Robust Variance Estimation Research Articles

Beyond a facility: A cross-sectional survey on WASH service levels and informal social accountability in childcare centres in Nairobi's informal settlements

Abstract Access to clean water, sanitation, and hygiene (WASH) services is crucial for a healthy start in life. Social accountability has a potential for enhancing WASH services in childcare centres. However, there are inadequate studies to understand how informal social accountability mechanisms contributes to WASH service provision. To address this gap, we conducted a cross-sectional survey in Korogocho and Viwandani informal settlements in Nairobi, Kenya, to explore the relationship between different levels of WASH services (ranging from basic to limited or nonexistent) and indicators of informal social accountability, including rewards, sanctions, voice, and responsiveness. We employed multinomial regression analysis, utilizing a robust error variance estimator to account for potential biases. Our findings revealed disparities in WASH service provision between the two studied areas, with childcare centres in Korogocho exhibiting higher access to basic WASH services compared to those in Viwandani. Our analysis also highlighted a significant association between informal social accountability mechanisms and the provision of WASH services. Notably, the sanction mechanism exhibited a correlation with all WASH services, suggesting its pivotal role in shaping service delivery outcomes. In light of these findings, it is imperative to prioritize efforts aimed at reinforcing social accountability mechanisms in WASH service delivery frameworks.

Ultrasonographic Fetal Nuchal Translucency Measurements and Cytogenetic Outcomes

Ultrasonographic measurement of fetal nuchal translucency is used in prenatal screening for trisomies 21 and 18 and other conditions. A cutoff of 3.5 mm or greater is commonly used to offer follow-up investigations, such as prenatal cell-free DNA (cfDNA) screening or cytogenetic testing. Recent studies showed a possible association with chromosomal anomalies for levels less than 3.5 mm, but extant evidence has limitations. To evaluate the association between different nuchal translucency measurements and cytogenetic outcomes on a population level. This population-based retrospective cohort study used data from the Better Outcomes Registry & Network, the perinatal registry for Ontario, Canada. All singleton pregnancies with an estimated date of delivery from September 1, 2016, to March 31, 2021, were included. Data were analyzed from March 17 to August 14, 2023. Nuchal translucency measurements were identified through multiple-marker screening results. Chromosomal anomalies were identified through all Ontario laboratory-generated prenatal and postnatal cytogenetic tests. Cytogenetic testing results, supplemented with information from cfDNA screening and clinical examination at birth, were used to identify pregnancies without chromosomal anomalies. Multivariable modified Poisson regression with robust variance estimation and adjustment for gestational age was used to compare cytogenetic outcomes for pregnancies with varying nuchal translucency measurement categories and a reference group with nuchal translucency less than 2.0 mm. Of 414 268 pregnancies included in the study (mean [SD] maternal age at estimated delivery date, 31.5 [4.7] years), 359 807 (86.9%) had a nuchal translucency less than 2.0 mm; the prevalence of chromosomal anomalies in this group was 0.5%. An increased risk of chromosomal anomalies was associated with increasing nuchal translucency measurements, with an adjusted risk ratio (ARR) of 20.33 (95% CI, 17.58-23.52) and adjusted risk difference (ARD) of 9.94% (95% CI, 8.49%-11.39%) for pregnancies with measurements of 3.0 to less than 3.5 mm. The ARR was 4.97 (95% CI, 3.45-7.17) and the ARD was 1.40% (95% CI, 0.77%-2.04%) when restricted to chromosomal anomalies beyond the commonly screened aneuploidies (excluding trisomies 21, 18, and 13 and sex chromosome aneuploidies). In this cohort study of 414 268 singleton pregnancies, those with nuchal translucency measurements less than 2.0 mm were at the lowest risk of chromosomal anomalies. Risk increased with increasing measurements, including measurements less than 3.5 mm and anomalies not routinely screened by many prenatal genetic screening programs.

Does acute cannabidiol (CBD) use impair performance? A meta-analysis and comparison with placebo and delta-9-tetrahydrocannabinol (THC)

Cannabidiol (CBD) is widely used and believed to be non-intoxicating, lacking acute performance effects (e.g., non-impairing). However, a synthesis of data has not evaluated this. This meta-analysis synthesized data from controlled human laboratory studies that evaluated if acute CBD use impairs performance. Performance on objective and subjective measures of cognitive and psychomotor function were used as markers for potential performance changes and impairment. Studies were identified through systematic database searches. Adult clinical trials measuring acute CBD effects (within 0–8 h of administration) were included. The primary outcome was the peak mean difference in performance measures between CBD and placebo. A secondary analysis utilizing delta-9-tetrahydrocannabinol (Δ9-THC) as a positive control for comparison to CBD was completed. Pooled Hedges’ g estimates were calculated using robust variance estimation (RVE) meta-regression. The omnibus RVE meta-analysis indicated a statistically significant, but small effect size (Hedge’s g < 0.2) for impaired performance following acute CBD consumption compared to placebo (N = 16 trials, Hedges’ g = 0.122, 95% CI: 0.023–0.221, p = 0.019). Measure type was a significant moderator with larger mean differences between CBD and placebo when subjective measures, specifically self-reported sedation, were used versus objective performance tasks (Hedges’ gSubjective = 0.288 versus Hedges’ gObjective = 0.048). Δ9-THC had a significantly greater magnitude of impairment compared to CBD (N = 8, Hedges’ g = 0.416, 95% CI: 0.017–0.816, p = 0.043). In summary, acute CBD consumption was associated with a small increase in subjective ratings of sedation, but no difference from placebo was observed across multiple domains of objectively assessed cognitive or psychomotor performance. These findings suggest that acute CBD alone is unlikely to significantly impair daily functioning or workplace performance.

Can the Inclusion of Forage Chicory in the Diet of Lactating Dairy Cattle Alter Milk Production and Milk Fatty Acid Composition? Findings of a Multilevel Meta-Analysis.

In traditional ryegrass/white clover (Lolium perenne L./Trifolium repens L.) pastoral systems, forage herbs such as chicory (Cichorium intybus L.) present an opportunity to fill feed deficits during late spring and summer. Although multiple research publications have evaluated the efficacy of chicory for enhancing milk production and milk fatty acid (FA) profile, no publication has quantitatively synthesised the body of research. This systematic review and meta-analysis examined the effect of chicory on milk production and composition, as well as on the milk fatty acid composition of dairy cattle. A total of 29 comparisons from 15 unique research publications involving 597 dairy cattle were used to develop a dataset for analysis. Three-level random-effect and robust variance estimator models were used to account for the hierarchical structure of the data and the dependency of effect sizes within publications. Chicory inclusion increased milk yield when compared to grass-based diets {weighted mean difference (WMD) = 1.07 (95% CI 0.54-1.60) kg/cow/d, p < 0.001}, but it provided a similar milk yield when compared to other forages such as legumes and herbs {dicots; WMD = -0.30, (95% CI -89-0.29) kg/cow/day, p = 0.312}. Increases in milk yield were congruent with differences in DM intake (p = 0.09) and ME intakes (p = 0.003), being similar in chicory-fed and dicot-fed cows but higher than grass-fed cows. Chicory feeding's effect on milk solids was twice as high during mid lactation {154 days in milk; WMD = 0.13, (95% 0.081-0.175) kg/cow/day, p < 0.001} as during late lactation {219 days in milk; WMD = 0.06, (95% 0.003-0.13) kg/cow/day, p = 0.041}. In line with milk yield, greater and more significant effect sizes were found for alpha linolenic acid {ALA; WMD = 0.20 (95% CI 0.06-0.35) g/100 g FA, p = 0.011} when chicory was compared to grass species only. Comparing chicory with dicots suggests that chicory inclusion did not impact ALA concentrations {WMD = 0.001 (95% CI -0.02-0.2) g/100 g FA, p = 0.99}. There were no differences in conjugated linoleic acid concentration in the milk of cows fed chicory or control diets. The study provides empirical evidence of chicory's efficacy for improved milk production and milk fatty acid composition.

Association between Body Appreciation and Depression, Anxiety, and Stress among Filipino Emerging Adults: Modification by Age and Sex at Birth

Emerging adulthood is a new stage of development that follows identity explorations during adolescence and precedes adulthood. During this phase, varied perceptions of body image may affect the mental health status of these individuals. This research examined the association between body appreciation (BA) as a measure of body image and mental health outcomes – particularly, depression, anxiety, and stress. A cross-sectional survey was used to ascertain data from 3,127 18–29-yr-old Filipinos (67% female; mean age = 21) residing in the Philippines using an online self-administered questionnaire. BA Scale-2 (BAS-2) measured BA, whereas DASS-21 assessed levels of depression, anxiety, and stress. Associations between BA, and mental health outcomes were estimated using Poisson regression models with a log-link function and a robust variance estimator. A higher BAS- 2 score (2nd–4th Quartiles) is associated with a reduced risk of severe/extreme levels of depression, anxiety, and stress than a low BAS-2 score (1st Quartile). Moreover, the association between BA and stress may be stronger among female participants (p-value interaction = 0.01) and late emerging adults (p-value interaction = 0.47). However, effect modification by age and sex was insignificant for the association between BA and anxiety and depression (p-values for interaction &gt; 0.15).

Study Partner Type and Adverse Event Reporting in Mild-to-Moderate Alzheimer's Disease Clinical Trials.

In randomized clinical trials (RCTs), monitoring adverse events (AEs) and serious AEs (SAEs) is critical. All Alzheimer's disease (AD) RCTs require participants to enroll with a study partner. We examined AE reporting rates in mild-to-moderate AD trials and their associations with study partner type. We estimated AE reporting rates using placebo data from seven independent RCTs conducted by the Alzheimer's Disease Cooperative Study. We assessed the heterogeneity of reporting rates as a function of visits using generalized estimating equations. In the primary analysis, we tested the hypotheses that the rates of reporting differed by study partner type and time they spent with the participant weekly using Poisson regression with robust variance estimation. In all regression models, log-transformed total patient years was included. The estimated reporting rates were 2.83 (95% CI: 2.66, 3.02), 1.18 (95% CI: 1.09, 1.28), 0.23 (95% CI: 0.19, 0.27), and 0.28 (95% CI: 0.24, 0.33) events per participant year for grade 1-3 AEs and SAEs, respectively. We estimated that greater number of visits per year was associated with increased reporting for grade 1-2 AEs and SAEs. We did not find evidence to suggest that AE reporting differed by study partner type or by time the study partner spent with the participant. Study partner type and time the study partner spent with the participant did not appear to impact AE reporting. Estimated reporting rates may be useful to evaluate safety in future studies, particularly those with no control arm and similar visit frequencies.

Abstract P323: Awareness of Recent Blood Pressure Levels and Blood Pressure Goals Among US Adults With Diabetes - National Health and Nutrition Examination Survey 2013-2020

Background: Reducing blood pressure (BP) is important for decreasing cardiovascular disease risk among adults with diabetes. Individuals with diabetes are recommended to know their BP level and BP goal. Methods: We used data from the 2013-2020 National Health and Nutrition Examination Surveys (NHANES) for US adults with diabetes (N=2,344). Diabetes was defined as having a prior diagnosis with use of insulin or glucose-lowering medication. Participants with diabetes were asked their most recent BP and their goal BP according to their doctor. Hypertension was defined as systolic/diastolic BP ≥140/90 mm Hg or self-reported antihypertensive medication use. Poisson regression with robust variance estimation was used to estimate associations of participant characteristics with knowing their recent BP level and BP goal for those without hypertension and with hypertension, separately. All analyses accounted for the NHANES complex survey design and were weighted to represent US adults with diabetes. Results: Among US adults with diabetes, 69.8% reported that they knew their recent BP level and 41.5% reported they knew their BP goal. Among those without hypertension and with hypertension, 58.7% and 75.5% reported knowing their recent BP level and 27.5% and 48.5%, respectively, reported knowing their BP goal, respectively. Among adults without hypertension and those with hypertension, non-Hispanic Black or Hispanic versus non-Hispanic White adults, with less than high school education, and without insurance were less likely to know their recent BP ( Table ). Hispanic versus non-Hispanic White adults without hypertension and adults with less than a high school education with hypertension were less likely to know their BP goal. Conclusion: Low percentages of US adults with diabetes knew their BP level and knew their BP goal.

Abstract P476: Changes in Olive Oil Consumption and Weight Changes in US Men and Women

Background: Olive oil intake is inversely associated with the risk of chronic diseases and mortality. However, it is unclear whether there is an association between olive oil intake and weight changes; because it is an energy-dense food concerns have been raised that high intake may contribute to weight gain. Therefore, we aimed to determine the associations between long-term changes in olive oil consumption and changes in weight. Methods: We examined data from 116,243 women and men from the Nurses’ Health Study (NHS, 1990-2010), NHSII (1991-2015), and Health Professional Follow-up Study (HPFS, 1990-2014), who were free from chronic diseases at baseline. We applied multivariable linear regression models with robust variance estimators to assess the association of changes in olive oil intake within each 4-year interval with concurrent weight changes. Results across the three cohorts were pooled using inverse-variance weights. Results: At baseline, mean ± SD age was 54.8 ± 6.6 years in the NHS, 45.3 ± 8.0 years in the NHS2, and 53.9 ± 7.2 years in the HPFS. Mean body mass index was 25 kg/m2 at baseline across the three cohorts. The mean weight gain over each 4-year follow-up cycle was highest in the NHS2 (1.8; 95%CI -6.8 to 11.3 kg), followed by the NHS (1.0; 95%CI -6.8 to 9.1 kg), and lastly the HPFS (0.6; 95%CI -5.4 to 6.8 kg). Pooling across the cohorts after adjustment for sociodemographic, lifestyle, and set of dietary factors (fruits, vegetables, red and processed meat, sugar sweetened beverages, coffee, refined grains), each ½ Tablespoon (7 grams) serving per day increment in olive oil was associated with a slightly lower 4-year weight gain of -0.06 kg (95%CI -0.08 to -0.04 kg; p&lt;0.0001). This inverse association was observed in the three cohorts, with a greater magnitude of association in the NHS2 (-0.08; 95%CI -0.10 to -0.05 kg; p&lt;0.0001), followed by the HPFS (-0.07; 95%CI -0.12 to -0.02 kg; p=0.003) and lastly the NHS (-0.05; 95%CI -0.07 to -0.01 kg; p=0.02). Results were attenuated after adjustment for the Alternative Healthy Eating index (pooled -0.03; 95%CI -0.05 to -0.02; p=0.0003). Conclusions: Long-term habitual increase in olive oil consumption was not associated with increased weight gain in middle-aged and older adults.

A systematic review and meta-analysis of test-retest reliability and stability of delay and probability discounting.

In this meta-analysis, we describe a benchmark value of delay and probability discounting reliability and stability that might be used to (a) evaluate the meaningfulness of clinically achieved changes in discounting and (b) support the role of discounting as a valid and enduring measure of intertemporal choice. We examined test-retest reliability, stability effect sizes (dz; Cohen, 1992), and relevant moderators across 30 publications comprising 39 independent samples and 262 measures of discounting, identified via a systematic review of PsychInfo, PubMed, and Google Scholar databases. We calculated omnibus effect-size estimates and evaluated the role of proposed moderators using a robust variance estimation meta-regression method. The meta-regression output reflected modest test-retest reliability, r = .670, p < .001, 95% CI [.618, .716]. Discounting was most reliable when measured in the context of temporal constraints, in adult respondents, when using money as a medium, and when reassessed within 1 month. Testing also suggested acceptable stability via nonsignificant and small changes in effect magnitude over time, dz = 0.048, p = .31, 95% CI [-0.051, 0.146]. Clinicians and researchers seeking to measure discounting can consider the contexts when reliability is maximized for specific cases.

Caught in the web: a meta-analysis of Internet addiction, excessive daytime sleepiness and depressive symptoms in adolescents

PurposeIn response to growing concerns over the negative consequences of Internet addiction on adolescents’ mental health, coupled with conflicting results in this literature stream, this meta-analysis sought to (1) examine the association between Internet addiction and depressive symptoms in adolescents, (2) examine the moderating role of Internet freedom across countries, and (3) examine the mediating role of excessive daytime sleepiness.Design/methodology/approachIn total, 52 studies were analyzed using robust variance estimation and meta-analytic structural equation modeling.FindingsThere was a significant and moderate association between Internet addiction and depressive symptoms. Furthermore, Internet freedom did not explain heterogeneity in this literature stream before and after controlling for study quality and the percentage of female participants. In support of the displacement hypothesis, this study found that Internet addiction contributes to depressive symptoms through excessive daytime sleepiness (proportion mediated = 17.48%). As the evidence suggests, excessive daytime sleepiness displaces a host of activities beneficial for maintaining mental health. The results were subjected to a battery of robustness checks and the conclusions remain unchanged.Practical implicationsThe results underscore the negative consequences of Internet addiction in adolescents. Addressing this issue would involve interventions that promote sleep hygiene and greater offline engagement with peers to alleviate depressive symptoms.Originality/valueThis study utilizes robust meta-analytic techniques to provide the most comprehensive examination of the association between Internet addiction and depressive symptoms in adolescents. The implications intersect with the shared interests of social scientists, health practitioners, and policy makers.

Dynamic Assessments of Word Reading Skills in Diverse School-Age Children: A Meta-Analysis

Purpose: Dynamic assessments evaluate ability to learn and may be less biased against children who historically have underperformed on static measures that evaluate acquired knowledge. This meta-analysis examined the validity of dynamic assessments of word reading skills (phonological awareness, sound–symbol knowledge, and decoding), as measured by the strength of their correlation with performance on word reading measures. The consistency of their validity across participant reading status (typically developing vs. at risk), language status (monolingual vs. bilingual), and age group (4–5 vs. 6–7 vs. 8–9 years) was also examined to determine whether this assessment approach is an equitable means of evaluating early word reading skills. Method: Electronic databases and preprint repositories were searched to identify studies that evaluated dynamic assessments of word reading skills conducted with children between the ages of 4 and 10 years. Pearson's correlation coefficients representing the relationship between dynamic assessments and word reading measures were extracted, and an overall pooled mean effect size was calculated using a random-effects meta-analysis with robust variance estimation. Subgroup analyses for participant reading status, language status, and age group were also conducted to determine whether there were significant differences in effect sizes across groups. Results: Thirty-five studies with 192 effect sizes were identified. Overall, dynamic assessments of word reading skills demonstrated strong correlations with word reading measures ( g = 0.49). Subgroup analysis by age indicated that dynamic assessments are significantly better suited to evaluate word reading in younger children (ages 4–5 and 6–7 years) than older students (ages 8–9 years; p = .0001). Validity was consistent across typically developing and at-risk participants and across bilinguals and monolinguals. There were few studies conducted with bilinguals despite dynamic assessment's purported application for this population. Conclusion: This meta-analysis provides preliminary evidence to support dynamic assessments as a valid and equitable means of evaluating word reading skills with diverse children aged 4–7 years. Supplemental Material: https://doi.org/10.23641/asha.25293046

Equivalencies Between Ad Hoc Strategies and Multivariate Models for Meta-Analysis of Dependent Effect Sizes

Meta-analyses of educational research findings frequently involve statistically dependent effect size estimates. Meta-analysts have often addressed dependence issues using ad hoc approaches that involve modifying the data to conform to the assumptions of models for independent effect size estimates, such as by aggregating estimates to obtain one summary estimate per study, conducting separate analyses of distinct subgroups of estimates, or combinations thereof. We show that these ad hoc approaches correspond exactly to certain multivariate models for dependent effect sizes. Specifically, we describe classes of multivariate random effects models that have likelihoods equivalent to those of models for effect sizes that have been averaged by study, classified into subgroups, or both. The equivalencies also apply to robust variance estimation methods.

Comparative effectiveness of sacubitril/valsartan versus angiotensin receptor blockers in patients with heart failure with preserved ejection fraction: A real-world study.

Sacubitril/valsartan (SAC/VAL) or angiotensin receptor blockers (ARBs) are recommended therapy for heart failure with preserved ejection fraction (HFpEF), but little is known about their real-world comparative effectiveness among patients with HFpEF. The objective of this study was to determine the comparative effectiveness of SAC/VAL vs ARBs in preventing HF-related hospitalization or all-cause hospitalization among patients with HFpEF. We conducted a cohort study using IBM MarketScan commercial and Medicare supplemental databases to identify patients aged 18 years or older with a diagnosis of HFpEF and initiation of SAC/VAL (2015-2020) or ARB (2009-2014) therapy. The index date was the date of the first SAC/VAL or ARB prescription fill. After propensity score (PS) matching with a ratio of 1 up to 3, Cox proportional hazards regression was used with robust variance estimators to compare the risks of HF-related hospitalization and all-cause hospitalization between the 2 therapies. Several subgroup and sensitivity analyses were conducted to check the robustness of the main analysis. After PS matching, 2,520 patients (846 receiving SAC/VAL and 1,674 receiving an ARB) were included in the final analyses. After controlling for covariates, there was no difference in the risk of HF-related hospitalization between SAC/VAL and ARB recipients (adjusted hazard ratio [aHR], 1.33; 95% confidence interval [CI], 0.99-1.77). There was also no difference in the risk of all-cause hospitalization between SAC/VAL and ARB recipients (aHR, 1.06; 95% CI, 0.91-1.24). Among individuals with private or Medicare Advantage insurance plans, there was no significant difference in the risk of HF-related hospitalization or all-cause hospitalization between adults with HFpEF who received SAC/VAL and those who received ARB therapy.

Assessment of suicidality in trials of psychological interventions for depression: a meta-analysis

Psychological interventions that are efficacious as treatments for depression could indirectly affect suicide-related outcomes. We examined suicidal thoughts and behaviours as eligibility criteria, outcomes, and adverse events across trials of psychotherapy for depression. We used a publicly available meta-analytic database developed through systematic searches (updated as of May 1, 2023) to identify randomised controlled trials in which a psychological intervention for depression was compared with an inactive or non-specific control condition in adults with depression and in which any suicide-related outcomes were reported. We also identified studies in which suicide risk was an exclusion criterion. We excluded inpatient studies and trials of unguided digital interventions or collaborative care that included a psychological component. Pairs of reviewers worked independently to select studies and extract data. In a random-effects meta-analysis with robust variance estimation, we assessed the effect of the psychological intervention on suicide outcomes in trials in which suicide was explicitly assessed as an outcome with clinical scales with established psychometric properties. Risk of bias was assessed with the Cochrane risk-of-bias tool (version 2). Of the 469 randomised trials we identified in which a psychological intervention was compared with an inactive control in people with depression, 251 excluded people judged at risk of suicide. Any assessment of suicide was included in only 45 trials, 12 of which assessed suicidal ideation or risk as an outcome. These 12 trials included 3930 participants, 2795 (71%) of whom were female and 1135 (29%) of whom were male; data for age and ethnicity were not consistently reported. Psychological interventions for depression were associated with a small reduction in suicidal ideation and risk in 11 trials (one trial reported only follow-up data) after the intervention (standardised mean difference -0·31 [95% CI -0·60 to -0·03]) but not at follow-up (-0·49 [-1·31 to 0·32]). Suicide-related adverse events were reported in 25 trials, and suicide-related serious adverse events (eg, suicide attempts, deaths by suicide) were reported in 13 trials. Heterogeneity was substantial across all analyses, and prediction intervals crossed zero. Trials of psychological interventions for depression rarely report assessments of suicide. Psychological interventions might reduce suicidal ideation in patients with depression, but more randomised controlled trials are required to clarify this effect. Monitoring and reporting of suicide-related adverse events should be improved in trials of psychological interventions for depression, and future trials should incorporate outcomes related to suicidal thoughts or behaviours. None. For the Spanish translation of the abstract see Supplementary Materials section.

Factors influencing the likelihood of accessing healthcare during the COVID-19 pandemic in Ireland: lessons for the future

Background Implementation of public health measures during the first wave of the coronavirus disease (COVID-19) pandemic, including travel restrictions and physical distancing, may have impacted population behaviour in seeking medical care. Identifying barriers to accessing healthcare is important, especially for vulnerable groups. Methods Data were collected through a nationally representative cross-sectional telephone survey during the first period of easing of COVID-19 restrictions in May and June 2020. Secondary data analysis of the dataset was carried out to examine the factors influencing the likelihood of individuals avoiding General Practitioner (G.P.) and hospital-based care. Poisson regression analyses were conducted to estimate risk ratios with robust variance estimation of the association between selected demographic and self-reported health factors and the risk of avoiding G.P. and hospital-based healthcare. Results Of the 969 participants, 152 (15.7%) deliberately avoided contacting their G.P. about non COVID-19 related concerns while 81 (8.4%) reported avoiding hospitals. Three groups, women (Rate Ratio (RR): 1.75, 95% Confidence Interval (CI): 1.28 – 2.40), individuals who reported experiencing an adverse life event within the last 3 months (RR: 1.79, 95% CI: 1.33 – 2.40), and those at an increased risk of infection (RR: 1.65, 95% CI: 1.06 – 2.58) were more likely to avoid contact with their G.P. Individuals at a higher risk of avoiding hospital-based care were those aged 50 – 59 years (RR: 2.27, 95% CI: 1.03 – 4.98) and 70 years+ (RR: 2.73, 95% CI: 1.24 – 6.01), individuals at an increased risk of infection (RR: 2.07, 95% CI: 1.20 – 3.56), smokers (RR: 1.68, 95% CI: 1.02 – 2.77) and those who agreed they were “likely to catch COVID-19” (RR: 2.80, 95% CI: 1.25 – 6.25). Conclusion These findings highlight the importance of public health awareness and education regarding accessing healthcare during a pandemic and should be considered in future pandemic preparedness.

Effect of Propofol Infusion on Need for Rescue Antiemetics in Postanesthesia Care Unit After Volatile Anesthesia: A Retrospective Cohort Study.

Postoperative nausea and vomiting (PONV) are frequent after volatile anesthesia. We hypothesized that coadministration of propofol with volatile anesthetic compared to pure volatile anesthetics would decrease the need for postoperative antiemetic treatments and shorten recovery time in the postanesthesia care unit (PACU). We retrospectively identified adult patients who underwent procedures using general anesthesia with volatile agents, with or without propofol infusion, from May 2018 through December 2020, and who were admitted to the PACU. Inverse probability of treatment weighting (IPTW) analysis was performed using generalized estimating equations with robust variance estimates to assess whether propofol was associated with decreased need for rescue antiemetics. Among 47,847 patients, overall IPTW rescue antiemetic use was 4.7% for 17,573 patients who received propofol and 8.2% for 30,274 who did not (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.49-0.61; P <.001). This effect associated with propofol was present regardless of the intensity of antiemetic prophylaxis (OR, 0.59, 0.51, and 0.58 for 0-1, 2, and ≥3 antiemetics used, respectively), procedural duration (OR, 0.54, 0.62, and 0.47 for ≤2.50, 2.51-4.00, ≥4.01 hours), and type of volatile agent (OR, 0.51, 0.52, and 0.57 for desflurane, isoflurane, and sevoflurane) (all P <.001). This effect was dose dependent, with little additional benefit for the reduction in the use of PACU antiemetics when propofol rate exceeded 100 μg/kg/min. Patients who received rescue antiemetics required longer PACU recovery time than those who did not receive antiemetics (ratio of the geometric mean, 1.31; 95% CI, 1.28-1.33; P <.001), but use of propofol did not affect PACU recovery time (ratio of the geometric mean, 1.00; 95% CI, 0.98-1.01; P =.56). The addition of propofol infusions to volatile-based anesthesia is associated with a dose-dependent reduction in the need for rescue antiemetics in the PACU regardless of the number of prophylactic antiemetics, duration of procedure, and type of volatile agent used, without affecting PACU recovery time.

Pelvic floor dysfunction after intervention, compared with expectant management, in prolonged second stage of labour: A population-based questionnaire and cohort study.

To investigate the effect of vacuum extraction (VE) or caesarean section (CS), compared with expectant management, on pelvic floor dysfunction (PFD) 1-2 years postpartum in primiparous women with a prolonged second stage of labour. A population-based questionnaire and cohort study. Stockholm, Sweden. A cohort of 1302 primiparous women with a second stage duration of ≥3 h, delivering from December 2017 to November 2018. The 1-year follow-up questionnaire from the Swedish National Perineal Laceration Register was distributed 12-24 months postpartum. Exposure was VE or CS at 3-4 h or 4-5 h, compared with expectant management. Pelvic floor dysfunction was defined as at least weekly symptoms of urinary incontinence, pelvic organ prolapse or a Wexner score of ≥4. The risk of PFD was calculated using Poisson regression with robust variance estimation, presented as crude and adjusted relative risks (RRs and aRRs) with 95% confidence intervals (95% CIs). The implication of obstetric anal sphincter injury (OASI) on pelvic floor disorders was investigated through mediation analysis. In total, 35.1% of women reported PFD. Compared with expectant management, the risk of PFD was increased after VE at 3-4 h (aRR 1.33, 95% CI 1.06-1.65) and 4-5 h (aRR 1.34, 95% CI 1.05-1.70), but remained unchanged after CS. The increased risk after VE was not mediated by OASI. Pelvic floor dysfunction was common in primiparous women after a prolonged second stage, and the risk of PFD increased after VE but was unaffected by CS, compared with expectant management. If a spontaneous vaginal delivery eventually occurred, allowing an extended duration of labour did not increase the risk of PFD.

Sex-steroid hormones and risk of postmenopausal estrogen receptor-positive breast cancer: a case-cohort analysis.

Sex-steroid hormones are associated with postmenopausal breast cancer but potential confounding from other biological pathways is rarely considered. We estimated risk ratios for sex-steroid hormone biomarkers in relation to postmenopausal estrogen receptor (ER)-positive breast cancer, while accounting for biomarkers from insulin/insulin-like growth factor-signaling and inflammatory pathways. This analysis included 1208 women from a case-cohort study of postmenopausal breast cancer within the Melbourne Collaborative Cohort Study. Weighted Poisson regression with a robust variance estimator was used to estimate risk ratios (RRs) and 95% confidence intervals (CIs) of postmenopausal ER-positive breast cancer, per doubling plasma concentration of progesterone, estrogens, androgens, and sex-hormone binding globulin (SHBG). Analyses included sociodemographic and lifestyle confounders, and other biomarkers identified as potential confounders. Increased risks of postmenopausal ER-positive breast cancer were observed per doubling plasma concentration of progesterone (RR: 1.22, 95% CI 1.03 to 1.44), androstenedione (RR 1.20, 95% CI 0.99 to 1.45), dehydroepiandrosterone (RR: 1.15, 95% CI 1.00 to 1.34), total testosterone (RR: 1.11, 95% CI 0.96 to 1.29), free testosterone (RR: 1.12, 95% CI 0.98 to 1.28), estrone (RR 1.21, 95% CI 0.99 to 1.48), total estradiol (RR 1.19, 95% CI 1.02 to 1.39) and free estradiol (RR 1.22, 95% CI 1.05 to 1.41). A possible decreased risk was observed for SHBG (RR 0.83, 95% CI 0.66 to 1.05). Progesterone, estrogens and androgens likely increase postmenopausal ER-positive breast cancer risk, whereas SHBG may decrease risk. These findings strengthen the causal evidence surrounding the sex-hormone-driven nature of postmenopausal breast cancer.

Time variation of high-risk groups for liver function deteriorations within fluctuating long-term liver function after hepatic radiotherapy in patients with hepatocellular carcinoma

PurposeThe purpose of this study is to find essential risk factors associated with liver function (LF) deteriorations within fluctuating long-term LF and their time-varying effects in patients with hepatocellular carcinoma (HCC) receiving hepatic radiotherapy and to identify high-risk groups for adverse LF deteriorations and their changes over time in facilitating the prevention of hepatic decompensation and the improvement of survival.Materials and methodsA total of 133 HCC patients treated by hepatic radiotherapy were enrolled. A study design was conducted to convert posttreatment long-term LF with fluctuating levels over time to recurrent LF events using defined upgrades in a grading scale. The hazard ratios (HR) of pretreatment biochemical, demographic, clinical, and dosimetric factors in developing posttreatment LF events were estimated using the Cox model. Methodologies of the counting process approach, robust variance estimation, goodness-of-fit testing based on the Schoenfeld residuals, and time-dependent covariates in survival analysis were employed to handle the correlation within subjects and evaluate the time-varying effects during long-term follow-up.ResultsBaseline LF score before radiotherapy and gender were significant factors. Initial HR in developing LF events was 1.17 (95% CI 1.11–1.23; P < 0.001) for each increase of baseline LF score and kept almost constant over time (HR, 1.00; 95% CI 1.00–1.01; P = 0.065). However, no difference was observed regarding initial hazards for gender (HR, 1.00; 95% CI 0.64–1.56; P = 0.994), but the hazard for women got higher monthly over time compared with men (HR, 1.04; 95% CI 1.01–1.07; P = 0.006).ConclusionsHigh-risk groups for adverse LF deteriorations after hepatic radiotherapy may change over time. Patients with poor baseline LF are vulnerable from the beginning. Women require prevention strategies and careful monitoring for deteriorations at a later stage.

Abstract WP242: Acute Ischemic Stroke With Atrial Fibrillation: Relation Between ω3/ω6 Poly Unsaturated Fatty Acids

Background &amp; Aims: Some poly unsaturated fatty acids (PUFA) are said to be associated with the development of atrial fibrillation (AF). Our aim is to elucidate the relation between PUFA and AF in acute ischemic stroke. Methods: Consecutive patients with ischemic stroke admitted between October 2012 and February 2022 were retrospectively screened. The inclusion criteria were as follows: 1) onset to door time within 7 days; and 2) availability of PUFA measurements from the day of the hospital visit or the next day. Plasma levels of PUFA, including eicosapentaenoic acid (ω3: EPA) docosahexaenoic acid (ω3: DHA), dihomo-γ-linolenic acid (ω6: DGLA), and arachidonic acids (ω6: AA), were assayed by gas chromatography. We investigated the association between each of PUFA levels and AF among the acute ischemic stroke patients. Results: We screened 2,122 consecutive ischemic stroke patients. Of them, 1,574 were identified (1,119 [71%] males, median age 69 years). In Poisson regression analysis with a robust variance estimator, factors associated with AF were lower DGLA level (prevalence ration (PR) 0.885, 95% CI 0.811 to 0.966, p = 0.006), lower AA level (PR 0.797, 95% CI 0.649 to 0.978, p = 0.029), and higher EPA/AA ratio (PR 1.353, 95% CI 1.036 to 1.766, p = 0.026). In Poisson regression analysis with a robust variance estimator for AF using PUFA quartile as indicator variables, negative linear trends were observed between the quartile of DGLA (Quartile 1: PR 1.884, Quartile 2: PR 1.530, Quartile 3: PR 1.429, Quartile 4: reference) and AA (Quartile 1: PR 1.499, Quartile 2: PR 1.199, Quartile 3: PR 1.137, Quartile 4: reference), and a positive linear trend between the quartile of EPA/AA ratio (Quartile 1: reference, Quartile 2: PR 1.544, Quartile 3: PR 1.629, Quartile 4: PR 1.781, Figure). Conclusions: In acute ischemic stroke, lower ω6 level and higher ω3/ω6 ratio were associated with the presence of AF. ω3/ω6 PUFA may have contrasting effects on the incidence of AF in acute ischemic stroke.