Covariate-adjusted Analyses Research Articles

Mixed Models for Repeated Measures Should Include Time-by-Covariate Interactions to Assure Power Gains and Robustness Against Dropout Bias Relative to Complete-Case ANCOVA.

In randomized trials with continuous-valued outcomes, the goal is often to estimate the difference in average outcomes between two treatment groups. However, the outcome in some trials is longitudinal, meaning that multiple measurements of the same outcome are taken over time for each subject. The target of inference in this case is often still the difference in averages at a given timepoint. One way to analyze these data is to ignore the measurements at intermediate timepoints and proceed with a standard covariate-adjusted analysis (e.g., ANCOVA) with the complete cases. However, it is generally thought that exploiting information from intermediate timepoints using mixed models for repeated measures (MMRM) (a) increases power and (b) more naturally "handles" missing data. Here, we prove that neither of these conclusions is entirely correct when baseline covariates are adjusted for without including time-by-covariate interactions. We back these claims up with simulations. MMRM provides benefits over complete-cases ANCOVA in many cases, but covariate-time interaction terms should always be included to guarantee the best results.

Pet ownership in pregnancy and methylation pattern in cord blood.

Having pets in the house during the first years of life has been shown to protect against allergies. However, the result of different studies is heterogeneous. The aim of this study was to evaluate the methylation pattern in cord blood in relation to pet ownership during pregnancy.We investigated the methylation patterns of 96 cord blood samples, participants of the Epigenetic Hallmark of Maternal Atopy and Diet—ELMA project, born to mothers who either owned pets (n = 32) or did not own pets (n = 64) during their pregnancy. DNA from cord blood was analysed using the Infinium methylation EPIC. For statistical analysis, RnBeads software was applied.We found 113 differentially methylated sites (DMs) in the covariate-adjusted analysis (FDR p < 0.05), with small methylation differences. The top DMs were associated with genes: UBA7, THRAP3, GTDC1, PDE8A and SBK2. In the regional analysis, two promoter regions presented with significance: RN7SL621P and RNU6-211P. Cis-regulatory element analysis revealed significant associations with several immune-related pathways, such as regulation of IL18, Toll signalling, IL6 and complement.We conclude that pet exposure during pregnancy causes subtle but significant changes in methylation patterns in cord blood, which are reflected in the biological processes governing both innate and adaptive immune responses.

Nonlinear associations between sleep patterns and sarcopenia risks in older adults.

Despite considering it as a common geriatric condition, sarcopenia is linked to various behavioral factors that may be changeable. As sleep is one of the important routines in physiological homeostasis, further investigating the underlying relationships of sleep behavior with sarcopenia is urgently needed. We examined the association between sleep parameters (ie, sleep duration, bedtime, wake time, or midsleep time) and sarcopenia risks in older adults, in the total sample and age group subsamples. A total of 1,068 older adults in Taiwan were included. Data on bedtime, wake time, and sleep duration were collected through telephone interview. Midsleep time was calculated by the midpoint of bedtime and wake time. Sarcopenia was screened by the SARC-F questionnaire composed of 5 questions (the strength, assistance in walking, rising from a chair, climbing stairs, and falls) as well as higher scores was related to greater risks. Generalized additive models were conducted to examine the nonlinear relationships between sleep parameters and sarcopenia risks. The covariate-adjusted analysis showed that a reverse J-shaped relationship for sleep duration and sarcopenia risk (P < .001) and a significant association for wake time and the SARC-F score (P = .009) in total sample, with considering age-related interaction. No associations were found in the other sleep parameters (bedtime and midsleep time) and sarcopenia in older adults. Similar associations were observed between wake time and the SARC-F score across age groups, while diverse associations of sleep duration with the SARC-F score were found in different age groups. The sleep pattern is significantly associated with sarcopenia risks in aging adults. Improving inappropriate sleep behaviors in older adults is suggested to prevent a decline in muscle function and promote healthy aging. Huang W-C, Lin C-Y, Togo F, etal. Nonlinear associations between sleep patterns and sarcopenia risks in older adults. J Clin Sleep Med. 2022;18(3):731-738.

Higher dietary fibre intake is associated with increased skeletal muscle mass and strength in adults aged 40years and older.

BackgroundSkeletal muscle mass begins to decline from 40 years of age. Limited data suggest that dietary fibre may modify lean body mass (BM), of which skeletal muscle is the largest and most malleable component. We investigated the relationship between dietary fibre intake, skeletal muscle mass and associated metabolic and functional parameters in adults aged 40 years and older.MethodsWe analysed cross‐sectional data from the US National Health and Nutrition Examination Survey between 2011 and 2018 from adults aged 40 years and older. Covariate‐adjusted multiple linear regression analyses were used to evaluate the association between dietary fibre intake and BM components (BM, body mass index [BMI], total lean mass, appendicular lean mass, bone mineral content, total fat, trunk fat; n = 6454), glucose homeostasis (fasting glucose, fasting insulin, HOMA2‐IR; n = 5032) and skeletal muscle strength (combined grip strength; n = 5326). BM components and skeletal muscle strength were expressed relative to BM (per kg of BM).ResultsHigher intakes of dietary fibre were significantly associated with increased relative total lean mass (β: 0.69 g/kg BM; 95% CI, 0.48–0.89 g/kg BM; P < 0.001), relative appendicular lean mass (β: 0.34 g/kg BM; 95% CI, 0.23–0.45 g/kg BM; P < 0.001), relative bone mineral content (β: 0.05 g/kg BM; 95% CI, 0.02–0.07 g/kg BM; P < 0.001) and relative combined grip strength (β: 0.002 kg/kg BM; 95% CI, 0.001–0.003 kg/kg BM; P < 0.001).Conversely, higher dietary fibre intakes were significantly associated with a lower BM (β: −0.20; 95% CI, −0.28 to −0.11 kg; P < 0.001), BMI (β: −0.08 kg/m2; 95%CI, −0.10 to −0.05 kg/m2), relative total fat (β: −0.68 g/kg BM; 95% CI, −0.89 to −0.47 g/kg BM; P < 0.001), relative trunk fat (β: −0.48 g/kg BM; 95%CI, −0.63 to −0.33 g/kg; P < 0.001), fasting glucose (β: −0.01 mmol/L; 95% CI, −0.02 to −0.00 mmol/L; P = 0.017), fasting insulin (β: −0.71 pmol/L; 95% CI, −1.01 to −0.41 pmol/L; P < 0.001) and HOMA2‐IR (β: −0.02 AU; 95% CI, −0.02 to −0.01 AU; P < 0.001).ConclusionsHigher dietary fibre intakes are associated with a lower BM and enhanced body composition, characterized by a reduction in fat mass and an increase in lean mass. Higher dietary fibre intakes were also associated with improvements in glucose homeostasis and skeletal muscle strength. Increasing dietary fibre intake may be a viable strategy to prevent age‐associated declines in skeletal muscle mass.

Short-Term Outcomes for Restorative and Non-Restorative Proctocolectomy in Older Adults

Curative surgery for ulcerative colitis can be subdivided into restorative (with pouch and anastomosis) and non-restorative operations. Restorative surgery in older adults is controversial, due to concerns about surgical risk and long-term functional outcome. The goal of this study is to compare 30-day outcomes for restorative and non-restorative surgery in older adults with ulcerative colitis. Data were obtained from the American College of Surgeons National Surgical Quality Initiative Program from 2012-2018. Patients were included if they were >65 years old and had ulcerative colitis. Restorative and non-restorative surgeries were defined with procedure codes. Patient characteristics and adverse surgical outcomes were compared between restorative and non-restorative surgeries utilizing chi-square tests and Fisher's exact tests. Multivariate logistic regression models were constructed to evaluate the association of restorative versus non-restorative surgery with adverse surgical outcomes while adjusting for potential confounders. Of 392 total patients, 95 had restorative and 297 had non-restorative surgery. Patients undergoing restorative surgery, compared to non-restorative surgery, were significantly younger (P<0.01), had lower incidences of steroid usage (P<0.001) and higher rates of readmission (P=0.02). There were no differences in post-operative complications between the groups in both unadjusted analyses and covariate-adjusted regression analysis (P > 0.05). In carefully selected older patients with ulcerative colitis, restorative surgery is associated with increased readmission, but otherwise similar rates of morbidity or mortality compared to non-restorative surgery. Data regarding postoperative functional outcome and quality of life are also needed to help select the most appropriate curative option for older adults.

A roadmap to using randomization in clinical trials

BackgroundRandomization is the foundation of any clinical trial involving treatment comparison. It helps mitigate selection bias, promotes similarity of treatment groups with respect to important known and unknown confounders, and contributes to the validity of statistical tests. Various restricted randomization procedures with different probabilistic structures and different statistical properties are available. The goal of this paper is to present a systematic roadmap for the choice and application of a restricted randomization procedure in a clinical trial.MethodsWe survey available restricted randomization procedures for sequential allocation of subjects in a randomized, comparative, parallel group clinical trial with equal (1:1) allocation. We explore statistical properties of these procedures, including balance/randomness tradeoff, type I error rate and power. We perform head-to-head comparisons of different procedures through simulation under various experimental scenarios, including cases when common model assumptions are violated. We also provide some real-life clinical trial examples to illustrate the thinking process for selecting a randomization procedure for implementation in practice.ResultsRestricted randomization procedures targeting 1:1 allocation vary in the degree of balance/randomness they induce, and more importantly, they vary in terms of validity and efficiency of statistical inference when common model assumptions are violated (e.g. when outcomes are affected by a linear time trend; measurement error distribution is misspecified; or selection bias is introduced in the experiment). Some procedures are more robust than others. Covariate-adjusted analysis may be essential to ensure validity of the results. Special considerations are required when selecting a randomization procedure for a clinical trial with very small sample size.ConclusionsThe choice of randomization design, data analytic technique (parametric or nonparametric), and analysis strategy (randomization-based or population model-based) are all very important considerations. Randomization-based tests are robust and valid alternatives to likelihood-based tests and should be considered more frequently by clinical investigators.

Simulated driving performance among daily and occasional cannabis users

ObjectiveDaily cannabis users develop tolerance to some drug effects, but the extent to which this diminishes driving impairment is uncertain. This study compared the impact of acute cannabis use on driving performance in occasional and daily cannabis users using a driving simulator. MethodsWe used a within-subjects design to observe driving performance in adults age 25 to 45 years with different cannabis use histories. Eighty-five participants (43 males, 42 females) were included in the final analysis: 24 occasional users (1 to 2 times per week), 31 daily users and 30 non-users. A car-based driving simulator (MiniSim™, National Advanced Driving Simulator) was used to obtain two measures of driving performance, standard deviation of lateral placement (SDLP) and speed relative to posted speed limit, in simulated urban driving scenarios at baseline and 30 min after a 15 min ad libitum cannabis smoking period. Participants smoked self-supplied cannabis flower product (15% to 30% tetrahydrocannabinol (THC). Blood samples were collected before and after smoking (30 min after the start of smoking). Non-users performed the same driving scenarios before and after an equivalent rest interval. Changes in driving performance were analyzed by repeated measures general linear models. ResultsMean whole blood THC cannabinoids concentrations post smoking were use THC = 6.4 ± 5.6 ng/ml, THC-COOH = 10.9 ± 8.79 ng/mL for occasional users and THC = 36.4 ± 37.4 ng/mL, THC-COOH = 98.1 ± 90.6 ng/mL for daily users. On a scale of 0 to 100, the mean post-use score of subjective high was similar in occasional users and daily users (52.4 and 47.2, respectively). In covariate-adjusted analysis, occasional users had a significant increase in SDLP in the straight road segment from pre to post compared to non-users; non-users decreased by a mean of 1.1 cm (25.5 cm to 24.4 cm) while occasional users increased by a mean of 1.9 cm (21.7 cm to 23.6 cm; p = 0.02). Daily users also increased adjusted SDLP in straight road segments from baseline to post-use (23.2 cm to 25.0 cm), but the change relative to non-users was not statistically significant (p = 0.08). The standardized mean difference in unadjusted SDLP from baseline to post-use in the straight road segments comparing occasional users to non-users was 0.64 (95% CI 0.09 – 1.19), a statistically significant moderate increase. When occasional users were contrasted with daily users, the baseline to post changes in SDLP were not statistically significant. Daily users exhibited a mean decrease in baseline to post-use adjusted speed in straight road segments of 1.16 mph; a significant change compared to slight speed increases in the non-users and occasional users (p = 0.02 and p = 0.01, respectively). ConclusionWe observed a decrement in driving performance assessed by SDLP after acute cannabis smoking that was statistically significant only in the occasional users in comparison to the nonusers. Direct contrasts between the occasional users and daily users in SDLP were not statistically significant. Daily users drove slower after cannabis use as compared to the occasional use group and non-users. The study results do not conclusively establish that occasional users exhibit more driving impairment than daily users when both smoke cannabis ad libitum.

Diabetes and cardiovascular diseases are associated with the worsening of intermittent hypoxaemia.

Intermittent hypoxaemia is a risk factor for numerous diseases. However, the reverse pathway remains unclear. Therefore, we investigated whether pre-existing hypertension, diabetes or cardiovascular diseases are associated with the worsening of intermittent hypoxaemia. Among the included 2,535 Sleep Heart Health Study participants, hypertension (n=1,164), diabetes (n=170) and cardiovascular diseases (n=265) were frequently present at baseline. All participants had undergone two polysomnographic recordings approximately 5.2years apart. Covariate-adjusted linear regression analyses were utilized to investigate the difference in the severity of intermittent hypoxaemia at baseline between each comorbidity group and the group of participants free from all comorbidities (n=1,264). Similarly, we investigated whether the pre-existing comorbidities are associated with the progression of intermittent hypoxaemia. Significantly higher oxygen desaturation index (β=1.77 [95% confidence interval: 0.41-3.13], p=0.011), desaturation severity (β=0.07 [95% confidence interval: 0.00-0.14], p=0.048) and desaturation duration (β=1.50 [95% confidence interval: 0.31-2.69], p=0.013) were observed in participants with pre-existing cardiovascular diseases at baseline. Furthermore, the increase in oxygen desaturation index (β=3.59 [95% confidence interval: 1.78-5.39], p<0.001), desaturation severity (β=0.08 [95% confidence interval: 0.02-0.14], p=0.015) and desaturation duration (β=2.60 [95% confidence interval: 1.22-3.98], p<0.001) during the follow-up were higher among participants with diabetes. Similarly, the increase in oxygen desaturation index (β=2.73 [95% confidence interval: 1.15-4.32], p=0.001) and desaturation duration (β=1.85 [95% confidence interval: 0.62-3.08], p=0.003) were higher among participants with cardiovascular diseases. These results suggest that patients with pre-existing diabetes or cardiovascular diseases are at increased risk for an expedited worsening of intermittent hypoxaemia. As intermittent hypoxaemia is an essential feature of sleep apnea, these patients could benefit from the screening and follow-up monitoring of sleep apnea.

P–330 Live birth after ART in patients with treated endometriosis versus those without endometriosis at laparoscopy

Abstract Study question Is endometriosis related to worse outcome of assisted reproductive techniques (ART)? Summary answer Cumulative incidence of live birth in patients with and without endometriosis at laparoscopy was similar, although deep endometriosis and adenomyosis were negative prognostic factors. What is known already Whether endometriosis has a negative impact on the outcome of ART is still a matter of debate. Most published data report on one fresh cycle only, usually without taking frozen embryos into account. Further, a large heterogeneity in study population has been acknowledged by several meta-analyses, as in the control groups endometriosis was not always excluded by laparoscopy, and in case of endometriosis the prior treatment history was variable or unclear. Study design, size, duration Retrospective longitudinal cohort study of 1462 patients (779 with laparoscopically treated endometriosis of any rASRM stage, and 683 without endometriosis at laparoscopy) undergoing ART treatment between July 2003 and December 2014. Primary outcome studied was time to ART live birth. Secondary outcomes include -amongst others- number of cycles needed per ART live birth, time to ART or spontaneous live birth, cycle cancellation rate, and pregnancy outcomes like miscarriage and ectopic pregnancy, and per cycle analyses. Participants/materials, setting, methods All patients with a history of laparoscopy prior to the start of their first ART were included for analysis. The ART was performed in a tertiary referral center of a large University Hospital. Primary outcome studied was the time from initiation of the first ART cycle to delivery of the first live born. Survival analysis was conducted using cumulative incidence functions and cause-specific hazards regression. Main results and the role of chance The study included 1462 patients who initiated 4537 ART cycles, of which 3672 (81%) fresh and 857 (19%) frozen cycles. The unadjusted hazard ratio (HR) of live birth was 1.01 (95% CI 0.88–1.16). After adjustment for potential confounders (age, maternal BMI, maternal smoking, secondary infertility, duration of infertility, anovulation, reduced ovarian reserve, tubal factor, male factor and therapy started before 2007) the HR was 0.99 (95% CI 0.86–1.14). Within the endometriosis population (n = 779), covariate-adjusted analyses suggested that presence of adenomyosis (HR = 0.54; 95% CI 0.34–0.86) and a history of deep endometriosis (HR = 0.74 – 95% CI 0.58–0.94) were associated with a lower cumulative incidence of live birth. In contrast, there was little support of an association with diagnosis of stage III/IV (HR = 1.15; 95% CI 0.84–1.59) or a history of ovarian endometriosis (HR = 0.97; 95% CI 0.72–1.30). Beside the effect of the different variables directly linked to endometriosis, maternal BMI (HR = 0.80; 95%CI 0.71–0.91) and smoking (HR = 0.69; 95%CI 0.52–0.92) also negatively affected live birth delivery rate per patient. Limitations, reasons for caution Practices and success rates of ART may have changed during the 11-year recruitment period. Restricting to women who underwent laparoscopy, while providing evidence of the presence or absence of endometriosis, may have induced selection bias. However, the advantage of this time period, was the high rate of pre-ART laparoscopy (+/–50%). Wider implications of the findings: As deep endometriosis and adenomyosis represent negative prognostic factors within the endometriosis population, future studies should focus on optimalisation of ART in these subgroups. Trial registration number S57393

Eliciting Preferences of Providers in Primary Care Settings for Post Hospital Discharge Patient Follow-Up.

Background: Post-hospital discharge follow-up has been a principal intervention in addressing gaps in care pathways. However, evidence about the willingness of primary care providers to deliver post-discharge follow-up care is lacking. This study aims to assess primary care providers’ preferences for delivering post-discharge follow-up care for patients with chronic diseases. Methods: An online questionnaire survey of 623 primary care providers who work in a hospital group of southeast China. Face-to-face interviews with 16 of the participants. A discrete choice experiment was developed to elicit preferences of primary care providers for post-hospital discharge patient follow-up based on six attributes: team composition, workload, visit pattern, adherence of patients, incentive mechanism, and payment. A conditional logit model was used to estimate preferences, willingness-to-pay was modelled, a covariate-adjusted analysis was conducted to identify characteristics related to preferences, 16 interviews were conducted to explore reasons for participants’ choices. Results: 623 participants completed the discrete choice experiment (response rate 86.4%, aged 33 years on average, 69.5% female). Composition of the follow-up team and adherence of patients were the attributes of greatest relative importance with workload and incentives being less important. Participants were indifferent to follow-up provided by home visit or as an outpatient visit. Conclusion: Primary care providers placed the most importance on the multidisciplinary composition of the follow-up team. The preference heterogeneity observed among primary care providers suggests personalized management is important in the multidisciplinary teams, especially for those providers with relatively low educational attainment and less work experience. Future research and policies should work towards innovations to improve patients’ engagement in primary care settings.

Alternative duty work as workplace-initiated procedure to reduce sickness absence

PurposeAlternative duty work is a procedure that enables an employee with a short-term disability to perform modified duties as an alternative to sickness absence. We examined whether the implementation of an alternative duty policy was associated with reduced sickness absence in the Finnish public sector.MethodsTwo city administrations (A and D) that implemented an alternative duty work policy to their employees (n = 5341 and n = 7538) served as our intervention cities, and two city administrations (B and C) that did not implement the policy represented the reference cities (n = 6976 and n = 6720). The outcomes were the number of annual days, all episodes, and short-term (< 10 days) episodes during the 2 years before versus the 2 years after the intervention year. We applied repeated measures negative binomial regression analyses, using the generalized estimating equations method and the difference-in-difference analysis to compare the intervention and control cities (adjusted for sex, age, type of job contract, occupational class).ResultsDuring the five-year study period, the number of sickness absence days and episodes increased in both the intervention and control cities. Covariate-adjusted analysis of relative risk showed that the overall increase in post- versus pre-intervention sickness absence days was smaller in intervention City A, RR = 1.14 (95% CI = 1.09–1.21) than in control cities B and C, RR = 1.19 (95% CI =1.14–1.24), group × time interaction p < 0.02. In intervention City D, we found a corresponding result regarding all sickness absence episodes and short-term sickness absence episodes but not days.ConclusionsThis follow-up suggests that implementing an alternative duty work policy may marginally decrease employees’ sickness absences.

Causal Effects of Positive Affect, Life Satisfaction, Depressive Symptoms, and Neuroticism on Kidney Function: A Mendelian Randomization Study.

Further investigation of the causal effects of psychologic wellbeing on kidney function is warranted. In this Mendelian randomization (MR) study, genetic instruments for positive affect, life satisfaction, depressive symptoms, and neuroticism were introduced from a previous genome-wide association study meta-analysis of European individuals. Summary-level MR was performed using the CKDGen data of European ancestry (n=567,460), and additional allele score-based MR was performed in the individual-level data of White British UK Biobank participants (n=321,024). In summary-level MR with the CKDGen data, depressive symptoms were a significant causative factor for kidney function impairment (CKD OR, 1.45; 95% confidence interval, 1.07 to 1.96; eGFR change [%] beta -2.18; 95% confidence interval, -3.61 to -0.72) and pleiotropy-robust sensitivity analysis results supported the causal estimates. A genetic predisposition for positive affect was significantly associated with better kidney function (CKD OR, 0.69; 95% confidence interval, 0.52 to 0.91), eGFR change [%] beta 1.50; 95% confidence interval, 0.09 to 2.93) and sensitivity MR analysis results supported the finding for CKD outcome, but was nonsignificant for eGFR. Life satisfaction and neuroticism exposures showed nonsignificant causal estimates. In the UK Biobank with covariate-adjusted allele score MR analysis, allele scores for positive affect and life satisfaction were causally associated with reduced risk of CKD and higher eGFR. In contrast, neuroticism allele score was associated with increased risk of CKD and lower eGFR, and depressive symptoms allele score was associated with lower eGFR, but showed nonsignificant association with CKD. Health care providers in the nephrology field should be aware of the causal linkage between psychologic wellbeing and kidney function.

Real-world comparative effectiveness of triplets containing bortezomib (B), carfilzomib (C), daratumumab (D), or ixazomib (I) in relapsed/refractory multiple myeloma (RRMM) in the US

Multiple available combinations of proteasome inhibitors, immunomodulators (IMIDs), and monoclonal antibodies are shifting the relapsed/refractory multiple myeloma (RRMM) treatment landscape. Lack of head-to-head trials of triplet regimens highlights the need for real-world (RW) evidence. We conducted an RW comparative effectiveness analysis of bortezomib (V), carfilzomib (K), ixazomib (I), and daratumumab (D) combined with either lenalidomide or pomalidomide plus dexamethasone (Rd or Pd) in RRMM. A retrospective cohort of patients initiating triplet regimens in line of therapy (LOT) ≥ 2 on/after 1/1/2014 was followed between 1/2007 and 3/2018 in Optum’s deidentified US electronic health records database. Time to next treatment (TTNT) was estimated using Kaplan-Meier methods; regimens were compared using covariate-adjusted Cox proportional hazard models. Seven hundred forty-one patients (820 patient LOTs) with an Rd backbone (VRd, n = 349; KRd, n = 218; DRd, n = 99; IRd, n = 154) and 348 patients (392 patient LOTs) with a Pd backbone (VPd, n = 52; KPd, n = 146; DPd, n = 149; IPd, n = 45) in LOTs ≥2 were identified. More patients ≥75 years received IRd (39.6%), IPd (37.8%), and VRd (36.7%) than other triplets. More patients receiving VRd/VPd were in LOT2 vs other triplets. Unadjusted median TTNT in LOT ≥ 2: VRd, 13.9; KRd, 8.7; IRd, 11.4; DRd, not estimable (NE); and VPd, 12.0; KPd, 6.7; IPd, 9.5 months; DPd, NE. In covariate-adjusted analysis, only KRd vs DRd was associated with a significantly higher risk of next LOT initiation/death (HR 1.72; P = 0.0142); no Pd triplet was significantly different vs DPd in LOT ≥ 2. Our data highlight important efficacy/effectiveness gaps between results observed in phase 3 clinical trials and those realized in the RW.

Does the timing of kindergarten absences matter for children's early school success?

Although we know that children who are more frequently absent from school do less well academically, we know little about whether absences matter for other domains of development and whether the timing of their absences matter. In order to address these gaps in knowledge, we examined the experiences of 1,131 kindergartners (64% Hispanic, 7% Black, 17% Asian/other, 12% White) from a mid-Atlantic state. Covariate-adjusted regression analyses showed that children who missed school more frequently did less well in terms of their academic achievement and executive function skills both in kindergarten and through the end of first grade. Importantly, however, there were no consistent differences in children's social behavior nor did outcomes vary as a function of whether their absences occurred in the fall as compared with spring. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Arteriovenous Vascular Access–Related Procedural Burden Among Incident Hemodialysis Patients in the United States

As the proportion of arteriovenous fistulas (AVFs) compared with arteriovenous grafts (AVGs) in the United States has increased, there has been a concurrent increase in interventions. We explored AVF and AVG maturation and maintenance procedural burden in the first year of hemodialysis. Observational cohort study. Patients initiating hemodialysis from July 1, 2012, to December 31, 2014, and having a first-time AVF or AVG placement between dialysis initiation and 1 year (N= 73,027), identified using the US Renal Data System (USRDS). Patient characteristics. Successful AVF/AVG use and intervention procedure burden. For each group, we analyzed interventional procedure rates during maturation maintenance phases using Poisson regression. We used proportional rate modeling for covariate-adjusted analysis of interventional procedure rates during the maintenance phase. During the maturation phase, 13,989 of 57,275 patients (24.4%) in the AVF group required intervention, with therapeutic interventional requirements of 0.36 per person. In the AVG group 2,904 of 15,572 patients (18.4%) required intervention during maturation, with therapeutic interventional requirements of 0.28 per person. During the maintenance phase, in the AVF group 12,732 of 32,115 patients (39.6%) required intervention, with a therapeutic intervention rate of 0.93 per person-year. During maintenance phase, in the AVG group 5,928 of 10,271 patients (57.7%) required intervention, with a therapeutic intervention rate of 1.87 per person-year. For both phases, the intervention rates for AVF tended to be higher on the East Coast while those for AVG were more uniform geographically. This study relies on administrative data, with monthly recording of access use. During maturation, interventions for both AVFs and AVGs were relatively common. Once successfully matured, AVFs had lower maintenance interventional requirements. During the maturation and maintenance phases, there were geographic variations in AVF intervention rates that warrant additional study.

Prevalence of overweight and obesity, and associations with socio-demographic factors in Kuwait

BackgroundKuwait is amongst countries in the Gulf region with high income economy. According to the World Health Organisation (WHO), one in five adults in the Gulf region is obese. This study sought to evaluate the prevalence and magnitude of association between overweight, obesity, central obesity, and socio-demographic factors in Kuwait.MethodsA population-based cross-sectional survey of diabetes and obesity in Kuwait – part of the Kuwait Diabetes Epidemiology Program – was conducted between 2011 and 2014, targeting adults aged 18–82 years using the WHO STEPwise approach to non-communicable disease surveillance. Body mass index (BMI) was calculated to classify overweight and obesity, and waist circumference (WC) used to express central obesity. Multivariable logistic regression was used to estimate relationships between socio-demographic factors, overweight (25.0–29.9 kg/m2), obesity (≥30.0 kg/m2) or central obesity (WC ≥ 80 cm women; WC ≥ 94 cm men).ResultsRecords for gender (56% Men), age, BMI, governorate, and nationality existed for 4901 individuals. Mean age and BMI were 43 years and 30 kg/m2, respectively. Non-Kuwaiti nationals were more prevalent than Kuwaitis (76% vs 24%). Prevalence rates for overweight, obesity and central obesity were 40.6% (95%CI: 38.4–42.8%), 42.1% (95%CI: 40.0–44.3%) and 73.7% (95%CI: 71.7–75.6%), respectively. The youngest age group (18–29 years) had rates of 38.2% (95%CI: 29.2–47.7%), 27.2% (95%CI: 19.0–36.7%) and 49.9% (95%CI: 40.6–59.1%) for overweight, obesity and central obesity, respectively. In covariate-adjusted analyses, the odds of being overweight was 26% greater for men than for women. Conversely, women had a 54% (95%CI: 19–99%) and 7-fold (95%CI, 5–10-fold) greater odds of obesity/central obesity, respectively, than men. Greater educational attainment, physical activity, and non-Kuwaiti status were associated with lower odds of obesity/central obesity. History of smoking, elevated blood pressure, higher income, being married, greater age and female sex related to greater odds of obesity/central obesity.ConclusionOverweight was greater in men, obesity greater in women. Overweight and obesity prevalence were high in young adults aged 18–29 years, a significant public health concern. Efforts to integrate mandatory physical education to the school curriculum and promoting the creation of recreation spaces/parks to promote physical activities, will play a vital role in the early prevention of overweight/obesity in Kuwait.

The last frontier for global non-communicable disease action: The emergency department-A cross-sectional study from East Africa.

IntroductionDeaths due to non-communicable diseases (NCDs) have surpassed those due to communicable diseases globally and are projected to do so in Africa by 2030. Despite demonstrated effectiveness in high-income country (HIC) settings, the ED is a primary source of NCD care that has been under-prioritized in Africa. In this study, we assess the burden of leading NCDs and NCD risk factors in Kenyan Casualty Department patients to inform interventions targeting patients with NCDs in emergency care settings.Materials and methodsUsing the WHO STEPwise approach to surveillance (STEPS) tool and the Personal Health Questionnaire (PHQ-9), we conducted a survey of 923 adults aged 18 and over at Kenyatta National Hospital Emergency Department (KNH ED) between May-October 2018. Age, income, household size(t-test), sex, education, marital status, work status, and poverty status (chi-squared test or fisher’s exact test) were assessed using descriptive statistics and analyzed using covariate-adjusted logistic analysis.ResultsOver a third of respondents had hypertension (35.8%, n = 225/628), 18.3% had raised blood sugar or diabetes (18.3%, n = 61/333), and 11.7% reported having cardiovascular disease (11.7%, n = 90/769). Having lower levels of education was associated with tobacco use (OR 6.0, 95% CI 2.808–12.618, p < 0.0001), while those with higher levels of education reported increased alcohol use (OR 0.620 (95% CI 0.386–0.994, p = 0. 0472). While a predominant proportion of respondents had had some form of screening for either hypertension (80.3%, n = 630/772), blood sugar (42.6%, n = 334/767) or cholesterol (13.9%, n = 109/766), the proportion of those on treatment was low, with the highest proportion being half of those diagnosed with hypertension reporting taking medication (51.6%, n = 116/225).ConclusionsThis study establishes the ED as a high-risk population with potential for high impact in East Africa, should targeted interventions be implemented. Comprehension of the unique epidemiology and characteristics of patients presenting to the ED is key to guide care in African populations.

Homeschool Student Physical Activity Compared to Public/Private School Students: The 2017 US National Household Travel Survey.

School is an important place for physical activity (PA); however, little is known about how homeschool students' PA levels compare with public and private school students. This study estimated the national prevalence of PA levels of homeschool students compared to public and private school students. We used the 2017 National Household Travel Survey for school-aged participants (N=31,486) to compare weekly PA (not active, light or moderate activity, or vigorous activity) by school type (public/private or homeschool) and school level (elementary, middle, and high school). Unadjusted analyses found higher prevalence of physical inactivity for homeschool students, 14.2% (95% CI, 9.7-18.7%), compared to public/private school students, 8.0% (95% CI, 7.1-9.0%). For students who reported any PA, there was no difference in mean number of episodes for light or moderate PA [public/private: 4.2 (95%, CI, 4.1-4.3), homeschool: 4.3 (95% CI, 3.9-4.6)], or vigorous PA [public/private: 5.6 (95% CI, 5.5-5.7); homeschool: 5.5 (95% CI, 4.9-6.0)]. Results were comparable for covariate-adjusted analyses. A higher percentage of homeschool students report being physically inactive compared to public/private school students. However, data with more specific measures of PA intensity and duration are required to determine the potential magnitude of reported differences in behavior.

Gender interaction effect on coronary lumen volume to mass ratio after administration of sublingual GTN powder compared to tablet in coronary computed tomography angiography (CCTA)

Abstract Funding Acknowledgements Type of funding sources: None. Background Nitroglycerin (GTN) results in improved CCTA image quality and diagnostic accuracy due to vasodilation and improved contrast density. Although studies have shown that sublingual (SL) GTN spray has greater vasodilation and faster onset and duration of action compared to SL tablet, it is not commonly used due to cost. The comparative efficacy of SL GTN powder in CCTA is unknown. Purpose The purpose of this study is to determine whether SL GTN powder can increase the coronary lumen volume (V) and the coronary lumen volume to left myocardial mass ratio (V/M) compared to SL GTN tablet. Methods 34 patients (17 females) with 0.8 mg SL GTN powder and 34 patients (17 females) with 0.8 mg SL GTN tablet administration were included in this retrospective case-control study. GTN was given 5 minutes pre-CCTA on a 256 slice single-heartbeat CT. Inclusion criteria: CAD-RADS 0 or 1, precontrast LM + LAD AJ-130 CAC &amp;lt; 100, heart rate less than 75, phase of the cardiac cycle diastole, successful motion correction, Likert score 4 or 5, right- or co-dominance. The primary outcome assessed was left main plus left anterior descending (LM + LAD) V between GTN powder vs tablet. The secondary outcomes were LM + LAD V divided by 1) length of LM + LAD (derived mean area, A), and 2) M (V/M). The outcomes were measured by blinded PI with 17 yrs CCTA experience on GE workstation, 2020 version. Categorical variables were compared by Chi-Squared tests and continuous variables were compared between powder and tablet groups by unpaired t-tests if normally distributed, and Mann-Whitney U tests otherwise. Exploratory outcome analyses tested route of administration by sex interactions and main effects by Two-Way ANOVA’s. Further covariate-adjusted analyses were conducted using multiple linear regression models. Results Baseline characteristics were similar between powder and tablet administration. No statistically significant difference in median V, LM + LAD derived A , or median V/M was observed. A sex main effect demonstrated that females had significantly smaller V (630.6 mm3 vs 951.7 mm3, p&amp;lt; 0.0001) and A (4.2 mm2 vs 6.4 mm2, p&amp;lt; 0.0001) compared to males. These V and A sex differences were also observed when BMI or weight were included as covariates. When V and A were normalized by M, both revealed sex interactions depending on formulation. While males had higher normalized V and A in powder vs tablet (p &amp;lt; 0.04), females had the opposite with higher normalized V and A with tablet compared to powder (p &amp;lt; 0.04). Conclusions SL administration of the GTN powder 5 minutes before CCTA did not result in greater vasodilatory effect compared to the GTN tablet. However, gender interaction effects were observed, with greater V/M and A/M ratio in males with powder and greater V/M and A/M in women with tablet. These results suggest a potential differential gender effect based on the formulation of GTN. Prospective studies are warranted to evaluate these findings. Abstract Figure. LM + LAD Lumen Volume to LV Mass by Sex

Multimorbidity patterns and their relationship to mortality in the US older adult population.

BackgroundUnderstanding patterns of multimorbidity in the US older adult population and their relationship with mortality is important for reducing healthcare utilization and improving health. Previous investigations measured multimorbidity as counts of conditions rather than specific combination of conditions.MethodsThis cross-sectional study with longitudinal mortality follow-up employed latent class analysis (LCA) to develop clinically meaningful subgroups of participants aged 50 and older with different combinations of 13 chronic conditions from the National Health Interview Survey 2002–2014. Mortality linkage with National Death Index was performed through December 2015 for 166,126 participants. Survival analyses were conducted to assess the relationships between LCA classes and all-cause mortality and cause specific mortalities.ResultsLCA identified five multimorbidity groups with primary characteristics: “healthy” (51.5%), “age-associated chronic conditions” (33.6%), “respiratory conditions” (7.3%), “cognitively impaired” (4.3%) and “complex cardiometabolic” (3.2%). Covariate-adjusted survival analysis indicated “complex cardiometabolic” class had the highest mortality with a Hazard Ratio (HR) of 5.30, 99.5% CI [4.52, 6.22]; followed by “cognitively impaired” class (3.34 [2.93, 3.81]); “respiratory condition” class (2.14 [1.87, 2.46]); and “age-associated chronic conditions” class (1.81 [1.66, 1.98]). Patterns of multimorbidity classes were strongly associated with the primary underlying cause of death. The “cognitively impaired” class reported similar number of conditions compared to the “respiratory condition” class but had significantly higher mortality (3.8 vs 3.7 conditions, HR = 1.56 [1.32, 1.85]).ConclusionWe demonstrated that LCA method is effective in classifying clinically meaningful multimorbidity subgroup. Specific combinations of conditions including cognitive impairment and depressive symptoms have a substantial detrimental impact on the mortality of older adults. The numbers of chronic conditions experienced by older adults is not always proportional to mortality risk. Our findings provide valuable information for identifying high risk older adults with multimorbidity to facilitate early intervention to treat chronic conditions and reduce mortality.