Generalized Linear Mixed Models Research Articles

Clinical efficacy of a two-piece abutment conforming to the concept of one abutment one time in the posterior region: A clinical pilot study.

To assess the impact of a two-piece abutment workflow on enhancing the stability of the alveolar bone and gingiva surrounding the dental implant, and to determine the level of patient satisfaction. A total of 48 patients with dentition defect in the posterior region were included and divided into two groups: the two-piece abutment workflow (TAW) and the sealing screw with submerged healing workflow (SHW). Marginal bone level (MBL), soft tissue indicators, oral hygiene indicators, and patient satisfaction were assessed and recorded partially at 0, 3, 6, and 12 months after surgery. The primary outcome was the change of MBL in different time periods. A generalized linear mixed model (GLMM) was used to take into account the correlated nature of the data, and adjust for potential confounding factors within inter-group differences. The survival rate of implants and prosthesis reached 100% at 12-month follow-up, with an average decrease of 0.25 mm (SD 0.23 mm) of MBL in the TAW group and 0.48 mm (SD 0.45 mm) in the SHW group. The change of MBL in the TAW group (0.15 ± 0.31 mm) was significantly lower than the SHW group (0.41 ± 0.41 mm) through the analysis of GLMM within 6 months, while no significance was found in 12 months. Moreover, less gingival pain and oppression during prosthesis loading, and less time consumption overall duration were showed in the TAW group through Visual Analogue Scale (VAS, p < 0.05). Within a 6-month period, the two-piece abutment workflow showed superior efficacy in preserving the integrity of the marginal bone level. Furthermore, it streamlined treatment procedures and mitigated discomfort, hence increasing patient satisfaction.

Adverse effects of meteorological factors and air pollutants on dry eye disease: a hospital-based retrospective cohort study

Although previous studies have suggested that meteorological factors and air pollutants can cause dry eye disease (DED), few clinical cohort studies have determined the individual and combined effects of these factors on DED. We investigated the effects of meteorological factors (humidity and temperature) and air pollutants [particles with a diameter ≤ 2.5 μ\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\upmu$$\\end{document}m (PM2.5), ozone (O3), nitrogen dioxide (NO2), and carbon monoxide (CO)] on DED. A retrospective cohort study was conducted on 53 DED patients. DED was evaluated by Symptom Assessment in Dry Eye (SANDE), tear secretion, tear film break-up time (TBUT), ocular staining score (OSS), and tear osmolarity. To explore the individual, non-linear, and joint associations between meteorological factors, air pollutants, and DED parameters, we used generalized linear mixed model (GLMM) and Bayesian kernel machine regression (BKMR). After adjusting for all covariates, lower relative humidity or temperature was associated with a higher SANDE (p < 0.05). Higher PM2.5, O3, and NO2 levels were associated with higher SANDE and tear osmolarity (p < 0.05). Higher O3 levels were associated with lower tear secretion and TBUT, whereas higher NO2 levels were associated with higher OSS (p < 0.05). BKMR analyses indicated that a mixture of meteorological factors and air pollutants was significantly associated with increased SANDE, OSS, tear osmolarity, and decreased tear secretion.

Preclinical evaluation of mucogingival defect treatment using piscine membranes: An in vivo assessment of wound healing.

Periodontitis is a bacteria-induced chronic inflammatory disease characterized by degradation of the supporting tissue and bone in the oral cavity. Treatment modalities seek to facilitate periodontal rehabilitation while simultaneously preventing further gingival tissue recession and potentially bone atrophy. The aim of this study was to compare two differently sourced membranes, a resorbable piscine collagen membrane and a porcine-derived collagen membrane, in the repair of soft tissue defects utilizing a preclinical canine model. This in vivo component consisted of 10 beagles which were subjected to bilateral maxillary canine mucogingival flap defects, as well as bilateral soft tissue defects (or pouches) with no periodontal ligament damage in the mandibular canines. Defects received either a piscine-derived dermal membrane, (Kerecis® Oral, Ísafjörður, Iceland) or porcine-derived dermal membrane (Geistlich Mucograft®, Wolhusen, Switzerland) in a randomized fashion (to avoid site bias) and were allowed to heal for 30, 60, or 90 days. Statistical evaluation of tissue thickness was performed using general linear mixed model analysis of variance and least significant difference (LSD) post hoc analyses with fixed factors of time and membrane. Semi-quantitative analysis employed for inflammation assessment was evaluated using a chi-squared test along with a heteroscedastic t-test and values were reported as mean and corresponding 95% confidence intervals. In both the mucogingival flap defects and soft tissue gingival pouches, no appreciable qualitative differences were observed in tissue healing between the membranes. Furthermore, no statistical differences were observed in the thickness measurements between piscine- and porcine-derived membranes in the mucogingival flap defects (1.05 mm [±0.17] and 1.29 mm [±0.17], respectively [p = .06]) or soft tissue pouches (1.36 mm [±0.14] and 1.47 mm [±0.14], respectively [p = .27]), collapsed over time. Independent of membrane source (i.e., piscine or porcine), similar inflammatory responses were observed in both the maxilla and mandible at the three time points (p = .88 and p = .79, respectively). Histologic and histomorphometric evaluation results indicated that both membranes yielded equivalent tissue responses, remodeling dynamics and healing patterns for the mucogingival flap as well as the soft tissue gingival pouch defect models.

Vaping habits and respiratory symptoms using a smartphone app platform

BackgroundWidespread use of e-cigarette (EC) or vaping products causes respiratory disorders including the nationwide outbreak of e-cigarette or vaping product use-associated lung injury (EVALI) in 2019. Chronic adverse health effects are now being reported as well. To address this important public health issue, an innovative approach of epidemic control and epidemiologic study is required. We aimed to assess the association between short-term and long-term use of EC products and respiratory health in adults using smartphone app data.MethodsA population-based, repeated measures, longitudinal smartphone app study that performed 8-day survey participation over 60 days for each participant from August 2020 to March 2021, including 306 participants aged 21 years and older in the US. The participants were asked to complete the respiratory health questionnaire daily, weekly, and monthly on their smartphone app. We analyzed the association between vaping habits and respiratory health using generalized linear mixed models (GLMMs).ResultsEC use in the previous 7 days was associated with frequent cough (OR: 5.15, 95% CI: 2.18, 12.21), chronic cough (OR: 3.92, 95% CI: 1.62, 9.45), frequent phlegm (OR: 3.99, 95% CI: 1.44, 11.10), chronic phlegm (OR: 3.55, 95% CI: 1.41, 8.96), episodes of cough and phlegm (OR: 4.68, 95% CI: 1.94, 11.28), mMRC grade 3–4 dyspnea (OR: 3.32, 95% CI: 1.35 to 8.13), chest cold (OR: 3.07, 95% CI: 1.29, 7.33), eye irritation (OR: 2.94, 95% CI: 1.34, 6.47) and nose irritation (OR : 2.02, 95% CI: 0.95, 4.30). Relatively long-term effects of the past 90 days EC use was associated with an increased risk of wheeze (OR: 3.04, 95% CI: 1.31, 7.03), wheeze attack (OR: 2.78, 95% CI: 1.07, 7.24), mMRC grade 3–4 dyspnea (OR: 2.54, 9% CI: 1.05 to 6.18), eye irritation (OR: 3.16, 95% CI: 1.49, 6.68), and eye irritation during the past month (OR: 3.50, 95% CI: 1.52, 8.04).ConclusionsIn this smartphone app-based repeated measures study, short-term and relatively long-term use of EC increased the risk of respiratory symptoms.

Assessing the Effectiveness of Multilevel Intervention Sequences on "Tension" Among Men Living with HIV: A Randomized-Control Trial.

Tension (often times called "Tenshun" in Hindi) is a cultural expression used to convey feelings of distress and common mental disorders in India and among South Asia communities. This study compared the effectiveness of different intervention sequences in reducing tension among alcohol-consuming men living with HIV in India. This secondary data analysis paper utilized data from a randomized trial study titled "Alcohol and Antiretroviral Therapy (ART) Adherence: Assessment, Intervention, and Modeling in India." The multilevel interventions, including individual counseling (IC), group intervention (GI), and collective advocacy (CA), were conducted sequentially over three cycles at three ART centers. Additionally, another ART center, serving as a pilot site, received all three interventions simultaneously in the final cycle. Participants completed surveys assessing demographic characteristics, tension, and other variables including HIV stigma, a 4-day ART adherence, HIV symptoms, and depressive symptoms at four time points: baseline, 9months, 18months, and 24months. General linear mixed models were employed to assess the intervention effects on tension. Out of 940 participants, 666 reported experiencing tension, including 54% reporting high tension. At site 1, the GI-CA-IC sequence resulted in a slope of -0.06, indicating that this sequence reduced tension from T1 to T4 compared to the control group (p < 0.01). Additionally, the pilot site where the intervention package was conducted simultaneously had a slope of -0.06, indicating that the intervention package also reduced tension compared to the control group (p < 0.01). Conversely, the CA-IC-GI sequence resulted in a slope of 0.07, indicating that this sequence resulted in significantly higher tension levels than the control group (p = 0.008) contrary to the expectation that the sequence would reduce tension. This study contributes valuable insights on the issue of tension among alcohol-consuming men living with HIV. The significant reduction in tension observed at the site using the GI-CA-IC sequence, which began with a group intervention, underscores the importance of intervention order and the importance of group intervention within multilevel intervention programs for tension reduction. Further research is needed to validate these observations and broaden our understanding of effective tension management strategies among people living with HIV in diverse settings. URL: clinicaltrials.gov. NCT03746457.

Fast maximum likelihood estimation for general hierarchical models

Hierarchical statistical models are important in applied sciences because they capture complex relationships in data, especially when variables are related by space, time, sampling unit, or other shared features. Existing methods for maximum likelihood estimation that rely on Monte Carlo integration over latent variables, such as Monte Carlo Expectation Maximization (MCEM), suffer from drawbacks in efficiency and/or generality. We harness a connection between sampling-stepping iterations for such methods and stochastic gradient descent methods for non-hierarchical models: many noisier steps can do better than few cleaner steps. We call the resulting methods Hierarchical Model Stochastic Gradient Descent (HMSGD) and show that combining efficient, adaptive step-size algorithms with HMSGD yields efficiency gains. We introduce a one-dimensional sampling-based greedy line search for step-size determination. We implement these methods and conduct numerical experiments for a Gamma-Poisson mixture model, a generalized linear mixed models (GLMMs) with single and crossed random effects, and a multi-species ecological occupancy model with over 3000 latent variables. Our experiments show that the accelerated HMSGD methods provide faster convergence than commonly used methods and are robust to reasonable choices of MCMC sample size.

Pre-Randomization Predictors of Study Discontinuation in a Preclinical Alzheimer’s Disease Randomized Controlled Trial

BackgroundParticipant discontinuation from study treatment in a clinical trial can leave a trial underpowered, produce bias in statistical analysis, and limit interpretability of study results. Retaining participants in clinical trials for the full study duration is therefore as important as participant recruitment.ObjectiveThis analysis aims to identify associations of pre-randomization characteristics of participants with premature discontinuation during the blinded phase of the Anti-Amyloid treatment in Asymptomatic AD (A4) Study.DesignAll A4 trial randomized participants were classified as having prematurely discontinued study during the blinded period of the study for any reason (dropouts) or completed the blinded phase of the study on treatment (completers).SettingThe trial was conducted across 67 study sites in the United States, Canada, Japan and Australia through the global COVID-19 pandemic.ParticipantsThe sample consisted of all 1169 A4 trial randomized participants.MeasurementsPre-randomization demographic, clinical, amyloid PET and genetic predictors of study discontinuation were evaluated using a univariate generalized linear mixed model (GLMM), with discontinuation status as the binary outcome, each predictor as a fixed effect, and site as a random effect to account for differences among study sites in the trial. Characteristics significant at p<0.10 were then included in a multivariable GLMM.ResultsAmong randomized participants, 339 (29%) discontinued the study during the blinded period (median follow-up time in trial: 759 days). From the multivariable analysis, the two main predictors of study discontinuation were screening State-Trait Anxiety Inventory (STAI) scores (OR = 1.07 [95%CI = 1.02; 1.12]; p=0.002) and age (OR = 1.06 [95%CI = 1.03; 1.09]; p<0.001). Participants with a family history of dementia (OR = 0.75 [95%CI = 0.55; 1.01]; p=0.063) and APOE ε4 carriers (OR = 0.79 [95%CI = 0.6; 1.04]; p=0.094) were less likely to discontinue from the study, with the association being marginally significant. In these analyses, sex, race and ethnicity, cognitive scores and amyloid/tau PET scores were not associated with study dropout.ConclusionsIn the A4 trial, older participants and those with higher levels of anxiety at baseline as measured by the STAI were more likely to discontinue while those who had a family history of dementia or were APOE ε4 carriers were less likely to drop out. These findings have direct implications for future preclinical trial design and selection processes to identify those individuals at greatest risk of dropout and provide information to the study team to develop effective selection and retention strategies in AD prevention studies.

Pricing risk contribution of general Takaful by spatial generalized linear mixed models at the level of tariff cells

PurposeThis study aims to price the risk contribution of general Takaful at the level of tariff cells, considering a spatial dependency framework.Design/methodology/approachThree different models, including a generalized linear model, a generalized linear mixed model (GLMM) and a spatial generalized linear mixed model (SGLMM), according to the actuarial modeling of general Takaful, are used to price pure risk contribution (PRC).FindingsThe results reveal that the SGLMM yields more accurate predictions of the PRC compared to the other models, emphasizing the significance of spatial modeling in this context. Following the estimation of the PRC, the gross contribution according to the mechanism of Takaful models is calculated considering the spatial model.Practical implicationsConsidering the similarities between Takaful and insurance, this study addresses the pricing of general Takaful within different Takaful models through a spatial dependency framework, such that the practical implications of the study are applicable for running Takaful's business in both Islamic and non-Islamic countries.Originality/valueMost studies consider only the social or practical view of Takaful. This study contributes to the broader knowledge and understanding of Takaful by presenting a conceptual understanding of Takaful and then investigates the practical application of pricing risk contribution using innovative modeling of claim frequency and severity at the level of tariff cells.

Performance of Hermetia illucens reared on pure, mixed, and sequentially mixed organic wastes regionally available in central Argentina

Abstract Black soldier fly larvae (Hermetia illucens L.) are proficient decomposers of organic matter. We compared experiments with local substrates containing: domestic residues (DR), and brewery wastes (BW) in pure form, or mixed with in two different proportions (BW70 or BW30), and two sequential diets in which larvae were fed first DR and then BW (DR/BW) or vice versa (BW/DR). The effects of the diets on life cycle parameters for mass production of H. illucens larvae were evaluated using general linear mixed models, ANOVA and Kruskal-Wallis. The pure DR diet significantly prolonged the developmental period (47.8 days), although the pupal stage was shorter in larvae fed on this diet (13.8 days). Larval survival was similar between treatments (over 85%), but pupal survival tended to be higher in the mixed diets (over 96%). Larval weights differed significantly between treatments, with mixed diets promoting greater weight gains than pure and sequential diets. Larvae fed a DR/BW diet gained more weight than those fed a BW/DR diet. The highest mean larval weights (0.23 g) were observed in the mixed diet BW70, followed by the sequential diet DR/BW (0.22 g). Mixed diet BW70 also resulted in larger wings and bodies in both sexes. Sequential diet BW/DR and pure diet DR resulted in the smallest adult sizes. Sex ratios varied, favouring male emergence (1.8 M:0.2 F) in pure diet DR and in both sequential mixed diets (1.7 M:0.3 F and 1.3 M:0.7 F, respectively). This study highlights the importance of higher total protein plus carbohydrate concentrations in diets for optimal larval rearing, favouring mixed diets BW70. Carbohydrate-rich substrates should be provided earlier in the cycle to benefit larval and adult performance. Locally available waste vegetable or fruit peels, brewery waste, and spent yerba mate proved to be viable substrates for larval rearing, providing economic and environmental benefits for H. illucens rearing.

Outcomes from Partner2Lose: a randomized controlled trial to evaluate 24-month weight loss in a partner-assisted intervention

BackgroundPartner support is associated with better weight loss outcomes in observational studies, but randomized trials show mixed results for including partners. Unclear is whether teaching communication skills to couples will improve weight loss in a person attempting weight loss (index participant).PurposeTo compare the efficacy of a partner-assisted intervention versus participant-only weight management program on 24-month weight loss.MethodsThis community-based study took place in Madison, WI. Index participants were eligible if they met obesity guideline criteria to receive weight loss counseling, were aged 18–74 years, lived with a partner, and had no medical contraindications to weight loss; partners were aged 18–74 years and not underweight. Couples were randomized 1:1 to a partner-assisted or participant-only intervention. Index participants in both arms received an evidence-based weight management program. In the partner-assisted arm, partners attended half of the intervention sessions, and couples were trained in communication skills. The primary outcome was index participant weight at 24 months, assessed by masked personnel; secondary outcomes were 24-month self-reported caloric intake and average daily steps assessed by an activity tracker. General linear mixed models were used to compare group differences in these outcomes following intent-to-treat principles.ResultsAmong couples assigned to partner-assisted (n = 115) or participant-only intervention (n = 116), most index participants identified as female (67%) and non-Hispanic White (87%). Average baseline age was 47.27 years (SD 11.51 years) and weight was 106.55 kg (SD 19.41 kg). The estimated mean 24-month weight loss was similar in the partner-assisted (2.66 kg) and participant-only arms (2.89 kg) (estimated mean difference, 0.23 kg [95% CI, -1.58, 2.04 kg], p=0.80). There were no differences in 24-month average daily caloric intake (estimated mean difference 50 cal [95% CI: -233, 132 cal], p=0.59) or steps (estimated mean difference 806 steps [95% CI: -1675, 64 steps], p=0.07). The percentage of participants reporting an adverse event with at least possible attribution to the intervention did not differ by arm (partner-assisted: 9%, participant-only, 3%, p = 0.11).ConclusionsPartner-assisted and individual weight management interventions led to similar outcomes in index participants.Trial registrationClinicaltrials.gov NCT03801174, January 11, 2019.

Effects of indoor plants on CO2 concentration, indoor air temperature and relative humidity in office buildings.

This experimental study investigates the influence of indoor plants on three aspects of air quality in office spaces: relative humidity, indoor air temperature, and carbon dioxide concentration. Employing a Latin square design, we rotated three different treatments across three offices over six time periods. These treatments included a control (no plants), a low-volume treatment (five plants), and a high-volume treatment (eighteen plants) of Nephrolepis exaltata (Boston fern). Air quality parameters were continuously monitored at five-minute intervals using Trace Gas Analyzers. Generalised linear mixed modelling (GLMM) was employed to examine the effect of each treatment on relative humidity, indoor air temperature and CO2 concentration. We observed a significant positive correlation between the number of indoor plants and relative humidity levels. In offices without any plants, the median relative humidity was 29.1%. This increased to 38.9% in offices with 5 plants and further to 49.2% in offices with 18 plants. However, we did not find significant associations between the number of indoor plants and indoor air temperature or corrected CO2 concentration. Our research provides support for the use of indoor plants to increase relative humidity, which can have health benefits in dry climates, but does not provide support for using indoor plants to regulate indoor air temperatures or CO2 concentration in office environments.

Effectiveness of bedside staplers in bariatric robotic procedures

BackgroundFew studies have evaluated the use of laparoscopic staplers in robotic procedures (bedside stapling, BS). This study aims to evaluate the effectiveness of BS compared with robotic staplers (RS) in bariatric robotic procedures.MethodsPatients who underwent robotic sleeve gastrectomy or gastric bypass elective procedures between 1/1/2021 and 12/31/2021 were extracted from PINC AI™ Healthcare Data. The following clinical outcomes were compared: blood transfusion, bleeding, anastomotic leak, intensive care unit (ICU) visit, and 30-day readmission, operating room (OR) time, inpatient costs, and length of stay. We evaluated baseline balance in BS and RS and bivariate association between covariates and outcomes using Chi-square or Fisher exact test and t-test or ANOVA. Multivariable general linear mixed models (GLMMs) with respective gamma or binomial distribution and log-link function were used to obtain adjusted outcomes variations between BS and RS.ResultsTotal of 7268 discharges were included with 1603 (22.1%) BS and 5665 (77.9%) RS cases. RS cases consisted of a higher number of patients who were Hispanic (17.0% vs. 9.4%), had Medicaid (26.9% vs. 19.4%) and underwent sleeve gastrectomy (68.4% vs. 53.5%). Higher proportions of RS cases were done by providers in Northeast region (35.5% vs. 24.3%), smaller size (< 500 beds; 71.1% vs. 52.3%), and teaching hospitals (59.4% vs. 39%). The adjusted outcomes variations demonstrated that patients that had RS were significantly more likely to have blood transfusions, ICU stays, increased ORT (19 min) and costs ($1273). Sensitivity analysis showed similar results, except no significant differences in blood transfusion rates in both groups.ConclusionsBedside staplers significantly reduce healthcare resource utilization with equivalent effectiveness and fewer ICU stays compared to robotic staplers.Graphical abstract

Model selection of GLMMs in the analysis of count data in single-case studies: A Monte Carlo simulation.

Generalized linear mixed models (GLMMs) have great potential to deal with count data in single-case experimental designs (SCEDs). However, applied researchers have faced challenges in making various statistical decisions when using such advanced statistical techniques in their own research. This study focused on a critical issue by investigating the selection of an appropriate distribution to handle different types of count data in SCEDs due to overdispersion and/or zero-inflation. To achieve this, I proposed two model selection frameworks, one based on calculating information criteria (AIC and BIC) and another based on utilizing a multistage-model selection procedure. Four data scenarios were simulated including Poisson, negative binominal (NB), zero-inflated Poisson (ZIP), and zero-inflated negative binomial (ZINB). The same set of models (i.e., Poisson, NB, ZIP, and ZINB) were fitted for each scenario. In the simulation, I evaluated 10 model selection strategies within the two frameworks by assessing the model selection bias and its consequences on the accuracy of the treatment effect estimates and inferential statistics. Based on the simulation results and previous work, I provide recommendations regarding which model selection methods should be adopted in different scenarios. The implications, limitations, and future research directions are also discussed.

A longitudinal multi-centric cohort study assessing infant neurodevelopment delay among women with persistent postpartum depression in Nepal

BackgroundInfant neurodevelopment in the first years after birth is determined by multiple factors, including parental care and maternal mental wellbeing. In this study, we aim to assess the impact of persistent maternal depressive symptoms during the first 3 months postpartum on infant neurodevelopment at 6 months.MethodsUsing a longitudinal cohort design, 1253 mother-infant pairs were followed up at 7, 45, and 90 days to assess postpartum depressive symptoms using the Edinburgh Postnatal Depression Scale (EPDS); infants were followed up at 6 months to assess neuro-developmental status using the WHO’s Infant and Young Child Development (IYCD) tool. A generalized linear regression model was used to assess the association between persistent postpartum depressive symptoms and infant neurodevelopmental delay at 6 months. A generalized linear mixed model (GLMM) with a hospital as a random intercept was used to assess the persistent postpartum depressive symptoms with an IYCD score. Linear regression was used to compare the IYCD scores between exposure groups.ResultsIn the study population, 7.5% of mothers had persistent depressive symptoms, and 7.5% of infants had neurodevelopmental delay. Infants born to mothers with persistent depressive symptoms had a higher proportion of neurodevelopmental delay than infants born to women without persistent symptoms (48.6% vs 5.1%; p < 0.001). In the adjusted regression model, infants whose mothers had persistent depressive symptoms at 7, 45, and 90 days had a 5.21-fold increased risk of neurodevelopmental delay (aRR, 5.21; 95% CI, 3.17, 8.55). Mean scores in the motor domain (12.7 vs 15.2; p < 0.001) and language domain (6.4 vs 8.5; p < 0.001) were significant when a mother had persistent depression vs. no depression. Mean scores in the general behavioral domain (5.9 vs 10.4, p < 0.001) and the socio-emotional domain (15.4 vs 17.7; p < 0.001) were significantly different when a mother had persistent depression vs no persistent depression.ConclusionsOur results suggest that 6-month-old infants are at higher risk for neurodevelopment delays if their mother reports persistent symptoms of depression from 7 to 90 days postpartum. The neurodevelopmental delay can be observed in all functional domains. Preventive intervention to reduce maternal postpartum depression may reduce the impact on infant developmental delay.

What Is the Value Proposition of Evidence-Based Guidelines? An Application of the Operative Value Index for Lumbar Fusions

Elective lumbar fusions have received criticism for inappropriate utilization. Here, we use a novel Operative Value Index (OVI) to assess whether "indicated," evidence-based lumbar fusions are associated with increased value (outcomes per dollar spent). This study is a retrospective analysis of a prospective observational cohort of 294 patients undergoing elective lumbar fusions at a single large academic institution. All patients were preoperatively evaluated by a panel of neurosurgeons for concordance with evidence-based medicine (EBM), determined through guidelines from the North American Spine Society. Oswestry Disability Index (ODI) scores were collected for all patients both preoperatively and at 6-months postoperatively. Time-driven activity-based costing was employed to determine both direct and indirect intraoperative costs. The OVI was defined as the percent improvement in ODI per $1000 spent intraoperatively. Generalized linear mixed model regression, adjusting for confounders, was performed to assess whether EBM-concordant surgeries were associated with higher OVI. Of 294 elective lumbar fusions, 92.9% (n= 273) were EBM-concordant. The average total cost of an EBM-concordant lumbar fusion was $17,932 (supplies: $13,020; personnel: $4314), compared to $20,616 (supplies: $15,467; personnel: $4758) for an EBM-discordant fusion. Average OVI was 2.27 for a concordant fusion, compared to 0.11 for a discordant fusion. Generalized linear mixed model analysis revealed that EBM-concordant cases were associated with significantly higher OVI (β-coefficient 2.0, P < 0.001). EBM-concordant fusions were associated with 2% greater improvement in ODI scores from baseline for every $1000 spent intraoperatively. Systematic methods for increasing guideline adherence for lumbar fusions could therefore improve value at scale.

Identifying Dementia Severity Among People Living With Dementia Using Administrative Claims Data

ObjectivesThere is currently no reliable tool for classifying dementia severity level based on administrative claims data. We aimed to develop a claims-based model to identify patients with severe dementia among a cohort of patients with dementia. DesignRetrospective cohort study. Setting and ParticipantsWe identified people living with dementia (PLWD) in US Medicare claims data linked with the Minimum Data Set (MDS) and Outcome and Assessment Information Set (OASIS). MethodsSevere dementia was defined based on cognitive and functional status data available in the MDS and OASIS. The dataset was randomly divided into training (70%) and validation (30%) sets, and a logistic regression model was developed to predict severe dementia using baseline (assessed in the prior year) features selected by generalized linear mixed models (GLMMs) with least absolute shrinkage and selection operator (LASSO) regression. We assessed model performance by area under the receiver operating characteristic curve (AUROC), area under precision-recall curve (AUPRC), and precision and recall at various cutoff points, including Youden Index. We compared the model performance with and without using Synthetic Minority Oversampling Technique (SMOTE) to reduce the imbalance of the dataset. ResultsOur study cohort included 254,410 PLWD with 17,907 (7.0%) classified as having severe dementia. The AUROC of our primary model, without SMOTE, was 0.81 in the training and 0.80 in the validation set. In the validation set at the optimized Youden Index, the model had a sensitivity of 0.77 and specificity of 0.70. Using a SMOTE-balanced validation set, the model had an AUROC of 0.83, AUPRC of 0.80, sensitivity of 0.79, specificity of 0.74, positive predictive value of 0.75, and negative predictive value of 0.78 when at the optimized Youden Index. Conclusions and ImplicationsOur claims-based algorithm to identify patients living with severe dementia can be useful for claims-based pharmacoepidemiologic and health services research.

Improving Parental Health Literacy in Primary Caregivers of 0- to 3-Year-Old Children Through a WeChat Official Account: Cluster Randomized Controlled Trial.

Parental health literacy is important to children's health and development, especially in the first 3 years. However, few studies have explored effective intervention strategies to improve parental literacy. This study aimed to determine the effects of a WeChat official account (WOA)-based intervention on parental health literacy of primary caregivers of children aged 0-3 years. This cluster randomized controlled trial enrolled 1332 caregiver-child dyads from all 13 community health centers (CHCs) in Minhang District, Shanghai, China, between April 2020 and April 2021. Participants in intervention CHCs received purposefully designed videos via a WOA, which automatically recorded the times of watching for each participant, supplemented with reading materials from other trusted web-based sources. The contents of the videos were constructed in accordance with the comprehensive parental health literacy model of WHO (World Health Organization)/Europe (WHO/Europe). Participants in control CHCs received printed materials similar to the intervention group. All the participants were followed up for 9 months. Both groups could access routine child health services as usual during follow-up. The primary outcome was parental health literacy measured by a validated instrument, the Chinese Parental Health Literacy Questionnaire (CPHLQ) of children aged 0-3 years. Secondary outcomes included parenting behaviors and children's health outcomes. We used the generalized linear mixed model (GLMM) for data analyses and performed different subgroup analyses. The β coefficient, risk ratio (RR), and their 95% CI were used to assess the intervention's effect. After the 9-month intervention, 69.4% (518/746) of caregivers had watched at least 1 video. Participants in the intervention group had higher CPHLQ total scores (β=2.51, 95% CI 0.12-4.91) and higher psychological scores (β=1.63, 95% CI 0.16-3.10) than those in the control group. The intervention group also reported a higher rate of exclusive breastfeeding (EBF) at 6 months (38.9% vs 23.44%; RR 1.90, 95% CI 1.07-3.38) and a higher awareness rate of vitamin D supplementation for infants younger than 6 months (76.7% vs 70.5%; RR 1.39, 95% CI 1.06-1.82). No significant effects were detected for the physical score on the CPHLQ, breastfeeding rate, routine checkup rate, and children's health outcomes. Furthermore, despite slight subgroup differences in the intervention's effects on the total CPHLQ score and EBF rate, no interaction effect was observed between these subgroup factors and intervention factors. Using a WHO literacy model-based health intervention through a WOA has the potential of improving parental health literacy and EBF rates at 6 months. However, innovative strategies and evidence-based content are required to engage more participants and achieve better intervention outcomes.

Associations of 24-hour movement behaviors with emotional and behavioral problems among Chinese adolescents.

The role of adherence to the recommendations for 24-hour movement behaviors (24-HMB), including physical activity (PA), screen time (ST), and sleep duration (SLP), in relation to emotional and behavioral problems in Chinese adolescents remains uncertain. This study aimed to investigate these associations and explore potential sex differences. This school-based cross-sectional study included 15,071 Chinese adolescents with a mean age of 14.53 (SD: 1.65) years. Data on emotional and behavioral problems and 24-HMB (including PA, ST, and SLP) were collected. Analysis was performed using general linear mixed models, with additional sex-stratified analyses conducted. The number of 24-HMB recommendations met was negatively associated with total difficulties (β estimate=-0.96, 95% CI: -1.07 to -0.85) and positively related to prosocial behavior (β estimate = 0.41, 95% CI: 0.37 to 0.46) among adolescents. Compared with none of the recommendations met, meeting all recommendations (total difficulties: β estimate=-2.98, 95% CI: -3.41 to -2.55; prosocial behaviors: β estimate = 1.05, 95%CI: 0.87 to 1.24) demonstrated the strongest association with both difficulties and prosocial behaviors, followed by meeting recommendations for PA + ST (total difficulties: β estimate=-2.15, 95% CI: -2.41 to -1.90; prosocial behaviors: β estimate = 0.98, 95% CI: 0.87 to 1.09). These associations were consistently significant in both boys and girls. Adherence to more 24-HMB recommendations, particularly meeting all recommendations or combined PA + ST recommendations, could improve emotional and behavioral well-being among adolescent girls and boys. The significance of balanced movement behaviors for promoting adolescent mental health merits increased attention.

Reviving health mediation during the COVID-19 crisis and beyond: an implementation study in deprived neighbourhoods of Marseille, France.

In 2020, during France's COVID-19 response, healthcare professionals from a hospital and an association initiated health mediation interventions in Marseille's vulnerable neighbourhoods, funded by the regional health authorities. This mixed method research evaluates the CORHESAN program that lasted until June 2022. We examined CORHESAN documents and reports, conducted interviews, and analysed activity data, comparing it to the COVID-19 hotspots identified on a weekly basis at the neighbourhood level, using generalised linear mixed models (GLMMs). CORHESAN was implemented by a team of up to nine health mediators, six private nurses hired on an ad hoc basis, supervised by a general coordinator and two part-time medical and nursing coordinators. Multiple partnerships were established with shelters, associations, social-housing landlords and local institutions. The team accompanied 6,253 people affected by COVID-19 or contact in the practical implementation of their isolation and contact tracing. Of the 5,180 nasopharyngeal samples for RT-PCR and 1,875 for antigenic testing: 12% were taken at home and 27% in partner facilities in the targeted neighbourhoods; 32% were taken from symptomatic patients and 30% in the context of contact tracing; and 40% were positive. Multiple awareness sessions on prevention methods and distributions of personal protection kits and self-diagnostic tests were conducted in the streets, in shelters, in associations or at home. A total of 5,929 doses of COVID-19 vaccine were administered in a walk-in vaccination centre, at temporary street vaccination posts, during operations at partner facilities, or during home-visits to patients with limited autonomy. GLMMs showed that the intervention significantly targeted its testing interventions in neighbourhoods with socioeconomic disadvantage and/or past under-testing (adjusted odds ratio (aOR), 2.75 [1.50-5.00]) and those with high hotspot level (aOR for level-3 versus level-0, 1.83 [1.24-2.71]). The pandemic emphasised the potential of health mediation interventions to address health disparities. Building on this, a new program began in July 2022, aiming at enhancing cancer screening and vaccinations in deprived areas of Marseille. Evaluations are ongoing to assess its activities and impact, and provide evidence to future implementation initiatives.

Sex-specific diet differences in harbor seals (Phoca vitulina) via spatial assortment.

The lack of recovery of Chinook salmon (Oncorhynchus tshawytscha) in the Pacific Northwest has been blamed in part on predation by pinnipeds, particularly the harbor seal (Phoca vitulina). Previous work at a limited number of locations has shown that male seal diet contains more salmon than that of female seals and that sex ratios at haul-out sites differ spatiotemporally. This intrapopulation variation in predation may result in greater effects on salmon than suggested by models assuming equal spatial distribution and diet proportion. To address the generality of these patterns, we examined the sex ratios and diet of male and female harbor seals from 13 haul-out sites in the inland waters of Washington State and the province of British Columbia during 2012-2018. DNA metabarcoding was conducted to determine prey species proportions of individual scat samples. The sex of harbor seals was then determined from each scat matrix sample with the use of quantitative polymerase chain reaction (qPCR). We analyzed 2405 harbor seal scat samples using generalized linear mixed models (GLMMs) to examine the factors influencing harbor seal sex ratio at haul-out sites and permutational multivariate analysis of variance (PERMANOVA) to examine the influence of sex and haul-out site on harbor seal diet composition. We found that the overall sex ratio was 1:1.02 (female:male) with notable spatiotemporal variation. Salmoniformes were about 2.6 times more abundant in the diet of males than in the diet of females, and Chinook salmon comprised ca. three times more of the average male harbor seal's diet than the average female's diet. Based on site-specific sex ratios and diet data, we identified three haul-out sites where Chinook salmon appear to be under high predation pressure by male harbor seals: Cowichan Bay, Cutts Area, and Fraser River. Our study indicates that combining sex-specific pinniped diet data with the sex ratio of haul-out sites can help identify priority sites of conservation concern.