Nevin Manimala

BMJ Open. 2021 Oct 11;11(10):e045086. doi: 10.1136/bmjopen-2020-045086.

ABSTRACT

OBJECTIVES: The influence of age on intensive care unit (ICU) decision-making is complex, and it is unclear if it is based on expected subjective or objective patient outcomes. To address recent concerns over age-based ICU decision-making, we explored patient-assessed quality of life (QoL) in ICU survivors before the COVID-19 pandemic.

DESIGN: A systematic review and meta-analysis of cohort studies published between January 2000 and April 2020, of elderly patients admitted to ICUs.

PRIMARY AND SECONDARY OUTCOME MEASURES: We extracted data on self-reported QoL (EQ-5D composite score), demographic and clinical variables. Using a random-effect meta-analysis, we then compared QoL scores at follow-up to scores either before admission, age-matched population controls or younger ICU survivors. We conducted sensitivity analyses to study heterogeneity and bias and a qualitative synthesis of subscores.

RESULTS: We identified 2536 studies and included 22 for qualitative synthesis and 18 for meta-analysis (n=2326 elderly survivors). Elderly survivors’ QoL was significantly worse than younger ICU survivors, with a small-to-medium effect size (d=0.35 (-0.53 and -0.16)). Elderly survivors’ QoL was also significantly greater when measured slightly before ICU, compared with follow-up, with a small effect size (d=0.26 (-0.44 and -0.08)). Finally, their QoL was also marginally significantly worse than age-matched community controls, also with a small effect size (d=0.21 (-0.43 and 0.00)). Mortality rates and length of follow-up partly explained heterogeneity. Reductions in QoL seemed primarily due to physical health, rather than mental health items.

CONCLUSIONS: The results suggest that the proportionality of age as a determinant of ICU resource allocation should be kept under close review and that subjective QoL outcomes should inform person-centred decision -aking in elderly ICU patients.

PROSPERO REGISTRATION NUMBER: CRD42020181181.

PMID:34635510 | DOI:10.1136/bmjopen-2020-045086

BMJ Evid Based Med. 2021 Oct 11:bmjebm-2020-111634. doi: 10.1136/bmjebm-2020-111634. Online ahead of print.

ABSTRACT

OBJECTIVES: To assess cost-effectiveness of direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKAs) for stroke prevention in atrial fibrillation (AF) by pooling incremental net benefits (INBs).

DESIGN: Systematic review and meta-analysis.

SETTING: We searched PubMed, Scopus and Centre for Evaluation of Value and Risks in Health Registry from inception to December 2019.

PARTICIPANTS: Patients with AF.

MAIN OUTCOME MEASURES: The INB was defined as a difference of incremental effectiveness multiplied by willing to pay threshold minus the incremental cost; a positive INB indicated favour treatment. These INBs were pooled (stratified by level of country income, perspective, time-horizon, model types) with a random-effects model if heterogeneity existed, otherwise a fixed effects model was applied. Heterogeneity was assessed using Q test and I² statistic. Risk of bias was assessed using the economic evaluations bias (ECOBIAS) checklist.

RESULTS: A total of 100 eligible economic evaluation studies (224 comparisons) were included. For high-income countries (HICs) from a third-party payer (TPP) perspective, the pooled INBs for DOAC versus VKA pairs were significantly cost-effective with INBs (95% CI) of $6632 ($2961.67 to $10 303.72; I²=59.9%), $6353.24 ($4076.03 to $8630.45; I²=0%), $7664.58 ($2979.79 to $12 349.37; I²=0%) and $8573.07 ($1877.05 to $15 269.09; I²=0%) for dabigatran, apixaban, rivaroxaban and edoxaban relative to VKA, respectively but only dabigatran was significantly cost-effective from societal perspective (SP) with an INB of $11 746.96 ($2429.34 to $21 064.59; I²=52.4%). The pooled INBs of all comparisons for upper-middle income countries (UMICs) were not significantly cost-effective. The ECOBIAS checklist indicated that risk of bias was mostly low for most items with the exception of five items which should be less influenced on pooling INBs.

CONCLUSIONS: Our meta-analysis provides comprehensive economic evidence that allows policy makers to generalise cost-effectiveness data to their local context. All DOACs may be cost-effective compared with VKA in HICs with TPP perspective. The pooling results produced moderate to high heterogeneity particularly in UMICs. Further studies are required to inform UMICs with SP.

PROSPERO REGISTERATION NUMBER: CRD 42019146610.

PMID:34635480 | DOI:10.1136/bmjebm-2020-111634

J Med Imaging Radiat Sci. 2021 Oct 8:S1939-8654(21)00223-X. doi: 10.1016/j.jmir.2021.09.010. Online ahead of print.

ABSTRACT

BACKGROUND: As new treatments and technologies have been introduced in radiation oncology, the clinical roles of radiation therapists (RTs) have expanded. However, there are few formal learning opportunities for RTs. An online, anatomy, radiology and contouring bootcamp (ARC Bootcamp) originally designed for medical residents was identified as a prospective educational tool for RTs. The purpose of this study was to evaluate an RT edition of the ARC Bootcamp on knowledge, contouring, and confidence, as well as to identify areas for future modification.

METHODS: Fifty licensed RTs were enrolled in an eight-week, multidisciplinary, online RT ARC Bootcamp. Contouring practice was available throughout the course using an online contouring platform. Outcomes were evaluated using a pre-course and post-course multiple-choice quiz (MCQ), contouring evaluation and qualitative self-efficacy and satisfaction survey.

RESULTS: Of the fifty enrolled RTs, 30 completed the course, and 26 completed at least one of the post-tests. Nineteen contouring dice similarity coefficient (DSC) scores were available for paired pre- and post-course analysis. RTs demonstrated a statistically significant increase in mean DSC scoring pooled across all contouring structures (mean ± SD improvement: 0.09 ± 0.18 on a scale from 0 to 1, p=0.020). For individual contouring structures, 3/15 reached significance in contouring improvement. MCQ scores were available for 26 participants and increased after RT ARC Bootcamp participation with a mean ± SD pre-test score of 18.6 ± 4.2 (46.5%); on a 40-point scale vs. post-test score of 24.5 ± 4.3 (61.4%) (p < 0.001). RT confidence in contouring, anatomy knowledge and radiographic identification improved after course completion (p < 0.001). Feedback from RTs recommended more contouring instruction, less in-depth anatomy review and more time to complete the course.

CONCLUSIONS: The RT ARC Bootcamp was an effective tool for improving anatomy and radiographic knowledge among RTs. The course demonstrated improvements in contouring and overall confidence. However, only approximately half of the enrolled RTs completed the course, limiting statistical power. Future modifications will aim to increase relevance to RTs and improve completion rates.

PMID:34635471 | DOI:10.1016/j.jmir.2021.09.010

An Pediatr (Engl Ed). 2021 Oct 9:S2341-2879(21)00161-7. doi: 10.1016/j.anpede.2020.08.013. Online ahead of print.

ABSTRACT

INTRODUCTION: Early identification of neonates exposed to drugs of abuse during pregnancy allows a more precise clinical management.

OBJECTIVES: To describe the clinical characteristics and to identify risk factors associated with the early detection of neonates exposed to drugs of abuse in a Neonatal Intermediate and Intensive Care Unit.

METHODS: Prospective observational study of neonates with and without clinical suspicion of prenatal exposure to drugs of abuse. Meconium was analyzed using standard chromatographic techniques. Univariate and multivariate statistical analyzes were performed.

RESULTS: 372 neonates were included. Exposure to drugs of abuse was detected in 49 (13.2%) cases: in 41 (83.7%) one drug and in 8 (16.3%) more than one. Somatometry at birth revealed: a) lower length percentile in those exposed to some drug, more than one and cannabis; b) lower weight percentile in those exposed to cannabis and of these compared to those exposed to alcohol. In neonates older than 34 pregnancy weeks (PW): a) lower length percentile in those exposed to any substance; b) lower percentile of length and weight in exposed to more than one. The most clinically relevant independent risk factors useful to detect cases of prenatal exposure to drugs of abuse were (Odds ratio (95% CI)): reason for admission other than prematurity (5.52 (2.55-1.93)), length percentile less than 33 (1.95 (1.05-3.60) and 2.14 (1.04-3.40) in older than 34 PW) and social dystocia/uncontrolled pregnancy in older than 34 PW (4.47 (1.03-19.29)).

CONCLUSIONS: There are somatometric alterations and risk factors that can help in the early detection of neonates exposed to drugs of abuse. The somatometric alterations identified can be useful to extend the differential diagnosis of these alterations and to study their causes.

PMID:34635463 | DOI:10.1016/j.anpede.2020.08.013

Stat Med. 2021 Oct 11. doi: 10.1002/sim.9218. Online ahead of print.

ABSTRACT

This article discusses regression analysis of clustered interval-censored failure time data in the presence of a cured fraction or subgroup. Such data often occur in many areas, including epidemiological studies, medical studies, and social sciences. For the problem, a class of semiparametric transformation nonmixture cure models is presented and for estimation, the maximum likelihood estimation procedure is derived. For the implementation of the proposed method, we develop a novel EM algorithm based on a Poisson variable-based augmentation. An extensive simulation study is conducted and suggests that the proposed approach works well in practical situations. Finally the method is applied to an example that motivated this study.

PMID:34634837 | DOI:10.1002/sim.9218

Neurosurgery. 2021 Oct 11:nyab360. doi: 10.1093/neuros/nyab360. Online ahead of print.

ABSTRACT

BACKGROUND: Few studies have assessed the impact of overlapping surgery during different timepoints of neurosurgical procedures.

OBJECTIVE: To evaluate the impact of overlap before the critical portion of surgery on short-term patient outcomes following lumbar fusion.

METHODS: In total, 3799 consecutive patients who underwent single-level, posterior-only lumbar fusion over 6 yr (2013-2019) at an academic hospital system were retrospectively studied. Outcomes included 30-d emergency department (ED) visit, readmission, reoperation, mortality, overall morbidity, and overall morbidity/surgical complications. Duration of overlap that occurred before the critical portion of surgery was calculated as a percentage of total beginning operative time. Univariate logistic regression was used to assess the impact of incremental 1% increases in the duration of overlap within the whole population and patients with beginning overlap. Subsequently, univariate analysis was used to compare exact matched patients with the least (bottom 40%) and most amounts of overlap (100% beginning overlap). Coarsened exact matching was used to match patients on key demographic factors, as well as attending surgeon. Significance was set at a P-value < .05.

RESULTS: Increased duration of beginning overlap was associated with a decrease in 30-d ED visit (P = .03) within all patients with beginning overlap, but not within the whole population undergoing lumbar fusion. Duration of beginning overlap was not associated with any other short-term morbidity or mortality outcome in either the whole population or patients with beginning overlap.

CONCLUSION: Increased duration of overlap before the critical step of surgery does not predict adverse short-term outcomes after single-level, posterior-only lumbar fusion.

PMID:34634816 | DOI:10.1093/neuros/nyab360

PLoS One. 2021 Oct 11;16(10):e0257682. doi: 10.1371/journal.pone.0257682. eCollection 2021.

ABSTRACT

In this paper, we present autopsych, a novel online tool that allows school assessment experts, test developers, and researchers to perform routine psychometric analyses and equating of student test data and to examine the effect of student demographic and group conditions on student test performance. The app extends current open-source software by providing (1) extensive embedded result narration and summaries for written reports, (2) improved handling of partial credit data via customizable item-person Wright maps, (3) customizable item- and person-flagging systems, (4) item-response theory model constraints and controls, (5) many-facets Rasch analysis to examine item bias, (6) Rasch fixed item equating for mapping student ability across test forms, (7) tabbed spreadsheet outputs and immediate options for secondary data analysis, (8) customizable graphical color schemes, (9) extended ANOVA analysis for examining group differences, and (10) inter-rater reliability analyses for the verifying the consistency of rater scoring systems. We present the app’s architecture and functionalities and test its performance with simulated and real-world small-, medium-, and large-scale assessment data. Implications and planned future developments are also discussed.

PMID:34634792 | DOI:10.1371/journal.pone.0257682

Lung Cancer. 2021 Sep 30;162:1-8. doi: 10.1016/j.lungcan.2021.09.020. Online ahead of print.

ABSTRACT

OBJECTIVES: Patients with lung cancer have high symptom burden and diminished quality of life. Electronic patient-reported outcome (PRO) platforms deliver repeated longitudinal surveys via web or telephone to patients and alert clinicians about concerning symptoms. This study aims to determine feasibility of electronic PRO monitoring in lung cancer patients receiving treatment in community settings.

METHODS: Adults receiving treatment for advanced or metastatic lung cancer at 26 community sites were invited to participate in a prospective trial of weekly electronic PRO symptom monitoring for 12 months (NCT03249090). Surveys assessing patients’ satisfaction with the electronic PRO system were administered at 3 months. Descriptive statistics were generated for demographics, survey completion rates, symptom occurrence, and provider PRO alert management approaches. Pairwise relationships between symptom items were evaluated using intra-individual repeated-measures correlation coefficients.

RESULTS: Lung cancer patients (n = 118) participating in electronic PROs were older (mean 64.4 vs 61.9 years, p = 0.03), had worse performance status (p = 0.002), more comorbidities (p = 0.02), and less technology experience than patients with other cancers. Of delivered weekly PRO surveys over 12 months, 91% were completed. Nearly all (97%) patients reported concerning (i.e., severe or worsening) symptoms during participation, with 33% of surveys including concerning symptoms. Pain was the most frequent and longest lasting symptom and was associated with reduced activity level. More than half of alerts to clinicians for concerning symptoms led to intervention. The majority (87%) would recommend using electronic PRO monitoring to other lung cancer patients.

CONCLUSIONS: Remote longitudinal weekly monitoring of patients with lung cancer using validated electronic PRO surveys was feasible in a multicenter, community-based pragmatic study. A high symptom burden specific to lung cancer was detected and clinician outreach in response to alerts was frequent, suggesting electronic PROs may be a beneficial strategy for identifying actionable symptoms and allow opportunities to optimize well-being in this population.

PMID:34634754 | DOI:10.1016/j.lungcan.2021.09.020

Ecotoxicol Environ Saf. 2021 Oct 8;226:112881. doi: 10.1016/j.ecoenv.2021.112881. Online ahead of print.

ABSTRACT

Geological disasters seriously threaten the safety of human life, property, ecological resources, and the environment. Effective control of geological disasters is the focus of achieving sustainable social development. The Helong City (Jilin Province, China) was selected as the case study. Combined with GIS technology, a new integrated prediction model of geological disaster susceptibility was developed to improve the accuracy of geological disaster assessment, reduce the cost of geological disaster treatment, and ensure the sustainable development of ecological environment. The research results showed that elevation and normalized difference vegetation index (NDVI) were the key factors affecting susceptibility. Compared with the conventional model, the accuracy of the developing integrated model FR-DT and FR-RF was improved by more than 6%, and the disaster points were more concentrated in the high susceptibility zone. Statistical results of disaster treatment cost estimation and gross domestic product (GDP) value showed that the integrated model can save about 10% of treatment cost, and the ratio of total GDP/disaster governance cost was higher. The performance of the integrated model FR-DT and FR-RF had obvious advantages over the conventional model in terms of prediction accuracy, prevention pertinence, and prevention cost. These research results promote the advancement of geological disaster prevention and control technology, ensure the safety of the geological environment, and are of great significance to the sustainable development of the regional economy.

PMID:34634737 | DOI:10.1016/j.ecoenv.2021.112881

J Environ Manage. 2021 Oct 8;301:113893. doi: 10.1016/j.jenvman.2021.113893. Online ahead of print.

ABSTRACT

Amongst different climatic and anthropogenic drivers, water resources management can cause massive changes to the natural regime of a lake after its regulation, thereby affecting the quantity and quality of water intended for satisfying the multiple basin water requirements. Here, we investigate the multi-decadal variation of the water levels and outflows of Lake Garda, the largest in Italy, where the dam operational rules and the related basin water needs heavily altered the annual and seasonal trend of the lake regime since its regulation in 1951. Daily lake levels and outflows were first collected and digitized for the period 1888-2020, thus providing a unique database of 133 years that allowed a consistent comparison between natural and regulated periods. Statistical analyses highlighted a significant change of the inter-annual trend of the lake outflows, which passed from upward to downward after regulation, against a constant increasing trend of the water levels. Conversely, water levels showed a more remarkable shifts on a seasonal scale if compared to the outflows, revealing the influence of summer and winter basin water needs. Additional analyses on the inter-annual variation of the main downstream water demands regulated by the dam, i.e. the irrigation, hydropower and fluvial ecosystem requirements, outlined their relevance in changing the lake regime, influencing dam operational policies, which progressively limited the share of water released for ecosystem integrity. A comparison between the lake levels and outflows recorded for the pre-regulation and post-regulation periods of some selected European perialpine lakes finally highlighted different effects on the lake regime, drawing attention to the importance of defining the role of the dam operational policies within the current scenario of climate change and changing water demands.

PMID:34634725 | DOI:10.1016/j.jenvman.2021.113893