Generalized Estimating Equations Research Articles

Behavioural economics to improve and motivate vaccination in primary care using nudges through the electronic health record: rationale and design of the BE IMMUNE randomised clinical trial

IntroductionAnnual influenza vaccination reduces disease burden but vaccination rates are suboptimal, with persistent disparities among subpopulations. The purpose of this trial is to evaluate multicomponent behavioural economic nudge interventions to clinicians and patients to increase influenza vaccination. This trial also includes an intensification nudge to reduce disparities in vaccination among older adult, primary care patients.MethodsThis is a two-part, multisite cluster randomised, pragmatic clinical trial. In the first part, a multicomponent nudge intervention will be tested over approximately 6 months (September 2023–February 2024). The second part consists of a replication trial conducted at an additional site during the following influenza season (September 2024–February 2025). Primary care clinics will be randomised to the nudge intervention or usual care. Eligible clinicians and patients at intervention clinics will receive the intervention, and patients deemed high risk for not receiving a vaccine will be further randomised to receive an intensification nudge. The primary outcome is vaccine completion during the eligible visit and the secondary outcome is vaccine completion within 3 months of the eligible visit.AnalysisThe effect of the clinic-level nudge intervention on the primary and secondary outcomes will be evaluated using generalised estimating equations (GEEs) with a clinic-level exchangeable working correlation to account for clustering of observations within the clinic. GEE models with an independent working correlation will be used to evaluate the impact of the additional intensification nudge on the primary and secondary outcomes.Ethics and disseminationThe University of Pennsylvania Institutional Review Board (IRB) approved this trial and serves as the single IRB of record (IRB #851838). Results will be disseminated via peer-reviewed publication and conference presentations.Trial registration numberNCT06057727.

Does Implementation of Office Based Addiction Treatment by a Nurse Care Manager Increase the Duration of OUD Treatment in Primary Care? A Secondary Analysis of the PROUD Randomized Control Trial

BackgroundImplementation of office-based addiction treatment (OBAT) by nurse care managers increases overall use of OUD medication, but it is unknown whether it increases treatment duration among treated patients. MethodsThe Primary Care Opioid Use Disorders Treatment (PROUD) trial was a pragmatic, cluster-randomized trial testing whether implementation of OBAT increased OUD treatment in 12 primary care clinics in 6 systems. One of 2 clinics per system was randomized to implement OBAT (intervention), the other, usual care (UC). We evaluated treatment duration for the 3 years after nurses began seeing patients at clinics randomized to intervention vs. UC. The primary sample included patients newly initiating OUD medication; the secondary sample included patients with ongoing OUD medication. The primary outcome was percentage of days with OUD medications after treatment initiation, modeled using linear generalized estimating equations (GEE). Modified Poisson GEE models assessed secondary outcomes (≥80% of days covered, ≥6 months on treatment). ResultsIn adjusted analyses, the mean difference between intervention and UC in percent days treated was 6.3% (95% CI -9.6%, 22.1%) in the primary sample and 2.3% (95% CI -36.4%, 31.8%) in the secondary sample. There was no significant difference in treatment duration between intervention and UC patients in either primary or secondary outcomes. ConclusionsImplementation of OBAT in this trial did not measurably increase duration of medication treatment among those treated for OUD compared to UC, suggesting that benefits of OBAT, at least in this trial, largely reflect increases in treatment access.

Alveolar Bone Reconstruction Simultaneous to Implant Removal due to Advanced Peri-Implantitis Defects: A Proof of Concept.

To evaluate the safety and effectiveness of alveolar bone reconstruction simultaneous to implant removal due to peri-implantitis. Partial or fully dentulous patients subjected to implant removal due to advanced peri-implantitis (≥ 50% of bone loss) lesions and seeking to have the failed implant replaced for esthetic or functional reasons were consecutively included. Guided bone regeneration was performed by means of a mixture of xenograft and autogenous bone and a ribose cross-linked barrier membrane. Re-entry for implant placement was performed at 4-month follow-up. Overall, six radiographic variables were assessed before (T0) and after (T1) alveolar bone reconstruction at four levels in ridge width (RW) and height (RH). Peri-implant conditions were evaluated at latest follow-up. Simple and multiple binary logistic regression models were calculated using generalized estimation equations to evaluate the effect of baseline upon reconstructive outcomes. In total, 20 patients (nimplant = 39) met the inclusion criteria. Alveolar RW and RH were augmented from T0 to T1 at all levels. All implants achieved primary stability. Only ~13% were subjected to ancillary bone regeneration simultaneous to implant placement. After a mean follow-up period after loading of ~2.2 years, ~70% implants demonstrated peri-implant health, while mucositis was diagnosed in the remaining implants. The performance of alveolar bone reconstruction in residual partially contained defects simultaneous to implant removal due to peri-implantitis lesions demonstrates being safe and effective for implant site development.

Examining the link between age of alcohol initiation, adolescent alcohol use and adult substance use

Abstract Background Understanding the relationship between adolescent alcohol use and adult substance use is important for prevention programmes. Existing evidence presents divergent findings and potential mechanisms are debated. Methods We estimated associations between the age of alcohol initiation and alcohol use at age 17 and substance use at age 20 in a nationally representative cohort (n = 4554). Weighted logistic regression models were fitted using Generalised Estimating Equations in multiply imputed and complete case data. Results Our analysis identified that 27% of participants reported first alcohol use at ≤ 14 years old, with 37% engaging in risky alcohol use by age 17. At age 20, 14% reported hazardous alcohol use, while 38% used tobacco, 24% cannabis, and 28% other drugs. The age at which alcohol was initiated and risky alcohol use at 17 years old were both strongly associated with alcohol, tobacco, cannabis and other illicit drug use at 20 years old. Sequential change in effect estimates coupled with non-overlapping confidence intervals suggest a dose-response relationship between age of alcohol initiation and tobacco and other drug use at age 20. Conclusions First use of alcohol at 14 or younger was common. Earlier alcohol initiation and risky alcohol use are each associated with substantially elevated risk for substance use at 20 years old even after accounting for common liability factors. Acknowledgement: Growing Up in Ireland (GUI) is funded by the Department of Children, Equality, Disability, Integration and Youth (DCEDIY). It is managed by DCEDIY in association with the Central Statistics Office (CSO). Results in this report are based on analyses of data from Research Microdata Files provided by the CSO. Neither the CSO nor DCEDIY take any responsibility for the views expressed or the outputs generated from these analyses. Key messages • Delaying alcohol initiation and preventing risky alcohol use during adolescence may reduce levels of substance use in young adults. • Self-reported early use of alcohol remains common.

High physical activity relates to higher risk of incident carotid plaque components

Abstract Background The rupture of carotid atherosclerotic plaque, primarily driven by plaque components, is among the leading causes of ischemic stroke. Although physical activity (PA) stands as a major modifiable target for prevention of atherosclerotic diseases, recent studies suggested a potential adverse impact of high-volume PA on atherosclerotic plaque burden in athletes. Data remains scarce from the community-dwelling population regarding to the impact of PA on the longitudinal change of carotid plaque components. Objectives To assess the association between PA and the incidence of carotid plaque components and explore whether the association of PA with stroke and all-cause mortality differs by the presence of plaque components. Methods Between 2007 and 2012, in a community- dwelling cohort in Netherlands, 1327 stroke-free persons (mean ± standard deviation age 72 ± 9 years, 45% women) with carotid atherosclerosis (carotid intima-media thickness > 2.5 mm) were invited for magnetic resonance imaging (MRI) to assess carotid plaque components. From these, 696 persons (1267 carotid arteries) underwent a follow-up MRI between 2014 and 2017 (median between-scan interval 6 years). Carotid plaque components included calcification, intraplaque hemorrhage (IPH), and lipid-rich necrotic core (LRNC). The volume of moderate, vigorous and total PA (unit: metabolic equivalent task hour, MET-h) was assessed using LASA Physical Activity Questionnaires around the time of the first MRI scan. Participants were followed for the occurrence of stroke or all-cause mortality until December 31, 2019. Generalized estimation equation and Cox regression models were used in the analyses, with adjustments for plaque size and other cardiovascular risk factors. Results Compared to lowest quintile PA group, participants in the highest quintile total PA group had a higher risk of new onset of plaque components, odds ratio (95%CI) 2.69 (1.21; 5.94) for calcification, 1.35 (0.82; 2.24) for LRNC and 1.93 (1.12; 3.34) for IPH (Figure 1). Similar associations were observed for vigorous PA but not for moderate PA. Over a median follow-up of 9.5 years, 118 persons suffered a stroke and 298 died. As shown in table 1, baseline IPH, rather than LRNC or calcification, modulated the associations of PA with stroke and all-cause mortality (P-interaction <0.05): higher total PA was associated with a lower risk of stroke among IPH-free persons, with the hazard ratio (95% CI) of 0.929 (0.867; 0.996) per 10 MET-h/week increase; no associations between PA and stroke were found among those with IPH. Similar associations were found between vigorous PA and all-cause mortality. Conclusions Among the middle-aged and elderly with subclinical atherosclerosis, high level PA, especially high vigorous PA, may lead to an unstable carotid plaque. The beneficial effect of PA on stroke and all-cause mortality is only among persons with a stable carotid plaque profile, especially without IPH.

Chinese Folk Songs Can Facilitate Chinese Language Learning - A Pilot Study.

While previous research has demonstrated the beneficial role of pop music in foreign language learning, there is a lack of studies exploring the potential impact of Chinese folk songs on Mandarin language acquisition. This study aimed to investigate whether a curriculum based on Chinese folk songs enhances the outcomes of Mandarin Chinese learning in foreign speakers. International students in a university in Beijing who were attending regular Mandarin courses were allocated into two groups: the group receiving an additional Chinese folk song-based curriculum (intervention) and the group not (control). Mandarin proficiency after one and two semesters between the two groups was assessed using the Chinese Proficiency Test (i.e., Hanyu Shuiping Kaoshi, HSK) by the Generalized Estimating Equations (GEE) analyses. 16 international students were analysed (intervention: 8; control: 8). After adjusting for time, the intervention group showed a significantly higher HSK score in listening section (adjusted β = 7.86, p = 0.015) than that of the control group. In conclusions, Chinese folk song-based curriculum has the potential to enhance Mandarin listening among foreign speakers.

Association between body mass index and mental health status among community-dwelling older adults

Abstract Background Maintaining a better physical and mental health status is an important issue for older adults in their later life. Although obesity has been suggested to reduce the risk of mood disorders in older adults, the findings are controversial. Thus, we aimed to investigate the association between body mass index (BMI) and mental health status among older adults in Taipei City and to elucidate risk factors contributing to mood disorders. Methods The elderly health examination database was obtained from the Department of Health, Taipei City government, from 2005 to 2016. A total of 80,121 older adults underwent at least two publicly funded health examinations, with 398,416 visits. We used the Brief Symptom Rating Scale (BSRS-5) questionnaire to estimated relative risks among potential risk factors with the generalized estimating equations (GEE) model to measure the mental health status of older adults. Mood disorders were defined as a score of ≥ 6 on BSRS-5. BMI, age, education level, gender, living alone, income status, number of chronic diseases, smoking, drinking, and exercise were included as covariates. Results Older adults who are overweight or obese have a lower risk for mood disorders (adjusted odds ratio [OR] = 0.82; 95% confidence interval [CI] = 0.79 - 0.85), while those underweight have a higher risk (OR = 1.31; 95% CI = 1.21 - 1.41). Other results show that being male (OR = 0.66; 95% CI = 0.63 - 0.69), higher education (OR = 0.72; 95% CI = 0.69 - 0.75), and have exercise habits (OR = 0.73; 95% CI = 0.70 - 0.76) were all positively correlated with better emotional status. However, low income (OR = 1.24, 95% CI = 1.14 - 1.35) and having more chronic diseases (OR = 1.99, 95% CI = 1.87 - 2.11) were all correlated with poor mental status among older adults. Conclusions Keeping an appropriate weight or even being overweight might be beneficial for older adults. In addition, encouraging older adults to maintain exercise habits can also help improve mood disorders. Key messages • Keeping an appropriate weight or even being overweight might be beneficial for older adults. • Encouraging the elderly to maintain exercise habits can also help improve mood disorders.

Association of park renovation with park use in New York City

Abstract Background Equity-driven citywide park redesign and renovation, such as the Community Parks Initiative (CPI), has the potential to increase park use and opportunities for physical activity in underserved communities. The objective of this study was to evaluate changes in patterns of park use following park redesign and renovation in low-income New York City (NYC) neighborhoods. Methods The Physical Activity and Redesigned Community Spaces study was a prospective quality improvement pre-post intervention study design with 33 intervention and 21 matched control neighborhood parks. Data were collected at baseline (prerenovation) and 2 follow-up points (3 months and 1-year post renovation) between 2016 to 2022 summers. Main outcomes encompassed park use and physical activity levels assessed using the well-validated System for Observing Play and Recreation in Communities. Park use was quantified by total number of park users, categorized by age group (≤20 years vs ≥ 21 years), sex, and physical activity level (sitting or standing vs walking or vigorous activity). Changes in outcomes between groups were compared via the generalized estimation equation. Results A total of 28,322 park users were observed across 1,458 scans. At baseline, 59.7% were 20 years or younger, 46.3% were female, and 43.8% were sitting or standing. Intervention parks showed more net park users compared with control parks from baseline to the final follow-up (difference-in-difference relative rate ratio, 1.69 [95% CI, 1.22-2.35] users/scan). The association was driven by a significant increase in adult users at intervention parks and an overall decrease in all users at control parks. Conclusions In this quality improvement study, park redesign and renovation were positively associated with park use in low-income neighborhoods. However, park renovations may need to be accompanied by other programmatic strategies to increase physical activity.

The Effect of Multidisciplinary Care on Polypharmacy in Advanced Cancer Patients near the End of Life

Abstract Objectives Multidisciplinary Team (MDT) aims to integrate cancer patient care plans and provide holistic care to improve clinical outcomes and quality of life. However, there is a lack of empirical evidence regarding the effect of MDT on polypharmacy in advanced cancer patients near the end of life, which warrants further investigation. Methods This retrospective cohort study utilizes the National Health Insurance Research Database (NHIRD), Taiwan Cancer Registry, and Cause of Death Statistics, provided by the Health and Welfare Data Science Center (HWDC), Ministry of Health and Welfare (MOHW). The study subjects were patients who were diagnosed with stage III or IV cancer, aged 65 or above, experienced recurrence or metastasis, and who died between 2014 and 2020. Propensity score matching (PSM) was employed, followed by analysis using the Generalized Estimating Equation (GEE) to examine the differences in the risk of polypharmacy in the last 30 days before death. In addition, to confirm the robustness of the results, we conducted two different sensitivity tests: the first way is to use different ages as sample selection criteria and only include people who died over 75 years old as study subjects; the second way is to use conditional logistic regression models as a multivariate statistical method. Results There were 35537 samples before matching, including 4942 who received MDT care and 30595 who did not. After 1:1 matching, 9884 patients were finally included in the analysis. The prevalence of polypharmacy significantly decreased during the study period from 59.90% to 58.80% (p = 0.03; trend test). When examined through different PIM criteria, patients who received care from MDT exhibited a lower risk of polypharmacy (OR = 0.91, 95% CI = 0.84-0.98). Conclusions Advanced cancer patients who received care from MDT during the end-of-life period had a significantly lower risk of polypharmacy. Key messages • The prevalence of polypharmacy significantly decreased during the study period from 2014 to 2020 among advanced cancer patients. • Advanced cancer patients who received care from MDT during the end-of-life period had a significantly lower risk of polypharmacy.

Effects of airway clearance in hospitalized children with neurologic impairment.

Airway clearance therapies (ACT) are often used to optimize respiratory function for children with neurologic impairment (CNI) hospitalized with acute respiratory infections (ARI). In a five-center retrospective cohort study of CNI aged 1-18 years hospitalized between 2013 and 2015 with ARI, we assessed the association of admission ACT with hospital outcomes (days to return to baseline respiratory support and length of stay [LOS]). Generalized estimated equation (GEE) models examined the association between ACT and outcomes, while accounting for clustering. Propensity scores estimating the likelihood of receiving ACT were included in the GEE models as inverse probability of treatment weights to account for confounding. In adjusted analyses, children receiving admission ACT required similar time to return to respiratory baseline (adjusted risk ratio [aRR] 1.24, 95%CI: 0.95,1.62) and had similar LOS (aRR 1.08, 95%CI: 0.88,1.32) compared with children not receiving ACT. Future studies should seek to identify subpopulations of CNI who benefit most from ACT.

Impact of surgical technique on postoperative ventricular arrhythmias in arrhythmic mitral valve prolapse

Abstract Background Mitral valve prolapse (MVP) is associated with progressive mitral regurgitation (MR) requiring surgical correction. A subset of patients with MVP may also constitute an "arrhythmic" phenotype suffering from malignant ventricular arrhythmias (VAs). Purpose To assess the impact of surgical technique for correction of degenerative MR including repair using artificial chords, repair with resection and mitral valve replacement (MVR) on longitudinal risk of VAs in patients with arrhythmic MVP. Methods Patients who had undergone mitral valve surgery for MVP with moderate to severe degenerative MR between 2010-2022 at a university hospital in Sweden were retrospectively included. Patients with ischemic heart disease, primary cardiomyopathy, channelopathy, or endocarditis were excluded. To examine changes in VAs (defined as sustained- or non-sustained ventricular tachycardias) as assessed by continuous Holter monitoring before and after surgery, generalized estimating equation (GEE) models were performed to account for the correlations between repeated monitoring in each patient and for differences in the time of measurement. Results Of 599 patients undergoing mitral valve surgery, 423 (71%) underwent repair using artificial chords, 62 (10%) repair with resection and 114 (19%) MVR. For those presenting with symptoms such as palpitations, presyncope, and/or syncope, Holter monitoring was conducted before (n=171; 29%) and/or after mitral valve surgery (n=184; 31%) (Figure 1). The distribution of VAs before and after surgery, stratified by surgical technique, is illustrated in Figure 2. In GEE models, repair using artificial chords was associated with increased postoperative VAs compared with the other surgical techniques (OR 2.14; 95% CI 1.19-3.83; p=0.01), repair with resection with reduced postoperative VAs compared with the other surgical techniques (OR 0.15; 95% CI 0.04-0.61; p=0.01), and no change in postoperative VAs was observed for MVR compared with the other surgical techniques (OR 0.724; 95% CI 0.39-1.35; p=0.31). The results remained similar after adjustment for age, sex, myxomatous disease/fibroelastic deficiency or bileaflet prolapse. Conclusion In patients with symptoms of palpitations, presyncope and/or syncope before or after mitral valve surgery, repair using artificial chords was associated with an increased risk of postoperative VAs. Prospective studies including continuous monitoring before and after surgery are needed to confirm these findings.

Impact of the transition to retirement on alcohol consumption: a longitudinal analysis within SHARE

Abstract In an ageing society, the impact of retirement on behavioural risk factors and health status needs to be carefully assessed. Evidence on the short-term and long-term effects of retirement on alcohol consumption are contrasting and inconsistent. A longitudinal study was conducted based on data from the Survey on Health, Ageing and Retirement (SHARE) collected between 2004 and 2020 in 27 European countries and Israel. A repeated measure generalised estimating equation (GEE) model was fitted to estimate the relative risks (RR) and corresponding 95% confidence intervals (CI) of alcohol consumption (frequency, quantity, and binge drinking) at different time periods before and after retirement. We selected a cohort of 8,998 individuals who were employed at baseline and retired during follow-up (median follow-up: 9 years; maximum: 16 years). Compared to the year of retirement, the RR for habitual daily or near-daily drinking was 0.88 (95%CI 0.76-1.02) 10 years before retirement and 0.92 (95%CI 0.83-1.02). This pattern reversed post-retirement with a RR of 1.12 (95%CI 1.01-1.23) 3-4 years after retirement and 1.28 (95%CI 1.11-1.48) 10 years or more after retirement. No significant changes in the consumption of high volumes (more than 8 units of alcohol) were observed: while the frequency of regular drinking might increase post-retirement, the instances of heavy episodic drinking do not necessarily rise. Additionally, a reduction in occasional heavy drinking episodes was noted both before (RR 0.86; 95%CI 0.77-0.95, 5-9 years prior) and after retirement (RR 0.78; 95%CI 0.66-0.93, more than 10 years after). These findings underscore the complexity of alcohol use behaviours in the context of retirement. The increase in regular drinking post-retirement might be attributed to changes in daily structure, social interactions, or coping mechanisms for life transitions. The decline in binge drinking suggests a shift towards more moderated consumption patterns as individuals age. Speakers/Panelists Licia Iacoviello University of Insubria, Varese, Italy João Vasco Santos University of Porto, CINTESIS, ARS Norte, Porto, Portugal

Examining factors associated with cocaine use in late adolescence and early adulthood

Abstract Background In 2022, cocaine was the leading problem drug for which individuals sought treatment in Ireland, overtaking opioids for the first time. Despite increasing concerns about cocaine, there is limited longitudinal research examining factors associated with cocaine use in the general youth population. We describe levels of use and associated factors at 17 and 20 years old Methods Past-year cocaine use was studied at age 17 (N = 5965) and 20 (N = 4679) in a nationally representative cohort. Individual, family, social and environmental exposure variables were selected a priori. Weighted logistic regression models were fitted using Generalised Estimating Equations to multiply imputed and complete case data. Results Cocaine use was reported by 220 (4%) at age 17, and 1072 (23%) at age 20. Both individual and community factors predict use. Earlier alcohol initiation and having friends who use cannabis were strongly associated with increased odds of cocaine use at both ages. Those with parents who reported that neighbourhood intoxication or drug-taking was common had elevated odds of cocaine use at age 17. Conclusions Past-year cocaine use at 20 years old in this cohort is substantially higher than other international cohort studies. Levels of cocaine use increase significantly between 17 and 20 years old. Acknowledgement: Growing Up in Ireland (GUI) is funded by the Department of Children, Equality, Disability, Integration and Youth (DCEDIY). It is managed by DCEDIY in association with the Central Statistics Office (CSO). Results in this report are based on analyses of data from Research Microdata Files provided by the CSO. Neither the CSO nor DCEDIY take any responsibility for the views expressed or the outputs generated from these analyses. Key messages • Our study underscores significant cocaine use rates and correlations with early substance initiation and neighbourhood factors. • This emphasizes the necessity of a comprehensive, multilevel strategy for preventing cocaine use.

The evolution of carotid atherosclerotic plaque composition: a prospective study

Abstract Background The rupture of carotid atherosclerotic plaque is one of the major causes of ischemic stroke, and largely determined by the composition of the plaque. To date, most studies on carotid plaque composition focused on individual plaque components, whilst the interplay between different components within the same plaque may be a critical driving force for plaque evolution and rupture. Objectives To determine the interplay between carotid plaque components over time and describe the dynamics of plaque composition with a specific focus on age- and sex-specific changes in a population-based setting. Methods From a population-based cohort in Netherlands, 802 participants (mean age ± SD 68 ± 8 years, 43% women) with subclinical carotid atherosclerosis underwent repeat magnetic resonance imaging (MRI) of carotid plaque (first scan between 2007 and 2012, second scan between 2014 to 2017). We evaluated carotid plaque composition, including calcification, lipid-rich necrotic core (LRNC) and intraplaque hemorrhage (IPH). To assess the relationship between the incidence of one specific component and baseline plaque composition, plaques with this specific component present at the baseline were excluded. Generalized estimation equation models were used with adjustments for baseline plaque size and cardiovascular risk factors. We demonstrated the evolution of plaque composition along age and by sex. Results Baseline presence of calcification in carotid plaque is independently associated with a higher incidence of IPH (adjusted odds ratio: 2.25; 95% confidence interval: 1.40 to 3.63). No associations were found between baseline plaque composition and the new onset of calcification or LRNC. The proportion of complex plaques with multiple components significantly increased at follow-up (Figure 1a). The plaque composition dramatically evolved over time and the proportion of plaques with two or more components started with 10% around 55 years and increased to over 50% after 70 years of age (Figure 1b). Although the age distribution was comparable between men and women, men were more likely to have and develop plaques with multiple vulnerable plaque components such as IPH (Figure 2). Conclusions A higher incidence of IPH was found in plaques with baseline calcification. The pre-existing plaque composition strongly determines how the plaque will evolve over time. Given the interplay between individual components, the overall plaque composition exhibits significant age- and sex- specific characteristics.

Discrete Choice Experiment on Financial Incentives for Engaging Young Adults in Vaping Cessation Programs

Introduction Contingency management involves rewarding individuals based on objective evidence of behavioral changes. This study explores preferences for financial incentives in vaping cessation programs. Methods A discrete choice experiment (DCE) was conducted among young adult current e-cigarette users aged 19-29. DCE attributes (and levels) included reward amount ($100, $300), reward schedule (consistent value, escalating value), reward procedure (gain-framed, loss-framed), vaping education modules (yes, no), text messaging support (yes, no), and cost ($30, $100). Participants were randomized into one of the four blocks, each containing four choice sets. Each choice set presented two hypothetical vaping cessation programs. Choice data (n × choice sets × alternative programs = 154 × 4 × 2 = 1,232 observations) were analyzed using generalized estimation equation models. Results Participants showed a preference for vaping cessation programs offering a higher reward amount (odds ratio [OR] = 11.5; 95% CI,7.0-19.2), gain-framed rewards for sustained abstinence (OR = 1.4; 95% CI,1.0-1.8), text messaging support (OR = 1.9; 95% CI,1.4-2.5), and a lower program cost (OR = 2.6; 95% CI,1.8-3.8). Interaction tests showed significant effects of the rewards procedure among daily e-cigarette users (adjusted OR [AOR] = 2.1; 95% CI,1.3-3.5), but not some-day users; and among those with no quit attempts in the past six months (AOR = 2.7; 95% CI,1.5-4.7), but not those with previous quit attempts. Female participants preferred text messaging support (AOR = 3.6; 95% CI,2.3-5.4), whereas male participants did not show this preference. Conclusion A multifaceted vaping cessation intervention augmented with financial incentives might improve participation and engagement among young adults. Future studies should investigate how these attributes can enhance program reach and vaping abstinence outcomes in real-world settings.

Influences of tea consumption on self-rated health and life satisfaction among older adults: Evidence from the CLHLS.

The benefits of tea consumption as a special diet for health and life satisfaction have attracted considerable attention; however, it is not clear whether the effect of tea consumption on self-rated health (SRH) and self-rated life satisfaction (SRL) is equal among all types of tea, and it is unclear whether these associations are impacted by gender and age in older adults. This study aimed to examine the associations between tea consumption, SRH and SRL in older adults and to explore the role of gender and age. Participants aged 65-105 (N = 78,345) were interviewed in the years 2002, 2005, 2008, 2011, 2014 and 2018 in the Chinese Longitudinal Healthy Longevity Study (CLHLS). Generalized estimation equations (GEE) with the identity link function were adopted to estimate the cross-sectional associations of tea consumption with SRH and SRL. GEE with the logic link function were used to explore the longitudinal associations of tea consumption with SRH decline and SRL decline. Drinking tea at present, especially scented tea, was significantly associated with better SRH and SRL for older adults. Male participants benefited more from tea consumption than females, and the protective effect of green tea consumption on improving SRH and SRL in males was evident. Older adults aged 90-105 with current tea consumption daily had better SRH and reduced risk of SRL decline.

Investigation of pregnancy tendency, reproductive characteristics, and disability in women with multiple sclerosis: A secondary data analysis of the national registry in Iran

Abstract Background: Multiple sclerosis (MS) predominantly affects women of childbearing age, significantly impacting their quality of life (QOL).The diagnosis of MS can influence pregnancy intention, and the level of disability associated with MS may change before and after pregnancy. This study aims to analyze the reproductive characteristics of Iranian female patients with MS (PwMS) and their association with the Expanded Disability Status Scale (EDSS) and pregnancy tendency, providing valuable insights into disease progression and the development of tailored treatments. Methods: A cross-sectional study was conducted using data from the nationwide MS registry of Iran (NMSRI) from 2018 to 2021. Patients without a documented history of pregnancy, MS type, or EDSS score were excluded from the study. Various statistical methods, including nonparametric tests, the generalized estimating equation (GEE) model, and multiple logistic regression, were employed to analyze the data. Results: The study included 1120 PwMS with a median diagnostic age of 31 and a disease duration of 6 years. The majority had relapsing-remitting MS (RRMS) and the mean EDSS score at bassline was 1.5 ± 1.4. A history of pregnancy or abortion was associated with higher EDSS scores. Multiparity before MS diagnosis was linked to EDSS score ≥ 5, while this EDSS range was associated with decreased parity after MS diagnosis (all P-values < 0.05). Conclusion: Pregnancy and parity can affect the disability in female PwMS irrespective of clinical symptoms, diagnosis age, and MS type. Moreover, the chance of parity may be affected by a higher disability score, which should be considered in the clinical setting.

Investigating the peri-saphenous vein graft fat attenuation index on computed tomography angiography: relationship with progression of venous coronary artery bypass graft disease and temporal trends

BackgroundTo clarify the fat attenuation index (FAI) change trend of peri-saphenous vein graft (SVG) and determine the association between FAI and graft disease progression based on CCTA images.MethodsPatients with venous coronary artery bypass grafts (CABGs) were consecutively enrolled in this retrospective study. In study 1, 72 patients who had undergone 1, 3, and 5 years of CCTA examinations without graft occlusion were recruited, and generalized estimation equation was used to analyze the peri-SVG FAI change trend over time. In study 2, 42 patients with graft disease progression and 84 patients as controls were propensity score-matched. Generalized linear mixed model and continuous net reclassification improvement (NRI) were used for assessing the associations with graft disease progression. Multivariable Cox regression analysis was used for assessing risk factors predicting cardiac events.ResultsIn study 1, both the FAI of proximal right coronary artery and SVG decreased over time. In study 2, the 1-year CTA-derived FAI of grafts and graft anastomosis were independent indicators of graft disease progression at the 3-year CCTA follow-up (graft: odds ratio [OR] = 1.106; 95% confidence interval [CI] = 1.030–1.188, P = 0.006; graft anastomosis: OR = 1.170, 95% CI = 1.091–1.254, P < 0.001). Inclusion of the graft anastomosis FAI significantly improved reclassification compared with graft FAI (continuous NRI = 0.638, 95% CI: 0.345–0.931, P < 0.001). Moreover, The graft anastomosis FAI was found to be a risk factor for cardiac events after CABG and no statistically significant difference was found in the graft FAI (graft anastomosis: HR = 1.158, 95% CI = 1.034–1.297, P = 0.011; graft: HR = 1.116, 95% CI = 0.995–1.251, P = 0.061).ConclusionsA synchronism was found in the FAI change trend between native coronary artery and venous graft, which both decreased over time. The CCTA-derived FAI of venous grafts showed the potential of demonstrating SVG disease progression and graft anastomosis served as the optimal measured location.

Factors Associated with the Development of Anti-drug Antibodies to TNFi and the Consequences for Axial Spondyloarthritis: A Two-year Follow-up Study.

To evaluate the development of anti-drug antibodies (ADAb) against tumor necrosis factor inhibitors (TNFi) therapy during a 2-year period and search the factors linked to patients with axial spondyloarthritis (axSpA). Biologic-naive patients with axSpA were included in this observational study. Serum drug levels and ADAb were measured at weeks 12, 24, 52, and 104 of treatment by enzyme-linked immunosorbent assay (ELISA). The development of ADAb and factors related to ADAb over time were investigated using generalized estimating equations (GEE). A total of 180 patients with axSpA (116 male, mean (±SD) 45.6 (±11.9) years) who started TNFi treatment (etanercept (32.2%), adalimumab (27.2%), golimumab (20.6%), infliximab (20%)) were included. In the etanercept treatment group, only 1 patient had ADAb at 12 weeks and 24 weeks. Anti-drug antibodies against TNFi drugs were present in the adalimumab group in 32.7% of patients and in the infliximab group in 21.2% of patients at 12 weeks, and the proportion of ADAb-positive patients were found to be stable throughout the follow-up for adalimumab- and infliximab-treated patients. In the golimumab group, one patient had ADAb against golimumab at 12 weeks and the proportion of ADAb-positive patients increased throughout follow-up. In longitudinal analysis, baseline age, TNFi type, longitudinal Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and ASDAS-CRP scores, serum C-eeactive protein (CRP) levels, presence of adverse events and treatment discontinuation were associated with the presence of ADAb. The development of ADAb against TNFi therapy is associated with younger age, high disease activity, the development of adverse events and more common treatment discontinuation in patients with axSpA during 2-year follow-up.

Changes in BMI prior to and during the COVID-19 pandemic among children: a retrospective cohort study in San Francisco, CA

BackgroundThe COVID-19 pandemic led to dramatic changes in the lives of children that impact cardiometabolic health. Cities and counties had varying policies with respect to school closure, recreational programs, and efforts to mitigate food insecurity and economic distress. Our objective was to evaluate changes in BMI-z score and prevalence of overweight/obesity prior to and during the pandemic among children in San Francisco, CA, where public schools were closed for 18-months.MethodsThis was an electronic medical record-based retrospective cohort study. We included 15,401 children, 4–17 years of age at study onset. Our exposure was time into each of three time periods: (1) March 2018-February 2019; (2) March 2019-February 2020; (3) March 2020-August 2021 (the pandemic period of school closure). Generalized estimating equations (GEE) were used to assess changes in BMI-z score and overweight/obesity across the three time periods. We assessed for effect modification by age-category, insurance status, and race/ethnicity.ResultsMean BMI-z score increased by 0.06 per year in time period 2, the year prior to the pandemic (p < 0.001, 95% CI: 0.04, 0.09), and by 0.12 per year during time period 3, the first 18 months of the pandemic (p < 0.001, 95% CI 0.10, 0.13). The proportion of children with overweight/obesity increased by 1.4% points per year during time period 2 (p = 0.012, 95% CI: 0.03, 2.46) and by 4.9% points per year during the first 18 months of the pandemic (p < 0.001, 95% CI: 4.11, 5.67). The effect modification analysis demonstrated that the youngest age group, publicly insured children (versus privately insured), and Black, Latino, and Asian children (versus White children) experienced greater increases in BMI-z score during the pandemic (p < 0.01 for all comparisons). The youngest age group (p = 0.022) and publicly insured children (versus privately insured children) (p < 0.001) also experienced greater increases in the proportion of children with overweight/obesity during the pandemic.ConclusionsAmong children in San Francisco, increases in BMI-z score and overweight/obesity were greater during the pandemic compared to prior changes, with the most pronounced increases among younger and publicly insured children. These findings support the need for more targeted and effective policies for addressing childhood overweight/obesity, especially among these high-risk populations.