Cochran-Armitage Test Research Articles

The survey of bone allograft transplantation in a Japanese regional bone bank

BackgroundIn reconstructive surgery for large bone defects, the demand for bone allografts has increased over the years; however, it is unclear how the supply and demand in Japanese regional bone banks have evolved over time. This study investigated the 15-year supply and demand of bone allografts stored in a regional bone bank, along with assessing the screening process's effectiveness. MethodsThe target period was 15 years from April 2005 to March 2020. The period was subdivided into three 5-year periods: first, second, and third. The study items included the number of bone allografts donated, the number of bone allografts used, donor and user facilities, surgical methods using bone allografts, and the number of bone allografts discarded. We used the Cochran-Armitage test for statistical analysis. ResultsA total of 1852 bone allografts were donated to the bone bank, and a total of 1721 were used. A total of 677 bone allografts grafts were provided in the first period, 738 in the second period, and 525 in the third period, indicating a decreasing trend. The average number of allografts per surgery was 2.8 in the first, 3.1 in the second, and 1.7 in the third, showing a decreasing trend. Concerning the percentage of each surgery using bone allografts, spine fusion decreased in the third period but not significantly, whereas primary hip arthroplasty increased significantly in the third period. The total number of discarded bone allografts was 4.8% of the total number of donated bone allografts, largely because of a lack of screening tests. ConclusionAlthough the number of allogeneic bone surgeries has been increasing over time, the number of allogeneic bone donations has shown a decreasing trend, and there is a need to develop a system that can provide surgeons with sufficient bone allografts.

Temporal trends of clinical outcomes in patients hospitalized with acute pericarditis: analysis of the nationwide database in Japan

Abstract Background Most patients with acute pericarditis are considered to have a good prognosis, but the short-term outcomes and whether they improve or worsen over time are unknown in large clinical databases. Purpose We sought to investigate in-hospital mortality and incidence of cardiac tamponade in patients hospitalized for acute pericarditis in Japan, as well as trends over time in these outcomes. Methods From the Japanese Registry of All Cardiac and Vascular Diseases database from 2016 to 2020, we analyzed 7,374 patients hospitalized for acute pericarditis at 871 certificated hospitals by Japanese Circulation Society. We included etiology of acute pericarditis by idiopathic, connective-tissue disease, and post-cardiac injury syndrome. The primary and secondary outcome was in-hospital mortality and incidence of cardiac tamponade, respectively. Cochran-Armitage test was performed. Results In Japanese acute pericarditis patients (mean age; 65.0 years, male 71.0%), the etiology was idiopathic 96.2%, connective-tissue disease 2.1%, and post-cardiac injury syndrome 1.7%. The mortality rate and incidence of cardiac tamponade were 2.2% and 5.3%, respectively. Secular trend in those rates remained unchanged over time (p-trend = 0.30 and 0.19). The rates of mortality and cardiac tamponade were 2.1% and 5.2% in idiopathic pericarditis, 1.3% and 10.5% in connective-tissue disease, and 7.0% and 3.9% in post-cardiac injury syndrome, respectively. Connective-tissue disease pericarditis was at higher risk of cardiac tamponade compared to idiopathic pericarditis (5.2 vs. 10.5%, P=0.004). In addition, compared to idiopathic pericarditis, postoperative cardiac pericarditis tended to have a higher mortality rate (2.1 vs. 7.0%, P<0.001). Conclusion The short-term prognosis of acute pericarditis did not change significantly over time. This finding that clinical outcomes differed depending on the underlying disease suggests to clinicians the importance of differential diagnosis.

Impact of the number of citizens officially certified for government-organized civilian cardiopulmonary resuscitation courses on the prognosis for patients with out-of-hospital cardiac arrest in Japan

Abstract Background To improve the prognosis of patients with out-of-hospital cardiac arrest (OHCA), the rate of high-quality cardiopulmonary resuscitation (CPR) and immediate use of automated external defibrillators (AEDs) by citizens must be further increased. Japanese government launched certified CPR courses for citizens throughout Japan in 1994 and the number of citizens certified on the course is increasing. However, the impact of the number of citizens officially certified for the courses on the rate of CPR implementation by citizens and the outcomes in patients with OHCA is unclear. Methods From a prospective, nationwide, population-based registry of patients with OHCA in Japan, we identified 350,444 patients from 2005 through 2020 with bystander-witnessed OHCA with 72,069 ventricular-fibrillation (VF) and the other non-VF cardiac arrests. The association between the number of citizens certified for the CPR courses and the rate of CPR implementation by citizens throughout Japan was analyzed by Poisson distribution and Cochran–Armitage test for trend. The primary outcome was survival at 1 month. The secondary outcomes were favorable neurologic outcome at 1 month. The associations between the CPR attempted by citizens [categorized into three (chest-compression-only CPR, chest compression with rescue breathing, and use of AEDs with chest compression and rescue breathing)] and outcomes were determined by multivariable mixed logistic regression analyses. Results Cumulative number of citizens certified for the CPR courses increased from 717,808 in 2005 to 34,938,322 in 2020, which reached to 27.8% of total Japanese population. Annual course receivers were also linearly increased during the period (Incidence Rate Ratios 1.03, p<0.001). Similarly, the rate of patients receiving CPR by citizens increased linearly from 40.6% in 2005 to 56.8% in 2020 (P for trend<0.001). In the multivariable mixed logistic regression analyses, higher CPR activity by citizens were significantly associated with better 1-year survival in both VF and non-VF patients even after adjusted for covariates [VF = chest compression: odds ratio (OR) 1.17; 95% confidence interval (CI) 0.98–1.39; P =0.078; chest compression with rescue breathing: OR 1.22; 95% CI 1.02–1.49; P =0.030; use of AEDs with chest compression and rescue breathing: OR 1.54; 95% CI 1.54–1.92; P <0.001 vs no CPR, non-VF= chest compression: OR 1.19; 95% CI 0.76–1.87; P =0.45; chest compression with rescue breathing: OR 2.26; 95% CI 1.34–3.82; P =0.020 vs non-CPR]. Similar results were also found in neurological outcomes in 1 month. Conclusions The rate of CPR implementation by citizens throughout Japan has continuously and linearly increased in these 15 years in proportion to the increase in the number of citizens certified for the government-organized CPR courses. Higher CPR activity by citizens were significantly associated with better 1-year survival and favorable functional status in both VF and non-VF patients.

Longer symptom onset-to-door time persists despite reductions in STEMI door-to-balloon time: insights from the victorian cardiac outcomes registry

Abstract Background Prompt revascularisation is central to achieving optimal outcomes for patients presenting with ST-segment elevation myocardial infarction (STEMI). To enable this, health systems have traditionally focused on the ‘door-to-balloon’ (DTB) component of total ischaemic time, while comparatively less attention has been given to symptom ‘onset-to-door’ (OTD) time. Objective To determine the temporal trends, predictors and outcomes among patients with increased OTD time. Methods Consecutive patients with STEMI treated with percutaneous coronary intervention (PCI) across 30 hospitals in the Victorian Cardiac Outcomes Registry were analyzed between 2014 and 2020. Linkage with data from Ambulance Victoria was performed for all patients transported via emergency medical services. Trends in OTD and DTB time were evaluated with Cochrane-Armitage test of trend. Characteristics and outcomes of patients with longer OTD time (>60 mins) were compared to those with shorter OTD time (<60 mins). Multivariable predictors of longer OTD were determined with logistic regression and presented as odds ratio and 95%CI in a forest plot. Results A total of 13,494 patients underwent PCI for STEMI with median OTD time of 150mins (86,328) and median DTB time of 66mins (43,107). DTB time progressively reduced over the study period (p=0.001) while the proportion of patients with longer OTD did not change (90.3%, p=0.91). Patients with longer OTD time were more likely to be older (>65yo = 41% vs. 35%, p<0.001), female (22 vs. 16%, p<0.001), live in a lower-socioeconomic area (36 vs. 28%, p<0.001), be treated for diabetes (17 vs. 13%, p<0.001), have developed their symptoms out-of-hours (65 vs. 60%, p=0.002) and present via ambulance [vs. self-present] (81 vs. 63%, p<0.001). Multivariable predictors of longer OTD time are presented in forest plot below. Higher rates of new renal impairment (6.7 vs. 5.0%, p=0.024) and 30-day MI (1.5 vs. 0.7%, p=0.017) were observed among patients with longer OTD, as were numerical trends in new 30-day heart failure (1.4 vs. 0.9%, p=0.22) and in-hospital shock (5.9 vs. 4.7%, p=0.081). Conclusion No change in the proportion of patients presenting with longer onset-to-door times was observed despite a parallel reduction in door-to-balloon time over the study period. Increased community awareness and education on the symptoms of myocardial infarction, particularly targeted at high risk demographic groups, are needed to further reduce ischaemic times.

Change in incidence of ischemic stroke and mortality among patients with atrial fibrillation over a period of 30 years, a nationwide, register-based cohort study

Abstract Background During the last decades we have faced large changes in lifestyle and cardiovascular risk factor patterns, as well as screening and treatment advances of patients with atrial fibrillation (AF). Aim To investigate trends in ischemic stroke (IS) and mortality in Sweden over a period of 30 years among patients with AF and compare it to matched controls without AF. Methods This is a Swedish nationwide registry-based retrospective case-control study of patients diagnosed with AF combining data from National Patient Register (NPR) and Cause of Death Register between 1987 and 2018. Controls were defined as Swedish inhabitants without AF and matched by age, sex and county. With the use of international classification of diseases (ICD) 9- and 10- codes we identified all patients diagnosed with AF, and comorbidities at baseline from NPR. Results In total, we identified 739,388 patients with AF and 1,386,448 matched controls. The mean age of the study population was 78.8 (12.6); and (46.2%) were female. Cochran-Armitage test showed a significant increase of all comorbidities over time, except for myocardial infarction for patients and PAH för controls. The Incidence rate for IS per 1000 person-year within one year declined from 40.9 (95% C.I.: 30.1-55.6) in 1987 to 16.2 (95% C.I.: 9.9-26.4) in 2017 (p <.0001) for patients with AF and from 12.2 (95% CI: 7.0-21.4) in 1987 to 6.2 (95% CI: 2.8-13.7) in 2017 (p <.0001) in controls. The prescription of oral anticoagulant therapy (OAK) increased from 40% in 2006 to almost 80% in 2018. The total 1-year mortality rate of IS was at 175.4 (151.3-203.4) for AF cases and 58.3 (45.1-75.4) for controls (p<0001). Compared to controls and adjusted for age, sex and comorbidities patients had HR for IS at 3.01 (95% CI: 2.89-3.13) between 1987 and 1999 that decreased to HR 2.75 (95% CI: 2.63-2.88) between 2010 and 2017 in patients with AF. After adjustment for baseline comorbidities and OAK the one-year risk for IS decreased from HR 1.01 (95% CI: 0.95-1.08) in 2012 to 0.41 (95% CI: 0.36-0.47) in patients and HR 0.50 (95% CI: 0.43-0.58) in 2012 to 0.37 (95% CI: 0.31-0.43) in controls, respectively (both p<0.0001). Conclusions This study revealed significant prognostic improvement of patients with AF showing decrease in the incidence rate and relative risk for IS, as well as all-cause mortality within one year of AF diagnose. The prescription of OACs almost doubled between 2006 and 2018 in patients with AF and was associated with a significant decrease of the relative risk for IS to almost same level as in controls without AF.

Abstract 14710: The Landscape of Pharmacological Interventional Trials for the Treatment or Prevention of Coronary Artery Disease: Analysis of clinicaltrials.gov Listings From 2008 to 2022

Background: Coronary artery disease (CAD) has been the leading cause of death and disability over the past two decades. Aims: To systematically assess the characteristics and trends of clinical trials pertaining to the treatment or prevention of CAD. Methods: The analysis included studies that (1) were registered in the ClinicalTrials.gov database from 2008 to 2022; (2) involved ≥1 pharmacological intervention; and (3) were designed to treat or prevent CAD or its complications. Study records were downloaded on December 27, 2022 for screening and analysis. Pharmacological interventions were classified according to the World Health Organization Anatomical Therapeutic Chemical Classification System. Annual trends by the year of study registration were assessed with a two-sided Cochran-Armitage test. Results: A total of 1,619 trials were identified from a pool of 437,319 studies. There was a declining trend in the number of CAD trials (Figure A). The majority of trials (47.5%) were targeted to enroll ≤100 participants, while 39.4% targeted 101-1000 participants, 10.5% targeted 1001-5000 participants, and 2.6% were mega-trials (>5000 participants). The distribution of study duration was as follows: ≤12 months (25.3%), 13-60 months (67.3%), and >60 months (7.5%). Of note, the open-label design was more commonly employed in treatment trials (41.8% vs. 31.6%; p=0.02), while the parallel assignment was more frequently utilized in prevention trials (88.8% vs. 82.0%; p=0.03). In addition, declining trends in the proportions of phase 3 trials (p=0.0008; Figure B) and trials of lipid-modifying (p=0.0043) or anti-thrombotic agents (p=0.03; Figure C) were observed. Conclusion: Between 2008 and 2022, the clinical trial landscape of CAD diminished and was mainly shaped by studies with small to moderate sample sizes and short to intermediate follow-up duration. Research focus trended toward study interventions other than anti-thrombotic or lipid-modifying agents.

Research on the association between the status of physical fitness and psychological distress among Chinese children and adolescents aged 13-18 years

Objective: To describe the status of physical fitness of children and adolescents aged 13-18 years in China in 2019 and analyze its association with psychological distress. Methods: Data were drawn from the 2019 Chinese National Survey on Students' Constitution and Health, and 90 633 Han children and adolescents aged 13-18 years were included. Physical fitness was evaluated by "National Students Constitutional Health Standards" (2014 revised edition). Psychological distress was classified according to the scores of the Kessler Psychological Distress Scale: ≤19, 20-24, 25-29, and ≥30 scores indicated no, mild, moderate, and severe psychological distress, respectively, with moderate and severe psychological distress collectively referred to as high psychological distress. The χ2 test was used to compare the distribution differences between boys and girls, the Cochran-Armitage test was used to analyze the trend, and the multinomial logistic regression in the mixed effect model was established to analyze the association between physical fitness and psychological distress. Results: In 2019, the unqualified rate of physical fitness among children and adolescents aged 13-18 years in China was 17.2%, and the prevalence of excellent and good physical fitness was 18.2%, which was lower among boys (15.9%) than girls (20.5%) with a statistically significant difference (P<0.05). The excellent and good physical fitness rate showed a significantly decreasing trend with age (trend test P<0.05). The rate of high psychological distress among children and adolescents aged 13-18 years in China in 2019 was 39.3%, with boys (37.0%) having a lower prevalence than girls (41.6%), supported by a statistically significant difference (P<0.05), and a decreasing trend with the degree of physical fitness was observed both in boys and girls (trend test P<0.05). The multinomial logistic regression model showed that the prevalence of moderate (OR=0.83, 95%CI: 0.79-0.88, P<0.001) and severe (OR=0.81, 95%CI: 0.77-0.86, P<0.001) psychological distress were both lower in children and adolescents with excellent and good physical fitness. Conclusion: The status of physical fitness and psychological distress of Chinese children and adolescents aged 13-18 in 2019 was not optimistic, with physical fitness showing a significantly negative association with psychological distress.

Disadvantaged Neighborhoods Continue to Bear the Burden of Gun Violence

IntroductionGun violence is a pervasive and dynamic public health crisis causing substantial burden on communities and healthcare systems in the United States. Risk factor and outcome analyses are crucial to develop effective interventions. The aim of this study was to assess firearm injury in a diverse community setting as it relates to neighborhood socioeconomic disadvantage and changes over time following large-scale local interventions. MethodsAll county residents with firearm injury presenting to a Level 1 Trauma Center from January 2012 to December 2021 were retrospectively reviewed. Area Deprivation Index (ADI) was used to measure neighborhood socioeconomic disadvantage based on a nine-digit zip code at patients’ home address. Injuries were also stratified by 5-year time periods, 2012-2016 and 2017-2021. Demographics and clinical data were analyzed including injury severity, hospital course, and discharge location. Data were compared by ADI quintile and between time periods using chi-squared, one-way analysis of variance, and Cochran-Armitage test. ResultsA total of 1044 injuries were evaluated. Patients were 93% male with mean age of 29 y (standard deviation 10.2) and were concentrated in the most disadvantaged neighborhoods (74% ADI Q5). Black or African American race was greater in the most disadvantaged ADI groups (76% versus 47%-66%; P <0.001). Percentage of total injuries in the most disadvantaged ADI group rose from 71% to 78% over time (P = 0.006). Mortality occurred in 154 (15%) patients overall, while most (71%) were discharged to home. Mortality declined from 18% to 11% over time (P <0.001). Medicaid utilization rose from 42% to 77% alongside a decrease in self-pay status from 44% to 4% (P <0.001). There were no clinically significant group differences in injury severity or clinical characteristics. ConclusionsFirearm injury remains concentrated in the most socioeconomically disadvantaged neighborhoods, and this disparity is increasing over time. Medicaid utilization rose and mortality decreased in this population over time. This research presents a method to inform and monitor local gun violence interventions using ADI to address public health equity.

Dose reduction of olaparib in older patients: Insights from an analysis of a National Database in Japan.

Although the advent of a poly polymerase inhibitors has greatly advanced the tailoring of cancer treatment, there is a dearth of real-world evidence on the actual use of olaparib in aging populations, especially those using national-level data. We extracted and analyzed all prescriptions of olaparib in female outpatients from the National Database Open Data Japan (NDB Open Data) from April 2019 to March 2021. The recommended standard dose of olaparib is four tablets of the 150 mg formulation per day, while the 100 mg formulation of olaparib can be considered as an alternative dose in the occurrence of hematologic toxicity. We calculated the proportion of 100 mg compared to the 150 mg prescriptions across age groups. A Cochrane-Armitage trend test was used to examine the association of age groups with the proportion of 100 mg prescriptions. The total number of prescriptions of the 100 mg formulation and the 150 mg formulation were 1449 222, and 4233 625, respectively. Overall, 45.1% (2567 513/5682 847 prescriptions) of olaparib were prescribed for patients 65 years of age or older in females. Stratified by age group, the proportion of 100 mg compared to the 150 mg prescriptions significantly increased with age (p < 0.0001). Given that the 100 mg formulation of olaparib can be considered as an alternative dose in Japan in the occurrence of hematologic toxicity, our observations indicate the dose reduction of olaparib in older patients in Japan. Further investigations are necessary to assess its efficacy and safety at a reduced dose.

Hospitalization Trends of Fractures Presenting to the Emergency Room From 2009 to 2021

Purpose&#x0D; Assessing trends in hospitalization rates due to fractures may be used as an indirect epidemiologic metric to predict future patient volumes, staffing needs, revenue, expenditures, and allocation of resources. The aim of this study is to analyze the trend of hospitalizations for patients who presented to Emergency Departments (EDs) with fractures from 2009 to 2021.&#x0D; Methods&#x0D; We extracted data from the National Electronic Injury Surveillance System (NEISS) database. All consecutive patients with a primary injury of fracture in the years 2009 to 2021 were eligible for inclusion in this study. The Cochran-Armitage test was used to assess the trend in fracture-related hospitalization rates over the years studied.&#x0D; Results&#x0D; This study showed a significant increase in hospitalizations due to fractures from 2009 to 2021 (p&lt;0.001). This increase in hospitalizations was observed consistently across various factors, including sex, fracture location, age categories, and the pre- and post- COVID-19 pandemic period. From 2009 to 2021, the mean age of patients presenting to EDs was increased from 34 to 40 (p&lt;0.001) and the percentage of women increased from 45% to 48%. There was a significant increase in hospitalizations across five fracture regions including the upper trunk, proximal and distal upper extremity, and proximal and distal lower extremity.&#x0D; Conclusions&#x0D; Our findings show hospitalization trends due to fractures have been increasing across the U.S. While reasons for this increased trend are multifactorial, increased utilization of urgent care for less severe injuries may be artificially driving these trends.

A retrospective cohort study, analyzing trends in management of upper urinary tract stones in the adult Israeli population.

To assess trends of surgical intervention in adults with upper urinary tract stones in Israel. A retrospective cohort study utilizing administrative databases held at Clalit Health Services, to identify all adults (⩾18 years) who underwent their first surgical treatment for upper tract urolithiasis. Descriptive statistics were employed to summarize baseline patient demographics and surgical trends were analyzed using the Cochrane-Armitage test for trend. Between 2003 and 2020, 36,624 adult patients were treated surgically for upper tract urinary stones. Mean age was 53.6 years (SD16.1). During the period investigated, the number of insured by Clalit Health Services increased by 25% and the total number of surgically treated stones increased by 98.7%. By type of procedure: Ureteroscopy (URS) increased by 351%, percutaneous nephrolithotripsy (PCNL) increased by 67%, shockwave lithotripsy (SWL) declined by 79%. The number of procedures per 100,000 population grew from to 37.5 in 2003 to 58.05 in 2022. The percentage increase in total number of surgical procedures was 103% and 90% in males and females, respectively. Our findings reveal significant increases in the total number of surgically treated stones over the investigated period. Notably, this increase far outpaced the growth in the number of individuals insured by Clalit Health Services. Further research and interventions are warranted to explore the underlying factors driving these trends and to develop targeted approaches for prevention, early detection, and minimally invasive treatment of upper urinary tract stones in Israel.

Trends and risk factors among adults admitted to the emergency department with fall-related eye injuries

Background/purposeEye injuries can happen to people of any age and for many reasons; among these is a fall. The aims of this study were to: (1) examine trends among fall-related eye injuries in working-age and older adults admitted to the emergency department (ED) from 2012 to 2021; and (2) investigate and compare the risk factors associated with fall-related eye injuries between working-age adults and older adults. DesignWe examined a retrospective cohort in the 2012–2021 National Electronic Injury Surveillance System (NEISS) databases. We used the Cochran-Armitage test for trend to determine the fall-related eye injury trend from 2012 to 2021. The associations among fall-related eye injuries, demographics, accident-related environments, and disposition, were analyzed using multivariable logistic regression analysis. ResultsAmong the total of 1,290,205 adults with eye injuries from 2012 to 2021, the incidence rate of fall-related eye injuries was higher in older adults (ranged from 9.0% to 17.4%) than in working-age adults (ranged from 3.7% to 7.1%). Over consecutive years, the number and annual incident rate of both working-age and older adults experiencing fall-related eye injuries increased significantly (all p ≤0.001). Patients who were female (odds ratio [OR] = 1.60, 95% confidence interval [CI] = 1.39–1.83), Black/African American (OR = 1.76, 95% CI = 1.47–2.10) had significantly higher odds of fall-related eye injuries. The highest odds ratios found among all of the reported product categories for the fall-related eye injuries were an accident with home structures such as doors (OR = 12.65, 95% CI = 10.00–16.01) and an accident with home furnishings (OR = 11.65, 95% CI = 9.18–14.78) compared to an accident with workshop equipment. Patients who experienced fall-related eye injuries were more likely to be hospitalized/ have an inpatient stay (OR = 7.41, 95% CI = 5.78–9.52) after the ED treatment than those who treated and released after ED visit. ConclusionAmong Americans treated in the ED for injury, fall-related eye injuries are increasingly common, especially among older adults, and associated with a need for inpatient care. Therefore, these findings suggest opportunities to investigate fall prevention and eye protection interventions, especially in the home setting.

Utilization of Radical Prostatectomy vs. Radiation Therapy for Gleason Grade Group 5 Prostate Cancer before and after USPSTF Grade D Recommendation against Prostate-Specific Antigen Screening in 2012

The 2012 United States Preventive Services Task Force (USPSTF) Grade D recommendation against prostate-specific antigen (PSA) screening has resulted in a shift to higher-stage prostate cancer (PC) at diagnosis. While incidence of low-risk prostate cancer has declined, more men are diagnosed with high-risk disease, and multimodal treatment is often required. The impact of this epidemiologic shift on practice patterns, specifically radical prostatectomy (RP) versus definitive radiation therapy (RT), for men with localized PC at high risk of recurrence is unknown. Herein, we evaluate the utilization of RP versus RT in the United States for Gleason grade group 5 (GG5) prostate cancer before and after 2012. We identified 34,011 men with localized GG5 PC treated with (1) RP or (2) RT plus androgen deprivation therapy (ADT) between 2004 and 2017 in the National Cancer Database. We excluded those who were clinically node-positive, had metastatic disease, or received chemotherapy or palliative-intent treatment. Chi-square was used to compare the relative use of RP and RT before versus after January 1, 2012, corresponding to the year of USPSTF recommendation against PSA screening. Annual use of RP versus RT from 2004 to 2017 was compared in academic and non-academic centers using Cochran-Armitage test for trend. Joinpoint regression assessed if 2012 was significant for inflection of crude rates of RP. Finally, we modeled the effect of treatment year (i.e., 2012-2017 versus 2004-2011) on use of RP using multivariable logistic regression. Sensitivity analysis tested an interaction term for facility type (i.e., academic versus community). Tests were two-sided with a 0.05 level of significance. Of the eligible men, 10,745 (31.6%) had T3-T4 disease. Between 2004 and 2011, 36.5% (n = 5,483) underwent RP; between 2012 and 2017, 42.3% (n = 8,034) underwent RP (p = .02). Across all centers, use of RP increased from 31% to 41% (p for trend <.001). In academic centers, use of RP increased from 32% to 44% (p for trend <.001); in community centers, use of RP increased from 30% to 39% (p for trend <.001). 2012 was associated with significant inflection for increase in RP use in all centers. On multivariable analysis, there was an increased odds of receiving RP after 2012 (adjusted OR 1.34, 95% CI 1.28-1.40, p<.001). No differential effect by facility type was observed (p = .15). Utilization of RP for GG5 PC has significantly increased in the United States over the past decade, particularly after the USPSTF Grade D recommendation against PSA screening in 2012. It remains unknown whether oncologic or functional outcomes may be compromised in this group of high-risk men, many of whom require post-prostatectomy RT and/or ADT. While historically rare, prospective comparison of RP versus RT+ADT for GG5 PC may be helpful given the evolving epidemiology of localized PC.

Disparities in Time to Prostate Cancer Treatment Initiation before and after the Affordable Care Act

Delayed access to care may contribute to disparities in prostate cancer (PCa). The Affordable Care Act (ACA) aimed at increasing access and reducing healthcare disparities, but its impact on timely treatment initiation for men with PCa is unknown. Men with intermediate- and high-risk PCa diagnosed 2010-2016 and treated with curative surgery or radiotherapy were identified in the National Cancer Database. Multivariable logistic regression modeled the effect of race and insurance type on treatment delay >180 days after diagnosis to start of surgery, radiotherapy, or hormonal therapy. Cochran-Armitage test measured annual trends in delays, and join point regression assessed if 2014, the year the ACA became fully operationalized, was significant for inflection in crude rates of major delays. Of 422,506 eligible men, 18,720 (4.4%) experienced >180-day delay in treatment initiation. Compared to White patients, Black (OR 1.79, 95% CI 1.72-1.87, p<.001) and Hispanic (OR 1.37, 95% CI 1.28-1.48, p<.001) patients had higher odds of delay. These disparities persisted when analyzing only patients treated after 2014 or for patients who had Medicare or Private insurance. Compared to uninsured patients, those with Medicaid had no difference in odds of delay (OR 0.94, 95% CI 0.84-1.06, p = .31), while those with private insurance (OR 0.57, 95% CI 0.52-0.63, p<.001) or Medicare (OR 0.64, 95% CI 0.58-0.70, p<.001) had lower odds of delay. These disparities persisted when analyzing only patients treated after 2014. Mean time to treatment significantly increased from 2010 to 2016 across all racial/ethnic groups (trend p<.001); 2014 was associated with a significant inflection for increase in rates of major delays. The impact of race and insurance status were independently associated with longer delays to PCa treatment in the US. These disparities were unaffected by implementation of the ACA. In fact, implementation of ACA was associated with increased delays in treatment initiation for all men, regardless of race. As the epidemiology of newly diagnosed prostate cancer in the United States continues to shift due to tempered screening and the COVID pandemic, further work will be needed to increase equity in prostate cancer care.

Implementing quality management strategies improves clinical quality as a voluntary medical male circumcision program in Namibia matures: a process analysis

BackgroundSurgical voluntary medical male circumcision (VMMC) is a safe procedure; however, maintaining quality standards at scale, particularly during scale-up, is a challenge making ongoing quality management (QM) efforts essential. This study describes program quality measured by rates of adverse events (AEs) over four years of VMMC implementation in Namibia, compares AE rates over time, and discusses QM processes that contextualize AE trends and illustrate improvements in quality as the program matured. The International Training and Education Center for Health (I-TECH) assisted the Namibian Ministry of Health and Social Services (MoHSS) in expanding VMMC in three regions among boys and men over 10 years of age between January 2015 and September 2019.MethodsA comprehensive package of QM strategies was implemented by multi-disciplinary onsite teams with support from national and international technical advisors. Retrospective routine MoHSS data from the VMMC register, client forms, and monthly AE reports were collected during implementation in the three regions to assess the impact of QM interventions on AEs and to calculate the proportion of clients who experienced AEs over time. The proportion of clients who experienced an AE over time was compared using a Cochran-Armitage test for trend.ResultsBetween January 2015 and September 2019, 40,336 clients underwent VMMC and 593 (1.5%) clients experienced a post-operative AE in the three supported regions. The AE rate was highest in the first quarter of clinical service delivery in each region (January-March 2015 in Oshana and Zambezi, October-December 2017 in //Kharas) but declined over the implementation period as the program matured. This observed trend between program maturity and declining AE rates over time was significant (p < 0.001) when compared using a Cochran-Armitage test for trend.ConclusionsAs the I-TECH-supported VMMC program matured, QM measures were introduced and routinized, and clinical quality improved over time with the rate of AEs decreasing significantly over the implementation period. Applying systematic and continuous QM processes and approaches across the continuum of VMMC services and considering local context can contribute to increased clinical safety. QM measures that are established in more mature program sites can be quickly adopted to respond to quality issues in program expansion sites.

Decreasing alcohol use among young adults presenting for service in the U.S. Air Force: An epidemiological surveillance study

ABSTRACT U.S. surveys demonstrate recent decreases in the prevalence of alcohol use and binge drinking among young adults. The current study aims to determine whether similar trends are evident in a similarly aged cohort of service members in the US Air Force to inform ongoing prevention efforts. Participants were 103,240 Air Force personnel in entry-level training between 2016 and 2019. Participants anonymously completed the AUDIT (Alcohol Use Disorder Identification Test) regarding their pre-service drinking. Logistic regression analyses and the Cochran-Armitage test were conducted to measure population trends over the study duration with stratification by age (<21 vs. ≥21) and evaluation of specific alcohol behaviors. Between 2016 and 2019, the proportion of young service members endorsing any alcohol use significantly decreased for both the <21 group (i.e. from 38.9% to 32.6%) and the ≥21 group (i.e. from 80.6% to 77.5%). Among those who endorsed drinking, a decrease over time in binge use was also observed from 46.6% to 37.8% for the <21 group and from 34.2% to 27.5% for the ≥21 group. Responses to other specific alcohol risk items and total AUDIT scores also demonstrated decreases. Binge use and risky drinking remained disproportionately common among those under the legal drinking age. It is encouraging to observe a shift toward abstinence and decreased binge use among this population of young military recruits. However, given the risk for many adverse health and legal consequences in this population, more work is needed to prevent problematic drinking, especially among those under the legal drinking age.

Predictors of Undergoing Revision Within 5 Years of Total Knee Arthroplasty: A Population-Based Study

BackgroundThe objective of this study was to identify the rate and risk factors for revision total knee arthroplasty (TKA) within the first 5 years postoperative. Our secondary objective was to identify the rate of additional surgical procedures and death. MethodsWe conducted a retrospective cohort study among patients in Ontario, Canada who underwent an elective, primary TKA between April 1, 2007, and March 31, 2014, for osteoarthritis. We excluded patients under 40 years and who had undergone a TKA within the previous 15 years. Our final study cohort included 94,193 patients. We reported the proportion of the study cohort who experienced revision surgery within 2 and 5 years of the primary TKA; secondary surgery within 5 years. We conducted Cochran-Armitage tests for trends to assess changes in the proportion of patients who experienced each of the study outcomes, and multivariable logistic regressions to evaluate predictors of a revision TKA. ResultsThere were 3,112 (3.3%) patients who had a revision within 5 years, and 1,866 (2.0%) within 2 years of their primary TKA. 3,316 (3.5%) had a secondary surgery (0.6% patellar resurfacing; 1.6% manipulation; 1.3% synovectomy; 0.5% washout; 0.9% debridement). Lower age, men, lower income, higher comorbidity score, depression, previous arthroscopy, lower surgeon volume, and general anesthesia were all significant positive predictors of revision. ConclusionsIn our study cohort, 2.0% of patients had a revision TKA within 2 years, and 3.3% within 5 years of their primary TKA. Preoperative identification of risk factors may reduce the future prevalence of revision TKAs.

The diagnostic likelihood ratio function and modified test for trend: Identifying, evaluating, and validating nontraditional biomarkers in case-control studies.

The ROC curve and its associated summary statistic, the AUC, are used to identify informative diagnostic biomarkers under the assumption that risk of disease is a monotone function of the biomarker. We refer to biomarkers that meet this assumption as traditional, and those that do not as nontraditional. Nontraditional biomarkers most often arise when both low and high biomarker values are associated with an outcome of interest, such as blood pressure with medical complications or leukocyte count with ICU prognosis. Since nontraditional biomarkers do not meet the assumptions for ROC-based analyses, we propose using the discrete diagnostic likelihood ratio (DLR) function to evaluate a wider class of informative biomarkers. We obtain the DLR function using the multinomial logistic regression (MLR) model to improve upon existing estimation techniques, and implement a likelihood ratio test to identify candidate informative traditional and nontraditional biomarkers. We propose a modification of the Cochran-Armitage test for trend that separates biomarkers deemed informative into traditional and nontraditional categories. The statistical properties of the likelihood ratio test and modified test for trend are explored under simulation. Together, these methods achieve the identification, evaluation, and validation of biomarkers from early discovery research. Finally, we show that incorporating covariates into the MLR model results in a covariate-adjusted DLR function that is useful for integrating multiple sources of information in clinical decision making. The methods are applied to gene expression data from subjects with high grade serous ovarian cancer, where stage, early stage vs late stage, is the outcome of interest.

Representation of Women in Published Articles at 3 Academic Pediatric Journals: 2001 to 2022.

To evaluate the representation of women authors and editorial board members at 3 pediatric journals. We conducted a retrospective review of original research articles published in Pediatrics, The Journal of Pediatrics, and JAMA Pediatrics from 2001 to 2022. We analyzed five 1-year intervals and inferred the binary gender of authors by first name. Cochran-Armitage tests evaluated trends in gender proportion of authorship and editorial board membership over time. Pearson's χ2 tests compared United States (US) authorship position and faculty rank as determined by Association of American Medical Colleges' data. From 2001 to 2022, 4426 original research articles were studied (exclusion rate <1%). There was a 23.7%, 15.9%, and 28.8% increase in proportion of women as first authors, senior authors, and editorial board members globally, with all trends significant over time (P < .01). In 2022, US women were 67.3% of first authors, only slightly lower than the 68.6% of women junior faculty (P = .01). US women were 48.0% of US senior authors, equivalent to the 47.5% of US women senior faculty (P = .18). US women represented 47.4% of US editorial board members, equivalent to their percentage as senior faculty (P = .98). The percentage of US and international women authorship and editorial board membership has steadily increased. The percentage of US women as junior faculty and first authors is almost equivalent. The percentage of US women as senior faculty, senior authors, and editorial board members is equivalent but significantly reduced from their junior faculty representation.

Trends and Inhospital Outcomes of Intravascular Imaging on Single-Vessel Coronary Chronic Total Occlusion Treated With Percutaneous Coronary Intervention

Intravascular imaging (IVI), including intravascular ultrasound (IVUS) and optical coherence tomography (OCT), improves outcomes of percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs). We sought to quantify temporal trends in the uptake of IVI for CTO-PCI in the United States. We identified adults who underwent single-vessel PCI for CTO between 2008 and 2020. We quantified yearly trends in the number of IVUS-guided and OCT-guided single-vessel CTO-PCIs by Cochran-Armitage and linear regression tests. We also examined the rates of inhospital mortality and other prespecified inhospital outcomes in patients who underwent CTO-PCIs with and without IVI, using logistic regression. Our study included a total of 151,998 PCIs on single-vessel CTOs, with the absolute number of CTO-PCIs decreasing from 12,345 in 2008 to 8,525 in 2020 (p trend <0.001). IVUS use has increased dramatically from 6% in 2008 to 18% in 2020 for single-vessel CTO-PCIs (p trend <0.001). Rates of OCT use have increased as well, from 0% in 2008 to 7% in 2020 (p trend <0.001). There was no difference in inhospital mortality between patients who underwent CTO-PCI with and without IVI (p logistic=0.60). In the largest national analysis of single-vessel CTO-PCI trends to date, we found that the use of IVUS has increased substantially accompanied by a similar but lesser increase in the use of OCT. There were no differences in rates of inhospital mortality between patients who underwent single-vessel CTO-PCIs with and without IVI.