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Nevin Manimala Statistics

Leveraging multivariate approaches to advance the science of early-life adversity

Child Abuse Negl. 2024 Mar 22:106754. doi: 10.1016/j.chiabu.2024.106754. Online ahead of print.

ABSTRACT

Since the landmark Adverse Childhood Experiences (ACEs) study, adversity research has expanded to more precisely account for the multifaceted nature of adverse experiences. The complex data structures and interrelated nature of adversity data require robust multivariate statistical methods, and recent methodological and statistical innovations have facilitated advancements in research on childhood adversity. Here, we provide an overview of a subset of multivariate methods that we believe hold particular promise for advancing the field’s understanding of early-life adversity, and discuss how these approaches can be practically applied to explore different research questions. This review covers data-driven or unsupervised approaches (including dimensionality reduction and person-centered clustering/subtype identification) as well as supervised/prediction-based approaches (including linear and tree-based models and neural networks). For each, we highlight studies that have effectively applied the method to provide novel insight into early-life adversity. Taken together, we hope this review serves as a resource to adversity researchers looking to expand upon the cumulative approach described in the original ACEs study, thereby advancing the field’s understanding of the complexity of adversity and related developmental consequences.

PMID:38521731 | DOI:10.1016/j.chiabu.2024.106754

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Evaluation of Left Ventricular Function in Patients With Severe Aortic Stenosis Utilizing Automated Cardiac Motion Quantitation Techniques

Ultrasound Med Biol. 2024 Mar 22:S0301-5629(24)00119-4. doi: 10.1016/j.ultrasmedbio.2024.03.001. Online ahead of print.

ABSTRACT

OBJECTIVE: The objective of this study is to explore the patterns of alteration in left ventricular systolic function among patients with severe aortic stenosis (SAS) through the application of automatic myocardial motion quantification (aCMQ) techniques. Furthermore, we seek to ascertain dependable quantitative markers for the assessment of impaired left ventricular function in patients with SAS and an ejection fraction (EF) ≥ 60%.

METHODS: Seventy patients who underwent echocardiography and received a diagnosis of severe aortic stenosis (SAS) in the hospital from November 2021 to August 2022 were selected for the SAS group and categorized into three subgroups based on ejection fraction (EF)-SAS group with EF ≥ 60%, SAS group with EF ranging from 50% to 59%, and SAS group with EF < 50%. Concurrently, 30 healthy individuals were recruited at the hospital during the same timeframe to serve as the control group. Participants from both groups underwent standard transthoracic echocardiography to assess conventional echocardiographic parameters. Dynamic images were examined using automatic myocardial motion quantification (aCMQ) software to derive longitudinal peak strain (LPS) parameters, which were then subjected to statistical analysis.

RESULTS: In comparison to the control group participants, the measurements of ascending aorta diameter (AoD), left atrium diameter (LAD), interventricular septal end diastolic thickness (IVSd), left ventricular posterior wall end diastolic thickness (LVPWd), peak systolic velocity (Vmax), and mean pressure gradient (MPG) were significantly higher in the SAS groups (p < 0.05). When compared to participants in the SAS group with an EF ≥ 60%, the values of IVSd, LVPWd, Vmax, and MPG in the SAS group with EF ranging from 50% to 59% were significantly elevated (p < 0.05). Similarly, left ventricular end-diastolic diameter (LVEDD), the ratio of early diastolic mitral inflow velocity to early diastolic mitral annular velocity (E/e’), and the ratio of early to late diastolic mitral inflow velocities (E/A) in the SAS group with EF < 50% were significantly elevated (p < 0.05). The absolute values of longitudinal peak strain (LPS) in the SAS groups were significantly lower in comparison to those in the control group (p < 0.05). Furthermore, all measurements of left ventricular global longitudinal systolic peak strain (GLPS) showed a positive correlation with MPG, a moderate negative correlation with aortic valve area index (AVAI), and a moderate positive correlation with E/A.

CONCLUSIONS: Patients with SAS and an EF < 50% exhibited the most profound impairment in left ventricular myocardial function. Utilizing the aCMQ technique enables the precise and quantitative evaluation of the severity of impaired left ventricular systolic function in patients within the SAS group with an EF ≥ 60%.

PMID:38521696 | DOI:10.1016/j.ultrasmedbio.2024.03.001

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The changing pattern of pediatric burns in a territory burn center before and during the COVID-19 pandemic in China: A retrospective study

J Tissue Viability. 2024 Mar 19:S0965-206X(24)00035-4. doi: 10.1016/j.jtv.2024.03.010. Online ahead of print.

ABSTRACT

BACKGROUND: Pediatric burn patients are an essential part of burn populations. However, there is limited publicly available data on the epidemiological impact of COVID-19 on pediatric burns in China.

OBJECTIVE: In this paper, pediatric burn patients admitted to the Department of Burn Surgery of the First Hospital of Jilin University before and during COVID-19 were retrospectively investigated to determine the impact of COVID-19 on pediatric burn inpatients.

METHODS: The information of inpatients from July 2017 to December 2019 (pre-COVID-19 group) and from January 2020 to June 2022 (COVID-19 group) in the Department of Burn Surgery at the First Hospital of Jilin University was retrospectively investigated. Demographic information of patients, length of hospital stay, total body surface area (TBSA) of burn injury, post-injury visit time, comorbidity, surgical methods, etc., were statistically analyzed.

RESULTS: The COVID-19 group included 154 (10.2%) patients, and the pre-COVID-19 group included 335 (19.4%) patients (P<0.001). There were no differences in gender, age, length of hospital stay, or etiology of burns between the two groups. Compared to the pre-COVID-19 group, patients in the pre-COVID-19 group experienced a significant delay in presentation (P<0.001), had a larger TBSA of burn wound (P < 0.001), were more prone to sustaining major burns (P < 0.001), a higher likelihood of undergoing operations (P = 0.03), higher cost (P<0.001) and more complications (P<0.001). Additionally, upper extremities were the most commonly part involved in both groups (P = 0.004), with the lower extremities showed a significant increase to be involved in burn injury during COVID-19 pandemic (P = 0.007). Furthermore, the majority of guardians did not take first aid measures in both groups following burn injury (P = 0.102).

CONCLUSIONS: During the COVID-19 pandemic period, scalds remained the main reason for hospitalization. The number of hospitalized patients has decreased dramatically, while the severity of burns has significantly increased, with a notable delay in hospital visits and an increased occurrence of complications.

PMID:38521680 | DOI:10.1016/j.jtv.2024.03.010

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Physiologic parameters and radiologic findings can predict pulmonary complications and guide management in traumatic rib fractures

Injury. 2024 Mar 13:111508. doi: 10.1016/j.injury.2024.111508. Online ahead of print.

ABSTRACT

BACKGROUND: Traumatic rib fracture is associated with a high morbidity rate and identifying patients at risk of developing pulmonary complications (PC) can guide management and potentially decrease unnecessary intensive care admissions. Therefore, we sought to assess and compare the utility of a physiologic parameter, vital capacity (VC), with the admission radiologic findings (RibScore) in predicting PC in patients with rib fractures.

METHODS: This is a single-center retrospective review (2015-2018) of all adult (≥18 years) patients admitted to a Level I trauma center with traumatic rib fracture. Exclusion criteria included no CT scan and absence of VC within 48 h of admission. The cohort was stratified into two groups based on presence or absence of PC (pneumonia, unplanned intubation, unplanned transfer to the intensive care unit for a respiratory concern, or the need for a tracheostomy). Multivariable logistic regression models were constructed to identify predictors of PC.

RESULTS: A total of 654 patients met the inclusion criteria of whom 70 % were males. The median age was 51 years and fall (48 %) was the most common type of injury. A total of 36 patients (5.5 %) developed a pulmonary complication. These patients were more likely to be older, had a higher ISS, and were more likely to require a tube thoracostomy placement. On multivariable logistic regression, first VC ≤30 % (AOR: 4.29), day 1 VC ≤30 % (AOR: 3.61), day 2 VC ≤30 % (AOR: 5.54), Δ(Day2-Day1 VC) (AOR: 0.96), and RibScore ≥2 (AOR: 3.19) were significantly associated with PC. On discrimination analysis, day 2 VC had the highest area under the receiver operating characteristic curve (AuROC), 0.81, and was superior to first VC and day 1 VC in predicting PC. There was no statistically significant difference in predicting PC between day 2 VC and RibScore. On multivariable analysis, first VC ≤30 %, day 1 VC ≤30 %, day 2 VC ≤30 %, and admission RibScore ≥2 were associated with prolonged hospital and ICU LOS.

CONCLUSION: VC and RibScore emerged as independent predictors of PC. However, VC was not found to be superior to RibScore in predicting PC. Further prospective research is warranted to validate the findings of this study.

PMID:38521636 | DOI:10.1016/j.injury.2024.111508

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Avelumab Plus Intermittent Axitinib in Previously Untreated Patients with Metastatic Renal Cell Carcinoma. The Tide-A Phase 2 Study

Eur Urol. 2024 Mar 22:S0302-2838(24)02132-8. doi: 10.1016/j.eururo.2024.02.014. Online ahead of print.

ABSTRACT

BACKGROUND: Combinations of vascular endothelial growth factor receptor (VEGFR) tyrosine kinase inhibitors (TKIs) plus immune checkpoint inhibitor (ICI) against PD1/PD-L1 are the standard first-line therapy for patients with metastatic renal cell carcinoma (mRCC), irrespective of the prognostic class.

OBJECTIVE: To investigate the feasibility and safety of withdrawing VEGFR-TKI but continuing anti-PD1/PD-L1 in patients who achieve a response to their combination.

DESIGN, SETTING, AND PARTICIPANTS: This was a single-arm phase 2 trial in patients with treatment-naïve mRCC with prior nephrectomy, without symptomatic/bulky disease and no liver metastases.

INTERVENTION: Enrolled patients received axitinib + avelumab; after 36 wk of therapy those who achieved a tumour response interrupted axitinib and continued avelumab maintenance until disease progression.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary endpoint was the rate of patients without progression 8 wk after the axitinib interruption. The secondary endpoints were the median value for progression-free (mPFS) and overall (mOS) survival and the safety in the overall population.

RESULTS AND LIMITATIONS: Seventy-nine patients were enrolled and 75 were evaluated for efficacy. A total of 29 (38%) patients had axitinib withdrawn, as per the study design, with 72% of them having no progression after 8 wk and thus achieving the primary endpoint. The mPFS of the overall population was 24 mo, while the mOS was not reached. The objective response rate was 76% (12% complete response and 64% partial response), with 19% of patients having stable disease. In the patients who discontinued axitinib, the incidence of adverse events of any grade was 59% for grade 3 and 3% for grade 4. This study was limited by the lack of a comparative arm.

CONCLUSIONS: The TIDE-A study demonstrates that the withdrawal of VEGFR-TKI with ICI maintenance is feasible for selected mRCC patients with evidence of a response to the VEGFR-TKI + ICI combination employed in first-line therapy. Axitinib interruption with avelumab maintenance leads to decreased side effects and should be investigated further as a new strategy to delay tumour progression.

PATIENT SUMMARY: We evaluated whether certain patients with advanced kidney cancer treated with the fist-line combination of axitinib plus avelumab can interrupt the axitinib in case of a tumour response after 36 wk of therapy. We found that axitinib interruption improved the safety of the combination, while the maintenance with avelumab might delay tumour progression.

PMID:38521617 | DOI:10.1016/j.eururo.2024.02.014

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Interdisciplinary Approach to Expedited Outpatient Gastrostomy Tube Placement in Head and Neck Cancer Patients: A Single Center Retrospective Study

Acad Radiol. 2024 Mar 22:S1076-6332(24)00149-1. doi: 10.1016/j.acra.2024.03.008. Online ahead of print.

ABSTRACT

RATIONALE AND OBJECTIVE: Treatment for head and neck cancer (HNC) can lead to decreased oral intake which often requires gastrostomy tube (g-tube) placement to provide nutritional support. A multidisciplinary team (MDT) consisting of interventional radiology (IR), HNC oncology and surgery, nutrition, and speech language pathology departments implemented an expedited outpatient g-tube placement pathway to reduce hospital stays and associated costs, initiate feeds sooner, and improve communication between care teams. This single center study investigates differences in complications, time to procedure and costs savings with implementing this pathway.

METHODS: 142 patients with HNC who underwent elective image guided g-tube placement by IR from 2015 to 2022 were identified retrospectively. 52 patients underwent the traditional pathway, and 90 patients underwent the expedited pathway. Patient demographics, procedure characteristics, periprocedural costs and 90-day complication rates were collected and compared statistically.

RESULTS: The 90-day complication rate was comparable between groups (traditional=32.7%; expedited=22.2%; p-value=0.17). The expedited pathway decreased the time from consult to procedure by 11.1 days (95% CI 7.6 – 14.6; p < 0.001) and decreased charge per procedure by $2940 (95% CI $989-$4891; p < 0.001).

CONCLUSION: A MDT for the treatment of patients with HNC successfully provided enteral nutrition support faster, with fewer associated costs, and in a more patient centered approach than previously done at this institution.

PMID:38521613 | DOI:10.1016/j.acra.2024.03.008

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Prognostic factors and prediction models for hospitalisation and all-cause mortality in adults presenting to primary care with a lower respiratory tract infection: a systematic review

BMJ Open. 2024 Mar 23;14(3):e075475. doi: 10.1136/bmjopen-2023-075475.

ABSTRACT

OBJECTIVE: To identify and synthesise relevant existing prognostic factors (PF) and prediction models (PM) for hospitalisation and all-cause mortality within 90 days in primary care patients with acute lower respiratory tract infections (LRTI).

DESIGN: Systematic review.

METHODS: Systematic searches of MEDLINE, Embase and the Cochrane Library were performed. All PF and PM studies on the risk of hospitalisation or all-cause mortality within 90 days in adult primary care LRTI patients were included. The risk of bias was assessed using the Quality in Prognostic Studies tool and Prediction Model Risk Of Bias Assessment Tool tools for PF and PM studies, respectively. The results of included PF and PM studies were descriptively summarised.

RESULTS: Of 2799 unique records identified, 16 were included: 9 PF studies, 6 PM studies and 1 combination of both. The risk of bias was judged high for all studies, mainly due to limitations in the analysis domain. Based on reported multivariable associations in PF studies, increasing age, sex, current smoking, diabetes, a history of stroke, cancer or heart failure, previous hospitalisation, influenza vaccination (negative association), current use of systemic corticosteroids, recent antibiotic use, respiratory rate ≥25/min and diagnosis of pneumonia were identified as most promising candidate predictors. One newly developed PM was externally validated (c statistic 0.74, 95% CI 0.71 to 0.78) whereas the previously hospital-derived CRB-65 was externally validated in primary care in five studies (c statistic ranging from 0.72 (95% CI 0.63 to 0.81) to 0.79 (95% CI 0.65 to 0.92)). None of the PM studies reported measures of model calibration.

CONCLUSIONS: Implementation of existing models for individualised risk prediction of 90-day hospitalisation or mortality in primary care LRTI patients in everyday practice is hampered by incomplete assessment of model performance. The identified candidate predictors provide useful information for clinicians and warrant consideration when developing or updating PMs using state-of-the-art development and validation techniques.

PROSPERO REGISTRATION NUMBER: CRD42022341233.

PMID:38521534 | DOI:10.1136/bmjopen-2023-075475

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Association of the triglyceride-glucose index with severity of coronary stenosis and in-hospital mortality in patients with acute ST elevation myocardial infarction after percutaneous coronary intervention: a multicentre retrospective analysis cohort study

BMJ Open. 2024 Mar 23;14(3):e081727. doi: 10.1136/bmjopen-2023-081727.

ABSTRACT

OBJECTIVES: To explore the impact of the triglyceride-glucose (TyG) index on the severity of coronary stenosis and the risk of in-hospital mortality in patients with acute ST segment elevation myocardial infarction (STEMI) after percutaneous coronary intervention (PCI).

DESIGN: A multicentre retrospective cohort study.

SETTING: Patients with STEMI undergoing PCI from three centres in China from 2015 to 2019.

PARTICIPANTS: A total of 1491 individuals presenting with STEMI were enrolled.

PRIMARY OUTCOME MEASURE: The degree of coronary stenosis was quantified by the Gensini score (GS). The association between the TyG index and the severity of coronary stenosis was explored by using a logistic regression analysis. Cox proportional hazards regression analyses were used to investigate the associations between the variables and in-hospital mortality.

RESULTS: We found a significant correlation between the TyG index and the degree of coronary stenosis in the present study. The TyG index was an independent risk factor for the severity of coronary stenosis (OR 2.003, p<0.001). Using the lowest tertile of the TyG (T1) group as a reference, the adjusted ORs for the T2 group and the T3 group and a high GS were 1.732 (p<0.001), 1.968 (p<0.001), respectively, and all p for trend <0.001. For predicting a high GS, the TyG index’s area under the curve was 0.668 (95% CI 0.635 to 0.700, p<0.001). Additionally, the TyG index was further demonstrated to be an independent predictor of in-hospital mortality in patients with STEMI (HR 1.525, p<0.001).

CONCLUSIONS: The TyG index was associated with the severity of coronary stenosis and all-cause in-hospital mortality in patients with STEMI, which may help physicians precisely risk-stratify patients and implement individualised treatment.

PMID:38521531 | DOI:10.1136/bmjopen-2023-081727

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Realist evaluation of maternity waiting home intervention models in Inhambane, Mozambique: protocol for a comparative embedded case study, the Mozambique-Canada Maternal Health Project

BMJ Open. 2024 Mar 23;14(3):e075681. doi: 10.1136/bmjopen-2023-075681.

ABSTRACT

INTRODUCTION: This is a study protocol that tests and refines realist theories regarding the uptake and scale-up of the linked maternity waiting home (hereafter MWH) and facility birth intervention in the Mozambican context. The theories were developed through a realist review of MWH-facility birth literature from low-income and middle-income countries. The aim of the proposed study is to contribute to a contextually refined understanding of the causal chains underlying MWH-facility birth adoption by pregnant women and their families, communities, the health system and donors.

METHODS AND ANALYSIS: The overarching methodology is mixed-methods realist evaluation. The study will adopt a comparative embedded case study design comparing three new masonry MWHs built by the Mozambique-Canada Maternal Health Project in Inhambane province with three older MWHs selected based on variation in the built environment. Baseline data on participating MWH-facility birth interventions will be collected through observations, reviews of routine data and analysis of statistics and reports from provincial and district health authorities and the Mozambique-Canada Maternal Health project. Realist interviews will be conducted with MWH users and non-users, companions of MWH users and non-users, partners of MWH users and non-users, and stakeholders within the health system and the non-governmental organisation sector. Realist focus groups will be used to collect data from community-level implementers. The analysis will be retroductive and use the context-mechanism-outcome configuration heuristic tool to represent generative causation. We will analyse data from intervention and comparator MWHs independently and compare the resulting refined programme theories. Data analysis will be done in NVivo 12.

ETHICS AND DISSEMINATION: Ethics approval for the project has been obtained from the Mozambique National Bioethics Committee (CNBS-Comité Nacional de Bioética para a Saúde) and the University of Saskatchewan Bioethical Research Ethics Board. The evaluation will adhere to the International Ethical Guidelines for Biomedical Research Involving Human Subjects and the African adaptation of evaluation ethics and principles. Evaluation results will be disseminated to stakeholders’ practice audiences through peer-reviewed publications, plain-language briefs, theory validation/feedback meetings and conference presentations.

PMID:38521527 | DOI:10.1136/bmjopen-2023-075681

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Development and validation of a novel score for predicting perioperative major adverse cardiovascular events in patients with stable coronary artery disease undergoing noncardiac surgery

Int J Cardiol. 2024 Mar 21:131982. doi: 10.1016/j.ijcard.2024.131982. Online ahead of print.

ABSTRACT

BACKGROUND: A model developed specifically for stable coronary artery disease (SCAD) patients to predict perioperative major adverse cardiovascular events (MACE) has not been previously reported.

METHODS: The derivation cohort consisted of 5780 patients with SCAD undergoing noncardiac surgery at the First Affiliated Hospital of Zhejiang University School of Medicine, from January 1, 2013 until May 31, 2021. The validation cohort consisted of 2677 similar patients from June 1, 2021 to May 31, 2023. The primary outcome was a composite of MACEs (death, resuscitated cardiac arrest, myocardial infarction, heart failure, and stroke) intraoperatively or during hospitalization postoperatively.

RESULTS: Six predictors, including Creatinine >90 μmol/L, Hemoglobin <110 g/L, Albumin <40 g/L, Leukocyte >10 ×109/L, high-risk Surgery (general abdominal or vascular), and American Society of Anesthesiologists (ASA) class (III or IV), were selected in the final model (CHALSA score). Each patient was assigned a CHALSA score of 0, 1, 2, 3, or > 3 according to the number of predictors present. The incidence of perioperative MACEs increased steadily across the CHALSA score groups in both the derivation (0.5%, 1.4%, 2.9%, 6.8%, and 23.4%, respectively; p < 0.001) and validation (0.3%, 1.5%, 4.1%, 9.2%, and 29.2%, respectively; p < 0.001) cohorts. The CHALSA score had a higher discriminatory ability than the revised cardiac risk index (C statistic: 0.827 vs. 0.695 in the validation dataset; p < 0.001).

CONCLUSIONS: The CHALSA score showed good validity in an external dataset and will be a valuable bedside tool to guide the perioperative management of patients with SCAD undergoing noncardiac surgery.

PMID:38521511 | DOI:10.1016/j.ijcard.2024.131982