3-level Model Research Articles

Hospital-Level Variation in COVID-19 Treatment Among Hospitalized Adults in the United States: A Retrospective Cohort Study.

Retrospective cohort study. To characterize variation in dexamethasone and remdesivir use over time among hospitals. Little is known about hospital-level variation in COVID-19 drug treatments in a large and diverse network in the United States. We selected individuals hospitalized with COVID-19 across 163 hospitals between February 23, 2020 and October 31, 2021 from using the HCA CHARGE, an electronic health record repository from a network of community health care facilities in the United States. We quantified receipt of dexamethasone, remdesivir, and combined use of dexamethasone and remdesivir during the hospital stay. We used 2-level logistic regression models to determine the intraclass correlation coefficient (ICC) at the hospital level, adjusting for patient and hospital characteristics. The ICC shows the proportion of total variation in drug use accounted for by hospitals. Among 161,667 individuals hospitalized with COVID-19, 73.0% were treated with dexamethasone, 49.1% with remdesivir, and 45.0% with both dexamethasone and remdesivir. The proportion of variation in dexamethasone use was 12.7% (adjusted ICC: 0.127), 8.5% for remdesivir, and 11.3% for combined drug use, indicating low interhospital variation. In the fully adjusted models, between-facility variation in dexamethasone use declined from 34.1% in February-March 2020 to 11.3% in January-March 2021 and then increased to 17.3% in July-October 2021. The variation in remdesivir use remained relatively stable during the study period. During the first 2 years of the pandemic, there was relatively consistent use of dexamethasone and remdesivir across the hospitals examined. Consistent adoption and implementation of treatment guidelines across the hospitals examined may have led to a decrease in variation in drug usage over time.

A systematic review and meta-analysis of cow-level factors affecting milk urea nitrogen and urinary nitrogen output under pasture-based diets

With dairy cattle farming under pressure to lower its environmental footprint it is important to find effective on-farm proxies for evaluation and monitoring of management practices aimed at reducing the risk of nitrogen (N) losses and optimizing N use efficiency of dairy farm systems. Urinary N (UN) is regarded as the most potent source of N emissions. In contrast to confinement systems, there have been few studies from pasture-based systems associating on-farm animal and nutritional factors with UN output. Thus, the aims of this meta-analysis were to collate a database from pasture-based research to: (a) investigate the associations of management, dietary, and animal variables with MUN concentration, and daily UN output; (b) describe the MUN-UN association; and (c) assess whether animal, management, and dietary factors influence the relationship. We developed a data set consisting of 95 observations representing 919 lactating dairy cattle fed pasture-based diets, which was compiled from 32 unique research publications that reported both MUN and UN output. Multi-level, mixed meta-analysis regression techniques were used to analyze the data. Initially, all variables were assessed as the sole fixed effect in a 2-level random effects model, accounting for within publication heterogeneity. Meta-regression techniques were then used to assess the relationship of all variables with MUN and UN output, respectively, accounting for 3 sources of variability: the sampling error of the individual observation, within publication heterogeneity, and among publication heterogeneity. At the univariable level, despite more than 10 dietary, animal, or management variables being significantly associated with MUN, none explained a large amount of the MUN variation. The variables that explained the greatest amount of variation were dietary crude protein (CP) content and the nitrogen: metabolizable energy content ratio, which explained about 33% and 31% of the variation in MUN concentrations, respectively. Combining factors in multiple regressions improved the model fit, such that the variation within publications explained by dietary CP and N intake increased to 40.0% in the final multiple meta-regression model. For UN output, individual variables explained a greater proportion of variance reported among observations, compared with MUN, whereby diet CP content (pseudo R2 = 66.1%), N to metabolizable energy intake ratio (pseudo R2 = 64.0%), N intake (pseudo R2 = 58.3%), and MUN (pseudo R2 = 43.5%) explained the greatest amount of the total variation. Milk urea nitrogen, N intake and dry matter intake were associated with UN output in the final multiple meta-regression model. Substantial heterogeneity existed in both MUN and UN among publications, with among publication heterogeneity accounting for 73.4% of all the variation noted in MUN, and 88.6% of all the variation in UN output. As such, the meta-analyses could not predict MUN and UN to any great extent. It is recommended that a consistent approach to measuring and reporting MUN concentrations and UN output is carried out for all future research in pasture-based systems.

Pooled analysis of the MANTICO2 and MONET randomized controlled trials comparing drug efficacy for early treatment of COVID-19 during Omicron waves

BackgroundThe clinical effectiveness of early therapies for mild-to-moderate COVID-19, comparing antivirals and monoclonal antibodies (mAbs) during the Omicron era, has not been conclusively assessed through a post-approval comparative trial. We present a pooled analysis of two randomized clinical trials conducted during Omicron waves. Methods The MANTICO2/MONET trial is a pooled analysis of two multicentric, independent, phase-4, three-arm, superiority, randomized, open-label trials. Nonhospitalized patients with early mild-to-moderate COVID-19 (≤5 days after symptoms’ onset) and at least one risk factor for disease progression were randomized 1:1:1 to receive 500mg of intravenous sotrovimab (SOT) or 600mg of intramuscular tixagevimab/cilgavimab (TGM/CGM) or oral 5-days course of nirmatrelvir/ritonavir (NMV/r) 300/100mg BID. Primary outcome was COVID-19-related hospitalization or death within 29 days after randomization. Fisher’s exact test for pooled data and incidence of failure was reported as overall and by arm with respective 95% CI.Pairwise comparisons across the arms were conducted using unadjusted exact logistic regression. An analysis by means of a doubly robust marginal model using augmented inverse probability weighting (AIPW) was also conducted to estimate the potential outcomes (Pom) in each treatment group and their difference by the average treatment effect (ATE). Analysis of symptom persistence within 30 days after randomization was performed using a 2-level hierarchical mixed-effects logistic model with a random intercept at the patient’s level. Point estimates and 95% confidence intervals were adjusted for age and sex and calculated using ANOVA-like methods for the mixedeffects logistic model. These trials are registred with the European Clinical Trials Database, EudraCT2021-002612-31 (MANTICO2) and EudraCT2021-004188-28 (MONET) and ClinicalTrials.gov, NCT05321394 (MANTICO2) Findings Between March 2022 and February 2023, 991 patients (SOT=332, TGM/CGM =327, NMV/r=332) were enrolled in 15 Italian centersThe overall mean age was 66 years; 482 participants (48.80%) were male and 856 vaccinated with at least a primary course ( 86%). Among the 8/991 hospitalizations observed, one resulted in death. The overall estimate of failure was 0.81% (95%CI; 0.35-1.58%). The odds ratio (OR) for the primary outcome in the NMV/r arm compared to the TGM/CGM and SOT arms was 8.41 (95% CI 1.21 to infinity; p=0.015) and 2.42 (95% CI 0.19 to infinity; p=0.499), respectively. No significant difference was observed between SOT and TGM/CGM (OR 0.32; 95% CI 0.032-1.83; p=0.174). Results were similar when we applied the marginal weighted model accounting for potential residual confounding bias. There was no evidence for a difference in the prevalence of symptoms between treatment groups, except for cough, which was higher in the SOT group compared to the other two groups at the 21-day follow-up (P=0.039) and a higher prevalence of nausea at the 7-day follow-up in the NMV/r group compared to the mAbs group (p=0.036). Interpretation NMV/r was superior to TGM/CGM in reducing hospital admission or death in clinical vulnerable patients with SARS-CoV-2 infection treated within 5 days of symptoms’ onset. No significant difference in symptom prevalence over time across the arms was found. Funding: The trials were funded by the Italian Agency of Drugs (AIFA) in 2021.

A field investigation of 3 masks proposed as respiratory protection for wildland firefighters: a randomized controlled trial in British Columbia, Canada.

Wildland firefighters are exposed through the lungs and skin to particulate matter, fumes, and vapors containing polycyclic aromatic hydrocarbons (PAH). Wearing respiratory protection should reduce pulmonary exposure, but there is uncertainty about the most effective and acceptable type of mask. Firefighters from 6 unit crews working with the British Columbia Wildfire Service were approached and those consenting were randomly allocated within each crew to a "no mask" control group or to use 1 of 3 types of masks: X, half-face respirator with P100/multi gas cartridge; Y, cloth with alpaca filter; Z mesh fabric with a carbon filter. Crews were followed for 3 consecutive firefighting days. The mask allocated was constant for each firefighter throughout. All participants completed a brief questionnaire at the start and end of each day, giving information on mask use, respiratory symptoms, and assessment of mask qualities. Spot urine samples were collected pre and post shift to assess 1-hydroxypyrene (1-HP) concentration as an indicator of total PAH absorption. Skin wipe samples from the hands and throat were collected pre and post shift and analyzed for PAH concentration. On each day monitored, 4 participants carried sampling pumps to measure total particulates and PAHs on particles and in vapor phase. The primary outcome was the concentration of urinary 1-HP at the end of the fire day. Secondary outcomes were changes in respiratory and eye symptoms during the course of the shift, reported mask use, and perception of mask qualities. The analysis used a 3-level random intercept regression model that clustered observations within individuals and crews. We aimed to detect any relation of allocated mask type to the 4 outcomes, having allowed for estimated exposure. Information was collected from 89 firefighters, including 14 women: 49% (37/75) of male firefighters were bearded. Nineteen fire days were monitored for a total of 263 firefighter × days, 64 to 68 for each intervention group. The end of shift 1-HP was higher than the start of the shift. Urinary 1-HP was more strongly related to PAHs on the skin than in the breathing zone. Men with beards had higher end-of-shift urinary log 1-HP/creat (ng/g) than other firefighters. None of the groups allocated a mask had lower 1-HP than the no-mask group, either in the study group overall or when stratified by beard-wearing. Among those without either beards or a failed fit-test, Mask Z reduced at the end of shift 1-HP where airborne PAH concentration was high. End-of-shift symptoms were related to particle mass in the breathing zone but was not mitigated by any of the masks. Hours electing not to wear a mask increased from the first to third shift for all mask types. Mask Z was rated as more comfortable than other types. Mask X was rated highest on fit and perceived protection. Mask Y gained the lowest ratings on fit, comfort and feelings of protection. Allocated masks did not provide protection overall, but the results highlighted the need for a wider understanding of the circumstances in which wearing efficient protection is well-advised.

Factorial Optimization of CoCuFe-LDH/Graphene Ternary Composites as Electrocatalysts for Water Splitting.

The layered double hydroxides (LDHs) have demonstrated significant potential as non-noble-metal electrocatalysts for the hydrogen evolution reaction (HER) and oxygen evolution reaction (OER). Their unique compositional and structural properties contribute to their efficiency and stability as catalysts. In this study, CoCuFe-LDH composites were grown on graphene (G) via a cost-effective and straightforward one-step hydrothermal process. A 2-level full-factorial model was employed to determine the impact of Co (1.5, 3, and 4.5 mmol) and graphene (10, 30, and 50 mg) concentrations on the onset potential of OER and HER, which were the chosen response variables. OER and HER activity variabilities were assessed in triplicate using Co[3]Cu[3]Fe[3]-LDH/G[30] (central point), which were determined at 0.01% and 0.02%, respectively. Statistical analyses demonstrated that Co[4.5]Cu[3]Fe[3]-LDH/G[10] and Co[1.5]Cu[3]Fe[3]-LDH/G[10] showed the lowest onset potential at 1.52 V and -0.32 V (V vs RHE) for the OER and HER, respectively, suggesting that a high cobalt concentration enhances OER performance, while optimal HER catalysis was achieved with lower cobalt concentrations. Moreover, the trimetallic composites exhibited good stability with negligible loss of catalytic activity over 24 h.

Shifting Grounds-Facilitating Self-Care in Testing for Sexually Transmitted Infections Through the Use of Self-Test Technology: Qualitative Study.

Chlamydia remains prevalent worldwide and is considered a global public health problem. However, testing rates among young sexually active people remain low. Effective clinical management relies on screening asymptomatic patients. However, attending face-to-face consultations of testing for sexually transmitted infections is associated with stigmatization and anxiety. Self-testing technology (STT) allows patients to test themselves for chlamydia and gonorrhea without the presence of health care professionals. This may result in wider access to testing and increase testing uptake. Therefore, the sexual health clinic at Odense University Hospital has designed and developed a technology that allows patients to get tested at the clinic through self-collected sampling without a face-to-face consultation. This study aimed to (1) pilot-test STT used in clinical practice and (2) investigate the experiences of patients who have completed a self-test for chlamydia and gonorrhea. The study was conducted as a qualitative study inspired by the methodology of participatory design. Ethnographic methods were applied in the feasibility study and the data analyzed were inspired by the action research spiral in iterative processes using steps, such as plan, act, observe, and reflect. The qualitative evaluation study used semistructured interviews and data were analyzed using a qualitative 3-level analytical model. The findings from the feasibility study, such as lack of signposting and adequate information, led to the final modifications of the self-test technology and made it possible to implement it in clinical practice. The qualitative evaluation study found that self-testing was seen as more appealing than testing at a face-to-face consultation because it was an easy solution that both saved time and allowed for the freedom to plan the visit independently. Security was experienced when the instructions balanced between being detail-oriented while also being simple and illustrative. The anonymity and discretion contributed to preserving privacy and removed the fear of an awkward conversation or being judged by health care professionals thus leading to the reduction of intrusive feelings. Accessible health care services are crucial in preventing and reducing the impact of sexually transmitted infections and STT may have the potential to increase testing uptake as it takes into account some of the barriers that exist. The pilot test and evaluation have resulted in a fully functioning implementation of STT in clinical practice.

Religiosity and Spirituality Development: An Accelerated Longitudinal Design.

The central aim of the present study was to model developmental trends in communal and independent religious practices, spirituality, positive and negative religious/spiritual coping, as well as their confluence, across ages 45-80. Participants derived from the Notre Dame Study of Health & Well-being (NDHWB), a longitudinal study spanning 10 years in an age-heterogeneous sample. Using 2-level multilevel models, we estimated no change, linear change, quadratic change, and cubic change functions across ages 45-80 in each construct. Cohort differences were also tested. Communal and independent practices, spirituality, negative religious/spiritual coping, as well as composite religiosity/spirituality, followed cubic trajectories across mid- to later life. Communal religious practices peaked twice: once at 45 and again around age 70. Independent practices, in contrast, peaked at age 45 and then declined in a stage-like manner until age 80. Spirituality reached its nadir around age 50 and peaked in the early 70s; the reverse was true for negative religious/spiritual coping. The change trajectory in composite religiosity/spirituality most resembled that of independent religious practices. Finally, positive religious/spiritual coping followed a linear trajectory, but a cohort difference precluded its interpretation as developmental change. Individuals appear to engage with their faith in different ways as they age, meaning extant conclusions about age-related differences and change in global religiosity/spirituality may be distorted.

Using the Preparation Phase of the Multiphase Optimization Strategy to Design an Antiextremism Program in Bahrain: Formative and Pilot Research.

Extremism continues to raise concerns about conflict and violent attacks that can lead to deaths, injuries, trauma, and stress. Adolescents are especially vulnerable to radicalization by extremists. Given its location in a region that often experiences extremism, Bahrain developed 4 peaceful coexistence lessons and 4 antiextremism lessons to be implemented as part of their Drug Abuse Resistance Education (D.A.R.E.) program. The aim of this study is to report the results of the preparation phase of the multiphase optimization strategy (MOST) to develop a peaceful coexistence program and an antiextremism program implemented by D.A.R.E. officers in Bahrain. We developed conceptual models for the peaceful coexistence and antiextremism programs, indicating which mediators each lesson should target, the proximal outcomes that should be shaped by these mediators, and the distal and ultimate outcomes that the intervention should change. We recruited 20 middle schools to pilot test our research protocol, survey measures, and the existing intervention lessons. A total of 854 seventh and ninth grade students completed a pretest survey, 4 peaceful coexistence intervention lessons, and an immediate posttest survey; and a total of 495 ninth grade students completed the pretest survey, 4 antiextremism lessons, and an immediate posttest survey. A series of 3-level models, nesting students within classrooms within schools, tested mean differences from pretest to posttest. Pilot test results indicated that most measures had adequate reliability and provided promising evidence that the existing lessons could change some of the targeted mediators and proximal outcomes. Specifically, students who completed the peaceful coexistence lessons reported significant changes in 5 targeted mediating variables (eg, injunctive norms about intolerance, P<.001) and 3 proximal outcomes [eg, social skills empathy (P=.008); tolerance beliefs (P=.041)]. Students who completed the antiextremism lessons reported significant changes in 3 targeted mediators [eg, self-efficacy to use resistance skills themselves (P<.001)], and 1 proximal outcome (ie, social skills empathy, P<.001). An effective antiextremism program has the potential to protect youth from radicalization and increase peaceful coexistence. We used the preparation phase of MOST to (1) develop a conceptual model, (2) identify the 4 lessons in each program as the components we will evaluate in the optimization phase of MOST, (3) pilot test the existing lessons, our newly developed measures, and research protocol, and (4) determine that our optimization objective will be all effective components. We will use these results to revise the existing lessons and conduct optimization trials to evaluate the efficacy of the individual lessons.

Center-level variation in hospitalization costs of pancreaticoduodenectomy for pancreatic cancer

BackgroundPancreaticoduodenectomy is a highly morbid operation with significant resource utilization. Using a national cohort, we examined the interhospital variation in pancreaticoduodenectomy hospitalization cost in the United States. MethodsAdults undergoing elective pancreaticoduodenectomy in the setting of pancreatic cancer were tabulated from the 2016–2020 Nationwide Readmissions Database. A 2-level mixed-effects model was developed to evaluate the interhospital variation in pancreaticoduodenectomy hospitalization costs. Institutions within the top decile of risk-adjusted expenditures were defined as high-cost hospitals. Multivariable regression models were fitted to examine the association between high-cost hospital status and outcomes of interest. To account for the effects of complications on expenditures, a subgroup analysis comprising of patients with no adverse events was conducted. ResultsThe study included an estimated 24,779 patients with a median hospitalization cost of $38,800. After mixed-effects modeling, 40.9% of the cost variation was attributable to hospital, rather than patient, factors. Multivariable regression models revealed an association between high-cost hospital status and greater odds of complications and longer length of stay. Among patients without an adverse event, interhospital cost variation remained significant at 61.0%, and treatment at high-cost hospitals was similarly linked to longer length of stay. ConclusionOur study identified significant interhospital variation in pancreaticoduodenectomy hospitalization costs in the United States. Although high-cost hospital status was associated with increased odds of complications, variation remained significant even among patients without an adverse event. These results suggest the important role of hospital practices as contributors to expenditures. Further efforts to identify drivers of costs and standardize pancreatic surgical care are warranted.

(116) SUBJECTIVE AND GENITAL SEXUAL RESPONSE IN FEMALE BREAST CANCER SURVIVORS: RESULTS FROM A PSYCHOPHYSIOLOGY STUDY

Abstract Introduction Sexual dysfunction is a prevalent concern affecting more than 70% of female breast cancer survivors, casting a substantial shadow on their quality of life. Beyond the physical impact of cancer and its treatments, the emotional and psychological toll of sexual dysfunction introduces additional challenges, amplifying stress levels and undermining overall well-being. Acknowledging the profound implications of sexual dysfunction in this group and the absence of therapies, there is an urgent need to delve deeper into the intricacies of its manifestations. Objective This study aimed to gather preliminary data on psychophysiological aspects of sexual function in premenopausal breast cancer patients undergoing antihormonal therapy and compare them with a healthy control group. Exploring sexual arousal in breast cancer patients may unveil potential targets for innovative treatment strategies to address sexual dysfunction in this population. Methods Participants were prescreened during a telephone interview. We included 40 premenopausal breast cancer survivors with an age range of 29 to 57 years (M = 43.5, SD = 6.36) on current hormonal treatment and 20 healthy controls with an age range of 22 to 35 (M = 27.55, SD = 3.19). Physiological measures (VPA and HRV), subjective sexual arousal (SSA) and self-reported orgasm were assessed in response to audiovisual stimuli and vibrotactile clitoral stimulation sexual stimuli in breast cancer survivors and healthy controls. Self-reported measures like the Female Sexual Function Index (FSFI), the Sexual Self-Esteem Inventory (SSEI) und the PROMIS29 were incorporated. Data were analyzed using 2-level mixed effect models. Results No significant differences in VPA scores were observed between healthy controls and breast cancer survivors. Both groups exhibited a greater genital response to clitoral vibrator use than to visual stimuli. Group differences emerged in SSA and HRV, with higher SSA and lower HRV being detected. Breast cancer survivors climaxed less frequently than healthy controls and had significantly lower self-reported sexual function. Conclusions Physiological measures of arousal in breast cancer survivors were comparable to healthy controls and only subjective arousal differed. This finding indicates that subjective arousal should be further explored as the focus of intervention and treatment methods for breast cancer patients experiencing sexual dysfunction. Our findings underscore the importance of tailored strategies that resonate with individual narratives, acknowledging the emotional intricacies of post-cancer sexual well-being. This study not only contributes to scientific knowledge but also calls for a compassionate and personalized treatment paradigm, enriching the landscape of survivorship care. Disclosure Yes, this is sponsored by industry/sponsor: WOW Tech GmbH Clarification: No industry support in study design or execution.

Gestational age-specific reference intervals for androgens in pregnancy.

Androgen could impact cervical remodelling during pregnancy, and a higher level is associated with adverse pregnancy outcomes. A population-based gestation age-specific reference interval (RI) of total testosterone (TT), androstenedione (A4), and 17-hydroxyprogesterone (17-OHP) can help to diagnose maternal hyperandrogenism. We enrolled 600 healthy Chinese women to obtain longitudinal serum samples across gestation. The serum androgen profile was measured by liquid chromatography-tandem mass spectrometry. The equations for medians of TT, A4, and 17-OHP were generated by MedCal, and the variances adjusted for 2-level modeling were generated by MLwiN, a system for the specification and analysis of a range of multilevel models. A4 and TT levels increased across the gestation, and they closely correlated with each other (R = 0.90, P=<0.001), whereas 17-OHP level decreased from 5th gestational week to 16th gestational week and then increased afterward towards the end of pregnancy. Women diagnosed with preeclampsia (PE) were found to have a significantly higher level of A4, TT, and 17-OHP when compared with non-PE cases with p ≤0.01, whereas mothers carrying male versus female fetuses have comparable levels of A4, TT, and 17-OHP. The study highlights a methodology for constructing gestational age-specific TT, A4, and 17-OHP levels to provide a better interpretation of results in a cohort of healthy Chinese women. The observation in PE supports previous findings, and the higher levels of TT, A4, and 17-OHP were observed before the onset of PE.

Incomplete tuberculosis reporting and registration to the surveillance system in southwestern China of Yunnan Province: an inventory survey

BackgroundThe real-world tuberculosis (TB) surveillance data was generally incomplete due to underreporting and underdiagnosis. The inventory study aimed to assess and quantify the incompletion of surveillance systems in southwestern China.MethodsThe inventory study was conducted at randomly selected health facilities (HF) by multi-stage stratified cluster sampling. The participants were included in the period between August of 2020 in province-level and prefecture-level HF, and in the period between June to December of 2020 in other categories of HF respectively. The clinical committee confirmed medical records were matched to the National Notifiable Disease Reporting System (NNDRS) and the Tuberculosis Information Management System (TBIMS) to define the report and register status. The underreporting and under-register rates were evaluated based on the matched data, and factors associated with underreport and under-register were assessed by the 2-level logistic multilevel model (MLM).ResultsWe enrolled 7,749 confirmed TB cases in the analysis. The province representative overall underreport rate to NNDRS was 1.6% (95% confidence interval, 95% CI, 1.3 − 1.9), and the overall under-register rate to TBIMS was 9.6% (95% CI, 8.9–10.3). The various underreport and under-register rates were displayed in different stratifications of background TB disease burden, HF level, HF category, and data source of the medical record in HF among prefectures of the province. The intraclass correlation coefficient (ICC) was 0.57 for the underreporting null MLM, indicating the facility-level cluster effect contributes a great share of variation in total variance. The two-level logistic MLM showed the data source of medical records in HF, diagnostic category of TB, and type of TB were associated with underreporting by adjusting other factors (p < 0.05). The ICC for under-register was 0.42, and the HF level, HF category, data source of medical records in HF, diagnostic category of TB and type of TB were associated with under-register by adjusting other factors (p < 0.05).ConclusionThe inventory study depicted incomplete TB reporting and registering to NNDRS and TBIMS in southwestern China. It implied that surveillance quality improvement would help advance the TB prevention and control strategy.

The Distribution of Risk Across Healthcare Providers and Reducing Misclassification

Four linear multilevel mixed-risk models were compared using model assumption tests and predictions. Models varied by the number of random intercepts from 1 to 4, producing 2-level through 5-level models of the same measure, operative time. Normality of the dependent variable and residuals, variance homoscedasticity, level-1, and level-2 exogeneity were tested using the robust test of the level-1 residuals variance by surgeon, estimates of density, skew, and the Hausman test. Measure (operative time by hospital and surgeon) aberrancy and risk classification were evaluated using traditional methods and used to assess distribution measures. The dependent variable and the level-1 residuals required transformation for linearity and variance stabilization, respectively. Normality criteria were met for both level-1 and level-2 residuals and standardized residuals. The likelihood ratio comparing the four models was significantly larger for the 5-level (1016.1; P&amp;lt;0.00005) model than the likelihood ratio for the four-level and other models. Shrinkage was greatest for the 2-level model (0.039; P&amp;lt;0.00005) and least for the 5-level model (0.028; P&amp;lt;0.00005). Level-1 variance homoscedasticity was confirmed by the robust variance test across all models (P&amp;gt;F=1). Aberrant value detection did not require the exclusion of any observations, while prediction intervals revealed low or high risk for 54.2% of surgeons for the 2-level model and 8.6% for the 5-level model. The traditional (c2 = -11.01; P=1) and instrumental variable (c2 = 21.06; P=1) Hausman tests show that the null hypothesis cannot be rejected for level-1 or level-2 exogeneity. Once level-1 and level-2 exogeneity was confirmed, and since deconfounding was a model consideration, causal inferential capacity was assumed. The likelihood ratio, residual variance, shrinkage, and predictions show that the 5-level model is preferred to the other models.

Regional Inequalities in Oral Frailty and Social Capital.

Oral frailty leads to poor nutritional status, which, in turn, leads to frailty. This cross-sectional study aimed to determine regional differences in the prevalence of oral frailty and to identify factors associated with oral frailty using 3-level multilevel models. This study comprised 165,164 participants aged ≥65 y without long-term care requirements in the Japan Gerontological Evaluation Study. The dependent variable was oral frailty, which was calculated based on age, number of teeth, difficulty in eating tough foods, and choking. The individual-level independent variables included sociodemographics, present illness, social participation, frequency of meeting friends, and social capital. The local district-level independent variable was social capital (n = 1,008) derived from exploratory factor analyses. The municipality-level independent variable was population density (n = 62). Three-level multilevel Poisson regression analysis was performed to calculate the prevalence ratios (PRs). The prevalence of oral frailty in municipalities ranged from 39.9% to 77.6%. Regarding district-level factors, higher civic participation was significantly associated with a lower probability of oral frailty. At the municipality level, the PR of the rural-agricultural area was 1.17 (95% confidence interval, 1.11-1.23) (reference: metropolitan). These results highlight the usefulness of oral frailty prevention measures in encouraging social participation in rural areas. The results of the present study showed regional differences in oral frailty. In particular, rural-agricultural areas show higher prevalence rates of oral frailty than those in metropolitan cities. Promoting measures of social participation among older adults may help prevent oral frailty in rural areas.

Temporal Proximity Matters: The Impact of Justice Information Timing on Psychological Contract Breach Resolution

Although scholars and practitioners argue that organizations should provide justice information in the aftermath of a psychological contract breach (PC breach) to prevent or reduce violation feelings, it remains unclear whether that information should be provided within a few hours, days, or weeks following a PC breach. We estimated a 2-level time-lagged regression model on experience sampling data from 76 (226 observations), 70 (213 observations), and 70 (344 observations) employees with different intervals to test the durability of informational justice as a moderator on the PC breach-violation feelings relationship. We found that justice information should be provided in close temporal proximity (i.e., within the same day; Study 1) of PC breach to reduce violation feelings. In contrast, neither justice information provided the day (Study 2) or week (Study 3) after a PC breach successfully moderated the PC breach-violation feelings relationship. The current paper underscores the importance of being informationally just in close temporal proximity to a PC breach in line with resolution velocity as an indicator of the effectiveness of the recovery process. We discuss theoretical and practical implications of these findings.

Validity of Using the Load-Velocity Relationship to Estimate 1 Repetition Maximum in the Back Squat Exercise: A Systematic Review and Meta-Analysis.

LeMense, AT, Malone, GT, Kinderman, MA, Fedewa, MV, and Winchester, LJ. Validity of using the load-velocity relationship to estimate 1 repetition maximum in the back squat exercise: a systematic review and meta-analysis. J Strength Cond Res 38(3): 612-619, 2024-The one repetition maximum (1RM) test is commonly used to assess muscular strength. However, 1RM testing can be time consuming, physically taxing, and may be difficult to perform in athletics team settings with practice and competition schedules. Alternatively, 1RM can be estimated from bar or movement velocity at submaximal loads using the minimum velocity threshold (MVT) method based on the load-velocity relationship. Despite its potential utility, this method's validity has yielded inconsistent results. The purpose of this systematic review and meta-analysis was to assess the validity of estimated 1RM from bar velocity in the back squat exercise. A systematic search of 3 electronic databases was conducted using combinations of the following keywords: "velocity-based training," "load-velocity profiling," "mean velocity," "mean propulsive velocity," "peak velocity," "maximal strength," "1RM," "estimation," "prediction," "back squat," and "regression." The search identified 372 unique articles, with 4 studies included in the final analysis. Significance was defined as a p level less than 0.05. A total of 27 effects from 71 subjects between the ages of 17-25 years were analyzed; 85.2% of effects were obtained from male subjects. Measured 1RMs ranged from 86.5 to 153.1 kg, whereas estimated 1RMs ranged from 88.6 to 171.6 kg. Using a 3-level random effects model, 1RM back squat was overestimated when derived from bar velocity using the MVT method (effect sizes [ES] = 0.5304, 95% CI: 0.1878-0.8730, p = 0.0038). The MVT method is not a viable option for estimating 1RM in the free weight back squat. Strength and conditioning professionals should exercise caution when estimating 1RM from the load-velocity relationship.

The Reexamination of the Moisture–Vortex and Baroclinic Instabilities in the South Asian Monsoon

Observational analyses reveal that a dominant mode in the South Asian Monsoon region in boreal summer is a westward-propagating synoptic-scale disturbance with a typical wavelength of 4000 km that is coupled with moistening and precipitation processes. The disturbances exhibit an eastward tilt during their development before reaching their maximum activity center. A 2.5-layer model that extends a classic 2-level quasi-geostrophic model by including a prognostic lower-tropospheric moisture tendency equation and an interactive planetary boundary layer was constructed. The eigenvalue analysis of this model shows that the most unstable mode has a preferred zonal wavelength of 4000 km, a westward phase speed of 6 m s−1, an eastward tilt vertical structure, and a westward shift of maximum moisture/precipitation center relative to the lower-tropospheric vorticity center, all of which agree with the observations. Sensitivity experiments show that the moisture–vortex instability determines, to a large extent, the growth rate, while the baroclinic instability helps set up the preferred zonal scale. Ekman-pumping-induced vertical moisture advection prompts an in-phase component of perturbation moisture relative to the low-level cyclonic center, allowing the generation of available potential energy and perturbation growth, regardless of whether or not a low-level mean westerly is presented. In contrast to a previous study, the growth rate is reversely proportional to the convective adjustment time. The current work sheds light on understanding the moisture–vortex and the baroclinic instability in a monsoonal environment with a pronounced easterly vertical shear.

Factors and Their Impact on Treatment Effect of Acupuncture in Different Outcomes: A Meta-Regression of Acupuncture Randomized Controlled Trials.

The effects of acupuncture have varied in different randomized controlled trials (RCTs), and there are many factors that influence treatment effect of acupuncture in different outcomes, with conflicting results. To identify factors and their impact on the treatment effect of acupuncture in different outcomes. Acupuncture RCTs were searched from 7 databases including Medline (PubMed), Embase, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, Wanfang Database, VIP Database, and China Biology Medicine disc between January 1st, 2015 and December 31st, 2019. Eligible studies must compare acupuncture to no acupuncture, sham acupuncture, or waiting lists, and report at least 1 patient-important outcome. A multi-level meta-regression was conducted using a 3-level robust mixed model and univariate analyses were performed for all independent variables, even those excluded from the multivariable model due to collinearities. We used thresholds of 0.2 and 0.4 for the difference of standardized mean differences (SMDs), categorising them as small (<0.2), moderate (0.2-0.4), or large (>0.4) effects. The pain construct analysis involved 211 effect estimates from 153 studies and 14 independent variables. High-frequency acupuncture treatment sessions produced larger effects compared to low-frequency sessions [large magnitude, the difference of adjusted SMDs 0.46, 95% confidence interval (CI) 0.07 to 0.84; P=0.02]. The non-pain symptoms construct analysis comprised 323 effect estimates from 231 studies and 15 independent variables. Penetrating acupuncture showed moderately larger effects when compared to non-penetrating acupuncture (0.30, 95% CI 0.06 to 0.53; P=0.01). The function construct analysis included 495 effect estimates from 274 studies and 14 independent variables. Penetrating acupuncture and the flexible acupuncture regimen showed moderately larger effects, compared to non-penetrating acupuncture and fixed regimen, respectively (0.40, 95% CI 0 to 0.80; P=0.05; 0.29, 95% CI 0.06 to 0.53; P=0.01). High-frequency acupuncture sessions appear to be a more effective approach to managing painful symptoms. Penetrating acupuncture demonstrated greater effect in relieving non-painful symptoms. Both penetrating acupuncture type and flexible acupuncture regimen were linked to significant treatment effects in function outcomes. Future studies should consider the factors that are significantly associated with the effects of acupuncture in patient-important outcomes.

Socio-economic, demographic, and contextual predictors of malnutrition among children aged 6-59 months in Nigeria.

Malnutrition has remained a global public health issue, particularly in low- and middle-income countries (LMICs). Researchers have committed to studying malnutrition (especially in children under the age of five) to address the nine malnutrition targets, set by the WHO to be achieved by 2025. This study seeks to evaluate the prevalence, the individual and contextual predictors of malnutrition among children aged 6-59 months across Nigeria and its states. Two separates, independently collected, nationally representative cross-sectional surveys, the National Human Development Report (NHDR 2018) and the 2018 Nigeria Demographic and Health Survey (2018 NDHS) were linked for this study. Spatial map was used to describe the prevalence of malnutrition, a 3-level multivariate multilevel logistic regression models were fitted where children/individuals (at level 1) were nested in communities/clusters (at level 2) and nested in states (at level 3). A weighted sample of 7,770 children 6-59 months were considered in this study. The results showed that an estimated 43.6% of children aged 6-59 months are poorly nourished in Nigeria. The proportions of poorly nourished children were generally highest in the Northern Nigeria. Child's gender, age, birth size, preceding birth order, anaemia status, maternal education, work status, body weight, household wealth status, number of bedrooms were among individual/household predictors of malnutrition. On the community level, being from community with high wealth index, distance to nearest health facilities is no big problem. Regional variations and gender inequality index were the state level predictors of malnutrition among children in Nigeria. This study has shown that two-third of children aged 6-59 months in Nigeria were poorly nourished, an indication of a growing concern of double burden of malnutrition in Nigeria.

Fabrication of Phytosome with Enhanced Activity of Sonneratia alba: Formulation Modeling and in vivo Antimalarial Study.

Sonneratia alba extract exhibits antimalarial activity, mainly due to its secondary metabolites-naphthoquinones, flavonoids, tannins, and saponins-where naphthoquinone is the primary active component. However, its low bioavailability limits its effectiveness. To improve this, a phytosome-based vesicular system was proposed. This study focused on formulating a phytosome with S. alba and developing a predictive model to enhance its antimalarial activity. Phytosomes were produced using antisolvent precipitation and optimized with 3-factor, 3-level Box-behnken model. Particle size, zeta potential, and entrapment efficiency were assessed. The optimized phytosomes were characterized by their physical properties and release profiles. Their antimalarial activity was tested in white BALB/c mice infected with Plasmodium berghei using Peter's 4-day suppressive test. The optimal phytosome formulation used a phospholipid-to-extract ratio of 1:3, reflux temperature of 50°C, and a duration of 2.62 hours. The phytosomes had a particle size of 471.8 nm, a zeta potential of -54.1 mV, and an entrapment efficiency (EE) of 82.4%. In contrast, the phytosome-fraction showed a particle size of 233.4 nm, a zeta potential of -61.5 mV, and an EE of 87.08%. TEM analysis confirmed both had a spherical shape. In vitro release rates at 24 hours were 86.2 for the phytosome-extract and 95.9% for the phytosome-fraction, compared to 46.9% and 37.7% for the extract and fraction alone. Overall, the phytosome formulation demonstrated good stability. The actual experimental values closely matched the predicted values from the Box-Behnken model, indicating a high degree of accuracy in the model. Additionally, the phytosomes exhibited significantly greater antimalarial activity than the S. alba extract and fraction alone. The findings indicated that the vesicular formulation in phytosomes can enhance the antimalarial activity of S. alba extract and fraction.