Multivariable Prediction Model for Futile Recanalization Therapies in Patients With Acute Ischemic Stroke.

BACKGROUND AND OBJECTIVES Very poor outcome despite intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) occurs in about 1 of 4 patients with ischemic stroke and is associated with a high logistic and economic burden. We aimed to develop and validate a multivariable prognostic model to identify futile recanalization therapies (FRT) in patients undergoing those therapies. MATERIALS AND METHODS Patients from a prospectively collected observational registry of a single academic stroke center treated with MT and/or IVT were included. The dataset was split into a training (N=1808, 80%) and internal validation (N=453, 20%) cohort. We used gradient boosted decision tree machine-learning models after k-NN imputation of 32 variables available at admission to predict FRT defined as modified Rankin-Scale (mRS) 5-6 at 3 months. We report feature importance, ability for discrimination, calibration and decision curve analysis. RESULTS 2261 patients with a median (IQR) age 75 years (64-83), 46% female, median NIHSS 9 (4-17), 34% IVT alone, 41% MT alone, 25% bridging were included. Overall 539 (24%) had FRT, more often in MT alone (34%) as compared to IVT alone (11%). Feature importance identified clinical variables (stroke severity, age, active cancer, prestroke disability), laboratory values (glucose, CRP, creatinine), imaging biomarkers (white matter hyperintensities) and onset-to-admission time as the most important predictors. The final model was discriminatory for predicting 3-month FRT (AUC 0.87, 95% CI 0.87-0.88) and had good calibration (Brier 0.12, 0.11-0.12). Overall performance was moderate (F1-score 0.63 ± 0.004) and decision curve analyses suggested higher mean net benefit at lower thresholds of treatment (up to 0.8). CONCLUSIONS This FRT prediction model can help inform shared decision making and identify the most relevant features in the emergency setting. While it might be particularly useful in low resource healthcare settings, incorporation of further multifaceted variables is necessary to further increase the predictive performance

Chronic cerebral infarctions and white matter lesions link to long-term survival after a first ischemic event: A cohort study.

BACKGROUND AND PURPOSE To investigate the association of different phenotypes, count, and locations of chronic covert brain infarctions (CBI) with long-term mortality in patients with first-ever manifest acute ischemic stroke (AIS) or transient ischemic attack (TIA). Additionally, to analyze their potential interaction with white matter hyperintensities (WMH) and predictive value in addition to established mortality scores. METHODS Single-center cohort study including consecutive patients with first-ever AIS or TIA with available MRI imaging from January 2015 to December 2017. Blinded raters adjudicated CBI phenotypes and WMH (age-related white matter changes score) according to established definitions. We compared Cox regression models including prespecified established predictors of mortality using Harrell's C and likelihood ratio tests. RESULTS A total of 2236 patients (median [interquartile range] age: 71 [59-80] years, 43% female, National Institutes of Health Stroke Scale: 2 [1-6], median follow-up: 1436 days, 21% death during follow-up) were included. Increasing WMH (per point adjusted Hazard Ratio [aHR] = 1.29 [1.14-1.45]), but not CBI (aHR = 1.21 [0.99-1.49]), were independently associated with mortality. Neither CBI phenotype, count, nor location was associated with mortality and there was no multiplicative interaction between CBI and WMH (p > .1). As compared to patients without CBI or WMH, patients with moderate or severe WMH and additional CBI had the highest hazards of death (aHR = 1.62 [1.23-2.13]). The Cox regression model including CBI and WMH had a small but significant increment in Harrell's C when compared to the model including 14 clinical variables (0.831 vs. 0.827, p < .001). DISCUSSION WMH represent a strong surrogate biomarker of long-term mortality in first-ever manifest AIS or TIA patients. CBI phenotypes, count, and location seem less relevant. Incorporation of CBI and WMH slightly improves predictive capacity of established risk scores

Context and Cardiovascular Risk Modification in Two Regions of Ontario, Canada: A Photo Elicitation Study

Cardiovascular diseases, which include coronary heart diseases (CHD), remain the leading cause of death in Canada and other industrialized countries. This qualitative study used photo-elicitation, focus groups and in-depth interviews to understand health behaviour change from the perspectives of 38 people who were aware of their high risk for CHD and had received information about cardiovascular risk modification while participating in a larger intervention study. Participants were drawn from two selected regions: Sudbury and District (northern Ontario) and the Greater Toronto Area (southern Ontario). Analysis drew on concepts of place and space to capture the complex interplay between geographic location, sociodemographic position, and people’s efforts to understand and modify their risk for CHD. Three major sites of difference and ambiguity emerged: 1) place and access to health resources; 2) time and food culture; and 3) itineraries or travels through multiple locations. All participants reported difficulties in learning and adhering to new lifestyle patterns, but access to supportive health resources was different in the two regions. Even within regions, subgroups experienced different patterns of constraint and advantage. In each region, “fast” food and traditional foods were entrenched within different temporal and social meanings. Finally, different and shifting strategies for risk modification were required at various points during daily and seasonal travels through neighbourhoods, to workplaces, or on vacation. Thus health education for CHD risk modification should be place-specific and tailored to the needs and resources of specific communities

Access to myocardial revascularization procedures: Closing the gap with time?

BACKGROUND: Early access to revascularization procedures is known to be related to a more favorable outcome in myocardial infarction (MI) patients, but access to specialized care varies widely amongst the population. We aim to test if the early gap found in the revascularization rates, according to distance between patients' location and the closest specialized cardiology center (SCC), remains on a long term basis. METHODS: We conducted a population-based cohort study using data from the Quebec's hospital discharge register (MED-ECHO). The study population includes all patients 25 years and older living in the province of Quebec, who were hospitalized for a MI in 1999 with a follow up time of one year after the index hospitalization. The main variable is revascularization (percutaneous transluminal coronary angioplasty or a coronary artery bypass graft). The population is divided in four groups depending how close they are from a SCC (<32 km, 32–64 km, 64–105 km and ≥105 km). Revascularization rates are adjusted for age and sex. RESULTS: The study population includes 11,802 individuals, 66% are men. The one-year incidence rate of MI is 244 individuals per 100,000 inhabitants. At index hospitalization, a significant gap is found between patients living close (< 32 km) to a SCC and patients living farther (≥32 km). During the first year, a gap reduction can be observed but only for patients living at an intermediate distance from the specialized center (64–105 km). CONCLUSION: The gap observed in revascularization rates at the index hospitalization for MI is in favour of patients living closer (< 32 km) to a SCC. This gap remains unchanged over the first year after an MI except for patients living between 64 and 105 km, where a closing of the gap can be noticed

Avoidable mortality across Canada from 1975 to 1999

BACKGROUND: The concept of 'avoidable' mortality (AM) has been proposed as a performance measure of health care systems. In this study we examined mortality in five geographic regions of Canada from 1975 to 1999 for previously defined avoidable disease groups that are amenable to medical care and public health. These trends were compared to mortality from other causes. METHODS: National and regional age-standardized mortality rates for ages less than 65 years were estimated for avoidable and other causes of death for consecutive periods (1975–1979, 1980–1985, 1985–1989, 1990–1994, and 1995–1999). The proportion of all-cause mortality attributable to avoidable causes was also determined. RESULTS: From 1975–1979 to 1995–1999, the AM decrease (46.9%) was more pronounced compared to mortality from other causes (24.9%). There were persistent regional AM differences, with consistently lower AM in Ontario and British Columbia compared to the Atlantic, Quebec, and Prairies regions. This trend was not apparent when mortality from other causes was examined. Injuries, ischaemic heart disease, and lung cancer strongly influenced the overall AM trends. CONCLUSION: The regional differences in mortality for ages less than 65 years was attributable to causes of death amenable to medical care and public health, especially from causes responsive to public health

A Joint Modeling Approach for Analysis of Longitudinal Body Weight and Sputum Status of Tuberculosis patients in Jimma University Specialized Hospital

Tuberculosis is a major public health problem even though it is treatable and curable. Weight and sputum conversion during anti tuberculosis (TB) treatment period is an important component and they have been described as a useful marker to assess the progress of TB patients’. Objective:-The objective of this study is to fit a joint model in which both the longitudinal weight and sputum status are studied to investigate their joint evolution and identify the risk factors for the body weight and sputum status of tuberculosis patients in Jimma University specialized Hospital during six months diagnosis period. Method: The data for this thesis were obtained from a retrospective study from TB patients registered between 2011 and 2013. The following statistical models were considered: linear mixed model for the separate body weight analysis, generalized linear mixed model for sputum status and a joint model with correlated random effects was fitted to simultaneously study the evolution over time of a longitudinal body Weight and Sputum status. The estimation of the model parameters was done by maximum and restricted likelihood and maximum likelihood based on adaptive Gaussian hermite Quadrature as implemented in the SAS procedure NLMXED. Result: The overall proportion of tuberculosis patients during follow up time having positive and negative sputum status is 39.3% and 60.7% respectively. Based on the data exploration the mean change of body weight has a linear relation with time. From the separate linear mixed model all covariates (types of TB, age, dose) are significant and their interaction by time were the risk factors for the body weight of TB patients. In case of separate generalized linear mixed model age, types of TB, dose and time have a significant effect on the sputum status of TB patients. Similar covariates were significant in the joint model of body weight and sputum status and estimates were found to be very close to separate analysis. But, the joint model yields higher precision and allows for quantifying the association between outcomes and association between the outcomes in this joint model was negative (ρ =-0.698, p=0.0001). Conclusion: The results of the separate and joint models almost the same. When the joint model is compared with the separate model, it is both the most parsimonious model and also fits the data better than the separate model. The joint model showed that the body weight and positive sputum status are inversely related each other

Effects of Flipped Explicit Reading Instruction on College EFL Trainees’ Reading Comprehension Proficiency

The flipped classroom, a contemporary model, and explicit reading instruction, a widely recognized conventional approach, both offer unique benefits and have their own place in education. This study aimed to investigate the effects of Flipped Explicit Reading Comprehension Instruction (FERCI) on college EFL trainees’ Reading Comprehension Proficiency (RCP) and its impact on course achievement test scores. Conducted at Injibara College of Teachers Education in Ethiopia, the study involved 53 participants from October 7 to February 6, 2023, utilizing a quasi-experimental pre-test-post-test non-equivalent group design. The participants were assigned into experimental (N=28) and control (N=25) groups. The experimental group received the course using FERCI, which involved providing educational content outside of the classroom through videos and readings before class, while the control group received explicit reading comprehension instruction (ERCI). Data were collected through RCP pre-tests, post-tests, and course achievement test scores. The results revealed that both FERCI and ERCI were significantly effective in enhancing RCP, with large effect sizes (eta squared = 0.93 for EG and 0.87 for CG) further supporting substantial improvements in both groups. However, both FERCI and ERCI had distinctive effects, with FERCI showing a significantly better (moderate effect size eta squared =. 464) impact on RCP test scores compared to ERCI