Medicaid Expansion and Racial-Ethnic and Sex Disparities in Cardiovascular Diseases Over 6 Years: A Generalized Synthetic Control Approach.

BACKGROUND: Studies have suggested Medicaid expansion enacted in 2014 has resulted in a reduction in overall cardiovascular disease (CVD) mortality in the United States. However, it is unknown whether Medicaid expansion has a similar effect across race-ethnicity and sex. We investigated the effect of Medicaid expansion on CVD mortality across race-ethnicity and sex. METHODS: Data come from the behavioral risk factor surveillance system and the US Centers for Disease Control's Wide-ranging Online Data for Epidemiologic Research, spanning the period 2000-2019. We used the generalized synthetic control method, a quasi-experimental approach, to estimate effects. RESULTS: Medicaid expansion was associated with -5.36 (mean difference [MD], 95% confidence interval [CI] = -22.63, 11.91) CVD deaths per 100,000 persons per year among Blacks; -4.28 (MD, 95% CI = -30.08, 21.52) among Hispanics; -3.18 (MD, 95% CI = -8.30, 1.94) among Whites; -5.96 (MD, 95% CI = -15.42, 3.50) among men; and -3.34 (MD, 95% CI = -8.05, 1.37) among women. The difference in mean difference (DMD) between the effect of Medicaid expansion in Blacks compared with Whites was -2.18; (DMD, 95% CI = -20.20, 15.83); between that in Hispanics compared with Whites: -1.10; (DMD, 95% CI = -27.40, 25.20) and between that in women compared with men: 2.62; (DMD, 95% CI = -7.95, 13.19). CONCLUSIONS: Medicaid expansion was associated with a reduction in CVD mortality overall and in White, Black, Hispanic, male, and female subpopulations. Also, our study did not find any difference or disparity in the effect of Medicaid on CVD across race-ethnicity and sex-gender subpopulations, likely owing to imprecise estimates.

Network interventions for managing the COVID-19 pandemic and sustaining economy.

Sustaining economic activities while curbing the number of new coronavirus disease 2019 (COVID-19) cases until effective vaccines or treatments become available is a major public health and policy challenge. In this paper, we use agent-based simulations of a network-based susceptible-exposed-infectious-recovered (SEIR) model to investigate two network intervention strategies for mitigating the spread of transmission while maintaining economic activities. In the simulations, we assume that people engage in group activities in multiple sectors (e.g., going to work, going to a local grocery store), where they interact with others in the same group and potentially become infected. In the first strategy, each group is divided into two subgroups (e.g., a group of customers can only go to the grocery store in the morning, while another separate group of customers can only go in the afternoon). In the second strategy, we balance the number of group members across different groups within the same sector (e.g., every grocery store has the same number of customers). The simulation results show that the dividing groups strategy substantially reduces transmission, and the joint implementation of the two strategies could effectively bring the spread of transmission under control (i.e., effective reproduction number ≈ 1.0).

Social network correlates of free and purchased insecticide-treated bed nets in rural Uganda.

BACKGROUND: Malaria is a major cause of mortality and morbidity in Uganda. Despite Uganda's efforts to distribute bed nets, only half of households have achieved the World Health Organization (WHO) Universal Coverage Criteria (one bed net for every two household members). The role of peer influence on bed net ownership remains underexplored. Data on the complete social network of households were collected in a rural parish in southwestern Uganda to estimate the association between household bed net ownership and peer household bed net ownership. METHODS: Data on household sociodemographics, bed net ownership, and social networks were collected from all households across one parish in southwestern Uganda. Bed nets were categorized as either purchased or free. Purchased and free bed net ownership ratios were calculated based on the WHO Universal Coverage Criteria. Using network name generators and complete census of parish residents, the complete social network of households in the parish was generated. Linear regression models that account for network autocorrelation were fitted to estimate the association between households' bed net ownership ratios and bed net ownership ratios of network peer households, adjusting for sociodemographics and network centrality. RESULTS: One thousand seven hundred forty-seven respondents were interviewed, accounting for 716 households. The median number of peer households to which a household was directly connected was 7. Eighty-six percent of households owned at least one bed net, and 41% of households met the WHO Universal Coverage Criterion. The median bed net ownership ratios were 0.67 for all bed nets, 0.33 for free bed nets, and 0.20 for purchased bed nets. In adjusted multivariable models, purchased bed net ownership ratio was associated with average household wealth among peer households (b = 0.06, 95% CI 0.03, 0.10), but not associated with average purchased bed net ownership ratio of peer households. Free bed net ownership ratio was associated with the number of children under 5 (b = 0.08, 95% CI 0.05, 0.10) and average free bed net ownership ratios of peer households (b = 0.66, 95% CI 0.46, 0.85). CONCLUSIONS: Household bed net ownership was associated with bed net ownership of peer households for free bed nets, but not for purchased bed nets. The findings suggest that public health interventions may consider leveraging social networks as tools for dissemination, particularly for bed nets that are provided free of charge.

DNA methylation signatures associated with prognosis of gastric cancer.

BACKGROUND: Few studies have examined prognostic outcomes-associated molecular signatures other than overall survival (OS) for gastric cancer (GC). We aimed to identify DNA methylation biomarkers associated with multiple prognostic outcomes of GC in an epigenome-wide association study. METHODS: Based on the Cancer Genome Atlas (TCGA), DNA methylation loci associated with OS (n = 381), disease-specific survival (DSS, n = 372), and progression-free interval (PFI, n = 383) were discovered in training set subjects (false discovery rates < 0.05) randomly selected for each prognostic outcome and were then validated in remaining subjects (P-values < 0.05). Key CpGs simultaneously validated for OS, DSS, and PFI were further assessed for disease-free interval (DFI, n = 247). Gene set enrichment analyses were conducted to explore the Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathways simultaneously enriched for multiple GC prognostic outcomes. Methylation correlated blocks (MCBs) were identified for co-methylation patterns associated with GC prognosis. Based on key CpGs, risk score models were established to predict four prognostic outcomes. Spearman correlation analyses were performed between key CpG sites and their host gene mRNA expression. RESULTS: We newly identified DNA methylation of seven CpGs significantly associated with OS, DSS, and PFI of GC, including cg10399824 (GRK5), cg05275153 (RGS12), cg24406668 (MMP9), cg14719951(DSC3), and cg25117092 (MED12L), and two in intergenic regions (cg11348188 and cg11671115). Except cg10399824 and cg24406668, five of them were also significantly associated with DFI of GC. Neuroactive ligand-receptor interaction pathway was suggested to play a key role in the effect of DNA methylation on GC prognosis. Consistent with individual CpG-level association, three MCBs involving cg11671115, cg14719951, and cg24406668 were significantly associated with multiple prognostic outcomes of GC. Integrating key CpG loci, two risk score models performed well in predicting GC prognosis. Gene body DNA methylation of cg14719951, cg10399824, and cg25117092 was associated with their host gene expression, whereas no significant associations between their host gene expression and four clinical prognostic outcomes of GC were observed. CONCLUSIONS: We newly identified seven CpGs associated with OS, DSS, and PFI of GC, with five of them also associated with DFI, which might inform patient stratification in clinical practices.

Inequality and visibility of wealth in experimental social networks.

Humans prefer relatively equal distributions of resources, yet societies have varying degrees of economic inequality. To investigate some of the possible determinants and consequences of inequality, here we perform experiments involving a networked public goods game in which subjects interact and gain or lose wealth. Subjects (n = 1,462) were randomly assigned to have higher or lower initial endowments, and were embedded within social networks with three levels of economic inequality (Gini coefficient = 0.0, 0.2, and 0.4). In addition, we manipulated the visibility of the wealth of network neighbours. We show that wealth visibility facilitates the downstream consequences of initial inequality-in initially more unequal situations, wealth visibility leads to greater inequality than when wealth is invisible. This result reflects a heterogeneous response to visibility in richer versus poorer subjects. We also find that making wealth visible has adverse welfare consequences, yielding lower levels of overall cooperation, inter-connectedness, and wealth. High initial levels of economic inequality alone, however, have relatively few deleterious welfare effects.

Change in clinical practice variations for antibiotic prescriptions across different pediatric clinics: A Japan's nationwide observational study.

BACKGROUND: In 2016, the Japanese government set the National Action Plan on antimicrobial resistance to reduce antibiotic prescriptions. However, the trends and variations of antibiotic prescription patterns in a routine healthcare setting during the fiscal year 2013-2018 across different clinics at a national level are unclear. METHODS: This retrospective cohort study included all clinics with >100 pediatric outpatients with infectious diseases per month during the fiscal year 2013-2018 using a national database in Japan. We investigated the trends in antibiotic prescription rates and their patterns and variations across different clinics over the six years following the 2019 World Health Organization Access, Watch, Reserve antibiotic groups, and Amoxicillin Index. RESULTS: A total of 2278 clinics with 94,414,170 infectious disease-related visits were eligible for the study. Most clinics showed higher Watch percentages (median 85.4%; IQR, 68.5-95.1) than Access percentages (median, 13.8%; IQR, 4.2-30.7) and Amoxicillin Index (median, 13.3%; IQR, 3.9-30.4). The introduction of the Action Plan changed annual absolute reductions in the antibiotic prescription rates from -16.0 DOTs/1000 visitors (95%CI, -16.4-15.6) to -239.3 per 1000 visitors (95%CI, -240.0-238.6). However, these impacts were heterogeneous across clinics. From 2013 to 2018, 41.4% reduced the antibiotic prescription rates by >33.3% (median, -1035.5 DOTs/1000 visitors; IQR, -1519.4-680.2), 18.7% did not change the rates (median, -40.3 DOTs/1000 visitors; IQR, -168.4-68.6), and 7.3% increased the rates by >10% (499.5 DOTs per 1000 visitors; IQR, 232.6-837.5). CONCLUSIONS: We observed the National Action Plan's impacts and extensive prescription variations across different pediatric clinics. However, one-fourth of clinics did not improve antibiotic prescription patterns even after introducing the Action Plan.

Review Article: The Role of Molecular Pathological Epidemiology in the Study of Neoplastic and Non-neoplastic Diseases in the Era of Precision Medicine.

Molecular pathology diagnostics to subclassify diseases based on pathogenesis are increasingly common in clinical translational medicine. Molecular pathological epidemiology (MPE) is an integrative transdisciplinary science based on the unique disease principle and the disease continuum theory. While it has been most commonly applied to research on breast, lung, and colorectal cancers, MPE can investigate etiologic heterogeneity in non-neoplastic diseases, such as cardiovascular diseases, obesity, diabetes mellitus, drug toxicity, and immunity-related and infectious diseases. This science can enhance causal inference by linking putative etiologic factors to specific molecular biomarkers as outcomes. Technological advances increasingly enable analyses of various -omics, including genomics, epigenomics, transcriptomics, proteomics, metabolomics, metagenomics, microbiome, immunomics, interactomics, etc. Challenges in MPE include sample size limitations (depending on availability of biospecimens or biomedical/radiological imaging), need for rigorous validation of molecular assays and study findings, and paucities of interdisciplinary experts, education programs, international forums, and standardized guidelines. To address these challenges, there are ongoing efforts such as multidisciplinary consortium pooling projects, the International Molecular Pathological Epidemiology Meeting Series, and the Strengthening the Reporting of Observational Studies in Epidemiology-MPE guideline project. Efforts should be made to build biorepository and biobank networks, and worldwide population-based MPE databases. These activities match with the purposes of the Big Data to Knowledge (BD2K), Genetic Associations and Mechanisms in Oncology (GAME-ON), and Precision Medicine Initiatives of the United States National Institute of Health. Given advances in biotechnology, bioinformatics, and computational/systems biology, there are wide open opportunities in MPE to contribute to public health.

The Activity Support Scale for Multiple Groups (ACTS-MG): Child-reported Physical Activity Parenting in African American and Non-Hispanic White Families.

This study aimed to assess the psychometric properties of a child-report, multidimensional measure of physical activity (PA) parenting, the Activity Support Scale for Multiple Groups (ACTS-MG), in African American and non-Hispanic white families. The ACTS-MG was administered to children aged 5 to 12 years. A three factor model of PA parenting (Modeling of PA, Logistic Support, and Restricting Access to Screen-based Activities) was tested separately for mother's and fathers' PA parenting. The proposed three-factor structure was supported in both racial groups for mothers' PA parenting and in the African American sample for fathers' PA parenting. Factorial invariance between racial groups was demonstrated for mother's PA parenting. Building on a previous study examining the ACTS-MG parent-report, this study supports the use of the ACTS-MG child-report for mothers' PA parenting. However, further research is required to investigate the measurement of fathers' PA parenting across racial groups.

Punishment is slower than cooperation or defection in online network games.

Punishment serves as a balancing force that dissuades people from acting selfishly, which complements cooperation as an essential characteristic for the prosperity of human societies. Past studies using economic games with two options (cooperation and defection) reported that cooperation decisions are generally faster than defection decisions and that time pressure possibly induces human players to be more intuitive and thus cooperative. However, it is unclear where punishment decisions sit on this time spectrum. Therefore, we recruited human players and implemented two series of online network games with cooperation, defection, and punishment options. First, we find that punishment decisions are slower than cooperation or defection decisions across both game series. Second, we find that imposing experimental time pressure on in-game decisions neither reduces nor increases the frequency of punishment decisions, suggesting that time pressure may not directly interact with the mechanisms that drive players to choose to punish.

Different time scales used for sexual partner surveys pose a challenge in modelling dynamics of sexually transmitted infections.

Mathematical models for sexually transmitted infections (STIs) are parameterised by empirical data on sexual behaviour (e.g. the number of partners over a given period) obtained from surveys. However, the time window for reporting sexual partnerships may vary between surveys and how data for different windows can be translated from one to another remains an open question. To highlight this issue, we compared the distributions of the number of sexual partners over one year and four weeks from the British National Surveys of Sexual Attitudes and Lifestyles. The results show that simple linear rescaling did not render the one-year and four-week partner distributions aligned. Parameterising STI models using survey-based sexual encounter rates without considering the implication of the reporting window used can lead to misleading results.

Treatment of portosystemic shunt-borne hepatic encephalopathy in a 97-year-old woman using balloon-occluded retrograde transvenous obliteration: A case report.

BACKGROUND: Hyperammonemia and hepatic encephalopathy are common in patients with portosystemic shunts. Surgical shunt occlusion has been standard treatment, although recently the less invasive balloon-occluded retrograde transvenous obliteration (B-RTO) has gained increasing attention. Thus far, there have been no reports on the treatment of portosystemic shunts with B-RTO in patients aged over 90 years. In this study, we present a case of hepatic encephalopathy caused by shunting of the left common iliac and inferior mesenteric veins, successfully treated with B-RTO. CASE SUMMARY: A 97-year-old woman with no history of liver disease was admitted to our hospital because of disturbance of consciousness. She had no jaundice, spider angioma, palmar erythema, hepatosplenomegaly, or asterixis. Her blood tests showed hyperammonemia, and abdominal contrast-enhanced computed tomography revealed a portosystemic shunt running between the left common iliac vein and the inferior mesenteric vein. She was diagnosed with hepatic encephalopathy secondary to a portosystemic shunt. The patient did not improve with conservative treatment: Lactulose, rifaximin, and a low-protein diet. B-RTO was performed, which resulted in shunt closure and improvement in hyperammonemia and disturbance of consciousness. Moreover, there was no abdominal pain or elevated levels of liver enzymes due to complications. The patient was discharged without further consciousness disturbance. CONCLUSION: Portosystemic shunt-borne hepatic encephalopathy must be considered in the differential diagnosis for consciousness disturbance, including abnormal behavior and speech.

The role of perceived health in retention disparity: A HIV-testing-related behavioral intervention among African American and Latinx men who have sex with men in the United States.

Retention in healthcare and health behavior remains a critical issue, contributing to inequitable distribution of intervention benefits. In diseases such as HIV, where half of the new infections occur among racial and sexual minorities, it is important that interventions do not enlarge pre-existing health disparities. To effectively combat this public health issue, it is crucial that we quantify the magnitude of racial/ethnic disparity in retention. Further, there is a need to identify mediating factors to this relationship to inform equitable intervention design. In the present study, we assess the racial/ethnic disparity in retention in a peer-led online behavioral intervention to increase HIV self-testing behavior and identify explanatory factors. The research used data collected from the Harnessing Online Peer Education (HOPE) HIV Study that included 899 primarily African American and Latinx men who have sex with men (MSM) in the United States. Results show that African American participants had higher lost-to-follow-up rates at 12-week follow-up compared to Latinx participants (11.1% and 5.8% respectively, Odds Ratio = 2.18, 95% confidence interval: 1.12 - 4.11, p = 0.02), which is substantially mediated by participants' self-rated health score (14.1% of the variation in the African American v.s. Latinx difference in lost-follow-up, p = 0.006). Thus, how MSM perceive their health may play an important role in their retention in HIV-related behavioral intervention programs and its racial/ethnic disparity.

Population ageing and wellbeing: lessons from Japan's long-term care insurance policy.

Japan's population is ageing rapidly because of long life expectancy and a low birth rate, while traditional supports for elderly people are eroding. In response, the Japanese Government initiated mandatory public long-term care insurance (LTCI) in 2000, to help older people to lead more independent lives and to relieve the burdens of family carers. LTCI operates on social insurance principles, with benefits provided irrespective of income or family situation; it is unusually generous in terms of both coverage and benefits. Only services are provided, not cash allowances, and recipients can choose their services and providers. Analysis of national survey data before and after the programme started shows increased use of formal care at lower cost to households, with mixed results for the wellbeing of carers. Challenges to the success of the system include dissatisfaction with home-based care, provision of necessary support for family carers, and fiscal sustainability. Japan's strategy for long-term care could offer lessons for other nations.

Future of Japan's system of good health at low cost with equity: beyond universal coverage.

Japan's premier health accomplishment in the past 50 years has been the achievement of good population health at low cost and increased equity between different population groups. The development of Japan's policies for universal coverage are similar to the policy debates that many countries are having in their own contexts. The financial sustainability of Japan's universal coverage is under threat from demographic, economic, and political factors. Furthermore, a series of crises-both natural and nuclear-after the magnitude 9·0 Great East Japan Earthquake on March 11, 2011, has shaken up the entire Japanese social system that was developed and built after World War 2, and shown existing structural problems in the Japanese health system. Here, we propose four major reforms to assure the sustainability and equity of Japan's health accomplishments in the past 50 years-implement a human-security value-based reform; redefine the role of the central and local governments; improve the quality of health care; and commit to global health. Now is the time for rebirth of Japan and its health system.

Health benefits of reduced patient cost sharing in Japan.

OBJECTIVE: To assess the effect on out-of-pocket medical spending and physical and mental health of Japan's reduction in health-care cost sharing from 30% to 10% when people turn 70 years of age. METHODS: Study data came from a 2007 nationally-representative cross-sectional survey of 10 293 adults aged 64 to 75 years. Physical health was assessed using a 16-point scale based on self-reported data on general health, mobility, self-care, activities of daily living and pain. Mental health was assessed using a 24-point scale based on the Kessler-6 instrument for nonspecific psychological distress. The effect of reduced cost sharing was estimated using a regression discontinuity design. FINDINGS: For adults aged 70 to 75 years whose income made them ineligible for reduced cost sharing, neither out-of-pocket spending nor health outcomes differed from the values expected on the basis of the trend observed in 64- to 69-year-olds. However, for eligible adults aged 70 to 75 years, out-of-pocket spending was significantly lower (P < 0.001) and mental health was significantly better (P < 0.001) than expected. These differences emerged abruptly at the age of 70 years. Moreover, the mental health benefits were similar in individuals who were and were not using health-care services (P = 0.502 for interaction). The improvement in physical health after the age of 70 years in adults eligible for reduced cost-sharing tended to be greater than in non-eligible adults (P = 0.084). CONCLUSION: Reduced cost sharing was associated with lower out-of-pocket medical spending and improved mental health in older Japanese adults.

Scale development of health status for secondary data analysis using a nationally representative survey.

OBJECTIVES: Scale development of health-related quality of life (HRQOL) measures, including physical and mental health measures, among public datasets from Japan is needed for comparative studies on health conditions among different age, gender, and socio-economic subgroups. Multi-attributable scales of continuous/discrete variables on HRQOL could be more flexible for different kinds of epidemiologic and socio-econometric studies rather than single-item measures. The objectives of this study were to create multi-dimensional scales for physical, mental, and summary health measures and to describe the age-related trends of these scales in Japan. METHODS: We utilized data from the 2007 Comprehensive Survey of the Living Conditions of People on Health and Welfare (LCPHW: Kokumin Seikatsu Kiso Chosa) (n = 383,745) to measure physical health (0 = worst score, 16 = best score) by summarizing four items: general health status, bedridden status/mobility, self-care/usual activities, and pain (0 = worst score, 4 = best score for each item). Mental health was measured using a Japanese version of K6 (0 = worst score, 4 = best score, modified from original version in which 24 = worst score and 0 = best score). We then created a summary health scale using the simple sum of physical and mental health (0 = worst score, 20 = best score). The reliability and validity of the scales were evaluated and their age-related trends described. RESULTS: The internal consistency reliability of the physical and summary health scales was not sufficiently high (Cronbach's α = 0.64 and 0.67, respectively) and the age-related trend was smooth and monotonous. The internal consistency reliability of the mental health scale (K6) was high (Cronbach's α = 0.90), while the age-related trend peaked at age 65-74 years. CONCLUSIONS: While K6 was a measure with high reliability for describing mental health, use of the physical and summary health scale in the Japanese population requires further discussion. Additional validation tests of the summary scales also need to be performed, in which our methodology is applied to other data sets that include strict diagnostic results based on a structural interview.

The consequence of financial incentives for not prescribing antibiotics: a Japan's nationwide quasi-experiment.

BACKGROUND: For addressing antibiotic overuse, Japan designed a health care policy in which eligible medical facilities could claim a financial reward when antibiotics were not prescribed for early-stage respiratory and gastrointestinal infections. The policy was introduced in a pilot manner in paediatric clinics in April 2018. METHODS: We conducted a quasi-experimental, propensity score-matched, difference-in-differences (DID) design to determine whether the nationwide financial incentives for appropriate non-prescribing of antibiotics as antimicrobial stewardship [800 JPY (≈7.3 US D) per case] were associated with changes in prescription patterns, including antibiotics, and health care use in routine paediatric health care settings at a national level. Data consisted of 9 253 261 cases of infectious diseases in 553 138 patients treated at 10 180 eligible or ineligible facilities. RESULTS: A total of 2959 eligible facilities claimed 316 770 cases for financial incentives and earned 253 million JPY (≈2.29 million USD). Compared with ineligible facilities, the introduction of financial incentives in the eligible facilities was associated with an excess reduction in antibiotic prescriptions [DID estimate, -228.6 days of therapy (DOTs) per 1000 cases (95% CI, -272.4 to -184.9), which corresponded to a relative reduction of 17.8% (95% CI, 14.8 to 20.7)]. The introduction was also associated with excess reductions in drugs for respiratory symptoms [DID estimates, -256.9 DOTs per 1000 cases (95% CI, -379.3 to -134.5)] and antihistamines [DID estimate, -198.5 DOTs per 1000 cases (95% CI, -282.1 to -114.9)]. There was no excess in out-of-hour visits [DID estimate, -4.43 events per 1000 cases (95% CI, -12.8 to 3.97)] or hospitalizations [DID estimate, -0.08 events per 1000 cases (95% CI, -0.48 to 0.31)]. CONCLUSIONS: Our findings suggest that financial incentives to medical facilities for not prescribing antibiotics were associated with reductions in prescriptions for antibiotics without adverse health care consequences. Japan's new health policy provided us with policy options for immediately reducing inappropriate antibiotic prescriptions by relatively small financial incentives.