Category: Statistics

J Appl Clin Med Phys. 2022 May 9:e13630. doi: 10.1002/acm2.13630. Online ahead of print.

ABSTRACT

PURPOSE: Deep learning-based knowledge-based planning (KBP) methods have been introduced for radiotherapy dose distribution prediction to reduce the planning time and maintain consistent high-quality plans. This paper presents a novel KBP model using an attention-gating mechanism and a three-dimensional (3D) U-Net for intensity-modulated radiation therapy (IMRT) 3D dose distribution prediction in head-and-neck cancer.

METHODS: A total of 340 head-and-neck cancer plans, representing the OpenKBP-2020 AAPM Grand Challenge data set, were used in this study. All patients were treated with the IMRT technique and a dose prescription of 70 Gy. The data set was randomly divided into 64%/16%/20% as training/validation/testing cohorts. An attention-gated 3D U-Net architecture model was developed to predict full 3D dose distribution. The developed model was trained using the mean-squared error loss function, Adam optimization algorithm, a learning rate of 0.001, 120 epochs, and batch size of 4. In addition, a baseline U-Net model was also similarly trained for comparison. The model performance was evaluated on the testing data set by comparing the generated dose distributions against the ground-truth dose distributions using dose statistics and clinical dosimetric indices. Its performance was also compared to the baseline model and the reported results of other deep learning-based dose prediction models.

RESULTS: The proposed attention-gated 3D U-Net model showed high capability in accurately predicting 3D dose distributions that closely replicated the ground-truth dose distributions of 68 plans in the test set. The average value of the mean absolute dose error was 2.972 ± 1.220 Gy (vs. 2.920 ± 1.476 Gy for a baseline U-Net) in the brainstem, 4.243 ± 1.791 Gy (vs. 4.530 ± 2.295 Gy for a baseline U-Net) in the left parotid, 4.622 ± 1.975 Gy (vs. 4.223 ± 1.816 Gy for a baseline U-Net) in the right parotid, 3.346 ± 1.198 Gy (vs. 2.958 ± 0.888 Gy for a baseline U-Net) in the spinal cord, 6.582 ± 3.748 Gy (vs. 5.114 ± 2.098 Gy for a baseline U-Net) in the esophagus, 4.756 ± 1.560 Gy (vs. 4.992 ± 2.030 Gy for a baseline U-Net) in the mandible, 4.501 ± 1.784 Gy (vs. 4.925 ± 2.347 Gy for a baseline U-Net) in the larynx, 2.494 ± 0.953 Gy (vs. 2.648 ± 1.247 Gy for a baseline U-Net) in the PTV_70, and 2.432 ± 2.272 Gy (vs. 2.811 ± 2.896 Gy for a baseline U-Net) in the body contour. The average difference in predicting the D₉₉ value for the targets (PTV_70, PTV_63, and PTV_56) was 2.50 ± 1.77 Gy. For the organs at risk, the average difference in predicting the $D_{max}$ (brainstem, spinal cord, and mandible) and $D_{mean}$ (left parotid, right parotid, esophagus, and larynx) values was 1.43 ± 1.01 and 2.44 ± 1.73 Gy, respectively. The average value of the homogeneity index was 7.99 ± 1.45 for the predicted plans versus 5.74 ± 2.95 for the ground-truth plans, whereas the average value of the conformity index was 0.63 ± 0.17 for the predicted plans versus 0.89 ± 0.19 for the ground-truth plans. The proposed model needs less than 5 s to predict a full 3D dose distribution of 64 × 64 × 64 voxels for a new patient that is sufficient for real-time applications.

CONCLUSIONS: The attention-gated 3D U-Net model demonstrated a capability in predicting accurate 3D dose distributions for head-and-neck IMRT plans with consistent quality. The prediction performance of the proposed model was overall superior to a baseline standard U-Net model, and it was also competitive to the performance of the best state-of-the-art dose prediction method reported in the literature. The proposed model could be used to obtain dose distributions for decision-making before planning, quality assurance of planning, and guiding-automated planning for improved plan consistency, quality, and planning efficiency.

PMID:35533234 | DOI:10.1002/acm2.13630

Dementia (London). 2022 May 9:14713012221094979. doi: 10.1177/14713012221094979. Online ahead of print.

ABSTRACT

OBJECTIVES: To describe the perceived and unmet needs for health and social services and their relative importance among families coping with dementia in urban China.

METHODS: We used data from a cross-sectional survey conducted between 2018 and 2019 in two cities in eastern China. Trained staff conducted structured interviews of family caregivers of people living with dementia at home to obtain individual characteristics as well as types of service needs of families coping with dementia. Service needs and utilization in 24 types of services across five domains (daily living, medical/nursing, rehabilitation, mental health, and other) were examined. Descriptive statistics were used to describe characteristics of the dyads and the ranking of services based on the percentage of respondents with perceived/unmet needs.

RESULTS: A total of 170 (87.6%) family caregivers completed the interviews. The mean age of the care recipient was 77.2 years (range: 60-102) and 65.3% were female. The mean age of family caregivers was 58.4 years (range: 28-90), and 57.1% were female. The top five services used by the care recipients were: primary care, medication management, housekeeping, activities of daily living assistance, and adult day service. The five services with the most unmet needs were: legal assistance (42.7%), hospice care (44.7%), respiratory secretion management (expectoration) (57.6%), life enrichment activities (65.4%), and companion care (67.0%). Except for transportation and dressing/grooming, working and nonworking caregivers reported similar relative importance of service needs.

CONCLUSIONS: The findings suggest that people living with dementia and their family require a wide range of services and supports to live in the community. Future research and policy efforts should target the unmet needs of families to improve dementia care in the community and promote aging-in-place.

PMID:35533235 | DOI:10.1177/14713012221094979

J Clin Pediatr Dent. 2022 Mar 1;46(2):137-142. doi: 10.17796/1053-4625-46.2.8.

ABSTRACT

OBJECTIVE: YKL-40, a new biomarker of localized inflammation, is secreted by macrophages and regulates inflammation and immune responses. The aim of this study was to investigate YKL-40 levels in saliva and compare the level of this mediator in healthy and unhealthy oral cavity.

STUDY DESIGN: 80 children (42-girl, 38-boy), aged 6-15 (mean±SD: 9.35±2.08) were included in this cross-sectional study. The children were divided into four groups: Group-I (control, n=20, dmft/DMFT=0), Group-II (n=20, exist of dental caries), Group-III (n=20, exist of advanced dental caries without pulp exposure), and Group-IV (n=20, exist of advanced dental caries with pulp exposure). The dmft/DMFT, dmfs/DMFS, and the number of advanced dental caries according to the ICDAS and pufa/PUFA index were recorded. Saliva was collected and YKL-40 concentrations were measured.

RESULTS: The highest level of YKL-40 was obtained in Group IV, followed by Groups III, II, and I, respectively (p<0.01). There was a positive correlation between YKL-40 and the number of caries There were no statistically significant difference in YKL-40 levels in terms of age and gender (p>0.05).

CONCLUSIONS: The advanced dental caries with pulp exposure may play an important role in the increasing levels of YKL-40 in saliva.

PMID:35533232 | DOI:10.17796/1053-4625-46.2.8

Photobiomodul Photomed Laser Surg. 2022 May 9. doi: 10.1089/photob.2021.0038. Online ahead of print.

ABSTRACT

Background: With laser irradiation emerging as an adjunctive treatment utilized in nonsurgical periodontal therapy, it is important to understand the variance of penetration depth among the different laser wavelengths. Purpose: To evaluate the thermal penetration depth, as a photothermal effect, of carbon dioxide (CO₂)-, erbium: doped yttrium-aluminum-garnett (Er:YAG)-, and erbium, chromium: yttrium-scandium-gallium-garnett (Er,Cr:YSGG)-lasers on the bovine gingiva in an in vitro model. Methods: Four mandibles from freshly slaughtered cows were utilized in this study. Buccal and lingual root debridement was provided using three different laser wavelengths, all in pulsed settings. A CO₂– (10,600 nm), Er:YAG- (2940 nm), and Er,Cr:YSGG- (2780 nm) were utilized to irradiate pockets of two mandibular posterior teeth in each group. Laser power output settings were set to 2 W. The posterior teeth were irradiated for 30 sec buccal and 30 sec lingual of each tooth for all selected treatment test groups. Instrumentation with curettes was performed as a control group. Gingival flaps, including the entire gingiva, were fixed in 10% formalin and stained via Elastin van Gieson. Sections were examined microscopically to evaluate thermal damage and statistically compared using mixed effect model with Tukey adjustment. Results: The CO₂-laser irradiation presented a statistically significant lower mean compared to Er,Cr:YSGG-laser (p < 0.0001). Er,Cr:YSGG-laser had a higher penetration depth compared to Er:YAG-laser (p < 0.0001). There was no statistically significant difference found in penetration depth between CO₂– and Er:YAG-laser irradiation. Conclusions: It can be concluded that all tested pulsed lasers had minimal penetration depth into the gingiva. However, the pulsed CO₂– and Er:YAG-lasers presented lower thermal effects compared to Er,Cr:YSGG-laser in vitro.

PMID:35533016 | DOI:10.1089/photob.2021.0038

Am J Hum Biol. 2022 May 9:e23757. doi: 10.1002/ajhb.23757. Online ahead of print.

ABSTRACT

OBJECTIVES: To clarify the potential risk factors and etiology of low back pain (LBP)-related disability, including structural changes of the spine (spinal scoliosis) and body composition components in a population with a high prevalence of LBP.

METHODS: In this cross-sectional study, two self-reported validated questionnaires were used to collect back pain and disability data in an ethnically homogeneous family-based population sample (N = 1078). The scoliosis angle of trunk rotation was measured by a scoliometer on three spinal levels while the patient was bent forward. Body composition parameters, including relative to weight (WT), fat, relative skeletal muscle mass (SMM/WT), and total body water were determined by bioelectrical impedance analysis. Statistical analysis was conducted, accounting for the familial composition of the sample.

RESULTS: The mixed multiple regression analyses with several LBP-related phenotypes as dependent variables consistently showed significant independent associations with scoliosis and SMM/WT, irrespective of other covariates. The odds ratios (OR)/95% CI for scoliosis ranged between 1.40 (1.19-1.64) and 1.51 (1.27-1.80), and from 0.61(0.51-0.72), to 0.71(0.58-0.87) for SMM/WT, depending on the LBP phenotype. The genetic components of the respective correlations between the LBP-phenotypes and scoliosis or SMM/WT were negligible.

CONCLUSIONS: The associations between LBP-related conditions and postured scoliosis and SMM/WT were consistent and significant and therefore may serve as markers in predicting the development of LBP-related disability. We interpret the origin of these correlations as the evolutionary event due to the imperfect spine anatomy adaptation to a vertical posture resulting from a quick transition to bipedalism from a quadrupedal ancestor.

PMID:35533002 | DOI:10.1002/ajhb.23757

J Patient Saf. 2022 Apr 30. doi: 10.1097/PTS.0000000000001016. Online ahead of print.

ABSTRACT

OBJECTIVES: Although patient safety continues to be a priority in the U.S. healthcare system, delays in diagnosis, treatment, or surgery still led to adverse events for patients. The purpose of this study was to review root cause analysis (RCA) reports in the Veterans Health Administration to identify the root causes and contributing factors of delays in diagnosis, treatment, or surgery in an effort to prevent avoidable delays in future care.

METHODS: The RCA reports from Veterans Health Administration hospitals from October 2016 through September 2019 were reviewed and the root causes and contributory factors were identified. These elements were coded by consensus and analyzed using descriptive statistics.

RESULTS: During the 3-year study period, 206 RCAs were identified and 163 were analyzed that were specific to delays in diagnosis, treatment, and surgery. The reports identified 24 delays in diagnosis, 117 delays in treatment, and 22 delays in surgery. Delays occurred most often in outpatient settings.

CONCLUSIONS: Results supported the need for standardization of care processes and procedures, improved communication between and within department personnel, and improved policies and procedures that will be followed as intended. By reviewing adverse events, root causes, and contributing factors identified by local RCA teams, strategies can be developed to reduce delays in diagnosis and treatment of patients and lead to safer care.

PMID:35532991 | DOI:10.1097/PTS.0000000000001016

J Patient Saf. 2022 May 4. doi: 10.1097/PTS.0000000000001015. Online ahead of print.

ABSTRACT

OBJECTIVES: Generic exchange is common practice in most healthcare systems. This study investigated how patients with Parkinson disease (PD) perceived a switch of their levodopa medication and the resulting effects on their PD symptoms.

METHODS: A questionnaire was developed, piloted, and finally distributed to 13,857 members of the national PD patient support group. It was designed to be completed by patients and their pharmacies. χ2 tests for independence statistics with or without Monte Carlo simulation were performed. Cramér φ and Cramér V were calculated. McNemar test was used to investigate whether a generic switch of a levodopa-containing medication had an impact on PD symptoms.

RESULTS: Analyses were done with 410 finalized respondents of 13,857 distributed questionnaires. More than half of the responders were 75 years or older and rated themselves Hoehn and Yahr stages 3 to 5. Most patients were confused by a change of their medication. A total of 54.7% of the switchers (n = 148) reported swallowing difficulties with medication, which was significantly more frequent than with nonswitchers (37.3% of 204, P = 0.001). Adverse effects related to the switch were reported by 26.6% of all switchers (switchback rate, 20.5%). The patients at higher Hoehn and Yahr stages were affected to a greater extend.

CONCLUSIONS: Patients, who experienced any brand switch of their levodopa medication, frequently expressed distrust and confusion. Swallowing difficulties and negative effects on their symptoms were problems, which were more pronounced in advanced disease stages. It remains unclear whether the detrimental impact on therapy was caused by the brand switch or by a nocebo effect.

PMID:35532994 | DOI:10.1097/PTS.0000000000001015

J Patient Saf. 2022 May 6. doi: 10.1097/PTS.0000000000001014. Online ahead of print.

ABSTRACT

OBJECTIVE: A key quality indicator in any health system is its ability to reduce morbidity and mortality. In recent years, healthcare organizations in the United States have been held to stricter measures of accountability to provide safe, quality care. This study aimed to explore the contextual factors driving racial disparities in hospital-acquired conditions incident rates among Medicare recipients in Magnet and non-Magnet hospitals.

METHODS: A cross-sectional observational study was performed using data from Hospital-Acquired Condition Reduction Program. Performance from 1823 hospitals were used to examine the association between Magnet recognition and community’s racial and ethnic differences in hospital performance on the Hospital-Acquired Condition Reduction Program. The unit of analysis was the hospital level. A propensity score matching approach was used to take into account differences in baseline characteristics when comparing Magnet and non-Magnet hospitals. The outcome measures were risk-standardized hospital performance on the Hospital-Acquired Condition Reduction Program domains and overall performance.

RESULTS: Study findings show that Magnet hospitals had decreased methicillin-resistant Staphylococcus aureus (MRSA) rate (β = -0.22; 95% confidence interval, -0.36 to -0.08) compared with non-Magnet hospitals. No other statistical difference was identified.

CONCLUSIONS: Results from this study show community’s racial and ethnic differences in hospital-acquired conditions occurrence differ between Magnet and non-Magnet hospitals for MRSA, indicating its association with nursing practice. However, because this improvement is limited to only MRSA, there are likely opportunities for Magnet hospitals to continue process improvements focused on additional Hospital-Acquired Condition Reduction Program measures.

PMID:35532988 | DOI:10.1097/PTS.0000000000001014

JMIR Form Res. 2022 May 9;6(5):e30320. doi: 10.2196/30320.

ABSTRACT

BACKGROUND: Evidence-based digital health tools allow clinicians to keep up with the expanding medical literature and provide safer and more accurate care. Understanding users’ online behavior in low-resource settings can inform programs that encourage the use of such tools. Our program collaborates with digital tool providers, including UpToDate, to facilitate free subscriptions for clinicians serving in low-resource settings globally.

OBJECTIVE: We aimed to define segments of clinicians based on their usage patterns of UpToDate, describe the demographics of those segments, and relate the segments to self-reported professional climate measures.

METHODS: We collected 12 months of clickstream data (a record of users’ clicks within the tool) as well as repeated surveys. We calculated the total number of sessions, time spent online, type of activity (navigating, reading, or account management), calendar period of use, percentage of days active online, and minutes of use per active day. We defined behavioral segments based on the distributions of these statistics and related them to survey data.

RESULTS: We enrolled 1681 clinicians from 75 countries over a 9-week period. We based the following five behavioral segments on the length and intensity of use: short-term, light users (420/1681, 25%); short-term, heavy users (252/1681, 15%); long-term, heavy users (403/1681, 24%); long-term, light users (370/1681, 22%); and never-users (252/1681, 15%). Users spent a median of 5 hours using the tool over the year. On days when users logged on, they spent a median of 4.4 minutes online and an average of 71% of their time reading medical content as opposed to navigating or managing their account. Over half (773/1432, 54%) of the users actively used the tool for 48 weeks or more during the 52-week study period. The distribution of segments varied by age, with lighter and less use among those aged 35 years or older compared to that among younger users. The speciality of medicine had the heaviest use, and emergency medicine had the lightest use. Segments varied strongly by geographic region. As for professional climate, most respondents (1429/1681, 85%) reported that clinicians in their area would view the use of a online tool positively, and compared to those who reported other views, these respondents were less likely to be never-users (286/1681, 17% vs 387/1681, 23%) and more likely to be long-term users (655/1681, 39% vs 370/1681, 22%).

CONCLUSIONS: We believe that these behavioral segments can help inform the implementation of digital health tools, identify users who may need assistance, tailor training and messaging for users, and support research on digital health efforts. Methods for combining clickstream data with demographic and survey data have the potential to inform global health implementation. Our forthcoming analysis will use these methods to better elucidate what drives digital health tool use.

PMID:35532985 | DOI:10.2196/30320

J Patient Saf. 2022 May 4. doi: 10.1097/PTS.0000000000001010. Online ahead of print.

ABSTRACT

BACKGROUND: Global efforts are being made to improve health care standards and the quality of care provided. It has been shown through research that the introduction of patient safety (PS) and quality improvement (QI) concepts in the medical curriculum prepares medical students to face future challenges in their professional careers.

PURPOSE: This study aimed to evaluate how a brief course on QI and PS affects the knowledge, efficacy, and system thinking of medical students.

METHODS: A 5-day QI and PS intervention course was implemented at the Aga Khan University medical college for 98 third-year medical students in March 2021. This weeklong course of lectures, interactive sessions, and hands-on skill workshops was conducted before the students began their clinical rotations. Students’ knowledge, self-efficacy, and system thinking were assessed with pretest and posttest. Students were also asked to write personal reflections and fill out a satisfaction survey at the end of the intervention.

RESULTS: Comparisons of pretest and posttest scores showed that the course significantly improved students’ knowledge by a mean of 2.92 points (95% confidence interval, 2.30-3.53; P < 0.001) and system thinking by 0.16 points (95% confidence interval, 0.03-0.29; P = 0.018) of the maximum scores of 20 and 5 points, respectively. The students’ self-assessment of PS knowledge also reflected statistically significant increases in all 9 domains (P < 0.001). Students reported positive experiences with this course in their personal reflections.

CONCLUSIONS: The medical students exhibited increases in knowledge, self-efficacy, and system thinking after this weeklong intervention. The design of the course can be modified as needed and implemented at other institutions in low- and middle-income countries. A targeted long-term assessment of knowledge and attitudes is needed to fully evaluate the impact of this course.

PMID:35532980 | DOI:10.1097/PTS.0000000000001010