Mediation Analysis Research Articles

VA-ECMO-related complications seem not causally related to mortality in patients with acute myocardial infarction complicated by cardiogenic shock

Abstract Background Recently published randomized controlled trials and an individual patient data meta-analysis showed that the routine use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) did not reduce mortality compared to medical therapy alone in patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS). Purpose The aim of this study was to investigate as to whether possible VA-ECMO-related medical complications might be associated with an increased mortality risk, which might explain the observed equipoise among mortality outcomes between VA-ECMO and usual care in patients with AMI-CS. Methods Using data from the randomized ECLS-SHOCK trial (Extracorporeal Life Support in Infarct-Related Cardiogenic Shock), which compared routine VA-ECMO use versus medical therapy alone. Causal mediation analyses (primary analysis; VA-ECMO-related complications used as a mediator), logistic regression and causes of death analyses (secondary analyses) were utilised to test potential effects of possible VA-ECMO-related complications on 30-day mortality. Analyses were adjusted for risk factors of bleeding and vascular complications. Results In total, 417 patients were included in this analysis. Moderate and severe bleeding as well as peripheral vascular complications requiring intervention were identified as possible VA-ECMO-related complications. A total of 88 patients (21.1%) developed possible VA-ECMO-related complications, which mostly occurred within five days after randomisation and more frequently in the VA-ECMO group than in the control group: 49 (23.4%) vs. 20 (9.6%) patients, p<0.001 for bleeding and 23 (11.0%) vs. 8 (3.8%) patients, p=0.01 for peripheral vascular complications, respectively. Causal mediation analyses revealed no significant mediation effect of possible VA-ECMO-related complications on 30-day mortality (p=n.s.; Figure). Logistic regression and causes of death analyses of possible VA-ECMO-related complications confirmed no significant associations between the incidence of VA-ECMO-related complications and mortality (p=n.s.). Conclusion VA-ECMO use in patients with AMI-CS was associated with increased incidences of moderate to severe bleeding as well as vascular complications warranting intervention. In this causal mediation analysis, VA-ECMO-related complications do not appear to mediate an increased mortality risk.

The relationship between sleep quality, depression, and smartphone addiction in pregnant women: a mediation analysis

ABSTRACT In recent years, the prevalence of smartphone addiction has significantly increased. This situation has raised concerns about its potential impact on health aspects, such as sleep quality and mental health, particularly among vulnerable populations like pregnant women. This study aimed to identify the factors that determine sleep quality in pregnant women and examine the relationship between smartphone addiction, depression, and sleep quality. This descriptive correlational study included 257 pregnant women in their second and third trimesters who were registered at six family health centers between September 2022 and March 2023. Data were collected using a sociodemographic questionnaire, the Smartphone Addiction Scale Short Form, Edinburgh Postnatal Depression Scale, and Pittsburgh Sleep Quality Index. Regression and mediation analyses were performed for the data. Of the participants, 44.4 percent had poor sleep quality. Depression and third trimester were significant determinants of sleep quality. The bootstrapping results revealed that smartphone addiction led to an increase in the level of depression (β = 0.145; p < .001). Depression worsened sleep quality (β = 0.262; p < .001). The smartphone addiction did not significantly affect sleep quality (β = 0.020; p = .279). Depression mediates the relationship between sleep quality and smartphone addiction (β = 0.038; 95 percent CI [0.018: 0.062]). The study highlights that while smartphone addiction does not directly impact sleep quality in pregnant women, it is associated with increased depression levels, which subsequently worsen sleep quality. It is recommended that healthcare providers monitor smartphone usage and mental health in pregnant women to mitigate the risk of sleep disturbances and improve overall well-being.

Causal relationships between three plasma proteins and non-alcoholic fatty liver disease, mediated by Epstein-Barr virus EA-D antibody levels: a mendelian randomization study

Non-alcoholic fatty liver disease (NAFLD) is a major global health concern, with its prevalence increasing steadily. While plasma proteins have been implicated in NAFLD, establishing causal relationships has been challenging due to confounding factors in observational studies. This study aims to explore the causal relationships between plasma proteins and NAFLD using Mendelian randomization (MR) analysis. We utilized genome-wide association study (GWAS) data from multiple sources to conduct MR analyses. Plasma protein data were obtained from the deCODE open database, and NAFLD data were sourced from the Finnish genetic sample collection (FinnGen). We performed MR analysis to identify plasma proteins causally related to NAFLD and explored the potential mediation effect of antibody-immune responses. Our MR analysis identified three plasma proteins—KNG1, MICB, and PKD2—with significant causal relationships to NAFLD. Mediation analysis further revealed that KNG1 negatively mediated the risk of NAFLD through Epstein-Barr virus EA-D antibody levels, while MICB and PKD2 positively mediated NAFLD risk through the same antibody levels. This study provides novel genetic evidence of causal relationships between specific plasma proteins and NAFLD risk. Measuring the levels of KNG1, MICB, PKD2, and Epstein-Barr virus EA-D antibody levels in patients may help clinicians assess NAFLD risk more accurately. Further clinical research is warranted to validate these findings and explore their potential therapeutic implications.

Associations Between Adverse Childhood Experiences, Adolescent Behavioral Health Challenges, and High School Dropout.

Adverse childhood experiences (ACEs) are associated with behavioral health challenges and high school dropout, and behavioral health is associated with high school dropout. Less is known about the role of behavioral health challenges in the relationship between ACEs and high school dropout. Using data from the Panel Study of Income Dynamics (2013) and its 2014 Childhood Retrospective Circumstances Study supplement, the current study conducts mediational path analysis to examine the direct and indirect effects of cumulative ACEs on high school dropout via adolescent depression, anxiety, and substance use. Experiencing more ACEs was associated with depression, anxiety, and substance use. Only depression and substance use were associated with high school dropout. There was a significant direct effect between increased ACEs and high school dropout and significant indirect effects via depression and substance use, but not anxiety. Adolescent behavioral health interventions to address the long-term effects of ACEs may also support academic achievement. School-based interventions, particularly those aligned with trauma-sensitive school frameworks and engaging various school personnel, including school nurses, should be considered. Community- and policy-level interventions aimed at primary prevention of ACEs are also needed.

The Impact of Student Attitude on Information, Communication, Creation Skills and Student Engagement

The Malaysian education system is guided by the Malaysia Education Blueprint, which drives the overall quality and effectiveness of education in the country. This study provides insights and assists in forming informed guidelines for the Ministry of Education regarding the impact of skill factors. The relationship between the direct effects of these three primary skills and attitudes is supported by Self-Efficacy Theory (SET). The indirect relationship, where attitude mediates the effects of these skills on student engagement, is supported by Self-Determination Theory (SDT) and Social Cognitive Theory (SCT). A questionnaire was distributed to local university students currently in their fourth semester and analyzed using the Structural Equation Model using Partial Least Square (PLS). The structural model results direct relationship between attitude and student engagement and between information skills and attitude. In addition, the mediation analysis shows that the relationship between information skills and student engagement, mediated by student attitude, was significant. Based on these results, it is recommended that the Ministry of Education focus on providing supportive resources, such as learning environments and training for educators, in the upcoming Malaysia Education Blueprint for 2026 to 2036. Additionally, offering Digital Literacy Programs to equip students with information skills can positively influence student attitudes and thereby increase the level of student engagement, which is crucial for improving the academic performance and achievement of Malaysia’s educational system. Future research should include a cross-cultural comparison to reconsider educational theories for Asian countries, as many theories are currently based on Western educational settings and contexts.

Social Comparison, Belongingness, Self-Doubt, and Stress: The Case of Hispanic Students at Hispanic Majority Institutions

Social comparison processes can affect academic and interpersonal outcomes for minoritized college students. However, the literature has not addressed how these processes play out for Hispanic students who attend Hispanic Majority Institutions, in which Hispanic students comprise more than 50% of the population. In this study, such students ( N = 191) completed online assessments for social comparison orientation (SCO), belongingness, academic self-concept, and perceived stress. Results showed that, regarding belongingness, SCO was positively correlated to rejection/exclusion, but not acceptance/inclusion. Regarding academic self-concept, SCO was positively correlated to self-doubt, but not self-confidence. Mediation analyses showed that perceived stress fully mediated the relationship between SCO and rejection/exclusion, and partially mediated the relationship between SCO and academic self-doubt. In other words, SCO was associated with increased stress, which was then associated with increased feelings of rejection/exclusion and self-doubt about academic abilities. These findings offer additional insight into Hispanic college students’ experience.

Dynapenic abdominal obesity and activities of daily living disability among older adults residing in low- and middle-income countries

BackgroundDynapenic abdominal obesity (DAO) may be associated with an increased risk of disability. However, to date, this has not been investigated in low- and middle-income countries (LMICs), while the mediators are largely unknown.AimsTherefore, we aimed to investigate the association between DAO and activities of daily living (ADL) disability, and to identify potential mediators among older adults from six LMICs.MethodsCross-sectional, nationally representative data from the WHO Study on global AGEing and adult health were analyzed. Data on 20,198 adults aged ≥ 60 years were analyzed [mean (SD) age 69.3 (13.1) years; 54.1% females]. Dynapenia was defined as handgrip strength of < 26 kg for men and < 16 kg for women. Abdominal obesity was defined as waist circumference of > 88 cm for women and > 102 cm for men. DAO was defined as having both dynapenia and abdominal obesity. Disability was defined as severe or extreme difficulty in conducting at least one of six types of ADL. Multivariable logistic regression and mediation analysis were conducted.ResultsCompared to no dynapenia and no abdominal obesity, DAO was significantly associated with 2.08 (95%CI = 1.37–3.17) times higher odds for ADL disability Mediation analysis showed that diabetes (mediated percentage 4.7%), hypertension (7.2%), and angina (7.7%) were significant mediators in the association between DAO and ADL disability.ConclusionsDAO was associated with increased odds for ADL disability among older adults from LMICs. Future longitudinal studies are warranted to assess temporal associations, and whether addressing or preventing DAO can impact on future occurrence of disability.

Self-Efficacy, Patient Activation, and the Burden of Inflammatory Bowel Disease on Patients' Daily Lives.

The effective management of inflammatory bowel disease (IBD) requires complex self-management behaviors. Both patient activation (the degree to which patients are willing and able to engage in care) and self-efficacy (one's confidence in performing certain behaviors) are thought to play an important role in chronic disease self-management, but patient activation is a broad concept that can be more difficult to precisely target than self-efficacy. We aimed to describe the relationship between patient activation, self-efficacy, and the burden of IBD on patients' daily lives. Patients with IBD were recruited from a single center to complete a survey including the Patient Activation Measure (PAM-13®), the IBD Self-Efficacy Scale (IBD-SES), and an IBD-specific patient-reported outcome measure. Using multivariable linear regression, we examined the relationship between IBD burden, self-efficacy, and patient activation, adjusting a priori for age, gender, IBD type, IBD medications, active corticosteroid use, anxiety, and depression. We performed a post-hoc mediation analysis to examine self-efficacy as a potential mediator in the relationship between patient activation and the burden of IBD on patient's daily lives. A total of 132 patients with IBD completed the survey (59% Crohn's disease, 41% ulcerative colitis, 52% female). Higher levels of patient activation and higher levels of self-efficacy were each associated with lower IBD burden (patient activation: ß = -1.9, p < 0.001, self-efficacy: ß = -2.6, p < 0.001). Post hoc mediation analysis confirmed that the relationship between patient activation and daily IBD burden was mediated by self-efficacy (Average Causal Mediation Effect = -1.00, p < 0.001, proportion mediated = 0.62, p < 0.001). The relationship between patient activation and IBD burden is highly mediated by self-efficacy, suggesting that self-efficacy could be a more precise target for intervention. Future studies could focus on targeting self-efficacy to build individuals' confidence in IBD self-management and testing of IBD-tailored self-management programs to ultimately improve disease outcomes.

Community-Based Tourism Implementation as Mediator on the Relationship between Community Participation and Socio-Economic Sustainability of Tourism

This study explored the mediating effect of community-based tourism implementation on the relationship between community participation and the socio-economic sustainability of tourism in Marilog District. This study employed a quantitative method and stratified random sampling to select the 380 respondents. The survey was distributed to two areas in Marilog District: Barangay Baganihan and Barangay Datu Salumay. The data was evaluated to ascertain whether the variables had a statistical relationship. This study used non-experimental quantitative research, the descriptive-correlation approach, and mediation analysis. The weighted mean, Pearson product-moment correlation coefficient, multiple regression analysis, and path analysis were used to analyze the data. The result revealed that the respondents have high levels of community participation, socio-economic sustainability, and community-based tourism implementation. The relationship between community participation and socio-economic sustainability, community participation and community-based tourism implementation, and socio-economic sustainability and community-based tourism implementation were statistically significant. However, the indirect effect of community participation in socio-economic sustainability through community-based tourism implementation is insignificant and statistically supported by this study, indicating no significant mediation. The study findings’ implications are presented.

The causal effects of placental weight on atherosclerotic cardiovascular disease: a Mendelian randomization and mediation analysis

IntroductionPrevious studies have linked placental weight (PW) to cardiovascular diseases, but the causality and potential mediators underlying this relationship are still unknown.Material and methodsWe conducted Mendelian randomization (MR) analysis via summary statistics from genome-wide association studies (GWAS), including PW adjusted for sex, 21 candidate mediators and atherosclerotic cardiovascular disease (ASCVD), which includes coronary heart disease (CHD) and ischemic stroke (IS).Two-step MR was employed to identify and assess the mediation proportion of potential mediators in the association between PW and ASCVD. Additionally, we conducted a repeated analysis using PW adjusted for gestational age and sex.ResultsUnivariable MR (UVMR) analysis revealed that for each 1-SD decrease in fetal genotype-determined PW adjusted for sex only, the risk of CHD increased by 24% (95% CI: 1.05–1.46) and the risk of large artery stroke (LAS) increased by 46% (95% CI: 1.13–1.89). Similar results were obtained in repeated analyses. The mediation MR analysis revealed that the causal relationship between fetal genotype-determined PW and CHD risk was primarily mediated by birthweight, type 2 diabetes, and education, each mediating 3.66% to 40.80% of the total effect. The causal relationship between fetal genotype-determined PW and LAS risk was mediated mainly by type 2 diabetes, which accounted for 22.11% of the total effect.ConclusionsThis study elucidated a unidirectional causal relationship between lower PW and a greater ASCVD risk, with factors such as birthweight, type 2 diabetes, and education mediating the association between PW and ASCVD.

Self-confidence as a mediator in the relationship between executive functioning and depression among ICU survivors: a latent variable analysis

BackgroundExecutive dysfunction and depression are common among ICU survivors, yet the mechanisms linking these two factors remain poorly understood. Self-confidence has been implicated as a key mediator in the relationship between cognitive impairments and mental health outcomes. This study aimed to explore the mediating role of self-confidence in the association between executive functioning and depression in ICU survivors.MethodA provisional questionnaire was used in a cross-sectional study to assess quality of life in 395 adult ICU survivors, each with a minimum 72-h stay at one of three ICUs at a Swedish university hospital, six months to three years post-discharge. Responses to questions on executive function, self-confidence, and depression were analysed. Structural equation modelling and confirmatory factor analysis were employed to examine the mediating effect of self-confidence on the relationship between executive function and depression. Model fit was evaluated using established indicators. Reliability of the measures was assessed using McDonald’s Omega and Cronbach’s Alpha.ResultsA significant positive correlation was found between depressive symptoms and both diminished self-confidence (r = 0.80, p < 0.001) and poorer executive function (r = 0.55, p < 0.001). Additionally, a correlation was observed between reduced self-confidence and compromised executive function (r = 0.62, p < 0.001). Age was negatively associated with depression, self-confidence, and executive function, while male gender was positively correlated with higher self-confidence.Mediation analysis revealed that the effect of impaired executive function on depressive symptoms was fully mediated by diminished self-confidence (B = 0.45; 95% CI 0.34–0.59). The direct effect of executive function on depression became non-significant when self-confidence was included in the model (B = 0.07, p = 0.18), suggesting complete mediation. The overall model fit was satisfactory (CFI = 0.962; RMSEA = 0.075), highlighting the robustness of the mediation pathway.ConclusionsSelf-confidence mediates the relationship between executive function and depression among ICU survivors. Interventions aimed at enhancing self-confidence could mitigate depressive symptoms in the ICU survivor population. Longitudinal studies are needed to confirm these findings and further explore the causal pathways involved.Trial registration ClinicalTrials.gov Ref# NCT02767180; Registered 28 April 2016.

Synergizing Systems Thinking and Technology-Enhanced Learning for Sustainable Education Using the Flow Theory Framework

In an era where digital technologies are integral to daily life and sustainable education is increasingly critical, developing higher-order thinking skills with appropriate information and communication technology (ICT) support is crucial for achieving Sustainable Development Goals (SDGs). The purpose of this study was to examine synergies of systems thinking and technology-enhanced learning from the perspective of flow theory within the context of sustainable education. We surveyed more than 65 pre-service preschool teachers engaged in a design, technology, and engineering (DTE) course at the University of Ljubljana. Mapping of systems thinking revealed that pre-service preschool teachers needed support regarding feedback and understanding the interrelationship dimension of systems thinking—essential components of sustainable education. Predictive and mediation analyses yielded noteworthy results. Participants in the ICT-enhanced DTE course rated their cognitive and social engagement above the mid-point of the scale, with this higher engagement correlating with higher systems thinking crucial for sustainable education. In contrast, their aesthetic engagement was below the mid-point of the scale. Experiencing a flow state during ICT activities positively influenced systems thinking, particularly in terms of clear goals and autotelic experiences. Flow theory thus emerges as a solid and appropriate framework to use for studying synergies in technology-enhanced systems thinking for sustainable education. These findings underscore the importance of integrating systems thinking into curricula to enhance learning outcomes and prepare students for future challenges, thereby contributing to the achievement of SDGs through sustainable education.

Effect of engagement in personal growth initiative skills on depression, anxiety, and stress: Multilevel mediation analysis with intensive longitudinal data.

The current study examined the association between the possession of personal growth initiative (PGI) skills and symptoms of mental illness (i.e., depression, anxiety, and stress) and the potential mediating role of daily engagement of PGI skills during the COVID-19 pandemic. The participants consisted of 73 individuals (Mage = 41.62, SDage = 12.44) who were recruited from Amazon's Mechanical Turk (MTurk). Data for possessed PGI was collected in April 2020, and the daily survey started approximately 1 month later at the beginning of May 2020 for 29 days. Controlling for demographic variables, multilevel mediation models revealed significant association between PGI skills and PGI engagement. However, our hypothesized indirect effects were not found. When inspecting the direct effects controlling for the effect of PGI engagement and demographic variables, the paths between PGI skills and both depression and anxiety were negatively associated. When examining the effect of time, there were no significant changes during the period of 29 days in the levels of PGI skills among individuals. However, a significant fluctuation within individuals in how much participants have utilized PGI skills during the study period was found. The current study highlights the influence of PGI skills at both the between-individual as well as within-individual levels in predicting symptoms of mental illness, and it also uncovers the role of PGI skills by separating into general PGI skills and individual's daily engagement in utilizing the PGI skills in predicting symptoms of mental illness.

Professional values, cultural competence, and moral sensitivity of surgical nurses: Mediation analysis and structural equation modeling.

Developing a framework that illustrates causal relationships and an in-depth comprehension of contextual elements is essential for steering the development of ethical interventions to enhance nurses' ethical decision-making. To examine the relationship between cultural competence, professional nursing values, and moral sensitivities of surgical nurses with a mediation analysis and structural equation model. This study is descriptive and correlational. and research context: This study was conducted with a total of 201 surgical nurses from two university hospitals in Konya, Türkiye. Data were gathered face-to-face between June and October 2023 with the Moral Sensitivity Questionnaire (MSQ), Nurses Professional Values Scale-Revised (NPVS-R), and Nurse Cultural Competence Scale (NCCS). Ethical approval from X University Ethics Committee was obtained (Number: 2023/419). In this study, the mean scores for the surgical nurses were as follows: 89.3 ± 19.33 on the MSQ, 113.1 ± 20.74 on the NPVS-R, and 72.06 ± 18.61 on the NCCS. Nurses' cultural competence level significantly affected their professional nursing values (β = 0.192; p = .007; R2 = 0.04), and their professional nursing values, in turn, had a significant effect on their moral sensitivities (β = -0.363; p < .001; R2 = 0.16). However, it was determined that the direct effect of nurses' cultural competence level on their moral sensitivity was not statistically significant. In contrast, the indirect effect of nurses' cultural competence level on their moral sensitivity, mediated by their professional nursing values was seen to be statistically significant (B = -0.070; p = .008). This study showed that there is a significant positive relationship between the professional nursing values and cultural competence levels of surgical nurses and that as professional nursing values increase, their moral sensitivity also rises. Sensitivity with higher professional nursing values. Additionally, it was found that nurses' professional values served as a mediating factor between their levels of cultural competence and moral sensitivity. Therefore, it is crucial to enhance the cultural competence, professional nursing values, and moral sensitivity of nursing students and registered surgical nurses and to improve their reasoning and decision-making skills in ethical dilemmas.

Effect of psychosocial safety climate on work-family conflict and psychological health among working couples.

The purpose of the study was to look into how work-family conflict (WFC), family-work conflict (FWC), and psychological health are affected by the psychosocial safety climate (PSC). First, the study suggested that for both husband and wife, PSC moderates the relationship between job demands and WFC. Second, the study predicted FWC mediates the relationship between WFC and depressive symptoms through the "crossover" process. The study design used a multi-source sample that involved 350 teachers and their working spouses (n = 700). The analysis of mediation and moderation among job demands, WFC, FWC, PSC, and depressive symptoms was conducted using SPSS and structural equation modeling AMOS software. For the teacher's sample, based on behavioral (β = 0.166, p < 0.05) and strain-based (β = 0.170, p < 0.05) aspects, the hierarchical regression analysis revealed that the PSC moderates the relationship between physical demand and WFC. The results also showed that the relationship between time-based WFC and emotional demand is moderated by PSC (β = 0.103, p < 0.05). Next, the analysis found that PSC moderates the association between cognitive demand and WFC of strain-based (β = 0.179, p < 0.05). For the spouse's sample, according to the analysis, PSC moderates the relationship between strain-based WFC and physical demand (β = 0.091, p < 0.05). The study also revealed that FWC serves as a mediator in the relationship between WFC and depressive symptoms in both husbands (β = 0.233, p < 0.01) and wives (β = 0.135, p < 0.001). Overall, this study contributes significant insights to the current literature by examining the impact of PSC on the psychological well-being of individuals and others through the crossover process.

Venture Capital, Environmental Regulation and Regional Green Innovation: Evidence from China

Venture capital can promote green innovation by providing financial support for green innovation activities. Based on panel data from 30 provincial-level administrative regions in China, this research analyzes the impact of venture capital on green innovation and its underlying mechanisms. The results show that venture capital significantly promotes regional green innovation. Through the mediation analysis, it is found that venture capital primarily promote green innovation by increasing R&amp;amp;D investment and improving the level of research team level. The increase in R&amp;amp;D investment is the main pathway through which venture capital influences the level of green innovation, as firms receiving venture capital are more willing to allocate these funds towards green innovation activities. The study also finds that the impact of venture capital on green innovation is influenced by environmental regulation, with an upper limit to the intensity of environmental regulation. Environmental regulation below this limit value amplifies the positive effect of venture capital on green innovation, while regulation exceeding this threshold reduces the effect of venture capital on green innovation. The article confirms the important role of venture capital in promoting green innovation, enriches the research on the innovation effects of venture capital, and provides theoretical references for green development.

Gestational diabetes and future cardiovascular diseases: associations by sex-specific genetic data.

Observational studies have highlighted that gestational diabetes mellitus is associated with a higher risk of cardiovascular diseases, but the causality remains unclear. Herein, the causality between genetic predisposition to gestational diabetes mellitus and the risk of cardiovascular diseases was investigated using sex-specific Mendelian randomization analysis. Linkage disequilibrium score regression analysis and two-sample Mendelian randomization analysis were applied to infer the genetic correlation and causality, respectively. Mediation analysis was conducted using a two-step Mendelian randomization approach. Sensitivity analyses were performed to differentiate causality from pleiotropy. The genome-wide association study summary statistics for gestational diabetes mellitus were obtained from FinnGen consortium, while for cardiovascular diseases were generated based on individual-level genetic data from the UK Biobank. Linkage disequilibrium score regression analyses revealed that gestational diabetes mellitus had a significant genetic correlation with coronary artery disease and myocardial infarction after Benjamini-Hochberg correction in ever-pregnant women. In Mendelian randomization analyses, odds ratios (95% confidence interval) for coronary artery disease and myocardial infarction were 1.09 (1.01-1.17) and 1.12 (.96-1.31) per unit increase in the log-odds of genetic predisposition to gestational diabetes mellitus in ever-pregnant women, respectively. Further, Type 2 diabetes and hypertension were identified as mediators for the causality of genetic predisposition to gestational diabetes mellitus on coronary artery disease. In sensitivity analyses, the direction of odds ratio for the association between instrumental variables with gestational diabetes mellitus-predominant effects and the risk of coronary artery disease was consistent with the primary results in ever-pregnant women, although not statistically significant. This study demonstrated a suggestive causal relationship between genetic predisposition to gestational diabetes mellitus and the risk of coronary artery disease, which was mainly mediated by Type 2 diabetes and hypertension. These findings highlight targeting modifiable cardiometabolic risk factors may reduce the risk of coronary artery disease in women with a history of gestational diabetes mellitus.

Longitudinal mediation analysis with multilevel and latent growth models: a separable effects causal approach

BackgroundCausal mediation analysis is widespread in applied medical research, especially in longitudinal settings. However, estimating natural mediational effects in such contexts is often difficult because of the presence of post-treatment confounding. Moreover, many models frequently used in applied research, like multilevel and latent growth models, present an additional difficulty, i.e. the presence of latent variables. In this paper, we propose a causal interpretation of these two classes of models based on a novel type of causal effects called separable, which overcome some of the issues of natural effects.MethodsWe formally derive conditions for the identifiability of separable mediational effects and their analytical expressions based on the g-formula. We carry out a simulation study to investigate how moderate and severe model misspecification, as well as violation of the identfiability assumptions, affect estimates. We also present an application to real data.ResultsThe results show how model misspecification impacts the estimates of mediational effects, particularly in the case of severe misspecification, and that the bias worsens over time. The violation of assumptions affects separable effect estimates in a very different way for the mixed effect and the latent growth models.ConclusionOur approach allows us to give multilevel and latent growth models an appealing causal interpretation based on separable effects. The simulation study shows that model misspecification can heavily impact effect estimates, highlighting the importance of careful model choice.

Mediating effects of physical activities and cognitive function on the relationship between dietary diversity and all-cause mortality in community-dwelling older adults.

Although dietary diversity (DD) has been confirmed to be associated with multiple health outcomes and longevity in older people, the related mechanisms have not been elucidated. In this study, we explored the mediating roles of physical activities and cognitive function in the relationship between DD and all-cause mortality. We recruited 34 068 community-dwelling older adults aged ≥60 years from the Chinese Longitudinal Healthy Longevity Study and followed them up until 2018. Dietary diversity score (DDS) was assessed by the intake frequency of nine food sources. We evaluated physical activities and cognitive function using the Katz index and Mini-Mental State Examination. We explored the mediating roles of physical activities and cognitive function between DDS and all-cause mortality using mediated analyses in Cox proportional risk regression models. A total of 25 362 deaths were recorded during 148 188.03 person-years of follow-up. Participants with physical disability and cognitive impairment had lower DDS than the normal group (P < 0.001). After controlling for all covariates, DDS, physical activities, and cognitive functioning were negatively associated with all-cause mortality. Physical activities and cognitive function mediated 18.29% (95% confidence interval (CI) = 12.90-23.10) and 27.84% (95% CI = 17.52-37.56) of the total effect of DDS on mortality, respectively. Physical activities and cognitive function mediated the association between DDS and all-cause mortality. Maintaining DD may benefit early death prevention by reducing physical disability and cognitive impairment in community-dwelling older people.

Loneliness and Problematic Internet Use in Adolescents: The Mediating Role of Dissociation

Background/Objectives. Problematic Internet uUse (PIU) is a multifaceted syndrome characterized by excessive or poorly controlled preoccupations, urges, or behaviors regarding Internet use leading to significant impairments in daily life and mental health. Previous research has separately related PIU to loneliness and dissociation, both in adults and adolescents. The aim of the present study is to analyze the mutual relationship between PIU, loneliness, and dissociation in an adolescent sample, in particular evaluating the indirect effect of dissociation on the relationship between loneliness and PIU. Methods. A cross-sectional design was used with 243 Italian high school students (69.1% females), from year 9 to 13 (age: M = 17.1, SD = 1.4 years), who participated in the study from January to June 2020. They completed measures of PIU (Generalized Problematic Internet Use Scale-2), loneliness (UCLA Loneliness Scale), and dissociation (Adolescent Dissociative Experiences Scale). Socio-demographic and contextual variables were also collected (i.e., age, gender, type of school, school year, sport practice, hobby engagement, assessment before/during the COVID-19 pandemic). Data were analyzed using regression, Pearson’s correlation, and mediation analysis. Results. Severe PIU was observed in 8.6% of the sample. None of the socio-demographic and contextual variables had a significant effect on PIU. Positive medium-sized correlations were observed between PIU, loneliness, and dissociation. Mediation analyses showed an indirect effect of loneliness on PIU through dissociation. Conclusions. Feelings of loneliness may significantly exacerbate adolescents’ PIU by increasing their dissociative tendency. Understanding this dynamic is crucial for developing targeted interventions to address both loneliness and dissociation in efforts to mitigate PIU among adolescents.