Tag: nevin manimala

J Comput Graph Stat. 2023;32(3):1036-1045. doi: 10.1080/10618600.2022.2141752. Epub 2022 Nov 30.

ABSTRACT

Individualized treatment effect lies at the heart of precision medicine. Interpretable individualized treatment rules (ITRs) are desirable for clinicians or policymakers due to their intuitive appeal and transparency. The gold-standard approach to estimating the ITRs is randomized experiments, where subjects are randomized to different treatment groups and the confounding bias is minimized to the extent possible. However, experimental studies are limited in external validity because of their selection restrictions, and therefore the underlying study population is not representative of the target real-world population. Conventional learning methods of optimal interpretable ITRs for a target population based only on experimental data are biased. On the other hand, real-world data (RWD) are becoming popular and provide a representative sample of the target population. To learn the generalizable optimal interpretable ITRs, we propose an integrative transfer learning method based on weighting schemes to calibrate the covariate distribution of the experiment to that of the RWD. Theoretically, we establish the risk consistency for the proposed ITR estimator. Empirically, we evaluate the finite-sample performance of the transfer learner through simulations and apply it to a real data application of a job training program.

PMID:37997592 | PMC:PMC10664843 | DOI:10.1080/10618600.2022.2141752

AEM Educ Train. 2023 Nov 22;7(6):e10908. doi: 10.1002/aet2.10908. eCollection 2023 Dec.

ABSTRACT

BACKGROUND: Cultural sensitivity (CS) training is vital to pediatric emergency medicine (PEM) curricula. This study aimed to explore CS in Yale PEM fellows and emergency medicine (EM) residents at Indus Hospital and Health Network (IHHN) in Pakistan through distance simulation activities.

METHODS: This mixed-methods analysis of an educational intervention was conducted at Yale University in collaboration with IHHN. We approached seven U.S. PEM fellows and 22 Pakistani EM residents. We performed a baseline CS assessment using the Clinical Cultural Competency Questionnaire (CCCQ). Afterward, the U.S. PEM fellows facilitated the Pakistani EM residents through six distance simulation sessions. Qualitative data were collected through online focus groups. The CCCQ was analyzed using descriptive statistics, and content analysis was used to analyze the data from the focus groups.

RESULTS: Seven U.S. PEM fellows and 18 of 22 Pakistani EM residents responded to the CCCQ at the beginning of the module. The mean (±SD) CCCQ domain scores for the U.S. PEM fellows versus the Pakistani EM residents were 2.56 (±0.37) versus 2.87 (±0.72) for knowledge, 3.02 (±0.41) versus 3.33 (±0.71) for skill, 2.86 (±0.32) versus 3.17 (±0.73) for encounter/situation, and 3.80 (±0.30) versus 3.47 (±0.47) for attitude (each out of 5 points). Our qualitative data analysis showed that intercultural interactions were valuable. There is a common language of medicine among the U.S. PEM fellows and Pakistani EM residents. The data also highlighted a power distance between the facilitators and learners, as the United States was seen as the standard of “how to practice PEM.” The challenges identified were time differences, cultural practices such as prayer times, the internet, and technology. The use of local language during debriefing was perceived to enhance engagement.

CONCLUSION: The distance simulation involving U.S. PEM fellows and Pakistani EM residents was an effective approach in assessing various aspects of intercultural education, such as language barriers, technical challenges, and religious considerations.

PMID:37997591 | PMC:PMC10664395 | DOI:10.1002/aet2.10908

AEM Educ Train. 2023 Nov 22;7(6):e10917. doi: 10.1002/aet2.10917. eCollection 2023 Dec.

ABSTRACT

OBJECTIVES: Cricothyrotomy is a high-stakes emergency procedure. Because the procedure is rare, simulation is often used to train residents. The Accreditation Council for Graduate Medical Education (ACGME) requires performance of three cricothyrotomies during residency, but the optimal number of training repetitions is unknown. Additional repetitions beyond three could increase proficiency, though it is unknown whether there is a threshold beyond which there is no benefit to additional repetition. The objective of this study was to establish a minimum number of simulated cricothyrotomy attempts beyond which additional attempts did not increase proficiency.

METHODS: This was a prospective, observational study conducted over 3 years at the simulation center of an academic emergency medicine residency program. Participants were residents participating in a cricothyrotomy training as part of a longitudinal airway curriculum course. The primary outcome was time to successful completion of the procedure as first-year residents. Secondary outcomes included time to completion as second- and third-year residents. Procedure times were plotted as a function of attempt number. Data were analyzed using descriptive statistics, repeated-measures analysis of variance, and correlation analysis. Preprocedure surveys collected further data regarding procedure experience, confidence, and comfort.

RESULTS: Sixty-nine first-year residents participated in the study. Steady improvement in time to completion was seen through the first six attempts (from a mean of 75 to 41 sec), after which no further significant improvement was found. Second- and third-year residents initially demonstrated slower performance than first-year residents but rapidly improved to surpass their first-year performance. Resident mean times at five attempts were faster with each year of residency (first-year 48 sec, second-year 30 sec, third-year 24 sec). There was no statistically significant correlation between confidence and time to complete the procedure.

CONCLUSIONS: Additional repetition beyond the ACGME-endorsed three cricothyrotomy attempts may help increase proficiency. Periodic retraining may be important to maintain skills.

PMID:37997589 | PMC:PMC10664393 | DOI:10.1002/aet2.10917

J Transl Med. 2023 Nov 24;21(1):847. doi: 10.1186/s12967-023-04737-9.

ABSTRACT

BACKGROUND: In primary open-angle glaucoma (POAG), lowering intraocular pressure (IOP) is the only proven way of slowing vision loss. Schlemm’s canal (SC) is a hybrid vascular and lymphatic vessel that mediates aqueous humour drainage from the anterior ocular chamber. Animal studies support the importance of SC endothelial angiopoietin-TEK signalling, and more recently TIE1 signalling, in maintaining normal IOP. However, human genetic support for a causal role of TIE1 and TEK signalling in lowering IOP is currently lacking.

METHODS: GWAS summary statistics were obtained for plasma soluble TIE1 (sTIE1) protein levels (N = 35,559), soluble TEK (sTEK) protein levels (N = 35,559), IOP (N = 139,555) and POAG (N_cases = 16,677, N_controls = 199,580). Mendelian randomization (MR) was performed to estimate the association of genetically proxied TIE1 and TEK protein levels with IOP and POAG liability. Where significant MR estimates were obtained, genetic colocalization was performed to assess the probability of a shared causal variant (PP_shared) versus distinct (PP_distinct) causal variants underlying TIE1/TEK signalling and the outcome. Publicly available single-nucleus RNA-sequencing data were leveraged to investigate differential expression of TIE1 and TEK in the human ocular anterior segment.

RESULTS: Increased genetically proxied TIE1 signalling and TEK signalling associated with a reduction in IOP (- 0.21 mmHg per SD increase in sTIE1, 95% CI = – 0.09 to – 0.33 mmHg, P = 6.57 × 10^-4, and – 0.14 mmHg per SD decrease in sTEK, 95% CI = – 0.03 to – 0.25 mmHg, P = 0.011), but not with POAG liability. Colocalization analysis found that the probability of a shared causal variant was greater for TIE1 and IOP than for TEK and IOP (PP_shared/(PP_distinct + PP_shared) = 0.98 for TIE1 and 0.30 for TEK). In the anterior segment, TIE1 and TEK were preferentially expressed in SC, lymphatic, and vascular endothelium.

CONCLUSIONS: This study provides novel human genetic support for a causal role of both TIE1 and TEK signalling in regulating IOP. Here, combined evidence from cis-MR and colocalization analyses provide stronger support for TIE1 than TEK as a potential IOP-lowering therapeutic target.

PMID:37996923 | DOI:10.1186/s12967-023-04737-9

BMC Med Educ. 2023 Nov 23;23(1):897. doi: 10.1186/s12909-023-04861-6.

ABSTRACT

OBJECTIVES: Abdominal palpation is an essential examination to diagnose various digestive system diseases. This study aimed to develop an objective and standardized test based on abdominal palpation simulators, and establish a credible pass/fail standard of basic competency.

METHODS: Two tests were designed using the newly developed Jucheng abdominal palpation simulator (test 1) and the AbSim simulator (test 2), respectively. Validity evidence for both tests was gathered according to Messick’s contemporary framework by using experts to define test content and then administering the tests in a highly standardized way to participants of different experience. Different simulator setups modified by the built-in software were selected from hepatomegaly, splenomegaly, positive McBurney’s sign plus rebound tenderness, gallbladder tenderness (Murphy’s sign), pancreas tenderness, and a normal setup without pathologies, with six sets used in test 1 and five sets used in test 2. Different novices and experienced were included in the tests, and test 1 was also administered to an intermediate group. Scores and test time were collected and analyzed statistically.

RESULTS: The internal consistency reliability of test 1 and test 2 showed low Cronbach’s alphas of 0.35 and -0.41, respectively. Cronbach’s alpha for palpation time across cases were 0.65 for test 1 and 0.76 for test 2. There was no statistical difference in total time spent and total scores among the three groups in test 1 (P-values (ANOVA) were 0.53 and 0.35 respectively), nor between novices and experienced groups in test 2 (P-values (t-test) were 0.13 and 1.0 respectively). It was not relevant to try to establish pass/fail standards due to the low reliability and lack of discriminatory ability of the tests.

CONCLUSIONS: It was not possible to measure abdominal palpation skills in a valid way using either of the two standardized, simulation-based tests in our study. Assessment of the patient’s abdomen using palpation is a challenging clinical skill that is difficult to simulate as it highly relies on tactile sensations and adequate responsiveness from the patients.

PMID:37996904 | DOI:10.1186/s12909-023-04861-6

BMC Health Serv Res. 2023 Nov 23;23(1):1293. doi: 10.1186/s12913-023-10266-4.

ABSTRACT

BACKGROUND: As approximately 3/4 of the population lives in county-level divisions in China, the allocation of health resources at the county level will affect the realization of health equity. This study aims to evaluate the disparity in hospital beds at the county level in China, analyze its causes, and discuss measures to optimize the allocation.

METHODS: Data were drawn from the Chinese County/City Statistical Yearbook (2001-2020). The health resource density index (HRDI) was applied to mediate between the influence of demographic and geographical factors on the allocation of hospital beds. The trends of HRDI allocation were evaluated through the growth incidence curve and the probability density function. The regional disparity in the HRDI was examined through the Lorenz curve, and Dagum Gini coefficient. The contribution of the Gini coefficient and its change were assessed by using the Dagum Gini decomposition method.

RESULTS: From 2000 to 2019, the number of hospital beds per thousand people at the county level in China increased dramatically by 1.49 times. From the aspect of the HRDI, there were large regional disparities at the national level, with a Gini coefficient of 0.367 in 2019 and in the three subregions. In 2019, the Gini coefficient of the HRDI exhibited regional variations, with the highest value observed in the western region, followed by the central region and the eastern region. Decomposition reveals that the contribution of interregional disparity changed from the dominant factor to the least important factor, accounting for 29.79% of the overall disparity and the contribution of trans-variation intensity increased from 29.19% to 39.75%, whereas the intraregional disparity remained stable at approximately 31% and became the second most important factor.

CONCLUSION: The regional disparity in hospital beds allocation at the county level in China was large and has not improved substantially. Trans-variation intensity was the main reason for the overall disparity and changes, and the intraregional disparity was more important than the interregional disparity for the overall disparity.

PMID:37996897 | DOI:10.1186/s12913-023-10266-4

Res Involv Engagem. 2023 Nov 24;9(1):105. doi: 10.1186/s40900-023-00516-4.

ABSTRACT

BACKGROUND: Incorporating Public and Patient Involvement (PPI) into doctoral research is valued by PhD funders and scholars. Providing early career researchers with appropriate training to develop skills to conduct meaningful PPI involvement is important. The Health Research Board (HRB) Collaborative Doctoral Award in MultiMorbidity programme (CDA-MM) embedded formal PPI training in its structured education. The four participating PhD scholars established a PPI panel comprising people living with two or more chronic conditions, presenting an opportunity for experiential PPI training. This study aimed to evaluate the process and impact of embedding PPI training in a structured PhD programme.

METHODS: This study was a longitudinal mixed-methods evaluation, conducted over 24 months (June 2020 to June 2022). A process evaluation provided an understanding of how PPI was embedded and explored the experiences of key stakeholders involved. An impact evaluation assessed the impact of embedding PPI training in the programme. Participants included PhD scholars, PPI contributors and PhD supervisors. The data collection and analysis was led by an independent researcher not aligned with the CDA-MM. Data collection methods included five focus groups, individual interviews (n = 6), an impact log, activity logs and group reflections. Qualitative data were analysed using thematic and content analysis and quantitative data analysed using descriptive statistics.

RESULTS: Embedding formal and experiential PPI training in a structured PhD programme is feasible. Both approaches to training are fundamental to building PPI capacity. Involvement of an experienced and knowledgeable PPI lead throughout is perceived as critical. The PPI panel approach offered a good example of embedded consultation and worked well in a structured PhD programme, providing PhD scholars with ample opportunities for learning about PPI and its implementation. For PPI contributors, culture was the most important indicator of quality and was positively evaluated. Key roles for PhD supervisors were identified. Embedding formal and experiential PPI training impacted positively on many different aspects of individual PhD research projects and on PhD scholars as researchers. There were positive impacts for PPI contributors and PhD supervisors.

CONCLUSIONS: Embedding formal and experiential PPI training in a structured PhD programme is a novel approach. The evaluation has identified a number of lessons that can inform future doctoral programmes seeking to embed formal and experiential PPI training.

PMID:37996882 | DOI:10.1186/s40900-023-00516-4

BMC Endocr Disord. 2023 Nov 24;23(1):257. doi: 10.1186/s12902-023-01512-1.

ABSTRACT

BACKGROUND: The low-grade chronic inflammation in diabetes plays an important role in development of cardiovascular and renal complications. Sodium-glucose co-transporter-2 (SGLT2) inhibitors are recognized as protective agents for cardio-renal complications. Interleukin-6 (IL-6) is positively associated with the pathophysiology of metabolic-related pathologies. The aim of this meta-analysis is to investigate the effect of SGLT2 inhibitors on blood IL-6 concentration in randomized controlled trials (RCTs).

METHODS: Embase, PubMed, and Scopus were systematically searched up to 1^st of November 2023. The eligible studies were RCTs with adult population that had provided blood IL-6 for both control and intervention groups. Cochrane risk-of-bias tool were for study quality assessment. Data were analyzed using random effect model via Stata statistical software.

RESULTS: Eighteen studies with a total of 5311 patients were included. Of which 3222 and 2052 patients were in intervention and control arm, respectively. Of the total population, 49.7% were men. The study durations ranged from 8 to 52 weeks. The pooled analysis showed a significant association between the use of SGLT2 inhibitors and lower IL-6 levels (standardized mean difference (SMD) = -1.04, Confidence Interval (CI): -1.48; -0.60, I² = 96.93%). Dapagliflozin was observed to have a higher IL-6-lowering effect (SMD = -1.30, CI: -1.89; -0.71, I² = 92.52) than empagliflozin or canagliflozin. Sub-group analysis of control groups (SMD = -0.58 (-1.01, -0.15) and -1.35 (-2.00, -0.70 for the placebo and active control sub-groups, respectively) and duration of interventions (SMD = -0.78 (-1.28, -0.28) and -1.20 (-1.86, -0.55) for study duration of ≤ 12 and > 12 weeks, respectively) did not change the results. Meta-regression analysis showed a significant correlation between the level of HbA_1c and IL-6-lowering efficacy of SGLT2 inhibitors.

CONCLUSION: IL-6 levels are significantly reduced with the use of SGLT2 inhibitors with HbA_1c as the only marker influencing such reductions, and dapagliflozin had the highest potency. The anti-inflammatory effect of SGLT2 inhibitors supports their broader use to address diabetic complications related to inflammatory responses.

PMID:37996879 | DOI:10.1186/s12902-023-01512-1

BMC Health Serv Res. 2023 Nov 23;23(1):1287. doi: 10.1186/s12913-023-10284-2.

ABSTRACT

BACKGROUND: While the number of medical images has increased substantially, the demand has outpaced access, resulting in long wait times in many countries. Long wait times are a key problem for patient safety and quality of care as they can result in prolonged suffering, delayed diagnosis and treatment, as well as poorer prognosis and loss of lives. Surprisingly, little is known about wait times for imaging services.

OBJECTIVE: Investigate wait times for specific imaging services in Norway and to compare wait times with the total number of examinations and their development over time.

METHODS: Data from the wait time registry at the Norwegian Directorate of Health from 2018 to 2021 as well as data on outpatient imaging provided by the Norwegian Health Economics Administration (HELFO) and in-patient data afforded by fourteen hospital trusts and hospitals in Norway were analysed. Data include the total number of imaging examinations according to the Norwegian Classification of Radiological Procedures (NCRP). Analyses were performed with descriptive statistics.

RESULTS: Wait times vary through the months of the year. Conventional X-ray (XR) had the shortest wait times (3.0-4.4 weeks), and Magnetic Resonance Imaging (MRI) and ultrasound (US) had the lengthiest (8.7-12.0 and 7.9-11.4 weeks respectively). The wait times were lengthiest during the summer and winter holidays. Variations in wait times were also found for specific examination types between Norway’s four public health regions. In addition, there was variation over time within the health regions. The wait times with the private health providers were substantially lower than with the public health providers. From 2018 to 2021, the wait time for MRIs increased by 6.6%, while the number of examinations (per 10,000) increased by 8.6%. Those regions with the highest number of examinations per 1,000 inhabitants per year had the lowest wait times.

CONCLUSION: Wait times for diagnostic imaging procedures varied with time, region, and modality in Norway from 2018 to 2021. Long wait times may entail many negative consequences for patients, professionals, and the healthcare system. Reducing long wait times is an obvious way to improve the quality, safety, and efficiency of care.

PMID:37996873 | DOI:10.1186/s12913-023-10284-2

BMC Oral Health. 2023 Nov 23;23(1):915. doi: 10.1186/s12903-023-03653-0.

ABSTRACT

BACKGROUND: Lower third molars (L3M) are the last teeth to erupt in the oral cavity. Uneruption of these teeth still raises questions about its causes, in the literature (1) genetic factors, (2) dental lamina activity and, mainly, (3) insufficient growth and development of the bone bases are included. While the lack of space theory influenced by mandibular morphology and size of L3M was argued to be the main reason for L3M impaction, there is a limitation in the literature in examining such association using more accurate tomographic analysis obtained from CBCT. This work aimed to evaluate the relationship between mandibular morphology and the eruption of L3M.

METHODS: In this regard, 85 Cone Beam Computed Tomographies (CBCT), with 147 L3M, were selected from the archives of the Department of Surgery, Stomatology, Pathology and Radiology, Bauru School of Dentistry, obtained using an Accuitomo® Morita device and using the Dolphin Imaging 11.9 software. L3M eruption was related to linear measurements of jaw length (Co-Gn), retromolar space dimension (D2R), mesiodistal width of the L3M crowns, mandibular first molars (L1M) and mandibular canines (LC) and the angle mandibular (Ar-Go-Me). Independent samples t-test, chi-square tests and logistic regression were performed adopting a significance level of 5%.

RESULTS: The average mandible length of 116.446 mm + 6.415 mm, retromolar space of 11.634 mm + 2.385 mm, mesiodistal size of the L3M of 10.054 mm + 0.941 mm, sum of the mesiodistal widths of the L1M and LC of 15.564 mm + 1.218 mm and mandibular angle of 127.23° + 6.109. There was no statistically significant association between these factors and the eruption.

CONCLUSION: With the results obtained in this study, we conclude that the length and angle of the mandible, teeth size and dimension of the retromolar space are not associated with the L3M eruption.

PMID:37996868 | DOI:10.1186/s12903-023-03653-0