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1.
BMC Health Serv Res ; 22(1): 18, 2022 Jan 02.
Artigo em Inglês | MEDLINE | ID: mdl-34974837

RESUMO

BACKGROUND: As the global burden of malaria decreases, routine health information systems (RHIS) have become invaluable for monitoring progress towards elimination. The District Health Information System, version 2 (DHIS2) has been widely adopted across countries and is expected to increase the quality of reporting of RHIS. In this study, we evaluated the quality of reporting of key indicators of childhood malaria from January 2014 through December 2017, the first 4 years of DHIS2 implementation in Senegal. METHODS: Monthly data on the number of confirmed and suspected malaria cases as well as tests done were extracted from the Senegal DHIS2. Reporting completeness was measured as the number of monthly reports received divided by the expected number of reports in a given year. Completeness of indicator data was measured as the percentage of non-missing indicator values. We used a quasi-Poisson model with natural cubic spline terms of month of reporting to impute values missing at the facility level. We used the imputed values to take into account the percentage of malaria cases that were missed due to lack of reporting. Consistency was measured as the absence of moderate and extreme outliers, internal consistency between related indicators, and consistency of indicators over time. RESULTS: In contrast to public facilities of which 92.7% reported data in the DHIS2 system during the study period, only 15.3% of the private facilities used the reporting system. At the national level, completeness of facility reporting increased from 84.5% in 2014 to 97.5% in 2017. The percentage of expected malaria cases reported increased from 76.5% in 2014 to 94.7% in 2017. Over the study period, the percentage of malaria cases reported across all districts was on average 7.5% higher (P < 0.01) during the rainy season relative to the dry season. Reporting completeness rates were lower among hospitals compared to health centers and health posts. The incidence of moderate and extreme outlier values was 5.2 and 2.3%, respectively. The number of confirmed malaria cases increased by 15% whereas the numbers of suspected cases and tests conducted more than doubled from 2014 to 2017 likely due to a policy shift towards universal testing of pediatric febrile cases. CONCLUSIONS: The quality of reporting for malaria indicators in the Senegal DHIS2 has improved over time and the data are suitable for use to monitor progress in malaria programs, with an understanding of their limitations. Senegalese health authorities should maintain the focus on broader adoption of DHIS2 reporting by private facilities, the sustainability of district-level data quality reviews, facility-level supervision and feedback mechanisms at all levels of the health system.


Assuntos
Sistemas de Informação em Saúde , Malária , Criança , Confiabilidade dos Dados , Humanos , Incidência , Malária/diagnóstico , Malária/epidemiologia , Senegal/epidemiologia
2.
NPJ Vaccines ; 6(1): 147, 2021 Dec 09.
Artigo em Inglês | MEDLINE | ID: mdl-34887436

RESUMO

Older adults (≥65 years of age) bear a significant burden of severe disease and mortality associated with influenza, despite relatively high annual vaccination coverage and substantial pre-existing immunity to influenza. To test the hypothesis that host factors, including age and sex, play a role in determining the effect of repeated vaccination and levels of pre-existing humoral immunity to influenza, we evaluated pre- and post-vaccination strain-specific hemagglutination inhibition (HAI) titers in adults over 75 years of age who received a high-dose influenza vaccine in at least four out of six influenza seasons. Pre-vaccination titers, rather than host factors and repeated vaccination were significantly associated with post-vaccination HAI titer outcomes, and displayed an age-by-sex interaction. Pre-vaccination titers to H1N1 remained constant with age. Titers to H3N2 and influenza B viruses decreased substantially with age in males, whereas titers in females remained constant with age. Our findings highlight the importance of pre-existing immunity in this highly vaccinated older adult population and suggest that older males are particularly vulnerable to reduced pre-existing humoral immunity to influenza.

3.
BMC Med Res Methodol ; 21(1): 249, 2021 11 14.
Artigo em Inglês | MEDLINE | ID: mdl-34773969

RESUMO

BACKGROUND: Scleroderma is a serious chronic autoimmune disease in which a patient's disease state manifests in several irregularly spaced longitudinal measures of lung, heart, skin, and other organ systems. Threshold crossings of pulmonary and cardiac measures indicate potentially life-threatening key clinical events including interstitial lung disease (ILD), cardiomyopathy, and pulmonary hypertension (PH). The statistical challenge is to accurately and precisely predict these events by using all of the clinical history for the patient at hand and for a reference population of patients. METHODS: We use a Bayesian mixed model approach to simultaneously characterize each individual's future trajectories for several biomarkers. We estimate this model using a large population of patients from the Johns Hopkins Scleroderma Center Research Registry. The joint probabilities of critical lung and heart events are then calculated as a byproduct of the mixed model. RESULTS: The performance of this approach is substantially better than standard, more common alternatives. In order to predict an individual's risks in a clinical setting, we also develop a cross-validated, sequential prediction (CVSP) algorithm. As additional data are observed during a patient's visit, the algorithm sequentially produces updated predictions for the future longitudinal trajectories and for ILD, cardiomyopathy, and PH. The updated prediction distributions with little additional computing, for example within an electronic health record (EHR). CONCLUSIONS: This method that generates real-time personalized risk estimates has been implemented within the electronic health record system for clinical testing. To our knowledge, this work represents the first approach to compute personalized risk estimates for multiple scleroderma complications.


Assuntos
Hipertensão Pulmonar , Doenças Pulmonares Intersticiais , Teorema de Bayes , Humanos , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/epidemiologia , Modelos Lineares , Pulmão , Doenças Pulmonares Intersticiais/diagnóstico , Doenças Pulmonares Intersticiais/epidemiologia
5.
Artigo em Inglês | MEDLINE | ID: mdl-34583972

RESUMO

INTRODUCTION: This study evaluates the association of multidimensional social determinants of health (SDoH) with non-adherence to diabetic retinopathy examinations. RESEARCH DESIGN AND METHODS: This was a post-hoc subgroup analysis of adults with diabetes in a prospective cohort study of enrollees in the Washington, DC Medicaid program. At study enrollment, participants were given a comprehensive SDoH survey based on the WHO SDoH model. Adherence to recommended dilated diabetic retinopathy examinations, as determined by qualifying Current Procedural Terminology codes in the insurance claims, was defined as having at least one eye examination in the 2-year period following study enrollment. RESULTS: Of the 8943 participants enrolled in the prospective study, 1492 (64% female, 91% non-Hispanic Black) were included in this post-hoc subgroup analysis. 47.7% (n=712) were adherent to the recommended biennial diabetic eye examinations. Not having a regular provider (eg, a primary care physician) and having poor housing conditions (eg, overcrowded, inadequate heating) were associated with decreased odds of adherence to diabetic eye examinations (0.45 (95% CI 0.31 to 0.64) and 0.70 (95% CI 0.53 to 0.94), respectively) in the multivariate logistic regression analysis controlling for age, sex, race/ethnicity, overall health status using the Chronic Disability Payment System, diabetes severity using the Diabetes Complications Severity Index, history of eye disease, and history of diabetic eye disease treatment. CONCLUSIONS: A multidimensional evaluation of SDoH revealed barriers that impact adherence to diabetic retinopathy examinations. Having poor housing conditions and not having a regular provider were associated with poor adherence. A brief SDoH assessment could be incorporated into routine clinical care to identify social risks and connect patients with the necessary resources to improve adherence to diabetic retinopathy examinations.


Assuntos
Diabetes Mellitus , Retinopatia Diabética , Adulto , Retinopatia Diabética/diagnóstico , Retinopatia Diabética/epidemiologia , Feminino , Humanos , Masculino , Estudos Prospectivos , Determinantes Sociais da Saúde , Inquéritos e Questionários , Estados Unidos
6.
Open Forum Infect Dis ; 8(9): ofab448, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34584899

RESUMO

Background: Males experience increased severity of illness and mortality from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) compared with females, but the mechanisms of male susceptibility are unclear. Methods: We performed a retrospective cohort analysis of SARS-CoV-2 testing and admission data at 5 hospitals in the Maryland/Washington DC area. Using age-stratified logistic regression models, we quantified the impact of male sex on the risk of the composite outcome of severe disease or death (World Health Organization score 5-8) and tested the impact of demographics, comorbidities, health behaviors, and laboratory inflammatory markers on the sex effect. Results: Among 213 175 SARS-CoV-2 tests, despite similar positivity rates, males in age strata between 18 and 74 years were more frequently hospitalized. For the 2626 hospitalized individuals, clinical inflammatory markers (interleukin-6, C-reactive protein, ferritin, absolute lymphocyte count, and neutrophil:lymphocyte ratio) were more favorable for females than males (P < .001). Among 18-49-year-olds, male sex carried a higher risk of severe outcomes, both early (odds ratio [OR], 3.01; 95% CI, 1.75 to 5.18) and at peak illness during hospitalization (OR, 2.58; 95% CI, 1.78 to 3.74). Despite multiple differences in demographics, presentation features, comorbidities, and health behaviors, these variables did not change the association of male sex with severe disease. Only clinical inflammatory marker values modified the sex effect, reducing the OR for severe outcomes in males aged 18-49 years to 1.81 (95% CI, 1.00 to 3.26) early and 1.39 (95% CI, 0.93 to 2.08) at peak illness. Conclusions: Higher inflammatory laboratory test values were associated with increased risk of severe coronavirus disease 2019 for males. A sex-specific inflammatory response to SARS-CoV-2 infection may underlie the sex differences in outcomes.

7.
J Health Popul Nutr ; 40(1): 24, 2021 05 26.
Artigo em Inglês | MEDLINE | ID: mdl-34039435

RESUMO

BACKGROUND: Topical treatment with sunflower seed oil (SSO) or Aquaphor® reduced sepsis and neonatal mortality in hospitalized preterm infants <33 weeks' gestational age in Bangladesh. We sought to determine whether the emollient treatments improved neurodevelopmental outcomes during early childhood. METHODS: 497 infants were randomized to receive SSO, Aquaphor®, or neither through the neonatal period or hospital discharge. 159 infant survivors were enrolled in the longitudinal follow-up study using a validated Rapid Neurodevelopmental Assessment tool and the Bayley Scales of Infant Development II (BSID II) administered at three-monthly intervals for the first year and thereafter at six-monthly intervals. Lowess smoothing was used to display neurodevelopmental status across multiple domains by age and treatment group, and Generalized Estimating Equations (GEE) were used to compare treatment groups across age points. RESULTS: 123 children completed at least one follow-up visit. Lowess graphs suggest that lower proportions of children who received massage with either SSO or Aquaphor® had neurodevelopmental delays than control infants in a composite outcome of disabilities. In GEE analysis, infants receiving SSO showed a significant protective effect on the development of fine motor skills [odds ratio (OR) 0.92, 95% confidence interval (CI) 0.86-0.98, p=0.006]. The Psychomotor Development Index (PDI) in the BSID II showed significantly lower disability rates in the Aquaphor group (23.6%) compared to the control (55.2%) (OR 0.21, 95% CI 0.06-0.72, p=0.004). CONCLUSIONS: Emollient massage of very preterm, hospitalized newborn infants improved some child neurodevelopmental outcomes over the first 2 years of follow-up. Findings warrant further confirmatory research. TRIAL REGISTRATION: ClinicalTrials.gov (98-04-21-03-2) under weblink https://clinicaltrials.gov/ct2/show/NCT00162747.


Assuntos
Emolientes , Recém-Nascido Prematuro , Bangladesh , Criança , Desenvolvimento Infantil , Pré-Escolar , Emolientes/uso terapêutico , Seguimentos , Humanos , Lactente , Recém-Nascido , Recém-Nascido de muito Baixo Peso
8.
Am J Epidemiol ; 190(10): 2094-2106, 2021 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-33984860

RESUMO

Longitudinal trajectories of vital signs and biomarkers during hospital admission of patients with COVID-19 remain poorly characterized despite their potential to provide critical insights about disease progression. We studied 1884 patients with severe acute respiratory syndrome coronavirus 2 infection from April 3, 2020, to June 25, 2020, within 1 Maryland hospital system and used a retrospective longitudinal framework with linear mixed-effects models to investigate relevant biomarker trajectories leading up to 3 critical outcomes: mechanical ventilation, discharge, and death. Trajectories of 4 vital signs (respiratory rate, ratio of oxygen saturation (Spo2) to fraction of inspired oxygen (Fio2), pulse, and temperature) and 4 laboratory values (C-reactive protein (CRP), absolute lymphocyte count (ALC), estimated glomerular filtration rate, and D-dimer) clearly distinguished the trajectories of patients with COVID-19. Before any ventilation, log(CRP), log(ALC), respiratory rate, and Spo2-to-Fio2 ratio trajectories diverge approximately 8-10 days before discharge or death. After ventilation, log(CRP), log(ALC), respiratory rate, Spo2-to-Fio2 ratio, and estimated glomerular filtration rate trajectories again diverge 10-20 days before death or discharge. Trajectories improved until discharge and remained unchanged or worsened until death. Our approach characterizes the distribution of biomarker trajectories leading up to competing outcomes of discharge versus death. Moving forward, this model can contribute to quantifying the joint probability of biomarkers and outcomes when provided clinical data up to a given moment.


Assuntos
Biomarcadores/metabolismo , COVID-19/metabolismo , Avaliação de Resultados em Cuidados de Saúde , Pneumonia Viral/metabolismo , COVID-19/diagnóstico , COVID-19/epidemiologia , Estudos de Casos e Controles , Progressão da Doença , Feminino , Humanos , Estudos Longitudinais , Masculino , Maryland/epidemiologia , Pandemias , Pneumonia Viral/epidemiologia , Pneumonia Viral/virologia , Valor Preditivo dos Testes , Estudos Retrospectivos , SARS-CoV-2 , Sinais Vitais
10.
Microorganisms ; 9(4)2021 03 27.
Artigo em Inglês | MEDLINE | ID: mdl-33801760

RESUMO

Streptococcus pneumoniae serotype 1 (ST1) was an important cause of invasive pneumococcal disease (IPD) globally before the introduction of pneumococcal conjugate vaccines (PCVs) containing ST1 antigen. The Pneumococcal Serotype Replacement and Distribution Estimation (PSERENADE) project gathered ST1 IPD surveillance data from sites globally and aimed to estimate PCV10/13 impact on ST1 IPD incidence. We estimated ST1 IPD incidence rate ratios (IRRs) comparing the pre-PCV10/13 period to each post-PCV10/13 year by site using a Bayesian multi-level, mixed-effects Poisson regression and all-site IRRs using a linear mixed-effects regression (N = 45 sites). Following PCV10/13 introduction, the incidence rate (IR) of ST1 IPD declined among all ages. After six years of PCV10/13 use, the all-site IRR was 0.05 (95% credibility interval 0.04-0.06) for all ages, 0.05 (0.04-0.05) for <5 years of age, 0.08 (0.06-0.09) for 5-17 years, 0.06 (0.05-0.08) for 18-49 years, 0.06 (0.05-0.07) for 50-64 years, and 0.05 (0.04-0.06) for ≥65 years. PCV10/13 use in infant immunization programs was followed by a 95% reduction in ST1 IPD in all ages after approximately 6 years. Limited data availability from the highest ST1 disease burden countries using a 3+0 schedule constrains generalizability and data from these settings are needed.

11.
Microorganisms ; 9(4)2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33916227

RESUMO

Pneumococcal conjugate vaccine (PCV) introduction has reduced pneumococcal meningitis incidence. The Pneumococcal Serotype Replacement and Distribution Estimation (PSERENADE) project described the serotype distribution of remaining pneumococcal meningitis in countries using PCV10/13 for least 5-7 years with primary series uptake above 70%. The distribution was estimated using a multinomial Dirichlet regression model, stratified by PCV product and age. In PCV10-using sites (N = 8; cases = 1141), PCV10 types caused 5% of cases <5 years of age and 15% among ≥5 years; the top serotypes were 19A, 6C, and 3, together causing 42% of cases <5 years and 37% ≥5 years. In PCV13-using sites (N = 32; cases = 4503), PCV13 types caused 14% in <5 and 26% in ≥5 years; 4% and 13%, respectively, were serotype 3. Among the top serotypes are five (15BC, 8, 12F, 10A, and 22F) included in higher-valency PCVs under evaluation. Other top serotypes (24F, 23B, and 23A) are not in any known investigational product. In countries with mature vaccination programs, the proportion of pneumococcal meningitis caused by vaccine-in-use serotypes is lower (≤26% across all ages) than pre-PCV (≥70% in children). Higher-valency PCVs under evaluation target over half of remaining pneumococcal meningitis cases, but questions remain regarding generalizability to the African meningitis belt where additional data are needed.

12.
medRxiv ; 2021 Apr 07.
Artigo em Inglês | MEDLINE | ID: mdl-33851190

RESUMO

Background: Rates of severe illness and mortality from SARS-CoV-2 are greater for males, but the mechanisms for this difference are unclear. Understanding the differences in outcomes between males and females across the age spectrum will guide both public health and biomedical interventions. Methods: Retrospective cohort analysis of SARS-CoV-2 testing and admission data in a health system. Patient-level data were assessed with descriptive statistics and logistic regression modeling was used to identify features associated with increased male risk of severe outcomes. Results: In 213,175 SARS-CoV-2 tests, despite similar positivity rates (8.2%F vs 8.9%M), males were more frequently hospitalized (28%F vs 33%M). Of 2,626 hospitalized individuals, females had less severe presenting respiratory parameters and males had more fever. Comorbidity burden was similar, but with differences in specific conditions. Medications relevant for SARS-CoV-2 were used at similar frequency except tocilizumab (M>F). Males had higher inflammatory lab values. In a logistic regression model, male sex was associated with a higher risk of severe outcomes at 24 hours (odds ratio (OR) 3.01, 95%CI 1.75, 5.18) and at peak status (OR 2.58, 95%CI 1.78,3.74) among 18-49 year-olds. Block-wise addition of potential explanatory variables demonstrated that only the inflammatory labs substantially modified the OR associated with male sex across all ages. Conclusion: Higher levels of clinical inflammatory labs are the only features that are associated with the heightened risk of severe outcomes and death for males in COVID-19. Trial registration: NA. Funding: Hopkins inHealth; COVID-19 Administrative Supplement (HHS Region 3 Treatment Center), Office of the ASPR; NIH/NCI U54CA260492 (SK), NIH/NIA U54AG062333 (SK).

13.
JAMA Netw Open ; 4(3): e213071, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33760094

RESUMO

Importance: Clinical effectiveness data on remdesivir are urgently needed, especially among diverse populations and in combination with other therapies. Objective: To examine whether remdesivir administered with or without corticosteroids for treatment of coronavirus disease 2019 (COVID-19) is associated with more rapid clinical improvement in a racially/ethnically diverse population. Design, Setting, and Participants: This retrospective comparative effectiveness research study was conducted from March 4 to August 29, 2020, in a 5-hospital health system in the Baltimore, Maryland, and Washington, DC, area. Of 2483 individuals with confirmed severe acute respiratory syndrome coronavirus 2 infection assessed by polymerase chain reaction, those who received remdesivir were matched to infected individuals who did not receive remdesivir using time-invariant covariates (age, sex, race/ethnicity, Charlson Comorbidity Index, body mass index, and do-not-resuscitate or do-not-intubate orders) and time-dependent covariates (ratio of peripheral blood oxygen saturation to fraction of inspired oxygen, blood pressure, pulse, temperature, respiratory rate, C-reactive protein level, complete white blood cell count, lymphocyte count, albumin level, alanine aminotransferase level, glomerular filtration rate, dimerized plasmin fragment D [D-dimer] level, and oxygen device). An individual in the remdesivir group with k days of treatment was matched to a control patient who stayed in the hospital at least k days (5 days maximum) beyond the matching day. Exposures: Remdesivir treatment with or without corticosteroid administration. Main Outcomes and Measures: The primary outcome was rate of clinical improvement (hospital discharge or decrease of 2 points on the World Health Organization severity score), and the secondary outcome, mortality at 28 days. An additional outcome was clinical improvement and time to death associated with combined remdesivir and corticosteroid treatment. Results: Of 2483 consecutive admissions, 342 individuals received remdesivir, 184 of whom also received corticosteroids and 158 of whom received remdesivir alone. For these 342 patients, the median age was 60 years (interquartile range, 46-69 years), 189 (55.3%) were men, and 276 (80.7%) self-identified as non-White race/ethnicity. Remdesivir recipients had a shorter time to clinical improvement than matched controls without remdesivir treatment (median, 5.0 days [interquartile range, 4.0-8.0 days] vs 7.0 days [interquartile range, 4.0-10.0 days]; adjusted hazard ratio, 1.47 [95% CI, 1.22-1.79]). Remdesivir recipients had a 28-day mortality rate of 7.7% (22 deaths) compared with 14.0% (40 deaths) among matched controls, but this difference was not statistically significant in the time-to-death analysis (adjusted hazard ratio, 0.70; 95% CI, 0.38-1.28). The addition of corticosteroids to remdesivir was not associated with a reduced hazard of death at 28 days (adjusted hazard ratio, 1.94; 95% CI, 0.67-5.57). Conclusions and Relevance: In this comparative effectiveness research study of adults hospitalized with COVID-19, receipt of remdesivir was associated with faster clinical improvement in a cohort of predominantly non-White patients. Remdesivir plus corticosteroid administration did not reduce the time to death compared with remdesivir administered alone.


Assuntos
Monofosfato de Adenosina/análogos & derivados , Alanina/análogos & derivados , Antivirais/uso terapêutico , COVID-19/tratamento farmacológico , Hospitalização , Monofosfato de Adenosina/uso terapêutico , Idoso , Alanina/uso terapêutico , Baltimore , COVID-19/virologia , Estudos de Casos e Controles , Pesquisa Comparativa da Efetividade , District of Columbia , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , SARS-CoV-2 , Resultado do Tratamento
14.
Ann Emerg Med ; 77(5): 511-522, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33715829

RESUMO

STUDY OBJECTIVE: We evaluate the relationship between social determinants of health and emergency department (ED) visits in the Medicaid Cohort of the District of Columbia. METHODS: We conducted a retrospective cohort analysis of 8,943 adult Medicaid beneficiaries who completed a social determinants of health survey at study enrollment. We merged the social determinants of health data with participants' Medicaid claims data for up to 24 months before enrollment. Using latent class analysis, we grouped our participants into 4 distinct social risk classes based on similar responses to the social determinants of health questions. We classified ED visits as primary care treatable or ED care needed, using the Minnesota algorithm. We calculated the adjusted log relative primary care treatable and ED care needed visit rates among the social risk classes by using generalized linear mixed-effects models. RESULTS: The majority (71%) of the 49,111 ED visits made by the 8,943 participants were ED care needed. The adjusted log relative rate of both primary care treatable and ED care needed visit rates increased with each higher (worse) social risk class compared with the lowest class. Participants in the highest social risk class (ie, unemployed and many social risks) had a log relative primary care treatable and ED care needed rate of 39% (range 28% to 50%) and 29% (range 21% to 38%), respectively, adjusted for age, sex, and illness severity. CONCLUSION: There is a strong relationship between social determinants of health and ED utilization in this Medicaid sample that is worth investigating in other Medicaid samples and patient populations.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Determinantes Sociais da Saúde/estatística & dados numéricos , Adulto , District of Columbia/epidemiologia , Emergências/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Atenção Primária à Saúde/estatística & dados numéricos , Estudos Retrospectivos , Inquéritos e Questionários , Estados Unidos , Adulto Jovem
15.
Ann Intern Med ; 174(6): 777-785, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33646849

RESUMO

BACKGROUND: Predicting the clinical trajectory of individual patients hospitalized with coronavirus disease 2019 (COVID-19) is challenging but necessary to inform clinical care. The majority of COVID-19 prognostic tools use only data present upon admission and do not incorporate changes occurring after admission. OBJECTIVE: To develop the Severe COVID-19 Adaptive Risk Predictor (SCARP) (https://rsconnect.biostat.jhsph.edu/covid_trajectory/), a novel tool that can provide dynamic risk predictions for progression from moderate disease to severe illness or death in patients with COVID-19 at any time within the first 14 days of their hospitalization. DESIGN: Retrospective observational cohort study. SETTINGS: Five hospitals in Maryland and Washington, D.C. PATIENTS: Patients who were hospitalized between 5 March and 4 December 2020 with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) confirmed by nucleic acid test and symptomatic disease. MEASUREMENTS: A clinical registry for patients hospitalized with COVID-19 was the primary data source; data included demographic characteristics, admission source, comorbid conditions, time-varying vital signs, laboratory measurements, and clinical severity. Random forest for survival, longitudinal, and multivariate (RF-SLAM) data analysis was applied to predict the 1-day and 7-day risks for progression to severe disease or death for any given day during the first 14 days of hospitalization. RESULTS: Among 3163 patients admitted with moderate COVID-19, 228 (7%) became severely ill or died in the next 24 hours; an additional 355 (11%) became severely ill or died in the next 7 days. The area under the receiver-operating characteristic curve (AUC) for 1-day risk predictions for progression to severe disease or death was 0.89 (95% CI, 0.88 to 0.90) and 0.89 (CI, 0.87 to 0.91) during the first and second weeks of hospitalization, respectively. The AUC for 7-day risk predictions for progression to severe disease or death was 0.83 (CI, 0.83 to 0.84) and 0.87 (CI, 0.86 to 0.89) during the first and second weeks of hospitalization, respectively. LIMITATION: The SCARP tool was developed by using data from a single health system. CONCLUSION: Using the predictive power of RF-SLAM and longitudinal data from more than 3000 patients hospitalized with COVID-19, an interactive tool was developed that rapidly and accurately provides the probability of an individual patient's progression to severe illness or death on the basis of readily available clinical information. PRIMARY FUNDING SOURCE: Hopkins inHealth and COVID-19 Administrative Supplement for the HHS Region 3 Treatment Center from the Office of the Assistant Secretary for Preparedness and Response.


Assuntos
COVID-19/mortalidade , COVID-19/patologia , Mortalidade Hospitalar , Gravidade do Paciente , Pneumonia Viral/mortalidade , Medição de Risco/métodos , Idoso , Idoso de 80 Anos ou mais , Progressão da Doença , District of Columbia/epidemiologia , Feminino , Hospitalização , Humanos , Masculino , Maryland/epidemiologia , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/virologia , Valor Preditivo dos Testes , Prognóstico , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , SARS-CoV-2
16.
JCO Clin Cancer Inform ; 5: 304-314, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33760638

RESUMO

PURPOSE: The Bone Metastases Ensemble Trees for Survival (BMETS) model uses a machine learning algorithm to estimate survival time following consultation for palliative radiation therapy for symptomatic bone metastases (SBM). BMETS was developed at a tertiary-care, academic medical center, but its validity and stability when applied to external data sets are unknown. PATIENTS AND METHODS: Patients treated with palliative radiation therapy for SBM from May 2013 to May 2016 at two hospital-based community radiation oncology clinics were included, and medical records were retrospectively reviewed to collect model covariates and survival time. The Kaplan-Meier method was used to estimate overall survival from consultation to death or last follow-up. Model discrimination was estimated using time-dependent area under the curve (tAUC), which was calculated using survival predictions from BMETS based on the initial training data set. RESULTS: A total of 216 sites of SBM were treated in 182 patients. Most common histologies were breast (27%), lung (23%), and prostate (23%). Compared with the BMETS training set, the external validation population was older (mean age, 67 v 62 years; P < .001), had more primary breast (27% v 19%; P = .03) and prostate cancer (20% v 12%; P = .01), and survived longer (median, 10.7 v 6.4 months). When the BMETS model was applied to the external data set, tAUC values at 3, 6, and 12 months were 0.82, 0.77, and 0.77, respectively. When refit with data from the combined training and external validation sets, tAUC remained > 0.79. CONCLUSION: BMETS maintained high discriminative ability when applied to an external validation set and when refit with new data, supporting its generalizability, stability, and the feasibility of dynamic modeling.


Assuntos
Neoplasias Ósseas , Aprendizado de Máquina , Idoso , Neoplasias Ósseas/mortalidade , Humanos , Cuidados Paliativos , Estudos Retrospectivos
17.
Biometrics ; 2021 Mar 31.
Artigo em Inglês | MEDLINE | ID: mdl-33788259

RESUMO

Compositional data are common in many fields, both as outcomes and predictor variables. The inventory of models for the case when both the outcome and predictor variables are compositional is limited, and the existing models are often difficult to interpret in the compositional space, due to their use of complex log-ratio transformations. We develop a transformation-free linear regression model where the expected value of the compositional outcome is expressed as a single Markov transition from the compositional predictor. Our approach is based on estimating equations thereby not requiring complete specification of data likelihood and is robust to different data-generating mechanisms. Our model is simple to interpret, allows for 0s and 1s in both the compositional outcome and covariates, and subsumes several interesting subcases of interest. We also develop permutation tests for linear independence and equality of effect sizes of two components of the predictor. Finally, we show that despite its simplicity, our model accurately captures the relationship between compositional data using two datasets from education and medical research.

18.
J Neurosci ; 41(4): 663-673, 2021 01 27.
Artigo em Inglês | MEDLINE | ID: mdl-33257325

RESUMO

Age-related memory deficits are correlated with neural hyperactivity in the CA3 region of the hippocampus. Abnormal CA3 hyperactivity in aged rats has been proposed to contribute to an imbalance between pattern separation and pattern completion, resulting in overly rigid representations. Recent evidence of functional heterogeneity along the CA3 transverse axis suggests that proximal CA3 supports pattern separation while distal CA3 supports pattern completion. It is not known whether age-related CA3 hyperactivity is uniformly represented along the CA3 transverse axis. We examined the firing rates of CA3 neurons from young and aged, male, Long-Evans rats along the CA3 transverse axis. Consistent with prior studies, young CA3 cells showed an increasing gradient in mean firing rate from proximal to distal CA3. However, aged CA3 cells showed an opposite, decreasing trend, in that CA3 cells in aged rats were hyperactive in proximal CA3, but possibly hypoactive in distal CA3, compared with young (Y) rats. We suggest that, in combination with altered inputs from the entorhinal cortex and dentate gyrus (DG), the proximal CA3 region of aged rats may switch from its normal function that reflects the pattern separation output of the DG and instead performs a computation that reflects an abnormal bias toward pattern completion. In parallel, distal CA3 of aged rats may create weaker attractor basins that promote abnormal, bistable representations under certain conditions.SIGNIFICANCE STATEMENT Prior work suggested that age-related CA3 hyperactivity enhances pattern completion, resulting in rigid representations. Implicit in prior studies is the notion that hyperactivity is present throughout a functionally homogeneous CA3 network. However, more recent work has demonstrated functional heterogeneity along the CA3 transverse axis, in that proximal CA3 is involved in pattern separation and distal CA3 is involved in pattern completion. Here, we show that age-related hyperactivity is present only in proximal CA3, with potential hypoactivity in distal CA3. This result provides new insight in the role of CA3 in age-related memory impairments, suggesting that the rigid representations in aging result primarily from dysfunction of computational circuits involving the dentate gyrus (DG) and proximal CA3.


Assuntos
Envelhecimento/fisiologia , Região CA3 Hipocampal/crescimento & desenvolvimento , Região CA3 Hipocampal/fisiologia , Animais , Giro Denteado/crescimento & desenvolvimento , Giro Denteado/fisiologia , Fenômenos Eletrofisiológicos , Córtex Entorrinal/crescimento & desenvolvimento , Córtex Entorrinal/fisiologia , Interneurônios/fisiologia , Masculino , Neurônios/fisiologia , Células Piramidais/fisiologia , Ratos , Ratos Long-Evans
19.
Med Care ; 59(3): 251-258, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33273298

RESUMO

OBJECTIVE: To develop distinct social risk profiles based on social determinants of health (SDH) information and to determine whether these social risk groups varied in terms of health, health care utilization, and costs. METHODS: We prospectively enrolled 8943 beneficiaries insured by the District of Columbia Medicaid program between September 2017 and December 2018. Participants completed a SDH survey and we obtained their Medicaid claims data for a 2-year period before study enrollment. We used latent class analysis (LCA) to identify distinct social risk profiles based on their SDH responses. We assessed the relationship among different SDH as well as the relationship among the social risk classes and health, health care use and costs. RESULTS: The majority of SDH were moderately to strongly correlated with one another. LCA yielded 4 distinct social risk groups. Group 1 reported the least social risks with the most employed. Group 2 was distinguished by financial strain and housing instability with fewer employed. Group 3 were mostly unemployed with limited car and internet access. Group 4 had the most social risks and most unemployed. The social risk groups demonstrated meaningful differences in health, acute care utilization, and health care costs with group 1 having the best health outcomes and group 4 the worst (P<0.05). CONCLUSIONS: LCA is a practical method of aggregating correlated SDH data into a finite number of distinct social risk groups. Understanding the constellation of social challenges that patients face is critical when attempting to address their social needs and improve health outcomes.


Assuntos
Equidade em Saúde/estatística & dados numéricos , Nível de Saúde , Medicaid/estatística & dados numéricos , Determinantes Sociais da Saúde/estatística & dados numéricos , Estudos de Coortes , District of Columbia , Feminino , Habitação/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Pobreza/estatística & dados numéricos , Estados Unidos
20.
Ann Intern Med ; 174(1): 33-41, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32960645

RESUMO

BACKGROUND: Risk factors for progression of coronavirus disease 2019 (COVID-19) to severe disease or death are underexplored in U.S. cohorts. OBJECTIVE: To determine the factors on hospital admission that are predictive of severe disease or death from COVID-19. DESIGN: Retrospective cohort analysis. SETTING: Five hospitals in the Maryland and Washington, DC, area. PATIENTS: 832 consecutive COVID-19 admissions from 4 March to 24 April 2020, with follow-up through 27 June 2020. MEASUREMENTS: Patient trajectories and outcomes, categorized by using the World Health Organization COVID-19 disease severity scale. Primary outcomes were death and a composite of severe disease or death. RESULTS: Median patient age was 64 years (range, 1 to 108 years); 47% were women, 40% were Black, 16% were Latinx, and 21% were nursing home residents. Among all patients, 131 (16%) died and 694 (83%) were discharged (523 [63%] had mild to moderate disease and 171 [20%] had severe disease). Of deaths, 66 (50%) were nursing home residents. Of 787 patients admitted with mild to moderate disease, 302 (38%) progressed to severe disease or death: 181 (60%) by day 2 and 238 (79%) by day 4. Patients had markedly different probabilities of disease progression on the basis of age, nursing home residence, comorbid conditions, obesity, respiratory symptoms, respiratory rate, fever, absolute lymphocyte count, hypoalbuminemia, troponin level, and C-reactive protein level and the interactions among these factors. Using only factors present on admission, a model to predict in-hospital disease progression had an area under the curve of 0.85, 0.79, and 0.79 at days 2, 4, and 7, respectively. LIMITATION: The study was done in a single health care system. CONCLUSION: A combination of demographic and clinical variables is strongly associated with severe COVID-19 disease or death and their early onset. The COVID-19 Inpatient Risk Calculator (CIRC), using factors present on admission, can inform clinical and resource allocation decisions. PRIMARY FUNDING SOURCE: Hopkins inHealth and COVID-19 Administrative Supplement for the HHS Region 3 Treatment Center from the Office of the Assistant Secretary for Preparedness and Response.


Assuntos
COVID-19/mortalidade , Mortalidade Hospitalar , Hospitalização , Índice de Gravidade de Doença , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Progressão da Doença , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Pandemias , Estudos Retrospectivos , Fatores de Risco , SARS-CoV-2 , Estados Unidos/epidemiologia
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