Generalized Estimating Equations Research Articles

Effects of Tactile Massage in Improving Older Residents' Psychological Health in Long-Term Care Facilities: A Randomised Controlled Trial.

Loneliness, anxiety and depressive symptoms are common among older residents in long-term care facilities (LTCFs), which can negatively impact their quality of life and increase mortality rates. Addressing these psychological health issues is an important task for nursing staff. There is a need for easy and accessible interventions to improve older residents' negative emotions. Tactile massage (TM) is a form of touch therapy that induces oxytocin, which can help individuals feel relaxed, experience pleasure and reduce anxiety. TM can also provide a sense of security and care for individuals. This study aimed to evaluate the effects of TM in improving older residents' psychological health in LTCFs. In this study, we applied a two-arm randomised controlled trial research design. We used convenience sampling to enrol 55 older residents in three long-term care facilities who were randomly assigned to an intervention group and a comparison group. The intervention group received TM by research assistants on both hands for 15 min per time, twice a week for 4 weeks and the comparison group received regular care. Data were collected before and after the intervention. Generalised estimating equations (GEEs) were used to evaluate the effectiveness of the intervention. There were no significant differences in loneliness, anxiety, depressive symptoms, happiness, ear temperature, heart rate or diastolic blood pressure between the two groups after the intervention. However, the intervention group had significant improvements in comfort (B = 0.86, p < 0.001), relaxation (B = 1.00, p < 0.001), respiratory rate (B = -0.16, p = 0.021) and systolic blood pressure (B = - 4.17, p = 0.002) compared to the control group. TM can help older residents who live in LTCFs feel relaxed and comfortable. TM can be easily implemented as it requires no tools. We recommend that nursing staff and healthcare professionals incorporate TM as part of their care routines. They also can encourage family members to perform TM on residents during their visits to enhance residents' comfort and relaxation. The Consolidated Standards of Reporting Trials (CONSORT) checklist was used for this paper. ClinicalTrials.gov (NCT05052138).

Abstract P332: High Shared Decision-Making Scores Associated with Blood Pressure Control: The Office Guidelines Applied to Practice (Office-GAP) IMPACT Program

Introduction: Cardiovascular disease (CVD) mortality is higher in people with diabetes mellitus due to the increased prevalence of CVD risk factors. The Office-Gap IMPACT Program (Office-Guidelines Applied to Practice Improving Diabetic Patients’ Adherence to Treatment and Prevention of Cardiovascular Disease) is a patient activation cluster-randomized trial (intervention: Office-GAP + text vs. control: text alone) seeking to improve communication and patient-provider partnerships through patient and provider training in shared decision-making (SDM), use of a guideline-based checklist, and text messaging to improve medication adherence in Federally Qualified Health Care Centers. Hypothesis: We assessed the hypothesis that individual level demographic and clinical characteristics of patients enrolled in Office-GAP IMPACT would be associated with patient-reported SDM using the CollaboRATE 3-item instrument, which measures three core SDM domains: (1) explanation of health issues, (2) elicitation of patient preferences and (3) integration of patient preferences into decisions with a 10-point response scale for each domain ranging from 0 “No effort was made” to 9 “Every effort was made.” Methods: The CollaboRATE was completed three months after baseline. A top-scoring method (a rating of 9 for all three items) was used to dichotomize CollaboRATE responses into two categories - participants who reported the highest levels of SDM on each of the three items versus those who did not. Accounting for the cluster-randomized design, generalized estimating equations (GEEs) were used to compare demographics and baseline factors that may be associated with the outcome. Results: A total of 288 patients were enrolled (intervention, N=158 and control, N=130). Among those with non-missing CollaboRATE scores, 152 (73% ± 3%) had high SDM. The inverse probability of non-missing weighting method was used to account for the missing data in CollaboRATE. Results from the weighted univariable models suggested older patients, history of smoking, and those with BP under control (&lt; 140/90 mmHg) at baseline were more likely to be satisfied with the SDM process. In multivariable logistic regressions, only BP control was statistically significant after adjusting for other factors. Conclusions: In conclusion, participants with BP control had higher SDM scores, which could lead to better health outcomes. Providers should include the practice of SDM principles in every clinical encounter.

Acute effect of different types of moderate intensity physical exercise on affective response and mood state in individuals with substance use disorder

Substance use disorder (SUD) affects a significant percentage of people around the world, negatively influencing aspects of physical and mental health. Physical exercise can promote acute and chronic effects on the affective response and mood of individuals and has shown promising effects in all phases of rehabilitation. The objective of this study was to verify the acute effects of two types of physical exercises at moderate intensity on the mood state and on the affective response of individuals hospitalized for the treatment of SUD. For this purpose, 43 individuals (31 men and 12 women) underwent two physical exercise sessions (one aerobic and one functional) and a control session. Before and immediately after the sessions, subjects answered questionnaires about mood, affective valence, and perceived arousal. Generalized estimating equations (GEE) followed by the Bonferroni post hoc test were used to assess the effect of timing and session on the variables. The results showed significant improvements after both physical exercise sessions in mood (reduction in levels of tension, depression, anger, fatigue, and confusion) and in affective valences (feeling of pleasure and arousal perception), with no changes after the control session. It is observed that different types of physical exercises can positively impact the mental health of individuals undergoing treatment for SUD and should be used as a non-pharmacological strategy in the rehabilitation process.

DSD-related attitudes and beliefs held by pediatric endocrinologists and urologists: Insights from the North American disorders/differences of sex development (DSD) clinician survey

Disorders/Differences of Sex Development (DSD) encompass congenital conditions with atypical development of chromosomal, gonadal, or anatomical sex. Due to the rarity and complexity of these conditions, strong evidence for clinical practices is scarce, leading to controversies in management. This study, part of a broader project, examines changes over time in the attitudes and beliefs of DSD healthcare providers, focusing on factors contributing to patients' life satisfaction and the influence of medical specialty, gender, and age. Participants included active members of the Pediatric Endocrine Society (PES) and the Societies for Pediatric Urology (SPU) at three time points: 2003-2004 (T1), 2010-2011 (T2), and 2020 (T3). A survey covering predictors of patient life satisfaction, attitudes and beliefs regarding DSD care and outcomes, and participant characteristics was administered. Data were analyzed using descriptive statistics and Generalized Estimating Equations (GEE). Demographics: Participation rates were 56% (PES) and 64.7% (SPU) at T1, 41.1% (PES) and 52.3% (SPU) at T2, and 25.6% (PES) and 51.2% (SPU) at T3. Most participants were male (T1: 70.6%, T2: 61.7%, T3: 70.6%). Factors Affecting Life Satisfaction: Both endocrinologists and urologists ranked "gender identity consistent with assigned sex" as most important. Over time, the endorsement of some factors, such as performing genital surgery at Centers of Excellence, increased, while others, like the influence of prenatal androgen exposure determining gender identity, varied by specialty and gender. Attitudes and Beliefs: Across 18 statements, responses indicated three clusters with strong agreement, moderate agreement, and strong disagreement. Statements on the importance of family background and avoiding gender discordance were consistently endorsed, while those on delaying hypospadias repair until consent were least endorsed. The study highlights variability in beliefs about DSD management over time, influenced by specialty, gender, and age. Despite consensus on some care principles, discrepancies remain, particularly regarding the impact of prenatal androgens and the timing of surgical interventions. These findings underscore the need for regular interdisciplinary communication to align clinical practices with evidence-based guidelines and address subjective beliefs. The survey illustrates evolving perspectives among DSD healthcare providers, emphasizing the need for continued dialogue and education to bridge gaps between clinical evidence and practice. Collaborative efforts, such as the international I-DSD and the U.S. DSD Translational Research Network, are crucial for advancing patient-centered care in this field.

Thyroid Hormone Replacement Dosing after Bariatric Surgery in Patients with Primary Hypothyroidism And Severe Obesity: Tehran Obesity Treatment Study.

Background: Obesity and hypothyroidism are common medical conditions that are associated with each other. Bariatric surgery (BS) is a common approach used to achieve substantial weight loss in obese patients. However, there is limited evidence regarding the need for postsurgery levothyroxine (LT4) dose adjustment in patients with hypothyroidism undergoing BS. Methods: This was a three-year prospective cohort study assessing postsurgery LT4 requirements with attention to body composition changes. The current study included 1030 patients with hypothyroidism, who underwent sleeve gastrectomy (SG) (n = 707, 88.3% women) or one anastomosis gastric bypass (OAGB) (n = 323, 92% women). Patients were followed for 36 months after surgery. A bioelectrical impedance analyzer was used for body composition assessment. LT4 requirements were assessed by generalized estimating equation (GEE) methods adjusted for weight as a time-varying covariate. Results: During the follow-up, TSH (mIU/L) and T4 (ng/dL) measurements did not significantly change in the OAGB group over time. However, in the SG group, TSH measurement decreased over time (ptrend = <0.001). In the third year of the follow-up, 56.1% and 33.3% of patients in the SG and OAGB groups experienced LT4 (μg/day) dose reduction, while 24.4% and 9.1% of the participants experienced LT4 dose increments, respectively. GEE analysis showed a significant increase in the LT4/fat mass (FM) (μg/kg) ratio after 36 months of follow-up compared with the baseline in both the SG [1.8 (1.5-2.2) to 2.7 (2.0-3.5), ptrend = 0.039)] and OAGB [1.7 (1.4-2.2) to 3.2 (2.7-4.8), ptrend = <0.001)] groups. Moreover, patients who underwent OAGB experienced greater LT4/FM (μg/kg) dose adjustments compared to those undergoing SG (pbetween = 0.060). In both groups, after the first year, the increase in LT4/FM (μg/kg) plateaued (pinteraction = 0.009). Conclusion: Most hypothyroid patients experienced either a reduction or no change in LT4 (μg/day) dosage after 36 months in both surgical groups. The LT4/FM (μg/kg) was significantly increased in patients undergoing either SG or OAGB with greater alterations in the latter. Further studies on larger populations and with longer duration of follow-up are needed to confirm our results.

P048 CARDIOBREATH APPLICATION: SLOW BREATH TO DECREASE BLOOD PRESSURE AND IMPROVE AUTONOMIC MODULATION

CardioBreath is an application of slow deep breath for increasing cardiovascular performance in health and sports. Biological signals like spontaneous respiratory rate (SRR) are employed to prescribe slow respiratory exercises. Heart rate (HR) collected by the app is employed to track results. It aims to increase vagal modulation and decrease arterial pressure. The aim of this study is to verify the accuracy of CardioBreath data collection of SRR and HR. Following this, the evaluation of the cardiac vagal modulation evoked by the audiovisual lessons of slow breath of CardioBreath. Methods: Coherence of biological signals: Healthy individuals have been assessed using CardioBreath data collection of HR to compare their values simultanealy with those from Polar V 800, (ten sets each participant. SRR was collected by CardioBreath compared to visual counting (five sets). Pair wise t-test comparisons were performed in order to detect diferences between evaluations. Cardiac vagal modulation has been collected by Finometer and analyzed by Cardioseries, before (baseline evaluation) and after randomized audiovisual lessons of the CardioBreath App. These data will be analyzed by GEE (generalized estimation equation). All data are demonstrated as Mean (M) ± Standard deviation (SD) (p&lt; 0,05) Partial Results: 50 healthy individuals participated of the first phase of the research, aged from 21 to 57 years old generating 460 analyzed pairs: HRApp 71.66 ± 11.68 bpm versus HRPolar 72.02 ± 13.24 bpm (p = 0.66). A total of 225 pairs have been analyzed for SRR: SRRApp 13.88 ± 4.63 cpm versus SRRvisual 13.82 ± 4.48 com (p = 0.44). Conclusions: The comparison of biological signals of CardioBreath App demonstrate that either HR and SRR are in coherence with data obtained by the Polar V 800 (HR) and visual method (SRR). New data of the autonomic responses of lessons of the CardioBreath App will be available in September. More on CardioBreath App at www.cardiobreath.com (only in Portuguese)

Lidocaine pre-treatment for Succinylcholine induced postoperative myalgia and associated factors: Longitudinal study

IntroductionPostoperative myalgia in surgical patients is mainly caused by the routinely administered depolarizing muscle relaxant, Succinylcholine. There are many proposed strategies but no one were indicated as ideal preventive mechanisms for Succinylcholine induced post-operative myalgia. Even if data were sparse, Lidocaine pretreatment can reduce postoperative myalgia which requires further supportive evidences urging the initiation of this study. MethodsProspective longitudinal cohort study was conducted from March to May 2021 at Dessie Comprehensive Specialized Hospital on 208 adult surgical patients. Patients pretreated with Lidocaine preoperatively were grouped as exposed and others as unexposed. Patients meeting the inclusion criteria during the study period were selected sequentially from the daily operation schedule list. Postoperative myalgia level was measured using post-operative myalgia survey repeatedly. The result was analyzed by Cochran's Q test and generalized estimating equation (GEE). Adjusted odds ratio with 95 % confidence interval and p value < 0.05 was used to show the difference, direction and strength of association. ResultExposure specific incidence rate showed that 22 %, 22 % and 29.8 % of patients exposed to Lidocaine and 40.6 %, 42.7 % and 34 % not exposed to Lidocaine developed myalgia at 12, 24, and 48 h respectively. There is no significant difference in the incidence of myalgia over time between the repeated measurements in Lidocaine exposed patients (p = 0.513) but in non-exposed patients (p = 0.003). Also, there is no difference in the distribution of other predictors between Lidocaine exposed and non-exposed groups (p > 0.05). Exposure to Lidocaine reduces postoperative myalgia significantly [AOR = 0.33, 95 % CI = (0.17,0.66)]. Multimodal analgesia [AOR = 0.32, 95 % CI = (0.18,0.55)], non-steroidal anti-inflammatory drugs alone [AOR = 0.47, 95 % CI = (0.29,0.76)], postoperative immobility [AOR = 0.61, 95 % CI = (0.47,0.8)], and being male [AOR = 0.48, 95 % CI = (0.26,0.87)] were other determinants in reducing Succinylcholine induced postoperative myalgia. ConclusionLidocaine pretreatment can significantly reduce the occurrence of Succinylcholine induced postoperative myalgia. Additionally, usage of multimodal analgesia with non-steroidal anti-inflammatory drugs or even only non-steroidal anti-inflammatory drugs in the intraoperative and postoperative period can reduce Succinylcholine induced postoperative myalgia.

Nurse-led proactive mobile application in symptom management for children with medical complexity: Study protocol for a randomized controlled trial.

To investigate the effect of a nurse support using a proactive mobile app to enhance parental self-efficacy in symptom management for children with medical complexity. A single-blinded, randomized controlled trial with a two-armed repeated measures design. Eligible parents and the children will be recruited from the special schools and non-government offices. They will be randomly assigned either to the intervention or control groups. Subjects in the study group will receive nurse parental support using a symptom management mobile app for 3 months. The control group will receive the usual care that is available in the community. Data will be collected pre-intervention (T1), immediately after the intervention (T2), and three-month after intervention (T3). The primary outcome is parental self-efficacy. The secondary outcomes include child's symptom burden and their health service utilization. Primary outcome will be compared across two groups in T2 and T3 using with control for the pre-test value of parental self-efficacy. Generalized estimating equation (GEE) will be used to address secondary objectives from T1 to T3 with appropriate link function. As a result of the successful implementation of this nurse-led symptom management, parental self-efficacy will be enhanced. Both the symptoms reported by the children and their health service utilization will be reduced. Findings of this study will help in service delivery improvements because it maximizes the availability and accessibility of paediatric health service to parents and the children in local communities. The evidence produced in this study will enlarge the knowledge base that supports evidence-based paediatric home nursing service with the use of health technology in symptom management. This evidence will also contribute to the development of other symptom management programs for other paediatric patient groups. NCT05765643 (ClinicalTrials.gov identifier). Parents of children with medical complexity contributed in mobile application development by giving comments on the usability of mobile application. Improve health service delivery: Home nursing service may not be sustainable in a long run in Hong Kong, as the health care system has been facing a serious nursing workforce shortage in recent years. Besides, these services are affected or even suspended during the community outbreak of infectious disease, like recent coronavirus disease pandemic. Nurse parental support in symptom management for the CMC using a proactive mobile health application will help in service delivery improvements because it maximizes the availability and accessibility of paediatric health service to parents and their CMC in local communities. Improve physical and psychological health of parents and their CMC: The success of program implementation will help to increase parental self-efficacy in symptom management for their CMC, as a result of decrease of children's symptom burden. Improve knowledge base: The evidence produced in this study will (1) enlarge the knowledge base that supports evidence-based paediatric community nursing service related to symptom management for the CMC. This evidence will contribute to the development of other symptom management programs for other paediatric patient groups.

Psychosocial functioning and its influencing factors in patients with depression post-remission: Implications for assessment and interventions

Background: Enhancing psychosocial functioning is crucial for reducing relapse in depression, but methods for monitoring and recovery are unclear. MethodA 1-year follow-up study assessed psychosocial functioning in 182 patients with remitted depression at baseline (T0) as well as at 1, 2, 6, 9, and 12 months post-remission (T1–T5). Using generalized estimating equations (GEE) and multiple linear regression (MLR), we analyzed the impact of changes in psychosocial functioning on relapse/recurrence risk, and assessed the influence of various factors. ResultsAn increase in psychosocial functioning significantly lowered relapse/recurrence odds by 54.2 %, averaging a risk reduction of 3.1 %. GEE analyses indicated subjective depressive symptoms (β = −0.315) most significantly impacted psychosocial functioning, followed by social support (β = 0.236), positive coping (β = 0.225), and negative automatic thoughts (β = −0.183). Negative coping and expressed emotion exhibited non-significant effects. MLR revealed that the impact of negative automatic thoughts was most significant at initial remission, but the relative importance of residual subjective depressive symptoms, positive coping, and social support on psychosocial functioning remained stable over time. LimitationsPredetermined follow-up assessments may not fully capture psychosocial functioning at relapse/recurrence, and the inclusion of factors might not be sufficiently comprehensive. ConclusionsRecovery of psychosocial functioning significantly reduces relapse risk in post-remission patients with depression more than residual subjective depressive symptoms. The degree of influence of factors on psychosocial functioning can change with the length of remission time.

Abstract P398: The effects of care by hypertension specialists on cardiovascular outcome, blood pressure control and cost-effectiveness among uncontrolled hypertensive patients

Background: Studies suggested that physician specialty had an impact on patient outcomes of cardiovascular disease. However, the effects of care by hypertension specialists on clinical outcomes and financial burden among uncontrolled hypertensive patients are unknown. Objective: This study was to assess the effects of care by hypertension specialists on risk of cardiovascular outcomes, blood pressure (BP) control, and cost-effectiveness among patients with uncontrolled hypertension. Methods: A retrospective cohort study of patients aged 45-79 years who were admitted for uncontrolled hypertension was conducted. We assessed the relationship between care by hypertension specialists and major adverse cardiovascular events (MACE), BP control, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) by the Cox regression, the generalized estimating equations (GEE) model, and the Markov model, respectively. Results: A total of 10680 patients with uncontrolled hypertension were followed up for a median of 4.0 years. Among the 5646 (52.9%) patients received care by hypertension specialists and had fewer MACE than the non-specialists group (21.5 vs 39.7 per 1000-person-year; hazard ratio 0.67; 95% CI: 0.57 to 0.79) according to multiple Cox regression after stabilized inverse probability of treatment weighting. At 4 years, the odds ratio between the hypertension specialist group and the non-specialist group was 0.83 (95% CI: 0.79 to 0.86). Odds ratios with declining trend were observed at 1, 2, and 3 years. Over a lifetime horizon, the ICERs of the hypertension specialists group was USD 6295.37 per QALY gained compared with the non-specialists group. Conclusions: This study provided some evidence that care by hypertension specialists was associated with reduced risk of MACE and improved BP control in patients with uncontrolled hypertension, and was cost-effective.

Risk Factors for Secondary-Inserted Orthodontic Miniscrew Stability Following Original Insertion Failure.

The objective of this study was to examine the variables that influence the stability of secondary orthodontic anchoring miniscrews after the occurrence of initial installation failure. The secondary insertion was defined as reinserted, which was inserted to the orthotopic (i.e., inserted between the roots of the original two adjacent teeth with the mesiodistal, height and insertion angle slightly altered) and ectopic (i.e., inserted between neighboring tooth roots). A total of 100 miniscrews were reinserted in 71 patients who experienced primary insertion failure. The analysis considered 15 independent variables related to systemic factors and site characteristics. The success rate and risk factors associated with reinsertion were assessed using univariate analysis (Chi-square Test for categorical variables and Mann-Whitney U test for continuous variables) and correlation analysis (Spearman correlation analysis to exclude variables that might cause interference in a multivariable model). Significant parameters from univariate analysis were then integrated into a generalized estimating equation (GEE) model. The success rate of reinsertion was 66.00% (66/100), and the cancellous bone density and the patient's age had a strong correlation with the stability of reinserted miniscrews. The study indicates that younger patients with miniscrews reinserted in areas of high cancellous bone density are more likely to experience instability. This finding warrants careful consideration by orthodontists when performing miniscrew reinsertion procedures.

The Impact of Signaling in Diagnostic Radiology Residency

Signaling in the US Residency MATCH process allows medical students to indicate preference for specific programs. In diagnostic radiology, "Gold" and "Silver" signals significantly increase the chances of securing interviews from targeted programs. Specialty advisors should strategically evaluate applicant competitiveness and program desirability to optimize signal placement. MethodsThis study included fourth-year medical students and US or Canadian medical school graduates applying for the 2024 Match. Participants completed a survey on signaling use, interview invitations, and the resources and advice received. ResultsInterview invitations for programs with gold, silver, and non-signaled programs were analyzed using the Wilcoxon signed-rank test and Generalized Estimating Equation (GEE) models. ConclusionSignaling significantly increases the likelihood of receiving interviews in diagnostic radiology, emphasizing the importance of strategic signal placement. Further research is needed to assess its overall impact on the MATCH process.

Immediate Implants in Fibulas: Does the Implant to Fibula Osteotomy Distance Impact Early Implant Failure?

BackgroundWhen placing dental implants in the free fibula flap, the osteotomy cut edge poses a unique challenge in that an optimal distance has not yet been established. PurposeThe study aimed to measure the association between implant-to-fibula osteotomy edge distance and early implant failure in patients who received free fibula flap reconstruction with immediate implants. Study DesignA retrospective cohort study was designed and implemented. The study population was composed of patients who underwent free fibula flap transfer with immediate dental implant placement for the treatment of benign or malignant conditions of the head and neck from 2015 to 2022 at John Peter Smith Hospital. Subjects were excluded if the implant was in the middle of the free flap bordered by adjacent implants, was >10mm from the osteotomy edge, or had insertional torque values of ≤30 Ncm. Predictor VariablePrimary predictor variable was the implant distance in millimeters from the fibula osteotomy edge. Outcome VariablePrimary outcome variable was early implant failure, defined as implant exfoliation noted by the patient or failure due to implant movement or pain necessitating explantation within 6 months of placement. CovariatesThe covariates were age, sex, diabetes diagnosis, American Society of Anesthesiologists classification, smoking status, history of head and neck radiation, pathology treated, and if postoperative radiation treatment was received. AnalysesA generalized estimating equations (GEE) model was used to assess the relation between the primary predictor and outcome. A p-value of <0.05 was considered statistically significant. ResultsThe sample was composed of 48 subjects who had 130 implants placed, with early failures occurring in 5 implants (3.9%) in 3 subjects. The mean age of the sample was 49 years (SD 20) and 29 (60%) were male. The mean implant distances for early failures and non-failures were 3.5 mm (SD 1.04) and 4.3 mm (SD 1.5), respectively. There was a statistically significant relation between implant distance and early implant failure (P = .005, OR 0.6, 95% CI 0.39 to 0.85). ConclusionsThis study found that shorter distances between the implant and the edge of the fibula osteotomy are associated with early implant failure.

Lisdexamfetamine maintenance treatment for binge-eating disorder following successful treatments: randomized double-blind placebo-controlled trial.

Controlled research examining maintenance treatments for responders to acute interventions for binge-eating disorder (BED) is limited. This study tested efficacy of lisdexamfetamine (LDX) maintenance treatment amongst acute responders. This prospective randomized double-blind placebo-controlled single-site trial, conducted March 2019 to September 2023, tested LDX as maintenance treatment for responders to acute treatments with LDX-alone or with cognitive-behavioral therapy (CBT + LDX) for BED with obesity. Sixty-one (83.6% women, mean age 44.3, mean BMI 36.1 kg/m2) acute responders were randomized to LDX (N = 32) or placebo (N = 29) for 12 weeks; 95.1% completed posttreatment assessments. Mixed-models and generalized-estimating equations comparing maintenance LDX v. placebo included main/interactive effects of acute (LDX or CBT + LDX) treatments to examine their predictive/moderating effects. Relapse rates (to diagnosis-level binge-eating frequency) following maintenance treatments were 10.0% (N = 3/30) for LDX and 17.9% (N = 5/28) for placebo; intention-to-treat binge-eating remission rates were 59.4% (N = 19/32) and 65.5% (N = 19/29), respectively. Maintenance LDX and placebo did not differ significantly in binge-eating but differed in weight-loss and eating-disorder psychopathology. Maintenance LDX was associated with significant weight-loss (-2.3%) whereas placebo had significant weight-gain (+2.2%); LDX and placebo differed significantly in weight-change throughout treatment and at posttreatment. Eating-disorder psychopathology remained unchanged with LDX but increased significantly with placebo. Acute treatments did not significantly predict/moderate maintenance-treatment outcomes. Adults with BED/obesity who respond to acute lisdexamfetamine treatment (regardless of additionally receiving CBT) had good maintenance during subsequent 12-weeks. Maintenance lisdexamfetamine, relative to placebo, did not provide further benefit for binge-eating but was associated with significantly better eating-disorder psychopathology outcomes and greater weight-loss.

Effectiveness of a cognitive behavioural therapy (CBT)-based intervention for reducing anxiety among adolescents in the Colombo District, Sri Lanka: cluster randomized controlled trial

Anxiety disorders are found to be the most prevalent psychological problems among children and adolescents. Cognitive behaviour therapy (CBT) was found to be effective at reducing anxiety. The purpose of this study was to assess the effectiveness of a universal school-based intervention for reducing anxiety among Grade 9 schoolchildren. A randomized controlled cluster trial was conducted by randomly assigning 36 schools in the Colombo district in Sri Lanka into study and control arms, each comprising 18 schools with 360 students. The levels of anxiety, self-esteem and depression status were assessed using the validated Screen for Child Anxiety Related Disorders (SCARED) tool and the Rosenberg self-esteem scale, respectively, and the Depression, Anxiety and Stress Scale 21 (DASS-21) at baseline, after intervention, and after 3 months. A CBT-based universal intervention package was administered weekly by a trained teacher for eight weeks with a one-month self-practice period to a randomly selected Grade 9 class in each school in the study arm. The control arm received routine care. Anxiety and self-esteem scores and depression status were compared between the two arms after the intervention and at 3 months of follow-up using the generalized estimation equation (GEE), controlling for confounding and clustering. The nonresponse and loss to follow-up rates were < 1%. When comparing the study arm with the control arm using GEE, anxiety levels were significantly lower [β = (-0.096), 95% CI = (-0.005) − (-0.186), p = 0.038] at follow-up but not postintervention [β = (-0.024), 95% CI = 0.006 − (-0.055), p = 0.115]. There were no significant differences in depression status after intervention (OR = 0.257, 95% CI =0.052–1.286; p = 0.098) or follow-up (OR = 0.422, 95% CI 0.177–1.008; p = 0.052), and self-esteem significantly increased after intervention (β = 0.811, 95% CI = 0.314–1.309; p = 0.001) but not at follow-up [β=0.435, 95% CI=(-0.276)-1.145, p=0.231]. This study revealed that the universal package based on CBT is effective at reducing anxiety and improving self-esteem among adolescents. The trial registration number and date were SLCTR/2018/018 and 19th of June 2018 respectively.

Employment status of older nursing staff aged 55 years and older in care facilities: A nationwide cross-sectional study in Japan.

An aging nursing workforce requires addressing shortages due to retirement. This nationwide descriptive cross-sectional study in Japan clarified the employment status of older nursing staff aged ≥ 55 years by facility type during January-March 2022. Questionnaires were sent to 8,000 nursing directors, with 1,658 valid responses (response rate: 20.7%). Descriptive statistics and Kruskal-Wallis or χ2 tests analyzed inter-facility differences. A violin plot depicted the proportion of older nursing staff across facilities by age group, and generalized estimating equation (GEE) models examined associated factors at the facility level. Older nursing staff's distribution differed significantly across age groups (p < 0.01), from 0% to 100% within the same facility type. Some facilities had high percentages of staff working beyond retirement age. GEE results showed higher percentages of full-time employees and nurses were negatively associated with the percentage of older nursing staff across most facility types (p < 0.05). For those aged ≥ 65 years, the total population was positively associated with employment in bedded clinics (coef. = 0.07, 95% CI: 0.01 to 0.14, p = 0.03), but negatively associated with the total population (coef. = -0.06, 95% CI: -0.10 to -0.01, p = 0.02) and percentage of the population aged ≥ 65 (coef. = -0.76, 95% CI: -1.43 to -0.08, p = 0.03) in long-term care insurance facilities. Working conditions and environments should be improvement to potentially retain older nursing staff. Job seekers should be matched with managers' needs in facilities with a higher proportion of older nursing staff to ensure a sustainable workforce.

Governance and Efficiency in Brazilian Water Utilities: An Analysis Based on Revenue Collection Efficiency

This study analyzed the relevance of governance structure for efficient revenue collection by Brazilian water utilities (WUs). Data were collected from the National Information System on Sanitation (SNIS) for 127 Brazilian WUs, covering a balanced longitudinal panel from 2018 to 2022. The governance structures evaluated included ownership (public or private) and corporatization (publicly traded or not). We searched scientific databases and did not find any studies on the efficiency of specific WUs in collecting customer bills for services rendered and its relationship with this type of governance; thus, this is the main innovative contribution of this study to the literature. In the first stage, this study utilized the dynamic slack-based model (DSBM) to assess revenue collection efficiency. In the second stage, an econometric model with generalized estimating equation (GEE) was used to explain the efficiency. The findings revealed a global average inefficiency in revenue collection of 50.47%. Corporatization was linked to higher collection efficiencies, while ownership type was significantly linked with lower collection efficiency. Factors such as tariff accessibility, urbanization, and the COVID-19 pandemic also influenced efficiency. This study suggests that regulatory bodies should consider these insights to implement policies that prevent inefficiencies from affecting the tariff system for services.

Longitudinal associations of effort and reward at work with changes in cognitive function: evidence from a national study of U.S. workers.

This study aimed to examine longitudinal associations of workplace effort and reward with changes in cognitive function among United States workers. Data from the national, population-based Midlife in the United States (MIDUS) study with a 9-year follow-up were used. Validated workplace effort and reward scales were measured at baseline, and cognitive outcomes (including composite cognition, episodic memory, and executive functioning) were measured with the Brief Test of Adult Cognition by Telephone (BTACT) at baseline and follow-up. Multivariable linear regression analyses based on generalized estimating equations (GEE) examined the longitudinal associations under study. Among this worker sample of 1,399, after accounting for demographics, socioeconomics, lifestyle behaviors, health conditions, and job control, high reward at baseline was associated with increased composite cognition (regression coefficient: 0.118 [95% CI: 0.049, 0.187]), episodic memory (0.106 [0.024, 0.188]), and executive functioning (0.123 [0.055, 0.191]) during follow-up. The joint exposure of 'high effort and high reward' was also associated with increased composite cognition (0.130 [0.030, 0.231]), episodic memory (0.131 [0.012, 0.250]), and executive functioning (0.117 [0.017, 0.216]), while the combination of 'low effort and high reward' was associated with increased composite cognition (0.106 [0.009, 0.204]) and executive functioning (0.139 [0.042, 0.235]). Findings suggest that workplace high reward is related to improved cognitive scores among United States workers. Future research should investigate larger cohorts over longer timespans and expand into disease outcomes such as dementia. If these findings emerge as causal, relevant workplace rewards to promote worker cognitive health should be considered.

Factors affecting growth hormone treatment in short stature children born small for gestational age in China: a single-centre, real-world study.

The study aimed to evaluate the factors influencing recombinant human growth hormone (rhGH) treatment in Chinese children with short stature born small for gestational age (SGA). A single-centre, real-world retrospective study was conducted in short stature children born SGA in China. Outcomes were observed at 6, 12, 18, 24, 30, and 36 months. Outcome measures included height standard deviation score (HTSDS), height, growth velocity (GV), and change of HTSDS (ΔHTSDS). The study used the generalized estimating equation (GEE) to identify potential influencing factors, such as rhGH treatment duration, age at rhGH initiation, sex, 11p15 hypomethylation, GH secretion, and birth weight. A subgroup analysis was conducted to investigate the impact of 11p15 hypomethylation related to SGA or impaired GH secretion. Of all 101 SGA patients included in the screening, 41 were eligible for inclusion in the study. The mean age at rhGH initiation was 5.6 ± 2.4 years. The results of the GEE analysis showed a significant association between time after rhGH initiation and HTSDS, height, GV, and ΔHTSDS. GV increased after treatment, with the highest increase observed in the first six months. Additionally, the study found negative correlations between 11p15 hypomethylation and GV, as well as between birth weight and both GV and ΔHTSDS. The study found a positive correlation between impairment in GH secretion and both GV and ΔHTSDS. No statistically significant difference was observed in the comparison of GV or ΔHTSDS between the initiation age of GH treatment and 11p15 hypomethylation. After 24 and 30 months of rhGH treatment, patients with impaired GH secretion had significantly higher ΔHTSDS scores. In short stature Chinese children born SGA, those without SGA-related 11p15 hypomethylation or with impaired GH secretion showed better response to rhGH treatment. These findings highlight the importance of pre-treatment evaluation, including genetic and endocrine assessments.

Effectiveness of a training program for caregivers of institutionalized older people on sedentary behavior, physical activity, and functionality of residents

Training caregivers of institutionalized older adults about an expanded care approach seems to be a way to maintain the resident's capabilities from the long-term care perspective. Objective: to analyze the effectiveness of training for caregivers of institutionalized older adults on sedentary behavior (SB), physical activity (PA) levels, and functionality of residents. Methods: Instructional training (four weeks) followed by the caregiver goal application period (12 weeks). Primary outcomes: Sedentary behavior (accelerometry) and functional mobility (Timed Up and Go). Secondary: physical function (SPPB), the performance of activities of daily living (Barthel Index), physical activity (accelerometer), handgrip strength, and anthropometric measurements. All analyses were conducted according to the intention-to-treat principle. Generalized Estimating Equations (GEE) and the Bonferroni post-hoc test were applied for comparison between time points (pre and post-intervention) and groups (p&lt;0.05). Results: 49 older adults participated in the study, 25 of which comprised the intervention group (IG) and 24 the control group (CG). There was a group and time interaction effect, and the IG showed a reduction in SB (p=.017), increased light PA (p=.006), and total PA (p=.018). There were no changes in moderate PA and functionality. Although not statistically significant, the Barthel Index increased by 6.8 points in the IG, a clinically meaningful difference. Conclusion: The caregiver training strategy can be important in reducing SB and promoting participation in PA, which is relevant, considering the profile of the institutionalized older adult population. Keywords: Sedentary Behavior; Physical Functional Performance; Older Adults; Caregivers; Nursing home.