Mixed-effects Regression Analysis Research Articles

Two-Dimensional and Point Shear-Wave Elastography to Predict Esophageal Varices and Clinically Significant Portal Hypertension in Patients with Chronic Liver Disease

Introduction: The non-invasive assessment of disease severity remains pivotal in patients with chronic liver disease (CLD) as it has wide implications in predicting liver-related complications or death. Shear-wave elastography (SWE) is an emerging ultrasound-based method to non-invasively measure liver stiffness. The aim of our study was to evaluate two-dimensional (2D) and point (p) SWE to predict the presence of esophageal varices (EV) or clinically significant portal hypertension (CSPH). Methods: This was a retrospective analysis of a prospectively performed cohort study of patients with CLD treated in the outpatient clinic of the Frankfurt University Hospital. PSWE using the Hitachi HI Vision ASCENDUS system and the Siemens ACUSON S2000TM system or 2D-SWE using the Toshiba APLIO500 system were analyzed at baseline and during follow-up to predict EV or surrogate parameters of CSPH. ROC curves were calculated for pooled liver stiffness measurements (LSMs) using a bootstrap approach. A combined model of SWE and platelet count was created and a mixed-effect logistic regression analysis using log-transformed values was performed. Results: Overall, 511 patients with CLD and 919 consecutive LSMs were included and 315 patients (61.6%) had signs of CSPH. 2D-SWE performed best to predict EV and CSPH, and the addition of platelet count to the predictive model significantly increased test results for EV (AUC 0.83, 95%-CI: 0.76–0.89; difference in AUC 0.11, 95%-CI: 0.03–0.19, p = 0.004), but only marginally for CSPH (AUC 0.75, 95%-CI: 0.64–0.85; difference in AUC 0.06, 95%-CI: 0.02–0.14, p = 0.150). LSM > 18.5 and >20 kPa were indicative of CSPH and EV, while LSM < 10 kPa and <11 kPa ruled out CSPH and EV, respectively. Conclusions: Our study found that 2D-SWE in combination with platelet count performed best (in comparison to the other SWE methods) to predict EV or CSPH in patients with CLD. Future prospective trials are needed to validate our results.

Quantitative assessment of cervical disc degeneration using disc signal intensity index.

The assessment of disc degeneration remains a significant challenge in clinical research. Pfirrmann grade is a frequently used classification for lumbar disc degeneration on MRI. However, there has been no gold standard for cervical spine disc degeneration. Recently, we introduced the Disc Signal Intensity Index (DSI2) as a quantitative disc assessment for the lumbar spine, which is easily measurable in the cervical spine. The aim of this study was to apply DSI2 in the cervical intervertebral disc and investigate the factors associated with the cervical disc degeneration. Cross-sectional study using retrospectively collected data. Cervical MRIs from a database of patients undergoing ACDF between 2015 and 2018 were retrospectively reviewed. Demographic variables included age, sex, body mass index (BMI), race, smoking status, and comorbidities such as diabetes, chronic kidney disease, and coronary artery disease. DSI2 measurements were performed on midsagittal T2-weighted MRI images by determining the intensity within regions of interest (ROI). One ROI was set in the cerebrospinal fluid (CSF) and three ROIs were set per disc at the anterior, middle, and posterior third. The mean of the three measurements per disc was then divided by that of the CSF to calculate the DSI2 score. Multivariable linear regression analyses with mixed model were conducted to determine the potential contributing factors for disc degeneration. A total of 149 patients and 770 discs were included in the final analysis. Ninety-three patients (37.6%) were female and the mean (SD) age was 55.6 (11.7) years. The distribution of DSI2 scores among the different Pfirrmann grades was as follows: Grade 1: 0.259±NA; Grade 2: 0.226±0.090; Grade 3: 0.175±0.070; Grade 4: 0.136±0.060; Grade 5: 0.131±0.050. Multivariable linear mixed-effect regression analysis, setting with DSI2 as the objective variable, demonstrated that age (β= -0.130, p< 0.05), BMI (β= -2.06, p< 0.05), Modic changes (Type1 β= -2.70, p<0.01) were independent contributors to disc degeneration. The segments C4/5 and C7/T1 were less prone to disc degeneration (C4/5: β=1.37, p<0.001; C7/T1: β= 2.63, p<0.001) and the history of diabetes (β=5.31, p<0.01) was associated with high DSI2.(p<0.01) CONCLUSIONS: The present study provides valuable insights for identifying risk factors in degenerative cervical conditions utilizing the DSI2. The DSI2 method emerges as a promising alternative for future disc research, excelling in the detection of subtle progressions of degeneration and distinguishing itself from the subjective Pfirrmann grading system.

The relationship between indoor airborne culturable bacteria with passenger flow in 132 traffic stations during 2019–2020, China

This study aims to provide technical support for the development of a rational administration strategy for indoor environment and passenger flow of stations. The analysis was conducted monitor data of long distance bus stations and train/high speed railway stations from the National project. The monitor and surveyed data included indoor airborne culturable bacteria (IAB), passenger flow, area and height of stations. Data analysis involved the use of paired non-parametric tests, correlation analysis, and mixed linear regression methods. A total of 132 pairs of stations were examined in this study. Additionally, significant variations were observed in the monitoring results for the IAB and passenger flow between 2019 and 2020 (p < 0.05). Specifically, the median values of these two factors in 2020 decreased by 50.52% and 48.33%, respectively, compared to 2019. (p < 0.05). A positive relationship between the daily average passenger flow and the IAB in long distance bus stations and train stations, particularly pronounced with medium sized waiting rooms, which located in subtropical cities with a general level of economic development. The mixed effect regression analysis revealed a significant association between passenger flow (OR = 1.564, 1.288–1.898), per capita volume (OR = 0.856, 0.733–0.998), and per capita area (OR = 0.806, 0.678–0.956) with the IAB (p < 0.05) just in long distance bus stations. It is crucial to regulate passenger flow and per capita area in the waiting room of long distance bus stations to mitigate the spread of airborne culturable bacteria during infectious disease epidemics.

Early sexual debut among adolescent girls and young women in Sierra Leone: A multilevel analysis of prevalence and predictors

BackgroundEarly sexual debut among young women is associated with adverse sexual and reproductive health outcomes, including unintended pregnancies and sexually transmitted infections. Despite its negative impact, there is limited research on this issue in Sierra Leone. This study aims to address this gap by examining the prevalence of early sexual debut and its associated factors among adolescent girls and young women aged 15–24 years in Sierra Leone.MethodsData from the 2019 Sierra Leone Demographic and Health Survey was used for the study. Provincial variations in the proportion of early sexual debut were visualised using a spatial map. A mixed-effect multilevel binary logistic regression analysis was performed to examine the factors associated with early sexual debut. The results were presented as adjusted odds ratios (aOR) with a 95% confidence interval (CI) and intraclass correlation coefficients.ResultsThe prevalence of early sexual debut was 26.1% [24.3, 28.0]. Adolescent girls and young women aged 20–24 were less likely to engage in early sexual debut [aOR = 0.52; 95% CI: 0.41, 0.65] than those aged 15–19. The odds of early sexual debut was lower among adolescent girls and young women with secondary/higher education [aOR = 0.62; 95% CI: 0.45, 0.85] compared to those with no education. Adolescent girls and young women who used the internet in the last 12 months [aOR = 0.50; 95% CI: 0.34, 0.73] and those who belonged to the Fullah ethnic group [aOR = 0.25; 95% CI: 0.07, 0.85] were less likely to engage in early sexual debut relative to those who did not use the internet and those belonging to the Creole ethnic group respectively. Adolescent girls and young women who intend to use contraceptives [aOR = 0.60; 95% CI: 0.46, 0.77] and those who do not intend to use contraceptives [aOR = 0.65; 95% CI: 0.49, 0.88] were less likely to engage in early sexual debut than those who were using contraceptives. Conversely, adolescent girls and young women who were working [aOR = 1.41; 95% CI: 1.12, 1.77] had higher odds for early sexual debut than those not working. The odds of early sexual debut were higher among adolescent girls and young women who were married/cohabiting [aOR = 1.72; 95% CI: 1.32, 2.22] and previously married [aOR = 3.26; 95% CI: 1.61, 6.56] than those who were never married. Adolescent girls and young women living in the North Western area [aOR = 1.81; 95% CI: 1.05, 3.13] had higher odds for early sexual debut than those living in the Eastern province.ConclusionEarly sexual debut is prevalent among adolescent girls and young women in Sierra Leone. Age, education, internet use, ethnicity, contraceptive use intention, marital status, employment status, and province of residence were the factors associated with early sexual debut. The study underscores the need for policymakers, government, and non-governmental organisations to design and implement comprehensive and multifaceted interventions to promote informed decision-making and reproductive health among adolescent girls and young women in Sierra Leone.

Performance of high-resolution diffusion-weighted magnetic resonance imaging for detecting clinically occult early breast cancers: a multi-reader study.

To compare mammography, breast ultrasound (US), high-resolution diffusion-weighted magnetic resonance imaging (DW-MRI), dynamic contrast-enhanced breast MRI (DCE-MRI), and their combinations for detecting clinically occult early breast cancers (EBCs), including ductal carcinoma in situ (DCIS). Three hundred and three consecutive women with screening imaging-detected early breast cancers (60 pure DCIS, 36 DCIS with microinvasion, and 207 invasive carcinoma less than 20mm) who underwent breast MRI at 3T including DW-MRI (b-values of 0, 800 and 1200s/mm2; in-plane resolution, 1.1 × 1.1 mm2 or 1.3 × 1.3 mm2; section thickness, 3mm) were retrospectively reviewed. Three radiologists independently reviewed each examination. Statistical analysis included Chi-square test, McNemar test for comparison of cancer detection rates, and Fleiss' Kappa for interreader agreement. Mixed-effect logistic regression analysis was employed to evaluate factors associated with cancer detection on DW-MRI. The overall cancer detection rates were 54.8% on mammography, 71.0% on breast US, 81.5% on DW-MRI, and 87.1% on DCE-MRI. On McNemar test, DW-MRI detected more cancers than mammography (adjusted p < 0.001), and its combination with mammography showed a similar cancer detection rate to DCE-MRI combined with mammography (adjusted p = 0.808). On multivariable analysis, histologic type, lesion size, ADC and CNR on DW-MRI were independent factors for cancer detection on DW-MRI. The interreader agreement for cancer detection was moderate to substantial (Fleiss' kappa: 0.52-0.65) across each modality. High-resolution DW-MRI plus mammography showed comparable cancer detection rate to DCE-MRI plus mammography for detecting clinically occult EBCs including DCIS.

Gender disparity and post-traumatic stress disorder and elevated psychological distress in humanitarian migrants resettled in Australia: the moderating role of socioeconomic factors.

Humanitarian migrants are at increased risk of post-traumatic stress disorder (PTSD) and elevated psychological distress. However, men and women often report varying degrees of stress and experience different challenges during migration. While studies have explored PTSD, psychological distress, gender, and resettlement stressors, they have not explored the interplay between these factors. This study aims to address that gap by investigating gender disparities in PTSD and psychological distress among humanitarian migrants in Australia, with a focus on the moderating role of socioeconomic factors. This study used data from five waves of the Building a New Life in Australia (BNLA) survey, a longitudinal study of 2,399 humanitarian migrants who arrived in Australia in 2013. PTSD and psychological distress were measured using the PTSD-8 and Kessler-6 (K6) scales, respectively. We conducted generalised linear mixed-effect logistic regression analyses stratified by gender. Female humanitarian migrants exhibited a significantly higher prevalence of PTSD and psychological distress than males over five years of resettlement in Australia. Women facing financial hardship, unemployment, or residing in short-term housing reported greater levels of PTSD and distress compared to men. Women facing financial hardship, inadequate housing, and unemployment exhibit higher rates of PTSD and psychological distress, underscoring the significant impact of socioeconomic factors. Addressing these challenges at both individual and systemic levels is essential for promoting well-being and managing mental health among female humanitarian migrants.

Early Surgical Intervention Results in Better Patient-Reported Outcomes Than Delayed Treatment in Patients Undergoing Anterior Cruciate Ligament Reconstruction in the Presence of Concomitant Medial Collateral Ligament Injury

PurposeTo investigate the influence of the timing of ACL reconstruction (ACLR) on patient-reported outcomes, comparing those with and without concomitant medial collateral ligament (MCL) injury. MethodsThis study included patients who underwent ACLR between September 2015 and October 2020. Inclusion criteria required patients to have preoperative and postoperative patient-reported outcome measures (PROMs) and a follow-up period of at least 2 years. Patients who sustained a grade 2 or 3 MCL injury with an ACL tear were compared to patients with no MCL injury as a control. All patients underwent ACL reconstruction using either bone-tendon-bone (BTB) autograft or BTB Allograft. Patient-reported outcomes (International Knee Documentation Committee (IKDC), Lysholm, and Knee Osteoarthritis and Score (KOOS)) were recorded, and outcomes were analyzed by sex and time from index injury. A stratified linear mixed-effects regression analysis was conducted. ResultsA total of 253 eligible patients with 2-year outcomes were enrolled. Combined ACL/MCL injury had lower IKDC (β=-6.1 vs β=-8.3, p=0.003), KOOS QOL (β=-9.3 vs β=-11, p=0.004), and KOOS Sport (β=-12 vs β=-13 , p=0.08) if performed after 6 weeks from index injury. Isolated ACL injuries showed lower KOOS ADL (β=-2.4, p=0.045) if surgery performed between 3-6 months. For combined ACL/MCL injury, autograft (compared to allograft) was found to have worse IKDC (β=-11 (-18, -4.2), p=0.002), Lysholm (β=-9.2 (-15, -3.1), p=0.004), KOOS QOL(β=-11 (-20, -1.6), p=0.023), KOOS Pain (β=-5.1 (-10, -0.03), p=0.049), KOOS Symptoms (β=-7.6 (-10, -0.03), p=0.02), and KOOS Sports (β=-21 (-32, -10), p=<0.001). ConclusionPatients undergoing ACL reconstruction with a grade 2 or 3 MCL injury have improved patient-reported outcomes if surgery is performed within 6 weeks from the time of injury. In this cohort, allografts resulted in better outcome scores compared with autografts. Level of EvidenceLevel III Retrospective Cohort Study

What factors influence women's empowerment in Ethiopia? A multilevel analysis of Ethiopia's demographic and health survey data.

Women's empowerment has been a global priority, as countries can achieve significant growth and economic development by empowering women. Understanding the individual and community-level factors that influence women's empowerment is crucial for policymakers to develop effective policies and to improve women's empowerment. A community-based cross-sectional survey was conducted in 11 administrative regions of Ethiopia. The analysis included a weighted sample of 7,108 married women of reproductive age (15-49 years) from the 2,016 Ethiopian Demographic and Health Survey (EDHS). A multilevel mixed-effect binary logistic regression analysis was used to examine the individual and community-level factors associated with women's empowerment. In the final model, significant variables were identified using a p-value of <0.05 and an adjusted odds ratio (AOR) with a 95% confidence interval (CI). The overall magnitude of women's empowerment was 23.7% (95% CI: 22.7-24.7). Only 30.9% of women reported participating in household decision-making, and 32.5% disagreed with all the reasons justifying wife-beating. At individual-level, factors positively associated with women's empowerment included secondary (AOR: 2.72 (1.77-4.23), and higher (AOR: 3.65 (1.81-7.34) education. However, belonging to the Muslim religion was negatively associated with women's empowerment (AOR: 0.63 (0.47-0.85). At the community level, wealthy communities were positively associated with women's empowerment (AOR: 1.60 (1.05-2.44). Conversely, residing in rural areas (AOR: 0.49 (0.29-0.83), and living in the Afar (AOR: 0.35 (0.17-0.70), Amhara (AOR: 0.45 (0.26-0.79), Oromia (AOR: 0.43 (0.26-0.73), South Nation Nationalities, and Peoples (SNNP) (AOR: 0.42 (0.24-0.75), and Gambella (AOR: 0.36 (0.20-0.66) regional states were negatively associated with women's empowerment. The overall magnitude of women's empowerment in this study was low. Factors that positively influenced empowerment included attending secondary and higher education, as well as residing in communities with higher wealth status. On the other hand, being Muslim, residing in rural areas, and living in the Afar, Amhara, Oromia, SNNPR, Gambella, and Tigray regions were negatively associated with women's empowerment. As a result, the government of Ethiopia needs to design community-based women's empowerment strategies and involve women in income-generation activities that improve their participation in household decision-making to empower them.

Effectiveness, cost-effectiveness, and positive externalities of integrated chronic care for adults with major depressive disorder in Malawi (IC3D): a stepped-wedge, cluster-randomised, controlled trial

In low-income and middle-income countries, individuals with major depressive disorder often do not receive screening and treatment. We assessed effectiveness and cost-effectiveness of an integrated care model for treating major depressive disorder in Malawi, accounting for two sets of positive externalities: household benefits and improvements in comorbidities. In this stepped-wedge, cluster-randomised, controlled trial, 14 health facilities in Neno District, Malawi, introduced screening, diagnosis, and treatment for people with major depressive disorder, using a stepped-care model of group Problem Management Plus and antidepressant therapy. Adults (ie, aged ≥18 years) residing in facility catchment areas, newly diagnosed with major depressive disorder, and actively enrolled in an integrated chronic care clinic were eligible for inclusion. People identified with high suicidal risk or psychotic symptoms were excluded. Health facilities were categorised into two strata (ie, health centres or secondary hospitals) and randomly allocated to one of five trial sequences, with intervention initiation staggered across sequences in 3-month periods. Participants were masked to trial sequence, data collectors were masked to treatment assignment, and the chief statistician was masked to treatment assignment until analysis. Services were delivered by counsellors and clinical officers at integrated chronic care clinics, and assessments took place at 3-month intervals over 27 months. Primary outcomes were changes in depressive symptom severity (measured with the Patient Health Questionnaire-9 [PHQ-9]), current depressive episode (PHQ-9 score of >10), and functioning (measured with the WHO Disability Assessment Schedule 2.0) over the 27-month period. Longitudinal mixed-effects regression analyses assessed outcomes from an intention-to-treat perspective. The trial was registered with ClinicalTrials.gov (NCT04777006) and is completed. Between Sept 1, 2021, and April 28, 2022, we conducted 15 562 screenings, resulting in 506 (3%) adults identified with major depressive disorder and 487 (3%) enrolled (395 [81%] women and 92 [19%] men). Assignment to IC3D corresponded to a 2·60-point (95% CI -3·35 to -1·86; d -0·61) reduction in depressive symptoms and 1·69-point (-2·73 to -0·65; -0·27) improvement in functioning, reflecting a reduced odds of depression after treatment roll-out (adjusted odds ratio 0·62, 95% CI 0·51 to 0·74). Integrated care for people with major depressive disorder and chronic health conditions is effective at reducing depressive symptoms, improving functioning, and reducing the odds of depression, and facilitates expansion of services through existing infrastructure. National Institute of Mental Health.

Regional distribution and factors associated with early marriage in Ghana: a cross-sectional study

BackgroundEarly marriage, the formal or informal union before age 18, remains a critical challenge in several low-and middle-income countries. It has adverse health and education-related implications on child brides. This study examined the regional distribution of early marriage and its associated factors in Ghana.MethodsWe performed a cross-sectional analysis of data extracted from the 2022 Ghana Demographic and Health Survey. Our study comprised 10,098 ever married/cohabiting aged 15 to 49. Regional variations in the prevalence of child marriage were visualised using a spatial map. A mixed-effect multilevel binary logistic regression analysis was performed to assess the factors associated with early marriage. The results were presented as adjusted odds ratios (aOR) with a 95% confidence interval (CI).ResultsThe prevalence of early marriage was 29.2% [27.9, 30.6] in Ghana. Women in the North East 38.2% [33.4, 43.2], Western North 36.7% [32.1, 41.5] and Ahafo regions 35.8% [32.0, 39.8] had the highest prevalence of early marriage, whilst women in the Western 22.2% [18.4, 26.5] and Greater Accra 19.7% [15.8, 24.3 regions] had the lowest prevalence of early marriage in Ghana. The odds of early marriage was lower among women aged 20-49 compared to those aged 15-19. Women with secondary [aOR = 0.40; 95% CI 0.33, 0.48] and higher education [aOR = 0.07; 95% CI 0.04, 0.12], those who belonged to the Gurma ethnic group [aOR = 0.59; 95% CI 0.41, 0.84], and women from richer [aOR = 0.64; 95% CI: 0.47, 0.87] and richest [aOR = 0.42; 95% CI 0.28, 0.64] households were less likely to be married early compared to those with no education, those belonging to the Akan ethnic group, and those from the poorest wealth quintile households, respectively. The odds of early marriage was higher among women whose family size was five or more [aOR = 1.50; 95% CI 1.31, 1.72] and women living in the Central [aOR = 1.72; 95% CI 1.16, 2.54], Volta [aOR = 1.97; 95% CI 1.17, 3.30], Eastern [aOR = 1.53; 95% CI 1.01, 2.29], Ashanti [aOR = 1.98; 95% CI 1.33, 2.97], Western North [aOR = 1.77; 95% CI 1.18, 2.65], and Ahafo regions [aOR = 1.74; 95% CI 1.18, 2.56].ConclusionAbout one in three marriages were early in Ghana, with variations across the regions. Age, wealth index, ethnicity, level of education, family size, and region were identified as factors associated with early marriages. The government and policymakers in Ghana should increase access to and completion of secondary education for girls, as it is crucial in reducing early marriage. Providing programmes that economically empower women and girls can decrease their vulnerability to early marriage. More vigorous enforcement of laws against early marriage is necessary. Engaging with communities, including tribal leaders, is essential to shift cultural attitudes toward early marriage.

Regional disparities and socio-demographic factors associated with eight or more antenatal care visits in Ghana

BackgroundAntenatal care is vital for maternal health and wellbeing, with the World Health Organization recommending a minimum of eight visits during pregnancy. In this study, we examined the regional disparities and factors associated with eight or more antenatal care visits in Ghana.MethodsWe performed a cross-sectional analysis of data from the 2022 Ghana Demographic and Health Survey. Our study comprised 3,893 women of reproductive age with birth history in the last two years before the survey. Regional disparities in the proportion of eight or more antenatal care visits were visualised using a spatial map. A mixed-effect multilevel binary logistic regression analysis was conducted to determine the factors associated with eight or more antenatal care visits using a four-modeled approach. The results were presented as adjusted odds ratios (aOR) with a 95% confidence interval (CI).ResultsThe prevalence of eight or more antenatal care visits in Ghana was 38.4% [95% CI = 36.0–41.0]. The regions with the highest prevalence were Eastern, Greater Accra, Western, and Volta. Those with the lowest prevalence were Northern, North East, Savannah, and Oti. The odds of eight or more antenatal care visits were lower among women aged 40–49 [aOR = 0.42, 95% CI = 0.18–0.96], women with four or more children [aOR = 0.57, 95% CI = 0.36–0.93], women who wanted pregnancy later [aOR = 0.63, 95% CI = 0.46–0.85], and women in five regions: Western North [aOR = 0.43, 95% CI = 0.19–0.94], Bono [aOR = 0.33, 95% CI = 0.14–0.76], Northern [aOR = 0.29, 95% CI = 0.13–0.66], Savannah [aOR = 0.30, 95% CI = 0.14–0.65] and North East [aOR = 0.33, 95% CI = 0.14–0.75]. Women in the richer [aOR = 1.99, 95% CI = 1.19–3.33] and richest [aOR = 4.82, 95% CI = 2.45–9.51] wealth index showed a higher likelihood of completing eight or more antenatal care visits relative to women in the poorest wealth index.ConclusionA significant proportion of women in Ghana fall short of the recommended eight or more antenatal care visits. Age, parity, desired pregnancy timing, wealth status, and region of residence are associated with the number of antenatal care visits. Women in five regions (Bono, Northern, North East, Savannah, and Western North) are significantly less likely to have eight or more antenatal care visits than those in the Western region. The government and policymakers should design programs to address the needs of older women, those with high parity, and women who want to delay pregnancy. Increased healthcare resources, educational campaigns, and addressing regional barriers to antenatal care access are crucial. Promoting public health initiatives to emphasise the importance of completing the recommended number of antenatal care visits for a healthy pregnancy is essential.

The interplay among sleep patterns, social habits, and environmental cues: insights from the Spanish population and implications for aligning daily rhythms.

The interplay among sleep patterns, social habits and environmental cues is becoming increasingly more important for public health and wellbeing due to its connection to circadian desynchronization. This paper explores said connections in Spain (which has an official and solar time mismatch), introducing the "Three Times Score" ‒which is based on questions widely used in the field‒ as a complementary tool for exploring the interplay of daily rhythms. The questionnaire covers sleep-related habits, social time, and environmental time. The study includes 9,947 participants (34.89 ± 12.15 y/o, mean ± SD; 5,561 women) from different Spanish regions. Sleep parameters were obtained for work and free days, as well as a modified version of the sleep-corrected midsleep on free days (MBFbc) and a parameter similar to social jet lag, both derived from bed time rather than sleep time. A number of indexes were computed to compare bed and work-related habits, together with natural light/dark cycle, along with the Three Times Score. Mixed-effect regression analysis was used to test whether the biological, social and environmental factors included in the study significantly predicted the sleep-related parameters: bedtime, wake-up time, time in bed and mid-bedtime. Temporal differences were found between work and free days, with waking-up occurring 2 h earlier on work days (7:10 ± 0:01) than on free days (9:15 ± 0:01). Bed times were 1 h earlier on work days (23:46 ± 0:01) than on free days (00:45 ± 0:01), whereas time in bed was over 1 h shorter on work (7 h 23 min) versus free (8 h 29 min) days. Strong correlations were found between work starting time and waking-up and bedtimes on workdays. Women went to bed earlier and woke up later, spending more time in bed. Differences in sleep habits were observed between work and free days across all age groups. The group of younger adults (18-30) reported going to bed later than older and younger groups, especially on free days. Adolescents and young adults also woke-up later than other age groups, especially on free days. Social jet lag (relative to bed time) and desynchronization indexes also varied with age, with younger adult participants exhibiting higher levels. Seasonal differences were limited, with minor variations between winter and summer. According to the multiple regression analysis, social (day type, work start time, alarm clock usage), biological (age, gender, in most cases related to sex) and environmental (sunset time) factors significantly contribute to predicting sleep/bed related schedules. This study provides insights into sleep habits in the Spanish population, introducing the Three Times Score as a complementary tool for exploring the interactions between sleep/bed-related habits, natural darkness and work-related schedules. Understanding this interplay is crucial for developing tailored interventions to improve sleep and wellbeing.

Body mass index is associated with disability at discharge as indicated by the modified Rankin Scale in patients with ischemic stroke: a JROAD-DPC study

ABSTRACT Background Body mass index (BMI) of patients with ischemic stroke (IS) has been associated with prognosis and disability in studies in the United States. Although the Asian population is leaner, the optimal BMI for stroke-related disability remains unknown. Objectives To clarify the association between BMI and disability in patients with IS from a national database in Japan. Methods The present study included 522,421 patients with IS identified in the JROAD-DPC database from April 2016 to March 2020. We used the WHO classification of BMI, which divides Asia-Pacific patients into five groups, to categorize BMI and the modified Rankin Scale (mRS) to assess stroke-related disability at admission and discharge. After multiple imputation for missing values, we conducted a multiple mixed-effect logistic regression analysis for poor mRS score (>2) in September 2023. In addition, we created a restricted cubic spline model between the odds ratio (OR) for poor mRS and BMI. Results The mRS score worsened during hospitalization in 60.1% of the patients with IS, and 45.7% had a poor mRS score at discharge. Overweight patients had the lowest OR of having a poor mRS score (OR: 0.898, 95% confidence interval: 0.895–0.902). The spline curve for the OR for poor mRS score was U-shaped with a BMI of 24.7 kg/m2as the apex value. Conclusion The present study revealed a U-shaped relationship between BMI and stroke-related disability, with overweight patients having the lowest OR for disability at discharge.

Water insecurity may exacerbate food insecurity even in water-rich environments: Evidence from the Bolivian Amazon

Globally, challenges with water and food are two of the most pressing problems people face. Yet hydrologically water-rich environments and rural environments are often overlooked in these discussions due to abundance of natural water resources. Here we test the relationship between water and food insecurity among 270 Tsimane' households in the Bolivian Amazon. Water challenges were evaluated with the Household Water Insecurity Experiences Scale (HWISE), water quality perception, objective water quality analyses, and water access via the JMP drinking water ladder. Food insecurity was measured with the Household Food Insecurity Access Scale (HFIAS), and quantitative measures of food frequency recall were used to further test the water and food insecurity relationship. Using multilevel mixed-effects linear regression, each point increase in HWISE score was associated with 0.47 point (95 % CI: 0.30, 0.62, p < 0.001) higher food insecurity, and households with access to improved water sources had between 1.25 and 1.36 points (95 % CI: −2.61, −0.01, p < 0.05) lower food insecurity compared to households reliant on surface water. These relationships held true independent of quantitative measures of both fish and meat consumption. Using mixed-effects logistic regression analyses, each point increase in HWISE score was associated with 43 % (95 % CI: 1.25–1.66, p < 0.001) increased odds of experiencing severe food insecurity. Households changing what was eaten due to experienced water problems was associated with 2.33 points (95 % CI: 0.41, 4.25, p < 0.05) higher food insecurity. This relationship held true independent of perceived water quality, indicating other structural water problems may be important here in the household water and food insecurity relationship. These results demonstrate that even in water-rich environments, like the Amazon, water and food insecurity are interconnected. Further, despite the challenging conditions, equitable structural interventions, like the development of improved water infrastructure, are critical for the provision of clean drinking water and may simultaneously help alleviate food insecurity.

Effect of thrombolysis type on the efficacy of aspiration versus stent retriever first line thrombectomy: results from the AcT trial

BackgroundIntravenous (IV) tenecteplase is increasingly being used in lieu of alteplase for acute ischemic stroke. We sought to study the influence of IV tenecteplase versus IV alteplase on the efficacy...

Ethnicity and access to water, sanitation, and hygiene in Bangladesh: a study using MICS data and policy reviews.

Safe drinking water, sanitation, and hygiene (WASH) are crucial to human health. Reducing inequalities and ensuring universal access to WASH are essential to achieving the agenda of sustainable development. We aimed to measure access to WASH among ethnic minority populations in Bangladesh and understand the situation and factors affecting WASH practices among them. Additionally, we reviewed policy related to WASH to highlight the inequality faced by ethnic minority populations. We utilized data from the multiple indicator cluster survey-2019. We used the chi-square test for bivariate analysis and multilevel mixed-effect logistic regression analyses to identify the effect of ethnicity on WASH in Bangladesh after controlling selected covariates. Furthermore, we systematically reviewed Bangladesh's WASH-related policies and programs. While 98.5% of Bengalis had access to basic drinking water services, the percentage is 60.6% for the ethnic minority population. For improved sanitation facilities not shared with others, the difference between Bengali and ethnic populations was 22.3% (64.6% vs. 42.3%). On the other hand, 75% of the Bengali population had a handwashing facility with water and soap, and 50% of the ethnic population had them. Ethnicity appeared to be a statistically significant predictor of every component of WASH. Compared to Bengali, the ethnic population had 87%, 45%, 31%, and 45% less access to water (aOR = 0.13, p ≤ 0.001), sanitation (aOR = 0.55, p ≤ 0.001), and handwashing (aOR = 0.69, p ≤ 0.05), and WASH facilities aOR = 0.55, p ≤ 0.001), respectively. Among the policies of Bangladesh, only one identified action for WASH rights of ethnic minorities. The government should identify the issues of WASH among ethnic minorities and represent them adequately in policies to achieve the aim of 'leaving none behind' of sustainable development goals.

Unmet Financial Needs of People with Psychotic Disorders-A Cross-Sectional Study in People with Psychotic Disorders, Parents, Siblings, and Controls.

Background. Psychotic disorders have a strong negative impact on people's lives, including their financial situation. This study aimed to examine differences in unmet financial needs between people with psychotic disorders, parents, siblings, and controls. Secondly, we aimed to examine whether family clustering contributes to unmet financial needs. Lastly, we aimed to examine to what extent demographic, economic, psychiatric, functional, and cognitive characteristics and substance use predict unmet financial needs in people with psychosis. Methods. Data from the first assessment of people with psychosis (n = 956), siblings (n = 889), parents (n = 858), and controls (n = 496) included in the Genetic Risk and Outcome of Psychosis study were used. Group differences were assessed with Kruskal-Wallis tests (aim 1), while a mixed-effects logistic regression analysis and explorative and confirmative ordinal logistic regression analyses were conducted for aims 2 and 3, respectively. Results. Twenty-four percent of people with psychotic disorders reported unmet financial needs. These levels of unmet financial needs were significantly higher than levels for siblings, parents, and controls. We found a negligible influence of (direct) familial clustering on unmet financial needs. Lastly, cannabis and tobacco use significantly and consistently predicted higher levels of unmet financial needs of people with psychosis. Conclusions. Relatively high levels of unmet financial needs occurred in a heterogeneous group of people with psychosis, especially when people used cannabis or tobacco. Unmet financial needs can have detrimental consequences for mental health, stigmatization, leisure time activities, and social engagement. Thus, it is pivotal to recognize unmet financial needs, especially combined with substance use, as a crucial stressor for people with psychosis.

Comparison of Terminal Elbow Extension between Humans and Baboons (Papio anubis).

It is assumed that hyperextension of the elbow joint beyond 0° in humans is due to local ligament and other soft tissue laxity. The common extant old-world olive baboon (Papio anubis), with a quadrupedal gait, commonly has a mild elbow joint flexion contracture. This study compares anatomic and functional roles of the olecranon-coronoid notch angle of the proximal ulna and the anterior direction of its opening on terminal elbow extension in humans and baboons. Active terminal elbow extension was measured in 211 elbows of skeletally mature humans using the neutral zero method. Passive elbow extension and radiographs were performed on 60 extremities of 30 anesthetized baboons. The mean olecranon-coronoid notch angle for humans and baboons was 22.2 ± 6.0° and 11.3 ± 3.2°, respectively (P < 0.001). Mixed effect regression analysis showed that the magnitude of the angle was a significant predictor of terminal elbow extension (P < 0.001) when accounting for species. Also, the causal mediation analysis showed that 18% of the difference in terminal elbow extension between species could be attributed to the olecranon-coronoid notch angle (P < 0.001). Anatomic dissection of 16 baboon arms showed that sectioning of all the anterior soft tissue structures increased mean terminal elbow extension from -18.2 ± 5.9° to -7.1 ± 6.0° and that further elbow extension was blocked primarily by the intact humeroulnar joint. The size of the notch angle and the positioning of its anterior proximal opening played a significant role in deciding terminal elbow extension in both species.

Environmental surveillance for Salmonella Typhi in rivers and wastewater from an informal sewage network in Blantyre, Malawi.

Environmental surveillance for Salmonella Typhi may provide information on the community-level dynamics of typhoid fever in resource poor regions experiencing high disease burden. Many knowledge gaps concerning the feasibility of ES remain, especially in areas lacking formal sewage systems. We implemented protocols for S. Typhi ES, including site selection and catchment population estimation, sample concentration and testing using qPCR for S. Typhi specific gene targets. Between May 2021 and May 2022, we collected grab samples and Moore swabs from 43 sites in Blantyre, Malawi. Catchment characteristics, water quality, and human faecal contamination (qPCR for Bacteroides HF183) were also recorded. Their association with S. Typhi detection was investigated using a logistic mixed-effects regression analysis. Prevalence of S. Typhi in ES samples was 2.1% (1.1-4.0%) and 3.9% (1.9-7.9%) for grab and Moore swab samples, respectively. HF183 was associated S. Typhi positivity, with a unit increase in log genome copies/microlitre increasing the odds of detection of S. Typhi by 1.56 (95% CI: 1.29-1.89) and 1.33 (1.10-1.61) in Moore swabs and grab samples, respectively. The location and timing of S. Typhi detection through ES was not associated with the incidence of typhoid fever reported in associated catchment populations. During this period of relatively low typhoid fever incidence, wastewater surveillance continued to detect S. Typhi in human sewage and wastewater suggesting that ES using natural river systems can be a sensitive indicator of transmission.

Assessment of twelve echovirus virus-neutralisation assays in Europe: recommendations for harmonisation of non-polio enterovirus sero-surveillance studies

Non-polio enteroviruses (NPEV) cause significant disease worldwide. Population-based sero-surveillance, by measuring antibodies against specific NPEV types, provides additional information on past circulation and the prediction for future upsurges. Virus neutralisation assays (VNA), the current method of choice for measuring NPEV type specific antibodies, are not entirely standardised. Via the European Non-Polio Enterovirus Network, we organised a VNA quality assessment in which twelve laboratories participated. We provided five echovirus (E) types (E1, E18, E30 G2, E30 G6 and E6) and intravenous immunoglobulins (IVIG) as a sample for the NPEV VNA quality assessment. Differences in VNA protocols and neutralising Ab (nAb) titres were found between the participating laboratories with geometric coefficients of variation ranging from 10.3–62.9 %. Mixed-effects regression analysis indicated a small but significant effect of type of cell line used. Harmonisation of cell line passage number, however, did not improve variation between laboratories. Calibration by making use of a reference sample, reduced variation between laboratories but differences in nAb titres remained higher than two log2 dilution steps. In conclusion, sero-surveillance data from different laboratories should be compared with caution and standardised protocols are needed.