Top Decile Research Articles

A global climatology of sting-jet extratropical cyclones

Abstract. Sting jets have been identified in the most damaging extratropical cyclones impacting northwest Europe. Unlike the cold conveyor belt and other long-lived cyclone wind jets, sting jets can lead to regions of exceptionally strong near-surface winds and damaging gusts over just a few hours and with much smaller wind “footprints”. They descend into the frontal-fracture region found in warm-seclusion cyclones. Previous research has focused almost exclusively on North Atlantic–European cyclones, but there are no known physical reasons why sting jets should not develop elsewhere, and recognition of their existence can inform weather nowcasting and wind warnings. We have produced the first climatology of sting-jet cyclones over the major ocean basins. A sting-jet precursor diagnostic has been applied to more than 10 000 warm-seclusion cyclones in the top intensity decile, tracked using 43 extended winters of ERA5 reanalysis data. Cyclones with sting-jet precursors are found to occur over the North Pacific and Southern oceans for the first time, and they are more prevalent in the Northern Hemisphere (27 % of all top decile cyclones) compared to the Southern Hemisphere (15 %). These cyclones have distinct characteristics to those without the precursor, including initiating closer to the Equator, deepening faster in mean-sea-level pressure (MSLP), and having stronger near-surface winds, even in the reanalysis data that are too coarse to fully resolve sting jets. Composite analysis reveals systematic differences in structural evolution, including in potential vorticity (PV) and jet crossing. These differences evidence the climatological consequences of strong diabatic cloud processes on cyclone characteristics, implying that sting jets are likely to be enhanced by climate change.

Commercial prices and care for Medicare beneficiaries with prostate cancer

ObjectiveTo examine the relationship between market dynamics, in the form of commercial prices paid to urologists, and utilization of services, as measured by Medicare spending, in men with newly diagnosed prostate cancer. MethodsWe performed a retrospective national cohort study of Medicare beneficiaries with newly diagnosed prostate cancer between 2014 and 2019, with follow-up through 2020.The primary exposure was the commercial price index (i.e., the ratio of commercial prices to Medicare prices for a common set of services performed by urologists). The primary outcome was Medicare spending for prostate cancer, in the 12-month period after diagnosis. ResultsAcross zip codes, commercial prices were, on average, 190% of Medicare prices (range 102-421%), with mean spending per beneficiary of $16,704. There was an inverse relationship between the price index and Medicare spending for men for prostate cancer. Specifically, standardized Medicare spending was $1,485 (95%CI $939 to $2,030) higher per beneficiary among those managed in zip codes at the bottom decile for commercial prices compared to the top decile. This effect was similar in the subgroup of men who underwent treatment, where standardized Medicare spending was $1,461 (95%CI $848 to $2,073) higher per beneficiary among those managed in zip codes in the bottom decile for commercial prices compared to the top decile. Conclusions and RelevanceCommercial prices for a set of frequently performed services are substantial higher than those paid by Medicare and vary widely across zip codes. Higher commercial prices were associated with significantly lower utilization, as measured by standardized Medicare spending, in men with newly diagnosed prostate cancer.

Use of diagnostic subtraction angiography for ischemic stroke (US DUTCH study) Regional variation and time-trend among medicare beneficiaries

IntroductionThere are no guideline recommendations for DSA in the ischemic stroke work-up. We studied the rate of DSA in ischemic stroke, the recent time-trend, hospital variation and associated factors. MethodsThis is a retrospective cross-sectional study among Medicare fee-for-service beneficiaries with ischemic stroke admitted between 2016 and 2020 in the United States. ICD-10 codes were used to determine ischemic stroke diagnosis and procedure codes for thrombectomy and DSA. Hospital trends and factors associated with DSA performance were analyzed in hospitals with DSA capacity. Results7.373 (0.7 %) of the 1,085,644 ischemic stroke patients, had a DSA for diagnostic purposes. In the patients that were admitted to a hospital with DSA facility, the following factors showed the strongest association with DSA: younger age (aOR=0.81 [95 % confidence interval (CI):0.81-0.83]), thrombectomy rate in that hospital (aOR=2549 [95 %CI:610-10663]), transfer (aOR=1.41[95 %CI:1.34-1.50]) and carotid disease (aOR=5.8 [95 %CI:5.6-6.1]). There was large variation in the hospital DSA rate, varying from 0.07 % to 11.1 %. Of the variance of DSA rates, 15 % was attributed to the residual effect hospital propensity to perform DSA. The top decile of hospitals with the highest DSA rate, performed DSA's in >2.3 % of patients, compared to the 0.6 % median. There was no change in DSA rates over time. ConclusionDSA is used infrequently in acute ischemic stroke patients and did not change between 2016 to 2020. Hospital variation in DSA use was however large, and not solely explained by patient and facility factors.

Commercial prices and their influence on urology practices: Prostate cancer care among men with Medicare.

For men with prostate cancer, there is substantial variation in the use of conservative management, such as active surveillance. Commercial prices, which vary across urology practices, may afford incentives that foster physician behaviors associated with utilization. Such behaviors may "spillover" to the Medicare population and affect quality. This study evaluated the effects of practice-level commercial prices on health care utilization and quality in men with prostate cancer insured by traditional Medicare. From a 20% Medicare sample, the authors identified men with newly diagnosed prostate cancer between 2014-2019 (n=44,653). Using commercial payments from the MarketScan database, they developed a practice-level commercial price index (ratio of commercial prices to Medicare prices). They examined the association of the price index with price standardized spending, overtreatment (treatment among those with >50% noncancer mortality within 10 years), and underuse of diagnostic testing in active surveillance (at least one prostate-specific antigen test and one confirmatory test-MRI, prostate biopsy, genomic test-within 12 months of diagnosis). Practice-level commercial price indices varied from 1.34 (134% of Medicare prices), for practices in the bottom decile, to 3.00, for practices in the top decile. Increasing price index was associated with lower odds of overtreatment (odds ratio, 0.86; 95% confidence interval, 0.76-0.97; p=.01), but not price standardized spending or underuse of diagnostic testing in active surveillance. Commercial prices vary markedly across urology practices. Among newly diagnosed men with traditional Medicare, those managed by practices with higher commercial price indices had lower odds of overtreatment, suggesting improved prostate cancer care quality.

Sex and Racial Disparities in Hospitalization and Outcomes of Multiple Myeloma with ESRD

Background/Objectives: Renal failure severe enough to require dialysis (ESRD) complicates multiple myeloma (MM) in up to 10% of hospitalizations. This study examined disparities in hospitalization and outcomes among MM and ESRD patients according to sex and race Methods: From the nationwide inpatient sample database, we analyzed 4,615 adult hospitalizations for patients with MM and ESRD between January 1, 2016, and December 31, 2020. Baseline sex and race characteristics were analyzed using chi-square tests and Student's t-test. Hierarchical multivariable logistic regression analysis evaluated the odds of primary and secondary outcomes. All patient refined-diagnosis-related groups (APR-DRG) metrics and the Charlson comorbidity index (CCI) metrics were used to adjust illness severity, baseline risk of mortality, and comorbidity burden. Prolonged hospitalization was defined as the length of hospital stay in the top decile (23 days). Results: Women with MM and ESRD were significantly older (65.5 vs. 58.1 years; P = 0.045) and had a higher prevalence of COPD (17.5 vs. 12.1%; P = 0.022), lymphopenia (14.1% vs. 6.9%; P 0.001), osteoporosis (4% vs. 0.5%; P 0.001), and electrolyte abnormalities (1.7% vs. 0.4; P = 0.014), whereas men had higher prevalence of tobacco use (35.2% vs. 22.6%; P < 0.001), coronary artery disease (163.5% vs. 10.2%; P = 0.008), and previous PCI (4.6% vs. 1.4%; P = 0.010). Compared with nonwhite patients, White Americans were older (67.3 vs. 63.6; P < 0.001) and had a higher prevalence of obesity (6.7% vs. 3.8%; P = 0.047), diabetes (37.3% vs. 24.3%; P < 0.001), and electrolyte abnormalities (2.3% vs. 1%; P = 0.032). A higher prevalence of COPD (17.6% vs. 11%; P = 0.004) was observed in nonwhite patients. Compared with female sex, male sex was significantly correlated with greater odds of mortality (11.6% vs. 9.7%; aOR: 1.32; 95% CI: 1.03-2.08; P = 0.030), bone marrow transplantation (25.0% vs. 22.3%; aOR: 1.15; 95% CI: 1.03-1.58; P = 0.037), and any MACE (3.9% vs. 2.1%; aOR: 3.9; 95% CI: 1.12-1.0; 1.06-2.29; P=0.028). Female sex was correlated with greater odds of VTE (11.3% vs. 7.6%; aOR: 1.59; 95% CI: 1.17-2.61; P = 0.039), depression (1.4% vs. 0.5%; aOR: 1.08; 95% CI: 1.04-1.22; P = 0.028), and prolonged hospitalization (15.5% vs. 13.1%; aOR: 1.24; 95% CI: 1.14-2.66; P = 0.027). White race was correlated with a greater likelihood of ASCT (10.6%; aOR: 1.15; 95% CI: 1.08-1.93; P = 0.026) and depression (1.4%; aOR: 1.08; 95% CI: 1.04-1.32; P = 0.028). Black race was correlated with greater odds of VTE (12.1%; aOR: 1.35; 95% CI: 1.24-1.93; P = 0.048) and any MACE (2.8%; aOR: 1.32; 95% CI: 1.07-3.27; P = 0.035) and lower odds of ASCT (5.4%; aOR: 0.45; 95% CI: 0.27-0.76; P = 0.003). Hispanic and Asian/Pacific Islander descent were associated with significantly higher mortality (12.1%, P = 0.015 and 12.2%, P = 0.002, respectively) and greater likelihood of major transfusion (36.4%, P = 0.029 and 30.3%, P = 0.049, respectively). Asian/Pacific Islander descent was also correlated with greater odds of ARF (39.4%; aOR: 1.61; 95% CI: 1.34-2.46; P = 0.016). Native American descent was correlated with a greater risk of VTE (8.9%; aOR: 4.14; 95% CI: 0.90-8.97; P = 0.068). No significant differences in mean hospital stay and hospital cost were observed by race and sex among patients with MM and ESRD. Conclusion: Male patients exhibited higher odds of mortality, bone marrow transplantation, and major adverse cardiovascular events, whereas female patients exhibited greater odds of venous thromboembolism, depression, and prolonged hospital stays. Racial disparities were also evident; white patients were more likely to receive autologous stem cell transplantation and report depression, whereas nonwhite patients, especially those of Black, Hispanic, Asian/Pacific Islander descent, had higher risk of venous thromboembolism, major adverse cardiovascular events, and mortality.

Circulating metabolites associate with the QT interval in individuals without prevalent cardiovascular disease

Abstract Background Patients with metabolic syndrome have a higher prevalence of heart-rate corrected QT (QTc) interval prolongation. Despite this the effect of circulating metabolites on the QTc is largely unknown and limited to small studies. Purpose To test for association of circulating metabolites with the QTc interval in the UK Biobank study. Methods Participants were identified from the UK Biobank with same day plasma metabolite profiling and electrocardiograms. All 249 metabolites measured underwent quality control and log transformation to account for rightward skew and zero values. 149 metabolites with inter-correlations >0.7 were excluded. Participants taking QTc-prolonging medication or with a history of ischaemic heart disease or heart failure up to 6 months after the visit, were excluded. Participants were allocated to a training group (N=21,610) or an independent test group (N=5,304), if samples were obtained at recruitment or at a second visit, respectively. In the training group, each metabolite was tested separately for association with the QTc in linear regression analyses, adjusted for clinical covariates (age, sex, fasting time, body mass index (BMI), systolic blood pressure (SBP), smoking status, diabetes, lipid-lowering drug use and dietary factors). Significant metabolites (P<5x10-4) underwent validation in the test group. Sex-stratified analyses were also performed. In the training group, variables in two models underwent regularisation by LASSO regression (10-fold cross-validation) to reduce multicollinearity and downweigh less important variables; 1) clinical variables, 2) clinical variables and validated metabolites. Coefficients were used for QTc prediction in the test group. Significance between the models was evaluated by fisher’s transformation of R-squared statistics. Results In the per metabolite multivariate analysis, 56 metabolites were associated with the QTc interval. 19 metabolites validated in the test group. For 14 of these, absolute effect sizes were >5ms when comparing individuals in the top decile of the metabolite distribution verses the bottom (Figure 1), including the ketone body 3-hydroxybutyrate (9ms), and omega-6 fatty acid to total fatty acid ratio (7.2ms). For associations in males and females separately, significant effect size differences (P<0.05) were observed for 9 metabolites (Figure 2). In the training group, the combined LASSO model selected 17 (of 19) metabolites along with age, sex, SBP and BMI. In the test group, this model R-squared was 0.115 compared with 0.081 for clinical covariates alone, representing a significant 41.9% increase in QTc variation explained (P=0.002). Conclusions This study demonstrates clinically relevant metabolite associations with the QTc in individuals without cardiovascular disease and explain a significant proportion of QTc variation. Further investigation is warranted to test for direct effects on cardiac electrophysiology and proarrhythmic potential.Validated metabolitesSignificant sex differences

Who Bears the Welfare Costs of Monopoly? The Case of the Credit Card Industry

Abstract We measure the distribution of welfare losses from non-competitive behaviour in the U.S. credit card industry during the 1970s and 1980s. The early credit card industry was characterized by regional monopolies. Ensuing legal decisions led to competitive reforms that resulted in greater, but still limited, oligopolistic competition. We measure the distributional consequences of these reforms by developing and estimating a heterogeneous agent, defaultable debt framework with oligopolistic lenders. The transition from monopoly to oligopolistic competition yields welfare gains equivalent to a one-time transfer worth $3,600 (in 2016 dollars) for the bottom decile of earners (roughly 50% of their annual income) versus $1,200 for the top decile of earners. As the credit market expands, low-income households benefit more since they rely disproportionately on credit to smooth consumption. Greater competition also explains rising bankruptcies, chargeoffs, and credit to income ratios. Lastly, we bound the welfare gains from competition by computing a perfectly competitive benchmark. Aggregate welfare gains are 40% larger from perfect competition but distributed similarly to oligopolistic competition.

12620 Developing Hospital Protocols For Managing Patients With Hypertriglyceridemia-induced Acute Pancreatitis In Diabetic Ketoacidosis Hospitalizations

Abstract Disclosure: U. Agbedia-ejughemre: None. Methods: We queried the combined 2017-2020 nationwide inpatient sample database for all adult hospitalizations for DKA with and without HTG-AP using the ICD-10 revision codes. Baseline characteristics were compared between DKA hospitalizations with and without HTG-AP using Pearson’s χ2 tests and Student’s t-test for categorical and continuous variables. Study endpoints were the incidence, predictors, and outcomes of HTG-AP, including mortality, hospitalization duration, mean hospital costs, and acute in-hospital complications (sepsis, ARDS, and acute renal failure). Predictors of HTG-AP were assessed using stepwise multivariable logistic regression analysis. Illness severity, baseline risk of mortality, and comorbidity burden were adjusted using APR-DRG metrics and CCI. Prolonged hospitalization was defined as the length of hospital stay in the top decile of hospital stay for all hospitalizations in the study. Results: We analyzed 630,435 hospitalizations for DKA. The study cohort was 51.4% male, 57.6% white Americans and 26.1% Blacks, with a mean age of 40 (SD, 16.2) years. Incidence of HTG-AP was 2.1% (13,445). Hospitalizations with HTG-AP were older (mean age: 44 vs. 40 years; P<0.001) and had greater comorbidity (CCI score of 2: 38.7 vs. 33.8; P<0.001) compared with DKA hospitalizations without HTG-AP. While DKA hospitalizations showed an uptrend, increasing from 105,769 to 199,429 hospitalizations (Average annual percent change [AAPC]: 27.04%; P=0.029), the incidence of HTG-AP showed a downtrend from 2650 (2.5%) to 4085 (2.0%) (P=0.006). Predictors of HTG-AP included Hispanic (aOR: 2.45; 95% CI: 1.95-3.07; P<0.001) or Asian race (aOR: 2.48; 95% CI: 1.37-4.48; P=0.003), private insurance (aOR: 1.57; 95% CI: 1.10-2.25; P=0.013), self-pay (aOR: 2.2; 95% CI: 1.49-3.27; P<0.001), APR-DRG moderate risk of mortality (aOR: 1.52; 1.21-1.92; P<0.001), APR-DRG major loss of function (aOR: 1.46; 95% CI: 1.31-1.69; P<0.001), dyslipidemia (aOR: 1.87; 95% CI: 1.47-2.38; P<0.001), hypertension (aOR: 1.39; 95% CI: 1.13-1.72; P=0.002), obesity (aOR: 3.09; 95% CI: 2.42-3.96; P<0.001), obstructive sleep apnea (aOR: 2.05; 95% CI: 1.35-3.10; P=0.001), chronic liver disease (aOR: 9.44; 95% CI: 6.61-13.48; P<0.001), old MI (aOR: 2.11; 95% CI: 1.02-4.38; P=0.045), and COPD (aOR: 2.31; 95% CI: 1.47-3.64; P<0.001). DKA hospitalizations with HTG-AP were correlated with higher risk of septicemia (aOR: 1.20; 95% CI: 1.05-1.69; P=0.029), ARDS (aOR: 1.24; 95% CI; 1.04-2.07; P=0.004), and resource use, including prolonged hospitalization (26.3% vs. 11.1%; P<0.001), and higher mean hospital costs ($57,773 vs. $32,692; P<0.001). Conclusion: HTG-AP was linked to worse outcomes, excluding mortality, in hospital admissions for DKA. There is a need for enhanced diagnostic guidelines and protocols targeting this subgroup of patients could improve outcomes. Presentation: 6/2/2024

Multi-trait and multi-ancestry genetic analysis of comorbid lung diseases and traits improves genetic discovery and polygenic risk prediction.

While respiratory diseases such as COPD and asthma share many risk factors, most studies investigate them in insolation and in predominantly European ancestry populations. Here, we conducted the most powerful multi-trait and -ancestry genetic analysis of respiratory diseases and auxiliary traits to date. Our approach improves the power of genetic discovery across traits and ancestries, identifying 44 novel loci associated with lung function in individuals of East Asian ancestry. Using these results, we developed PRSxtra (cross TRait and Ancestry), a multi-trait and -ancestry polygenic risk score approach that leverages shared components of heritable risk via pleiotropic effects. PRSxtra significantly improved the prediction of asthma, COPD, and lung cancer compared to trait- and ancestry-matched PRS in a multi-ancestry cohort from the All of Us Research Program, especially in diverse populations. PRSxtra identified individuals in the top decile with over four-fold odds of asthma and COPD compared to the first decile. Our results present a new framework for multi-trait and -ancestry studies of respiratory diseases to improve genetic discovery and polygenic prediction.

Identification of Immune Checkpoint Inhibitor–Induced Diabetes

Immune checkpoint inhibitors (ICIs) have revolutionized cancer care; however, accompanying immune-related adverse events (irAEs) confer substantial morbidity and occasional mortality. Life-threatening irAEs may require permanent cessation of ICI, even in patients with positive tumor response. Therefore, it is imperative to comprehensively define the spectrum of irAEs to aid individualized decision-making around the initiation of ICI therapy. To define incidence, risk factors, and clinical spectrum of an irreversible and life-threatening irAE: ICI-induced diabetes. This cohort study, conducted at an academic integrated health care system examined 14 328 adult patients treated with ICIs, including 64 patients who developed ICI-induced diabetes, from July 2010 to January 2022. The data were analyzed from 2022 to 2023. Cases of ICI-induced diabetes were manually confirmed; detailed clinical phenotyping was performed at diagnosis and 1-year follow-up. For 862 patients, genotyping data were available, and polygenic risk for type 1 diabetes was determined. For ICI-induced diabetes cases and controls, demographic characteristics, comorbidities, tumor category, and ICI category were compared. Among ICI-induced diabetes cases, markers of glycemic physiology were examined at diagnosis and 1-year follow-up. For patients with available genotyping, a published type 1 diabetes polygenic score (T1D GRS2) was calculated. Of 14 328 participants, 6571 (45.9%) were women, and the median (range) age was 66 (8-106) years. The prevalence of ICI-induced diabetes among ICI-treated patients was 0.45% (64 of 14 328), with an incidence of 124.8 per 100 000 person-years. Preexisting type 2 diabetes (odds ratio [OR], 5.91; 95% CI, 3.34-10.45) and treatment with combination ICI (OR, 2.57; 95% CI, 1.44-4.59) were significant clinical risk factors of ICI-induced diabetes. T1D GRS2 was associated with ICI-induced diabetes risk, with an OR of 4.4 (95% CI, 1.8-10.5) for patients in the top decile of T1D GRS2, demonstrating a genetic association between spontaneous autoimmunity and irAEs. Patients with ICI-induced diabetes were in 3 distinct phenotypic categories based on autoantibodies and residual pancreatic function, with varying severity of initial presentation. The results of this analysis of 14 328 ICI-treated patients followed up from ICI initiation determined the incidence, risk factors and clinical spectrum of ICI-induced diabetes. Widespread implementation of this approach across organ-specific irAEs may enhance diagnosis and management of these conditions, and this becomes especially pertinent as ICI treatment rapidly expands to treat a wide spectrum of cancers and is used at earlier stages of treatment.

Device-measured physical activity and cardiac structure by magnetic resonance.

Although extreme cardiac adaptions mirroring phenotypes of cardiomyopathy have been observed in endurance athletes, adaptions to high levels of physical activity within the wider population are under-explored. Therefore, in this study, associations between device-measured physical activity and clinically relevant cardiac magnetic resonance volumetric indices were investigated. Individuals without known cardiovascular disease or hypertension were included from the UK Biobank. Cardiac magnetic resonance data were collected between 2015 and 2019, and measures of end-diastolic chamber volume, left ventricular (LV) wall thickness, and LV ejection fraction were extracted. Moderate-to-vigorous-intensity physical activity (MVPA), vigorous-intensity physical activity (VPA), and total physical activity were assessed via wrist-worn accelerometers. A total of 5977 women (median age and MVPA: 62 years and 46.8 min/day, respectively) and 4134 men (64 years and 49.8 min/day, respectively) were included. Each additional 10 min/day of MVPA was associated with a 0.70 [95% confidence interval (CI): 0.62, 0.79] mL/m2 higher indexed LV end-diastolic volume (LVEDVi) in women and a 1.08 (95% CI: 0.95, 1.20) mL/m2 higher LVEDVi in men. However, even within the top decile of MVPA, LVEDVi values remained within the normal ranges [79.1 (95% CI: 78.3, 80.0) mL/m2 in women and 91.4 (95% CI: 90.1, 92.7) mL/m2 in men]. Associations with MVPA were also observed for the right ventricle and the left/right atria, with an inverse association observed for LV ejection fraction. Associations of MVPA with maximum or average LV wall thickness were not clinically meaningful. Results for total physical activity and VPA mirrored those for MVPA. High levels of device-measured physical activity were associated with cardiac remodelling within normal ranges.

Through the secret gate: a study of member-contributed submissions in PNAS

This work studies “Contributed” articles in the Proceedings of the National Academy of Sciences of the United States of America (PNAS), a streamlined submission track for members of the US National Academy of Sciences (NAS). We assess the characteristics and impact of those articles and the background and status of their authors, by comparing these articles to PNAS articles following the traditional editorial process. Analyzing over 46,000 articles published between 2007 and 2020, we find: Firstly, and perhaps most centrally, (1) Contributed articles generally appear in lower per-author citation deciles than Direct submissions, but are more likely to appear in the overall top citation deciles of authors; (2) PNAS-Contributed articles tend to spend less time in the review process than Direct submissions; (3) Direct submissions tend to be slightly higher cited than Contributed articles, which are particularly overrepresented amongst least-cited PNAS papers. Disciplinary differences were negligible; (4) authors with lower mean normalized citation scores are profiting most from articles published as Contributed papers, in terms of citation impact; (5) NAS members tend to publish most Contributed articles in the first years after becoming an NAS member, with men publishing more of these articles than women; (6) Contributing authors take up a unique niche in terms of authorship roles, mainly performing supervisory and conceptualisation tasks, without the administration and funding acquisition tasks usually associated with last authors.

A field survey on the dietary use of traditional Chinese medicine in selected regions with the Cantonese, Hakka, and Teochew populations in Guangdong province, China.

The purpose of this study was to assess the dietary consumption patterns of traditional Chinese medicine (TCM) among the population in Guangdong province. Employing a cross-sectional design, the survey was conducted from 2019 to 2021 to examine the inclusion of TCM in the diet of participants in Guangdong province. Information regarding consumption of TCM during the preceding 12 months was collected using a food frequency questionnaire. The participant cohort comprised a total of 3031 participants, consisting of 1081 Cantonese, 967 Hakka, and 983 Teochew individuals. The survey included 42 TCM, with consumption rates ranging from 2.6% to 47.3%. The top five TCM comprised Citri Reticulatae Pericarpium (47.3%), Lonicerae Japonicae Flos (47.0%), Codonopsis Radix (46.4%), Polygonati Odorati Rhizoma (43.1%), and Siraitiae Fructus (41.5%), along with Panacis Quinquefolii Radix (41.5%). These TCM possess recognized therapeutic properties within TCM for clearing heat, drying dampness, and detoxification. Within the top decile of 10 TCM, only Lonicerae Japonicae Flos was ubiquitous across all three sub-populations. Nonetheless, 11 TCM from the top 20 and 17 TCM from the top 30 overlapped among the three sub-populations. The study revealed substantial variability in the consumption rates of different TCM. Notably, those with traditional Chinese medicine effects of clearing heat, drying dampness, and detoxification exhibited higher consumption rates. Disparities in the consumption rates of these TCM were noted among the Cantonese, Hakka, and Teochew populations.

Exploring the linguistic complexity of third-grade numerical literacy

Reading numbers aloud, a central aspect of numerical literacy, is a challenging skill to acquire, but the origins of this difficulty remain poorly understood. To investigate this matter, we examined the performance of 127 third- and fourth-grade children who read aloud, in Hebrew, numbers with 2–5 digits. We found several key observations. First, we observed a substantial variation among the 3rd graders—7% and 59% errors in the top and bottom deciles, respectively. Second, the task difficulty stemmed from syntactic processing: Most errors were distortions of the number’s syntax, as opposed to digit substitutions or transpositions, and the main factor affecting a specific number’s difficulty was not its magnitude, as is commonly assumed, but rather its syntactic structure. Third, number reading performance was not predicted by a school-like task that assessed syntactic-conceptual knowledge of the decimal system structure, but rather by knowledge of specific syntactic-verbal rules, suggesting that the syntactic-verbal knowledge is separate from the syntactic-conceptual knowledge. Last, there was a double dissociation between 4-digit numbers and 5-digit numbers, which in Hebrew have completely different syntactic structures: Half of the children showed a significant advantage in one number length compared to the other, with equal numbers of children preferring either length. This indicates that the different syntactic-verbal rules are learned relatively independently of each other, with little or no generalization from one rule to another. In light of these findings, we propose that schools should specifically teach number reading, with focus on specific syntactic-verbal rules.

An Alternative Non-Invasive Screening Model for Liver Fibrosis among US Adults at Risk of MASLD.

Background and Aims: Screening for liver fibrosis presents a clinical challenge. This study aimed to explore a useful alternative method for assessing fibrosis risk among US adults at risk of metabolic dysfunction-associated steatotic liver disease (MASLD). Methods: A liver stiffness score (LSS) model was proposed and tested using data from 3976 participants at possible risk of MASLD, obtained from the US National Health and Nutrition Examination Survey (NHANES). Results: The LSS model was developed using liver stiffness measurements, blood biochemistry, and body measurement data from 2414 NHANES participants at risk of MASLD, sampled between 2017 and 2020: LSS = exp(0.007035 × bodyweightkg - 0.1061 × raceblack1,0 + 0.183221 × diabetes1,0 + 0.008539 × ASTIU/L - 0.0018 × plateletcount1000cell/UL - 0.21011 × albuming/dL + 2.259087). The probability (P) of having fibrosis F3 + F4 is calculated as follows: P = 0.0091 × LSS2 - 0.0791 × LSS + 0.1933. The developed LSS model was tested on 1562 at-risk participants from the 2017-2018 cycle. The results showed that the LSS model achieved AUROC values of 0.79 and 0.78 for diagnosing cirrhosis (F4) and advanced fibrosis (F3 + F4) in the US population, respectively. It outperformed existing models such as NFS, FIB-4, SAFE, and FIB-3. For screening F3 + F4 fibrosis, the LSS model's top decile outperformed the NFS and FIB-4 models by 37.7% and 42.6%, respectively. Additionally, it showed superior performance compared to the waist circumference classification method by 29.5%. Conclusions: derived from an ethnically diverse population dataset, the LSS screening model, along with its probability equation, may offer clinicians a valuable alternative method for assessing the risk of liver fibrosis in the at-risk adult population.

Concentration of High-Cost Head and Neck Cancer Surgical Patients.

Health care costs are disproportionately concentrated among a small number of patients. We sought to identify variables associated with high-cost patients and high hospital concentration of high-cost patients and to examine associations with short-term outcomes in head and neck cancer (HNCA) surgery. The Nationwide Inpatient Sample was used to identify 170,577 patients who underwent HNCA surgery in 2001-2011. High-cost patients were defined as patients whose costs of care were in the top decile, and high-concentration hospitals were defined as those whose percentage of high-cost patients was in the top decile. Multivariable regression was used to evaluate associations between cost and patient and hospital variables, postoperative complications, and in-hospital mortality. Costs associated with high-cost patients were 4.47-fold greater than the remaining 90% of patients. High-concentration hospitals treated 36% of all high-cost patients. High-cost patients were more likely to be non-white (OR = 2.08 [1.45-2.97]), have oral cavity cancer (OR = 1.21 [1.05-1.39]), advanced comorbidity (OR = 1.53 [1.31-1.77]), Medicaid (OR = 1.93 [1.62-2.31]) or self-pay payor status (OR = 1.72 [1.38-2.14]), income>50th percentile (OR = 1.25 [1.05-1.51]), undergo major procedures (OR = 3.52 [3.07-4.05]) and have non-routine discharge (OR = 7.50 [6.01-9.35]). High-concentration hospitals were more likely to be teaching hospitals (OR = 3.14 [1.64-6.05]) and less likely to be urban (OR = 0.20 [0.04-0.93]). After controlling for all other variables, high-cost patients were associated with an increased odds of mortality (OR = 8.00 [5.89-10.85]) and postoperative complications (OR = 5.88 [5.18-6.68]). High-concentration hospitals were associated with an increased odds of postoperative complications (OR = 1.31 [1.08-1.61]) but were not associated with increased mortality (OR = 0.98 [0.67-1.44]). High-cost HNCA surgical patients are associated with increased postoperative morbidity and mortality, and are disproportionately concentrated at teaching hospitals. 4 Laryngoscope, 134:4971-4978, 2024.

Center-level variation in hospitalization costs of pancreaticoduodenectomy for pancreatic cancer

BackgroundPancreaticoduodenectomy is a highly morbid operation with significant resource utilization. Using a national cohort, we examined the interhospital variation in pancreaticoduodenectomy hospitalization cost in the United States. MethodsAdults undergoing elective pancreaticoduodenectomy in the setting of pancreatic cancer were tabulated from the 2016–2020 Nationwide Readmissions Database. A 2-level mixed-effects model was developed to evaluate the interhospital variation in pancreaticoduodenectomy hospitalization costs. Institutions within the top decile of risk-adjusted expenditures were defined as high-cost hospitals. Multivariable regression models were fitted to examine the association between high-cost hospital status and outcomes of interest. To account for the effects of complications on expenditures, a subgroup analysis comprising of patients with no adverse events was conducted. ResultsThe study included an estimated 24,779 patients with a median hospitalization cost of $38,800. After mixed-effects modeling, 40.9% of the cost variation was attributable to hospital, rather than patient, factors. Multivariable regression models revealed an association between high-cost hospital status and greater odds of complications and longer length of stay. Among patients without an adverse event, interhospital cost variation remained significant at 61.0%, and treatment at high-cost hospitals was similarly linked to longer length of stay. ConclusionOur study identified significant interhospital variation in pancreaticoduodenectomy hospitalization costs in the United States. Although high-cost hospital status was associated with increased odds of complications, variation remained significant even among patients without an adverse event. These results suggest the important role of hospital practices as contributors to expenditures. Further efforts to identify drivers of costs and standardize pancreatic surgical care are warranted.

Identifying vulnerable mother-infant dyads: a psychometric evaluation of two observational coding systems using varying interaction periods.

Clinical services require feasible assessments of parent-infant interaction in order to identify dyads requiring parenting intervention. We assessed the reliability and predictive validity of two observational tools and tested whether briefer forms could be identified which retain acceptable psychometric properties over short observation periods. A stratified high-risk community sample of 250 mother-infant dyads from The Wirral Child Health and Development Study completed 7-min play-based interaction at 6-8 months. Film-footage was independently coded by two trained raters using PIIOS and NICHD-SECCYD systems. Incremental predictive validity was assessed from 3, 5 and 7 min observation to attachment outcomes (Strange Situation; 14 months) and infant mental health (BITSEA; 14 and 30 months). Excellent inter-rater reliability was evident at code and subscale level for each tool and observation period. Stability of within-rater agreement was optimal after 5 min observation. ROC analysis confirmed predictive (discriminant) validity (AUCs >0.70) to top decile age 2 mental health outcomes for PIIOS total score and a brief 3-item composite from NICHD-SECCYD (sensitivity, intrusiveness, positive regard; NICHD-3), but not to attachment outcomes. Logistic regression showed dyads rated at-risk for externalizing problems using NICHD-3 were also at significantly higher risk for insecurity at 14 months (OR = 2.7, p = 0.004). PIIOS total and NICHD-3 ratings from 5 min observation are both reliable and valid tools for use in clinical practice. Findings suggest NICHD-3 may have greater utility due to its comparative brevity to train and code, with suitability for use over a broader developmental time frame (3-24 months).

Hospital-level variation in costs of elective nonruptured abdominal aortic aneurysm repair

BackgroundWith the aging population in the United States, the incidence of abdominal aortic aneurysms is shifting to older ages. Given changing demographic characteristics and increasing health care expenditures, the present study evaluated the degree of center-level variation in the cost of elective abdominal aortic aneurysm repair. MethodsWe identified all adult (≥18 years) hospitalizations for elective repair of nonruptured abdominal aortic aneurysms in the 2017 to 2020 Nationwide Readmissions Database. Hierarchical mixed-effects models were used to rank hospitals based on risk-adjusted costs. The interclass coefficient was used to calculate the amount of variation attributable to hospital-level characteristics. High-cost hospitals were classified as centers in the top decile of costs. The association of high-cost hospitals status with outcomes of interest was examined. ResultsAn estimated 62,626 patients underwent abdominal aortic aneurysm repair, and 5,011 (8.0%) were managed at high-cost hospitals. Compared with non–high-cost hospitals, high-cost hospitals were more commonly large (52.6% vs 48.3%) metropolitan (78.3% vs 66.9%) teaching centers (all P < .001). The interclass coefficient found that 28% of the observed variation in cost is attributable to hospital factors. After adjustment, high-cost hospitals were associated with increased odds of gastrointestinal (adjusted odds ratio = 1.42; 95% CI, 1.05–1.90) and infectious (adjusted odds ratio = 1.35; 95% CI, 1.14–1.59) complications. Finally, the Elixhauser index (β = +$2,700/unit; 95% CI, $2,500–$3,000) and open repair (β = +$4,100; 95% CI, $3,100–$5,200) were associated with increased costs. ConclusionWe observed significant variation in cost attributable to center-level differences. Our findings have implications for reimbursement paradigms and the establishment of quality and cost benchmarks in the elective repair of abdominal aortic aneurysm.

Genetic drivers and cellular selection of female mosaic X chromosome loss.

Mosaic loss of the X chromosome (mLOX) is the most common clonal somatic alteration in leukocytes of femaleindividuals1,2, but little is known about its genetic determinants or phenotypic consequences. Here, to address this, we used data from 883,574 female participants across 8 biobanks; 12% of participants exhibited detectable mLOX in approximately 2% of leukocytes. Female participants with mLOX had an increased risk of myeloid and lymphoid leukaemias. Genetic analyses identified 56 common variants associated with mLOX, implicating genes with roles in chromosomal missegregation, cancer predisposition and autoimmune diseases. Exome-sequence analyses identified rare missense variants in FBXO10 that confer a twofold increased risk of mLOX. Only a small fraction of associations was shared with mosaic Y chromosome loss, suggesting that distinct biological processes drive formation and clonal expansion of sex chromosome missegregation. Allelic shift analyses identified X chromosome alleles that are preferentially retained in mLOX, demonstrating variation at many loci under cellular selection. A polygenic score including 44 allelic shift loci correctly inferred the retained X chromosomes in 80.7% of mLOX cases in the top decile. Our results support a model in which germline variants predispose femaleindividuals to acquiring mLOX, with the allelic content of the X chromosome possibly shaping the magnitude of clonal expansion.