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

Socioeconomic inequalities in patient-reported outcome measures among total hip and knee arthroplasty patients: a comprehensive analysis of instruments and domains

BACKGROUND

Prior to total hip and knee arthroplasty (THA/TKA), patients with low socioeconomic status (SES) report worse Patient-Reported Outcome Measures (PROMs), persisting postoperatively. This study explores which self-reported PROMs and their specific domains are most involved.

METHODS

We obtained data from the Dutch Arthroplasty Registry (2014-2022), including over 100,000 THA/TKA patients with complete preoperative and 12-month follow-up PROMs. The EQ-5D-3L and EQ-5D-5L, EQ Visual Analogue Scale (VAS), Oxford Hip and Oxford Knee Score (OHS/OKS), and Numerical Rating Scales (NRS) for pain and satisfaction (TKA only, at 12-month follow-up) were obtained. The PROMs were transformed to a 0-100 scale for direct comparison. A SES-indicator based on neighborhood income, unemployment rate, and education level was divided into quintiles, which are equal groups representing 20% of the Dutch population, and was ranked from least to most deprived. Through linear regression we contrasted the most and least deprived groups, adjusting for patient and surgical characteristics. The contribution (percentage) of each domain to the overall health inequalities was estimated for the EQ-5D's and the OHS/OKS.

RESULTS

In TKA patients, the most compared to the least deprived group had a lower preoperative EQ-5D-3L score: -2.1 [95% confidence interval - 2.6, -1.6], p < 0.001. At 12-month follow-up, the difference was smaller: EQ-5D-3L 1.3 [-1.9, -0.7], p < 0.001. A larger difference between the most and least deprived was present in OKS (preoperatively: -4.3 [-5.3, -3.4], p < 0.001; 12-month: -1.8 [-2.5, -1.2], p < 0.001). The difference in EQ VAS was smaller (preoperatively: -0.8 [-1.5, -0.1], p = 0.024; 12-month: -0.5 [-1.2, 0.1], p = 0.108). The difference in NRS pain (in rest) was comparable to those in EQ-5D-3L and OKS (preoperatively: -4.5 [-5.4, -3.5], p < 0.001; 12-month: -2.7 [-3.5, -1.9], p < 0.001), while no difference between the most and least deprived in NRS satisfaction was observed at 12 months. For EQ-5D-3L, the domain usual activities accounted for up to 46% of the difference between SES groups, while anxiety/depression played a limited role (up to 17%). For OHS/OKS, functioning contributed most in THA (up to 61%) and pain contributed most in TKA (up to 68%). Differences in PROM scores between SES groups, and how these differences compared across PROMs, were similar in THA patients. Overall, the EQ-5D-5L produced similar patterns compared to the EQ-5D-3L.

CONCLUSIONS

Deprived THA/TKA patients have poorer pre- and postoperative health, which was primarily related to worse functioning and pain; the clinical relevance of these differences remain uncertain. These differences did not translate into worse overall health (EQ VAS) or into higher dissatisfaction among deprived patients. Future research should investigate whether the EQ VAS and satisfaction measure reflected health differences between SES groups or were biased by reporting heterogeneity, where respondents interpreted the wording differently.

Association of blood eosinophil counts with pulmonary and extrapulmonary comorbidities in patients with chronic obstructive pulmonary disease: data from NHANES 2013-2018

BACKGROUND

Chronic obstructive pulmonary disease (COPD) involves systemic inflammation and is often accompanied by comorbidities. Blood eosinophil count (BEC) is a key marker of airway inflammation, used for patient stratification and treatment guidance. However, the association between BEC (< 300 vs. ≥ 300 cells/µL) and pulmonary or extrapulmonary comorbidities in COPD remains unclear.

METHODS

This study analyzed COPD patients from the 2013-2018 National Health and Nutrition Examination Survey (NHANES). Weighted multivariable logistic regression models examined associations between BEC and comorbidities, adjusting for potential confounders. Associations were quantified using odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

A total of 614 COPD patients were included (395 with BEC < 300 cells/µL, 219 with BEC ≥ 300 cells/µL). Patients with BEC ≥ 300 cells/µL had a higher prevalence of extrapulmonary comorbidities than those with BEC < 300 cells/µL (85.35% vs. 71.48%). Adjusted analysis showed that BEC ≥ 300 cells/µL was significantly associated with increased odds of any extrapulmonary comorbidity (OR = 2.03, 95% CI: 1.19-3.44, p = 0.009), congestive heart failure (OR = 1.69, 95% CI: 1.02-2.82, p = 0.043), and renal dysfunction (OR = 1.95, 95% CI: 1.01-3.79, p = 0.048), but not with pulmonary comorbidities. Sensitivity analyses using 3- and 4-level BEC categories revealed consistent trends, with higher BEC levels significantly associated with greater prevalence of at least one extrapulmonary comorbidity.

CONCLUSIONS

In COPD, higher BEC (≥ 300 cells/µL) is significantly associated with extrapulmonary comorbidities, particularly congestive heart failure and renal dysfunction, but not pulmonary comorbidities.

Prognostic Value of Multiple Circulating Biomarkers for Ventricular Arrhythmias in Left Ventricular Hypertrabeculation - Longitudinal Cohort Study

BACKGROUND

Ventricular arrhythmia (VA) is an independent risk factor for adverse outcomes in patients with left ventricular hypertrabeculation (LVHT). This study explored the predictive value of biomarkers for VAs in LVHT.

METHODS AND RESULTS

This cohort study retrospectively enrolled 265 LVHT patients (mean [±SD] age 44.2±17.0 years, 65.7% male) with data available for N-terminal pro B-type natriuretic peptide, big endothelin-1, high-sensitivity C-reactive protein, uric acid, and free fatty acid. The primary outcome was a composite of non-sustained ventricular tachycardia, sustained ventricular tachycardia, ventricular fibrillation, and appropriate implantable cardioverter defibrillator therapy. Over a median follow-up of 4.34 years, 82 (30.9%) patients experienced VAs. Multivariable Cox regression analysis revealed that baseline concentrations of big endothelin-1 were independently associated with the occurrence of VAs (hazard ratio 1.513; 95% confidence interval 1.136-2.013; P=0.005). Restricted cubic spline analysis showed that susceptibility to VAs increased markedly with increases in big endothelin-1 concentrations. Subgroup analysis revealed that LVHT patients with big endothelin-1 concentrations >0.63 pmol/L should be closely monitored for VAs, particularly when higher concentrations are accompanied by cardiomyopathies, left ventricular (LV) end-diastolic diameters ≥60 mm, or LV ejection fraction <50%. Individuals with elevated big endothelin-1 concentrations and isolated hypertrabeculation in the LV lateral wall had a significantly greater risk of VAs (log-rank P=0.002).

CONCLUSIONS

Big endothelin-1 concentrations and the location of hypertrabeculation can help with risk stratification for VAs in LVHT.

Effectiveness and safety of remdesivir and nirmatrelvir-ritonavir in mild to moderate COVID-19 in spanish hospital emergency departments

BACKGROUND AND OBJECTIVES

Remdesivir and nirmatrelvir-ritonavir (NTV/r) are the antiviral drugs available in Spain to prevent progression of mild-moderate COVID-19 in vulnerable populations. The pivotal clinical trials of both were conducted under different epidemiological conditions than the current ones. Therefore, their effect in the current setting is uncertain.

PATIENTS AND METHODS

A retrospective, multicentre, observational cohort study was conducted in 16 Spanish hospital emergency departments (ED). Data were collected from all patients with mild to moderate COVID-19 who presented to an ED in the first seven days after symptom onset between 1st January and 31st August 2022. The incidence of hospitalisation or death from any cause at 30 days (composite endpoint) after discharge from the ED was assessed, as was the occurrence of serious adverse drug reactions (ADRs). Data were analysed using Cox multiple regression and standardised survival curves.

RESULTS

A total of 2533 patients were included. The use of NTV/r was associated with a reduced risk of the combined endpoint compared to standard of care (SOC): adjusted hazard ratio (aHR) 0.528, 97.5% confidence interval (97.5%CI): 0.330-0.845; number of patients to treat to avoid an event, 24 (97,5%CI 13-283). No difference was detected between remdesivir and SOC: aHR 0.835: 97,5%CI: 0.524-1.394. No serious ADRs were identified.

CONCLUSION

Early use of NTV/r was associated with less risk of progression of mild to moderate COVID-19 in vulnerable patients, while no differences were found between remdesivir and SOC. Their use was safe.

Age-related differences in men's preferences and barriers to healthcare: Insights from a national Australian survey

OBJECTIVES

The high burden of preventable disease among men in many countries has highlighted the urgency of promoting stronger engagement by men in health services and programs. In order to inform prevention and early intervention strategies in Australia, this study aimed to examine how age and other socio-demographic factors moderate help-seeking preferences among men in this population, and the major psychosocial and practical barriers to healthcare use for men across the life course.

DESIGN

Cross-sectional survey using a nationally representative sample.

SETTING

Online survey in March 2021.

PARTICIPANTS

English-speaking Australian men aged 18-years and older, recruited using a probabilistic sampling method. Of the 1,409 men invited to participate, 1,282 (91%) completed the survey.

MAIN OUTCOME MEASURES

Preferences for help-seeking related to physical and mental health, and psychosocial and practical barriers to help-seeking.

RESULTS

Compared to men aged 70 years and over, younger men were less likely to choose professional sources of help, with those aged 18-29 years showing the lowest odds when needing assistance for physical (OR = 0.28, 95% CI 0.17-0.49) and mental health (OR = 0.28, 95% CI 0.16-0.46). Men in this youngest age group also reported experiencing more practical barriers to healthcare access with 77 out of 241 (32%) men experiencing three or more barriers to healthcare engagement, compared to 16 out of 172 (9.3%) men over 70 years. Multivariable analysis showed that younger age was associated with higher psychosocial barriers to help-seeking.

CONCLUSIONS

Age is a significant factor in men's health help-seeking preferences in Australia and these findings highlight the unique help-seeking profile of younger men. Younger Australian men are less likely to seek help proactively, and encounter more practical and psychosocial barriers than older men. The findings underscore the necessity for public health strategies to engage younger men effectively in proactive health management.

Impact of surgical approach on complications by sex following ventral and incisional hernia repair

PURPOSE

Female patients are more likely than male patients to experience postoperative complications following hernia repair, but the drivers of this phenomenon remain unexplored. Whether surgical approach differentially impacts the likelihood of postoperative complications by sex following ventral and incisional hernia repair (VIHR) remains unknown.

METHODS

Adult patients from the Michigan Surgical Quality Collaborative Core Optimization Hernia Registry (MSQC-COHR) were included in this study. MSQC-COHR is a representative, random sample of adult patients from 70 hospitals across Michigan. All elective VIHR performed between January 1, 2020, to September 30, 2023, were included. The primary outcome was any 30-day complication. A multivariable logistics mixed effects model was used to measure the adjusted associations between the observed covariates and the likelihood of 30-day complications. Sex and surgical approach were interacted to test for potential differential effects of surgical approach on 30-day complications by sex.

RESULTS

Among 10,675 patients who underwent elective VIHR, 254 (2.4%) experienced postoperative complications. Of these, 152 (59.8%) patients were female. In bivariate analyses, female patients more often experienced a 30-day complication, regardless of operative approach (3.3% vs. 1.7%, p < 0.001). By surgical approach, female patients were found to have 4.2% (95% CI: 3.2-5.1) probability of 30-day complications after open repair, versus 1.5% (95% CI: 1.0-2.1) following MIS VIHR. Male patients had 2.1% (95% CI: 1.5-2.7) probability of 30-day complications after open repair, versus 1.5% (95% CI: 0.9-1.9) following MIS VIHR. Comparatively, female patients were 2.7 times more likely to experience complications after open repair compared to MIS repair, while male patients were 1.4 times more likely to have complications after open vs. MIS repair.

CONCLUSION

Following both open and MIS VIHR, female patients have a higher risk of postoperative complications compared to male patients, with this risk increasing after open repairs. The outcome disparity persists even after accounting for differences in comorbidities and hernia characteristics. Although this sex-based outcome disparity is not fully eliminated, MIS approaches mitigate the gap, suggesting that MIS repairs should be prioritized in female patients when feasible.

Does personal relevance moderate communication effects? The example of risk communication about 5G-related electromagnetic fields

Background

Technological advancements, such as the introduction of the fifth generation technology standard 5G, offer opportunities but also raise concerns. Although no evidence suggests negative effects of radiofrequency electromagnetic fields (RF-EMF) within defined exposure limits, authorities responsible for risk communication provide precautionary advice to help citizens reduce personal exposure. However, previous research indicates that precautionary information can increase risk perception and decrease trust.

Methods

This cross-sectional study investigated effects of precautionary information on risk perception and trust in the context of 5G, using large general population samples in Germany and Greece. For the first time, personal relevance was examined as a potential moderating factor, using a novel approach to assess practical and thematic relevance. Participants were first surveyed on their relevance of the topic, then provided with basic information about "RF-EMF and health", and, in the experimental group, with additional precautionary information. Different measures for risk perception and trust followed. We expected higher risk perception and lower trust for the experimental group, and assumed that at lower personal relevance, this effect would be stronger.

Results

Contrary to expectations, precautionary information increased just one risk perception measure and only in Germany. The anticipated moderating effect of personal relevance was not found, but relevance itself significantly predicted risk perception, with higher relevance correlating with higher risk perception. Exploratory findings revealed higher risk perception among females compared to males and in Greece compared to Germany.

Conclusions

That there were only few effects of the precautionary information may be linked to the focus on actions to reduce personal exposure when using mobile devices. The results underline the importance of considering personal relevance and demographic factors in risk communication and highlight directions for future research.

Disparities in the Clinical Provision of Deep Brain Stimulation: A Systematic Scoping Review and Grounded-Theory Qualitative Analysis

BACKGROUND

Deep Brain Stimulation (DBS) has been an established treatment for movement disorders since its FDA approval in 1996. However, disparities in DBS care, particularly concerning race, gender, socioeconomic status, and geography, remain a significant concern globally.

OBJECTIVES

This systematic scoping review and grounded theory qualitative analysis aimed to synthesize existing research on worldwide disparities in DBS provision and to develop theoretical solutions to enhance equity and improve the quality of research in DBS disparities.

METHODS

A systematic search identified 46 studies, which were critically appraised for quality and analyzed using grounded theory methods to extract core conceptual categories.

RESULTS

We characterized three principles of DBS disparities: intersectionality, reciprocal interactivity and influence of patients and providers, and the interposition of simultaneous barriers; together these highlight the role of individual, systemic, and structural factors in generating DBS disparities. Racial minorities, women, socioeconomically disadvantaged individuals, and patients in certain geographic regions were consistently found to have reduced access to DBS. Gaps in the research include a calcified research infrastructure, insufficient attention to cultural and societal contexts, and reliance on conjecture without empirical support.

CONCLUSIONS

We propose a multi-level approach to address DBS disparities, including reciprocal education between patients and clinicians, enhanced screening and referral networks, and policy reforms at institutional and governmental levels. These findings will facilitate further hypothesis-driven research and foster more equitable access to DBS globally.

OARSI initiative to develop classification criteria for early-stage symptomatic knee OA (EsSKOA): What conditions should be considered in the differential diagnosis of EsSKOA?

OBJECTIVE

Classification criteria for early-stage symptomatic knee osteoarthritis (EsSKOA) should discriminate individuals with EsSKOA from those with other causes of knee symptoms. We sought to identify conditions in the differential diagnosis of EsSKOA in adults with knee symptoms.

DESIGN

We conducted an online survey of clinicians. Those consulting monthly on at least five people with undiagnosed knee symptoms were eligible. From qualitative work and clinical experience, we developed three case scenarios representing possible EsSKOA: 1. 40-year-old with 1 month of knee stiffness and swelling; 2. 50-year-old with 8 months of knee discomfort while walking; and 3. 60-year-old with intense knee discomfort getting out of a car 1 week ago. For each scenario, participants indicated conditions on a pre-defined list that they would consider in the differential diagnosis, and the top three diagnoses based on clinical experience. The proportions that considered each condition and among the top three diagnoses for each scenario were summarized overall and by clinical discipline.

RESULTS

127 clinicians responded (43% female, 48% in practice ≤15 years, 50% university-affiliated practice, 7 clinical disciplines). Knee OA and meniscal injuries were among the top three conditions in the differential diagnosis for all three scenarios, followed by immune-mediated and crystal-induced inflammatory arthritis (scenario 1), patellofemoral pain syndrome (scenario 2), and collateral ligament injuries (scenario 3).

CONCLUSION

The differential diagnosis for EsSKOA in adults presenting with undiagnosed knee symptoms includes symptomatic established radiographic knee OA, patellofemoral pain syndrome, meniscal and collateral ligament injuries, and immune-mediated and crystal-induced inflammatory arthritis.

Intensive care nurses' knowledge and attitudes towards catheter-related bloodstream infections and evidence-based nursing: results from a descriptive and cross-sectional survey conducted in a hospital in Türkiye

BACKGROUND

Intensive care units pose a risk for catheter-related infections because they are the setting of frequent catheter use. This study aimed to determine intensive care nurses' knowledge and attitudes towards preventing catheter-related bloodstream infections and their attitudes towards evidence-based practices.

METHODS

This descriptive and cross-sectional survey was conducted between June and October 2021 among 148 nurses working in the adult intensive care units of a hospital in Istanbul. Data were collected using a descriptive characteristics form, the Peripheral and Central Venous Catheter-Related Bloodstream Infection Prevention Knowledge and Attitude Scale, and the Attitude Towards Evidence-Based Nursing. Data were analysed with Pearson correlation test, linear regression analysis, t-test and ANOVA test.

RESULTS

A significant (148/162) portion of the intensive care nurses participated in the survey, with a response rate of 91%. Among the participants, 83.8% had received training on preventing catheter-related bloodstream infections. The nurses had good knowledge and attitudes towards preventing catheter-related bloodstream infections (62.80 ± 4.78) and moderate attitudes towards evidence-based nursing (48.30 ± 4.40). A weak positive correlation was found between knowledge and attitude towards preventing catheter-related infections total score and attitudes towards evidence-based nursing total score (r = 0.334, p < 0.001). The change in total knowledge and attitudes towards preventing catheter-related infections score explained 10.6% of the variation in total attitude towards evidence-based nursing score (R2 = 0.106).

CONCLUSION

The increase in nurses' knowledge and attitudes towards preventing catheter-related bloodstream infections was associated with better attitudes towards evidence-based nursing. It is recommended that continuing education be provided to nurses on evidence-based practices, including catheter-related infection precautions.

CLINICAL TRIAL NUMBER

Not applicable.

Disrupted spatial but not temporal aspects of nociceptive processing determine painful polyneuropathies

ABSTRACT

Polyneuropathy remains a diagnostic and clinical challenge, with limited understanding of the mechanisms underlying painful and nonpainful phenotypes. While previous studies have examined various characteristics of these patients, the temporal and spatial dynamics of endogenous pain modulation remains not fully elucidated. In this study, offset analgesia (OA) and spatial summation of pain (SSp) were used as measures of pain modulation in individuals with distal symmetric polyneuropathy, stratified by the presence (n = 30) or absence of pain (n = 30), and compared with healthy controls (n = 30). All participants underwent quantitative sensory testing and assessments of OA and SSp using a thermal stimulator applied to the dorsum of the foot. Patients with painful polyneuropathy exhibited enhanced SSp compared with the pain-free polyneuropathy group and healthy controls (P < 0.05), and impaired OA compared with healthy controls (P < 0.05). The pain-free neuropathy group showed less efficient OA and a slightly enhanced SSp, but this finding did not reach significance. The data suggest that changes in spatial summation were primarily driven by heightened pain responses to nociceptive input from smaller areas, rather than larger ones. Notably, spatial summation and the effects of OA were found to be correlated, irrespective of pain diagnosis. These findings underscore specific impairments in endogenous pain modulation in individuals with painful neuropathy, thus advancing our understanding of its pathophysiological mechanisms. They further highlight the differential roles of spatial and temporal dynamics in pain modulation across various neuropathic populations, offering promising avenues for improved diagnostics and prognostics related to polyneuropathy-associated pain.

Conflict-attributable mortality in Tigray Region, Ethiopia: Evidence from a survey of the Tigrayan diaspora

BACKGROUND

The war in Tigray Region, Ethiopia (November 2020 to November 2022) ended with formal commitments to accountability, but these have yet to produce publicly available accounts of the harms caused by the conflict.

METHODS

We carried out an online survey of the Tigrayan diaspora to estimate mortality amongst children, adults, and older adults during, and prior to, the war-period. We collected retrospective demographic information on respondents', and their spouses', extended family inside Tigray. To mitigate selection bias, we standardised mortality estimates by rural-urban residence and wealth index.

RESULTS

Of 1011 participant-reported decedents, 810 died within Tigray, and 310 of these individuals died during the war-period. Of the 310 deaths in Tigray during the war-period, 224 (72.3%) died from intentional injuries. The standardised mortality rate for adults (15-49 years) was 21.3 per 1000 person-years (29.4 for men, 14.8 for women) during the war, and 1.0 in the preceding period (2010-2020). The mortality rate amongst older adults (≥ 60 years) was 45.1 per 1000 person-years during the war-period, compared to 22.8 in 2010-2020, and is higher than the period encompassing the Ethiopian Civil War (1974-1991) and Tigray/Wollo Famine (1984-1985). The mortality ratio (men to women) was approximately 2:1 in both adults, and older adults. The mortality rate amongst adults and older adults had been declining across the pre-war periods. Few deaths were reported amongst children. We estimate that the conflict has resulted in more than 102,000 deaths amongst those aged ≥ 15 years.

CONCLUSIONS

Our study suggests a significant elevation in all-cause mortality, largely driven by intentional injuries. Although our pre-war-period data are likely under-reported, comparisons with other pre-war estimates corroborate these plausible elevations, particularly amongst adults. The mortality ratio, when compared to those from other settings, does not support assertions that the military strategy primarily involved the targeting of adult males, and instead suggests widespread killing of women and older adults who would not have posed a combat threat.

Endovascular Therapy for Late-Window M2-Segment Middle Cerebral Artery Occlusion: Analysis of the CLEAR Study

BACKGROUND

There is uncertainty about whether patients with M2 occlusion benefit from endovascular therapy (EVT) in the late (6-24-hour) time window. We evaluated the clinical outcomes of patients with M2 occlusion selected for EVT compared with those who received medical management (MM) in the late window.

METHODS

This multinational cohort study was conducted at 66 sites across 10 countries (January 2014 to May 2022). We included consecutive patients with late-window stroke due to M2 occlusion, baseline National Institutes of Health Stroke Scale score of ≥5, and premorbid modified Rankin Scale score of ≤2 who received EVT or MM alone. The primary end point was 90-day ordinal shift in the modified Rankin Scale score. Safety end points were symptomatic intracranial hemorrhage and 90-day mortality. Differences in outcomes were determined using inverse probability of treatment weighting-adjusted logistic regression models.

RESULTS

Among 5098 patients, 496 met inclusion criteria (median [interquartile range] age, 74 years [62-81 years]; baseline National Institutes of Health Stroke Scale score, 12 [8-17]), of whom 394 (79.4%) received EVT and 102 (20.6%) MM. In inverse probability of treatment weighting adjusted analyses, there was no favorable 90-day ordinal modified Rankin Scale shift (odds ratio, 1.39 [95% CI, 0.92-2.12]) and no difference of functional independence rates (modified Rankin Scale score of 0-2; odds ratio, 1.72 [95% CI, 0.93-3.15]) with EVT compared with MM. Moreover, symptomatic intracranial hemorrhage risk (odds ratio, 3.46 [95% CI, 0.50-23.92]) and 90-day mortality (odds ratio, 1.11 [95% CI, 0.66-1.87]) were not statistically different between treatment groups.

CONCLUSIONS

In patients with M2 occlusion in the 6- to 24-hour time window, there was no difference in disability outcomes or symptomatic intracranial hemorrhage risk between patients treated with EVT compared with MM. Results of ongoing randomized trials will provide further insight.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04096248.

Single Center Implementation of a Postpartum Pharmacologic Thromboprophylaxis Protocol

This study aimed to evaluate trends in the frequency of pharmacologic prophylaxis following the implementation of a postpartum venous thromboembolism (VTE) prevention protocol. Secondarily, to evaluate the association between protocol implementation and incidence of VTE and complications.Retrospective cohort of patients delivering from 2015 to 2022 at a single academic institution. Those with an antepartum VTE or receiving therapeutic anticoagulation were excluded. An inpatient thromboprophylaxis protocol was implemented in January 2017 and further updated in July 2020 to expand risk factors to qualify for prophylaxis and extend the length of therapy to the outpatient setting (total 14 days). The cohort was divided into three time periods: preimplementation (January 1, 2025-December 31, 2016), initial protocol (January 1, 2017-June 30, 2020), and updated (July 1, 2020-December 31, 2022) protocol. The primary outcome was the receipt of inpatient heparin-based pharmacologic prophylaxis. Secondary outcomes included filling an outpatient pharmacologic prophylaxis prescription, VTE, and wound complications observed through 6 weeks postpartum. Baseline characteristics and outcomes were compared across the three protocol periods. Logistic regression modeling estimated the association between outcomes and the updated protocol period compared with prior periods.Overall, 22.6% (95% confidence interval [CI]: 22.1-23.0) of 34,217 included deliveries received inpatient pharmacologic prophylaxis: 7.7% (7.1-8.2%) preimplementation, 15.8% (15.2-16.4%) initial protocol, and 41.2% (40.4-42.1%) during the updated protocol period. The rates of inpatient and outpatient prophylaxis increased significantly over time (p < 0.001 test of trend). Delivery in the updated protocol period was not associated with differences in VTE (pre: 0.1%, initial: 0.2%, and updated: 0.1%) nor wound complications (pre: 3.4%, initial: 2.7%, and updated: 2.7%).Single-center implementation of a postpartum prophylaxis protocol resulted in increased use of inpatient and outpatient pharmacologic prophylaxis without changes in rates of VTE or wound complications. · Implementation of a postpartum thromboprophylaxis protocol resulted in increased rates of pharmacologic prophylaxis.. · No differences in wound complications were observed by the protocol period.. · Rates of VTE did not change over time..

Foetal Cardiac Function in Early Labour and Intrapartum Outcomes: A Prospective Observational Study

OBJECTIVE

To assess foetal myocardial deformation in normo-oxygenated foetuses in early labour and its relationship with intrapartum outcomes.

DESIGN

Single centre prospective study.

SETTING

Referral tertiary maternity unit.

POPULATION

Uncomplicated singleton term pregnancies in early labour.

METHODS

Two-dimensional (2D) ultrasound clips of the 4-chamber view of the foetal heart were collected in labour and sent to TomTec software for the offline speckle tracking echocardiography analysis. The left (LV) and right ventricular (RV) myocardial (MyoGLS) and endocardial longitudinal (EndoGLS) strain were evaluated.

MAIN OUTCOME MEASURES

Operative delivery including caesarean or assisted vaginal birth due to suspected intrapartum foetal compromise (IFC) as defined by standard CTG criteria.

RESULTS

In total, 208 cases were included. Operative delivery due to suspected IFC was recorded in 20 (9.6%) cases and was associated with higher LV ejection fraction (EF) (47.4 + 8.2 vs. 40.9 + 12.9%, p = 0.03) and increased RV MyoGLS (-15.9 + 4.0 vs. -12.5 + 4.3%, p < 0.01) and RV EndoGLS (-17.7 + 4.4 vs. -14.3 + 4.7%, p < 0.01) compared to cases not having operative delivery due to suspected IFC. Maternal age (OR 1.138, 95% CI [1.010-1.281], p = 0.03), baseline foetal heart rate at acquisition (OR 1.068, 95% CI [1.007-1.134], p = 0.03) and RV MyoGLS (OR 0.575, 95% CI [0.366-0.903], p = 0.02) were independently associated with the primary outcome.

CONCLUSIONS

Increased right ventricular myocardial deformation is associated with operative delivery due to suspected IFC, suggesting an early cardiac response to labour-related hypoxia.

Age-stratified associations between radiotherapy and SPMs for FPHNC: a population-based cohort study

BACKGROUND

Second primary malignancies (SPMs) account for over 30% of total deaths in head and neck cancer (HNC) patients. The increasing use of radiotherapy raises concerns about the elevated risk of radiation-associated SPMs. This study aimed to investigate the age-stratified association between radiotherapy and SPM risk in survivors of non-metastatic primary HNC.

METHODS

Using data from the Surveillance, Epidemiology, and End Results program (2004-2015), incidence rate ratios (IRRs) and standardized incidence ratios (SIRs) were evaluated for solid and hematologic SPMs associated with radiotherapy within different age groups. Follow-up for hematologic and solid SPMs began 2 and 5 years, respectively, after the diagnosis of first primary HNC. The IRRs for SPMs were compared between radiotherapy-exposed and unexposed groups using multivariable modified Poisson regression. The SIRs were computed as the ratio of observed cancers in the cohort to expected cases derived from sex-, age-, and calendar year-matched general population incidence rates.

RESULTS

The study included 75,209 2-year survivors, with 73.2% being male and a median age of 60 years. Of these, 58,063 had survived 5 years or more. Radiotherapy was associated with an increased risk of solid SPMs [IRR = 1.16, 95% confidence interval (CI) 1.08-1.24; P < 0.001]. The associations varied significantly among young (aged 15-39 years), middle-aged (aged 40 - 64 years), and elderly (aged 65-89 years) patients. Specifically, radiotherapy was associated with an increased risk of solid SPMs in middle-aged patients (IRR = 1.21, 95% CI 1.11-1.32; P < 0.001), and a decreased risk of hematologic SPMs in elderly patients (IRR = 0.77, 95% CI 0.60-0.99; P = 0.045). Compared with the general population, young patients had an elevated risk of radiotherapy-associated second primary non-Hodgkin lymphoma (SIR = 4.01, 95% CI 1.47-8.74). Middle-aged patients showed the highest SIR for SPMs in the bones/joints (SIR = 7.72, 95% CI 4.32-12.73), while elderly patients had the highest SIR for second primary esophageal malignancies (SIR = 3.87, 95% CI 2.91-5.05). Males were more likely to develop solid SPMs compared to females.

CONCLUSIONS

This study reveals an age-stratified association between radiotherapy and the risk of SPMs in HNC patients. These findings highlight the importance of considering patient age when making treatment decisions for HNC and suggest that long-term surveillance is necessary for high-risk groups.

Laxative use and 28-day mortality in critically ill sepsis patients: a retrospective cohort study using MIMIC-IV (v3.1)

OBJECTIVE

This study investigates the impact of four laxatives-Senna, Docusate Sodium, Polyethylene Glycol, and Lactulose on 28-day mortality, ICU-free days, ventilator-free days, bowel recovery, and Clostridium difficile (C-diff) infection in critically ill sepsis patients to identify optimal bowel management strategies for improving survival and recovery.

METHODS

Using the MIMIC-IV database (v3.1), we analyzed 7163 ICU sepsis patients (median age: 67.5 years; 63% male), assessing 28-day mortality, ICU-free days, vasopressor-free days, ventilator-free days, bowel sound recovery, and C-diff incidence, with propensity score matching and multivariable adjustments for confounders, alongside subgroup analyses by sex, age, Charlson Comorbidity Index, and Sequential Organ Failure Assessment score.

RESULTS

Docusate Sodium was associated with significantly lower 28-day mortality (adjusted HR: 0.43; 95% CI 0.36-0.52), more ICU-free days, and better bowel recovery compared to Senna, while Lactulose was linked to higher mortality (adjusted HR: 1.82; 95% CI 1.45-2.27), fewer ICU-free days, and increased C. difficile risk, with subgroup analyses confirming these trends across sex, age, and comorbidity strata.

CONCLUSION

Docusate sodium appears to be a safer and more effective bowel management option for critically ill patients with sepsis. In contrast, the association between lactulose use and adverse outcomes may primarily reflect the severity of underlying liver disease rather than a direct drug effect. These findings underscore the importance of individualized laxative selection based on patients' clinical context in critical care practice.

Tools used to appraise the quality of studies included in systematic reviews and meta-analyses in human genetics: a systematic review

Quality assessment of primary studies is an essential component of systematic reviews (SRs). This methodological review systematically examines the choice, format and utilization of critical appraisal (CA) tools in SRs with or without meta-analyses in the field of human genetics. We searched MEDLINE, Embase, Web of Science, and PubMed up to January 2024. Two reviewers independently performed title, abstract, full-text screening and data extraction. This PROSPERO registered methodological review followed PRISMA guidelines. Meta-analysis and full-scale risk-of-bias assessment of SRs were not relevant. Among 149 randomly selected SRs, 136 mentioned CA tools (156 citations). Nineteen different generic tools constituted 71.2% of citations. NOS, QUADAS and the Cochrane risk-of-bias tool represented 36.5, 11.5, and 8.3% of tools, respectively. Ninety-three reviews stated following reporting guidelines, with 22 PRISMA checklists accessible. Detailed presentation of results was observed for 65.8% of generic and 37.8% of customized tools (p = 0.0013). Results for NOS were less often detailed than for other generic tools (p < 0.0001). Few SRs used CA results for study selection, data analysis, or discussion of findings. In conclusion, this first review of CA tools in human genetics SRs highlights a lack of transparency regarding utilization of CA tools and deficiencies in reporting of CA results.Registration: PROSPERO (CRD42023449349).

Human Papillomavirus Positivity and Cognitive Function in Older U.S. Adults: A Cross-Sectional Population-Based Study

Prior research has reported an association between human papillomavirus (HPV) seropositivity and dementia or Alzheimer's disease. This study aimed to cross-sectionally investigate the association between HPV seropositivity and cognitive function in older adults. The data used for this study were from the 2011-2014 National Health and Nutrition Examination Survey (NHANES) cycles. To account for the complex survey design and missing data, we applied survey-weighted regression models to each imputed dataset, using multiple imputation techniques. Across all cognitive test outcomes, no statistically significant association was observed between HPV status and cognitive performance after controlling for covariates. These findings suggest that there may not be a significant association between HPV infection and cognitive scores in this NHANES sample. Stakeholders, including policymakers and healthcare providers, should consider these findings in their professional decision-making. Future research should investigate the association between HPV seropositivity and cognition using other samples in order to further characterize the association between HPV and cognitive function in older adults.

Association of the triglyceride-glucose index with all-cause and cardiovascular mortality among individuals with cardiovascular-kidney-metabolic syndrome: a population-based cohort study using data from the US National Health and Nutrition Examination Survey, 1999-2018

OBJECTIVE

The study investigated the association between the triglyceride-glucose (TyG) index (a surrogate measure for insulin resistance) and all-cause and cardiovascular disease (CVD) mortality among individuals with cardiovascular-kidney-metabolic syndrome.

DESIGN

Population-based cohort study.

SETTING

US National Health and Nutrition Examination Survey, 1999-2018.

PARTICIPANTS

A total of 13 585 participants who had valid data were included in this analysis.

OUTCOME MEASURES

Data from the participants were linked to death certificates to obtain follow-up mortality information from the National Death Index. Cox proportional hazards models were used to assess the associations between the TyG index and all-cause and CVD mortality. Non-linear associations and threshold effects were investigated using restricted cubic spline regression and a two-piecewise Cox proportional hazards model.

RESULTS

During a median follow-up of 99 months, a total of 2876 (16.24%) deaths occurred, of which 961 were attributed to CVD. Each one-unit increase in the TyG index was associated with an 8.9% relative increase in the hazard of all-cause mortality (HR 1.089, 95% CI 1.013 to 1.171) and a 19.5% relative increase in the hazard of CVD mortality (HR 1.195, 95% CI 1.027 to 1.390). Non-linear relationships were identified between the TyG index and all-cause and CVD mortality, with threshold values of 8.97 and 8.81 for all-cause and CVD mortality, respectively. A significant interaction effect was found between age and the TyG index.

CONCLUSION

There was a U-shaped relationship between the TyG index and both all-cause and CVD mortality. The thresholds of the TyG index may serve as potential tools for managing populations with cardiovascular-kidney-metabolic syndrome to reduce mortality risk.

Is there a place for laparoscopic reoperation for complications after minimally invasive pancreatectomy?

INTRODUCTION

Although the use of the minimally invasive approach is expanding in pancreatic surgery, indications and results of laparoscopic reinterventions after pancreatectomy are unknown.

METHODS

Based on the multicenter AFC (Association Française de Chirurgie) cohort (2010-2021), patients who underwent open (open reoperation group) or laparoscopic (laparoscopic reoperation group) reoperation within 90 days after minimally invasive pancreatectomy were included and compared. Inverse probability of treatment weighting analysis was performed to determine the impact of laparoscopic reoperation on postoperative mortality.

RESULTS

Of the 3,412 patients who underwent minimally invasive pancreatectomy, 298 (8.7%) underwent reoperation, with a median delay of 9 days (interquartile range: 4-19 days). Most frequent causes of reintervention were pancreatic fistula with uncontrolled sepsis (postoperative pancreatic fistula) (23%) and hemorrhage (postpancreatectomy hemorrhage) (46%). Sixty-five patients (22%) underwent laparoscopic and 233 (78%) open reoperation. Laparoscopic reoperation was mostly performed for postoperative pancreatic fistula drainage (43%), postpancreatectomy hemorrhage (26%), bowel obstruction (20%), or peritonitis (8%). Patients in the laparoscopic reoperation group were more often reoperated on after distal pancreatectomy (54% vs 36% in open reoperation group, P = .017). After pancreatoduodenectomy, laparoscopic reoperation was more often performed for bowel obstruction compared with open reoperation (20% vs 4%, P = .005). After reintervention, the postoperative mortality rate was 13%. Hospital stay was significantly shorter after laparoscopic reoperation (28 vs 36 days, P = .037). After adjustment for inverse probability of treatment weighting, laparoscopic revision was statistically associated with less postoperative mortality (odds ratio = 0.81, 95% confidence interval: 0.81-0.95).

CONCLUSION

The laparoscopic approach may be an option for surgical reintervention after minimal invasive pancreatectomy in non-life-threatening indications, mainly after distal pancreatectomy for postoperative pancreatic fistula drainage or after pancreatoduodenectomy for occlusion.

Urinary albumin-to-creatinine ratio in patients with hypertension and risk of major cardiovascular events

INTRODUCTION/AIMS

Evaluation of urinary albumin-to-creatinine ratio (uACR) is a key component in the management of hypertension, yet there is a lack of data on the association between uACR and major cardiovascular events (MACEs) in large hypertensive cohorts, and it is also unknown how often uACR is measured among these patients.We aimed to evaluate the usage of uACR in a nationwide population of patients with hypertension. Furthermore, we sought to assess the risk of cardiorenal events according to uACR, among patients with hypertension.

METHODS

We used Danish nationwide registries to identify patients who initiated antihypertensive treatment. The patients were grouped at treatment initiation according to uACR: normoalbuminuria, microalbuminuria, macroalbuminuria and no uACR measurement, and followed for 2 years, to evaluate the risk of a MACE, hospitalisation for heart failure (HF), 40% decline in estimated glomerular filtration rate (eGFR) and end-stage kidney disease (ESKD) according to uACR.

RESULTS

We included 144 644 patients, of whom 116 039 (80%) did not have their uACR evaluated at treatment initiation. Patients with macroalbuminuria comprised the greatest 2 year absolute risk of MACE (5.3%, 95% CI: 4.0% to 6.6%) and had a greater risk of MACE (HR: 2.02, 95% CI: 1.54 to 2.66), HF (HR: 1.99, 95% CI: 1.35 to 2.95), 40% decline in eGFR (HR: 4.81, 95% CI: 3.78 to 6.10) and ESKD (HR: 4.52, 95% CI: 3.00 to 6.82) compared with patients with normoalbuminuria. Increased risk of MACE, HF and 40% decline in eGFR among patients with macroalbuminuria was persistent across subgroups of eGFR 120-30 mL/min/1.73 m².

CONCLUSIONS

In this real-world cohort, uACR was not regularly measured among patients initiating antihypertensive treatment. Nonetheless, the 2-year risks of cardiorenal events were considerably higher among patients with albuminuria compared with patients without.

Structured Early Follow-Up in Head and Neck Squamous Cell Carcinomas: A Retrospective Cohort Study

Background/Objectives: The various head and neck squamous cell carcinoma (HNSCC) subtypes are among the most common cancers globally, with significant recurrence rates within the first two years post-treatment. Despite advancements in treatment, structured early follow-up remains crucial for timely diagnosis and effective salvage treatment. Methods: This retrospective study examines the impact of implementing a structured initial restaging between three and six months after the conclusion of initial treatment. The study population included 532 patients treated with curative intent at the University Medicine of Greifswald, Germany, between 2010 and 2019. Patients were divided into two groups: standard follow-up (SF) and adapted follow-up (AF). The AF group received standardized post-treatment restaging, including imaging and panendoscopy or PET-CT exams. Results: We found a trend towards earlier diagnosis and a reduction in recurrences, although these differences were not statistically significant. Secondary cancers were observed more frequently in the AF group, significantly affecting overall survival. Conclusions: Our cohort supports structured initial cancer follow-up in HNSCC. Although not significant, an initial multimodal exam after treatment was well tolerated and showed a trend toward earlier diagnosis.

Serum uric acid and coronary artery disease risk: a 10-year prospective cohort study in healthy adults

BACKGROUND

The role of serum uric acid (SUA) as an independent risk factor for coronary artery disease (CAD) remains controversial, particularly in understudied Middle Eastern populations with distinct metabolic and dietary profiles.

OBJECTIVE

To investigate the association between SUA levels and 10-year CAD incidence in a healthy Iranian cohort, adjusting for cardiometabolic confounders and exploring sex-specific relationships.

METHODS

A 10-year prospective cohort study was conducted using data from the Yazd Healthy Heart Project. Cluster-random sampling recruited adults aged 20-74 years free of baseline cardiovascular disease. Participants with existing coronary artery disease, insufficient data, or loss to follow-up were excluded. Serum uric acid levels were stratified into quartiles, and Cox proportional hazards models adjusted for demographic, lifestyle, and metabolic variables were analyzed using SPSS (version 27.0).

RESULTS

Over 15,420 person-years, 225 incident CAD cases occurred (14.5% cumulative incidence). In crude analysis, the highest SUA quartile (Q4: > 5.2 mg/dL) was associated with increased CAD risk (HR = 1.66, 95% CI: 1.14-2.43). However, this association attenuated after adjustment for confounders (fully adjusted HR = 1.03, 95% CI: 0.62-1.69). Sex-stratified analysis revealed a transient association in women (crude HR = 2.13, 95% CI: 1.14-3.96), which dissipated post-adjustment, while no significant association was observed in men.

CONCLUSION

Elevated SUA levels were not independently associated with CAD risk in this healthy Middle Eastern cohort. Initial associations were attributable to confounding by metabolic factors such as obesity, dyslipidemia, and hypertension. These findings underscore the importance of contextualizing SUA's role within population-specific risk profiles and highlight the need for nuanced risk stratification strategies.

Comparison between hyperechoic and normo-echoic amniotic membranes in patients with preterm premature rupture of membranes regarding pregnancy outcome

PURPOSE

To evaluate the amniotic membrane echogenicity as a marker of early delivery among pregnant women presenting with leakage of amniotic fluid.

METHODS

This prospective cohort study was commenced at the Obstetrics and Gynecology Department at Suez Canal University Hospital from March 2023 to March 2024. The study recruited 72 pregnant females aged 20-45 years with singleton pregnancies and presented with preterm leakage of amniotic fluid. The gestational age was between 28 and 37 weeks. The sonographic appearance of the amniotic membranes close to the internal os was evaluated using transvaginal ultrasound. The membranes were classified as hyperechoic when they showed echogenic similarity to the fetal bones (either skull, femur, or pelvic bones) or normo-echoic. The primary outcome measures were the time interval from admission to delivery and the incidence of spontaneous preterm labor.

RESULTS

The mean age of patients was 26.06 years old, with mean gestational age at hospital entry 32.47, with no statistically significant difference between hyperechoic and normo-echoic membranes groups. The admission to delivery time was longer among the normo-echoic group (20 days versus 7.1 days, p value = 0.001). The incidence of spontaneous preterm delivery was 71.9% in the hyperechoic membranes group versus 50% in the normo-echoic membrane group.

CONCLUSION

The existence of fetal membranes with increased echogenicity overriding the cervix could anticipate an unavoidable preterm birth in patients diagnosed with preterm premature rupture of membranes.

Mortality trends of infective endocarditis in Spain (2003-2022)

BACKGROUND

Infective endocarditis (IE) is a life-threatening infection with high morbidity and mortality. Trends in IE-related mortality have been less extensively studied compared to incidence. This study aimed to examine IE mortality trends in Spain from 2003 to 2022.

METHODS

This longitudinal ecological study analyzed data from the Spanish National Statistics Institute. Age-standardized mortality rates (ASMRs) were calculated, and joinpoint regression and age-period-cohort (APC) models were used to identify trends and underlying factors.

RESULTS

A total of 25,327 deaths from IE occurred, with a higher number in women. Mortality was strongly age-related, with the vast majority in those over 65. Joinpoint analysis revealed increasing ASMRs in men for all ages and the 65+ age group, while rates remained stable in women. The 35-64 age group showed a decrease in rates for both sexes. A-P-C analysis confirmed age as a significant effect, with mortality rates increasing with age for both sexes. Cohort effects showed a decline in mortality risk in successive birth cohorts, particularly those born after the 1920s and 1930s. Period effects demonstrated a decline in IE mortality risk over the study period.

CONCLUSION

IE mortality trends in Spain are complex, with significant progress in reducing mortality rates, particularly among younger adults and women. However, challenges remain, especially for older men. These findings highlight the need for targeted interventions and further research to understand the factors driving mortality changes and improve outcomes for all affected by IE.

Pretransplant Physical Activity and Cardiovascular Risk Factors in Kidney Transplant Candidates: A Cross-Sectional Study

Background/Objectives: Individuals with chronic kidney disease often face significant physical and clinical challenges, such as muscle weakness, fatigue, and reduced cardiorespiratory capacity, that impact their quality of life. Physical activity has emerged as an effective intervention to counteract these effects, with clinical guidelines recommending exercise as a standard treatment for kidney transplant recipients. The aim of this study was to assess pretransplant physical activity levels in a cohort of transplant patients and analyze their relationships with cardiovascular risk factors. Methods: A cross-sectional, analytical, and correlational study was conducted from September 2020 to June 2022 with a sample of 122 kidney transplant recipients assessed before kidney transplantation. Sociodemographic data, anthropometric data, comorbidities, renal replacement therapy types, and clinical and analytical data were collected from the patients' clinical records. Physical activity was assessed via the International Physical Activity Questionnaire. Results: The average time spent waiting for transplantation was 423 ± 405 days, which was longer (387 ± 524) in the group of those under 65 years than in those over 65 years (194 ± 256) (p = 0.010). The median energy expenditure was 1742 (IQR = 1719) METs. In addition, 15.6% of the participants reported inactivity. Men reported higher physical activity levels (median: 2076 METs/week; IQR: 2037) than women did (median: 1386 METs/week; IQR: 1238). A higher level of physical activity was found in non-dialysis patients, overweight patients, and those with a history of stroke. A significant positive correlation was found between physical activity levels and serum urea. Conclusions: Increased physical activity levels were observed in men and in participants under 65 years of age. Patients with cardiovascular risk factors, such as hypertension, diabetes mellitus, dyslipidemia, overweight and obesity, reported lower activity levels, whereas those with a prior history of cerebrovascular accidents engaged in more physical activity. This study highlights the importance of assessing physical activity and promoting exercise for chronic kidney disease patients awaiting kidney transplantation. Further research is needed to explore the evolution of physical activity in this population and its impact post-transplantation.

Impact of ventilatory and laboratory parameter trajectories on short-term survival in acute respiratory distress syndrome patients: a retrospective study using joint models

BACKGROUND

Clinical research is based on the parameters at defined time points, such as admission, diagnosis or discharge, for the purpose of risk factor analysis in relation to outcome. However, these parameters are collected with greater frequency in clinical practice. The objective of this study was to demonstrate a correlation between the time course of closely monitored parameters, such as blood gases, ventilatory parameters or routine laboratory values, and the survival of patients with acute respiratory distress syndrome (ARDS) caused by pneumonia.

METHODS

This single-center, retrospective study included 274 ARDS patients with primary pneumonia requiring invasive mechanical ventilation. Patients were treated at a German university hospital between January 2014 and April 2021. Ethical approval was obtained from the local ethics committee (BO-EK-374072021). Longitudinal data on ventilatory and inflammatory parameters were collected during ICU stays. The analysis was conducted using descriptive statistics, cox regression and joint models. Joint modelling was used to integrate the progression of these parameters with survival outcomes, with the modelling of longitudinal data performed using quadratic B-splines.

RESULTS

The cohort included 274 patients, with an ICU mortality rate of 49.6%. Non-survivors were older (67 vs. 62 years, p < 0.001) and had higher SOFA scores at admission (10 vs. 8, p < 0.001). Differences in ventilatory parameters, including driving pressure and the PaO₂/FIO₂ ratio, as well as inflammatory markers such as procalcitonin, were observed between survivors and non-survivors during the ICU stay. The joint model analysis revealed a significant effect of the time course of parameters, such as positive end-expiratory pressure (PEEP), peak airway pressure (Ppeak), driving pressure, minute ventilation, tidal volume, C-reactive protein (CRP) and procalcitonin on mortality. The increase over time (slope-dependent association) for these parameters was strongly associated with mortality. For example, driving pressure was associated with mortality both by its current value (HR 1.16) and by its increase over time (HR 7.10). Similarly, tidal volume (HR 0.72 and 0.07), minute ventilation (HR 0.91 and 0.36), PEEP (HR 1.32 and 13.52), Ppeak (HR 1.20 and 3.28) and CRP (HR 1.14 and 4.25) showed a current value association and a strong slope-dependent association with mortality.

CONCLUSION

This study underscores the importance of analyzing the dynamics of clinical parameters rather than static values for ARDS management. The findings suggest that changes in routine clinical parameters over time provide valuable prognostic information and should be prioritized in risk assessment and therapeutic decision making.

Concentrated growth factor with guided tissue regeneration for shallow infrabony defects: A one-year prospective study

BACKGROUND

This study evaluated the efficacy of concentrated growth factor (CGF) sticky bone combined with guided tissue regeneration (GTR) in treating shallow infrabony defects and explored factors influencing clinical outcomes.

METHODS

Thirteen patients with 31 shallow defects (≤3 mm) were treated using CGF sticky bone (CGF + deproteinized bovine bone mineral), covered with a collagen membrane and CGF membrane. Probing depth (PD), clinical attachment level (CAL), and gingival recession (REC) were examined at baseline and 1 year post surgery. The distance between the base of the defect and the cementoenamel junction (BD-CEJ) were measured on periapical radiographs. Gingival volume and thickness were assessed with digital intraoral scans. Linear regression identified factors influencing CAL gain, PD reduction, and bone gain (ΔBD-CEJ).

RESULTS

One year post surgery, CAL increased by 2.48 ± 1.72 mm (p < 0.001), PD reduced by 2.90 ± 1.40 mm (p < 0.001), and bone gain was 2.46 ± 1.71 mm (p < 0.001). REC remained stable (p = 0.254), and the volume and thickness of gingival contour showed no significant changes (p = 0.751 and p = 0.915, respectively). Greater baseline attachment loss was associated with higher CAL gain (coefficient 0.436, p = 0.001). Deeper preoperative PD predicted greater PD reduction (coefficient 0.573, p = 0.029). Greater bone gain was correlated with lower baseline bone height (coefficient 0.305, p = 0.018).

CONCLUSIONS

CGF sticky bone combined with GTR demonstrates benefits in CAL gain, PD reduction, and bone gain while preventing REC and gingival contour collapse in the treatment of shallow infrabony defects with residual pockets after initial therapy.

CLINICAL TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2300069617).

PLAIN LANGUAGE SUMMARY

This study explored a novel approach to treating shallow bone defects around teeth using a combination of concentrated growth factor (CGF) sticky bone and guided tissue regeneration (GTR). The treatment involved using a specially prepared bone graft material (CGF sticky bone) along with a collagen membrane and a CGF membrane. The researchers tracked the changes in gum and bone health in 13 patients with 31 shallow defects over 1 year. The results showed significant improvements: Gum attachment levels increased by an average of 2.48 mm, gum pockets reduced by 2.90 mm, and bone growth averaged 2.46 mm. Notably, gum recession and gingival contour remained stable, meaning the treatment did not compromise the appearance of the gums. The study also found that patients with worse gum or bone loss at the start of the treatment tended to experience the greatest improvements. These findings suggest that CGF sticky bone combined with GTR is a promising option for restoring shallow bone defects, particularly in cases where traditional therapy has left residual gum pockets.

Childhood Influenza Vaccination Is Not a Priority for Parents: A National, Cross-Sectional Survey of Barriers to Childhood Influenza Vaccination in Australia

Background/objectives: Influenza vaccines are recommended and free in Australia for children aged <5 years, but uptake remains low at 25.8% compared to the targets of 40% and 50%. National data on barriers hindering paediatric influenza vaccination can inform strategies to improve uptake. The aim of this study was to measure barriers to influenza vaccination in Australian children aged <5 years. Methods: A national, cross-sectional survey of parents of children aged <5 years was conducted in March/April 2024. Parents were recruited using an online panel and asked about their intention to get an influenza vaccine for their youngest child in the upcoming influenza season. An adapted version of the validated Vaccine Barriers Assessment Tool measured 14 influenza vaccination barriers. Analysis assessed the prevalence of barriers and differences between parents intending to and those unsure or not intending to vaccinate by calculating the prevalence difference and 95% confidence interval. Results: A total of 2000 parents were recruited nationally. The most common barrier was parents feeling distressed when thinking about vaccinating their child against influenza (66.1% of intending parents, 65.6% of unsure/not intending parents). The barrier with the largest difference between intending and not intending/unsure parents was not prioritising their child's influenza vaccination (47.2% vs. 6.1%, PD = 41.1 ppts, 95% CI: 35.9%, 46.3%). Other barriers with large differences were parents not feeling guilty if their unvaccinated child got influenza (41.5% vs. 7.5%, PD = 34.0 ppts, 95% CI: 28.8%, 39.1%) and parents not believing that influenza vaccines are effective (31.3% vs. 3.0%, PD = 28.2 ppts, 95% CI: 23.6%, 32.9%). Conclusions: Parents should be encouraged and supported to prioritise influenza vaccination alongside routine childhood vaccines in campaigns that emphasise disease risk and the importance, safety and effectiveness of influenza vaccination, and by optimising access to influenza vaccination. We recommend conducting similar surveys regularly to monitor trends in parental barriers to childhood influenza vaccination.

Comparing Survivorship of Symmetric Versus Asymmetric Tibial Augments in Aseptic Revision Total Knee Arthroplasty

BACKGROUND

This study evaluated the presence of radiolucency in patients who underwent aseptic revision total knee arthroplasty (arTKA) using either symmetric or asymmetric modular tibial augments and compared 5-year all-cause and non-septic revision-free survivorship between groups. The authors hypothesized that tibial constructs with asymmetric augments would be more prone to radiolucency, but that there would be no difference between groups regarding implant survivorship at five years.

METHODS

An institutional database was queried from January 2013 to September 2023 to identify patients who underwent arTKA where tibial augments were utilized. Patients who had proximal tibial reconstructions (PTRs), distal femoral reconstructions (DFRs), or hinge constructs, as well as patients who did not have a minimum of one year of follow-up, were excluded. Included patients were then stratified into symmetric and asymmetric tibial augment groups. Postoperative radiographs were reviewed for radiolucent lines through available follow-up. Kaplan-Meyer survivorship curves were then created to compare rates of revision between both groups over five years. A total of 76 patients who had symmetrical augments and 27 patients who had asymmetrical augments were analyzed at a mean follow-up time of 3.5 years (range, 1.0 to 10.1) and 4.4 years (range, 1.0 to 8.8), respectively.

RESULTS

Radiolucency was noted in 44.4% (12 of 27) of patients who had asymmetric augments and 44.7% (34 of 76) of those who had symmetric augments (P = 1.0). Overall, the 5-year all-cause revision-free survivorship for the entire cohort was 76.6%. The 5-year all-cause and non-septic revision-free survival were lower in patients who had asymmetric tibial augments compared to symmetric (56.1 versus 85.5%; P = 0.021 and 64.8 versus 89%; P = 0.019, respectively). Patients who had symmetric tibial augments had 84% less risk of non-septic revision when compared to patients who had asymmetric tibial augments (P = 0.035). Sub-analysis demonstrated that asymmetric tibial augment constructs with metaphyseal cones had similar 5-year non-septic revision-free survivorship to symmetric tibial augment constructs with (75.0 versus 97.0%; P = 0.13) or without metaphyseal cones (75.0 versus 82.5%; P = 0.54).

CONCLUSION

Patients who had symmetric tibial augment constructs exhibited similar rates of radiolucency, but higher survivorship compared to those who had asymmetric constructs overall. However, when metaphyseal cones were utilized, survivorship was equivalent. Therefore, their use in asymmetric tibial augment constructs is likely beneficial.

Immune-mediated adverse events following atezolizumab and bevacizumab in a multinational Latin American cohort of unresectable hepatocellular carcinoma

AIMS

Latin America has been underrepresented in trials evaluating immunotherapy for hepatocellular carcinoma (HCC). We aimed to describe the incidence of immune-related adverse events (irAEs) and their impact on outcomes in a Latin American cohort.

METHODS

A multicenter prospective study was conducted in Argentina, Brazil, Chile, and Colombia, including patients who received atezolizumab plus bevacizumab. A time-covarite proportional hazard analysis evaluated the effect of irAEs.

RESULTS

99 patients were included. The median treatment duration was 6 months, with a median survival of 17.0 months (95% CI: 12.6-19.8). The irAE incidence rate was 2.1 cases per 100 persons-months (cumulative incidence 18.1% (95% CI: 11.1-27.2%)). Median time to irAE was 2.3 months (range 1.4-4.8), most frequently hepatitis (n = 6), thyroiditis (n = 5), and 8/18 required steroids. Follow-up, treatment duration, and overall survival were similar regardless of the occurrence of irAEs (HR = 1.71, 95% CI: 0.76-3.86; P = 0.19). Baseline alpha-feto protein ≥400 ng/ml (HR: 2.9 (95% CI: 1.1-7.6)) was independently associated with irAE.

CONCLUSION

The incidence of irAEs in this cohort is lower than reported in controlled trials, withouut impact on survival outcomes. Education and early recognition are crucial to ensure that these events are identified and addressed.

Additional value of uterine artery Doppler pulsatility index for ultrasound diagnosis of placental site trophoblastic tumor: prospective cohort study

OBJECTIVES

The ultrasound diagnosis of placental site trophoblastic tumor (PSTT) is challenging owing to a lack of pathognomonic features. Differential diagnosis from other forms of gestational trophoblastic neoplasia (GTN) is critical owing to major differences in prognosis and treatment. Doppler measurement of uterine artery (UtA) pulsatility index (PI) has been proposed for the diagnosis and management of GTN. The aim of this study was to evaluate the added value of UtA-PI Doppler measurement during the standard transvaginal ultrasound (TVS) assessment, in patients with PSTT as compared to those with other GTN.

METHODS

This was a single-center prospective cohort study involving ultrasound assessment of all GTN cases referred to and treated at the trophoblast unit of San Raffaele Hospital, Milan, Italy, between 2011 and 2023. TVS assessment included: grayscale analysis for the detection of myometrial or endometrial abnormalities, color and power Doppler assessment of lesions with scoring of vascularization, and spectral pulsed-wave Doppler for measurement of mean UtA-PI from the left and right UtAs. Sonographic findings were compared between patients with PSTT and those with other forms of GTN (postmolar, invasive mole or choriocarcinoma), using non-parametric two-tailed statistical analysis.

RESULTS

A total of 73 GTN cases were recruited, comprising nine (12.3%) with PSTT and 64 (87.7%) with other GTN. A significant difference was detected between other-GTN and PSTT cases when comparing rates of substantial endometrial vascularity on Doppler (50% vs 0%; P = 0.013) and mean UtA-PI measurements (median, 1.5 (interquartile range (IQR), 1.0-2.4) vs 2.2 (IQR, 1.5-2.7); P = 0.014; area under the receiver-operating-characteristics curve, 0.768 (95% CI, 0.610-0.888)).

CONCLUSIONS

This study describes UtA-PI as a novel and effective marker allowing for the ultrasound differentiation of PSTT from other forms of GTN. The significantly higher mean UtA-PI and lower endometrial vascularity observed in PSTT as compared with other GTN suggests a unique vascularization pattern, with a potential role in differential diagnosis and management. © 2025 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

No independent association between dietary calcium/vitamin D and appendicular lean mass index in middle-aged women: NHANES cross-sectional analysis (2011-2018)

Skeletal muscle preservation during midlife is critical for preventing sarcopenia in aging populations. While calcium and vitamin D are recognized for their musculoskeletal benefits, their specific associations with muscle mass in middle-aged women remain unclear. This cross-sectional study analyzed data from 2,496 women aged 40-59 years in the NHANES (2011-2018). Multivariable linear regression models adjusted for demographics, lifestyle factors, and comorbidities evaluated associations between dietary calcium, vitamin D intakes and appendicular lean mass index (ALMI), with subgroup analyses by menopausal status and other covariates. After full adjustment, neither dietary calcium nor vitamin D intake showed significant associations with ALMI. Null findings persisted across all subgroups. Dietary calcium and vitamin D intake were not independently associated with ALMI in middle-aged women. These results highlight the need to investigate broader nutritional patterns or synergistic mechanisms influencing muscle health during midlife.

Sleepiness, fatigue, and obstructive sleep apnea in stroke patients

OBJECTIVES

Obstructive sleep apnea (OSA) impacts approximately 70% of stroke patients, often causing fatigue and sleepiness. Although continuous positive airway pressure (CPAP) reduces sleepiness, systematic OSA screening is not standard in post-stroke care, and the effect of untreated OSA on fatigue is unclear. This study investigated changes in sleepiness and fatigue among OSA patients following ischemic stroke or transient ischemic attack (TIA) who underwent CPAP treatment.

METHODS

This prospective multi-center cohort study, ischemic stroke and TIA patients were screened for OSA using respiratory polygraphy. CPAP-eligible patients (Apnea-Hypopnea Index ≥15) were assessed with the Epworth Sleepiness Scale (ESS) and Visual Analogue Scale-Fatigue (VAS-F) at baseline and seven to eight months post-stroke. CPAP compliance was classified into high (≥70%), moderate (50-69%), and low (<50%) compliance based on nights using CPAP more than four hours per night. Poisson regression models analyzed differences in ESS and VAS-F between compliance groups, with low-compliance as the reference.

RESULTS

Of 2605 patients, 1518 (mean age: 70 ± 12 years; 61% male) were screened, and 648 were CPAP-eligible. At follow-up, 333 patients were assessed (49% lost to follow-up). Sleepiness significantly decreased in the high-compliance group compared to low-compliance (p<0.001). Fatigue levels decreased across all compliance groups, b no differences were observed between groups.

CONCLUSIONS

High CPAP compliance in post-stroke or TIA patients with OSA was associated with a reduction in sleepiness but not fatigue. These findings support the recommendation to systematically screen post-stroke patients for OSA and encourage CPAP compliance to mitigate sleepiness.

Reoperation and mortality following elective surgery for chronic and recurrent colonic diverticular disease: A nationwide population-based cohort study

PURPOSE

The ideal treatment for chronic and recurrent colonic diverticular disease (crDD) remains unresolved, partly due to lacking evidence regarding surgical safety. This study evaluated 90-day reoperation and mortality rates following elective surgery for crDD and explored predictors for reoperation and mortality.

METHODS

This national cohort study included all patients with crDD undergoing elective colonic resection or stoma formation in Denmark from 1996-2021. Outcomes were the 90-day cumulative incidence proportion (CIP) of reoperation and mortality, and predictors were explored in Cox proportional hazard models.

RESULTS

Among 35,174 patients with crDD, 3,584 (10%) underwent elective surgery. The 90-day reoperation rate was 18.0%; mortality was 1.6%. During the 25-year period, the reoperation rate declined 30%, from 19.5% to 13.8%, and mortality declined 74%, from 2.7% to 0.7%. Among 2,942 patients with colonic resection and no stoma formation, the reoperation rate due to anastomotic leak was 3.0% overall and 0.9% in the most recent years. Mortality was 18 times higher in patients aged ≥ 80 years versus those aged < 60 years (CIP 8.0% versus 0.4%). The reoperation rate was increased in patients with ≥ 4 hospital contacts or ≥ 3 admissions compared to patients with fewer contacts, while mortality was not associated with the number of hospital contacts before surgery.

CONCLUSION

Elective surgery in crDD was safe with careful patient selection. The risk of reoperation due to anastomotic leak was very low. Patients with most hospital contacts had an increased reoperation rate, supporting consideration for elective surgery early in patients with disabling diverticular disease.

Registered nurses' perceptions of their leadership close to older adults in municipal home healthcare: a cross-sectional questionnaire study

BACKGROUND

Registered nurses lead the nursing care close to older adults in home healthcare. It is expected that there will be an increased need for home healthcare. In addition, more advanced care is now being performed in home healthcare, leading to increased demands for registered nurses. Therefore, the aims of this study are to explore and compare registered nurses' perceptions of their leadership close to older adults in municipal home healthcare, as well as to correlate their perceptions with age and work experience.

METHODS

This study is a part of a larger web-based questionnaire survey, with a non-experimental and cross-sectional design. Descriptive and analytical statistics were used. A total of n = 71 registered nurses leading close to older adults participated, in seven municipalities in two geographic areas in Sweden.

RESULTS

The registered nurses perceived their ability as leaders close to older adults as high. The registered nurses had neither low or high trust in care staff's competence. They perceived to have space and access neither in a low or high degree in their work to develop sufficient competence in leadership and having nursing responsibility on an organisational level. Registered nurses' perceptions of their leadership differed depending on whether they had a specialist education or not; those with specialist education perceived to a higher degree that they could apply their professional experience in their work; interact with the older adult and their next of kin; assess individual needs and based on a holistic view of the older adult, create good relationships with the older adults' next of kin.

CONCLUSIONS

Registered nurses' specialist education may strengthen their leadership in home healthcare. Further research is needed to gain new knowledge of registered nurses' leadership in home healthcare, as well as care staff's' experiences of registered nurses' leadership in municipal home healthcare.

Longitudinal Observational Study on Quality of Life in Patients with Chronic Wounds Using DLQI and EQ-5D

Background and Objectives: Chronic wounds severely impair patients' quality of life (QoL), impacting physical, emotional, and functional well-being. Understanding the multidimensional effects of treatment is key to implementing effective, patient-centered care strategies. This study aimed to assess changes in QoL among patients with chronic wounds using the Dermatology Life Quality Index (DLQI) and EuroQol-5D (EQ-5D), comparing outcomes across treatment modalities. Materials and Methods: A longitudinal observational study was conducted between 2019 and 2024 across three hospitals in the Valencian Community. A total of 278 patients with venous lower-limb ulcers of more than six weeks' duration were included. Quality-of-life assessments were performed at baseline, one-month follow-up, and discharge. Treatments included alginate, foam, moist wound healing (MWH), compression therapy, and negative-pressure wound therapy (NPWT). Statistical analysis involved Friedman's test and repeated-measures ANOVA. Results: Significant improvements were observed in overall QoL across most treatment modalities. EQ-5D scores progressively increased, while DLQI scores decreased. Pain, embarrassment, and limitations in daily life (e.g., shopping and social activities) showed marked reductions. MWH and foam demonstrated the most favorable impact on QoL, while NPWT showed more modest improvements, possibly due to patient complexity. Notably, the variable "sexuality" remained unchanged (mean = 0.00), possibly due to underreporting or communication barriers. Conclusions: Chronic wound treatments significantly improve patients' quality of life, particularly in terms of pain and social functioning. The use of combined tools (DLQI and EQ-5D) allows for a more comprehensive understanding of these outcomes. These findings highlight the importance of tailoring wound care to individual needs and addressing psychosocial domains, including sexuality. Community nursing, nutritional support, and long-term follow-up should be incorporated into care plans to optimize results, especially in older adults.

Inverted L-shape association between a body shape index and peak expiratory flow among middle-aged and older adults: findings from the China Health and Retirement Longitudinal Study (CHARLS)

BACKGROUND

Peak expiratory flow (PEF) serves as a direct indicator of the functional status of the respiratory system. Higher body fat content, especially abdominal obesity, may relate to a deterioration in long-term respiratory function. The "A Body Shape Index" (ABSI) better assesses abdominal obesity, but its association with PEF is poorly understood.

METHODS

The analysis demonstrated data from 14,386 middle-aged and older adults from the 2015 China Health and Retirement Longitudinal Study (CHARLS). ABSI, a sex-specific metric integrating waist circumference, weight, and height via allometric modeling derived from Chinese anthropometrics, was analyzed against PEF/PEF prediction using multivariable linear and spline regressions to characterize nonlinear associations. Threshold effects, subgroup, and sensitivity analyses ensured robustness.

RESULTS

This research showed a negative relationship between ABSI and both PEF and PEF predictions. An inverted L-shaped curve in the spline analysis characterized the association between ABSI and PEF/PEF prediction across the sexes. The ABSI threshold was 0.0782 and 0.0691 in males and females, respectively.

CONCLUSIONS

Abdominal obesity negatively affects respiratory function, with ABSI thresholds varying by sex. Therefore, weight management should focus on a healthy ABSI to reduce abdominal obesity and safeguard respiratory health.

Mediating role of emotional intelligence in the relationship between dual work stress and reflective ability among junior nurses

BACKGROUND

Junior nurses constitute the backbone of the nursing workforce, and their reflective ability is essential for clinical decision-making, as well as for driving innovation and improvement in nursing practices. Although numerous studies emphasize the importance of enhancing reflective ability in junior nurses, the specific relationships among emotional intelligence, dual work stress, and reflective ability remain unclear.

OBJECTIVE

To explore the mediating effect of emotional intelligence on the relationship between dual work stress and reflective ability among junior nurses, with the aim of providing evidence-based guidance for nursing managers to improve reflective ability in clinical settings.

METHODS

A cross-sectional study was conducted between October 2023 and January 2024, involving 308 junior nurses from three tertiary hospitals in Jiaxing City, Zhejiang Province, selected through convenience sampling. Data were collected using a demographic questionnaire, the Challenge-Hindrance Stressor Scale, the Emotional Intelligence Scale, and the Reflective Ability Scale.

RESULTS

Challenge stress among junior nurses was 18.00 (13.00, 23.00), hindrance stress was 17.00 (12.00, 21.00), emotional intelligence was 54.00 (40.00, 67.00), and reflective ability was 59.00 (46.00, 71.00). Challenge stress showed positive correlations with emotional intelligence and reflective ability (r = 0.382 and 0.379, respectively, P < 0.01), while hindrance stress showed negative correlations with both (r = - 0.279 and - 0.381, P < 0.01). Emotional intelligence was also positively correlated with reflective ability (r = 0.378, P < 0.01). In addition, emotional intelligence partially mediated the effects of both challenge stress and hindrance stress on reflective ability, with mediation values of 0.095 and - 0.048, accounting for 32.0% and 16.7% of the total effect, respectively.

CONCLUSION

Junior nurses demonstrated a moderate level of reflective ability and a moderately low level of emotional intelligence. Both hindrance stress and challenge stress were reported at moderate levels. These findings underscore the importance for nursing managers to acknowledge the impact of dual work stress and emotional intelligence on reflective ability. It is recommended to establish and implement effective stress management strategies with a focus on enhancing emotional intelligence among junior nurses. Such initiatives may improve reflective ability, thereby contributing to higher nursing quality and promoting professional development in the field.

CLINICAL TRIAL NUMBER

Not applicable.

Coronary artery bypass grafting with or without preoperative physiological stenosis assessment: a SWEDEHEART study

BACKGROUND AND AIMS

Physiological flow assessment of coronary stenoses, such as fractional flow reserve, are routinely used to guide percutaneous coronary intervention, but it has not been equally recognized to guide coronary artery bypass grafting (CABG). Mid-term outcomes in CABG patients with and without preoperative flow assessment were compared.

METHODS

All patients with first-time isolated CABG in Sweden 2013-2020 were identified in the SWEDEHEART registry (n = 18 211), which also provided information on flow assessment. Data were linked with three mandatory national registries. Median follow-up was 3.6 years (range 0-7.5). Incidence of all-cause mortality, stroke, new myocardial infarction, new coronary angiography, and new revascularization was compared using adjusted Cox regression models. The proportional hazard assumption was violated for new angiography and revascularization. Hence, follow-up was divided into 0-2 and >2 years.

RESULTS

Overall, 2869 patients (15.8%) had flow assessment before surgery, increasing from 7.1% in 2013% to 21.5% in 2020. Patients with flow assessment were younger, had a lower EuroSCORE II, and received fewer distal anastomoses (3.0 ± 0.9 vs 3.2 ± 1, P < .001). There were no associations between flow assessment and mortality, post-discharge myocardial infarction, or stroke. New angiography and new revascularization were not significantly different 0-2 years, but preoperative flow assessment was associated with a higher risk for new angiography [adjusted hazard ratio (aHR) 1.32, 95% confidence interval (CI) 1.08-1.62, P = .008] and new revascularization (aHR 1.55, 95% CI 1.18-2.04, P = .002) >2 years after CABG.

CONCLUSIONS

Preoperative flow assessment was not associated with improved clinical outcomes but with a higher risk for new angiography and new revascularization >2 years after CABG. The results suggest that the use of flow assessment with current cut-off levels may not be applicable in CABG, and further studies are needed.

Sex differences in physical activity dose-response effects on site-specific bone mineral density during childhood and adolescence

Physical activity (PA) serves as a modifiable determinant of bone mineral density (BMD). However, sex- and site-specific dose-response relationships remain poorly defined. Leveraging data from the National Health and Nutrition Examination Survey (NHANES 2011-2014), this cross-sectional study investigated sex-specific associations between accelerometer-derived PA (volume and intensity) and site-specific BMD in 2,659 children and adolescents aged 8-19 years. BMD assessment was conducted via dual-energy X-ray absorptiometry, and PA was quantified using monitor-independent movement summary units (MIMS). Linear and nonlinear analyses revealed distinct patterns: boys exhibited stronger linear associations between PA volume and BMD at weight-bearing sites (e.g., pelvis, arms, and legs; β = 0.003-0.004, P < 0.05), and girls demonstrated nonlinear thresholds (e.g., volume threshold: 15.0 × 103 MIMS/day). Both sexes had intensity-driven thresholds (~ 45-49 MIMS/min), with diminishing returns above these values (β = 0.010 in boys; stagnation in girls). Directional trends suggest the greater BMD gains per standard deviation (SD) increase in PA for boys compared with that for girls across most skeletal regions (e.g., total body less head: 0.131 SD vs. 0.106 SD for intensity). However, statistical significance (P < 0.05) was observed only for arm BMD responses. Mechanistic analyses highlighted the corresponding biomechanical principles, with weight-bearing regions showing stronger PA-BMD links than nonweight-bearing sites (e.g., spine). These findings underscore the importance of prioritizing high-intensity, weight-bearing activities, particularly for girls, to optimize skeletal health during growth. Public health strategies should focus on achieving, rather than exceeding, the identified daily 60 min intensity thresholds (~ 45-49 MIMS/min) through school- and community-based interventions.

Differential effect of triglycerides on the prognosis of patients with a first versus recurrent acute coronary syndrome

BACKGROUND

There is divergent evidence of triglycerides on cardiovascular prevention that might be explained by confounding factors.

METHODS

We performed a multicenter and retrospective study using the ongoing registries of acute coronary syndrome (ACS) patients of 8 hospitals from Spain. Triglycerides were measured during the hospitalization, and mortality and major adverse cardiovascular events (MACE) were analysed through follow-up.

RESULTS

We included 14,483 patients discharged after an ACS. Median triglycerides level was 120.5 (interquartile range [IQRS] 90-197) mg/dL and was slightly higher in patients with recurrent ACS (135 IQR 98-186 vs. 129 IQR 95-175; p < .01). Through the follow-up, 34.7% of the patients experienced a first MACE rate and 15.0% died. Multivariate analysis identified that triglycerides levels were associated with a higher risk of MACE (HR 1.01 95% CI 1.00-1.02, p = .021) but not with all-cause mortality (HR: 1.00 95% .99-1.02, p = .17). A significant interaction (p = .01) was observed for triglycerides and previous ACS for both endpoints and, therefore, analyses were performed separately. Triglycerides were only associated with a higher risk of MACE in patients with recurrent ACS (HR 1.03 95% CI 1.01-1.05, p = .012) and a higher risk of death in patients with a first ACS (HR 1.02 95% CI 1.01-1.04, p = .02).

CONCLUSIONS

Previous ACS modifies the risk of triglycerides on MACE and mortality in patients discharged after an ACS. Triglycerides might be considered a target for treatment in patients after a first or recurrent ACS, although the expected benefit on outcomes might be different.

The Use of Griffiths III in the Appraisal of the Developmental Profile in Autism: A Systematic Search and Review

BACKGROUND

Griffiths III is a child-friendly and play-oriented direct gold-standard measure of a 0-6-year-old child's developmental profile. It is a measure that helps practitioners in detecting the weaknesses in children who have an increased likelihood or a diagnosis of neurodevelopmental disorders, e.g., autism.

OBJECTIVES

Following the PICO protocol, two research questions addressed the current systematic search and review (Prospero registration: CRD42024554286): What is(are) the main developmental domain(s) evaluated by Griffiths III impaired in autism? (RQ1); Using Griffiths III, what is(are) the main developmental domain(s) improved after an autism-specific early intervention? (RQ2).

METHODS

Six studies have been reviewed: three case-control studies, a case report study, and two studies examining the effectiveness of early autism-specific interventions. According to the study design, the methodological quality was evaluated using three standardised protocols: STROBE; JBI; CEC.

RESULTS

The results highlighted that the Language and Communication and Personal-Social-Emotional domains are the most impaired in autistic children and in those with an increased likelihood (RQ1). The results outlined that early target intervention enhanced the same domains (RQ2).

CONCLUSIONS

In conclusion, the findings highlight the importance of screening not only for autism traits but also for impairments in language, communication, and socio-emotional skills. The future direction of the results is discussed.

Community-level determinants of loneliness and social isolation: a population-based cohort study across younger and older adults

Introduction

Loneliness and social isolation (SI) are critical public health issues with well-documented effects on health and well-being. However, much of existing observational and intervention research has focused predominantly on individual-and interpersonal-level factors. This longitudinal study addresses significant knowledge gaps by comprehensively examining the independent influence of multiple community-level determinants on loneliness and SI and uniquely comparing these effects across younger (18-30 year) and older (60 + years) adults within an Australian population cohort over a 12-year period.

Methods

Using longitudinal data from the Household, Income and Labour Dynamics in Australia (HILDA) survey, we analysed data from four wave pairs (2006/07, 2010/11, 2014/15, 2018/19) to investigate associations between loneliness and SI and nine community and neighbourhood-level variables. We employed lagged mixed-effects Poisson regression models to calculate risk ratios (RR) adjusted for individual-and interpersonal-level factors.

Results

Our findings reveal that low community engagement is the strongest risk factor for loneliness and SI in both younger (Loneliness, RR = 1.34; SI, RR = 1.58) and older populations (Loneliness, RR = 1.35; SI = 2.02). Low neighbourhood social cohesion was found to significantly increase loneliness and SI in older adults (Loneliness, RR = 1.15; SI, RR = 1.36) and to increase SI in younger adults (RR = 1.54). We also observed distinct age-specific effects, with cultural practices, altruism, and perceived neighbourhood safety having differential impacts across age groups.

Discussion

Our findings highlight the critical need for community-level interventions to address loneliness and SI, suggesting that focusing solely on individual-related factors is insufficient. Tailoring public health strategies to enhance community dynamics may be essential in reducing loneliness and SI among vulnerable populations, particularly in areas with low social cohesion and community engagement offerings.

Functional limitations and suicidal ideation: Independent, interactive, and cumulative associations in a nationally representative sample

BACKGROUND

Suicidal ideation is a critical public health issue, often linked to functional limitations that hinder daily activities. However, the independent, interactive, and cumulative effects of specific types and quantities of functional limitations on suicidal ideation remain underexplored.

METHODS

Data were analyzed from 12,263 U.S. adults in the National Health and Nutrition Examination Survey (NHANES, 2013-2018). Functional limitations were assessed across six domains: vision, hearing, cognitive, mobility, dressing/bathing, and errands. Multivariable logistic regression and interaction models were used to examine associations between functional limitations and suicidal ideation. Dose-response relationships were evaluated using restricted cubic spline regression.

RESULTS

Vision (OR = 1.77, 95 % CI = 1.00-3.13), cognitive (OR = 5.52, 95 % CI = 3.63-8.39), and errand limitations (OR = 1.75, 95 % CI = 1.09-2.79) were independently associated with suicidal ideation. A significant interaction effect was observed between hearing and cognitive limitations, with the co-occurrence amplifying suicidal ideation risk (OR = 5.80, 95 % CI = 3.84-8.78). Additionally, a dose-response relationship was found, with individuals experiencing ≥5 limitations having the highest risk.

CONCLUSIONS

Functional limitations, particularly cognitive and errand-related impairments, are strongly associated with suicidal ideation. Interaction effects and cumulative impacts underscore the need for integrated mental and physical healthcare approaches. Tailored interventions targeting specific limitations and addressing cumulative burdens may mitigate suicidal ideation in this vulnerable population.

Impact of surgical technique on hemodynamic instability in patients with pheochromocytoma: a single-centre retrospective cohort study

BACKGROUND

Endoscopic adrenalectomy by either transperitoneal laparoscopic (TLA) or posterior retroperitoneoscopic approach (PRA) is the preferred treatment for pheochromocytoma (PCC). PRA shows advantages in patient outcome, but blood pressure fluctuations may occur due to limited working space and increased CO2-pressure. We investigated the impact of surgical technique on intraoperative hemodynamic instability in patients with PCC.

METHODS

Patients who had endoscopic adrenalectomy for PCC consecutively from 2007 to 2022 were included in this retrospective cohort study. The primary outcome was hemodynamic instability (HI-score) and secondary outcomes were hemodynamic parameters and drug administration.

RESULTS

Overall, 101 patients met the inclusion criteria, 57 had TLA and 44 PRA. The two groups were similar in baseline characteristics. The HI-score was higher in PRA than in TLA (97 vs 46, p < 0.001) due to more frequent (IQR: 2-5 vs IQR: 1-3, p = 0.025) and longer episodes of hypotension (5.6% vs 7.1%, p = 0.013), and longer episodes of bradycardia (9.9% vs 16.9%, p = 0.038). On the contrary, TLA patients had higher maximum systolic blood pressure (169 mmHg vs 157 mmHg, p = 0.046), more frequent episodes of tachycardia (31.6% vs 6.8%, p = 0.002) and higher maximum heart rate (90 bpm vs 80 bpm, p = 0.024). PRA patients needed more vasoconstrictive drugs (97.7% vs 78.9%, p = 0.017) and fluid infusion (1111 ml/h vs 798 ml/h, p = 0.004), whereas TLA patients received more vasodilating drugs (64.9% vs 38.6%, p = 0.009).

CONCLUSIONS

PRA was associated with higher hemodynamic instability than TLA reflected by hypotension, need for vasoconstrictive drugs and fluid infusion in a selected cohort of patients with pheochromocytoma.

Muscle Recruitment and Asymmetry in Bilateral Shoulder Injury Prevention Exercises: A Cross-Sectional Comparison Between Tennis Players and Non-Tennis Players

Background/Objectives: Shoulder injuries are common in overhead sports like tennis due to repetitive unilateral movements that can lead to muscle imbalances. This study aimed to compare muscle recruitment and asymmetry during bilateral shoulder injury prevention exercises (performed with both arms simultaneously) in tennis players versus non-tennis athletes. Methods: Thirty-nine athletes (sixteen tennis players, twenty-three non-tennis athletes) performed two bilateral scapular retraction exercises at 45° and 90° shoulder abduction. Surface electromyography (sEMG) recorded the activation of the middle and lower trapezius. Root Mean Square (RMS), peak RMS and muscle symmetry indices were analyzed. Results: Tennis players showed significantly lower trapezius activation, especially during prone retraction at 90°. Muscle symmetry was slightly higher in tennis players at 90°, but asymmetry increased at 45°, suggesting angle-specific adaptations. Conclusions: Repetitive asymmetric loading in tennis may reduce the activation of scapular stabilizers and contribute to muscular imbalances. Including targeted bilateral exercises in training may help improve scapular muscle function and reduce injury risk in overhead athletes.

Establishing Reference Values for Pulse Wave Velocity in Young People

BACKGROUND

Aortic pulse wave velocity (PWV) is an indicator of vascular aging and has proven to be effective in adult cardiovascular risk assessment. To use it in young people to identify those who may be at increased cardiovascular disease risk, reference values need to be determined. The Youth Vascular Consortium is a large, international database which was established to investigate vascular aging in youth. Using data from the Youth Vascular Consortium, this study aimed to develop reference values for aortic PWV in healthy young people.

METHODS

This is a retrospective, multicenter study. Data on demographics, anthropometric, biochemical, and vascular aging measures from participants aged 1 year to 40 years were harmonized. Generalized additive models were used to derive percentile curves for PWV and predicted percentiles at years of age were reported by sex, continent, and device.

RESULTS

Data from 19 930 participants (mean age=17 years, 51% female, 71% European), classified as healthy based on blood pressure, body mass index, serum glucose, and cholesterol levels, were included to construct the reference values. Six devices were used to assess aortic PWV (29% SphygmoCor). Device-specific percentile curves for aortic PWV were constructed, and an increasing trend was identified for both sexes with age.

CONCLUSIONS

This study provided reference values for aortic PWV assessed with 6 devices for healthy young people by age and sex. These percentiles may be applied clinically to identify youth with impaired vascular aging and, thus, those who may be at risk of developing overt cardiovascular disease in the future.

Increasing incidence and burden of obstructive sleep apnoea in the Finnish population: A cohort study from 2005 to 2019

BACKGROUND

Obstructive sleep apnoea (OSA) is a significant public health problem. We sought to characterize the typical features of patients with OSA and to study the burden and treatment of OSA in Finland from 2005 to 2019.

METHODS

Our data included adult patients with OSA (n = 50 317) treated in 2005-2019 in secondary care in the Hospital District of Helsinki and Uusimaa (HUS). We collected diagnosis and procedure codes and healthcare contacts from HUS data lake. Word search from patient records included body mass index (BMI), smoking status, Epworth Sleepiness scale (ESS), apnoea-hypopnea-index (AHI), continuous positive airway pressure (CPAP) treatment, and Mallampati score. ResMed Airview program was used to calculate the prevalence of CPAP treatment in 2018-2022.

FINDINGS

The annual incidence of OSA increased from 99 per 100 000 to 564 per 100 000 (+470 %) during 2005-2019. The most significant increase in healthcare contacts occurred in remote care and nurse visits from 336 to 35 959 per year (+10 602 %) and from 1051 to 23 609 per year (+2146 %), respectively. The prevalence of CPAP treatment increased from 0·74 % to 2·48 % during 2018-2022 (+235 %).

INTERPRETATION

As the prevalence of OSA is increasing, the need for more efficient treatment protocols was seen as a shift towards telemedicine and as an increase in nurse visits. Data lake offers an efficient way to analyse large data sets of OSA patient characteristics and treatment strategies.