Category: Statistics

J Voice. 2023 Feb 10:S0892-1997(23)00023-1. doi: 10.1016/j.jvoice.2023.01.018. Online ahead of print.

ABSTRACT

OBJECTIVES: Unilateral vocal fold paresis or paralysis (UVFP) is a condition for which radiographic evaluation and laryngeal electromyography (LEMG) are valuable to evaluate severity of injury and direct treatment plans. Despite extensive research involving findings suggestive of UVFP with radiographic imaging, no study has attempted to determine which findings suggestive of UVFP on imaging are clinically significant and suggest a need for intervention. The purpose of this study was to evaluate whether the severity of vocal fold paresis/paralysis affects the likelihood of encountering radiographic findings suggestive of UVFP. We also aimed to determine which findings suggestive of UVFP on imaging were clinically significant and were associated with surgical intervention.

MATERIALS AND METHODS: A retrospective chart review was conducted of patients who had been diagnosed with unilateral vocal fold paresis or paralysis and had been evaluated by CT scan and/or magnetic resonance imaging and laryngeal electromyography (EMG) between the dates of January 1, 2017 and January 9, 2018. Fisher’s exact testing with Monte Carlo Simulation was utilized to determine statistical significance of identified relationships. Univariate analysis was conducted to assess for individual relationships between imaging results and the potential predictor variables. Chi square analysis was conducted with the various categorical variables to assess for any potential relationships to imaging results. Statistical significance was determined utilizing chi square analysis.

RESULTS: After data collection, 130 patients were included in the study population. Of the 112 patients with documented MRI results, 17% had a reported imaging abnormality suggestive of true vocal fold paresis or paralysis (VFP). Of the 71 patients with documented CT Neck results, 15.4% had an abnormality potentially concerning for true VFP. The average decrease in recruitment of the right and left SLN was 23.8% and 26.1%, respectively. The average decrease in recruitment of the right and left RLN was 37.3% and 57.78%, respectively. Seventy four percent of patients who exhibited abnormal MRI were found to have isolated SLN weakness, and 21% of patients were found to have a combined SLN and ipsilateral RLN weakness. In patients with abnormal CT scans 45% were found to have isolated SLN weakness, and 35% were found to have a combined SLN and RLN weakness. MRI imaging again failed to display any significant degree of paresis. However, abnormal CT results displayed severe CN X paresis in 36.84% vs 1.96% in normal scans. The chance of an abnormal MRI and CT result was 2.78 and 5.55 times greater, respectively, for each increase in the degree of severity of CN X paresis. When looking at the ability of imaging to predict the chance of a patient undergoing surgery, 34.8% of patients with an abnormal MRI underwent surgery compared to just 14.61% of those with normal scans. For CT scans, 35% of patients with an abnormal scan underwent surgery, compared with only 15.69% with normal imaging. When pooled, over 33% of patients with any abnormal imaging underwent a laryngeal procedure compared to 13% of patients with normal imaging.

CONCLUSIONS: There is a relationship between severity of vocal fold paresis found on laryngeal EMG and likelihood of detection on imaging. While CT was more likely to find characteristics of UVFP than MRI, patients who had an abnormal finding on either modality were more likely to undergo surgical intervention. These findings highlight the importance of early referral of patients with abnormal laryngeal imaging to an otolaryngologist for evaluation and possible intervention.

PMID:36775753 | DOI:10.1016/j.jvoice.2023.01.018

Neurocirugia (Astur : Engl Ed). 2023 Feb 10:S2529-8496(22)00100-9. doi: 10.1016/j.neucie.2022.07.001. Online ahead of print.

ABSTRACT

INTRODUCTION AND OBJECTIVES: Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is a recognized treatment for drug-refractory Parkinson’s disease (PD). However, the therapeutic success depends on the accuracy of targeting. This study aimed to evaluate potential accuracy differences in the placement of the first and second electrodes implanted, by comparing chosen electrode trajectories, STN activity detected during microelectrode recording (MER), and the mismatch between the initially planned and final electrode positions on each side.

MATERIALS AND METHODS: In this retrospective cohort study, we analyzed data from 30 patients who underwent one-stage bilateral DBS. For most patients, three arrays of microelectrodes were used to determine the physiological location of the STN. Final target location depended also on the results of intraoperative stimulation. The choice of central versus non-central channels was compared. The Euclidean vector deviation was calculated using the initially planned coordinates and the final position of the tip of the electrode according to a CT scan taken at least a month after the surgery.

RESULTS: The central channel was chosen in 70% of cases on the first side and 40% of cases on the second side. The mean length of high-quality STN activity recorded in the central channel was longer on the first side than the second (3.07±1.85mm vs. 2.75±1.94mm), while in the anterior channel there were better MER recordings on the second side (1.59±2.07mm on the first side vs. 2.78±2.14mm on the second). Regarding the mismatch between planned versus final electrode position, electrodes on the first side were placed on average 0.178±0.917mm lateral, 0.126±1.10mm posterior and 1.48±1.64mm inferior to the planned target, while the electrodes placed on the second side were 0.251±1.08mm medial, 0.355±1.29mm anterior and 2.26±1.47mm inferior to the planned target.

CONCLUSION: There was a tendency for the anterior trajectory to be chosen more frequently than the central on the second side. There was also a statistically significant deviation of the second electrodes in the anterior and inferior directions, when compared to the electrodes on the first side, suggesting that another cause other than brain shift may be responsible. We should therefore factor this during planning for the second implanted side. It might be useful to plan the second side more anteriorly, possibly reducing the number of MER trajectories tested and the duration of surgery.

PMID:36775743 | DOI:10.1016/j.neucie.2022.07.001

Prim Care Diabetes. 2023 Feb 10:S1751-9918(23)00032-3. doi: 10.1016/j.pcd.2023.02.001. Online ahead of print.

ABSTRACT

AIMS: To evaluate whether the prescription of SGLT2-inhibitors in primary care patients with type 2 diabetes (T2DM) and a very high risk was according to the newest updated Dutch general practitioners’ practice guidelines on T2DM.

METHODS: This observational study with routine care data was conducted in a primary care setting in the Netherlands. The very high-risk population size was identified and analyzed via descriptive statistics. In this high-risk group the percentage of patients treated with SGLT2-inhibitors was assessed.

RESULTS: Of the 1492 T2DM patients managed in primary care, 475 (31.8%) were classified as very high-risk based on (a history of) ischemic cardiovascular disease, chronic kidney disease, and/or heart failure. Of the very high-risk patients, 49 (10.3%) received SGLT2-inhibitors conform the guidelines. Of the remaining 426 high-risk patients 334 (70.3%) had no contraindication (eGFR <30 ml/min/1.73 m² or HbA1c <53 mmol/mol) for initiating SGLT2-i prescription according to the guidelines. None of these patients received an GLP-1 agonist as alternative.

CONCLUSIONS: The vast majority of very high-risk type 2 diabetes patients were not prescribed SGLT2-I. There is substantial room for improvement in the management of these critical T2DM patients because most of them had no contraindications for initiating SGLT2-I prescription.

PMID:36775727 | DOI:10.1016/j.pcd.2023.02.001

Nutr Metab Cardiovasc Dis. 2023 Jan 29:S0939-4753(23)00022-4. doi: 10.1016/j.numecd.2023.01.011. Online ahead of print.

ABSTRACT

BACKGROUND AND AIMS: The relationship between reproductive factors and type 2 diabetes (T2D) is controversial; therefore, we explored the causal relationship of age at menarche (AAM), age at natural menopause (ANM), with the risk of T2D and glycemic traits using two-sample Mendelian randomization.

METHODS AND RESULTS: We used publicly available data at the summary level of genome-wide association studies, where AAM (N = 329,345), ANM (N = 69,360), T2D (N = 464,389). The inverse variance weighting (IVW) method was employed as the primary method. To demonstrate the robustness of the results, we also conducted various sensitivity analysis methods including the MR-Egger regression, the weighted median (WM) and the MR Pleiotropy RESidual Sum and Outlier (MR-PRESSO) test. After excluding IVs associated with confounders, we found a causal association between later AAM and reduced risk of T2D (OR 0.81 [95% CI 0.75, 0.87]; P = 2.20 × 10^-8), lower levels of FI (β -0.04 [95% CI -0.06, -0.01]; P = 2.19 × 10^-3), FPG (β -0.03 [95% CI -0.05, -0.007]; P = 9.67 × 10^-5) and HOMA-IR (β -0.04 [95% CI -0.06, -0.01]; P = 4,95 × 10^-3). As for ANM, we only found a causal effect with HOMA-IR (β -0.01 [95% CI -0.02, -0.005]; P = 1.77 × 10^-3), but not with T2D.

CONCLUSIONS: Our MR study showed a causal relationship between later AAM and lower risk of developing T2D, lower FI, FPG and HOMA-IR levels. This may provide new insights into the prevention of T2D in women.

PMID:36775707 | DOI:10.1016/j.numecd.2023.01.011

Clin Ther. 2023 Jan 16:S0149-2918(23)00023-1. doi: 10.1016/j.clinthera.2023.01.003. Online ahead of print.

ABSTRACT

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic has had a profound impact on everyday life, the environment, and health care services. A shift from in-person medical appointments to telemedicine was a main adjustment. Such changes can have repercussions on the control and management of chronic respiratory diseases, such as asthma. The available data suggest that there was an overall decrease in asthma-related morbidities during the first year of the pandemic. Therefore, the goal of this study was to quantify the effects of the pandemic on the prescribing of antiasthmatic treatments in outpatient care (public and private health care).

METHODS: This before-after study used a time series approach based on data from monthly prescriptions of antiasthmatic drugs (anti-inflammatory drugs and bronchodilators) dated between April 2018 and March 2021. An interrupted time series (ITS) design was used for assessing changes in antiasthmatic prescribing patterns in the short and long terms after COVID-19 was recognized as a pandemic. The results are complemented with seasonal autoregressive integrated moving average (sARIMA) models.

FINDINGS: The ITS analysis showed a non-significant increase in antiasthmatic prescribing in the short term. In the long term, after the pandemic was declared, a statistically significant decrease was observed in the prescribing of antiasthmatics (in anti-inflammatory drugs and, more pronounced, in bronchodilators). In the sARIMA model, the mean monthly volume of antiasthmatic prescriptions was 18.1% lower than predicted. The numbers of months outside of the 95% CIs were different between anti-inflammatory drugs (1 month) and bronchodilators (7 months).

IMPLICATIONS: The prescribing of antiasthmatic drugs in the long term was significantly decreased with the COVID-19 pandemic, with a greater effect in the case of bronchodilators.

PMID:36775690 | DOI:10.1016/j.clinthera.2023.01.003

Hepatobiliary Pancreat Dis Int. 2023 Feb 2:S1499-3872(23)00010-3. doi: 10.1016/j.hbpd.2023.01.010. Online ahead of print.

ABSTRACT

BACKGROUND: Grafts from older donors after circulatory death were associated with inferior outcome in liver transplants in the past. But it has seemed to remain controversial in the last decade, as a result of modified clinical protocols, selected recipients, and advanced technology of organ perfusion and preservation. The present study aimed to examine the impact of older donor age on complications and survival of liver transplant using grafts from donation after circulatory death (DCD).

METHOD: A total of 944 patients who received DCD liver transplantation from 2015 to 2020 were included and divided into two groups: using graft from older donor (aged ≥ 65 years, n = 87) and younger donor (age < 65 years, n = 857). Propensity score matching (PSM) was applied to eliminate selection bias.

RESULTS: A progressively increased proportion of liver transplants with grafts from older donors was observed from 1.68% to 15.44% during the study period. The well-balanced older donor (n = 79) and younger donor (n = 79) were 1:1 matched. There were significantly more episodes of biliary non-anastomotic stricture (NAS) in the older donor group than the younger donor group [15/79 (19.0%) vs. 6/79 (7.6%); P = 0.017]. The difference did not reach statistical significance regarding early allograft dysfunction (EAD) and primary non-function (PNF). Older livers had a trend toward inferior 1-, 2-, 3-year graft and overall survival compared with younger livers, but these differences were not statistically significant (63.1%, 57.6%, 57.6% vs. 76.9%, 70.2%, 67.7%, P = 0.112; 64.4%, 58.6%, 58.6% vs. 76.9%, 72.2%, 72.2%, P = 0.064). The only risk factor for poor survival was ABO incompatible transplant (P = 0.008) in the older donor group. In the subgroup of ABO incompatible cases, it demonstrated a significant difference in the rate of NAS between the older donor group and the younger donor group [6/8 (75.0%) vs. 3/14 (21.4%); P = 0.014].

CONCLUSIONS: Transplants with grafts from older donors (aged ≥ 65 years) after circulatory death are more frequently associated with inferior outcome compared to those from younger donors. Older grafts from DCD are more likely to develop NAS, especially in ABO incompatible cases.

PMID:36775686 | DOI:10.1016/j.hbpd.2023.01.010

J Med Imaging Radiat Sci. 2023 Jan 30:S1939-8654(23)00005-X. doi: 10.1016/j.jmir.2023.01.005. Online ahead of print.

ABSTRACT

BACKGROUND: Resilient health systems effectively respond to health crises and coordinate post-event recovery. Central to a resilient system is the willingness of its workforce to work in high-risk scenarios. This study explored traits that may affect Medical Radiation and Imaging Professionals (MRIPs) willingness to work during a pandemic. Specifically, intrapersonal traits of compassion, empathy, and resilience were examined. Understanding such relationships can inform interventions that enhance individuals’ willingness and health system resilience (HSR).

METHODS: In Fall 2020, a cross-sectional survey of Nova Scotian MRIPs was conducted. Witte’s Extended Parallel Process Model, Professional Quality of Life, Intrapersonal Reactivity Index and Adult Resilience Measures-17 tools were used to assess willingness, compassion, empathy, and resilience. Statistical tests included chi-square, binomial, and multinomial logistic regression.

RESULTS: MRIPs were willing to report to work during the SARS-CoV-2 pandemic if required (92%); asked but not required (89%); or regardless of severity (94%). Individuals with very high levels of willingness reported lower personal distress (a facet of empathy) compared to those with high (p=.018) or moderate levels (p=.005). MRIPs with < 10 years experience were more likely to report high personal distress (p≤.37). Job role was associated with willingness (p<.001). There were no significant associations between level of willingness, and gender, age, experience, education, or the intrapersonal traits resilience and compassion.

CONCLUSION: Willingness was associated with job role and levels of personal distress. Personal distress was higher in participants with less years of practice. Interventions to reduce personal distress in early career MRIPs may enhance willingness to work during crises and thereby support HSR.

PMID:36775684 | DOI:10.1016/j.jmir.2023.01.005

J Pediatr Surg. 2023 Jan 20:S0022-3468(23)00040-4. doi: 10.1016/j.jpedsurg.2023.01.021. Online ahead of print.

ABSTRACT

BACKGROUND: Global pandemics may limit access to specialized care, delaying diagnosis and treatment of common acute surgical diseases. We analyzed the impact of the novel coronavirus disease 2019 (COVID-19) pandemic on acute appendicitis at an urban tertiary care center. We hypothesize that pandemics are associated with delayed presentation and worsened clinical sequelae, specifically, higher incidences of perforation in children.

METHODS: We retrospectively assessed patients admitted to our institution with acute appendicitis in pre-pandemic control (February 2018-June 2019) and COVID-19 (February 2020-June 2021) cohorts. Primary outcomes included complicated appendicitis rates (perforation/abscess/bowel obstruction), COVID-19 status, complications and travel distance to our institution. 1107 patients met inclusion criteria: 491 (44.4%) during the control period and 616 (55.6%) in the COVID-19 cohort. Statistical analysis involved t-tests, contingency tables and logistic regression modelling for key variables.

RESULTS: A larger proportion of complicated appendicitis occurred during COVID-19 compared to controls (28.3% vs 38.8%, p < 0.001). Symptom duration at presentation and length of stay were not significantly different. Duration of antibiotic treatment, surgery length, readmission rate and travel distances were significantly higher during COVID-19. The pre-pandemic cohort had a significantly younger age distribution.

CONCLUSION: Pediatric appendicitis was significantly impacted during COVID-19, demonstrated by increased rates of complicated appendicitis, surgery duration and antibiotic duration. This may be an unintended secondary consequence of patients avoiding healthcare facilities for non-pandemic related illnesses or lockdown policies. Government policies directing all provincial pediatric appendicitis cases to pediatric institutions increased travel distances for our patients and had unanticipated consequences and resource requirements on tertiary healthcare.

LEVEL OF EVIDENCE: Level III for “Treatment Studies”.

PMID:36775681 | DOI:10.1016/j.jpedsurg.2023.01.021

Aust Crit Care. 2023 Feb 10:S1036-7314(22)00258-2. doi: 10.1016/j.aucc.2022.12.012. Online ahead of print.

ABSTRACT

OBJECTIVES: We aim to ascertain whether the benefit of early tracheostomy can be found in patients with severe traumatic brain injury (TBI) and stroke and if the benefit will remain considering distinct pathologies.

DATA SOURCES: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol, a search through Lilacs, PubMed, and Cochrane databases was conducted.

REVIEW METHODS: Included studies were those written in English, French, Spanish, or Portuguese, with a formulated question, which compared outcomes between early and late trach (minimum of two outcomes), such as intensive care unit (ICU) length of stay (LOS), duration of mechanical ventilation (MV), hospital LOS, mortality rates, or ventilator-associated pneumonia (VAP). Likewise, patients presented exclusively with head injury or stroke had minimum hospital stay follow-up, and as for severe TBI patients, they presented Glasgow Coma Scale ≤8 at admission. Evaluated outcomes were the risk ratio (RR) of VAP, risk difference (RD) of mortality, and mean difference (MD) of the duration of MV, ICU LOS, and hospital LOS.

RESULTS: The early and late tracheostomy cohorts were composed of 6211 and 8140 patients, respectively. The meta-analysis demonstrated that the early tracheostomy cohort had a lower risk for VAP (RR: 0.73 [95% confidence interval {CI}, 0.66, 0.81] p < 0.00001), shorter duration of MV (MD: -4.40 days [95% CI, -8.28, -0.53] p = 0.03), and shorter ICU (MD: -6.93 days [95% CI, -8.75, -5.11] p < 0.00001) and hospital LOS (MD: -7.05 days [95% CI, -8.27, -5.84] p < 0.00001). The mortality rate did not demonstrate a statistical difference.

CONCLUSION: Early tracheostomy could optimise patient outcomes by patients’ risk for VAP and decreasing MV durationand ICU and hospital LOS.

PMID:36775675 | DOI:10.1016/j.aucc.2022.12.012

Acad Radiol. 2023 Feb 10:S1076-6332(23)00027-2. doi: 10.1016/j.acra.2023.01.011. Online ahead of print.

ABSTRACT

RATIONALE AND OBJECTIVES: Work-life experience of physicians is a driver of work engagement vs. burnout. We aimed to determine individual and institutional factors affecting work-life experience of the clinical faculty at a large tertiary care academic medical center.

MATERIALS AND METHODS: The Department of Radiology clinical faculty (n = 62) were surveyed electronically in October 2022. Twenty-three questions, consisting of multiple choice, Yes/No, and Likert scale ratings were administered to obtain demographic information and data for life outside of work, life at work, and work-life integration for the prior 12 months. Work engagements in terms of clinical, research, administrative, and education; work practices including engagement in extra work and remote work; life responsibilities; and utilization of work-life balance strategies were analyzed for percentages and differences in seniority levels and genders. Ratings of faculty work engagement and life integration strategies were assessed utilizing a 1-5 Likert scale. Descriptive statistics were utilized to report mean, standard deviation, median, Q1 and Q3 for continuous measurements, while count and percentage for categories measurements. Comparisons between seniority and gender categories were conducted using independent t-test or Wilcoxon rank sum test depending on data normality assessed through histogram analysis. Chi-square test was used to make comparisons for categorical data. When encountered with small cell (category with <5 count), Fisher’s exact test was used for 2 × 2 table analysis and Freeman-Halton test was used for comparisons with more than two categories. SAS 9.4 was used for the data analysis.

RESULTS: Twenty-eight faculty (M:F = 17:11) responded to the survey (survey response rate 45%). The vast majority of faculty reported working extra hours, with 40% working at least 10 hours extra per week. Total of 42.9% reported performing clinical work in the extra hours worked. Total 70.4% of faculty had caregiver responsibilities and 64.3% reported other individual stresses (e.g., financial, family/social, health-related), which required consistent demand of time and effort. A total of 35.7% of faculty reported not being able to balance competing life and work demands. A total of 21.4% respondents reported not utilizing any individual healthy lifestyle choices on a consistent basis over the prior 12 months. Protected time off work and remote work were perceived as effective strategies to provide adequate work-life balance; however, remote work engagement was relatively minor and 35.7% bought back vacation. Total 53.6% respondents reported a level 4 (out of 5) rating for work being meaningful and being positively engaged in their work.

CONCLUSION: Institutions should invest in providing the infrastructure for physician work-life balance and in facilitating healthy lifestyle choices for physicians.

PMID:36775667 | DOI:10.1016/j.acra.2023.01.011