Nevin Manimala

BMC Med Res Methodol. 2024 Jul 5;24(1):145. doi: 10.1186/s12874-024-02270-x.

ABSTRACT

BACKGROUND: In binary classification for clinical studies, an imbalanced distribution of cases to classes and an extreme association level between the binary dependent variable and a subset of independent variables can create significant classification problems. These crucial issues, namely class imbalance and complete separation, lead to classification inaccuracy and biased results in clinical studies.

METHOD: To deal with class imbalance and complete separation problems, we propose using a fuzzy logistic regression framework for binary classification. Fuzzy logistic regression incorporates combinations of triangular fuzzy numbers for the coefficients, inputs, and outputs and produces crisp classification results. The fuzzy logistic regression framework shows strong classification performance due to fuzzy logic’s better handling of imbalance and separation issues. Hence, classification accuracy is improved, mitigating the risk of misclassified conditions and biased insights for clinical study patients.

RESULTS: The performance of the fuzzy logistic regression model is assessed on twelve binary classification problems with clinical datasets. The model has consistently high sensitivity, specificity, F1, precision, and Mathew’s correlation coefficient scores across all clinical datasets. There is no evidence of impact from the imbalance or separation that exists in the datasets. Furthermore, we compare the fuzzy logistic regression classification performance against two versions of classical logistic regression and six different benchmark sources in the literature. These six sources provide a total of ten different proposed methodologies, and the comparison occurs by calculating the same set of classification performance scores for each method. Either imbalance or separation impacts seven out of ten methodologies. The remaining three produce better classification performance in their respective clinical studies. However, these are all outperformed by the fuzzy logistic regression framework.

CONCLUSION: Fuzzy logistic regression showcases strong performance against imbalance and separation, providing accurate predictions and, hence, informative insights for classifying patients in clinical studies.

PMID:38970036 | DOI:10.1186/s12874-024-02270-x

BMC Musculoskelet Disord. 2024 Jul 5;25(1):516. doi: 10.1186/s12891-024-07627-3.

ABSTRACT

BACKGROUND: Sacral screw loosening is a typical complication after internal fixation surgery through the vertebral arch system. Bicortical fixation can successfully prevent screw loosening, and how improving the rate of bicortical fixation is a challenging clinical investigation.

OBJECTIVE: To investigate the feasibility of improving the double corticality of sacral screws and the optimal fixation depth to achieve double cortical fixation by combining the torque measurement method with bare hands.

METHODS: Ninety-seven cases of posterior lumbar internal fixation with pedicle root system were included in this study. Based on the tactile feedback of the surgeon indicating the expected penetration of the screw into the contralateral cortex of the sacrum, the screws were further rotated by 180°, 360°, or 720°, categorized into the bicortical 180° group, bicortical 360° group, and bicortical 720° group, respectively. Intraoperatively, the torque during screw insertion was recorded. Postoperatively, the rate of double-cortex engagement was evaluated at 7 days, and screw loosening was assessed at 1 year follow-up.

RESULTS: The bicortical rates of the 180° group, 360° group, and 720° group were 66.13%, 91.18% and 93.75%, respectively. There were statistically significant differences between the 180° group and both the 360° and 720° groups (P < 0.05). However, there was no statistically significant difference between the 360° group and the 720° group (P > 0.05).The rates of loosening of sacral screws in the 180° group, 360° group, and 720° group were 20.97%, 7.35% and 7.81%, respectively. There were statistically significant differences between the 180° group and both the 360° and 720° groups (P < 0.05). However, there was no statistically significant difference between the 360° group and the 720° group (P > 0.05). The bicortical 360° group achieved a relatively satisfactory rate of dual cortical purchase while maintaining a lower rate of screw loosening.

CONCLUSION: Manual insertion of sacral screws with the assistance of a torque measurement device can achieve a relatively satisfactory dual cortical purchase rate while reducing patient hospitalization costs.

PMID:38970034 | DOI:10.1186/s12891-024-07627-3

BMC Musculoskelet Disord. 2024 Jul 5;25(1):520. doi: 10.1186/s12891-024-07573-0.

ABSTRACT

OBJECTIVES: To compare 12-month spinal fusion surgery rates in the setting of low back pain among digital musculoskeletal (MSK) program participants versus a comparison cohort who only received usual care.

STUDY DESIGN: Retrospective cohort study with propensity score matched comparison cohort using commercial medical claims data representing over 100 million commercially insured lives.

METHODS: All study subjects experienced low back pain between January 2020 and December 2021. Digital MSK participants enrolled in the digital MSK low back program between January 2020 and December 2021. Non-participants had low back pain related physical therapy (PT) between January 2020 and December 2021. Digital MSK participants were matched to non-participants with similar demographics, comorbidities and baseline MSK-related medical care use. Spinal fusion surgery rates at 12 months post participation were compared.

RESULTS: Compared to non-participants, digital MSK participants had lower rates of spinal fusion surgery in the post-period (0.7% versus 1.6%; p < 0.001). Additionally, in the augmented inverse probability weighting (AIPW) model, digital MSK participants were found to have decreased odds of undergoing spinal fusion surgery (adjusted odds ratio: 0.64, 95% CI: 0.51-0.81).

CONCLUSIONS: This study provides evidence that participation in a digital MSK program is associated with a lower rate of spinal fusion surgery.

PMID:38970032 | DOI:10.1186/s12891-024-07573-0

BMC Med Genomics. 2024 Jul 5;17(1):180. doi: 10.1186/s12920-024-01956-x.

ABSTRACT

BACKGROUND: There is an association between migraine and dementia, however, their causal relationship remains unclear. This study employed bidirectional two-sample Mendelian randomization (MR) to investigate the potential causal relationship between migraine and dementia and its subtypes: Alzheimer’s disease (AD), vascular dementia (VaD), frontotemporal dementia (FTD), and dementia with Lewy bodies (DLB).

METHODS: Summary-level statistics data were obtained from publicly available genome-wide association studies (GWAS) for both migraine and five types of dementia. Single nucleotide polymorphisms (SNPs) associated with migraine and each dementia subtype were selected. MR analysis was conducted using inverse variance weighting (IVW) and weighted median (WM) methods. Sensitivity analyses included Cochran’s Q test, MR pleiotropy residual sum and outlier (MR-PRESSO) analysis, the intercept of MR-Egger, and leave-one-out analysis.

RESULTS: Migraine showed a significant causal relationship with AD and VaD, whereas no causal relationship was observed with all-cause dementia, FTD, or DLB. Migraine may be a potential risk factor for AD (odds ratio [OR]: 1.09; 95% confidence interval [CI]: 0.02-0.14; P = 0.007), while VaD may be a potential risk factor for migraine (OR: 1.04; 95% CI: 0.02-0.06; P = 7.760E-5). Sensitivity analyses demonstrated the robustness of our findings.

CONCLUSION: Our study suggest that migraine may have potential causal relationships with AD and VaD. Migraine may be a risk factor for AD, and VaD may be a risk factor for migraine. Our study contributes to unraveling the comprehensive genetic associations between migraine and various types of dementia, and our findings will enhance the academic understanding of the comorbidity between migraine and dementia.

PMID:38970023 | DOI:10.1186/s12920-024-01956-x

BMC Vet Res. 2024 Jul 5;20(1):292. doi: 10.1186/s12917-024-04170-0.

ABSTRACT

BACKGROUND: Hypertrophic cardiomyopathy (HCM) is a crucial heart disease in cats. The clinical manifestations of HCM comprise pulmonary edema, dyspnea, syncope, arterial thromboembolism (ATE), and sudden cardiac death. D-dimer and prothrombin time (PT) are powerful biomarkers used to assess coagulation function. Dysregulation in these two biomarkers may be associated with HCM in cats. This study aims to assess D-dimer levels, PT, and proteomic profiling in healthy cats in comparison to cats with symptomatic HCM.

RESULTS: Twenty-nine client-owned cats with HCM were enrolled, including 15 healthy control and 14 symptomatic HCM cats. The D-dimer concentration and PT were examined. Proteomic analysis was conducted by matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF) mass spectrometry and liquid chromatography-tandem mass spectrometry (LC-MS/MS). In symptomatic cats, D-dimer levels were statistically significantly higher (mean ± SEM: 372.19 ng/ml ± 58.28) than in healthy cats (mean ± SEM: 208.54 ng/ml ± 10.92) with P-value of less than 0.01, while PT was statistically significantly lower in symptomatic cats (mean ± SEM: 9.8 s ± 0.15) compared to healthy cats (mean ± SEM: 11.08 s ± 0.23) with P-value of less than 0.0001. The proteomics analysis revealed upregulation of integrin subunit alpha M (ITGAM), elongin B (ELOB), and fibrillin 2 (FBN2) and downregulation of zinc finger protein 316 (ZNF316) and ectonucleoside triphosphate diphosphohydrolase 8 (ENTPD8) in symptomatic HCM cats. In addition, protein-drug interaction analysis identified the Ras signaling pathway and PI3K-Akt signaling pathway.

CONCLUSIONS: Cats with symptomatic HCM have higher D-dimer and lower PT than healthy cats. Proteomic profiles may be used as potential biomarkers for the detection and management of HCM in cats. The use of D-dimer as a biomarker for HCM detection and the use of proteomic profiling for a better understanding of disease mechanisms remain to be further studied in cats.

PMID:38970022 | DOI:10.1186/s12917-024-04170-0

BMC Med Educ. 2024 Jul 5;24(1):729. doi: 10.1186/s12909-024-05679-6.

ABSTRACT

BACKGROUND: Clinical competence encompasses attitudes, skills, and knowledge regarding diverse client groups. Appropriate clinical competence requires an understanding of the cultural context in which healthcare is delivered. In conservative countries such as Israel, there is a noticeable scarcity of information regarding the clinical competency of physiotherapy students (PTSs) in effectively treating lesbian, gay, bisexual and transgender (LGBT) individuals. The objective of this study was to assess the level of LGBT clinical competence among PTSs in Israel.

METHODS: Conducted through an anonymous online self-report survey, this study gathered personal and academic background information and self-reported data on previous LGBT education during undergraduate studies of PTSs. It utilized the Hebrew version of the Lesbian, Gay, Bisexual, and Transgender Development of Clinical Skills Scale (LGBT-DOCSS) questionnaire. Descriptive statistics were computed for all outcome measures. The internal reliability of the LGBT-DOCSS was assessed. Total scores of the LGBT-DOCSS, along with scores in each of the three subscales (clinical preparedness, knowledge, and attitudes), were compared across different levels of religiosity and gender.

RESULTS: The sample comprised of 251 PTSs, with an average age of 25.57 ± 3.07 years (34.7% men, 65.3% women). All students reported a lack of LGBT community-related courses during their undergraduate studies. The translated Hebrew version demonstrated good internal consistency, with Cronbach’s alpha ranging from 0.65 to 0.83. The LGBT-DOCSS total score was 4.55 ± 0.61 out of 7, indicating a low level of clinical competency. The highest mean score was in the attitudes subscale (6.55 ± 0.87), which was significantly higher than the scores for the knowledge subscale (3.14 ± 1.46) and clinical preparedness subscale (3.36 ± 0.86). Religiousness was significantly associated with clinical preparedness and attitudes. Men exhibited higher self-reported levels of knowledge and clinical preparedness, albeit with more negative attitudes compare to women. Sexual orientation was significantly associated with clinical competency, with PTSs who identified as heterosexual demonstrating a lower level of clinical competency compared to participants who identified as non-heterosexual.

CONCLUSIONS: In Israel, PTSs demonstrated a low level of clinical competency in terms of self-reported knowledge and self-reported clinical preparedness but contrasting positive attitudes toward the LGBT community. Religiousness, gender and sexual orientation had a significant influence on competency levels.These preliminary findings highlight the urgent necessity to enhance the knowledge of PTSs regarding the LGBT community to improve their clinical competence.

TRIAL REGISTRATION NR: Not applicable.

PMID:38970017 | DOI:10.1186/s12909-024-05679-6

BMC Public Health. 2024 Jul 5;24(1):1800. doi: 10.1186/s12889-024-19290-3.

ABSTRACT

BACKGROUND: Autoimmune diseases (ADs) present significant health challenges globally, especially among adolescents and young adults (AYAs) due to their unique developmental stages. Comprehensive analyses of their burden are limited. This study leverages the Global Burden of Disease (GBD) 2021 data to assess the global, regional, and national burden and trends of major ADs among AYAs from 1990 to 2021.

METHODS: Utilizing data from the Global Burden of Disease (GBD) Study 2021 for individuals aged 15-39 years, we employed a direct method for age standardization to calculate estimates along with 95% uncertainty intervals (UIs) for assessing the age-standardized incidence rates (ASIR), prevalence rates (ASPR), and mortality rates (ASMR) of ADs. The diseases analyzed included rheumatoid arthritis (RA), inflammatory bowel disease (IBD), multiple sclerosis (MS), type 1 diabetes mellitus (T1DM), Asthma, and Psoriasis. Trends from 1990 to 2021 were analyzed using Joinpoint regression, providing average annual percentage changes (AAPC) and 95% confidence intervals (CIs).

RESULT: In 2021, the global ASIR, ASPR, and ASMR of RA among AYAs (per 100,000 population) were 9.46 (95% UI: 5.92 to 13.54), 104.35 (77.44 to 137.84), and 0.016 (0.013 to 0.019), respectively. For IBD, the corresponding rates were 4.08 (3.07 to 5.37), 29.55 (23.00 to 37.83), and 0.10 (0.07 to 0.12). MS exhibited rates of 1.40 (0.93 to 1.93), 16.05 (12.73 to 19.75), and 0.05 (0.04 to 0.05), respectively. T1DM had rates of 6.63 (3.08 to 11.84), 245.51 (194.21 to 307.56), and 0.54 (0.47 to 0.60). Asthma demonstrated rates of 232.22 (132.11 to 361.24), 2245.51 (1671.05 to 2917.57), and 0.89 (0.77 to 1.08). Psoriasis showed rates of 55.08 (48.53 to 61.93) and 426.16 (394.12 to 460.18) for ASIR and ASPR, respectively. From 1990 to 2021, the global ASIR of RA (AAPC = 0.47, 95% CI: 0.46 to 0.49), IBD (0.22 [0.12 to 0.33]), MS (0.22 [0.19 to 0.26]), T1DM (0.83 [0.80 to 0.86]), and Psoriasis (0.33 [0.31 to 0.34]) showed increasing trends, whereas Asthma (-0.96 [-1.03 to -0.88]) showed a decreasing trend. The global ASPR of RA (0.70 [0.68 to 0.73]), MS (0.35 [0.32 to 0.37]), T1DM (0.68 [0.66 to 0.69]), and Psoriasis (0.29 [0.27 to 0.32]) also showed increasing trends, whereas IBD (-0.20 [-0.27 to -0.13]) and Asthma (-1.25 [-1.31 to -1.19]) showed decreasing trends. Notably, the estimated global ASMR of RA (-2.35 [-2.57 to -2.12]), MS (-0.63 [-0.86 to -0.41]), T1DM (-0.35 [-0.56 to -0.14]), and Asthma (-1.35 [-1.44 to -1.26]) in AYAs declined. Additionally, the burden of disease for ADs in AYAs varies considerably across continents and between 204 countries and territories.

CONCLUSION: ADs among AYAs present a substantial public health burden with notable regional disparities in incidence, prevalence, and mortality rates. Understanding these patterns is essential for developing targeted public health interventions and policies to mitigate the impact of ADs in this population.

PMID:38970015 | DOI:10.1186/s12889-024-19290-3

J Neurosurg Spine. 2024 Jul 5:1-13. doi: 10.3171/2024.4.SPINE23917. Online ahead of print.

ABSTRACT

OBJECTIVE: Pedicle screw placement guidance is critical in spinal fusions, and spinal surgery robots aim to improve accuracy and reduce complications. Current literature has yet to compare the relative merits of available robotic systems. In this review, the authors aimed to 1) assess the current state of spinal robotics literature; 2) conduct a meta-analysis of robotic performance based on accuracy, speed, and safety; and 3) offer recommendations for robotic system selection.

METHODS: Following PRISMA guidelines, the authors conducted a systematic literature review across PubMed, Embase, Cochrane Library, Web of Science, and Scopus as of April 28, 2022, for studies on approved robots for placing lumbar pedicle screws. Three reviewers screened and extracted data relating to the study characteristics, accuracy rate, intraoperative revisions, and reoperations. Secondary performance metrics included operative time, blood loss, and radiation exposure. The authors statistically compared the performance of the robots using a random-effects model to account for variation within and between the studies. Each robot was also compared with performance benchmarks of traditional techniques including freehand, fluoroscopic, and CT-navigated insertion. Finally, we performed a Duval and Tweedie trim-and-fill test to assess for the presence of publication bias.

RESULTS: The authors identified 46 studies, describing 4670 patients and 25,054 screws, that evaluated 4 different robotic systems: Mazor X, ROSA, ExcelsiusGPS, and Cirq. The weighted accuracy rates of Gertzbein-Robbins classification grade A or B screws were as follows: ExcelsiusGPS, 98.0%; ROSA, 98.0%; Mazor, 98.2%; and Cirq, 94.2%. No robot was significantly more accurate than the others. However, the accuracy of the ExcelsiusGPS was significantly higher than that of traditional methods, and the accuracies of the Mazor and ROSA were significantly higher than that of fluoroscopy. The intraoperative revision rates were Cirq, 0.55%; ROSA, 0.91%; Mazor, 0.98%; and ExcelsiusGPS, 1.08%. The reoperation rates were Cirq, 0.28%; ExcelsiusGPS, 0.32%; and Mazor, 0.76% (no reoperations were reported for ROSA). Operative times were similar for all robots. Both the ExcelsiusGPS and Mazor were associated with significantly less blood loss than the ROSA. The Cirq had the lowest radiation exposure. Robots tended to be more accurate and generally their use was associated with fewer reoperations and less blood loss than freehand, fluoroscopic, or CT-navigated techniques.

CONCLUSIONS: Robotic platforms perform comparably based on key metrics, with high accuracy rates and low intraoperative revision and reoperation rates. The spinal robotics publication rate will continue to accelerate, and choosing a robot will depend on the context of the practice.

PMID:38968628 | DOI:10.3171/2024.4.SPINE23917

J Neurosurg. 2024 Jul 5:1-11. doi: 10.3171/2024.4.JNS24139. Online ahead of print.

ABSTRACT

OBJECTIVE: Deep brain stimulation (DBS) targeting the globus pallidus interna (GPi) has been shown to significantly improve motor symptoms for the treatment of medication-refractory Parkinson’s disease. Yet, heterogeneity in clinical outcomes persists, possibly due to suboptimal target identification within the GPi. By leveraging robust sampling of the GPi and 6-month postsurgical outcomes, this study aims to determine optimal symptom-specific GPi DBS targets.

METHODS: In this study, the authors analyzed the anatomical lead location and 6-month postsurgical, double-blinded outcome measures of 86 patients who underwent bilateral GPi DBS. These patients were selected from the multicenter Veterans Affairs (VA)/National Institutes of Neurological Disorders and Stroke (NINDS) Cooperative Studies Program (CSP) 468 study to identify the optimal target zones (“sweet spots”) for the control of overall motor (United Parkinson’s Disease Rating Scale [UPDRS]-III), axial, tremor, rigidity, and bradykinesia symptoms. Lead coordinates were normalized to Montreal Neurological Institute space and the optimal target zones were identified and validated using a leave-one-patient-out approach.

RESULTS: The authors’ findings revealed statistically significant optimal target zones for UPDRS-III (R = 0.37, p < 0.001), axial (R = 0.22, p = 0.042), rigidity (R = 0.20, p = 0.021), and bradykinesia (R = 0.23, p = 0.004) symptoms. These zones were localized within the primary motor and premotor subdivisions of the GPi. Interestingly, these zones extended beyond the GPi lateral border into the GPi-globus pallidus externa (GPe) lamina and into the GPe, but they did not reach the GPi ventral border, challenging traditional surgical approaches based on pallidotomies.

CONCLUSIONS: Drawing upon a robust dataset, this research effectively delineates specific optimal target zones for not only overall motor improvement but also symptom subscores. These insights hold the potential to enhance the precision of targeting in subsequent bilateral GPi DBS surgical procedures.

PMID:38968618 | DOI:10.3171/2024.4.JNS24139

J Infus Nurs. 2024 Jul-Aug 01;47(4):255-265. doi: 10.1097/NAN.0000000000000553. Epub 2024 Jul 4.

ABSTRACT

Oncology and critical care patients often require central vascular access devices (CVADs), which can make them prone to central line-associated bloodstream infections (CLABSIs) and thrombotic occlusions. According to the literature, CLABSIs are rampant and increased by 63% during the COVID-19 pandemic, highlighting the need for innovative interventions. Four percent ethylenediaminetetraacetic acid (4% EDTA) is an antimicrobial locking solution that reduces CLABSIs, thrombotic occlusions, and biofilm. This retrospective pre-post quality improvement project determined if 4% EDTA could improve patient safety by decreasing CLABSIs and central catheter occlusions. This was implemented in all adult cancer and critical care units at a regional cancer hospital and center. Before implementing 4% EDTA, there were 36 CLABSI cases in 16 months (27 annualized). After implementation, there were 6 cases in 6 months (12 annualized), showing a statistically significant decrease of 59% in CLABSIs per 1000 catheter days. However, there was no significant difference in occlusions (alteplase use). Eighty-eight percent of patients had either a positive or neutral outlook, while most nurses reported needing 4% EDTA to be available in prefilled syringes. The pandemic and nursing shortages may have influenced the results; hence, randomized controlled trials are needed to establish a causal relationship between 4% EDTA and CLABSIs and occlusions.

PMID:38968588 | DOI:10.1097/NAN.0000000000000553