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

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.

Mediating role of Interleukin-6 in the predictive association of diabetes with Hippocampus atrophy, Amyloid, Tau, and Neurofilament pathology at pre-clinical stages of diabetes-related cognitive impairment

Introduction

Type-2 diabetes (T 2 DM) has been associated with higher dementia risks, but the mechanisms are still unclear, and there is increasing evidence of the role of cytokines. Interleukin-6 (IL-6) mediating effect has never been explored.

Methods

The study included a subset of 1,927 participants from the Health and Aging Brain Study: Healthy Disparities (HABS-HD) cohort with complete data. Cross-sectional and longitudinal analyses were performed. Associations were studied using multivariable linear, logistic, and mediation analysis with non-parametric bootstrapping.

Results

T 2 DM and IL-6 were associated with worse executive function, Hippocampus atrophy, lower Aß 42 /Aß 40 ratio, and higher Aß 40 , Aß 42 , total Tau, and NfL levels. IL-6 mediated 5% of the association of T 2 DM with Aß 40 ([1.5%-10%], p- value<2×10 -16 ), 4% with Aß 42 ([0.7%-11%], p- value=0.014), 8% with TMT-B ([0.2%-35%], p- value=0.046), 11% with total Tau ([2.5%-40%], p- value=0.010), 5% with NfL ([1.6%-8%], p- value<2×10 -16 ), and 12% hippocampus atrophy ([3%-49%], p- value=0.004). The results, except TMT-B, were replicated in the longitudinal analysis of long-lasting T 2 DM on non-previously diagnosed cognitive impairment.

Conclusions

The study captured a pre-clinical stage of the T 2 DM-dementia association. The mediating effect of IL-6 is a novelty that has to be further explored and accounted for in risk stratification and preventive measures, particularly in ethnic minorities.

Graphical abstract

Menopausal symptoms among perimenopausal women in rural Turkey: a cross-sectional study

OBJECTIVE

This study aimed to evaluate the prevalence and severity of menopausal symptoms among perimenopausal women in a rural area of southeastern Turkey and their association with sleep quality, depression and sociodemographic and lifestyle-related factors.

METHODS

This cross-sectional study included 122 perimenopausal women aged 40-55 years residing in southeastern rural Turkey. Participants completed the Beck Depression Inventory (BDI), the Menopause Rating Scale (MRS) and the Pittsburgh Sleep Quality Index (PSQI), alongside demographic data collection.

RESULTS

The median age was 46 years (43-49 years). Higher MRS scores were significantly linked to a sedentary lifestyle, poor self-rated health and concerns about partner infidelity. MRS total scores were moderately correlated with global PSQI scores (r = 0.49, p < 0.001) and strongly correlated with BDI scores (r = 0.71, p < 0.001). Severe menopausal symptoms were significantly associated with poor sleep quality (odds ratio [OR] = 2.62; 95% confidence interval [CI]: 1.16-5.95), mild to severe depression (OR = 4.78; 95% CI: 2.08-10.98) and poor self-rated general health (OR = 2.76; 95% CI: 1.03-7.41), even after adjusting for age, parity and body mass index.

CONCLUSIONS

Perimenopausal women in southeastern rural Turkey experience severe menopausal symptoms that are significantly associated with self-rated general health, sleep quality and depression.

Preoperative cognitive function and surgical outcomes under general anesthesia among older patients

PURPOSE

To investigate whether preoperative cognitive impairment is associated with postoperative outcomes under general anesthesia.

METHODS

This population-based cohort study utilized a nationwide database in South Korea. We included patients who underwent surgery under general anesthesia at the hospital between January 1, 2021, and December 31, 2021. The Korean Dementia Screening Questionnaire-Cognition (KDSQ-C), a tool designed for efficient dementia screening, was used to evaluate preoperative cognitive impairment. The KDSQ-C is administered during biennial National Health Insurance Service medical evaluations beginning at age 66 years.

RESULTS

This study included 108,158 older patients who underwent surgery under general anesthesia. In a multivariable Cox regression model, patients with KDSQ-C ≥ 6 had a 35 % higher risk of 90-day mortality than those with KDSQ-C of 0-5 (hazard ratio [HR]: 1.35, 95 % confidence interval [CI]: 1.15, 1.57; P < 0.001). Increased 90-day mortality was observed in the following KDSQ-C groups compared to those with a score of 0-5: KDSQ-C 11-15 (HR: 1.54, 95 % CI: 1.13, 2.11; P = 0.007), KDSQ-C 16-20 (HR: 1.98, 95 % CI: 1.31, 2.99; P = 0.001), KDSQ-C 21-25 (HR: 1.99, 95 % CI: 1.29, 2.57; P = 0.004), and KDSQ-C 26-30 (HR: 2.03, 95 % CI: 1.26, 3.28; P = 0.004). Similar results were found in the analyses of one-year all-cause mortality and postoperative complications.

CONCLUSIONS

Older patients with preoperative cognitive impairment undergoing general anesthesia have higher mortality and morbidity rates, particularly in patients with KDSQ-C scores ≥11.

Gender differences in the impact of fatigue on lower limb landing biomechanics and their association with anterior cruciate ligament (ACL) injuries: A systematic review and meta-analysis

BACKGROUND

This meta-analysis examines the impact of neuromuscular fatigue on gender differences in lower limb landing biomechanics and its correlation with ACL injury risk.

METHODS

A comprehensive search was conducted in PubMed, Scopus, Web of Science, Embase, and the Cochrane Library up to March 2024.

RESULTS

Fourteen studies were included, averaging a quality score of 6.79; nine were high quality. Key findings: males showed a significant increase in knee flexion angle at initial contact (effect size -1.23), but females did not (-0.25). Both genders had significant changes in hip external rotation (males: 1.35, females: 1.20). Ankle peak dorsiflexion angle increased (-1.69) with no gender differences. Peak Knee extension moment increased in males (0.76) and females (0.48) with an overall effect size of 0.64, but no change in peak abduction moment. Peak Hip extension moment was significant in males (0.58) and overall (0.51), with no changes in internal rotation or adduction moments. Peak vertical ground reaction force showed no significant changes for either gender.

CONCLUSIONS

Fatigue alters knee biomechanics in males, raising ACL injury risk, and both genders show increased hip and ankle loads post-fatigue. These results suggest the need for gender-specific fatigue management strategies to mitigate ACL injury risk and call for further research into prevention mechanisms.

Reward Sensitivity in Patients Receiving Opioid Agonist and Antagonist Treatment for Opioid Use Disorder: An Observational Study

BACKGROUND

Disrupted reward processing is a core component in neurobiological theories of addictions, including opioid use disorder (OUD). While acute opioid agonist and antagonist administration can modulate reward behavior and experiences, it remains unclear how typical long-term OUD treatment with these medications impact patients' sensitivity to substance-free rewards. We therefore conducted a cross-sectional study of reward sensitivity in opioid agonist- and antagonist-treated OUD patients, and healthy volunteers.

METHODS

Ninety-six OUD patients on extended-release naltrexone (n=45) or opioid agonists (n=51) and 50 healthy volunteers completed a probabilistic reward task (PRT) and self-report measures of anhedonia, depression, preoccupation with immediate consequences, substance craving and life satisfaction in a single session. We used signal detection analysis and drift diffusion modeling to derive behavioral reward bias measures from PRT performance. Group differences were modeled with beta and linear regression.

RESULTS

Patients reported significantly greater anhedonia (Cohen's ds≥0.64), depression (ds≥0.53) and preoccupation with immediate consequences (ds≥0.54) than heathy volunteers, but differences between naltrexone- and opioid agonist-treated patients were non-significant (ds≤0.26). Group differences in behavioral reward bias were small and non-significant (ps=1, BF01s≥84.13). Anhedonia was significantly associated with lower life satisfaction (OR [95% CI]=1.10 [1.04, 1.17]). There were no other significant associations between reward sensitivity measures and life satisfaction or craving (ps≥0.31, BF01s≥2.58).

CONCLUSION

These data support an association between OUD and reduced well-being irrespective of opioid agonist or antagonist treatment, highlighting patients' need for psychosocial support and/or adjunct interventions. Major detrimental effects of naltrexone treatment on well-being seem unlikely from these and previous results.

Outcomes of intended temporary stomas in Crohn's disease (INTESTINE study): international, multicentre, retrospective study

BACKGROUND

Patients with ileocolic Crohn's disease often require surgery that can result in temporary stoma formation. Stomas are associated with a morbidity and can negatively impact quality of life. This study aimed to investigate the short-term (6-month) and mid-term (18-month) outcomes of intended temporary stomas in patients with Crohn's disease.

METHODS

A trainee-led, international multicentre, retrospective study was conducted on all patients who underwent surgery for Crohn's disease in collaborating centres over 4 years (2017-2020). The primary outcome was the proportion of patients with Crohn's disease who underwent stoma reversal surgery by 6- and 18-month postoperative follow-up. Secondary outcomes included: the time interval between formation and reversal of stoma and predictors for non-reversal and stoma-related morbidity (postoperative complications, related readmissions and complications due to stoma reversal surgery).

RESULTS

A total of 401 patients underwent stoma formation for Crohn's disease over the 4 years across the 44 collaborating centres. The temporary stomas had been reversed in 30.2% of patients at the 6-month and 56.9% at the 18-month follow-up. Reasons for non-reversal included ongoing medical treatment for Crohn's disease (respectively 6-month and 18-month: 37.6%, 39.3%), patient unfit for surgery (respectively 6-month and 18-month: 14.5%, 16.8%), patient preference (respectively 6-month and 18-month: 12.1%, 20.2%) and due to waiting lists (respectively 6-month and 18-month: 12.1%, 8.1%). Overall, 63.3% of patients had a temporary stoma reversed with a median time interval of 6 months. The stoma-related overall morbidity rate was 29.4%.

CONCLUSIONS

A large proportion of temporary stomas for Crohn's disease were not reversed at 6 and 18 months following initial surgery. Patients are exposed to the risk of non-reversal and risk of developing stoma complications for significantly longer intervals of time and, in some cases, indefinitely.

Impact of feeding strategy after pancreatoduodenectomy on delayed gastric emptying and hospital stay: nationwide study

BACKGROUND

Delayed gastric emptying is a major contributor to prolonged hospital stay following pancreatoduodenectomy. Although enhanced recovery after surgery guidelines recommend unrestricted feeding after pancreatoduodenectomy, nationwide studies evaluating the impact of different feeding strategies after surgery on delayed gastric emptying and length of hospital stay are limited. This study aimed to identify the use and impact of different feeding strategies after pancreatoduodenectomy on delayed gastric emptying and length of hospital stay.

METHODS

This nationwide cohort study included consecutive patients after pancreatoduodenectomy from the Dutch Pancreatic Cancer Audit (2021-2023). Primary endpoints were delayed gastric emptying grade B/C and length of hospital stay. Feeding strategies were categorized based on structured interviews with representatives from 15 centres. Multilevel analysis was used to assess associations between feeding strategy, delayed gastric emptying, and length of hospital stay. Predictors of delayed gastric emptying were determined.

RESULTS

Overall, 2354 patients undergoing pancreatoduodenectomy were included, of whom 526 (23%) developed delayed gastric emptying grade B/C. Median length of hospital stay was 13 days longer in patients with delayed gastric emptying (23 versus 10 days; P < 0.001). Feeding strategies were: unrestricted feeding (3 centres, 637 patients; delayed gastric emptying 18%); step-up feeding (9 centres, 1462 patients; delayed gastric emptying 24%); and artificial feeding (3 centres, 255 patients; delayed gastric emptying 25%). No association was observed between feeding strategy and delayed gastric emptying: step-up versus unrestricted feeding (odds ratio 1.14, 95% confidence interval 0.53 to 2.47) and artificial versus unrestricted feeding (odds ratio 1.76, 0.65 to 4.73). Similarly, no association was found between feeding strategy and length of hospital stay. The strongest predictor of delayed gastric emptying was pancreatic fistula after surgery (odds ratio 3.16, 2.47 to 4.05).

CONCLUSION

This study found no significant association between feeding strategy and incidence of delayed gastric emptying or length of hospital stay after pancreatoduodenectomy. Efforts to reduce delayed gastric emptying should focus on reducing pancreatic fistula after surgery.

Differences in Coronary Heart Disease and Stroke Incidence Among Single-Race and Multiracial Asian and Pacific Islander Subgroups in Hawaii and California: A Retrospective Cohort Study

BACKGROUND

Little is known about clinical and sociodemographic factors affecting coronary heart disease (CHD) and stroke incidence in single-race and multiracial American Asian, Native Hawaiian, and Pacific Islander subgroups. As the US population becomes more diverse, it is important to characterize differences in risks for CHD and stroke, and their contributing factors, in these populations.

METHODS AND RESULTS

The study population included 303 958 patients from Kaiser Permanente Hawaii and Palo Alto Medical Foundation in California. Self-reported race and ethnicity were derived from electronic health records and 12 mutually exclusive single-race and multiracial groups were created for analyses. Cox proportional hazard models were used to compare CHD and stroke incidence. Unadjusted models were compared with models adjusted for age, income, education, body mass index, smoking, and comorbidities. We found up to a 4-fold variation in CHD and stroke rates among American Asian, Native Hawaiian, and Pacific Islander subgroups. Multiracial subgroups had higher rates than single-race groups. While most single-race American Asian, Native Hawaiian, and Pacific Islander groups had lower CHD and stroke risks, middle-aged Asian Indian men and Native Hawaiian women had higher stroke risks than non-Hispanic White controls. Income, education, body mass index, smoking, and comorbidities contributed significantly to risks in all groups, especially in Native Hawaiian, Pacific Islander, and multiracial groups.

CONCLUSIONS

Risks for CHD and stroke vary by racial and ethnic subgroups, demonstrating the need to unmask risks by disaggregating racial and ethnic subgroups. Multiracial American Asian, Native Hawaiian, and Pacific Islander groups had higher risks that were only partially explained by modifiable risk factors. Future studies should further explore lifestyle, psychosocial, and sociocultural factors.

Clinical Management of Sleep Disturbances in Post-9/11 Men and Women Veterans: A 20-year Prospective Cohort Study

INTRODUCTION

Sleep disorders and chronic conditions that are comorbid with disordered sleep represent a high burden to the U.S. population, and Veterans have a particularly high risk for disordered sleep. Sleep disorders also present differently by sex and there is a rapidly growing proportion of women Veterans. Among the most recent Veteran cohort (i.e., discharged post-9/11), the extent of sleep disorders and how those conditions are managed is unknown. The objectives were to characterize the frequency of sleep assessment, diagnosis, and treatment among post-9/11 Veterans served by the Veterans Health Administration (VA), the timing of sleep management, and to determine if there were sex-based disparities in all sleep care.

METHODS

This prospective cohort study included all post-9/11 Veterans who enrolled in VA care, and completed ≥ 1 outpatient encounter, 10/1/2001-9/30/2021. Diagnostic and procedural codes, health factors, and dates were used to extract variables for assessment (e.g., behavioral, polysomnography), diagnoses (i.e., insomnia, sleep-related breathing [SRBD], comorbid insomnia and SRBD [COMISA], sleep-related movement [SRMD], or Other disorders), treatment of insomnia or SRBD, and time to sleep assessment, diagnosis, and treatment. Logistic regressions assessed likelihood of sleep care by sex.

RESULTS

The final sample included 1,113,633 patients (12% women, 61% White). Overall, 39% had sleep disorders - 27% with SRBD, 18% with insomnia, 8% with COMISA, 2% with SRMD, and 6% with Other. Men were more likely to have any diagnosis, especially SRBD. Women were assessed up to one year later than men and had greater odds of insomnia or SRMD. Women also had greater odds of insomnia treatment and those with SRBD were 31% less likely to receive treatment than men.

CONCLUSIONS

As managing sleep health is central to patient-centered care, concerted efforts are required to implement existing VA guidelines concerning sleep, bridging men and women Veteran's sleep needs with available resources.

Advancing Preoperative Planning in Perforator Flap Surgery with Photon-Counting Computed Tomography Angiography: Less Challenges with More Precision

BACKGROUND

Perforator flaps are crucial in plastic surgery, providing versatility in complex reconstructions. However, anatomical variations pose challenges in flap dissection and anastomosis. Conventional computed tomography angiography (CTA) is standard for preoperative planning but has limitations in evaluating small arteries. A novel technique, photon-counting computed tomography (PCCT), offers enhanced spatial resolution with lower radiation exposure.

METHODS

From December 2023 to September 2024, a pilot study was conducted at Peking Union Medical College Hospital in Beijing. Seven patients undergoing perforator flap reconstructions received preoperative PCCT angiography (experimental group). Five patients underwent conventional CTA scans (control group 1), and another five had flap reconstructions guided by traditional imaging methods (control group 2). Three flap types were analyzed: deep inferior epigastric perforator flap, anterolateral thigh perforator flap, and superficial circumflex iliac artery perforator flap. Imaging efficacy, radiation dose, and surgical outcomes were compared.

RESULTS

PCCT identified significantly more perforators (14.5 ± 2.1 vs. 10.2 ± 1.8, p < 0.05) and smaller branch diameters (0.8 ± 0.1 mm vs. 1.2 ± 0.2 mm, p < 0.05) compared to conventional CTA. The radiation dose was lower with PCCT (6.3 ± 1.1 mSv vs. 8.1 ± 0.9 mSv, p < 0.05). The experimental group experienced shorter operation and flap harvesting times, with fewer complications than control group 2.

CONCLUSION

PCCT angiography enhances preoperative assessment of perforator vessels by detecting more and smaller perforators while reducing radiation exposure, thereby improving surgical planning and outcomes in perforator flap reconstructions.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Association Between Estimated Glucose Disposal Rate and Stroke in Middle-Aged and Older Chinese Adults: A Nationwide Prospective Cohort Study

BACKGROUND

The estimated glucose disposal rate (eGDR) is recognized as a reliable marker of insulin resistance. However, the association between eGDR and the risk of stroke remains unclear.

METHODS AND RESULTS

A total of 13 706 middle-aged and older participants were enrolled from CHARLS (China Health and Retirement Longitudinal Study). The primary end point was the occurrence of stroke events. The Kaplan-Meier curves, Cox proportional hazard models, and restricted cubic spline analysis were applied to explore the association between eGDR and the risk of stroke according to sex, age, and glycemic status. A total of 1101 stroke events were recorded. Our findings revealed a significant nonlinear relationship between eGDR and the occurrence of stroke. The association was similar between men (hazard ratio [HR], 0.83 [95% CI, 0.80-0.87]) and women (HR, 0.86 [95% CI, 0.80-0.87]), as well as among participants with normal glucose tolerance (HR, 0.83 [95% CI, 0.79-0.87]), prediabetes (HR, 0.85 [95% CI, 0.82-0.89]), and diabetes (HR, 0.87 [95% CI, 0.82-0.92]). However, the association was stronger in middle-aged participants (HR, 0.82 [95% CI, 0.78-0.86]) compared with older individuals (HR, 0.87 [95% CI, 0.83-0.90]; P for interaction=0.019).

CONCLUSIONS

This study demonstrates that lower eGDR levels are significantly linked to increased stroke risk. The relationship between eGDR and stroke risk was similar across different sexes and glycemic statuses and was stronger in middle-aged participants compared with older participants.

Pharmacovigilance analysis of small bowel bleeding associated with NSAIDs

Background

Currently, the factors influencing small bowel bleeding caused by nonsteroidal anti-inflammatory drugs (NSAIDs) remain unclear.

Objectives

This study aimed to assess NSAID-associated small bowel bleeding and evaluate the impact of other drugs on it through a pharmacovigilance study, thereby providing valuable insights for clinical practice.

Design

Data on NSAID-associated small bowel bleeding were retrospectively extracted from two public adverse drug reaction databases-the Food and Drug Administration's (FDA) Adverse Event Reporting System (FAERS) and the Japan Pharmaceuticals and Medical Devices Agency's Adverse Drug Event Reporting (JADER)-from 2004 to 2023 for further analysis.

Methods

The reporting odds ratio (ROR), a pharmacovigilance technique, was employed to identify signals of adverse reactions, and the Chi-square test was utilized to assess differences between groups.

Results

Multiple NSAIDs associated with small bowel bleeding were identified in both databases. In the drug combination analysis, no significant differences in the risk of small bowel bleeding were found between NSAIDs combined with proton pump inhibitors (PPIs) and NSAIDs alone in FAERS (all p > 0.05). Decreasing risks were found when multiple NSAIDs were combined with rebamipide or probiotics compared to NSAIDs alone in JADER (p < 0.05 and ROR  < 1). In subgroup analyses of age and sex, older adults and males who used aspirin showed higher risk signals in both databases (all p < 0.05 and ROR  > 1).

Conclusion

PPIs did not show a significant impact on NSAIDs-associated small bowel bleeding, while rebamipide and probiotics may exhibited a preventive effect against NSAIDs-associated small bowel bleeding. Older adults and males constituted risk factors for aspirin-associated small bowel bleeding.

Perceptions of complementary, alternative, and integrative medicine: A global cross-sectional survey of cardiology researchers and clinicians

BACKGROUND

Complementary, alternative, and integrative medicine (CAIM) has been increasing in popularity among patients with cardiovascular illnesses. However, little is known about perceptions of CAIM among cardiology researchers and clinicians. In response, this study aimed to assess the practices, perceptions, and attitudes towards CAIM among cardiology researchers and clinicians.

METHODS

An anonymous, digital cross-sectional survey was administered to researchers and clinicians who have published articles in cardiology journals indexed in OVID MEDLINE. The survey was sent to 37,915 researchers and clinicians and included 5-point Likert scales, multiple-choice questions, and open-ended questions. Basic descriptive statistics were drawn from quantitative data, and a thematic content analysis was conducted to analyze open-ended responses.

RESULTS

Among the 309 respondents, the majority (n = 173, 55.99%) identified themselves as both researchers and clinicians in the field of cardiology. While 45.78% (n = 114) of participants expressed agreement regarding the safety of CAIM therapies, 44.40% (n = 111) disagreed on their efficacy. Most respondents believed in the value of conducting research on CAIM therapies (79.2%, n = 198). Respondents perceived mind-body therapies (57.61%, n = 159) and biologically based practices (47.46%, n = 131) as the most promising interventions for the prevention and treatment of cardiovascular conditions. Biofield therapies were the least favoured for integration into mainstream medical practices (11.93%, n = 29).

CONCLUSIONS

While cardiology researchers and clinicians perceive CAIM therapies to have potential, many are hesitant about integrating such interventions into the current medical system due to a perceived lack of scientific evidence and standardized products. Insights from this study may help establish educational resources for healthcare practitioners.

Information from digital and human sources: A comparison of chatbot and clinician responses to orthodontic questions

INTRODUCTION

This study aimed to investigate whether artificial intelligence (AI)-based chatbots can be used as reliable adjunct tools in orthodontic practice by evaluating chatbot responses and comparing them to those of clinicians with varying levels of knowledge.

METHODS

Large language model-based chatbots (ChatGPT-4, ChatGPT-4o, Microsoft Copilot, Google Gemini 1.5 Pro, and Claude 3.5 Sonnet) and clinicians (dental students, general dentists, and orthodontists; n = 30) were included. The groups were asked 40 true and false questions, and the accuracy rate for each question was assessed by comparing it to the predetermined answer key. The total score was converted into a percentage. The Kruskal-Wallis test and Dunn's multiple comparison tests were used to compare accuracy rates. The consistency of the answers given by chatbots at 3 different times was assessed by Cronbach α.

RESULTS

The accuracy ratio scores for students were significantly lower than Microsoft Copilot (P = 0.029), Claude 3.5 Sonnet (P = 0.023), ChatGPT-4o (P = 0.005), and orthodontists (P = 0.001). For dentists, the accuracy ratio scores were found to be significantly lower than ChatGPT-4o (P = 0.019) and orthodontists (P = 0.001). The accuracy rate of ChatGPT-4o was closest to that of orthodontists, whereas the accuracy rates of ChatGPT-4, Microsoft Copilot, Claude 3.5 Sonnet, and Google Gemini 1.5 Pro were lower than orthodontists but higher than general dentists. Although ChatGPT-4 demonstrated a high degree of consistency in its responses, evidenced by a high Cronbach α value (α = 0.867), ChatGPT-4o (α = 0.256) and Claude 3.5 Sonnet (α = 0.256) were the least consistent chatbots.

CONCLUSIONS

The study found that orthodontists had the highest accuracy rate, whereas AI-based chatbots had a higher accuracy rate compared with dental students and general dentists. However, ChatGPT-4 gave the most consistent answers, whereas ChatGPT-4o and Claude 3.5 Sonnet showed the least consistency. AI-based chatbots can be useful for patient education and general orthodontic guidance, but a lack of consistency in responses can lead to the risk of misinformation.

Housing Status and Longitudinal Care Patterns After Injury

STUDY OBJECTIVE

Injury is a leading cause of hospitalization in people experiencing homelessness, yet post-injury care use is unknown. We sought to understand care use patterns in the 12 months after injury in people experiencing homelessness versus housed low-income Medicaid beneficiaries.

METHODS

We conducted a retrospective cohort study examining injured Medicaid beneficiaries in San Francisco from 2015 to 2022. Our primary exposure was housing status at the time of injury, obtained from linking the county's only Level 1 Trauma Center's Trauma Registry to the county-wide Coordinated Care Management System integrated data system. The primary outcome was emergency department (ED) visits in the 12 months after injury. Secondary outcomes were hospital admissions, outpatient visits, and mental health encounters. We adjusted for demographic, clinical, and injury variables as well as preinjury care use.

RESULTS

Among 5,998 people, 32.9% (N=1,926) were experiencing homelessness at injury. Approximately 76.9% were men, 82.3% spoke English, and 26.9% were Black. Thirty-four percent of people experiencing homelessness had 4 or more ED visits in the 12 months following injury. People experiencing homelessness had a 0.99 greater adjusted increase in ED visits after injury compared with before injury versus housed low-income Medicaid beneficiaries (95% confidence interval 0.64 to 1.33; P<.001). This pattern was observed for inpatient admissions, outpatient visits, and mental health encounters. ED visits and mental health encounters persisted above preinjury levels for 12 months following injury for people experiencing homelessness.

CONCLUSION

The 12 months following injury had higher health-sector use among those experiencing homelessness than housed low-income Medicaid beneficiaries.

Cancer screening outside of age recommendations: a population-based study

BACKGROUND

Cancer screening outside of evidence-based recommendations can be considered a form of low-value care. We aimed to describe the frequency of colorectal, breast, cervical, and prostate cancer screening outside of recommended age guidelines in Switzerland.

METHODS

We analysed data from the 2022 Swiss Health Survey. Of 21,930 participants aged 15 or more, 20,515 (9,555 men and 10,960 women) were included in this study. We calculated age at last screening and classified individuals as having been not screened, screened within age-specific A, B, and C recommendations from the United States Preventive Services Taskforce (USPSTF), screened within age-specific A and B recommendations, or screened outside of recommendations.

RESULTS

Among adults aged 75 years and above (75+), 40.2% (men: 35.1%; women: 44.5%) had undergone cancer screening outside of USPSTF A, B, and C recommendations. This proportion was 26.0% for adults aged 85+ (men: 27.8%; women: 24.6%). Cervical cancer screening was the most frequently undertaken outside of recommended ages by older adults (women aged 75+: 37.1%), followed by prostate (men aged 75+: 34.0%), breast (women aged 75+: 17.8%), and colorectal cancer screening (adults aged 75+: 1.3%). Screening outside of recommendations was also observed among middle-aged adults 40-59 at 12.3% (men: 20.8%; women 4.0%), and younger-aged women 20-39 at 9.9%. Proportions for screening outside of USPSTF A and B recommendations were high (adults 75+: 50.4%; adults 85+: 40.6%; adults 40-59: 20.9%).

CONCLUSIONS

Cancer screening outside of recommendations is highly prevalent, particularly among older adults. Further research is needed to better understand drivers of this form of low-value care.

Incidental findings during lung low-dose computed tomography cancer screening in Australia and Canada, 2016-21: a prospective observational study

OBJECTIVES

To investigate the type and frequency of incidental findings in people at high risk of lung cancer who undergo baseline low-dose computed tomography (LDCT) lung cancer screening in Australia and Canada.

STUDY DESIGN

Prospective observational study; sub-study of the single-arm International Lung Screen Trial (ILST) lung cancer screening study.

SETTING, PARTICIPANTS

Australian and Canadian people enrolled in the ILST, 25 August 2016 - 21 November 2020; inclusion criteria: aged 50-80 years, active smoking history, and high risk of lung cancer (estimated six-year lung cancer risk of 1.51% or more, based on the PLCOm2012 risk prediction model; or a smoking history of 30 pack-years or more). Initial LDCT screening was undertaken at one of five participating hospitals in Australia and one in Canada.

MAIN OUTCOME MEASURES

Prevalence of incidental findings during baseline LDCT lung cancer screening (using a research checklist), by country, classified by experienced radiologists as requiring or not requiring clinical follow-up; reporting of incidental findings in clinical reports for treating physicians (two Australian sites only).

RESULTS

A total of 4403 participants completed baseline LDCT screening at the six participating hospitals. The mean age (64-65 years) and the proportions of participants who currently smoked (47-55%) were similar at all six sites; the proportion of female participants was larger in Sydney (52%) and Vancouver (51%) than the other sites (39-44%). At least one incidental finding was made during baseline LDCT screening of 3225 people (72.8%); findings in 454 people (10.3%) required clinical follow-up. The most frequent incidental findings were coronary artery calcification (3022 of 4380 participants with recorded results, 69.0%) and emphysema (2378 of 4401, 54.0%). Marked differences between the Australian and Canadian sites in the prevalence of incidental findings were noted, and also between the two Australian sites in their communication of incidental findings in clinical screening reports.

CONCLUSION

Incidental findings during lung cancer screening were frequent, and clinical reporting of these findings was inconsistent. When LDCT lung cancer screening is introduced in Australia, a standardised reporting template should be used to provide clear guidance about the clinical significance of such findings.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02871856 (prospective, 18 August 2016).

The impact of re-characterizing metastatic pancreatic neuroendocrine tumors: A prospective study

The biology of metastatic pancreatic neuroendocrine tumors (panNET) may alter over time. It remains to be defined if, how, and when this patient group should be recommended to re-evaluate the characteristics of their disease. This prospective single-center, longitudinal cohort study at Uppsala University Hospital, Sweden (NCT03130205), included metastatic panNET patients with progressive disease to participate in a standardized re-characterization protocol: clinical and biochemical analyses, core-needle biopsy, and dual-positron emission tomography/computed tomography (PET/CT) (18F-fluorodeoxyglucose (18F-FDG) and Gallium-68 DOTATOC (68Ga-DOTATOC)) with NETPET score assessments. At further disease progression, a second re-characterization was offered. The proportion of patients with a clinically significant change is reported and defined as information that could lead to a change in the therapeutic algorithm proposed in the European Neuroendocrine Tumor Society (ENETS) guidelines. Between 2017 and 2021, 21 patients with progressive metastatic panNETs were included. Before inclusion, 19 tumors were grade (G) 1 or 2, and two were G3. Sixteen patients underwent biopsy with collection of adequate tumor material, of whom 81.3% (n = 13/16) displayed an increase in the Ki-67 index, with transition from G2 to G3 in 50% (n = 8/16). Twelve and 15 patients were positive on 18F-FDG- and 68Ga-DOTATOC-positron emission tomography (PET), respectively. This corresponded to NETPET grades P1 (n = 2), P2b (n = 12), and P3b (n = 1). A clinically significant change was noted among 62% (n = 13/21) of patients at first re-characterization, leading to therapy change in 7 positron emission tomography/computed tomography (PET/CT) patients. After the second re-characterization, a significant clinical change occurred in 43% (n = 3/7) with a shift in therapy for one patient. This study shows that a considerable number of progressive metastatic panNETs experience significant changes in their disease characteristics over time. This may result in a revised treatment plan and highlights the need to re-evaluate all relevant aspects of panNET disease. Such comprehensive re-characterization is particularly crucial in the context of clinical trial inclusion.

The health-related quality of life among survivors with post-COVID conditions in the United States

BACKGROUND

Even after a mild initial SARS-CoV-2 infection, a considerable proportion of patients experience long-lasting symptoms. However, there is scarce data on how post-COVID conditions (PCCs) are associated with health-related quality of life (HRQL) among COVID survivors. We aimed to study this association among adult COVID survivors in the United States.

METHOD

The Behavioral Risk Factor Surveillance System 2022 data was utilized. The study population consisted of participants with a history of SARS-CoV-2 infection, categorized based on whether they had any PCCs. We evaluated the respondents' HRQL in the two groups according to 1) self-reported general health (SRGH), 2) self-reported mental health, 3) self-reported physical health, and 4) efficiency in daily activities.

RESULTS

A total of 108,237 COVID survivors were included (35% were 18-34 years old and 46.5% were male), among whom 22.7% had PCCs. Unfavorable SRGH was more common among COVID survivors with PCCs than those without PCCs (25.7% vs. 15.5%, p < 0.001). Also, rates of having unfavorable mental and physical health and compromised daily efficiency for more than 13 days a month were significantly higher among PCC-positive respondents (p < 0.001). In the regression analysis adjusted for sociodemographics, comorbidities, and behavioral determinants of health, the presence of PCCs appeared as independent associates of unfavorable SRGH (aOR: 1.39, CI95%: [1.28-1.52], p < 0.001). Among PCC-positive respondents, dizziness on standing, mood changes, and musculoskeletal pain accompanied the highest odds of unfavorable HRQL. Based on a multivariate logistic regression analysis, early middle age, obesity, physical inactivity, diabetes, cardiovascular and pulmonary diseases, cancer, depression, smoking, being single and less educated, and having low annual income were independent factors associated with increased odds of unfavorable SRGH among survivors with PCCs.

CONCLUSION

Our study corroborates that survivors with PCCs may experience significant adverse impacts on their health and daily life activities. Our results highlight the importance of further studies on PCCs' diagnosis, follow-up, and treatment.

Social determinants of health and intensive care unit admission rates and outcomes for children, Australia, 2013-2020: analysis of national registry data

OBJECTIVES

To investigate the influence of non-medical social determinants of health on rates of admission and outcomes for children admitted to intensive care units (ICUs) in Australia.

STUDY DESIGN

Retrospective cohort study; analysis of Australian and New Zealand Paediatric Intensive Care Registry data.

SETTING, PARTICIPANTS

Children (18 years or younger) admitted to Australian ICUs during 1 January 2013 - 31 December 2020.

MAIN OUTCOME MEASURES

Population-standardised ICU admission rates, overall and by residential socio-economic status (Index of Relative Socio-Economic Disadvantage [IRSD] quintile) and Indigenous status; likelihood of mortality in the ICU by residential socio-economic status (continuous, and quintile 1 v quintiles 2-5) and Indigenous status, adjusted for pre-illness, admission, and ICU and hospital factors.

RESULTS

Data for 77 233 ICU admissions of children were available. The ICU admission rate for Indigenous children was 1.91 (95% confidence interval [CI], 1.87-1.94), for non-Indigenous children 1.60 (95% CI, 1.57-1.64) per 1000 children per year. The rate was higher for children living in areas in the lowest IRSD quintile (1.93; [95% CI, 1.89-1.96]) than for those living in quintile 5 (1.26 [95% CI, 1.23-1.29] per 1000 children per year). Unadjusted in-ICU mortality was higher for Indigenous than non-Indigenous children (2.5% v 2.1%) and also for children living in the lowest IRSD quintile than in quintiles 2-5 (2.5% v 2.0%). After adjustment for all factors, mortality among Indigenous children was similar to that for non-Indigenous children (adjusted odds ratio [aOR], 1.15; 95% CI, 0.92-1.43); it was higher for children living in the lowest IRSD quintile than for those living in quintiles 2-5 (aOR, 1.18; 95% CI, 1.03-1.36). Remoteness and distance between home and ICU did not influence the likelihood of death in the ICU.

CONCLUSIONS

The population-standardised ICU admission rate is higher for Indigenous children and children residing in areas of greatest socio-economic disadvantage than for other children in Australia. Adjusted in-ICU mortality was higher for children from areas of greatest socio-economic disadvantage. Advancing health equity will require further investigation of the reasons for these differences.

A case scenario study on adherence to GINA recommendations by primary care physicians in an area of Southern Italy: the "Progetto Padre 2.0"

BACKGROUND

Accurate diagnosis and management of bronchial asthma are complex processes guided by national and international asthma guidelines, particularly the Global Initiative for Asthma (GINA). However, adherence to these guidelines is often suboptimal, varying across healthcare professionals and countries, which can lead to poor asthma control and increased healthcare costs.

AIM

In this observational study, we assessed the alignment to GINA recommendations in the diagnosis and management of asthma among 15 primary care physicians in two metropolitan areas of the Campania region, Southern Italy.

METHODS

120 patients were randomly selected from the electronic medical records of 15 primary care physicians. Afterwards, the alignment of diagnostic pathways and treatments with current GINA recommendations was assessed by an experienced chest physician. Three main outcomes were defined: diagnostic congruence, diagnostic workup congruence, and therapeutic congruence.

RESULTS

Overall, 26.7% of our sample presented with an incongruous asthma diagnosis, while only 46.7% patients had therapeutic prescriptions in line with the latest GINA document recommendations. Patients treated in accordance with GINA recommendations exhibited significantly higher ACT scores, averaging 20.5 ± 4.0, compared to those receiving non-guideline-directed therapy, who averaged 15.7 ± 6.1 (p < 0.001). Diagnostic congruence showed a direct correlation with atopy (r = 0.277, p = 0.002) and an inverse correlation with ACT score (r = -0.335, p < 0.001).

CONCLUSIONS

The results of this study indicate that adherence to asthma guidelines in the metropolitan areas of Naples and Benevento remains insufficient. Further research focused on developing individualized interventions to manage non-adherence is warranted.

Can shoulder dystocia be predicted before operative vaginal delivery using a score that includes ultrasonographic head-perineum distance measurement?

OBJECTIVE

The main study objective was to develop a novel shoulder dystocia (SD) prediction score using ultrasound-based head-perineum distance measured before an operative vaginal delivery (OVD).

METHODS

This retrospective unicentric study (Lille, France) included all cases of OVD of singleton pregnancies from March 2019 to October 2020, with cephalic presentation and > 37 weeks of gestation, for which intrapartum sonography was performed. A multiclass-penalized logistic regression model was used to develop the SD prognostic score, with missing values imputed by multiple imputations.

RESULTS

Among the 1708 patients with OVD, 773 who underwent ultrasound for head-perineum distance were included. SD occurred in 99 cases (12.8%). The SD's predicting factors (and their weights) included the following: maternal age younger than 28 years (3 points); multiparous (4 points); induced labor (4 points); gestational diabetes (3 points); and head-perineum distance without pressure (≤20 mm [-2 points], using 21-30 mm as reference, 31-40 mm [2 points], 41-50 mm [4 points], 51-60 mm [6 points], and >60 mm [8 points]). Three patient risk subgroups were categorized as score range (occurrence percentage) as low risk: < 3 (< 10%), high risk: 3-8 (10%-20%), and very high risk: > 8 (> 20%).

CONCLUSION

The developed scoring system may help predict SD occurrence during OVD using five delivery room parameters. Replication with other populations and prospective cohorts will be needed for validation.

Association between life's crucial 9 and lung health: a population-based study

BACKGROUND

As a cardiovascular health (CVH) assessment tool, Life's Crucial 9 (LC9) is often associated with diverse chronic health indicators. However, no study has yet explored the association of LC9 with multifactorial components of lung health. Thus, this study aimed to investigate the correlation of LC9 with lung health.

METHODS

This cross-sectional study used data from the National Health and Nutrition Examination Survey (NHANES), which covers individuals aged 40 years and older with complete LC9 and lung health data. Multiple regression was employed in linear relationships investigation, while Restricted Cubic Spline (RCS) was used to explore nonlinear relationships. Subgroup analyses and interaction tests demonstrated the stability of associations. Combining LC9 to build a Light Gradient Boosting Machine (LightGBM) machine learning (ML) model to predict lung health, Shapley Additive Explanations (SHAP) sorted the contribution of LC9 components to the model.

RESULTS

From a total of 10,461 study participants, 1725 had low CVH, 7476 had moderate CVH, and 1260 had high CVH. There was a strong positive correlation between LC9 score and lung health. This association remained consistent across subcomponent strata. RCS analysis revealed non-linear associations between LC9 and respiratory outcomes, including cough, asthma, and COPD. The LightGBM model incorporating LC9 demonstrated excellent predictive performance for lung health, with favorable metrics in Area Under the Curve (AUC), accuracy, and specificity. SHAP analysis identified depression, nicotine exposure, and BMI scores as the predominant contributors among LC9 components to the model's predictive capability.

CONCLUSION

Individuals with better CVH as assessed by LC9 tended to have better lung health. The combination of the LightGBM model could achieve better prediction results.

Higher vitamin K1 intakes are associated with lower subclinical atherosclerosis and lower risk for atherosclerotic vascular disease-related outcomes in older women

PURPOSE

Vitamin K may inhibit vascular calcification, a common attribute of atherosclerotic vascular diseases (ASVDs). We examined associations between dietary vitamin K1 intakes and both subclinical atherosclerosis and ASVD events, including hospitalisations and mortality, in older women.

METHODS

1,436 community-dwelling women (mean ± SD age 75.1 ± 2.7 years) were included. Vitamin K1 intakes were calculated from a validated food frequency questionnaire at baseline (1998), utilising a region-matched vitamin K food database. Common carotid artery intima-media thickness (CCA-IMT), a measure of subclinical atherosclerosis, was measured in 2001 (n = 1,090). Differences in CCA-IMT by quartiles (Q) of vitamin K1 intake were examined using multivariate analysis of variance. Associations between vitamin K1 intakes and ASVD outcomes (hospitalisations and/or deaths), obtained from linked health records over 14.5 years, were analysed using restricted cubic splines within multivariable-adjusted Cox-proportional hazard models.

RESULTS

Women with higher vitamin K1 intakes had a 5.6% lower mean CCA-IMT (Q4 [median 119 µg/day] compared to Q1 [median 49 µg/day], p < 0.001). Over 14.5 years, 620 (43.1%), 497 (34.6%) and 301 (20.9%) ASVD events, hospitalisations, and deaths were recorded, respectively. In multivariable-adjusted models, the highest vitamin K1 intakes (Q4, compared to Q1), were associated with lower relative hazards for ASVD events (HR 0.71 95%CI 0.55-0.92) and ASVD mortality (HR 0.57 95%CI 0.40-0.83), but not ASVD hospitalisations (HR 0.83 95%CI 0.63-1.11).

CONCLUSION

Vitamin K1 intakes of ~ 120 µg/day appear to be beneficial in lowering risk for subclinical and clinical ASVD in older women. These quantities can be attained by consuming vitamin K1 rich foods, such as leafy green vegetables.

Association between TG/HDL-C and depression in US adults: A nationally representative cross-sectional study

Lipid profile disturbances are frequently observed in depressive patients. Triglyceride-to-high-density lipoprotein cholesterol (TG/HDL-C) can be reflective of the level of blood lipids. However, it remains unclear whether higher TG/HDL-C increases the risk of depression. This study aimed to investigate the association between TG/HDL-C and depression. In this cross-sectional study, 20,406 participants were analyzed from the National Health and Nutrition Examination Survey between 2005 and 2020. A weighted multivariable logistic regression model, restricted cubic spline regression model and threshold effect analysis were used to explore the association of TG/HDL-C with depression risk. A total of 20,406 participants who had complete data on TG/HDL-C and depression measurement were included in this study (median age 47 years, 50.51% female). Participants with depression had higher TG/HDL-C than those without depression (0.97 [0.54-1.64] vs 0.82 [0.50-1.38], P < .001). TG/HDL-C was associated with an increased risk of depression after adjusting for all covariates (in model 3: odds ratio (OR) = 1.31, 95% confidence interval (CI): 1.04-1.64, P = .02). Moreover, a nonlinear J-shaped relationship was observed between TG/HDL-C ratio and the risk of depression, with an inflection point of 0.402 by threshold effect analysis. These findings indicate that TG/HDL-C has a J-shaped association with the risk of depression (P for non-linearity = .008).

A Comparative Study of CT Perfusion Postprocessing Tools in Medium/Distal Vessel Occlusion Stroke

BACKGROUND AND PURPOSE

CTP has been validated for stroke due to large vessel occlusion, but not for medium or distal vessel occlusions (MDVO). The aim of this study was to evaluate discrepancy of 2 widely used postprocessing tools for CTP in patients with medium/distal vessel occlusion (MDVO) stroke.

MATERIALS AND METHODS

This retrospective single-center cohort study comprised CTP data sets of patients with acute isolated MDVO and disabling stroke. CTP postprocessing included Syngo.via and RapidAI. Perfusion lesions were segmented and compared with regard to volume and spatial distribution of the perfusion abnormalities. For each patient, the results of the 2 postprocessing tools were deemed to represent agreement regarding volume and/or distribution according to a predefined classification scheme. Penumbra volumes were compared between postprocessing tools by using the t test for paired samples.

RESULTS

Fifty CTP data sets from 49 patients (mean age 75.3 ± 10.7 years, 33 male patients) were included. In <30% of patients, the predefined criteria for agreement were met which indicate at least 50% congruence regarding lesion size and lesion location as well as a maximum distance between lesion margins <50 mm. Comparison of tissue at risk volumes revealed outliers, volume disagreement, and distribution disagreement in up to 79.6%. The 2 postprocessing tools disagreed on presence and volume of an infarct core in up to 86% of patients. Penumbra volumes differed significantly between postprocessing tools (P < .001; mean difference 50.5 mL/16.9 mL).

CONCLUSIONS

Despite being in daily use, commercially available postprocessing tools for CTP provide discrepant results in patients with MDVO.

MultiAgency, prospective, exploratory, non-intervention, cohort Study on Human Impact Exposure oNboard high-speed boats (MASHIEN): protocol

INTRODUCTION

High-speed boat operations expose personnel to slamming-induced impacts, which can lead to musculoskeletal injuries and cognitive impairments. Despite existing safety measures, regulations and protocols, the risk of injuries remains significant. The MultiAgency, prospective, exploratory, non-intervention, cohort Study on Human Impact Exposure oNboard high-speed boats study aims to investigate the nature and magnitude of these impacts, their acute and long-term health effects, and potential injury prevention strategies to improve operational safety and performance.

METHODS AND ANALYSIS

This is an ongoing multicentre, prospective, non-intervention, observational cohort study. The first participant was enrolled on 23 August 2024. High-speed boat operators log self-reported pain data via a smartphone app, using a Visual Analogue Scale and pain drawings. Triaxial accelerometers are installed on boat hulls and worn by participants to measure impact exposure. Data analysis assesses correlations between exposure and reported pain, enabling the identification of risk factors and the development of safety guidelines for high-speed boat operations.

ETHICS AND DISSEMINATION

The study has received ethical approval from the relevant ethics committees, including the Swedish Ethics Review Authority (no. 2022-04931-01). All participants will provide informed consent before enrolment. The findings will be disseminated through technical reports, articles in peer-reviewed journals, conference presentations and direct engagement with military and maritime stakeholders to enhance training protocols and safety measures.

TRIAL REGISTRATION NUMBER

NCT05299736.

The Impact of Survival Benefit and Study Design on FDA Approval for Anticancer Drugs Over the Past Decades

Despite the tremendous effort in the oncology community, the success rate of anticancer development remained low at 30% to 40% from the Phase 3 study to the regulatory approval. The factors associated with the regulatory approval for market authorization have gained interest in the community to improve the success rate of drug development. Using the data from 208 Phase 3 studies for anticancer drugs, we explored the possible factors associated with the US Food and Drug Administration's (FDA's) approval by multivariate logistic regression analysis. The model incorporated 21 factors from therapeutic context, study design, and outcomes. The hazard ratio (HR) for overall survival (OS) showed a significant association with FDA approval (coefficient: -29.907, P < .001), and the age of control drugs in the market followed (coefficient: -2.581, P = .008). In the model, if the HR for OS changes from 0.75 to 0.85, the probability of FDA approval remarkably decreases from 79.6% to 16.4%. A 50% likelihood of FDA approval is predicted at HR 0.795 for OS. Furthermore, the P-value for the OS test and the width of the confidence interval on HR for OS showed a significant association with the probability of FDA approval. These findings consistently underscore the rigorous standard required for new anticancer drugs to obtain regulatory approval from the FDA.

Shoulder pain occurrence in asymptomatic overhead athletes: a prospective cohort study with a 6-month follow-up

PURPOSE

To identify interactions among variables of the upper limbs, trunk, and hip joint associated with shoulder pain occurrence in asymptomatic overhead athletes.

DESIGN

prospective cohort study.

SETTING

Sports club facilities.

PARTICIPANTS

Ninety-five adult asymptomatic overhead athletes from national first division teams, both sexes.

MAIN OUTCOMES MEASURES

Isometric strength of the shoulder ER muscles, serratus anterior, lower trapezius and hip abductors, HipSIT, shoulder internal rotation (IR) range of motion (ROM), low flexion test, closed kinetic chain upper extremity stability test (CKCUEST), seat medicine ball test (SMB-T), upper seat shot put test (USSP-T), upper quarter Y balance test [UQYBT] and leg lateral reach test (LLRT). Shoulder pain occurrence was registered during a 6-month follow-up.

RESULTS

The model correctly classified 77.4 % of the athletes who did not develop shoulder pain and 100.0 % of those who developed shoulder pain. The accuracy was 89 % (95 %CI:83 %,96 %). Athletes with UQYBT score under 88.5 %, and isometric strength of the shoulder ER muscles above 0.780 N/kg did not develop shoulder pain (RR:0.02, 95 %CI:0.001,0.44). Athletes with UQYBT score above 88.5 % and USSP-T performance above 3.175m developed shoulder pain (RR:14.09, 95 %CI: 3.27,60.56).

CONCLUSION

Shoulder pain occurrence in overhead athletes was associated with interactions among UQYBT, isometric strength of the shoulder ER muscles, and USSP-T.

Vehicle Age and Driver Assistance Technologies in Fatal Crashes Involving Teen and Middle-Aged Drivers

Importance

Motor vehicle crashes are the leading cause of death for US teens. Newer vehicles and driver assistance technologies show promise in reducing crashes and injury severities; however, research on the age and technologies of vehicles driven by teens involved in fatal crashes is limited.

Objective

To examine the differences in vehicle age and driver assistance technologies between vehicles driven by teen and middle-aged drivers involved in fatal crashes and to investigate the associations among vehicle age, driver assistance technologies, and driver death in these crashes.

Design, Setting, and Participants

This retrospective cohort study used fatal crash data (2016-2021) obtained from the Fatality Analysis Reporting System. Data analysis was restricted to passenger vehicles. Participants included teen drivers (15-18 years old) and middle-aged drivers (31-55 years old). All analyses were performed between December 1, 2023, and July 25, 2024.

Exposures

Exposures include the vehicle age (≤5, 6-15, or >15 years) and the number of driver assistance technologies installed (0 to 4).

Main Outcomes and Measures

The main outcome was whether the driver died in fatal crashes. Multivariable logistic regressions examined the associations between vehicle age (or driver assistance technologies installed) and driver death in fatal crashes, adjusting for driver sex, restraint use, and crash year.

Results

Among 81 145 drivers (49 838 male [61.4%]) involved in fatal crashes, there were 9809 teen drivers (mean [SD] age, 17.2 [0.9] years) and 71 336 middle-aged drivers (mean [SD] age, 41.7 [7.3] years). A higher proportion of teen drivers were operating vehicles older than 15 years compared with middle-aged drivers (2706 drivers [27.6%] vs 16 239 drivers [22.8%]). Driving vehicles aged 6 to 15 years (adjusted risk ratio [aRR], 1.19; 95% CI, 1.17-1.22) or older than 15 years (aRR, 1.31; 95% CI, 1.28-1.34) was associated with significantly higher odds of driver death in fatal crashes compared with driving vehicles 5 years old or newer, independently of driver age. Additionally, each installed driver assistance technology was associated with a 6% reduction (aRR, 0.94; 95% CI, 0.90-0.98) in the risk of driver death in fatal crashes.

Conclusions and Relevance

These findings suggest that older vehicles and those with fewer driver assistance technologies are associated with increased risk of driver death in fatal crashes; thus, teens should drive the safest vehicles available, not older family cars. The findings underscore the urgent need to ensure teens drive safer vehicles to protect their lives.

ARDS Weaning: The Impact of Abnormal Breathing Patterns Detected by Electric Tomography Impedance and Respiratory Mechanics Monitoring

Background: After the improvement of the initial phase of ARDS, when the patients begin spontaneous breathing and weaning from mechanical ventilation, some patients may present abnormal breathing patterns, whose evaluation of the repercussions were poorly studied. This study proposed to evaluate abnormal breathing patterns through the use of electrical impedance tomography (EIT), and clinical, respiratory mechanics, and ventilatory parameters according to the types of weaning from mechanical ventilation. Methods: This was a prospective cohort study of subjects with ARDS who were considered able to be weaned from mechanical ventilation in the clinical-surgical ICU. Weaning types were defined as simple, difficult, and prolonged weaning. EIT, ventilatory, lung mechanics, and clinical data were collected. Data were collected at baseline in a controlled ventilatory mode and, after neuromuscular blocker withdrawal, data were collected after 30 min, 2 h, and 24 h. EIT parameter analysis was performed for ventilation distribution in the lung regions, pendelluft, breath-stacking, reverse-trigger, double-trigger, and asynchrony index. Results: The study included 25 subjects who were divided into 3 groups (9/25 simple, 8/25 difficult, and 8/25 prolonged weaning). The prolonged weaning group showed more delirium, ICU-acquired weakness, stay in ICU, and hospital and ICU mortality. During the change from controlled to spontaneous mode, we observed increased tidal volumes and driving pressures, which were mainly found in the prolonged weaning group when compared with the simple weaning group. The prolonged weaning group showed a higher flow index, more asynchronies during volume-assisted ventilation, a higher incidence of pendelluft, and redistribution of ventilation to posterior regions visualized by EIT. Conclusions: The present study showed abnormal breathing patterns in the prolonged weaning group. The clinical occult findings of abnormal breathing patterns could be monitored, mainly through EIT and with better assessment of pulmonary mechanics.

Understanding ethnic inequalities in cancer diagnostic intervals: a cohort study of patients presenting suspected cancer symptoms to GPs in England

BACKGROUND

UK Asian and Black patients experience longer cancer diagnostic intervals - the period between initial symptomatic presentation in primary care and cancer diagnosis.

AIM

To determine whether the differences in diagnostic intervals are because of prolonged primary care, referral, or secondary care interval.

DESIGN AND SETTING

A cohort study was undertaken of 70 971 patients with seven cancers (breast, lung, prostate, colorectal, oesophagogastric, myeloma, ovarian) diagnosed after symptom presentation in English primary care.

METHOD

Data on symptom presentation and diagnosis were extracted from cancer registry-linked primary care and secondary care data. Primary interval was defined as the period between first primary care presentation and secondary care referral, referral interval as the period between referral and first secondary care appointment, and secondary care interval as the period between the first secondary care appointment and diagnosis. Accelerated failure time models were used to investigate ethnic differences across all four intervals.

RESULTS

Across all sites, the median diagnostic interval was 46 days, ranging from 13 days for breast cancer to 116 days for lung cancer. It was 14% longer for Black patients (adjusted time ratio [ATR] 1.14, 95% confidence interval [CI] = 1.05 to 1.25) and 13% longer for Asian patients (ATR 1.13, 95% CI = 1.03 to 1.23) compared with White patients. Site-specific analyses showed that, for myeloma, lung, prostate, and colorectal cancer, the secondary care interval was longer in Asian and Black patients, who also had a longer primary care interval in breast and colorectal cancer. There was little evidence of ethnic differences in referral interval.

CONCLUSION

This study found evidence of ethnic differences in diagnostic intervals, with prolonged secondary care intervals for four common cancers and prolonged primary care intervals for two. Although these differences are relatively modest, they are unjustified and may indicate shortcomings in healthcare delivery that disproportionately affect ethnic minorities.

Associations between self-reported and agency-reported child maltreatment and mental illness in later life: Results from the CALM study

BACKGROUND

Child maltreatment (CM), including physical, emotional, and sexual abuse, and neglect, has been consistently linked to various mental illnesses. Research directly comparing self-reported versus agency-reported CM, however, is limited, especially with official mental health services use.

OBJECTIVES

This study compared associations between hospital admissions and community mental health service use for mental illness in self-reported versus agency-reported CM.

PARTICIPANTS AND SETTING

Agency-reported CM from 0 to 15 years was linked to an Australian birth cohort via administrative record linkage, and self-reported CM was collected at 30-year follow-up.

RESULTS

The sample included 2392 individuals. Self-reported CM was significantly associated with admissions for any type of mental illness (ORadj = 2.84, 95%CI 1.95-4.13), psychotic disorders (ORadj = 3.26, 95%CI 1.79-5.95), and common mental disorders (ORadj = 3.38, 95%CI 2.13-5.36), as well as increased community mental health service use (ORadj = 3.66, 95%CI 2.43-5.52). Agency-reported CM was only associated with admissions for any type of mental illness (ORadj = 2.36, 95%CI 1.32-4.21), and increased community mental health service use (ORadj = 2.91, 95%CI 1.62-5.25).

CONCLUSION

Self-reported CM showed higher effect sizes with higher degrees of certainty with all forms of mental illness service use compared to agency-reported CM, highlighting the need to consider both in future research.

Association between physical activity and sedentary behaviour and changes in intrinsic capacity in Spanish older adults (Seniors-ENRICA-2): a prospective population-based study

BACKGROUND

Intrinsic capacity-the composite of all the physical and mental capacities of an individual-has been proposed by WHO as a marker of healthy ageing. However, the association of movement behaviours (physical activity and sedentary behaviour) with intrinsic capacity remains largely unexplored. We aimed to prospectively analyse the association of movement behaviours with intrinsic capacity in older adults.

METHODS

The Seniors-ENRICA-2 prospective, population-based study included a cohort of male and female community-dwelling older adults aged 65-94 years living in Spain. Accelerometer-based levels of sedentary, light physical activity (LPA), and moderate-to-vigorous physical activity (MVPA) were assessed at baseline. An intrinsic capacity composite score (with higher scores indicating higher intrinsic capacity) was calculated at baseline and at two follow-up assessments across six domains: vitality (handgrip strength, appetite, and weight loss), cognition (Mini-Mental State Examination), psychological (Geriatric Depression Scale), locomotion (Short Physical Performance Battery), vision, and hearing.

FINDINGS

Between Dec 2, 2015, and Nov 23, 2017, 3273 participants were recruited to the Seniors-ENRICA-2 study. 2477 (75·7%) of 3273 participants had complete data for movement behaviours and intrinsic capacity at baseline and were therefore included in the analyses. 1314 (53·0%) of 2477 participants were female and 1163 (47·0%) were male. 1463 (59·1%) of 2477 participants provided follow-up data over a median of 2·3 years (IQR 2·1 to 2·5) and 940 over 5·5 years (5·2 to 5·8). When analysed as a continuous variable, higher levels of MVPA (mean percentage change [MPC] per 15 min 0·63%, 95% CI 0·06 to 1·21), but not LPA (-0·39%,-0·85 to 0·07), were associated with improvements in intrinsic capacity during follow-up, whereas higher levels of sedentary behaviour were associated with declines in intrinsic capacity (-0·29%, -0·57 to -0·01). Analyses by tertiles of physical activity confirmed that the highest (MPC 4·83%, 95% CI 1·98 to 7·75) and intermediate (5·44%, 2·52 to 8·45) tertiles of MVPA were associated with improvements in intrinsic capacity compared with the lowest tertile. By contrast, compared with the highest tertile, the lowest (MPC 5·48%, 95% CI 2·88 to 8·02) and intermediate (5·73%, 3·16 to 8·22) tertiles of sedentary behaviour were associated with improvements in intrinsic capacity.

INTERPRETATION

Sedentary behaviour was associated with a reduction of intrinsic capacity, and MVPA (but not LPA) was associated with an improvement in intrinsic capacity in older adults. Our findings support the importance of promoting physical activity and reducing sedentary behaviour for healthy ageing.

FUNDING

Instituto de Salud Carlos III, Spanish Ministry of Science and Innovation, French Agence Nationale de la Recherche, European Regional Development Fund/European Social Fund, Fondo de Investigaciones Sanitarias, the EU NextGenerationEU/Plan de Recuperación, and Transformación y Resiliencia.

J-shaped association between apolipoprotein B and CV outcomes in statin-treated patients with chronic coronary syndrome

INTRODUCTION AND OBJECTIVES

The association between apolipoprotein B (apoB) and residual cardiovascular (CV) risk in patients with chronic coronary syndrome (CCS) remains unclear. We aimed to investigate the association between apoB levels and CV outcomes in statin-treated CCS patients.

METHODS

We enrolled 8641 statin-treated CCS patients at Fuwai Hospital. The patients were divided into 5 groups based on to apoB quintiles (Q1 to Q5). The primary endpoint was 3-year CV events, including CV death, nonfatal myocardial infarction, and nonfatal stroke.

RESULTS

During a median follow-up of 3.17 years, there were 232 (2.7%) CV events. After multivariable adjustment, a restricted cubic spline illustrated a J-shaped relationship between apoB levels and 3-year CV events, with the risk remaining flat until apoB levels exceeded 0.73g/L, after which the risk increased (nonlinear P <.05). Kaplan-Meier curves showed the lowest CV event rate in the Q3 group (0.68-0.78g/L). Compared with the Q3 group, multivariable Cox regression models revealed that both low (Q1, ≤0.57g/L) and high (Q5, >0.93g/L) apoB levels were associated with an increased risk of major adverse cardiac events (all P <.05). Notably, patients with low apoB levels (Q1) had the highest risk of CV death (HR, 2.44; 95%CI, 1.17-5.08).

CONCLUSIONS

Our analysis indicates that both low and high levels of apoB are associated with elevated CV risk, with the risk being particularly pronounced at higher levels (> 0.73g/L).

Early administration of romosozumab prevents rebound of bone resorption related to denosumab withdrawal in fractured post-menopausal women: a real-world prospective study

PURPOSE

The real-world effectiveness of switching from denosumab to romosozumab remains controversial. Sequential therapy with romosozumab was shown to be associated with inadequate suppression of bone resorption and there was anecdotal evidence of major osteoporotic fractures (MOFs) after transitioning from denosumab to romosozumab. This study evaluated the effects on bone resorption of early romosozumab administration 3 months after denosumab withdrawal in fractured women with post-menopausal osteoporosis.

METHODS

This prospective, single-center cohort study included 39 post-menopausal women with osteoporosis experiencing either MOFs or decrease in bone mineral density during long-term treatment with anti-resorptive drugs. Eighteen received romosozumab either 6 months (Group A) or 3 months (Group B) after their last denosumab dose, while 21 women switched from bisphosphonates to romosozumab and were enrolled as controls (Group C). Serum C-terminal telopeptide of type I collagen (CTX) levels were measured at baseline, 3 and 6 months.

RESULTS

All women of group A and 4 out of 8 women of group B showed a clinically significant increase of CTX values (i.e., change above the least significant change) (p = 0.023), which occurred earlier in group A as compared to group B. Moreover, 9/10 women of group A and 2/8 women of group B achieved values above the mean of reference range for pre-menopausal women (p = 0.013). In group C, serum CTX values did not change significantly during the follow-up. Two women in Group A experienced MOFs during the follow-up.

CONCLUSIONS

Early romosozumab administration after denosumab withdrawal may control bone turnover rebound and possibly prevent incidence of fractures in post-menopausal osteoporosis.

Depression and Heart Failure in US Veterans

Importance

Depression and heart failure (HF) affect millions of US adults. Incident HF risk following depression diagnosis is understudied.

Objective

To examine the association between incident HF and prevalent depression among veterans.

Design, Setting, and Participants

This cohort study analyzed sociodemographic and clinical data of US veterans participating in the Veterans Affairs (VA) Birth Cohort. Data were obtained from the VA Corporate Data Warehouse between January 1, 2000, and October 1, 2015. Participants were born between 1945 and 1965, were free of HF at baseline, and met a medical home definition (had 3 outpatient visits within 5 years). Statistical analysis was performed from May 2022 to February 2025.

Exposures

Prevalent depression, defined as 1 inpatient or 2 outpatient visits with International Classification of Diseases, Ninth Revision (ICD-9) or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes for depression.

Main Outcomes and Measures

The primary outcome was time to incident HF, defined as time from baseline to documented date of the first inpatient or second outpatient visit with ICD-9 or ICD-10 codes for HF. A Cox proportional hazards regression model adjusted for relevant covariates was used to assess the association of depression and incident HF.

Results

A total of 2 843 159 veterans (median [SD] age, 54 [49-59] years; 2 677 919 males [94.2%]; 556 914 [19.6%] self-identified as Black, 144 485 [5.1%] as Hispanic, 1 975 068 [69.5%] as White, and 99 011 [3.5%] as other race and ethnicity) were included. Participants were followed up for incident HF over a median (IQR) duration of 6.9 (3.4-11.0) years. Generally, 8.0% of participants (226 247 of 2 843 159) had prevalent depression at baseline. Females made up a larger percentage of those with vs without depression (11.4% vs 5.3%). Participants with depression demonstrated higher unadjusted incident HF rates compared with those without depression (136.9 [95% CI, 132.2-141.7] cases per 10 000 person-years vs 114.6 [95% CI, 113.4-115.9] cases per 10 000 person-years, respectively). After adjusting for sociodemographic and cardiovascular risk factors, depression was associated with an increase in incident HF hazard of 14.0% (hazard ratio [HR], 1.14; 95% CI, 1.13-1.16), with an estimated adjusted median (IQR) incidence rate difference of 16.0 (14.9-18.3) cases per 10 000 person-years. Among patients without comorbidities, depression was associated with a higher increase in incident HF hazard (HR, 1.58; 95% CI, 1.39-1.80), with an estimated adjusted median (IQR) rate difference of 14.2 (9.5-19.5) cases per 10 000 person-years.

Conclusions and Relevance

In this cohort study, depression among veterans was associated with an increased hazard of incident HF after controlling for demographic and cardiovascular risk factors. Higher incident HF rates in patients with depression remained consistent in an otherwise low-risk cohort.

Outcomes of Glenoid Labral Repair Using All-Suture Anchors

Background

In recent years, innovation in arthroscopic glenoid labral repair techniques has included the development of all-suture anchors. There are multiple potential advantages of all-suture anchors, including decreased bone removal, anchor migration, synovitis/chondral injury, and bone reaction. Despite these potential advantages, few studies have examined clinical outcomes of glenoid labral repair with all-suture anchors.

Purpose

To evaluate patient-reported and return-to-sport outcomes of arthroscopic glenoid labral repairs using all-suture anchors.

Study Design

Case series; Level of evidence, 4.

Methods

All patients who underwent arthroscopic glenoid labral repair using all-suture anchors at our institution over a 6-year period were identified. As a part of a longitudinal data repository, we collected baseline (presurgical) and follow-up patient-reported outcome data, with a minimum follow-up time of 2 years, using the American Shoulder and Elbow Surgeons (ASES) score and the Western Ontario Shoulder Instability Index (WOSI) score. For athletes, we also collected data on return to preinjury level of sport and relevant contextual factors. We compared baseline and follow-up ASES and WOSI scores and examined the association between demographic, injury, and surgery variables and ASES/WOSI scores at follow-up.

Results

Of 529 eligible patients, follow-up data were collected for 372 (70%). Of those, 51 underwent any type of subsequent ipsilateral shoulder surgery (14% of those with follow-up data [51/372]). In the remaining 321 patients (mean age at surgery, 23.9 years; 83% male), we collected both presurgical and follow-up outcome data (mean follow-up time, 3.3 years). Across all labral repair types, mean values significantly improved from baseline to follow-up for both the ASES (baseline, 62.1; follow-up, 92.7) and the WOSI (baseline, 47.5; follow-up, 85.4). Younger age, being a competitive athlete, and having a labral tear in the inferior location (vs not) were associated with higher ASES and WOSI scores at follow-up. Those with concomitant biceps tenodesis demonstrated lower ASES and WOSI scores at follow-up compared with those without tenodesis. Within competitive athletes (n = 201), 95% of athletes who attempted to return to preinjury level of sport were able to do so.

Conclusion

Among patients with follow-up data, 14% underwent subsequent ipsilateral shoulder procedures. Those who didn't undergo subsequent procedures demonstrated excellent patient-reported outcomes, including large and meaningful improvements in ASES and WOSI scores and a high level of return-to-sport in athletes, after arthroscopic all-suture anchor glenoid labral repair at a mean follow-up of 3.3 years.

Outcomes for Degenerative Cervical Myelopathy Following Implementation of the AO Spine International Guidelines: A Single-Centre Service Evaluation

IntroductionDegenerative cervical myelopathy (DCM) is a syndrome of symptomatic cervical spinal cord compression due to degenerative spinal changes. Until recently there was no formal consensus on exactly which patients are suitable for surgical or conservative management. The AO Spine international guidelines were introduced to address this issue, based on the best available current evidence. However, their implementation into routine clinical practice has not yet been reported. The objective was to evaluate surgical outcomes following the implementation of the AO Spine guidelines at our spinal neurosurgical centre.MethodsA service evaluation was conducted using data collected from electronic healthcare records for 259 patients, with outcomes of interest including change in mJOA score and complications. Data from 193 patients were included in the final analysis.ResultsThere was a mean improvement of the mJOA score by 1.53 points, 1.44 point and 1.92 points at post-operative intervals of 3 months (P < .001), 6 months (P < .001) and 12 months (P < .001). The percentage (number) of patients whose increase in mJOA score was greater than or equal to the minimal clinically importance difference (MCID) was 41% (44/107), 34% (33/96) and 43% (49/114) at these respective time intervals. Intraoperative complications occurred in 28 patients (11.7%). No association was found between BMI and postoperative change in mJOA score.ConclusionOur results are comparable to those from best practice data and suggest adherence to international guidelines provides a service that promotes meaningful recovery for patients with DCM. Therefore, our results offer support for implementation of the AO Spine international guidelines in clinical practice.

Clinical Relevance of 'Cap' and 'Track' Development after Recent Small Subcortical Infarct

OBJECTIVE

After a recent small subcortical infarct (RSSI), some patients develop perilesional or remote hyperintensities ('caps/tracks') to the index infarct on T2/FLAIR MRI. However, their clinical relevance remains unclear. We investigated the clinicoradiological correlates of 'caps/tracks', and their impact on long-term outcomes following RSSI.

METHODS

We identified participants with lacunar stroke and MRI-confirmed RSSI from 3 prospective studies. At baseline, we collected risk factors, RSSI characteristics, small vessel disease (SVD) features, and microstructural integrity on diffusion imaging. Over 1-year, we repeated MRI and recorded 'caps/tracks' blinded to other data. We evaluated predictors of 'caps/tracks', and their association with 1-year functional (modified Rankin Scale score ≥2), mobility (Timed Up-and-Go), cognitive outcomes (Montreal Cognitive Assessment [MoCA] score <26), and recurrent cerebrovascular events (stroke/transient ischemic attack/incident infarct) using multivariable regression.

RESULTS

Among 185 participants, 93 (50.3%) developed 'caps/tracks' first detected at median 198 days after stroke. 'Caps/tracks' were independently predicted by baseline factors: larger RSSI, RSSI located in white matter, higher SVD score, and higher mean diffusivity in normal-appearing white matter (odds ratio [OR] [95% confidence interval {CI}], 1.15 [1.07-1.25], 6.01 [2.80-13.57], 1.77 [1.31-2.44], 1.42 [1.01-2.03]). At 1 year, 'cap/track' formation was associated with worse functional outcome (OR: 3.17, 95% CI: 1.28-8.22), slower gait speed (β: 0.13, 95% CI: 0.01-0.25), and recurrent cerebrovascular events (hazard ratio [HR]: 2.05, 95% CI: 1.05-4.02), but not with cognitive impairment.

INTERPRETATION

'Caps/tracks' after RSSI are associated with worse clinical outcomes, and may reflect vulnerability to progressive SVD-related injury. Reducing 'caps/tracks' may offer early efficacy markers in trials aiming to improve outcome after lacunar stroke. ANN NEUROL 2025;97:942-955.

US State Policies and Mental Health Symptoms Among Sexual and Gender Minority Adults

Importance

A recent increase in state policies targeting gender minority (GM; transgender and gender-diverse) people may affect the mental health of sexual and gender minority (SGM; nonheterosexual and/or GM) people and GM people specifically.

Objective

To estimate changes in mental health symptoms associated with enactment of anti-GM state policies among SGM people and GM people specifically.

Design, Setting, and Participants

This repeated cross-sectional study used a staggered difference-in-differences analysis to examine the associations between anti-GM policies in the US and mean changes in mental health symptoms among 8733 SGM adults who completed annual questionnaires between April 1, 2020, and June 1, 2023, for The Population Research in Identity and Disparities for Equality (PRIDE) Study, a national, prospective, continuously enrolling online cohort study of SGM adults.

Exposures

Living in a state with 1 or more of the following enacted policies: (1) bathroom restrictions for GM people, (2) sports bans for GM young people participating in school sports, and (3) bans on gender-affirming care for young people.

Main Outcomes and Measures

Mean levels of anxiety (measured using the 7-item Generalized Anxiety Disorder scale [GAD-7]; total score range, 0-21), depression (measured using the 9-item Patient Health Questionnaire scale [PHQ-9]; total score range, 0-27), and posttraumatic stress disorder (PTSD) symptoms (measured using the 6-item PTSD Checklist scale [PCL-6]; total score range, 6-30). For all 3 scales, higher scores indicate more severe symptoms.

Results

Among all 8733 SGM participants in the sample (median age, 32.5 years [IQR, 26.0-45.0 years]; 2024 cisgender men [23.2%], 2355 cisgender women [27.0%], 2198 gender-diverse adults assigned female at birth [25.2%], 321 gender-diverse adults assigned male at birth [3.7%], 1294 transgender men [14.8%], and 541 transgender women [6.2%]), anti-GM policy enactment was associated with significant increases in anxiety (GAD-7 score, 0.8 points [95% CI, 0.2-1.4 points]) and PTSD (PCL-6 score, 0.8 points [95% CI, 0.1-1.4 points]) symptoms in states that enacted anti-GM policies compared with states that did not but was not associated with significant increases in depression symptoms (PHQ-9 score, 0.6 points [95% CI, -0.1 to 1.4 points]). In the GM subsample (n = 4354), nonsignificant changes in anxiety (GAD-7 score, 0.6 points [95% CI, -0.2 to 1.4 points]), depression (PHQ-9 score, 0.1 points [95% CI, -0.9 to 1.1 points]), and PTSD (PCL-6 score, 0.7 points [95% CI, -0.2 to 1.6 points]) symptoms were observed after policy enactment in states that enacted anti-GM policies compared with states that did not. Gender minority adults had high mental health symptoms across the study period.

Conclusions and Relevance

In this study of 8733 SGM adults using difference-in-differences analysis, anti-GM policies were associated with worse mental health symptoms among SGM adults but no changes in mental health symptoms among GM adults. As these policies proliferate, it is important to consider how they may affect mental health.

Effectiveness and tolerability of intravenous fosfomycin in treating complicated urinary tract infections caused by Escherichia coli: a prospective cohort study from the FOSFOMIC project

OBJECTIVES

The FOSFOMIC study assessed the clinical and microbiological effectiveness, and safety of intravenous fosfomycin in treating complicated urinary tract infections (cUTIs) caused by Escherichia coli, in comparison with other intravenous antimicrobials.

METHODS

A prospective, multinational matched cohorts study involving adults with community-acquired cUTIs and receiving targeted therapy with intravenous fosfomycin or other first-line drugs (beta-lactams or fluoroquinolones) was conducted from November 2019 to May 2023 in ten centres from Spain, Italy, and Türkiye. Matching criteria included type of infection acquisition, Charlson and Pitt scores. Endpoints were clinical and microbiological cure, mortality, recurrence, and adverse effects. Analyses used conditional logistic regression and desirability of outcome ranking (DOOR).

RESULTS

Overall, 155 matched pairs were included. Clinical and microbiological cure rates were 65.2% (101/155; 95% CI, 57.4-72.2) and 63.2% (98/155; 95% CI, 55.4-70.4) with fosfomycin and comparators, respectively (adjusted OR, 1.09; 95% CI, 0.68-1.73; p 0.73). Mortality rates were 1.9% (3/155; 95% CI, 0.7-5.5) and 5.8% (9/155; 95% CI, 3.1-10.7), respectively (p 0.11). Recurrence rates were 14.2% (22/155; 95% CI, 9.6-20.6) in the fosfomycin group vs. 10.3% (16/155; 95% CI, 6.1-16.1) (p 0.39). Severe adverse effects occurred in 1.9% (3/155; 95% CI, 0.7-5.5) of patients treated with fosfomycin vs. 0.6% (1/155; 95% CI, 0.0-3.3) in the control group (p 0.62). Non-severe adverse effects were more frequent with fosfomycin, affecting 23.3% (36/155; 95% CI, 17.0-30.7) compared with 7.7% (12/155; 95% CI, 4.1-13.1) in the control group (adjusted OR, 5.36; 95% CI, 2.04-14.1; p < 0.001). In DOOR analysis, fosfomycin demonstrated comparable effectiveness in treating pyelonephritis (probability of better DOOR, 54.0%; 95% CI, 48.5-59.6) and in comparison with ceftriaxone (50.3%; 95% CI, 44.7-55.8), without evidence of inferiority in bacteraemic urinary tract infections (DOOR, 47.3%; 95% CI, 41.7-52.8).

DISCUSSION

Fosfomycin is a viable option for treating cUTIs caused by E. coli, allowing for diversification in the treatment of these high-incidence infections.

Residential greenness and chronic obstructive pulmonary disease in a large cohort in southern China: Potential causal links, risk trajectories, and mediation pathways

INTRODUCTION

Residential greenness may influence COPD mortality, but the causal links, risk trajectories, and mediation pathways between them remain poorly understood.

OBJECTIVES

We aim to comprehensively identify the potential causal links, characterize the dynamic progression of hospitalization or posthospital risk, and quantify mediation effects between greenness and COPD.

METHODS

This study was conducted using a community-based cohort enrolling individuals aged ≥ 18 years in southern China from January 1, 2009 to December 31, 2015. Greenness was characterized by normalized difference vegetation index (NDVI) around participants' residential addresses. We applied doubly robust Cox proportional hazards model, multi-state model, and multiple mediation method, to investigate the potential causal links, risk trajectories among baseline, COPD hospitalization, first readmission due to COPD or COPD-related complications, and all-cause death, as well as the multiple mediation pathways (particulate matter [PM], temperature, body mass index [BMI] and physical activity) connecting greenness exposure to COPD mortality.

RESULTS

Our final analysis included 581,785 participants (52.52% female; average age: 48.36 [Standard Deviation (SD): 17.56]). Each interquartile range (IQR: 0.06) increase in NDVI was associated with a reduced COPD mortality risk, yielding a hazard ratio (HR) of 0.88 (95 % CI: 0.81, 0.96). Furthermore, we observed per IQR (0.04) increase in NDVI was inversely associated with the risk of multiple transitions (baseline - COPD hospitalization, baseline - death, and readmission - death risks), especially a declined risk of all-cause death after readmission (HR = 0.66 [95 %CI: 0.44, 0.99]). Within the observed association between greenness and COPD mortality, three mediators were identified, namely PM, temperature, and BMI (HR for the total indirect effect: 0.773 [95 % CI: 0.703, 0.851]), with PM showing the highest mediating effect.

CONCLUSIONS

Our findings revealed greenness may be a beneficial factor for COPD morbidity, prognosis, and mortality. This protective effect is primarily attributed to the reduction in PM concentration.

Accuracy of four sarcopenia screening methods in patients with chronic stroke in Thailand: a cross-sectional study

AIMS

The aim of this study was to evaluate the accuracy of screening tools for sarcopenia and to determine whether the same or different cutoff points should be applied in patients with chronic stroke.

MATERIALS AND METHODS

Sixty-eight participants with residual hemiparetic deficit for over 6 months were enrolled. We evaluated the accuracy of calf circumference, SARC-F questionnaire, SARC-CalF, and Ishii's score chart using the Asia Working Group for Sarcopenia (AWGS) 2019 revised criteria as the gold standard.

RESULTS

Sarcopenia was identified in 22 participants (32.4%) based on the AWGS criteria. Overall, SARC-F showed the lowest diagnostic accuracy. The Area Under the receiver operating characteristic Curves (AUC) of calf circumference, SARC-F, SARC-CalF, and Ishii's score chart were 0.77 (95% confidence interval [CI], 0.66-0.88), 0.58 (95% CI, 0.42-0.74), 0.75 (95% CI, 0.62-0.87), and 0.78 (95% CI, 0.65-0.90), respectively. The mean AUC of SARC-F was inferior to SARC-CalF (0.58 vs. 0.75, p = 0.035).

CONCLUSIONS

The accuracy and diagnostic properties of calf circumference, SARC-CalF, and Ishii's score chart were comparable (mean AUC of 0.77, 0.75, and 0.78, respectively). SARC-F showed the lowest accuracy (mean AUC = 0.58). The recommended screening tools are calf circumference, SARC-CalF, and Ishii's score chart. It is not recommended to rely solely on SARC-F for screening sarcopenia after stroke. We proposed potential new cutoff points for each screening instrument, including SARC-F, SARC-CalF, calf circumference in women, and Ishii's score chart for both men and women.

Did the COVID-19 consortium recommendations impact the treatment of breast cancer during the COVID-19 pandemic?

PURPOSE

We examined the impact of the COVID-19 consortium recommendations on the surgical management of breast cancer during the first year of the pandemic.

METHODS

Patients with newly diagnosed ER + DCIS, ER- DCIS, AJCC Stage cT1-2N0-1 ER + , HER2-, HER2 + , and triple negative breast cancer were identified from the National Cancer Database from 2018 to 2021. An interrupted time series design evaluated differences in surgical delay and use of neoadjuvant chemotherapy/immunotherapy (NAC) and endocrine therapy (NET) before and after the pandemic.

RESULTS

A total of 895116 female patients were included in the study with a mean age of 61.7 years. Time to surgery decreased by an average 5.5 days from January 2020 to May 2020 for all breast cancer types, corresponding with a 62.2% decrease in breast cancer diagnoses per month from January 2020 to April 2020. The use of NET increased from 5.6 to 23.6% from January to March 2020 for patients with ER + DCIS and 8.0 to 31.1% for ER + cT1-2N0 cancer (both p < 0.01). The use of NAC for HER2 + tumors and triple negative breast cancers has been increasing since 2018 and a larger than expected increase was seen from 57.2 to 63.6% for HER2 + tumors and 55.6 to 68.7% for triple negative breast cancers (both p < 0.01). Treatment practices returned to pre-pandemic levels in June 2020.

CONCLUSION

Prior to the publication of the Consortium recommendations, time to surgery decreased while the use of NET and NAC increased, with the resumption of pre-pandemic practices by June 2020.

Prevalence of Traditional, Complementary, and Integrative Medicine Training, Its Different Practices, and Associated Sociodemographic Factors: A Study with Brazilian Nurses

Objective: To analyze the prevalence of nurses trained in traditional, complementary, and integrative medicine (TCIM), the different practices, and associated sociodemographic factors. Methods: This quantitative, cross-sectional study was implemented online in Brazil from June 2021 to January 2022 among 1,154 nurses using a questionnaire comprising open- and closed-ended questions. The Stata IC software, version 16.0, was used in the statistical analysis. The dependent variable was training in TCIM, and the prevalence of different TCIM practices was also investigated. The independent variables included sociodemographic information. Descriptive and inferential statistical tests were performed. This study was approved by the Institutional Review Board at the Federal University of Rio Grande do Sul and was developed according to the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) initiative. Results: The prevalence of TCIM training was 43.50%. Most participants were women (89.49%), Brazilian (99.65%), aged 39.71 on average (SD = 10.37), and had an income of up to four times the minimum wage (52.43%). The prevalence of professionals implementing TCIM in their practice among those with training was 64.60%. They reported working up to 2 h a week (36.96%) in primary health care settings (33.40%) and providing individual consultations (78.0%). After the adjusted analysis, TCIM training appeared significantly associated with age (p < 0.001), the region where the workplace is located (p < 0.001), and income (p < 0.001). Auriculotherapy (59.96%) stood out among the TCIM practices in which nurses were trained. Conclusions: Almost half of the nurses working in Brazil have training in TCIM and sociodemographic factors such as age, region of work, and income are significantly associated with this training.

Natural history of groin hernias in women and factors leading to delay in repair: a single-institution study

BACKGROUND

The objective of this study was to describe the natural history of groin hernias in women at a high-volume tertiary medical center. Specifically, we abstracted the duration of symptoms prior to diagnosis, imaging modalities used, and operative findings. We hypothesized that females would experience a protracted preoperative clinical course.

METHODS

Our institutional hernia database was queried for elective groin hernia repairs from January 2018 to July 2023. Analyses were used to measure and describe demographics, clinical characteristics, and operative findings. In addition, patients' zip codes were linked to census track area deprivation index (ADI) values and a semi-qualitative inquiry was performed to explore reasons for the protracted preoperative clinical course.

RESULTS

Among 1331 patients, 8.4% were female. Majority were Caucasian (68.8%) and overweight (BMI 27.3 ± 5.8), averaging 61.2 years of age. Majority reported non-specific groin pain (73.8%) and an intermittent groin bulge (48.8%), with 40% experiencing symptoms for > 1 year. Patients averaged 1.2 clinic visits before seeing a surgeon. Indirect inguinal hernias were the most common (81.3%), followed by femoral (35%) and direct (26.3%). Sixty-three patients had preoperative imaging, including CT (56.8%), US (39.2%), and MRI (4.0%). The most common surgical approach was robotic (68.8%) followed by laparoscopic-TEP (22.5%). When stratified by duration of symptoms, ADI did not differ among our cohort (p = 0.497). Patient-related reasons for delaying surgery included interpersonal stressors (3.1%), symptoms not limiting ADLs (34.4%), and fear of mesh complications (3.1%). Providers advised against surgery due to malnutrition (3.1%), multiple prior repairs (9.4%), concomitant infection (3.1%), and severe ascites (6.3%).

CONCLUSION

Our study provides some insight into reasons for delay in inguinal hernia repair for women. While many reported symptoms for over a year, a minority sought treatment until they were ready to proceed with surgery. Future qualitative studies are needed to more thoroughly assess female's perspectives with groin hernias.

Risk of major adverse cardiovascular events and venous thromboembolic events between patients with psoriasis or psoriatic arthritis on tumor necrosis factor inhibitors, interleukin 17 inhibitors, interleukin 12/23 inhibitors, and interleukin 23 inhibitors: An emulated target trial analysis

BACKGROUND

The risk of major adverse cardiovascular events (MACEs) and venous thromboembolic events (VTEs) in patients with psoriatic disease receiving biologics is not fully understood.

OBJECTIVES

This study aimed to investigate whether novel biologic therapies (interleukin 17 inhibitor [IL-17i], interleukin 12/23 inhibitor [IL-12/23i], and interleukin 23 inhibitor [IL-23i]) for biologic-naïve patients with psoriasis or psoriatic arthritis (PsA) are associated with differences in the risks of MACE and VTE compared with those with tumor necrosis factor inhibitors (TNFis).

METHODS

An emulated target trial was designed by a nationwide cohort using data from the TriNetX Research Network. Biologic-naïve patients with psoriasis or PsA receiving biologics between 2014 and 2022 were enrolled. Treatment groups were determined by patients' first prescription of biologics. Three propensity-matched cohorts were established, namely, IL-17i versus TNFi, IL-12/23i versus TNFi, and IL-23i versus TNFi. The incidence rate and incidence rate ratios were estimated.

RESULTS

A total of 32,098 biologic-naïve patients with psoriasis or PsA treated with biologics were included. All enrollees were further categorized into 4 cohorts (20,314 in the TNFi cohort, 5073 in the IL-17i cohort, 3573 in the IL-12/23i cohort, and 3138 in the IL-23i cohort). No significant difference in the risks of MACE and VTE between biologics existed among patients with psoriatic disease. In the subgroup analyses for either psoriasis or PsA, no significant difference in the risks of MACE or VTE was noted among all comparisons in the subgroup. Among patients with preexisting hyperlipidemia and diabetes mellitus, the risks of MACE and VTE among patients using new biologics (IL-17i, IL-12/23i, or IL-23i) were lower than those using TNFi.

LIMITATIONS

The data lack psoriasis severity.

CONCLUSIONS

Among patients with psoriasis or PsA, no significant risk differences in MACE and VTE were detected between those with IL-17i, IL-12/23i, and IL-23i and those with TNFi. These findings can serve as a reference to health care providers and patients when making clinical decisions, thereby also providing evidence for future pharmacovigilance research.