Oral care practices and hospital-acquired pneumonia prevention: A national survey of Australian nurses.

BACKGROUND: Hospital-acquired pneumonia (HAP) also known as non-ventilator associated pneumonia, is one of the most common infections acquired in hospitalised patients. Improving oral hygiene appears to reduce the incidence of HAP. This study aimed to describe current practices, barriers and facilitators, knowledge and educational preferences of registered nurses performing oral health care in the Australian hospital setting, with a focus on the prevention of HAP. We present this as a short research report. METHODS: We undertook a cross sectional online anonymous survey of Australian registered nurses. Participants were recruited via electronic distribution through existing professional networks and social media. The survey used was modified from an existing survey on oral care practice. RESULTS: The survey was completed by 179 participants. Hand hygiene was considered a very important strategy to prevent pneumonia (n = 90, 58%), while 45% (n = 71) felt that oral care was very important. The most highly reported barriers for providing oral care included: an uncooperative patient; inadequate staffing; and a lack of oral hygiene requisite. Patients' reminders, prompts and the provision of toothbrushes were common ways believed to help facilitate improvements in oral care. CONCLUSION: Findings from this survey will be used in conjunction with consumer feedback, to help inform a planned multi-centre randomised trial, the Hospital Acquired Pneumonia PrEveNtion (HAPPEN) study, aimed at reducing the incidence of HAP. Findings may also be useful for informing studies and quality improvement initiatives aimed at improving oral care to reduce the incidence of HAP.

Hemorrhage and thrombosis in COVID-19-patients supported with extracorporeal membrane oxygenation: an international study based on the COVID-19 critical care consortium.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a rescue therapy in patients with severe acute respiratory distress syndrome (ARDS) secondary to COVID-19. While bleeding and thrombosis complicate ECMO, these events may also occur secondary to COVID-19. Data regarding bleeding and thrombotic events in COVID-19 patients on ECMO are sparse. METHODS: Using the COVID-19 Critical Care Consortium database, we conducted a retrospective analysis on adult patients with severe COVID-19 requiring ECMO, including centers globally from 01/2020 to 06/2022, to determine the risk of ICU mortality associated with the occurrence of bleeding and clotting disorders. RESULTS: Among 1,248 COVID-19 patients receiving ECMO support in the registry, coagulation complications were reported in 469 cases (38%), among whom 252 (54%) experienced hemorrhagic complications, 165 (35%) thrombotic complications, and 52 (11%) both. The hazard ratio (HR) for Intensive Care Unit mortality was higher in those with hemorrhagic-only complications than those with neither complication (adjusted HR = 1.60, 95% CI 1.28-1.99, p < 0.001). Death was reported in 617 of the 1248 (49.4%) with multiorgan failure (n = 257 of 617 [42%]), followed by respiratory failure (n = 130 of 617 [21%]) and septic shock [n = 55 of 617 (8.9%)] the leading causes. CONCLUSIONS: Coagulation disorders are frequent in COVID-19 ARDS patients receiving ECMO. Bleeding events contribute substantially to mortality in this cohort. However, this risk may be lower than previously reported in single-nation studies or early case reports. Trial registration ACTRN12620000421932 ( https://covid19.cochrane.org/studies/crs-13513201 ).

Perceived Barriers to Physical Activity Among Youth Living in Rural and Urban Canadian Communities: A Nationally Representative Cross-Sectional Study.

BACKGROUND: We used nationally representative data to explore associations among location of residence (rural/urban) and perceived barriers to physical activity (PA) in Canadian youth. METHODS: We analyzed the 2017 Canadian Community Health Survey, Barriers to Physical Activity Rapid Response data for 12- to 17-year-old youth. Nine items from the survey assessing perceived barriers to PA were combined into 3 barrier domains: resources, motivational, and socioenvironmental. The likelihood of reporting barriers to PA based on rural-urban location was examined using survey-weighted binary logistic regression following a model fitting approach. Sociodemographic factors were modeled as covariates and tested in interaction with location. For each barrier domain, we derived the best-fitting model with fewest terms. RESULTS: There were no location-specific effects related to reporting any barrier or motivation-related PA barriers. We found a sex by location interaction predicting the likelihood of reporting resource-related barriers. Rural boys were less likely to report resource-related barriers compared with urban boys (odds ratio [OR] = 0.42 [0.20, 0.88]). Rural girls were more likely to report resource-related barriers compared with boys (OR = 3.72 [1.66, 8.30]). Regarding socioenvironmental barriers, we observed a significant body mass index by location interaction demonstrating that rural youth with body mass index outside the "normal range" showed a higher likelihood of reporting socioenvironmental barriers compared with urban youth (OR = 2.38 [1.32, 4.30]). For urban youth, body mass index was unrelated to reporting socioenvironmental barriers (OR = 1.07 [0.67, 1.71]). CONCLUSION: PA barriers are not universal among Canadian youth. Our analyses highlight the importance of testing interactions in similar studies as well as considering key sociodemographic characteristics when designing interventions.

Comparative analysis of novel esophageal pressure monitoring catheters versus commercially available alternatives in a biomechanical model of the thoracic cavity.

Transpulmonary pressure can be estimated using esophageal balloon (EB) catheters, which come in a variety of manufacturing configurations. We assessed the performance of novel polyurethane EB designs, Aspisafe NG and NG+, against existing alternatives. We created a biomechanical model of the chest cavity using a plastic chamber and an ex-vivo porcine esophagus. The chamber was pressurized (- 20 and + 20 cmH2O) to simulate pleural pressures. We conducted tests with various EB inflation volumes and measured transesophageal pressure (TEP). TEP measurement was defined as accurate when the difference between pressure within the EB and chamber was 0 ± 1 cmH2O. We computed the minimal (Vaccuracy-min) and maximal (Vaccuracy-max) EB inflation volumes of accuracy. Inflation volumes were further validated using a surrogate method derived by the clinically validated positive pressure occlusion test (PPOT). When the esophageal balloons were filled with inflation volumes within the range provided by the manufacturers, the accuracy of TEP measurements was marginal. Our tests found median Vaccuracy-min across EB of 0.00-0.50 mL (p = 0.130), whereas Vaccuracy-max ranged 0.50-2.25 mL (p = 0.002). Post PPOT validation, median TEP was - 0.4 cmH2O (- 1.5 to 0.3) (p < 0.001 among catheters). The Aspisafe NG and NG+ were accurate in 81.7% and 77.8% of the measurements, respectively. We characterized two new EBs, which demonstrated good benchtop accuracy in TEP measurements. However, accuracy was notably influenced by the precise selection of EB inflation volumes.

Work outcomes in public safety personnel after potentially traumatic events: A systematic review.

BACKGROUND: It is well documented that public safety personnel are exposed to potentially traumatic events (PTEs) at elevated frequency and demonstrate higher prevalence of trauma-related symptoms compared to the general population. Lesser studied to date are the organizational consequences of workplace PTE exposure and associated mental health outcomes such as acute/posttraumatic stress disorder (ASD/PTSD), depression, and anxiety. METHODS: The present review synthesizes international literature on work outcomes in public safety personnel (PSP) to explore whether and how PTE and trauma-related symptoms relate to workplace outcomes. A total of N = 55 eligible articles examining PTE or trauma-related symptoms in relation to work outcomes were systematically reviewed using best-evidence narrative synthesis. RESULTS: Three primary work outcomes emerged across the literature: absenteeism, productivity/performance, and costs to organization. Across n = 21 studies of absenteeism, there was strong evidence that PTE or trauma-related symptoms are associated with increased sickness absence. N = 27 studies on productivity/performance demonstrated overall strong evidence of negative impacts in the workplace. N = 7 studies on cost to organizations demonstrated weak evidence that PTE exposure or trauma-related mental health outcomes are associated with increased cost to organization. CONCLUSIONS: Based on available evidence, the experience of workplace PTE or trauma-related symptoms is associated with negative impact on PSP occupational functioning, though important potential confounds (e.g., organizational strain and individual risk factors) remain to be more extensively investigated.

Sex differences in post-acute neurological sequelae of SARS-CoV-2 and symptom resolution in adults after coronavirus disease 2019 hospitalization: an international multi-centre prospective observational study.

Although it is known that coronavirus disease 2019 can present with a range of neurological manifestations and in-hospital complications, sparse data exist on whether these initial neurological symptoms of coronavirus disease 2019 are closely associated with post-acute neurological sequelae of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2; PANSC) and whether female versus male sex impacts symptom resolution. In this international, multi-centre, prospective, observational study across 407 sites from 15 countries (30 January 2020 to 30 April 2022), we report the prevalence and risk factors of PANSC among hospitalized adults and investigate the differences between males and females on neurological symptom resolution over time. PANSC symptoms included altered consciousness/confusion, fatigue/malaise, anosmia, dysgeusia and muscle ache/joint pain, on which information was collected at index hospitalization and during follow-up assessments. The analysis considered a time to the resolution of individual and all neurological symptoms. The resulting times were modelled by Weibull regression, assuming mixed-case interval censoring, with sex and age included as covariates. The model results were summarized as cumulative probability functions and age-adjusted and sex-adjusted median times to resolution. We included 6862 hospitalized adults with coronavirus disease 2019, who had follow-up assessments. The median age of the participants was 57 years (39.2% females). Males and females had similar baseline characteristics, except that more males (versus females) were admitted to the intensive care unit (30.5 versus 20.3%) and received mechanical ventilation (17.2 versus 11.8%). Approximately 70% of patients had multiple neurological symptoms at the first follow-up (median = 102 days). Fatigue (49.9%) and myalgia/arthralgia (45.2%) were the most prevalent symptoms of PANSC at the initial follow-up. The reported prevalence in females was generally higher (versus males) for all symptoms. At 12 months, anosmia and dysgeusia were resolved in most patients, although fatigue, altered consciousness and myalgia remained unresolved in >10% of the cohort. Females had a longer time to the resolution (5.2 versus 3.4 months) of neurological symptoms at follow-up for those with more than one neurological symptom. In the multivariable analysis, males were associated with a shorter time to the resolution of symptoms (hazard ratio = 1.53; 95% confidence interval = 1.39-1.69). Intensive care unit admission was associated with a longer time to the resolution of symptoms (hazard ratio = 0.68; 95% confidence interval = 0.60-0.77). Post-discharge stroke was uncommon (0.3% in females and 0.5% in males). Despite the methodological challenges involved in the collection of survey data, this international multi-centre prospective cohort study demonstrated that PANSC following index hospitalization was high. Symptom prevalence was higher and took longer to resolve in females than in males. This supported the fact that while males were sicker during acute illness, females were disproportionately affected by PANSC.

BCAR4 Expression as a Predictive Biomarker for Endocrine Therapy Resistance in Breast Cancer.

BACKGROUND: Breast cancer, particularly the estrogen receptor positive (ER+) subtype, remains a leading cause of cancer-related death among women. Endocrine therapy is the most effective treatment for ER+ breast cancer; however, the development of resistance presents a significant challenge. This study explored the role of the breast cancer antiestrogen resistance 4 (BCAR4) gene as a potential driver of resistance and a pivotal biomarker in breast cancer. PATIENTS AND METHODS: The researchers undertook a comprehensive analysis of 1743 patients spanning 6 independent cohorts. They examined the association of BCAR4 expression with patient outcomes across all breast cancer types and the PAM50 molecular subtypes. The relationship between elevated BCAR4 expression and resistance to endocrine therapy including AIs, the prevailing standard-of-care for endocrine therapy, was also investigated. RESULTS: This meta-analysis corroborated the link between BCAR4 expression and adverse outcomes as well as resistance to endocrine therapy in breast cancer. Notably, BCAR4 expression is clinically significant in luminal A and B subtypes. Additionally, an association between BCAR4 expression and resistance to AI treatment was discerned. CONCLUSION: This study expands on previous findings by demonstrating that BCAR4 expression is associated with resistance to newer therapies. The identification of patients with intrinsic resistance to hormone therapy is crucial to avoid ineffective treatment strategies. These findings contribute to our understanding of endocrine therapy resistance in breast cancer and could potentially guide the development of more effective treatment strategies.

Variability of oxygen requirements in critically ill COVID-19 patients.

Background: The global scarcity of medical oxygen has proven to be catastrophic during the surges in COVID-19 cases over the past two years, with the heaviest burden felt in low- and middle-income countries. Despite its criticality, data and analyses of oxygen consumption, even for typical clinical cases, are missing. Consequently, planning oxygen needs, particularly with variable surges in COVID-19 cases, has presented a substantial challenge to policymakers and hospital decision-makers. Methods: We performed a sub-analysis of the COVID-19 Critical Care Consortium database assessing the oxygen consumption requirements of COVID-19 patients admitted to intensive care units between February 2020 and October 2021. We calculated descriptive statistics for oxygen flow-rates, stratified by oxygen supplementation method, and developed a multi-state model for estimating the frequency, therapy duration, probability of transition, and number of oxygen therapy modes per patient. Results: Overall, 12 429 patients from 35 countries received oxygen support on at least one day of their hospitalisation. Of the patients with measurable flow rates, 6142 received invasive mechanical ventilation, 838 received high-flow nasal oxygen, and 257 received both modalities. The median flow rate for mechanical ventilation was 3.2 L per minute (interquartile range (IQR) = 2.0-4.9), with a median duration of 12 days (IQR = 6-24), while the median flow rate for high-flow nasal cannula was 40 L per minute (IQR = 15-55), with a median duration of three days (IQR = 2-6). Conclusions: Oxygen consumption among critical COVID-19 patients varies by mode of delivery (invasive ventilation vs high-flow nasal cannula), across patients, and over treatment duration. Therefore, it is essential that health facilities routinely monitor oxygen utilization to better inform oxygen delivery system design and regular supply planning. Registration: ClinicalTrials.gov: CTG2021-01 ACTRN12620000421932.

Mental health screening and referral to treatment in dental practices: A scoping review.

OBJECTIVE: The purpose of this study was to conduct a scoping review to examine and summarize the characteristics of research related to mental health (MH) screenings and/or referrals to treatment in dental practices. METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for Scoping Reviews and searched multiple databases for terms connected with dental care, MH concerns, screening, and referral. Included articles: (1) described care provided in a dental practice, (2) described a situation where the patient is experiencing the potential MH problem, (3) did not involve dental anxiety exclusively, and (4) involved some form of MH screening and/or referral to treatment. Article analysis included a summary of key study characteristics, types of evidence, study design, and central concepts and definitions. RESULTS: The search generated 2050 records, with 26 ultimately included. Most studies involved only adults (22, 85%), but only three (12%) reported on rurality (two urban; one mixed) and only two each (8%) reported race or ethnicity. Fifteen (58%) articles were prospective and 11 (42%) were retrospective. The studies varied widely in study designs, from 11 (42%) cross-sectional methodologies to only one (4%) randomized controlled trial. Thirty-four screening tools were used to screen for symptoms of 43 MH conditions, with depression and anxiety screened for most frequently. Few articles discussed making referrals, practice workflows, or follow-up outcomes. CONCLUSIONS: Included studies provide evidence of viable options for dental practitioners regarding MH screening, referring, and conducting follow-up, but lack specificity regarding these processes. Overall, more research is needed to clarify what workflows are most efficient for dental practitioners and efficacious in identifying patients with MH concerns.

Groundwater is a hidden global keystone ecosystem.

Groundwater is a vital ecosystem of the global water cycle, hosting unique biodiversity and providing essential services to societies. Despite being the largest unfrozen freshwater resource, in a period of depletion by extraction and pollution, groundwater environments have been repeatedly overlooked in global biodiversity conservation agendas. Disregarding the importance of groundwater as an ecosystem ignores its critical role in preserving surface biomes. To foster timely global conservation of groundwater, we propose elevating the concept of keystone species into the realm of ecosystems, claiming groundwater as a keystone ecosystem that influences the integrity of many dependent ecosystems. Our global analysis shows that over half of land surface areas (52.6%) has a medium-to-high interaction with groundwater, reaching up to 74.9% when deserts and high mountains are excluded. We postulate that the intrinsic transboundary features of groundwater are critical for shifting perspectives towards more holistic approaches in aquatic ecology and beyond. Furthermore, we propose eight key themes to develop a science-policy integrated groundwater conservation agenda. Given ecosystems above and below the ground intersect at many levels, considering groundwater as an essential component of planetary health is pivotal to reduce biodiversity loss and buffer against climate change.

Effect of a Financial Education and Coaching Program for Low-Income, Single Mother Households on Child Health Outcomes.

The financial difficulties of parents have a negative impact on the health of their children. This problem is more pronounced in single mother families. There is limited research on low-income, single mothers and how interventions to help them address financial difficulties may also benefit their children. The purpose of this study was to evaluate the effect of a year-long financial education and coaching program on school absenteeism and health care utilization of children in employed, low-income, single mother households. This was a post hoc analysis of the Finances First study, a randomized controlled trial conducted in 2017-2020 examining the impact of a financial coaching and education program on economic stability and health outcomes in 345 low-income, single mothers. Either generalized estimating equations (GEEs) or generalized linear mixed models (GLMMs) were used to account for relationships between participants. For the continuous outcomes of child absenteeism, physician visits, emergency room visits, and hospitalization days, a linear mixed-effects model was used. The Finances First study demonstrated improvements in various financial strain measures. Compared to the control group, children of intervention group participants experienced 1 fewer day of school absence (p = 0.049) and 1 fewer physician visit (p = 0.032) per year, but no impact was seen on emergency room visits (p = 0.55) or hospitalizations (p = 0.92). Addressing social determinants of health in parents is necessary for improving child health outcomes.

Effects of transfusing older red blood cells and platelets on obstetric patient outcomes: A retrospective cohort study.

OBJECTIVE: To investigate associations between transfusion of blood products close to the end of shelf-life and clinical outcomes in obstetric inpatients. METHODS: Mortality and morbidity were compared in patients transfused exclusively with red blood cells (RBC) stored for less than 21 days (fresh) versus RBC stored for 35 days or longer (old), and platelets (PLT) stored for 3 days or fewer (fresh) versus 4 days or longer (old) in Queensland, Australia from 2007 to 2013. Multivariable models were used to examine associations between these groups of blood products and clinical end points. RESULTS: There were 3371 patients who received RBC and 280 patients who received PLT of the eligible storage durations. Patients transfused with old RBC received fewer transfusions (2.7 ± 1.8 vs. 2.3 ± 1.0 units; P < 0.001). However, a higher rate of single-unit transfusions was also seen in those patients who exclusively received old RBC (252 [9.3%] vs. 92 [13.7%]; P = 0.003). Comparison of fresh vs. old blood products revealed no differences in the quantities of transfused RBC (9.5 ± 5.9 vs. 9.1 ± 5.2 units; P = 0.680) or PLT (1.5 ± 0.8 vs. 1.4 ± 1.1 units; P = 0.301) as well as the length of hospital stay for RBC (3 [2-5] vs. 3 [2-5] days; P = 0.124) or PLT (5 [4-8] vs. 6 [4-9] days; P = 0.120). CONCLUSION: Transfusing exclusively older RBC or PLT was not associated with increased morbidity or mortality.

Race and ethnicity in the COVID-19 Critical Care Consortium: demographics, treatments, and outcomes, an international observational registry study.

BACKGROUND: Improving access to healthcare for ethnic minorities is a public health priority in many countries, yet little is known about how to incorporate information on race, ethnicity, and related social determinants of health into large international studies. Most studies of differences in treatments and outcomes of COVID-19 associated with race and ethnicity are from single cities or countries. METHODS: We present the breadth of race and ethnicity reported for patients in the COVID-19 Critical Care Consortium, an international observational cohort study from 380 sites across 32 countries. Patients from the United States, Australia, and South Africa were the focus of an analysis of treatments and in-hospital mortality stratified by race and ethnicity. Inclusion criteria were admission to intensive care for acute COVID-19 between January 14th, 2020, and February 15, 2022. Measurements included demographics, comorbidities, disease severity scores, treatments for organ failure, and in-hospital mortality. RESULTS: Seven thousand three hundred ninety-four adults met the inclusion criteria. There was a wide variety of race and ethnicity designations. In the US, American Indian or Alaska Natives frequently received dialysis and mechanical ventilation and had the highest mortality. In Australia, organ failure scores were highest for Aboriginal/First Nations persons. The South Africa cohort ethnicities were predominantly Black African (50%) and Coloured* (28%). All patients in the South Africa cohort required mechanical ventilation. Mortality was highest for South Africa (68%), lowest for Australia (15%), and 30% in the US. CONCLUSIONS: Disease severity was higher for Indigenous ethnicity groups in the US and Australia than for other ethnicities. Race and ethnicity groups with longstanding healthcare disparities were found to have high acuity from COVID-19 and high mortality. Because there is no global system of race and ethnicity classification, researchers designing case report forms for international studies should consider including related information, such as socioeconomic status or migration background. *Note: "Coloured" is an official, contemporary government census category of South Africa and is a term of self-identification of race and ethnicity of many citizens of South Africa.

Work, travel, or leisure: comparing domain-specific physical activity patterns based on rural-urban location in Canada.

BACKGROUND: Physical activity occurs across various domains including leisure/recreation, for transportation, or for work or household reasons. Rural and urban active living environments are characterized by different opportunities for physical activity within each domain which may translate into different patterns of behavior. The aim of this study was to compare rural-urban differences in physical activity across different domains, and explore interactions between sociodemographic factors, physical activity domains, and rurality. METHODS: We used self-reported data collected across three physical activity domains (active transportation, recreation, occupational/household) and relevant sociodemographic variables from the Canadian Community Health Survey. Adjusting for sociodemographic factors, we did two separate cross-sectional analyses: 1) binary logistic regression to determine the odds of reporting any activity in each domain, and 2) ordinary least squares regression using the sub-samples reporting > 0 min per week of activity to compare how much activity was reported in each domain. RESULTS: Our final survey weighted sample of Canadian adults (mean age 47.4 years) was n = 25,669,018 (unweighted n = 47,266). Rural residents were less likely to report any active transportation (OR = 0.59, 95% CI [0.51, 0.67], p < .0001). For recreational physical activity, rural males had lower odds (OR = 0.75, 95% CI [0.67, 0.83], p < .0001) and rural females had higher odds (OR = 1.19, 95% CI [1.08, 1.30], p = .0002) of reporting any participation compared to urban residents. Rural males (OR = 1.90, 95% CI [1.74, 2.07], p < .0001) and females (OR = 1.33, 95% CI [1.21, 1.46], p < .0001) had higher odds of reporting any occupational or household physical activity. CONCLUSIONS: Urban residents tend to participate in more active transportation, while rural residents participate in more occupational or household physical activity. Location-based differences in physical activity are best understood by examining multiple domains and must include appropriate sociodemographic interactions, such as income and sex/gender.

A multicompartment population PK model to predict tenofovir and emtricitabine mucosal tissue concentrations for HIV prevention.

A priori use of mathematical modeling and simulation to predict outcomes from incomplete adherence or reduced frequency dosing strategies may mitigate the risk of clinical trial failure with HIV pre-exposure prophylaxis regimens. We developed a semi-physiologic population pharmacokinetic model for two antiretrovirals and their active intracellular metabolites in three mucosal tissues using pharmacokinetic data from a phase I, dose-ranging study. Healthy female volunteers were given a single oral dose of tenofovir disoproxil fumarate (150, 300, or 600 mg) or emtricitabine (100, 200, or 400 mg). Simultaneous co-modeling of all data was performed on a Linux cluster. A 16 compartment, bolus input, linear kinetic model best described the data, containing 986 observations in 23 individuals across three matrices and four analytes. Combined with a defined efficacious concentration target in mucosal tissues, this model can be used to optimize the dose and dosing frequency through Monte-Carlo simulations.

Characteristics and outcomes of patients with severe COVID-19 in Indonesia: Lessons from the first wave.

BACKGROUND: Indonesia's national response to COVID-19 evolved rapidly throughout 2020. Understanding pandemic response and outcomes is crucial for better mitigation strategies ahead. This study describes the characteristics and outcomes of patients admitted to ICU during the early stages of the pandemic. METHODS: This is a multi-centre prospective observational study including patients from twelve collaborating hospitals in Indonesia. All patients were clinically suspected or laboratory-confirmed COVID-19 cases admitted to ICU between January 2020 and March 2021. The primary outcome was monthly ICU mortality. Descriptive statistics of patient characteristics and treatment were generated as secondary outcomes. RESULTS: From 559 subjects, the overall mortality was 68% and decreased over the study period, while the mortality of patients that received mechanical ventilation was 92%, consistently high over the study period. Fatal cases showed 2- and 4-day delays from symptoms onset to hospital admissions and ICU admissions, respectively. Evidence-backed approaches which could influence patient outcome, such as extracorporeal membrane oxygenation, prone positioning, renal replacement therapy, and neuromuscular blockade were scarcely administered. CONCLUSIONS: The mortality rate of COVID-19 patients in Indonesia was extremely high during the first major outbreak of disease, particularly in those mechanically ventilated. Delayed admission and unavailability of evidence-based approaches due to high burden on health facility during COVID-19 crisis could be addressed by efficient public health measures and enhancing health infrastructure to improve the future pandemic response.

Evidence of questionable research practices in clinical prediction models.

BACKGROUND: Clinical prediction models are widely used in health and medical research. The area under the receiver operating characteristic curve (AUC) is a frequently used estimate to describe the discriminatory ability of a clinical prediction model. The AUC is often interpreted relative to thresholds, with "good" or "excellent" models defined at 0.7, 0.8 or 0.9. These thresholds may create targets that result in "hacking", where researchers are motivated to re-analyse their data until they achieve a "good" result. METHODS: We extracted AUC values from PubMed abstracts to look for evidence of hacking. We used histograms of the AUC values in bins of size 0.01 and compared the observed distribution to a smooth distribution from a spline. RESULTS: The distribution of 306,888 AUC values showed clear excesses above the thresholds of 0.7, 0.8 and 0.9 and shortfalls below the thresholds. CONCLUSIONS: The AUCs for some models are over-inflated, which risks exposing patients to sub-optimal clinical decision-making. Greater modelling transparency is needed, including published protocols, and data and code sharing.