Tag: statistics

JAMA Netw Open. 2024 Jun 3;7(6):e2415383. doi: 10.1001/jamanetworkopen.2024.15383.

ABSTRACT

IMPORTANCE: Lung cancer is the deadliest cancer in the US. Early-stage lung cancer detection with lung cancer screening (LCS) through low-dose computed tomography (LDCT) improves outcomes.

OBJECTIVE: To assess the association of a multifaceted clinical decision support intervention with rates of identification and completion of recommended LCS-related services.

DESIGN, SETTING, AND PARTICIPANTS: This nonrandomized controlled trial used an interrupted time series design, including 3 study periods from August 24, 2019, to April 27, 2022: baseline (12 months), period 1 (11 months), and period 2 (9 months). Outcome changes were reported as shifts in the outcome level at the beginning of each period and changes in monthly trend (ie, slope). The study was conducted at primary care and pulmonary clinics at a health care system headquartered in Salt Lake City, Utah, among patients aged 55 to 80 years who had smoked 30 pack-years or more and were current smokers or had quit smoking in the past 15 years. Data were analyzed from September 2023 through February 2024.

INTERVENTIONS: Interventions in period 1 included clinician-facing preventive care reminders, an electronic health record-integrated shared decision-making tool, and narrative LCS guidance provided in the LDCT ordering screen. Interventions in period 2 included the same clinician-facing interventions and patient-facing reminders for LCS discussion and LCS.

MAIN OUTCOME AND MEASURE: The primary outcome was LCS care gap closure, defined as the identification and completion of recommended care services. LCS care gap closure could be achieved through LDCT completion, other chest CT completion, or LCS shared decision-making.

RESULTS: The study included 1865 patients (median [IQR] age, 64 [60-70] years; 759 female [40.7%]). The clinician-facing intervention (period 1) was not associated with changes in level but was associated with an increase in slope of 2.6 percentage points (95% CI, 2.4-2.7 percentage points) per month in care gap closure through any means and 1.6 percentage points (95% CI, 1.4-1.8 percentage points) per month in closure through LDCT. In period 2, introduction of patient-facing reminders was associated with an immediate increase in care gap closure (2.3 percentage points; 95% CI, 1.0-3.6 percentage points) and closure through LDCT (2.4 percentage points; 95% CI, 0.9-3.9 percentage points) but was not associated with an increase in slope. The overall care gap closure rate was 175 of 1104 patients (15.9%) at the end of the baseline period vs 588 of 1255 patients (46.9%) at the end of period 2.

CONCLUSIONS AND RELEVANCE: In this study, a multifaceted intervention was associated with an improvement in LCS care gap closure.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04498052.

PMID:38848065 | DOI:10.1001/jamanetworkopen.2024.15383

JAMA Netw Open. 2024 Jun 3;7(6):e2415587. doi: 10.1001/jamanetworkopen.2024.15587.

ABSTRACT

IMPORTANCE: Racial and ethnic disparities have been observed in the outpatient visit rates for specialist care, including cancer care; however, little is known about patients’ experience at the critical step of attempting to access new clinic appointments for cancer care.

OBJECTIVE: To determine simulated English-speaking, Spanish-speaking, and Mandarin-speaking patient callers’ ability to access new clinic appointments for 3 cancer types (colon, lung, and thyroid cancer) that disproportionately impact Hispanic and Asian populations.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional audit study was conducted between November 2021 and March 2023 using 479 clinic telephone numbers that were provided by the hospital general information personnel at 143 hospitals located across 12 US states. Using standardized scripts, trained research personnel assigned to the roles of English-speaking, Spanish-speaking, and Mandarin-speaking patients called the telephone number for a clinic that treats colon, lung, or thyroid cancer to inquire about a new clinic appointment. Data analysis was conducted from June to September 2023.

MAIN OUTCOMES AND MEASURES: The primary outcome was whether the simulated patient caller was able to access cancer care (binary variable, yes or no), which was defined to include being provided with a clinic appointment date or scheduling information. Multivariable logistic regression analysis was performed to determine factors independently associated with simulated patient callers being able to access cancer care.

RESULTS: Of 985 total calls (399 English calls; 302 Spanish calls; 284 Mandarin calls), simulated patient callers accessed cancer care in 409 calls (41.5%). Differences were observed based on language type, with simulated English-speaking patient callers significantly more likely to access cancer care compared with simulated Spanish-speaking and Mandarin-speaking patient callers (English, 245 calls [61.4%]; Spanish, 110 calls [36.4%]; Mandarin, 54 calls [19.0%]; P < .001). A substantial number of calls ended due to linguistic barriers (291 of 586 Spanish or Mandarin calls [49.7%]) and workflow barriers (239 of 985 calls [24.3%]). Compared with English-speaking simulated patient callers, the odds of accessing cancer care were lower for Spanish-speaking simulated patient callers (adjusted odds ratio [aOR], 0.34; 95% CI, 0.25-0.46) and Mandarin-speaking simulated patient callers (aOR, 0.13; 95% CI, 0.09-0.19). Compared with contacting clinics affiliated with teaching hospitals, callers had lower odds of accessing cancer care when contacting clinics that were affiliated with nonteaching hospitals (aOR, 0.53; 95% CI, 0.40-0.70).

CONCLUSIONS AND RELEVANCE: In this cross-sectional audit study, simulated patient callers encountered substantial barriers when attempting to access clinic appointments for cancer care. These findings suggest that interventions focused on mitigating these barriers are necessary to increase access to cancer care for all patients.

PMID:38848062 | DOI:10.1001/jamanetworkopen.2024.15587

JAMA Netw Open. 2024 Jun 3;7(6):e2415983. doi: 10.1001/jamanetworkopen.2024.15983.

ABSTRACT

IMPORTANCE: Sport-related concussion (SRC), a form of mild traumatic brain injury, is a prevalent occurrence in collision sports. There are no well-established approaches for tracking neurobiologic recovery after SRC.

OBJECTIVE: To examine the levels of serum glial fibrillary acidic protein (GFAP) and neurofilament light (NfL) in Australian football athletes who experience SRC.

DESIGN, SETTING, AND PARTICIPANTS: A cohort study recruiting from April 10, 2021, to September 17, 2022, was conducted through the Victorian Amateur Football Association, Melbourne, Australia. Participants included adult Australian football players with or without SRC. Data analysis was performed from May 26, 2023, to March 27, 2024.

EXPOSURE: Sport-related concussion, defined as at least 1 observable sign and/or 2 or more symptoms.

MAIN OUTCOMES AND MEASURES: Primary outcomes were serum GFAP and NfL levels at 24 hours, and 1, 2, 4, 6, 8, 12, and 26 weeks. Secondary outcomes were symptoms, cognitive performance, and return to training times.

RESULTS: Eighty-one individuals with SRC (median age, 22.8 [IQR, 21.3-26.0] years; 89% male) and 56 control individuals (median age, 24.6 [IQR, 22.4-27.3] years; 96% male) completed a total of 945 of 1057 eligible testing sessions. Compared with control participants, those with SRC exhibited higher GFAP levels at 24 hours (mean difference [MD] in natural log, pg/mL, 0.66 [95% CI, 0.50-0.82]) and 4 weeks (MD, 0.17 [95% CI, 0.02-0.32]), and NfL from 1 to 12 weeks (1-week MD, 0.31 [95% CI, 0.12-0.51]; 2-week MD, 0.38 [95% CI, 0.19-0.58]; 4-week MD, 0.31 [95% CI, 0.12-0.51]; 6-week MD, 0.27 [95% CI, 0.07-0.47]; 8-week MD, 0.36 [95% CI, 0.15-0.56]; and 12-week MD, 0.25 [95% CI, 0.04-0.46]). Growth mixture modeling identified 2 GFAP subgroups: extreme prolonged (16%) and moderate transient (84%). For NfL, 3 subgroups were identified: extreme prolonged (7%), moderate prolonged (15%), and minimal or no change (78%). Individuals with SRC who reported loss of consciousness (LOC) (33% of SRC cases) had higher GFAP at 24 hours (MD, 1.01 [95% CI, 0.77-1.24]), 1 week (MD, 0.27 [95% CI, 0.06-0.49]), 2 weeks (MD, 0.21 [95% CI, 0.004-0.42]) and 4 weeks (MD, 0.34 [95% CI, 0.13-0.55]), and higher NfL from 1 week to 12 weeks (1-week MD, 0.73 [95% CI, 0.42-1.03]; 2-week MD, 0.91 [95% CI, 0.61-1.21]; 4-week MD, 0.90 [95% CI, 0.59-1.20]; 6-week MD, 0.81 [95% CI, 0.50-1.13]; 8-week MD, 0.73 [95% CI, 0.42-1.04]; and 12-week MD, 0.54 [95% CI, 0.22-0.85]) compared with SRC participants without LOC. Return to training times were longer in the GFAP extreme compared with moderate subgroup (incident rate ratio [IRR], 1.99 [95% CI, 1.69-2.34]; NfL extreme (IRR, 3.24 [95% CI, 2.63-3.97]) and moderate (IRR, 1.43 [95% CI, 1.18-1.72]) subgroups compared with the minimal subgroup, and for individuals with LOC compared with those without LOC (IRR, 1.65 [95% CI, 1.41-1.93]).

CONCLUSIONS AND RELEVANCE: In this cohort study, a subset of SRC cases, particularly those with LOC, showed heightened and prolonged increases in GFAP and NfL levels, that persisted for at least 4 weeks. These findings suggest that serial biomarker measurement could identify such cases, guiding return to play decisions based on neurobiologic recovery. While further investigation is warranted, the association between prolonged biomarker elevations and LOC may support the use of more conservative return to play timelines for athletes with this clinical feature.

PMID:38848061 | DOI:10.1001/jamanetworkopen.2024.15983

Clin Cancer Res. 2024 Jun 7. doi: 10.1158/1078-0432.CCR-24-0150. Online ahead of print.

ABSTRACT

PURPOSE: This study aimed to elucidate the impact of brain tumors on cerebral edema and glymphatic drainage, leveraging advanced imaging techniques to explore the relationship between tumor characteristics, glymphatic function, and aquaporin 4 (AQP4) expression.

EXPERIMENTAL DESIGN: In a prospective cohort from March 2022 to April 2023, patients with glioblastoma, brain metastases, and aggressive meningiomas, alongside age- and sex-matched healthy controls, underwent 3.0T MRI, including Diffusion Tensor Imaging Analysis Along the Perivascular Space (DTI-ALPS) index and Multiparametric MRI (MTP) for quantitative brain mapping. Tumor and peri-tumor tissues were analyzed for AQP4 expression via immunofluorescence. Correlations between imaging parameters, glymphatic function (DTI-ALPS index), and AQP4 expression were statistically assessed.

RESULTS: Among 84 patients (mean age: 55 ± 12 years; 38 males) and 59 controls (mean age: 54 ± 8 years; 23 males), brain tumor patients exhibited significantly reduced glymphatic function (DTI-ALPS index: 2.315 vs. 2.879; p = 0.001) and increased cerebrospinal fluid (CSF) volume (201.376 cm³ vs. 115.957 cm³; p = 0.001). A negative correlation was observed between tumor volume and the DTI-ALPS index (r: -0.715, p < 0.001), while AQP4 expression correlated positively with peritumoral brain edema (PTBE) volume (r: 0.989; p < 0.001) and negatively with PD in PTBE areas (ρ: -0.506; p < 0.001).

CONCLUSIONS: Our findings highlight the interplay between tumor-induced compression, glymphatic dysfunction, and altered fluid dynamics, showing the utility of DTI-ALPS and MTP in understanding the pathophysiology of tumor-related cerebral edema. These insights provide a radiological foundation for further neuro-oncological investigations into the glymphatic system.

PMID:38848042 | DOI:10.1158/1078-0432.CCR-24-0150

Drugs Aging. 2024 Jun 7. doi: 10.1007/s40266-024-01120-1. Online ahead of print.

ABSTRACT

BACKGROUND: Listing tools have been developed to improve medications in older patients, including the Fit fOR The Aged (FORTA) list, a clinically validated, positive-negative list of medication appropriateness. Here, we aim to validate MyFORTA, an automated tool for individualized application of the FORTA list.

METHODS: 331 participants of a multi-center cohort study (AgeCoDe) for whom the FORTA score (sum of overtreatment and undertreatment errors) had been determined manually (gold standard [GS]) were reassessed using the automated MyFORTA (MF) tool. This tool determines the score from ATC and ICD codes combined with clinical parameters.

RESULTS: The FORTA scores were 9.01 ± 2.91 (mean ± SD, MF) versus 6.02 ± 2.52 (GS) (p < 0.00001). Removing undertreatment errors for calcium/vitamin D (controversial guidelines) and influenza/pneumococcal vaccinations (no robust information in the database), the difference decreased: 7.5 ± 2.7 (MF) versus 5.98 ± 2.55 (GS) (p < 0.00001). The remaining difference was driven by, for example, missing nitro spray in coronary heart disease/acute coronary syndrome as the related information was rarely found in the database, but notoriously detected by MF. Three hundred and forty errors from those 100 patients with the largest score deviation accounted for 68% of excess errors by MF.

CONCLUSION: MF was more sensitive to detect medication errors than GS, all frequent errors only detected by MF were plausible, and almost no adaptations of the MF algorithm seem indicated. This automated tool to check medication appropriateness according to the FORTA list is now validated and represents the first clinically directed algorithm in this context. It should ease the application of FORTA and help to implement the proven beneficial effects of FORTA on clinical endpoints.

PMID:38848020 | DOI:10.1007/s40266-024-01120-1

J Autism Dev Disord. 2024 Jun 7. doi: 10.1007/s10803-024-06405-3. Online ahead of print.

ABSTRACT

The purpose of this study was to test the use of Pivotal Response Treatment (PRT) in the secondary school setting. There were two main goals: (a) to evaluate secondary education providers’ ability to implement PRT with fidelity following a PRT training program; and (b) to evaluate the effects of school-implemented PRT on the social communication skills of adolescents and young adults with ASD, specifically, question-asking behavior. This concurrent multiple baseline design study across dyads investigated the use of PRT in the secondary school setting with adolescents with ASD. Specifically, it examined the impact of PRT on question-asking behavior. Education providers (n = 3) were trained to implement PRT with a secondary student with ASD. All education providers improved in their ability to use PRT strategies, though struggled with fidelity. Two students exhibited clear effects with noteworthy improvement in their use of targeted question initiations. For targeted question initiations, the weighted value for the Tau-U phase contrast between aggregated baseline and intervention phases was 0.80 and statistically significant (p < .0001). PRT is a promising approach to increasing question-asking behavior in secondary students with ASD when implemented by a trained education provider. Continued research should be a matter of priority in order to expand social skills instruction for adolescents with ASD with the hope of ultimately making a positive difference in adult outcomes.

PMID:38848010 | DOI:10.1007/s10803-024-06405-3

J Interv Card Electrophysiol. 2024 Jun 7. doi: 10.1007/s10840-024-01831-w. Online ahead of print.

ABSTRACT

BACKGROUND: Catheter ablation is recognized as an effective treatment for atrial fibrillation (AF). Despite its effectiveness, significant sex-specific differences have been observed, which influence the outcomes of the procedure. This study explores these differences in a cohort of patients with persistent AF. We aim to assess sex differences in baseline characteristics, symptoms, quality of life, imaging findings, and response to catheter ablation in patients with persistent AF.

METHODS: This post hoc analysis of the DECAAF II trial evaluated 815 patients (161 females, 646 males). Between July 2016 and January 2020, participants were enrolled and randomly assigned to receive either personalized ablation targeting left atrial (LA) fibrosis using DE-MRI in conjunction with pulmonary vein isolation (PVI) or PVI alone. In this analysis, we aimed to compare female and male patients in the full cohort in terms of demographics, risk factors, medications, and outcomes such as AF recurrence, AF burden, LA volume reduction assessed by LGE-MRI before and 3 months after ablation, quality of life assessed by the SF-36 score, and safety outcomes. Statistical methods included t-tests, chi-square, and multivariable Cox regression.

RESULTS: Females were generally older with more comorbidities and experienced higher rates of arrhythmia recurrence post-ablation (53.3% vs. 40.2%, p < 0.01). Females also showed a higher AF burden (21% vs. 16%, p < 0.01) and a smaller reduction in left atrial volume indexed to body surface area post-ablation compared to male patients (8.36 (9.94) vs 11.35 (13.12), p-value 0.019). Quality of life scores were significantly worse in females both pre- and post-ablation (54 vs. 66 pre-ablation; 69 vs. 81 post-ablation, both p < 0.01), despite similar improvements across sexes. Safety outcomes and procedural parameters were similar between male and female patients.

CONCLUSION: The study highlights significant differences in the outcomes of catheter ablation of persistent AF between sexes, with female patients showing worse quality of life, higher recurrence of AF and AF burden after ablation, and worse LA remodeling.

PMID:38848006 | DOI:10.1007/s10840-024-01831-w

Musculoskelet Surg. 2024 Jun 7. doi: 10.1007/s12306-024-00840-2. Online ahead of print.

ABSTRACT

BACKGROUND: Major musculoskeletal oncology procedures often result in perioperative bleeding. This exposes patients to allogeneic red blood cell transfusion and its potential complications, thus increasing the risk of surgical wound infection and prolonged hospital stay. This study aimed to investigate the efficacy of oxidised cellulose, a topical haemostatic agent, in reducing postoperative blood loss and its subsequent risks.

METHODS: In this randomised controlled trial, 40 patients undergoing major musculoskeletal oncology procedures were assigned to control and intervention groups. Oxidised cellulose was inserted into the surgical wound after the resection’s conclusion before the wound’s closure to reduce postoperative bleeding for patients in the intervention group. Postoperative closed suction drain system (Redivac TM) volume, drop in haemoglobin level, allogeneic red blood cell transfusion rate, duration of surgery, and length of hospital stay were compared between the two groups.

RESULTS: The postoperative Redivac volume (Control: 432 MLS vs. Intervention: 431.75 MLS), drop in haemoglobin level (Control: 3.12 g/dL vs. Intervention: 3.06 g/dL), duration of surgery (Control: 134 vs. Intervention: 156 min), and allogeneic red blood cell transfusion were lower in the intervention group (Control: 204 MLS vs. Intervention: 170 MLS), but they were not statistically significant (p > 0.05) (Control: 134 vs. Intervention: 156 min). Mean hospital stay was similar in both groups (Control: 5.45 days vs. Intervention: 5.85 days).

CONCLUSION: Oxidised cellulose use does not significantly affect postoperative blood loss, the rate of allogeneic blood transfusion, and hospital stay. However, we believe its use contributes positively but not considerably towards lower postoperative blood loss in musculoskeletal oncology surgeries.

PMID:38848000 | DOI:10.1007/s12306-024-00840-2

Matern Child Health J. 2024 Jun 7. doi: 10.1007/s10995-024-03941-3. Online ahead of print.

ABSTRACT

OBJECTIVES: To assess the association between air pollution exposure and housing context during pregnancy and adverse birth outcomes.

METHODS: We linked air pollution data from the Environmental Protection Agency and housing data from the American Community Survey with birth records from Wisconsin counties over a 9-year period. We calculated average daily pregnancy exposure to fine particulate matter and ozone and modeled its relationship to preterm birth, low birthweight and NICU admission, adjusting for individual characteristics and housing context.

RESULTS: Ozone exposure and housing cost-burden had substantive and statistically significant negative associations with birthweight and gestational age, and positive associations with NICU admission, while a poor-quality housing environment had a significant negative effect on weeks of gestation. Fine particulate matter exposure had a negligible correlation with these outcomes.

CONCLUSIONS FOR PRACTICE: An additional tenth of one part-per-million daily average exposure to ozone is associated with a 33 g decrease in birthweight. This decrease in birthweight is about the same size as the association of gestational diabetes (32 g), larger than the association of chronic hypertension (22 g), and about 40% the size of the effect of smoking during pregnancy on birthweight (84 g). Given the magnitudes of the associations with atmospheric ozone and adverse birth outcomes, reducing atmospheric ozone should be a public health priority. Inclusion of controls for housing cost-burden and poor-quality housing reduces the magnitude of the association with mothers who identify as Black, suggesting the importance of these structural factors in understanding adverse birth outcomes by race.

PMID:38847990 | DOI:10.1007/s10995-024-03941-3

Mycopathologia. 2024 Jun 7;189(3):48. doi: 10.1007/s11046-024-00862-1.

ABSTRACT

The impact of invasive pulmonary aspergillosis (IPA) on non-neutropenic critically ill patients in intensive care units (ICU) has been demonstrated in recent decades. Furthermore, after the start of the COVID-19 pandemic, COVID-19 associated with pulmonary aspergillosis (CAPA) has become a major concern in ICUs. However, epidemiological data from different regions are scarce. We evaluated the prevalence and clinical-epidemiological data of IPA in patients with COVID-19 requiring mechanical ventilation (MV) in the ICU (“severe COVID-19”) and non-COVID ICU patients in MV of a tertiary hospital in the southern region of Brazil. Eighty-seven patients admitted between June 2020 and August 2022 were included; 31 with severe COVID-19. For the diagnosis of IPA or CAPA, algorithms including host factors and mycological criteria (positive culture for Aspergillus spp., immunoassay for galactomannan detection, and/or qPCR) were utilized. The overall incidence of IPA and CAPA in our ICU was 73 cases/1000 ICU hospitalizations. Aspergillosis occurred in 13% (4/31) of the COVID-19 patients, and in 16% (9/56) of the critically ill patients without COVID-19, with mortality rates of 75% (3/4) and 67% (6/9), respectively. Our results highlight the need for physicians enrolled in ICU care to be aware of aspergillosis and for more access of the patients to sensitive and robust diagnostic tests by biomarkers detection.

PMID:38847987 | DOI:10.1007/s11046-024-00862-1