Prognostic models for identifying risk of poor outcome in people with acute ankle sprains: the SPRAINED development and external validation study

BACKGROUND: Ankle sprains are very common injuries. Although recovery can occur within weeks, around one-third of patients have longer-term problems. OBJECTIVES: To develop and externally validate a prognostic model for identifying people at increased risk of poor outcome after an acute ankle sprain. DESIGN: Development of a prognostic model in a clinical trial cohort data set and external validation in a prospective cohort study. SETTING: Emergency departments (EDs) in the UK. PARTICIPANTS: Adults with an acute ankle sprain (within 7 days of injury). SAMPLE SIZE: There were 584 clinical trial participants in the development data set and 682 recruited for the external validation study. PREDICTORS: Candidate predictor variables were chosen based on availability in the clinical data set, clinical consensus, face validity, a systematic review of the literature, data quality and plausibility of predictiveness of the outcomes. MAIN OUTCOME MEASURES: Models were developed to predict two composite outcomes representing poor outcome. Outcome 1 was the presence of at least one of the following symptoms at 9 months after injury: persistent pain, functional difficulty or lack of confidence. Outcome 2 included the same symptoms as outcome 1, with the addition of recurrence of injury. Rates of poor outcome in the external data set were lower than in the development data set, 7% versus 20% for outcome 1 and 16% versus 24% for outcome 2. ANALYSIS: Multiple imputation was used to handle missing data. Logistic regression models, together with multivariable fractional polynomials, were used to select variables and identify transformations of continuous predictors that best predicted the outcome based on a nominal alpha of 0.157, chosen to minimise overfitting. Predictive accuracy was evaluated by assessing model discrimination (c-statistic) and calibration (flexible calibration plot). RESULTS: (1) Performance of the prognostic models in development data set - the combined c-statistic for the outcome 1 model across the 50 imputed data sets was 0.74 [95% confidence interval (CI) 0.70 to 0.79], with good model calibration across the imputed data sets. The combined c-statistic for the outcome 2 model across the 50 imputed data sets was 0.70 (95% CI 0.65 to 0.74), with good model calibration across the imputed data sets. Updating these models, which used baseline data collected at the ED, with an additional variable at 4 weeks post injury (pain when bearing weight on the ankle) improved the discriminatory ability (c-statistic 0.77, 95% CI 0.73 to 0.82, for outcome 1 and 0.75, 95% CI 0.71 to 0.80, for outcome 2) and calibration of both models. (2) Performance of the models in the external data set - the combined c-statistic for the outcome 1 model across the 50 imputed data sets was 0.73 (95% CI 0.66 to 0.79), with a calibration plot intercept of -0.91 (95% CI -0.98 to 0.44) and slope of 1.13 (95% CI 0.76 to 1.50). The combined c-statistic for the outcome 2 model across the 50 imputed data sets was 0.63 (95% CI 0.58 to 0.69), with a calibration plot intercept of -0.25 (95% CI -0.27 to 0.11) and slope of 1.03 (95% CI 0.65 to 1.42). The updated models with the additional pain variable at 4 weeks had improved discriminatory ability over the baseline models but not better calibration. CONCLUSIONS: The SPRAINED (Synthesising a clinical Prognostic Rule for Ankle Injuries in the Emergency Department) prognostic models performed reasonably well, and showed benefit compared with not using any model; therefore, the models may assist clinical decision-making when managing and advising ankle sprain patients in the ED setting. The models use predictors that are simple to obtain. LIMITATIONS: The data used were from a randomised controlled trial and so were not originally intended to fulfil the aim of developing prognostic models. However, the data set was the best available, including data on the symptoms and clinical events of interest. FUTURE WORK: Further model refinement, including recalibration or identifying additional predictors, may be required. The effect of implementing and using either model in clinical practice, in terms of acceptability and uptake by clinicians and on patient outcomes, should be investigated. TRIAL REGISTRATION: Current Controlled Trials ISRCTN12726986. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 64. See the NIHR Journals Library website for further project information. Funding was also recieved from the NIHR Collaboration for Leadership in Applied Health Research, Care Oxford at Oxford Health NHS Foundation Trust, NIHR Biomedical Research Centre, Oxford, and the NIHR Fellowship programme

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2015: A systematic analysis for the Global Burden of Disease Study 2015

Background: The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 provides an up-to-date synthesis of the evidence for risk factor exposure and the attributable burden of disease. By providing national and subnational assessments spanning the past 25 years, this study can inform debates on the importance of addressing risks in context. Methods: We used the comparative risk assessment framework developed for previous iterations of the Global Burden of Disease Study to estimate attributable deaths, disability-adjusted life-years (DALYs), and trends in exposure by age group, sex, year, and geography for 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2015. This study included 388 risk-outcome pairs that met World Cancer Research Fund-defined criteria for convincing or probable evidence. We extracted relative risk and exposure estimates from randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. We developed a metric that allows comparisons of exposure across risk factors—the summary exposure value. Using the counterfactual scenario of theoretical minimum risk level, we estimated the portion of deaths and DALYs that could be attributed to a given risk. We decomposed trends in attributable burden into contributions from population growth, population age structure, risk exposure, and risk-deleted cause-specific DALY rates. We characterised risk exposure in relation to a Socio-demographic Index (SDI). Findings: Between 1990 and 2015, global exposure to unsafe sanitation, household air pollution, childhood underweight, childhood stunting, and smoking each decreased by more than 25%. Global exposure for several occupational risks, high body-mass index (BMI), and drug use increased by more than 25% over the same period. All risks jointly evaluated in 2015 accounted for 57·8% (95% CI 56·6–58·8) of global deaths and 41·2% (39·8–42·8) of DALYs. In 2015, the ten largest contributors to global DALYs among Level 3 risks were high systolic blood pressure (211·8 million [192·7 million to 231·1 million] global DALYs), smoking (148·6 million [134·2 million to 163·1 million]), high fasting plasma glucose (143·1 million [125·1 million to 163·5 million]), high BMI (120·1 million [83·8 million to 158·4 million]), childhood undernutrition (113·3 million [103·9 million to 123·4 million]), ambient particulate matter (103·1 million [90·8 million to 115·1 million]), high total cholesterol (88·7 million [74·6 million to 105·7 million]), household air pollution (85·6 million [66·7 million to 106·1 million]), alcohol use (85·0 million [77·2 million to 93·0 million]), and diets high in sodium (83·0 million [49·3 million to 127·5 million]). From 1990 to 2015, attributable DALYs declined for micronutrient deficiencies, childhood undernutrition, unsafe sanitation and water, and household air pollution; reductions in risk-deleted DALY rates rather than reductions in exposure drove these declines. Rising exposure contributed to notable increases in attributable DALYs from high BMI, high fasting plasma glucose, occupational carcinogens, and drug use. Environmental risks and childhood undernutrition declined steadily with SDI; low physical activity, high BMI, and high fasting plasma glucose increased with SDI. In 119 countries, metabolic risks, such as high BMI and fasting plasma glucose, contributed the most attributable DALYs in 2015. Regionally, smoking still ranked among the leading five risk factors for attributable DALYs in 109 countries; childhood underweight and unsafe sex remained primary drivers of early death and disability in much of sub-Saharan Africa. Interpretation: Declines in some key environmental risks have contributed to declines in critical infectious diseases. Some risks appear to be invariant to SDI. Increasing risks, including high BMI, high fasting plasma glucose, drug use, and some occupational exposures, contribute to rising burden from some conditions, but also provide opportunities for intervention. Some highly preventable risks, such as smoking, remain major causes of attributable DALYs, even as exposure is declining. Public policy makers need to pay attention to the risks that are increasingly major contributors to global burden. Funding: Bill & Melinda Gates Foundation

Combination of searches for heavy spin-1 resonances using 139 fb−1 of proton-proton collision data at √s = 13 TeV with the ATLAS detector

A combination of searches for new heavy spin-1 resonances decaying into diferent pairings of W, Z, or Higgs bosons, as well as directly into leptons or quarks, is presented. The data sample used corresponds to 139 fb−1 of proton-proton collisions at √s = 13 TeV collected during 2015–2018 with the ATLAS detector at the CERN Large Hadron Collider. Analyses selecting quark pairs (qq, bb, tt¯, and tb) or third-generation leptons (τν and τ τ ) are included in this kind of combination for the frst time. A simplifed model predicting a spin-1 heavy vector-boson triplet is used. Cross-section limits are set at the 95% confdence level and are compared with predictions for the benchmark model. These limits are also expressed in terms of constraints on couplings of the heavy vector-boson triplet to quarks, leptons, and the Higgs boson. The complementarity of the various analyses increases the sensitivity to new physics, and the resulting constraints are stronger than those from any individual analysis considered. The data exclude a heavy vector-boson triplet with mass below 5.8 TeV in a weakly coupled scenario, below 4.4 TeV in a strongly coupled scenario, and up to 1.5 TeV in the case of production via vector-boson fusion

Measurement of vector boson production cross sections and their ratios using pp collisions at √s = 13.6 TeV with the ATLAS detector

Abstract available from publisher's website

Search for direct production of electroweakinos in final states with one lepton, jets and missing transverse momentum in pp collisions at √s = 13 TeV with the ATLAS detector

Searches for electroweak production of wino-like chargino pairs, χ˜ + 1 χ˜ − 1 , and of wino-like chargino and next-to-lightest neutralino, χ˜ ± 1 χ˜ 0 2 , are presented. The models explored assume that the charginos decay into a W boson and the lightest neutralino, χ˜ ± 1 → W±χ˜ 0 1 . The next-to-lightest neutralinos are degenerate in mass with the chargino and decay to χ˜ 0 1 and either a Z or a Higgs boson, χ˜ 0 2 → Zχ˜ 0 1 or hχ˜ 0 1 . The searches exploit the presence of a single isolated lepton and missing transverse momentum from the W boson decay products and the lightest neutralinos, and the presence of jets from hadronically decaying Z or W bosons or from the Higgs boson decaying into a pair of b-quarks. The searches use 139 fb−1 of √ s = 13 TeV proton-proton collisions data collected by the ATLAS detector at the Large Hadron Collider between 2015 and 2018. No deviations from the Standard Model expectations are found, and 95% confdence level exclusion limits are set. Chargino masses ranging from 260 to 520 GeV are excluded for a massless χ˜ 0 1 in chargino pair production models. Degenerate chargino and next-to-lightest neutralino masses ranging from 260 to 420 GeV are excluded for a massless χ˜ 0 1 for χ˜ 0 2 → Zχ˜ 0 1 . For decays through an on-shell Higgs boson and for mass-splitting between χ˜ ± 1 /χ˜ 0 2 and χ˜ 0 1 as small as the Higgs boson mass, mass limits are improved by up to 40 GeV in the range of 200–260 GeV and 280–470 GeV compared to previous ATLAS constraints

Search for the decay of the Higgs boson to a Z boson and a light pseudoscalar particle decaying to two photons

A search for the decay of the Higgs boson to a Z boson and a light, pseudoscalar particle, a, decaying respectively to two leptons and to two photons is reported. The search uses the full LHC Run 2 proton–proton collision data at √s = 13 TeV, corresponding to 139 fb−1 collected by the ATLAS detector. This is one of the first searches for this specific decay mode of the Higgs boson, and it probes unexplored parameter space in models with axion-like particles (ALPs) and extended scalar sectors. The mass of the a particle is assumed to be in the range 0.1–33 GeV. The data are analysed in two categories: a merged category where the photons from the a decay are reconstructed in the ATLAS calorimeter as a single cluster, and a resolved category in which two separate photons are detected. The main background processes are from Standard Model Z boson production in association with photons or jets. The data are in agreement with the background predictions, and upper limits on the branching ratio of the Higgs boson decay to Za times the branching ratio α = γγ are derived at the 95% confidence level and they range from 0.08% to 2% depending on the mass of the a particle. The results are also interpreted in the context of ALP models

Measurement of the Bs0→ μμ effective lifetime with the ATLAS detector

This paper reports the first ATLAS measurement of the B0s → μμ effective lifetime. The measurement is based on the data collected in 2015–2016, amounting to 26.3 fb−1 of 13 TeV LHC proton-proton collisions. The proper decay-time distribution of 58 ± 13 background-subtracted signal candidates is fit with simulated signal templates parameterised as a function of the B0s effective lifetime, with statistical uncertainties extracted through a Neyman construction. The resulting effective measurement of the B0s → μμ lifetime is 0.99+0.42−0.07 (stat.) ± 0.17 (syst.) ps and it is found to be consistent with the Standard Model

Evidence of pair production of longitudinally polarised vector bosons and study of CP properties in ZZ → 4ℓ events with the ATLAS detector at √s = 13 TeV

A study of the polarisation and CP properties in ZZ production is presented. The used data set corresponds to an integrated luminosity of 140 fb−1 of proton-proton collisions at a centre-of-mass energy of 13 TeV recorded by the ATLAS detector at the Large Hadron Collider. The ZZ candidate events are reconstructed using two same-flavour opposite-charge electron or muon pairs. The production of two longitudinally polarised Z bosons is measured with a significance of 4.3 standard deviations, and its cross-section is measured in a fiducial phase space to be 2.45 ± 0.60 fb, consistent with the next-to-leading-order Standard Model prediction. The inclusive differential cross-section as a function of a CP-sensitive angular observable is also measured. The results are used to constrain anomalous CP-odd neutral triple gauge couplings

Measurement of the tt¯ cross section and its ratio to the Z production cross section using pp collisions at √s = 13.6 TeV with the ATLAS detector

The inclusive top-quark-pair production cross section σtt¯ and its ratio to the Z-boson production cross section have been measured in proton–proton collisions at √s = 13.6 TeV, using 29 fb−1 of data collected in 2022 with the ATLAS experiment at the Large Hadron Collider. Using events with an opposite-charge electron-muon pair and b-tagged jets, and assuming Standard Model decays, the top-quark-pair production cross section is measured to be σtt¯=850±3(stat.)±18(syst.)±20(lumi.) pb. The ratio of the tt¯ and the Z-boson production cross sections is also measured, where the Z-boson contribution is determined for inclusive e+e− and μ+μ− events in a fiducial phase space. The relative uncertainty on the ratio is reduced compared to the tt¯ cross section, thanks to the cancellation of several systematic uncertainties. The result for the ratio, Rtt¯/Z=1.145±0.003(stat.)±0.021(syst.)±0.002(lumi.) is consistent with the Standard Model prediction using the PDF4LHC21 PDF set