Medical diagnostic accuracy measures: an innovative approach based on the area under predictive values curves.

Positive and negative estimates are commonly used by clinicians to evaluate the likelihood of a disease stage being present based on test results. The predicted values are dependent on the prevalence of the underlying illness. However, for certain diseases or clinical conditions, the prevalence is unknown or different from one region to another or from one population to another, leading to an erroneous diagnosis. This article introduces innovative post-test diagnostic precision measures for continuous tests or biomarkers based on the combined areas under the predictive value curves for all possible prevalence values. The proposed measures do not vary as a function of the prevalence of the disease. They can be used to compare different diagnostic tests and/or biomarkers' abilities for rule-in, rule-out, and overall accuracy based on the combined areas under the predictive value curves. The relationship of the proposed measures to other diagnostic accuracy measures is discussed. We illustrate the proposed measures numerically and use a real data example on breast cancer.

Mental health, physical activity, and sports among children with cerebral palsy.

BACKGROUND: People with cerebral palsy (CP) may be at an increased risk for mental health disorders due to co-occurring physical and communication limitations associated with the condition. Participation in physical activity (PA) and sports may provide opportunities to increase socialization and improve physical function. The purpose of this study was to examine associations between participation in daily PA and sports and mental health among children with CP. METHOD: Participants included children with CP (n = 458) and typically developing children (TDC) (n = 40 091) 6-17 years whose parents participated in the 2016-2020 National Survey of Children's Health. Mental health disorders included anxiety, depression, behavioural disorders and attention-deficit/hyperactivity disorder (ADHD). RESULTS: Compared with TDC, children with CP had a higher prevalence of mental health disorders (75.5% vs. 54.2%) and were more likely to receive mental health care (21.5% vs. 14.6%). Controlling for sociodemographic variables, children with CP were more likely to experience anxiety [odds ratio (OR) 2.6; 95% confidence interval (CI) = 2.1-3.3), depression (OR 1.8; 95% CI 1.3-2.4), behavioural disorders (OR 4.8; 95% CI 3.8-6.0) and ADHD (OR 2.1; 95% CI 1.6-2.6). The likelihood of these conditions decreased when children participated in sports for anxiety (OR 2.2; 95% CI 1.8-2.8), depression (OR = 1.4; 95% CI 1.0-2.0), behavioural disorders (OR 4.1; 95% CI 3.2-5.1) and ADHD (OR 1.9; 95% CI 1.5-2.5). The likelihood for anxiety (OR 2.3; 95% CI 1.8-2.8), depression (OR 1.4; 95% CI 1.0-1.9), behavioural disorders (OR 4.4; 95% CI 3.5-5.5) and ADHD (OR 1.9; 95% CI 1.5-2.4) also decreased with participation in daily PA. CONCLUSIONS: There is an overwhelming disparity in the number of children with CP who have a mental health disorder and those who receive mental health care. Increasing access to participation in sports and PA may be beneficial.

Care coordination for rural residents with chronic disease: Predictors of improved outcomes.

OBJECTIVE: The purpose of this study was to assess the effect of an integrated system of coordinated care on chronic disease health outcomes of patients with poorly controlled diabetes, hypertension, and congestive heart failure (CHF) living in a rural area. DESIGN AND SAMPLE: Longitudinal study of patients aged 18 years or older, living in a rural area, with diabetes glycated hemoglobin (A1C) > 8%, hypertension blood pressure (BP) > 150/90, heart failure, and suffering excessive weight gain and hospital admission in last 6 months. MEASURES: Dependent variables were A1C, cholesterol, microalbumin, body mass index (BMI), BP, emergency department (ED) visits, and hospital admissions. Predictor variables included time in the program, age, sex, race, and Diabetes Self-Management Education (DSME) completion. Descriptive variables included telemedicine and specialty referrals and travel savings. RESULTS: Time had a significant effect on A1C, microalbumin, BP, and ED visits. Race, sex, and DSME also impacted A1C and BP outcomes. CONCLUSIONS: Length of time in the program played a crucial role in improved outcomes for patients in the program for a year or more. Long-term, consistent reinforcement in the form of education and coordinated care provided by certified care coordination nurses achieve better health outcomes.

Hepatic proteomic assessment of oral ingestion of titanium dioxide nano fiber (TDNF) in Sprague Dawley rats.

Titanium dioxide nanofibers (TDNF) have been widely employed in pigments, sunscreens, paints, ointments, toothpaste and photocatalytic splitting of water. However, their potential toxicity has not been thoroughly examined. The goal of the present study is to examine hepatic effects associated with the ingestion of TDNF. TDNF was fabricated via electrospinning method and characterized. Six to seven weeks old male Sprague Dawley rats ingested (oral gavage) a total of 0 ppm, 40, 60 ppm TDNF for two weeks. After sacrifice, the liver was assessed for cellular effects using proteomic approach. The fibers diameter ranged from 0.18 - 0.29 µm, forming clusters and majority of the fibers were in the rutile phase. Proteomics assessment revealed more that more than 400 hundred proteins in the liver may be affected. These proteins are involved in such processes as catalysis of fatty acids by CoA, homocysteine metabolism, beta oxidation and the condensation of carbamoyl phosphate in the urea cycle among others. Further analysis of the protein associations showed that 325 biological processes, 140 molecular functions and 70 cellular components appear to be affected from the ingestion of TNDF. Quantitative analysis of specific mRNA transcripts indicated CMBL, GSTM1 and SDS were differentially expressed.

Significant Improvement of Somatic Symptom Disorder With Brief Psychoeducational Intervention by PMHNP in Primary Care.

OBJECTIVE: Patients with somatic symptom disorders (SSD) are prevalent in primary care, urgent care, and emergency rooms and present with reduced quality of life, increased disability, and suicidality . Criteria for SSD include (1) somatic symptoms that cause distress and disrupt life; (2) concurrent physical illness with thoughts and feelings that are disproportionate to the seriousness of the illness; and (3) distress which is persistent and causes suffering. The frequency of SSD in the general population is 5% to 7%; however, in primary care, it is 5% to 35% . Because patients present with anxiety, depression, and/or pain, providers are flummoxed when diagnostic findings do not match symptom intensity. The purpose of this project was to provide an intervention for patients with SSD and measure its effectiveness on their somatic symptoms. METHOD: This study provided a single-session, 30-minute psychoeducational intervention for patients to explain brain pathways for pain and the body's response to stress, including scientific benefits of exercise and healthy diet. Patients were asked questions using the motivational interviewing technique OARS (open-ended question, affirmation, reflection, summary) and were encouraged to talk about their concerns. The study used a pre- and post-intervention visual analogue scale and a self-reported Patient Health Questionnaire-15 both before and 3 weeks post-intervention. RESULTS: Measurements showed significant symptom improvement immediately after the intervention with sustained improvement 3 weeks post-intervention. CONCLUSIONS: This intervention demonstrates an effective treatment for this insidious illness, which plagues up to 35% of patients in primary care.

College Students' Experiences of Race-Related Bias or Hatred in Their Lifetimes and COVID-19 Era.

OBJECTIVE: The primary aim of this study was to investigate whether students in minority race categories are more likely to experience race-related bias and hatred in their lifetime and since the onset of COVID-19, after controlling the effect of demographic and other variables. METHODS: This quantitative study used primary data from the survey of 1249 college students at one of the universities in Georgia during April and May 2020. We performed multinomial logistic regression, computing 2 models for the 2 ordinal dependent variables concerning students' experience of race-related bias and hatred-(a) during their lifetime and (b) since the onset of COVID-19 in March 2020-both measured as "never," "rarely," "sometimes," and "fairly often or very often." RESULTS: During their lifetime, 47.5% of students had experienced some level of bias or hatred, ranging from "rarely" to "very often." Since the onset of COVID-19 on March 2 in Georgia, in a short period of 1 to 2 months, 17.6% of students reported experiencing race-related bias or hatred. Univariate statistics revealed substantial differences in race-related bias and hatred by race, experienced during students' lifetime as well as since the onset of COVID-19. Results of multinomial logistic regression showed that the odds of having experienced bias or hatred during their lifetime were significantly higher (P < .05) for the Black students than for White students (adjusted odds ratio [AOR] = 75.8, for very often or often vs never; AOR = 42 for sometimes vs never). Compared with White students, the odds of hatred and bias were also significantly higher for students who were Asian, multiple races, or another non-White race. The odds of having experienced race-related bias and hatred since the onset of COVID-19 were also higher for Black Asian, multiple races, and other non-White students. CONCLUSIONS: This study adds critical scientific evidence about variation in the perception of bias and hatred that should draw policy attention to race-related issues experienced by college students in the United States.

Treatment Adherence in Youth with First-Episode Psychosis: Impact of Family Support and Telehealth Delivery.

Mental health-care delivery to young people with first-episode schizophrenia presents significant challenges especially in underserved areas. This chart review reveals the importance of family support as a predictor for medication and treatment adherence with this vulnerable group. An unexpected disengagement rate of 47% was discovered. It was further discovered that receiving care with telehealth delivery was a significant predictor of lost to follow-up or treatment nonadherence. Recommendations include psychoeducation for families during the initial crisis, initiation of long-acting injectable antipsychotics early in care, a hybrid telehealth intervention with in-home medication delivery, and collaboration with educational, vocational county agencies for employment support. A system of care must be developed to support young people with this severe illness for optimum outcome and protection of long-term cognitive functioning.

Notes on the overlap measure as an alternative to the Youden index: How are they related?

The receiver operating characteristic (ROC) curve is frequently used to evaluate and compare diagnostic tests. As one of the ROC summary indices, the Youden index measures the effectiveness of a diagnostic marker and enables the selection of an optimal threshold value (cut-off point) for the marker. Recently, the overlap coefficient, which captures the similarity between 2 distributions directly, has been considered as an alternative index for determining the diagnostic performance of markers. In this case, a larger overlap indicates worse diagnostic accuracy, and vice versa. This paper provides a graphical demonstration and mathematical derivation of the relationship between the Youden index and the overlap coefficient and states their advantages over the most popular diagnostic measure, the area under the ROC curve. Furthermore, we outline the differences between the Youden index and overlap coefficient and identify situations in which the overlap coefficient outperforms the Youden index. Numerical examples and real data analysis are provided.

Strengthening First Responders' Coaching Proficiency through a Peer Fitness Leader Workshop: A Preliminary Efficacy Trial.

First responders require physical fitness to perform dangerous tasks in unpredictable environments. To promote physical fitness among first responders, many agencies use a peer fitness leader (PFL) approach; however, resources for the fitness, wellness, and health of PFLs are often minimal. This study's purpose was to investigate the effectiveness of a training workshop to increase PFL's training knowledge and coaching comfort (CC). Thirty-six PFLs (Experience: 14.6 ± 9.1 yrs; Age: 41.0 ± 9.8 yrs; BMI: 28.9 ± 7.0 kg·m-2) attended a one-day workshop. Paired samples t-tests assessed for differences between baseline and post-assessment knowledge scores. Pearson correlations described the bivariate relationship between baseline and post-assessment knowledge scores. Wilcoxon's Signed Rank Test determined associations between baseline and post-workshop CC variables. Spearman's Rho correlations described bivariate relationships between baseline and post-assessment values for each CC category. Kendall's Rank correlations investigated relationships between knowledge scores and total perceived CC for pre- and post-workshops. Statistical significance was set at p < 0.05. Results indicated an improvement from the baseline knowledge score (6.08 ± 1.46 points) and post-workshop knowledge score (7.03 ± 0.94 points); (t (25) = 3.85; p < 0.001). Similar trends were observed for all CC measures (Z > -3.42; p < 0.001). Differences were not observed between pre-workshop total CC and knowledge scores (τ = -0.03; p = 0.81) or following workshop completion (τ = -0.04; p = 0.76). Participants demonstrated varying exercise knowledge and CC, highlighting inconsistencies in exercise standards within first responder occupations. This investigation suggests the proposed pedagogy design may be a solution for agencies with limited budgets.

Benzimidazole F167Y polymorphism in the canine hookworm, Ancylostoma caninum: Widespread geographic, seasonal, age, and breed distribution in United States and Canada dogs.

Surveillance data for Ancylostoma spp. and the A. caninum benzimidazole treatment resistance associated F167Y polymorphism using molecular diagnostics was obtained in a large population of dogs from the United States and Canada. Real-time PCR (qPCR) for Ancylostoma spp. and allele-specific qPCR detecting a single nucleotide polymorphism (SNP) F167Y was used in 262,872 canine stool samples collected between March and December of 2022. Ancylostoma spp. was found at an overall prevalence of 2.5% (6538/262,872), with the highest prevalence in the Southern US, 4.4% (4490/103,095), and the lowest prevalence in Canada 0.6% (101/15,829). The A. caninum F167Y polymorphism was found with the highest prevalence (13.4%, n = 46/343) in the Western US and the lowest in Canada at 4.1% (4/97). The F167Y polymorphism was detected every month over the 10-month collection period. Seasonal distribution showed a peak in June for both Ancylostoma spp. (3.08%, 547/17,775) and A. caninum F167Y (12.25%, 67/547). However, the A. caninum F167Y polymorphism prevalence was highest in September (13.9%, 119/856). Age analysis indicates a higher prevalence of both hookworm infections and occurrence of resistant isolates in puppies. The breeds with the highest F167Y polymorphism prevalence in Ancylostoma spp. detected samples were poodles (28.9%), followed by Bernese Mountain dogs (25%), Cocker spaniels (23.1%), and greyhounds (22.4%). Our data set describes widespread geographic distribution of the A. caninum benzimidazole resistance associated F167Y polymorphism in the United States and Canada, with no clear seasonality compared to the Ancylostoma spp. prevalence patterns. The F167 polymorphism was present in all geographic areas with detected hookworms, including Canada. Our study highlights that the F167Y polymorphism is represented in many dog breeds, including greyhounds.

On diagnostic accuracy measure with cut-points criterion for ordinal disease classification based on concordance and discordance.

The accuracy of a diagnostic test has always been essential in detecting disease staging. Many diagnostic tests of accuracy measures are used in binary diagnosis tests. Some measures apply to multi-stage diagnosis. Yet, there are limitations to the implementation, and the performance highly depends on the distribution of diagnostic outcomes. Another essential aspect of medical diagnostic testing using biomarkers is to find an optimal cut-point that categorizes a patient as diseased or healthy. This aspect was extended to the diseases with more than two stages. We propose a diagnostic accuracy measure and optimal cut-points selection (CD), using concordance and discordance for k-stages diseases. The CD measure uses the classification agreement and disagreement between tests outcomes and diseases stages. Simulations for power studies suggest that CD can detect the differences between the null and alternative hypotheses that other methods cannot for some scenarios. Simulation results indicate that using CD measures to select optimal cut-points can provide relatively high correct classification rates than the existing measures and more balanced accurate classification rates than the generalized Youden Index (GYI). An illustration is provided using the ANDI data to choose biomarkers for diagnosing Alzheimer's Disease (AD) and select optimal cut-points for the chosen biomarkers.

Evolution of Physical Training in Police Academies: Comparing Fitness Variables.

The purpose of this study was to evaluate the effectiveness of three different physical training approaches to improving cadets' fitness variables. Retrospective data for male and female land management law enforcement officers attending a 15-week training program at three separate time points were provided for analysis. The time points reflected the three different training approaches, including calisthenic training (CT) = 83, functional fitness training (FT) = 90, and strength training (ST) = 110. Inferential data analysis was used to find which mode of exercise had the greatest impact on body composition, cardiovascular endurance, muscular strength, agility, and flexibility. All groups displayed decreases in body fat percentage, with weight loss being more significant within the CT and FT groups, while the ST group increased in body weight. The CT group had the greatest flexibility increases compared to the FT and ST groups. ST training elicited significantly smaller changes in cardiovascular endurance than the FT and CT groups. ST training showed greater improvements in lean mass, while CT and FT showed greater increases in flexibility and endurance. These results suggest that training protocols can increase performance and optimize the abilities to perform job tasks in tactical athletes.

The Impact of Gloves and Occupational Tasks on Handgrip Strength in Structural Firefighters.

Adequate handgrip strength (HGS) is important to safely perform fireground tasks. However, there is limited research describing the deleterious impact of glove use and fatigue from occupational tasks on HGS. Therefore, the aims of this investigation were to quantify the impact of glove use and occupational tasks on HGS, to explore the relationship between HGS versus the glove and task-induced decrement in HGS, and to evaluate the relationship between HGS and decrement in HGS versus occupational performance. Fourteen (Male: n = 13) career structural firefighters (Age: 35.5 ± 7.2 yr) performed a maximal isometric HGS assessment with and without gloves before and immediately following completion of a simulated fireground test (SFGT). General linear model with written contrast was used to identify significant differences in HGS between conditions. Pearson Correlations were used to describe bivariate relationships between the decrements in HGS and occupational task times. Significance was set at p < 0.05. There were significant main effects indicating that gloves, performing occupational tasks, and their combined effects decreased HGS (p < 0.001 for all). There were strong inverse relationships between baseline (barehanded) HGS versus the decrement in HGS from donning gloves (r = -0.82, p < 0.001) and from performing occupational tasks with gloves (r = -0.61, p = 0.021). Baseline HGS and the decrement in HGS due to wearing gloves and performing occupational tasks were not correlated to the timed completion of occupational tasks (p ≥ 0.27). These findings suggest that the use of regulation fire gloves and work-induced fatigue reduces HGS and these decrements are related to HGS. Practitioners are encouraged to utilize training strategies to optimize HGS among structural firefighters.

The Use of Penalized Regression Analysis to Identify County-Level Demographic and Socioeconomic Variables Predictive of Increased COVID-19 Cumulative Case Rates in the State of Georgia.

Systemic inequity concerning the social determinants of health has been known to affect morbidity and mortality for decades. Significant attention has focused on the individual-level demographic and co-morbid factors associated with rates and mortality of COVID-19. However, less attention has been given to the county-level social determinants of health that are the main drivers of health inequities. To identify the degree to which social determinants of health predict COVID-19 cumulative case rates at the county-level in Georgia, we performed a sequential, cross-sectional ecologic analysis using a diverse set of socioeconomic and demographic variables. Lasso regression was used to identify variables from collinear groups. Twelve variables correlated to cumulative case rates (for cases reported by 1 August 2020) with an adjusted r squared of 0.4525. As time progressed in the pandemic, correlation of demographic and socioeconomic factors to cumulative case rates increased, as did number of variables selected. Findings indicate the social determinants of health and demographic factors continue to predict case rates of COVID-19 at the county-level as the pandemic evolves. This research contributes to the growing body of evidence that health disparities continue to widen, disproportionality affecting vulnerable populations.

Adverse childhood experiences affect sleep duration for up to 50 years later.

STUDY OBJECTIVES: The main objective for this study was to assess the association of adverse childhood experiences (ACEs) and subsequent short sleep duration among adults. METHODS: This cross-sectional examination used data from the 2011 Behavioral Risk Factor Surveillance System, a nationwide telephone-administered survey. Participants completed a standardized questionnaire to report childhood experiences of abuse, neglect, household challenges, and sleep time. Multinominal logistic regression analyses included survey weighting procedures and adjusted for age, race, education, income, sex, and body mass index; associations were also examined by age strata, using age as a proxy for time since ACEs occurred. RESULTS: Complete data were available for 22 403 adults (mean age = 46.66 years) including 14 587 (65%) with optimum sleep duration (7-9 h/night) and 2069 (9%) with short sleep duration (<6 h/night). Compared with adults with optimum sleep duration, the number of ACEs was associated with the odds of short sleep duration (odds ratio [OR] = 1.22, 95% CI = 1.16 to 1.28), and the odds increased as the number of ACEs increased. The association held for each decade of age until the 60s, although the magnitude attenuated. Mental health challenges or poor physical health did not account for the association. CONCLUSION: ACEs increased the odds of chronic short sleep duration during adulthood and showed both a time-dependent and dose-response nature. These associations were independent of self-reported mental health challenges or poor physical health. The association of ACEs with short sleep duration throughout the adult lifespan emphasizes the importance of child health and identifying underlying psychological challenges in adults with sleep difficulties.

A Serious Flaw in Nutrition Epidemiology: A Meta-Analysis Study.

Background Many researchers have studied the relationship between diet and health. Specifically, there are papers showing an association between the consumption of sugar sweetened beverages and Type 2 diabetes. Many meta-analyses use individual studies that do not attempt to adjust for multiple testing or multiple modeling. Hence the claims reported in a meta-analysis paper may be unreliable as the base papers do not ensure unbiased statistics. Objective Determine (i) the statistical reliability of 10 papers and (ii) indirectly the reliability of the meta-analysis study. Method We obtained copies of each of the 10 papers used in a metaanalysis paper and counted the numbers of outcomes, predictors, and covariates. We estimate the size of the potential analysis search space available to the authors of these papers; i. e. the number of comparisons and models available. The potential analysis search space is the number of outcomes times the number of predictors times 2 c , where c is the number of covariates. This formula was applied to information found in the abstracts (Space A) as well as the text (Space T) of each base paper. Results The median and range of the number of comparisons possible across the base papers are 6.5 and (2 12,288), respectively for Space A, and 196,608 and (3072-117,117,952), respectively for Space T. It is noted that the median of 6.5 for Space A may be misleading as each study has 60-165 foods that could be predictors. Conclusion Given that testing is at the 5% level and the number of comparisons is very large, nominal statistical significance is very weak support for a claim. The claims in these papers are not statistically supported and hence are unreliable so the meta-analysis paper is also unreliable.

Georgia's collaborative approach to expanding mosquito surveillance in response to Zika virus: a case study.

Zika virus (ZIKV) was declared an international public health emergency by the World Health Organization on February 1, 2016. Due to the known and estimated range of the ZIKV mosquito vectors, southern and central US states faced increased risk of ZIKV transmission. With the state of Georgia hosting the world's busiest international airport, a climate that supports the ZIKV vectors, and limited surveillance (13 counties) and response capacity, the Department of Public Health (DPH) was challenged to respond and prevent ZIKV transmission. This case study describes and evaluates the state's surveillance capacity before and after the declaration of ZIKV as a public health emergency. METHOD: We analyzed surveillance data from the DPH to compare the geographical distribution of counties conducting surveillance, total number, and overall percentage of mosquito species trapped in 2015 to 2016. Counties conducting surveillance before and after the identification of the ZIKV risk were mapped using ArcMap 10.4.1. Using SAS (version 9.2) (SAS Institute, Inc, Cary, NC), we performed the independent 2 sample t test to test for differences in prevalence in both years, and a χ² analysis to test for differences between numbers of species across the 13 counties. In addition, weighted frequency counts of mosquitoes were used to test (χ²) an association between major mosquito vector species and 7 urban counties. Lastly, using data from 2012-2016, a time-trend analysis was conducted to evaluate temporal trends in species prevalence. RESULTS: From 2015 to 2016, surveillance increased from 13 to 57 (338% increase) counties geographically dispersed across Georgia. A total of 76,052 mosquitoes were trapped and identified in 2015 compared to 144,731 (90.3% increase) in 2016. Significant differences between species (P<.001) and significant associations (P<.0001) between 7 urban counties and major mosquito vectors were found. Significant differences in prevalence were found between several species and year highlighting species-year temporal trends. CONCLUSIONS: The DPH collaborative response to ZIKV allowed a rapid increase in its surveillance footprint. Existing and new partnerships were developed with the military and local health departments to expand and share data. This additional surveillance data allowed DPH to make sound public health decisions regarding mosquito-borne disease risks and close gaps in data related to vector distribution.