Category: Statistics

Parkinsonism Relat Disord. 2021 Nov 5;93:19-26. doi: 10.1016/j.parkreldis.2021.10.030. Online ahead of print.

ABSTRACT

BACKGROUND: The association between nonalcoholic fatty liver disease (NAFLD) and Parkinson’s disease (PD) remains uncertain. This study sought to assess the sex-specific association between NAFLD and PD risk considering that sex is an important factor in both conditions.

METHODS: We included 2,651,169 men and 2,998,904 women (≥40 years of age) who underwent health examinations in 2009 using database of the Korean National Health Insurance Service. To define NAFLD, the Fatty Liver Index (FLI) was used and a score of at least 60 points was regarded as suggesting the presence of NAFLD. Cox proportional hazards analyses were performed to evaluate the association between the presence of NAFLD/each component of FLI and the risk of PD. All analyses were stratified by sex.

RESULTS: The median follow-up duration was 7.3 years in both men and women. Of the total study population, 23,233 patients with PD (10,578 men and 12,655 women) were identified. Among men, a decreased risk of PD was observed in those with NAFLD [adjusted hazard ratio (aHR): 0.86, 95% confidence interval (CI): 0.82-0.91]. In contrast, among women, an increased risk of PD was observed in those with NAFLD (aHR: 1.09, 95% CI: 1.02-1.16). This different association according to sex was more prominent among younger participants but was not significant in the old age group.

CONCLUSIONS: NAFLD defined by FLI is differently associated with the risk of PD by sex (i.e., low risk of PD in men with NAFLD vs. high risk of PD in women with NAFLD).

PMID:34763304 | DOI:10.1016/j.parkreldis.2021.10.030

J Hazard Mater. 2021 Oct 22;424(Pt C):127540. doi: 10.1016/j.jhazmat.2021.127540. Online ahead of print.

ABSTRACT

Monitored Natural Attenuation (MNA) is a preferred remedy for sites contaminated with 1,4-dioxane due to its low cost and limited environmental impacts compared to active remediation. Having a robust estimate of the rate at which biodegradation occurs is an essential component of assessing MNA. In this study, an assay was developed using ¹⁴C-labeled 1,4-dioxane to measure rate constants for biodegradation based on accumulation of ¹⁴C products. Purification of the ¹⁴C-1,4-dioxane stock solution lowered the level of ¹⁴C impurities to below 1% of the total ¹⁴C activity. This enabled determination of rate constants in groundwater as low as 0.0021 yr^-1, equating to a half-life greater than 300 years. Of the 54 groundwater samples collected from 10 sites in the US, statistically significant rate constants were determined with the ¹⁴C assay for 24. The median rate constant was 0.0138 yr^-1 (half-life = 50 yr); the maximum rate constant was 0.367 yr^-1 (half-life = 1.9 yr). The results confirmed that biodegradation of 1,4-dioxane is occurring at 9 of the 10 sites sampled, albeit with considerable variability in the level of activity. The specificity of the assay was confirmed using acetylene and the absence of oxygen to inhibit monooxygenases.

PMID:34763286 | DOI:10.1016/j.jhazmat.2021.127540

Breast. 2021 Nov 2;60:230-237. doi: 10.1016/j.breast.2021.11.002. Online ahead of print.

ABSTRACT

PURPOSE: To assess whether contralateral parenchymal enhancement (CPE) on MRI is associated with gene expression pathways in ER+/HER2-breast cancer, and if so, whether such pathways are related to survival.

METHODS: Preoperative breast MRIs were analyzed of early ER+/HER2-breast cancer patients eligible for breast-conserving surgery included in a prospective observational cohort study (MARGINS). The contralateral parenchyma was segmented and CPE was calculated as the average of the top-10% delayed enhancement. Total tumor RNA sequencing was performed and gene set enrichment analysis was used to reveal gene expression pathways associated with CPE (N = 226) and related to overall survival (OS) and invasive disease-free survival (IDFS) in multivariable survival analysis. The latter was also done for the METABRIC cohort (N = 1355).

RESULTS: CPE was most strongly correlated with proteasome pathways (normalized enrichment statistic = 2.04, false discovery rate = .11). Patients with high CPE showed lower tumor proteasome gene expression. Proteasome gene expression had a hazard ratio (HR) of 1.40 (95% CI = 0.89, 2.16; P = .143) for OS in the MARGINS cohort and 1.53 (95% CI = 1.08, 2.14; P = .017) for IDFS, in METABRIC proteasome gene expression had an HR of 1.09 (95% CI = 1.01, 1.18; P = .020) for OS and 1.10 (95% CI = 1.02, 1.18; P = .012) for IDFS.

CONCLUSION: CPE was negatively correlated with tumor proteasome gene expression in early ER+/HER2-breast cancer patients. Low tumor proteasome gene expression was associated with improved survival in the METABRIC data.

PMID:34763270 | DOI:10.1016/j.breast.2021.11.002

Epilepsy Res. 2021 Oct 26;178:106796. doi: 10.1016/j.eplepsyres.2021.106796. Online ahead of print.

ABSTRACT

OBJECTIVE: Patients with epilepsy, mainly drug-resistant, have reduced heart rate variability (HRV), linked to an increased risk of sudden death in various other diseases. In this context, it could play a role in SUDEP. Generalized convulsive seizures (GCS) are one of the most consensual risk factors for SUDEP. Our objective was to assess the influence of GCS in HRV parameters in patients with drug-resistant epilepsy.

METHODS: We prospectively evaluated 121 patients with refractory epilepsy admitted to our Epilepsy Monitoring Unit. All patients underwent a 48-hour Holter recording. Only patients with GCS were included (n = 23), and we selected the first as the index seizure. We evaluated HRV (AVNN, SDNN, RMSSD, pNN50, LF, HF, and LF/HF) in 5-min epochs (diurnal and nocturnal baselines; preictal – 5 min before the seizure; ictal; postictal – 5 min after the seizure; and late postictal – >5 h after the seizure). These data were also compared with normative values from a healthy population (controlling for age and gender).

RESULTS: We included 23 patients, with a median age of 36 (min-max, 16-55) years and 65% were female. Thirty percent had cardiovascular risk factors, but no previously known cardiac disease. HRV parameters AVNN, RMSSD, pNN50, and HF were significantly lower in the diurnal than in the nocturnal baseline, whereas the opposite occurred with LF/HF and HR. Diurnal baseline parameters were inferior to the normative population values (which includes only diurnal values). We found significant differences in HRV parameters between the analyzed periods, especially during the postictal period. All parameters but LF/HF suffered a reduction in that period. LF/HF increased in that period but did not reach statistical significance. Visually, there was a tendency for a global reduction in our patients’ HRV parameters, namely AVNN, RMSSD, and pNN50, in each period, comparing with those from a normative healthy population. No significant differences were found in HRV between diurnal and nocturnal seizures, between temporal lobe and extra-temporal-lobe seizures, between seizures with and without postictal generalized EEG suppression, or between seizures of patients with and without cardiovascular risk factors.

SIGNIFICANCE/CONCLUSION: Our work reinforces the evidence of autonomic cardiac dysfunction in patients with refractory epilepsy, at baseline and mainly in the postictal phase of a GCS. Those changes may have a role in some SUDEP cases. By identifying patients with worse autonomic cardiac function, HRV could fill the gap of a lacking SUDEP risk biomarker.

PMID:34763267 | DOI:10.1016/j.eplepsyres.2021.106796

Clin Nutr. 2021 Oct 22;40(12):5764-5770. doi: 10.1016/j.clnu.2021.10.012. Online ahead of print.

ABSTRACT

BACKGROUND & AIMS: Body weight changes reflect and impact several health conditions in older age, but little is known about its relationship with multimorbidity. We aimed to study the association of long-terms trajectories of body mass index (BMI) with contemporaneous changes in multimorbidity -and multimorbidity type- development in a population-based cohort of older adults.

METHODS: Twelve-year BMI trajectories (2001-2013) were identified in subjects aged 60+ years from the Swedish National Study on Aging and Care in Kungsholmen (SNAC-K) using growth mixture models (N = 2189). Information on 60 chronic diseases and multimorbidity was ascertained based on clinical examinations, lab tests, medications, and inpatient and outpatient medical records. Linear mixed models were used to study the association between BMI trajectories and the speed of chronic disease accumulation, in general and by groups of cardiovascular and neuropsychiatric diseases.

RESULTS: Eighty percent of the study population was included in what we defined a stable BMI trajectory, 18% in a slow-decline trajectory with an accelerated BMI decline from age 78 onwards, and 2% in a fast-decline trajectory that reached underweight values before age 85. A significantly higher yearly rate of chronic disease accumulation was observed in the fast-decline versus stable trajectory (β = 0.221, 95% CI 0.090-0.352) after adjusting the model for age cohort, sex, education and time to death. Subjects in the slow-decline trajectory showed a significantly higher yearly rate of cardiovascular disease accumulation (β = 0.016, 95% CI 0.000-0.031); those in the fast-decline trajectory showed a faster accumulation of both cardiovascular (β = 0.020, 95% CI -0.025, 0.064) and neuropsychiatric diseases (β = 0.102, 95% CI 0.064-0.139), even if the former association did not reach statistical significance.

CONCLUSION: Our results provide further evidence of the importance of carefully monitoring older adults with sustained weight loss, which is an early indicator of accelerated health deterioration, reflected in our study by a faster accumulation of chronic -especially neuropsychiatric- diseases.

PMID:34763261 | DOI:10.1016/j.clnu.2021.10.012

Epilepsy Res. 2021 Sep 24;178:106772. doi: 10.1016/j.eplepsyres.2021.106772. Online ahead of print.

ABSTRACT

BACKGROUND: Depression, being the most frequent psychiatric comorbidity, has always been closely linked with epilepsy. However, there is a lack of screening for depressive symptoms resulting in failure to detect depression among people with epilepsy (PWE). While many studies have described the risks associated with depression in epilepsy, very few have elaborated whether these risks are similar for undiagnosed depression, especially in a multiethnic community.

METHODS: We aim to investigate the prevalence and associated risk factors of undiagnosed depression in PWE through a cross-sectional study at a tertiary teaching hospital. Epilepsy patients aged between 18 and 65 years old were recruited after excluding those with background illnesses, which may contribute to depressive symptoms. A total of 129 participants were recruited. We collated their demographic and clinical details before interviewing them using two questionnaires; the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) and Beck’s Depression Inventory-II (BDI-II). Subsequently, if a participant is screened positive for depression, the diagnosis is confirmed using the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) questionnaire and a psychiatric clinic referral is offered.

RESULTS: Among the 129 participants, 9.3 % had undiagnosed major depressive disorder (MDD), which had a female preponderance (66.7 %). Risk factors of undiagnosed depression among PWE include low socioeconomic backgrounds (p = 0.026), generalized epilepsy (p = 0.036) and temporal lobe epilepsy (p = 0.010). Otherwise, while some variables such as being underweight and unmarried may be seen in a higher proportion in those who were depressed; we did not find a statistically significant relationship among them.

CONCLUSION: The prevalence of undiagnosed depression among PWE is higher when compared to population-based studies carried out in Western countries. While questionnaires to screen for depression are widely available, their infrequent use would lead to failure in identifying patients who may benefit from psychosocial support and treatment, which would subsequently improve their disease outcomes and quality of life. This study recommends the use of screening questionnaires to identify undiagnosed depression in PWE.

PMID:34763265 | DOI:10.1016/j.eplepsyres.2021.106772

Am J Emerg Med. 2021 Nov 2;51:197-201. doi: 10.1016/j.ajem.2021.10.041. Online ahead of print.

ABSTRACT

BACKGROUND: Malnutrition is an important contributing factor to mortality in cancer patients. Several scoring systems can be used to evaluate malnutrition in cancer patients. We hypothesized that one or more of these scoring systems should be used to assess malnutrition in emergency departments (EDs).

METHODS: This prospective observational study was conducted in the ED of a tertiary care center. From October 1, 2019, to March 31, 2020, we prospectively collected data on cancer patients aged 18 and over who were evaluated in the ED but did not present with any nutrition-related complaint, and not had any prior nutritional support. Malnutrition levels were determined using the Patient-Generated Subjective Global Assessment (PG-SGA¹) instrument. The patients were grouped according to the presence and degree of malnutrition (PG-SGA categories A and B vs PG-SGA category C) and their need for nutritional intervention according to the Nutritional Triage Recommendation Scores (NTRS² < 9 vs NTRS ≥9).

RESULTS: Twelve female (31.5%) and 26 male (68.5%) cancer patients, with a mean age of 70.29 ± 11.49 years, were enrolled in the study. According to the PG-SGA, 84.2% of the patients were at risk for malnutrition, and 97.4% required nutritional intervention. Thirty patients (78.9%) had experienced problems with eating in the preceding two weeks. There were statistically significant differences in these patients’ body mass indexes (BMIs) (25.46 ± 4.3 kg/m² vs 20.95 ± 3.66 kg/m², p < 0.05) and ages (64.6 ± 10.5 years vs 74.9 ± 10.3 years, p < 0.05) according to the PG-SGA. There were also statistically significant differences between the patients’ BMIs (25.73 ± 3.51 kg/m² vs 22.11 ± 4.50 kg/m², p < 0.05), according to the NTRS. There was no relationship between whether the patients had undergone surgery to remove tumors (p > 0.05), chemotherapy (p > 0.05), or radiotherapy (p > 0.05) according to the PG-SGA and NTRS.

CONCLUSION: Malnutrition is common in cancer patients. These patients may be malnourished even if their BMI is within normal limits. Malnutrition can be detected and evaluated in the ED using instruments such as the PG-SGA. We suggest that evaluation for malnutrition should be a standard component of patient care in the ED.

PMID:34763239 | DOI:10.1016/j.ajem.2021.10.041

Neural Netw. 2021 Oct 23;145:189-198. doi: 10.1016/j.neunet.2021.10.015. Online ahead of print.

ABSTRACT

In this paper, the issue of synchronization is investigated for coupled neural networks subject to stochastic deception attacks. Firstly, a general differential inequality with delayed impulses is given. Then, the established differential inequality is further extended to the case of delayed stochastic impulses, in which both the impulsive instants and impulsive intensity are stochastic. Secondly, by modeling the stochastic discrete-time deception attacks as stochastic impulses, synchronization criteria of the coupled neural networks under the corresponding attacks are given. Finally, two numerical examples are provided to demonstrate the correctness of the theoretical results.

PMID:34763245 | DOI:10.1016/j.neunet.2021.10.015

Am J Emerg Med. 2021 Oct 24;51:184-191. doi: 10.1016/j.ajem.2021.10.031. Online ahead of print.

ABSTRACT

INTRODUCTION: Cardiopulmonary arrest (CPA) care in the Emergency Department (ED) has had to be modified during the coronavirus disease (COVID-19) pandemic. Scarce literature exists on comfort of clinicians (defined as physicians, nurses & advanced practice providers-APP’s) in these new roles and their perceived understanding of new algorithms.

METHODS: Routine CPA care in our ED was modified during the COVID-19 pandemic. This involved clinicians in shared leadership roles alongside COVID-19 specific changes to CPA algorithms. The new protocol was operationalized through a two-step educational intervention involving didactic education and in-situ simulations. Univariate analyses using student’s t-test assessed effectiveness of this educational intervention with clinician comfort as team leaders and perceived knowledge as primary outcomes on a scale of 1 (strongly disagree) to 5 (strongly agree). Subgroup analysis across physicians (attending & resident), nurses & APP’s were also undertaken with an alpha of 0.05, and p values <0.05 were considered statistically significant. Secondary outcomes of task saturation, procedural safety and error prevention were also analyzed.

RESULTS: Across 83 of 95 total participants, our primary outcome of clinician comfort in the team leader role improved from a mean value of 3.41 (SD: 1.23) pre-intervention to 4.11 (SD: 0.88) with a p-value <0.001 post intervention. Similar and statistically significant findings in clinician comfort were noted across all subgroups except attending physicians and APP’s. Perceived knowledge increased from a mean value of 3.54 (SD: 1.06) pre-intervention to a mean value of 4.24 (SD: 0.67) with a p-value <0.001 post intervention. Similar and statistically significant findings in perceived knowledge were noted across all subgroups except APP’s. Responses were registered in either the strongly agree or agree category with regards to task saturation (89%), procedural safety (93%) and error prevention (71%) across all clinicians post intervention.

CONCLUSION: Our pilot investigation of the effectiveness of an educational intervention of a novel CPA protocol in the ED during the COVID-19 pandemic reached statistical significance with regards to clinician comfort in shared leadership roles and perceived knowledge. These findings suggest that the protocol is rapidly teachable, usable and can be efficiently disseminated across ED clinicians of varying experience, especially in pandemic settings. Further work regarding effectiveness of this new protocol in real life cardiac arrest scenarios is warranted.

PMID:34763237 | DOI:10.1016/j.ajem.2021.10.031

Am J Emerg Med. 2021 Oct 24;51:192-196. doi: 10.1016/j.ajem.2021.10.029. Online ahead of print.

ABSTRACT

OBJECTIVES: There has been increased focus nationally on limiting opioid prescriptions. National data demonstrates a decrease in annual opioid prescriptions among emergency medicine physicians. We analyzed data from 2012 to 2020 from a large academic health system in California to understand trends in opioid prescribing patterns for emergency department (ED) discharged patients and assessed the potential impact of two initiatives at limiting local opioid prescriptions.

METHODS: In 2012-2020, monthly ED visit data was used to evaluate the total number of outpatient opioid prescriptions and percent of ED visits with opioid prescriptions (as primary outcomes). Descriptive statistics, graphic representation, and segmented regression with interrupted times series were used based on two prespecified time points associated with intensive local initiatives directed at limiting opioid prescribing1) comprehensive emergency medicine resident education and 2) electronic health record (EHR)-based intervention.

RESULTS: Between March 2012 and July 2020, a total of 41,491 ED discharged patients received an opioid prescription. The three most commonly prescribed drugs were hydrocodone (84.1%), oxycodone (10.8%), and codeine (2.8%). After implementing comprehensive emergency medicine resident education, the total number of opioid prescriptions, the percentage of opioid prescriptions over total ED visit numbers and the total tablet number showed decreasing trends (p’s ≤ 0.01), in addition to the natural (pre-intervention) decreasing trends. In contrast, later interventions in the EHR tended to show attenuated decreasing trends.

CONCLUSIONS: From 2012 to 2020, we found that total opioid prescriptions decreased significantly for discharged ED patients. This trend is seen nationally. However, our specific interventions further heightened this downward trend. Evidence-based legislation, policy changes, and educational initiatives that impact prescribing practices should guide future efforts.

PMID:34763238 | DOI:10.1016/j.ajem.2021.10.029