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Associations of environmental variables with physical activity and sedentary time using data from the Canadian Longitudinal Study on Aging, and the Canadian Urban Environmental Health Research Consortium (Canadian Active Living Environments (Can-ALE) dataset, and Normalized Difference Vegetation Index (NDVI, greenness) dataset) were assessed. The main outcome variables were physical activity and sedentary time as measured by a modified version of the Physical Activity for Elderly Scale. The sample consisted of adults aged 45 and older (n = 36 580, mean age 62.6 ± 10.2, 51% female). Adjusted ordinal regression models consistently demonstrated that those residing in neighbourhoods in the highest Can-ALE category (most well-connected built environment) reported more physical activity and sedentary time. For example, males aged 75+ in the highest Can-ALE category had 2 times higher odds of reporting more physical activity (OR = 2.0, 95% CI = 1.1–3.5) and 1.8 times higher odds of reporting more sedentary time (OR = 1.8, 95% CI = 1.0–3.4). Neighbourhoods with higher greenness scores were also associated with higher odds of reporting more physical activity and sedentary time. It appears that an environment characterized by higher Can-ALE and higher greenness may facilitate physical activity, but it also facilitates more leisure sedentary time in older adults; research using device measured total sedentary time, and consideration of the types of sedentary activities being performed is needed. Novelty: Middle-aged and older adults living in neighbourhoods with higher Can-ALE scores and more greenness report more physical activity and leisure sedentary time Greenness is important for physical activity and sedentary time in middle-aged adults

OBJECTIVE: To determine the influence of major depressive disorders (MDD) on the cognitive function of adults living with HIV and the prevalence of neurocognitive impairment and major depressive disorders. METHODS: The study was a cross-sectional design conducted in a referral hospital in Dodoma region central Tanzania, with a sample of 397 participants attained through systematic sampling. Neurocognitive impairment was assessed by Montreal Cognitive Assessment (MoCA), while MDD was assessed using Mini International Neuropsychiatric Interview (M.I.N.I). Two-sample independent t-tests were done to compute the significance of the mean change of MoCA score between those with or without MDD. Univariate and multivariate ordinal logistic regression models were computed to determine the association between MDD and neurocognitive impairment across all cognitive domains. RESULTS: Of 397 recruited participants, 266 (66.00%) met the criteria for neurocognitive disorder and 22 (5.51%) had major depressive disorder. Participants with MDD performed significantly poorer on cognitive testing than those without MDD (mean difference = 3.74, p-value = 0.0009). Under univariate ordinal regression, impairments in the particular domains of visuospatial-executive function, attention, language, abstraction and orientation were significantly associated with MDD and abstraction (AOR: 3.922, 95% CI: 1.546–9.947, p = 0.0004) remained significant under multivariable regression. CONCLUSION: Major depressive disorder may negatively influence neurocognitive performance in both severity and pattern of presentation. Routine screening for depressive symptoms in HIV care can be beneficial for the overall patient’s outcome. Systematic and well-designed studies in the area are crucial for understanding the interaction of neuropsychiatric disorders in the HIV population.

As demand increased for mental health services, especially in university counseling centers, providers have seen increasing numbers of clients. The effect of this increase on therapist caseloads is explored, with a recognition that past research on therapist caseloads lacks direct and fluctuating measures of caseload that reflect practice in naturalistic settings. Using a large dataset from a counseling center (N = 18,322), therapist caseload was conceptualized dynamically over rolling 30-day periods, using within-therapist counts of therapy sessions, unique clients seen, and the proportion of unique clients to sessions. Analysis of variance was used first to test for differences in caseload between months, years, then to test for differences between therapists (n = 173). Hierarchical linear models were constructed to examine the relationship between changes in therapist caseload across time and client outcome. Logistic and ordinal regression approaches were used to further examine this relationship for clinically significant change. Results included finding a small, but significant, effect of therapist caseload on outcome, with this finding discussed in the context of the effect sizes in the literature on therapist effects. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Background Evaluating measurement bias is vital to ensure equivalent assessment across diverse groups. One approach for evaluating test bias, differential item functioning (DIF), assesses item-level bias across specified groups by comparing item-level responses between groups that have the same overall score. Previous DIF studies of the Beck Anxiety Inventory (BAI) have only assessed bias across age, sex, and disease duration in monolingual samples. We expand this literature through DIF analysis of the BAI across age, sex, education, ethnicity, cognitive status, and test language. Methods BAI data from a sample (n = 527, mean age=61.4 ± 12.7, mean education=10.9 ± 4.3, 69.3% female, 41.9% Hispanic/Latin American) from rural communities in West Texas, USA were analyzed. Item response theory (IRT) / logistic ordinal regression DIF was conducted across dichotomized demographic grouping factors. The Mann-Whitney U test and Hedge's g standardized mean differences were calculated before and after adjusting for the impact of DIF. Results Significant DIF was demonstrated in 10/21 items. An adverse impact of DIF was not identified when demographics were assessed individually. Adverse DIF was identified for only one participant (1/527, 0.2%) when all demographics were aggregated. Limitations These results might not be generalizable to a sample with broader racial representation, more severe cognitive impairment, and higher levels of anxiety. Conclusions Minimal item-level bias was identified across demographic factors considered. These results support prior evidence that the BAI is valid for assessing anxiety across age and sex while contributing new evidence of its clinical relevance across education, ethnicity, cognitive status, and English/Spanish test language.

In the coming three decades, world waste will be expected to increase by 70%. Coupled with the absence of waste management technologies, unregulated dumping remained a threat to sustainable development in developing countries. To this end, this study emphasized to trace socially acceptable and environmentally friendly solid waste dumpsite for the northeastern arid cities of Ethiopia. The tuneful integration of GIS and MCDA was used for the end-to-end processing of 17 variables. At the earlier, to increase alternative dumpsites and seeking for safe zone outside the cities, 20 km buffer at Semera-logia city was used as a spatial scope of the study. Fifteen key informants (KIs) from related departments of the city and Samara University were selected to validate the model result. In the end, Ordinal Regression (OR) analysis was used to test the significance of the criteria's on suitable dumpsite selection. The pair-wise comparison matrix shows that variables such as distance from surface water (11.32%), distance from the settlement (9.88%), distance from boreholes (8.87%), and aquifer productivity (8.51%) were the top weighed criteria for the study area. The weighted overlay result shows that 10.75% and 38.64% of the study area are found to be convenient and prohibited for dumping, respectively. Indeed, the KIs were agreed on 77% of the validation points and the agreement decreases from points of not-suitable to highly suitable. Except for aquifer productivity, all the 16 variables are significantly and negatively affect dumpsites suitability. This result can be further used as a preliminary database for experts to design landfill structures and also management operations for decision-makers.Implications: The identification of potential dumpsite is an important step towards maximizing efficiency and building sustainability in the arid areas. The decision-making process shall be based on the empirical investigation. The decision-making process on dumpsite selection were well thought out both the socio-economic and environmental factors. In owing process, the empirical investigation that was conducted focusing on socio-economic dimension jeopardized other components of the environments. The approach that considers both socio-economic and spatial factors was all-inclusive. Overall, decision-makers could have a good insight to work on prioritizing dumpsite alternatives and implement feasible waste management actions.

Background and aim Frailty Phenotype (FP) is very common in Heart Failure (HF) and both syndromes worsen one another. The aim of this study is to first describe FP in a sample of Portuguese HF patients, and to analyse its association with nutritional and clinical statuses, namely muscle mass, obesity and functional class. Methods and results In this cross-sectional study, a sample of 136 heart failure outpatients (24-81 years, 33.8% women) was randomly selected from the appointments’ listings of a HF and Transplant clinic in a Portuguese University Hospital. FP was assessed according to Fried et al.; muscle mass was estimated from mid-upper arm muscle circumference; weight status was assessed using body mass index; HF functional classes were registered. The association between participants’ characteristics and FP categories was analysed using logistic ordinal regression. The frequency of pre-frailty and frailty is 57.4% and 15.4%, respectively. Within frail individuals, 52.4% were under the age of 65. In multivariable analysis, frailty was positively associated with being 70 or older (OR = 3.44) and obese (OR = 2.66), and negatively associated with muscle mass (OR = 0.77) and with being at class I (OR = 0.14) or class II (OR = 0.29) of HF functional classes. Conclusion Muscle mass seems to be an important predictor of frailty in HF patients and should be taken into account when designing intervention plans that allow for reverting or modifying frailty and pre-frailty. Younger patients should be monitored for the presence and evolution of FP.

Objectives: To evaluate the demographic and clinical characteristics of patients with Behcet's syndrome (BS), and to define their associations with the presence of major organ involvement (MOI).Method: Medical records of 2118 patients (964 males, 1154 females) were analysed retrospectively. MOI was defined as the presence of at least one of vascular, eye, nervous, or gastrointestinal system involvement. Univariable and multivariable binary and ordinal logistic regression analyses were applied to assess the factors that were potentially associated with MOI.Results: The mean ± sd age at diagnosis was 30.5 ± 9.4 years. Genital ulcer and joint involvement were more common in females (both p < 0.001), while MOI was more frequent in males (p < 0.001). Genital ulcer (p < 0.001) and vascular involvement (p = 0.006) were more common in patients with a younger age at diagnosis, while joint involvement was more common in older patients. A total of 1097 patients (51.8%) had at least one MOI, 322 (15.2%) at least two MOIs, and 48 (2.3%) at least three MOIs. Male gender, smoking history, and absence of genital ulcer were significantly associated with MOI in multivariable binary logistic regression. Multivariable ordinal regression analyses confirmed the association between MOI and male gender and smoking, but not the protective effect of genital ulcers. In both regression analyses, we found no significant effects of age, human leucocyte antigen-B51, skin involvement, or joint involvement on MOI.Conclusion: Male gender and positive smoking history have a significant influence on the presence of MOI in patients with BS.

Driver mental fatigue leads to thousands of traffic accidents. The increasing quality and availability of low-cost electroencephalogram (EEG) systems offer possibilities for practical fatigue monitoring. However, non-data-driven methods, designed for practical, complex situations, usually rely on handcrafted data statistics of EEG signals. To reduce human involvement, we introduce a data-driven methodology for online mental fatigue detection: self-weight ordinal regression (SWORE). Reaction time (RT), referring to the length of time people take to react to an emergency, is widely considered an objective behavioral measure for mental fatigue state. Since regression methods are sensitive to extreme RTs, we propose an indirect RT estimation based on preferences to explore the relationship between EEG and RT, which generalizes to any scenario when an objective fatigue indicator is available. In particular, SWORE evaluates the noisy EEG signals from multiple channels in terms of two states: shaking state and steady state. Modeling the shaking state can discriminate the reliable channels from the uninformative ones, while modeling the steady state can suppress the task-nonrelevant fluctuation within each channel. In addition, an online generalized Bayesian moment matching (online GBMM) algorithm is proposed to online-calibrate SWORE efficiently per participant. Experimental results with 40 participants show that SWORE can maximally achieve consistent with RT, demonstrating the feasibility and adaptability of our proposed framework in practical mental fatigue estimation.

Purpose: To investigate the relationship between the training load (TL = rate of perceived exertion × training time) and wellness index (WI) in soccer. Methods: The WI and TL data were recorded from 28 subelite players (age = 20.9 [2.4] y; height = 181.0 [5.8] cm; body mass = 72.0 [4.4] kg) throughout the 2017/2018 season. Predictive models were constructed using a supervised machine learning method that predicts the WI according to the planned TL. The validity of our predictive model was assessed by comparing the classification’s accuracy with the one computed from a baseline that randomly assigns a class to an example by respecting the distribution of classes (B1). Results: A higher TL was reported after the games and during match day (MD)-5 and MD-4, while a higher WI was recorded on the following days (MD-6, MD-4, and MD-3, respectively). A significant correlation was reported between daily TL (TLMDi) and WI measured the day after (WIMDi+1) (r = .72, P

PURPOSE To report changes in denture satisfaction and oral health-related quality of life (OHRQoL) in edentulous patients treated with two-implant mandibular overdentures (IODs) over a follow-up of 8 to 10 years. MATERIALS AND METHODS This is a follow-up of a previous study carried out between 1997 and 2005. The patients were originally randomly divided into one group receiving IODs and another group who had their conventional mandibular dentures relined (RCD group). The RCD group was offered and received IODs at the 2-year follow-up. The participants completed a self-administered questionnaire containing demographics, 15 variables related to denture satisfaction, and 20 questions from the Oral Health Impact Profile (OHIP-20). Changes over time were analyzed using multilevel linear models for denture satisfaction and multilevel ordinal regression analyses for OHIP-20 variables. Comparisons between groups were analyzed using Mann-Whitney U test for ordinal and t test for metric data. RESULTS Disregarding patients who passed away during follow-up, the 29 responders represented a response rate of 76%. The degree of denture satisfaction and the OHIP-20 scores remained high and stable in the IOD group over the 10-year observation period for all but one variable. The same factors showed only a modest improvement in the RCD group for the first 2 years; however, during the subsequent 8 years of the observation period (after receiving IODs), denture satisfaction and OHIP-20 scores improved to the same level as the original IOD group. CONCLUSION The positive effect on denture satisfaction and OHRQoL of edentulous patients treated with two-implant mandibular overdentures remained unchanged 8 to 10 years after treatment.

Objective The prevalence of social media for sharing personal thoughts makes it a viable platform for the assessment of suicide risk. However, deep learning models are not able to capture the diverse nature of linguistic choices and temporal patterns that can be exhibited by a suicidal user on social media and end up overfitting on specific cues that are not generally applicable. We propose Adversarial Suicide assessment Hierarchical Attention (ASHA), a hierarchical attention model that employs adversarial learning for improving the generalization ability of the model. Material and Methods We assess the suicide risk of a social media user across 5 levels of increasing severity of risk. ASHA leverages a transformer-based architecture to learn the semantic nature of social media posts and a temporal attention-based long short-term memory architecture for the sequential modeling of a user’s historical posts. We dynamically generate adversarial examples by adding perturbations to actual examples that can simulate the stochasticity in historical posts, thereby making the model robust. Results Through extensive experiments, we establish the face-value of ASHA and show that it significantly outperforms existing baselines, with the F1 score of 64%. This is a 2% and a 4% increase over the ContextBERT and ContextCNN baselines, respectively. Finally, we discuss the practical applicability and ethical aspects of our work pertaining to ASHA, as a human-in-the-loop framework. Discussion and Conclusions Adversarial samples can be helpful in capturing the diverse nature of suicidal ideation. Through ASHA, we hope to form a component in a larger human-in-the-loop infrastructure for suicide risk assessment on social media.

Objective To describe patterns of use of self-administered nitrous oxide (N2O) during labor and to determine if maternal and neonatal process and outcome measures differ for women who use N2O compared to women who do not use N2O. Design Retrospective, full-census, observational cohort. Setting An upper midwestern U.S., urban, 75-bed quaternary perinatal center with more than 5,000 annual births. Participants The participants included two groups of women: 400 who used N2O during labor and a comparison group of 6,733 who met N2O eligibility but did not use N2O. Methods We used descriptive statistics to examine patterns of use of N2O during labor between January 2015 and March 2017. We examined associations of N2O with process (length of first and second stages of labor, time from hospital admission to birth, time from birth to hospital discharge, and total length of stay) and outcome measures (shoulder dystocia, instrumentation, vaginal lacerations, Apgar scores at 5 minutes, nursery disposition) using multivariate linear, logistic, and ordinal regression models. Results Three percent (12/400) of women who used N2O discontinued because of side effects. Among participants with vaginal births who used N2O, 17.6% (62/352) used N2O as the only form of pain medication during labor. We found no significant differences in maternal and neonatal outcome measures between the two groups. Among the process measures examined, we found a mean 2-hour-longer time from admission to birth and total length of stay in the N2O group (p Conclusion Most participants who used N2O (290/352, 82.3%) transitioned to other pain modalities during labor. Maternal and neonatal process and outcome measures were comparable relative to other pain management modalities, with the exception of longer time durations for two measures.

Research on esports activity usually captures it from the perspective of involvement in gaming. This study presents the results of the first research in Poland (N = 438) on esports betting (ESB). ESB is compared to other forms of e-gambling and involvement in pay-to-win games. The aim was to build a predictive model of gambling disorder among people betting on esports. A predictive model of gambling disorder based on ordinal regression was built, including sociodemographic variables, involvement in esports betting, involvement in other Internet activities connected to ESB, as well as psychological variables—motivation to gamble and coping strategies. The results showed that gambling disorder among esports bettors is associated with time spent on one game session, placing other forms of online gambling bets once a week or more often, and paying in pay-to-win games. Gambling disorder was also predicted by escape coping strategies and lower engaged strategies as well as financial and coping motivation to bet on esports results. The results show the crucial role of psychological factors (motivation, coping) in the development of esports betting addiction. Esports betting is an activity associated with both gambling and gaming—involvement in both activities explains the development of ESB addiction. There is a need for further research focused on the specificity of esports betting behavior to discover the direction of links among gaming, gambling, and esports gambling.

OBJECTIVE: We developed a diagnostic overuse index that identifies hospitals with high levels of diagnostic intensity by comparing negative diagnostic testing rates for common diagnoses. METHODS: We prospectively identified candidate overuse metrics, each defined by the percentage of patients with a particular diagnosis who underwent a potentially unnecessary diagnostic test. We used data from seven states participating in the State Inpatient Databases. Candidate metrics were tested for temporal stability and internal consistency. Using mixed-effects ordinal regression and adjusting for regional and hospital characteristics, we compared results of our index with three Dartmouth health service area-level utilization metrics and three Medicare county-level cost metrics. RESULTS: The index was comprised of five metrics with good temporal stability and internal consistency. It correlated with five of the six prespecified overuse measures. Among the Dartmouth metrics, our index correlated most closely with physician reimbursement, with an odds ratio of 2.02 (95% CI, 1.11-3.66) of being in a higher tertile of the overuse index when comparing tertiles 3 and 1 of this Dartmouth metric. Among the Medicare county-level metrics, our index correlated most closely with standardized costs of procedures per capita, with an odds ratio of 2.03 (95% CI, 1.21-3.39) of being in a higher overuse index tertile when comparing tertiles 3 and 1 of this metric. CONCLUSIONS: We developed a novel overuse index that is preliminary in nature. This index is derived from readily available administrative data and shows some promise for measuring overuse of diagnostic testing at the hospital level.

Objective To better understand the experiences of female and underrepresented minority (URM) medical students pursuing urology and determine if discrimination was perceived at any point during the application process. Methods After the rank list submission deadline (January 2, 2020), we emailed an anonymous survey to all 353 applicants to our institution for the 2020 AUA Residency Match (80.0% of applicants nationally). The survey inquired about their experiences pursuing urology and the residency match process. Ordinal regression models were used to identify any significant predictors of survey responses. Results One hundred ninety applicants (136 male [72%], 54 female [28%]) completed the survey. A significantly higher percentage of females vs males noted discrimination (odds ratio: 2.53; confidence interval: 1.37-4.74, Fig. 1). URM students also reported higher frequencies of discrimination than non-URM students (odds ratio: 2.27; confidence interval: 1.07-4.83). Thirty-two percent of respondents tested positive on the Maslach Burnout Inventory; we did not identify any predictors of burnout. Higher proportions of female residents, faculty and leadership at a particular program had a more favorable impact on the rank lists of female applicants compared with males. Higher proportions of URM residents, faculty and leadership at a particular program had a more favorable impact on the rank lists of URM applicants compared with non-URM. Conclusion Our collective findings suggest that URM and female medical students have less favorable experiences interacting with urology trainees and faculty than do their nonminority and male counterparts. Higher percentages of female and URM urology residents and faculty promote effective recruitment of female and URM applicants.

Summary The purpose of our study was to determine the health literacy level of the study participants and examine the relationship between health literacy levels and sociodemographic characteristics, health self-assessment levels and health protective behaviors. We recruited 826 individuals into the study, selecting the participants by using a systematic random sampling method. Data were collected with a descriptive information form, the European Health Literacy Scale and a General Health Behaviors Scale. The analysis of the data was carried out using numbers and percentages, the Chi Square test and ordinal regression analysis. We found that the level of health literacy was inadequate in 25.9% of the study participants, problematic/limited in 41.4% had, adequate in 23.6% and excellent in 9.1%. A statistically significant correlation was found between an adequate level of health literacy and being relatively more educated, having a chronic disease, being able to follow up on health news, reading publications on health and being better able to evaluate one’s own health (p < 0.05). Additionally, a statistically significant correlation was observed between adequate health literacy levels and being in the later stages of the transtheoretical model in terms of general health behaviors in the domains outside of monitoring one’s own weight and avoiding the sun (p < 0.05). The level of adequate health literacy was discovered to be lower in our study than in Europe. Health protective behaviors show an increase among individuals who display an adequate level of health literacy.

Hopelessness is an important symptom of adolescent depression, being associated with both risk of suicide and poor treatment response, but predictors of hopelessness are understudied. Conflict with parents is common in adolescent depression, but parents and adolescents often disagree when reporting conflict severity. Discrepancy in reporting may be an indicator of the parent–adolescent dyad lacking a shared representation of the state of their relationship. This could make conflicts seem unresolvable to the adolescent, leading to expectations of persistent stress and lack of support, increasing hopelessness. This study employed latent difference scores, ordinal regression and cross-validation to evaluate the hypothesis that discrepancy in report of parent–adolescent conflict would predict hopelessness among depressed adolescents. Parents reporting less conflict than the adolescent was associated with increased adolescent hopelessness, giving preliminary support to the hypothesis.

Objectives The Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) item bank has been developed to standardize patient-reported PF across medical fields. However, evidence of scoring equivalence across cardiology and rheumatology patients is still missing. Therefore, this study aims to investigate both (1) the extent of disease-related differential item functioning (DIF) and (2) the impact of the disease group on using subdomain-specific item sets for generating PROMIS PF scores in cardiology and rheumatology patients. Study Design and Setting Ordinal regression was used to evaluate DIF between cardiology (n = 201) and rheumatology (n = 200) inpatients. To explore the disease-specific impact of PF subdomains on scoring, we compared scores derived from the full item bank with scores derived from subdomain-specific item sets for each disease group. Results DIF was detected in 18 items, predominately from the upper extremity subdomain. When upper extremity items were used, cardiology patients reached systematically higher scores than using the full item bank. Rheumatology patients scored substantially higher when mobility items were used. Conclusion Applying the PROMIS PF metric to disease-specific item sets including items from differing subdomains may lead to biased comparisons of PF levels across disease groups. Disease-specific item parameters should be provided for items showing DIF, and subdomain-related content balancing is recommended for scoring the generic PROMIS PF construct.

Background Advocacy regarding child health policy is a core tenet of pediatrics. Previous research has demonstrated that most pediatric providers believe collective advocacy and political involvement are essential aspects of their profession, but less is known about how pediatric providers engage with families about policy issues that impact child health. The objectives of this study were to examine providers’ perceptions and practices with regards to discussing health policy issues with families and to identify provider characteristics associated with having these discussions. Methods In this cross-sectional mixed methods study, pediatric resident physicians, attending physcians, and nurse practitioners at primary care clinics within a large academic health system were surveyed to assess (1) perceived importance of, (2) frequency of, and (3) barriers to and facilitators of health policy discussions with families. Multivariable ordinal regression was used to determine provider characteristics (including demographics, practice location, and extent of civic engagement) associated with frequency of these discussions. A subset of providers participated in subsequent focus groups designed to help interpret quantitative findings. Results The overall survey response rate was 155/394 (39%). The majority of respondents (76%) felt pediatricians should talk to families about health policy issues affecting children, but most providers (69%) reported never or rarely having these discussions. Factors associated with discussing policy issues included being an attending physician/nurse practitioner (OR 8.22, 95% CI 2.04–33.1) and urban practice setting (OR 3.85, 95% CI 1.03–14.3). Barriers included feeling uninformed about relevant issues and time constraints. In provider focus groups, four key themes emerged: (1) providers felt discussing policy issues would help inform and empower families; (2) providers frequently discussed social service programs, but rarely discussed policies governing these programs; (3) time constraints and concerns about partisan bias were a barrier to conversations; and (4) use of support staff and handouts with information about policy changes could help facilitate more frequent conversations. Conclusions Pediatric providers felt it was important to talk to families about child health policy issues, but few providers reported having such conversations in practice. Primary care practices should consider incorporating workflow changes that promote family engagement in relevant health policy discussions.

Background One of the main goals in the treatment of first-episode psychosis (FEP) is achieving functional remission. This study aims to analyze whether initial neurocognitive status and the use of specific pharmacological and psychosocial treatment options in FEP can predict general functioning after 18 months of treatment. Methods We conducted a longitudinal naturalistic study with a sample of 129 patients with FEP treated at 2 Croatian psychiatric clinics from 2016until 2018. Ordinal regression was used to predict the global level of functioning assessed with the Global Assessment of Functioning scale (GAF) at the 18th month of treatment from the baseline symptoms (assessed with a set of neurocognitive tests) and different treatment options. Results Higher score on GAF at the 18th month was significantly predicted by female sex, better baseline verbal memory and GAF scores, and the type of treatment. Group multimodal psychosocial treatment, antipsychotic polytherapy, and not being treated with sedatives at baseline predicted better GAF scores at follow-up. In the exploratory analysis, taking sedatives in the final assessment and being rehospitalized due to relapse predicted worse GAF scores at the end of follow-up. Conclusions Although baseline neurocognitive features and baseline general functioning seem to influence the overall long-term functioning of persons with FEP, addition of a multimodal group psychosocial treatment program and appropriate medication seem to be equally important for improving the patients' level of functioning after the FEP.

OBJECTIVE Anchor-based methods to calculate the minimal clinically important difference (MCID) of a patient-reported outcome measure (PROM) may suffer from recall bias. This has never been investigated for otolaryngic PROMs. We sought to identify evidence of recall bias in calculation of MCIDs of PROMs for patients with chronic rhinosinusitis (CRS). DESIGN Retrospective analysis of data from two previous studies calculating the MCID of the 22-item Sinonasal Outcome Test (SNOT-22) and 5-dimensonal EuroQol questionnaire (EQ-5D) in CRS patients. SETTING Tertiary rhinology clinic. PARTICIPANTS Adults with CRS. MAIN OUTCOME MEASURES SNOT-22 score, and EQ-5D visual analog scale scores (EQ-5D VAS) and health utility values (EQ-5D HUV) before and after medical treatment for CRS. After treatment, participants were asked to rate the change in sinonasal symptoms and general health (the anchor question) as "Much worse," "A little worse," "About the same," "A little better" or "Much better." Participants' responses to the anchor question were checked for association with post-treatment and pre-treatment scores using ordinal regression. RESULTS On univariate association, post-treatment SNOT-22 and EQ-5D scores were associated with respective participants' anchor question responses (P

Purpose Understanding clerics and healers' knowledge, attitude, and practice towards epilepsy are crucial to identify the mechanisms of epilepsy stigma in Ethiopia. The objective of this study is to characterize the social and demographic determinants of knowledge, attitude, and practices of clerics and healers towards people with epilepsy in Addis Ababa, Ethiopia. Methods A total of 440 clerics and healers were interviewed by trained data collectors using a pretested structured questionnaire. The count sum of outcome variables was grouped into “biological and cultural” knowledge attitude and practice scores. Ordinal regression analysis was performed for each outcome variable against socio-demographic variables of interest. Results The percentage of responses matching cultural causes (58%) surpassed biological causes. The most frequently mentioned cultural cause was an evil spirit (22.5%). While the most frequently mentioned biological cause was a head injury (12%). Consistent with the above findings, cultural treatment responses (77%) exceeded biological treatment responses. The most commonly referred cultural treatment response was Church healing session (12%). The type of faith followed by the study participants positively correlated with higher cultural knowledge, attitude, and practice score. Conclusions Clerics and traditional healers in Ethiopia have a partiality to the cultural epilepsy explanation model. Cultural metaphors attached to an evil spirit, curse of God, and witchcraft have formed and fostered existing ‘epilepsy societal norms’ in Ethiopia. The findings of this study contribute to the understanding of epilepsy stigma and treatment gap. Besides, it provided direction to design and implement epilepsy stigma intervention programs in Ethiopia.

Background Hippocampal sclerosis (HS) is associated with post-surgery outcome in patients with temporal lobe epilepsy (TLE), and an automated method that quantifies HS severity is still lacking. Here, we aim to propose an MRI-based HS index (HSI) that integrates hippocampal volume and FLAIR signal to measure the severity of HS. Methods Forty-two pre-surgery TLE patients were included retrospectively, with T1-weighted (T1W) and FLAIR images acquired from each subject. Two experienced neurosurgeons (W.D. and C.S.) and one neurologist (Q.L.) rated HS severity with a four-class grading scale (normal, mild, moderate and severe) based on both hippocampal volume loss and increased FLAIR signal. A consensus of HS severity for each subject was made by voting among the three visual rating results. Regarding the automatic quantification, the hippocampal volume was quantified by AccuBrain on T1W image, and the FLAIR signal of hippocampus was calculated as the mean intensity of hippocampal region on the FLAIR image (normalized by the mean intensity of gray matter). To fit the HSI from visual rating, we applied ordinal regression with the voted visual rating as the dependent variable, and hippocampal volume and FLAIR signal as the independent variables. The HSI was calculated by weighting the predicted probabilities of the four-class grading scales from ordinal regression. Results The intra-class correlation coefficient (single measure) of the three raters was 0.806. The generated HSI was significantly correlated with the visual rating scales of the three raters (W.D.: 0.823, Q.L.: 0.817, C.S.: 0.717). HSI scores well differentiated the different HS categories as defined by the agreed HS visual rating (normal vs. mild: p p p = 0.001). Conclusions The proposed HSI was consistent with visual rating scales from epileptologists and sensitive to HS severity. This MRI-based index may help to evaluate HS severity in clinical practice. Further validations are needed to associate HSI with post-surgery outcomes.

This paper demonstrates the use of two Bayesian statistical models to analyze single-event sonic boom exposure and human annoyance data from community response surveys. Each model is fit to data from a NASA pilot study. Unlike many community noise surveys, this study used a panel sample to collect multiple observations per participant instead of a single observation. Thus, a multilevel (also known as hierarchical or mixed-effects) model is used to account for the within-subject correlation in the panel sample data. This paper describes a multilevel logistic regression model and a multilevel ordinal regression model. The paper also proposes a method for calculating a summary dose-response curve from the multilevel models that represents the population. The two models' summary dose-response curves are visually similar. However, their estimates differ when calculating the noise dose at a fixed percent highly annoyed.

ObjectiveStudies of epilepsy surgery outcomes are often small and thus underpowered to reach statistically valid conclusions. We hypothesized that ordinal logistic regression would have greater statistical power than binary logistic regression when analyzing epilepsy surgery outcomes.MethodsWe reviewed 10 manuscripts included in a recent meta-analysis which found that mesial temporal sclerosis (MTS) predicted better surgical outcome after a stereotactic laser amygdalohippocampectomy (SLAH). We extracted data from 239 patients from eight studies which reported four discrete Engel surgical outcomes after SLAH, stratified by the presence or absence of MTS.ResultsThe rate of freedom from disabling seizures (Engel I) was 64.3% (110/171) for patients with MTS compared to 44.1% (30/68) without MTS. The statistical power to detect MTS as a predictor for better surgical outcome after a SLAH was 29% using ordinal regression, which was significantly more than the 13% power using binary logistic regression (paired t-test, pConclusionOrdinal regression should be considered when analyzing ordinal outcomes (such as Engel surgical outcome), especially for datasets with small sample sizes.

ObjectiveIn many countries the retirement age is rising. Consequently, age-related hearing loss is an increasing occupational health problem. This study examined the association between hearing loss and sustainable employability of teachers.DesignFor this cross-sectional study a survey and an online hearing screening test were used. Sustainable employability was measured with the Capability Set for Work Questionnaire (CSWQ), examining seven work values. CSWQ-scores of teachers with poor, insufficient, and good hearing were investigated with ordinal regression analyses. Work values and discrepancies between the importance and achievement of the values were examined by chi-square tests.Study sampleDutch teachers (N = 737) of whom 146 (20%) had insufficient and 86 (12%) poor hearing.ResultsTeachers with insufficient (OR = 0.64; 95% CI 0.46–0.89) and poor (OR = 0.55; 95% CI 0.36–0.83) hearing had lower CSWQ-scores compared with good hearing teachers. Adjustment for covariates, in particular for self-rated health, attenuated the associations. Compared with good hearing teachers, teachers with poor hearing reported more discrepancies in using their knowledge and skills and setting their own goals at work.ConclusionsHearing loss was negatively associated with sustainable employability of teachers. This emphasises the importance of assessing the hearing status of teachers.

Introduction: We aimed to develop and validate an Expanded Disability Status Scale (EDSS) model through clinical, optical coherence tomography (OCT), and magnetic resonance imaging (MRI) measures. Methods: Sixty-four multiple sclerosis (MS) patients underwent peripapillary retinal nerve fiber layer and segmented macular layers evaluation through OCT (Spectralis, Heidelberg Engineering). Brain parenchymal fraction was quantified through Freesurfer, while cervical spinal cord (SC) volume was assessed manually guided by Spinal Cord Toolbox software analysis. EDSS, neuroradiological, and OCT assessment were carried out within 3 months. OCT parameters were calculated as the average of both nonoptic neuritis (ON) eyes, and in case the patient had previous ON, the value of the fellow non-ON eye was taken. Brain lesion volume, sex, age, disease duration, and history of disease-modifying treatment (1st or 2nd line disease-modifying treatments) were tested as covariables of the EDSS score. Results: EDSS values correlated with patient’s age (r = 0.543, p = 0.001), SC volume (r = −0.301, p = 0.034), and ganglion cell layer (GCL, r = −0.354, p = 0.012). Using these correlations, an ordinal regression model to express probability of diverse EDSS scores were designed, the highest of which was the most probable (Nagelkerke R2 = 43.3%). Using EDSS cutoff point of 4.0 in a dichotomous model, compared to a cutoff of 2.0, permits the inclusion of GCL as a disability predictor, in addition to age and SC. Conclusions: MS disability measured through EDSS is an age-dependent magnitude that is partly conditioned by SC and GCL. Further studies assessing paraclinical disability predictors are needed.

The purpose of this study was to examine the association between neighborhood social deprivation and individual-level characteristics on breast cancer staging in African American and white breast cancer patients. We established a retrospective cohort of patients with breast cancer diagnosed from 1996 to 2015 using the South Carolina Central Cancer Registry. We abstracted sociodemographic and clinical variables from the registry and linked these data to a county-level composite that captured neighborhood social conditions—the social deprivation index (SDI). Data were analyzed using chi-square tests, Student’s t-test, and multivariable ordinal regression analysis to evaluate associations. The study sample included 52,803 female patients with breast cancer. Results from the multivariable ordinal regression model demonstrate that higher SDI (OR = 1.06, 95% CI: 1.02–1.10), African American race (OR = 1.35, 95% CI: 1.29–1.41), and being unmarried (OR = 1.17, 95% CI: 1.13–1.22) were associated with a distant stage at diagnosis. Higher tumor grade, younger age, and more recent year of diagnosis were also associated with distant-stage diagnosis. As a proxy for neighborhood context, the SDI can be used by cancer registries and related population-based studies to identify geographic areas that could be prioritized for cancer prevention and control efforts.

Background: The contradictory nature of behavioral addictions has sustained a nondefinitive debate regarding their construct validity. Objective(s): The current study aims at exploring mechanisms underlying two distinct classes of behaviors-behavioral addictions characterized by core alterations in reward processing systems (ARPS) and behaviors with a main function of maladaptive coping. Methods: This case-control study included 99 treatment-seeking individuals with a primary diagnosis of alcohol use disorder (male: N = 68; female: N = 31) and 74 healthy control (HC) subjects (male: N = 38; female: N = 36). The severity of maladaptive behaviors was measured through the Shorter PROMIS Questionnaire (SPQ). Latent mechanisms were assessed by the Disinhibition Domain of the Personality Inventory for DSM-5 (PID-5-DI) and the Acceptance and Action Questionnaire-II (AAQ-II). Results: The clinical group showed higher severity of behavioral addictions than HC. This difference was not replicated for the other class of maladaptive behaviors, except for compulsive buying. Ordinal regression analysis showed that the clinical group significantly predicted SPQ scores reflecting ARPS, SPQ shopping and starving subscales. This was not replicated for the overall SPQ score capturing maladaptive coping and binge eating behaviors. Controlling for PID-5-DI and AAQ-II scores, which were significantly associated to SPQ subscales, effects of the aforementioned clinical group were not significant. Conclusions: The study highlighted distinct and common mechanisms underlying different classes of maladaptive behaviors. Results supported future neuroscience research for clarifying the role of ARPS in compulsive sex and buying in order to consider them as addictive disorders.

Background: The Animated Activity Questionnaire (AAQ) was developed in the Netherlands to assess activity limitations in individuals with hip/knee osteoarthritis (HKOA). The AAQ is easy to implement and minimizes the disadvantages of questionnaires and performance-based tests by closely mimicking real-life situations. The AAQ has already been cross-culturally validated in six other countries. Objective: To assess the cross-cultural validity, the construct validity, the reliability of the AAQ in a Brazilian sample of individuals with HKOA, and the influence of formal education on the construct validity of the AAQ. Methods: The Brazilian sample (N = 200), mean age 64.4 years, completed the AAQ and the Western Ontario and McMaster Universities Index (WOMAC). A subgroup of participants performed physical function tests and completed the AAQ twice with a one-week interval. The Dutch sample (N = 279) was included to examine Differential Item Functioning (DIF) between the scores obtained in the Netherlands and Brazil. For this purpose, ordinal regression analyses were used to evaluate whether individuals with the same level of activity limitations from the two countries (the Dutch as the reference group) scored similarly in each AAQ item. To evaluate the construct validity, correlation coefficients were calculated between the AAQ, the WOMAC domains, and the performance-based tests. To evaluate reliability, the Cronbach's alpha coeffi-cient, the intraclass correlation coefficient, and the standard error of measurement (SEM) were calculated. Results: The AAQ showed significant correlations with all the WOMAC domains and performance -based tests (rho=0.46-0.77). The AAQ showed high internal consistency (Cronbach's alpha=0.94), excellent test-retest reliability (ICC2,1 = 0.98), and small SEM (2.25). Comparing to the scores from the Netherlands, the AAQ showed DIF in two items, however, they did not impact on the total AAQ score (rho=0.99). Conclusion: Overall, the AAQ showed adequate cross-cultural validity, construct validity, and reliability, which enables its use in Brazil and international/multicenter studies. (c) 2021 Associacao Brasileira de Pesquisa e Pos-Graduacao em Fisioterapia. Published by Elsevier Espana, S.L.U. All rights reserved.

Background: Although in clinical practice an impairment of sensory perception is frequently reported by depressed patients no mention of these symptoms is made in DSM-5, ICD-10 or ICD-11. Previous studies on colour perception have largely relied on patient self-reports and few have studied colour discrimination.Methods: The ability to discriminate small colour differences was assessed in 30 patients currently experiencing a moderate to severe depressive episode (ICD-10: F32.1-2, F33.1-2 or F31.3-4) and 32 healthy controls using the colour buttons of the Farnsworth Munsell 100-Hue test. Data were analysed by standard tests for comparing two groups (t-test, Mann-Whitney U-test, Chi-square test) and by ordinal regression and generalised estimating equation models.Results: Depressed patients failed significantly earlier (i.e., at larger differences between adjacent buttons) to discriminate between colours. This finding was retained after adjustment for potential confounders. There was no significant association with age, gender or depression score.Conclusions: We found a reduction in the ability to discriminate colours in depressed patients. This finding underlines the importance of sensory deficits as part of the symptomatology of depression. Sensory impairments should be taken into account in clinical care of patients with depression and should be included in diagnostic manuals. Further studies in larger samples including intra-individual comparisons between the depressed and the remitted state of patients are needed.Key pointsIn clinical practice, an impairment of sensory perception is frequently reported by depressed patients.However, no mention of these symptoms is made in the commonly used diagnostic manuals.In this pilot study, depressed patients and controls differed significantly in terms of the ability to discriminate colours with patients performing worse than their healthy counterparts.Sensory impairments should be taken into account in clinical care of patients with depression and should be included in diagnostic manuals.

Introduction Evidence indicates HIV oral pre‐exposure prophylaxis (PrEP) is highly efficacious and effective. Substantial early discontinuation rates are reported by many programs, which may be misconstrued as program failure. However, PrEP use may be non‐continuous and still effective, since HIV risk fluctuates. Real‐world PrEP use phenomena, like restarting and cyclical use, and the temporal characteristics of these use patterns are not well described. The objective of our study was to characterize and identify predictors of use patterns observed in large PrEP scale‐up programs in Africa. Methods We analysed demographic and clinical data routinely collected during client visits between 2017 and 2019 in three Jhpiego‐supported programs in Kenya, Lesotho and Tanzania. We characterized duration on/off PrEP and, using ordinal regression, modelled the likelihood of spending additional time off and identified factors associated with increasing cycle number. The Andersen‐Gill model was used to identify predictors of time to PrEP discontinuation. To analyse factors associated with a client's first return following initiation, we used a two‐step Heckman probit. Results Among 47,532 clients initiating PrEP, approximately half returned for follow‐up. With each increase in cycle number, time off PrEP between use cycles decreased. The Heckman first‐step model showed an increased probability of returning versus not by older age groups and among key and vulnerable population groups versus the general population; in the second‐step model older age groups and key and vulnerable populations were less likely in Kenya, but more likely in Lesotho, to return on‐time (refill) versus delayed (restarting). Conclusions PrEP users frequently cycle on and off PrEP. Early discontinuation and delays in obtaining additional prescriptions were common, with broad predictive variability noted. Time off PrEP decreased with cycle number in all countries, suggesting normalization of use with experience. More nuanced measures of use are needed than exist for HIV treatment if effective use of PrEP is to be meaningfully measured. Providers should be equipped with measures and counselling messages that recognize non‐continuous and cyclical use patterns so that clients are supported to align fluctuating risk and use, and can readily restart PrEP after stopping, in effect empowering them further to make their own prevention choices.

This editorial overview provides an introduction to the Suicide and Life-Threatening Behaviors Special Issue: "Analytic and Methodological Innovations for Suicide-Focused Research." We outline several challenges faced by modern suicidologists, such as the need to integrate different analytical and methodological techniques from other fields with the unique data problems in suicide research. Therefore, the overall aim of this issue was to provide up-to-date methodological and analytical guidelines, recommendations, and considerations when conducting suicide-focused research. The articles herein present this information in an accessible way for researchers/clinicians and do not require a comprehensive background in quantitative methods. We introduce the topics covered in this special issue, which include how to conduct power analyses using simulations, work with large data sets, use experimental therapeutics, and choose covariates, as well as open science considerations, decision-making models, ordinal regression, machine learning, network analysis, and measurement considerations. Many of the topics covered in this issue provide step-by-step walkthroughs using worked examples with the accompanied code in free statistical programs (i.e., R). It is our hope that these articles provide suicidologists with valuable information and strategies that can help overcome some of the past limitations of suicide research, and improve the methodological rigor of our field.

Background Several studies have examined the relationship between cognition and oral health in older populations. To further understand this relationship, we examined the associations between cognitive function, chewing capacity and the number of teeth present in community-dwelling older males in Australia. Methods Data were obtained from cross-sectional analysis of fourth wave of the Concord Health and Ageing in Men Project (CHAMP). Participants were 369 community-dwelling males aged 78 years or over. Cognitive function was measured utilising the Mini-Mental State Examination (MMSE). Chewing capacity was determined on ability to chew food items of different textures, and oral health data were collected. Ordinal regression was used to analyse associations between MMSE (four categories) and chewing capacity and number of natural teeth present. Results Overall, 67.5% of participants reported that they could chew all 11 listed food items. Participants with fewer than 20 teeth were statistically significantly more likely to have cognitive impairment (unadjusted odds ratio (OR) 1.87; 95% confidence interval (CI) 1.25-2.79, adjusted OR 1.62; 95% CI 1.07-2.43). Participants with limited chewing capacity were also more likely to have cognitive impairment (unadjusted OR 1.91; 95% CI 1.25-2.94, adjusted OR 1.61; 95% CI 1.03-2.49). Conclusions This study suggests either that older men with fewer than 20 natural teeth and those with limited chewing capacity are more likely to have an associated cognitive impairment or that those with cognitive impairment are more likely to have fewer teeth and limited chewing capacity. Further longitudinal studies should clarify these relationships.

Background Ethiopia is one of the developing countries where child under-nutrition is prevalent. Prior studies employed three anthropometric indicators for identifying factors of children’s under-nutrition. This study aimed at identifying the factors of child under-nutrition using a single composite index of anthropometric indicators. Methods Data from Ethiopia’s Demographic and Health Survey 2016 was the base for studying under-nutrition in a sample of 9494 children below 59 months. A single composite index of under-nutrition was created from three anthropometric indices through principal component analysis recoded into an ordinal outcome. In line with World Health Organization 2006 Child Growth Standards, the three anthropometric indices involve z-score of height-for-age (stunting), weight-for-height (wasting) and weight-for-age (underweight). Partial proportional odds model was fitted and its relative performance compared with some other ordinal regression models to identify significant determinants of under-nutrition. Results The single composite index of anthropometric indicators showed that 49.0% (19.8% moderately and 29.2% severely) of sampled children were undernourished. In the Brant-test of proportional odds model, the null hypothesis that the model parameters equal across categories was rejected. Compared to ordinal regression models, partial proportional odds model showed an improved fit. A child with mother’s body mass index less than 18.5 kg, from poorest family and a husband without education, and male to be in a severe under-nutrition status was 1.4, 1.8 1.2 and 1.2 times more likely to be in worse under-nutrition status compared to its reference group respectively. Conclusion Authors conclude that the fitted partial proportional odds model indicated that age and sex of the child, maternal education, region, source of drinking water, number of under five children, mother’s body mass index and wealth index, anemic status of child, multiple births, fever of child before 2 months of the survey, mother’s age at first birth, and husband’s education were significantly associated with child under-nutrition. Thus, it is argued that interventions focus on improving household wealth index, food security, educating mothers and their spouses, improving maternal nutritional status, and increasing mothers’ health care access.

Major depressive disorder is a common psychiatric illness. At present, there are no objective, non-verbal, automated markers that can reliably track treatment response. Here, we explore the use of video analysis of facial expressivity in a cohort of severely depressed patients before and after deep brain stimulation (DBS), an experimental treatment for depression. We introduced a set of variability measurements to obtain unsupervised features from muted video recordings, which were then leveraged to build predictive models to classify three levels of severity in the patients' recovery from depression. Multiscale entropy was utilized to estimate the variability in pixel intensity level at various time scales. A dynamic latent variable model was utilized to learn a low-dimensional representation of factors that describe the dynamic relationship between high-dimensional pixels in each video frame and over time. Finally, a novel elastic net ordinal regression model was trained to predict the severity of depression, as independently rated by standard rating scales. Our results suggest that unsupervised features extracted from these video recordings, when incorporated in an ordinal regression predictor, can discriminate different levels of depression severity during ongoing DBS treatment. Objective markers of patient response to treatment have the potential to standardize treatment protocols and enhance the design of future clinical trials.

Objective: Clinical options for managing nonmetastatic prostate cancer (PCa) vary. Each option has side effects associated with it, leading to difficulty in decision‐making. This study aimed to assess the relationship between patient involvement in treatment decision‐making and subsequent decision regret (DR), and quantify the impact of health‐related quality of life (HRQL) outcomes on DR. Methods: Men living in the United Kingdom, 18 to 42 months after diagnosis of PCa, were identified from cancer registration data and sent a questionnaire. Measures included the Decision Regret Scale (DRS), Expanded Prostate cancer Index Composite short form (EPIC‐26), EQ‐5D‐5L, and an item on involvement in treatment decision‐making. Multivariable ordinal regression was utilized, with DR categorized as none, mild, or moderate/severe regret. Results: A total of 17 193 men with stage I‐III PCa completed the DRS: 36.6% reported no regret, 43.3% mild regret, and 20.0% moderate/severe regret. The odds of reporting DR were greater if men indicated their views were not taken into account odds ratio ([OR] = 6.42, 95% CI: 5.39‐7.64) or were involved “to some extent” in decision‐making (OR = 4.63, 95% CI: 4.27‐5.02), compared with men who were “definitely” involved. After adjustment, including for involvement, men reporting moderate/big problems with urinary, bowel, or sexual function were more likely to experience regret compared with men with no/small problems. Better HRQL scores were associated with lower levels of DR. Conclusions: This large‐scale study demonstrates the benefit of patient involvement in treatment decision‐making for nonmetastatic PCa. However, men experiencing side effects and poorer HRQL report greater DR. Promoting engagement in clinical decision‐making represents good practice and may reduce the risk of subsequent regret.

Most older adults perceive themselves as good drivers; however, their perception may not be accurate, and could negatively affect their driving safety. This study examined the accuracy of older drivers’ self-awareness of driving ability in their everyday driving environment by determining the concordance between the perceived (assessed by the Perceived Driving Ability [PDA] questionnaire) and actual (assessed by electronic Driving Observation Schedule [eDOS]) driving performance. One hundred and eight older drivers (male: 67.6%; age: mean = 80.6 years, standard deviation [SD] = 4.9 years) who participated in the study were classified into three groups: underestimation (19%), accurate estimation (29%), and overestimation (53%). Using the demographic and clinical functioning information collected in the Candrive annual assessments, an ordinal regression showed that two factors were related to the accuracy of self-awareness: older drivers with better visuo-motor processing speed measured by the Trail Making Test (TMT)-A and fewer self-reported comorbid conditions tended to overestimate their driving ability, and vice versa.

Many high-throughput genomic applications involve a large set of potential covariates and a response which is frequently measured on an ordinal scale, and it is crucial to identify which variables are truly associated with the response. Effectively controlling the false discovery rate (FDR) without sacrificing power has been a major challenge in variable selection research. This study reviews two existing variable selection frameworks, model-X knockoffs and a modified version of reference distribution variable selection (RDVS), both of which utilize artificial variables as benchmarks for decision making. Model-X knockoffs constructs a ‘knockoff’ variable for each covariate to mimic the covariance structure, while RDVS generates only one null variable and forms a reference distribution by performing multiple runs of model fitting. Herein, we describe how different importance measures for ordinal responses can be constructed that fit into these two selection frameworks, using either penalized regression or machine learning techniques. We compared these measures in terms of the FDR and power using simulated data. Moreover, we applied these two frameworks to high-throughput methylation data for identifying features associated with the progression from normal liver tissue to hepatocellular carcinoma to further compare and contrast their performances.

Continuous response variables are often transformed to meet modeling assumptions, but the choice of the transformation can be challenging. Two transformation models have recently been proposed: semiparametric cumulative probability models (CPMs) and parametric most likely transformation models (MLTs). Both approaches model the cumulative distribution function and require specifying a link function, which implicitly assumes that the responses follow a known distribution after some monotonic transformation. However, the two approaches estimate the transformation differently. With CPMs, an ordinal regression model is fit, which essentially treats each continuous response as a unique category and therefore nonparametrically estimates the transformation; CPMs are semiparametric linear transformation models. In contrast, with MLTs, the transformation is parameterized using flexible basis functions. Conditional expectations and quantiles are readily derived from both methods on the response variable's original scale. We compare the two methods with extensive simulations. We find that both methods generally have good performance with moderate and large sample sizes. MLTs slightly outperformed CPMs in small sample sizes under correct models. CPMs tended to be somewhat more robust to model misspecification and outcome rounding. Except in the simplest situations, both methods outperform basic transformation approaches commonly used in practice. We apply both methods to an HIV biomarker study.

OBJECTIVE National initiatives and funding agencies may deprioritize voice disorders relative to conditions such as malignancy, pulmonary, or cardiac disease. It is unknown whether the impact of voice problems is outweighed by other potentially more serious disease states. Our objective was thus to quantify the extent to which voice contributes to general health status when adjusting for concurrent, more life-threatening comorbidities. METHODS Adults (n = 430) presenting to a tertiary care academic center with a primary voice complaint completed the Voice Handicap Index-10 (VHI-10) and the Patient-Reported Outcomes Measurement Information System global health short-form instrument (PROMIS). Medical comorbidities were categorized via the Deyo modification of the Charlson Comorbidity Index. The influence of voice and comorbid conditions on general health scores was assessed through multivariate ordinal regression. The potential for effect modification was also evaluated. RESULTS VHI-10 mean scores were 11.4 (95% confidence interval [CI], 10.5 to 12.4). PROMIS physical and mental health t scores were 49.0 (95% CI, 48.0 to 49.9) and 51.6 (95% CI, 50.6 to 52.5), respectively. Global and social item scores were 3.4 (95% CI, 3.3 to 3.5) and 3.7 (95% CI, 3.6 to 3.8), respectively. The most prevalent comorbid conditions were pulmonary disease, malignancy, and connective tissue disorders. In all analyses, voice handicap was a significant predictor of general health, even when adjusting for comorbid conditions (VHI-10 β = -1.349, P

© 2019 The Authors Objective: To quantify barriers to healthcare for young people (12–24 years) and identify socio-demographic correlates and predictors. Methods: This cross-sectional survey targeted young people living in New South Wales, Australia, with oversampling of marginalised groups. Principles Component Analysis (PCA) identified clusters of barriers. Ordinal regression identified predictors of each barrier cluster. Results: A total of 1,416 young people completed surveys. Participants with chronic conditions and increasing psychological distress reported a greater number of barriers. Of 11 potential barriers to visiting a health service, cost was most common (45.8%). The PCA identified three clusters: structural barriers (61.3%), attitudinal barriers (44.1%) and barriers relating to emerging autonomy (33.8%). Conclusions: Barriers to healthcare reported by young people are multi-dimensional and have changed over time. Structural barriers, especially cost, are the most prominent among young people. Approaches to overcome structural barriers need to be addressed to better support marginalised young people's healthcare access. Implications for public health: Understanding predictors of different barrier types can inform more targeted approaches to improving access. Equitable access to healthcare is a priority for early diagnosis and treatment in young people, especially reducing out of pocket costs.

BACKGROUND Shared decision making (SDM) is very important from patients' perspective. This process has not yet been evaluated in Romania. The study aims to evaluate SDM from the patients' perspective and to evaluate patients' characteristics that associate with SDM. MATERIAL AND METHODS A cross-sectional multicentric study comprising eight recruitment centres was performed. Inpatients and outpatients who referred to Hospital Units treating autoimmune diseases or atrial fibrillation were included. Another sample consisted of members of the Autoimmune Disease Patient Society, who completed an online anonymous questionnaire. All participants completed the Romanian translated version of the 9-item Shared Decision Making Questionnaire (SDM-Q-9), as these samples were used for the validation of this questionnaire, too. Patients had to refer to the visit in which the decision concerning the antithrombotic treatment was taken (atrial fibrillation patients), or the immunosuppressive treatment was last time changed (autoimmune disease patients). Ordinal regression having the total SDM score as dependent variable was used. RESULTS A total of 665 questionnaires were filled in within the hospital setting (n = 324; 48.7%) and online (n = 341; 51.3%). The median score for SDM was 34 of 45, but it differed between hospital completion -39/45 and online completion (anonymous) -20/45 (P < .001). Patients with higher education were influenced most by the setting, giving the best marks in hospital and low marks online, while those with lower education gave lower marks in both settings. In ordinal regression with SDM score as dependent variable, hospital completion of the questionnaire (OR = 9.5, 95% confidence interval, 5.69-16), collagen disease diagnosis (OR = 2.4, 95% confidence interval, 1.39-4.14), and immunosuppressive treatment (OR = 2.16, 95% confidence interval, 1.43-3.26) were independent predictors. CONCLUSION In our study, full anonymity was associated with significantly lower scores for the SDM process. The patients with higher education were most influenced by this condition, while those with the lowest education were the most critical.

Background High population levels of sitting is contributing to high rates of chronic health problems. Therefore, the aim of this study was to identify the sitting time messages with the greatest potential to reduce sitting behaviour, as well as identify how this may differ according to demographic, behavioural and psychosocial characteristics. Methods Australian adults (N = 1460) were asked to report the likelihood that they would adhere to seven messages promoting reduced sitting time and two messages promoting increased physical activity (from ‘not at all likely’ to ‘very likely’). Ordinal regression models were used to compare messages on the likelihood of adherence and whether likelihood of adherence differed as a function of demographic, psychosocial and behavioural characteristics. Results Likelihood of adherence was highest for the messages, ‘Stand and take a break from sitting as frequently as you can’ (83% respectively) and ‘Avoid sitting for more than 10 hours during the entire day’ (82%) and was significantly lower for the message, ‘Sit as little as possible on all days of the week’ (46%) compared to all other messages. Conclusions To increase likelihood of adherence messages should be specific, achievable and promote healthy alternatives to sitting (e.g. standing). Messages promoting standing as a healthy alternative to sitting may be more likely to engage people with high sitting behaviour and messages promoting physical activity may be more likely to engage males and retired adults. Electronic supplementary material The online version of this article (10.1186/s12889-019-7189-z) contains supplementary material, which is available to authorized users.

Background Hypertension (HTN) is the most important risk factor for death and disability worldwide. Hypertensive patients’ HTN knowledge was shown to be associated with control of HTN. Understanding factors affecting HTN knowledge might help control HTN. Objectives To examine differences in HTN knowledge by age, gender, ethnicity, years of education and whether HTN was diagnosed, and to explore whether HTN knowledge is affected by self-measurement of blood pressure (BP), in Israel's general population. Methods A cross-sectional, descriptive, correlational design was used. A convenience sample of 430 Israeli adults, sampled in community centers across Israel, in four age groups (18–34, 35–49, 50–64, and above 64) were interviewed by 17 registered nurses, using a structured questionnaire with open-ended questions, during March 2017 and March 2018. ANOVA and chi-square tests for assessing differences between age groups in sociodemographic characteristics and BP measurement were used. Factors predicting knowledge of various HTN aspects and total HTN knowledge were explored by logistic and ordinal regression analyses. Results Older participants, those with more years of education, and those who self-measured blood pressure had better knowledge of particular aspects of HTN and higher total HTN knowledge. Women had greater knowledge of normal systolic and diastolic BP. Conclusions Higher age, more years of education, and blood pressure self-measurement were associated with higher total HTN knowledge. The attention of health authorities should be drawn to improving HTN knowledge among younger adults, and to including blood pressure self-measurement in the regular practices of the general population.

Background Sunscreens, unlike prescription medications, are purchased by consumers directly from retailers. The proportion of online sunscreen sales is increasing. It is therefore important for dermatologists to know what factors influence online sunscreen purchases to optimize appropriate recommendations. Methods Data on the top 100 best-selling sunscreens from an online retailer were collected. Variables included cost, formulation, product claims, ingredients, consumer ratings, and number of reviews. Ordinal logistic regression was used to analyze the impact of collected variables on position on the best-seller list. Results Ninety-six of the 100 search results could be defined as actual sunscreens with a total of 41 788 reviews. The median price per ounce was $3.02 (range $0.34-$309.18). The most popular formulations were lotions. The most common unregulated claim was "non-greasy" found in 57.3% of sunscreens. For 26 unregulated product claims analyzed, the mean number of claims per sunscreen was 5.2. Using an ordinal regression model, the following factors were found to significantly influence sunscreen sales: number of reviews, the claim "decreases the risk of skin cancer and early aging," and the presence of six or more unregulated claims. Conclusions Multiple sunscreen options exist for consumers with varying price points, active ingredients, and formulations. Consumers who purchase online prefer sunscreens with a higher number of reviews and more unregulated marketing claims. FDA-regulated claims such as "decreases the risk of skin cancer and early aging" are not as impactful in this purchasing cohort. To facilitate usage, dermatologists should be cognizant of factors that influence sunscreen selection among this group.

Background Self-perceived health is an essential measure of health status and even a paramount predictor of mortality. So long as it is said that oral health (OH) and general health (GH) are mirrors to each other. This study sought to determine how Yemeni adults rate their OH and GH, whether such a self-rating influenced by some potential risk factors, and whether both ratings (OH and GH) are correlated. Methods A sample of 587 Yemeni dental patients aged 20 years and over were consecutively recruited. A structured interview form was used covering the following variables: age, gender, marital status, educational level, presence of dental prosthesis (DP), smoking and Qat chewing habits as independent variables, along with questions on “perceived oral health (POH)” and “perceived general health (PGH)” as dependent variables. The bivariate and multiple ordinal regression analyses were applied at P-value

To understand the sexual risk behavior of men with traditional male circumcision and medical male circumcision in the context of the World Health Organization's (WHO) campaign for voluntary medical male circumcision (VMMC) scale-up, we investigated ten countries prioritized for the scale-up from the Demographic and Health Surveys. Male respondents aged 15-49 were selected. Ordinal regression was used to analyze the relationship between three sexual risk behaviors-condom use with non-cohabiting partners, number of non-cohabiting partners, and partner type-and circumcision status (traditionally circumcised before and after the VMMC scale-up, medically circumcised before and after the scale-up, and not circumcised), while controlling for social demographic covariates. We found evidence that some sexual risky behavior, specifically lower condom use and higher number of sexual partners, was associated with traditional circumcision. This finding suggests that messages about the protective effect of male circumcision may not have reached men with traditional circumcision. We suggest that WHO's VMMC campaign should include communities where traditional male circumcision is popular. We looked for, but did not find, evidence of differences between groups circumcised at different times, which could have indicated sexual risk compensation.

Food insecurity is associated with several negative health outcomes, many of which can be detrimental to youth during the vulnerable life stage of adolescence. Among a sample of 1493 high school students, the current study utilizes a risks and resources model to examine ways that risks and resources come together to shape the lives and health of youth, making them more vulnerable or shielding them from food insecurity and its related negative health outcomes. A number of factors are proposed as important correlates of food insecurity measured at four perceived levels of aggregation: individual, family, school/peer, and community. These risks and resources are analyzed using a three-step ordinal regression model. Analyses reveal depression, intact family, student risk, and neighborhood risk are positively related to food insecurity, despite significant sociodemographic differences. In addition, self-esteem, eating meals with family, and peer social capital are all significant and negatively related to food insecurity. Collectively, these findings tell an important story about adolescent food insecurity and the relationships that social and psychological circumstances have with varying levels of food insecurity. This study highlights the importance of children and adolescents as reliable respondents and spokespersons of their own experiences with food insecurity.

Objectives To assess the oral health of older people who visit the community dental practice from both the dentists’ and the patients’ perspective. Materials and methods In this exploratory cross-sectional study the oral health of Dutch community dwelling older people was assessed. A representative sample of general dental practitioners was asked to randomly and prospectively select one older patient and describe this patient using a specially-developed registration form; in addition the patient was requested to complete a questionnaire. The oral health of older people was described from the perspective of the dentists and the perspective of the older people themselves based on the definition of oral health from the World Dental Federation (FDI]. Relations between oral health of older people and dentist and older patient characteristics were analysed using Spearman’s rank correlation coefficient (rho) and an ordinal regression model. Results In total, 923 dentists were asked to participate in the study; data was available for 39.4% dentist-patient pairs. Dentists assessed the oral health of older patients as good or acceptable in 51.4% of the cases while this was the case in 76.2% of older patients themselves. The assessment of the dentist gets more negative with high treatment intensity and with older patients having certain diseases and more medication, while the assessment is more positive for older patients who visit the dentist on a regular basis. Older people’s assessment of their oral health gets more negative by being female and with high treatment intensity, having certain diseases and higher use of medication. Conclusions and clinical relevance Chronically illness as expressed by the number of diseases and the use of medication, seems to be a risk factor for poor oral health. Older patients themselves assess their oral health differently, mostly more positive, than their dentist.