women was extracted from the 2016 NNMSS. The study analysed the levels of ferritin, soluble transferrin receptor (sTfR), red blood cell (RBC) folate, and zinc of the participants. Multivariable logistic analysis was carried out to assess factors associated with micronutrient deficiencies. The prevalence of ferritin, sTfR, folate, and zinc was observed to be 19%, 13%, 16%, and 21%, respectively. Non-pregnant women from the Janajati region were significantly less prone to high levels of ferritin [adjusted odds ratio (AOR): 0.45; 95% confidence interval (CI): 0.25, 0.80], and those who had body mass index (BMI) of 25 kg/m2 or higher had significantly elevated ferritin levels [AOR: 2.69; 95% CI: 1.01, 7.17]. Non-pregnant women aged 35-49 years were significantly less predisposed to folate deficiency [AOR: 0.58; 95% CI: 0.40, 0.83], and the odds of zinc deficiency were significantly lower among non-pregnant women from wealthier households [AOR: 0.48; 95% CI: 0.31, 0.76]. This study provides further insight into screening high-risk subgroups and instituting public health interventions to address the prevailing micronutrient deficiencies among non-pregnant Nepalese women.

Homozygous MTHFR C677T carriers develop idiopathic portal vein thrombosis 20 years earlier than wild type

The aim of this study was to evaluate the impact of methylene tetrahydrofolate reductase (MTHFR) rs1801133 (C→T667 transition) on age at first idiopathic portal vein thrombosis (PVT) and to identify clinical and/or laboratory variables influencing age at first PVT, including plasma homocysteine and the prothrombin rs1799963 PT (G→A transition at position 20210) (PT) mutation. A retrospective cross-sectional cohort, including 15 MTHFR TT, 32 MTHFR TC and 22 MTHFR CC idiopathic PVT participants contributing demographics, age at PVT, plasma concentrations of homocysteine and of natural anticoagulants. MTHFR TT carriers presented with a lower age at PVT than heterozygous or wild-type genotypes (31 ± 8 vs. 48 ± 15 vs. 52 ± 13 years, P  = 0.001) and were more likely to have a plasma HC concentration above the cut-off (73.3 vs. 32 vs. 50%, P  = 0.04). MTHFR TT and protein C predicted age at PVT ( P  < 0.0001 and P  = 0.06); MTHFR TT predicted plasma homocysteine ( P  = 0.05). In the MTHFR TT group, plasma homocysteine inversely related to protein C ( P  = 0.03). Plasma homocysteine predicted the extent of PVT ( P  = 0.03). Compound MTHFR TT + PT GA did not lower age at first PVT compared to MTHFR TT alone (35 ± 9 vs. 30 ± 8 years). MTHFR TT is associated with a 20-year earlier PVT presentation than heterozygous and wild-type MTHFR genotypes. The inverse relation between plasma homocysteine and protein C contributes to the prematurity of PVT in the MTHFR TT group, whereas plasma homocysteine contributes to the extent of PVT. The recent exclusion of MTHFR genotyping from the thrombophilia screen needs revisiting in this setting.

Von Willebrand factor for outcome prediction within different clinical stages of advanced chronic liver disease

BACKGROUND AND AIMS

The prognostic performance of von Willebrand factor (VWF) may vary across clinical stages of advanced chronic liver disease (ACLD). Therefore, we investigated the evolution of VWF and other biomarkers throughout the full ACLD spectrum and evaluated their stage-specific prognostic utility.

METHODS

We retrospectively included Viennese ACLD patients with available information on hepatic venous pressure gradient (HVPG), C-reactive protein (CRP)/VWF levels and outcomes. ACLD stages were defined according to D'Amico et al. We included an external validation cohort from Padua.

RESULTS

We observed gradual increases in VWF throughout ACLD stages. In contrast, HVPG levelled off in decompensated ACLD (dACLD), whereas MELD showed only minor changes in the early stages and CRP did not increase until stage 3. VWF was associated with hepatic decompensation/liver-related death in compensated ACLD (cACLD) in a fully adjusted model, while it was not independently predictive of ACLF/liver-related death in dACLD. After backward selection, HVPG/CRP/VWF remained the main predictors of hepatic decompensation/liver-related death in cACLD. Notably, the performance of the non-invasive CRP/VWF-based model was comparable to invasive HVPG-based models (C-index:0.765 ± 0.034 vs. 0.756 ± 0.040). The discriminative ability of the CRP/VWF-based model was confirmed in an external validation cohort using another VWF assay which yielded systematically lower values.

CONCLUSION

VWF is the only biomarker that gradually increases across all ACLD stages. It is of particular prognostic value in cACLD, where a CRP/VWF-based model is equivalent to an invasive HVPG-based model. Systematic differences in VWF underline the importance of interlaboratory surveys. Moreover, our findings reinforce the notion that, already in cACLD, inflammation is a key disease-driving mechanism.

Association Between Opioid-Related Mortality and History of Surgical Procedure: A Population-Based Case-Control Study

Objective

This study examined whether there is an association between opioid-related mortality and surgical procedures.

Methods

A case-control study design using deceased controls compared individuals with and without opioid death and their exposure to common surgeries in the preceding 4 years. This population-based study used linked death and hospitalization databases in Canada (excluding Quebec) from January 01, 2008 to December 31, 2017. Cases of opioid death were identified and matched to 5 controls who died of other causes by age (±4 years), sex, province of death, and date of death (±1 year). Patients with HIV infection and alcohol-related deaths were excluded from the control group. Logistic regression was used to determine if there was an association between having surgery and death from an opioid-related cause by estimating the crude and adjusted odds ratios (ORs) with the corresponding 95% confidence interval (CI). Covariates included sociodemographic characteristics, comorbidities, and the number of days of hospitalization in the previous 4 years.

Results

We identified 11,865 cases and matched them with 59,345 controls. About 11.2% of cases and 12.5% of controls had surgery in the 4 years before their death, corresponding to a crude OR of 0.89 (95% CI: 0.83-0.94). After adjustment, opioid mortality was associated with surgical procedure with OR of 1.26 (95% CI: 1.17-1.36).

Conclusions

After adjusting for comorbidities, patients with opioid mortality were more likely to undergo surgical intervention within 4 years before their death. Clinicians should enhance screening for opioid use and risk factors when considering postoperative opioid prescribing.

Donor Blood Tests do Not Predict Pancreas Graft Survival After Simultaneous Pancreas Kidney Transplantation; a National Cohort Study

Simultaneous pancreas-kidney (SPK) transplantation improves quality of life and limits progression of diabetic complications. There is reluctance to accept pancreata from donors with abnormal blood tests, due to concern of inferior outcomes. We investigated whether donor amylase and liver blood tests (markers of visceral ischaemic injury) predict pancreas graft outcome using the UK Transplant Registry (2016-2021). 857 SPK recipients were included (619 following brainstem death, 238 following circulatory death). Peak donor amylase ranged from 8 to 3300 U/L (median = 70), and this had no impact on pancreas graft survival when adjusting for multiple confounders (aHR = 0.944, 95% CI = 0.754-1.81). Peak alanine transaminases also did not influence pancreas graft survival in multivariable models (aHR = 0.967, 95% CI = 0.848-1.102). Restricted cubic splines were used to assess associations between donor blood tests and pancreas graft survival without assuming linear relationships; these confirmed neither amylase, nor transaminases, significantly impact pancreas transplant outcome. This is the largest, most statistically robust study evaluating donor blood tests and transplant outcome. Provided other factors are acceptable, pancreata from donors with mild or moderately raised amylase and transaminases can be accepted with confidence. The use of pancreas grafts from such donors is therefore a safe, immediate, and simple approach to expand the donor pool to reach increasing demands.

High-risk TP53 mutations predict poor primary treatment response of patients with head and neck squamous cell carcinoma

OBJECTIVES

Head and neck squamous cell carcinoma (HNSCC) poses a diagnostic and therapeutic challenge worldwide and is associated with a poor survival rate. Due to the variability in the efficacy of treatments for HNSCC, new predictive biomarkers of therapy outcomes are needed. Recently, we developed an algorithm that employs the mutational profile of TP53 as an independent prognostic factor in HNSCC. In this study, we investigated its role as a predictive biomarker of treatment outcomes in HNSCC patients. We also tested the usefulness of two classification systems for TP53 mutational landscapes.

MATERIALS AND METHODS

Clinical and genomic data were retrieved from The Cancer Genome Atlas database. We built a multivariate stepwise backward binary regression model to assess the role of TP53 mutations in predicting therapeutic outcomes.

RESULTS

Cases harbouring high-risk-of-death mutations reported an odds ratio of 3.301 for stable or progressive disease compared to wild-type cases, while no significant difference in treatment outcomes was found between cases with low-risk-of-death mutations and wild-type TP53. Our analysis found that older patients with a history of alcohol consumption had a higher risk of stable/progressive disease.

CONCLUSIONS

This study improves current evidence on the role of TP53 mutations in treatment response in HNSCC patients.

Applying models of care for total hip and knee arthroplasty: External validation of a published predictive model to identify extended stay risk prior to lower-limb arthroplasty

OBJECTIVE

This study aimed to externally validate a reported model for identifying patients requiring extended stay following lower limb arthroplasty in a new setting.

DESIGN

External validation of a previously reported prognostic model, using retrospective data.

SETTING

Medium-sized hospital orthopaedic department, Australia.

PARTICIPANTS

Electronic medical records were accessed for data collection between Sep-2019 and Feb-2020 and retrospective data extracted from 200 randomly selected total hip or knee arthroplasty patients.

INTERVENTION

Participants received total hip or knee replacement between 2-Feb-16 and 4-Apr-19. This study was a non-interventional retrospective study.

MAIN MEASURES

Model validation was assessed with discrimination, calibration on both original and adjusted forms of the candidate model. Decision curve analysis was conducted on the outputs of the adjusted model to determine net benefit at a predetermined decision threshold (0.5).

RESULTS

The original model performed poorly, grossly overestimating length of stay with mean calibration of -3.6 (95% confidence interval -3.9 to -3.2) and calibration slope of 0.52. Performance improved following adjustment of the model intercept and model coefficients (mean calibration 0.48, 95% confidence interval 0.16 to 0.80 and slope of 1.0), but remained poorly calibrated at low and medium risk threshold and net benefit was modest (three additional patients per hundred identified as at-risk) at the a-priori risk threshold.

CONCLUSIONS

External validation demonstrated poor performance when applied to a new patient population and would provide limited benefit for our institution. Implementation of predictive models for arthroplasty should include practical assessment of discrimination, calibration and net benefit at a clinically acceptable threshold.

Treatment regimens and survival among patients with head and neck squamous cell carcinoma from Mizo tribal population in northeast India - a single centre, retrospective cohort study

Background

Patients with early-stage head and neck squamous cell carcinoma (HNSCC) are treated using a single-modality approach that involves either surgery (S) or radiotherapy (RT). Conversely, those with advanced-stage disease are treated using a multi-modality approach incorporating a combination of chemotherapy (CT), RT and S. In addition to behavioural factors, such as alcohol and tobacco use, clinical parameters, such as leukocyte and neutrophil counts and T and N classification, have been linked to the survival of patients with head and neck cancer. This retrospective study was designed to provide insights into the types of treatment (induction chemotherapy [IC], concurrent chemoradiotherapy [CCRT], S and RT) administered to patients with HNSCC in Mizoram, analyse their 2-year outcome, and identify potential factors that may affect the response to treatment.

Methods

A retrospective cohort study was conducted using patients diagnosed with HNSCC between 2017 and 2020 in Mizoram, northeast India. Data on clinical and demographic factors and treatments provided were collected from medical records from the Mizoram State Cancer Institute, Mizoram. Overall survival (OS) and progression free survival (PFS) were determined for each factor using the Kaplan-Meier method and compared using the log-rank test. Cox regression analysis was used to identify the factors that affected OS and PFS. Multicollinearity test was performed between the predictors using a variance inflation factor cut-off point of 2.

Findings

A retrospective study was performed on 210 patients with HNSCC who were followed up for a period of 2 years. The findings revealed that hypopharynx was the most affected site, followed by the nasopharynx, oral cavity, oropharynx, and larynx. Regarding treatment regimens, 85/210 (40.5%) of the patients received IC along with CCRT or RT in a sequential manner. Moreover, 86/210 (41.0%) underwent CCRT alone, 22/210 (10.5%) received RT alone and 17/210 (8.1%) underwent surgery followed by adjuvant CCRT or RT. Two-year OS and PFS estimated using the Kaplan-Meier analysis were 78.1% (95% CI = 72.4%-84.2%) and 57.4% (95% CI = 50.8%-64.8%), respectively. Log-rank test showed that leucocytosis (p = 0.015) and neutrophilia (p = 0.014) exerted effects on OS, whereas nodal involvement (p = 0.005), neutrophilia (p = 0.043) and IC (p = 0.010) exerted effects on PFS. Multivariate analysis indicated that leucocytosis (p = 0.010 [OS], 0.025 [PFS]), neutrophilia (p = 0.029, 0.033), cancer site (laryngeal) (p = 0.009, 0.028) and nodal involvement (N2) (p = 0.020, 0.001) were predictors of poor OS and PFS.

Interpretation

OS was better than PFS in HNSCC patients from Mizo population. Multi-modality approach offered survival advantages over single-modality approach. Leucocytosis, neutrophilia, nodal involvement, and cancer sites were associated with poor OS and PFS. More comprehensive research with a larger sample size is needed to confirm the findings from this study.

Funding

There is no funding for this study.

Clinical characteristics of new-onset diabetes after liver transplantation and outcomes

Background

We aimed to identify the characteristics of new-onset diabetes after liver transplantation (LT) (NODAT) and investigate its impacts on post-transplant outcomes.

Methods

Adult LT patients between 2014 and 2020 who used tacrolimus as initial immunosuppression and survived 3 months at least were evaluated. Patients who developed NODAT within 3 months after LT were classified as NODAT group. Also, patients were further classified as history of diabetes before LT (PHDBT) and non-diabetes (ND) groups. Patient characteristics, post-LT outcomes, and cardiovascular and/or pulmonary complications were compared.

Results

A total of 83, 225, and 263 patients were classified into NODAT, PHDBT, and ND groups. The proportion of cholestatic liver disease and rejection within 90 days were higher in NODAT group. Mean serum tacrolimus concentration trough level in the first week after LT was 7.12, 6.12, and 6.12 ng/mL (p < 0.001). Duration of corticosteroids was significantly longer in NODAT compared to PHDBD or ND (416, 289, and 228 days, p < 0.001). Three-year graft and patient survival were significantly worse in NODAT than ND (80.5% vs. 95.0%, p < 0.001: 82.0% vs. 95.4%, p < 0.001) but similar to PHDBT. Adjusted risks of 3-year graft loss and patient death using Cox regression analysis were significantly higher in NODAT compared to ND (adjusted hazard ratio [aHR] 3.41, p = 0.004; aHR 3.61, p = 0.004). Incidence rates of cardiovascular or pulmonary complications after LT in NODAT were significantly higher than ND but similar to PHDBT.

Conclusion

Higher initial tacrolimus concentration and early rejection might be risk factors for NODAT. NODAT was associated with worse post-transplant outcomes.