ADSS: A Composite Score to Detect Disease Progression in Alzheimer's Disease

Background

Composite scores have been increasingly used in trials for Alzheimer's disease (AD) to detect disease progression, such as the AD Composite Score (ADCOMS) in the lecanemab trial.

Objective

To develop a new composite score to improve the prediction of outcome change.

Methods

We proposed to develop a new composite score based on the statistical model in the ADCOMS, by removing duplicated sub-scales and adding the model selection in the partial least squares (PLS) regression.

Results

The new AD composite Score with variable Selection (ADSS) includes 7 cognitive sub-scales. ADSS can increase the sensitivity to detect disease progression as compared to the existing total scores, which leads to smaller sample sizes using the ADSS in trial designs.

Conclusions

ADSS can be utilized in AD trials to improve the success rate of drug development with a high sensitivity to detect disease progression in early stages.

Assessment of Humoral Immune Responses to Repeated Influenza Vaccination in a Multiyear Cohort: A 5-Year Follow-up

The long-term effects of host factors on vaccine-elicited immune responses have not been well studied, and the interactions of host factors with annual influenza vaccinations are yet to be explored. We analyzed data from a cohort of 386 individuals who received the standard-dose influenza vaccine and enrolled in ≥2 seasons from 2016 to 2020. Our analyses indicated disparate vaccine-elicited immune responses between males and females in adults when they were repeatedly vaccinated for at least 2 seasons. Notably, we found interactive effects between age and body mass index (BMI) on overall immune responses, and between sex at birth and BMI in adults.

Cognitive training for children with ADHD: composite cognitive score outcome in a randomized controlled trial

PURPOSE OF THE ARTICLE

Cognitive training for Attention Deficit/Hyperactivity Disorder (ADHD) has shown promising, although mixed results. In post-hoc analyses, we evaluate effects of cognitive training using a novel composite cognition score as the outcome for children attending at least 16 sessions of training, dose-response of training and associations between symptoms and cognitive functioning.

MATERIALS AND METHODS

Children (age 6-13) with ADHD were randomized to intervention (n = 26) or control (n = 34). For the current analysis, we restricted the intervention group to children, who completed at least 16 sessions of cognitive training (n = 26) and examined a dose response within that group.

RESULTS

Cognition improved significantly in the intervention, but not control group. Amount of the completed training sessions correlated significantly with the amount of cognitive improvement.

CONCLUSION

Variations in dose and frequency of training may be an important source of the variance in previous studies.

Comparative evaluation of weighted mean and composite score for combining assessments

OBJECTIVES

Approaches for combining scores have been based on weighted mean (WM) without consideration for psychometric characteristics of each individual assessments. This study evaluates consequences of WM and composite score (CS) approach.

METHODS

Data from two longitudinal cohorts (n = 219) were utilized for performance in three Operative Dentistry courses as basis to compare the two score-combining methods. Four assessments (two written and two practical exams) from each course were combined using WM and CS approaches. WM scores were calculated by multiplying the score by its weight and summing across assessments. The CS approach follow a modification of the Kane and Case method, by standardizing scores, taking into account the reliability and associations between each assessment score. t-Tests and Pearson's correlation were used to evaluate the consequences of the WM and CS approaches. In addition, changes in each student's rank across WM and CS were determined.

RESULTS

Combining scores using CS method produced lower scores and higher percentage failure in all courses compared to WM. Students ranks were changed significantly when CS was used with only 15% of the cohorts retained their ranks.

CONCLUSIONS

CS produced a composite that is correlated with WM but still being substantively different providing meaningful and psychometrically rigorous information.

Application of a composite scoring protocol to identify factors that contribute to the risk of overweight and obesity in Irish children

BACKGROUND

Investigations into the main drivers of childhood obesity are vital to implement effective interventions to halt the global rise in levels. The use of a composite score may help to identify children most at risk of overweight/obesity.

OBJECTIVES

To investigate the cumulative impact of factors associated with overweight/obesity risk in children.

METHODS

Data were analysed from the Irish National Children's Food Survey II which included 600 children, aged 5-12-years. The risk factors examined included social class, parental, early life, lifestyle, and dietary components. A composite score was calculated which ranged from 0 (no risk factors for overweight/obesity) to 4 (4 risk factors for overweight/obesity).

RESULTS

In model 1 (%BF) the four factors associated with overweight/obesity risk were having a parent with overweight/obesity (odds ratio 3.1; 95% confidence interval 1.9-4.8), having a high birth weight of ≥4 kg (2.5; 1.6-3.9), being from a low social class (2.3; 1.4-3.8) and low physical activity (1.9; 1.2-2.8). Children who scored 3-4 points on the composite score had a 10-fold (10.0; 4.2-23.9) increased risk of overweight/obesity compared to those with 0 points, a sevenfold (7.2; 3.9-13.5) increased risk compared to those with 1 point and a threefold (2.6; 1.4-4.8) increased risk compared to those with 2 points, with similar results observed in model 2 (BMI).

CONCLUSION

The use of a composite score is a beneficial means of identifying children at risk of overweight/obesity and may prove useful in the development of effective interventions to tackle childhood obesity.

Longitudinal Amyloid Cognitive Composite in Preclinical Alzheimer's Disease

BACKGROUND

Previous studies have developed several cognitive composites in preclinical AD. However, more sensitive measures to track cognitive changes and therapeutic efficacy in preclinical Alzheimer's disease (AD) are needed considering diverse sociocultural and linguistic backgrounds. This study developed a composite score that can sensitively detect the Aβ-related cognitive trajectory of preclinical AD using Korean data.

METHODS

A total of 196 cognitively normal (CN) participants who underwent amyloid positron emission tomography were followed-up with neuropsychological assessments. We developed the Longitudinal Amyloid cognitive Composite in Preclinical AD (LACPA) using the linear mixed-effects model (LMM) and z-scores. The LMM was also used to investigate the longitudinal sensitivity of LACPA and the association between time-varying brain atrophy and LACPA.

RESULTS

Considering the group-time interaction effects of each subtest, the Seoul Verbal Learning Test-Elderly's version (SVLT-E) immediate recall/delayed recall/recognition, the Korean Trail Making Test B time, and the Korean Mini-Mental State Examination were selected as components of LACPA. LACPA exhibited a significant group-time interaction effect between the Aβ+ and Aβ- groups (t = -3.288, p = 0.001). Associations between time-varying LACPA and brain atrophy were found in the bilateral medial temporal, right lateral parietal, and right lateral frontal regions, and hippocampal volume.

CONCLUSION

LACPA may contribute to reduction in time and financial burden when monitoring Aβ-related cognitive decline and therapeutic efficacy of the disease-modifying agents specifically targeting Aβ in secondary prevention trials.

Z Scores, Standard Scores, and Composite Test Scores Explained

Patients may be assessed using a battery of tests where different tests yield scores in different units, where different tests have different minimum and maximum scores, and where higher or lower scores mean different things in different tests. Therefore, a composite test score cannot be obtained by simple addition or averaging of scores in the individual tests. However, if performances in individual tests are converted to Z scores, the Z scores can be added or averaged to yield a composite score that can be interpreted or processed using conventional statistical methods. This article explains in simple ways how Z scores are calculated, what the properties of Z scores are, how Z scores can be interpreted, and how Z scores can be converted into other standard scores.

A Novel Multi-Dimensional Clinical Response Index Dedicated to Improving Global Assessment of Pain in Patients with Persistent Spinal Pain Syndrome after Spinal Surgery, Based on a Real-Life Prospective Multicentric Study (PREDIBACK) and Machine Learning Techniques

The multidimensionality of chronic pain forces us to look beyond isolated assessment such as pain intensity, which does not consider multiple key parameters, particularly in post-operative Persistent Spinal Pain Syndrome (PSPS-T2) patients. Our ambition was to produce a novel Multi-dimensional Clinical Response Index (MCRI), including not only pain intensity but also functional capacity, anxiety-depression, quality of life and quantitative pain mapping, the objective being to achieve instantaneous assessment using machine learning techniques. Two hundred PSPS-T2 patients were enrolled in the real-life observational prospective PREDIBACK study with 12-month follow-up and received various treatments. From a multitude of questionnaires/scores, specific items were combined, as exploratory factor analyses helped to create a single composite MCRI; using pairwise correlations between measurements, it appeared to more accurately represent all pain dimensions than any previous classical score. It represented the best compromise among all existing indexes, showing the highest sensitivity/specificity related to Patient Global Impression of Change (PGIC). Novel composite indexes could help to refine pain assessment by informing the physician's perception of patient condition on the basis of objective and holistic metrics, and also by providing new insights regarding therapy efficacy/patient outcome assessments, before ultimately being adapted to other pathologies.

Combined Lifestyle Behaviors and the Incidence of Common Cancer Types in the Norwegian Women and Cancer Study (NOWAC)

INTRODUCTION

Only a small number of studies have examined the impact of combined lifestyle behaviors on cancer incidence, and never in a Norwegian population.

PURPOSE

To examine linear and nonlinear associations of combined lifestyle factors, assessed through a healthy lifestyle index (HLI), with the incidence of postmenopausal breast, colorectal, lung, postmenopausal endometrial, postmenopausal ovarian, pancreatic, and kidney cancer among women in Norway.

METHODS

This prospective study included 96,869 women enrolled in the Norwegian Women and Cancer (NOWAC) cohort. Baseline information on lifestyle factors was collected between 1996 and 2004. The HLI was constructed from five lifestyle factors: physical activity level, body mass index, smoking, alcohol consumption, and diet. Each factor contributed 0 to 4 points to the HLI score, which ranged from 0 to 20, with higher scores representing a healthier lifestyle. Multiple imputation was used to handle missing data. Cox proportional hazard regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI). Restricted cubic splines were used to examine nonlinearity in the associations.

RESULTS

The HRs for a one-point increment on the HLI score were 0.97 (95% CI: 0.96-0.98) for postmenopausal breast cancer, 0.98 (0.96-1.00) for colorectal cancer, 0.86 (0.84-0.87) for lung cancer, 0.93 (0.91-0.95) for postmenopausal endometrial cancer, 0.99 (0.96-1.02) for postmenopausal ovarian cancer, 0.92 (0.89-0.95) for pancreatic cancer, and 0.94 (0.91-0.97) for kidney cancer. Nonlinearity was observed for the inverse associations between HLI score and the incidence of lung cancer and postmenopausal breast cancer.

CONCLUSION

Based on our results, healthier lifestyle, as assessed by the HLI score, was associated with lower incidence of postmenopausal breast, colorectal, lung, postmenopausal endometrial, pancreatic, and kidney cancer among women, although the magnitude and linearity varied. Adoption of healthier lifestyle behaviors should be a public health priority to reduce the cancer burden among Norwegian women.

Prostac: A New Composite Score With Potential Predictive Value in Prostate Cancer

Prostate cancer (PCa) is the most commonly diagnosed solid organ cancer in men worldwide. Current diagnosis of PCa includes use of initial prostate specific antigen assay which has a high false positive rate, low specificity, and low sensitivity. The side effects of unnecessary prostate biopsies that healthy men are subjected to, often result in unintended health complications. New PCa biomarkers are being discovered to address this unmet need. Here, we report on the creation of a composite score (Prostac) based on three recently discovered PCa biomarkers, Plasmacytoma Variant Translocation 1 (PVT1) exons 4A, 4B, and 9. Statistical analysis of copy numbers derived from a real-time quantitative polymerase chain (qPCR) reaction - based assay, showed these PCa biomarkers to be linearly separable and significantly over expressed in PCa epithelial cells. We train a supervised learning algorithm using support vector machines to generate a classification hyperplane from which a user-friendly composite score is developed. Cross validation of Prostac using data from prostate epithelial cells (RWPE1) and PCa cells (MDA PCa 2b) accurately classified 100% of PCa cells. Creation of the Prostac score lays the groundwork for clinical trial of its use in PCa diagnosis.

A Novel Predictive Composite Score Development in a Cohort of 1089 Patients Undergoing Laparoscopic Cholecystectomy

BACKGROUND

Optimal use of interventional procedures and diagnostic tests for patients with suspected choledocholithiasis depends on accurate pretest risk estimation. We sought to define sensitivity/specificity of transaminases in identifying choledocholithiasis and to incorporate them into a biochemical marker composite score that could accurately predict choledocholithiasis.

METHODS

All adult patients who underwent laparoscopic cholecystectomy by our Emergency Surgery Service between 2010 and 2018 were reviewed. Admission total bilirubin (TB), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) was captured. Choledocholithiasis was confirmed via intraoperative cholangiogram, endoscopic retrograde cholangiopancreatography, or magnetic resonance cholangiopancreatography. Area under receiver operating characteristic curve (AUC) or C-statistic for AST, ALT, ALP, and TB as a measure of detecting choledocholithiasis was calculated. For score development, our database was randomly dichotomized to derivation and validation cohort and a score was derived. The score was validated by calculating its C-statistic.

RESULTS

1089 patients were included; 210 (20.3%) had confirmed choledocholithiasis. The AUC was .78 for TB, .77 for ALP and AST, and .76 for ALT. 545 and 544 patients were included in the derivation and the validation cohort, respectively. The elements of the derived score were TB, AST, and ALP. The score ranged from 0 to 4. The AUC was .82 in the derivation and .77 in the validation cohort. The probability of choledocholithiasis increased from 8% to 89% at scores 0 to 4, respectively.

CONCLUSIONS

Aspartate aminotransferase predicted choledocholithiasis adequately and should be featured in choledocholithiasis screening algorithms. We developed a biochemical composite score, shown to be accurate in preoperative choledocholithiasis risk assessment in an emergency surgery setting.

Longitudinal Assessment of Immune Responses to Repeated Annual Influenza Vaccination in a Human Cohort of Adults and Teenagers

Background: The overall performance of a multiple component vaccine assessed by the vaccine-elicited immune responses across various strains in a repeated vaccination setting has not been well-studied, and the comparison between adults and teenagers is yet to be made.

Methods: A human cohort study was conducted at the University of Georgia, with 140 subjects (86 adults and 54 teenagers) repeatedly vaccinated in the 2017/2018 and 2018/2019 influenza seasons. Host information was prospectively collected, and serum samples were collected before and after vaccination in each season. The association between host factors and repeated measures of hemagglutination inhibition (HAI) composite scores was assessed by generalized linear models with generalized estimating equations.

Results: The mean HAI composite scores for the entire sample (t = 4.26, df = 139, p < 0.001) and the teenager group (t = 6.44, df = 53, p < 0.001) declined in the second season, while the changes in the adults were not statistically significant (t = −1.14, df = 85, p = 0.26). A mixture pattern of changes in both directions was observed in the adults when stratified by prior vaccination. In addition, the regression analysis suggested an interactive effect of age and BMI on the HAI composite scores in the overall population (beta = 0.005; 95% CI, 0.0008–0.01) and the adults (beta = 0.005; 95% CI, 0.0005–0.01).

Conclusions: Our study found distinct vaccine-elicited immune responses between adults and teenagers when both were repeatedly vaccinated in consecutive years. An interactive effect of age and BMI on the HAI composite scores were identified in the overall population and the adults.

Considerations for a combined index for limited cutaneous systemic sclerosis to support drug development and improve outcomes

Systemic sclerosis (SSc; systemic scleroderma) is characterized by a heterogeneous range of clinical manifestations. SSc is classified into limited cutaneous SSc (lcSSc) and diffuse cutaneous subgroups (dcSSc) based on the extent of skin involvement. Randomized controlled trials in scleroderma have mainly focused on dcSSc partly because the measurement of skin involvement, critical for evaluating a therapeutic intervention is more dynamic in this subset. Nonetheless, lcSSc, the most common cutaneous subset (about 2/3), is also associated with significant morbidity and detrimental impact on health-related quality of life. The lack of interventional studies in lcSSc is partly due to a lack of relevant outcome measures to evaluate this subgroup. Combining several clinically meaningful outcomes selected specifically for lcSSc may improve representativeness in clinical trials and responsiveness of outcomes measured in randomized controlled trials. A composite index dedicated to lcSSc combining such relevant outcomes could advance clinical trial development for lcSSc by providing the opportunity to test and select among candidate drugs that could act as disease-modifying treatments for this neglected subgroup of SSc. This proposed index would include items selected by expert physicians and patients with lcSSc across domains grounded in the lived experience of lcSSc. This article reviews the reasons behind the relative neglect of lcSSc, discusses the current state of outcome measures for lcSSc, identifies challenges, and proposes a roadmap for a combined lcSSc-specific treatment response index.

Development and validation of the Uniform Data Set (v3.0) executive function composite score (UDS3-EF)

Introduction

Cognitive composite scores offer a means of precisely measuring executive functioning (EF).

Methods

We developed the Uniform Data Set v3.0 EF composite score (UDS3‐EF) in 3507 controls from the National Alzheimer's Coordinating Center dataset using item‐response theory and applied nonlinear and linear demographic adjustments. The UDS3‐EF was validated with other neuropsychological tests and brain magnetic resonance imaging from independent research cohorts using linear models.

Results

Final model fit was good‐to‐excellent: comparative fit index = 0.99; root mean squared error of approximation = 0.057. UDS3‐EF scores differed across validation cohorts (controls > mild cognitive impairment > Alzheimer's disease‐dementia ≈ behavioral variant frontotemporal dementia; P < 0.001). The UDS3‐EF correlated most strongly with other EF tests (βs = 0.50 to 0.85, Ps < 0.001) and more with frontal, parietal, and temporal lobe gray matter volumes (βs = 0.18 to 0.33, Ps ≤ 0.004) than occipital gray matter (β = 0.12, P = 0.04). The total sample needed to detect a 40% reduction in UDS3‐EF change (n = 286) was ≈40% of the next best measure (F‐words; n = 714).

Conclusions

The UDS3‐EF is well suited to quantify EF in research and clinical trials and offers psychometric and practical advantages over its component tests.

Modeling Measurement Errors of the Exogenous Composites From Congeneric Measures in Interaction Models

We investigated the performance of two single indicator methods: latent moderated structural equation (LMS) and reliability-adjusted product indicator (RAPI) methods, on testing interaction effects with congeneric measures, which vary in factor loadings and error variances under a common factor. Additionally, in the simulation study, we compared the performance of four reliability estimates (Cronbach's alpha, omega composite, Coefficient H, and greatest lower bound [GLB]) to adjust for the exogenous composites' measurement errors. Results from the study showed that: while estimating interaction effects with exogenous composites from congeneric measures, the four reliability estimates performed comparably well. Recommendations on the choice of reliability estimates between the LMS and the RAPI methods under different sample sizes and population reliability conditions are further discussed.

Composite Score Is a Better Reflection of Patient Response to Chronic Pain Therapy Compared With Pain Intensity Alone

OBJECTIVE

The pain Numeric Rating Scale (NRS) score became standard when pain was introduced as the fifth vital sign in the 1990s. Although plagued with issues, it remains the basis for primary outcome measures in clinical trials for chronic pain therapies. Multidimensional composite scoring that considers all aspects of the chronic pain experience may provide a more meaningful response measure. Herein we propose a multidimensional responder index.

MATERIALS AND METHODS

Data were extracted from an ongoing prospective, multicenter study on DeRidder Burst spinal cord stimulation (B-SCS) for chronic back and/or leg pain (NCT03082261). The analysis cohort consisted of subjects who completed the NRS, Pain Catastrophizing Scale (PCS), EuroQol-5D (EQ-5D), and eight-item Patient-Reported Outcomes Measurement Information System Physical Function preoperatively and at 12 months after implant.

RESULTS

A principal component analysis showed that each of the four measures contributed equally to the variance in the data set, confirming that pain score should not be used alone. Subjects who failed to respond on NRS responded on both PCS and EQ-5D. Eighty-one percent of subjects responded on at least two measures. The responder algorithm yielded an 84% success rate at both 6- and 12-month time points.

CONCLUSIONS

Our study suggests that therapeutic response, similar to the chronic pain experience, is multidimensional. Careful consideration should be made to incorporate composite endpoints in future SCS clinical trials.

The Relationship Between the Golf-Specific Movement Screen and Golf Performance

CONTEXT

Golf requires effective movement patterns to produce an effective swing and performance.

OBJECTIVE

To determine the relationship between the Titleist Performance Institute golf-specific functional movement screening (GSFMS) composite and individual element scores and golf performance by assessing a player's handicap, clubhead speed, side accuracy, ball speed, peak pelvis rotation speed, swing sequence, and common swing faults.

DESIGN

Cohort study, clinical measurement.

SETTING

English golf club.

PARTICIPANTS

A total of 11 amateur golfers: 5 males (age: 37.2 [18.7] y, height: 184.4 [9.6] cm, body mass: 89.5 [13.4] kg, and handicap: 9 [6.6]) and 6 females (age: 53.7 [15.0] y, height: 166.8 [5.5] cm, body mass: 67.9 [16.6] kg, and handicap: 13 [6.1]).

MAIN OUTCOME MEASURES

GSFMS composite and individual element scores and golf performance variables.

RESULTS

Significant relationships existed between GSFMS composite scores and handicap (r = -.779, P = .01); clubhead speed (r = .701, P = .02); ball speed (r = .674, P = .02); and peak pelvis rotation speed (r = .687, P = .02). Significant relationships existed between 90°/90° golf position and clubhead speed (r = .716, P = .01); ball speed (r = .777, P = .01); seated trunk rotation and peak pelvis rotation speed (r = .606, P = .048); single-leg balance and handicap (r = -.722, P = .01); torso rotation and handicap (r = -.637,P = .04); and torso rotation and peak pelvis rotation speed (r = .741, P = .01). Single-leg balance, overhead deep squat, and pelvic tilt were the GSFMS tests which participants had most difficulty in performing. The most common swing faults identified included loss of posture, slide, chicken winging, and early hip extension.

CONCLUSIONS

The GSFMS may be used to identify movement limitations that relate to golfing performance. These findings may potentially allow intervention to correct movement patterns and potentially improve golf performance.

Composite Scores of Plasma Tau and β-Amyloids Correlate with Dementia in Down Syndrome

Dementia frequently occurs in Down syndrome (DS) patients, and early intervention is important in its management. We have previously demonstrated a positive correlation of plasma β-amyloid Aβ42 levels and negative correlations of Aβ40 and tau levels with dementia in DS. In this study, we examined more cases and constructed composite scores with both tau and amyloids to correlate with dementia in DS. Plasma Aβ42, Aβ40, and tau proteins were measured by an immunomagnetic reduction assay in DS patients. Data were randomly and repeatedly split into training and validating sets, and logistic regression was applied to calculate the area under the curve (AUC) for each biomarker. A total of 73 DS patients (among them, 23 had neurodegeneration) and 77 controls were recruited. In DS patients without dementia, plasma Aβ40 and tau levels were highly elevated, but Aβ42 levels were lower than those of the healthy controls. DS patients with dementia, compared with DS patients with no dementia, had a large decline in Aβ40 and tau but a rise in Aβ42. For biomarker scores correlating with dementia, Aβ40 revealed an AUC of 0.912; the composite score of Aβ40 × tau revealed an AUC of 0.953; and a combined composite score of 0.1 for Aβ40 × Tau +0.9 Tau × Aβ40/Aβ42 achieved the highest AUC of 0.965. Therefore, composite biomarker scores including both plasma tau and β-amyloid levels correlate with dementia in DS better than using individual biomarker scores. The pattern of tau decline and Aβ42 rise in DS patients with dementia are also different from previous findings in Alzheimer's disease.

Prevalence of community health-promoting practices in Singapore

Both living and working environments have a substantial influence on promoting healthy living habits. A holistic and accurate assessment of the community health-promoting practices is important to identify gaps and to make continuous, tangible improvements. The aim of the study is to assess the prevalence of the Singapore community health-promoting practices. The community health-promoting practices in all residential zones of an electoral constituency were assessed based on a composite health promotion scoring system comprising of 44 measurable elements under the 5 domains of community support and resources; healthy behaviours; chronic conditions; mental health; and common medical emergencies. An alphabetical grading system was used based on the score ranges: grade 'A' (75% and above), grade 'B' (60% to below 75%), grade 'C' (50% to below 60%) and grade 'D' (below 50%). The community health-promoting practices were graded 'D' with an overall average score of 41%. The constituency achieved grade 'C' (59%) for mental health domain and grade 'B' (72%) for common medical emergencies. The health-promoting practices for the other domains were graded 'D' (<50%) except for healthy behaviour (physical activity) sub-domain which achieved grade 'B' (65%). Significant gaps were identified in the community health-promoting practices. The residential zones may benefit from the scoring system to identify gaps and prioritize high-impact strategies to improve their health practices.

Quality of Care for Patients with Acute Myocardial Infarction (AMI) in Pakistan: A Retrospective Study

A wide variation exists in the practice patterns of acute myocardial infarction (AMI) care worldwide, leading to differences in clinical outcomes. This study aims to evaluate the quality of process care and its impact on in-hospital outcomes among AMI patients in Pakistan, as no such study has been conducted in Pakistan thus far based upon recommended guidelines. We investigated a sample of 2663 AMI patients across 11 territory hospitals in Punjab province of Lahore, Faisalabad, Multan, Rawalpindi, and Islamabad from January 1, 2016 to December 31, 2017, with an in-hospital mortality rate of 8.6%. We calculated compliance rates of quality indicators (QIs) for all eligible patients. The association between process care and in-hospital outcome was assessed using hierarchical generalized linear model that adjusted for patient and hospital characteristics. In addition, we examined the effect of patient composite scores on clinical outcomes. Aspirin (73.08%) and clopidogrel (67.86%) indicated relatively better conformance than other QIs. The percutaneous coronary intervention also showed significantly low adherence. All QIs showed no significant association with in-hospital mortality. In contrast, 4 out of 8 QIs were observed positively correlated with in-hospital length of stay (LOS). The overall patient composite score was found to be statistically significant with in-hospital LOS. The assessment of quality of care showed low adherence to clinical care recommendations, and increased adherence was associated with longer in-hospital LOS among AMI patients. Evaluation of valid QIs for AMI treatment and their impact on in-hospital outcomes is an important tool for improving health care delivery in the overall AMI population in Pakistan. Low adherence to performance measures strongly compel to focus on guideline-based tools for AMI in Pakistan.

Comparison of weighted and composite scores for pre-clinical dental learners

PURPOSE

The weighted mean (WM) method for combining scores of assessment components can provide outcomes with biased reliability and score precision. The objective of this study was to compare the traditional WM with another method utilising the composite score (CS) principle for combining scores of a final summative assessment exercise for a pre-clinical dental course.

METHODS

Data were collected from the final examination of third-year Preclinical Operative and Esthetic Dentistry course consisting of 3 parts: practical competency, objective structured practical examination and a written examination with weights of 33%, 17% and 50%, respectively. Scores from the 3 components were combined using the WM and CS methods. Weighted kappa was used to compare both approaches for agreement, and students' ranks were also compared.

RESULTS

Combining scores using CS scheme produced lower scores overall compared to WM with more apparent effect for the male group. Agreement between WM and CS was moderate (κ = 0.44) with major differences between students' ranks across the 2 modalities as only 21% of the cohort retained their ranks.

CONCLUSION

The CS method produced more reliable scores, resulting in moderate agreement with the WM and major shift in students' ranks. These findings necessitate further validity considerations before implementing the CS method and call for further studies that examine the consequences of composite measures in dental education.

Evaluation of Two Methods for Modeling Measurement Errors When Testing Interaction Effects With Observed Composite Scores

Path models with observed composites based on multiple items (e.g., mean or sum score of the items) are commonly used to test interaction effects. Under this practice, researchers generally assume that the observed composites are measured without errors. In this study, we reviewed and evaluated two alternative methods within the structural equation modeling (SEM) framework, namely, the reliability-adjusted product indicator (RAPI) method and the latent moderated structural equations (LMS) method, which can both flexibly take into account measurement errors. Results showed that both these methods generally produced unbiased estimates of the interaction effects. On the other hand, the path model-without considering measurement errors-led to substantial bias and a low confidence interval coverage rate of nonzero interaction effects. Other findings and implications for future studies are discussed.

Taking advantage of public reporting: An infection composite score to assist evaluating hospital performance for infection prevention efforts

BACKGROUND

The standardized infection ratio (SIR) evaluates individual publicly reported health care-associated infections, but it may not assess overall performance.

METHODS

We piloted an infection composite score (ICS) in 82 hospitals of a single health system. The ICS is a combined score for central line-associated bloodstream infections, catheter-associated urinary tract infections, colon and abdominal hysterectomy surgical site infections, and hospital-onset methicillin-resistant Staphylococcus aureus bacteremia and Clostridium difficile infections. Individual facility ICSs were calculated by normalizing each of the 6 SIR events to the system SIR for baseline and performance periods (ICS_ib and ICS_ip, respectively). A hospital ICS_ib reflected its baseline performance compared with system baseline, whereas a ICS_ip provided information of its outcome changes compared with system baseline.

RESULTS

Both the ICS_ib (baseline 2013) and ICS_ip (performance 2014) were calculated for 63 hospitals (reporting at least 4 of the 6 event types). The ICS_ip improved in 36 of 63 (57.1%) hospitals in 2014 when compared with the ICS_ib in 2013. The ICS_ib 2013 median was 0.96 (range, 0.13-2.94) versus the 2014 ICS_ip median of 0.92 (range, 0-6.55). Variation was more evident in hospitals with ≤100 beds. The system performance score (ICS_sp) in 2014 was 0.95, a 5% improvement compared with 2013.

CONCLUSIONS

The proposed ICS may help large health systems and state hospital associations better evaluate key infectious outcomes, comparing them with historic and concurrent performance of peers.

Efficacy and Safety of MMFS-01, a Synapse Density Enhancer, for Treating Cognitive Impairment in Older Adults: A Randomized, Double-Blind, Placebo-Controlled Trial

Background:

Cognitive impairment is a major problem in elderly, affecting quality of life. Pre-clinical studies show that MMFS-01, a synapse density enhancer, is effective at reversing cognitive decline in aging rodents.

Objective:

Since brain atrophy during aging is strongly associated with both cognitive decline and sleep disorder, we evaluated the efficacy of MMFS-01 in its ability to reverse cognitive impairment and improve sleep.

Methods:

We conducted a randomized, double-blind, placebo-controlled, parallel-designed trial in older adult subjects (age 50–70) with cognitive impairment. Subjects were treated with MMFS-01 (n = 23) or placebo (n = 21) for 12 weeks and cognitive ability, sleep quality, and emotion were evaluated. Overall cognitive ability was determined by a composite score of tests in four major cognitive domains.

Results:

With MMFS-01 treatment, overall cognitive ability improved significantly relative to placebo (p = 0.003; Cohen’s d = 0.91). Cognitive fluctuation was also reduced. The study population had more severe executive function deficits than age-matched controls from normative data and MMFS-01 treatment nearly restored their impaired executive function, demonstrating that MMFS-01 may be clinically significant. Due to the strong placebo effects on sleep and anxiety, the effects of MMFS-01 on sleep and anxiety could not be determined.

Conclusions:

The current study demonstrates the potential of MMFS-01 for treating cognitive impairment in older adults.

Understanding latent structures of clinical information logistics: A bottom-up approach for model building and validating the workflow composite score

BACKGROUND AND PURPOSE

Clinical information logistics is a construct that aims to describe and explain various phenomena of information provision to drive clinical processes. It can be measured by the workflow composite score, an aggregated indicator of the degree of IT support in clinical processes. This study primarily aimed to investigate the yet unknown empirical patterns constituting this construct. The second goal was to derive a data-driven weighting scheme for the constituents of the workflow composite score and to contrast this scheme with a literature based, top-down procedure. This approach should finally test the validity and robustness of the workflow composite score.

METHODS

Based on secondary data from 183 German hospitals, a tiered factor analytic approach (confirmatory and subsequent exploratory factor analysis) was pursued. A weighting scheme, which was based on factor loadings obtained in the analyses, was put into practice.

RESULTS

We were able to identify five statistically significant factors of clinical information logistics that accounted for 63% of the overall variance. These factors were "flow of data and information", "mobility", "clinical decision support and patient safety", "electronic patient record" and "integration and distribution". The system of weights derived from the factor loadings resulted in values for the workflow composite score that differed only slightly from the score values that had been previously published based on a top-down approach.

CONCLUSION

Our findings give insight into the internal composition of clinical information logistics both in terms of factors and weights. They also allowed us to propose a coherent model of clinical information logistics from a technical perspective that joins empirical findings with theoretical knowledge. Despite the new scheme of weights applied to the calculation of the workflow composite score, the score behaved robustly, which is yet another hint of its validity and therefore its usefulness.

Late Responses in the Electrodiagnosis of Cervical Radiculopathies

Backround and aim

This paper aims to assess the parameters of late responses and then determine their usefulness in patients with cervical radiculopathy.

Patients and methods

We studied a total of 114 patients with bilateral assessment of median and ulnar nerves and of F and A waves parameters.

Results

We draw attention to the need of bilateral electrodiagnostic examination due to changes occurring in a third of cases also in the asymptomatic limb. Pluriradicular injuries occurred in one third of cases. The root that was most commonly affected in cases of uniradicular lesion was C7. The parameters with the most important alterations were persistence, tacheodispersion and chronodispersion, which were changed in about a half of the patients. With regard to the A wave, it occurred in a small number of cases, about 10%, with an average amplitude of about 120 μV and an average latency of 15ms. The distance from the point of stimulation where the collateral branch appeared was calculated to be approximately 35 cm.

Conclusions

Among the F wave parameters, persistence, tacheodispersion and chronodispersion are recommended to be studied; these parameters were also included in the composite score along with the AAEM recommendations.

Spinal muscular atrophy functional composite score: A functional measure in spinal muscular atrophy

INTRODUCTION

With clinical trials underway, our objective was to construct a composite score of global function that could discriminate among people with spinal muscular atrophy (SMA).

METHODS

Data were collected from 126 participants with SMA types 2 and 3. Scores from the Hammersmith Functional Motor Scale-Expanded and Upper Limb Module were expressed as a percentage of the maximum score and 6-minute walk test as percent of predicted normal distance. A principal component analysis was performed on the correlation matrix for the 3 percentage scores.

RESULTS

The first principal component yielded a composite score with approximately equal weighting of the 3 components and accounted for 82% of the total variability. The SMA functional composite score, an unweighted average of the 3 individual percentage scores, correlated almost perfectly with the first principal component.

CONCLUSIONS

This combination of measures broadens the spectrum of ability that can be quantified in type 2 and 3 SMA patients.

A Top-down Approach

BACKGROUND

Availability and usage of individual IT applications have been studied intensively in the past years. Recently, IT support of clinical processes is attaining increasing attention. The underlying construct that describes the IT support of clinical workflows is clinical information logistics. This construct needs to be better understood, operationalised and measured.

OBJECTIVES

It is therefore the aim of this study to propose and develop a workflow composite score (WCS) for measuring clinical information logistics and to examine its quality based on reliability and validity analyses.

METHODS

We largely followed the procedural model of MacKenzie and colleagues (2011) for defining and conceptualising the construct domain, for developing the measurement instrument, assessing the content validity, pretesting the instrument, specifying the model, capturing the data and computing the WCS and testing the reliability and validity.

RESULTS

Clinical information logistics was decomposed into the descriptors data and information, function, integration and distribution, which embraced the framework validated by an analysis of the international literature. This framework was refined selecting representative clinical processes. We chose ward rounds, pre- and post-surgery processes and discharge as sample processes that served as concrete instances for the measurements. They are sufficiently complex, represent core clinical processes and involve different professions, departments and settings. The score was computed on the basis of data from 183 hospitals of different size, ownership, location and teaching status. Testing the reliability and validity yielded encouraging results: the reliability was high with r(split-half) = 0.89, the WCS discriminated between groups; the WCS correlated significantly and moderately with two EHR models and the WCS received good evaluation results by a sample of chief information officers (n = 67). These findings suggest the further utilisation of the WCS.

CONCLUSION

As the WCS does not assume ideal workflows as a gold standard but measures IT support of clinical workflows according to validated descriptors a high portability of the WCS to other hospitals in other countries is very likely. The WCS will contribute to a better understanding of the construct clinical information logistics.

The potential of composite cognitive scores for tracking progression in Huntington's disease

BACKGROUND

Composite scores derived from joint statistical modelling of individual risk factors are widely used to identify individuals who are at increased risk of developing disease or of faster disease progression.

OBJECTIVE

We investigated the ability of composite measures developed using statistical models to differentiate progressive cognitive deterioration in Huntington's disease (HD) from natural decline in healthy controls.

METHODS

Using longitudinal data from TRACK-HD, the optimal combinations of quantitative cognitive measures to differentiate premanifest and early stage HD individuals respectively from controls was determined using logistic regression. Composite scores were calculated from the parameters of each statistical model. Linear regression models were used to calculate effect sizes (ES) quantifying the difference in longitudinal change over 24 months between premanifest and early stage HD groups respectively and controls. ES for the composites were compared with ES for individual cognitive outcomes and other measures used in HD research. The 0.632 bootstrap was used to eliminate biases which result from developing and testing models in the same sample.

RESULTS

In early HD, the composite score from the HD change prediction model produced an ES for difference in rate of 24-month change relative to controls of 1.14 (95% CI: 0.90 to 1.39), larger than the ES for any individual cognitive outcome and UHDRS Total Motor Score and Total Functional Capacity. In addition, this composite gave a statistically significant difference in rate of change in premanifest HD compared to controls over 24-months (ES: 0.24; 95% CI: 0.04 to 0.44), even though none of the individual cognitive outcomes produced statistically significant ES over this period.

CONCLUSIONS

Composite scores developed using appropriate statistical modelling techniques have the potential to materially reduce required sample sizes for randomised controlled trials.

Efficacy of miglustat in Niemann-Pick C disease: a single centre experience

Niemann-Pick disease type C (NPC) is a lysosomal storage disease characterized by progressive neurological degeneration. Miglustat is the first approved specific therapy and its efficacy in stabilizing or slowing disease progression has been demonstrated in previous studies. We evaluated data from 10 NPC patients treated with Miglustat in a single study centre. All disease manifestations were assessed and patients were stratified according to age at onset of neurological symptoms. Neurological data were recorded by using a modified version of the NP-C disability scale; a "composite score" and a "mean annual change" were calculated to evaluate disease progression. We observed a mean annual change of the composite score of 0.04 in our cohort, indicating slower progression of neurological symptoms if compared with the natural history of the disease. The evidence of slower disease evolution in patients treated with Miglustat suits with previous data and here it is also emphasized by the comparison between disease progression in two early-infantile onset patients receiving different Miglustat dosages. Evaluation of the mean annual change for individual subgroups of patients evidenced minor values in juvenile patients, highlighting better response in such class of patients. Among individual neurological parameters, swallowing showed the minor mean annual change (0.02), indicating better response to therapy. We underline the importance of using a standardized disability scale to quantify and compare neurological features and their evolution over time.

Comparison of two methods for composite score generation in dry eye syndrome

PURPOSE

To compare two methods of composite score generation in dry eye syndrome (DES).

METHODS

Male patients seen in the Miami Veterans Affairs eye clinic with normal eyelid, corneal, and conjunctival anatomy were recruited to participate in the study. Patients filled out the Dry Eye Questionnaire 5 (DEQ5) and underwent measurement of tear film parameters. DES severity scores were generated by independent component analysis (ICA) and latent class analysis (LCA).

RESULTS

A total of 247 men were included in the study. Mean age was 69 years (SD 9). Using ICA analysis, osmolarity was found to carry the largest weight, followed by eyelid vascularity and meibomian orifice plugging. Conjunctival injection and tear breakup time (TBUT) carried the lowest weights. Using LCA analysis, TBUT was found to be best at discriminating healthy from diseased eyes, followed closely by Schirmer's test. DEQ5, eyelid vascularity, and conjunctival injection were the poorest at discrimination. The adjusted correlation coefficient between the two generated composite scores was 0.63, indicating that the shared variance was less than 40%.

CONCLUSIONS

Both ICA and LCA produced composite scores for dry eye severity, with weak to moderate agreement; however, agreement for the relative importance of single diagnostic tests was poor between the two methods.

A study of Two Clinical Performance Scores: Assessing the Psychometric Characteristics of a Combined Score Derived from Clinical Evaluation Forms and OSCEs

Background/Purpose - It is important to improve the quality of clinical skill assessments. In addition to using the OSCE, the clinical skills of medical students are assessed with clinical evaluation forms (CEFs). The purpose of this study is to examine the psychometric characteristics of an OSCE/CEF composite score. Methods - This study included 2 medical student classes from a large medical school. Students completed approximately 12 OSCEs and were rated over 33 times on a CEF. The reliability of the CEF and OSCE were estimated. A correlation between the mean OSCE score and the mean CEF was calculated and corrected for attenuation. Classical methods were used to examine composite score reliability. Results - For both classes there was a statistically significant correlation between the CEF and OSCE (r = .27 & .42, p = .003 & .0001). The disattenuated correlations were .44 and .68. Weighting the OSCE in the composite score as high as .4 was associated with only a small decrease in composite reliability. Conclusion - These results demonstrate that assessment information based on simulated and actual patient encounters can be combined into a composite. Since a composite score may provide a more valid measure of clinical performance, this study supports using a combined CEF and OSCE measure.