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

Association between intravenous 5 % albumin administration and acute kidney injury after partial nephrectomy. A retrospective study

BACKGROUND

Acute kidney injury (AKI) after partial nephrectomy is a frequent postoperative complication that can affect nearly half of patients, according to various studies. In the current study, we investigated the association of intraoperative administration of 5 % albumin, compared with crystalloids alone, with AKI after partial nephrectomy.

METHODS

This single-center retrospective study included adult patients undergoing partial nephrectomy. The primary endpoint was AKI within 72 h after surgery using the KIDGO definition. Secondary endpoints were time-to-AKI, reoperations, AKI severity and length of hospital stay. We used propensity score-based nearest-neighbor methods balance the patient baseline characteristics.

RESULTS

A total of 1688 patients were included in the analysis, with 809 receiving 5 % albumin and 879 in the control group. After matching, 729 patients received 5 % albumin, while 674 were controls. The incidence of acute kidney injury (AKI) was significantly higher in the 5 % albumin group (32.78 %) compared to the control group (25.51 %). Multivariate analysis revealed that receiving 5 % albumin was associated with a 32 % increased risk of developing AKI. Furthermore, the analysis indicated that this association was dose-dependent.

CONCLUSION

Our study suggests that intraoperative administration of 5 % albumin may not be a risk factor for AKI after partial nephrectomy. Given the discrepancy between these results and previous studies, a future prospective randomized controlled trial is needed to confirm our findings.

Impact of coal mine dust exposure and cigarette smoking on lung disease in Appalachian coalminers

INTRODUCTION

Interactions have been demonstrated between cigarette smoking (CS) and occupational exposures to several particles. This study tested the postulate that CS interacts with coal mine dust exposure to impact and change radiological and histological endpoints of coal mine dust lung disease.

METHODS

A retrospective evaluation of coalminers with a high-resolution computed tomography (HRCT) of the chest was conducted at West Virginia University Hospital (2015- 2022). There was a consensus review of both radiology and histology findings and their comparative analysis with a non-miner surgical resection cohort collected from thoracic oncology clinic.

RESULTS

The study cohort (n=556) was divided into groups: coal-/smoking- (8.3%), coal-/smoking+ (26.6%), coal+/smoking- (22.3%), and coal+/smoking+ (42.8%). Miners were older males with a median duration of coal mine work (CMW) of 30-years. Ever-smokers (66% of miner cohort and 76% of non-miner cohort) smoked 35 and 28 composite pack years (CPY) respectively, where miners had greater intensity of smoking (22 vs 18 cigarettes/day) compared to non-miners. On HRCT, 1/3rd and 1/5th of miners had simple and complicated coal workers' pneumoconiosis (sCWP and cCWP), respectively. 35% of ever-smoking miners had radiologic patterns for probable usual interstitial pneumonitis, nonspecific interstitial pneumonitis, desquamative interstitial pneumonitis, and combined pulmonary fibrosis and emphysema. Radiologically, both coal-/smoking+ and coal+/smoking+ showed excessive emphysema (70-80%). Histologically, miners had more fibrosis (47% and 50% in coal+/smoking- and coal+/smoking+ vs. 11% and 28% in coal-/smoking- and coal-/smoking+). Never-smoking miners demonstrated more histological evidence of CWP than ever-smokers (60% and 27%); in addition, they had radiologic and histologic emphysema (30%), radiologic interstitial lung disease (ILD) (14.5%) and histologic evidence of fibrosis (47%). Ever-smokers demonstrated histologic emphysema more frequently (33% and 67% in coal+/smoking- and coal+/smoking+ vs. 24% and 72% in coal-/smoking- and coal-/smoking+). Logistic regression modeling showed the following associations: radiologic and histologic emphysema with CPY; histologic fibrosis, any ILD (not including RB-ILD), CPFE and anthracosis with both CPY and CMW; radiologic RB-ILD inclusive of small-opacities, cCWP with both CMW and silica; and sCWP and pulmonary artery dilation with CMW. Interestingly, CPY≥30 negatively correlated with radiologic cCWP and histologic CWP. Mortality was increased in smokers (14% and 29% in coal+/smoking- and coal+/smoking+ vs. 4% and 20% in coal-/smoking- and coal-/smoking+) with predictors being radiologic ILD, histologic CWP, and related co-morbid diseases including COPD, chronic kidney disease, and gastroesophageal reflux.

CONCLUSION

CS demonstrated a major impact on miners' health including changing radiologic and histologic endpoints of interstitial lung diseases and emphysema.

Usual walking Pace and risk of 28 cancers- results from the UK biobank

BACKGROUND

Usual walking pace represents a practical indicator of overall health. However, its association with cancer development remains unexplored. We investigated the relation between self-reported walking pace and cancer risk.

METHODS

Using baseline UK Biobank data from 2006 to 2010, excluding the first two years of follow-up to reduce reverse causation, we employed multivariable Cox regression to assess the association between walking pace (slow, steady average, brisk) and risk of 28 cancer types, accounting for overall physical activity and walking volume.

RESULTS

After a median follow-up of 10.9 years (interquartile range 10.1-11.8), 8.3% of 334,924 participants received a cancer diagnosis. Brisk compared to slow walking pace was associated with multivariable-adjusted lower risks of five cancers, including anal (hazard ratio 0.30; 95% confidence interval: 0.14-0.63), hepatocellular carcinoma (0.39; 0.23-0.66), small intestine (0.46; 0.24-0.87), thyroid (0.50; 0.29-0.86), and lung cancer (0.60; 0.51-0.70). Our findings were consistent across various sensitivity analyses, which assessed sex and age differences, residual confounding, and reverse causation.

CONCLUSIONS

Self-reported walking pace was inversely associated with risk of five cancer types, even when accounting for overall physical activity and walking volume. Adopting a brisk walking pace may represent a pragmatic target for public health interventions to decrease cancer risk, particularly in circumstances where increases in walking volume or frequency prove impractical.

Endorsement of reporting guidelines and clinical trial registration by tropical medicine and infectious disease journals: A cross-sectional study

BACKGROUND

Studies published in academic medical journals inform and influence healthcare decisions. Sufficient study reporting is primarily charged to researchers. However, journals can promote more complete reporting of their published studies. Recommending or requiring reporting guideline use and prospective trial registration may ensure published studies adhere to rigorous reporting standards. This study aimed to evaluate 'instructions to authors' pages of tropical medicine and infectious disease (TM/ID) journals to assess endorsement of reporting guidelines (RGs) for common medical study designs and clinical trial registration.

METHODS

Using a cross-sectional design guided by the Strengthening the Reporting of Observational Studies in Epidemiology checklist, we examined the top 100 infectious disease (ID) journals identified by the 2021 Scopus CiteScore tool and the 21 tropical medicine (TM) journals identified by Clarivate Web of Science. Each editorial journal staff was contacted for specific study designs accepted. Data were extracted from journals' 'instructions to authors' webpages with any discrepancies being resolved through consensus. We assessed adherence to RGs and clinical trial registration.

RESULTS

This study identified 293 TM/ID journals. Among the top 100 ID journals selected (Scopus CiteScore), 2 unfit journals were replaced. Among the 28 TM journals selected (Clarivate Web of Science), 5 were removed due to being duplicates and 2 were removed due to not being published in English. The Enhancing the QUAlity and Transparency Of health Research (EQUATOR) Network was cited by 49% of journals, while 85% of journals referenced the International Committee of Medical Journal Editors (ICMJE). Consolidated Standards of Reporting Trials (CONSORT) was most cited (73%), Quality of Reporting of Meta-analyses was least (2.6%). Clinical trial registration was mentioned by 73% of the journals.

CONCLUSIONS

TM and ID journals demonstrated suboptimal endorsement of various RGs. Among our findings, however, CONSORT and clinical trial registration garnered over 70% endorsement. We propose journals streamline RGs, establish user-friendly 'instructions to authors' pages and mandate reporting guideline adherence. These insights inform future research on enhancing reporting guideline use and TM/ID research quality.

Psychosis and bipolar disorder risk in child and adolescent mental health services in the UK: population cohort study

BACKGROUND

Current approaches to identifying individuals at risk for psychosis capture only a small proportion of future psychotic disorders. Recent Finnish research suggests a substantial proportion of individuals at risk of psychosis attend child and adolescent mental health services (CAMHS) earlier in life, creating important opportunities for prediction and prevention. To what extent this is true outside Finland is unknown.

AIMS

To establish the proportion of psychotic and bipolar disorder diagnoses that occurred in individuals who had attended CAMHS in Wales, UK, and whether, within CAMHS, certain factors were associated with increased psychosis risk.

METHOD

We examined healthcare contacts for individuals born between 1991 and 1998 (N = 348 226), followed to age 25-32. Using linked administrative healthcare records, we identified all psychotic and bipolar disorder diagnoses in the population, then determined the proportion of cases where the individual had attended CAMHS. Regression analyses examined associations between sociodemographic and clinical risk markers with psychotic and bipolar disorder outcomes.

RESULTS

Among individuals diagnosed with a psychotic or bipolar disorder, 44.78% had attended CAMHS (hazard ratio = 6.28, 95% CI = 5.92-6.65). Low birth weight (odds ratio = 1.33, 95% CI = 1.15-1.53), out-of-home care experience (odds ratio = 2.05, 95% CI = 1.77-2.38), in-patient CAMHS admission (odds ratio = 1.49, 95% CI = 1.29-1.72) and attending CAMHS in childhood (in addition to adolescence; odds ratio = 1.16, 95% CI = 1.02-1.30) were all within-CAMHS risk markers for psychotic and bipolar disorders.

CONCLUSIONS

A substantial proportion (45%) of future psychotic and bipolar disorder cases emerge in individuals who had attended CAMHS, demonstrating large-scale opportunities for early intervention and prevention within CAMHS.

Quality of life in diverticular disease: translation and validation of the Danish version of the diverticulitis quality of life instrument (DV‑QOL)

PURPOSE

This study aimed to translate and validate the Danish version of the DV-QOL questionnaire, originally developed in 2015, to assess the impact of diverticular disease on quality of life (QOL) in Danish-speaking patients with diverticulosis.

METHODS

Following international standards, the DV-QOL was translated. A cross-sectional survey was conducted in 2023 with Danish-speaking subjects. The survey included the Danish DV-QOL, an anchor QOL question, and the EuroQol visual analogue scale. Psychometric properties were evaluated for validity, internal consistency, and the ability to identify significant impacts on QOL.

RESULTS

The validation cohort included 16,766 subjects. The DV-QOL score showed a strong correlation with overall QOL (p < 0.001) and high discriminative validity (p < 0.001). Reliability was confirmed with an inter-item correlation of 0.41 and a Cronbach's α of 0.92. The score accurately identified patients with a significant impact of bowel function on QOL, achieving 82% sensitivity and 79% specificity.

CONCLUSION

The Danish DV-QOL is a valid and reliable tool for measuring diverticular disease-specific QOL, beneficial for both clinical and research applications in understanding the impact of the disease and patient outcomes.

Immediate or delayed initiation of renal replacement therapy in patients with leptospirosis and acute kidney injury: a target trial emulation

BACKGROUND

Anecdotal evidence suggests that early renal replacement therapy (RRT) may improve the mortality associated with acute kidney injury (AKI) in patients with leptospirosis. Conversely, several randomized controlled trials (RCTs) conducted in intensive care units have refuted the positive impact of early RRT on mortality in patients with AKI and other causes of sepsis.

METHODS

In this emulated RCT utilizing a propensity score-weighted logistic regression performed in the two academic centers on the island of La Réunion, France, between 2010 and 2020, we evaluated the impact of the timing of RRT on a composite outcome of mortality or new-onset or worsening chronic kidney disease (CKD) within a year, in patients hospitalized with leptospirosis, Stage 3 AKI, and no immediate need for RRT.

RESULTS

We included 295 consecutive patients with leptospirosis and Stage 3 AKI: 82 (28%) began RRT within 48 h of admission ("early" group), 213 (72%) did not start RRT within 48 h ("delayed" group). In the delayed group, 53/213 (25%) patients eventually required RRT. 59/295 patients (20%) met the primary outcome: 32 (15%) in the delayed group and 27 (33%) in the early group. The odds ratio (OR) for primary outcome occurrence before weighing was 2.78 (95% confidence interval CI 1.53 to 5.01, p < 0.001; reference: delayed group) and after weighting was 2.08 (95% CI: 1.01 to 4.26, p = 0.046). In secondary analyses, there was a significantly higher probability of CKD occurrence in the early group (OR 2.74, 95% CI 1.25 to 6.0, p = 0.012). Mortality at 1 year did not differ between groups (OR 0.76, 95% CI 0.21 to 2.68, p = 0.666).

CONCLUSION

Early initiation of RRT may be associated with an increased risk of death and development of CKD within 1 year in patients with leptospirosis and Stage 3 AKI.

Spinal posture, stiffness and motor control during pushing and pulling in flexion and active extension patterns of chronic nonspecific low back pain

This cross-sectional study aimed to compare the change in spinal posture, mechanical stiffness, and motor control of the thoracolumbar spine in individuals who were asymptomatic and those with chronic nonspecific low back pain (LBP) of flexion pattern (FP) or active extension pattern (AEP) during pushing and pulling tasks performed in standing. The real-time thoracolumbar posture, mechanical stiffness, electromyographic amplitude and synergy between specified trunk muscle pairs (Internal Oblique and Multifidus, Rectus Abdominis and Erector Spinae, Internal Oblique and Rectus Abdominis, Multifidus and Erector Spinae) were analysed during quiet standing, standing pushing and pulling tasks against a load standardized at 15% of the individual body weight in a total of 39 individuals (asymptomatic, n = 14; FP, n = 11; AEP, n = 14). Pulling task resulted in greater lumbar posterior translation (p = 0.009) and Rectus Abdominis activity (p = 0.006), but smaller lumbar lordosis (p < 0.001) when compared to pushing task. Pulling task also resulted smaller lumbar lordosis (p < 0.001) and thoracic kyphosis (p = 0.003) comparing to upright standing. AEP group showed a significantly greater amplitude of their Internal Oblique activity when compared to those who were asymptomatic across all tasks (p = 0.001). Findings suggested that pulling manoeuvre in standing produced greater shear at the lumbar spine than that of pushing manoeuvre. Individuals with low back pain executed the low-load push/pull tasks with the motor strategy largely comparable to asymptomatic group. Future studies investigating the cumulative effect of repetitive push/pull loadings on the movement and motor control of the spine are warranted to better understand the long-term impacts on spinal health.

Acute coronary syndromes: mechanisms, challenges, and new opportunities

Despite advances in research and patient management, atherosclerosis and its dreaded acute and chronic sequelae continue to account for one out of three deaths globally. The vast majority of acute coronary syndromes (ACS) arise from either plaque rupture or erosion, but other mechanisms, including calcific nodules, embolism, spontaneous coronary artery dissection, coronary spasm, and microvascular dysfunction, can also cause ACS. This ACS heterogeneity necessitates a paradigm shift in its management that extends beyond the binary interpretation of electrocardiographic and biomarker data. Indeed, given the evolution in the global risk factor profile, the increasing importance of previously underappreciated mechanisms, the evolving appreciation of sex-specific disease characteristics, and the advent of rapidly evolving technologies, a precision medicine approach is warranted. This review provides an update of the mechanisms of ACS, delineates the role of previously underappreciated contributors, discusses sex-specific differences, and explores novel tools for contemporary and personalized management of patients with ACS. Beyond mechanistic insights, it examines evolving imaging techniques, biomarkers, and regression- and machine learning-based approaches for the diagnosis (e.g. CoDE-ACS, MI3) and prognosis (e.g. PRAISE, GRACE, SEX-SHOCK scores) of ACS, along with their implications for future ACS management. A more individualized approach to patients with ACS is advocated, emphasizing the need for innovative studies on emerging technologies, including artificial intelligence, which may collectively facilitate clinical decision-making within a more mechanistic framework, thereby personalizing patient care and potentially improving long-term outcomes.

Antimicrobial Resistance Trends, Predictors, and Burden in England: A retrospective study using the Clinical Practice Research Datalink from 2015-2021

OBJECTIVES

Evidence describing the burden of antimicrobial resistance (AMR) to healthcare systems is essential to inform healthcare policy to tackle AMR. This study aims to investigate trends, predictors, and clinical and economic burden of AMR within the English National Health Service.

METHODS

Retrospective cohort study assessing 1,036,850 patients diagnosed with an infection as a hospital inpatient linked to the Clinical Practice Research Datalink within England between 2015 and 2021. Resistance was identified with specific ICD-10 codes. Predictors of AMR were determined using logistic regression and extreme gradient boosting trees. A 1:1 propensity score matched cohort of 78,153 patients with an AMR infection compared to those without was created. Incidence Rate Ratios (IRRs) were estimated between those two groups for hospital length of stay (from admission to discharge), re-hospitalisations within 1-year of diagnosis of infection, and total hospital costs. Acceleration Factors (AFs) were estimated for time to all-cause mortality and first re-hospitalisation.

RESULTS

Between 2015 and 2020, AMR had a proportional increase of 10%. Resistant infections are associated with an additional 9.2 days length of stay and an additional hospitalisation cost of £3,441 per patient compared with infections not reported as resistant. Within 1, 3, and 5-years 3.2%, 6.3%, and 7.3% more patients with AMR infections died and 7.8%, 5.3%, and 3.6% more patients were re-hospitalised, respectively. AFs indicated patients with AMR infections die 27% earlier and re-hospitalised 26% earlier than those with non-AMR infections.

CONCLUSION

AMR is a significant and growing threat to healthcare; this analysis suggests AMR is associated with significant excess of healthcare use and increased mortality and readmission.

Unveiling taurine's protective role in ischemic stroke: insights from bidirectional Mendelian randomization and LC-MS/MS analysis

Ischemic stroke remains a leading cause of mortality and disability globally, emphasizing the urgent need for innovative preventative and therapeutic strategies. Taurine, a critical amino sulfonic acid, has garnered attention for its neuroprotective effects, yet its precise role in ischemic stroke remains elusive. This study utilized a bidirectional Mendelian Randomization (MR) approach to explore the causal relationship between plasma taurine levels and ischemic stroke risk, employing genome-wide association study (GWAS) datasets. In parallel, a novel high-sensitivity liquid chromatography-tandem mass spectrometry (LC-MS/MS) method was developed to quantify plasma taurine levels in ischemic stroke patients and healthy controls. Our findings reveal a significant inverse association between taurine levels and stroke risk, with IVW analysis showing beta = -0.001 and P = 0.0085. Furthermore, LC-MS/MS analysis demonstrated that plasma taurine levels in patients with ischemic stroke were notably lower at 36.07 ± 5.37 μmol/L compared to controls at 108.66 ± 25.11 μmol/L, confirming taurine's potential as a protective factor. These results suggest taurine as a promising biomarker and therapeutic target for stroke prevention and recovery. This study not only highlights the importance of taurine in cerebrovascular health but also provides a foundation for personalized intervention strategies.

Using data linkage for mental health research in Australia

Data linkage is a powerful tool for understanding the multifaceted needs and priorities of mental health care from the perspective of users and providers. Its potential remains underutilised in Australian settings - the Productivity Commission Inquiry into Mental Health in 2020 highlighted a significant gap: routinely collected administrative data are seldom leveraged in mental health research and service evaluation. In this manuscript, we provide insights into how data linkage has been used in mental health research, the type of questions that can be addressed, the steps involved in conducting data linkage research and the benefits and limitations of the use of this methodology. We propose crucial recommendations for advancing this field including: enhancing education for stakeholders (including the public, data custodians, ethics committees and policy makers); fostering stronger collaborative relationships with individuals with lived experiences throughout the research journey; improving infrastructure and resources for data linkage activities and linking data across sectors to address complex meaningful research questions. Data linkage is not just a method but a critical strategy to transform mental health research and service evaluation, ensuring more informed, effective and holistic mental health care.

Analysis of sleep disorders and their influencing factors in patients with ankylosing spondylitis

OBJECTIVES

Sleep disorders are a common symptom in Ankylosing Spondylitis (AS) patients. In this cross-sectional study, we aimed to understand the current status of sleep disorders in AS patients and to analyze potential factors influencing sleep disorders.

METHODS

A total of 205 AS patients were recruited in the survey. The content included the self-designed demographic data questionnaire, The MOS 36-Item Short Form Health Survey (SF-36), Visual Analogue Scale (VAS), Multidimensional Fatigue Inventory (MF-20), Self-Rating Anxiety and Depression Scale, Pittsburgh Sleep Quality Index questionnaire (PSQI), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI) and Bath Ankylosing Spondylitis Metrology Index (BASMI). These data were analyzed using chi-square test, independent sample t-test, Mann-Whitney U test, Pearson correlation analysis, single-factor linear regression analysis, and multiple linear stepwise regression analysis.

RESULTS

The results showed that the average sleep total score was 8.82 ± 4.146, and the prevalence of sleep disorders was approximately 66.8% in AS patients. Age (F = 29.710, P < 0.001), disease duration (F = 13.025, P < 0.001), anxiety (F = 36.060, P < 0.001), depression (F = 11.808, P < 0.001), and quality of life (t = 6.665, P < 0.001) significantly impacted the sleep total score. Pearson correlation analysis revealed a significant negative correlation between SF-36 total score and sleep total score (r = ‒0.449, P < 0.01), while positive correlations were observed for VAS score, fatigue, anxiety, depression, BASDAI, BASFI, BASMI, age, and disease duration (all P < 0.01). Multivariate analysis showed that age, disease duration, nocturnal pain VAS score, total back pain VAS score, peripheral joint pain VAS score, total fatigue score, total anxiety score, and BASMI total score significantly predicted sleep total score (R² = 0.755, F = 45.334, P < 0.001).

CONCLUSION

These findings suggest that medical professionals should pay increased attention to the observed associations between sleep disorders and clinical factors in AS patients, and consider implementing targeted interventions to address sleep-related issues.

Differences in Productivity and Clinical Care Between Permanent Staff, Employed Travel, and Locum Tenens Emergency Physicians

STUDY OBJECTIVE

Emergency department (ED) staffing shortages have increased reliance on locum tenens physicians (locums). We compared productivity, quality, utilization, and clinical practice measures between permanent staff, employed travelers, and locums during their first 100 shifts at a site.

METHODS

We performed a retrospective cohort study comparing outcomes between the 3 physician types with linear regression, using data from a national ED group from January 2021 to July 2023 from sites that used travelers or locums. Covariates included patient characteristics, case mix, ED volume and boarding, date and time, count of prior shifts at the site, shifts in the prior 30 days at the site, and site-fixed effects.

RESULTS

We included 67,400 shifts worked by 1,195 staff, 37 travelers, and 266 locums at 126 sites. Mean patients per hour was similar between staff and travelers (1.8 vs 1.8, adjusted coefficient [ß] 0.003, 95% confidence interval [CI] -0.051 to 0.057) but modestly higher for staff vs locums (1.8 vs 1.7, ß 0.101, 95% CI 0.052 to 0.150). Mean relative value units per patient was higher for staff vs locums (4.7 vs 4.4, ß 0.127, 95% CI 0.097 to 0.157). We observed no statistical differences in 72-hour returns, admissions or transfers, coagulation testing among discharged chest pain patients, brain computed tomography (CT) orders for syncope, D-dimer with CT pulmonary angiogram, overall CT orders, ED length of stay, or discharge opioid prescriptions.

CONCLUSION

Locums were less productive than staff during their first 100 shifts. Other measures were similar among groups.

Association between leuko-glycemic index and mortality in critically ill patients with non-traumatic subarachnoid hemorrhage: analysis of the MIMIC-IV database

Background

Non-traumatic subarachnoid hemorrhage (NTSAH), primarily caused by intracranial aneurysm rupture, represents a significant global health challenge due to its high mortality and morbidity. The leuko-glycemic index (LGI), a biomarker reflecting oxidative stress and inflammation, has been associated with adverse cardiovascular outcomes. However, its prognostic value in critically ill NTSAH patients remains uncertain. Understanding the relationship between LGI and patient outcomes is essential to improve clinical management of NTSAH.

Methods

We identified NTSAH patients from the Medical Information Mart for Intensive Care-IV (MIMIC-IV, version 2.2) database. Participants were divided into quartiles based on their LGI scores. Mortality was evaluated at multiple time points: ICU stay, in-hospital, and at 1-, 6-, and 12-month post-admission. The association between LGI and mortality was examined using multivariate Cox proportional hazards regression. Restricted cubic spline (RCS) analysis was employed to delineate the relationship between LGI scores and mortality risk and to identify the cutoff value. The robustness of these findings were confirmed through subgroup analyses, interaction tests, and likelihood ratio tests.

Results

A total of 750 patients were included, with 57% being female. Mortality rates were 17% in the ICU, 20% in-hospital, 21% at 1 month, 27% at 6 months, and 29% at 1 year. Multivariate Cox regression analysis revealed that higher LGI score were significantly associated with increased mortality at 1 month, 6 months, and 1 year. RCS analysis demonstrated a positive correlation between elevated LGI scores and mortality risk.

Conclusion

LGI is significantly associated with mortality in critically ill NTSAH patients, suggesting its potential as a prognostic biomarker for risk stratification. Further validation through prospective cohort studies is necessary to confirm these findings.

Neck Active Monitoring After Partial Laryngectomy for cT2N0M0 True Vocal Cord SCC: A 10-Year STROBE Analysis

OBJECTIVE

To evaluate 10-year nodal outcome of active monitoring of the neck for cT2N0M0 true vocal cord (TVC) squamous cell carcinoma (SCC) after frontline partial laryngectomy (PL).

STUDY DESIGN

Retrospective observational study adhering to the STROBE guideline.

SETTING

French academic tertiary referral care center.

PATIENTS

Inception cohort of 81 isolated and untreated cT2N0M0 TVC SCC consecutively managed between 1983 and 2013 with frontline PL and active monitoring of the neck. 85% of patients were followed until death or for at least 10 years.

MAIN OUTCOME MEASURES

Main endpoint was 10-year actuarial nodal control analysis. Secondary endpoints were the search for potential variables increasing the risk for nodal recurrence, management of nodal recurrence, and analysis of the oncologic consequences of nodal recurrence. The significance threshold was set at p < 0.005.

RESULTS

The 10-year actuarial nodal control estimate was 90% with salvage treatment, yielding a 99% overall nodal control rate. On univariate analysis, none of the variables assessed significantly statistically increased the risk for nodal recurrence. The 10-year actuarial estimate of distant metastasis was 0% in patients with nodal control as compared with 35% in patients with nodal recurrence (p < 0.0001). The 10-year actuarial survival estimate was 0% in patients with nodal recurrence as compared with 67% in patients with nodal control (p < 0.0001). Among the 37 patients who died, uncontrolled SCC was the cause of death in 33% of patients who had a nodal recurrence and 3% of those who did not.

CONCLUSION

Active monitoring of the neck for cT2N0M0 TVC SCC managed with PL, although not detrimental in terms of overall nodal control, is impaired by the negative oncological impact of nodal recurrence.

LEVEL OF EVIDENCE: 4

Association of dietary inflammatory index with gynecological cancers in NHANES 2011-2018

Objective

This study aimed to analyze the association between the Dietary Inflammatory Index (DII) and the risk of gynecological cancers using data collected from the National Health and Nutrition Examination Survey (NHANES) between 2011 and 2018.

Methods

The data for this study were obtained from NHANES, conducted between 2011 and 2018, and included a total of 8,380 women. To examine the association between the Dietary Inflammatory Index and gynecological cancers, weighted multivariable logistic regression analyses were performed, using DII both as a continuous variable and as a categorical variable divided into tertiles. Subgroup analyses stratified by DII and gynecological cancer characteristics were conducted to further explore this association. Additionally, restricted cubic spline (RCS) analysis was applied to evaluate potential non-linear relationships between DII and gynecological cancer risk.

Results

Among the 8,380 women included in the analysis, the mean age was 47.02 (SD: 16.91) years, and 196 participants self-reported a diagnosis of gynecological cancer. In fully adjusted models, DII was significantly positively associated with the prevalence of gynecological cancer, whether analyzed as a continuous variable (OR = 1.15, 95% CI: 1.00-1.33, p = 0.046) or as a categorical variable (highest tertile compared to the lowest tertile: OR = 2.14, 95% CI: 1.14-4.04, p = 0.021, p for trend = 0.021). Restricted cubic spline analysis confirmed a linear relationship between DII and gynecological cancer risk (p for non-linear association = 0.1984). Subgroup analyses revealed a significant interaction effect with smoking status (p for interaction = 0.037).

Conclusion

Our findings suggest that higher DII scores are positively associated with an increased risk of gynecological cancer. These results contribute to the existing literature and underscore the need for further validation through larger prospective cohort studies.

Long-Term Health-Related Quality of Life Following Survival of Acute Respiratory Distress Syndrome and Extracorporeal Membrane Oxygenation Due to COVID-19

Background: Patients suffering from severe COVID-19 often develop acute respiratory distress syndrome (ARDS), necessitating intensive care unit (ICU) and extracorporeal membrane oxygenation (ECMO). Survivors frequently experience negative impacts on their health-related quality of life. These individuals may experience a range of symptoms and may require extended hospitalization and rehabilitation. The objective of this prospective cohort study was to assess the long-term health-related quality of life in intensive care survivors of COVID-19-related ARDS who received ECMO therapy, >18 months after their ICU discharge. Methods: The health-related quality of life of COVID-19 survivors who had received extracorporeal membrane oxygenation was evaluated using an augmented version of the Short-Form Health Survey-36, >18 months after their ICU discharge. The outcomes were compared to preexisting data from a meta-analysis analyzing patients with non-COVID-19 ARDS and ECMO therapy. Results: Of the 43 eligible patients (mean age 52 ± 9.5 years), 18 patients (46.2%) responded to the written invitation and were included in this study. The four subscales of the Short-Form Health Survey-36 survey, performed via telephone interview, that showed the most severe limitations (points) were role limitation due to physical problems (37.5), emotional problems (47.9), social functioning (38.1), and general health (49.2). The general health, energy/fatigue (vitality), and physical functioning significantly correlated with higher age (p = 0.004, p = 0.003, and p = 0.05, respectively). A longer duration of extracorporeal membrane oxygenation was positively associated with an improved energy/fatigue ratio (vitality) and emotional well-being (p = 0.04 and p = 0.02, respectively). Compared to survivors of non-COVID-19 ARDS treated with ECMO, the survivors in our cohort scored significantly lower on social functioning, physical functioning, and general health (p < 0.01, p = 0.02, p < 0.01). Conclusions: Patients who have recovered from intensive care treatment for COVID-19-related ARDS and have received ECMO therapy continue to experience more severe impairments in their physical, mental, and cognitive health-related quality of life. A longer ECMO duration may improve outcomes in this selected patient population.

Assessing the relationship between supervisor knowledge sharing and innovative behaviors among clinical nurses: the mediating role of organizational learning

BACKGROUND

In today's rapidly evolving healthcare environment, nurses' innovative behaviors are crucial for improving patient care quality and organizational effectiveness. While supervisor knowledge-sharing behavior has been identified as a potential innovation driver, the mechanisms influencing nurses' innovative behaviors remain unclear.

OBJECTIVE

To investigate the mediating role of organizational learning in the relationship between supervisors' knowledge sharing behavior and nurses' innovative behaviors in clinical settings.

METHODS

A cross-sectional study was conducted among 450 nurses from university hospitals of Ardabil University of Medical Sciences, Iran, between September and November 2024. Data were collected using the Supervisor Knowledge Sharing Behavior Questionnaire (SKSBQ), Innovative Behavior Inventory (IBI), and Organizational Learning Instrument-Development Stages (OLI-DS). Structural equation modeling (SEM) analyses were performed to test the hypothesized relationships.

RESULTS

Findings revealed significant positive correlations between supervisor knowledge sharing behavior, organizational learning, and innovative behaviors. SEM results confirmed that organizational learning partially mediated the relationship between supervisor knowledge sharing behavior and nurses' innovative behaviors.

CONCLUSION

The findings highlight the crucial role of supervisor knowledge sharing behavior in fostering nurses' innovative behaviors directly and through the mediating effect of organizational learning. Healthcare organizations should prioritize developing supervisors' knowledge sharing capabilities and establishing robust organizational learning cultures to enhance innovation among nursing staff.

RCT CODE

Not applicable.

Activity-Related Breathlessness and Physical Activity in Women with Sedentary Behavior: A Cross-Sectional Study

Background: Sedentary behavior is a considerable health risk, which is related to a variety of chronic diseases and a lower quality of life. Breathlessness, or dyspnea, is a significant barrier to physical exercise, especially in sedentary populations. This study aimed to assess the relationship between activity-related dyspnea and physical activity levels in women with sedentary behavior, while also identifying demographic and health factors that influence this association. Methods: This study used a cross-sectional design conducted in Saudi Arabia, utilizing an electronic survey for data collection. The participants were Saudi females aged 20-50 years with sedentary behavior, who reported sitting for 6 h or more each day. A self-administered online questionnaire was used to collect data, which examined sociodemographic information, breathlessness (assessed via the Modified Medical Research Council (mMRC) breathlessness scale and the Dyspnea-12 (D-12) questionnaire), and physical activity levels using the Godin Leisure-Time Exercise Questionnaire (GLTEQ). Only healthy volunteers without chronic or respiratory problems were included. Results: Among 646 participants, 95.2% reported breathlessness, with Grade 2 (32.2%) being most common. Physical activity levels were low, with 37.36% insufficiently active. Significant differences in dyspnea scores were observed across activity levels (H(2) = 50.43, p < 0.0001), with more active individuals reporting less dyspnea. Ordinal logistic regression showed that higher mMRC scores were strongly associated with lower activity (OR = 0.19, 95% CI [0.16, 0.23], p < 0.001). Dyspnea-12 physical domain scores also correlated inversely with activity (OR = 0.93, 95% CI [0.90, 0.96], p < 0.001), while the emotional domain was not significant. Conclusions: The study revealed a significant association between higher breathlessness severity and lower physical activity levels among Saudi women with sedentary behavior. Dyspnea was prevalent, with 95.2% of participants experiencing some degree of breathlessness. Future longitudinal or interventional studies are required to determine the direction of this relationship and explore whether interventions targeting breathlessness management could support increased physical activity or if greater activity itself may help alleviate dyspnea.

Cardiac Autonomic Modulation and Cognitive Performance in Community-Dwelling Older Adults: A Preliminary Study

BACKGROUND/OBJECTIVES

Cognitive decline has been increasingly linked to cardiac autonomic regulation; however, its specific associations with cognitive domains, such as information processing speed and executive function, remain unclear. This preliminary study examined the relationship between cardiac autonomic modulation and cognitive performance in older adults.

METHODS

A cross-sectional study was conducted with 101 older adults (aged ≥60 years) attending a university hospital outpatient clinic. Participants were classified as without cognitive impairment (WCI) or cognitively impaired and not demented (CIND) based on neuropsychological assessments. Heart rate variability (HRV) was measured at rest, focusing on the time-domain parameters (SDNN, rMSSD, and pNN50). Trail making test parts A and B (TMT-A and TMT-B) were used to assess information processing speed and executive function, respectively. Analyses of covariance (ANCOVAs) were performed, adjusting for confounding variables including age, sex, and comorbidities.

RESULTS

Participants in the CIND group had significantly lower HRV indices than those in the WCI group (SDNN, p < 0.05, d = 0.44; rMSSD, p < 0.05, d = 0.39; pNN50, p < 0.05, d = 0.40), indicating reduced parasympathetic modulation. Higher HRV values were observed in individuals with preserved processing speed and executive function. Specifically, pNN50 was significantly associated with processing speed (p = 0.04), and SDNN was significantly correlated with executive function (p = 0.02). These associations persisted even after adjusting for confounding factors.

CONCLUSIONS

Reduced cardiac autonomic modulation, especially lower parasympathetic activity, is significantly associated with cognitive impairment in older adults. Lower pNN50 values were correlated with slower information processing speed, and lower SDNN was associated with poorer executive function. These findings support the potential use of HRV as a physiological biomarker to detect cognitive changes during ageing.

Permissive Telehealth State Licensure Policies Are Associated with Increased Telehealth Utilization

Background: State professional licensure has been cited as a significant barrier to widespread telehealth adoption, and states have developed strategies to reduce such licensure burdens through policy changes. We aimed to measure the association between state-level medical licensure policies and outpatient telehealth utilization between 2018 and 2022 among Medicare beneficiaries. Methods: We conducted a quasi-experimental study of a 5% sample of age-qualifying Medicare fee-for-service beneficiaries between January 2018 and December 2022. We assessed state-level medical licensure policy for telehealth visits, captured as participation in Interstate Medical Licensure Compact (IMLC) before the COVID-19 public health emergency (PHE) and/or policy relaxation during the COVID-19 PHE. Outcomes included out-of-state telehealth (OOS-TH) and in-state telehealth (IS-TH). We evaluated the association between state-level policies and outcomes through logistic regression, adjusting for patient-level characteristics and month/year of the encounter. Results: We analyzed 141,199,029 outpatient encounters for 1,682,501 Medicare beneficiaries. In the pre-COVID-19 era, IMLC participation was associated with higher OOS-TH (adjusted odds ratio [aOR]: 2.24; 95% confidence interval [CI]: 2.09-2.40) but not IS-TH (aOR: 0.98; 95% CI: 0.96-1.01). In the COVID-19 era, we observed higher IS-TH in IMLC-only states (aOR: 1.09; 95% CI: 1.08-1.10) and states with COVID-19 policy relaxations (aOR: 1.11; 95% CI: 1.10-1.12). We observed lower OOS-TH utilization by IMLC participation (aOR: 0.74; 95% CI: 0.72-0.75) and COVID-19 policy relaxations (aOR: 0.83; 95% CI: 0.81-0.85). Conclusions: Permissive licensure policies were higher telehealth utilization, though we observed mixed effects in telehealth type (IS-TH vs. OOS-TH) and by time (pre-COVID-19 vs. COVID-19). Variability in IS-TH and OOS-TH utilization may indicate that while local policies can improve telehealth access, interstate barriers still exist.

Exploring a diverse set of specifications related to associations between adolescent smoking, vaping, and emotional problems: a multiverse analysis

PURPOSE

The epidemiological landscape of adolescent smoking, vaping, and emotional problems has drastically changed over the past two decades. Whether and why these problems co-occur remains unclear, though this understanding is crucial for global policy and prevention efforts. The nature of co-occurring problems may be influenced by different researcher decisions when defining, operationalizing, and modeling these relationships. This study uses multiverse analysis (also known as specification curve analysis or vibration of effects), which models all justifiable measurement and analytic specifications in a single sample, to unpack the impact of researcher decisions when modeling these relationships.

METHODS

Multiverse analyses were done with 3,648 unique models using a longitudinal sample of 6,639 Australian adolescents (aged ∼14.7-15.7, 2021-2022).

RESULTS

Consistent co-occurrence of smoking or vaping and emotional problems was seen across unadjusted or only demographic-adjusted cross-sectional models (100 %). However, the temporality of relationships, choice of confounders, and operationalization of emotional problems substantially impacted findings. Emotional problems appeared to lead to reports of past 6 month smoking more-so than the reverse (88 % vs. 9 % unadjusted/demographic-adjusted), depression-focused measures yielded more consistent associations with smoking or vaping than anxiety-focused, and certain confounders (i.e., conduct, ADHD, other substances) explained most of the associations between adolescent smoking or vaping and emotional problems. Decision related to missingness or binary versus continuous outcomes did not meaningfully impact findings.

CONCLUSIONS

While adolescent smoking or vaping and emotional problems commonly co-occur, methodological choices regarding timing, definitions, and confounding significantly influence the perceived strength of these relationships. Hence, such nuances demand careful consideration when interpreting evidence for policy.

Incidence and Risk Factors for Postoperative Complications in Patients Undergoing Extraoral Drainage for Maxillofacial Abscess: A Retrospective Cohort Study

Background: The standard treatment for maxillofacial abscesses is surgical drainage combined with antibiotics, a frequent procedure in maxillofacial surgery departments. However, postoperative complications following this surgery are poorly described in the literature. Identifying their incidence and risk factors could help improve patient outcomes and healthcare planning. Objectives: The primary aim was to identify postoperative complications within 30 days after maxillofacial abscess surgery; the secondary aim was to explore their associated risk factors. Methods: A monocentric retrospective cohort study included patients with maxillofacial abscesses who underwent extraoral incision and drainage under general anesthesia at the Department of Cranio-Maxillofacial and Oral Surgery at a tertiary hospital in Switzerland between January 2012 and August 2023. Postoperative complications within 30 days were recorded and classified according to the validated Dindo-Clavien classification system. Univariable and multivariable logistic regression analyses were conducted to identify risk factors for postoperative complications. Results: A total of 253 participants were analyzed. The overall complication rate was 24.1%, with 15.8% major complications (Dindo-Clavien grade ≥ 3). The most common minor complications (Dindo-Clavien grade < 3) were hypokalemia and lower-extremity edema, with an incidence of 6.4%. The most common major complications were persistent and recurrent abscesses, with an incidence rate of 10.4%. These complications occurred in the early (median range 1-5 days) and delayed (median range 14-15 days) postoperative courses, respectively. Overall, the mortality rate was 0.4%. On multivariable analysis, an American Society of Anesthesiologists (ASA) score > 2 was associated with overall and major postoperative complications (odds ratio [OR], 3.38; 95% CI 1.75-6.51; p < 0.001 and OR, 3.76; 95% CI 1.83-7.72; p < 0.001, respectively). Additionally, female sex (OR, 1.97; 95% CI 1.05-3.70; p = 0.036) and C-reactive protein level > 50 mg/L (OR, 2.25; 95% CI 1.01-4.98; p = 0.046) were associated with overall postoperative complications. Conclusions: This study introduces a novel application of the Dindo-Clavien classification to maxillofacial abscess surgery, providing a standardized framework for assessing postoperative complication severity. Through this approach, we identified ASA score > 2, female sex, and CRP level > 50 mg/L as risk factors for postoperative complications. Our findings highlight the importance of close monitoring during the first five postoperative days to detect early complications, such as persistent abscesses, and recommend standardized outpatient follow-up for at least two weeks to identify delayed complications, like recurrence.

Exposure to polycyclic aromatic hydrocarbons, heavy metals, and per- and polyfluoroalkyl substances and their associations with serum lipid profiles in the general Korean adult population

BACKGROUND

Previous studies on associations between polycyclic aromatic hydrocarbons (PAHs) and lipid profiles are limited. We investigated the associations between urinary PAH metabolites and serum lipid profiles using a representative sample of Korean adults.

METHODS

This study utilized data from the Korean National Environmental Health Survey (2018-2020) (n = 2,516). The associations of PAH metabolites, heavy metals, and per- and polyfluoroalkyl substances (PFASs), which are ubiquitous pollutants, with lipid indicators and dyslipidemia types were evaluated using linear and logistic regression models, respectively. We examined the associations between a mixture of PAH metabolites, heavy metals, and PFASs and lipid profiles using quantile g-computation analyses.

RESULTS

A doubling of 1-hydroxypyrene (1-OHP) concentrations was associated with higher total cholesterol (TC) [β = 2.50 mg/dL, 95% confidence interval (CI): 1.09, 3.91], low-density lipoprotein cholesterol (LDL-C) (β = 2.39 mg/dL, 95% CI: 1.14, 3.63), and non-high-density lipoprotein cholesterol (non-HDL-C) concentrations (β = 2.13 mg/dL, 95% CI: 0.77, 3.49). A doubling of 1-OHP concentrations was also linked to higher odds of high TC [odds ratio (OR) = 1.15, 95% CI: 1.02, 1.30]. Additionally, 2-naphthol concentrations were associated with higher odds of high TC (OR = 1.14, 95% CI: 1.00, 1.29) and high LDL-C (OR = 1.27, 95% CI: 1.06, 1.51). Lead concentrations were associated with higher levels of TC, LDL-C, non-HDL-C, and high-density lipoprotein cholesterol (HDL-C), as well as with higher odds of high TC, high LDL-C, and high non-HDL-C. Mercury concentrations were associated with higher levels of TC, LDL-C, and non-HDL-C, and with higher odds of high TC. Several PFASs, such as perfluorooctanoic acid, perfluorononanoic acid, and perfluorodecanoic acid, were also associated with lipid profiles. A mixture of PAH metabolites, heavy metals, and PFASs was associated with higher TC, LDL-C, non-HDL-C, and HDL-C concentrations. This mixture was also linked to higher odds of high TC and high LDL-C.

CONCLUSION

Concentrations of PAH metabolites, heavy metals, and PFASs were associated with unfavorable lipid profiles in the general adult population.

Association between the dietary index for gut microbiota and atherosclerotic cardiovascular disease risk among US elderly adults: a cross‑sectional study

BACKGROUND

Gut microbes are important for the development of atherosclerotic cardiovascular disease (ASCVD), and the dietary index for gut microbiota (DI-GM), a new measure of gut flora-friendly diets, has not been systematically investigated in relation to ASCVD.

OBJECTIVE

This study aimed to evaluate the correlation between DI-GM and the risk of ASCVD in American older adults, also to analyze the mediating role of body mass index (BMI).

METHODS

Researchers selected 2234 elderly participants ≥ 65 years of age from the National Health and Nutrition Examination Survey (NHANES) from 2015 to 2018 for a cross-sectional cohort study. Stratified analyses were taken based on DI-GM quartile. To achieve our research objectives, we employed logistic regression analysis, smooth curve fitting, interaction effects analysis, and mediation analysis.

RESULTS

After adjusting for confounders, individuals with higher DI-GM had a significantly lower risk of ASCVD (highest quartile vs. lowest quartile OR = 0.73, 95% CI: 0.52-1.01, P < 0.001). DI-GM was linearly negatively associated with ASCVD (P = 0.13) and the association was stable in the diabetes subgroup (interaction P > 0.05), but age, gender and BMI may modify the association between DI-GM and ASCVD (interaction P < 0.05). BMI mediated 11.51% of the association between DI-GM and ASCVD (95% CI: 2.54%-54.1%, P = 0.016).

CONCLUSION

DI-GM is likely to be a promising indicator for the assessment of the risk of ASCVD, with BMI exhibiting a partial mediating effect in this association. Future studies should prioritize a comprehensive investigation of the underlying mechanisms by which DI-GM contributes to atherogenesis, with the aim of enhancing the efficacy of early prevention strategies for ASCVD.

Clinical Behavior of Breast Cancer in Young BRCA Carriers and Prediagnostic Awareness of Germline BRCA Status

PURPOSE

To investigate the clinical behavior of breast cancer in young BRCA carriers according to the specific BRCA gene (BRCA1 v BRCA2) and the association of the timing of genetic testing (before v at diagnosis) with prognosis.

METHODS

This was an international, multicenter, hospital-based, retrospective cohort study that included 4,752 patients harboring germline pathogenic/likely pathogenic variants (PVs) in BRCA1 or BRCA2, who were diagnosed with stage I-III invasive breast cancer at 40 years or younger between January 2000 and December 2020 in 78 centers worldwide (ClinicalTrials.gov identifier: NCT03673306).

RESULTS

Compared with BRCA2 carriers (n = 1,683), BRCA1 carriers (n = 3,069) had more frequently hormone receptor-negative (74.4% v 15.5%) and high-grade (77.5% v 49.1%) tumors. Similar outcomes were observed in BRCA1 and BRCA2 carriers but with a different pattern and risk of disease-free survival events over time. Compared with patients tested for BRCA at diagnosis (ie, between 2 months before and up to 6 months after diagnosis; n = 1,671), those tested before diagnosis (ie, any time up to 2 months before diagnosis; n = 411) had smaller tumors (T1: 61.3% v 32.4%), less nodal involvement (N0: 65.9% v 50.8%), less frequently received chemotherapy (84.4% v 92.9%), and axillary dissection (37.5% v 47.4%). Patients tested before diagnosis had better overall survival (OS; unadjusted hazard ratio [HR], 0.61 [95% CI, 0.40 to 0.92]); however, this result lost statistical significance after adjustment for potential confounders including tumor stage (adjusted HR, 0.74 [95% CI, 0.47 to 1.15]).

CONCLUSION

This global study provides evidence on the different clinical behavior of breast cancer in young BRCA1 and BRCA2 carriers. Identifying a BRCA PV in healthy individuals was associated with earlier-stage breast cancer diagnosis and lower treatment burden, as well as better unadjusted OS.

Distant Metastasis After Chemoradiation and Image Guided Adaptive Brachytherapy in Locally Advanced Cervical Cancer

PURPOSE

This study aimed to assess patterns and risks of distant metastasis (DM) in patients with cervical cancer treated with chemoradiation therapy and MR-image guided adaptive brachytherapy (IGABT) and to explore a potential dose-effect relationship of concomitant cisplatin.

METHODS AND MATERIALS

Data were derived from EMBRACE I, an international, prospective, and multicenter cohort study conducted at 24 centers across Europe, Asia, and North America from July 30, 2008, to December 29, 2015. The study included 1416 patients with biopsy-confirmed cervical cancer (International Federation of Gynecology and Obstetrics [FIGO2009] stage IB-IVA or stage IVB limited to paraaortic lymph nodes below the L1/L2 interspace). Treatment involved external beam radiation therapy (45-50.4 Gy), weekly cisplatin (40 mg/m², 30 mg/m², or paused), and IGABT. DM was defined as extra-pelvic recurrence excluding paraaortic nodes.

RESULTS

The analysis included 1318 patients with a median age of 49 years and a median follow-up of 52 months. The 5-year cumulative incidence of DM was 14%, with the lungs (26%), mediastinal lymph nodes (15%), and bones (10%) identified as the most common metastatic sites. Key risk factors for DM included nonsquamous histology (HR, 1.89; 95% CI, 1.30-2.75), nodal involvement at diagnosis (pelvic-only nodes: HR, 1.56; 95% CI, 1.07-2.26; paraaortic nodes: HR, 3.15; 95% CI, 1.93-5.16), and large target volume at brachytherapy (HR, 1.93; 95% CI, 1.21-3.08). Patients receiving fewer than 4 cycles of chemotherapy demonstrated a significantly higher risk of DM (HR, 1.52; 95% CI, 1.08-2.13).

CONCLUSION

DM is a substantial burden in patients with locally advanced cervical cancer, with the lungs, distant lymph nodes, and bones being the most frequent sites. Risk factors such as nonsquamous histology, nodal involvement, and large target volumes at brachytherapy are critical considerations for identifying high-risk patients in future studies. These findings highlight the need for tailored strategies to mitigate DM in this patient population.

International Region of Birth and Long-Term Outcomes for Patients Undergoing Colorectal Cancer Resection in an Australian Population

BACKGROUND

Overseas birth is associated with a survival advantage in colorectal cancer in Australia. We wished to analyse this survival based on global region of birth, controlling for cancer-specific and other causes of death.

METHODS

A database of resected colorectal cancers from 2010 to 2016 (n = 1596) was grouped according to patient global region of birth. Chi-squared testing was used to compare factors including patient demographics and AJCC stage. Kaplan-Meier and competing-risk analysis were used to compare 5-year survival outcomes between patients born in different regions, and regression analysis was used to control for age.

RESULTS

751 (47.1%) patients were born overseas. 385 (24.1%) originated from Europe, 124 (7.8%) from East and SE Asia, 92 (5.8%) from the Middle East, and the remainder from other global regions. Immigrants from East or SE Asia were more likely to present with node-positive disease (p = 0.048) than those born in Australia. Immigrants from East and SE Asia and the Middle East had significantly better all-cause 5-year survival than patients born in Australia (73.4% and 80.4% vs. 60.4%, p < 0.0001). Immigrants from the Middle East retained their cancer-specific survival advantage after competing risk analysis (HR 0.76, p = 0.027). Immigrants from Europe displayed no significant difference in all-cause or disease-specific survival compared to individuals born in Australia.

CONCLUSION

Patients born in the Middle East appear to have a colorectal cancer-specific survival advantage compared to those born in Australia, unrelated to stage at presentation. This has significant implications for prognosis and future research directions.

Impact of intraoperative dexmedetomidine on clear cell renal cell carcinoma progression: a retrospective cohort study

BACKGROUND

Dexmedetomidine, an α-2 adrenoreceptor agonist, is commonly administered during cancer surgery as an adjuvant sedative because of its general anaesthetic agent-sparing effects. We investigated the association between ADRA2 gene expression and dexmedetomidine on oncological outcomes after surgery for clear cell renal cell carcinoma (RCC).

METHODS

We conducted an in silico analysis using a publicly available database and a retrospective study in patients with clear cell RCC. The associations between ADRA2A expression and recurrence-free survival and overall survival were analysed. The same outcomes were investigated in a cohort of patients who underwent partial or total nephrectomy and received dexmedetomidine or not. A propensity score matching strategy was utilised to account for selection bias, and a multivariable analysis was performed to control for variables implicated in survival.

RESULTS

Expression of the ADRA2A gene at the tumour level was not associated with recurrence-free survival; however, higher levels of expression were significantly associated with shorter overall survival. A total of 1766 patients with clear cell RCC were included in the retrospective study. Dexmedetomidine administration was not associated with higher rates of recurrence or mortality or with a significant impact on recurrence-free survival or overall survival.

CONCLUSIONS

Intraoperative administration of dexmedetomidine was not associated with a significant impact on cancer progression and survival. The role of ADRA2A as a prognosis biomarker for clear cell RCC warrants further study.

Perceived health, quality of life and happiness among older professional artisans in a UNESCO Creative City of crafts and folk art

Globally, it is a priority to understand how to improve health, quality of life, and happiness in a long-lived and rapidly aging population. Evidence on the health outcomes of working in later life is mixed, with some studies suggesting it benefits mental health by preserving identity, status, social participation, and a sense of purpose, while others highlight potential adverse effects. Research on aging at work has seldom focused on older adults professionally engaged in artistic activities, particularly across different craft sectors, in contrast to the extensive research on art-based interventions aimed at promoting well-being among older individuals. This study aims to describe the perceptions of health, quality of life, and happiness among older professional artisans from a UNESCO Creative City of Crafts and Folk Art in Portugal, and examine the associations with sociodemographic and professional variables. A cross-sectional study was conducted, involving primary data collection through a survey administered in the participants' (N = 55) work environments. Eligible participants were individuals aged 55 or older, living in the community, and working in various craft sectors. The artisans completed the WHOQOL-BREF scale, were assessed for depressive symptoms with the PHQ-8 scale, and were inquired on happiness with life using an item from the European Survey on Aging Protocol (ESAP). Most artisans perceived their overall quality of life as 'good', with the psychological domain receiving the highest score (M = 84.92; SD = 10.98). Most artisans (56.4%) also reported feeling 'very happy' and being satisfied or very satisfied with their health (60%). Age was positively correlated with happiness (p = 0.020). A significant difference was observed in the WHOQOL-BREF environment domain between craft sectors (p = 0.023). An association was observed between different craft sectors and their perceived benefits, particularly regarding health, quality of life, and well-being. This study contributes to aging research by focusing on professional activity in the craft and folk art sector, highlighting the intersection of aging, work, and artistic engagement, and offering insights for policy development to support aging craftspeople and promote traditional crafts.

Total neoadjuvant therapy in high-risk rectal cancer: organ preservation and survival outcomes in a single-center retrospective cohort

Background

Rectal cancer poses a significant global health burden. Conventional neoadjuvant chemoradiotherapy (nCRT) demonstrates limited efficacy in achieving disease-free survival (DFS) and organ preservation. Total neoadjuvant therapy (TNT), an emerging paradigm integrating systemic chemotherapy with radiotherapy, aims to address these limitations.

Objectives

To evaluate the short- and long-term oncological outcomes and organ preservation feasibility of TNT in high-risk locally advanced rectal cancer (LARC) patients.

Designs

A retrospective study was conducted to analyze the short-term and long-term results after total nCRT.

Methods

This retrospective study involved 110 rectal cancer patients with high-risk features treated at the Fudan University Shanghai Cancer Center from 2008 to 2022. Patients underwent comprehensive staging and received nCRT followed by either total mesorectal excision (TME) or a watch and wait (W&W) strategy. The regimen included concurrent chemoradiotherapy with 50 Gy/25 fractions and at least six cycles of induction or consolidation chemotherapy. Both short-term and long-term outcomes were collected and analyzed.

Results

Among the LARC patients, 73.6% were stage III, and 47.3% opted for the W&W strategy. The combined rate of clinical complete response or confirmed pathological complete response (pCR) reached 49.1%. During follow-up, 10% of patients experienced local regrowth. The 3-year DFS and overall survival (OS) rates were 75.7% and 92.4%, respectively. The W&W strategy could achieve superior outcomes than patients without pCR in DFS (p = 0.021) and OS (p = 0.006).

Conclusion

TNT demonstrates durable survival outcomes and facilitates organ preservation in over 50% of high-risk LARC patients. Intensive surveillance is critical for the early detection of local regrowth.

Trial registration

Our study is retrospective in nature, rather than a prospective clinical trial. Therefore, registration was not conducted, and the Clinical Trial Number is not applicable.

Ahmed AB, Elbadawi MH, Khalid L, Abdalhamed TYM, Sosal W, Haiba AM. Prevalence of depression among diabetic patients and its relationship to diabetes self-care activities, disease profile, and social factors in Khartoum State, Sudan: A cross-sectional study

Depression is common among individuals with diabetes mellitus, yet many cases go undiagnosed. It is linked to poorer treatment outcomes. However, data from developing countries remains limited. This study aimed to assess the prevalence and severity of depression among diabetic patients in Khartoum State. It also examined the association between depression and diabetes self-care activities in addition to other clinical and personal factors. A descriptive cross-sectional study was conducted at 3 diabetic outpatient clinics in Khartoum State. Depression was measured using the Patient Health Questionnaire 9, while diabetes self-management behaviors were evaluated using the Self-Reported Diabetes Self-Care Activities Questionnaire. Clinical and personal characteristics were also collected. Associations between depression and various factors were analyzed using the chi-square test and Fisher's exact test, with a P-value of less than .05 considered statistically significant. A total of 163 participants were included. The overall prevalence of depression among diabetic patients was 86.5%, with the majority experiencing minimal (33.1%) and mild (30.1%) depression. Depression was significantly associated with the type of diabetes medications (P = .011) and a family history of psychiatric illness (P = .001). Depression was also significantly linked to the loss of a close person (P-value = .001) and lack of social support (P-value = .018), as well as various aspects of diabetes self-care activities. This study revealed a high prevalence of depression among diabetic patients in Khartoum State. Depression was strongly associated with various diabetes self-care activities as well as other clinical and personal factors. Integrating mental health support into diabetes care programs is essential to improve outcomes. Future population-based studies with more robust methodologies are recommended.

Comparative Safety of Second-Line Antihyperglycemic Agents in Older Adults with Type 2 Diabetes: A Multinational Real-World Evidence From LEGEND-T2DM

Background

As prescribing of newer antihyperglycemic agents expands, there remains limited comparative safety data for older adults-a population particularly vulnerable to adverse drug events and underrepresented in clinical trials. We aimed to evaluate the real-world safety of second-line antihyperglycemic agents among older adults with type 2 diabetes.

Methods

We conducted a multinational cohort study using nine harmonized electronic health record and claims databases from the U.S. and Europe, applying a consistent analytical framework based on the LEGEND-T2DM initiative. Among adults aged ≥65 years who initiated a second-line agent after metformin monotherapy, we compared safety outcomes across four drug classes: GLP-1 receptor agonists (GLP1RAs), SGLT2 inhibitors (SGLT2Is), DPP-4 inhibitors (DPP4Is), and sulfonylureas (SUs). We used propensity score adjustment, empirical calibration, and prespecified diagnostics to estimate hazard ratios (HRs) for 18 safety outcomes.

Results

In a cohort of 1.8 million older adults, both GLP1RAs and SGLT2Is were linked to significantly lower risks of hypoglycemia (HR 0.21 [95% CI, 0.16-0.27] for GLP1RA vs SU; HR 0.21 [0.13-0.33] for SGLT2I vs SU) and hyperkalemia (HR 0.63 [0.50-0.81] for GLP1RA vs SU; HR 0.75 [0.63-0.90] for SGLT2I vs SU) and peripheral edema (HR 0.81 [0.71-0.92] for GLP1RAs vs. DPP4Is; HR 0.62 [0.46-0.84] for SGLT2Is vs. SU). However, SGLT2Is were associated with a higher risk of diabetic ketoacidosis compared to both GLP1RAs (HR 2.03 [1.38-2.99]) and SUs (HR 1.64 [1.27-2.11]). GLP1RAs had significantly higher risks of nausea (HR 0.63 [0.55-0.72]) and vomiting (HR 0.63 [0.57-0.69]) relative to SGLT2Is. Results were consistent across both on-treatment and intent-to-treat sensitivity analyses.

Conclusion

In older adults with type 2 diabetes, GLP1RAs and SGLT2Is demonstrated more favorable safety profiles than SUs and DPP4Is across multiple clinically relevant outcomes. These results support more informed, safety-conscious prescribing in a population underrepresented in clinical trials yet highly susceptible to adverse effects.

The association between weight-waist-adjustment index and serum folate in US adults: NHANES 2013 to 2018

Obesity is closely related to human metabolism and a variety of diseases. The association between weight-waist-adjustment index (WWI, a new index for obesity) and serum folate has not been sufficiently explored. Data from the National Health and Nutrition Examination Survey (2013-2018) was used to explore the correlation between WWI and serum folate. 12,757 adult participants were included in our study. In order to discern the relationship, we conducted weighted multiple linear regression analysis, generalized weighted smooth curve fitting and threshold effect analyses. Additionally, we executed subgroup analysis and interaction tests. There was a negative correlation between WWI and serum folate. In subgroup analysis, the relationship between WWI and serum folate were more pronounced among females, the elderly (65-80 years), nonsmokers, and those with hypertension or stroke. Furthermore, a nonlinear association between WWI and serum folate was found using smooth curve fitting (likelihood ratio = 0.014), with a threshold identified at WWI of 7.42. We discovered a stronger association between WWI and serum folate than other obesity markers including body mass index and waist circumference. Our study could help obese people predict serum folate and manage their nutrition well.

10-Year Clinical Review of Revision Hip Arthroplasty Following Previous Metal on Metal Hip Procedures with Preoperative Magnetic Resonance Imaging and Metal Ion Analysis: Abductor Tendon Avulsion Predicts Dislocation

INTRODUCTION

There is a paucity of long-term data following the revision of previous metal-on-metal (MoM) hip procedures. We hypothesized that functional and clinical results would be poor and that pre-revision serum ion levels and magnetic resonance imaging (MRI) findings could predict the outcome.

METHODS

All patients who had completed a minimum of 10 years following the revision of a MoM hip procedure at our institution were contacted. Data recorded were post-revision complication, re-revision, Oxford Hip Score, and EuroQol-5-Dimension Score, along with pre-revision serum ion levels and MRI findings. There were 56 aseptic MoM revisions from a consecutive series of 86 that reached > 10 years of follow-up. The mean age at revision surgery was 60 years (range, 31 to 75), and the mean follow-up was 138 months (range, 120 to 161).

RESULTS

The mean Oxford Hip Score was 37.4 and was lower in the MoM resurfacing group (mean 36.1) versus the MoM THA group (mean 38.0), P=0.46. The mean EQ-5D was 8.9. Re-revision rate was 16%, which was associated with the exchange of both components, P=0.029. The overall dislocation rate was 11%, and 5% developed infection. Preoperative MRI was available for 46 hips: abductor tendon avulsion was present in 30% and was positively associated with postoperative dislocation, P=0.043. Pseudotumor formation was present in 20%. The mean metal ion levels preoperatively were cobalt, 366.1 nmol/L, and chromium, 211.6 nmol/L, with cobalt levels above our mean value of 366.1 nmol/L associated with Goutallier grades 3/4 abductor insufficiency, P=0.033, and trending towards association with pseudotumor formation, P=0.087.

CONCLUSION

Satisfactory patient-reported functional outcomes are attainable at over 10 years following revision surgery for failed MoM hip surgery. However, there is a significant risk of re-revision and dislocation, which may be predicted with MRI evidence of abductor insufficiency and adverse reaction to metal debris.

Race disparities in dental care use from adolescence to middle adulthood in the USA

BACKGROUND

This study examines the longitudinal patterns of dental care use from adolescence to middle adulthood (ages 11-43) and investigates racial and ethnic disparities in these patterns.

METHODS

Data from Waves I through V of the National Longitudinal Study of Adolescent to Adult Health (1993-2018; ages 11-43). Semiparametric group-based trajectory model identified distinct dental care use trajectories. Multinomial logistic regression was used to estimate membership in these trajectory groups by race/ethnicity while accounting for covariates, including socioeconomic status, biological sex, nativity and unmet healthcare needs.

RESULTS

The analysis identified four distinct dental care use trajectories (1): Intermittent decreasing dental care use (37.9%), (2) intermittent increasing dental care use (22.5%), (3) high dental care use (22.5%) and (4) low dental care use (17.0%). Non-Hispanic black and Hispanic respondents were more likely than non-Hispanic white respondents to belong to low dental care use and intermittent decreasing dental care use groups relative to high dental care use. Additionally, non-Hispanic black respondents were more likely than non-Hispanic white respondents to belong to the Intermittent Increasing Dental Use group. Higher socioeconomic status was inversely associated with low and intermittent use group membership. Males and those with unmet healthcare needs at Wave I were also more likely to belong to trajectories with low and intermittent dental care use.

CONCLUSIONS

Findings reveal persistent racial disparities in dental care use from adolescence into adulthood. Further research is needed to understand the individual and structural factors perpetuating racial disparities in dental care use over the life course.

Association of total cholesterol to high-density lipoprotein cholesterol ratio with diabetes risk: a retrospective study of Chinese individuals

A common complication of type 2 diabetes is hypercholesterolemia in many patients. It is still unclear, nevertheless, how high-density lipoprotein cholesterol ratio (TC/HDL-C), total cholesterol, and diabetes are related. The purpose of this study is to look at the prediction ability and causal relationship between TC/HDL-C and diabetes. This study included 117,268 subjects who were undergoing physical examinations. The subjects were grouped into four equal groups according to the TC/HDL-C quartiles; the main outcome was the occurrence of diabetes events. TC/HDL-C is calculated as total cholesterol divided by high-density lipoprotein cholesterol. In 3.1 years (± 0.95) of follow-up, 795 women (0.68%) and 1,894 men (1.62%) received new diabetes diagnoses. TC/HDL-C is an independent predictor of new-onset diabetes, according to multivariable Cox regression analysis (HR 1.27 per SD increase, 95% CI: 1.09-1.48, P for trend < 0.001). It turned out that a cutoff value of 3.55 (area under the curve 0.64, sensitivity 0.66, specificity 0.56), was ideal for TC/HDL-C in predicting new-onset diabetes. A subgroup analysis demonstrated that the younger population had a significantly higher risk of TC/HDL-C-related diabetes than the middle-aged group (interaction P < 0.05). After controlling for confounding variables, this Chinese cohort study reveals a direct correlation between TC/HDL-C and diabetes, with a stronger independent association observed in younger and middle-aged individuals.

Unchanged Early Diffusion Tensor Imaging Along Perivascular Space Index After Amyloid-Targeting Disease-Modifying Therapy in Alzheimer's Disease: A Preliminary Study

Purpose

No longitudinal imaging biomarkers have been validated to capture early glymphatic changes during disease-modifying therapy (DMT) for Alzheimer's disease (AD). This study investigated whether the diffusion tensor imaging along the perivascular space (DTI-ALPS) index can detect early treatment-related changes in participants with AD who initiate amyloid-targeting DMT.

Methods

Thirteen participants with AD (mean age, 72 years; 8 women) who initiated lecanemab therapy prospectively underwent DTI at baseline and three months. Projection and association fiber regions of interest, predefined in the HCP-1065 atlas, were inversely warped to the native space with vector-aware linear and non-linear registration, enabling a fully automated DTI-ALPS index calculation. Within-participant variances were obtained from 23 healthy volunteers in the OASIS dataset and used to set an equivalence margin of ±0.05 and determine a required sample size of 13. The primary end-point was equivalence of pre- and post-treatment DTI-ALPS indices (a two one-sided test; one-sided α = 0.05). Second, a paired t-test was used to assess the changes. The intraclass correlation coefficients (ICCs) of the DTI-ALPS indices were also evaluated in identical machine environments and between different environments.

Results

Baseline and three-month DTI-ALPS indices were 1.515 and 1.513, respectively. The mean change was 0.002 (90% confidence interval: -0.049, +0.045), entirely within the pre-specified margin; both one-sided p-values were < 0.05, confirming statistical equivalence. A paired t-test showed no significant difference (p = 0.94). Automated processing yielded perfect within-platform reproducibility (ICC = 1.00) and excellent cross-platform reliability (ICC = 0.99).

Conclusion

The DTI-ALPS index, an imaging metric associated with glymphatic activity, did not change during the first three months of lecanemab therapy. Although this finding suggests that glymphatic alterations may not be detectable early after treatment initiation, larger cohorts and longer follow-up periods are required to clarify the temporal relationship between DTI-ALPS index dynamics and therapeutic effects.

Long-term mortality risk in US adults with a history of kidney stones: results from NHANES III with over 30 years of follow-up

PURPOSE

To investigate the association between a history of kidney stones and long-term all-cause and cause-specific mortality in a nationally representative sample of US adults.

METHODS

This observational study included adults who participated in the Third National Health and Nutrition Examination Survey (NHANES III, 1988-1994). Kidney stone history was self-reported during the survey. Vital status and causes of death during follow-up were ascertained via the National Death Index through December 31, 2019. Weighted Cox proportional hazards models estimated hazard ratios (HRs) for the association between kidney stone history and all-cause, cardiovascular, cancer, and renal mortality. Models were progressively adjusted for demographic, socioeconomic, and clinical variables to account for confounding factors.

RESULTS

The final analytic sample comprised 19,578 participants (weighted kidney stone prevalence = 5.3%) with 420,947 person-years of follow-up (range: 0-31 years). Stone formers were older than non-stone formers (mean age 54 vs. 43 years) with a higher prevalence of comorbidities. In the unadjusted model, kidney stone history was associated with increased all-cause mortality risk (HR = 1.82; 95% CI 1.63-2.03). However, this association was attenuated in the fully adjusted model (HR = 0.89; 95% CI 0.79-1.01). No significant differences were observed between groups for cardiovascular (HR = 0.87; 95% CI 0.73-1.03), cancer (HR = 1.01; 95% CI 0.74-1.37), or renal mortality (HR = 0.99; 95% CI 0.31-3.16) in fully adjusted models.

CONCLUSION

In this nationally representative cohort of US adults, a history of kidney stones was not associated with an increased risk of all-cause or cause-specific mortality after adjustment for confounders.

Prediction of Postoperative Lung Graft Dysfunction During the Procedure: A Single-Center Cohort Study of Cystic Fibrosis Patients

OBJECTIVES

To predict severe primary graft dysfunction (PGD3) after double-lung transplantation in cystic fibrosis (CF) patients using intraoperative data.

DESIGN

A retrospective single-center cohort study.

SETTING

University Hospital, France.

PARTICIPANTS

CF patients who underwent double-lung transplantation between 2012 and 2019. Patients younger than age 18 and those with multiorgan transplants, retransplantation, or intraoperative cardiopulmonary bypass were excluded.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Sixty-nine variables were recorded in real-time across the nine time-points. PGD3 occurred in 24 patients (15.5%). PGD3 WAS ASSESSED ON POSTOPERATIVE DAY 3: A logistic regression model to predict PGD3 was developed using data collected at nine predefined time-points during surgery, from start (recipient and donor variables) to finish. The model's area under the curve improved progressively during surgery, rising from 0.764 to 0.892. The optimal model incorporated five variables: three associated with reduced PGD3 risk (preoperative pulmonary hypertension, donor body mass index, and PaO₂/FiO₂ ratio at surgery's end) and two were linked to increased risk (lactate level at second pulmonary artery clamping and extracorporeal membrane oxygenation [ECMO] use at surgery's end). The risk of PGD3 increased by a factor of 11.48 (95% CI 4.48-29.39; p < 0.001) when ECMO was required at the end of surgery and by 1.29 (95% CI: 1.02-1.63; p = 0.035) for each 1 mEq/L rise in lactate concentration at time-point 7 (second pulmonary artery clamping).

CONCLUSIONS

This predictive model underscores the adverse impact of sustained ECMO placed at the end of surgery and elevated intraoperative lactate levels on PGD3 risk.

The role of cardiovascular disease in the association between estimated glucose disposal rate and chronic kidney disease

Chronic kidney disease (CKD) is characterized as a progressive dysfunction of the kidney. The estimated glucose disposal rate (eGDR) is widely recognized as a dependable marker of insulin resistance (IR). Nonetheless, the potential link between eGDR and CKD incidence remains insufficiently clarified. This study utilized data from the China Health and Retirement Longitudinal Study (CHARLS). The outcome of this study was CKD events. We performed adjusted Cox proportional hazards regression, restricted cubic splines (RCS), and mediation analyses. Among the 6,737 participants followed for a median of 108 months, 1,356 (20.13%) developed CKD. Relative to the lowest quartile (Q1) of eGDR, the adjusted HR for the highest quartile (Q4) was 0.85 (95% CI: 0.72-0.99). Each standard deviation increase in eGDR was linked to a 7% reduction in CKD risk (HR: 0.93, 95% CI: 0.88-0.99). The RCS curve indicated a linear relationship between eGDR and CKD risk (threshold = 8.21). The cardiovascular disease (CVD) significantly mediated 27.0% of the association between eGDR and CKD risk. This study demonstrates a significant inverse correlation between eGDR levels and CKD risk in middle-aged and elderly individuals within the Chinese population. Moreover, CVD emerges as a key intermediary linking eGDR and the heightened risk of CKD.

Efficacy of Tele-Critical Care in Managing Critically Ill Patients With COVID-19: Analysis of Outcomes From an Integrated Health System

Background: The implications of splitting medical management and advanced procedural care are unique to critical care medicine. As tele-critical care adoption accelerates, examining the equivalence between in-person intensivist care and tele-intensivist staffing is needed. We sought to examine the equivalence of patient outcomes associated with tele-intensivist and in-person intensivist care of critically ill patients with COVID-19. Methods: In this retrospective multi-center cohort study, 1,885 consecutive critical care hospitalizations of subjects with COVID-19 receiving tele-intensivist or in-person intensivist care at 5 hospitals in Texas participating in the Society of Critical Care Medicine Discovery Viral Respiratory Illness Universal Study COVID-19 registry were included. The main outcomes were mortality, length of stay, and duration of invasive ventilation. Results: Of the 1,885 ICU admissions, 491 (26%) were managed in 4 hospitals with tele-intensivist staffing and compared with 1,394 (74%) ICU admissions managed by the same intensivists via in-person staffing (1 hospital). Propensity score matching for controlled comparison of tele-intensivist and in-person intensivist groups revealed no difference in ICU or in-hospital mortality, length of stay, or duration of invasive ventilation. Conclusions: Mortality, length of stay, and duration of invasive ventilation of subjects receiving tele-intensivist care were similar to subjects in the same healthcare system receiving in-person intensivist care.

A multicenter study of the real-world effectiveness and safety of risankizumab in Crohn's disease

BACKGROUND

We aimed to evaluate the effectiveness and safety of risankizumab (RZB) for Crohn's disease (CD) in routine clinical practice.

METHODS

We performed a retrospective review of a multicenter consortium of CD patients treated with RZB. Co-primary outcomes were week 12 clinical remission (Harvey Bradshaw Index [HBI] score of ≤4 or physician global assessment in those without HBI or with ileostomy) and 6-month endoscopic remission (Simplified Endoscopic Mucosal Assessment for Crohn's Disease of 0-1 or absence of ulcers). Secondary outcomes included steroid-free clinical remission, clinical response, radiographic response, cumulative clinical and endoscopic remission rates at 6 and 12 months, and adverse events.

RESULTS

A total of 309 patients were included (median disease duration 14 years [IQR, 6-24]; median follow-up 7.1 months [IQR, 4.1-10.3]). Most patients (85.8%) were advanced therapy (AT)-exposed, and 169 (54.7%) had prior ustekinumab (UST) exposure. Week 12 clinical remission rates were 49.7% (98/197) overall, and 44.2% (50/113) vs 57.1% (48/84) in UST-exposed vs naïve patients (P = .073). Among those with active disease on baseline endoscopy (n = 122) who had an available follow-up at 6 months, 52.4% (22/42) achieved endoscopic remission. Cumulative rates of clinical and endoscopic remission at 12 months were 65.0% and 49.5%, respectively. Cumulative 12-month endoscopic remission was 33.9% (19/56) in UST-exposed and 68.1% (32/47) in UST-naïve patients (P < .001). Risankizumab was well-tolerated with no new safety signals identified.

CONCLUSIONS

In this large multicenter cohort of patients with CD, RZB was well-tolerated and effective in achieving favorable clinical and endoscopic outcomes in both AT-exposed and naïve populations, including those with exposure to UST.

Nonlinear associations of serum vitamin D levels with advanced liver disease and mortality: a US Cohort Study

Background

Vitamin D deficiency is prevalent and linked to chronic diseases; its association with advanced liver disease progression requires clarification.

Objectives

To investigate the association between vitamin D levels and risks of liver cirrhosis, hepatocellular carcinoma (HCC), and mortality, and assess risk changes after achieving sufficiency post-supplementation.

Design

This was a retrospective cohort study.

Methods

Utilized TriNetX US data (3,905,594 patients, 2000-2024). Adults with vitamin D deficiency (20.00-30.00 ng/mL) were compared with those with sufficient levels (30.01-80.00 ng/mL). Follow-up was initiated from the first vitamin D test or start of supplementation to minimize immortal time bias. Propensity score matching (1:1) balanced >20 baseline confounders.

Results

After matching, 1,204,760 patients with vitamin D deficiency and 1,204,760 with sufficient vitamin D levels were included. Vitamin D deficiency was associated with an increased risk of liver cirrhosis (hazard ratio (HR), 1.30; 95% confidence interval (CI), 1.25-1.36), HCC (HR, 1.22; 95% CI, 1.08-1.37), and all-cause mortality (HR, 1.14; 95% CI, 1.13-1.16). Achieving sufficient vitamin D levels reduced the risk of all-cause mortality (HR, 0.93; 95% CI, 0.88-0.99) and aligned HCC outcomes (HR, 1.16; 95% CI, 0.68-2.00). However, it did not significantly reduce the risk of liver cirrhosis (HR, 2.05; 95% CI, 1.69-2.50). Dose-response analysis showed a U-shaped relationship for liver cirrhosis and HCC, with the lowest risks at 40-60 ng/mL.

Conclusion

Serum vitamin D levels showed a nonlinear association with liver cirrhosis and HCC risk; deficiency independently increased the risks for cirrhosis, HCC, and mortality. Supplementation achieving sufficiency reduced mortality and normalized HCC risk but not cirrhosis risk, potentially reflecting limitations in reversing established disease. The lowest liver disease risk was associated with vitamin D levels of 40-60 ng/mL in this cohort, although causality and the clinical benefit of targeting this specific range require confirmation.

Incidence, Disease Burden, and Clinical Presentation of Patients Newly Diagnosed With Inflammatory Bowel Disease in a Population-Based Inception Cohort

BACKGROUND AND AIMS

Emerging data indicate a stabilizing incidence of inflammatory bowel diseases (IBD), including ulcerative colitis (UC), Crohn's disease (CD), and IBD unclassified (IBDU) in Western countries. We aimed to investigate the incidence of IBD, its initial clinical presentation, and patient-reported burden.

METHODS

Copenhagen IBD Inception Cohort is a prospective, population-based cohort of patients with newly diagnosed IBD according to the ECCO guidelines in the period between May 2021 and May 2023, within a catchment area covering 20% of the Danish population.

RESULTS

Based on 554 patients (UC: 308, CD: 201, and IBDU: 18), the incidence rates per 100 000 person-years were as follows: IBD: 23.4 (95% confidence interval, 21.5-25.4), UC: 14.0 (12.6-15.6), CD: 8.6 (7.4-9.8), and IBDU: 0.8 (0.5-1.3). The median diagnostic delay was significantly shorter for UC (2.5 months [interquartile range {IQR} 1-6]) than for CD (5 months [IQR 1.5-11], p < 0.01). Moderate-to-severe disability was reported by 34% of CD patients and 22% of UC patients (p = 0.01), severe fatigue by 30% and 26% (p = 0.43), and severely impaired health-related quality of life (HRQoL) by 43% and 30% of patients, respectively (p = 0.01). Hospitalization rates (UC: 20%, CD: 34%, p < 0.01), and need for immunomodulators, biologics, or surgery within 3 months of diagnosis, were high in both UC (3%, 7%, and 37%, respectively) and CD (31%, 18%, and 10%, respectively).

CONCLUSIONS

We found a high incidence of IBD in Copenhagen with a substantial disease burden characterized by early and high requirements for advanced therapies and high rates of fatigue, disability, and impaired HRQoL at diagnosis.

Prevalence and Symptomatic Benefit of Antibiotic Use in End-of-Life Patients in Saudi Arabia: An Observational Cohort Study

OBJECTIVES

Antibiotic use in patients with advanced cancer at the end of life (EoL) is common but controversial, with limited evidence on its efficacy in improving symptoms. This study aimed to evaluate the prevalence of antibiotic use during the final 30 days of life in patients with advanced cancer and its impact on symptom improvement within a palliative care setting in Saudi Arabia. Methods: A retrospective cohort study was conducted in the palliative care department of King Fahad Medical City, Riyadh, Saudi Arabia. The study included all advanced cancer patients who received inpatient palliative care and died between January 2022 and March 2023. Medical records data were analyzed to assess infection-related symptoms, antibiotic use, and symptom improvement 3 days (D3) post-diagnosis. Results: A total of 220 patients were included, with a mean age of 61 ± 17 years and a mean palliative performance scale of 37%. Antibiotics were prescribed to 89% of patients, primarily empirically (82%). Piperacillin/tazobactam (53%) and meropenem (17%) were the most commonly used antibiotics. Symptom improvement at D3 was observed in 54% of symptomatic patients (n = 95). Improvements were significant for fever (42% to 15%, P < .001), pain (58% to 37%, P < .001), cough (16% to 7%, P = .004), and shortness of breath (32% to 20%, P = .003). The logistic regression model analysis identified no significant predictors of symptom improvement. Conclusion: Antibiotics are widely used EoL care for advanced cancer patients, but their impact on symptom improvement is modest. The findings underscore the need for judicious antibiotic use, guided by individualized care goals and interdisciplinary collaboration, to optimize symptom management while minimizing unnecessary interventions.

Trajectories of long-term survival after status epilepticus

OBJECTIVES

To investigate the trajectories of clinical characteristics and prognostic factors among long-term survivors of status epilepticus (SE), given the high mortality during acute hospitalization and in subsequent years.

METHODS

Adult patients (≥18 years of age) with first-time, non-anoxic SE were identified and included from University Hospitals in Oslo (Norway), Odense (Denmark), Frankfurt, and Marburg (Germany). Demographics, etiology, comorbidities, and seizure characteristics were assessed. Poisson regression was used to model mortality rates over the follow-up period.

RESULTS

Between 2001 and 2017, we included 1306 patients (median follow-up: 17.4 months). The estimated cumulative proportion surviving at 3, 12, 24, and 36 months were 94.0%, 73.0%, 51.1%, and 39.5%, respectively, with a similar increase in mortality after discharge across all cohorts. Daily mortality peaked during the first 150 days; mortality trajectories differed depending on etiology, SE duration, and age. The clinical characteristics of survivors changed during long-term follow-up; long-term survivors (>36 months) were younger, had shorter SE durations, and had different underlying etiologies. The relative impact of different prognostic factors on the daily mortality shifted during long-term follow-up. Although most established prognostic factors strongly influenced in-hospital mortality, the relative impact of SE duration, comorbidities, and remote symptomatic etiologies first peaked after 6 months.

SIGNIFICANCE

The optimal time point to assess survival in the acute phase is at 6 months, whereas evaluating survival after 2.5 years provides reliable estimates of long-term mortality. Assessing SE survival at discharge underestimates the impact of remote symptomatic etiologies and duration of SE on long-term survival.

Subgrouping suicidal ideations: an ecological momentary assessment study in psychiatric inpatients

BACKGROUND

Suicidal ideation (SI) is one of the strongest predictors of suicide attempts, yet reliable prediction models for suicide risk remain scarce. A key challenge is that SI can fluctuate over time, potentially reflecting different subgroups that may offer important insights for suicide risk prediction. This study aims to build upon previous approaches that averaged SI trajectories by adopting a method that respects the temporal nature of SI.

METHODS

First, we applied longitudinal clustering to ecological momentary assessment (EMA) data on SI, with five daily assessments over 28 days from 51 psychiatric patients (61% female, mean age = 35.26, SD = 12.54). We used the KmlShape algorithm, which takes raw SI scores and the measurement occasion index as input. Second, we regressed each identified subgroup against established clinical risk factors for SI, including a history of suicidal thoughts and behaviors, hopelessness, depression diagnosis, anxiety disorder diagnosis, and history of abuse.

RESULTS

Four distinct subgroups with unique SI patterns were identified: (1) "High SI, moderate variability" (high mean, medium variability, high maximum); (2) "Lowest SI, lowest variability" (lowest mean, lowest variability, lowest maximum); (3) "Low SI, moderate variability" (low mean, medium variability, high maximum); and (4) "Highest SI, highest variability" (highest mean, highest variability, highest maximum). Furthermore, these subgroups were significantly associated with clinical characteristics. For instance, the subgroup with the least severe SI ("lowest SI, lowest variability") showed the lowest levels of hopelessness (beta = -0.95, 95% CI = -1.04, -0.86), whereas the subgroup with the most severe SI ("highest SI, highest variability") exhibited the highest levels of hopelessness (beta = 0.84, 95% CI = 0.72, 0.95).

CONCLUSION

Applying longitudinal clustering to EMA data from patients with SI enables the identification of well-defined and distinct SI subgroups with clearer clinical characteristics. This approach is a crucial step toward a deeper understanding of SI and serves as a foundation for enhancing prediction and prevention efforts.

TRIAL REGISTRATION

10DL12_183251.