Category: Statistics

Anesthesiology. 2023 Nov 17. doi: 10.1097/ALN.0000000000004839. Online ahead of print.

ABSTRACT

BACKGROUND: An intraoperative transfer of care from one anesthesia provider to another, or handover, may result in information loss and contribute to adverse patient outcomes. In 2019 we undertook a quality improvement effort to increase the use of a structured intraoperative handover tool incorporated in the electronic medical record. We hypothesized that intraoperative handovers of anesthesia care would be associated with adverse patient outcomes, and that increased use of a structured tool would attenuate this effect.

METHODS: This study included adult patients undergoing non-cardiac surgery of at least 1-hour duration performed during the period 2016-2021. Cases with a handover were identified if either there was a change of attending anesthesiologist or change of nurse anesthetist or resident for > 35 minutes. Our primary outcome was the occurrence of a composite of postoperative mortality and major postoperative morbidity. The effect of the intervention was analyzed by examining the quarterly change in odds ratio for the primary outcome for cases with and without a handover.

RESULTS: A total of 121,077 cases, 40.4% of which had a handover, were included. After weighting, the composite outcome was statistically associated with handovers (3517/48,986 [7.2%] in handover cases, vs. 4470/72,091 [6.2%] in non-handover cases, odds ratio 1.08, 95% CI: 1.04, 1.12). Time series analysis showed a marked increase in usage of the structured tool following the initial intervention. The odds ratio for the composite outcome showed a significant decrease over time following the initial intervention (t = -3.97, p < 0.001), with the slope of the OR vs. time curve decreasing from 0.002 (95% CI: 0.001, 0.004; P=0.018) to -0.011 (-0.01, -0.018; P < 0.001).

CONCLUSION: Intraoperative handovers are significantly associated with adverse outcomes even after controlling for multiple confounding variables. Use of a structured handover tool during anesthesia care may attenuate the adverse effect.

PMID:37976442 | DOI:10.1097/ALN.0000000000004839

JCO Clin Cancer Inform. 2023 Sep;7:e2300070. doi: 10.1200/CCI.23.00070.

ABSTRACT

PURPOSE: This discussion paper outlines challenges and proposes solutions for successfully implementing prediction models that incorporate patient-reported outcomes (PROs) in cancer practice.

METHODS: We organized a full-day multidisciplinary meeting of people with expertise in cancer care delivery, PRO collection, PRO use in prediction modeling, computing, implementation, and decision science. The discussions presented here focused on identifying challenges to the development, implementation and use of prediction models incorporating PROs, and suggesting possible solutions.

RESULTS: Specific challenges and solutions were identified across three broad areas. (1) Understanding decision making and implementation: necessitating multidisciplinary collaboration in the early stages and throughout; early stakeholder engagement to define the decision problem and ensure acceptability of PROs in prediction; understanding patient/clinician interpretation of PRO predictions and uncertainty to optimize prediction impact; striving for model integration into existing electronic health records; and early regulatory alignment. (2) Recognizing the limitations to PRO collection and their impact on prediction: incorporating validated, clinically important PROs to maximize model generalizability and clinical engagement; and minimizing missing PRO data (resulting from both structural digital exclusion and time-varying factors) to avoid exacerbating existing inequalities. (3) Statistical and modeling challenges: incorporating statistical methods to address missing data; ensuring predictive modeling recognizes complex causal relationships; and considering temporal and geographic recalibration so that model predictions reflect the relevant population.

CONCLUSION: Developing and implementing PRO-based prediction models in cancer care requires extensive multidisciplinary working from the earliest stages, recognition of implementation challenges because of PRO collection and model presentation, and robust statistical methods to manage missing data, causality, and calibration. Prediction models incorporating PROs should be viewed as complex interventions, with their development and impact assessment carried out to reflect this.

PMID:37976441 | DOI:10.1200/CCI.23.00070

J Spec Oper Med. 2023 Nov 17:5TNR-B19B. doi: 10.55460/5TNR-B19B. Online ahead of print.

ABSTRACT

This study evaluated the effect of an airway localization device (ALD) on surgical cricothyrotomy (SC) success rates and prehospital provider confidence. SC is indicated in 0.62% to 1.8% of all patients with military trauma, especially those presenting with traumatic airway obstruction. The effect of ALD was evaluated in an airway mannequin model during SC with the Committee on Tactical Combat Casualty Care (CoTCCC)-recommended Control-Cric Cricothyrotomy System. Outcomes included procedural time, Likert measures of operator confidence, and qualitative data/feedback for suggested future improvements in device design and training. The average procedural times of the hospital corpsmen (HM) including 20 men and 8 women were 67 seconds (without ALD) and 87 seconds (with ALD) respectively, which were statistically significant. Provider confidence for all SC procedural steps increased significantly after SC with and without ALD. The average procedural times of the Navy Special Operations Forces (SOF) group comprising 8 males were 56 seconds (without ALD) and 64 seconds (with ALD), which was not statistically significant. Provider confidence for two SC procedural steps (adequate hook retraction and first-attempt SC tube insertion) increased significantly after SC with and without ALD. First-attempt SC success rates were 90% in each group. Both groups provided feedback on the Control-Cric and ALD, with qualitative feedback analyzed for further SC training recommendations. Procedural times were increased with ALD when compared to those without ALD, although the increase may not be clinically significant in this classroom setting.

PMID:37976434 | DOI:10.55460/5TNR-B19B

J Aging Health. 2023 Nov 17:8982643231215475. doi: 10.1177/08982643231215475. Online ahead of print.

ABSTRACT

OBJECTIVES: To determine if the association between posttraumatic stress disorder (PTSD) and substance use (alcohol misuse or smoking tobacco) is mediated/moderated by exercise or volunteering among aging (≥40 years) men who have sex with men (MSM), and if this mediation/moderation differs by HIV serostatus.

METHODS: Multicenter AIDS Cohort Study data were used. Three datasets with PTSD measured during different time periods (10/1/2017-3/31/2018, 898 men; 4/1/2018-9/30/2018, 890 men; 10/1/2018-3/31/2019, 895 men) were analyzed. Longitudinal mediation analyses estimated the mediation effect of exercise and volunteering on the outcomes.

RESULTS: Nine percent of MSM had evidence of PTSD. There was no statistically significant mediation effect of exercise or volunteering regardless of substance use outcome. The odds of smoking at a future visit among MSM with PTSD were approximately double those of MSM without PTSD. Results did not differ by HIV serostatus.

DISCUSSION: There is a particular need for effective smoking cessation interventions for aging MSM with PTSD.

PMID:37976419 | DOI:10.1177/08982643231215475

Hepatology. 2023 Nov 17. doi: 10.1097/HEP.0000000000000694. Online ahead of print.

ABSTRACT

BACKGROUND AND AIMS: A simple non-invasive score, the Agile3+ score, combining liver stiffness measurement (LSM), aspartate aminotransferase/alanine aminotransferase ratio, platelet count, diabetes status, sex, and age, has been proposed for identification of advanced fibrosis in patients with suspected non-alcoholic fatty liver disease (NAFLD). We performed a systematic review and meta-analysis of observational studies to evaluate the diagnostic accuracy of the Agile 3+ score in identifying patients with NAFLD and advanced fibrosis. Recently, an International consensus changed the nomenclature of NAFLD into metabolic-associated steatotic liver disease (MASLD), so currently, the two terms are interchangeable.

METHODS: We systematically searched MEDLINE, Ovid Embase, Scopus, and Cochrane Library electronic databases for full-text published articles in any language from the inception to the 24th of April 2023. We included original articles reporting data on the sensitivity and specificity of the Agile 3+ score, according to previously described rule-out (≤0.451) and rule-in (≥0.679) cut-offs.

RESULTS: We included 6 observational studies (total 6955 participants) with biopsy-proven NAFLD (mean age 53 [SE 4] years, mean BMI 30.9 [SE 2.3] Kg/m2, 54.0% men, prevalence of diabetes 59.6%). The pooled prevalence of advanced fibrosis (≥F3) was 42.1%. By the rule-out cut-off, the overall sensitivity and specificity were 88% (95%CI 81-93%; I2=89.2%) and 65% (95%CI 54-75%; I2=97.6%), respectively. By the rule-in cut-off, the overall sensitivity and specificity were 68% (95%CI 57-78%; I2=91.1%) and 87% (95%CI 80-92%; I2=96.7%), respectively. Meta-regression analyses reported that the diagnostic accuracy was partly mediated by age (p<0.01), BMI (p<0.01), and, although not statistically significant, sex (p=0.06).

CONCLUSION: Our systematic review and meta-analysis suggest that Agile3+ accurately diagnoses NAFLD with advanced fibrosis and can identify patients eligible for biopsy and emerging pharmacotherapies.

PMID:37976417 | DOI:10.1097/HEP.0000000000000694

Hepatology. 2023 Nov 17. doi: 10.1097/HEP.0000000000000691. Online ahead of print.

ABSTRACT

BACKGROUND AIMS: Treatment of hepatorenal syndrome-acute kidney injury (HRS-AKI), with terlipressin and albumin, provides survival benefit, but may be associated with cardiopulmonary complications. We analysed the predictors of terlipressin response and mortality using point-of-care echocardiography (POC-Echo), cardiac and renal biomarkers.

APPROACH: Between December 2021 and January 2023, patients with HRS-AKI were assessed with POC-Echo and lung ultrasound within 6h of admission, at the time of starting terlipressin(48h), and at 72h. Volume expansion was done with 20% albumin, followed by terlipressin infusion. Clinical data, POC-Echo data, and serum biomarkers were prospectively collected. Cirrhotic Cardiomyopathy(CCM) was defined per 2020 criteria.

RESULTS: One hundred and forty patients were enrolled [84% men, 59% alcohol-associated disease, mean MELDNa-25±standard deviation(SD) 5.6]. Median daily dose of infused terlipressin was 4.3(interquartile range:3.9-4.6)mg/day; mean duration-6.4± SD-1.9 days; complete response was in 62% and partial response in 11%. Overall mortality was 14% and 16% at 30 and 90 days, respectively. Cut-offs for prediction of terlipressin nonresponse were cardiac variables-[E/e’>12.5(indicating increased left filling pressures, C-statistic-0.774), e’ velocity<7 cm/s (indicating impaired relaxation; C-statistic-0.791), >20.5% reduction in cardiac index at 72h(C-statistic-0.885); p<0.001] and pre-treatment biomarkers (Cystatin C>2.2 mg/l, C-statistic-0.640 and NT-ProBNP>350 pg/mL, C-statistic-0.655;p<0.050). About 6% of all HRS-AKI patients and 26% of patients with CCM had pulmonary edema. Presence of CCM(aHR1.9;CI-1.8-4.5,p=0.009) and terlipressin nonresponse (aHR 5.2;CI-2.2-12.2, p<0.001) were predictors of mortality independent of age, gender, obesity, DM-2, etiology and baseline creatinine.

CONCLUSIONS: Cirrhotic cardiomyopathy and reduction in cardiac index, reliably predict terlipressin non-response. CCM is independently associated with poor survival in HRS-AKI.

PMID:37976391 | DOI:10.1097/HEP.0000000000000691

Chron Respir Dis. 2023 Jan-Dec;20:14799731231211845. doi: 10.1177/14799731231211845.

ABSTRACT

BACKGROUND: Early commencement of rehabilitation might counteract the loss of muscle strength due to a chronic obstructive pulmonary disease acute exacerbation (COPDAE). Blood flow restriction resistance exercise (BFR-RE) using a low intensity of training load has demonstrated muscle strength gain in varieties of clinical populations. This trial aimed at studying the efficacy and acceptability of BFR-RE in patients with post-COPDAE which was not reported before.

METHOD: A prospective, assessor blinded, randomized controlled study with 2-week in-patient rehabilitation program with BFR-RE was compared to a matched program with resistance exercise without BFR in patients with post-COPDAE. The primary outcome was the change of muscle strength of knee extensor of dominant leg. The secondary outcomes included changes of hand grip strength (HGS), 6-minute walk test (6MWT) distance, short physical performance battery (SPPB) scores, COPD assessment test (CAT) scores; acceptability and feasibility of BFR-RE; and 1-month unplanned re-admission rate.

RESULTS: Forty-Five post-COPDAE patients (mean age = 76 ± 10, mean FEV1%=49% ± 24%) were analyzed. After training, BFR-RE group and control group demonstrated a statistically significant median muscle strength gain of 20 (Interquartile range (IQR) 3 to 38) Newton(N) and 12 (IQR -9 to 30) N respectively. BFR-RE group showed a significant change in SPPB scores, but not in 6MWT distance and HGS after training. Between groups did not have statistically significant different in all primary and secondary outcomes, though with similar acceptability. Drop-out rate due to training-related discomfort in BFR-RE group was 3.7%.

CONCLUSION: BFR-RE is feasible and acceptable in patients with post-COPDAE. A 2-week inpatient pulmonary rehabilitation with BFR-RE improved muscle strength of knee extensors, but not a greater extent than the same rehabilitation program with resistance exercise without BFR. Further studies could be considered with a longer training duration and progression of resistance load. [ClinicalTrials.gov Identifier: NCT04448236].

PMID:37976375 | DOI:10.1177/14799731231211845

West Afr J Med. 2023 Nov 10;40(11 Suppl 1):S24-S25.

ABSTRACT

INTRODUCTION: Though some studies showed biochemical and haematologic derangements in patients with pulmonary tuberculosis (PTB), but information with regards to the correlation between serum albumin and packed cell volume (PCV) is scarce. The aim of this study was to determine the correlation between serum albumin level and PCV in newly diagnosed patients with PTB at Abubakar Tafawa Balewa University Teaching Hospital (ATBUTH), Bauchi, Northeastern Nigeria.

METHODOLOGY: This was a cross-sectional study of consecutive newly diagnosed patients with PTB who were Sputum smear-positive as determined by Gene Expert/Rif MTB machine and HIV-negative by ‘Determine’ test, that were recruited from the medical outpatient department (MOPD) and directly observed treatment short course (DOTS) clinic of ATBUTH, Bauchi. The study was conducted between 2019-2022. Three milliliters of blood sample was analyzed at ATBUTH laboratory for serum albumin and PCV. Extracted data was analyzed using IBM SPSS version 23.0 software.

RESULT: There were 61 patients studied comprising 46 (75.4%) males and 15 (24.6%) females with male to female ratio of 3:1. Their ages range from 14-64 years old. The mean age ± standard deviation (SD) of the patients was 32.21 ± 13.67 years. The mean ± SD of serum albumin and PCV were 2.99 ± 0.55 g/dl, 33.42 ± 5.66 % respectively. Pearson’s product-moment correlation coefficient (r) was +0.475, p = 0.000 which was statistically significant at the 0.01 level suggesting a positive correlation between serum albumin and PCV.

CONCLUSION: There was a significant correlation between serum albumin level and PCV in the patients studied.

PMID:37976370

Sci Adv. 2023 Nov 15;9(46):eade7130. doi: 10.1126/sciadv.ade7130. Epub 2023 Nov 17.

ABSTRACT

Toward the poles, life on land is increasingly dominated by microorganisms, yet the evolutionary origin of polar microbiomes remains poorly understood. Here, we use metabarcoding of Arctic, sub-Antarctic, and Antarctic lacustrine benthic microbial communities to test the hypothesis that high-latitude microbiomes are recruited from a globally dispersing species pool through environmental selection. We demonstrate that taxonomic overlap between the regions is limited within most phyla, even at higher-order taxonomic levels, with unique deep-branching phylogenetic clades being present in each region. We show that local and regional taxon richness and net diversification rate of regionally restricted taxa differ substantially between polar regions in both microeukaryotic and bacterial biota. This suggests that long-term evolutionary divergence resulting from low interhemispheric dispersal and diversification in isolation has been a prominent process shaping present-day polar lake microbiomes. Our findings illuminate the distinctive biogeography of polar lake ecosystems and underscore that conservation efforts should include their unique microbiota.

PMID:37976353 | DOI:10.1126/sciadv.ade7130

Biomol Biomed. 2023 Nov 16. doi: 10.17305/bb.2023.9829. Online ahead of print.

ABSTRACT

This study undertakes a comprehensive comparison of five different interventions for the treatment of type-1 retinopathy of prematurity (ROP) and aggressive posterior retinopathy of prematurity (APROP), offering insights into their relative efficacies and contributing to better clinical decision-making. The aim of this study was to compare the efficacy of intravitreal aflibercept (IVA), intravitreal bevacizumab (IVB), intravitreal conbercept (IVC), intravitreal ranibizumab (IVR), and laser therapy in treating these conditions. We conducted a search for relevant randomized controlled trials (RCTs) in databases, namely PubMed, Embase, Cochrane Library, Web of Science, and Ovid, focusing on these five treatment modalities for ROP. The quality of included studies was evaluated using the Cochrane Risk of Bias Assessment Tool, and data analysis was performed using STATA software. The results from our network meta-analysis (NMA) indicated that IVA significantly prolonged the interval between initial treatment and relapse in patients, with a surface under the cumulative ranking cruve (SUCRA) value of 99.1%. Additionally, patients in the IVB group had a significantly higher spherical equivalent refraction (SER) after surgery, with a SUCRA value of 84.4%. Furthermore, IVR was the most effective in reducing the duration of peripheral retinal vascularization, with a SUCRA value of 95.6%. However, no statistically significant differences were found in relapse rates among the five treatment options. Our analysis concludes that intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) drug monotherapy generally offer better outcomes than laser treatment for ROP. Nonetheless, additional RCTs are necessary to further evaluate the safety of anti-VEGF agents.

PMID:37976345 | DOI:10.17305/bb.2023.9829