Jacobs Institute of Women's Health
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Predicting hospital admissions, ICU utilization, and prolonged length of stay among febrile pediatric emergency department patients using incomplete and imbalanced electronic health record (EHR) data strategies
No full textOBJECTIVE: Determine the efficacy of commonly used approaches to handling missing and/or imbalanced Electronic Health Record (EHR) data on the performance of predictive models targeting risk of admission, intensive care unit (ICU) use, or prolonged length of stay (PLOS) among presenting febrile pediatric emergency department (ED) patients. MATERIALS AND METHODS: Historical ED EHR data was used to train a series of XGBoost (XGB) and logistic regression (LR) classifiers. Data handling strategies included imputation methods (multiple imputation (MI), median imputation, complete case (CC) analysis), and imbalanced data corrections (minority oversampling, stratified sub-group analysis). Model performance was evaluated using discriminative (AUC, AUPRC) and calibration metrics (Brier score, Z-scores, p-values). RESULTS: Among the study population, 34 % were admitted, 2 % utilized the ICU, and 7 % had a PLOS. Significant data missingness was observed and determined to be not at random (MNAR). In predicting admissions using data recorded within the first two hours of presentation, LR trained using full cohort with median imputation was comparable to MI yielding well-calibrated admissions models with an AUC/AUPRC of 0.82/0.73 while CC analysis yielded an AUC/AUPRC of 0.76/0.78. XGB, trained with unimputed data, produced a well-calibrated admissions classifier with an AUC/AUPRC of 0.85/0.78. In contrast, imbalanced data correction techniques, including synthetic minority oversampling (SMOTE), risk stratification, or the use of XGB did not significantly improve the poor AUPRC and calibration performance of LR models predicting ICU and PLOS. CONCLUSION: Both XGB and LR with median imputation demonstrated robust performance in predicting admissions in the presence of missing data. However, deriving clinically useful models for rare outcomes, such as ICU use or PLOS, remains a challenge due to poor precision/recall and calibration performance. Further research is needed to improve the prediction of rare outcomes in this population
A Meta-Analysis Studying the Difference in Response to Trastuzumab-Deruxtecan Based on HER2 Immunohistochemistry Staining in HER2 Low Metastatic Breast Cancer Patients
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Improving outcomes for people who are homeless and have severe mental illness in Ethiopia, Ghana and Kenya: overview of the HOPE programme
No full textAIM: HOPE (National Institute for Health and Care Research Global Health Research Group on Homelessness and Mental Health in Africa) aims to develop and evaluate interventions that address the unmet needs of people who are homeless and have severe mental illness (SMI) living in three African countries in ways that are rights-based, contextually grounded, scalable and sustainable. METHODS: We will work in the capital city (Addis Ababa) in Ethiopia, a regional city (Tamale) in Ghana, and the capital city (Nairobi) and a rural county (Makueni) in Kenya to understand different approaches to intervention needed across varied settings.We will be guided by the MRC/NIHR framework on complex interventions and implementation frameworks and emphasise co-production. Formative work will include synthesis of global evidence (systematic review, including grey literature, and a Delphi consensus exercise) on interventions and approaches to homelessness and SMI. We will map contexts; conduct focused ethnography to understand lived experiences of homelessness and SMI; carry out a cross-sectional survey of people who are homeless (n = 750 Ghana/Ethiopia; n = 350 Kenya) to estimate prevalence of SMI and identify prioritised needs; and conduct in-depth interviews and focus group discussions with key stakeholders to understand experiences, challenges and opportunities for intervention. This global and local evidence will feed into Theory of Change (ToC) workshops with stakeholders to establish agreement about valued primary outcomes, map pathways to impact and inform selection and implementation of interventions. Intervention packages to address prioritised needs will be co-produced, piloted and optimised for feasibility and acceptability using participatory action research. We will use rights-based approaches and focus on community-based care to ensure sustainability. Realist approaches will be employed to analyse how contextual variation affects mechanisms and outcomes to inform methods for a subsequent evaluation of larger scale implementation. Extensive capacity-strengthening activities will focus on equipping early career researchers and peer researchers. People with lived experience of SMI and policymakers are an integral part of the research team. Community engagement is supported by working closely with multisectoral Community Advisory Groups. CONCLUSIONS: HOPE will develop evidence to support action to respond to the needs and preferences of people experiencing homelessness and SMI in diverse settings in Africa. We are creating a new partnership of researchers, policymakers, community members and people with lived experience of SMI and homelessness to enable African-led solutions. Key outputs will include contextually relevant practice and policy guidance that supports achievement of inclusive development
Hurricane Helene\u27s Impact on Peritoneal Dialysis Supply Chain: A Case Study in Healthcare System Vulnerability
No full textAssociation between Induction Start Time and Labor Duration in Nulliparous Women Undergoing Elective Induction of Labor
No full textThis study aimed to examine the association between elective induction of labor (EIOL) start time and labor duration among nulliparous women.The ARRIVE trial was a multicenter randomized controlled trial of induction of labor at 39 to 39 weeks versus expectant management in low-risk nulliparous women. In this secondary analysis, we included participants randomized to the induction group who had an EIOL without spontaneous labor or rupture of membranes prior to the induction start. The start time of EIOL was categorized as: early a.m. (midnight to 5:59 a.m.), late AM (6 AM-11:59 a.m.), early p.m. (noon-5:59 p.m.), or late p.m. (6 p.m.-11:59 p.m.). The primary outcome was labor duration. Cesarean delivery rates by induction start time were also examined. Multivariable analysis was conducted controlling for age, body mass index, insurance status, and modified Bishop score on admission (\u3c5 or ≥5).Of 3,062 women randomized to EIOL, 2,197 were included in this analysis. EIOL occurred in the early a.m. in 13%, in late a.m. in 28%, in early p.m. in 13%, and in late p.m. in 45%. Participants induced in the late a.m. had the shortest mean labor durations (21.5 ± 11.3 hours) and the highest frequency of delivery at \u3c 24 hours (68%). In adjusted analyses, induction in the late a.m. (vs. grouped other time periods) remained significantly associated with shorter labor duration (-1.5 hours; confidence interval: -2.5 and -0.4; p = 0.006), and there was no interaction between Bishop score and time of EIOL. Cesarean delivery rates did not differ by start time.Induction of labor starting between 6 a.m. and 11:59 a.m. was associated with shorter labor durations, independent of baseline maternal characteristics including cervical status on admission. · Women were associated with shorter labor durations. · Cesarean delivery rates did not differ by EIOL start time.. · Differences in labor management by time of day may in part explain these findings.
Manufacture of Necator americanus as an infectious challenge agent: Accelerating human hookworm vaccine development
No full textHookworms infect 450 million people globally and account for the loss of 5 million disability-adjusted life years annually. Over the last decade, the Human Hookworm Vaccine (HHV) candidate N. americanus Glutathione-S-Transferase-1 (Na-GST-1) has advanced to efficacy testing. This manuscript describes the manufacture of third-stage N. americanus larvae (NaL3) as an infectious challenge agent to provide proof-of-concept for the efficacy of Na-GST-1 prior to more extensive and more resource-intensive vaccine field trials in hookworm endemic areas. NaL3 were produced from fecal samples of three hookworm-infected human donors by a modified Harada and Mori method that complied with current Good Manufacturing Practices (cGMP). A series of lot release tests assessed the purity (bioburden), viability (potency), and identity (speciation) of NaL3 before administration to participants in a hookworm vaccine challenge model (HVCM) in Washington, DC. Twenty-four production runs yielded an average of 947 NaL3 per lot, which were approved for clinical to inoculate of 39 participants in a Hookworm Vaccine Challenge Model. This manuscript describes the unique manufacture and testing for NaL3 in compliance with cGMP
Cost-effectiveness and clinical outcomes comparison between noninvasive ventilation and high-flow nasal cannula use in patients with multiple rib fractures
No full textBACKGROUND: Patients with multiple rib fractures often require advanced respiratory support to prevent intubation and associated morbidity. Noninvasive ventilation (NIV) and high-flow nasal cannula (HFNC) are commonly used, but direct comparisons of clinical outcomes and cost-effectiveness remain limited. This study aimed to compare NIV versus HFNC using a large, nationwide US database. METHODS: This retrospective cohort study used the 2020-2021 National Inpatient Sample database to identify adult trauma patients (18-89 years) with two or more rib fractures who received either NIV or HFNC without prior intubation. To focus on isolated thoracic injuries, patients with significant injuries elsewhere (Abbreviated Injury Scale score ≥3) or who died within 24 hours were excluded. Inverse probability of treatment of weighting was used to balance patient characteristics, including demographics, comorbidities, and injury severity. Primary outcomes included mortality, tracheostomy, pulmonary complications, and intubation rates. Hospital length of stay and total costs were also assessed. Cost-effectiveness analyses were conducted with intubation avoidance as the effectiveness measure, and a willingness-to-pay threshold of US 42,505 vs. US $32,024, p \u3c 0.001). Cost-effectiveness analysis revealed that NIV dominated HFNC, yielding better outcomes at lower costs. CONCLUSION: Among patients with multiple rib fractures, NIV yielded superior clinical outcomes, shortened hospital stays, and reduced costs compared with HFNC. These findings suggest that NIV may be a more cost-effective and clinically advantageous choice. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III
Associations of Patient Age, Tumor Nephrectomy Weight, and Tumor Diameter with Event-Free and Overall Survival in Stage I or II Favorable Histology Wilms Tumor: A Pooled Analysis of Children\u27s Oncology Group Studies AREN0532 and AREN03B2
No full textOBJECTIVE: To evaluate age, TNW, or tumor diameter (TD) as continuous prognostic variables for outcomes in early stage FHWT after accounting for biology and treatment. SUMMARY OF BACKGROUND DATA: Patient age (\u3c 2 vs. ≥ 2 years) and tumor nephrectomy weight (TNW; \u3c 550g vs. ≥ 550 grams) have been used to risk stratify children with stage I favorable histology Wilms tumor (FHWT) on Children\u27s Oncology Group (COG) studies and select patients for omission of chemotherapy. METHODS: Included patients had stage I or II FHWT per central review and were treated with nephrectomy only, EE4A, or DD4A on COG trials. Restricted cubic splines models were used to estimate the stage-specific effects of age, TNW, and TD on event-free survival (EFS) and overall survival (OS), accounting for treatment and biology. RESULTS: In pooled analyses of 775 stage I and 936 stage II patients, age was not significantly associated with EFS or OS for stage I or II patients after accounting for adverse biology that is more prevalent with older age. Greater TNW and larger TD were associated with increased risk of relapse in stage I and increased risk of death in stage II, but not when restricted to patients less than 4 years old. CONCLUSIONS: Age, TNW, and TD are each prognostic for EFS or OS in some cohorts of patients with stage I or II FHWT. However, after accounting for adverse biology that becomes more prevalent at older ages, these factors are no longer independently prognostic. The next COG FHWT study will implement and validate these findings
Factors associated with mortality of hospitalized road traffic injury patients in 4 low- and middle-income countries
No full textOBJECTIVES: Road traffic injuries (RTIs) are an important public health problem, especially in low- and middle-income countries (LMICs), and are highly preventable with evidence-based interventions. This study aimed to describe the sociodemographic characteristics, risk factors, and patterns of injury that are associated with in-hospital mortality among patients with RTIs. METHODS: A prospective observational study was conducted at 8 hospitals in Cambodia, Ethiopia, Mexico, and Zambia with adult patients who sustained moderate to severe RTIs and were admitted to participating hospitals for at least 24 h. Bivariate and multivariable logistic regression models were used to examine the association between relevant variables and death in-hospital. RESULTS: The majority of RTI deaths occurred among males aged 18 to 44 who were pedestrians or riders of 2- or 3-wheeled vehicles. The following variables were associated with in-hospital mortality: Riding a 2- or 3-wheeler (adjusted odds ratio [AOR] 3.30, 95% confidence interval [CI] 1.06-10.23), moderate-severe Glasgow Coma Scale (GCS; AOR 10.27, 95% CI 4.72-22.33), and low systolic blood pressure (AOR 5.97, 95% CI 1.97-18.04). CONCLUSIONS: The findings reinforce the important role of traumatic brain injury (TBI) in RTI deaths and highlight the need for capacity building to develop local neurosurgery expertise to manage and treat TBI in LMICs. Evidence-based prevention strategies such as lowering speed limits in urban areas, protecting users via dedicated footpaths and cycle paths, and increasing helmet use are recommended to mitigate the impact of RTIs and reduce mortality among vulnerable road users. In addition, triage systems should be in place to identify patients with moderate-severe GCS and low systolic blood pressure for immediate and intensive care