Persistently high hepatitis C rates in haemodialysis patients in Brazil [a systematic review and meta-analysis]

We conducted a systematic review and meta-analysis of studies assessing HCV infection rates in haemodialysis patients in Brazil (Prospero CRD #42021275068). We included studies on patients under haemodialysis, comprising both convenience samples and exhaustive information from selected services. Patients underwent HCV serological testing with or without confirmation by HCV RNA PCR. Exclusion criteria were the following: absence of primary empirical information and studies without information on their respective settings, study year, accurate infection rates, or full specification of diagnostic tests. Studies with samples ≤ 30 and serial assessments with repeated information were also excluded. Reference databases included PubMed, LILACS, Scopus, and Web of Science for the period 1989–2019. A systematic review was carried out, followed by two independent meta-analyses: (i) studies with data on HCV prevalence and (ii) studies with a confirmatory PCR (i.e., active infection), respectively. A comprehensive set of different methods and procedures were used: forest plots and respective statistics, polynomial regression, meta-regression, subgroup influence, quality assessment, and trim-and-fill analysis. 29 studies and 11,290 individuals were assessed. The average time patients were in haemodialysis varied from 23.5 to 56.3 months. Prevalence of HCV infection was highly heterogeneous, with a pronounced decrease from 1992 to 2001, followed by a plateau and a slight decrease in recent years. The summary measure for HCV prevalence was 34% (95% CI 26–43%) for studies implemented before 2001. For studies implemented after 2001, the corresponding summary measure was 11% (95% CI 8–15%). Estimates for prevalence of active HCV infection were also highly heterogeneous. There was a marked decline from 1996 to 2001, followed by a plateau and a slight increase after 2010. The summary measure for active HCV infection was 19% (95% CI 15–25%) in studies carried out before 2001. For studies implemented after 2001, the corresponding summary measure was 9% (95% CI 6–13%). Heterogeneity was pervasive, but different analyses helped to identify its underlying sources. Besides the year each study was conducted, the findings differed markedly between geographic regions and were heavily influenced by the size of the studies and publication biases. Our systematic review and meta-analysis documented a substantial decline in HCV prevalence among Brazilian haemodialysis patients from 1992 to 2015. CKD should be targeted with specific interventions to prevent HCV infection, and if prevention fails, prompt diagnosis and treatment. Although the goal of HCV elimination by 2030 in Brazil remains elusive, it is necessary to adopt measures to achieve micro-elimination and to launch initiatives towards targeted interventions to curb the spread of HCV in people with CKD, among other high-risk groups. This is of particular concern in the context of a protracted COVID-19 pandemic and a major economic and political crisis.

Victimization experience does matter: Testing the effect of different types of victimization on fear of crime among adolescents

The aim of the present study is to thoroughly examine the relationship between adolescent fear of crime and a wide variety of offences which commonly affect children. The analysed data comes from the Urban Youth Victimization Survey conducted among 9th grade students in the Czech Republic. The results unequivocally demonstrate that victimization experience, when measured properly, substantially affects adolescent fear of crime. All analysed types of victimization are associated with fear of crime, though the strongest effects were found for cyber-victimization and bullying rather than conventional violent and property crimes. Furthermore, a poly-victimization scale was revealed to be a highly effective tool for capturing overall victimization by using a single summary measure.

Neighborhood Characteristics and Accelerated Aging: Evidence From the Health and Retirement Study

An individual’s rate of aging directly impacts one’s functioning, morbidity and mortality. Identifying factors related to accelerated or delayed aging may provide important information for potential areas of intervention. While race/ethnicity, socioeconomic status and behavior characteristics have been linked to biological aging, it is unclear whether neighborhood characteristics are associated with one’s rate of aging. We use a novel aging measure, Expanded Biological Age, from the 2016 Health and Retirement Study Venous Blood Study (HRS-VBS) to investigate whether individuals living with unfavorable neighborhood conditions are experiencing accelerated aging compared to those living in more favorable conditions. We constructed a summary measure of expanded biological age using 22 novel biomarkers in the HRS-VBS; we then regressed the summary measure on age and used the residuals as indicators of accelerated or delayed aging. We measured neighborhood physical disorder, presence of green space, and perceived social cohesion using the 2016 HRS Interviewer Observation data and Self-Administered Questionnaire. We find that individuals living with higher levels of neighborhood physical disorder appeared 1.05 years older biologically than the average for those of the same chronological age. Individuals living near green space including parks were 1.5 years younger biologically than expected based on their chronological age though this association was marginally significant. We did not find an association between neighborhood social cohesion and accelerated aging. This implies that living with severe neighborhood disorder, characterized by presence of disrepair, trash/litter, and abandoned structures, and living near green space, play an important role in who lives longer.

Using a Social Determinants of Health Summary Measure to Predict General Health Status in the BRFSS

Purpose This study aims to assess the relationship between social determinants of health (SDoH) burden and overall health. Design Three years of Behavioral Risk Factor Surveillance System (BRFSS) data (2017–2019) were combined for this cross-sectional study. Setting Massachusetts. Subjects Out of a possible 21,312 respondents, 16,929 (79%) were eligible for inclusion. Measures To create the SDoH summary measure, items assessing social risk experiences including financial instability (1 item), housing instability (2 items), perceptions of neighborhood crime (1 item), and food insecurity (2 items) were summed to create a count of risk experiences. Outcome measures included self-rated general health, days of poor physical health, and days of poor mental health. Analysis Multivariable logistic regression was used to evaluate the association between each outcome and the SDoH summary measure, adjusting for demographic confounders. Results In adjusted analyses, respondents who reported experiencing 1, 2, 3, or 4+ SDoH had a 1.6 (95% CI: 1.3–2.0), 2.9 (95% CI: 2.3–3.7), 3.2 (95% CI: 2.4–4.3), or 5.3 (95% CI: 4.0–7.0) increased odds (respectively) of self-rated fair/poor health, compared to those who reported zero SDoH. The adjusted relationship between the SDoH summary measure and physical health and mental health was similar in magnitude and statistically significant. Conclusions These results demonstrate that the overall burden of risk due to SDoH is an important predictor of health.

The aggregate effect of implementation strength of family planning programs on modern contraceptive use at the health systems level in rural Malawi

To explore the association between the strength of implementation of family planning (FP) programs on the use of modern contraceptives. Specifically, how strongly these programs are being implemented across a health facility’s catchment area in Malawi and the odds of a woman in that catchment area is using modern contraceptives. This information can be used to assess whether the combined impact of multiple large-scale FP programs is leading to change in the health outcomes they aim to improve. We used data from the 2017 Implementation Strength Assessment (ISA) that quantified how much of family planning programs at the health facility and community health worker levels were being implemented across every district of Malawi. We used a summary measure developed in a previous study that employs quantitative methods to combine data across FP domains and health system levels. We tested the association of this summary measure for implementation strength with household data from the 2015 Malawi Demographic Health Survey (DHS). We found that areas with stronger implementation of FP programs had higher odds of women using modern contraceptives compared with areas with weaker implementation. The association of ISA with use of modern contraception was different by education, marital status, and geography. After controlling for these factors, we found that the adjusted odds of using a modern contraceptive was three times higher in catchment areas with high implementation strength compared to those with lower strength. Metrics that summarize how strongly FP programs are being implemented were used to show a statistically significantly positive relationship between increasing implementation strength and higher rates of modern contraceptive use. Decisionmakers at the various levels of health authority can use this type of summary measure to better understand the combined impact of their diverse FP programming and inform future programmatic and policy decisions. The findings also reinforce the idea that having a well-supported and supplied cadre of community health workers supplementing FP provision at the health facility can be an important health systems mechanism, especially in rural settings and to target youth populations.

From raw data to a score: Comparing quantitative methods that construct multi-level composite implementation strength scores of family planning programs in Malawi

Background: Data that capture implementation strength can be combined in multiple ways across content and health system levels to create a summary measure that can help us to explore and compare program implementation across facility catchment areas. Summary indices can make it easier for national policymakers to understand and address variation in strength of program implementation across jurisdictions. In this paper we describe development of an index that we used to describe the district level strength of implementation of the Malawi national family planning program. Methods: To develop the index, we used data collected during a 2017 national, health facility and community health worker Implementation Strength Assessment survey in Malawi to test different methods to combine indicators within and then across domains (4 methods: simple additive, weighted additive, principal components analysis, exploratory factor analysis) and combine scores across health facility and community health worker levels (2 methods: simple average and mixed effects model) to create a catchment area-level summary score for each health facility in Malawi. We explored how well each model captures variation and predicts couple years protection and how feasible it is to conduct each type of analysis and the resulting interpretability. Results: We found little difference in how the four methods combined indicator data at the individual and combined levels of the health system. However, there were major differences when combining scores across health system levels to obtain a score at the health facility catchment area level. The scores resulting from the mixed effects model were able to better discriminate differences between catchment area scores compared to the simple average method. The scores using the mixed effects combination method also demonstrated more of a dose and response relationship with couple years protection. Conclusions: The summary measure that was calculated from the mixed effects combination method captured the variation of strength of implementation of the Malawi national family planning program at the health facility catchment area level. However, the best method for creating an index should be based on pros and cons listed, not least, analyst capacity and ease of interpretability of findings. Ultimately, the resulting summary measure can aid decisionmakers in understanding the combined effect of multiple aspects of programs being implemented in their health system and comparing strengths of programs across geographies.

Estimands in published protocols of randomised trials: urgent improvement needed

Background An estimand is a precise description of the treatment effect to be estimated from a trial (the question) and is distinct from the methods of statistical analysis (how the question is to be answered). The potential use of estimands to improve trial research and reporting has been underpinned by the recent publication of the ICH E9(R1) Addendum on the use of estimands in clinical trials in 2019. We set out to assess how well estimands are described in published trial protocols. Methods We reviewed 50 trial protocols published in October 2020 in Trials and BMJ Open. For each protocol, we determined whether the estimand for the primary outcome was explicitly stated, not stated but inferable (i.e. could be constructed from the information given), or not inferable. Results None of the 50 trials explicitly described the estimand for the primary outcome, and in 74% of trials, it was impossible to infer the estimand from the information included in the protocol. The population attribute of the estimand could not be inferred in 36% of trials, the treatment condition attribute in 20%, the population-level summary measure in 34%, and the handling of intercurrent events in 60% (the strategy for handling non-adherence was not inferable in 32% of protocols, and the strategy for handling mortality was not inferable in 80% of the protocols for which it was applicable). Conversely, the outcome attribute was stated for all trials. In 28% of trials, three or more of the five estimand attributes could not be inferred. Conclusions The description of estimands in published trial protocols is poor, and in most trials, it is impossible to understand exactly what treatment effect is being estimated. Given the utility of estimands to improve clinical research and reporting, this urgently needs to change.

Sex differences in distributed error-related neural activation in binge drinking young adults

Detecting and responding to errors is central to goal-directed behavior and cognitive control, which are thought to be supported by a network of structures that includes the anterior cingulate cortex and anterior insula. Notable sex differences in the maturational timing of cognitive control neural systems create differential periods of vulnerability for psychiatric conditions, such as substance use disorders, between males and females. Here we examined sex differences in error-related activation across an array of distributed brain regions during a go/no-go task in a sample of binge drinking college students. Regions of interest previously linked to error-related activation, including the anterior cingulate cortex, insula, and frontoparietal structures, were selected in a term-based meta-analysis and individual differences in their activation were indexed using a multivariate summary measure. Males exhibited significantly higher levels of this multivariate summary measure than females. Males also reported significantly greater substance use; however, substance use did not significantly predict neural activation in a linear regression analysis. These findings suggest that males have more marked responses to errors across a network of regions linked to performance monitoring and cognitive control.