Risk factors associated with 30-day hospital readmissions among persons living with HIV in Nantong, China

OBJECTIVE

To estimate 30-day hospital readmission rates among persons living with HIV (PLWH) at the Nantong Infectious Disease Hospital in China and analyse the related risk factors.

METHODS

A single-centre retrospective cohort study was conducted. There were 894 PLWH records obtained from the electronic medical record (EMR) system at the Nantong Infectious Disease Hospital in China, from October 2013 to February 2018. The 30-day readmission rates were calculated, and the risk factors were analysed by generalised estimating equations (GEEs).

RESULTS

A total of 1153 hospitalizations from 894 patients were recorded between October 2013 and February 2018. The median time of 30-day readmissions was 13 days (interquartile range (IQR), 6-23). The reasons for all causes, acquired immunodeficiency syndrome (AIDS)-defining illnesses (ADIs), and non-AIDS-defining infections (non-ADIs) were 9.08, 13.52, and 7.91%, respectively. The results from the GEE analysis demonstrated that the risk factors associated with 30-days readmissions were as follows: no antiretroviral therapy (ART) prior to hospitalisations (odds ratio (OR) = 1.90, 95% confidence interval (CI): 1.21-3.00), low CD4 counts (OR = 2.17, 95% CI: 1.33-3.54), and multiple comorbidities (OR = 6.45, 95% CI: 1.62-25.73).

CONCLUSION

Early detection of HIV infection and early initiation of ART treatment are the keys to controlling 30-day readmissions.

Comparison of small-sample standard-error corrections for generalised estimating equations in stepped wedge cluster randomised trials with a binary outcome: A simulation study

Generalised estimating equations with the sandwich standard-error estimator provide a promising method of analysis for stepped wedge cluster randomised trials. However, they have inflated type-one error when used with a small number of clusters, which is common for stepped wedge cluster randomised trials. We present a large simulation study of binary outcomes comparing bias-corrected standard errors from Fay and Graubard; Mancl and DeRouen; Kauermann and Carroll; Morel, Bokossa, and Neerchal; and Mackinnon and White with an independent and exchangeable working correlation matrix. We constructed 95% confidence intervals using a t-distribution with degrees of freedom including clusters minus parameters (DFC-P), cluster periods minus parameters, and estimators from Fay and Graubard (DFFG), and Pan and Wall. Fay and Graubard and an approximation to Kauermann and Carroll (with simpler matrix inversion) were unbiased in a wide range of scenarios with an independent working correlation matrix and more than 12 clusters. They gave confidence intervals with close to 95% coverage with DFFG with 12 or more clusters, and DFC-P with 18 or more clusters. Both standard errors were conservative with fewer clusters. With an exchangeable working correlation matrix, approximated Kauermann and Carroll and Fay and Graubard had a small degree of under-coverage.

Anxiety and depression are associated with long-term outcomes of hepatocellular carcinoma: A nationwide study of a cohort from Taiwan

OBJECTIVES

A natural experimental design was coupled with propensity score matching to assess the risks of anxiety and depression and to assess the longitudinal effects of anxiety and depression on healthcare utilisation and mortality in hepatocellular carcinoma (HCC) patients.

METHODS

This nationwide population-based cohort study retrospectively analysed 7304 patients treated for HCC during 1996-2010. Generalised estimating equations were used to estimate differences-in-differences models for examining the effects of anxiety and depression disorders.

RESULTS

Independent risk factors for anxiety and depression in the HCC patients were female gender (hazard ratio (HR) 1.45; P < 0.001), Charlson co-morbidity index score (HR 1.12; P = 0.005), and liver cirrhosis (HR 1.35; P = 0.004). Anxiety and depression (differences-in-differences value) had a significant (P < 0.001) positive net effect on number of physician visits. Furthermore, the mean overall survival time was 83.4 months (SD 5.4 months) in the anxiety/depression group and 65.4 months (SD 4.8 months) in the non-disorder group. Additionally, the overall survival rate was significantly higher in the anxiety/depression group compared to the non-disorder group during the study period (P = 0.003).

CONCLUSIONS

Anxiety disorders and depression disorders are associated with a significantly increased overall survival rate in HCC patients. However, further studies are needed to investigate this association.

Pathways from Food Consumption Score to Cardiovascular Disease: A Seven-Year Follow-Up Study of Indonesian Adults

Background: Available prospective studies of food insecurity and cardiovascular diseases (CVD) have included obesity and hypertension as the modifiable risk factors. Studies using the physical activity measures are lacking, and where to contribute to counterbalance the risk associated with food insecurity and CVD remains unclear. We aimed to use structural equation modelling (SEM) to explore the complex direct and indirect factor variables influencing cardiovascular disease (CVD) during a seven-year follow-up study. Methods: For 3955 adults who participated in the Indonesian Family Life Surveys in 2007 and 2014, we used SEM to examine the direct and indirect relationships of food consumption score, body shape index, physical activity volume, and blood pressures on CVD. Results: Based on the beta coefficients from a regression analysis, the significant direct effects (p < 0.001) for CVD were food consumption score (FCS), a body shape index (ABSI), vigorous physical activity volume (VPAV), and systolic blood pressure (SBP). Indirect (p = 0.004–p < 0.001) effects for CVD were FCS, ABSI, moderate physical activity volume (MPAV), and VPAV. Food-insecure people are more likely to consume high-calorie diets that lead to obesity, which, together with a lack of vigorous physical activity, leads to hypertension and CVD. Conclusions: Of the multiple factors influencing CVD, the modifiable risk factors were FCS, ABSI, and VPAV. Hence, the recommendations for CVD prevention should include targeting food insecurity, body shape index, and vigorous physical activity besides the measurement of blood pressure.

Accounting for twin births in sample size calculations for randomised trials

BACKGROUND

Including twins in randomised trials leads to non-independence or clustering in the data. Clustering has important implications for sample size calculations, yet few trials take this into account. Estimates of the intracluster correlation coefficient (ICC), or the correlation between outcomes of twins, are needed to assist with sample size planning. Our aims were to provide ICC estimates for infant outcomes, describe the information that must be specified in order to account for clustering due to twins in sample size calculations, and develop a simple tool for performing sample size calculations for trials including twins.

METHODS

ICCs were estimated for infant outcomes collected in four randomised trials that included twins. The information required to account for clustering due to twins in sample size calculations is described. A tool that calculates the sample size based on this information was developed in Microsoft Excel and in R as a Shiny web app.

RESULTS

ICC estimates ranged between -0.12, indicating a weak negative relationship, and 0.98, indicating a strong positive relationship between outcomes of twins. Example calculations illustrate how the ICC estimates and sample size calculator can be used to determine the target sample size for trials including twins.

CONCLUSIONS

Clustering among outcomes measured on twins should be taken into account in sample size calculations to obtain the desired power. Our ICC estimates and sample size calculator will be useful for designing future trials that include twins. Publication of additional ICCs is needed to further assist with sample size planning for future trials.

The relationship between game-based performance indicators and developmental level in junior Australian football: Implications for coaching

Identifying performance differences between juniors at different stages of a talent pathway may assist with the development of prospective talent. This study investigated the relationship between game-based performance indicators and developmental level in junior Australian football (AF). Players were categorised into 2 groups according to developmental level; U16 and U18. Physical and technical skill performance indicators were collated for all U16 (n = 200) and U18 (n = 244) participants of their respective 2014 national championships. Data were acquired from all 28 games (12 U16, 16 U18); resulting in 1360 player observations (568 U16, 792 U18). Microtechnology and a commercial provider facilitated the quantification of 15 performance indicators. Generalised estimating equations (GEEs) modelled the extent to which these performance indicators were associated with developmental level. The GEE model revealed that "contested marks" and "contested possessions" had the strongest association with the U16 level, while "total marks" and "clearances" had the strongest association with the U18 level. The remaining performance indicators were not developmentally discriminant. These results indicate that there are distinctive features of gameplay more associated with the U16 and U18 levels in AF. Coaches may wish to consider these results when constructing training drills designed to minimise developmental gaps.

Analysis of Randomised Trials Including Multiple Births When Birth Size Is Informative

BACKGROUND

Informative birth size occurs when the average outcome depends on the number of infants per birth. Although analysis methods have been proposed for handling informative birth size, their performance is not well understood. Our aim was to evaluate the performance of these methods and to provide recommendations for their application in randomised trials including infants from single and multiple births.

METHODS

Three generalised estimating equation (GEE) approaches were considered for estimating the effect of treatment on a continuous or binary outcome: cluster weighted GEEs, which produce treatment effects with a mother-level interpretation when birth size is informative; standard GEEs with an independence working correlation structure, which produce treatment effects with an infant-level interpretation when birth size is informative; and standard GEEs with an exchangeable working correlation structure, which do not account for informative birth size. The methods were compared through simulation and analysis of an example dataset.

RESULTS

Treatment effect estimates were affected by informative birth size in the simulation study when the effect of treatment in singletons differed from that in multiples (i.e. in the presence of a treatment group by multiple birth interaction). The strength of evidence supporting the effectiveness of treatment varied between methods in the example dataset.

CONCLUSIONS

Informative birth size is always a possibility in randomised trials including infants from both single and multiple births, and analysis methods should be pre-specified with this in mind. We recommend estimating treatment effects using standard GEEs with an independence working correlation structure to give an infant-level interpretation.

Maternal dietary patterns during pregnancy and child internalising and externalising problems. The Generation R Study

BACKGROUND & AIMS

Maternal nutritional factors during pregnancy have been linked to foetal brain development and subsequent offspring behaviour. Less is known about associations between maternal dietary patterns and offspring behaviour.

METHODS

Within a population-based cohort, we assessed maternal diet using a food frequency questionnaire. Three dietary patterns were derived by means of Principal Component Analysis. Child internalising (emotionally reactive, anxious/depressed or withdrawn, having somatic complaints) and externalising problems (inattention, aggression) were assessed with the Child Behaviour Checklist at 1.5, 3 and 6 years in 3104 children. We assessed the association of maternal Mediterranean, Traditionally Dutch and Confectionary dietary pattern during pregnancy with child internalising and externalising problems.

RESULTS

After adjustment, the Mediterranean diet was negatively associated (ORper SD in Mediterranean score = 0.90, 95% CI: 0.83-0.97) and the Traditionally Dutch diet was positively associated with child externalising problems (ORper SD in Traditionally Dutch score = 1.11, 95% CI: 1.03-1.21). Neither diet was associated with internalising problems.

CONCLUSIONS

Both low adherence to the Mediterranean diet and high adherence to the Traditionally Dutch diet during pregnancy are associated with an increased risk of child externalising problems. Further research is needed to unravel the effects of nutrient interplay during and after pregnancy on child behavioural development.

Effectiveness of breed-specific legislation in decreasing the incidence of dog-bite injury hospitalisations in people in the Canadian province of Manitoba

Background

The city of Winnipeg was the first among several jurisdictions in Manitoba, Canada, to introduce breed specific legislation (BSL) by banning pit-bull type dogs in 1990. The objective of the present work was to study the effectiveness of BSL in Manitoba.

Methods

Temporal differences in incidence of dog-bite injury hospitalisations (DBIH) within and across Manitoba jurisdictions with and without BSL were compared. Incidence was calculated as the number of unique cases of DBIH divided by the total person-years at risk and expressed as the number per 100 000 person-years. Year of implementation determined the pre-BSL and post-BSL period for jurisdictions with BSL; for jurisdictions without BSL to date, the entire study period (1984–2006) was considered as the preimplementation period. The annual number of DBIH, adjusted for total population at risk, was modelled in a negative binomial regression analysis with repeated measures. Year, jurisdiction and BSL implementation were independent variables. An interaction term between jurisdiction and BSL was introduced.

Results

A total of 16 urban and rural jurisdictions with pit-bull bans were identified. At the provincial level, there was a significant reduction in DBIH rates from the pre-BSL to post-BSL period (3.47 (95% CI 3.17 to 3.77) per 100 000 person-years to 2.84 (95% CI 2.53 to 3.15); p=0.005). In regression restricted to two urban jurisdictions, DBIH rate in Winnipeg relative to Brandon (a city without BSL) was significantly (p<0.001) lower after BSL (rate ratio (RR)=1.10 in people of all ages and 0.92 in those aged <20 years) than before (RR=1.29 and 1.28, respectively).

Conclusions

BSL may have resulted in a reduction of DBIH in Winnipeg, and appeared more effective in protecting those aged <20 years.