Proportional Odds Logistic Regression Research Articles

Refining outcome prediction after traumatic brain injury with machine learning algorithms.

Outcome after traumatic brain injury (TBI) is typically assessed using the Glasgow outcome scale extended (GOSE) with levels from 1 (death) to 8 (upper good recovery). Outcome prediction has classically been dichotomized into either dead/alive or favorable/unfavorable outcome. Binary outcome prediction models limit the possibility of detecting subtle yet significant improvements. We set out to explore different machine learning methods with the purpose of mapping their predictions to the full 8 grade scale GOSE following TBI. The models were set up using the variables: age, GCS-motor score, pupillary reaction, and Marshall CT score. For model setup and internal validation, a total of 866 patients could be included. For external validation, a cohort of 369 patients were included from Leuven, Belgium, and a cohort of 573 patients from the US multi-center ProTECT III study. Our findings indicate that proportional odds logistic regression (POLR), random forest regression, and a neural network model achieved accuracy values of 0.3-0.35 when applied to internal data, compared to the random baseline which is 0.125 for eight categories. The models demonstrated satisfactory performance during external validation in the data from Leuven, however, their performance were not satisfactory when applied to the ProTECT III dataset.

Age is Associated with Level of First-Time Anterior Cervical Discectomy and Fusion: An Ordinal Analysis of Factors Influencing Timing of Cervical Degeneration

Symptomatic cervical spondylosis is often treated with anterior cervical decompression and fusion (ACDF). However, few factors can predict which cervical level will degenerate and require intervention. This analysis evaluates pre-procedural factors associated with level of first-time single-level ACDF. We performed a retrospective analysis of patients who underwent single-level ACDF without prior history of spine surgery. Mann Whitney U-tests and Spearman rank-order correlation were performed for analyses of associations between variables of interest and ACDF level. Adjusted odds-ratios were calculated by proportional-odds logistic regression, with age, sex, body mass index (BMI), current tobacco use, history of neck trauma, preoperative radicular symptoms, and preoperative myelopathic symptoms as covariates. 141 patients met inclusion criteria, and age demonstrated a negative correlation with ACDF level, such that younger patients tended to have ACDF performed at inferior subaxial levels (p=0.0006, rho = -0.31, moderately strong relationship). Patients with pre-operative radicular symptoms and myelopathic symptoms were more likely to have ACDF performed at inferior (p=0.0001) and superior (p<0.0001) levels, respectively. Patient sex, BMI, current tobacco use, and history of neck trauma were not predictive of ACDF level. When adjusting for the above variables in a proportional-odds ordinal logistic regression model, a one year increase in age conferred a 4% increase in the odds of requiring an ACDF at a given superior level compared to the adjacent inferior level. Age is correlated with level of first-time single level ACDF. Individual subaxial levels may have unique biomechanical properties that influence degeneration.

The Injury Prevention Program to Reduce Early Childhood Injuries: A Cluster Randomized Trial.

The American Academy of Pediatrics designed The Injury Prevention Program (TIPP) in 1983 to help pediatricians prevent unintentional injuries, but TIPP's effectiveness has never been formally evaluated. We sought to evaluate the impact of TIPP on reported injuries in the first 2 years of life. We conducted a stratified, cluster-randomized trial at 4 academic medical centers: 2centers trained their pediatric residents and implemented TIPP screening and counseling materials at all well-child checks (WCCs) for ages 2 to 24 months, and 2 centers implemented obesity prevention. At each WCC, parents reported the number of child injuries since the previous WCC. Proportional odds logistic regression analyses with generalized estimating equation examined the extent to which the number of injuries reported were reduced at TIPP intervention sites compared with control sites, adjusting for baseline child, parent, and household factors. A total of 781 parent-infant dyads (349 TIPP; 432 control) were enrolled and had sufficient data to qualify for analyses: 51% Hispanic, 28% non-Hispanic Black, and 87% insured by Medicaid. Those at TIPP sites had significant reduction in the adjusted odds of reported injuries compared with non-TIPP sites throughout the follow-up (P = .005), with adjusted odds ratios (95% CI) of 0.77 (0.66-0.91), 0.60 (0.44-0.82), 0.32 (0.16-0.62), 0.26 (0.12-0.53), and 0.27 (0.14-0.52) at 4, 6, 12, 18, and 24 months, respectively. In this cluster-randomized trial with predominantly low-income, Hispanic, and non-Hispanic Black families, TIPP resulted in a significant reduction in parent-reported injuries. Our study provides evidence for implementing the American Academy of Pediatrics' TIPP in routine well-child care.

Surrogate Perception of Disability after Hospitalization for Traumatic Brain Injury.

The Glasgow Outcome Scale Extended (GOSE) is a measure of recovery after traumatic brain injury (TBI). Public surveys rate some GOSE states as worse than death. Direct family experience caring for patients with TBI may impact views of post-TBI disability. We conducted a national cross-sectional computer-adaptive survey of surrogates of TBI dependents incurring injury more than 1 year earlier. Using a standard gamble approach in randomized order, surrogates evaluated preferences for post-TBI GOSE states from GOSE 2 (bedridden, unaware) to GOSE 8 (good recovery). We calculated median (interquartile range [IQR]) health utilities for each post-TBI state, ranging from -1 to 1, with 0 as reference (death = GOSE 1), and assessed sociodemographic associations using proportional odds logistic regression modeling. Of 515 eligible surrogates, 298 (58%) completed scenarios. Surrogates were median aged 46 (IQR 35 to 60), 54% married, with Santa Clara strength of faith 14 (10 to 18). TBI dependents had a median GOSE5 (3 to 7). Median (IQR) health utility ratings for GOSE 2, GOSE 3, and GOSE 4 were -0.06 (-0.50 to -0.01), -0.01 (-0.30 to 0.45), and 0.30 (-0.01 to 0.80), rated worse than death by 91%, 65%, and 40%, respectively. Surrogates rated GOSE 4 (daily partial help) worse than the general population. Married surrogates rated GOSE 4 higher (p < 0.01). Higher strength of faith was associated with higher utility scores across GOSE states (p = 0.034). In this index study of surrogate perceptions about disability after TBI, poor neurologic outcomes-vegetative, needing all-day or partial daily assistance-were perceived as worse than death by at least 1 in 3 surrogates. Surrogate perceptions differed from the unexposed public. Long-term perceptions about post-TBI disability may inform earlier, tailored shared decision-making after neurotrauma.

The effect of vertical skeletal proportions, skeletal maturation, and age on midpalatal suture maturation: a CBCT-based study

BackgroundMidpalatal suture (MPS) maturation may be influenced by a range of parameters including age, gender, and vertical skeletal pattern. We therefore aimed to evaluate the effect of Frankfurt-mandibular angle (FMA), skeletal maturation, and age on the timing of MPS maturation.MethodsIn this cross-sectional study, cone-beam computed tomography (CBCT) and lateral cephalograms were used to assess the MPS and cervical vertebral maturation (CVM) stage. A proportional odds logistic regression model was used to assess associations between age adjusted for gender and MPS maturation, and a regression analysis was performed to analyze the effect of vertical pattern on these associations.ResultsA total of 201 patients (84 male and 117 female) with a mean age of 13.48 (SD 1.94) were included. With increasing age, the odds of belonging to a higher maturation stage increased (OR: 2.14; 95% CI 1.789; 2.567; P < 0.001); however, no association between FMA and MPS maturation was observed (OR: 1.01; 95% CI 0.964; 1.051; P = 0.76). A strong correlation between MPS maturation and CVM stage was not reported. Males had a higher probability of belonging to a lower MPS maturation stage (OR: 0.24; 95% CI 0.136; 0.415; P < 0.001).ConclusionsBased on this cross-sectional analysis, midpalatal sutural maturation classification is associated with chronological age and occurs later in males. Neither CVM staging nor variation in vertical skeletal proportions were useful predictors of midpalatal maturation stage.

FAMILY CAREGIVER COMFORT WITH TELEHEALTH TECHNOLOGIES: DIFFERENCES BY RACE/ETHNICITY IN A CROSS SECTIONAL SURVEY

Abstract Telehealth has seen widespread use since the onset of the COVID-19 pandemic, and 82% patients required assistance in accessing their telehealth appointments. This assistance commonly comes from a family caregiver who may or may not be comfortable using the technologies associated with telehealth. The objective of our study was to analyze a demographically representative survey of US family caregivers to understand the level of comfort using telehealth technologies among family caregivers through a secondary analysis of survey data collected during the COVID-19 pandemic in 2020. Level of caregiver comfort using computers, smartphones, and tablets was determined through three Likert-style questions. Proportional odds logistic regression was used to understand the associations between demographic variables and level of caregiver comfort using each technology, when adjusting for covariates. A total of 340 caregivers were included in the analysis. Compared to Non-Hispanic White caregivers, Asian caregivers had a higher odds (OR 3.14; 95%CI 1.36, 8.02; p=0.01) of expressing comfort using computers; Black caregivers (OR 0.46; 95%CI 0.21, 0.98; p=0.04) and Hispanic caregivers (OR 0.36; 95%CI 0.17, 0.79 p=0.01) expressed lower odds of comfort using smartphones; and Asian caregivers had a higher odds (OR 4.64; 95%CI 2.05, 11.69; p=0.001) of expressing comfort using tablets. : There are identified disparities in level of technological comfort using computers, smartphones, and tablets by different racial and ethnic groups. Health systems should consider early stakeholder involvement in the design of telehealth technologies and culturally responsive training materials on telehealth technology use to reduce disparities in comfort using telehealth technologies.

Convergent and clinical validity of a remote smartphone‐based self‐assessment of cognition, function, and behavior in early Alzheimer’s disease

AbstractBackgroundTrials in early Alzheimer’s disease (eAD) require the quantification of cognitive and functional progression. Compared with traditional in‐clinic assessments, remote assessments via digital health technologies (DHT) enable the collection of a broader palette of cognitive and functional measures at higher frequency and in patients' home environments. However, these must demonstrate validity against standard clinical outcome measures and relevant biomarkers. To this end, the present study aims to determine the reliability, convergent clinical, and functional neuroanatomic validity of a novel DHT, the Alzheimer’s Disease Digital Assessment Suite (AD‐DAS), for individuals on the AD continuum.MethodsIn total, 123 participants from 2 countries across 5 sites (3 USA, 2 Spain) participated (https://www.isrctn.com/ISRCTN17035495): 32 healthy controls (HC), 31 amyloid‐PET negative and 30 amyloid‐PET positive subjective cognitive decline (SCDn, SCDP, respectively), and 30 eAD. All participants completed standard in‐clinic neuropsychological assessments and remotely performed the AD‐DAS tasks daily for 28 days without supervision. AD‐DAS comprised 9 active tasks of cognitive/motor functioning and 4 survey questionnaires. Convergent and clinical validity analysis were performed using linear and proportional odds logistic regression modeling with age, sex, education, and site as covariates, respectively. Functional neuroanatomic validity was tested with voxel‐based morphometry (VBM) analyses with anatomic MRIs.ResultsOutcome metrics from all AD‐DAS cognitive/motor tasks correlated with their corresponding clinical comparators (ρpartial (range) = 0.16 ‐ 0.52), supporting their convergent validity. Similarly, outcome metrics from all tasks significantly differentiated the eAD from all the other groups in the expected directions (odds ratio (range) = 0.01 ‐ 61), supporting their clinical validity. The reliability of the outcome metrics ranged from good to excellent (interclass correlation coefficient (range) = 0.71 ‐ 0.91). VBM analyses provided independent and largely confirmatory results, further validating the AD‐DAS.ConclusionsThe AD‐DAS remote, smartphone‐based assessments of cognition show good to excellent test‐retest reliability, and preliminary analyses indicate that they may show convergent, clinical and exploratory functional neuroanatomic validity. Thus, these results provide a foundation for building towards the overarching goals of remote screening, prediction of progression, and monitoring of cognitive decline for future clinical trials and clinical care for preclinical and eAD.

Preliminary validation of a dual‐task gait assessment in early Alzheimer’s Disease

AbstractBackgroundEarly stages of Alzheimer’s disease (eAD) are marked by changes in gait characteristics that may be measured using simple smartphone‐based gait tasks. Here we present an assessment of cognitive‐motor‐interference where participants walk for 30 seconds with a smartphone placed in a running belt while counting backwards, called the 30‐Second Walk Test Dual Task (30sWTDT). We report the preliminary reliability and validation of the 30sWTDT in a cohort of healthy individuals (HC), individuals with subjective cognitive decline amyloid‐PET negative and positive (SCDn and SCDp, respectively) and eAD.Method123 participants (32 HC, 31 SCDn, 30 SCDp and 30 eAD) were recruited as a part of a Proof‐of‐Concept study of the Alzheimer’s Disease Digital Assessment Suite (AD‐DAS) (https://www.isrctn.com/ISRCTN17035495). Participants performed 9 sessions of 30sWTDT over 28 days on provisioned smartphones. Feasibility was evaluated as the proportion of completed 30sWTDT relative to the total number of expected sessions. Two gait characteristic metrics were estimated: variability in step frequency (VSF) and the 25th percentile in step power (25SP). Intraclass correlation coefficients (ICC) tested the metrics’ reliability. Convergent validity was established as partial correlation between VSF/25SP and adjusted mean duration in Timed 25 foot Walk Test (T25WT). Clinical validity was evaluated using a proportional odds logistic regression model to differentiate between groups.ResultAmong the 97.5% of participants who completed the study (i.e., n = 120), participants completed 88.9% of all assigned 30sWTDT tasks, with no group difference in adherence. VSF and 25SP metrics showed moderate (ICC = 0.74) and good (ICC = 0.79) reliability, respectively. Both metrics significantly distinguished between HC and all other study groups (odds ratio = [0.012,0.029]), and were associated with T25WT adjusted mean duration (adjusted r2 = [0.09,0.069]).ConclusionPreliminary findings demonstrate that a smartphone‐based 30sWTDT can be successfully self‐administered by cognitively healthy participants and individuals on the eAD continuum. Participants show high adherence in an ecologically valid environment. 30sWTDT differentiated HC from all other groups with subjective or objective cognitive problems, indicating a lack of specificity of gait characteristics to differentiate between increasing levels of cognitive impairment. These findings require replication in larger independent datasets.

Convergent and clinical validity of a remote smartphone‐based self‐assessment of cognition, function, and behavior in early Alzheimer’s disease

AbstractBackgroundTrials in early Alzheimer’s disease (eAD) require the quantification of cognitive and functional progression. Compared with traditional in‐clinic assessments, remote assessments via digital health technologies (DHT) enable the collection of a broader palette of cognitive and functional measures at higher frequency and in patients' home environments. However, these must demonstrate validity against standard clinical outcome measures and relevant biomarkers. To this end, the present study aims to determine the reliability, convergent clinical, and functional neuroanatomic validity of a novel DHT, the Alzheimer’s Disease Digital Assessment Suite (AD‐DAS), for individuals on the AD continuum.MethodIn total, 123 participants from 2 countries across 5 sites (3 USA, 2 Spain) participated (https://www.isrctn.com/ISRCTN17035495): 32 healthy controls (HC), 31 amyloid‐PET negative and 30 amyloid‐PET positive subjective cognitive decline (SCDn, SCDP, respectively), and 30 eAD. All participants completed standard in‐clinic neuropsychological assessments and remotely performed the AD‐DAS tasks daily for 28 days without supervision. AD‐DAS comprised 9 active tasks of cognitive/motor functioning and 4 survey questionnaires. Convergent and clinical validity analysis were performed using linear and proportional odds logistic regression modeling with age, sex, education, and site as covariates, respectively. Functional neuroanatomic validity was tested with voxel‐based morphometry (VBM) analyses with anatomic MRIs.ResultOutcome metrics from all AD‐DAS cognitive/motor tasks correlated with their corresponding clinical comparators (ρpartial (range) = 0.16 ‐ 0.52), supporting their convergent validity. Similarly, outcome metrics from all tasks significantly differentiated the eAD from all the other groups in the expected directions (odds ratio (range) = 0.01 ‐ 61), supporting their clinical validity. The reliability of the outcome metrics ranged from good to excellent (interclass correlation coefficient (range) = 0.71 ‐ 0.91). VBM analyses provided independent and largely confirmatory results, further validating the AD‐DAS.ConclusionThe AD‐DAS remote, smartphone‐based assessments of cognition show good to excellent test‐retest reliability, and preliminary analyses indicate that they may show convergent, clinical and exploratory functional neuroanatomic validity. Thus, these results provide a foundation for building towards the overarching goals of remote screening, prediction of progression, and monitoring of cognitive decline for future clinical trials and clinical care for preclinical and eAD.

Clinical Outcome Prediction of Early Brain Injury in Aneurysmal Subarachnoid Hemorrhage: the SHELTER-Score

BackgroundDespite intensive research on preventing and treating vasospasm and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage (aSAH), mortality and morbidity rates remain high. Early brain injury (EBI) has emerged as possibly the major significant factor in aSAH pathophysiology, emphasizing the need to investigate EBI-associated clinical events for improved patient management and decision-making. This study aimed to identify early clinical and radiological events within 72 h after aSAH to develop a conclusive predictive EBI score for clinical practice.MethodsThis retrospective analysis included 561 consecutive patients with aSAH admitted to our neurovascular center between 01/2014 and 09/2022. Fourteen potential predictors occurring within the initial 72 h after hemorrhage were analyzed. The modified Rankin Scale (mRS) score at 6 months, discretized to three levels (0–2, favorable; 3–5, poor; 6, dead), was used as the outcome variable. Univariate ordinal regression ranked predictors by significance, and forward selection with McFadden’s pseudo-R2 determined the optimal set of predictors for multivariate proportional odds logistic regression. Collinear parameters were excluded, and fivefold cross-validation was used to avoid overfitting.ResultsThe analysis resulted in the Subarachnoid Hemorrhage Associated Early Brain Injury Outcome Prediction score (SHELTER-score), comprising seven clinical and radiological events: age (0–4 points), World Federation of Neurosurgical Societies (0–2.5 points), cardiopulmonary resuscitation (CPR) (2 points), mydriasis (1–2 points), midline shift (0.5–1 points), early deterioration (1 point), and early ischemic lesion (2 points). McFadden’s pseudo-R2 = 0.339, area under the curve for death or disability 0.899 and 0.877 for death. A SHELTER-score below 5 indicated a favorable outcome (mRS 0–2), 5–6.5 predicted a poor outcome (mRS 3–5), and ≥ 7 correlated with death (mRS 6) at 6 months.ConclusionsThe novel SHELTER-score, incorporating seven clinical and radiological features of EBI, demonstrated strong predictive performance in determining clinical outcomes. This scoring system serves as a valuable tool for neurointensivists to identify patients with poor outcomes and guide treatment decisions, reflecting the great impact of EBI on the overall outcome of patients with aSAH.

Early progression of chronic histologic lesions in kidney transplant biopsies is not associated with HLA histocompatibility.

Early progression of chronic histologic lesions in kidney allografts represents the main finding in graft attrition. The objective of this retrospective cohort study was to elucidate whether HLA histocompatibility is associated with progression of chronic histologic lesions in the first year post-transplant. Established associations of de novo donor-specific antibody (dnDSA) formation with HLA mismatch and microvascular inflammation (MVI) were calculated to allow for comparability with other study cohorts. We included 117 adult kidney transplant recipients, transplanted between 2016 and 2020 from predominantly deceased donors, who had surveillance biopsies at 3 and 12 months. Histologic lesion scores were assessed according to the Banff classification. HLA mismatch scores [i.e. eplet, predicted indirectly recognizable HLA-epitopes algorithm (PIRCHE-II), HLA epitope mismatch algorithm (HLA-EMMA), HLA whole antigen A/B/DR] were calculated for all transplant pairs. Formation of dnDSAs was quantified by single antigen beads. More than one-third of patients exhibited a progression of chronic lesion scores by at least one Banff grade in tubular atrophy (ct), interstitial fibrosis (ci), arteriolar hyalinosis (ah) and inflammation in the area of interstitial fibrosis and tubular atrophy (i-IFTA) from the 3- to the 12-month biopsy. Multivariable proportional odds logistic regression models revealed no association of HLA mismatch scores with progression of histologic lesions, except for ah and especially HLA-EMMA DRB1 [odds ratio (OR)=1.10, 95% confidence interval (CI) 1.03-1.18]. Furthermore, the established associations of dnDSA formation with HLA mismatch and MVI (OR=5.31, 95% CI 1.19-22.57) could be confirmed in our cohort. These data support the association of HLA mismatch and alloimmune response, while suggesting that other factors contribute to early progression of chronic histologic lesions.

The relationship between mood and anxiety and cognitive phenotypes in adults with pharmacoresistant temporal lobe epilepsy.

Patients with temporal lobe epilepsy (TLE) are often at a high risk for cognitive and psychiatric comorbidities. Several cognitive phenotypes have been identified in TLE, but it is unclear how phenotypes relate to psychiatric comorbidities, such as anxiety and depression. This observational study investigated the relationship between cognitive phenotypes and psychiatric symptomatology in TLE. A total of 826 adults (age = 40.3, 55% female) with pharmacoresistant TLE completed a neuropsychological evaluation that included at least two measures from five cognitive domains to derive International Classification of Cognitive Disorders in Epilepsy (IC-CoDE) cognitive phenotypes (i.e., intact, single-domain impairment, bi-domain impairment, generalized impairment). Participants also completed screening measures for depression and anxiety. Psychiatric history and medication data were extracted from electronic health records. Multivariable proportional odds logistic regression models examined the relationship between IC-CoDE phenotypes and psychiatric variables after controlling for relevant covariates. Patients with elevated depressive symptoms had a greater odds of demonstrating increasingly worse cognitive phenotypes than patients without significant depressive symptomatology (odds ratio [OR] = 1.123-1.993, all corrected p's < .05). Number of psychotropic (OR = 1.584, p < .05) and anti-seizure medications (OR = 1.507, p < .001), use of anti-seizure medications with mood-worsening effects (OR = 1.748, p = .005), and history of a psychiatric diagnosis (OR = 1.928, p < .05) also increased the odds of a more severe cognitive phenotype, while anxiety symptoms were unrelated. This study demonstrates that psychiatric factors are not only associated with function in specific cognitive domains but also with the pattern and extent of deficits across cognitive domains. Results suggest that depressive symptoms and medications are strongly related to cognitive phenotype in adults with TLE and support the inclusion of these factors as diagnostic modifiers for cognitive phenotypes in future work. Longitudinal studies that incorporate neuroimaging findings are warranted to further our understanding of the complex relationships between cognition, mood, and seizures and to determine whether non-pharmacologic treatment of mood symptoms alters cognitive phenotype.

Differences in Health Professionals’ Engagement With Electronic Health Records Based on Inpatient Race and Ethnicity

US health professionals devote a large amount of effort to engaging with patients' electronic health records (EHRs) to deliver care. It is unknown whether patients with different racial and ethnic backgrounds receive equal EHR engagement. To investigate whether there are differences in the level of health professionals' EHR engagement for hospitalized patients according to race or ethnicity during inpatient care. This cross-sectional study analyzed EHR access log data from 2 major medical institutions, Vanderbilt University Medical Center (VUMC) and Northwestern Medicine (NW Medicine), over a 3-year period from January 1, 2018, to December 31, 2020. The study included all adult patients (aged ≥18 years) who were discharged alive after hospitalization for at least 24 hours. The data were analyzed between August 15, 2022, and March 15, 2023. The actions of health professionals in each patient's EHR were based on EHR access log data. Covariates included patients' demographic information, socioeconomic characteristics, and comorbidities. The primary outcome was the quantity of EHR engagement, as defined by the average number of EHR actions performed by health professionals within a patient's EHR per hour during the patient's hospital stay. Proportional odds logistic regression was applied based on outcome quartiles. A total of 243 416 adult patients were included from VUMC (mean [SD] age, 51.7 [19.2] years; 54.9% female and 45.1% male; 14.8% Black, 4.9% Hispanic, 77.7% White, and 2.6% other races and ethnicities) and NW Medicine (mean [SD] age, 52.8 [20.6] years; 65.2% female and 34.8% male; 11.7% Black, 12.1% Hispanic, 69.2% White, and 7.0% other races and ethnicities). When combining Black, Hispanic, or other race and ethnicity patients into 1 group, these patients were significantly less likely to receive a higher amount of EHR engagement compared with White patients (adjusted odds ratios, 0.86 [95% CI, 0.83-0.88; P < .001] for VUMC and 0.90 [95% CI, 0.88-0.92; P < .001] for NW Medicine). However, a reduction in this difference was observed from 2018 to 2020. In this cross-sectional study of inpatient EHR engagement, the findings highlight differences in how health professionals distribute their efforts to patients' EHRs, as well as a method to measure these differences. Further investigations are needed to determine whether and how EHR engagement differences are correlated with health care outcomes.

Job strain, occupation, and bladder health among women.

Lower urinary tract symptoms (LUTS) are common among employed women. An underexplored topic is whether characteristics of women's occupations may influence LUTS. The present study examined whether job strain and its individual components (psychological demands, decision latitude) were associated with greater LUTS and their impact and whether, compared to managerial and professional occupations, occupations characterized by manual labor, sales, service, nursing, and teaching were associated with greater LUTS and their impact. Coronary Artery Risk Development in Young Adults cohort study data were analyzed. Job strain and occupation were assessed in 1987-88 and 1995-96. In 2012-13, LUTS and their impact were assessed. LUTS/impact category (a composite variable ranging from bladder health to mild, moderate, and severe LUTS/impact) was regressed on job strain and occupation in separate analyses, adjusting for age, race, parity, education, and financial hardship (n = 1006). Job strain and its individual components were not associated with LUTS/impact. In comparison to managerial and professional occupations, service occupations in 1987-88 and 1995-96 were both associated with greater odds of LUTS/impact in proportional odds logistic regression analyses. Employment as a nurse, health assistant, or health aide in 1995-96 was associated with greater odds of any LUTS/impact versus bladder health. Support positions in 1987-88 and sales positions in 1995-96 were associated with greater odds of moderate or severe LUTS/impact versus bladder health or mild LUTS/impact. Future research should examine characteristics of workplaces that may promote or constrain bladder health (e.g., time and autonomy to void when desired, infrastructure to void).

Financial strain across 25 years and women’s bladder health: a life course perspective

A small number of cross-sectional studies have found that financial insecurity-a social determinant of health-is associated with lower urinary tract symptoms. This study aimed to examine (1) whether women in the Coronary Artery Risk Development in Young Adult Study with higher levels of financial strain, assessed at 7 time points across 25 years beginning in 1985-1986, were more likely to report lower urinary tract symptoms and impact after the 2010-2011 financial strain assessment and (2) whether healthcare access and comorbidities mediated potential associations. This prospective cohort study recruited Black and White participants aged 18 to 30 years at baseline (1985-1986) from the populations of 4 US cities. The analytical sample was composed of women with complete data for analyses involving financial strain trajectories across 7 assessments (n=841) and mediation tests of data collected at 4 assessments (n=886). The outcome variable was previously developed through a cluster analysis of urinary incontinence severity, urinary incontinence impact, other lower urinary tract symptoms severity, and their impact in 2012-2013, which yielded 4 lower urinary tract symptoms and impact cluster categories: women with no symptom or very mild symptoms and no impact vs women with mild, moderate, or severe symptoms and impact. Financial strain was defined as finding it "very hard," "hard," or "somewhat hard" (vs "not very hard") to pay for the very basics, such as food, heating, and medical care. Using proportional odds logistic regression, cluster categories were regressed on the financial strain trajectory group, adjusting for age, race, education, and parity. For mediation analyses, separate financial strain variables (difficulty paying for the very basics, such as food and heating, and difficulty paying for medical care) were created by combining 1995-1996 and 2000-2001 values. Two healthcare access variables (difficulty receiving care and underutilization of care) and a single comorbidity index (smoking, physical inactivity, body mass index, hypertension, diabetes mellitus, and depressive symptoms) were created by combining 2005-2006 and 2010-2011 values. Regression analyses and structural equation modeling were used to test whether healthcare access and comorbidities mediated associations between financial strain and lower urinary tract symptoms and impact cluster categories. In comparison to women who were consistently not financially strained, women who were consistently strained (odds ratio, 2.10; 95% confidence interval, 1.13-3.91), shifted into being strained (odds ratio, 2.00; 95% confidence interval, 1.29-3.10), or experienced >1 shift in strain (odds ratio, 1.99; 95% confidence interval, 1.46-2.71) had roughly twice the odds of reporting greater lower urinary tract symptoms and impact. Underutilization of healthcare and comorbidities mediated the association between difficulty paying for medical care and lower urinary tract symptoms and impact. In the structural equation model, difficulty paying for medical care and underutilization of care were associated (β=.31; P<.01), as was underutilization of care and greater lower urinary tract symptoms and impact (β=.09; P<.01). Moreover, difficulty paying for medical care and the comorbidity index were associated (β=.34; P<.01), as was the comorbidity index and greater lower urinary tract symptoms and impact (β=.24; P<.01). Collectively, these mediation pathways eliminated a direct association between difficulty paying for medical care and lower urinary tract symptoms and impact. Underutilization of healthcare and comorbidities explained an association between financial strain (difficulty paying for medical care) and lower urinary tract symptoms and impact. Research is needed to confirm the findings and examine other mechanisms that may further explain the association. Accumulated evidence may inform future policies and practices.

Early surgery versus conservative treatment in patients with traumatic intracerebral hematoma: a CENTER-TBI study

PurposeEvidence regarding the effect of surgery in traumatic intracerebral hematoma (t-ICH) is limited and relies on the STITCH(Trauma) trial. This study is aimed at comparing the effectiveness of early surgery to conservative treatment in patients with a t-ICH.MethodsIn a prospective cohort, we included patients with a large t-ICH (< 48 h of injury). Primary outcome was the Glasgow Outcome Scale Extended (GOSE) at 6 months, analyzed with multivariable proportional odds logistic regression. Subgroups included injury severity and isolated vs. non-isolated t-ICH.ResultsA total of 367 patients with a large t-ICH were included, of whom 160 received early surgery and 207 received conservative treatment. Patients receiving early surgery were younger (median age 54 vs. 58 years) and more severely injured (median Glasgow Coma Scale 7 vs. 10) compared to those treated conservatively. In the overall cohort, early surgery was not associated with better functional outcome (adjusted odds ratio (AOR) 1.1, (95% CI, 0.6–1.7)) compared to conservative treatment. Early surgery was associated with better outcome for patients with moderate TBI and isolated t-ICH (AOR 1.5 (95% CI, 1.1–2.0); P value for interaction 0.71, and AOR 1.8 (95% CI, 1.3–2.5); P value for interaction 0.004). Conversely, in mild TBI and those with a smaller t-ICH (< 33 cc), conservative treatment was associated with better outcome (AOR 0.6 (95% CI, 0.4–0.9); P value for interaction 0.71, and AOR 0.8 (95% CI, 0.5–1.0); P value for interaction 0.32).ConclusionsEarly surgery in t-ICH might benefit those with moderate TBI and isolated t-ICH, comparable with results of the STITCH(Trauma) trial.

Family Caregiver Comfort with Telehealth Technologies: Differences by Race and Ethnicity in a Cross-Sectional Survey.

Background: Telehealth has seen widespread use since the onset of the COVID-19 pandemic, and 82% patients required assistance in accessing their telehealth appointments. This assistance commonly comes from a family caregiver who may or may not be comfortable using the technologies associated with telehealth. The objective of our study was to analyze a demographically representative survey of U.S. family caregivers to understand the level of comfort using telehealth technologies among family caregivers. Methods: A secondary analysis of survey data collected during the COVID-19 pandemic in 2020. Level of caregiver comfort using computers, smartphones, and tablets was determined through three Likert-style questions. Proportional odds logistic regression was used to understand the associations between demographic variables and level of caregiver comfort using each technology, when adjusting for covariates. Results: A total of 340 caregivers were included in the analysis. Compared with non-Hispanic white caregivers, Asian caregivers had higher odds (odds ratio [OR] 3.14; 95% confidence interval [CI] 1.36, 8.02; p = 0.01) of expressing comfort using computers; black caregivers (OR 0.46; 95% CI 0.21, 0.98; p = 0.04) and Hispanic caregivers (OR 0.36; 95% CI 0.17, 0.79; p = 0.01) expressed lower odds of comfort using smartphones; and Asian caregivers had higher odds (OR 4.64; 95% CI 2.05, 11.69; p = 0.001) of expressing comfort using tablets. Conclusion and Implications: There are identified disparities in the level of technological comfort using computers, smartphones, and tablets by different racial and ethnic groups. Health systems should consider early stakeholder involvement in the design of telehealth technologies, culturally responsive training materials on telehealth technology use to reduce disparities in comfort using telehealth technologies.

Statistical post‐processing of visibility ensemble forecasts

AbstractTo be able to produce accurate and reliable predictions of visibility has crucial importance in aviation meteorology, as well as in water‐ and road transportation. Nowadays, several meteorological services provide ensemble forecasts of visibility; however, the skill and reliability of visibility predictions are far reduced compared with other variables, such as temperature or wind speed. Hence, some form of calibration is strongly advised, which usually means estimation of the predictive distribution of the weather quantity at hand either by parametric or nonparametric approaches, including machine learning‐based techniques. As visibility observations—according to the suggestion of the World Meteorological Organization—are usually reported in discrete values, the predictive distribution for this particular variable is a discrete probability law, hence calibration can be reduced to a classification problem. Based on visibility ensemble forecasts of the European Centre for Medium‐Range Weather Forecasts covering two slightly overlapping domains in Central and Western Europe and two different time periods, we investigate the predictive performance of locally, semi‐locally and regionally trained proportional odds logistic regression (POLR) and multilayer perceptron (MLP) neural network classifiers. We show that while climatological forecasts outperform the raw ensemble by a wide margin, post‐processing results in further substantial improvement in forecast skill, and in general, POLR models are superior to their MLP counterparts.

Correlation of the Critical Care Pain Observation Tool and Numeric Rating Scale in Intensive Care Unit Patients.

We sought to determine the correlation between the Numeric Rating Scale (NRS) and Critical-Care Pain Observation Tool (CPOT) to determine whether clinical factors modified the relationship between NRS and CPOT assessments. We included nonventilated adults admitted to the MICU or SICU who could self-report pain and had at least 3 paired NRS and CPOT assessments. We performed Spearman correlation to assess overall correlation and performed proportional odds logistic regression to evaluate whether the relationship between NRS and CPOT assessments was modified by clinical factors. Nursing staff performed NRS and CPOT assessments every 4 h in 1302 patients, leading to 61,142 matched assessments. We found that the NRS and CPOT have a Spearman correlation coefficient of 0.56 and an intraclass correlation coefficient of 0.32 in intensive care unit patients. Factors that modified the relationship between the NRS and CPOT included the presence of delirium (P < .001) and lower mean daily Richmond Agitation Sedation Scale (<0.001). The correlation coefficient between the NRS and the CPOT was found to be 0.56. The presence of delirium, decreased level of arousal, modified the relationship between the NRS and CPOT. Self-reported and behavioral pain assessments cannot be used interchangeably in critically ill adults.

Validation of the test for finding word retrieval deficits (WoFi) in detecting Alzheimer's disease in a naturalistic clinical setting

BackgroundDetecting impaired naming capacity contributes to the detection of mild (MildND) and major (MajorND) neurocognitive disorder due to Alzheimer’s disease (AD). The Test for Finding Word retrieval deficits (WoFi) is a new, 50-item, auditory stimuli-based instrument.ObjectiveThe study aimed to adapt WoFi to the Greek language, to develop a short version of WoFi (WoFi-brief), to compare the item frequency and the utility of both instruments with the naming subtest of the widely used Addenbrooke’s cognitive examination III (ACEIIINaming) in detecting MildND and MajorND due to AD.MethodsThis cross-sectional, validation study included 99 individuals without neurocognitive disorder, as well as 114 and 49 patients with MildND and MajorND due to AD, respectively. The analyses included categorical principal components analysis using Cramer’s V, assessment of the frequency of test items based on corpora of television subtitles, comparison analyses, Kernel Fisher discriminant analysis models, proportional odds logistic regression (POLR) models and stratified repeated random subsampling used to recursive partitioning to training and validation set (70/30 ratio).ResultsWoFi and WoFi-brief, which consists of 16 items, have comparable item frequency and utility and outperform ACEIIINaming. According to the results of the discriminant analysis, the misclassification error was 30.9%, 33.6% and 42.4% for WoFi, WoFi-brief and ACEIIINaming, respectively. In the validation regression model including WoFi the mean misclassification error was 33%, while in those including WoFi-brief and ACEIIINaming it was 31% and 34%, respectively.ConclusionsWoFi and WoFi-brief are more effective in detecting MildND and MajorND due to AD than ACEIIINaming.