The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies

Cannabis use and psychotic-like experiences: A systematic review of biological vulnerability, potency effects, and clinical trajectories

Epidemiological data have provided evidence that psychotic-like experiences (PLEs) occur in the general population without clinical impairment. According to the psychosis continuum hypothesis, PLEs are subject to multiple risk factors. This review synthesizes current research on biological, substance use-related, and environmental risk factors for PLEs in non-clinical populations. PubMed/Medline and Scopus databases were searched for peer-reviewed studies published until January 2024 investigating risk factors for PLEs in non-clinical samples. Following PRISMA guidelines, 38 full-text articles were analyzed after title/abstract and full-text screening (PROSPERO registration ID: N 1001,807). Four main risk factor categories emerged. Biological vulnerabilities included specific metabolic profiles, genetic predisposition, and neurobiological alterations. Substance use patterns, particularly high-potency cannabis, showed significant associations with PLEs, with evidence for bidirectional relationships. Socio-demographic factors revealed influences of digital media use, ethnic density, and gender differences. Outcome studies demonstrated associations between PLEs and consequences including suicidal behavior and cognitive impairments. Findings suggest a complex interplay between multiple risk factors in PLE development. More attention should be paid to the interaction between biological vulnerabilities and environmental factors, as these experiences may represent important markers for mental health outcomes. A comprehensive assessment approach and proactive early intervention strategies are essential for the timely identification and management of at-risk individuals. Our findings support a multifactorial model where genetic vulnerabilities, cannabis use patterns, and socio-environmental factors influence PLE trajectories. The bidirectional cannabis-PLE relationship suggests self-regulatory mechanisms that could inform preventive interventions. Early identification of PLEs in young cannabis users represents a crucial opportunity for targeted clinical interventions.

Sociodemographic disparities in incidence and survival for pediatric out-of-hospital cardiac arrest in the United States

BACKGROUND

Sociodemographic disparities in pediatric out-of-hospital cardiac arrest (OHCA) outcomes exist; differences in pediatric OHCA incidence remain unknown. This study investigated the association between race, ethnicity, and socioeconomic status (SES) with pediatric OHCA incidence and survival. We hypothesized that children who are Black, Hispanic/Latino, or of lower SES would have higher incidence and lower survival rates compared to children who are White or of higher SES.

METHODS

This is a retrospective cohort study (2015-2019) of the Cardiac Arrest Registry to Enhance Survival database. We included OHCAs among children < 18 years. The exposures were race, ethnicity, or SES index score. The SES index score incorporated race or ethnicity, household income, high school graduation rates, and unemployment rates on a scale from 0 to 4, with 4 indicating the highest-risk neighborhoods. The primary outcome was incidence (measured per 100,000 children of a particular group). Secondary outcomes included survival to hospital discharge and survival with a favorable neurologic outcome.

RESULTS

Among 6945 OHCAs, 2320 (33.4%) occurred in Black children, 739 (10.6%) in Hispanic/Latino children, 2161 (31.1%) in White children, 188 (2.7%) in children of Other race, and 2855 (41.2%) in highest-risk neighborhoods. Black children had the highest OHCA incidence (15.5) as compared to Hispanic/Latino children (3.3) and White children (3.8), p < 0.001. OHCA incidence was higher in highest-risk neighborhoods (11.6) compared to lowest-risk neighborhoods (4.3), p < 0.001. Black children had lower odds of survival to hospital discharge (adjusted odds ratio [aOR] 0.73, 95% CI 0.59-0.91) and neurologically favorable survival (aOR 0.64, 95% CI 0.50-0.82) compared to White children. Hispanic/Latino children did not have significantly worse survival outcomes compared to White children. Children from the highest-risk neighborhoods had lower odds of survival to hospital discharge (aOR 0.64, 95% CI 0.50-0.81) and neurologically favorable survival (aOR 0.54, 95% CI 0.41-0.71) compared to children from the lowest-risk neighborhoods.

CONCLUSIONS

Black children have over four times the OHCA incidence compared to White and Hispanic/Latino children. Children from the highest-risk neighborhoods have more than twice the OHCA incidence compared to children from the lowest-risk neighborhoods. Black children and children from the highest-risk neighborhoods have significantly lower OHCA survival rates.

Heart Rate Variability Does Not Predict Recurrence of Apnoea of Prematurity After Ceasing Caffeine Therapy: A Prospective Cohort Study

AIM

We evaluated whether sample entropy of heart rate time series could serve as a biomarker for guiding caffeine cessation in preterm infants treated for apnoea of prematurity (AOP). We also assessed associations of sample entropy with weeks of gestation, clinical morbidity, AOP frequency and caffeine reinitiation.

METHODS

We conducted a prospective single-centre study at the University Children's Hospital Basel, Switzerland, from July 2019 to June 2020. We included 61 hospitalised preterm infants born before 32 weeks of gestation. Heart rate was derived from the clinical standard monitoring system at caffeine cessation, 3 days later, and at discharge. Sample entropy was calculated from 90-min recordings using custom-written analytical software.

RESULTS

We obtained valid data from 44/61 infants (72%) with a mean of 28.4 weeks of gestation (range: 24.0-31.7). Twenty-eight (64%) were male. Sample entropy at caffeine cessation was positively associated with weeks of gestation (R2 = 0.15, p = 0.01) and negatively with bronchopulmonary dysplasia (R2 = 0.18, p = 0.01). It did not predict AOP frequency or caffeine reinitiation.

CONCLUSION

Sample entropy at caffeine cessation is associated with maturation at birth and bronchopulmonary dysplasia but does not predict AOP within 3 days of cessation. Further studies should assess longitudinal measurements to predict respiratory control in preterm infants.

TRIAL REGISTRATION

clinicaltrials.gov: NCT04303494.

Penetrating trauma in Spain: analysis of the Spanish trauma registry (RETRAUCI)

OBJECTIVE

To describe the epidemiology of penetrating trauma, mortality associated factors and its management in Spanish intensive care units.

DESIGN

Multicenter, prospective registry. A comparison is established between two cohorts defined by the type of trauma (blunt and penetrating).

PATIENTS

Patients with traumatic injury admitted to the participating ICUs from June 2015 to June 2022.

INTERVENTIONS

None.

MAIN VARIABLE OF INTEREST

Epidemiology, injury pattern, prehospital and hospital care, resource utilization, and clinical outcomes.

RESULTS

12,806 patients were eligible, of whom 821 (6.4%) suffered penetrating trauma; 418 patients (50.9%) from stab wounds, 93 (11.3%) from gunshot wounds, and 310 (37.8%) from other objects. The most common intent was assault (47.7%). The mean ISS was 15.2 ± 10.6 in penetrating trauma and 19.8 ± 11.9 in blunt trauma (p < 0.001). ICU mortality was 7.8% compared to 11.7% in blunt trauma, with deaths more frequently occurring within the first 24 hours (64% vs. 39%). Factors associated with mortality included female sex, prior use of antithrombotic agents, older age, higher NISS score, and the presence of cranial trauma or shock.

CONCLUSIONS

Penetrating trauma is an emergent pathology in our context with high complexity, highlighting the need for focused study and documentation, protocol development, and resource optimization to provide quality care.

The Role of County-Level Persistent Poverty in Stroke Mortality in the USA

Stroke is a major health concern in the USA, disproportionately affecting socioeconomically disadvantaged groups. This study investigates the link between persistent poverty and stroke mortality rates in residents aged 65 and above, positing that sustained economic challenges at the county level correlate with an increase in stroke-related deaths. Persistent poverty refers to a long-term state where a significant portion of a population lives below the poverty threshold for an extended period, typically measured over several decades. It captures the chronic nature of economic hardship faced by a community across multiple generations. Utilizing data from the CDC Wonder database and the American Community Survey, we conducted a comprehensive analysis across US counties, differentiating them by persistent poverty status. Our results indicate a statistically significant link between persistent poverty and increased mortality from ischemic and hemorrhagic strokes; counties afflicted by long-standing poverty were associated with an additional 33.49 ischemic and 8.16 hemorrhagic stroke deaths per 100,000 residents annually compared to their wealthier counterparts. These disparities persisted when controlling for known stroke risk factors and other socioeconomic variables. These results highlight the need for targeted public health strategies and interventions to address the disparities in stroke mortality rates and the broader implications for healthcare equity. The study underscores the vital role of socioeconomic context in health outcomes and the urgency of addressing long-term poverty as a key determinant of public health.

Retrospective analysis of low-dose versus higher-dose haloperidol in older emergency department patients

BACKGROUND

A reduced initial dose of injectable haloperidol is recommended in older patients for treatment of acute agitation based on limited studies.

OBJECTIVE

Assess the effectiveness and safety of higher-dose versus low-dose injectable haloperidol in older patients presenting to the emergency department (ED).

METHODS

This was a retrospective, propensity-score matched, cohort analysis conducted at a two-campus healthcare system. Patients ≥65 years old administered injectable haloperidol in the ED were classified as receiving low-dose (≤ 0.5 mg) or higher-dose (> 0.5 mg) haloperidol. Exclusion criteria included acute alcohol withdrawal; ED or hospital stay shorter than four hours; and any of the following before injectable haloperidol administration: safety watch, physical restraint requirement, and administration of oral haloperidol, other acute antipsychotics, or benzodiazepines. The primary outcome was composite treatment failure, defined as need for repeat injectable haloperidol, alternative sedative, restraints, or safety watch within four hours of haloperidol administration. Secondary safety outcomes included escalation of respiratory support, extrapyramidal symptoms, falls, and hospital admission.

RESULTS

Sixty-nine patients per group were matched. There was no statistically significant difference in composite treatment failure (P = 0.087). However, patients in the higher-dose group were more likely to require alternative sedatives (P = 0.035). There were no significant differences between groups for any safety outcomes.

CONCLUSION

This study suggests low-dose (≤ 0.5 mg) injectable haloperidol may be at least as safe and effective as higher doses (> 0.5 mg) in agitated older adults. Low-dose injectable haloperidol may be preferred in mild to moderately agitated older adults, reserving higher doses for severe agitation.

Needs and Demands of e-Mental Health Interventions for Elite Athletes: User-Centered Design Approach Based on a Cross-Sectional Study

Introduction: Elite athletes experience sport-specific stressors and are at risk of developing mental health symptoms during and after their careers. E-Mental health interventions may pioneer a new approach to health care, which could help overcome barriers regarding its accessibility for elite athletes. This study aims to examine the needs and demands regarding the design and content of e-mental health interventions for elite athletes. Methods: A cross-sectional study was conducted via a web-based survey with N = 275 elite athletes, of which 167 were female and who participated in a variety of individual and/or team sports. Previous experience using e-mental health interventions was assessed. Needs and demands regarding format, frequency, content, and topics of an e-mental health intervention were analyzed descriptively and were compared between individual and team athletes using ANOVAs. Results: Elite athletes expressed a preference for an individual program via smartphone app (94.2%) with audio/video material (69.1%) and interactive tasks (60.4%). Regarding the frequency of e-mental health intervention, athletes in individual (62.2%) and team sports (60.0%) both preferred weekly intervention with sessions lasting between 20 and 30 min, whereas athletes engaged in both kinds of sports favored an intervention either on a weekly basis (44.7%) or on request (38.3%). The most relevant topics of e-mental health interventions for elite athletes were "Coping with pressure" (92%) and "Self-worth/self-esteem" (90%). Conclusions: The results of this study highlight the potential relevance of a user-centered design approach and could contribute valuable insights into developing e-mental health interventions for elite athletes.

Head Posture and Upper Spine Morphological Deviations in Patients With Hypermobile Ehlers-Danlos Syndrome

OBJECTIVE

To compare head posture and upper spine morphology in hypermobile Ehlers-Danlos syndrome (hEDS) patients with healthy controls with neutral occlusion.

MATERIALS AND METHODS

The study consisted of 27 hEDS patients (23 females, 4 males, mean age 36.41 ± 11.35) and 39 healthy controls (28 females, 11 males, mean age 31.85 ± 11.35) with neutral occlusion and no previous orthodontic treatment. Head posture was analysed by angular measurements on lateral cephalograms taken in natural head position and upper spine morphology was assessed on Cone Beam Computed Tomography (CBCT) by visual analysis of fusion and partial cleft of the upper spine and compared by general linear and logistic analyses adjusted for age and gender.

RESULTS

In total, upper spine morphological deviations occurred significantly more often in hEDS patients (51.9%) compared to controls (15.4%) (p = 0.007). Out of the two categories of upper spine morphological deviations (fusion anomalies and posterior arch deficiencies (PAD)), PAD occurred significantly more often in hEDS patients (48.1%) compared to controls (12.8%) (p = 0.007). The differences remained significant when p-values were corrected for multiple testing comparing groups. Head posture was almost significantly more extended in hEDS patients compared to controls when the p-values were corrected for multiple testing comparing groups (NSL/VER, p = 0.089; NSL/OPT, p = 0.080).

CONCLUSIONS

The results of the present study indicate that upper spine morphology is affected in hEDS patients. The results may contribute to a further understanding of the spinal phenotypic spectrum in hEDS patients and thus prove valuable in the diagnostics and treatment of hEDS patients.

Association Between Objective Sleep and Clinical Outcomes in Older Adults With Low Back Pain Receiving Physical Therapy Care: A Secondary Analysis of a Responsiveness Study

BACKGROUND/OBJECTIVES

Sleep seems to be associated with worse low back pain (LBP) outcomes in older adults; however, studies investigating the association of objective sleep with future changes in LBP outcomes are lacking. The objectives of this study are as follows: (a) to investigate the association between objectively measured sleep with changes in clinical outcomes in older adults with LBP receiving physical therapy care and (b) to examine the cross-sectional association between sleep and pain catastrophizing.

METHODS

This was a prospective cohort study. We recruited older adults (≥60 years old) with chronic LBP undergoing physical therapy treatment. At baseline, we assessed participants' sleep (actigraphy for 10-14 days), pain intensity, disability, pain catastrophizing, and covariates. After 8 weeks, we reassessed pain intensity, disability, and self-perceived recovery. We ran linear regression models and Spearman coefficient tests.

RESULTS

Fifty-eight participants were included, and 51 completed follow-up assessments (60.8% women; mean age 70.1 ± 5.6 years). We found no associations between sleep quantity and efficiency with changes in pain intensity, disability, and self-perceived recovery after 8 weeks of physical therapy care. We found a correlation between sleep fragmentation and pain catastrophizing (r = .30; 95% confidence interval: [.03, .54]).

CONCLUSION

Objective sleep quantity and efficiency may not be associated with changes in LBP outcomes after physical therapy care in older adults. Among the sleep domains evaluated, sleep fragmentation may be the sleep domain with the strongest association with pain catastrophizing. Significance/Implications: Objectively measured sleep might not be a prognostic factor for LBP improvement in older adults. Future studies should explore the association between sleep fragmentation and pain catastrophizing.

Factors Associated With Health-Related Quality of Life Among Community-Dwelling Older Adults Without Social Participation in Japan: A Cross-Sectional Study

This study aimed to identify the characteristics of community-dwelling older adults who exhibited high health-related quality of life (HRQOL) without social participation. This cross-sectional observational study collected data using a mailed questionnaire. This study included 1,183 community-dwelling older adults aged ≥65 years who lived in Japan. HRQOL was assessed via the EuroQol 5-Dimensions 5-Levels (EQ-5D-5L). Multivariate analysis was performed; full health status (EQ-5D-5L = 1) was used as the objective variable, and socio-demographic, lifestyle, and health-related variables were used as the explanatory variables. Driving (OR = 3.846), economic situation (1.938), purpose in life (2.211), primary illness (0.398), low physical function (0.051), and depressive symptoms (0.288) were associated with higher HRQOL among community-dwelling older adults without social participation. This exploratory study suggests the possibility of promoting and improving the HRQOL of community-dwelling older adults without social participation by strengthening specific factors among them.

Outcomes of redo vs primary carotid endarterectomy in the transcarotid artery revascularization era

OBJECTIVE

Outcomes following redo carotid endarterectomy (rCEA) have been shown to be worse than those after primary CEA (pCEA). Additional research has shown that outcomes are better with transcarotid artery revascularization (TCAR) for restenosis after CEA compared with rCEA and transfemoral carotid artery stenting; however, not all patients are eligible for TCAR or transfemoral carotid artery stenting. Given the increasing utilization of endovascular techniques, this study aims to evaluate changes in outcomes of rCEA vs pCEA before and after the approval of TCAR by the United States Food and Drug Administration in 2015.

METHODS

All patients between 2003 and 2023 who underwent CEA in the Vascular Quality Initiative were included and categorized as pCEA or rCEA. Cochrane-Armitage trend testing was used to examine trends in proportion of rCEA compared with pCEA, and the Mann-Kendall trend test was used for perioperative outcomes following rCEA overtime. Multivariable logistic regression was used to compare in-hospital stroke/death, stroke, death, and stroke/death/myocardial infarction following rCEA vs pCEA after stratifying patients into two cohorts: 2003 to 2015 and 2016 to 2023 (before and after introduction of TCAR). Analysis was also performed based on preoperative symptoms.

RESULTS

Of 198,150 patients undergoing CEA, 98.4% were pCEA and 1.6% were rCEA. During the study period, the proportion of rCEA in the Vascular Quality Initiative decreased from 2.3% to 1.0% as endovascular methods became more available (P < .001). Trend testing of individual outcomes showed an increase in the stroke/death rate following rCEA over time (P = .019) despite an improvement in the death rate (P = .009). From 2003 to 2015, patients undergoing rCEA had higher odds of stroke/death compared with pCEA (2.4% vs 1.2%; adjusted odds ratio [aOR], 1.81; 95% confidence interval [CI], 1.14-2.73; P = .007). Higher stroke/death rates after rCEA persisted only in asymptomatic patients (2.3% vs 1.1%; aOR, 2.03; 95% CI, 1.19-3.25; P = .006); however, there was no difference in symptomatic patients (3.0% vs 2.0%; aOR, 1.37; 95% CI, 0.51;3.01; P = .50). In the late period, rCEA had higher odds of stroke/death compared with pCEA (3.1% vs 1.3%; aOR, 2.45; 95% CI, 1.85-3.18; P < .001), and the association was seen in asymptomatic patients (1.9% vs 1.0%; aOR, 1.95; 95% CI, 1.29-2.82; P < .001) and symptomatic patients (6.3% vs 2.0%; aOR, 3.23; 95% CI, 2.17-4.64; P < .001).

CONCLUSIONS

The proportion of rCEAs done yearly in the United States has been decreasing as endovascular options became available. As the rate of rCEA has decreased, outcomes have been worsening, with an increasing stroke/death rate seen over time, driven primarily by worse outcomes in symptomatic patients. Stroke/death rates for asymptomatic patients fall within Society for Vascular Surgery guidelines, and so the choice between rCEA, CAS, or medical management should be made after shared decision-making between a patient and their surgeon. However, with an in-hospital stroke death rate of over 6% symptomatic patients should be selected very carefully, as some are less likely to benefit from rCEA.

The Clinical and Molecular Response of Pyoderma Gangrenosum to IL-23 Blockade: Result from a Proof-of-Concept Open-Label Clinical Trial

Pyoderma gangrenosum is a severe ulcerative disease with a great need for novel therapies. A major barrier to the development of novel therapies is a lack of understanding of disease pathogenesis. We present the results of a proof-of-concept open-label clinical trial of IL-23p19 antagonism with tildrakizumab in pyoderma gangrenosum. Gene expression analysis identified proinflammatory genes associated with IFN responses and dendritic cell activity, including IFI27, XBP1, SAA1 LGALS3, and signal transducer and activator of transcription 3 significantly downregulated in lesional tissue after 12 weeks of therapy. Immunohistochemistry confirmed reduction in IL-17A- and IL-17F-positive cells as well as reduction in TNF-a-, C5a-, and IL-1B-positive cells in week 12 samples compared with those at baseline. Significant reduction in serum inflammation was observed through serum proteomics, with IL-8, IL-6, and CASP-8 levels reduced comparable with those in healthy controls at week 12. Clinical outcomes demonstrated significant reduction in ulcer size, pain, itch, and QOL outcomes in line with the molecular findings. Differential expression of key inflammatory cytokines such as IL-8, CXCL5, PD-L1, SPP1, and matrix metalloproteinase 1 was observed in tissue and serum when stratified by clinical responders and nonresponders. These data provide insights into the clinical relevance of alterations in molecular markers in pyoderma gangrenosum and the potential for the identification of clinically relevant biomarkers of disease activity.

Persistent Tissue-Level Hypoperfusion (No-Reflow) Negates the Clinical Benefit of Successful Thrombectomy

BACKGROUND

Tissue-level hypoperfusion (no-reflow) persists in 30% of patients with seemingly successful upstream angiographic recanalization at thrombectomy. We investigated the clinical impact of the no-reflow phenomenon by comparing patients with no-reflow versus patients with varying degrees of angiographic recanalization.

METHODS

In a post hoc pooled analysis of the EXTEND-IA (Endovascular Therapy for Ischemic Stroke With Perfusion-Imaging Selection) and EXTEND-IA TNK (Tenecteplase Versus Alteplase Before Thrombectomy for Ischemic Stroke) part 1 and 2 trials, clinical and radiological outcomes were compared between patients with (1) full angiographic recanalization with no-reflow (extended Thrombolysis in Cerebral Infarction [eTICI] 2c3-NoReflow), defined as >15% reduction in relative cerebral blood flow or Volume within the infarct relative to a contralateral homolog on 24-hour-follow-up perfusion computed tomography or magnetic resonance imaging despite eTICI grade 2c-3 angiographic recanalization, (2) full angiographic recanalization and tissue reperfusion (eTICI 2c3-CompleteFlow), (3) partial angiographic recanalization (eTICI 2b), and (4) unsuccessful thrombectomy (eTICI 0-2a). The primary outcome, functional independence at 90 days, was investigated using a mixed effect logistic regression model, both unadjusted and adjusted for a priori-selected covariates, namely age, premorbid modified Rankin Scale, baseline National Institutes of Health Stroke Scale, and baseline core volume.

RESULTS

Among 537 patients from the overall pooled cohort, 456 patients were included in the analysis. The mean age of the included patients was 71 years old, and 54% were male. A favorable outcome (90-day modified Rankin Scale score of 0-2 or return to baseline modified Rankin Scale) was observed in 43.33% (n=13/30) of patients with eTICI 2c3-NoReflow, 67.50% (n=81/120) of eTICI 2c3-CompleteFlow, 63.03% (n=150/238) of eTICI 2b, and 50.00% (n=34/68) of unsuccessful thrombectomy. In multivariable analysis, patients with eTICI 2c3-NoReflow had lower odds of favorable outcome compared with those with eTICI 2c3-CompleteFlow (adjusted odds ratio, 0.31 [95% CI, 0.12-0.77]; P=0.01) and eTICI 2b (adjusted odds ratio, 0.40 [95% CI, 0.17-0.96]; P=0.04) but not unsuccessful thrombectomy (adjusted odds ratio, 1.02 [95% CI, 0.38-2.73]; P=0.97). Patients with eTICI 2c3-NoReflow had similar follow-up infarct volume to unsuccessful thrombectomy (β=-8.26 [95% CI, -27.38 to 10.86]; P=0.40) and eTICI 2b (β=9.38 [95% CI, -7.33 to 26.09]; P=0.27) but had larger infarcts compared with eTICI 2c3-CompleteFlow (β=18.85 [95% CI, 1.16-36.54]; P=0.04).

CONCLUSIONS

When no-reflow occurred, clinical and radiological outcomes in patients with full angiographic recanalization were similar to patients with unsuccessful thrombectomy. Preventing or reversing no-reflow has the potential to augment the clinical benefit of reperfusion treatment in ischemic stroke.

Effectiveness of subtemporal decompression for the management of slit ventricle syndrome

OBJECTIVES

To assess the effectiveness of subtemporal decompression in the management of slit ventricle syndrome.

METHODS

We conducted a retrospective review of all patients with slit ventricle syndrome (SVS) who underwent subtemporal decompression (STD) at our centre between 2010 and 2021. Cases were identified using the hospital database. Medical records for each patient were reviewed, including operative and radiological reports.

RESULTS

Fifteen patients underwent STD for the management of SVS. Median age at time of STD was 9.18 years. Aetiology of hydrocephalus consisted of spinal dysraphism (5), idiopathic (4), post-infectious (1), post-haemorrhagic (3), secondary to tumour (1), and craniofacial anomalies (1). Median age at first shunt insertion was 3.4 months. Median pre-operative period assessed, from initial shunt insertion to STD, was 4.54 (interquartile range [IQR] 3.12-10.47) years. Twelve patients underwent ≥1 shunt revision prior to STD. All patients had a diagnosis of SVS at time of STD. Presenting symptoms, for the admission in which STD was performed, included nausea (9), vomiting (8), lethargy (8), headache (12), irritability (5), and visual disturbances (6). One third underwent shunt revision at the time of STD. Two patients developed post-operative complications requiring further surgery (meningitis requiring shunt revision: 1; wound debridement: 1). Three patients developed uncomplicated post-operative pyrexia, which was managed with antibiotics. Median duration of post-operative follow-up was 5.4 (IQR 1.73-8.54) years. Eleven patients underwent ≥1 shunt related procedure following STD. Wilcoxon signed-rank test demonstrated a significant difference in number of shunt related procedures before (median = 5, IQR 1-8) and after (median = 3, IQR 0-5) STD (Z = -2.083, p = .037). All patients reported subjective symptom improvement post-operatively. Thirteen patients experienced symptom recurrence at a median duration of 10 months post-operatively.

CONCLUSIONS

STD was associated with a reduction in the amount of shunt related procedures required in this group of patients with SVS. Further study is required to confirm this association.

Multidimensional outcomes associated with chronic fatigue over 12 months in youth with emerging mood disorders

BACKGROUND

Complaints of chronic fatigue lasting weeks or longer are common during adolescence. Little is known about factors associated with chronic fatigue in youth with mood disorders or potential sex-specific associations.

METHODS

496 young people (mean age = 18.36-years, SD = 3.22; 69 % female) seeking help for mental healthcare were assessed on psychological symptoms, lifestyle, and sleep at baseline and 12-months later. Fatigue was defined as a score of ≥3 on the somatic subscale of the Somatic and Psychological Health Report. Logistic regression models were used to examine associations between clinical, lifestyle, and related factors and chronic fatigue caseness, including main effects and sex interactions.

RESULTS

Half (52 % [N = 260]) of the sample reported fatigue at both baseline and 12-month follow-up ("chronic fatigue"). Univariately, chronic fatigue cases were more commonly at later clinical stages of mental disorder and had worse mental health, sleep disturbance, and disability at baseline and follow-up. In covariate-adjusted analyses, being a chronic fatigue case was associated with persistently elevated anxiety and, at 12-month follow-up, more disability, weight gain, and shorter sleep duration. In sex-interaction analyses, chronic fatigue in females was associated with longer sleep latency at follow-up (OR = 1.97), but not in males.

CONCLUSION

Chronic fatigue was common and associated with poorer mental health and functioning longitudinally. While there were no sex differences in the rates of chronic fatigue, there were some sex differences in the factors associated with it. Systematic screening and early intervention for chronic fatigue, considering sex-specific factors, may improve multidimensional outcomes in youth with emerging mood disorders.

Textbook outcomes as a novel patient-centric metric to inform carotid revascularization

OBJECTIVE

The recent National Coverage Determination surrounding carotid stenting and shared decision-making has ushered in an era of patient-centric carotid care. However, historical carotid intervention endpoints have lacked patient-centered nuances to inform clinical decisions. Accordingly, we aimed to create a comprehensive novel, patient-centric textbook outcome (TO) to inform treatment paradigms.

METHODS

We developed a novel composite TO for patients who underwent carotid revascularization reflecting a combination of patient-centric outcomes derived from previous patient interviews and the published literature. We defined a TO to include freedom from postprocedural neurologic events, myocardial infarction, cranial nerve injury, return to the operating room, reperfusion syndrome, or access site complications. The endpoint also included discharge on postprocedural day 1, home discharge, and 30-day survival. We measured the risk of a TO vs non-TO among asymptomatic patients undergoing carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), or transfemoral carotid artery stenting (TF-CAS) in the Vascular Quality Initiative (VQI) from 2016 to 2023.

RESULTS

We studied 72,778 patients who underwent carotid revascularization, 70.3% CEA, 21.0% TCAR, and 8.7% TF-CAS. The mean age across all patients was 71.6 ± 8.4 years, 39.9% were female, and 91.7% were White. A TO was achieved in 76.9% of patients, and was 76.7% after CEA, 76.5% after TCAR, and 79.1% after TF-CAS (P < .001). Postprocedural length of stay was 2 days or more in 21.0% of patients, and was 21.1% after CEA, 21.6% after TCAR, and 18.4% after TF-CAS (P < .001). Postprocedural neurologic events occurred in 1.0% of patients after CEA, 1.3% after TCAR, and 1.4% after TF-CAS (P = .037). A sensitivity analysis of the TO that did not include postprocedural length of stay demonstrated a non-TO in 5.9% of patients after CEA, 5.5% after TCAR, and 6.3% after TF-CAS (P = .070). Patients who did not achieve a TO had inferior 5-year survival compared with patients who did have a TO across all three cohorts (log-rank P < .001).

CONCLUSIONS

This novel patient-centric endpoint demonstrated that a substantial percentage of patients fail to achieve a TO in current practice, and that failure to achieve a TO was associated with inferior 5-year survival. These findings are particularly important in light of the recent Medicare mandate for a shared decision-making approach to carotid care delivery and may help to best align patient preferences with procedure type.

Correlating the abdominal drawing in manoeuvre between ultrasound imaging, pressure biofeedback and manual palpation measurements in participants with low back pain: An observational cross-sectional study

BACKGROUND

Physiotherapists have several options to measure lateral abdominal muscle (LAM) activity clinically, including ultrasound imaging (USI), pressure biofeedback units (PBU) and manual palpation scales. However, the concurrent validity of these tools is yet to be examined. Understanding how these tools correlate will help physiotherapists make informed choices about tool selection.

OBJECTIVES

To determine the correlation between the prone PBU test, manual palpation and USI measures (preferential activation, preferential activation modified and transversus abdominis muscle ratios and transversus abdominis slide) for examining the ADIM.

DESIGN

Observational cross-sectional study.

METHOD

58 participants with LBP underwent measurement of LAM activation using the three measurement tools across two sessions (7-14 days apart). Results were analysed using correlation coefficients and tested for statistical significance.

RESULTS/FINDINGS

Reliability of activation measures ranged from moderate to good. Correlations were found between manual palpation, PBU and USI, however, were non-significant after a Holm-Bonferroni correction.

CONCLUSIONS

The findings question the concurrent validity of these tools, suggesting one cannot be used in place of another for measuring LAM activation during the ADIM.

Safety Reporting in Trials on Atrial Fibrillation: An Observational Study of ClinicalTrials.gov Registry and Corresponding Publications

BACKGROUND

Adverse events (AE) in clinical trials should be reported fully and transparently as inconsistent reporting endangers patients and can lead to incorrect conclusions about medical procedures. Atrial fibrillation (AF) is a highly prevalent disease with different therapeutic options available. With an increasing incidence of AF, potential AEs are important factor in the choice of treatment. The aim of our study was to assess the completeness of AE reporting for the registered trials of interventions for AF treatment in a clinical trial registry and the consistency of their reporting in corresponding publications.

METHODS

This was an observational, cross-sectional study of clinical trials of AF registered in ClinicalTrials.gov, as well as of corresponding publications.

FINDINGS

Out of 340 registry items retrieved by our search, 130 items reported on the treatment of AF, and 75 corresponding publications were identified (39.2%) and included in the analysis. Both number of serious AEs (SAE) and other AEs (OAE) as well as the number of patients affected were underreported in corresponding publications when compared with trial registry. For trials reporting nonpharmacological interventions (e.g., medical devices and procedures) there was a higher number of discrepancies in the number of SAEs and the number of patients affected, and information on SAEs or OAEs were more often omitted from publication.

INTERPRETATION

The reporting of AEs in AF trials is inconsistent and incomplete and presents a serious problem for patients' safety. Inadequate reporting raises concerns for the credibility of trials results as well as for clinical practice guidelines and justifies the calls for improvements in reporting and regulations of clinical trials of interventions for AF.

Long-term Prognosis of Athletes With Patellar Tendinopathy Receiving Physical Therapy: Patient-Reported Outcomes at 5-Year Follow-up

BACKGROUND

Patellar tendinopathy (PT) is a highly prevalent injury among jumping athletes. The long-term prognosis of athletes with PT following physical therapy is unknown.

PURPOSE

To assess self-perceived recovery rate and the 5-year change in pain levels, disability, and sports participation, and to explore the prognostic factors associated with self-perceived recovery.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Athletes with PT who were previously enrolled in a randomized trial and received education, load management advice, and exercise therapy instructions at baseline were eligible. An online questionnaire was sent 5 years after inclusion. Self-perceived recovery was assessed by a dichotomized 7-point global rating of change (recovery was defined as "significantly improved" to "completely recovered"). Pain levels during sports (0-10 points) and disability assessed by the Victorian Institute of Sport Assessment-Patellar (VISA-P) score were recorded at baseline and 5 years. Sports participation was categorized into return to performance, return to sport, return to participation, and quitting sports. Nonparametric tests were performed to compare scores at baseline and 5 years. Logistic regression models were used to identify prognostic factors.

RESULTS

Of 76 eligible participants, 58 (76%) responded (mean age, 30 years [SD, 4 years]; 28% female). At a mean follow-up of 5 years, 76% of participants felt recovered. Pain levels during sports (median, 7 points [IQR, 7-8 points] to 2 points [IQR, 1-4 points]) and VISA-P score (median, 57 [IQR, 45-66] to 82 [IQR, 74-97] points) significantly improved from baseline to 5 years (all P < .001). In total, 41 participants (71%) returned to their desired sports (68% to performance and 32% below preinjury level), 12 participants (21%) returned to participation in other sports, and 5 (9%) completely ceased sports participation. Participants who felt unrecovered had higher levels of pain and disability and lower return to performance (all P < .05). No prognostic factors were identified that were associated with self-perceived recovery.

CONCLUSION

Athletes with PT after physical therapy can expect a generally acceptable long-term prognosis. However, almost one-quarter did not feel recovered and perceived worse patient-reported outcomes. Clinicians treating athletes with PT may use these findings to estimate the average prognosis.

COVID-19 Pandemic Impacts on Behavioral and Emotional Health of Young Children With Autism

Objective

To test initial hypotheses that the coronavirus disease 2019 (COVID-19) pandemic was associated with decreases in adaptive behavior and increases in behavioral and emotional problems of children with autism; greater impacts for children who lost specialty services; and greater behavioral and emotional problems for children with autism vs control participants.

Method

Eligible participants (N = 1,158) enrolled in phase 3 of the multisite, case-control Study to Explore Early Development (SEED) before March 31, 2020, were between 2 and 5 years old, and completed follow-up assessments between January and July 2021. Caregivers completed a COVID-19 Impact Assessment Questionnaire, Vineland Adaptive Behavior Scales (VABS), and Child Behavior Checklist (CBCL) for 274 children with autism and 385 control participants.

Results

Mean VABS communication scores of children with autism decreased significantly (mean difference [SD] = -4.2 [10.5]) between prepandemic and pandemic periods, while VABS composite (+2.0 [9.0]), daily living (+5.5 [11.4]), socialization (+2.3 [10.0]), and CBCL (-3.2 [8.4]) scores improved. In contrast, CBCL scores worsened in population control participants (+3.4 [8.8]). Children with autism who missed specialty appointments scored significantly lower on VABS during the pandemic vs children who did not miss appointments (VABS Composite 70.6; 95% CI 68.8-72.4 vs 74.5; 95% CI 71.8-77.2).

Conclusion

While stay-at-home policies of the COVID-19 pandemic may have beneficially impacted daily living skills, socialization, and behavioral and emotional well-being of children with autism, benefits may have occurred at the cost of communication skills. These findings indicate the need for strategies to maintain therapeutic services in future emergency settings.

Diversity & Inclusion Statement

We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. We worked to ensure that the study questionnaires were prepared in an inclusive way. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science.

Mortality due to carbapenem-resistant Acinetobacter baumannii bacteraemia: a 5-year cohort study in intensive care patients

OBJECTIVES

Carbapenem-resistant Acinetobacter baumannii (CRAB) has emerged as a major and difficult-to-treat nosocomial pathogen. This study estimated the mortality associated with CRAB bacteraemia in patients receiving treatment in the intensive care unit. A susceptible-infection counterfactual framework was applied to reflect the potential benefit of improved antimicrobial therapy.

METHODS

A 5-year (2019-2023) cohort study was conducted in a tertiary-care referral hospital in Greece. Competing risks survival analysis methods were applied to estimate excess in-hospital mortality because of CRAB bacteraemia by comparing patients infected by CRAB with those infected by other more susceptible Gram-negative bacteria (GNB).

RESULTS

The cohort comprised 400 intensive care patients with GNB bacteraemia (median age 70 years, 65% man). CRAB was the most common pathogen (43%), followed by Klebsiella pneumoniae (12%), Escherichia coli (11%), and Pseudomonas aeruginosa (10%). Patients with CRAB bacteraemia experienced significantly higher in-hospital mortality at 14 days (35% vs. 21%), 28 days (53% vs. 30%), and overall (74% vs. 52%) than patients with other GNB bacteraemia. Multivariable competing risks regression confirmed that CRAB bacteraemia was independently associated with an increased risk of 28-day inpatient death (cause-specific hazard ratio: 1.80, 95% CI: 1.28-2.54; sub-distribution hazard ratio: 1.84, 95% CI: 1.28-2.62), simultaneously lowering the probability of discharge alive (cause-specific hazard ratio: 0.68, 95% CI: 0.38-1.21; sub-distribution hazard ratio: 0.52, 95% CI: 0.30-0.91). Estimation of the attributable fraction suggested that effective antimicrobial management may result in a relative decrease in the risk of in-hospital mortality by 44% (95% CI: 22-61%) in patients with CRAB bacteraemia.

DISCUSSION

CRAB's detrimental role as a leading cause of increased inpatient mortality and prolongation of hospitalization in intensive care patients was demonstrated. These outcomes could improve substantially if more effective antimicrobial treatment becomes available. Nevertheless, considering that CRAB is predominantly a hospital-acquired pathogen, efforts should always be directed towards preventing nosocomial transmission.

Factors and outcomes associated with National Institutes of Health stroke scale scores in acute ischemic stroke patients undergoing thrombectomy in United States

BACKGROUND AND PURPOSE

The National Institutes of Health Stroke Scale (NIHSS) is the standard for assessing neurological deficits in acute ischemic stroke patients undergoing thrombectomy. However, data on NIHSS scores in patients undergoing thrombectomy at national-level studies in the United States are lacking.

METHODS

Acute ischemic stroke patients admitted between 2018 and 2021 were identified using ICD-10-CM codes from the Nationwide In-patient Sample, with NIHSS scores categorized into specific strata (0-9, 10-19, 20-29, 30-42). We analyzed the effect of NIHSS scores on in-hospital mortality, routine discharge without palliative care (based on discharge disposition), and length and costs of hospitalization after adjusting for potential confounders.

RESULTS

The NIHSS score strata among 108,990 acute ischemic stroke patients undergoing thrombectomy were: NIHSS score 0-9 (29.6 %), 10-19 (40.6 %), 20-29 (26.4 %), and 30-42 (3.4 %). Patients in the Midwest and West regions (adjusted odds ratio [adjusted OR] = 1.51, p = 0.002 and adjusted OR = 1.63, p < 0.001, respectively), those treated in rural hospitals (adjusted OR = 1.35, p = 0.009) and those who were self-pay (adjusted OR = 1.51, p = 0.048) had higher odds of being in higher NIHSS score strata. Patients in higher NIHSS score strata (NIHSS score 10-19, 20-29, and 30-42 had significantly lower odds of discharge home without palliative care (adjusted OR= 0.50, 0.32, and 0.22 respectively, all p < 0.001) and higher odds of in-hospital mortality (adjusted OR = 1.51, 2.30, and 3.80 respectively, all p < 0.001) compared to those in NIHSS score strata of 0-9. Patients in higher NIHSS score strata had significantly higher hospital stays and higher hospitalization costs.

CONCLUSIONS

We provide a comprehensive national-level analysis of NIHSS scores in acute ischemic stroke patients undergoing thrombectomy which may assist in understanding variations in outcomes and resource utilizations in United States.

Abdominal muscles' thickness and bladder neck position in regular runners and controls: A comparative ultrasonography study

AIM

The aim of the present study was to compare and quantify with transabdominal ultrasound the IRD, the thickness of the external oblique (EO), internal oblique (IO), transversus abdominis (TrA), rectus anterior (RA) and the location of the bladder neck between runners and controls at rest and during response to different exercises.

METHODS

A total of 38 women, aged 18-45 years, were recruited from a private rehabilitation center specializing in sports health, and divided into two groups: runners (n = 19) and sedentary women (n = 19). Thickness measurements, using suprapubic ultrasongraphy in B-Mode, of the EO, IO, TrA and RA muscles were taken at rest and during active contraction. Location of the bladder neck at rest and during pelvic floor muscle (PFM) contraction was taken with the transducer located suprapubically in M-Mode.

RESULTS

There were no significant differences in EO TrA or RA muscle thickness at rest and during muscle contraction between runners and controls. For the IO muscle, significant differences were observed during ASLR, with runners showing greater muscle thickness (p = 0.032). Bladder neck displacement during a voluntary PFM contraction demonstrated statistically larger cranial movement for the runners of mean 0.76 ± 0.31 cm than mean 0.40 ± 0.26 cm for the sedentary group (p = 0.001).

CONCLUSIONS

regular running is associated with increased thickness of the IO during ASLR, and significantly greater cranial bladder neck displacement during PFM contraction.

Lessons from a Pilot Study of a Culturally Tailored Financial Well-Being Intervention Among Latino Family Caregivers

Financial strain disproportionally affects the growing population of Latino family caregivers. This pilot study aimed to test the feasibility of a culturally tailored psychoeducational intervention for Latino caregivers designed to reduce financial strain by improving resourcefulness and self-efficacy. Feasibility was assessed according to participant demands, ability to deliver the intervention, and preliminary efficacy. From May 2022 to September 2023, Confidently Navigating Financial Decisions and Enhancing Financial Wellbeing in Dementia Caregiving (CONFIDENCE) was administered to 69 caregivers over 11 cohorts in a community setting. Caregivers attended an average of 3.13 (SD = 0.17) of five sessions. Eligible caregivers were given the option to participate in a single-arm pre- and post-test study. Results from N = 20 caregivers indicated reduced levels of financial strain 2 months post-intervention (p-value = .013). Findings also showed improvements resourcefulness and self-efficacy. Although CONFIDENCE appears feasible to deliver and may affect desired outcomes, future studies should reduce intervention demands to improve attendance.Trial RegistrationThis trial is registered at ClinicalTrials.gov (NCT05292248).

The role of peripheral perfusion index in predicting biphasic reactions in anaphylaxis patients

BACKGROUND/AIM

Anaphylaxis is a rapidly onset, life-threatening hypersensitivity reaction, and in some patients, a biphasic reaction may develop following initial treatment. This study aims to investigate the prognostic value of the peripheral perfusion index (PPI) in predicting biphasic reactions among patients presenting to the emergency department with anaphylaxis.

MATERIAL AND METHODS

The study is prospective and single-centered. A total of 104 patients aged 18 years and older, diagnosed with anaphylaxis in the emergency department, were included. PPI values, along with other vital signs, were measured at 0, 10, 20, and 30 min, as well as after symptom resolution. All patients were observed for a minimum of 6 h to monitor for the development of biphasic reactions.

RESULTS

The median PPI value at the 0-min mark was 2.20 (IQR, 1.52-3.67), while the median PPI value after symptom resolution was 4.20 (IQR, 3.10-6.35). A biphasic reaction occurred in 10.6 % of patients. Among patients who developed a biphasic reaction, PPI values at 0, 10, 20, and 30 min were significantly lower compared to those who did not (p < 0.05). In ROC analysis, a PPI cutoff of ≤2.17 for predicting biphasic reactions yielded 57 % sensitivity and 91 % specificity (AUC = 0.75).

CONCLUSION

PPI may serve as an accessible and cost-effective test in emergency departments for continuous monitoring of patients diagnosed with anaphylaxis, allowing for assessment of treatment response, early detection of biphasic reactions, and risk evaluation.

Central/mixed venous oxygen saturation and lactate levels might be of limited use as physiologic transfusion triggers in cardiac surgery: Results of a retrospective analysis

BACKGROUND

Current guidelines differ in their recommendations regarding the use of physiologic transfusion triggers to guide transfusion practice. Data on the interaction between haemoglobin (Hb) and physiologic transfusion triggers, or their response to packed red blood cell (pRBC) transfusions are limited.

OBJECTIVES

This study aimed to evaluate the interactions between Hb, mixed/central venous oxygen saturation (SvO 2 ) and lactate levels as well as their changes (ΔSvO 2 , Δlactate) in response to pRBC transfusion in cardiac surgery patients.

DESIGN

Retrospective exploratory data analysis.

SETTING

A 22-bed intensive care unit (ICU) at a single tertiary academic centre and university hospital in Austria.

PATIENTS

Adult (age ≥ 18 years) patients who underwent cardiac surgery.

MAIN OUTCOME MEASURES

Pearson correlation coefficients ( r ) and coefficients of determination ( r2 ) between Hb, mixed/central venous oxygen saturation (SvO 2 ), and lactate levels. Pearson correlation coefficients ( r ) and coefficients of determination ( r2 ) between ΔSvO 2 , Δlactate and pretransfusion Hb.

RESULTS

A total of 5025 cardiac surgery patients, in whom 20 542 blood gas analyses were performed, were included in the final analysis. Correlations between Hb levels and SvO 2 ( r2  = 0.026, P  < 0.001) and between Hb and lactate levels ( r2  = 0.001, P  < 0.001) were statistically significant but weak overall. No correlations were found between ΔSvO 2 ( r2  = 0.002, P  = 0.13) or Δlactate ( r2  = 0.003, P  = 0.087) and pretransfusion Hb levels.

CONCLUSIONS

Hb, SvO 2 and lactate levels were only weakly correlated with each other, and changes in SvO 2 and lactate levels in response to pRBC transfusion did not correlate with pretransfusion Hb. Our findings question the usefulness of SvO 2 and lactate levels as physiologic transfusion triggers to guide transfusion practice in cardiac surgery patients.

TRIAL REGISTRATION

Johannes Kepler University Ethics Committee Study Reference Number 1063/2023.

Faecal mucoprotein MUC2 is decreased in multiple sclerosis and is associated with mucin degrading bacteria

BACKGROUND

The gut microbiome is altered in MS and may contribute to disease by disrupting the intestinal barrier. The colonic mucus barrier, which is primarily composed of mucin protein 2 (MUC2), plays a crucial role in providing a barrier between colonic epithelial cells and the microbiome. Disruption of intestinal epithelial and mucus barriers has been reported in inflammatory bowel disease (IBD) and Parkinson's disease (PD) but has not been studied in the context of the microbiome in multiple sclerosis (MS).

METHODS

We investigated the epithelial tight junction protein zonulin occludins 1 (ZO-1), mucus protein MUC2, inflammatory stool markers (calprotectin), and gut microbiota composition in a cohort of subjects with relapsing and progressive MS.

FINDINGS

MUC2 was decreased in stool of subjects with both relapsing and progressive MS. ZO-1 was elevated in the serum of subjects with progressive MS but was not altered in the stool. Inflammatory markers typically elevated in IBD and PD, including calprotectin, were not altered in MS stool, suggesting disease specificity of altered gut physiology in MS. Microbiota with known mucus degrading capacity were elevated in the stool of subjects with MS and negatively correlated with mucus protein levels.

INTERPRETATION

Taken together, these findings suggest reduced gut barrier function in MS which is linked to increased mucin degrading bacteria.

FUNDING

This work was supported by grants from the National MS Society, the NIH/NINDS, the Nancy Davis Race to Erase MS Young Investigator Award, the Water Cove Charitable Foundation, and the Clara E. and John H. Ware Jr.

FOUNDATION

Surgical smoke-related occupational injuries among medical professionals in the operating room

ObjectiveThe use of energy devices during surgery can cause the spread of surgical smoke into the operating room. The concentration of smoke particles during laparoscopic surgery is higher than that during open surgery. This study aimed to quantify polycyclic aromatic hydrocarbons during laparoscopic surgery and evaluate the carcinogenic risks to healthcare workers, as the current relevant data are insufficient.MethodsThis prospective observational study collected and classified surgical smoke generated during laparoscopic surgery. Quantitative and qualitative analyses of polycyclic aromatic hydrocarbons were performed using gas chromatography-mass spectrometry.ResultsMultiple types of polycyclic aromatic hydrocarbons were generated during laparoscopic surgery. The polycyclic aromatic hydrocarbon concentrations remained below the carcinogenic risk levels in both laparoscopic liver cancer surgery and rectal cancer resection procedures.ConclusionThe deposition pattern and concentration of polycyclic aromatic hydrocarbons generated during laparoscopic liver and rectal cancer resection surgeries in the human respiratory tract are different. The potential toxicity of polycyclic aromatic hydrocarbons in the smoke to the health of healthcare workers should not be ignored.

Associations of high-density lipoprotein cholesterol, particles and subspecies with the risk of hypertension: findings from the PREVEND prospective study

OBJECTIVE

The prospective associations of high-density lipoprotein cholesterol (HDL-C), HDL particle (HDL-P) and subspecies concentrations with the risk of hypertension are uncertain. We aimed to evaluate the associations of HDL parameters with incident hypertension risk and their interplay with alcohol consumption in the PREVEND study.

METHODS

HDL parameters as measured by nuclear magnetic resonance spectroscopy and self-reported alcohol consumption were assessed in 3263 participants (mean age, 49 years; 45.8% males) without a history of hypertension at baseline. Multivariable-adjusted hazard ratios (HRs) with 95% CIs for hypertension per 1 standard deviation increment in HDL parameters were calculated.

RESULTS

During a median follow-up of 7.2 years, 825 participants developed hypertension. In analysis adjusted for several potential confounders, including alcohol consumption, there were inverse associations of HDL-C, HDL-P, medium HDL, HDL size, H3P and H4P with hypertension risk: HRs [95% confidence interval (CI) of 0.88 (0.81-0.97), 0.92 (0.86-0.99), 0.86 (0.80-0.93), 0.89 (0.82-0.98), 0.92 (0.85-0.98), and 0.87 (0.81-0.94), respectively]. Sex or alcohol consumption did not modify the associations of HDL parameters with hypertension risk. Compared with abstainers, the multivariable adjusted HRs (95% CI) of hypertension for occasional to light, moderate and heavy alcohol consumers were 0.84 (0.70-1.00), 0.83 (0.68-1.02), and 0.97 (0.69-1.37), respectively; the associations persisted on further adjustment for HDL parameters.

CONCLUSIONS

There are inverse associations of HDL-C, HDL-P, medium HDL, HDL size, H3P and H4P with hypertension risk, which are not confounded or modified by alcohol consumption. Light and moderate alcohol consumption is modestly and inversely associated with hypertension risk, independently of HDL parameters.

All are not created equal: Method descriptions in an epidemiology publication differ among media summaries - A case study comparison

It is common to see mass media headlines about health-related topics in traditional and online news outlets, as well as on social media platforms. What a consumer might not realize is that often these headlines are a distillation of results reported in epidemiologic publications. Journalists make decisions about what information to include and exclude, hopefully without compromising the main conclusions. In this exercise, sixty-three media articles that summarized one peer-reviewed journal publication (Zhang et al., 2021) describing results from a cohort study on coffee and tea consumption and risk of stroke and dementia were compared to determine the consistency of details among them. The most heterogeneity was observed in whether articles compared results with other literature. There was some variation in inclusion of a measure of frequency within the study population, and in details describing measurement of exposure. However, most of the articles were consistent in either including or excluding other methodological details in the main text. The results of the present comparison have implications for readers, researchers, and journalists. Readers must know that media summaries of peer reviewed studies are just that - summaries. It is likely that some information from the original source is not represented by the article, and that additional information might be necessary to craft an informed opinion on a given topic.

Increasing incidences of acetabular, pelvic, and proximal femur fractures in The Netherlands

PURPOSE

This study aims to investigate incidence rates of acetabular, pelvic, and proximal femur fractures in The Netherlands over a 10-year period (2012-2022). With an aging population, understanding trends in these osteoporotic fractures is essential for improving patient outcomes and guiding healthcare strategies.

METHODS

A retrospective cohort study was conducted using data from two national databases, forming a 'hospitalised' and an 'all patients' cohort. The study population included patients diagnosed with acetabular, pelvic, and proximal femur fractures in The Netherlands during the study period. Incidence rates were calculated per 100,000 person-years and linear regression was used to assess temporal trends. Age-adjustments were performed using Dutch population data from the Central Bureau of Statistics (CBS). Comparative analyses between the two cohorts were conducted to identify discrepancies.

RESULTS

A total of 283,991 patients were identified (12,020 acetabular, 70,595 pelvic and 201,376 proximal femur fractures). Of these patients, 159,563 were hospitalised (7123 acetabular, 24,192 pelvic, and 128,252 proximal femur fractures). Incidence rates of acetabular fractures increased by 26 % (hospitalised) and 98 % (all patients), while pelvic fractures showed stagnation in hospitalised patients (-0.13 %) but a 44 % rise in all patients. Proximal femur fractures increased by 5 % (hospitalised) and 15 % (all patients). Significant differences between the databases were noted across all fracture types.

CONCLUSION

The incidence of acetabular, pelvic, and proximal femur fractures has significantly increased in the last decade, most notably in acetabular and pelvic fractures. Furthermore, a shift toward out-patient treatment of acetabular and pelvic fractures was found. These findings highlight the need for improved fracture prevention and out-patient management strategies, while also underscoring the need for a nationwide registration for these injuries.

Associations of protein intake with the risk of fractures: A prospective cohort study of UK biobank participants

PURPOSE

To evaluate the associations between protein intake and fractures risk in a large population-based cohort.

METHODS

We conducted a prospective population-based study of UK Biobank. Participants aged 40-69 who completed the Oxford WebQ dietary questionnaire at least once were included. Exposures were percentage of energy provided by protein and its components (animal and vegetable protein). Participants were categorized into quintiles based on these exposures. The primary outcome was composite fracture, and secondary outcomes included osteoporotic and hip fractures, defined by ICD-10 codes. We used Cox proportional hazard models and restricted cubic splines (RCS) to assess the association between exposure and outcomes, as well as their dose-response relationships.

RESULTS

This study included 132,807 participants (mean [SD] age, 56.8 [8.0] years; 68,769 [51.8 %] female). During a median follow-up of 12.4 years, 6,673 composite fractures, 4,496 osteoporotic fractures and 930 hip fractures occurred. Regarding protein intake, compared to the lowest quintile (Q1), individuals in the highest quintile (Q5) had significantly lower risks of composite fracture (HR 0.82, 95 % CI 0.75-0.90), osteoporotic fracture (HR 0.81, 95 % CI 0.72-0.91) and hip fracture (HR 0.63, 95 % CI 0.49-0.82). Similar results were observed for animal and vegetable protein intake. RCS revealed a negative linear dose-response relationship between protein intake and fractures risk.

CONCLUSION

Increased protein intake can significantly reduce the risk of fractures and may serve as an important dietary strategy for promoting bone health.

Associations of Bronchopulmonary Dysplasia and Infection with School-Age Brain Development in Children Born Preterm

OBJECTIVE

To determine the association of bronchopulmonary dysplasia (BPD) and culture-positive infection with neurodevelopment and white matter maturation at 8 years of age in children born preterm.

STUDY DESIGN

Prospective cohort study of 164 children born at 24-32 weeks of gestation followed to 8 years of age (89 male, median [IQR] age: 8.24 [8.07-8.58] years). At age 8, IQ (Weschler Abbreviated Scale of Intelligence, second Ed), working memory (Wechsler Intelligence Scale for Children, fifth Ed), visual-motor (Beery-Buktenica Developmental Test of Visual-Motor Integration sixth Ed), and motor outcomes (Movement Assessment Battery for Children-2) were assessed. Diffusion tensor imaging and tract-based spatial statistics were used to assess fractional anisotropy (FA).

RESULTS

Fifty of 164 children had BPD and 72/164 had culture-positive infection. At 8 years, BPD was associated with a 9.8-point decrease in motor (CI -17.9 to -1.8, P = .02) and 6.0-point decrease in visual-motor scores (CI -10.5 to -1.5, P = .009), whereas infection was associated with a 6.3-point decrease in IQ (CI -12.3 to -0.3, P = .04), after adjusting for gestational age and white matter injury volume. BPD was associated with left hemisphere-dominant FA reductions, which were associated with worse motor (P = .000006) and visual-motor (P = .00005) outcomes, whereas infection was associated with bilateral FA reductions, which were associated with lower IQ scores (P = .03) and poorer working memory (P = .01) at 8 years.

CONCLUSIONS

This cohort study of children born very preterm suggests that BPD and culture-positive infection are distinctly associated with impaired white-matter development and poor neurodevelopmental outcomes. These findings imply neonatal illnesses impact the brain nonuniformly, suggesting opportunities for targeted intervention.

Clinical indicators for predicting physical activity levels in long-term COVID-19: Insights from physical exertion and oxygen saturation

INTRODUCTION

Long COVID-19 syndrome, affecting approximately 80% of adults after SARS-CoV-2 infection, often reduces physical activity due to fatigue and breathing difficulties, leading to impaired physical function and lung capacity. This cross-sectional study examined predictive variables such as physical exertion, heart rate, and oxygen saturation to assess physical activity levels in adults with long COVID-19 syndrome.

METHODS

We recruited 34 adults aged 19-55 with a COVID-19 history and assigned them to the long-COVID-19 and control group. They were evaluated using the 6-Minute Walk Test, modified Borg Dyspnoea Scale, heart rate, maximum oxygen uptake, and the IPAQ-Short Form for daily physical activity assessment.

RESULTS

The Borg Dyspnoea Scale, maximum oxygen uptake, and resting oxygen saturation emerged as crucial indicators for predicting physical activity levels in post-COVID-19 individuals. Compared to these variables, resting and post-exercise heart rates were statistically insignificant.

CONCLUSION

Physical exertion and oxygen saturation are potentially crucial predictors of physical activity levels in individuals with persistent post-COVID-19 symptoms. These findings offer valuable insights for managing long COVID-19 syndrome, emphasising the need for tailored interventions to address reduced physical activity levels in affected individuals.

Prevalence of Metabolic-Associated Steatotic Liver Disease in Patients With Primary Aldosteronism

OBJECTIVE

To assess the prevalence of metabolic associated steatotic liver disease (MASLD) in patients with primary aldosteronism (PA) compared to benign adrenal adenomas, and to evaluate the impact of hormonal excess in inducing MASLD.

DESIGN

Single-centre retrospective study.

METHODS

Hepatic steatosis was assessed by liver/spleen (L/S) ratio from unenhanced abdomen computed tomography images (reference value < 1.1) in a cohort of 41 patients with PA without cortisol cosecretion, 20 unilateral (uPA) and 21 bilateral (BPA), 50 with nonfunctioning adrenal incidentalomas (NF-AI), 48 with mild autonomous cortisol secretion (MACS) and 10 with adrenal Cushing Syndrome (CS).

RESULTS

Hepatic steatosis was increased in patients with PA at diagnosis: L/S ratio was lower in PA than NF-AI (1.1 vs. 1.25, p < 0.001) and MACS (1.1 vs. 1.21, p 0.007), but was similar to adrenal CS (1.1 vs. 1.15, p = 0.147). A improvement in L/S ratio after medical or surgical treatment was observed in PA patients, resulting in reduced liver steatosis. MASLD prevalence was higher in PA compared to MACS (49% vs. 25%, p < 0.05) and NF-AI (49% vs. 14%, p < 0.001), but similar to CS (49% vs. 45%, p = 0.61). uPA patients had higher MASLD prevalence compared to BPA group 71% (53%-89%) versus 25% (7%-43%).

CONCLUSIONS

Prevalence of MASLD was increased in PA (higher in uPA than BPA) compared to MACS and NFAI, and similar to adrenal CS.

SURGE-ahead postoperative delirium prediction: external validation and open-source library

PURPOSE

In this prospective external validation study, we examined the performance of the Supporting SURgery with GEriatric Co-Management and AI (SURGE-Ahead) postoperative delirium (POD) prediction algorithm. SURGE-Ahead is a collaborative project that aims to develop a clinical decision support system that uses predictive models to support geriatric co-management in surgical wards. Delirium is a common complication in older adults after surgery, leading to poor outcomes and increased healthcare costs. Early and accurate prediction of POD is crucial for timely intervention and prevention strategies.

METHODS

The SURGE-Ahead algorithm utilizes a linear support vector machine model with a comprehensive set of 15 clinical and demographic features. In our validation, we analyzed 173 study participants, of which 50 developed POD.

RESULTS

The study found that the SURGE-Ahead POD prediction algorithm yielded state-of-the-art performance, using only preoperative data, with a receiver operating characteristics area under the curve of 0.86. In addition, the SURGE-Ahead algorithm exhibited good calibration as shown by a Brier Score of 0.14. The algorithm is openly available on GitHub, facilitating its implementation and adaptation to different surgical settings.

CONCLUSION

Our findings contribute to the development of reliable POD prediction tools, ultimately supporting the improvement of patient care in hospitalized older adults.

Temporal trends and risk factors associated with stroke mortality among cancer patients

BACKGROUND

This study aimed to explore the risk of stroke death (SD) in cancer patients, estimate rates, and identify risk factors associated with SD.

METHODS

In this retrospective study, we used the 17 National Cancer Institute Surveillance, Epidemiology, and End Results registries (2000-2020). A total of 5,922,533 patients diagnosed with their first primary cancer were included. The primary outcome was the standardized mortality ratio (SMR) of SD in cancer patients. Secondary outcomes included SD incidence rates and risk factors. Rates were calculated per 100,000 persons with the annual percentage change (APC).

RESULTS

Among included patients, 56,686 (2.0 %) died due to stroke. Compared to the general population, younger patients (≤39 years) (SMR: 2.31) and patients receiving no treatment (SMR: 1.36) had the highest risk. Cancer types with the fastest-declining SD rates were in the male genital (APC: -13.9 %) and breast (APC: -11.8 %). Older age (hazard ratio [HR]: 1.11, p < 0.001), male sex (HR: 1.06, p < 0.001), and non-white race (HR: 1.13, p < 0.001) were associated with increased risk of SD. Cancers of the nervous system (HR: 3.42, p < 0.001), respiratory (HR: 1.38, p < 0.001), and head and neck (HR: 1.37, p < 0.001) had higher risk of SD vs. breast cancer. Patients with primary chemotherapy (HR: 0.69, p < 0.001) and radiotherapy (HR: 0.69, p < 0.001) demonstrated less risk vs. those without treatment.

CONCLUSION

SD has declined over the years for both sexes and all cancer types. Older age, non-white race, and certain cancers (nervous system, respiratory system, and head and neck) pose significant risks for SD.

Survival analysis in adult Burkitt Lymphoma in Colombia according to HIV status

INTRODUCTION

Burkitt lymphoma is a highly aggressive Non-Hodgkin Lymphoma, is considered a rare tumor, accounts for only 1-2 % of adult lymphomas in North America. The two-year Overall survival rates was reported between 67 % and 84 %. Statistics from developing countries comes mainly from children studies in Africa where Burkitt Lymphoma is endemic. In Latin American countries, information about survival in adult population is scarce with limited number of patients and poor survival outcomes mainly in HIV associated Burkitt Lymphoma. The aim of this study is to evaluate survival in adults' patients with BL, and HIV status in a Colombian cohort.

MATERIALS AND METHODS

A retrospective cohort study was conducted to determine the demographic characteristics, treatment, and survival of adult Burkitt Lymphoma patients in Colombia. The study included adult patients diagnosed with Burkitt Lymphoma between 2004 and 2023, and calculate Overall survival and progression free survival of the population, and according to HIV status RESULTS: 83 patients were included for analysis with 49 (59 %) patients with a sporadic variant and 34 (41 %) with an immunodeficiency-associated variant. The median age at diagnosis was 40 years, IQR (30 - 52), The 36-months OS was 49.9 % (95 % CI; 39.6 - 62.9 %)), and 36-months PFS was 51.5 % (95 % CI¸41.5 - 64.5). For HIV patients 36-months OS was 41 % (95 % CI; 26.7 - 62.7 %) and 59.2 % (95 % CI; 45.8 - 76.6 %) HIV negative HR 1.72 (95 % CI; 0.93 - 1.19 (p = 0.08).

CONCLUSION

this study suggests an OS survival inferior than reported for developed countries with inferior survival rates in HIV patients.

Haemostatic changes detected by thromboelastography in chronic kidney disease: A systematic review and meta-analysis

Haemostasis in Chronic Kidney Disease (CKD) is complex, with patients experiencing both thrombotic and haemorrhagic risks. Current therapies, such as dialysis and blood transfusions, often rely on clinical judgment, which may not fully address these haemostatic abnormalities. This systematic review and meta-analysis aimed to determine whether Thromboelastography (TEG) offers a better ability to assess coagulation abnormalities in CKD compared to standard coagulation tests like activated partial thromboplastin time (aPTT), and prothrombin time (PT). A search across five databases identified 10 studies comparing TEG parameters in CKD patients versus healthy controls. TEG detected hypercoagulability in CKD, with significant reductions in Kinetics Time (P = 0.04), increases in Alpha angles (P = 0.02), and elevated Maximum Amplitude values (P = 0.0006). However, Reaction Time (P = 0.43) and Lysis 30 (P = 0.28) showed no significant differences. Standard coagulation tests, including aPTT and PT, also showed no significant differences between groups (P = 0.30 and P = 1.00), suggesting their limitations in detecting the complex haemostatic changes in CKD. Platelet counts were lower in CKD patients (P = 0.0009) but remained within normal ranges. Elevated fibrinogen levels (P = 0.003), linked to chronic inflammation, indicated a prothrombotic profile. Despite high heterogeneity in some parameters due to variability in CKD stages and treatment types, TEG demonstrates a more detailed assessment of haemostatic changes in CKD, suggesting its potential as a predictive tool for managing coagulation abnormalities.

Predictors of preschool attention-deficit/hyperactivity disorder diagnosis: a population-based study using national registers

BACKGROUND

The diagnosis of attention-deficit/hyperactivity disorder (ADHD) in preschool years (before age 6 years) is a marker of severity and poor prognosis. This study investigated a broad range of predictors of ADHD diagnosis during preschool age.

METHODS

Population-based cohort study using Swedish registers. The final sample consisted of all children born in Sweden between 2001 and 2007 who could be linked to both of their biological parents, excluding those who died or emigrated (n = 631,695). Follow-up was completed December 31, 2013. Cox proportional-hazards models for survival analysis were used to identify the predictors that increased the risk of receiving a clinical diagnosis of ADHD from 3 to 5 years. Hazard ratios (HR) with 95% confidence intervals (CI) were presented for each of the 41 selected predictors covering early-onset psychiatric comorbidities, nonpsychiatric medical conditions, parental history and perinatal factors.

RESULTS

At the end of follow-up, 1,686 preschoolers (2.7% of the whole sample) had received a diagnosis of ADHD. We found that 39 out of 41 predictors were associated with increased risk of a later diagnosis of preschool ADHD. Novel associations with preschool ADHD diagnosis were found for gastroesophageal reflux disease (HR = 3.48), premature contractions during pregnancy (HR = 2.03), and criminal conviction history from any parent (HR = 2.14).

CONCLUSIONS

A large number of novel and well-established predictors of preschool ADHD diagnosis were identified. This broad set of early predictors may direct future clinical research and assist in early identification of preschool ADHD.

Neural Mechanisms of Poststroke Urinary Incontinence: Results From an fMRI Study

BACKGROUND

Urinary incontinence after a stroke significantly affects patient outcomes and quality of life. It is commonly associated with uninhibited detrusor contractions, but the underlying neural mechanisms remain poorly understood. This study aimed to explore the brain activity patterns associated with volitional and involuntary bladder contractions in stroke survivors.

METHODS

This cohort study enrolled 15 stroke survivors with documented urinary incontinence and 9 healthy controls. Participants underwent simultaneous blood oxygen level-dependent functional magnetic resonance imaging of the brain and urodynamics, capturing 25 involuntary and 23 volitional bladder emptying events in patients with stroke and 35 volitional voiding events in healthy individuals. We used general linear modeling in functional magnetic resonance imaging analysis to discern neural activity patterns during these events and in the phases leading up to them, aiming to identify neural mechanisms underlying involuntary versus volitional urinary control. Statistical significance for neuroimaging analyses was set at P<0.005 with a minimum cluster size of 25 voxels.

RESULTS

During volitional emptying events, both healthy controls and stroke survivors exhibited increases in activation in regions implicated in sensorimotor control and executive decision-making, such as the brainstem, cingulate cortex, prefrontal cortex, and motor areas. In contrast, involuntary emptying events were associated with minimal changes in brain activity, suggesting minimal cortical involvement. Bladder filling preceding volitional contractions was associated with activity in the salience network (insula, anterior cingulate gyrus) in stroke survivors and healthy controls. Conversely, although there was an increase in overall blood oxygen level-dependent signal, activation of the salience network was conspicuously absent during bladder filling preceding involuntary contractions.

CONCLUSIONS

The findings suggest that the salience network plays an important role in maintaining urinary continence in stroke survivors. The inability to activate the salience network may underpin the pathophysiology of poststroke urinary incontinence. Interventions aimed at modulating this network could potentially ameliorate lower urinary tract symptoms in this patient population.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05301335.

Inefficient impact absorption and reduced shock attenuation in female runners with stress urinary incontinence

Running has been associated with stress urinary incontinence (SUI) in female runners, with prevalence reaching 44 %. Surprisingly, many of these runners exhibit pelvic floor muscle strength and endurance that is similar or even greater compared to continent runners. Therefore, this study aimed to investigate other potential mechanisms associated with SUI in female runners, focusing on impact absorption and muscle function. Thirty-two female runners were divided into two groups: runners with and without SUI. Pelvic floor muscle function was assessed using the Peritron®, whereas the maximum isometric strength of the trunk and lower limb muscles was measured using a portable handheld dynamometer. Kinetic data, including vertical ground reaction force (GRF), energy absorption at the ankle, knee, and hip joints, and shock attenuation between the tibia and femur, were collected using a 3-D motion analysis system on an instrumented treadmill during running. Group comparisons were performed using the Student t-test and Mann-Whitney at a 0.05 significance level. There were no differences in pelvic floor, trunk and lower limb muscle function between groups. Despite similar vertical GRF, runners with SUI exhibited lower energy absorption at the ankle (p = 0.019; d = 0.54), higher energy absorption at the hip (p < 0.001; d = 0.85) and reduced shock attenuation between the tibia and femur (p = 0.038; d = 0.80) during running compared to continent runners. Runners with SUI differed in energy absorption and shock attenuation patterns, particularly at the hip and ankle. These findings suggest that incontinent runners exhibit inefficient energy absorption throughout the kinetic chain experiencing greater pelvic demands.

Quantitative evaluation of early antifibrinolytic therapy on 90-day mortality in elderly patients with acute traumatic subdural hematoma: insights from a prospective cohort study

BACKGROUND AND OBJECTIVES

Acute traumatic subdural hematomas (aTSDH) represent a frequent and critical neurosurgical emergency, associated with a significant risk of mortality. Elderly patients with symptomatic aTSDH may benefit from early antifibrinolytic therapy (EAFT). We aim to investigate whether EAFT can improve clinical outcomes in aTSDH patients and to explore the factors influencing mortality, using data from a nationwide, multicenter, prospective cohort study.

METHODS

Multicenter, prospective cohort study at 30 trauma centers from 2023 to 2024 enrolled 963 patients diagnosed aTSDH. After screening, 297 patients aged 60 years or older met inclusion criteria. The primary outcome was 90-day mortality. Secondary outcomes included vascular occlusion, brain rebleeding, sepsis, gastrointestinal bleeding, and renal failure.

RESULTS

A total of 297 aTSDH patients were identified, of whom 195 received EAFT, and 102 were in the control group. After propensity score matching (PSM), 80 patients in each group were compared. There were no significant differences in 90-day mortality (before PSM, P = 0.439; after PSM, P = 0.828). The difference between the two group in the incidence of brain rebleeding, sepsis, gastrointestinal bleeding, and renal failure were similar before and after PSM. The EAFT group had a significantly higher incidence of vascular occlusion compared to the control group (before PSM, P = 0.014; after PSM, P = 0.027). In multivariate logistic regression (odds ratio [95% confidence interval]), increased 90-day mortality was predicted by larger hematoma volume (2.329 [1.123-4.830], P = 0.023) and greater midline shift (2.251 [1.065-4.755], P = 0.034). Sensitivity analysis indicated that there was heterogeneity in the treatment effects between the two groups across different midline shift categories (before PSM, P = 0.012; after PSM, P = 0.043).

CONCLUSION

EAFT may not significantly reduce mortality in elderly aTSDH patients and could potentially increase the risk of vascular occlusion. Therefore, its use in this population should be approached with caution, carefully assessing the potential risks.

Expectations about the benefit of exercise, not surgery, are associated with future pain and physical function in patients with non-specific low back pain

Beliefs can affect perceived harms and benefits of a treatment. The purpose of this study was to assess the relationship between beliefs about exercise and surgery effectiveness and pain interference and physical function in patients with non-specific low back pain. This was a cohort of 629 pooled clinical trial participants receiving non-pharmacological pain management. Participants either agreed (somewhat or completely) or disagreed that surgery would be beneficial or that exercise would make their symptoms worse. Those that agreed were categorized as having high expectations about the treatment. The influence of high expectations on short-term (6-week) and long-term (6-month) PROMIS Pain Interference scores was modeled with generalized linear (Gaussian) models. In a subset of 510 patients, the same analysis was conducted using PROMIS Physical function scores. The cohort was 28.8% female, mean(SD) age of 33.4(8.3) years and 83.1% active-duty. In all 67.1% had low expectations of exercise and 11.0% had high expecations of surgery. High expectations for surgery were not a significant predictor of pain interference or physical function. High expectations for exercise predicted lower pain interference (ß=-2.146, 95CI -3.366, -0.926; P<0.001) and higher physical function (ß=1.807, 95CI 0.586, 3.027; P=0.004) at 6 weeks and 6 months. High expectations for exercise were uncommon (about 33%) but associated with better outcomes out to six months. One in 10 patients had high expectations for surgery but this was not associated with outcomes. A better understanding of treatment expectations may present opportunities to improve engagement and education strategies for patients with low back pain. PERSPECTIVE: The results of this study show that exercise expectations predict outcomes for those that get exercise, but expectations about treatment in general may not be as helpful as asking specifically about a given treatment. These finding can potentially help clinicians better understand how to improve patient engagement and education strategies.

Association Between Severity of COVID-19 and Social Determinants of Health with Adverse Pregnancy Outcomes in a Study of Mother-Infant Pairs in Los Angeles, California

Previous cross-sectional studies have investigated social determinants of health (SDOH) among pregnant women with COVID-19. However, there are scant data on the impact of these determinants on maternal outcomes from cohorts of pregnant women with COVID-19. We evaluated the association between social determinants of health and both COVID-19 severity and adverse pregnancy outcomes (APOs) in a cohort of pregnant women in Los Angeles (L.A.) County, California. The APOs considered were fetal loss, gestational hypertensive disorders, prolonged rupture of membranes, and maternal death. We recruited pregnant women with confirmed SARS-CoV-2 and collected data on maternal COVID-19 severity, trimester at diagnosis, comorbidities, mode of delivery, COVID-19 vaccination, APOs, maternal age, medical insurance type, race/ethnicity, and neighborhood income. Participants who were obese were more likely to experience severe COVID-19 (OR: 3.61, 95% CI: 1.44-9.46), while even one vaccine dose before COVID-19 infection was associated with reduced odds of severe disease (OR:0.14, 95% CI: 0.02-0.52). Pregnant participants living in low-income areas were more likely to experience APOs (p = 0.01) and severe COVID-19 (p = 0.009). This suggests that economic inequities could negatively impact maternal outcomes among pregnant women with COVID-19. We also found that SDOH moderated severity effects on APOs in Black women vs. non-Black women. These findings underscore the importance of considering social determinants of health to improve maternal health.

The Effectiveness of Superparamagnetic Iron Oxide Nanoparticles in Reducing Unnecessary Sentinel Lymph Node Biopsies

BACKGROUND

Sentinel lymph node biopsy (SLNB) is routinely performed at the time of mastectomy for noninvasive breast disease owing to the potential upgrade on final pathology, resulting in 80% of patients receiving unnecessary SLNB. Superparamagnetic iron oxide nanoparticles (SPIO) are a tracer with extended lymph node marking, facilitating delayed node retrieval in the event of an invasive upgrade. This study assesses the utilization and efficacy of SPIO for potential delayed SLNB for patients undergoing mastectomy.

PATIENTS AND METHODS

A retrospective cohort study identified SPIO use from September 2019 to August 2023. Two-sample t-tests, chi squared, and ANOVA were performed to compare indication, clinicopathology, and surgery details among those with or without SPIO injection in patients undergoing mastectomy for ductal carcinoma in situ (DCIS).

RESULTS

A total of 77 patients received SPIO injection: 33 (42.9%) for potential delayed SLNB and 44 (57.1%) for same-day SLNB. Indications for SPIO use for delaying SLNB were DCIS (23; 69.7%), abnormal imaging (5; 15.2%), high-risk lesions (3; 9.1%), and breast cancer gene (BRCA) mutation (2; 6.1%). A total of 9 out of 33 (27.3%) patients experienced an upgrade and underwent SLNB at a mean of 20 days (range 11-27) after mastectomy, with no differences in the number of nodes removed (2 versus 2.51 nodes; p = 0.61). Of patients undergoing mastectomy for DCIS, 23 (29.5%) received SPIO, while 54 (70.1%) underwent immediate SLNB. Deep inferior epigastric perforator flap reconstruction (p = 0.0021) and necrosis on core needle biopsy (p = 0.00014) were associated with immediate SLNB.

CONCLUSIONS

When utilized at the time of mastectomy for noninvasive disease, most patients receiving SPIO were spared unnecessary axillary surgery and the associated morbidities.

Illness Expectations and Asthma Symptoms: A 6-Month Longitudinal Study

BACKGROUND

After receiving a diagnosis, individuals often develop expectations about how their condition will evolve. This cognitive framework, known as 'Illness Expectations' (IEs), encompasses future-oriented beliefs regarding the course of the illness and its symptoms. In chronic conditions such as asthma, IEs may play a critical role in shaping patient-reported outcomes and clinical markers of disease progression. This study aims to empirically evaluate the impact of IEs on asthma symptoms and respiratory function.

METHODS

A cohort of 310 individuals diagnosed with asthma was followed over a 6-month period, with three assessment points. Asthma control was measured using the Asthma Control Test (ACT), while respiratory function was evaluated through forced expiratory volume in 1 s (FEV1) using spirometry. IEs were assessed using the validated 'Illness Expectation Test' (IET), which captures both explicit (conscious) and implicit (unconscious) expectations. Predictive analyses were conducted using latent growth modelling and linear regression to examine the influence of IEs on asthma symptoms and respiratory function over time.

RESULTS

People with more negative explicit IEs about their asthma reported worse symptoms over time (β = -0.50, SE = 0.21, p = 0.01). Implicit IEs were not statistically significant (β = -0.014, SE = 0.008, p = 0.09). Explicit IEs about symptom progression were also associated with changes in lung function, with more negative expectations predicting greater declines in respiratory performance (β = 0.51, SE = 0.11, p = 0.001).

CONCLUSIONS

These findings suggest that IEs may be meaningfully associated with asthma outcomes, highlighting their potential relevance in understanding patient experiences and symptom perception. These results support further research into interventions targeting cognitive frameworks, with the aim of informing more personalised, patient-centred approaches to asthma management.

PATIENT OR PUBLIC CONTRIBUTION

This study was developed in response to patient-reported challenges in asthma management, particularly around understanding and managing IEs. Patients contributed to identifying key areas of concern, and their perspectives informed the choice of outcomes and tools. While direct involvement in recruitment and dissemination was limited due to the pandemic, the study's design and focus were guided by patient priorities, with potential applications in clinical consultations and future co-designed interventions.

Stereotactic Radiosurgery Dose Reduction for Melanoma Brain Metastases Patients on Immunotherapy or Target Therapy: A Single-Center Experience

BACKGROUND AND OBJECTIVES

Better local control but higher rates of adverse radiation events (ARE) have been reported when combining American Society for Radiation Oncology (ASTRO)-guideline-suggested dose (SD) stereotactic radiosurgery (SRS) with immunotherapy or targeted therapy for melanoma brain metastases. The objective of this study is to explore the efficacy and safety of lower prescription doses compared with ASTRO guidelines for single-fraction SRS for patients with melanoma metastases who are concurrently receiving immunotherapy or targeted therapy.

METHODS

We conducted a retrospective, single-center study on 194 patients who underwent SRS between 2009 and 2022. After propensity score matching, 71 patients with 292 metastases were included in the ASTRO-SD (20-24 Gy for <2 cm, 18 Gy for ≥2 to <3 cm) group and 33 patients with 292 metastases in the reduced dose (RD, <20 Gy for <2 cm, <18 Gy for ≥2 to <3 cm) group.

RESULTS

The median diameter (5.4 vs 5.2 mm, P = .6), prescription volume (0.2 vs 0.2 cm 3 , P = .2), and radiographic follow-up (11 vs 12 months, P = .2) were similar in the 2 groups. The cumulative incidence of progressing metastases was significantly higher in the SD compared with the RD group ( P = .018). Higher prescription volumes and ASTRO-suggested radiation doses were associated with local progression in multivariable analysis. Radiographic AREs were significantly more common in the SD compared with the RD group (8.6% vs 3.1%, P = .005). BRAF and other tyrosine kinase inhibitors' concurrent use, higher prescription volumes, and ASTRO-suggested radiation doses were associated with an increased risk of radiographic ARE.

CONCLUSION

This study provides evidence that RD SRS could offer reduced toxicity rates, while maintaining high local control as compared with the current guideline-SDs for the treatment of melanoma brain metastases.

Atrioventricular Area Difference Aids Diastolic Filling in Patients with Repaired Tetralogy of Fallot

A hydraulic force aids diastolic filling of the left ventricle (LV) and is proportional to the difference in short-axis area between the left ventricle and atrium; the atrioventricular area difference (AVAD). Patients with repaired Tetralogy of Fallot (rToF) and pulmonary regurgitation (PR) have reduced LV filling which could lead to a negative AVAD and a hydraulic force impeding diastolic filling. The aim was to assess AVAD and to determine whether the hydraulic force aids or impedes diastolic filling in patients with rToF and PR, compared to controls. Twelve children with rToF (11.5 [9-13] years), 12 pediatric controls (10.5 [9-13] years), 12 adults with rToF (21.5 [19-27] years) and 12 adult controls (24 [21-29] years) were retrospectively included. Cine short-axis images were acquired using cardiac magnetic resonance imaging. Atrioventricular area difference was calculated as the largest left ventricular short-axis area minus the largest left atrial short-axis area at beginning of diastole and end diastole and indexed to height (AVADi). Children and adults with rToF and PR had higher AVADi (0.3 cm2/m [- 1.3 to 0.8] and - 0.6 [- 1.5 to - 0.2]) at beginning of diastole compared to controls (- 2.7 cm2/m [- 4.9 to - 1.7], p = 0.015) and - 3.3 cm2/m [- 3.8 to - 2.8], p = 0.017). At end diastole AVADi did not differ between patients and controls. Children and adults with rToF and pulmonary regurgitation have an atrioventricular area difference that do not differ from controls and thus a net hydraulic force that contributes to left ventricular diastolic filling, despite a small underfilled left ventricle due to pulmonary regurgitation.