Performance of models for estimating absolute risk difference in multicenter trials with binary outcome

Association of glucagon-like peptide-1 receptor agonists with serious liver events among patients with type 2 diabetes: A Scandinavian cohort study

BACKGROUND AND AIMS

Clinical trials suggest that glucagon-like peptide-1 (GLP-1) receptor agonists may have beneficial effects on NAFLD, but the impact on hard hepatic end points is unknown. We assessed the association between the use of GLP-1 receptor agonists and the risk of serious liver events in routine clinical practice.

APPROACH AND RESULTS

Cohort study using data from nationwide registers in Sweden, Denmark, and Norway, 2007-2020, including 91,479 initiators of GLP-1 receptor agonists and 244,004 initiators of the active comparator, dipeptidyl peptidase-4 inhibitors, without a history of chronic liver disease other than NAFLD/NASH. The primary outcome was serious liver events: a composite of incident compensated and decompensated cirrhosis and HCC. Secondary outcomes were the individual components of the primary outcome. Cox regression was used to estimate HRs, using propensity score weighting to control for confounding. Users of GLP-1 receptor agonists had 608 serious liver events (adjusted incidence rate: 16.9 events per 10,000 person-years), compared with 1770 events among users of dipeptidyl peptidase-4 inhibitors (19.2 events per 10,000 person-years). The adjusted HR was 0.85 (95% CI: 0.75 to 0.97), and the rate difference was -2.1 (-4.4 to 0.1) events per 10,000 person-years. In secondary outcome analyses, the adjusted HR was 0.85 (0.75 to 0.97) for compensated and decompensated cirrhosis and 1.05 (0.80 to 1.39) for HCC.

CONCLUSIONS

The use of GLP-1 receptor agonists was associated with a significantly reduced risk of serious liver events, driven by a reduction of compensated and decompensated cirrhosis.

COVID-19 and COVID-19 vaccination experiences and perceptions among health workers during the pandemic in Ebonyi state, Nigeria: An analytical cross-sectional study

BACKGROUND

COVID-19 continues to be a disease of global public health importance and requires long-term management and control. Health workers' (previous) experiences and perceptions regarding the COVID-19 pandemic and COVID-19 vaccination/vaccination process will influence not only their subsequent use of control measures but also public experiences/perceptions. We explored the COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions, and their predictors, among the health workers in Ebonyi state, Nigeria.

METHODS

We conducted an online-offline analytical cross-sectional survey between March 12 and May 9, 2022 among all categories of health workers (clinical/non-clinical, public/private) working/living in Ebonyi state who consented to participate and were selected by convenience/snowballing techniques. A structured electronic questionnaire was used to collect data: self-administered via WhatsApp and interviewer-administered via KoBoCollect for participants who did not have WhatsApp. Data was analysed using descriptive statistics and bivariate/multivariate generalized linear models.

RESULTS

Of the 1276 health workers surveyed: 55.8% had strong COVID-19 experience and perception, 80.7% had good COVID-19 vaccination expectation and perception, and 87.7% had positive COVID-19 vaccination process experience and perception. The most important predictors of the extent and level of COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions were level of place of work (primary-secondary/tertiary), level of attitude towards COVID-19 (vaccination), and level of knowledge about COVID-19. Another important predictor was place of work (public/private).

CONCLUSIONS

The evidence indicate the factors that should guide subsequent policy actions in the strategies to enhance the COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions of health workers (and their use of control measures) in Ebonyi state, Nigeria, and other similar contexts. It also indicate factors to be considered by future policy actions regarding similar diseases.

The neighborhood food environment modifies the association between infant feeding and childhood obesity

BACKGROUND

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) issues infant formula to infants who are not fully breastfed, and prior research found elevated obesity risk among children receiving lactose-reduced infant formula with corn syrup solids (CSSF) issued by WIC. This study was conducted to evaluate associations between a broader set of specialty infant formulas issued by WIC and child obesity risk, whether neighborhood context (e.g. neighborhood food environment) modifies associations, and whether racial/ethnic disparities in obesity are partly explained by infant formula exposure and neighborhood context.

METHODS

WIC administrative data, collected from 2013-2020 on issued amount (categorical: fully formula fed, mostly formula fed, mostly breastfed, fully breastfed) and type of infant formula (standard cow's milk formula, and three specialty formulas: any CSSF, any soy-based formula, and any cow's milk-based formula with added rice starch) and obesity at ages 2-4 years (defined as a Body Mass Index z-score ≥ 95th percentile according to World Health Organization growth standard) were used to construct a cohort (n = 59,132). Associations of infant formula exposures and race/ethnicity with obesity risk were assessed in Poisson regression models, and modification of infant feeding associations with obesity by neighborhood context was assessed with interaction terms.

RESULTS

Any infant formula exposure was associated with significantly higher obesity risk relative to fully breastfeeding. Receipt of a CSSF was associated with 5% higher obesity risk relative to the standard and other specialty infant formulas (risk ratio 1.05, 95% confidence interval 1.02, 1.08) independent of breastfeeding duration and receipt of other specialty infant formulas. The association between CSSF and obesity risk was stronger in neighborhoods with healthier food environments (10% higher risk) compared to less healthy food environments (null). Racial/ethnic disparities in obesity risk were robust to adjustment for infant formula exposure and neighborhood environment.

CONCLUSIONS

Among specialty infant formulas issued by WIC, only CSSFs were associated with elevated obesity risk, and this association was stronger in healthier food environments. Future research is needed to isolate the mechanism underlying this association.

Pneumococcal conjugate vaccination schedules in infants-acquisition, immunogenicity, and pneumococcal conjugate and yellow fever vaccine co-administration study: statistical analysis plan

RATIONALE

The effectiveness of immunisation with pneumococcal conjugate vaccine (PCV) has been demonstrated in many countries. However, the global impact of PCV is limited by its cost, which has prevented its introduction in some countries. Reducing the cost of PCV programmes will facilitate further vaccine introductions and improve the sustainability of PCV in low-income countries when they transition from subsidised vaccine supply. We are conducting a large, population-level, cluster-randomised field trial (PVS) of an alternative reduced-dose schedule of PCV compared to the standard schedule. We are also conducting a nested sub-study at the individual level to investigate the immunogenicity of the two schedules and their effects on pneumococcal carriage acquisition (PVS-AcqImm).

METHODS AND DESIGN

PVS-AcqImm is a prospective, cluster-randomised trial of an alternative schedule of one dose of PCV scheduled at age 6 weeks with a booster dose at age 9 months compared to the standard of three primary doses scheduled at 6, 10, and 14 weeks of age. Sub-groups within the alternative schedule group receive yellow fever vaccine separately or co-administered with PCV at 9 months of age. The primary endpoints are (a) concentrations of vaccine-type anti-pneumococcal IgG at 18 months of age, (b) proportions with yellow fever neutralising antibody titre ≥ 1:8 4 weeks after separate or co-administration of PCV and yellow fever vaccines, and (c) rate of nasopharyngeal vaccine-type pneumococcal acquisition from 10-14 months of age. Participants and field staff are not masked to group allocation while measurement of the laboratory endpoints is masked. Approximately equal numbers of participants are resident in each of 28 randomly allocated geographic clusters (14 clusters in each group); 784 enrolled for acquisition measurements and 336 for immunogenicity measurements.

PURPOSE

This statistical analysis plan (SAP) describes the PVS-AcqImm cohort and follow-up criteria to be used in different analyses. The SAP defines the endpoints and describes how adherence to the interventions will be presented. We describe the approach to analyses and how we will account for the effect of clustering. Defining the SAP prior to the conduct of analysis will avoid bias in analyses that may arise from prior knowledge of trial findings.

TRIAL REGISTRATION

ISRCTN, ISRCTN7282161328. Registered on 28 November 2019. https://www.isrctn.com/ISRCTN72821613 .

PROTOCOL

MRCG SCC number 1670, LSHTM Ref 17683. Current protocol version: 6.0, 24 May 2021. Version: 1.0 (5 April 2023); SAP revisions-none.

COVID-19 information sources, knowledge, attitude, control practices and the predictors among health workers during the pandemic in Ebonyi state, Nigeria

The COVID-19 pandemic has changed into an endemic COVID-19 disease and health workers continue to be at high risk. The situation requires continued use of COVID-19 control measures by health workers and this will likely depend on their sources of information/knowledge/attitude about COVID-19 and previous use of COVID-19 control measures. We explored the COVID-19 information sources, knowledge, attitude, control practices, and the predictors, among health workers in Ebonyi state, Nigeria. We implemented an online-offline analytical cross-sectional survey from March 12 to May 9, 2022 among all categories of health workers (clinical/non-clinical, public/private) working/living in Ebonyi state who gave consent and were selected via convenience/snowballing sampling. Data was collected with a structured self-administered/interviewer-administered questionnaire via WhatsApp/KoBoCollect. Descriptive/inferential analyses were done including multivariate generalized linear models. 1276 health workers were surveyed. The commonest individual source of information about COVID-19 was health workers (used by 83.8%), followed by radio (67.9%), television (59.6%), family members/relatives/friends (57.9%) etc. The main individual source of information for majority of the participants was health workers (for 35.0%) followed by radio (24.5%), television (14.4%) etc. The most trusted individual source of information for majority of the participants was health workers (for 39.4%) followed by radio (26.0%), television (14.3%) etc. Interpersonal sources were the main/most trusted source of information for the majority (48.0%/49.8%) followed by traditional media (39.4%/40.6%) and internet/social media/SMS (12.6%/9.6%). 42.3%, 81.3%, and 43.0% respectively had good knowledge, good attitude, and good control practice about COVID-19. The most important predictors of the main/most trusted sources of information about COVID-19 were place of work (public/private), level of place of work (primary-secondary/tertiary), age, and years of working experience. Good knowledge about COVID-19, good attitude towards COVID-19, strong COVID-19 experience/perception, working at a tertiary facility, tertiary education, and decrease in years of working experience were strong predictors of good control practice about COVID-19. This study's evidence regarding the commonest/main/most trusted information sources and control practice about COVID-19 should be considered by later COVID-19/similar health emergencies' policy actions to optimise emergency health information dissemination and use of control measures by health workers in Ebonyi state/Nigeria/other similar settings.

Confidence distributions for treatment effects in clinical trials: Posteriors without priors

An attractive feature of using a Bayesian analysis for a clinical trial is that knowledge and uncertainty about the treatment effect is summarized in a posterior probability distribution. Researchers often find probability statements about treatment effects highly intuitive and the fact that this is not accommodated in frequentist inference is a disadvantage. At the same time, the requirement to specify a prior distribution in order to obtain a posterior distribution is sometimes an artificial process that may introduce subjectivity or complexity into the analysis. This paper considers a compromise involving confidence distributions, which are probability distributions that summarize uncertainty about the treatment effect without the need for a prior distribution and in a way that is fully compatible with frequentist inference. The concept of a confidence distribution provides a posterior-like probability distribution that is distinct from, but exists in tandem with, the relative frequency interpretation of probability used in frequentist inference. Although they have been discussed for decades, confidence distributions are not well known among clinical trial statisticians and the goal of this paper is to discuss their use in analyzing treatment effects from randomized trials. As well as providing an introduction to confidence distributions, some illustrative examples relevant to clinical trials are presented, along with various case studies based on real clinical trials. It is recommended that trial statisticians consider presenting confidence distributions for treatment effects when reporting analyses of clinical trials.

Effectiveness of a comprehensive package based on electronic medication monitors at improving treatment outcomes among tuberculosis patients in Tibet: a multicentre randomised controlled trial

BACKGROUND

WHO recommends that electronic medication monitors, a form of digital adherence technology, be used as a complement to directly observed treatment (DOT) for tuberculosis, as DOT is inconvenient and costly. However, existing evidence about the effectiveness of these monitors is inconclusive. Therefore, we evaluated the effectiveness of a comprehensive package based on electronic medication monitors among patients with tuberculosis in Tibet Autonomous Region (hereafter Tibet), China.

METHODS

This multicentre, randomised controlled trial recruited patients from six counties in Shigatse, Tibet. Eligible participants had drug-susceptible tuberculosis and were aged 15 years or older when starting standard tuberculosis treatment. Tuberculosis doctors recruited patients from the public tuberculosis dispensary in each county and the study statistician randomly assigned them to the intervention or control group based on the predetermined randomised allocation sequence. Intervention patients received an electronic medication monitor box. The box included audio medication-adherence reminders and recorded box-opening data, which were transmitted to a cloud-based server and were accessible to health-care providers to allow remote adherence monitoring. A linked smartphone app enabled text, audio, and video communication between patients and health-care providers. Patients were also provided with a free data plan. Patients selected a treatment supporter (often a family member) who was trained to support patients with using the electronic medication monitor and app. Patients in the control group received usual care plus a deactivated electronic medication monitor, which only recorded and transmitted box-opening data that was not made available to health-care providers. The control group also had no access to the app or trained treatment supporters. The primary outcome was a binary indicator of poor monthly adherence, defined as missing 20% or more of planned doses in the treatment month, measured using electronic medication monitor opening data, and verified by counting used medication blister packages during consultations. We recorded other secondary treatment outcomes based on national tuberculosis reporting data. We analysed the primary outcome based on the intention-to-treat population. This trial is registered at ISRCTN, 52132803.

FINDINGS

Between Nov 17, 2018, and April 5, 2021, 278 patients were enrolled into the study. 143 patients were randomly assigned to the intervention group and 135 patients to the control group. Follow-up ended when the final patient completed treatment on Oct 4, 2021. In the intervention group, 87 (10%) of the 854 treatment months showed poor adherence compared with 290 (37%) of the 795 months in the control group. The corresponding adjusted risk difference for the intervention versus control was -29·2 percentage points (95% CI -35·3 to -22·2; p<0·0001). Five of the six secondary treatment outcomes also showed clear improvements, including treatment success, which was found for 133 (94%) of the 142 individuals in the intervention arm and 98 (73%) of the 134 individuals in the control arm, with an adjusted risk difference of 21 percentage points (95% CI 12·4-29·4); p<0·0001.

INTERPRETATION

The interventions were effective at improving tuberculosis treatment adherence and outcomes, and the trial suggests that a comprehensive package involving electronic medication monitors might positively affect tuberculosis programmes in high-burden and low-resource settings.

FUNDING

TB REACH.

COVID-19 and COVID-19 vaccination experiences and perceptions and their predictors among community members during the COVID-19 pandemic in Ebonyi state, Nigeria: an analytical cross-sectional study

BACKGROUND

COVID-19 is still a disease of global public health importance which requires long term application of control measures as millions of new infections or re-infections and thousands of related deaths still occur worldwide and the risk of an upsurge from new strains of the virus continues to be a threat. The decrease in the use of and non-use of preventive public health measures are among the factors fuelling the disease. The (previous) experiences and perceptions of people regarding the COVID-19 pandemic, COVID-19 vaccination, and the vaccination process are factors that will influence subsequent use of preventive/control measures. We explored the COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions, and their predictors, among the community members in Ebonyi state, Nigeria.

METHODS

We conducted an analytical cross-sectional study between March 12 and May 9, 2022 among all consenting/assenting community members aged 15 years and above in 28 randomly selected geographical clusters. A structured interviewer-administered electronic questionnaire in KoBoCollect installed in android devices was used to collect data which was analysed using descriptive statistics and bivariate and multivariate generalized estimating equations.

RESULTS

Of the 10,825 community members surveyed: only 31.6% had strong COVID-19 experience and perception, 72.2% had good COVID-19 vaccination expectation and perception, and only 54.2% had positive COVID-19 vaccination process experience and perception. The most important predictors of the extent/level of COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions were level of attitude towards COVID-19 and COVID-19 vaccination and level of knowledge about COVID-19. Other important predictors were marital status, educational level, and main occupation.

CONCLUSIONS

This study's evidence, including the identified predictors, will inform subsequent policy actions regarding COVID-19 in the strategies to improve the COVID-19 and COVID-19 vaccination and the vaccination process experiences and perceptions of community members (and their use of preventive/control measures) in Ebonyi state and Nigeria, and other similar contexts. It will also inform future policy actions/strategies regarding similar diseases.

Effect of Mavacamten in Women Compared With Men With Obstructive Hypertrophic Cardiomyopathy: Insights From EXPLORER-HCM

BACKGROUND

Compared with men, women with hypertrophic cardiomyopathy (HCM) have a higher incidence of heart failure and worse outcomes. We investigated baseline clinical and echocardiographic characteristics and response to mavacamten among women compared with men in the EXPLORER-HCM study (Clinical Study to Evaluate Mavacamten [MYK-461] in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy).

METHODS

A prespecified post hoc analysis of sex from the blinded, randomized EXPLORER-HCM trial of mavacamten versus placebo in symptomatic patients with obstructive HCM was performed. Baseline characteristics were compared with t tests for continuous variables (expressed as mean values) and χ2 tests for categorical variables. Prespecified primary, secondary, and exploratory end points and echocardiographic measurements from baseline to end of treatment (week 30) were analyzed with ANCOVA for continuous end points and a generalized linear model with binomial distribution for binary end points, with adjustment for each outcome's baseline value, New York Heart Association class, β-blocker use, and ergometer type.

RESULTS

At baseline, women (n=102) were older (62 years versus 56 years; P<0.0001), had lower peak oxygen consumption (16.7 mL·kg-1·min-1 versus 21.3 mL·kg-1·min-1; P<0.0001), were more likely to be assigned New York Heart Association class III (42% versus 17%; P<0.0001), had worse health status (Kansas City Cardiomyopathy Questionnaire-Clinical Summary Score 64 versus 75; P<0.0001), and had higher baseline plasma NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels (1704 ng/L versus 990 ng/L; P=0.004) than men (n=149). After 30 weeks of mavacamten treatment, similar improvements were observed in women and men in the primary composite end point (percentage difference on mavacamten versus placebo, 22% versus 19%, respectively; P=0.759) and in the secondary end points of change in postexercise left ventricular outflow tract gradient (-42.4 mm Hg versus -33.6 mm Hg; P=0.348), change in peak oxygen consumption (1.2 mL·kg-1·min-1 versus 1.6 mL·kg-1·min-1; P=0.633), and percentage achieving ≥1 New York Heart Association class improvement (41% versus 28%; P=0.254). However, women had greater improvement in health status (Kansas City Cardiomyopathy Questionnaire-Clinical Summary Score 14.8 versus 6.1; P=0.026) and in the exploratory end point of NT-proBNP levels (-1322 ng/L versus -649 ng/L; P=0.0008).

CONCLUSIONS

Although at baseline women with symptomatic obstructive HCM enrolled in EXPLORER-HCM were older and had worse heart failure and health status than men, treatment with mavacamten resulted in similar improvements in the primary and most secondary EXPLORER-HCM end points and greater improvements in health status and NT-proBNP.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03470545.

Massachusetts' opioid limit law associated with a reduction in postoperative opioid duration among orthopedic patients

Postoperative orthopedic patients are a high-risk group for receiving long-duration, large-dosage opioid prescriptions. Rigorous evaluation of state opioid duration limit laws, enacted throughout the country in response to the opioid overdose epidemic, is lacking among this high-risk group. We took advantage of Massachusetts' early implementation of a 2016 7-day-limit law that occurred before other statewide or plan-wide policies took effect and used commercial insurance claims from 2014-2017 to study its association with postoperative opioid prescriptions greater than 7 days' duration among Massachusetts orthopedic patients relative to a New Hampshire control group. Our sample included 14 097 commercially insured, opioid-naive adults aged 18 years and older undergoing elective orthopedic procedures. We found that the Massachusetts 7-day limit was associated with an immediate 4.23 percentage point absolute reduction (95% CI, 8.12 to 0.33 percentage points) and a 33.27% relative reduction (95% CI, 55.36% to 11.19%) in the percentage of initial fills greater than 7 days in the Massachusetts relative to the control group. Seven-day-limit laws may be an important state-level tool to mitigate longer duration prescribing to high-risk postoperative populations.

A prospective, comparative study of clinical outcomes following clinic-based versus self-use of medical abortion

BACKGROUND

To determine whether clinical outcomes differ among women accessing a combined medical abortion regimen from a health clinic when compared with those accessing it from a pharmacy.

METHODS

We conducted a multicentre, prospective, comparative, non-inferiority study of participants aged ≥15 years seeking medical abortion from five clinics and five adjacent pharmacy clusters in three provinces of Cambodia. Participants were recruited in-person at the point of purchase (clinic or pharmacy). Follow-up for self-reported pill use, acceptability, and clinical outcomes occurred by telephone at days 10 and 30 after mifepristone administration.

RESULTS

Over 10 months, we enrolled 2083 women with 1847 providing outcome data: 937 from clinics and 910 from pharmacies. Most were early in their pregnancy (mean gestational age of 6.3 and 6.1 weeks, respectively) and almost all took the pills correctly (98% and 96%,). Additional treatment needed to complete the abortion was non-inferior for the pharmacy group (9.3%) compared with the clinic group (12.7%). More from the clinic group received additional care from a provider, such as antibiotics or diagnostics tests, than those from the pharmacy group (11.5% and 3.2%,), and one ectopic pregnancy (pharmacy group) was successfully treated. Most said they felt prepared for what happened after taking the pills (90.9% and 81.3%, respectively, p=0.273).

CONCLUSIONS

Self-use of a combined medical abortion product resulted in comparable clinical outcomes as use following a clinical visit, consistent with existing literature on its safety and efficacy. Registration and availability of medical abortion as an over-the-counter product would likely increase women's access to safe abortion.

Pivmecillinam with Amoxicillin/Clavulanic acid as step down oral therapy in febrile Urinary Tract Infections caused by ESBL-producing Enterobacterales (PACUTI)

BACKGROUND

Oral treatment alternatives for febrile urinary tract infections are limited in the era of increasing antimicrobial resistance. We aim to evaluate if the combination of pivmecillinam and amoxicillin/clavulanic acid is non-inferior to current alternatives for step-down therapy in adult patients with febrile urinary tract infection.

METHODS

We plan to perform an investigator-initiated non-inferiority trial. Adult hospitalised patients treated with 1-5 days of intravenous antibiotics for acute febrile urinary tract infection caused by extended spectrum beta-lactamase (ESBL) producing Enterobacterales will be randomised 1:1 to either control (7-10 days of either oral ciprofloxacin 500 mg twice daily or oral trimethoprim-sulfamethoxazole 800 mg/160 mg twice daily or intravenous ertapenem 1 g once daily, depending on sex, drug allergy, glomerular filtration rate and susceptibility testing) or intervention (10 days of pivmecillinam 400 mg three times daily and amoxicillin/clavulanic acid 500/125 mg three times daily). The primary outcome will be clinical cure 10 days (+/- 2 days) after antibiotic treatment completion. Clinical cure is defined as being alive with absence of fever and return to non-infected baseline of urinary tract symptoms without additional antibiotic treatment or re-hospitalisation (for urinary tract infection) based on a centralised allocation-blinded structured telephone interview. We plan to recruit 330 patients to achieve 90% power based on a sample size simulation analysis using a two-group comparison, one-sided alpha of 2.5%, an absolute non-inferiority margin of 10% and expecting 93% clinical cure rate and 10% loss to follow-up. The primary endpoint will be analysed using generalised estimated equations and reported as risk difference for both intention-to-treat and per protocol populations. Patients are planned to be recruited from at least 10 centres in Sweden from 2023 to 2026.

DISCUSSION

If the combination of pivmecillinam and amoxicillin/clavulanic acid is found to be non-inferior to the control drugs there are potential benefits in terms of tolerability, frequency of interactions, outpatient treatment, side effects, nosocomial infections and drive for further antimicrobial resistance compared to existing drugs.

TRIAL REGISTRATION

NCT05224401. Registered on February 4, 2022.

Age 18-30 trajectories of binge drinking frequency and prevalence across the past 30 years for men and women: Delineating when and why historical trends reversed across age

Historical analyses based on US data indicate that recent cohorts engage in lower binge drinking at age 18 relative to past cohorts, but by the mid- to late-20s the reverse is true: recent cohorts engage in higher binge drinking relative to past cohorts. We pinpoint when - both developmentally and historically - this reversal manifested, examine possible reasons for this reversal, and examine sex convergence in these developmental and historical patterns. As part of the US national Monitoring the Future Study, over 75,000 youths from the high school classes of 1976-2006 were surveyed biennially between ages 18 and 30. We found that the reversal primarily manifested between ages 18 and 24 for men and 18 and 22 for women. We also found that the reversal emerged gradually across the last three decades, suggesting it is the result of a broad and durable historical shift. Our findings indicated that historical variation in social roles and minimum legal drinking age collectively accounted for only a modest amount of the reversal, although marriage was the most influential among the factors examined here. Finally, we found evidence that sex convergence in binge drinking was developmentally limited and far more pronounced at the beginning of the transition to adulthood.

Prevalent diabetes and long-term cardiovascular outcomes in adult sepsis survivors: a population-based cohort study

BACKGROUND

Sepsis survivors are at elevated risk for cardiovascular disease during long-term follow-up. Whether diabetes influences cardiovascular risk after sepsis survival remains unknown. We sought to describe the association of diabetes with long-term cardiovascular outcomes in adult sepsis survivors.

METHODS

Population-based cohort study in the province of Ontario, Canada (2008-2017). Adult survivors of a first sepsis-associated hospitalization, without pre-existing cardiovascular disease, were included. Main exposure was pre-existing diabetes (any type). The primary outcome was the composite of myocardial infarction, stroke, and cardiovascular death. Patients were followed up to 5 years from discharge date until outcome occurrence or end of study period (March 2018). We used propensity score matching (i.e., 1:1 to patients with sepsis but no pre-existing diabetes) to adjust for measured confounding at baseline. Cause-specific Cox proportional hazards models with robust standard errors were used to estimate hazard ratios (HR) alongside 95% confidence intervals (CI). A main secondary analysis evaluated the modification of the association between sepsis and cardiovascular disease by pre-existing diabetes.

RESULTS

78,638 patients with pre-existing diabetes who had a sepsis-associated hospitalization were matched to patients hospitalized for sepsis but without diabetes. Mean age of patients was 71 years, and 55% were female. Median duration from diabetes diagnosis was 9.8 years; mean HbA1c was 7.1%. Adult sepsis survivors with pre-existing diabetes experienced a higher hazard of major cardiovascular disease (HR 1.25; 95% CI 1.22-1.29)-including myocardial infarction (HR 1.40; 95% CI 1.34-1.47) and stroke (HR 1.24; 95% CI 1.18-1.29)-during long-term follow-up compared to sepsis survivors without diabetes. Pre-existing diabetes modified the association between sepsis and cardiovascular disease (risk difference: 2.3%; 95% CI 2.0-2.6 and risk difference: 1.8%; 95% CI 1.6-2.0 for the effect of sepsis-compared to no sepsis-among patients with and without diabetes, respectively).

CONCLUSIONS

Sepsis survivors with pre-existing diabetes experience a higher long-term hazard of major cardiovascular events when compared to sepsis survivors without diabetes. Compared to patients without sepsis, the absolute risk increase of cardiovascular events after sepsis is higher in patients with diabetes (i.e., diabetes intensified the higher cardiovascular risk induced by sepsis).

COVID-19 vaccination acceptance (uptake, hesitancy, intention to receive and timeliness of the intention to receive) and the determinants among health workers in Ebonyi state, Nigeria: an analytical cross-sectional study

OBJECTIVES

Health workers are at particular risk of contracting the COVID-19. However, non-acceptance of COVID-19 vaccination has been a noticeable challenge the world over and in Nigeria where supply constraints have also been an issue. We evaluated COVID-19 vaccination acceptance (the uptake, hesitancy, intention to receive and timeliness of the intention to receive) and the determinants, and the predictive power of acceptance factor compared with availability/access factor, among health workers in Ebonyi state.

METHODS

We conducted an online-offline survey, between 12 March 2022 and 9 May 2022, among all consenting health workers (clinical/non-clinical, public/private) working/living in Ebonyi state and who were selected by convenience and snowballing techniques. Data were collected using structured self-administered questionnaire distributed via WhatsApp and interviewer-administered questionnaire in KoBoCollect installed in android devices. Data were analysed using descriptive statistics and generalised linear models.

RESULTS

1276 health workers were surveyed. Uptake was 68.2% vaccinated, 47.4% fully vaccinated and 20.9% partially vaccinated. Hesitancy was 22.6% or 71.2% among the unvaccinated (76.3% of hesitancy due to refusal and 23.7% to delay). Intention to receive was 36.0% of which 55.1% gave the intended time (days) to receive with a median (IQR) of 30 days (7-133). The strongest and most important predictor of COVID-19 vaccination acceptance was COVID-19 vaccination expectations and perceptions. Other important predictors were COVID-19/COVID-19 vaccination process experiences and perceptions. Acceptance factor was a stronger predictor compared with availability/access factor.

CONCLUSION

The slow pace of COVID-19 vaccination coverage among the health workers in Ebonyi state/Nigeria may encounter a bottle-neck due to the high refusal rate among the unvaccinated. COVID-19 vaccination policy interventions in Nigeria and other similar settings should, in addition to sustaining availability and access, prioritise improvement of COVID-19 vaccination expectations and perceptions (regarding importance/safety/effectiveness) and COVID-19 risk communication among the health workers.

TRIAL REGISTRATION NUMBER

ISRCTN16735844.

HOPPSA update: changes in the study protocol of Hysterectomy and OPPortunistic SAlpingectomy, a registry-based randomized controlled trial

BACKGROUND

The HOPPSA trial is a multi-center national registry-based randomized controlled trial to test the safety and effectiveness of performing opportunistic salpingectomy at hysterectomy to reduce the risk of epithelial ovarian cancer (EOC). The study protocol was first published in January 2019 and is available at https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-018-3083-8 . Here, we report amendments made to the study protocol since commencement of the trial.

CHANGES IN METHODS AND ANALYSIS

The primary outcomes analyses have been changed. (1) Complications will be analyzed using binomial generalized estimating equation (GEE) with log link function, while the unadjusted analyses according to Miettinen and Nurminen will be performed as a sensitivity analysis. (2) Absolute change in Menopause Rating Scale (MRS) will primarily be analyzed using a mixed effects model, adjusted for baseline MRS and center as a random effect. (3) Time to EOC will be analyzed using the mixed effects Cox regression model with center as random effect, while the unadjusted log-rank test will be performed as a sensitivity analysis. The primary outcome Complications will be based solely on the specific assessment in the GynOp quality registry. The Clavien-Dindo classification will be evaluated as a secondary outcome. Furthermore, MRS is also measured three years postoperatively to better pinpoint the onset of menopausal symptoms.

DISCUSSION

The changes to the protocol mainly concern the analyses of data. No changes to recruitment, randomization, intervention, or follow-up of primary outcomes have been made. An interim analysis during 2021 concluded that the study should continue until the target sample size is reached.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03045965 . Registered 8 February 2017.

Valproic acid as adjuvant treatment for convulsive status epilepticus: a randomised clinical trial

BACKGROUND

Generalised convulsive status epilepticus (GCSE) is a medical emergency. Guidelines recommend a stepwise strategy of benzodiazepines followed by a second-line anti-seizure medicine (ASM). However, GCSE is uncontrolled in 20-40% patients and is associated with protracted hospitalisation, disability, and mortality. The objective was to determine whether valproic acid (VPA) as complementary treatment to the stepwise strategy improves the outcomes of patients with de novo established GCSE.

METHODS

This was a multicentre, double-blind, randomised controlled trial in 244 adults admitted to intensive care units for GCSE in 16 French hospitals between 2013 and 2018. Patients received standard care of benzodiazepine and a second-line ASM (except VPA). Intervention patients received a 30 mg/kg VPA loading dose, then a 1 mg/kg/h 12 h infusion, whilst the placebo group received an identical intravenous administration of 0.9% saline as a bolus and continuous infusion. Primary outcome was proportion of patients discharged from hospital by day 15. The secondary outcomes were seizure control, adverse events, and cognition at day 90.

RESULTS

A total of 126 (52%) and 118 (48%) patients were included in the VPA and placebo groups. 224 (93%) and 227 (93%) received a first-line and a second-line ASM before VPA or placebo infusion. There was no between-group difference for patients hospital-discharged at day 15 [VPA, 77 (61%) versus placebo, 72 (61%), adjusted relative risk 1.04; 95% confidence interval (0.89-1.19); p = 0.58]. There were no between-group differences for secondary outcomes.

CONCLUSIONS

VPA added to the recommended strategy for adult GCSE is well tolerated but did not increase the proportion of patients hospital-discharged by day 15.

TRIAL REGISTRATION NO

NCT01791868 (ClinicalTrials.gov registry), registered: 15 February 2012.

AIDS Drug Assistance Program disenrollment is associated with loss of viral suppression beyond differences in homelessness, mental health, and substance use disorders: An evaluation in Washington state 2017-2019

AIDS Drug Assistance Programs (ADAPs) are state-administered programs that pay for medical care for people living with HIV in the US. Maintaining enrollment in the programs is challenging, and a large proportion of clients in Washington state (WA) fail to recertify and are disenrolled. In this study we sought to quantify the impact of disenrollment from ADAPs on viral suppression. We conducted a retrospective cohort study of the 5238 clients in WA ADAP from 2017 to 2019 and estimated the risk difference (RD) of viral suppression before and after disenrollment. We performed a quantitative bias analysis (QBA) to assess the effect of unmeasured confounders, as the factors that contribute to disenrollment and medication discontinuation may overlap. Of the 1336 ADAP clients who disenrolled ≥1 time, 83% were virally suppressed before disenrollment versus 69% after (RD 12%, 95%CI 9-15%). The RD was highest among clients with dual Medicaid-Medicare insurance (RD 22%, 95%CI 9-35%) and lowest among privately insured individuals (RD 8%, 95%CI 5-12%). The results of the QBA suggest that unmeasured confounders do not negate the overall RD. The ADAP recertification procedures negatively impact the care of clients who struggle to stay in the program; alternative procedures may reduce this impact.

COVID-19 vaccination acceptance among community members and health workers in Ebonyi state, Nigeria: study protocol for a concurrent-independent mixed method analyses of intention to receive, timeliness of the intention to receive, uptake and hesitancy to COVID-19 vaccination and the determinants

INTRODUCTION

The COVID-19 pandemic has gravely affected the lives and economies of the global population including Nigeria. The attainment of herd immunity through mass COVID-19 vaccination is the foremost control strategy, however, the deployments of COVID-19 vaccinations are facing challenges of non-acceptance. Despite the efforts of the Nigerian government and COVAX facility in making COVID-19 vaccination more available/accessible, the vaccination rate remains unexpectedly very low in Nigeria/Ebonyi state. Therefore, it is important to investigate the acceptability of COVID-19 vaccination to elucidate the explanations for the very low coverage rate. This study aims to evaluate/explore COVID-19 vaccination acceptance and the determinants among community members and health workers in Ebonyi state, Nigeria.

METHODS AND ANALYSES

The study is an analytical cross-sectional survey with a concurrent-independent mixed method design. Quantitative data will be collected from all consenting/assenting community members aged 15 years and above, in 28 randomly selected geographical clusters, through structured interviewer-administered questionnaire household survey using KoBoCollect installed in android devices. Quantitative data will be collected from all consenting health workers, selected via convenience and snowball techniques, through structured self-administered questionnaire survey distributed via WhatsApp and interviewer-administered survey using KoBoCollect installed in android devices. Qualitative data will be collected from purposively selected community members and health workers through focus group discussions. Quantitative analyses will involve descriptive statistics, generalised estimating equations (for community members data) and generalised linear model (for health workers data). Qualitative analyses will employ the thematic approach.

ETHICS AND DISSEMINATION

Ethical approval for this study was obtained from the Ebonyi State Health Research and Ethics Committee (EBSHREC/15/01/2022-02/01/2023) and Research and Ethics Committee of Alex Ekwueme Federal University Teaching Hospital Abakaliki (14/12/2021-17/02/2022), and verbal consent will be obtained from participants. Study findings will be reported at local, national and international levels as appropriate.

TRIAL REGISTRATION NUMBER

ISRCTN16735844.

Complications, Readmissions, Revisions, and Patient-reported Outcomes in Patients With Parkinson Disease Undergoing Elective Spine Surgery: A Propensity-matched Analysis

STUDY DESIGN

Retrospective analysis on prospectively collected data.

OBJECTIVE

To determine the effectiveness of elective spine surgery in patients with Parkinson disease (PD).

BACKGROUND CONTEXT

PD has become increasingly prevalent in an aging population. While surgical treatment for degenerative spine pathology is often required in this population, previous literature has provided mixed results regarding its effectiveness.

METHODS

Data from the Quality Outcomes Database (QOD) was queried between April 2013 and January 2019. Three surgical groups were identified: (1) elective lumbar surgery, (2) elective cervical surgery for myelopathy, (3) elective cervical surgery for radiculopathy. Patients without PD were propensity matched against patients with PD in a 5:1 ratio without replacement based on American Society of Anesthesiology grade, arthrodesis, surgical approach, number of operated levels, age, and baseline Oswestry Disability Index, Numerical Rating Scale (NRS) extremity pain, NRS back pain, and EuroQol 5-Dimensions (EQ-5D). The mean difference was calculated for continuous outcomes (Oswestry Disability Index, NRS leg pain, NRS back pain, and EQ-5D at 3 and 12 mo after surgery) and the risk difference was calculated for binary outcomes (patient satisfaction, complications, readmission, reoperation, and mortality).

RESULTS

For the lumbar analysis, PD patients had a higher rate of reoperation at 12 months (risk difference=0.057, P =0.015) and lower mean EQ-5D score at 12 months (mean difference=-0.053, P =0.005) when compared with patients without PD. For the cervical myelopathy cohort, PD patients had lower NRS neck pain scores at 3 months (mean difference=-0.829, P =0.005) and lower patient satisfaction at 3 months (risk difference=-0.262, P =0.041) compared with patients without PD. For the cervical radiculopathy cohort, PD patients demonstrated a lower readmission rate at 3 months (risk difference=-0.045, P =0.014) compared with patients without PD.

CONCLUSION

For the matched analysis, in general, patients with and without PD had similar patient-reported outcomes and complication, readmission, and reoperation rates. These results demonstrate that a diagnosis of PD alone should not represent a major contraindication to elective spine surgery.

Lactose-reduced infant formula with corn syrup solids and obesity risk among participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

BACKGROUND

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), a federal nutrition assistance program supporting low-income families, serves half of United States-born infants, most of whom are issued infant formula by age 2 mo. Obesity prevalence is high among children of low-income households, particularly formula-fed children.

OBJECTIVES

This study was conducted to determine whether glucose-based lactose-reduced infant formula made with corn syrup solids (CSSF) is associated with increased obesity risk compared with non-CSSFs that are lactose based.

DESIGN

WIC administrative data on infant formula issuance and child weights and lengths were collected prospectively in Southern California between 2012 and 2020. Included children stopped breastfeeding by 3 mo, were issued cow's milk-based formula through 12 mo, and were enrolled through the final year of WIC eligibility at age 4 y ( n = 15,246). CSSF issuance was assessed continuously (range 0-13 mo) and dichotomously (any, none). Poisson and linear risk regression with robust SE estimates generated risk ratios (RRs), risk differences, and CIs for child obesity [BMI for age (in kg/m 2) ≥95th percentile].

RESULTS

Any CSSF was issued to 23% of children, and 25% were obese at age 4 y. Children with any CSSF issuance had 10% higher obesity risk (RR: 1.10; 95% CI: 1.02, 1.20) than children with no CSSF issuance at age 2 y. Associations remained significant through age 4 y (RR: 1.07; 95% CI: 1.01,1.14), independent of maternal weight status, total formula issued and breastfeeding duration, and were not modified by child race or sex. Obesity risk increased with additional mo of CSSF exposure, reaching 16% higher risk (RR: 1.16; 95% CI: 1.05, 1.28) at age 2 y for children with 12 mo of CSSF.

CONCLUSIONS

CSSF issuance is associated with increased obesity risk in the first 5 y life in a dose dependent manner, independently of maternal weight status, breastfeeding duration, and total formula issuance.

Improving Antibiotic Stewardship for Diarrheal Disease With Probability-Based Electronic Clinical Decision Support: A Randomized Crossover Trial

IMPORTANCE

Inappropriate use of antibiotics for diarrheal illness can result in adverse effects and increase in antimicrobial resistance.

OBJECTIVE

To determine whether the diarrheal etiology prediction (DEP) algorithm, which uses patient-specific and location-specific features to estimate the probability that diarrhea etiology is exclusively viral, impacts antibiotic prescriptions in patients with acute diarrhea.

DESIGN, SETTING, AND PARTICIPANTS

A randomized crossover study was conducted to evaluate the DEP incorporated into a smartphone-based electronic clinical decision-support (eCDS) tool. The DEP calculated the probability of viral etiology of diarrhea, based on dynamic patient-specific and location-specific features. Physicians were randomized in the first 4-week study period to the intervention arm (eCDS with the DEP) or control arm (eCDS without the DEP), followed by a 1-week washout period before a subsequent 4-week crossover period. The study was conducted at 3 sites in Bangladesh from November 17, 2021, to January 21, 2021, and at 4 sites in Mali from January 6, 2021, to March 5, 2021. Eligible physicians were those who treated children with diarrhea. Eligible patients were children between ages 2 and 59 months with acute diarrhea and household access to a cell phone for follow-up.

INTERVENTIONS

Use of the eCDS with the DEP (intervention arm) vs use of the eCDS without the DEP (control arm).

MAIN OUTCOMES AND MEASURES

The primary outcome was the proportion of children prescribed an antibiotic.

RESULTS

A total of 30 physician participants and 941 patient participants (57.1% male; median [IQR] age, 12 [8-18] months) were enrolled. There was no evidence of a difference in the proportion of children prescribed antibiotics by physicians using the DEP (risk difference [RD], -4.2%; 95% CI, -10.7% to 1.0%). In a post hoc analysis that accounted for the predicted probability of a viral-only etiology, there was a statistically significant difference in risk of antibiotic prescription between the DEP and control arms (RD, -0.056; 95% CI, -0.128 to -0.01). No known adverse effects of the DEP were detected at 10-day postdischarge.

CONCLUSIONS AND RELEVANCE

Use of a tool that provides an estimate of etiological likelihood did not result in a significant change in overall antibiotic prescriptions. Post hoc analysis suggests that a higher predicted probability of viral etiology was linked to reductions in antibiotic use.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT04602676.

A predictive clinical model for moderate to severe intraventricular hemorrhage in very low birth weight infants

IMPORTANCE

Intraventricular hemorrhage (IVH) occurs in 15-45% of all very low birth weight (VLBW) preterm infants. Despite improvements in the perinatal care, the incidence of IVH remains high. As more preterm infants survive, there will be a larger burden of neurodevelopmental abnormalities borne by former preterm infants.

OBJECTIVE

The objective of this study was to develop a predictive clinical model of IVH risk within the first few hours of life in an effort to augment perinatal counseling and guide the timing of future targeted therapies aimed at preventing or slowing the progression of disease.

DESIGN

This is a prospective observational cohort study of VLBW infants born in the NICU at John's Hopkins Children's Center from 2011 to 2019. The presence and severity of IVH was defined on standard head ultrasound screening (HUS) using the modified Papile classification. Clinical variables were identified as significant using absolute risk regression from a general linear model. The model predictors included clinically meaningful variables that were not collinear.

SETTING

This study took place at the Johns Hopkins Children's Center Level IV NICU.

PARTICIPANTS

The study sample included VLBW infants treated in the neonatal intensive care unit (NICU) at John's Hopkins Children's Center from 2011 to 2019. A total of 683 infants included in the study had no or grade I IVH, and 115 infants had grades II through IV IVH. Exclusion criteria included admission to the JHH NICU after 24 h of age, BW > 1500 g, and failure to consent.

MAIN OUTCOME

The main outcome of this study was the presence of grades II-IV IVH on standard head ultrasound screening using the modified Papile classification [1].

RESULTS

A total of 798 VLBW infants were studied in this cohort and 14.4% had moderate to severe IVH. Fifty four percent of the cohort was black, 33% white, and half of the cohort was male. A higher gestational age, 5-min Apgar score, hematocrit, and platelet count were significantly associated with decreased incidence of IVH in a multi-predictor model (ROC 0.826).

CONCLUSION AND RELEVANCE

In the face of continued lack of treatments for IVH, prevention is still a primary goal to avoid long-term developmental sequela. This model can be used for perinatal counseling and may provide important information during the narrow therapeutic window for targeted prevention therapies.

"Sedation versus General Anesthesia For Tracheal Intubation In Children With Difficult Airways: A Cohort Study from the Pediatric Difficult Intubation Registry."

BACKGROUND

Sedated and awake tracheal intubation approaches are considered safest in adults with difficult airways, but little is known about the outcomes of sedated intubations in children. The primary aim of our study is to compare the first attempt success rate of tracheal intubation during sedated tracheal intubation vs. tracheal intubation under general anesthesia (GA). We hypothesized that sedated intubation would be associated with a lower first attempt success rate and more complications than general anesthesia.

METHODS

We used data from an international observational registry, Pediatric Difficult Intubation Registry, which prospectively collects data about tracheal intubation in children with difficult airways. We compared the use of sedation versus general anesthesia for tracheal intubation. Our primary outcome was the first-attempt success of tracheal intubation. Secondary outcomes included the number of intubation attempts and non-severe and severe complications. We used propensity score matching with a matching ratio up to 1:15 to reduce bias due to measured confounders.

RESULTS

Between 2017 and 2020, 34 hospitals submitted 1839 anticipated difficult airway cases that met inclusion criteria for the study. Of these, 75 patients received sedation and 1764 patients received GA. Propensity score matching resulted in 58 patients in the sedation group and 522 patients in the GA group. The rate of first-attempt success of tracheal intubation was 28/58 (48.3%) in the sedation group and 250/522 (47.9%) in the GA-group (OR 1.06, 95% CI 0.60 - 1.87; p=0.846); The median number of intubations attempts was 2 [IQR 1, 3] in the sedation group and 2 [IQR 1, 2] in the GA group. The GA group had 6/522 (1.1%) intubation failures versus 0/58 in the sedation group. However, Sixteen of fifty-eight (27.6%) sedation cases had to be converted to GA for successful tracheal intubation. Complications were similar between the groups, and the rate of severe complications was low.

CONCLUSION

Sedation and GA had a similar rate of first-attempt success of tracheal intubation in children with difficult airways; however, 27.6% of the sedation cases needed to be converted to GA to complete tracheal intubation. Complications overall were similar between the groups, and the rate of severe complications was low.

Impact of a Postintensive Care Unit Multidisciplinary Follow-up on the Quality of Life (SUIVI-REA): Protocol for a Multicenter Randomized Controlled Trial

Background

Critically ill patients are at risk of developing a postintensive care syndrome (PICS), which is characterized by physical, psychological, and cognitive impairments and which dramatically impacts the patient’s quality of life (QoL). No intervention has been shown to improve QoL. We hypothesized that a medical, psychological, and social follow-up would improve QoL by mitigating the PICS.

Objective

This multicenter, randomized controlled trial (SUIVI-REA) aims to compare a multidisciplinary follow-up with a standard postintensive care unit (ICU) follow-up.

Methods

Patients were randomized to the control or intervention arm. In the intervention arm, multidisciplinary follow-up involved medical, psychological, and social evaluation at ICU discharge and at 3, 6, and 12 months thereafter. In the placebo group, patients were seen only at 12 months by the multidisciplinary team. Baseline characteristics at ICU discharge were collected for all patients. The primary outcome was QoL at 1 year, assessed using the Euro Quality of Life-5 dimensions (EQ5D). Secondary outcomes were mortality, cognitive, psychological, and functional status; social and professional reintegration; and the rate of rehospitalization and outpatient consultations at 1 year.

Results

The study was funded by the Ministry of Health in June 2010. It was approved by the Ethics Committee on July 8, 2011. The first and last patient were randomized on December 20, 2012, and September 1, 2017, respectively. A total of 546 patients were enrolled across 11 ICUs. At present, data management is ongoing, and all parties involved in the trial remain blinded.

Conclusions

The SUVI-REA multicenter randomized controlled trial aims to assess whether a post-ICU multidisciplinary follow-up improves QoL at 1 year.

Trial Registration

Clinicaltrials.gov NCT01796509; https://clinicaltrials.gov/ct2/show/NCT01796509

International Registered Report Identifier (IRRID)

DERR1-10.2196/30496

Screening for Atrial Fibrillation in Older Adults at Primary Care Visits: VITAL-AF Randomized Controlled Trial

BACKGROUND

Undiagnosed atrial fibrillation (AF) may cause preventable strokes. Guidelines differ regarding AF screening recommendations. We tested whether point-of-care screening with a handheld single-lead ECG at primary care practice visits increases diagnoses of AF.

METHODS

We randomized 16 primary care clinics 1:1 to AF screening using a handheld single-lead ECG (AliveCor KardiaMobile) during vital sign assessments, or usual care. Patients included were ages ≥65 years. Screening results were provided to primary care clinicians at the encounter. All confirmatory diagnostic testing and treatment decisions were made by the primary care clinician. New AF diagnoses during the 1-year follow-up were ascertained electronically and manually adjudicated. Proportions and incidence rates were calculated. Effect heterogeneity was assessed.

RESULTS

Of 30 715 patients without prevalent AF (n=15 393 screening [91% screened], n=15 322 control), 1.72% of individuals in the screening group had new AF diagnosed at 1 year versus 1.59% in the control group (risk difference, 0.13% [95% CI, -0.16 to 0.42]; P=0.38). In prespecified subgroup analyses, new AF diagnoses in the screening and control groups were greater among those aged ≥85 years (5.56% versus 3.76%, respectively; risk difference, 1.80% [95% CI, 0.18 to 3.30]). The difference in newly diagnosed AF between the screening period and the previous year was marginally greater in the screening versus control group (0.32% versus -0.12%; risk difference, 0.43% [95% CI, -0.01 to 0.84]). The proportion of individuals with newly diagnosed AF who were initiated on oral anticoagulants was not different in the screening (n=194, 73.5%) and control (n=172, 70.8%) arms (risk difference, 2.7% [95% CI, -5.5 to 10.4]).

CONCLUSIONS

Screening for AF using a single-lead ECG at primary care visits did not affect new AF diagnoses among all individuals aged 65 years or older compared with usual care.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03515057.

Evaluating the heterogeneous effect of a modifiable risk factor on suicide: The case of vitamin D deficiency

OBJECTIVES

To illustrate the use of machine learning methods to search for heterogeneous effects of a target modifiable risk factor on suicide in observational studies. The illustration focuses on secondary analysis of a matched case-control study of vitamin D deficiency predicting subsequent suicide.

METHODS

We describe a variety of machine learning methods to search for prescriptive predictors; that is, predictors of significant variation in the association between a target risk factor and subsequent suicide. In each case, the purpose is to evaluate the potential value of selective intervention on the target risk factor to prevent the outcome based on the provisional assumption that the target risk factor is causal. The approaches illustrated include risk modeling based on the super learner ensemble machine learning method, Least Absolute Shrinkage and Selection Operator (Lasso) penalized regression, and the causal forest algorithm.

RESULTS

The logic of estimating heterogeneous intervention effects is exposited along with the illustration of some widely used methods for implementing this logic.

CONCLUSIONS

In addition to describing best practices in using the machine learning methods considered here, we close with a discussion of broader design and analysis issues in planning an observational study to investigate heterogeneous effects of a modifiable risk factor.

Association of an Advance Care Planning Video and Communication Intervention With Documentation of Advance Care Planning Among Older Adults: A Nonrandomized Controlled Trial

IMPORTANCE

COVID-19 has disproportionately killed older adults and racial and ethnic minority individuals, raising questions about the relevance of advance care planning (ACP) in this population. Video decision aids and communication skills training offer scalable delivery models.

OBJECTIVE

To assess whether ACP video decision aids and a clinician communication intervention improved the rate of ACP documentation during an evolving pandemic, with a focus on African American and Hispanic patients.

DESIGN, SETTING, AND PARTICIPANTS

The Advance Care Planning: Communicating With Outpatients for Vital Informed Decisions trial was a pre-post, open-cohort nonrandomized controlled trial that compared ACP documentation across the baseline pre-COVID-19 period (September 15, 2019, to March 14, 2020), the COVID-19 wave 1 period (March 15, 2020, to September 14, 2020), and an intervention period (December 15, 2020, to June 14, 2021) at a New York metropolitan area ambulatory network of 22 clinics. All patients 65 years or older who had at least 1 clinic or telehealth visit during any of the 3 study periods were included.

MAIN OUTCOMES AND MEASURES

The primary outcome was ACP documentation.

RESULTS

A total of 14 107 patients (mean [SD] age, 81.0 [8.4] years; 8856 [62.8%] female; and 2248 [15.9%] African American or Hispanic) interacted with clinicians during the pre-COVID-19 period; 12 806 (mean [SD] age, 81.2 [8.5] years; 8047 [62.8%] female; and 1992 [15.6%] African American or Hispanic), during wave 1; and 15 106 (mean [SD] 80.9 [8.3] years; 9543 [63.2%] female; and 2535 [16.8%] African American or Hispanic), during the intervention period. Clinicians documented ACP in 3587 patients (23.8%) during the intervention period compared with 2525 (17.9%) during the pre-COVID-19 period (rate difference [RD], 5.8%; 95% CI, 0.9%-7.9%; P = .01) and 1598 (12.5%) during wave 1 (RD, 11.3%; 95% CI, 6.3%-12.1%; P < .001). Advance care planning was documented in 447 African American patients (30.0%) during the intervention period compared with 233 (18.1%) during the pre-COVID-19 period (RD, 11.9%; 95% CI, 4.1%-15.9%; P < .001) and 130 (11.0%) during wave 1 (RD, 19.1%; 95% CI, 11.7%-21.2%; P < .001). Advance care planning was documented for 222 Hispanic patients (21.2%) during the intervention period compared with 127 (13.2%) during the pre-COVID-19 period (RD, 8.0%; 95% CI, 2.1%-10.9%; P = .004) and 82 (10.2%) during wave 1 (RD, 11.1%; 95% CI, 5.5%-14.5%; P < .001).

CONCLUSIONS AND RELEVANCE

This intervention, implemented during the evolving COVID-19 pandemic, was associated with higher rates of ACP documentation, especially for African American and Hispanic patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04660422.

Effect of Moderate Hypothermia vs Normothermia on 30-Day Mortality in Patients With Cardiogenic Shock Receiving Venoarterial Extracorporeal Membrane Oxygenation: A Randomized Clinical Trial

IMPORTANCE

The optimal approach to the use of venoarterial extracorporeal membrane oxygenation (ECMO) during cardiogenic shock is uncertain.

OBJECTIVE

To determine whether early use of moderate hypothermia (33-34 °C) compared with strict normothermia (36-37 °C) improves mortality in patients with cardiogenic shock receiving venoarterial ECMO.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial of patients (who were eligible if they had been endotracheally intubated and were receiving venoarterial ECMO for cardiogenic shock for <6 hours) conducted in the intensive care units at 20 French cardiac shock care centers between October 2016 and July 2019. Of 786 eligible patients, 374 were randomized. Final follow-up occurred in November 2019.

INTERVENTIONS

Early moderate hypothermia (33-34 °C; n = 168) for 24 hours or strict normothermia (36-37 °C; n = 166).

MAIN OUTCOMES AND MEASURES

The primary outcome was mortality at 30 days. There were 31 secondary outcomes including mortality at days 7, 60, and 180; a composite outcome of death, heart transplant, escalation to left ventricular assist device implantation, or stroke at days 30, 60, and 180; and days without requiring a ventilator or kidney replacement therapy at days 30, 60, and 180. Adverse events included rates of severe bleeding, sepsis, and number of units of packed red blood cells transfused during venoarterial ECMO.

RESULTS

Among the 374 patients who were randomized, 334 completed the trial (mean age, 58 [SD, 12] years; 24% women) and were included in the primary analysis. At 30 days, 71 patients (42%) in the moderate hypothermia group had died vs 84 patients (51%) in the normothermia group (adjusted odds ratio, 0.71 [95% CI, 0.45 to 1.13], P = .15; risk difference, -8.3% [95% CI, -16.3% to -0.3%]). For the composite outcome of death, heart transplant, escalation to left ventricular assist device implantation, or stroke at day 30, the adjusted odds ratio was 0.61 (95% CI, 0.39 to 0.96; P = .03) for the moderate hypothermia group compared with the normothermia group and the risk difference was -11.5% (95% CI, -23.2% to 0.2%). Of the 31 secondary outcomes, 30 were inconclusive. The incidence of moderate or severe bleeding was 41% in the moderate hypothermia group vs 42% in the normothermia group. The incidence of infections was 52% in both groups. The incidence of bacteremia was 20% in the moderate hypothermia group vs 30% in the normothermia group.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial involving patients with refractory cardiogenic shock treated with venoarterial ECMO, early application of moderate hypothermia for 24 hours did not significantly increase survival compared with normothermia. However, because the 95% CI was wide and included a potentially important effect size, these findings should be considered inconclusive.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02754193.

Evaluation of the Swedish school-based program "tobacco-free DUO" in a cluster randomized controlled trial (TOPAS study). Results at 2-year follow-up

Friends' and parents' tobacco use are strong predictors of tobacco uptake among adolescents, however the effectiveness of interventions based on public commitments and agreements to remain tobacco-free are not established. Here, we evaluated the effectiveness of the school-based Swedish program Tobacco-Free Duo (T-Duo) in preventing adolescents from initiating tobacco use (TOPAS study). T-Duo is a multi-component intervention witha formal agreement between a student and an adult partner to remain tobacco-free during the entire 3-year study period as core component. The standardized educational component of the same program was used as comparator (control). Primary outcome was the probability to "remain a non-user" of i) cigarettes and secondary outcomes ii) other types of tobacco at second (21-month) follow-up. Analysis was conducted according to Intention To Treat. In total 1776 adolescents (51% female) aged 12-13 in grade 7 from 34 participating high schools in Sweden were included at baseline in 2018, of which 1489 were retained after 21 months. The Risk Ratio (RR) of not having tried cigarettes 21-months after initiation of the intervention was 1.03(CI 0.98-1.08), Bayes Factor(BF) = 0.93, Absolute Risk Difference(ARD) = 3.1%. Similar associations were found for never smoked a whole cigarette and never use of other tobacco/nicotine products. There was a minimal reduction of tobacco use initiation among Swedish adolescents assigned to a multi-component intervention (T-Duo) compared to those assigned to standardized classroom education after 2 schoolyears. However, for most outcomes' findings were inconclusive and not reliably different from zero. Trial registration: ISRCTN5285808 (doi:https://doi.org/10.1186/ISRCTN52858080); Study protocol: DERR1-https://doi.org/10.2196/21100. Registration: Current Controlled Trials ISRCTN52858080 Date: January 4, 2019, retrospectively registered. Protocol: Galanti, M.R., Pulkki-Brännström, A.-M., Nilsson, M., 2020. Tobacco-free duo adult-child contract for prevention of tobacco use among adolescents and parents: protocol for a mixed-design evaluation. JMIR Res. Protoc. 9, e21100. doi:10.2196/21100.

Postoperative outcomes of cancer surgery in patients with and without kidney failure with dialysis therapy: A matched-pair cohort study

Background

The difference in outcomes of cancer surgery between patients with and without kidney failure with dialysis therapy (KFDT) remains uncertain.

Methods

Using 2010–18 data in a national inpatient database in Japan, we identified patients who had undergone resection of colorectal, lung, gastric or breast cancer. We matched selected patient characteristics, type of cancer, surgical procedure and hospital of up to four patients without KFDT to each patient with KFDT. We assessed 30-day mortality and postoperative complications.

Results

Through matching, we identified 2248 patients with KFDT (807 with colorectal, 579 with lung, 500 with gastric and 362 with breast cancer) and 8210 patients without KFDT (2851 with colorectal, 2216 with lung, 1756 with gastric and 1387 with breast cancer). Postoperative complications occurred in a higher proportion of patients with KFDT than of those without KFDT after colorectal {20.3% versus 14.6%; risk difference (RD): 5.7% [95% confidence interval (95% CI) 2.6%–8.8%]}, lung [18.0% versus 12.9%; RD: 5.1% (95% CI 1.6%–8.4%)], gastric [25.0% versus 13.2%; RD: 11.8% (95% CI 7.6%–16.2%)] and breast cancer surgery [7.5% versus 3.5%; RD: 3.9% (95% CI 1.1%–6.9%)]. Patients with KFDT had a higher 30-day mortality than those without KFDT after gastric cancer surgery [1.6% versus 0.3%; RD: 1.3% (95% CI 0.1%–2.3%)]. Heart failure and ischemic heart disease occurred more frequently in patients with KFDT.

Conclusions

Patients with KFDT had higher rates of postoperative complications and 30-day mortality; however, RDs varied between cancer types. The higher rates of postoperative complications in patients with KFDT were mainly attributable to cardiovascular complications.

The changing relationship between health risk behaviors and depression among birth cohorts of Canadians 65+, 1994-2014

BACKGROUND AND OBJECTIVE

The older adult residents of Canada form an increasingly larger proportion of the population and are becoming better educated and have more income. Depression is a common mental disorder, particularly among seniors. Several health risk behaviors-physical inactivity, tobacco use, and alcohol consumption-are linked to mental health problems. This study examines whether these health risk behaviors and their association with depression among Canadians 65+ born in eight cohorts between 1910-1914 and 1945-1949, have changed.

METHODS

Pooled data drawn from 11 nationally representative health surveys conducted by Statistics Canada between 1994 and 2014 are analyzed-88,675 survey participants met inclusion criteria. Depression was assessed by the Composite International Diagnostic Interview-Short Form. Health risk behaviors examined were physical activity/inactivity, smoking, and alcohol use. A Cochran Armitage trend test for categorical outcomes and a log-binomial modeling for binary outcomes were used to estimate the risk ratios across cohorts.

RESULTS

The proportions of Canadians 65+ who are physically active, regular drinkers, and regular smokers have increased; however, depression prevalence fluctuated non-significantly. Depression increased among all health risk behaviors, particularly in recent birth cohorts. Depression among physically inactive seniors, current smokers, and non-drinkers was significantly higher than among active, non-smokers, and regular drinkers (all P < 0.05). Physical inactivity and smoking-attributable depression risk showed an increasing linear trend across birth cohorts (RR = 1.67, P < 0.001; RR = 1.79, P < 0.001). For seniors born between 1915 and 1944, regular drinking was associated with a significant decrease in depression (all P < 0.001), but the protective effects of regular drinking became non-existent in the most recent 1945-1949 birth cohort (RR = 1.09, P < 0.05, after adjusting for covariates).

CONCLUSION

Inactivity and smoking were consistently associated with a significantly increased risk of depression among Canadian residents 65+, with smoking becoming more firmly connected to depression risk in more recent birth cohorts. In contrast, moderate alcohol use was associated with a decreased risk of depression, but that protective effect ceased in most recent birth cohort. Identifying the changing relationships between health risk behaviors and depression is meaningful for developing prevention strategies for depression and other emotional and mental health problems.

Incentivizing Excellent Care to At-Risk Groups with a Health Equity Summary Score

BACKGROUND

Social risk factors (SRFs) such as minority race-and-ethnicity or low income are associated with quality-of-care, health, and healthcare outcomes. Organizations might prioritize improving care for easier-to-treat groups over those with SRFs, but measuring, reporting, and further incentivizing quality-of-care for SRF groups may improve their care.

OBJECTIVE

To develop, as a proof-of-concept, a Health Equity Summary Score (HESS): a succinct, easy-to-understand score that could be used to promote high-quality care to those with SRFs in Medicare Advantage (MA) health plans, which provide care for almost twenty million older and disabled Americans and collect extensive quality measure and SRF data.

DESIGN

We estimated, standardized, and combined performance scores for two sets of quality measures for enrollees in 2013-2016 MA health plans, considering both current levels of care, within-plan improvement, and nationally benchmarked improvement for those with SRFs (specifically, racial-and-ethnic minority status and dual-eligibility for Medicare and Medicaid).

PARTICIPANTS

All MA plans with publicly reported quality scores and 500 or more 2016 enrollees.

MAIN MEASURES

Publicly reported clinical quality and patient experience measures.

KEY RESULTS

Almost 90% of plans measured for MA Star Ratings received a HESS; plans serving few patients with SRFs were excluded. The summary score was moderately positively correlated with publicly reported overall Star Ratings (r = 0.66-0.67). High-scoring plans typically had sizable enrollment of both racial-and-ethnic minorities (38-42%) and dually eligible beneficiaries (29-38%).

CONCLUSIONS

We demonstrated the feasibility of developing and estimating a HESS that is intended to promote and incentivize excellent care for racial-and-ethnic minorities and dually eligible MA enrollees. The HESS measures SRF-specific performance and does not simply duplicate overall plan Star Ratings. It also identifies plans that provide excellent care to large numbers of those with SRFs. Our methodology could be extended to other SRFs, quality measures, and settings.

High-Sensitivity Cardiac Troponin on Presentation to Rule Out Myocardial Infarction: A Stepped-Wedge Cluster Randomized Controlled Trial

BACKGROUND

High-sensitivity cardiac troponin assays enable myocardial infarction to be ruled out earlier, but the safety and efficacy of this approach is uncertain. We investigated whether an early rule-out pathway is safe and effective for patients with suspected acute coronary syndrome.

METHODS

We performed a stepped-wedge cluster randomized controlled trial in the emergency departments of 7 acute care hospitals in Scotland. Consecutive patients presenting with suspected acute coronary syndrome between December 2014 and December 2016 were included. Sites were randomized to implement an early rule-out pathway where myocardial infarction was excluded if high-sensitivity cardiac troponin I concentrations were <5 ng/L at presentation. During a previous validation phase, myocardial infarction was ruled out when troponin concentrations were <99th percentile at 6 to 12 hours after symptom onset. The coprimary outcome was length of stay (efficacy) and myocardial infarction or cardiac death after discharge at 30 days (safety). Patients were followed for 1 year to evaluate safety and other secondary outcomes.

RESULTS

We enrolled 31 492 patients (59±17 years of age [mean±SD]; 45% women) with troponin concentrations <99th percentile at presentation. Length of stay was reduced from 10.1±4.1 to 6.8±3.9 hours (adjusted geometric mean ratio, 0.78 [95% CI, 0.73-0.83]; P<0.001) after implementation and the proportion of patients discharged increased from 50% to 71% (adjusted odds ratio, 1.59 [95% CI, 1.45-1.75]). Noninferiority was not demonstrated for the 30-day safety outcome (upper limit of 1-sided 95% CI for adjusted risk difference, 0.70% [noninferiority margin 0.50%]; P=0.068), but the observed differences favored the early rule-out pathway (0.4% [57/14 700] versus 0.3% [56/16 792]). At 1 year, the safety outcome occurred in 2.7% (396/14 700) and 1.8% (307/16 792) of patients before and after implementation (adjusted odds ratio, 1.02 [95% CI, 0.74-1.40]; P=0.894), and there were no differences in hospital reattendance or all-cause mortality.

CONCLUSIONS

Implementation of an early rule-out pathway for myocardial infarction reduced length of stay and hospital admission. Although noninferiority for the safety outcome was not demonstrated at 30 days, there was no increase in cardiac events at 1 year. Adoption of this pathway would have major benefits for patients and health care providers. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03005158.

Serial Neurologic Assessment in Pediatrics (SNAP): A New Tool for Bedside Neurologic Assessment of Critically Ill Children

OBJECTIVES

We developed a tool, Serial Neurologic Assessment in Pediatrics, to screen for neurologic changes in patients, including those who are intubated, are sedated, and/or have developmental disabilities. Our aims were to: 1) determine protocol adherence when performing Serial Neurologic Assessment in Pediatrics, 2) determine the interrater reliability between nurses, and 3) assess the feasibility and acceptability of using Serial Neurologic Assessment in Pediatrics compared with the Glasgow Coma Scale.

DESIGN

Mixed-methods, observational cohort.

SETTING

Pediatric and neonatal ICUs.

SUBJECTS

Critical care nurses and patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Serial Neurologic Assessment in Pediatrics assesses Mental Status, Cranial Nerves, Communication, and Motor Function, with scales for children less than 6 months, greater than or equal to 6 months to less than 2 years, and greater than or equal to 2 years old. We assessed protocol adherence with standardized observations. We assessed the interrater reliability of independent Serial Neurologic Assessment in Pediatrics assessments between pairs of trained nurses by percent- and bias- adjusted kappa and percent agreement. Semistructured interviews with nurses evaluated acceptability and feasibility after nurses used Serial Neurologic Assessment in Pediatrics concurrently with Glasgow Coma Scale during routine care. Ninety-eight percent of nurses (43/44) had 100% protocol adherence on the standardized checklist. Forty-three nurses performed 387 paired Serial Neurologic Assessment in Pediatrics assessments (149 < 6 mo; 91 ≥ 6 mo to < 2 yr, and 147 ≥ 2 yr) on 299 patients. Interrater reliability was substantial to near-perfect across all components for each age-based Serial Neurologic Assessment in Pediatrics scale. Percent agreement was independent of developmental disabilities for all Serial Neurologic Assessment in Pediatrics components except Mental Status and lower extremity Motor Function for patients deemed "Able to Participate" with the assessment. Nurses reported that they felt Serial Neurologic Assessment in Pediatrics, compared with Glasgow Coma Scale, was easier to use and clearer in describing the neurologic status of patients who were intubated, were sedated, and/or had developmental disabilities. About 92% of nurses preferred to use Serial Neurologic Assessment in Pediatrics over Glasgow Coma Scale.

CONCLUSIONS

When used by critical care nurses, Serial Neurologic Assessment in Pediatrics has excellent protocol adherence, substantial to near-perfect interrater reliability, and is feasible to implement. Further work will determine the sensitivity and specificity for detecting clinically meaningful neurologic decline.

Twelve-Month Outcomes of Community-Based Differentiated Models of Multimonth Dispensing of ART Among Stable HIV-Infected Adults in Lesotho: A Cluster-Randomized Noninferiority Trial

BACKGROUND

Lesotho adopted the test-and-treat approach for HIV treatment in June 2016, which increased antiretroviral treatment (ART) clinic volume. We evaluated community-based vs. facility-based differentiated models of multimonth dispensing of ART among stable HIV-infected adults in Lesotho.

METHODS

Thirty facilities were randomized to 3 arms, facility 3-monthly ART (3MF) (control), community ART groups (3MC), and 6-monthly community distribution points (6MCD). We estimated risk differences (RDs) between arms using population-averaged generalized estimating equations, controlling for baseline imbalances and specifying for clustering. The primary outcome was retention in ART care by intention-to-treat and virologic suppression as a secondary outcome (ClinicalTrials.gov: NCT03438370).

RESULTS

A total of 5,336 participants were enrolled, with 1898, 1558, and 1880 in 3MF, 3MC, and 6MCD, respectively. Retention in ART care was not different across arms and achieved the prespecified noninferiority limit (-3.25%) between 3MC vs. 3MF (control); 6MCD vs. 3MF; and 6MCD vs. 3MC, adjusted RD = -0.1% [95% confidence interval (CI): -1.6% to 1.5%], adjusted RD = -1.3% (95% CI: -3.0% to 0.5%), and adjusted RD = -1.2% (95% CI: -2.9% to 0.5%), respectively. After 12 months, 98.6% (n = 1503), 98.1% (n = 1126), and 98.3% (n = 1285) were virally load (VL) suppressed in 3MF, 3MC, and 6MCD, respectively. There were no differences in VL between 3MC vs. control and 6MCD vs. control, risk ratio (RR) = 1.00 (95% CI: 0.98 to 1.01) and RR = 1.00 (95% CI: 0.98 to 1.01), respectively.

CONCLUSIONS

There were no differences in retention and VL suppression for stable HIV-infected participants receiving multimonth dispensing of ART within community-based differentiated models when compared with the facility-based standard-of-care model.

Hospital-based acute care in the last 30 days of life among patients with chronic disease that received early, late or no specialist palliative care: a retrospective cohort study of eight chronic disease groups

OBJECTIVE

For eight chronic diseases, evaluate the association of specialist palliative care (PC) exposure and timing with hospital-based acute care in the last 30 days of life.

DESIGN

Retrospective cohort study using administrative data.

SETTING

Alberta, Canada between 2007 and 2016.

PARTICIPANTS

47 169 adults deceased from: (1) cancer, (2) heart disease, (3) dementia, (4) stroke, (5) chronic lower respiratory disease (chronic obstructive pulmonary disease (COPD)), (6) liver disease, (7) neurodegenerative disease and (8) renovascular disease.

MAIN OUTCOME MEASURES

The proportion of decedents who experienced high hospital-based acute care in the last 30 days of life, indicated by ≥two emergency department (ED) visit, ≥two hospital admissions,≥14 days of hospitalisation, any intensive care unit (ICU) admission, or death in hospital. Relative risk (RR) and risk difference (RD) of hospital-based acute care given early specialist PC exposure (≥90 days before death), adjusted for patient characteristics.

RESULTS

In an analysis of all decedents, early specialist PC exposure was associated with a 32% reduction in risk of any hospital-based acute care as compared with those with no PC exposure (RR 0.69, 95% CI 0.66 to 0.71; RD 0.16, 95% CI 0.15 to 0.17). The association was strongest in cancer-specific analyses (RR 0.53, 95% CI 0.50 to 0.55; RD 0.31, 95% CI 0.29 to 0.33) and renal disease-specific analyses (RR 0.60, 95% CI 0.43 to 0.84; RD 0.22, 95% CI 0.11 to 0.34), but a~25% risk reduction was observed for each of heart disease, COPD, neurodegenerative diseases and stroke. Early specialist PC exposure was associated with reducing risk of four out of five individual indicators of high hospital-based acute care in the last 30 days of life, including ≥two ED visit,≥two hospital admission, any ICU admission and death in hospital.

CONCLUSIONS

Early specialist PC exposure reduced the risk of hospital-based acute care in the last 30 days of life for all chronic disease groups except dementia.

Effectiveness of a universal vaccination program with an HPV quadrivalent vaccine in young Brazilian women

We examined human papillomavirus (HPV) vaccine effectiveness in a nationwide sample of women aged 16 to 25 years who utilized the public health system in Brazil. This was a cross-sectional, multicentric survey conducted between September 2016 and November 2017 (POP-Brazil Study). A total of 5,945 young adult women were recruited from 119 public primary care units from all 27 federative units of Brazil by trained health professionals. The participants participated in a face-to-face interview and provided biological samples for genital HPV analysis. HPV genotyping was performed using a Linear Array HPV genotyping test in a central laboratory. Sampling weights were applied to the data. Overall, 11.92% (95% CI 10.65, 13.20) of the participants reported having been vaccinated. The frequency of vaccination was highest in 16- to 17-year-old women, with a decreasing vaccination rate with increasing age, and vaccinated women were more likely to belong to the high socioeconomic status group. The use of a quadrivalent vaccine decreased the HPV types 6, 11, 16, and 18 by 56.78%, from 15.64% in unvaccinated women to 6.76% in vaccinated women (P < 0.01), even after adjustment for age. Those who received the vaccine had lower HPV 16 (2.34% in vaccinated vs 8.91% in unvaccinated, P < 0.01) and 6 rates (2.06% vs 5.77%, P < 0.01). Additionally, a higher rate of high-risk HPV types other than HPV 16 and 18 (40.47% in vaccinated vs 32.63% in unvaccinated, P < 0.01) was observed. In conclusion, the results of this study support the effectiveness of HPV vaccination in Brazil. Continuous surveillance must be assured to monitor the HPV infection rate in the vaccination era.

Valproic Acid as an Adjuvant Treatment for Generalized Convulsive Status Epilepticus in Adults Admitted to Intensive Care Units: Protocol for a Double-Blind, Multicenter Randomized Controlled Trial

Background

Generalized convulsive status epilepticus (GCSE) is a frequent medical emergency. GCSE treatment focuses on the administration of benzodiazepines followed by a second-line antiepileptic drug (AED). Despite this stepwise strategy, GCSE is not controlled in one-quarter of patients and is associated with protracted hospitalization, high mortality, and long-term disability. Valproic acid (VPA) is an AED with good tolerability and neuroprotective properties.

Objective

This study aims to demonstrate that administration of VPA as an adjuvant for first- and second-line treatment in GCSE can improve outcomes.

Methods

A multicenter, double-blind, randomized controlled trial was conducted, comparing VPA with a placebo in adults admitted to intensive care units (ICUs) for GCSE in France. GCSE was diagnosed by specifically trained ICU physicians according to standard criteria. All patients received standard of care, including a benzodiazepine and a second-line AED (not VPA), at the discretion of the treating medical team. In the intervention arm, VPA was administered intravenously at a loading dose of 30 mg/kg over 15 minutes, followed by a continuous infusion of 1 mg/kg/hour over the next 12 hours. In the placebo group, an identical intravenous administration of 0.9% saline was used. The primary outcome was the proportion of patients discharged alive from the hospital by day 15. Secondary outcomes were frequency of refractory and super refractory GCSE, ICU-related morbidity, adverse events related to VPA, and cognitive dysfunction at 3 months. Statistical analyses will be performed according to the intent-to-treat principle.

Results

The first patient was randomized on February 18, 2013, and the last patient was randomized on July 7, 2018. Of 248 planned patients, 98.7% (245/248) were enrolled across 20 ICUs. At present, data management is still ongoing, and all parties involved in the trial remain blinded.

Conclusions

The Valproic Acid as an Adjuvant Treatment for Generalized Convulsive Status Epilepticus (VALSE) trial will evaluate whether the use of VPA as an adjuvant for first- and second-line treatment in GCSE improves outcomes.

Trial Registration

ClinicalTrials.gov NCT01791868; https://clinicaltrials.gov/ct2/show/NCT01791868.

International Registered Report Identifier (IRRID)

DERR1-10.2196/22511

Hypofractionated radiotherapy in locally advanced bladder cancer: an individual patient data meta-analysis of the BC2001 and BCON trials

BACKGROUND

Two radiotherapy fractionation schedules are used to treat locally advanced bladder cancer: 64 Gy in 32 fractions over 6·5 weeks and a hypofractionated schedule of 55 Gy in 20 fractions over 4 weeks. Long-term outcomes of these schedules in several cohort studies and case series suggest that response, survival, and toxicity are similar, but no direct comparison has been published. The present study aimed to assess the non-inferiority of 55 Gy in 20 fractions to 64 Gy in 32 fractions in terms of invasive locoregional control and late toxicity in patients with locally advanced bladder cancer.

METHODS

We did a meta-analysis of individual patient data from patients (age ≥18 years) with locally advanced bladder cancer (T1G3 [high-grade non-muscle invasive] or T2-T4, N0M0) enrolled in two multicentre, randomised, controlled, phase 3 trials done in the UK: BC2001 (NCT00024349; assessing addition of chemotherapy to radiotherapy) and BCON (NCT00033436; assessing hypoxia-modifying therapy combined with radiotherapy). In each trial, the fractionation schedule was chosen according to local standard practice. Co-primary endpoints were invasive locoregional control (non-inferiority margin hazard ratio [HR]=1·25); and late bladder or rectum toxicity, assessed with the Late Effects Normal Tissue Task Force-Subjective, Objective, Management, Analytic tool (non-inferiority margin for absolute risk difference [RD]=10%). If non-inferiority was met for invasive locoregional control, superiority could be considered if the 95% CI for the treatment effect excluded the null effect (HR=1). One-stage individual patient data meta-analysis models for the time-to-event and binary outcomes were used, accounting for trial differences, within-centre correlation, randomised treatment received, baseline variable imbalances, and potential confounding from relevant prognostic factors.

FINDINGS

782 patients with known fractionation schedules (456 from the BC2001 trial and 326 from the BCON trial; 376 (48%) received 64 Gy in 32 fractions and 406 (52%) received 55 Gy in 20 fractions) were included in our meta-analysis. Median follow-up was 120 months (IQR 99-159). Patients who received 55 Gy in 20 fractions had a lower risk of invasive locoregional recurrence than those who received 64 Gy in 32 fractions (adjusted HR 0·71 [95% CI 0·52-0·96]). Both schedules had similar toxicity profiles (adjusted RD -3·37% [95% CI -11·85 to 5·10]).

INTERPRETATION

A hypofractionated schedule of 55 Gy in 20 fractions is non-inferior to 64 Gy in 32 fractions with regard to both invasive locoregional control and toxicity, and is superior with regard to invasive locoregional control. 55 Gy in 20 fractions should be adopted as a standard of care for bladder preservation in patients with locally advanced bladder cancer.

FUNDING

Cancer Research UK.

Outcomes of Three- Versus Six-Monthly Dispensing of Antiretroviral Treatment (ART) for Stable HIV Patients in Community ART Refill Groups: A Cluster-Randomized Trial in Zimbabwe

Introduction:

Multimonth dispensing (MMD) of antiretroviral treatment (ART) aims to reduce patient-related barriers to access long-term treatment and improve health system efficiency. However, randomized evidence of its clinical effectiveness is lacking. We compared MMD within community ART refill groups (CARGs) vs. standard-of-care facility-based ART delivery in Zimbabwe.

Methods:

A three-arm, cluster-randomized, pragmatic noninferiority trial was performed. Thirty health care facilities and associated CARGs were allocated to either ART collected three-monthly at facility (3MF, control); ART delivered three-monthly in CARGs (3MC); or ART delivered six-monthly in CARGs (6MC). Stable adults receiving ART ≥six months with baseline viral load (VL) <1000 copies/ml were eligible. Retention in ART care (primary outcome) and viral suppression (VS) 12 months after enrollment were compared, using regression models specified for clustering (ClinicalTrials.gov: NCT03238846).

Results:

4800 participants were recruited, 1919, 1335, and 1546 in arms 3MF, 3MC, and 6MC, respectively. For retention, the prespecified noninferiority limit (-3.25%, risk difference [RD]) was met for comparisons between all arms, 3MC (94.8%) vs. 3MF (93.0%), adjusted RD = 1.1% (95% CI: -0.5% to 2.8%); 6MC (95.5%) vs. 3MF: aRD = 1.2% (95% CI: -1.0% to 3.6%); and 6MC vs. 3MC: aRD = 0.1% (95% CI: -2.4% to 2.6%). VL completion at 12 months was 49%, 45%, and 8% in 3MF, 3MC, and 6MC, respectively. VS in 3MC (99.7%) was high and not different to 3MF (99.1%), relative risk = 1.0 (95% CI: 1.0-1.0). VS was marginally reduced in 6MC (92.9%) vs. 3MF, relative risk = 0.9 (95% CI: 0.9-1.0).

Conclusion:

Retention in CARGs receiving three- and six-monthly MMD was noninferior versus standard-of-care facility-based ART delivery. VS in 3MC was high. VS in six-monthly CARGs requires further evaluation.

First-attempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial

BACKGROUND

Orotracheal intubation of infants using direct laryngoscopy can be challenging. We aimed to investigate whether video laryngoscopy with a standard blade done by anaesthesia clinicians improves the first-attempt success rate of orotracheal intubation and reduces the risk of complications when compared with direct laryngoscopy. We hypothesised that the first-attempt success rate would be higher with video laryngoscopy than with direct laryngoscopy.

METHODS

In this multicentre, parallel group, randomised controlled trial, we recruited infants without difficult airways abnormalities requiring orotracheal intubation in operating theatres at four quaternary children's hospitals in the USA and one in Australia. We randomly assigned patients (1:1) to video laryngoscopy or direct laryngoscopy using random permuted blocks of size 2, 4, and 6, and stratified by site and clinician role. Guardians were masked to group assignment. The primary outcome was the proportion of infants with a successful first attempt at orotracheal intubation. Analysis (modified intention-to-treat [mITT] and per-protocol) used a generalised estimating equation model to account for clustering of patients treated by the same clinician and institution, and adjusted for gestational age, American Society of Anesthesiologists physical status, weight, clinician role, and institution. The trial is registered at ClinicalTrials.gov, NCT03396432.

FINDINGS

Between June 4, 2018, and Aug 19, 2019, 564 infants were randomly assigned: 282 (50%) to video laryngoscopy and 282 (50%) to direct laryngoscopy. The mean age of infants was 5·5 months (SD 3·3). 274 infants in the video laryngoscopy group and 278 infants in the direct laryngoscopy group were included in the mITT analysis. In the video laryngoscopy group, 254 (93%) infants were successfully intubated on the first attempt compared with 244 (88%) in the direct laryngoscopy group (adjusted absolute risk difference 5·5% [95% CI 0·7 to 10·3]; p=0·024). Severe complications occurred in four (2%) infants in the video laryngoscopy group compared with 15 (5%) in the direct laryngoscopy group (-3·7% [-6·5 to -0·9]; p=0·0087). Fewer oesophageal intubations occurred in the video laryngoscopy group (n=1 [<1%]) compared with in the direct laryngoscopy group (n=7 [3%]; -2·3 [-4·3 to -0·3]; p=0·028).

INTERPRETATION

Among anaesthetised infants, using video laryngoscopy with a standard blade improves the first-attempt success rate and reduces complications.

FUNDING

Anaesthesia Patient Safety Foundation, Society for Airway Management, and Karl Storz Endoscopy.

Analysis of multicenter clinical trials with very low event rates

INTRODUCTION

In a five-arm randomized clinical trial (RCT) with stratified randomization across 54 sites, we encountered low primary outcome event proportions, resulting in multiple sites with zero events either overall or in one or more study arms. In this paper, we systematically evaluated different statistical methods of accounting for center in settings with low outcome event proportions.

METHODS

We conducted a simulation study and a reanalysis of a completed RCT to compare five popular methods of estimating an odds ratio for multicenter trials with stratified randomization by center: (i) no center adjustment, (ii) random intercept model, (iii) Mantel-Haenszel model, (iv) generalized estimating equation (GEE) with an exchangeable correlation structure, and (v) GEE with small sample correction (GEE-small sample correction). We varied the number of total participants (200, 500, 1000, 5000), number of centers (5, 50, 100), control group outcome percentage (2%, 5%, 10%), true odds ratio (1, > 1), intra-class correlation coefficient (ICC) (0.025, 0.075), and distribution of participants across the centers (balanced, skewed).

RESULTS

Mantel-Haenszel methods generally performed poorly in terms of power and bias and led to the exclusion of participants from the analysis because some centers had no events. Failure to account for center in the analysis generally led to lower power and type I error rates than other methods, particularly with ICC = 0.075. GEE had an inflated type I error rate except in some settings with a large number of centers. GEE-small sample correction maintained the type I error rate at the nominal level but suffered from reduced power and convergence issues in some settings when the number of centers was small. Random intercept models generally performed well in most scenarios, except with a low event rate (i.e., 2% scenario) and small total sample size (n ≤ 500), when all methods had issues.

DISCUSSION

Random intercept models generally performed best across most scenarios. GEE-small sample correction performed well when the number of centers was large. We do not recommend the use of Mantel-Haenszel, GEE, or models that do not account for center. When the expected event rate is low, we suggest that the statistical analysis plan specify an alternative method in the case of non-convergence of the primary method.

Effect of an Additional 30 Minutes Spent Outdoors during Summer on Daily Steps and Individually Experienced Heat Index

Spending time outdoors is associated with increased physical activity; however, high ambient temperature/humidity, together with built environment features in urban versus rural environments, may influence physical activity. We conducted an intervention trial with 89 urban and 88 rural participants performing normal activities on Days 1-2 (baseline) and spending an additional 30 min outdoors on Days 3-7 (intervention) in the summer. Participants wore a pedometer with real-time visual feedback to track daily steps taken and a thermometer clipped to their shoe to track temperatures experienced individually. Hygrometer-thermometers were deployed in participants' neighborhoods to collect finer resolution ambient heat indexes in addition to regional weather station measurements. Using linear mixed effects models and adjusting for ambient conditions and individual-level factors, participants on average walked 637 (95%CI (83, 1192)) more steps and had a 0.59 °C (95%CI (0.30, 0.88)) lower daily mean individually experienced heat index during intervention days compared to baseline days. The intervention benefit of increased physical activity was greater in rural residents who were less active at baseline, compared to urban residents. Our results suggest adding a small amount of additional time outdoors may improve physical activity without increasing participants' heat exposure, even during summer in a humid subtropical climate.

Lower-Dose Zinc for Childhood Diarrhea - A Randomized, Multicenter Trial

BACKGROUND

The World Health Organization recommends 20 mg of zinc per day for 10 to 14 days for children with acute diarrhea; in previous trials, this dosage decreased diarrhea but increased vomiting.

METHODS

We randomly assigned 4500 children in India and Tanzania who were 6 to 59 months of age and had acute diarrhea to receive 5 mg, 10 mg, or 20 mg of zinc sulfate for 14 days. The three primary outcomes were a diarrhea duration of more than 5 days and the number of stools (assessed in a noninferiority analysis) and the occurrence of vomiting (assessed in a superiority analysis) within 30 minutes after zinc administration.

RESULTS

The percentage of children with diarrhea for more than 5 days was 6.5% in the 20-mg group, 7.7% in the 10-mg group, and 7.2% in the 5-mg group. The difference between the 20-mg and 10-mg groups was 1.2 percentage points (upper boundary of the 98.75% confidence interval [CI], 3.3), and that between the 20-mg and 5-mg groups was 0.7 percentage points (upper boundary of the 98.75% CI, 2.8), both of which were below the noninferiority margin of 4 percentage points. The mean number of diarrheal stools was 10.7 in the 20-mg group, 10.9 in the 10-mg group, and 10.8 in 5-mg group. The difference between the 20-mg and 10-mg groups was 0.3 stools (upper boundary of the 98.75% CI, 1.0), and that between the 20-mg and 5-mg groups was 0.1 stools (upper boundary of the 98.75% CI, 0.8), both of which were below the noninferiority margin (2 stools). Vomiting within 30 minutes after administration occurred in 19.3%, 15.6%, and 13.7% of the patients in the 20-mg, 10-mg, and 5-mg groups, respectively; the risk was significantly lower in the 10-mg group than in the 20-mg group (relative risk, 0.81; 97.5% CI, 0.67 to 0.96) and in the 5-mg group than in the 20-mg group (relative risk, 0.71; 97.5% CI, 0.59 to 0.86). Lower doses were also associated with less vomiting beyond 30 minutes after administration.

CONCLUSIONS

Lower doses of zinc had noninferior efficacy for the treatment of diarrhea in children and were associated with less vomiting than the standard 20-mg dose. (Funded by the Bill and Melinda Gates Foundation; ZTDT ClinicalTrials.gov number, NCT03078842.).

Statistical analysis plan for a cluster-randomised trial assessing the effectiveness of implementation of a bedside evidence-based checklist for clinical management of brain-dead potential organ donors in intensive care units: DONORS (Donation Network to Optimise Organ Recovery Study)

Background

The quality of clinical care of brain-dead potential organ donors may help reduce donor losses caused by irreversible or unreversed cardiac arrest and increase the number of organs donated. We sought to determine whether an evidence-based, goal-directed checklist for donor management in intensive care units (ICUs) can reduce donor losses to cardiac arrest.

Methods/design

The DONORS study is a multicentre, cluster-randomised controlled trial with a 1:1 allocation ratio designed to compare an intervention group (goal-directed checklist for brain-dead potential organ donor management) with a control group (standard ICU care). The primary outcome is loss of potential donors due to cardiac arrest. Secondary outcomes are the number of actual organ donors and the number of solid organs recovered per actual donor. Exploratory outcomes include the achievement of relevant clinical goals during the management of brain-dead potential organ donors. The present statistical analysis plan (SAP) describes all primary statistical procedures that will be used to evaluate the results and perform exploratory and sensitivity analyses of the trial.

Discussion

The SAP of the DONORS study aims to describe its analytic procedures, enhancing the transparency of the study. At the moment of SAP subsmission, 63 institutions have been randomised and were enrolling study participants. Thus, the analyses reported herein have been defined before the end of the study recruitment and database locking.

Trial registration

ClinicalTrials.gov, NCT03179020. Registered on 7 June 2017.

Interventions supporting long term adherence and decreasing cardiovascular events after myocardial infarction (ISLAND): pragmatic randomised controlled trial

OBJECTIVE

To test a scalable health system intervention to improve long term adherence to secondary prevention treatments among patients who have had a recent myocardial infarction.

DESIGN

Three arm, pragmatic randomised controlled trial with blinded outcome assessment.

SETTING

Nine cardiac centres in Ontario, Canada.

PARTICIPANTS

2632 patients with obstructive coronary artery disease after a myocardial infarction, identified from a centralised cardiac registry.

INTERVENTIONS

Participants were randomised 1:1:1 to receive usual care, five mail-outs developed through a user centred design process, or mail-outs plus phone calls. The phone calls were delivered first by an interactive automated system to screen for non-adherence to treatment. Trained lay health workers followed up as necessary. Interventions were coordinated centrally but delivered from each patient's hospital site.

MAIN OUTCOME MEASURES

Co-primary outcomes were completion of cardiac rehabilitation and adherence to recommended medication. Data were collected by blinded assessors through patient report and from administrative health databases at 12 months.

RESULTS

2632 patients (mean age 66, 71% male) were randomised: 878 to the full intervention (mail plus phone calls), 878 to mail only, and 876 to usual care. Of the respondents, 174 (27%) of 643 in the usual care group, 200 (32%) of 628 in the mail only group, and 196 (37%) of 531 allocated to the full intervention completed cardiac rehabilitation (adjusted odds ratio 1.55, 95% confidence interval 1.18 to 2.03). In the mail plus phone group, 11.7%, 6.0%, 14.4%, 32.9%, and 35.0% reported adherence to 0, 1, 2, 3, and 4 drug classes after one year, respectively, in comparison with 12.5%, 6.8%, 13.6%, 30.2%, and 36.8% in the mail only group, and 12.2%, 8.4%, 13.1%, 30.3%, and 36.1% in the usual care group, respectively (mail only v usual care, odds ratio 0.98, 95% confidence interval 0.81 to 1.19; full intervention v usual care, 0.99, 0.82 to 1.20).

CONCLUSIONS

Scalable interventions delivered by mail plus phone can increase completion of cardiac rehabilitation after myocardial infarction but not adherence to medication. More intensive interventions should be tested to improve adherence to medication and to evaluate the association between attendance at cardiac rehabilitation and adherence to medication.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02382731, registered 9 March 2015 before any patient enrolment.

Fertility Intentions and Clinical Care Attendance Among Women Living with HIV in South Africa

Poor HIV care retention impedes optimal treatment outcomes in persons living with HIV. Women trying to become pregnant may be motivated by periconception horizontal and vertical transmission concerns and thus more likely to attend HIV care visits than women not trying to conceive. We estimated the effect of fertility intentions on HIV care attendance over 12 months among non-pregnant, HIV-positive women aged 18-35 years who were on or initiating antiretroviral therapy in Johannesburg, South Africa. The percentage of women attending an HIV care visit decreased from 93.4% in the first quarter to 82.8% in the fourth quarter. Fertility intentions were not strongly associated with care attendance in this cohort of reproductive-aged women; however, attendance declined over time irrespective of childbearing plans. These findings suggest a need for reinforced efforts to support care engagement and risk reduction, including safer conception practices for women wishing to conceive.

Use of Oral Vancomycin for Clostridioides difficile Infection and the Risk of Vancomycin-Resistant Enterococci

Background

Vancomycin is now a preferred treatment for all cases of Clostridioides difficile infection (CDI), regardless of disease severity. Concerns remain that a large-scale shift to oral vancomycin may increase selection pressure for vancomycin-resistant Enterococci (VRE). We evaluated the risk of VRE following oral vancomycin or metronidazole treatment among patients with CDI.

Methods

We conducted a retrospective cohort study of patients with CDI in the US Department of Veterans Affairs health system between 1 January 2006 and 31 December 2016. Patients were included if they were treated with metronidazole or oral vancomycin and had no history of VRE in the previous year. Missing data were handled by multiple imputation of 50 datasets. Patients treated with oral vancomycin were compared to those treated with metronidazole after balancing on patient characteristics using propensity score matching in each imputed dataset. Patients were followed for VRE isolated from a clinical culture within 3 months.

Results

Patients treated with oral vancomycin were no more likely to develop VRE within 3 months than metronidazole-treated patients (adjusted relative risk, 0.96; 95% confidence interval [CI], .77 to 1.20), equating to an absolute risk difference of −0.11% (95% CI, −.68% to .47%). Similar results were observed at 6 months.

Conclusions

Our results suggest that oral vancomycin and metronidazole are equally likely to impact patients’ risk of VRE. In the setting of stable CDI incidence, replacement of metronidazole with oral vancomycin is unlikely to be a significant driver of increased risk of VRE at the patient level.

In this multicenter, retrospective cohort study of patients with Clostridioides difficile infection, the use of oral vancomycin did not increase the risk of vancomycin-resistant Enterococci infection at 3 or 6 months compared to metronidazole.

Pitfalls of using the risk ratio in meta-analysis

For meta-analysis of studies that report outcomes as binomial proportions, the most popular measure of effect is the odds ratio (OR), usually analyzed as log(OR). Many meta-analyses use the risk ratio (RR) and its logarithm because of its simpler interpretation. Although log(OR) and log(RR) are both unbounded, use of log(RR) must ensure that estimates are compatible with study-level event rates in the interval (0, 1). These complications pose a particular challenge for random-effects models, both in applications and in generating data for simulations. As background, we review the conventional random-effects model and then binomial generalized linear mixed models (GLMMs) with the logit link function, which do not have these complications. We then focus on log-binomial models and explore implications of using them; theoretical calculations and simulation show evidence of biases. The main competitors to the binomial GLMMs use the beta-binomial (BB) distribution, either in BB regression or by maximizing a BB likelihood; a simulation produces mixed results. Two examples and an examination of Cochrane meta-analyses that used RR suggest bias in the results from the conventional inverse-variance-weighted approach. Finally, we comment on other measures of effect that have range restrictions, including risk difference, and outline further research.