Poisson Mixed Models Research Articles

Nonstationary longitudinal autoregressive mixed model for count data with measurement error in covariates: Estimation and asymptotics

Several methods have been proposed in the literature for computing unbiased and efficient estimates of the parameters of generalized linear models when the covariates are measured with error. However, to our knowledge, no documented research on computational techniques for parameter estimation currently exist in the literature when the data is a longitudinal count data influenced by an unobservable latent variable and observable covariates that are measured with error. In this paper, we propose a nonstationary conditionally Poisson mixed model for such data and develop unbiased estimating equations with iterative methods for computing estimates of the effect of the covariates, variance of the latent variable, and the correlation index parameter. The performance of the iterative methods is examined through extensive simulation studies. The results show that the methods performed well when the magnitude of the measurement error is not so large as to dominate or mask the effect of the true covariates. Using observed longitudinal count data on the number of patents awarded to 168 firms in the United States from 1974 to 1979 along with associated covariate information on the type of firm, log of the book value of capital in 1972 and research and development (R & D) expenditures we have demonstrated how the methods proposed in this paper can be applied to a real data. In addition, we derive the influence function of the estimator of the covariate effect and discuss the asymptotic properties of the estimator. Journal of Statistical Research 2024, Vol. 58, No. 1, pp. 151-180.

Psychosocial Risks and Adolescent Mental Health: The Moderating Role of Objective Neighborhood Characteristics

PurposeAlthough previous studies have examined the association between youth psychosocial risks and their perceptions of their neighborhood, it is unclear how objective neighborhood characteristics are associated with psychosocial risks and mental health symptoms among adolescents. We investigated how neighborhood characteristics moderate the relationship between youth psychosocial characteristics and mental health symptoms. MethodsThis cross-sectional study examined 13,837 emergency department visits by 14–18-year-olds who completed a standardized Behavioral Health Screening in a tertiary pediatric hospital in Philadelphia from 2013 to 2020. Psychosocial risk factors and mental health symptoms were assessed based on self-reported survey responses. We characterized neighborhoods as low-, moderate-, and high-stress based on gun violence incidence from 2013 to 2020 and the census tract–level Child Opportunity Index. Mixed effects logistic regression and Poisson models were used to examine moderation effects. ResultsThe 9,814 included patients were 64% female and 64% non-Hispanic Black. The following psychosocial risk factors were associated with two to eight times higher odds of depressive symptoms and suicide risk: exposure to trauma, bullying at school, at-risk substance use, fighting, and retaliation. Adolescents living in high-stress neighborhoods were twice as likely to report fighting and retaliation and reported more psychosocial risk factors than those in low-stress neighborhoods. Odds of mental health symptoms increased with the number of psychosocial risk factors, particularly in youth from low-stress neighborhoods. DiscussionObjective neighborhood characteristics had a significant interaction effect on the relationship between psychosocial risks and depression and suicide risk among adolescents seeking care in a pediatric emergency department.

Weight Velocity in Addition to Latest Weight Does Not Improve the Identification of Wasting or the Prediction of Stunting and Mortality: A Longitudinal Analysis Using Data from Malawi, South Africa, and Pakistan

BackgroundIn low/middle-income countries, most nutritional assessments use the latest weights, without reference to growth trajectory. ObjectivesThis study explores whether velocity, in addition to the latest weight, improves the prediction of wasting, stunting, or mortality in the first 2 years of life. MethodsWe analyzed a combined data set with weight and height data collected monthly in the first year of 3447 children from Pakistan, Malawi, and South Africa, with height and survival recorded till 24 m. The main exposures were weight-for-age z-score (WAZ) at the end of each 2-m period and weight velocity-for-age z-score (WVZ2) across that period. The outcomes were wasting, stunting, or all-cause mortality in the next 1–2 mo. As a sensitivity analysis, we also used WVZ over 6 mo (WVZ6), with matching WAZ. Cox proportional hazard models with repeated growth measures were used to study the association between exposures and mortality. Mixed Poisson models were used for stunting and wasting. ResultsChildren who were already stunted or wasted were most likely to remain so. Higher WVZ2 was associated with a lower risk of subsequent stunting (risk ratio [RR]: 0.95; 95% confidence interval [CI]: 0.93, 0.96), but added minimal prediction (difference in AUC = 0.004) compared with a model including only WAZ. Similarly, lower WVZ2 was associated with wasting (RR: 0.74; 95% CI 0.72, 0.76) but the prediction was only marginally greater than for WAZ (difference in AUC = 0.015). Compared with WAZ, WVZ6 was less predictive for both wasting and stunting. Low WVZ6 (but not WVZ2) was associated with increased mortality (hazard ratios: 0.75, 95% CI: 0.67, 0.85), but added only marginal prediction to a model including WAZ alone (difference in C = 0.015). ConclusionsThe key anthropometric determinant of impending wasting, stunting, and mortality appears to be how far below the normal range the child’s weight is, rather than how they reached that position.

Daily-Level Associations between Situational Familiarity with Location and People and Use of Alcohol-related Protective Behavioral Strategy Among Adolescents and Young Adults.

Despite protective behavioral strategies (PBS) being an important part of alcohol prevention programs, utilization of PBS is sub-optimal, and research is needed to determine factors associated with use and non-use of PBS. The present study examined daily-level associations between situational familiarity (i.e., familiarity with locations and people) and the use of alcohol-related PBS among adolescents and young adults. Participants (analysis N = 564, 55.1% females, 45.2% White, Non-Hispanic, ages 15 to 25, mean = 21.07 years [SD = 2.79]) were part of a longitudinal ecological momentary assessment burst study on cognitions and alcohol use. Mixed effects Poisson models were used to analyze data for engagement in PBS (i.e., serious harm reduction, stopping/limiting, and manner of drinking PBS). Within-person results indicated when participants had elevated (i.e., higher than their own average) familiarity with their location, they were less likely to use serious harm reduction PBS (Rate ratio [RR] = 0.94, p < 0.001) and stopping/limiting PBS (RR = 0.95, p < 0.001). Results showed that on drinking days with elevated familiarity with people, individuals were more likely to use serious harm reduction PBS (RR = 1.03, p = 0.01). There were no significant daily-level associations between familiarity with people or location and manner of drinking PBS. The study suggests PBS use, particularly for serious harm reduction and stopping/limiting strategies, varies among adolescents and young adults based on familiarity with location and people. Alcohol prevention interventions, including just-in-time interventions, should consider how to promote PBS use particularly in familiar locations and with less familiar people.

Risk factors and prediction of hypoglycaemia using the Hypo-RESOLVE cohort: a secondary analysis of pooled data from insulin clinical trials

Aims/hypothesisThe objective of the Hypoglycaemia REdefining SOLutions for better liVES (Hypo-RESOLVE) project is to use a dataset of pooled clinical trials across pharmaceutical and device companies in people with type 1 or type 2 diabetes to examine factors associated with incident hypoglycaemia events and to quantify the prediction of these events.MethodsData from 90 trials with 46,254 participants were pooled. Analyses were done for type 1 and type 2 diabetes separately. Poisson mixed models, adjusted for age, sex, diabetes duration and trial identifier were fitted to assess the association of clinical variables with hypoglycaemia event counts. Tree-based gradient-boosting algorithms (XGBoost) were fitted using training data and their predictive performance in terms of area under the receiver operating characteristic curve (AUC) evaluated on test data. Baseline models including age, sex and diabetes duration were compared with models that further included a score of hypoglycaemia in the first 6 weeks from study entry, and full models that included further clinical variables. The relative predictive importance of each covariate was assessed using XGBoost’s importance procedure. Prediction across the entire trial duration for each trial (mean of 34.8 weeks for type 1 diabetes and 25.3 weeks for type 2 diabetes) was assessed.ResultsFor both type 1 and type 2 diabetes, variables associated with more frequent hypoglycaemia included female sex, white ethnicity, longer diabetes duration, treatment with human as opposed to analogue-only insulin, higher glucose variability, higher score for hypoglycaemia across the 6 week baseline period, lower BP, lower lipid levels and treatment with psychoactive drugs. Prediction of any hypoglycaemia event of any severity was greater than prediction of hypoglycaemia requiring assistance (level 3 hypoglycaemia), for which events were sparser. For prediction of level 1 or worse hypoglycaemia during the whole follow-up period, the AUC was 0.835 (95% CI 0.826, 0.844) in type 1 diabetes and 0.840 (95% CI 0.831, 0.848) in type 2 diabetes. For level 3 hypoglycaemia, the AUC was lower at 0.689 (95% CI 0.667, 0.712) for type 1 diabetes and 0.705 (95% CI 0.662, 0.748) for type 2 diabetes. Compared with the baseline models, almost all the improvement in prediction could be captured by the individual’s hypoglycaemia history, glucose variability and blood glucose over a 6 week baseline period.Conclusions/interpretationAlthough hypoglycaemia rates show large variation according to sociodemographic and clinical characteristics and treatment history, looking at a 6 week period of hypoglycaemia events and glucose measurements predicts future hypoglycaemia risk.Graphical

Insurance Status and Access to Otolaryngology Care: National Mystery Caller Study in the United States.

To investigate potential differences in new patient appointment wait times for otolaryngology care based on insurance types and explore factors influencing these wait times. A cross-sectional audit study, using a "mystery caller" approach, analyzed with a linear mixed Poisson model to adjust for confounding factors. A total of 612 physicians across 49 states and the District of Columbia, representing 6 otolaryngology subspecialties, were included. Otolaryngology physicians were contacted by mystery callers via telephone with scripted clinical vignettes as patients with either Medicaid or Blue Cross/Blue Shield (BCBS) insurance. Callers requested next available appointment. Wait times for new patient appointments were recorded and analyzed in R using a generalized linear mixed Poisson model. A total of 1183 of 1224 calls reached a representative. Medicaid patients waited 5.73% longer (P < .001) compared to BCBS patients (IRR: 1.06; confidence interval [CI]: 1.03-1.09; P < .001), with respective mean wait times of 36.8 days (SE ± 1.6) and 32.4 days (SE ± 1.6). Longer waiting times were also associated with physicians affiliated with universities (P = .001) and certain subspecialties, such as pediatric otolaryngology (P < .001) and neurotology (P = .008). Regional differences were also observed, with specific AAO-HNS regions showing shorter wait times. The model achieved a conditional R-squared value of 0.947. This study reveals disparities in wait times for otolaryngology care based on insurance type, with extended wait times for Medicaid beneficiaries. The findings highlight a potential access to care disparity, which begets the need for strategies that ensure equitable access to otolaryngology care and further research to understand the underlying reasons for these potential disparities.

Mixed effects modelling of excess mortality and COVID-19 lockdowns in Thailand

Accurate mortality data are critical for understanding the impact of COVID-19 and learning lessons from crisis responses. But published statistics risk misrepresenting deaths due to limited testing, underreporting, and lack of subnational data, especially in developing countries. Thailand experienced four COVID-19 waves between January 2020 and December 2021, and used a color-coded, province-level system for lockdowns. To account for deaths directly and indirectly caused by COVID-19, this paper uses mixed effects modelling to estimate counterfactual deaths for 2020–2021 and construct a monthly time series of provincial excess mortality. A fixed effects negative binomial and mixed effects Poisson model both substantiate other studies’ estimates of excess deaths using subnational data for the first time. Then, panel regression methods are used to characterize the correlations among restrictions, mobility, and excess mortality. The regressions show that mobility reductions modestly curbed mortality immediately upon imposition, suggesting that aversion of non-COVID deaths was a major aspect of the lockdowns’ effect in Thailand. However, the estimates are imprecise. An auto-regressive distributed lag model suggests that the effect of lockdowns was through reduced mobility, but the effectiveness appears to have varied over the course of the pandemic.

Abstract 36: Clinical Guidelines May Help Mitigate the Impact of Physician Implicit Bias on Patient Care and Treatment

Introduction: We previously found that physician pro-White implicit bias was associated with the performance of low-value revascularization procedures for Black patients with claudication. These treatments are commonly considered risk greater than benefit but are not expressly discouraged by guidelines. We sought to investigate whether implicit bias is less likely to impact care in settings with well-defined Class Ia-supported guidelines. Hypothesis: We hypothesized that a physician’s implicit bias would not be associated with the performance of clinical practices as outlined in the 2016 AHA/ACC Guidelines on the Management of Patients with Lower Extremity Peripheral Artery Disease. Methods: We measured implicit bias via the race Implicit Association Test (IAT) using a sample of physicians from the Society for Vascular Surgery’s Vascular Quality Initiative (VQI). The IAT asks participants to classify sequential images of Black and White faces to positive and negative attributes. Based on reaction times and responses on the IAT, physicians were categorized as having no bias, pro-Black bias, or pro-White bias. IAT results were then weighted to reflect the overall VQI demographics and linked to peripheral revascularization data. We used mixed effects logistic regression models to assess the association of physician implicit bias category with pre-operative prescriptions of antiplatelets (ASA, P2Y12) and statins, as well as current smoking status (reported as aORs). All models included a random intercept for the physician and were adjusted for year, physician race/ethnicity, and patient factors of race/ethnicity, diabetes, and hypertension. We examined effect modification by patient race/ethnicity through the inclusion of an interaction term with physician implicit bias category. Finally, we calculated a summary index across the four primary clinical practices and assessed the association with physician implicit bias category via a mixed effects Poisson model (reported as IRRs). Results: A total of 218 physicians successfully completed the IAT and were linked to 6,588 peripheral revascularizations they completed for claudication. We found no significant associations between the physician’s implicit bias category and the performance of any of the assessed guideline metrics for their Black or White patients (Summary Index - IRR: 1.02, 95% CI: 0.98-1.06). Additionally, we found no evidence of effect modification by patient race/ethnicity (ASA - aOR: 0.91, 95% CI: 0.61-1.34; P2Y12 - aOR: 1.22, 95% CI: 0.88-1.69; Statin - aOR: 1.12, 95% CI: 0.76-1.67). Conclusions: The performance of guideline-driven practices were not associated with a physician’s measured racial implicit bias. We provide preliminary evidence that appropriately designed guidelines could be successful in combatting Black-White health inequities stemming from the implicit bias of physicians.

Increasing vaccinations through an on-site school-based education and vaccination program: A city-wide cluster randomized controlled trial.

Vaccination rates for mumps, measles, and rubella (MMR) and tetanus, diphtheria, pertussis, and polio (Tdap-IPV) fall short of global targets, highlighting the need for vaccination interventions. This study examines the effectiveness of a city-wide school-based educational vaccination intervention as part of an on-site vaccination program aimed at increasing MMR and Tdap-IPV vaccination rates versus on-site vaccination alone among sociodemographically diverse students from Berlin, Germany. The study was a 1:1 two-arm cluster randomized controlled trial, with schools randomly assigned to either the Educational Class Condition (ECC) or the Low-Intensity Information Condition (LIIC). Both received an on-site vaccination program, while students in the ECC received an additional educational unit. Primary outcomes were MMR and Tdap-IPV vaccination rates. In total, 6512 students from 25 randomly selected urban area secondary schools participated. For students providing their vaccination documents on the day of the intervention (2273, 34.9%), adjusted Poisson mixed models revealed significant between-group differences in favor of the ECC (MMR: logRR = 0.47, 95%CI [0.01,0.92], RR = 1.59; Tdap-IPV: logRR = 0.28, 95%CI [0.10,0.47], RR = 1.32). When adjusting for socioeconomic and migration background, between-group differences became non-significant for MMR but remained significant for Tdap-IPV. Findings suggest that educational, school-based on-site vaccination appears to be a promising strategy for increasing vaccination uptake in adolescents.

Patient burden and joint inflammation during development of RA from arthralgia: is it similar in ACPA-positive and ACPA-negative disease?

ACPA-positive and ACPA-negative RA differ in underlying risk factors but have a similar clinical presentation at RA diagnosis. It is unknown what the ACPA-associated differences or similarities are during the symptomatic at-risk stage of RA, i.e. clinically suspect arthralgia (CSA). To deepen insights into these differences/similarities, we compared the course of symptoms/impairments and subclinical joint inflammation in the CSA phase during progression to inflammatory arthritis (IA) or to CSA resolution. A total of 845 CSA patients were followed for a median of 24 months; 136 patients developed IA and an additional 355/505 patients had resolution of CSA according to rheumatologists. Patient burden (pain, morning stiffness, fatigue, functional disabilities, presenteeism) was assessed at baseline and 4, 12 and 24 months and at IA development. Subclinical joint inflammation in the hands and feet was assessed over time with 1.5T MRI. Linear and Poisson mixed models were used. In both ACPA-positive and ACPA-negative patients, patient burden increased towards IA development and decreased towards CSA resolution. However, patient burden was lower in ACPA-positive vs ACPA-negative disease at all timepoints. Conversely, subclinical joint inflammation tended to increase more rapidly during development of ACPA-positive IA [incidence rate ratio (IRR) 1.52 (95% CI 0.94, 2.47), P = 0.089] and remained higher over time in ACPA-positive CSA patients achieving resolution compared with ACPA-negative patients [IRR 1.52 (95% CI 1.07, 2.15), P = 0.018]. Although correlation coefficients between changes in patient burden and subclinical joint inflammation during progression to IA were weak, they were consistently higher in ACPA-positive than ACPA-negative disease, e.g. ρ = 0.29 vs 0.12 for functional disabilities. During RA development and CSA resolution, ACPA-positive CSA patients have lower patient burden but more subclinical joint inflammation than ACPA-negative CSA patients. These data strengthen the notion that the development of ACPA-positive and ACPA-negative RA is pathophysiologically different and encourage further research on these differences.

Tropical cyclone-specific mortality risks and the periods of concern: A multicountry time-series study.

More intense tropical cyclones (TCs) are expected in the future under a warming climate scenario, but little is known about their mortality effect pattern across countries and over decades. We aim to evaluate the TC-specific mortality risks, periods of concern (POC) and characterize the spatiotemporal pattern and exposure-response (ER) relationships on a multicountry scale. Daily all-cause, cardiovascular, and respiratory mortality among the general population were collected from 494 locations in 18 countries or territories during 1980 to 2019. Daily TC exposures were defined when the maximum sustained windspeed associated with a TC was ≥34 knots using a parametric wind field model at a 0.5° × 0.5° resolution. We first estimated the TC-specific mortality risks and POC using an advanced flexible statistical framework of mixed Poisson model, accounting for the population changes, natural variation, seasonal and day of the week effects. Then, a mixed meta-regression model was used to pool the TC-specific mortality risks to estimate the overall and country-specific ER relationships of TC characteristics (windspeed, rainfall, and year) with mortality. Overall, 47.7 million all-cause, 15.5 million cardiovascular, and 4.9 million respiratory deaths and 382 TCs were included in our analyses. An overall average POC of around 20 days was observed for TC-related all-cause and cardiopulmonary mortality, with relatively longer POC for the United States of America, Brazil, and Taiwan (>30 days). The TC-specific relative risks (RR) varied substantially, ranging from 1.04 to 1.42, 1.07 to 1.77, and 1.12 to 1.92 among the top 100 TCs with highest RRs for all-cause, cardiovascular, and respiratory mortality, respectively. At country level, relatively higher TC-related mortality risks were observed in Guatemala, Brazil, and New Zealand for all-cause, cardiovascular, and respiratory mortality, respectively. We found an overall monotonically increasing and approximately linear ER curve of TC-related maximum sustained windspeed and cumulative rainfall with mortality, with heterogeneous patterns across countries and regions. The TC-related mortality risks were generally decreasing from 1980 to 2019, especially for the Philippines, Taiwan, and the USA, whereas potentially increasing trends in TC-related all-cause and cardiovascular mortality risks were observed for Japan. The TC mortality risks and POC varied greatly across TC events, locations, and countries. To minimize the TC-related health burdens, targeted strategies are particularly needed for different countries and regions, integrating epidemiological evidence on region-specific POC and ER curves that consider across-TC variability.

Pilot Study of aNovel Online Comprehensive Pelvic Floor Program for Urinary Incontinence in Women.

Urinary incontinence (UI) is common in women and has a vast impact on quality of life (QOL), financial health, and work disability. Robust evidence demonstrates the efficacy of comprehensive conservative therapy (pelvic floor muscle training [PFMT], and behavioral and dietary modification) in the treatment of UI. However, numerous barriers impede access to this care, including limited specialized therapists, financial barriers, and scheduling obstacles. To address these barriers, we developed a novel comprehensive online pelvic floor program (oPFP). We performed a prospective study assessing continence and QOL outcomes in women with stress urinary incontinence (SUI), urge urinary incontinence (UUI), or mixed urinary incontinence (MUI) treated with oPFP between May 2019 and November 2022. Outcomes were assessed at baseline and following completion of the 2-month program using the validated International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms, Urgency Perception Scale (UPS), Incontinence Impact Questionnaire (IIQ-7) questionnaires, and 24-h bladder diary. Data were analyzed using linear, Poisson mixed models, or generalized estimating equations. Twenty-eight women (2 SUI, 3 UUI, 23 MUI) were enrolled and 19 (2 SUI, 2 UUI, 15 MUI) completed the study. Following oPFP, participants showed significantly improved SUI domain scores (3.04 ± 0.19 vs 1.81 ± 0.23, p < 0.001), UPS reason score (2.52 ± 0.18 vs 2.05 ± 0.14, p = 0.003), IIQ-7 sum scores (5.16 ± 0.88 vs 3.07 ± 0.70, p = 0.038), and daily incontinence episodes (2.96 ± 0.60 vs 1.06 ± 0.29, p < 0.001). Mean patient-reported improvement was 5.4 ± 2.5 (ten-point Likert scale). Of respondents, 89% reported program satisfaction, ease of use, and would recommend the program to others. The oPFP results in significant improvements to a variety of UI and QOL measures. This program provides an important UI treatment option and gives women greater access to effective conservative therapy.

유창성 장애의 언어치료 관련 경시적 계수자료의 유연한 분석

In this study, the goal was to apply a flexible and easy-to-manage analysis method through a model that includes a dispersion parameter in the longitudinal analysis method of count data. In the analysis of count data, it may be inconvenient to change the statistical model depending on whether there is under- or over-dispersion. To compensate for these weaknesses, We have applied a statistical method including a dispersion parameter to the statistical model. The count data covered were included in the diagnosis of fluency disorders and the evaluation of the effectiveness of speech therapy. but research on speech-language therapy is limited by being conducted on small numbers of subjects for several reasons. Therefore, statistical analysis methods that work only on large samples, are complex, or require excessive calculations in the model fitting process were not appropriate for the field. With this background, we applied the Conway-Maxwell Poisson model to longitudinal data analysis of fluency disorders. We evaluated whether the model that reflects the level of data dispersion in the model was consistent with the speech therapy data for fluency disorders by comparing it to the existing Poisson mixed model and linear mixed model. In particular, the Conway-Maxwell Poisson model had the advantage of reflecting well when the degree of dispersion was different for each group or specific subgroup.

Modelling occurrence and quantity of longitudinal semicontinuous data simultaneously with nonparametric unobserved heterogeneity

AbstractSemicontinuous data frequently occur in longitudinal studies. The popular two‐part modelling approach deals with longitudinal semicontinuous data by analyzing the occurrence of positive values and the intensity of positive values separately; however, this separation may break down the natural sequence of semicontinuous data within a subject and destroy its serial dependence structure. In this article, we introduce a Tweedie compound Poisson mixed model to study the occurrence of positive values and the quantity of the semicontinuous response simultaneously. In our approach, covariate effects on the semicontinuous response are assessed directly. The correlation within a subject and the unobserved heterogeneity are incorporated with serially correlated nonparametric random effects. Our model unifies subject‐specific and population‐averaged interpretations. We illustrate the approach with applications to a Brief Symptom Inventory study and an infants' fluoride intake study.

Trends in Incidence of Carbapenem-Resistant Enterobacterales in 7 US Sites, 2016─2020.

We described changes in 2016─2020 carbapenem-resistant Enterobacterales (CRE) incidence rates in 7 US sites that conduct population-based CRE surveillance. An incident CRE case was defined as the first isolation of Escherichia coli, Klebsiella spp., or Enterobacter spp. resistant to ≥1 carbapenem from a sterile site or urine in a surveillance area resident in a 30-day period. We reviewed medical records and classified cases as hospital-onset (HO), healthcare-associated community-onset (HACO), or community-associated (CA) CRE based on healthcare exposures and location of disease onset. We calculated incidence rates using census data. We used Poisson mixed effects regression models to perform 2016─2020 trend analyses, adjusting for sex, race/ethnicity, and age. We compared adjusted incidence rates between 2016 and subsequent years using incidence rate ratios (RRs) and 95% confidence intervals (CIs). Of 4996 CRE cases, 62% were HACO, 21% CA, and 14% HO. The crude CRE incidence rate per 100 000 was 7.51 in 2016 and 6.08 in 2020 and was highest for HACO, followed by CA and HO. From 2016 to 2020, the adjusted overall CRE incidence rate decreased by 24% (RR, 0.76 [95% CI, .70-.83]). Significant decreases in incidence rates in 2020 were seen for HACO (RR, 0.75 [95% CI, .67-.84]) and CA (0.75 [.61-.92]) but not for HO CRE. Adjusted CRE incidence rates declined from 2016 to 2020, but changes over time varied by epidemiologic class. Continued surveillance and effective control strategies are needed to prevent CRE in all settings.

The status of active after-school clubs among primary school children in England (UK) after the COVD-19 lockdowns: implications for policy and practice

BackgroundChildren’s physical activity in England is more dependent on active clubs after the COVID-19 pandemic. However, it is unclear how the COVID-19 pandemic and related cost-of-living crisis have impacted on active club participation, costs and provision. This mixed-methods natural experiment explored school-based and community-based active clubs after lockdowns, using a unique combination of data sources to highlight implications for policy and practice post-COVID-19.MethodsCross-sectional questionnaire data on school and community active clubs were collected from 10-11-year-old children pre-COVID-19 in 2017-18 (N = 1,296; 50 schools), in 2021 (N = 393; 23 schools), and 2022 (N = 463; 27 schools). Club participation and attendance frequency were modelled using logistic and Poisson mixed effects models, adjusted for child age, gender and household education. In 2021 and 2022, parents reported expenditure on community-based clubs and schools provided data on school-based club provision, with data summarised descriptively. Qualitative data were collected in 2021 and 2022, with one-to-one interviews with school staff (N = 18) and parents (N = 43), and twelve child focus groups (N = 92), and analysed using the framework method.ResultsSchool-based active club participation was higher in 2022 compared to pre-pandemic (50% /43%), while community-based club participation was lower (74%/80%). Children attended 0.3 fewer clubs per week. Those from lower education households were less likely to participate in both types of active clubs, and girls less likely to attend community clubs. In 2022, the median cost of community and school club sessions were £6.67 and £3.88 respectively, with 52% of school-based clubs free to parents. Schools offered an average of 3.4 active clubs per week for 10-11-year-olds in 2022, with 34% partly/wholly subsidised. Qualitative analysis highlighted the impact of the cost-of-living crisis and COVID-19 pandemic on family resources, encouraging a shift to more affordable and convenient school-based active clubs, which negatively impacted the community-based active club environment. However, many schools struggled to meet this increased demand.ConclusionsFindings emphasise the importance for policymakers to support schools to meet increased demand for clubs and community clubs to increase affordable and convenient physical activity opportunities. Targeted support is needed to prevent socioeconomic and gender inequalities.

Randomized controlled trial on the effect of 1-hour infusion of vincristine versus push injection on neuropathy in children with cancer (final analysis).

Vincristine is an integral component of treatment for children with cancer. Its main dose-limiting side effect is vincristine-induced peripheral neuropathy (VIPN). The VINCA trial was a randomized controlled trial that explored the effect of 1-hour infusion compared with push injection of vincristine on the development of VIPN in children with cancer. The short-term outcomes (median follow-up 9 months) showed that there was no difference in VIPN between the randomization groups. However, 1-hour infusion was less toxic in children who also received azoles. We now report the results of the final analyses (median follow-up 20 months), which includes treatment outcome as a secondary objective (follow-up 3 years). VIPN was measured 1-7 times per participant using the Common Terminology Criteria for Adverse Events (CTCAE) and the pediatric-modified total neuropathy score. Poisson mixed model and logistic generalized estimating equation analysis for repeated measures were performed. Forty-five participants per randomization group were included. There was no significant effect of 1-hour infusion compared with push injection on VIPN. In participants receiving concurrent azoles, the total CTCAE score was significantly lower in the one-hour group (rate ratio 0.52, 95% confidence interval 0.33-0.80, p = 0.003). Four patients in the one-hour group and one patient in the push group relapsed. Two patients in the one-hour group died. 1-hour infusion of vincristine is not protective against VIPN. However, in patients receiving concurrent azoles, 1-hour infusion may be less toxic. The difference in treatment outcome is most likely the result of differences in risk profile.

Unmasking the COVID-19 pandemic prevention gains: excess mortality reversal in 2022

ObjectivesThe purpose of this study was to assess the long-term effectiveness of COVID-19 pandemic prevention measures in saving lives after European governments began to lift restrictions. Study designExcess mortality interrupted time series. MethodsCountry-level weekly data on deaths were fitted to the Poisson mixed linear model to estimate excess deaths. Based on this estimate, the percentage of excess deaths above the baseline during the pandemic (week 11 in 2020 to week 15 in 2022) (when public health interventions were in place) and during the post-pandemic period (week 16 in 2022 to week 52 in 2022) were calculated. These results were fitted to the linear regression model to determine any potential relationship between mortality during these two periods. ResultsThe model used in this study had high predictive value (adjusted R2 = 59.4%). Mortality during the endemic (post-pandemic) period alone increased by 7.2% (95% confidence interval [CI]: 5.7, 8.6) above baseline, while each percentage increase in mortality during the pandemic corresponded to a 0.357% reduction (95% CI: 0.243, 0.471) in mortality during the post-pandemic period. ConclusionsThe most successful countries in terms of protective measures also experienced the highest mortality rates after restrictions were lifted. The model used in this study clearly shows a measure of bidirectional mortality displacement that is sufficiently clear to mask any impact of long COVID on overall mortality. Results from this study also seriously impact previous cost-benefit analyses of pandemic prevention measures, since, according to the current model, 12.2% (95% CI: 8.3, 16.1) of the gains achieved in pandemic containment were lost after restrictions were lifted.

The influence of LEED enhanced indoor air quality credit achievement on COVID-related school closures

School closures during the COVID-19 pandemic have highlighted the importance of in-person learning on child health and wellness. Improving indoor air quality (IAQ) is a critical undertaking to keep children in school during outbreak events. Our primary objective was to evaluate the impact of Enhanced IAQ credit achievement among LEED-certified schools on the ability to remain open during the pandemic. In this analysis, schools that achieved LEED Enhanced IAQ credits for increased ventilation or outdoor air delivery monitoring were assigned to the treatment group; LEED schools without these credits were in the control group. We used LASSO regression to select potential confounders for treatment models. Inverse treatment probability weights were used to control for confounding in mixed effects Poisson models in which the response variable was the number of COVID-related school closure days during the 2021-22 academic year. Although effect estimates for the treatment were not significant, they were consistently in the inverse direction (incidence rate ratio (IRR) [95% CI]: 0.90 [0.80, 1.01]). Models may have lacked power to detect significance due to many schools having zero COVID-related closures during the 2021-22 academic year. An important secondary finding was a 53% decrease in COVID-related closure days (95% CI: 7%–77%) associated with a 10% increase in county residents who reported ‘Always’ using a mask in public. This study contributes to the current understanding of the indoor environment and airborne disease transmission. Efforts to monitor and improve IAQ in schools are important avenues to support community, student, and staff health.

Pregnancy Outcomes in Women Infected With COVID-19: A Retrospective Cohort Study

Introduction: Studies of the impact of the novel coronavirus 2019 (COVID-19) on pregnancy outcomes have yielded conflicting results. Objective: This study examined pregnancy outcomes in COVID-19-infected and non-infected pregnant women. Materials and Methods: In this retrospective cohort study, we included all pregnant women with (n=42) and without COVID-19 infection (n=185) admitted to a training and treatment center in Babol City, Iran, from March to November 2020. We abstracted the records of all pregnancies in women with COVID-19 (exposed cohort) and women without COVID-19 (non-exposed cohort). Patient information was taken from their medical records. The chisquare test and Student t-test were used for data analysis. Modified Poisson regression and mixed linear model were used to assess the adjusted risk ratio (aRR) and adjusted mean difference (aMD) between COVID-19 infection and pregnancy outcomes. Results: A total of 227 pregnant women (42 in the exposure group, 185 in the non-exposed group) were included in the study. The mean age of mothers was 28.12±6.27 years, and also 48.5% of them had their first pregnancy. In comparison with non-infected women, women with COVID-19 faced the highest risk of cesarean section (aRR: 2.22, 95% CI, 1.35%-3.65%, P=0.002) and preterm birth (aRR: 1.22, 95% CI, 1.02%-1.48%, P=0.026). Also, pregnant women with COVID-19 had a significantly higher duration of hospital stay (aMD: 2.20, 95% CI, 1.32%-3.08%, P=0.001) compared to pregnant women without COVID-19. There was no significant difference between the two groups in terms of postpartum hemorrhage and premature rupture of membranes. Conclusion: This study suggests that COVID-19 infection is associated with an increased risk of cesarean section, preterm birth, and increased duration of hospital stay but not with other outcomes. However, the current evidence does not support its causal effects, given the methodological limitations and small sample size.