Random Effects Logistic Regression Models Research Articles

“Mate! I’m running 10 min late”: An investigation into the self-regulation of mobile phone tasks while driving

The adaptive behaviour of mobile phone distracted drivers has been a topic of much discussion in the recent literature, but the mechanisms of behavioural adaptation are still unclear. This study investigated the influence of driving demands, secondary task characteristics, and personal characteristics on behavioural adaptation of mobile phone distracted drivers. In particular, distracted drivers’ self-regulation at strategic, tactical, and operational levels was investigated through a driving simulator experiment. In a high-fidelity driving simulator, participants driving through various driving conditions (e.g. interactions with pedestrian crossings, signalized intersections, merging ramps, roundabouts, etc.) needed to decide where and how to perform the following four mobile phone tasks: (a) ring a doctor and cancel an appointment, (b) text a friend and tell him/her that the participant will be arriving 10 min late, (c) share the doctor’s phone number with a friend, and (d) take a ‘selfie’. At a strategic level, the decision to pull over was modelled as a function of self-reported personal/attitudinal characteristics with a logistic regression model. Similarly, tactical self-regulation (decision to engage in a task while driving in a specific situation) and operational self-regulation (decision to temporarily stop the mobile phone task) were modelled as a function of driving demands and personal/attitudinal characteristics using a random-effects logistic regression model, which accounts for correlations resulting from multiple observations of a driver. Results suggest that tactical self-regulation is more common among distracted drivers followed by operational and strategic self-regulation. Personal beliefs regarding how safe it is to use the mobile phone for texting/browsing while driving were predictors of self-regulation for all levels. Drivers were observed to use the mobile phone more when the driving demands are low, e.g. while stopped at an intersection. This research suggests that distracted drivers engage in various levels of self-regulation, and future research could be focused on further theoretical refinement and development of technology-based interventions.

Impact of data aggregation approaches on the relationships between operating speed and traffic safety

The impact of operating speed on traffic crash occurrence has been a controversial topic in the traffic safety discipline as some studies reported a positive association whereas others indicated a negative relationship between speed and crashes. Two major issues thought to be accountable for such conflicting findings are the application of inappropriate statistical methods and the use of sample datasets with varying levels of aggregation. The main objective of this study is therefore to investigate the impacts of data aggregation schemes on the relationships between operating speed and traffic safety. A total of three aggregation approaches were examined: (1) a segment-based dataset in which crashes are grouped by roadway segment, (2) a scenario-based dataset where crashes are aggregated by traffic operating scenarios, and (3) a disaggregated crash-level dataset consisting of information from individual crashes. The first two aggregation approaches were used in examining the relationships between operating speed and crash frequency using Bayesian random-effects negative binomial models. The third disaggregated crash risk analysis was conducted utilizing Bayesian random-effects logistic regression models. From the modeling results, it has been concluded that the scenario-based approach shared similar findings with those of the disaggregated crash risk analysis approach in which a U-shaped relationship between operating speed and crash occurrence was identified. However, the commonly adopted segment-based aggregation approach revealed a monotonous negative relationship between speed and crash frequency. The implications of the different analyses results and the potential applications of the results on speed management systems have therefore been discussed.

Prediction models for clustered data with informative priors for the random effects: a simulation study

BackgroundRandom effects modelling is routinely used in clustered data, but for prediction models, random effects are commonly substituted with the mean zero after model development. In this study, we proposed a novel approach of including prior knowledge through the random effects distribution and investigated to what extent this could improve the predictive performance.MethodsData were simulated on the basis of a random effects logistic regression model. Five prediction models were specified: a frequentist model that set the random effects to zero for all new clusters, a Bayesian model with weakly informative priors for the random effects of new clusters, Bayesian models with expert opinion incorporated into low informative, medium informative and highly informative priors for the random effects. Expert opinion at the cluster level was elicited in the form of a truncated area of the random effects distribution. The predictive performance of the five models was assessed. In addition, impact of suboptimal expert opinion that deviated from the true quantity as well as including expert opinion by means of a categorical variable in the frequentist approach were explored. The five models were further investigated in various sensitivity analyses.ResultsThe Bayesian prediction model using weakly informative priors for the random effects showed similar results to the frequentist model. Bayesian prediction models using expert opinion as informative priors showed smaller Brier scores, better overall discrimination and calibration, as well as better within cluster calibration. Results also indicated that incorporation of more precise expert opinion led to better predictions. Predictive performance from the frequentist models with expert opinion incorporated as categorical variable showed similar patterns as the Bayesian models with informative priors. When suboptimal expert opinion was used as prior information, results indicated that prediction still improved in certain settings.ConclusionsThe prediction models that incorporated cluster level information showed better performance than the models that did not. The Bayesian prediction models we proposed, with cluster specific expert opinion incorporated as priors for the random effects showed better predictive ability in new data, compared to the frequentist method that replaced random effects with zero after model development.

Creating Individual Surgeon Performance Assessments in a Statewide Hospital Surgical Quality Improvement Collaborative

Surgeon performance profiling is of great interest to surgeons, hospitals, health plans, and the public, yet efforts to date have been contested, with stakeholders at odds over the selection, reliability, and validity of metrics used. We sought to create surgeon-level comparative assessments within the Illinois Surgical Quality Improvement Collaborative. American College of Surgeons NSQIP data were obtained for 51 Illinois hospitals covering a 30-month period from 2014 to 2016. Surgeon-level, risk-adjusted outcomes rates were estimated from 3-level crossed random effects logistic regression models and classified as low, as expected, or high for each of 7 postoperative outcomes. Model intra-class correlations and provider-specific reliability statistics were calculated. A total of 123,141 cases were analyzed for 2,724 surgeons. Median provider case volume was 17 (interquartile range 4 to 54). Overall crude complication rates ranged from 0.62% to 7.14% across the 7 outcomes investigated. Surgeon-level variance estimates were low (intra-class correlation coefficients between 0.007 and 0.074). No performance outliers were detected for 3 of the outcomes measures, while a small number of outliers were identified for any morbidity (11 surgeons), surgical site infection (10 surgeons), death or serious morbidity (8 surgeons), and reoperation (1 surgeon). Among all physicians, median reliability was below 0.1 for each outcome. Few individual surgeon performance outliers could be detected in NSQIP clinical registry data for a statewide hospital collaborative over a 30-month period using postoperative patient outcomes. Low surgeon-specific case volumes and minimal variance between surgeons may limit the utility of American College of Surgeons NSQIP outcomes measures for individual profiling. Alternative metrics, such as process measures, patient experience, composite measures, or technical skill assessments should be explored for surgeon-level measurement.

Individual Surgeon's Contribution to Value.

Estimating surgeon-level value in health care remains relatively unexplored. American College of Surgeons National Surgical Quality Improvement Program Participant Use Files (2005-2013) were linked with total costs at a single institution. Random intercepts in 3-level random effects logistic regression models predicted 30-day postoperative mortality or morbidity for each surgeon each year. Value was defined as quality (morbidity or mortality) divided by costs for surgeons performing general surgery and vascular procedures. Forty-four surgeons performed 11 965 surgeries. Risk-adjusted costs trended down over time. For all surgeries, mortality value increased by 3.27 per year (95% confidence interval = 2.54-4.01; P < .001) on a 100-point scale, while morbidity value did not change. Of 21 surgeons with data for 5 years or longer, mortality value increased for all surgeons except one. Continuous increase in complication rates from 2008 contributed to decreased morbidity value. Value may assist surgeons in exploring performance opportunities better than morbidity or mortality alone.

Universal test and treat is not associated with sub-optimal antiretroviral therapy adherence in rural South Africa: the ANRS 12249 TasP trial.

Introduction HIV treatment guidelines now recommend antiretroviral therapy (ART) initiation regardless of CD4 count to maximize benefit both for the individual and society. It is unknown whether the initiation of ART at higher CD4 counts would affect adherence levels. We investigated whether initiating ART at higher CD4 counts was associated with sub‐optimal adherence (<95%) during the first 12 months of ART.MethodsA prospective cohort study nested within a two‐arm cluster‐randomized trial of universal test and treat was implemented from March 2012 to June 2016 to measure the impact of ART on HIV incidence in rural KwaZulu‐Natal. ART was initiated regardless of CD4 count in the intervention arm and according to national guidelines in the control arm. ART adherence was measured monthly using a visual analogue scale (VAS) and pill counts (PC). HIV viral load was measured at ART initiation, three and six months, and six‐monthly thereafter. We pooled data from participants in both arms and used random‐effects logistic regression models to examine the association between CD4 count at ART initiation and sub‐optimal adherence, and assessed if adherence levels were associated with virological suppression.ResultsAmong 900 individuals who initiated ART ≥12 months before study end, median (IQR) CD4 at ART initiation was 350 cells/mm3 (234, 503); median age was 34.6 years (IQR 27.4 to 46.4) and 71.7% were female. Adherence was sub‐optimal in 14.7% of visits as measured by VAS and 20.7% by PC. In both the crude analyses and after adjusting for potential confounders, adherence was not significantly associated with CD4 count at ART initiation (adjusted OR for linear trend in sub‐optimal adherence with every 100 cells/mm3 increase in CD4 count: 1.00, 95% CI 0.95 to 1.05, for VAS, and 1.03, 95% CI 0.99 to 1.07, for PC). Virological suppression at 12 months was 97%. Optimal adherence by both measures was significantly associated with virological suppression (p < 0.001 for VAS; p = 0.006 for PC).ConclusionsWe found no evidence that higher CD4 counts at ART initiation were associated with sub‐optimal ART adherence in the first 12 months. Our findings should alleviate concerns about adherence in individuals initiating ART at higher CD4 counts, however long‐term outcomes are needed. ClinicalTrials.gov NCT01509508.

Risk factors for peripartum hysterectomy among women with postpartum haemorrhage: analysis of data from the WOMAN trial

BackgroundPeripartum hysterectomy can cause significant morbidity and mortality. Most studies of peripartum hysterectomy are from high income countries. This cohort study examined risk factors for peripartum hysterectomy using data from Africa, Asia, Europe and the Americas.MethodsWe used data from the World Maternal Antifibrinolytic (WOMAN) trial carried out in 193 hospitals in 21 countries. Peripartum hysterectomy was defined as hysterectomy within 6 weeks of delivery as a complication of postpartum haemorrhage. Univariable and multivariable random effects logistic regression models were used to analyse risk factors. A hierarchical conceptual framework guided our multivariable analysis.ResultsFive percent of women had a hysterectomy (1020/20,017). Haemorrhage from placenta praevia/accreta carried a higher risk of hysterectomy (17%) than surgical trauma/tears (5%) and uterine atony (3%). The adjusted odds ratio (AOR) for hysterectomy in women with placenta praevia/accreta was 3.2 (95% CI: 2.7–3.8), compared to uterine atony. The risk of hysterectomy increased with maternal age. Caesarean section was associated with fourfold higher odds of hysterectomy than vaginal delivery (AOR 4.3, 95% CI: 3.6–5.0). Mothers in Asia had a higher hysterectomy incidence (7%) than mothers in Africa (5%) (AOR: 1.2, 95% CI: 0.9–1.7).ConclusionsPlacenta praevia/accreta is associated with a higher risk of peripartum hysterectomy. Other risk factors for hysterectomy are advanced maternal age, caesarean section and giving birth in Asia.

Naloxone laws facilitate the establishment of overdose education and naloxone distribution programs in the United States

BackgroundThe opioid overdose crisis in the United States continues to worsen. Opioid overdose mortality is entirely preventable with timely administration of naloxone. Since 2001, many states have passed laws to create an enabling environment for the implementation of overdose education and naloxone distribution (OEND) programs. We assessed whether state-level naloxone laws and their provisions stimulated the implementation of OEND programs in the United States. MethodsCovering the period from 2000 to 2014, we utilized five data sources including the Westlaw legal database, the Prescription Drug Abuse Policy System, the Harm Reduction Coalition’s OEND database, National Center of Health Statistics and the United States Census. Random effects logistic regression models with robust variances were used to examine the association of naloxone access laws and their provisions with OEND program implementation as of 2014. ResultsAt the end of 2014, 8% of counties had OEND programs implemented within them. Counties within states that had a naloxone law (aOR = 28.98; p < 0.001) or a law with any one of the six provisions – third party (aOR = 12.86; p = 0.001), standing order (aOR = 11.45; p < 0.001), possession (aOR = 45.97; p < 0.001), prescriber immunity (aOR = 5.19; p = 0.007), dispenser immunity (aOR = 3.50; p = 0.028) or layperson dispensing (aOR = 12.91; p = 0.001) – had increased odds of an OEND program implemented within them, compared to counties within states without a law or specific provision, respectively. ConclusionOur findings suggest that naloxone laws facilitated the implementation of OEND programs. With only 8% of counties having an OEND program within them, future studies should investigate strategies to improve the implementation of OEND programs.

Agricultural land use and infectious disease risks in southeast Asia: a systematic review and meta analyses

BackgroundAgricultural land use and land-use change activities are a major contributor to biodiversity loss, pollution, and carbon emissions. Evidence from multiple studies also implicates agricultural activities as a factor underlying a range of human infectious disease risks. However, these links have not been systematically assessed or quantified, hindering efforts to incorporate human health effects into land-use decision and policy making. In this study, we test and quantify the association between exposure to agricultural land use and human infectious disease risks, focusing on the highly diverse yet tractable example of southeast Asia. MethodsWe systematically reviewed English peer-reviewed publications from PubMed, EMBASE, Medline, Global Health, Google Scholar, and Web of Science databases between April 24, and Sept 10, 2017. Only studies done in southeast Asia testing the association between land use or changes in land use and infectious disease prevalence or incidence in human beings were included. We extracted crude and adjusted odds ratios (ORs) from the original studies, and for studies that did not present ORs, we calculated crude ORs provided sufficient data were available. We did a meta-analysis with mutually exclusive estimates using a random effects logistic regression model, with heterogeneity of effects addressed using prespecified subgroup analysis, the I2 test for heterogeneity and the Cochrane Q test. We assessed publication bias using funnel plots, a linear regression test, and the trim and fill method, and explored the effect of potential unmeasured confounders with an E-value analysis. The primary outcome was risk of infection in people who worked in agriculture or lived in an agricultural setting. FindingsOf 15 476 unique citations generated from our literature search, 37 articles were included in our meta-analysis. Our results showed that people who live or work in or near agricultural land are more likely to be infected with a pathogen than controls (OR 1·54, 95% CI 1·30–1·83, p<0·0001, E=2·16). Significant between-study heterogeneity was found, thereby warranting the use of subgroup analysis (land-use types and disease categories). No evidence of significant publication or measured or unmeasured confounder bias was detected. InterpretationThe results suggest that agricultural land use consistently exacerbates human infectious disease risks in southeast Asia, highlighting a clear need to consider human health effects of agricultural land use and land-use change policies alongside effects and benefits in other sectors. Although responses clearly vary by land-use and disease types, generalisable results from this and further studies could help identify co-management opportunities for health and the environment. FundingHS has received funding from the Grantham Institute and Commonwealth Scientific and Industrial Research Organisation (CSIRO). PH has received funding from the Natural Environment Research Council.

S125. Degree of resolution of neuromonitoring alerts predicts the likelihood of neurological deficits in extradural cervical spine surgery: Review of 30,921 procedures

Introduction Multimodality intraoperative neuromonitoring (IONM) is frequently used during extradural spine surgery. Further understanding about the clinical significance of the reversibility of IONM alerts may provide guidance regarding the need to alter the intraoperative surgical technique. We asked whether the presence of an IONM alert, and the degree to which it resolved intraoperatively, predicted the likelihood of a postoperative neurological deficit. Methods We performed a retrospective review of a multi-institutional database to analyze a series of 30,921 consecutive extradural cervical spine procedures performed between October 2015 and October 2017 at 517 U.S. institutions. Within each case, the presence or absence of an IONM alert was recorded, as well as the degree of resolution at the conclusion of surgery for those cases with one or more alerts (fully resolved, partially resolved, unresolved). Presence or absence of a neurological deficit was recorded in the postoperative period. Relative odds of new-onset post-operative neurological deficit according to IONM alert resolution status were assessed using a random effects logistic regression model controlling for patient age, gender, number of vertebral levels addressed, surgical approach (anterior (A), posterior (P), or combined A/P), anesthesia regimen, trauma status, surgeon, surgical neurophysiologist, and hospital. Results There were 785, 497, and 2332 cases with no, partial, or full resolution of alerts, respectively. After controlling for all of the above named factors, we found that relative to cases with no IONM alerts, cases with alerts had significantly higher risk of neurologic deficit following an expected relative risk gradient. Cases with fully resolved IONM alerts were more than twice as likely to experience a deficit (OR = 2.5, 95%CI: 1.3–4.9, p Conclusion Degree of resolution of IONM alerts helps to predict the likelihood of a neurological deficit in the postoperative setting in patients undergoing extradural spine surgery. While risk of a neurological deficit is highest when alerts do not resolve, there is also a slightly increased risk of a neurological deficit with full resolution. Awareness of these relationships helps the surgical team make decisions intraoperatively, and allows the surgeon to counsel the patient.

Availability of Outpatient Addiction Treatment and Use of Emergency Department Services Among Medicaid Enrollees

The study examined whether the number of outpatient addiction programs accepting Medicaid in South Carolina counties is linked to repeat use of the emergency department for addiction-related conditions. The study included the population all adult Medicaid enrollees (N=2,401) in South Carolina with at least one addiction-related emergency service visit in 2012 or 2013. A random-effects logistic regression model was used to examine the association between outpatient addiction treatment availability and repeat use by Medicaid enrollees of emergency services for addiction-related conditions. Enrollees in counties with two or more programs that accept Medicaid were less likely to have a repeat addiction-related emergency service visit than enrollees in counties with only one program that accepts Medicaid. Availability of outpatient addiction treatment may reduce the need for addiction-related emergency services. Research is needed to explore potential causal mechanisms underlying this observed relationship.

The Effects of Respondent and Question Characteristics on Respondent Answering Behaviors in Telephone Interviews

AbstractIn a standardized telephone interview, respondents ideally are able to provide an answer that easily fits the response task. Deviations from this ideal question answering behavior are behavioral manifestations of breakdowns in the cognitive response process and partially reveal mechanisms underlying measurement error, but little is known about what question characteristics or types of respondents are associated with what types of deviations. Evaluations of question problems tend to look at one question characteristic at a time; yet questions are comprised of multiple characteristics, some of which are easier to experimentally manipulate (e.g., presence of a definition) than others (e.g., attitude versus behavior). All of these characteristics can affect how respondents answer questions. Using a landline telephone interview, we use cross-classified random effects logistic regression models to simultaneously evaluate the effects of multiple question and respondent characteristics on six different respondent behaviors. We find that most of the variability in these respondent answering behaviors is associated with the questions rather than the respondents themselves. Question characteristics that affect the comprehension and mapping stages of the cognitive response process are consistently associated with answering behaviors, whereas attitude questions do not consistently differ from behavioral questions. We also find that sensitive questions are more likely to yield adequate answers and fewer problems in reporting or clarification requests than nonsensitive questions. Additionally, older respondents are less likely to answer adequately. Our findings suggest that survey designers should focus on questionnaire features related to comprehension and mapping to minimize interactional and data quality problems in surveys and should train interviewers on how to resolve these reporting problems.

Associations between dairy cow inter-service interval and probability of conception

Recent research has indicated that the interval between inseminations in modern dairy cattle is often longer than the commonly accepted cycle length of 18–24 days. This study analysed 257,396 inseminations in 75,745 cows from 312 herds in England and Wales. The interval between subsequent inseminations in the same cow in the same lactation (inter-service interval, ISI) were calculated and inseminations categorised as successful or unsuccessful depending on whether there was a corresponding calving event. Conception risk was calculated for each individual ISI between 16 and 28 days. A random effects logistic regression model was fitted to the data with pregnancy as the outcome variable and ISI (in days) included in the model as a categorical variable. The modal ISI was 22 days and the peak conception risk was 44% for ISIs of 21 days rising from 27% at 16 days. The logistic regression model revealed significant associations of conception risk with ISI as well as 305 day milk yield, insemination number, parity and days in milk. Predicted conception risk was lower for ISIs of 16, 17 and 18 days and higher for ISIs of 20, 21 and 22 days compared to 25 day ISIs. A mixture model was specified to identify clusters in insemination frequency and conception risk for ISIs between 3 and 50 days. A “high conception risk, high insemination frequency” cluster was identified between 19 and 26 days which indicated that this time period was the true latent distribution for ISI with optimal reproductive outcome. These findings suggest that the period of increased numbers of inseminations around 22 days identified in existing work coincides with the period of increased probability of conception and therefore likely represents true return estrus events.

Traffic safety in an aging society: Analysis of older pedestrian crashes

ABSTRACTOlder pedestrians are a growing and vulnerable road user group. This article analyzes various driver, vehicle type, vehicle movement, location, and environment factors associated with older adult pedestrians (age 65+) in comparison with younger adult pedestrians (ages 18–59) using the 2012–2013 U.S. General Estimate Systems (GES) database. A random-effects logistic regression model, which captures regional heterogeneity, was used to classify pedestrian traffic crashes as either involving an older or a younger pedestrian to analyze the factors linked to older vs. younger adult pedestrians. The results show that the older the vehicle driver, the more likely the crash was to be classified as an older pedestrian crash. Improved street crossing environment and intersections, due to older adults' higher involvement in crashes with turning vehicles, are critical to promote older pedestrian safety. Pedestrian safety on nonroadways needs more attention because older pedestrian crashes are more likely in parking lots and driveways compared to younger pedestrians. The results show an especially negative impact of sport utility vehicles and minivans on older adult pedestrian safety. This is a concern because heavier and higher vehicles are more likely to cause greater injuries than smaller cars.

Is the weekend effect really ubiquitous? A retrospective clinical cohort analysis of 30-day mortality by day of week and time of day using linked population data from New South Wales, Australia

ObjectiveTo examine the associations between day of week and time of admission and 30-day mortality for six clinical conditions: ischaemic and haemorrhagic stroke, acute myocardial infarction, pneumonia, chronic obstructive pulmonary...

The Presence of Diabetes and Higher HbA1c Are Independently Associated With Adverse Outcomes After Surgery.

Limited studies have examined the association between diabetes and HbA1c with postoperative outcomes. We investigated the association of diabetes, defined categorically, and the association of HbA1c as a continuous measure, with postoperative outcomes. In this prospective, observational study, we measured the HbA1c of surgical inpatients age ≥54 years at a tertiary hospital between May 2013 and January 2016. Patients were diagnosed with diabetes if they had preexisting diabetes or an HbA1c ≥6.5% (48 mmol/mol) or with prediabetes if they had an HbA1c between 5.7 and 6.4% (39 and 48 mmol/mol). Patients with an HbA1c <5.7% (39 mmol/mol) were categorized as having normoglycemia. Baseline demographic and clinical data were obtained from hospital records, and patients were followed for 6 months. Random-effects logistic and negative binomial regression models were used for analysis, treating surgical units as random effects. We undertook classification and regression tree (CART) analysis to design a 6-month mortality risk model. Of 7,565 inpatients, 30% had diabetes, and 37% had prediabetes. After adjusting for age, Charlson comorbidity index (excluding diabetes and age), estimated glomerular filtration rate, and length of surgery, diabetes was associated with increased 6-month mortality (adjusted odds ratio [aOR] 1.29 [95% CI 1.05-1.58]; P = 0.014), major complications (1.32 [1.14-1.52]; P < 0.001), intensive care unit (ICU) admission (1.50 [1.28-1.75]; P < 0.001), mechanical ventilation (1.67 [1.32-2.10]; P < 0.001), and hospital length of stay (LOS) (adjusted incidence rate ratio [aIRR] 1.08 [95% CI 1.04-1.12]; P < 0.001). Each percentage increase in HbA1c was associated with increased major complications (aOR 1.07 [1.01-1.14]; P = 0.030), ICU admission (aOR 1.14 [1.07-1.21]; P < 0.001), and hospital LOS (aIRR 1.05 [1.03-1.06]; P < 0.001). CART analysis confirmed a higher risk of 6-month mortality with diabetes in conjunction with other risk factors. Almost one-third of surgical inpatients age ≥54 years had diabetes. Diabetes and higher HbA1c were independently associated with a higher risk of adverse outcomes after surgery.

Social Engagement and Its Change are Associated with Dementia Risk among Chinese Older Adults: A Longitudinal Study

This study aimed to examine the association of social engagement (SE) and changes in SE with the risk of dementia among older adults in China. Data were collected from the 2002, 2005, 2008/2009, and 2011/2012 waves of the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Random-effects logistic regression models were used to examine the association of SE and changes in SE with the risk of dementia. Of the 7511 older Chinese adults aged 65 years and over, 338 developed dementia during the 9-year follow-up. SE was associated with dementia risk after adjusting for sociodemographic characteristics, lifestyles and health status (odds ratio (OR) = 0.71, 95% confidence interval (CI) = 0.63–0.81). Participants with consistently high or increased SE had a lower risk of dementia than those with consistently low SE ((OR = 0.14, 95% CI = 0.06–0.28 and OR = 0.33, 95% CI = 0.23–0.48, respectively). Higher SE can reduce the risk of dementia. Furthermore, consistently high or increasing SE is associated with a lower risk of dementia.

Higher third-generation cephalosporin prescription proportion is associated with lower probability of reducing carbapenem use: a nationwide retrospective study

BackgroundThe ongoing extended spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) pandemic has led to an increasing carbapenem use, requiring release of guidelines for carbapenem usage in France in late 2010. We sought to determine factors associated with changes in carbapenem use in intensive care units (ICUs), medical and surgical wards between 2009 and 2013.MethodsThis ward-level multicentre retrospective study was based on data from French antibiotic and multidrug-resistant bacteria surveillance networks in healthcare facilities. Antibiotic use was expressed in defined daily doses per 1000 patient-days. Factors associated with the reduction in carbapenem use (yes/no) over the study period were determined from random-effects logistic regression model (493 wards nested within 259 healthcare facilities): ward characteristics (type, size…), ward antibiotic use (initial antibiotic use [i.e., consumption of a given antibiotic in 2009], initial antibiotic prescribing profile [i.e., proportion of a given antibiotic in the overall antibiotic consumption in 2009] and reduction in the use of a given antibiotic between 2009 and 2013) and regional ESBL-PE incidence rate in acute care settings in 2011.ResultsOver the study period, carbapenem consumption in ICUs (n = 85), medical (n = 227) and surgical wards (n = 181) was equal to 73.4, 6.2 and 5.4 defined daily doses per 1000 patient-days, respectively. Release of guidelines was followed by a significant decrease in carbapenem use within ICUs and medical wards, and a slowdown in use within surgical wards. The following factors were independently associated with a higher probability of reducing carbapenem use: location in Eastern France, higher initial carbapenem prescribing profile and reductions in consumption of fluoroquinolones, glycopeptides and piperacillin/tazobactam. In parallel, factors independently associated with a lower probability of reducing carbapenem use were ICUs, ward size increase, wards of cancer centres, higher initial third-generation cephalosporin (3GC) prescribing profile and location in high-risk regions for ESBL-PE.ConclusionsOur study suggests that a decrease in 3GCs in the overall antibiotic use and the continuation of reduction in fluoroquinolone use, could allow reducing carbapenem use, given the well-demonstrated role of 3GCs and fluoroquinolones in the occurrence of ESBL-PE. Thus, antibiotic stewardship programs should target wards with higher 3GC prescription proportions to reduce them.

Service Quality beyond Access: A Multilevel Analysis of Neonatal, Infant, and Under-Five Child Mortality Using the Indian Demographic and Health Survey 2015~2016

Purpose: The purpose of this study was to derive contextual indicators of medical provider quality and assess their relative importance along with the individual utilization of antenatal care (ANC) and institutional births with a skilled birth attendant (SBA) in India using a multilevel framework. Methods: The 2015~2016 Demographic and Health Survey (DHS) from India was used to assess the outcomes of neonatal, infant, and under-five child mortality. The final analytic sample included 182,980 children across 28,283 communities, 640 districts, and 36 states and union territories. The contextual indicators of medical provider quality for districts and states were derived from the individual-level number of ANC visits (<4 or≥4) and institutional delivery with SBA. A series of random effects logistic regression models were estimated with a stepwise addition of predictor variables. Results: About half of the mothers (47.3%) had attended≥4 ANC visits and 75.8% delivered in institutional settings with SBAs. Based on ANC visits, 276~281 districts (43.1~43.9%) and 13~16 states (36.5~44.4%) were classified as “low” quality areas, whereas 268~285 districts (41.9~44.5%) and 8~9 states (22.2~25.0%) were classified as “low” quality areas based on institutional delivery with SBAs. Conditional on a comprehensive set of covariates, the individual use of both ANC and SBA were significantly associated with all mortality outcomes (OR: 1.17, 95% CI: 1.08, 1.26, and OR: 1.10, 95% CI: 1.02, 1.19, respectively, for under-five child mortality) and remained robust even after adjusting for contextual indicators of medical provider quality. Districts and states with low quality were associated with 57~61% and 27~43% higher odds of under-five child mortality, respectively. Conclusion: When simultaneously considered, district- and state-level provider quality mattered more than individual access to care for all mortality outcomes in India. Further investigations are needed to assess the importance of improving the quality of health service delivery at higher levels to prevent unnecessary child deaths in developing countries.

Bovine herpesvirus-1 in three major milk sheds of Ethiopia: Serostatus and association with reproductive disorders in dairy cattle

Bovine herpesvirus-1 (BHV-1) causes infectious bovine rhinotracheitis (IBR), and infectious pustular vulvovaginitis (IPV) in cows and infectious pustular balanopostitis (IPB) in bulls worldwide. Infection of seronegative cattle with BHV-1 leads to abortion, retention of fetal membranes, increased service per conception, metritis and oophoritis. As part of an ongoing study on infectious causes of reproductive disorders in Ethiopia, this investigation aims at assessing the role of BHV-1 in the disorders and the risk factors affecting its seroprevalence. A cross-sectional study was conducted on a total of 1379 randomly selected dairy cattle from 149 herds. These dairy cattle were sampled from milks sheds of central (n = 555), western (n = 195) and southern (n = 629) Ethiopia. Blocking enzyme-linked immunosorbent assay (B-ELISA) was applied to detect antibodies specific to BHV-1. Additionally, a semi-structured questionnaire was administered and farm records were assessed to capture potential risk factors associated with BHV-1 seropositivity. Univariable and multivariable random-effects logistic regression analyses were used to assess potential risk factors associated with BHV-1 serostatus. Model fitness and reliability were assessed using the Hosmer and Lemeshow method and the receiver operating curve (ROC) respectively. An overall herd level BHV-1 seroprevalence of 81.8% (95% confidence interval (CI): 74.7–87.7%) and individual animal level seroprevalence of 41.0% (95% CI: 38.4–43.7%) were found. In a random-effects multivariable logistic regression model, the seroprevalence of BHV-1 exposure was higher in dairy cattle from breeding (Odds ratio [OR] = 1.3; p = 0.036) than in commercial (OR = 0.9; p = 0.137) and small-holder farms. Geographically, the prevalence was higher in western (OR = 1.4; p < 0.001) and southern Ethiopia (OR = 1.2; p < 0.001) than in central regions. BHV-1 seropositive cows had higher (p < 0.05) odds of clinical reproductive disorders including abortion, retained fetal membranes, stillbirth, birth of weak calf and metritis compared to seronegative cows. Thus, it is suggested that BHV-1 should be considered as differential diagnosis among improved dairy cattle herds with reproductive disorders in Ethiopia.