In health research publications, the number of authors is strongly associated with collective self-citations but less so with citations by others.

OBJECTIVE: . This study investigated the associations between the number of authors and collective self-citations versus citations by others. STUDY DESIGN AND SETTING: . We analyzed 88,594 health science articles published in 2015 and citations they received until 2020. The main variables were the number of authors, the number of citations by co-authors (collective self-citations), and the number of citations by others. RESULTS: . The number of authors correlated more strongly with the number of citations by co-authors than with citations by others (Spearman r 0.31 vs. 0.23; mutually adjusted r 0.26 vs. 0.12). The percentage of self-citations among all citations was 10.6% for single-authored articles, and increased gradually with the number of authors to 34.8% for ≥ 50 authors. Collective self-citations increased the proportion of articles reaching or exceeding 30 total citations by 0.7% for single-authored articles, but by 11.6% for articles written by ≥ 50 authors. CONCLUSIONS: . If citations by others reflect scientific utility, then another mechanism must explain the excess of collective self-citations observed for multi-authored articles. The results support the hypothesis that the authors' own motivations explain this excess. The evaluation of scientific utility should also be based on citations by others, excluding collective self-citations.

Authorship and citation patterns of highly cited biomedical researchers: a cross-sectional study.

BACKGROUND: Scientific productivity is often evaluated by means of cumulative citation metrics. Different metrics produce different incentives. The H-index assigns full credit from a citation to each coauthor, and thus may encourage multiple collaborations in mid-list author roles. In contrast, the Hm-index assigns only a fraction 1/k of citation credit to each of k coauthors of an article, and thus may encourage research done by smaller teams, and in first or last author roles. Whether H and Hm indices are influenced by different authorship patterns has not been examined. METHODS: Using a publicly available Scopus database, I examined associations between the numbers of research articles published as single, first, mid-list, or last author between 1990 and 2019, and the H-index and the Hm-index, among 18,231 leading researchers in the health sciences. RESULTS: Adjusting for career duration and other article types, the H-index was negatively associated with the number of single author articles (partial Pearson r -0.06) and first author articles (-0.08), but positively associated with the number of mid-list (0.64) and last author articles (0.21). In contrast, all associations were positive for the Hm-index (0.04 for single author articles, 0.18 for first author articles, 0.24 for mid-list articles, and 0.46 for last author articles). CONCLUSION: The H-index and the Hm-index do not reflect the same authorship patterns: the full-credit H-index is predominantly associated with mid-list authorship, whereas the partial-credit Hm-index is driven by more balanced publication patterns, and is most strongly associated with last-author articles. Since performance metrics may act as incentives, the selection of a citation metric should receive careful consideration.

Aortic Dilatation on the Edge of Dissection-Do We Operate Too Late? The Ratio between Ascending and Descending Aorta DiameteR (RADAR).

(1) Background: There is a need for a novel surrogate marker to ease decision making when facing ascending aortic dilatation. In this article, we study the ratio between ascending and descending aorta diameters as a potential one. (2) Methods: Retrospective observational cohort study, including all the patients who underwent surgery for acute type A aorta dissection (aTAAD) between January 2014 and September 2020 at our center. A total of 50 patients were included. Clinical and demographic data were collected. The anatomical measurements were made including orthogonal maximal diameters of the ascending and descending aorta, post-dissection whole circumference length (post-wCL), post-dissection true lumen circumference length (post-tCL), and surface and sphericity indices of the ascending and descending aorta. Pre-dissection ascending aorta diameter (pre-AAD) and pre-dissection descending aorta diameter (pre-DAD) were calculated as well as the ratio between them and compared with reference values. (3) Results: Of the pre-AAD patients, 96% had smaller than the recommended 55 mm. The ratio between the descending and ascending aorta pre-dissection diameters was significantly smaller compared to the reference value (0.657 ± 0.125 versus 0.745 ± 0.016 with a mean difference of -0.088 and a p < 0.001). (4) Conclusions: The 55 mm threshold for aorta maximal diameter is an insufficient criterion when assessing the risk of dissection. The ratio between DAD and AAD is a parameter worthy of analysis as a tool to stratify the risk of dissection.

Evidence of Lack of Treatment Efficacy Derived From Statistically Nonsignificant Results of Randomized Clinical Trials.

Importance: Many randomized clinical trials yield statistically nonsignificant results. Such results are difficult to interpret within the dominant statistical framework. Objective: To estimate the strength of evidence in favor of the null hypothesis of no effect vs the prespecified effectiveness hypothesis among nonsignificant primary outcome results of randomized clinical trials by application of the likelihood ratio. Design, Setting, and Participants: Cross-sectional study of statistically nonsignificant results for primary outcomes of randomized clinical trials published in 6 leading general medical journals in 2021. Outcome measures: The likelihood ratio for the null hypothesis of no effect vs the effectiveness hypothesis stated in the trial protocol (alternate hypothesis). The likelihood ratio quantifies the support that the data provide to one hypothesis vs the other. Results: In 130 articles that reported 169 statistically nonsignificant results for primary outcomes, 15 results (8.9%) favored the alternate hypothesis (likelihood ratio, <1), and 154 (91.1%) favored the null hypothesis of no effect (likelihood ratio, >1). For 117 (69.2%), the likelihood ratio exceeded 10; for 88 (52.1%), it exceeded 100; and for 50 (29.6%), it exceeded 1000. Likelihood ratios were only weakly correlated with P values (Spearman r, 0.16; P = .045). Conclusions: A large proportion of statistically nonsignificant primary outcome results of randomized clinical trials provided strong support for the hypothesis of no effect vs the alternate hypothesis of clinical efficacy stated a priori. Reporting the likelihood ratio may improve the interpretation of clinical trials, particularly when observed differences in the primary outcome are statistically nonsignificant.

A new clinical severity score for the management of acute small bowel obstruction in predicting bowel ischemia: a cohort study.

BACKGROUND: Small bowel obstruction (SBO) is a common hospital admission diagnosis. Identification of patients who will require a surgical resection because of a nonviable small bowel remains a challenge. Through a prospective cohort study, the authors aimed to validate risk factors and scores for intestinal resection, and to develop a practical clinical score designed to guide surgical versus conservative management. PATIENTS AND METHODS: All patients admitted for an acute SBO between 2004 and 2016 in the center were included. Patients were divided in three categories depending on the management: conservative, surgical with bowel resection, and surgical without bowel resection. The outcome variable was small bowel necrosis. Logistic regression models were used to identify the best predictors. RESULTS: Seven hundred and thirteen patients were included in this study, 492 in the development cohort and 221 in the validation cohort. Sixty-seven percent had surgery, of which 21% had small bowel resection. Thirty-three percent were treated conservatively. Eight variables were identified with a strong association with small bowel resection: age 70 years of age and above, first episode of SBO, no bowel movement for greater than or equal to 3 days, abdominal guarding, C-reactive protein greater than or equal to 50, and three abdominal computer tomography scanner signs: small bowel transition point, lack of small bowel contrast enhancement, and the presence of greater than 500 ml of intra-abdominal fluid. Sensitivity and specificity of this score were 65 and 88%, respectively, and the area under the curve was 0.84 (95% CI: 0.80-0.89). CONCLUSION: The authors developed and validated a practical clinical severity score designed to tailor management of patients presenting with an SBO.

REPRESENT: REPresentativeness of RESearch data obtained through the 'General Informed ConsENT'.

BACKGROUND: We assessed potential consent bias in a cohort of > 40,000 adult patients asked by mail after hospitalization to consent to the use of past, present and future clinical and biological data in an ongoing 'general consent' program at a large tertiary hospital in Switzerland. METHODS: In this retrospective cohort study, all adult patients hospitalized between April 2019 and March 2020 were invited to participate to the general consent program. Demographic and clinical characteristics were extracted from patients' electronic health records (EHR). Data of those who provided written consent (signatories) and non-responders were compared and analyzed with R studio. RESULTS: Of 44,819 patients approached, 10,299 (23%) signed the form. Signatories were older (median age 54 [IQR 38-72] vs. 44 years [IQR 32-60], p < .0001), more comorbid (2614/10,299 [25.4%] vs. 4912/28,676 [17.1%] with Charlson comorbidity index ≤ 4, p < .0001), and more often of Swiss nationality (6592/10,299 [64%] vs. 13,813/28,676 [48.2%], p < .0001). CONCLUSIONS: Our results suggest that actively seeking consent creates a bias and compromises the external validity of data obtained via 'general consent' programs. Other options, such as opt-out consent procedures, should be further assessed.

Adjustment for baseline characteristics in randomized trials using logistic regression: sample-based model versus true model.

BACKGROUND: Adjustment for baseline prognostic factors in randomized clinical trials is usually performed by means of sample-based regression models. Sample-based models may be incorrect due to overfitting. To assess whether overfitting is a problem in practice, we used simulated data to examine the performance of the sample-based model in comparison to a "true" adjustment model, in terms of estimation of the treatment effect. METHODS: We conducted a simulation study using samples drawn from a "population" in which both the treatment effect and the effect of the potential confounder were specified. The outcome variable was binary. Using logistic regression, we compared three estimates of the treatment effect in each situation: unadjusted, adjusted for the confounder using the sample, adjusted for the confounder using the true effect. Experimental factors were sample size (from 2 × 50 to 2 × 1000), treatment effect (logit of 0, 0.5, or 1.0), confounder type (continuous or binary), and confounder effect (logit of 0, - 0.5, or - 1.0). The assessment criteria for the estimated treatment effect were bias, variance, precision (proportion of estimates within 0.1 logit units), type 1 error, and power. RESULTS: Sample-based adjustment models yielded more biased estimates of the treatment effect than adjustment models that used the true confounder effect but had similar variance, accuracy, power, and type 1 error rates. The simulation also confirmed the conservative bias of unadjusted analyses due to the non-collapsibility of the odds ratio, the smaller variance of unadjusted estimates, and the bias of the odds ratio away from the null hypothesis in small datasets. CONCLUSIONS: Sample-based adjustment yields similar results to exact adjustment in estimating the treatment effect. Sample-based adjustment is preferable to no adjustment.

Prevalence of childhood exposure to intimate partner violence in low-income and lower-middle-income countries: a systematic review.

OBJECTIVE: To determine the proportion of children in low-income and lower-middle-income countries exposed to intimate partner violence (IPV). DESIGN: Systematic review. DATA SOURCES: PubMed, CINAHL, ERIC, PsycINFO, Web of Science, WHO Global Index Medicus, and Violence and Abuse Abstracts, hand searching of specialised journals from inception until 19 May 2019. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Primary quantitative studies that included a measure of self-reported exposure to IPV prior to age 18 and were conducted in low-income and lower-middle-income countries. DATA EXTRACTION AND SYNTHESIS: Data were screened, extracted and appraised by two independent reviewers. The prevalence estimates were pooled using a random-effects model. Outcomes included lifetime and past-year prevalence of childhood exposure to IPV. Meta-regression was used to explore heterogeneity. Publication bias was assessed using a funnel plot and Egger's regression test. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. RESULTS: Sixty-two studies with a total of 231 512 participants were included. Eighty-five lifetime prevalence estimates and 6 estimates of past-year prevalence were available for synthesis. The average lifetime prevalence of childhood exposure to IPV was 29% (95% CI 26% to 31%). The average past-year prevalence in children was 35% (95% CI 21% to 48%). The lifetime prevalence disaggregated by WHO regions ranged from 21% to 34%. There were no statistical differences in prevalence estimates between samples of men and women. CONCLUSION: Almost one-third of children in low-income and lower-middle-income countries have been exposed to IPV in their lifetime. There was large heterogeneity between estimates that was not explained by available study and sample characteristics. Our findings indicate that children's exposure to IPV in low-income and lower-middle-income countries is common and widespread; prevention of this major public health exposure should be a priority. PROSPERO REGISTRATION NUMBER: CRD42019119698.

Post-exposure Lopinavir-Ritonavir Prophylaxis versus Surveillance for Individuals Exposed to SARS-CoV-2: The COPEP Pragmatic Open-Label, Cluster Randomized Trial.

BACKGROUND: Since the beginning of the COVID-19 pandemic, no direct antiviral treatment is effective as post-exposure prophylaxis (PEP). Lopinavir/ritonavir (LPV/r) was repurposed as a potential PEP agent against COVID-19. METHODS: We conducted a pragmatic open-label, parallel, cluster-randomised superiority trial in four sites in Switzerland and Brazil between March 2020 to March 2021. Clusters were randomised to receive LPV/r PEP (400/100 mg) twice daily for 5 days or no PEP (surveillance). Exposure to SARS-CoV-2 was defined as a close contact of >15 minutes in <2 metres distance or having shared a closed space for ≥2 hours with a person with confirmed SARS-CoV-2 infection. The primary outcome is the occurrence of COVID-19 defined by a SARS-CoV-2 infection (positive oropharyngeal SARS-CoV-2 PCR and/or a seroconversion) and ≥1 compatible symptom within 21 days post-enrolment. ClinicalTrials.gov (Identifier: NCT04364022); Swiss National Clinical Trial Portal: SNCTP 000003732. FINDINGS: Of 318 participants, 157 (49.4%) were women; median age was 39 (interquartile range, 28-50) years. A total of 209 (179 clusters) participants were randomised to LPV/r PEP and 109 (95 clusters) to surveillance. Baseline characteristics were similar, with the exception of baseline SARS-CoV-2 PCR positivity, which was 3-fold more frequent in the LPV/r arm (34/209 [16.3%] vs 6/109 [5.5%], respectively). During 21-day follow-up, 48/318 (15.1%) participants developed COVID-19: 35/209 (16.7%) in the LPV/r group and 13/109 (11.9%) in the surveillance group (unadjusted hazard ratio 1.44; 95% CI, 0.76-2.73). In the primary endpoint analysis, which was adjuted for baseline imbalance, the hazard ratio for developing COVID-19 in the LPV/r group vs surveillance was 0.60 (95% CI, 0.29-1.26; p =0.18). INTERPRETATION: The role of LPV/r as PEP for COVID-19 remains unanswered. Although LPV/r over 5 days did not significantly reduce the incidence of COVID-19 in exposed individuals, we observed a change in the directionality of the effect in favour of LPV/r after adjusting for baseline imbalance. LPV/r for this indication merits further testing against SARS-CoV-2 in clinical trials. FUNDING: Swiss National Science Foundation (project no.: 33IC30_166819) and the Private Foundation of Geneva University Hospitals (Edmond Rothschild (Suisse) SA, Union Bancaire Privée and the Fondation pour la recherche et le traitement médical).

Physicians' Views and Agreement about Patient- and Context-Related Factors Influencing ICU Admission Decisions: A Prospective Study.

BACKGROUND: Single patient- and context-related factors have been associated with admission decisions to intensive care. How physicians weigh various factors and integrate them into the decision-making process is not well known. OBJECTIVES: First, to determine which patient- and context-related factors influence admission decisions according to physicians, and their agreement about these determinants; and second, to examine whether there are differences for patients with and without advanced disease. METHOD: This study was conducted in one tertiary hospital. Consecutive ICU consultations for medical inpatients were prospectively included. Involved physicians, i.e., internists and intensivists, rated the importance of 13 factors for each decision on a Likert scale (1 = negligible to 5 = predominant). We cross-tabulated these factors by presence or absence of advanced disease and examined the degree of agreement between internists and intensivists using the kappa statistic. RESULTS: Of 201 evaluated patients, 105 (52.2%) had an advanced disease, and 140 (69.7%) were admitted to intensive care. The mean number of important factors per decision was 3.5 (SD 2.4) for intensivists and 4.4 (SD 2.1) for internists. Patient's comorbidities, quality of life, preferences, and code status were most often mentioned. Inter-rater agreement was low for the whole population and after stratifying for patients with and without advanced disease. Kappa values ranged from 0.02 to 0.34 for all the patients, from -0.05 to 0.42 for patients with advanced disease, and from -0.08 to 0.32 for patients without advanced disease. The best agreement was found for family preferences. CONCLUSION: Poor agreement between physicians about patient- and context-related determinants of ICU admission suggests a lack of explicitness during the decision-making process. The potential consequences are increased variability and inequity regarding which patients are admitted. Timely advance care planning involving families could help physicians make the decision most concordant with patient preferences.

Systemic Fairness for Sharing Health Data: Perspectives From Swiss Stakeholders.

Introduction: Health research is gradually embracing a more collectivist approach, fueled by a new movement of open science, data sharing and collaborative partnerships. However, the existence of systemic contradictions hinders the sharing of health data and such collectivist endeavor. Therefore, this qualitative study explores these systemic barriers to a fair sharing of health data from the perspectives of Swiss stakeholders. Methods: Purposive and snowball sampling were used to recruit 48 experts active in the Swiss healthcare domain, from the research/policy-making field and those having a high position in a health data enterprise (e.g., health register, hospital IT data infrastructure or a national health data initiative). Semi-structured interviews were then conducted, audio-recorded, verbatim transcribed with identifying information removed to guarantee the anonymity of participants. A theoretical thematic analysis was then carried out to identify themes and subthemes related to the topic of systemic fairness for sharing health data. Results: Two themes related to the topic of systemic fairness for sharing health data were identified, namely (i) the hypercompetitive environment and (ii) the legal uncertainty blocking data sharing. The theme, hypercompetitive environment was further divided into two subthemes, (i) systemic contradictions to fair data sharing and the (ii) need of fair systemic attribution mechanisms. Discussion: From the perspectives of Swiss stakeholders, hypercompetition in the Swiss academic system is hindering the sharing of health data for secondary research purposes, with the downside effect of influencing researchers to embrace individualism for career opportunities, thereby opposing the data sharing movement. In addition, there was a perceived sense of legal uncertainty from legislations governing the sharing of health data, which adds unreasonable burdens on individual researchers, who are often unequipped to deal with such facets of their data sharing activities.

How to use likelihood ratios to interpret evidence from randomized trials.

OBJECTIVE: The likelihood ratio is a method for assessing evidence regarding two simple statistical hypotheses. Its interpretation is simple - for example, a value of 10 means that the first hypothesis is 10 times as strongly supported by the data as the second. A method is shown for deriving likelihood ratios from published trial reports. STUDY DESIGN: The likelihood ratio compares two hypotheses in light of data: that a new treatment is effective, at a specified level (alternate hypothesis: for instance, the hazard ratio equals 0.7), and that it is not (null hypothesis: the hazard ratio equals 1). The result of the trial is summarised by the test statistic z (ie, the estimated treatment effect divided by its standard error). The expected value of z is 0 under the null hypothesis, and A under the alternate hypothesis. The logarithm of the likelihood ratio is given by z·A - A2/2. The values of A and z can be derived from the alternate hypothesis used for sample size computation, and from the observed treatment effect and its standard error or confidence interval. RESULTS: Examples are given of trials that yielded strong or moderate evidence in favor of the alternate hypothesis, and of a trial that favored the null hypothesis. The resulting likelihood ratios are applied to initial beliefs about the hypotheses to obtain posterior beliefs. CONCLUSIONS: The likelihood ratio is a simple and easily understandable method for assessing evidence in data about two competing a priori hypotheses.

Serum NGAL, BNP, PTH, and albumin do not improve glomerular filtration rate estimating formulas in children.

Glomerular filtration rate (GFR) is difficult to measure, and estimating formulas are notorious for lacking precision. This study aims to assess if the inclusion of additional biomarkers improves the performance of eGFR formulas. A hundred and sixteen children with renal diseases were enrolled. Data for age, weight, height, inulin clearance (iGFR), serum creatinine, cystatin C, neutrophil gelatinase-associated lipocalin (NGAL), parathyroid hormone (PTH), albumin, and brain natriuretic peptide (BNP) were collected. These variables were added to the revised and combined (serum creatinine and cystatin C) Schwartz formulas, and the quadratic and combined quadratic formulas. We calculated the adjusted r-square (r2) in relation to iGFR and tested the improvement in variance explained by means of the likelihood ratio test. The combined Schwartz and the combined quadratic formulas yielded best results with an r2 of 0.676 and 0.730, respectively. The addition of BNP and PTH to the combined Schwartz and quadratic formulas improved the variance slightly. NGAL and albumin failed to improve the prediction of GFR further. These study results also confirm that the addition of cystatin C improves the performance of estimating GFR formulas, in particular the Schwartz formula.Conclusion: The addition of serum NGAL, BNP, PTH, and albumin to the combined Schwartz and quadratic formulas for estimating GFR did not improve GFR prediction in our population. What is Known: • Estimating glomerular filtration rate (GFR) formulas include serum creatinine and/or cystatin C but lack precision when compared to measured GFR. • The serum concentrations of some biological parameters such as neutrophil gelatinase-associated lipocalin (NGAL), parathyroid hormone (PTH), albumin, and brain natriuretic peptide (BNP) vary with the level of renal function. What is New: • The addition of BNP and PTH to the combined quadratic formula improved its performance only slightly. NGAL and albumin failed to improve the prediction of GFR further.

Emergency Computed Tomography: How Misinterpretations Vary According to the Periods of the Nightshift?

OBJECTIVE: To evaluate the accuracy of initial computed tomography (CT) interpretations made by radiology residents during nightshifts in the emergency department. METHODS: Preliminary CT reports performed by radiology residents during 120 consecutive nightshifts (08:30 pm to 08:30 am) were reviewed, attendings' final interpretation being the reference standard. Nightshifts were divided into four consecutive periods of 3 hours. Major misinterpretations were related to potentially life-threatening conditions if not treated immediately after CT. The rate of misinterpretations was calculated for all CT examinations, separately for nightshift's periods and for residents' training years. RESULTS: Misinterpretations were recorded in 155 (7.4%) of 2102 CT examinations, 0.6% (13/2102) were major. There were 2.2% (4/186) major misinterpretations that occurred during the last period of the nightshift versus 0.4% (9/1916) during the first periods of the night (P < 0.05). Of all misinterpretations, 8.5% (130/1526) were made by third- and fourth-year residents and 4.3% (25/576) by fifth-year residents (P < 0.005). CONCLUSIONS: Major misinterpretations occur at the end of the nightshift, which may be explained by the fatigue effect. The rate of misinterpretations is lower among fifth-year residents, which may be related to their prior experience in reading emergency cases.

Inconsistencies Between Two Cross-Cultural Adaptations of the Hospital Survey on Patient Safety Culture Into French.

OBJECTIVES: Two cross-cultural adaptations of the 12-dimension Hospital Survey on Patient Safety Culture (HSOPSC) into French coexist: the Occelli and Vlayen versions. The objective of this study was to assess the psychometric properties of the Occelli version in comparison with those reported for the Vlayen and the original US versions of this instrument. METHODS: Using the original data from a cross-sectional study of 5,064 employees at a single university hospital in France, we examined the acceptability, internal consistency, factorial structure, and construct validity of the Occelli version of the HSOPSC. RESULTS: The response rate was 76.8% (n = 3888). Our study yielded lower missing value rates (median, 0.4% [range, 0.0%-2.4%] versus 0.8% [range, 0.2%-11.4%]) and lower dimension scores (median, 3.19 [range, 2.67-3.54] versus 3.42 [range, 2.92-3.96]) than those reported for the Vlayen version. Cronbach alphas (median, 0.64; range, 0.56-0.84) compared unfavorably with those reported for the Vlayen (median, 0.73; range, 0.57-0.86) and original US (median, 0.78; range, 0.63-0.84) versions. The results of the confirmatory factor analysis were consistent between the Vlayen and Occelli versions, making it possible to conduct surveys from the 12-dimensional structure with both versions. CONCLUSIONS: The inconsistencies observed between the Occelli and Vlayen versions of the HSOPSC may reflect either differences between the translations or heterogeneity in the study population and context. Current evidence does not clearly support the use of one version over the other. The two cross-cultural adaptations of the HSOPSC can be used interchangeably in French-speaking countries.

Physicians' predictions of long-term survival and functional outcomes do not influence the decision to admit patients with advanced disease to intensive care: A prospective study.

BACKGROUND: Long-term survival and functional outcomes should influence admission decisions to intensive care, especially for patients with advanced disease. AIM: To determine whether physicians' predictions of long-term prognosis influenced admission decisions for patients with and without advanced disease. DESIGN: A prospective study was conducted. Physicians estimated patient survival with intensive care and with care on the ward, and the probability of 4 long-term outcomes: leaving hospital alive, survival at 6 months, recovery of functional status, and recovery of cognitive status. Patient mortality at 28 days was recorded. We built multivariate logistic regression models using admission to the intensive care unit (ICU) as the dependent variable. SETTING/PARTICIPANTS: ICU consultations for medical inpatients at a Swiss tertiary care hospital were included. RESULTS: Of 201 evaluated patients, 105 (52.2%) had an advanced disease and 140 (69.7%) were admitted to the ICU. The probability of admission was strongly associated with the expected short-term survival benefit for patients with or without advanced disease. In contrast, the predicted likelihood that the patient would leave the hospital alive, would be alive 6 months later, would recover functional status, and would recover initial cognitive capacity was not associated with the decision to admit a patient to the ICU. Even for patients with advanced disease, none of these estimated outcomes influenced the admission decision. CONCLUSIONS: ICU admissions of patients with advanced disease were determined by short-term survival benefit, and not by long-term prognosis. Advance care planning and developing decision-aid tools for triage could help limit potentially inappropriate admissions to intensive care.

Prevalence of childhood exposure to intimate partner violence and associations with mental distress in Cambodia, Malawi and Nigeria: A cross-sectional study.

BACKGROUND: Research from high-income countries shows that witnessing intimate partner violence (IPV) between caregivers is experienced by up to a third of all children and is related to poor mental health outcomes. Much less is known about the burden of witnessing IPV in low- and middle-income countries. OBJECTIVES: This study seeks to explore the magnitude of witnessing IPV between caregivers, its association with other types of violence and the relationship between witnessing IPV in the past and current mental distress. PARTICIPANTS AND SETTING: Representative data from the Violence against Children Surveys (VACS) from Cambodia (N = 2373), Malawi (N = 2147) and Nigeria (N = 4098) are employed. METHODS: Logistic regression was applied to assess the association between witnessing IPV in childhood and mental distress in adulthood. RESULTS: Between 22.4 % and 34.3 % of participants witnessed IPV between their caregivers during childhood. Respondents who witnessed IPV had higher odds of mental distress, compared to those who did not witness IPV in Cambodia (OR 2.73 [2.02, 3.72] for females, OR 2.38 [1.67, 3.41] for males) and Malawi (OR 2.48 [1.43, 4.28] for females, OR 1.66 [1.11, 2.48] for males). In Nigeria only male respondents who witnessed IPV had higher odds of mental distress (OR 2.12 [1.60, 2.80]), but females had no significant association (OR 0.91 [0.68, 1.20]). CONCLUSIONS: The findings highlight the association of negative mental health consequences faced by children living in households with intimate partner violence for selected low- and middle-income countries. Children's exposure to IPV should be considered when providing support to survivors of IPV. Special considerations should be made to provide culturally and resource-appropriate support.

Efficacy of pragmatic same-day ring prophylaxis for adult individuals exposed to SARS-CoV-2 in Switzerland (COPEP): protocol of an open-label cluster randomised trial.

INTRODUCTION: Lopinavir/ritonavir (LPV/r) has been proposed as repurposed drugs for pre-exposure and postexposure prophylaxis as well as therapy of COVID-19. Coronavirus postexposure prophylaxis (COPEP) trial aims at assessing their efficacy as postexposure ring-prophylaxis among adults exposed to SARS-CoV-2. METHODS AND ANALYSIS: COPEP is a two-arm open-label cluster-randomised trial conducted in three cantons of Switzerland. Asymptomatic contacts (≥16 years) of individuals diagnosed with COVID-19 will be randomised (2:1) to either LPV/r (400 mg/100 mg two times per day) for 5 days, or a standard of care arm (no treatment). Asymptomatic individuals may be either SARS-CoV-2 positive or negative. Contacts living in the single household will form a cluster and will be randomised into the same arm. All participants will be followed-up for 21 days and undergo daily monitoring for COVID-19 symptoms. The primary endpoint is 21-day incidence of laboratory-confirmed COVID-19 with ≥1 compatible symptom, analysed in an intention-to-treat (ITT) analysis. The secondary endpoints include the 21-day incidence of COVID-19 as well as SARS-CoV-2 infection in a modified ITT analysis, excluding participants who had a positive SARS-CoV-2 RT-PCR from oropharyngeal swab and/or a positive SARS-CoV-2 IgG serology at baseline. Assuming a 21-day incidence for COVID-19 of 20% among contacts without postexposure chemoprophylaxis, to detect a relative risk reduction of 60% (ie, translating in an absolute reduction from 20% to 8%), with a power of 80%, an alpha of 5%. Accounting for design effect of cluster design of circa 1.1, we plan to enrol 200 participants to the LPV/r arm and 100 to the standard of care arm, 300 participants in total. ETHICS AND DISSEMINATION: Ethics approval has been granted by the Commission Cantonale d'Ethique de la Recherche, Ethikkommission Nordwest- und Zentralschweiz and Comitato Etico Cantonale (ref 2020-00864) and Swissmedic (2020DR3056). Results from this trial will be disseminated via journal articles and presentations at national and international conferences. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov Registry (NCT04364022); Swiss National Clinical Trial Portal Registry (SNCTP 000003732). REGISTERED REPORT IDENTIFIER: CCER 2020-0864.