Category: Statistics

J Med Internet Res. 2024 Oct 22;26:e58312. doi: 10.2196/58312.

ABSTRACT

BACKGROUND: Frailty represents a state of susceptibility to stressors and constitutes a dynamic process. Untreated, this state can progress to disability. Hence, timely detection of alterations in patients’ frailty status is imperative to institute prompt clinical interventions and impede frailty progression. With this aim, the FACET (Frailty Care and Well Function) technological ecosystem was developed to provide clinically gathered data from the home to a medical team for early intervention.

OBJECTIVE: The aim of this study was to assess whether the FACET technological ecosystem prevents frailty progression and improves frailty status, according to the frailty phenotype criteria and Frailty Trait Scale-5 items (FTS-5) at 3 and 6 months of follow-up.

METHODS: This randomized clinical trial involved 90 older adults aged ≥70 years meeting 2 or more Fried frailty phenotype criteria, having 4 or more comorbidities, and having supervision at home. This study was conducted between August 2018 and June 2019 at the geriatrics outpatient clinics in Getafe University Hospital and Albacete University Hospital. Participants were randomized into a control group receiving standard treatment and the intervention group receiving standard treatment along with the FACET home monitoring system. The system monitored functional tests at home (gait speed, chair stand test, frailty status, and weight). Outcomes were assessed using multivariate linear regression models for continuous response and multivariate logistic models for dichotomous response. P values less than .05 were considered statistically significant.

RESULTS: The mean age of the participants was 82.33 years, with 28% (25/90) being males. Participants allocated to the intervention group showed a 74% reduction in the risk of deterioration in the FTS-5 score (P=.04) and 92% lower likelihood of worsening by 1 point according to Fried frailty phenotype criteria compared to the control group (P=.02) at 6 months of follow-up. Frailty status, when assessed through FTS-5, improved in the intervention group at 3 months (P=.004) and 6 months (P=.047), while when the frailty phenotype criteria were used, benefits were shown at 3 months of follow-up (P=.03) but not at 6 months.

CONCLUSIONS: The FACET technological ecosystem helps in the early identification of changes in the functional status of prefrail and frail older adults, facilitating prompt clinical interventions, thereby improving health outcomes in terms of frailty and functional status and potentially preventing disability and dependency.

TRIAL REGISTRATION: ClinicalTrials.gov NCT03707145; https://clinicaltrials.gov/study/NCT03707145.

PMID:39436684 | DOI:10.2196/58312

JAMA Netw Open. 2024 Oct 1;7(10):e2440140. doi: 10.1001/jamanetworkopen.2024.40140.

ABSTRACT

IMPORTANCE: Health centers are vital primary care safety nets for underserved populations, but optimal clinician staffing associated with quality care is unclear. Understanding the association of clinician staffing patterns with quality of care may inform care delivery, scope-of-practice policy, and resource allocation.

OBJECTIVE: To describe the association of clinician staffing models and ratios with quality-of-care metrics in health centers.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study of US health centers used data from the 2022 Health Resources and Services Administration Uniform Data System (UDS).

EXPOSURE: Clinician staffing ratios, expressed as the fraction of full-time equivalents (FTEs) per 1000 visits of physicians, advanced practice registered nurses (APRNs), and physician associates (PAs) to total clinician FTEs at each health center.

MAIN OUTCOMES AND MEASURES: Percentage of eligible patients receiving the corresponding service or outcome for 14 individual clinical quality metrics collected by the UDS, including infant immunizations; screening for cancer, depression, tobacco use, hypertension, HIV, and glycated hemoglobin levels; weight and body mass index (BMI) assessment; and appropriate statin, aspirin, and/or antiplatelet therapy.

RESULTS: This analysis of 791 health centers serving 16 114 842 patients (56.6% female) identified 5 clinician staffing models: balanced (similar FTEs of physicians, APRNs, and PAs; 152 [19.2%] of health centers), higher FTEs of APRNs than physicians (174 [22.0%]), higher FTEs of physicians than APRNs (160 [20.2%]), approximately equal FTEs of physicians and APRNs (263 [33.2%]), and large scale (42 [5.3%]). Adjusted linear models showed positive associations between physician FTEs per 1000 visits and cervical (β, 14.9; 95% CI, 3.1-26.7), breast (β, 15.7; 95% CI, 3.2-28.1), and colorectal (β, 18.3; 95% CI, 6.0-30.6) cancer screening. Generalized additive models showed nonlinear positive associations beginning at a physician FTE ratio of 0.45 (95% CI, 0.02-6.22) for infant vaccinations, 0.39 (95% CI, 0.05-2.21) for cervical cancer screening, 0.39 (95% CI, 0.02-1.67) for breast cancer screening, 0.47 (95% CI, 0.00-5.76) for HIV testing, and 0.70 (95% CI, 0.18-19.96) for depression in remission; APRN FTE ratio of 0.45 (95% CI, 0.17-7.46) for adult BMI assessment; and PA FTE ratio of 0.16 (95% CI, 0.11-3.88) for infant vaccinations. Staffing models were not associated with 7 of the 14 metrics analyzed.

CONCLUSIONS AND RELEVANCE: In this cross-sectional study of health centers, physician FTE ratio was associated with higher performance in cancer screening, infant vaccinations, and HIV testing; APRN FTE ratio was associated with higher performance in preventative health assessments; and PA FTE ratio was associated with higher performance in infant vaccination. These findings suggest that targeted staffing strategies may be associated with quality of care in certain domains and that tailored approaches to health center staffing based on community-specific needs are warranted.

PMID:39436649 | DOI:10.1001/jamanetworkopen.2024.40140

JAMA Netw Open. 2024 Oct 1;7(10):e2440411. doi: 10.1001/jamanetworkopen.2024.40411.

ABSTRACT

IMPORTANCE: There is a need for early and equitable detection of cognitive impairment among older adults.

OBJECTIVE: To examine the prevalence of unrecognized cognitive impairment among older adults receiving primary care from federally qualified health centers (FQHCs).

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study was conducted at 5 FQHCs providing primary care in Indianapolis, Indiana, between 2021 and 2023. Participants were adults aged 65 years and older, without a diagnosis of mild cognitive impairment (MCI), dementia, or severe mental illness. Data analysis was performed from September 2023 to April 2024.

MAIN OUTCOMES AND MEASURES: The primary outcome was a diagnosis of dementia or MCI, as determined by an interdisciplinary clinical team using data from structured patient and study partner interviews, medical record reviews, and a detailed cognitive assessment, including neuropsychological testing. Differences between participants determined to have normal cognition, MCI, and dementia were assessed statistically using analysis of variance for continuous variables, χ2 or Fisher exact tests for categorical variables, or Fisher exact test alone when expected cell counts were 5 or less.

RESULTS: A total of 844 eligible individuals were consecutively approached, 294 consented to participate, and 204 completed the study (mean [SD] age, 70.0 [5.1] years; 127 women [62.3%]). One hundred eight participants (52.9%) were African American, 5 (2.5%) were Hispanic, 199 (97.5%) were not Hispanic, and 90 (44.1%) were White. The mean (SD) duration of education was 13.1 (2.6) years, and the mean (SD) Area Deprivation Index score was 78.3 (19.9), indicating a high level of neighborhood disadvantage. In total, 127 patients (62.3%) met the diagnostic criteria for MCI, 25 (12.3%) had dementia, and 52 (25.5%) had no cognitive impairment. Compared with non-Hispanic White individuals and after adjusting for age, sex, and education level, African American individuals were more than twice as likely to have MCI or dementia (odds ratio, 2.73; 95% CI, 1.38-5.53; P = .02).

CONCLUSIONS AND RELEVANCE: This cross-sectional study found that unrecognized cognitive impairment is ubiquitous among older adults from underrepresented, minoritized racial and ethnic groups and those who are socially vulnerable receiving primary care from FQHCs. To overcome the disparity in early detection of cognitive impairment, timely, equitable, scalable, and sustainable detection approaches need to be developed.

PMID:39436648 | DOI:10.1001/jamanetworkopen.2024.40411

JAMA Netw Open. 2024 Oct 1;7(10):e2440510. doi: 10.1001/jamanetworkopen.2024.40510.

ABSTRACT

IMPORTANCE: A major portion of adolescents and adults seeking psychiatric treatment report nonsuicidal self-injury (NSSI) within the past month, yet the short-term course of NSSI among these patients remains poorly understood.

OBJECTIVE: To advance the understanding of the short-term course of NSSI cognitions (ie, thoughts, urges, and self-efficacy to resist self-injury) and behavior.

DESIGN, SETTING, AND PARTICIPANTS: A cohort study was conducted using an intensive longitudinal design with ecological momentary assessment, including 6 daily surveys and event registrations of self-injury for 28 days. Data were collected from June 2021 to August 2023. Individuals using mental health services in the Flanders region in Belgium reporting past-month NSSI urges and/or behavior at intake were recruited by referral.

MAIN OUTCOMES AND MEASURES: Nonsuicidal self-injury thoughts, urges, self-efficacy, and behavior. Sociodemographic and clinical baseline characteristics served as between-person variables. Descriptive and variability statistics and dynamic structural equation modeling were used.

RESULTS: Participants completed a mean (SD) of 121 (34.5) surveys, totaling 15 098 longitudinal assessments (median adherence, 78.6%; IQR, 59.5%-88.7%). Among 125 patients (87.2% female; median age, 22.0 [range, 15-39] years; 52.8% heterosexual), NSSI thoughts and urges were present during most assessments but were low in intensity (individual means [SD] on a 0- to 6-point scale, 1.52 [1.13] for urges; 1.57 [1.18] for thoughts). The prevalence of NSSI behavior was 84.0% monthly, 49.90% weekly, and 18.19% daily. Between-patient variability was substantial (intraclass correlation coefficient, 0.43-0.47; range of individual means for cognitions, 0-6; individual frequency behavior, 0-103), with recency and frequency of NSSI thoughts and behavior at intake consistently associated with individual differences in the course of NSSI. The greatest variability was observed within patients (root mean square of successive differences from 1.31 for self-efficacy to 1.40 for instability of thoughts), characterized by changes in the intensity of cognitions by more than 1 within-person SD between assessments less than 2 hours apart in 1 of 5 instances. Nonsuicidal self-injury behavior is rare in the morning, increased in the afternoon, and most frequent in the evening. Nonsuicidal self-injury cognitions were contemporaneous and temporally associated with each other’s course, with higher-than-usual thoughts and lower self-efficacy uniquely signaling heightened risk for NSSI behavior in the next 2 hours.

CONCLUSIONS AND RELEVANCE: In this cohort study of treatment-seeking individuals, NSSI cognitions and behavior appeared to be dynamic over the short term. These findings suggest the potential utility of self-monitoring outside the therapy setting and the need to focus assessment and interventions on the evening hours.

PMID:39436647 | DOI:10.1001/jamanetworkopen.2024.40510

BJU Int. 2024 Oct 22. doi: 10.1111/bju.16547. Online ahead of print.

ABSTRACT

OBJECTIVE: To determine the diagnostic test accuracy of multiparametric magnetic resonance imaging (mpMRI) in detecting seminal vesicle invasion (SVI).

METHODS: The Medical Literature Analysis and Retrieval System Online (MEDLINE), PubMed, the Excerpta Medica dataBASE (EMBASE) and Cochrane databases were search up to May 2023. We included studies that investigated the accuracy of mpMRI in detecting SVI when compared to radical prostatectomy specimens as the reference standard. Data extraction was performed by two independent reviewers to construct 2 × 2 tables, as well as patient and study characteristics. The methodological quality of the included studies was assessed with the Quality of Assessment of Diagnostic Accuracy Studies-2 tool. Sensitivity and specificity were pooled and presented graphically with summary receiver operator characteristic (SROC) plots.

RESULTS: A total of 27 articles with 4862 patients were included for analysis. The summary sensitivity and specificity were 0.57 (95% confidence interval [CI] 0.45-0.68) and 0.95 (95% CI 0.92-0.99), respectively. Meta-regression indicated that there was no evidence that coil strength (P = 0.079), coil type (P = 0.589), year of publication (P = 0.503) or use of the Prostate Imaging-Reporting and Data System (P = 0.873) significantly influenced these results. The summary diagnostic odds ratio was 28.3 (95% CI 15.0-48.8) and the area under the curve for the SROC curve was 0.87. The I² statistic was a modest 11.9%. In general, methodological quality was good.

CONCLUSION: The use of mpMRI in detecting SVI has excellent specificity but poor sensitivity. Both endorectal coils and magnetic field strength do not significantly impact the accuracy of MRI. These findings suggest that mpMRI cannot reliably rule out SVI in patients with prostate cancer.

PMID:39436642 | DOI:10.1111/bju.16547

BJS Open. 2024 Sep 3;8(5):zrae115. doi: 10.1093/bjsopen/zrae115.

ABSTRACT

BACKGROUND: A national guideline on peripheral arterial disease management in England was issued in August 2012. The impact on revascularization rates was examined and variation with socioeconomic deprivation assessed.

METHODS: Annual hospital admissions for England over 10 years (2008-2009 to 2017-2018) were examined using interrupted time series analysis. A pragmatic approach was used to classify admissions for revascularization into moderate and severe categories.

RESULTS: There were 309 839 admissions (56% for moderate peripheral arterial disease), with an overall annual admission rate for revascularization of 86 per 100 000 population aged 25+ years. The rate for moderate peripheral arterial disease marginally increased by 0.29 per 100 000 per year (95% c.i. -0.22 to 0.80) from 2008-2009 to 2012-2013. Following guideline introduction, this rate decreased. The equivalent for severe peripheral arterial disease increased by 1.33 per 100 000 (0.78 to 1.88). Following guideline introduction, this rate plateaued. The change in rate (slope) for moderate peripheral arterial disease of -2.81 per 100 000 per year (-3.52 to -2.10) after guideline introduction was greater than the change in rate for severe peripheral arterial disease of -1.95 per 100 000 per year (-2.73 to -1.17). For moderate peripheral arterial disease, the annual rate in the most socioeconomically deprived category was 15.6 per 100 000 lower in 2017-2018 compared with 2012-2013 (24.3% decrease). The impact progressively diminished with decreasing deprivation. In the least deprived category, the reduction was 5.2 per 100 000 (12.9% decrease). For severe peripheral arterial disease, the decrease was 1.2 per 100 000 (3.1% reduction) with no consistent variation in relation to deprivation.

CONCLUSION: Introduction of the national peripheral arterial disease management guideline in England was associated with a reduction in admission rates for revascularization, especially for moderate peripheral arterial disease, with greater reduction in rates for moderate peripheral arterial disease in more socioeconomically deprived areas. Association, however, does not necessarily imply causation and alternative explanations cannot be ruled out.

PMID:39436641 | DOI:10.1093/bjsopen/zrae115

Radiol Med. 2024 Oct 22. doi: 10.1007/s11547-024-01897-6. Online ahead of print.

ABSTRACT

OBJECTIVE: This study, derived from the phase 3 SAFE trial (ClinicalTrials.gov identifier: NCT2236806), explores subclinical cardiac damage in breast cancer patients receiving anthracycline-based chemotherapy and left-sided breast radiation therapy (RT).

MATERIALS AND METHODS: Eligible patients were randomized to a cardioprotective pharmacological therapy (bisoprolol, ramipril, or both) or placebo, with cardiac surveillance at multiple time-point using standard and 3-dimensional echocardiography. Dosimetric parameters were analysed, including mean heart dose (MHD) and various metrics for heart substructures, employing advanced contouring techniques and auto-contouring software.

RESULTS: In the analysis of left-sided breast RT patients, the study encompassed 39 out of 46 irradiated individuals, focusing on GLS and 3D-LVEF outcomes with ≥ 10% worsening, defined as subclinical heart damage. Distinct RT schedules were used, with placebo exhibiting the highest ≥ 10% worsening (36.4%). In terms of treatment arms, bisoprolol exhibited 11.1% worsening, while ramipril 16.7% and bisoprolol + ramipril 25%. For patients with no subclinical damage, the mean MHD was 1.5 Gy; for patients with subclinical heart damage, the mean MHD was 1.6 Gy (p = 0.94). Dosimetric parameters related to heart and heart substructures (left anterior descending artery, right and left atrium, right and left ventricle) showed no statistically significant differences between patients with and without subclinical damage.

CONCLUSION: Our results emphasize the crucial role of cardioprotective measures in mitigating adverse effects, highlighting RT as having negligible influence on cardiac performance. An extended follow-up assessment of the whole series is warranted to determine whether a subclinical effect could significantly influence clinical outcomes and cardiac events.

PMID:39436588 | DOI:10.1007/s11547-024-01897-6

Environ Monit Assess. 2024 Oct 22;196(11):1090. doi: 10.1007/s10661-024-13232-7.

ABSTRACT

Microplastics (MPs) and heavy metal pollution pose significant environmental threat, potentially leading to agroecosystem toxicity and jeopardizing food security. Therefore, this study aims to evaluate the abundance and risk assessment of these pollutants in five different farmlands of Ernakulam district, India. Results showed that MPs content in agricultural fields near commercialized areas such as Kakkanad Nedungapuzha, Nedumbassery, and Kadamakuddy was dominant compared to Nechoor, a rural area. The average microplastic abundance was found to be 45.6 ± 26.4 items kg⁻¹ dw. Polypropylene (PP) and polyethylene (PE) were the dominant polymers found in the soil samples, constituting 45% and 25% of the microplastic content, respectively. The pollution load index of MPs indicates that the sampling sites are considered to be polluted as PLI > 1 with hazard level I. The heavy metal pollution status follows the order: Cu (80.3 to 724 mg/kg) > Zn (77 to 543.5 mg/kg) > Cr (171.65 to 334.65 mg/kg) > As (10.25 to 79.5 mg/kg) > Pb (2.05 to 30.3 mg/kg) > Cd (0.3 to 14.35 mg/kg). Calculated pollution load index (PLI) geo-accumulation index (Igeo), ecological risk assessment values indicate that commercialized regions exhibit high levels of trace metals, namely Cu, Zn, As, Cd, and Cr, posing a significant concern for the agricultural ecosystem. Our results indicate heightened microplastics and heavy metals prevalence in farmlands adjacent to commercial zones, necessitating immediate preventive action to mitigate increasing concentrations.

PMID:39436565 | DOI:10.1007/s10661-024-13232-7

Acta Neurol Belg. 2024 Oct 22. doi: 10.1007/s13760-024-02667-x. Online ahead of print.

ABSTRACT

BACKGROUND AND OBJECTIVE: Intramedullary mature teratomas in adults are rare tumors that pose significant diagnostic and therapeutic challenges due to their diverse tissue composition and intramedullary location. This review, which includes an illustrative case, aims to provide a comprehensive overview of the clinical presentation, diagnosis, treatment, and outcomes of adult intramedullary mature teratomas through a systematic review of 89 cases.

METHODS: A systematic review was conducted following PRISMA guidelines, using keyword combinations in PubMed, MEDLINE, and Web of Science databases until June 2024. Inclusion criteria were adult patients (> 18 years) with histopathologically confirmed intramedullary mature teratomas. Statistical analyses examined relationships between the extent of resection (EoR), tumor location, and patient outcomes.

RESULTS: Among the 89 cases, the mean age was 39.94 ± 13.52 years, with a male-to-female ratio of 1.39:1. Tumors were most commonly located in the conus region (51.2%). Surgical resection was the primary treatment, with 43 cases undergoing partial resection and 33 gross total resection. No statistically significant differences in outcomes were found between EoR, sex, associated anomalies, or specific outcomes. However, younger patients showed improved outcomes for lower limb weakness and sphincter dysfunction. Recurrence was noted in three cases, all located in the conus.

CONCLUSION: Intramedullary mature teratomas require a nuanced approach that balances complete resection and neurological preservation. Early diagnosis and individualized surgical planning are crucial for optimizing outcomes. Despite the challenges, effective management is achievable, and ongoing research is essential to refining treatment strategies for this rare tumor.

PMID:39436559 | DOI:10.1007/s13760-024-02667-x

Acta Neurol Belg. 2024 Oct 22. doi: 10.1007/s13760-024-02672-0. Online ahead of print.

ABSTRACT

OBJECTIVE: To evaluate the safety and efficacy of bridging intravenous thrombolysis plus mechanical thrombectomy (MT) versus direct MT in different age groups of patients with acute ischemic stroke (AIS) secondary to large vessel occlusion (LVO) of the anterior circulation.

METHODS: Consecutive patients from the prospective endovascular stroke registry of the Comprehensive Stroke Center, University of Rome Tor Vergata, Italy, between January 2015 and June 2021 were retrospectively analyzed. Patients were divided into age groups (≤ 80 years old and > 80 years old); for each age group, they were further divided in the bridging therapy group and the direct MT group. We performed a propensity score analysis according to baseline characteristics. Safety outcomes were any intracerebral hemorrhage (ICH), symptomatic ICH (sICH) and 3-month mortality. Efficacy outcomes were successful recanalization (modified Thrombolysis in Cerebral Infarction, mTICI, score ≥ 2b) and 3-month functional independence (modified Rankin Scale, mRS, ≤ 2).

RESULTS: We included 761 AIS patients with anterior circulation LVO (mean age 73.5 ± 12.8 years; 44.8% males; mean baseline NIHSS 16 ± 5). After propensity score, there were 365 patients ≤ 80 years old (52% bridging therapy) and 187 patients > 80 years old (57% bridging therapy). In both age groups of patients, we found no statistically significant differences in the rates of any ICH, sICH, successful recanalization and 3-month mortality and functional independence between bridging therapy and direct MT groups.

CONCLUSION: In our population, safety and efficacy outcomes of bridging therapy versus direct MT did not differ in both AIS patients ≤ 80 and > 80 years old.

PMID:39436555 | DOI:10.1007/s13760-024-02672-0