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

Associations between procedural volume, costs, and outcomes of septal reduction therapies for obstructive hypertrophic cardiomyopathy in US hospitals

AIM

We assessed the relationship between hospital septal reduction therapy (SRT) procedural volume and clinical outcomes, healthcare resource utilization, and hospital costs.

METHODS

This cross-sectional study used 2012-2022 US hospital data from the PINC AI Healthcare Database for adults with hypertrophic cardiomyopathy (HCM) undergoing alcohol septal ablation (ASA) or septal myectomy (SM; with or without mitral valve repair or replacement [MVRR]). We categorized hospital procedural volume into tertiles according to the numbers of procedures performed and made pairwise comparisons of patient characteristics, clinical events, healthcare utilization, and hospital costs between tertiles. We conducted multivariable analyses (adjusted for patient, clinical, and hospital characteristics) for index hospitalization length of stay, cost, and 30-day readmission rates.

RESULTS

Overall, 3,068 patients with HCM (across 315 hospitals) underwent SRT (ASA: 1,400; SM: 1,668). Index visit in-hospital mortality was 1.1-1.5% among individuals undergoing ASA, 3.2-7.4% for SM with MVRR, and 2.8-3.8% for SM without MVRR. There were no significant differences in in-hospital mortality or stroke/transient ischemic attack at index visits between the hospital procedural volume tertiles for ASA or SM. Adjusted hospital length of stay, costs, and readmission rates were significantly greater in low-volume than high-volume hospitals for ASA (p < 0.001). Similar trends were reported for SM for length of stay and costs (p < 0.001).

LIMITATIONS

This study relied upon accurate and complete reporting of diagnoses and procedures by hospitals. Patients were not randomly assigned, potentially leading to selection bias. Only in-hospital costs were evaluated. Follow-up events were only captured if they occurred in the same healthcare facility.

CONCLUSIONS

Resource utilization and in-hospital costs for patients undergoing SRT are lower in high procedural volume hospitals than low procedural volume hospitals. SRT procedure volume remains low even in hospitals with the highest relative procedural volumes, highlighting a need for globally accessible therapies that improve outcomes.

Stress hyperglycemia ratio as a predictor of acute kidney injury and its outcomes in critically ill patients

This study investigated stress hyperglycemia ratio (SHR) for acute kidney injury (AKI) and clinical outcomes in intensive care unit (ICU). Key outcomes were AKI within 48 h after ICU admission, acute kidney disease (AKD), ICU mortality, 28-day mortality, 90-day mortality and 1-year mortality. The associations between SHR and outcomes was estimated via logistic regression, Cox proportional hazards regression, and restricted cubic spline (RCS) analyses. Subgroup analyses assessed the consistency of these associations. Totally 3,714 patients were included from the Medical Information Mart for Intensive Care IV. SHR was associated with an increased risk of AKI (ORadjusted 1.29 95%CI 1.05-1.59). Among AKI patients, SHR was associated with increased risks of AKD (ORadjusted 1.94 95%CI 1.57-2.39), ICU mortality (ORadjusted 2.31 95%CI 1.60-3.32), 28-day mortality (HRadjusted 1.39 95%CI 1.29-1.50), 90-day mortality (HRadjusted 1.37 95%CI 1.26-1.48), and 1-year mortality (HRadjusted 1.37 95%CI 1.27-1.47). RCS analysis revealed a linear relationship with AKI, a J-shaped relationship with AKD, and a U-shaped relationship with mortality. Subgroup analysis confirmed the consistency of relationship between SHR and AKI. SHR demonstrates significant associations with AKI incidence, and correlates with AKD progression/mortality in critically ill adult ICU patients, suggesting its potential as a risk stratification and prognostic tool for AKI management, though further prospective validation is required.

Comparison of the efficacy of vaginal micronised progesterone tablet and gel for in vitro fertilisation

BACKGROUND

Luteal phase support (LPS) with progesterone is a generally accepted practice after controlled ovarian stimulation, although the best protocols for LPS have been debated. We aimed to compare the efficacy of vaginal micronised progesterone tablets and 8% vaginal progesterone gel for LPS using real-world data.

METHODS

This retrospective study included 459 in vitro fertilisation/intracytoplasmic sperm injection cycles performed at a university hospital from 2005 to 2019. All cycles were followed by fresh day 3 embryo transfer (ET). Either progesterone tablets or gel was used for LPS. To control the conditional probability of progesterone tablets or gel use, doubly robust inverse probability weighting composed of inverse-probability-of-treatment weighting (IPTW) and regression adjustment (RA). IPTW was performed based on the covariate balancing propensity score (CBPS).

RESULTS

Progesterone tablets were administered in 65 cycles, and progesterone gel was administered in 394 cycles. Women who used progesterone tablets were more likely to be older (36 vs. 34 years), have primary infertility (78.5% vs. 61.4%), use gonadotropin-releasing hormone antagonist (60.0% vs. 43.2%), and have fewer retrieved oocytes (seven vs. nine) and transferred embryos (two vs. three) than participants who used progesterone gel. After IPTW-CBPS and RA analysis for the above covariates, the adjusted odds for clinical pregnancy in women who used progesterone tablets were 1.10 times compared with women who used progesterone gel; however, the 95% confidence interval did not reach statistical significance (0.96-1.26).

CONCLUSIONS

Clinical pregnancy was comparable between vaginal micronised progesterone tablets and vaginal progesterone gel for LPS in fresh day 3 ET cycles.

Right versus left thoracic approach esophagectomy for patients with neoadjuvant immunochemotherapy

BACKGROUND

The purpose of this study was to investigate the safety and efficacy of left thoracic approach (LTA) and right thoracic approach (RTA) in patients with esophageal squamous cell carcinoma (ESCC) after neoadjuvant immunochemotherapy (NICT).

METHODS

This study included 83 ESCC patients who underwent right transthoracic esophagectomy (n = 61) and left transthoracic esophagectomy (n = 22) after NICT in our hospital from October 2019 to September 2023. The data of these patients were retrospectively analyzed.

RESULTS

Compared with the LTA group, the RTA group had a longer operation time (245.6 ± 27.8 min vs. 356.5 ± 83.2 min, p < 0.001) and more lymph nodes were removed (21.0 ± 7.9 vs. 29.3 ± 10.8, p = 0.001). The 3-year disease free survival (DFS) of the LTA group and the RTA group were 61.0% and 65.7% (p = 0.861), and the 3-year overall survival (OS) were 60.7% and 77.4% (p = 0.753) respectively. There was no significant difference in prognosis between the two groups. Lymphovascular invasion was an independent risk factor for DFS (HR = 4.042, p = 0.004) and OS (HR = 4.607, p = 0.003) in patients with ESCC undergoing NICT combined with surgery.

CONCLUSION

There was no difference in postoperative complications and short-term survival in patients with ESCC underwent surgery after NICT regardless of left or right thoracic approach. It is worth noting that lymphovascular invasion has an important impact on the prognosis of these patients.

Association between renal mean perfusion pressure and prognosis in patients with sepsis-associated acute kidney injury: insights from the MIMIC IV database

OBJECTIVE

To investigate the association between renal mean perfusion pressure (MPP) and prognosis in sepsis-associated acute kidney injury (SA-AKI).

METHODS

Data were extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Group-based trajectory modeling (GBTM) was applied to identify dynamic MPP patterns, while restricted cubic spline (RCS) curves were utilized to confirm the non-linear relationship between MPP and mortality. Cox regression analysis assessed the risk of mortality across different MPP levels, adjusting for potential confounders. Subgroup analyses and sensitivity analyses were conducted to ensure the robustness of the findings.

RESULTS

A total of 2318 patients with SA-AKI were stratified into five MPP trajectories by GBTM. Patients in Traj-1 and Traj-2, characterized by consistently low MPP (<60 mmHg), demonstrated markedly higher 90-d mortality (62.86% and 26.98%). RCS curves revealed a non-linear inverse relationship between MPP and 90-d mortality, identifying 60 mmHg as the optimal threshold. Patients with MPP ≤ 60 mmHg exhibited significantly elevated 90-d mortality compared to those with MPP > 60 mmHg (29.81% vs. 20.88%). Cox regression analysis established Traj-1 and Traj-2 as independent risk factors for increased mortality relative to Traj-3 (60-70 mmHg), with hazard ratios (HRs) of 4.67 (95%-CI 3.28-6.67) and 1.45 (95%-CI 1.20-1.76). MPP > 60 mmHg was significantly associated with reduced 90-d mortality (HR 0.65, 95%-CI 0.55-0.77). Subgroup and PSM analyses supported these findings.

CONCLUSIONS

Dynamic MPP trajectory serves as a valuable prognostic biomarker for SA-AKI. Early monitoring of MPP trends offers critical insights into renal perfusion management, potentially improving outcomes in SA-AKI.

A prospective cohort study estimating total pre-surgical healthcare costs before and two-year total societal costs after resective brain surgery, and quality of life of patients with drug-resistant epilepsy undergoing surgery

BACKGROUND

In contrast to clinical effectiveness of resective epilepsy surgery (RES) for patients with drug-resistant epilepsy, societal costs of RES is still unclear. The aim of this study was to report on total societal costs up until two years after surgery and analyse the trend of post-surgical costs over time. Secondary objectives included assessing quality of life (QoL) changes and identifying determinants of post-surgical costs.

METHODS

Data were derived from the patients' entire medical history based on hospital files and accompanied by validated questionnaires before and 3-, 6-, 12-, and 24-months post-surgery to additionally include medical consumption outside of the hospital, productivity losses and gains, and QoL. To explore the trend of post-surgical costs over time and identify determinants of post-surgical costs, linear mixed effects and linear regression models were performed.

RESULTS

The study included 44 patients. Mean complete costs from diagnostics and treatment strategies in the period before referral for pre-surgical evaluation up until two years after RES were €121,856 (Interquartile range = €76,058-€137,027). Post-surgical costs significantly decreased 12 months (mean 3-month difference = €-6,675, p = 0.000) and 24 months (mean 3-month difference = €-7,690, p = 0.000) after surgery compared to 3 months before surgery. Higher post-surgical costs were associated with a clinically relevant increase in disease-specific QoL after RES (p = 0.000), previous ketogenic diet (p = 0.005), RES in the left hemisphere (p = 0.014), previous RES (p = 0.007), and higher diagnostics and treatment strategies costs before referral for pre-surgical evaluation (p = 0.021). For disease-specific and generic QoL, 20 (45%) patients reached a clinically relevant QoL increase two years after surgery compared to before RES.

CONCLUSION

In conclusion, RES leads to significant reduction in costs 2 years post-surgery. History of RES and ketogenic diet, clinically relevant disease-specific QoL increase, surgery in the left hemisphere, and higher costs of diagnostics and treatment strategies before referral for pre-surgical evaluation were significant determinants for higher post-surgical costs after RES.

Utilization of lactate trajectory models for predicting acute kidney injury and mortality in patients with hyperlactatemia: insights across three independent cohorts

This study aims to investigate the association between lactate trajectories and the risk of acute kidney injury (AKI) and hospital mortality in patients with hyperlactatemia. We conducted a multicenter retrospective study using data from three independent cohorts. By the lactate levels during the first 48 h of ICU admission, patients were classified into distinct lactate trajectories using group-based trajectory modeling (GBTM) method. The primary outcomes were AKI incidence and hospital mortality. Logistic regression analysis assessed the association between lactate trajectories and clinical outcomes, with adjusting potential confounders. Patients were divided into three trajectories: mild hyperlactatemia with rapid recovery (Traj-1), severe hyperlactatemia with gradual recovery (Traj-2), and severe hyperlactatemia with persistence (Traj-3). Traj-3 was an independent risk factor of both hospital mortality (all p < 0.001) and AKI development (all p < 0.001). Notably, Traj-2 was also associated with increased risk of mortality and AKI development (all p < 0.05) using Traj-1 as reference, except for the result in the Tianjin Medical University General Hospital (TMUGH) cohort for mortality in adjusted model (p = 0.123). Our finding was still robust in subgroup and sensitivity analysis. In the combination cohort, both Traj-2 and Traj-3 were considered as independent risk factor for hospital mortality and AKI development (all p < 0.001). When compared with the Traj-3, Traj-2 was only significantly associated with the decreased risk of hospital mortality (OR 0.17, 95% CI 0.14-0.20, p < 0.001), but no with the likelihood of AKI development (OR 0.90, 95% CI 0.77-1.05, p = 0.172). Lactate trajectories provide valuable information for predicting AKI and mortality in critically ill patients.

Interactive effect of sleep duration and trouble sleeping on frailty in chronic kidney disease: findings from NHANES, 2005-2018

BACKGROUND

Both sleep disorders and chronic kidney disease (CKD) are recognized as significant public health concerns. In the general population, sleep disorders have been shown to be associated with frailty in the elderly. This study aims to evaluate the association between sleep duration and trouble sleeping with frailty in CKD patients, as well as the potential interactive effect between these two factors.

METHODS

This cross-sectional study analyzed data from the National Health and Nutrition Examination Survey (NHANES) spanning 2005-2018. Sleep duration and trouble sleeping was self-reported. Frailty was assessed using a 49-item frailty index. The associations between sleep duration, trouble sleeping, and frailty were analyzed using weighted multivariate logistic regression and restricted cubic splines. Subgroup analysis was conducted to determine the consistency of the study's conclusions across various subgroups.

RESULTS

A total of 5,211 adult CKD patients were included in this analysis. Regression analysis results indicated that short sleep duration (OR = 1.364, 95% CI: 1.152-1.616), long sleep duration (OR = 1.648, 95% CI: 1.259-2.157), and trouble sleeping (OR = 2.572, 95% CI: 2.102-3.147) were significantly associated with an increased risk of frailty in CKD patients, with an interaction between sleep duration and trouble sleeping. Subgroup analysis revealed that the effects of trouble sleeping and sleep duration on frailty symptoms in CKD patients exhibit significant variation across age groups (p < 0.05 for interaction), with no notable differences observed in other subgroups. RCS results demonstrated a U-shaped relationship between frailty and sleep duration, with the lowest risk of frailty at 7.12 h of sleep.

CONCLUSION

Our findings indicated that both sleep duration and trouble sleeping were significantly associated with frailty in CKD patients, with a notable interaction between these two factors. Therefore, prevention and intervention strategies for frailty in CKD patients should address multiple aspects of sleep health.

Identification of L-shaped curve association between serum bicarbonate concentrations and short-term outcomes in patients with acute kidney injury: a retrospective cohort study

OBJECTIVE

This study aims to investigate the association between serum bicarbonate levels and short-term outcomes in patients with acute kidney injury (AKI), with a focus on 14-day mortality and AKI progression within a 14-day period.

METHODS

We conducted a secondary analysis using data from the Electronic Alerts for Acute Kidney Injury Amelioration (ELAIA) study. Serum bicarbonate levels and their associated outcomes were collected for all participants. Cox regression analysis and smooth curve fitting methods were employed to achieve the research objectives.

RESULTS

A total of 5,835 patients with AKI were included in the study. After adjustment for confounding factors, patients with serum bicarbonate concentrations below 22 mmol/L had a higher risk of both 14-day mortality and AKI progression compared to those with levels between 22 and 26 mmol/L (hazard ratio [HR] 1.90; 95% confidence interval [CI], 1.51-1.83 for mortality and HR 1.45; 95% CI, 1.23-1.71 for AKI progression, respectively). In contrast, patients with bicarbonate concentrations above 26 mmol/L had a lower risk of 14-day mortality (HR 0.70; 95% CI, 0.53-0.94) and AKI progression (HR 0.90; 95% CI, 0.74-1.10). Subsequent exploratory subgroup analyses revealed no statistically significant interactions (all p-values for interaction > 0.05) between 14-day mortality and serum bicarbonate levels.

CONCLUSIONS

In this cohort of AKI patients, serum bicarbonate concentrations below 22 mmol/L were associated with increased risks of 14-day mortality and AKI progression, while concentrations above 26 mmol/L were linked to a reduced risk of 14-day mortality.

Sex differences in the associations of dietary protein intake with lean mass and grip strength in children and adolescents

BACKGROUND

Childhood and adolescence are critical developmental periods during which dietary protein plays a crucial role in musculoskeletal health. While the significance of protein in muscle development is well acknowledged, the complex associations between dietary protein intake and musculoskeletal parameters during these stages remain incompletely elucidated.

METHODS

This cross-sectional study utilized data from the National Health and Nutrition Examination Survey (NHANES) 2011-2014 cycles, including 3,455 children and adolescents aged 8-19 years. Dietary protein intake was assessed through two 24-hour dietary recalls. Appendicular lean mass index (ALMI) and combined grip strength were measured as indicators of musculoskeletal health. Multivariate linear regression models and smooth curve fitting techniques were employed to analyze associations.

RESULTS

Higher protein intake was positively associated with both ALMI (β = 0.003, 95% CI: 0.002, 0.004, p < 0.001) and combined grip strength (β = 0.043, 95% CI: 0.027, 0.058, p < 0.001) in fully adjusted models. Notably, sex-specific effects were observed, with stronger associations in boys, particularly in the 8-11 years age group.

CONCLUSIONS

This study reveals significant positive associations between dietary protein intake and musculoskeletal health indicators in children and adolescents, with pronounced sex-specific effects. These findings underscore the importance of adequate protein intake during critical developmental periods and may inform targeted nutritional strategies for optimizing long-term musculoskeletal health.

Upper limb symptoms in breast cancer survivors with lymphedema: A latent class analysis and network analysis

Objective

Breast cancer survivors (BCS) with lymphedema experience multiple symptoms in upper limbs that significantly impact their quality of life. The complexity of symptomology and the connection among these symptoms are unclear. This study aimed to identify upper limb symptom subgroups and symptom networks among BCS.

Methods

This secondary analysis included individuals with lymphedema (defined as an inter-limb circumference difference of ≥ 2 cm) from three cross-sectional studies among post-surgery BCS. Upper limb symptoms were assessed by the Breast Cancer and Lymphedema Symptom Experience Index. Descriptive analysis, latent class analysis, logistic regression analysis, and network analysis were performed.

Results

A total of 341 BCS with upper limb lymphedema were included. Swelling, heaviness and tightness were the most prevalent symptoms. Four distinct latent classes were identified: "Severe symptom" group (Class 1: 9.4%), "Movement-limitation and lymph-stasis" group (Class 2: 24.6%), "Lymph-stasis" group (Class 3: 37.5%), and "Mild symptom" group (Class 4: 28.4%). BCS with axillary lymph node dissection, radiotherapy, longer post-surgery duration, and without medical insurance were less likely to belong to the mild symptom group (P ​< ​0.001). Symptom network density decreased from Class 1 to 4. Core symptoms for each symptom network were tenderness, firmness, arm-swelling, and heaviness, respectively.

Conclusions

This study identified four distinct categories of upper limb symptoms and influencing factors among individuals with breast cancer-related lymphedema (BCRL). Our findings suggest the need to consider individualized approaches to symptom management and support for BCRL, taking into account their specific symptom clusters and associated risk factors.

Shrunken pore syndrome in heart transplantation: a pore ready to close?

Background: A newly discovered renal syndrome, shrunken pore syndrome (SPS), has been shown to increase mortality regardless of renal function. SPS is defined as an estimated glomerular filtration rate (eGFR) of cystatin C ≤ 60% than eGFRcreatinine. We set out to study SPS in relation to the survival of heart transplantation patients with a follow-up of up to 12 years. Methods. This was a single-center cohort study including 253 consecutive patients undergoing heart transplantation. The prevalence of SPS at different time points post-transplantation and its effect on survival was evaluated using Kaplan-Meier's analysis and multivariable Cox proportional hazards regression. Results. The prevalence of SPS was 7.5% the day after transplantation (D1), which rose to 71% week 4 after surgery. There was no difference in survival for patients with SPS D1 compared to patients without SPS D1. Patients with SPS 4 weeks compared to patients without SPS 4 weeks after transplantation showed a 5- and 10-year survival of 73% vs. 93% (p = .02) and 63% vs. 90% (p = .005), respectively. SPS developed during the postoperative period was also found to be an independent predictor of mortality (HR 4.65; 95% CI 1.36-15.8). Discussion. SPS that developed in the postoperative course after heart transplantation was found to be an independent predictor of mortality with a severe negative impact on 5- and 10-year survival.

Comparative effectiveness of romosozumab versus teriparatide for fracture prevention: A new-user, active comparator design

BACKGROUND

Comparative evidence on the effectiveness of romosozumab and teriparatide in preventing osteoporotic fractures remains limited. This study evaluated their effectiveness in fracture prevention.

METHODS

This observational new-user cohort study used the DeSC Healthcare database, a nationwide claims database in Japan. Patients aged ≥40 years with osteoporosis, defined by International Classification of Diseases, 10th Revision codes or prior fragility fractures, who newly initiated romosozumab or teriparatide between March 2019 and August 2021 were included. The primary outcome was the major osteoporotic fractures within 1 year. Secondary outcomes included 2-years fracture incidence and individual fracture types. Cox proportional hazards models, weighted by inverse probability-of-treatment derived from propensity scores, were used to estimate hazard ratios (HRs) with 95 % confidence intervals (CIs), accounting for patient- and facility-level confounders.

RESULTS

Among 35,547 observations (romosozumab: 9603; teriparatide: 25,944), the mean ages were 80.3 and 80.0 years, 85.2 % and 81.3 % were women, and 64.4 % and 71.9 % had a history of fragility fracture, respectively. The 1-year incidences of major osteoporotic fractures were 10.14 per 100 person-years (teriparatide) and 7.01 per 100 person-years (romosozumab) (HR: 0.80, 95 % CI: 0.71, 0.89). Romosozumab was also associated with lower rates of composite fractures over 2 years (HR: 0.81, 95 % CI: 0.72, 0.90); vertebral fractures over 1 and 2 years; and proximal humeral, distal forearm, and proximal femoral fractures over 1 year.

CONCLUSIONS

In this nationwide Japanese cohort, romosozumab use was associated with a lower incidence of major osteoporotic fractures compared to teriparatide over both 1- and 2-year follow-up periods among high-risk patients with osteoporosis.

Risk factors for transitions and outcomes of subsyndromal delirium in the ICU: Post-hoc analysis of a prospective multicenter cohort study

PURPOSE

Identify risk factors for progression to delirium and outcomes of subsyndromal delirium (SSD) in critically ill adults.

METHODS

Multicenter prospective study screening patients with the Intensive Care Delirium Screening Checklist (ICDSC), excluding those with primary neurologic diagnosis or persistent coma. SSD was defined as an ICDSC score 1-3. Main outcomes were risk factors for SSD progression and association with hospital mortality. Secondary outcomes included ICU mortality and length of stay.

RESULTS

Among 1572 patients, 562 (35.8 %) had no delirium, 488 (31 %) SSD without delirium, 180 (11.5 %) SSD progressing to delirium and 174 (11.1 %) delirium without prior SSD. For 168 (10.7 %) delirium status was unknown. SSD onset risk factors were female sex, higher APACHE IV score, and medical /emergency surgery admissions. SSD progression risk factors included higher APACHE IV score, medical/emergency surgery admissions, metabolic acidosis and morphine dosage in the first 24 h. SSD patients had lower hospital mortality than delirium patients (OR 0.57, 95 %CI 0.36 to 0.90), but no significant difference compared to non-delirious patients (OR 1.30, 95 %CI 0.69 to 2.42). SSD patients had shorter ICU stays than delirium patients but longer than non-delirious patients.

CONCLUSIONS

This study identified risk profiles and validated SSD as an intermediate prognostic condition, supporting early interventions to prevent delirium-associated harms.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT01952899 (registered September 30, 2013).

Association between estimated pulse wave velocity and hip fracture in middle-aged and older adults: A prospective cohort study in China

BACKGROUND

Hip fractures represent a significant public health challenge among middle-aged and older adults, with substantial implications for health and quality of life. This study aimed to investigate the association between estimated pulse wave velocity (ePWV) and hip fracture risk, with a comprehensive analysis of both overall and female population cohorts.

METHODS

Utilizing data from the China Health and Retirement Longitudinal Study (CHARLS), this prospective cohort study included 11,024 participants aged 45 and older, with a 9-year follow-up period (2011-2020). The research employed Cox proportional hazards models to analyze the overall population and a specific female subgroup. The female subgroup analysis uniquely adjusted for menopausal status to provide a nuanced assessment of ePWV's relationship with hip fracture risk. Restricted cubic spline (RCS) analysis and threshold analysis were conducted to explore nonlinear associations between ePWV and hip fracture risk.

RESULTS

During the follow-up period, 471 hip fractures were documented. In the overall population, each increment in ePWV quartile was associated with a significant 32 % increase in hip fracture risk (Hazard Ratio [HR]: 1.32, 95 % Confidence Interval [CI]: 1.18-1.49, p < 0.001). The female subgroup analysis, after adjusting for menopausal status, revealed a 29 % increased hip fracture risk per ePWV quartile increment (HR: 1.29, 95 % CI: 1.09-1.53, p < 0.05). Nonlinear analysis identified a critical threshold at 11.18 m/s, beyond which hip fracture risk significantly increased [HR (95%CI): 1.28 (1.12-1.47)].

CONCLUSIONS

The ePWV significantly correlates with hip fracture risk in middle-aged and older Chinese adults, offering novel insights into the relationship between arterial stiffness and fracture vulnerability. Future research should validate these findings and explore vascular health-based strategies for hip fracture prevention.

Factor Analytic Adaptation Study of the Groningen Reflection Ability Scale (GRAS) in Senior Nursing Students

BACKGROUND AND PURPOSE

Reflection is a cyclical and iterative learning process that incorporates critically analyzing experiences, deriving lessons, establishing learning objectives, and implementing newly acquired knowledge in similar situations. This study evaluated the psychometric properties of the Turkish version of the Groningen Reflection Ability Scale (GRAS) among nursing students.

METHODS

This study is a factor analytic investigation with a nested cross-sectional design. This study included 252 fourth-year nursing students and was carried out between 10 March 2024 and 10 May 2024. Data analysis was conducted using the Content Validity Index (CVI), Exploratory Factor Analysis (EFA), Confirmatory Factor Analysis (CFA), Cronbach's alpha for internal consistency, test-retest reliability, and item-total score correlation.

RESULTS

The Turkish version of the GRAS consists of 23 items divided into three sub-dimensions: self-reflection, empathic reflection, and reflective communication. The internal consistency and reliability of the overall scale and its three sub-dimensions were acceptable. The three-factor construct validity of the Turkish version, identified through Exploratory Factor Analysis, was successfully confirmed with Confirmatory Factor Analysis.

CONCLUSION

The Turkish version of the GRAS is a valid and reliable instrument for evaluating reflective practice skills among fourth-year nursing students in Türkiye.

IMPLICATIONS

Nursing Practice: Evaluating reflective practice skills plays an important role in enhancing nursing students' critical thinking and their ability to provide patient-centered care. Policy Development and Implementation: Institutional policies should prioritize the standardized evaluation of reflective abilities within nursing education to maintain consistency and effectiveness. Education: Integrating reflection-based strategies into nursing curricula promotes self-awareness and professional growth.

FUTURE RESEARCH

Further studies should investigate the long-term influence of structured reflection on clinical competence and patient outcomes.

Establishment and validation of a clinical prediction model for colorectal adenoma risk factors

Colorectal adenomas are benign tumors of the colorectal mucosal epithelium that have malignant potential and are regarded as precancerous lesions of colorectal cancer, for which the specific risk factors are unclear. The present study aimed to identify independent risk factors for colorectal adenoma to develop a prediction model and test its predictive value. A retrospective analysis was performed using data from patients who underwent electronic colonoscopy at the Department of Proctology (Affiliated Hospital of Shandong University of Traditional Chinese Medicine; Jinan, China) from January 2013 to December 2023 and had polyps removed during colonoscopy. Patients with colorectal adenoma were included in the case group, whilst those with no visible abnormalities on endoscopy or with non-adenomatous polyps were included as a control group. The patients were randomly divided into a training and validation group in a 7:3 ratio. Variables were screened using single-component analysis and the filtered variables were employed in multivariate logistic regression to create a clinical prediction model. Finally, the model was internally and externally validated. A total of 730 patients were included in the present study, with 286 assigned to the case group and 444 to the control group. After the initial screening of 39 variables, 12 continued to the next round, resulting in four potential predictors including age, daily number of bowel movements, thrombin time and the number of polyps. A prediction model was created based on these variables. Regarding internal validation, the C-index was 0.7054 [95% confidence interval (CI), 0.6596-0.7512] and the prediction probability in the calibration curve was close to the diagonal line of the calibration graph, indicating that the prediction probability of the model was reasonable. Regarding external validation, the C-index in the validation cohort was 0.6306 (95% CI, 0.5560-0.7053) and the calibration curve also demonstrated good identification capabilities. The Hosmer-Lemeshow test revealed that the model had a reasonable calibration degree, with χ2=9.7893, degree of freedom=8 and P=0.28. The receiver operating characteristic curve and decision curve analysis for the training and validation cohorts demonstrated good efficacy and an ideal application value. In conclusion, the model constructed in the present study demonstrated moderate predictive accuracy for colorectal adenoma risk, laying the groundwork for early detection of colorectal adenoma and secondary prevention of colorectal cancer.

How far are we from bringing intensive care bundle for intracerebral hemorrhage into the real-world setting? A 5-year population based-study

INTRODUCTION

Comprehensive care bundles including rapid blood pressure management, anticoagulation reversal, neurosurgical consultation, control of blood glucose and body temperature, can improve short- and medium-term outcomes in patients with intracerebral hemorrhage (ICH). This study assessed how the acute management of ICH practices evolved in a real-world setting over five years characterized by global changes in ICH care.

METHODS

This study analysed ICH cases from a population-based stroke registry between 2018 and 2022. We collected demographic and clinical data, focusing on key parameters of ICH management, such as systolic blood pressure, anticoagulation reversal, neurosurgical referrals, blood glucose, and body temperature. We also examined yearly trends in control of parameters over time.

RESULTS

We included 460 patients with ICH (55.4% male, median age 79 years, interquartile range 69-85). At onset, 266 patients (57.8%) had high SBP (SBP ≥ 140 mmHg), 286 (70.3%) hyperglycemia (blood glucose ≥ 108 mg/dL), and 63 (17.3%) hyperpyrexia (body temperature ≥ 37.0*C). Anticoagulation was reversed in 21.4% of anticoagulated patients within 24 h. Neurosurgical referrals were made for 84.6% of patients while only 12.4% underwent surgery. From 2018 to 2022, anticoagulation reversal rates increased from 0 to 88.9% (p < 0.001), while neurosurgical referrals not followed by surgery decreased from 79.5 to 55.7% (p < 0.001).

CONCLUSIONS

This real-world study demonstrates suboptimal management of key factors associated with ICH prognosis; nevertheless, it highlights improvement over time. There is a need for structured interventions to improve the timely and consistent application of simple yet effective measures yielding the potential to improve patients' outcomes.

Home-Based Daratumumab in Patients With Multiple Myeloma

OBJECTIVE

Multiple myeloma is an incurable cancer with lifelong treatment needs. This, together with a global nursing shortage, calls for new approaches for future treatment. In this study, we therefore investigated the feasibility of home-based subcutaneous daratumumab administered by primary care nurses outside the hospital.

METHODS

Applying a mixed-methods prospective design, we included 30 patients; 18 had completed ≥ 6 cycles of daratumumab treatment, and 12 were newly started. New patients were followed for six 28-day cycles, with every second treatment administered outside the hospital. Patients already on treatment were followed for seven cycles with 2/3 treatments administered outside the hospital.

RESULTS

Of 123 administrations planned at the hospital, 122 (97.6%) were administered and three were cancelled. Of 144 administrations planned outside the hospital, 133 (92.4%) were administered, six were redirected to the hospital, and five were cancelled. No significant difference between numbers of cancellations/redirections was observed. Patients spent significantly longer time on treatment at the hospital, even when deducting travel time. Reducing patients' visits to the hospital did not cause additional unplanned contacts with the healthcare system.

CONCLUSION

This study thus concludes that administration of daratumumab outside the hospital is safe, feasible, and time saving.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05306587.

Association Between Adverse Childhood Experiences and Sleep Duration in US Children: Analysis of 2020-2021 National Survey of Children's Health

BACKGROUND

Adverse childhood experiences (ACEs) and suboptimal sleep both negatively associate with cardiovascular health. Although an association between ACEs and suboptimal sleep in youth has been reported, there has been no investigation for differential effects among ACE subdomains.

OBJECTIVE

We examined associations between total and subdomain ACEs and sleep duration, and age as a moderator.

METHODS

Using the 2020-2021 National Survey of Children's Health and the American Heart Association Life's Essential 8 scoring algorithm, we created 3 sleep subgroups: (1) optimal, (2) suboptimal (≥1 to <2 hours below or ≥1 hour above optimal), and (3) very suboptimal (≥2 hours below optimal). We assessed association between ACEs (total and subdomains) and sleep duration using multinomial logistic regression, controlling for sex, age, race/ethnicity, caregiver's education, household income, habitual bedtime, and physical activity. We tested the interactions between ACEs and child's age.

RESULTS

In children aged 6 to 17 years (N = 58 964), mean sleep duration score was 77.2 (95% confidence interval, 76.6-77.9). The mean number of ACEs was 0.89 (95% confidence interval, 0.87-0.91). Adjusting for covariates, each additional ACE increased the likelihood of falling into the suboptimal subgroup by 8% and the very suboptimal subgroup by 26%. There was an association between each subdomain of ACE and suboptimal sleep duration, with no significant interaction with age.

CONCLUSIONS

Our findings show a dose-response relationship between ACEs and suboptimal sleep duration-a new cardiovascular health indicator in Life's Essential 8. Healthcare providers should screen for ACEs and suboptimal sleep in children to reduce future cardiovascular disease risk.

The prognostic value of baseline EARL standardized FDG PET indices in pediatric and adolescent high-grade osteosarcoma

OBJECTIVE

To investigate the prognostic value of baseline European Association of Nuclear Medicine Research Ltd. (EARL) standardized [18F]fluorodeoxyglucose positron emission tomography-computed tomography ([18F]FDG PET-CT) quantitative values for survival and to evaluate cutoff values identified in other studies.

MATERIALS AND METHODS

Pediatric and adolescent patients with high-grade osteosarcoma were included. Baseline [18F]FDG PET-CT, with EARL-accredited reconstructions, was the standard diagnostic staging procedure. Cox proportional hazard analysis for event-free survival (EFS) and overall survival (OS) was performed with clinical prognostic factors. Kaplan-Meier analysis and log-rank tests were applied to investigate the prognostic performance of the [18F]FDG PET indices.

RESULTS

In total, 66 patients were included in this study. In the univariable Cox regression analysis, peak lean-body mass corrected SUV (SULpeak) (hazard ratio (HR): 1.04), total lesion glycolysis (TLG) (HR: 1.0), and metabolic tumor volume (MTV) (HR: 1.0) were not associated with EFS or OS. Log-rank analysis showed a significant difference in EFS for all SULmax and SULpeak cutoffs. For MTVtotal the maximum Youden, and for TLGtotal, the maximum Youden and maximally selected rank cutoff resulted in a significant EFS difference. No cutoff for any measure showed a significant difference in OS between the groups. ROC curves for event status had an AUC of 0.67, 0.66, 0.64, and 0.64 for SULmax, SULpeak, MTVtotal, and TLGtotal, respectively.

CONCLUSION

In this study, the baseline EARL-standardized [18F]FDG PET indices of children and adolescents with osteosarcoma were not prognostic of EFS or OS. The proposed prognostic cutoffs from earlier studies suffer from important technical and statistical issues.

KEY POINTS

Question Prognostic value of baseline [18F]FDG PET-CT imaging markers have been reported for histologic response and survival in high-grade osteosarcoma but have not been validated for clinical practice. Findings Baseline SUVpeak, TLGtotal, and MTVtotal measured on EARL-accredited reconstructions were not prognostic factors for survival in pediatric and adolescent patients with high-grade osteosarcoma. Clinical relevance A wide range of values for SUVpeak and SUVmax cutoffs with similar prognostic value were identified, questioning the value of a single proposed cutoff. Lack of validation, with important technical and statistical issues of proposed prognostic cutoffs, limits clinical implementation.

Associations Between 24-h Movement Behaviours and Health in 3- and 4-Year-Old Children From a Low-Income Country: The SUNRISE Ethiopia Study

BACKGROUND

There is little evidence on the associations between 24-h movement behaviours and health in children from low-income countries. We examined the associations of physical activity, sedentary behaviour, screen time and sleep with adiposity, motor skills and executive functions among 3- and 4-year-old children in Ethiopia.

METHODS

Cross-sectional study conducted in Adama city and Lume Woreda, Oromia region, Ethiopia. We recruited children from kindergartens and rural Kebeles or villages. Children's time spent in physical activity, sedentary behaviour and sleep were measured using hip worn ActiGraph accelerometers. Children's screen time was parent-reported. Linear mixed models tested associations of 24-h movement behaviours with adiposity (BMI z-score), motor skills (NIH Toolbox) and executive functions (Early Years Toolbox). All models accounted for child sex, age and dietary diversity as fixed effects and clustering of children within kindergarten/villages as a random effect.

RESULTS

A total of 430 children participated (4.2 ± 0.6 years). Children who slept longer had lower adiposity (-0.12, 95% CI: -0.19, -0.06). Those who had higher levels of total physical activity (TPA) (0.06, 95% CI 0.01, 0.13) and moderate to vigorous-intensity physical activity (MVPA) (0.03, 95% CI 0.01, 0.06) had higher scores on handgrip strength. Children who spent more time in sedentary behaviour had lower handgrip strength (-0.08, 95% CI -0.16, -0.01). There were no significant associations with executive functions.

CONCLUSIONS

Strategies to improve adiposity and motor skills should focus on promoting healthy levels of 24-h movement behaviours, especially adequate sleep and time spent in physical activity in Ethiopian children.

Pathway plaques and diffusion-weighted lesion analysis after endovascular treatment of unruptured intracranial aneurysms: a prospective study

OBJECTIVES

To evaluate the prevalence and predictors of ischemic lesions on thin-slice DWI (2 mm) in endovascular treatments for unruptured intracranial aneurysms (UIA), particularly explore the potential relationship with pathway plaques.

METHODS

Participants eligible for endovascular treatments with UIA at a national stroke center between March 2023 and August 2023 were prospectively enrolled. All participants performed thin-slice DWI (slice thickness of 2 mm) before and after procedures. Three-dimensional joint intra-and extracranial vessel wall MRI (3D-vwMRI, voxel size 0.6 × 0.6 × 0.6 mm3) was scheduled to evaluate the pathway plaques for all participants. The DWI-positive numbers were ordered and divided into four equal parts, with each quartile representing 25% of the data set.

RESULTS

A total of 106 participants were included. Overall, none of the participants exhibited preoperative DWI-positive lesions. Following the intervention, 93.4% (99/106) of participants exhibited new DWI-positive lesions on postoperative MRI, including 5.7% (6/106) with symptomatic ischemic stroke. Compared with the lowest quartile of ischemic lesions, the highest quartile was associated with increased odds of the presence of plaque (OR = 9.4, 95% CI: 2.0-45.4; p = 0.005). The history of previous stroke (OR = 4.6, 95% CI: 1.6-14.6; p = 0.007) and the presence of plaque in the pathway (OR = 3.4, 95% CI: 1.6-7.7; p = 0.002) were identified as independent predictors of higher quartiles of DWI-positive numbers.

CONCLUSIONS

As revealed by thin-slice DWI, ischemic lesions related to the endovascular treatments for UIA occurred more frequently than anticipated. A history of the previous stroke and the pathway plaques were independent predictors of higher quartiles of DWI-positive numbers.

KEY POINTS

Question Previous studies using conventional MRI may underestimate DWI-positive lesions. The procedural risk of UIA coexisting with atherosclerotic plaques is still unclear. Findings Thin-slice DWI showed ischemic lesions occurred frequently (93.4%). Three-dimensional-intra-and extracranial Vessel Wall MRI revealed a positive correlation between pathway plaques and DWI lesions. Clinical relevance Neuro-interventionalists should exercise caution when managing patients with a history of previous stroke in the presence of plaques in the treatment pathway. More vigilant pre-procedural imaging should be considered to assess unstable plaque in high-risk patients.

Racial/ethnic disparities in all-cause and cause-specific death among patients with colorectal cancer in the United States from 1992 to 2021: a registry-based cohort retrospective analysis

BACKGROUND

Inequality in mortality among patients with colorectal cancer in the United States has been documented, but the trends over time and the factors contributing to racial/ethnic disparities in all-cause and cause-specific death are unknown.

METHODS

This cohort study used the Surveillance, Epidemiology, and End Results (SEER) registry to analyze patients diagnosed with colorectal cancer from 1992 to 2021. We calculated the cumulative incidence of death for all racial/ethnic groups (Black, White, Hispanic, Asian or Pacific Islander [API], and American Indian or Alaska Native [AI/AN]) by diagnostic period and cause of death. We quantified absolute disparities using rate change in 5-year cumulative incidence of death and used discrete-time models to estimate relative racial/ethnic disparities and the contribution of factors to disparities in death.

RESULTS

The 5-year cumulative incidence of colorectal cancer and all-cause death among Black patients decreased. AI/AN and Black patients consistently had the highest risk of death between 1992 and 2021. Between Black and White, the adjusted HR for all-cause death difference increased from 1.14 (1.10-1.17) in 1992-1996 to 1.29 (1.23-1.35) in 2017-2021. Adjustment for stage at diagnosis, first course of therapy and socioeconomic status explained 46.5 % of the Black-White disparities and 38.4 % of the AI/AN-White all-cause death disparities.

CONCLUSION

Persistent racial/ethnic disparities in patients with colorectal cancer, especially in AI/AN and Black, call for new interventions to eliminate health disparities. Our study provides vital evidence to address racial/ethnic inequality.

Risk of acute kidney injury after contrast-enhanced MRI examinations in a pediatric population

OBJECTIVES

To investigate the associations between gadolinium-based contrast agent (GBCA) administration and the occurrence of acute kidney injury (AKI) in pediatric patients, and to determine the risks associated with AKI.

MATERIALS AND METHODS

This retrospective study was conducted on pediatric patients who underwent contrast-enhanced or unenhanced MRI between January 1st, 2015, and June 30th, 2021. Examinations were included if they had data on height and serum creatinine levels within 3 months before and 2 days after the examinations. AKI was defined according to the AKI Network criteria. Multivariable generalized estimating equations, propensity score analyses, and inverse probability of treatment weighting analysis were used to evaluate associations between GBCA and AKI. Subgroup analyses were conducted to evaluate the interaction effects of GBCA and each subgroup variable (age, sex, examination type, admission type, chronic kidney disease stage, diabetes mellitus, cardiovascular disease, or surgery or contrast-enhanced CT performed 7 days before and 2 days after MRI).

RESULTS

A total of 2508 examinations were included (1996 with contrast-enhanced, 512 with unenhanced MRI). AKI occurred in 1.5% of the contrast group and 1.2% of the noncontrast group. Multivariable analysis showed no significant difference in AKI incidence between the groups (adjusted OR, 1.29 [95% CI: 0.53, 3.11]; p = 0.58). Propensity score matching and inverse probability of treatment weighting analysis also showed no significant association (p = 0.22 and p = 0.21, respectively). Subgroup analysis showed no significant interaction between GBCA and any of the subgroup variables.

CONCLUSION

The study found no significant association between gadolinium-based contrast agent administration and the occurrence of acute kidney injury in pediatric patients.

KEY POINTS

Question There is limited data on the development of acute kidney injury following exposure to gadolinium-based contrast agent in pediatric patients. Findings There was no significant association between the administration of gadolinium-based contrast agent and occurrence of acute kidney injury in pediatric patients. Clinical relevance The administration of gadolinium-based contrast agents does not increase the risk of acute kidney injury in pediatric patients following MRI.

Uterine "twisting sign": A new potential ultrasonographic soft marker for deep endometriosis

OBJECTIVE

The objective of the current study was to evaluate the "twisting sign," defined as uterine fundus rotation observed on transvaginal sonography (TVS), as a potential soft marker for deep endometriosis (DE) and its association with specific DE localizations and indirect signs.

METHODS

A prospective observational study was conducted at an endometriosis referral center. We enrolled 158 reproductive-aged women with pelvic pain requiring specialist evaluation. Exclusion criteria included prior endometriosis diagnosis or conditions affecting uterine positioning, such as large myomas, uterine malformations, or previous pelvic surgery. Standardized TVS assessments, following IDEA (International Deep Endometriosis Analysis) criteria, were performed by a single experienced operator. The twisting sign was defined as a uterine rotation angle between 15° and 90° in the fundal transverse section.

RESULTS

The twisting sign was detected in 24.1% of participants and was significantly associated with posterior compartment DE, particularly rectosigmoid nodules (44.8.7% vs. 14.0%, P < 0.001) and uterosacral ligament involvement (41.4% vs. 23.3%, P = 0.046). It was also linked to indirect DE markers, including ovarian fixation to the uterine wall (37.9% vs. 19.4%, P = 0.031) and absence of the posterior sliding sign (37.9% vs. 9.3%, P < 0.001). Multivariate analysis confirmed the twisting sign as an independent predictor of rectosigmoid junction nodules (odds ratio [OR], 9.84 [95% confidence interval [CI], 1.69-58.83], P = 0.012) and absence of the posterior sliding sign (OR, 6.63 [95% CI, 1.88-24.34], P = 0.004).

CONCLUSION

The twisting sign may represent a novel and potentially valuable ultrasonographic marker of DE, particularly in the posterior pelvic compartment. It likely reflects mechanical distortion of the uterine axis due to DE nodules and adhesions. Multicenter validation is warranted.

Translating advocacy into action: exploring oncology healthcare professionals' awareness and use of the Clinical Oncology Society of Australia position statement on exercise in cancer care

PURPOSE

The Clinical Oncology Society of Australia (COSA) position statement on exercise in cancer care encourages all healthcare professionals to discuss, recommend, and refer people with cancer to exercise; however, use of these recommendations in practice is unknown.

METHODS

Oncology healthcare professionals working in Australia were invited to complete a cross-sectional online survey that assessed contextual factors that influence implementation of COSA exercise guidance in cancer care, based on the Consolidated Framework for Implementation Research.

RESULTS

We received 133 survey responses. Most were women (74%), nurses (35%), or oncologists (26%), involved in cancer care for > 10 years (63%), and in a public hospital setting (69%). Most participants agreed that exercise is beneficial (94%) and the COSA recommendations would positively influence patients' exercise behaviours (94%). However, only 35% routinely apply COSA recommendations in practice, and only 35% believe they are the best person to provide exercise support. Patient-level barriers included needing additional support to access exercise (92%), most commonly financial (74%). Organisational-level barriers included a lack of dedicated resources to support delivering exercise guidance (69%), and not believing providing exercise guidance is an important part of their role (51%). Only 24% agreed their organisation revised practice based on the COSA recommendations.

CONCLUSION

Despite most oncology healthcare professionals agreeing that exercise is beneficial, and that the COSA recommendations are important for patients, only a minority actually apply the recommendations in their practice. Targeted implementation efforts are needed to facilitate use of COSA exercise guidance in clinical practice.

Unmet health-related needs in patients with Crohn's disease in Belgium: a mixed-methods study

BACKGROUND

Measuring health-related unmet needs is crucial for identifying innovation gaps and developing targeted strategies to address them. This study focused on measuring the unmet needs of patients with Crohn's disease in Belgium using a standardised methodology that can facilitate comparisons across different diseases. Crohn's disease is a chronic condition characterised by a rising incidence over the past century and limited progress in understanding its causes or advancing effective treatments.

METHODS

We conducted an online survey (n = 150) and semi-structured interviews (n = 20) with adults affected by Crohn's disease. Descriptive statistics were used to analyse survey results, and thematic analysis was applied to interview transcripts. Unmet needs were classified a-priori into health, healthcare, and social aspects.

RESULTS

The study revealed unmet needs beyond the well-known symptoms of Crohn's. One in five survey respondents waited over a year for a diagnosis, and 18% considered their treatment as rather or very burdensome. At least 75% reported diarrhoea, fatigue, and abdominal cramps as rather or very burdensome, and around 40% experienced rather or very burdensome stress, anxiety, or depression. These symptoms, perceived as invisible, caused embarrassment, impacted sexual and family life, and led to social withdrawal. Psychological support was generally deemed insufficient, and around 40% of survey participants would have liked to be more involved in treatment decision-making. Only 50% of respondents who had interrupted work for at least a month returned to previous work levels, and 65% of the whole sample experienced financial impacts due to the disease.

CONCLUSIONS

Crohn's patients experienced not only burdensome physical symptoms, but were also frequently affected by significant psychological symptoms, which significantly affected their quality of life. Although specialist care was adequate, faster diagnosis and better psychological support are needed. Future studies should explore the unmet needs of children and adolescents with Crohn's disease to complete the picture.

Comparative Analysis of ChatGPT-3.5 and GPT-4 in Open-Ended Clinical Reasoning Across Dental Specialties

PURPOSE

The integration of large language models (LLMs) such as ChatGPT into health care has garnered increasing interest. While previous studies have assessed these models using structured multiple-choice questions, limited research has evaluated their performance on open-ended, scenario-based clinical tasks, particularly in dentistry. This study aimed to evaluate and compare the clinical reasoning capabilities of ChatGPT-3.5 and GPT-4 in formulating treatment plans across seven dental specialties using realistic, open-ended clinical scenarios.

METHODS

A cross-sectional analytical study, reported in accordance with the STROBE guidelines, was conducted using 70 dental cases spanning endodontics, oral and maxillofacial surgery, oral medicine, orthodontics, paediatric dentistry, periodontology, and radiology. Each case was submitted to both ChatGPT-3.5 and GPT-4 (paid version, November 2024). Responses were evaluated by specialty-specific expert panels using a three-level rubric (poor, average, good). Statistical analyses included chi-square tests and Fisher-Freeman-Halton exact tests (α = 0.05).

RESULTS

GPT-4 significantly outperformed GPT-3.5 in overall response quality (67.1% vs. 44.3% rated as 'good'; p = 0.016). Although no significant differences were observed across most specialties, GPT-4 showed a statistically superior performance in oral and maxillofacial surgery. Its advantage was more pronounced in complex cases, aligning with the model's enhanced contextual reasoning.

CONCLUSION

GPT-4 demonstrated superior accuracy and consistency compared to GPT-3.5, particularly in clinically complex and integrative tasks. These findings support the potential of advanced LLMs as adjunct tools in dental education and decision-making, though specialty-specific applications and expert oversight remain essential.

Appearances can be deceiving: differences in FeNO values among COPD and severe asthmatic patients stratified according to peripheral eosinophilic count

Eosinophilic COPD (eCOPD) and eosinophilic severe asthma (eSA) appear to share relevant clinical features, including responsiveness to steroids and higher exacerbation rates. However, data on the expression of T2-high inflammation biomarkers and, in particular comparison of fractional exhaled nitric oxide (FeNO) levels between the two diseases is lacking. The aim of the current retrospective observational study was to investigate whether FeNO values might differ between eCOPD and eSA patients. Sixty patients with SA and 40 with COPD were enrolled. They were divided in four groups: eosinophilic COPD (eCOPD) and eosinophilic severe asthma (eSA), if the blood eosinophil count (BEC) was ≥ 300 cells/μL; non-eosinophilic COPD (neCOPD) and non-eosinophilic severe asthma (neSA) if the BEC was <100 cells/μL. FeNO values, lung function and demographic data were compared between the groups. Overall, COPD patients were older, with a higher prevalence of males and had more impaired lung function than asthmatic patients. When comparing FeNO levels among the four groups, a significant difference was found between eCOPD and eSA patients (p = 0.001), as well as eCOPD and neCOPD patients (p = 0.021). Finally, neCOPD patients showed significantly lower FeNO values in comparison with neSA patients (p = 0.005). Such results were confirmed after adjusting for age, sex, and smoking history. Our preliminary results hint at the possibility that, despite an apparently similar eosinophilic phenotype, eCOPD patients might present with different FeNO values in comparison with eSA patients, possibly reflecting different underlying disease mechanisms.

Prognostic significance of receptor conversion following neoadjuvant therapy in breast cancer: a systematic review & meta-analysis

PURPOSE

Receptor conversion following neoadjuvant therapy in breast cancer may influence prognosis and adjuvant treatment decisions. This systematic review and meta-analysis evaluated the prognostic significance of changes in hormone receptor (HR) and HER2 status after neoadjuvant therapy.

METHODS

This study was performed in accordance with PRISMA guidelines. A systematic search of the literature was conducted to identify studies assessing the prognostic effect of receptor conversion after neoadjuvant treatment in breast cancer. Studies reporting receptor status before and after neoadjuvant therapy, with associated survival outcomes, were included. Pooled hazard ratios (HRs) for disease-free survival (DFS) and overall survival (OS) were calculated using random-effects models.

RESULTS

Twenty-two studies (n = 5370) were included in this meta-analysis. HR gain demonstrated significantly improved DFS (HR 0.49, 95 % CI 0.25-0.97; p = 0.04), but no OS benefit. HR loss was associated with both significantly worse DFS (HR 3.42, 95 % CI 1.93-6.08; p < 0.001) and OS (HR 1.99, 95 % CI 1.04-3.84; p = 0.04). HER2 gain had a negative impact on DFS (HR 1.89, 95 % CI 1.00-3.58; p = 0.05), with no significant effect on OS. HER2 loss was associated with significantly poorer DFS (HR 1.92, 95 % CI 1.51-2.43; p < 0.001) and OS (HR 2.20, 95 % CI 1.44-3.38; p < 0.001).

CONCLUSION

This systematic review and meta-analysis demonstrates that receptor conversion following neoadjuvant therapy in breast cancer significantly impacts survival outcomes. Specifically, gaining HR positivity is associated with improved DFS, while losing HR positivity correlates with worse DFS and OS. With regards to HER2, gaining positivity is associated with worse DFS, and losing positivity is associated with worse DFS and OS, compared to patients who maintain their initial status. These findings underscore the potential importance of reassessing receptor status after neoadjuvant therapy to tailor subsequent treatment decisions accurately.

Assessing the efficiency and effectiveness of community-based voluntary counseling and testing for HIV in Turin: insights from the fast-track cities initiative - a cross-sectional study

BACKGROUND

This study evaluated the efficiency and effectiveness of Community-Based Voluntary Counseling and Testing (CBVCT) for HIV in Turin as part of the Fast-Track Cities initiative. It aimed to understand demographic characteristics and risk behaviors to identify factors associated with routine testing. The findings can help to better tailor interventions for reducing HIV transmission and improving public health outcomes.

METHODS

A cross-sectional design was employed, utilizing anonymous questionnaires administered throughout 2022. Participants were individuals attending rapid serological testing sessions for HIV organized by third-sector associations in Turin, Northern Italy. The sample comprised 795 participants who attended HIV testing sessions. Data were collected via paper-based questionnaires (n = 495), later digitized for analysis. Descriptive statistics, univariate, and logistic regression analyses were conducted to examine socio-demographic characteristics, risk behaviors, and testing outcomes. Cost-effectiveness was evaluated using a Markov model stratifying patients by CD4 + levels to assess QALYs and direct healthcare costs.

RESULTS

The study achieved a high HIV testing rate of 99.9%, with a positivity rate of 0.5%. All individuals with reactive tests were successfully linked to care. Syphilis testing had a lower uptake (76.7%) and identified a positivity rate of 0.7%. Significant demographic and behavioral differences were found: previously tested participants are more likely to be older (p < 0.001, OR = 1.15) than first-time testers, more likely to be MSM (Men who have Sex with Men) than MSF (Men who have Sex with Female) and FSM (Female who has Sex with Male) (p < 0.001, OR = 0.132; p < 0.001, OR = 0.183); and are more likely to have had a history of sexually transmitted infections (STIs)(p = 0.003, OR = 0.128). Immediate HIV diagnosis and access to antiviral therapy reduce healthcare costs by €3,841 per patient, with total savings of €23,808 due to lower treatment expenses before immunodeficiency onset.

CONCLUSIONS

CBVCT programs in Turin demonstrated high feasibility and effectiveness in engaging the target population and ensuring linkage to care. However, syphilis testing requires greater integration. The findings highlight the need for targeted interventions to address disparities in testing behaviors and reinforce the economic sustainability of early HIV diagnosis and treatment.

First trimester mRNA COVID-19 vaccination and risk of congenital malformation: a prospective observational embryotox cohort study

OBJECTIVES

This observational cohort study evaluates the risk of major birth defects following maternal mRNA COVID-19 vaccination in the first trimester of pregnancy.

METHODS

Outcomes of prospectively ascertained pregnancies with at least one mRNA COVID-19 vaccination in the first trimester (gestational week 2+0 to 12+6) were compared with a cohort of unvaccinated pregnant women of the same period, whose data were collected using the same approach. The enrolment of study cases was conducted over a period of 21 months. For inclusion in the study, a structured pregnancy follow-up had to be completed afterwards. The reported congenital anomalies were classified according to EUROCAT. Relevant maternal characteristics were considered and adjusted odds ratios (aOR) were calculated using logistic regression.

RESULTS

The exposed study cohort included 1,828 pregnant women who were vaccinated with an mRNA vaccine in the first trimester. The unexposed comparison cohort consisted of 1,955 pregnant women. 68 major congenital malformations have been observed in the vaccinated and 53 in the unexposed cohort (3.86% vs. 3.09%). The analysis resulted in an aOR of 1.30 (95% CI: 0.90-1.86). A wide range of performed sensitivity analyses was in line with this finding.

CONCLUSIONS

We did not detect a statistically significant increase in the overall birth defect rate after maternal mRNA COVID-19 vaccination in the first trimester.

Remnant cholesterol is associated with poor prognosis in patients with hepatitis B-related acute-on-chronic liver failure: a Chinese population-based study

BACKGROUND

Hepatitis B-related acute-on-chronic liver failure (HBV-ACLF) patients possess adverse lipid homeostatic alterations, subsequently affecting their treatment regimens and prognoses. However, the precise association between one lipid homeostasis indicator, remnant cholesterol (RC), and HBV-ACLF prognoses have not been fully elucidated. In this retrospective study, the relationship between RC with 28- and 90-day HBV-ACLF prognoses was delineated.

METHODS

595 HBV-ACLF patients were recruited, and data collected for laboratory parameters at admission, as well as whether poor 28- and 90-day prognoses occurred during the follow-up period, in the form of mortality, or liver transplantation. Patients were divided into 3 groups, based on RC tertiles (Q1-3), and 4 multivariate Cox regression analyses were conducted to identify the associations between RC levels and ACLF prognoses; these analyses excluded different confounding factors, based on the Strengthening the Reporting of Observational Studies in Epidemiology statement. Stratified analysis was conducted to investigate the association between RC and ACLF risk among different subgroups, based on age, sex as well as complications and artificial liver treatment. RC accuracy versus that of other lipid indicators to predict 28- and 90-day ACLF survival was evaluated by restricted cubic spline and receiver operating characteristic (ROC) curve analyses, while Kaplan-Meier curves measured cumulative 28- and 90-day mortality risks.

RESULTS

For all 4 regression models, higher RC were associated with worse liver function, coagulation, and HBV-ACLF prognoses. Restricted cubic spline analysis identified a non-linear relationship between RC and HBV-ACLF prognoses, in which the Q3 RC tertile had the lowest 28-day and 90-day HBV-ACLF survival rates; this was further confirmed by Kaplan-Meier analysis. Additionally, subgroup analysis found that higher RC correlated to worse ACLF prognoses among hypoproteinemia patients. Moreover, RC, compared to total cholesterol, triglycerides, high- and low-density lipoprotein cholesterol, as well as non-high density lipoprotein, was the most accurate in predicting poor 28- and 90-day ACLF prognoses.

CONCLUSIONS

Elevated RC was significantly associated with poorer 28- and 90-day HBV-ACLF prognoses, even after accounting for all other traditional risk factors. Therefore, monitoring RC, along with interventions to reduce their levels, could aid in improving ACLF patient outcomes.

The U-shaped relationship between serum osmolality and the risk of sepsis-associated delirium development: a retrospective study

OBJECTIVE

We aim to investigate the association between serum osmolality and the risk of developing delirium in septic patients.

METHODS

Adult septic patients meeting the Sepsis-3 definition were included. Delirium was screened according to the Confusion Assessment Method for the ICU (CAM-ICU) tool. Patients lacked of serum osmolality results and those with delirium prior to sepsis occurrence were excluded. The association between osmolality and delirium was visualized using both restricted cubic splines (RCS) and local weighted scatter plot smoothing (LOWESS) methods. Logistic regression, subgroup and sensitivity analysis were performed to determine the predictive value of osmolality on delirium.

RESULTS

A total of 17,171 septic patients were included. A U-shaped pattern was observed between serum osmolality and delirium risk (P for non-linear < 0.001). Compared with intermediate range (286-301 mmol/L), patients in the low and high osmolality groups had an increased percentage of delirium. Compared with intermediate osmolality, low and high osmolality could increase the risk of delirium by 21.6-34.5% (OR 1.216-1.345) and 18.4-53.3% (OR 1.184-1.533). All subgroups analysis supported that abnormal osmolality is an independent risk factor for delirium (OR > 1), and a more significant association was found in SOFA < 6 subgroup. In sensitivity analysis, the presence of comorbidities made no influence on this U-shaped relationship. After balancing the baseline information by propensity score matching (PSM), patients in the intermediate range still had a lower incidence of delirium.

CONCLUSION

There was a U-shaped association between serum osmolality and the risk of sepsis-associated delirium. Further high-quality research is needed to verify our findings.

CLINICAL TRIAL NUMBER

Not applicable.

Predicting rapid kidney function decline in middle-aged and elderly Chinese adults using machine learning techniques

The rapid decline of kidney function in middle-aged and elderly people has become an increasingly serious public health problem. Machine learning (ML) technology has substantial potential to disease prediction. The present study use dataset from the Chinese Health and Retirement Longitudinal Study (CHARLS) and utilizes advanced Gradient Boosting algorithms to develop predictive models. Least Absolute Shrinkage and Selection Operator (LASSO) regression was used to identify the key predictors, and multivariate logistic regression was utilized to validate the independent predictive power of the variables. Furthermore, the study integrated SHapley Additive exPlanations (SHAP) to boost the interpretability of the model. The findings show that the Gradient Boosting Model demonstrated robust performance across both the training and test datasets. Specifically, it attained AUC values of 0.8 and 0.765 in the training and test sets, respectively, while achieving accuracy scores of 0.736 and 0.728 in these two datasets. LASSO regression identified key influencing factors, including estimated glomerular filtration rate (eGFR), age, hemoglobin (Hb), glucose, and systolic blood pressure (SBP). Multivariate linear regression further confirmed the independent associations between these variables and rapid kidney function deterioration (P < 0.05). This study developed a risk assessment model for rapid kidney function deterioration that is applicable to middle-aged and elderly populations in China.

Diagnostic yield of standardized screening for deep venous thrombosis in patients with acute cerebral ischemia and cardiac right-to-left shunt

BACKGROUND

Paradoxical embolism is a potential pathophysiology in patients with acute ischemic stroke or transient ischemic attack (TIA) and patent foramen ovale (PFO) or atrial septal defect (ASD). We sought to determine the frequency of deep vein thrombosis (DVT) detection by standardized lower extremity venous compression ultrasound (LE-CUS) in patients with acute cerebral ischemia and cardiac right-to left shunt due to PFO or ASD on transoesophageal echocardiogram (TEE).

METHODS

We analysed consecutive patients (01/2015-12/2020) with acute cerebral ischemia and PFO or ASD on TEE, who received DVT screening by LE-CUS per institutional standard. We determined clinical baseline variables including shunt-size categorized as small, medium or large, and analysed the frequency of DVT. We performed multivariable analysis to identify predictors for presence of DVT on LE-CUS.

RESULTS

Among 1564 patients with acute ischemic stroke (n = 1326) or TIA (n = 238) who received TEE, 390 patients had PFO and 10 patients ASD, of whom 274 were screened for DVT by LE-CUS (153 [55.8%] female, age 64 years [51-76], NIHSS score 4 [1-9.5]). Of these, 55 patients (20.1%) had DVT on LE-CUS. Among patients with DVT, 23 of 76 patients (30.3%) who received LE-CUS within 72 h from admission compared to 32 of 198 patients (16.2%) who received LE-CUS at later time points had presence of DVT (p = 0.012). The percentage of patients with DVT tended to be higher among patients with cryptogenic ischemic stroke compared to patients with other stroke etiologies (21.8% [49 of 225] vs. 12.2% [6 of 49]; p = 0.168). Presence of DVT was associated with female sex (OR 2.24, 95%CI 1.09-4.62), NIHSS score (OR 1.06, 95%CI 1.03-1.10), Wells score (OR 1.54, 95%CI 1.11-2.13) and shunt size (OR 3.32, 95%CI 1.86-5.91).

CONCLUSIONS

Our data suggest a high diagnostic yield (> 20%) of standardized screening for DVT with LE-CUS in patients with acute cerebral ischemia and PFO or ASD. This particularly applies to females, patients with more severe baseline deficits and large right-to-left shunt. These findings may not be generalizable to all patients with PFO or ASD and need prospective validation.

Clinical Frailty Scale versus Geriatric-8 in predicting quality of life among older adults receiving curative cancer treatment

INTRODUCTION

Frailty assessment is fundamental to geriatric oncology (GO), with GO guidelines endorsing Geriatric-8 (G8) as a frailty screening tool. Although the Clinical Frailty Scale (CFS) is widely used in geriatrics, no studies have examined its quality of life (QoL) utility in GO. We compare CFS and G8 in their ability to predict quality of life among older adults receiving curative cancer treatment.

PATIENTS AND METHODS

One hundred thirteen patients (age ≥ 65 years) were recruited from a 2000-bed university-affiliated tertiary hospital between August 2020 and May 2024. Patient demographics, CFS and G8 were collected. The EORTC QLQ-ELD14 and the EQ5D-VAS were measured at start of treatment, and monthly after for 3 months. Patients were stratified by CFS or G8 and compared with QoL at various time points controlled for age, gender, BMI, and G8.

RESULTS

Using CFS, frail subjects had poorer QoL in the EORTC QLQ-ELD14 subscales for mobility (p < 0.001), joint stiffness (p < 0.001), maintaining purpose (p = 0.03), and EQ5D-VAS (p = 0.003) at start of treatment; mobility (p = 0.004 and p = 0.009) and EQ5D-VAS (p = 0.03 and p = 0.009) scores at one and 2 months. QoL scores between groups were similar at 3 months. Using G8, only EQ5D-VAS was poorer for frail subjects at start of treatment (p = 0.02). CFS remained a significant indicator of poor QoL controlled for age, gender, BMI, and G8.

CONCLUSION

CFS is a significant and better indicator of poor QoL in older adults with cancer receiving curative treatment compared to G8. Further research should explore implementation of supportive care for specific QoL deficit detected by CFS.

TRIAL REGISTRATION

NCT04513977; Date 2020-08-14.

Assisted reproductive technology in young BRCA carriers with a pregnancy after breast cancer: An international cohort study

INTRODUCTION

Very limited data exist on assisted reproductive technology (ART) use in BRCA1/2 carriers conceiving after breast cancer. This study aimed to investigate the safety of ART to achieve a pregnancy after breast cancer in BRCA1/2 carriers.

METHODS

This is an international, hospital-based, retrospective cohort study including BRCA1/2 carriers with a pregnancy after prior breast cancer diagnosis at ≤ 40 years of age between 2000 and 2020. Outcomes were compared between young BRCA1/2 carriers who conceived using ART and those who conceived spontaneously.

RESULTS

Among 543 BRCA1/2 carriers with a pregnancy after breast cancer, 436 conceived spontaneously and 107 using ART. Of 107 pregnancies achieved with ART, 45 (42.1 %) were obtained using oocytes/embryo cryopreserved at diagnosis, 33 (30.8 %) after controlled ovarian stimulation for in-vitro-fertilization/intracytoplasmic sperm injection or ovulation induction for intrauterine insemination or planned intercourse after anticancer treatments, 21 (19.6 %) after oocyte donation, while for 8 (7.5 %) patients type of ART was missing. Compared to patients in the no-ART group, those in the ART group were older at the time of conception, had more frequently hormone receptor-positive breast cancer and a longer median time from cancer diagnosis to conception. At a median follow-up of 5.2 years after conception, no apparent detrimental effect of ART on disease-free survival was observed (adjusted HR=0.72, 95 % CI 0.39-1.34).

CONCLUSION

In young BRCA1/2 carriers with a pregnancy after breast cancer, ART use did not appear to be associated with increased risk of DFS events.

Comparison of triglyceride-glucose related indices in prediction of cardiometabolic disease incidence among US midlife women

The effects of triglyceride-glucose (TyG) related indices on cardiometabolic disease (CMD) are still unclear. Our study aimed to investigate the relationship between the TyG-related indices and CMD risk among midlife women. This retrospective observational cohort study utilized data from the 2020 SWAN participants. The TyG index was computed as Ln [fasting triglyceride (mg/dL) × fasting glucose (mg/dL)/2]. Modified TyG indices were created by integrating TyG with body mass index (BMI), waist circumference (WC), and waist-to-height ratio (WHtR). Multivariate Cox proportional hazards regression and receiver operating characteristic (ROC) analyses were conducted to assess the associations and predictive capacities of TyG and its related indices with CMD incidences. The mean age of participants was 45.7 years, comprising 420 (20.8%) Black, 184 (9.1%) Chinese, 225 (11.1%) Japanese, and 1191 (58.9%) Caucasian or Hispanic women. Over a 10-year follow-up, 837 women (41.4%) developed CMD. Compared to the lowest quartile, the adjusted hazard ratios (95% confidence intervals) for incident CMD in the highest quartile for TyG, TyG-BMI, TyG-WC, and TyG-WHtR were 1.78 (1.41-2.25), 3.26 (2.51-4.24), 3.13 (2.41-4.06), and 3.19 (2.47-4.12), respectively. The area under the ROC curve for modified TyG indices was significantly higher than that for the TyG index alone. Both the TyG and modified TyG indices were significantly associated with new-onset CMD, with modified TyG indices showing superior performance in identifying individuals at risk for CMD.

Single Large-Scale Mitochondrial Deletion Syndromes: Neuroimaging Phenotypes and Longitudinal Progression in Pediatric Patients

BACKGROUND AND PURPOSE

Single large-scale mitochondrial deletion syndrome (SLSMD) comprises devastating mitochondrial diseases often classified into 3 major clinical syndromes: Kearns-Sayre syndrome (KSS), chronic progressive external ophthalmoplegia (CPEO), and Pearson syndrome (PS). Nevertheless, there remains large clinical variability and overlap among these SLSMD groups. Therefore, further stratification is required for more precise prognostication and clinical management. Through detailed description and analysis of longitudinal neuroimaging changes, we sought to determine the neuroradiologic hallmarks of SLSMDs and define their expected imaging progression to further delineate their natural history.

MATERIALS AND METHODS

A retrospective, longitudinal study of 40 children with SLSMDs at 3 mitochondrial disease centers was performed. MRI review assessed the prevalence and progression of brain lesions in different regions with statistical significance testing and Kaplan-Meier analysis. Hierarchical cluster analysis was performed for involved brain regions to stratify findings into imaging phenotype groups.

RESULTS

Among 40 patients with SLSMD (median age 9.26 years; interquartile range: 5.16-13.1), 67.5% had KSS, 15% had KSS with a prior history of PS (PS→KSS), and 10% had PS only. A well-delineated phenotype could not be specified for 1 (2.5%) and 2 (5%) individuals who had CPEO-plus (CPEO + extraocular symptoms). Regardless of presentation, initial MRI of patients with KSS revealed lesions within selective areas of the upper brainstem tegmentum. Follow-up MRIs in 26 patients showed well-defined progression along other select brainstem and white matter regions. Log-rank tests demonstrated varying onset times by lesion type. Cluster analysis revealed 2 distinct neuroimaging groups: 1) KSS, CPEO-plus, and PS→KSS versus 2) PS and not otherwise specified individuals. KSS, CPEO-plus, and PS→KSS showed indistinguishable neuroimaging features regardless of the initial clinical presentation.

CONCLUSIONS

We describe the first comprehensive longitudinal neuroimaging pattern analysis in a multicenter, international SLSMDs disease pediatric cohort, delineating a predictable progression of brain lesions, regardless of clinical phenotype.

Biomarker-Specific Survival and Medication Cost for Patients With Non-Small Cell Lung Cancer

Importance

Targeted therapies and immunotherapies prolong survival but are associated with high costs for patients with advanced non-small cell lung cancer (aNSCLC). To date, little is known about survival and medication cost by biomarker status in the US.

Objective

To estimate survival and medication cost by aNSCLC biomarker status.

Design, Setting, and Participants

This retrospective cohort study using Flatiron Health data identified patients diagnosed with aNSCLC from January 1, 2016, through December 31, 2022. Each patient had received at least 1 biomarker test and 1 documented line of therapy; follow-up was through September 31, 2023. Patients were categorized based on the presence of driver alterations, including ALK rearrangement, BRAF variation, or EGFR variation. Patients without driver alterations were divided into 3 groups based on their programmed cell death 1 ligand 1 (PD-L1) expression (<1%, 1%-49%, or ≥50%).

Main Outcomes and Measures

The primary outcome was medication costs, which were a function of survival probability and monthly medication costs. The secondary outcome was medication costs per survivor, defined as the mean aggregate medication costs within each patient cohort for each 1- or 2-year survivor.

Results

The study cohort consisted of 26 635 patients with aNSCLC (mean [SD] age at diagnosis, 68.9 [10.0] years; 13 750 [52%] male; 2610 [10%] African American, 687 [3%] Asian, 18 352 [69%] White, and 4986 [19%] other race, including any race other than African American, Asian, or White). The median overall survival was 39.9 (95% CI, 33.9-48.5) months for patients with ALK rearrangement, 27.0 (95% CI, 24.8-28.8) months for EGFR variation, 18.7 (95% CI, 16.0-20.6) months for BRAF variation, 12.3 (95% CI, 12.0-12.7) months for PD-L1 less than 1%, 13.7 (95% CI, 13.1-14.3) months for PD-L1 of 1% to 49%, and 16.2 (95% CI, 15.3-17.0) months for PD-L1 of 50% or greater. The 1- and 2-year medication costs per patient for the overall cohort were $120 420 (95% CI, $115 540-$126 470) and $182 560 (95% CI, $172 900-$196 040), respectively. Patients with EGFR variation or PD-L1 of 50% or greater incurred relatively higher 1-year medication cost ($131 700 [95% CI, $125 340-$138 280] and $123 590 [95% CI, $115 970-$130 840], respectively) compared with patients with PD-L1 less than 1% ($110 350 [95% CI, $101 680-$120 040]). Patients with ALK rearrangement or EGFR variation incurred the highest 2-year medication cost ($242 130 [95% CI, $206 220-$267 330] and $241 940 [95% CI, $230 840-$254 730], respectively), whereas patients with PD-L1 less than 1% and PD-L1 of 1% to 49% had the lowest 2-year medication cost ($156 340 [95% CI, $142 450-$172 800] and $163 410 [95% CI, $152 410-$174 180], respectively). The medication costs per 1-year survivor were $152 370 (95% CI, $133 550-$178 080) for patients with ALK rearrangement, $175 720 (95% CI, $167 330-$185 390) for EGFR variation, $211 100 (95% CI, $195 030-$229 400) for PD-L1 less than 1%, $210 260 (95% CI, $193 190-$226 580) for PD-L1 of 1% to 49%, and $211 630 (95% CI, $198 670-$224 210) for PD-L1 of 50% or greater, whereas the costs per 2-year survivor were $363 480 (95% CI, $314 710-$401 320) for patients with ALK rearrangement, $468 400 (95% CI, $441 340-$497 860) for patients with PD-L1 of 50% or greater, $460 790 (95% CI, $427 340-$494 080) for patients with PD-L1 of 1% to 49%, and $500 220 (95% CI, $456 900-$556 730) for patients with PD-L1 less than 1%.

Conclusions and Relevance

In this cohort study, patients with aNSCLC with driver alterations experienced better survival and incurred lower medication costs per survivor than those without driver variation, indicating the need to develop more affordable and effective medications for patients without driver alterations.

Volume and Intensity of Walking and Risk of Chronic Low Back Pain

Importance

Chronic low back pain (LBP) is a prevalent and costly condition, and regular physical activity may reduce its risk. Walking is a common and accessible form of physical activity, but its association with the risk of chronic LBP is unclear.

Objective

To examine whether accelerometer-derived daily walking volume and walking intensity are associated with the risk of chronic LBP.

Design, Setting, and Participants

This prospective population-based cohort study used data from the Trøndelag Health (HUNT) Study in Norway, with a baseline in 2017 to 2019 and follow-up in 2021 to 2023. The study included individuals without chronic LBP at baseline and with at least 1 valid day of device-measured walking.

Exposure

Daily walking volume (minutes per day) and walking intensity, expressed as metabolic equivalent of task (MET) per minute.

Main Outcomes and Measures

The primary outcome was self-reported chronic LBP at follow-up, defined as pain lasting 3 months or longer in the past 12 months. Poisson regression was used to estimate adjusted risk ratios (RRs) with 95% CIs of chronic LBP according to daily walking volume and mean walking intensity.

Results

A total of 11 194 participants aged 20 years or older (mean [SD] age, 55.3 [15.1] years; 6564 women [58.6%]) were included in the analysis. At follow-up (mean [SD] follow-up time, 4.2 [0.3] years), 1659 participants (14.8%) reported chronic LBP. Continuous measures of both walking volume and walking intensity were inversely associated with the risk of chronic LBP using restricted cubic splines models. Compared with participants walking less than 78 minutes per day, those walking 78 to 100 minutes per day had an RR for chronic LBP of 0.87 (95% CI, 0.77-0.98), those walking 101 to 124 minutes per day had an RR of 0.77 (95% CI, 0.68-0.87), and those walking 125 minutes or more per day had an RR of 0.76 (95% CI, 0.67-0.87). Compared with a mean walking intensity of less than 3.00 MET per minute, participants with walking intensity of 3.00 to 3.11 MET per minute had an RR for chronic LBP of 0.85 (95% CI, 0.75-0.96), those with walking intensity of 3.12 to 3.26 MET per minute had an RR of 0.82 (95% CI, 0.72-0.93), and those with walking intensity greater than or equal to 3.27 MET per minute had an RR of 0.82 (95% CI, 0.72-0.93). After mutual adjustment, the association remained largely similar for walking volume but was attenuated for walking intensity.

Conclusions and Relevance

In this cohort study, daily walking volume and walking intensity were inversely associated with the risk of chronic LBP. The findings suggest that walking volume may have a more pronounced benefit than walking intensity.

Parental Firearm Storage and Their Teens' Perceived Firearm Access in US Households

Importance

Firearm access increases fatal and nonfatal firearm injury risk among teens. Identifying parental firearm storage behaviors associated with teen access may inform efforts to prevent teen firearm injuries.

Objective

To examine the associations between parent-reported household firearm storage behaviors and teen perceived access to firearms.

Design, Setting, and Participants

This cross-sectional study used national survey data of US firearm-owning parents and their teens (aged 14 to 18 years) surveyed between June and July 2020, with a response rate of 31% for parents and 21% for teens. Analyses were conducted January to May 2024.

Exposures

The number of firearms stored in the household as (1) unlocked, (2) loaded, (3) unlocked and loaded, and (4) unlocked or loaded.

Main Outcomes and Measures

Teen perceived firearm access, overall and stratified by teen gender, parental education, and urbanicity. Survey-weighted logistic regression analyses assessed the associations between the number of firearms parents reported storing in each unsecured state (unlocked and loaded, unlocked, loaded, and unlocked or loaded) and teen perceived firearm access, overall and stratified by teen gender, parental education, and urbanicity (metropolitan vs nonmetropolitan). The areas under the receiver operating characteristic curves (AUROC) were used to identify the firearm storage behaviors with the best ability to estimate teen perceived firearm access.

Results

Analyses included 487 parent-teen dyad respondents. The mean (SE) ages of parents and teens were 46.6 (0.80) and 16.0 (0.12) years, respectively. Most parent respondents were male (58.1%; 95% CI, 50.3%-65.8%) and White (73.5%; 95% CI, 66.1%-80.9%), and most teen respondents were female (55.7%; 95% CI, 47.8%-63.6%) and White (69.5%; 95% CI, 61.8%-77.2%). All 4 unsecured firearm storage behaviors were associated with greater teen perceived firearm access (odds ratio [OR], 1.27-1.44; 95% CI, 0.99-2.10), but associations disappeared after restricting to those who stored at least 1 firearm unsecured (OR, 0.99-1.18; 95% CI, 0.67-1.89). The number of firearms stored unlocked performed the best in estimating teen perceived access to firearms in US households (AUROC, 65.7; 95% CI, 61.4-70.1), regardless of teen gender, parental education, and urbanicity. However, sensitivity of this measure was universally low (range, 42%-64%). Additionally, 36.3% (95% CI, 23.6%-49.0%) of teens reported access to a firearm in households where all firearms were stored locked and unloaded.

Conclusions and Relevance

This study found that parent-reported firearm storage may be a poor estimator of teen perceived firearm access, regardless of teen gender, parental education, and urbanicity. Strictly focusing safety efforts on locked and unloaded firearm storage may not fully negate teen's perceptions that they can access and load household firearms. Storing additional firearms securely may not prevent teen access if at least 1 household firearm remains unlocked.

Smartphone-activated volunteer responders and survival to discharge after out-of-hospital cardiac arrests in Victoria, 2018-23: an observational cohort study

OBJECTIVES

To compare the likelihood of patient survival to discharge and of bystander cardiopulmonary resuscitation (CPR) and defibrillation for cases of out-of-hospital cardiac arrest in which at least one smartphone-activated volunteer responder (SAVR) arrived before emergency medical services (EMS) with cases in which EMS arrived first.

STUDY DESIGN

Population-based observational cohort study; analysis of Victorian Ambulance Cardiac Arrest Registry (VACAR) data.

SETTING

Victoria, 12 February 2018 - 31 August 2023.

PARTICIPANTS

All cases of out-of-hospital cardiac arrest not witnessed by EMS personnel, except events in residential aged care facilities, in which EMS personnel did not attempt resuscitation, or for which the EMS dispatch code was ineligible for SAVR activation; events during coronavirus disease 2019 pandemic lockdowns were also excluded (SAVR program pause: rural areas: 23 March 2020 - 16 October 2020; metropolitan areas: 23 March 2020 - 9 November 2020).

MAIN OUTCOME MEASURES

Primary outcome: survival to hospital discharge.

SECONDARY OUTCOMES

bystander CPR, bystander defibrillation, any return of spontaneous circulation.

RESULTS

Of 9196 cases of out-of-hospital cardiac arrest included in our analysis, 1158 (12.6%) had been attended by SAVRs: before EMS arrival in 564 cases (48.7%) and after EMS arrival in 594 cases (51.3%). The risk-adjusted odds of patient survival to hospital discharge were higher for events in which SAVRs arrived before EMS than for those not attended by SAVRs (adjusted odds ratio [aOR], 1.37; 95% confidence interval [CI], 1.02-1.85), as were those of bystander CPR (aOR, 7.59; 95% CI, 4.97-11.6) and bystander defibrillation (aOR, 16.0; 95% CI, 9.23-27.7); the likelihood of return of spontaneous circulation was similar for the two event groups. SAVRs arriving after EMS did not influence any of the assessed outcomes.

CONCLUSION

The arrival of SAVRs before EMS personnel was associated with greater likelihood of patient survival to hospital discharge and of bystander CPR and defibrillation.

Discordance between measures of Mycobacterium tuberculosis sensitization and type 2 diabetes mellitus in the United States (NHANES): A population-based cohort study

OBJECTIVE

We examined how latent TB infection (LTBI), evaluated by cell-mediated immune responses to Mycobacterium tuberculosis (Mtb) antigens, impacts glucose metabolism in US adults.

METHODS

Mtb sensitization was evaluated by interferon-γ (IFN-γ) release assay (IGRA+: assay reactivity) and tuberculin skin testing (TST+: skin induration ≥10 mm), and categorized as: IGRA-/TST- (TB uninfected controls); IGRA-/TST+; IGRA+/TST-; or IGRA+/TST+. Diabetes was ascertained by fasting plasma glucose (FPG) ≥7.0 mmol/L, HbA1c ≥6.5% and/or antidiabetic medication. Adjusted generalized additive models examined nonlinear effects of skin induration and IFN-γ reactivity on FPG and HbA1c; and LTBI on diabetes prevalence.

RESULTS

Among 1787 (IGRA-/TST-), 101 (IGRA-/TST+), 92 (IGRA+/TST-), and 99 (IGRA+/TST+) adults, skin induration linearly associated with FPG [effective degrees of freedom (EDF) =1.01; p<0.001] and non-linearly with HbA1c [EDF=1.76; p=0.003]. IFN-γ reactivity correlated with neither FPG [p=0.58] nor HbA1c [p=0.94]. Relatedly, adjusted diabetes prevalence was greater in IGRA-/TST+ [24.9%; p=0.048] and IGRA+/TST+ [27.3%; p=0.004] but not IGRA+/TST- [15.9%; p=0.69] individuals than among controls [15.3%].

CONCLUSIONS

LTBI associated with glycemic measures and diabetes when assessed by skin induration, but not IFN-γ release. This suggests an association with innate immune activation rather than acquired T-cell response, as determined by ex vivo IFN-γ release assay.

Aggression and sport: A cross-sectional study on behavioral tendencies of athletes

This cross-sectional study aimed to measure aggression in a more heterogeneous population of athletes, with the purpose of determining whether some specific conditions are related to aggressive behaviour. Athletes of 18-64 years old were enrolled in the study. The Italian version of Buss Perry Aggression Questionnaire (BPAQ) was self-administered. A total of 390 questionnaires were collected. Males showed higher levels of physical aggression (19.58 ± 6.32) than females (15.69 ± 6.65), p < 0.001 and a significant reduction in all domains of the questionnaire with advancing age, except for physical aggression. Furthermore, subjects who practiced full contact sports showed higher levels of physical aggression (20.23 ± 6.68) than those who practiced partial contact (17.89 ± 5.86) or non-contact sports (17.19 ± 6.64) p < 0.006. Finally, those who have played competitively in the past showed lower levels of anger (14.95 ± 5.22) than those who have played amateurishly (16.05 ± 5.54), p < 0.05. Age and gender appeared to be significant in aggression scores. Martial artists and combat sports players showed significantly higher levels of physical aggression than those who practice partial contact or non-contact sports. The type of sport (individual or team players), the practice time (beginners or experts) and the current level of sport (amateurs or competitive players) did not affect the aggression scores. Instead, the past level of sport participation is correlated with current anger.

Sarcopenia, Muscle Mass and Protein Intake in Adults Older Than 65 Years After Earlier Bariatric Surgery

BACKGROUND

Metabolic and bariatric surgery (MBS) is a proven treatment for obesity. Yet weight loss is accompanied by loss of muscle which may predispose to sarcopenia. The prevalence of low muscle mass in older adults after MBS remains unexplored, even though this group is more vulnerable to sarcopenia.

METHODS

This cross-sectional study investigated sarcopenia and low muscle mass by comparing adults older than 65 years with previous MBS (BAR) to patients following nonsurgical obesity management (CON). A sample size of 100 was estimated from appendicular lean mass (ALM) in a similar study in younger adults. Patients were recruited from the University Hospitals Leuven Obesity Clinic, Belgium. Study assessments included dual-energy X-ray absorptiometry, handgrip, short battery of physical performance, blood sampling and self-reported dietary intake. Sarcopenia was defined according to the European Working Group on Sarcopenia in Older People (EWGSOP1) criteria using obesity-specific cut-off points and sarcopenic obesity by the European Society for Enteral and Parenteral Nutrition (ESPEN) and the European Association of the Study of Obesity (EASO) consensus definition. Main endpoints were sarcopenia and ALM normalized to body mass index (%ALM/BMI). A multiple linear regression model was fitted to predict ALM.

RESULTS

We included 50 participants per group (male, BAR 40%, CON 35%). BAR participants were older (68.3 ± 3.2 years vs. 70.7 ± 3.9, p < 0.01), and more had diabetes (52% vs. 28%). BAR lost more bodyweight after MBS than CON following nonsurgical treatment (BAR 31.6 ± 9.5% vs. CON 12.1 ± 8.42%, p < 0.001). Fat free mass (FFM) was lower for BAR than for CON, but %ALM/BMI was not different (64.7 ± 18.1% vs. 62.6 ± 15.8, p = 0.53). Twenty percent to 56% of participants had low muscle mass, depending on sex and criterium, but only 3% met the criteria for sarcopenia and 9% for sarcopenic obesity. Protein intake tended to be higher in BAR than in CON (1.36 ± 0.36 g/kg FFM/day vs. 1.25 ± 0.27, p = 0.09). Most participants did not meet optimal protein intake recommendations after BMS nor for older adults in general. In the linear regression model, muscle mass increased with male sex, BMI, adiposity and protein intake and decreased with age, (adjusted R2 0.80). Neither BAR compared to CON nor surgery type or other clinical parameters influenced muscle mass.

CONCLUSION

Older adults with previous MBS were not more likely to develop sarcopenia than older adults following nonsurgical treatment. Rather, age, adiposity and low protein intake lower muscle mass, predisposing to sarcopenia.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT05582668.

Predictive Modeling of Endograft Limb Occlusion after Endovascular Aneurysm Repair: A Propensity Score Matching Analysis

BACKGROUND

Endovascular aneurysm repair (EVAR) is widely used to treat abdominal aortic aneurysm (AAA). However, it carries the risk of complications that often require further interventions. Endograft limb occlusion (ELO), though relatively rare, significantly affects patient outcomes. This study investigates factors influencing and predicting ELO risk after EVAR.

METHODS

All patients who underwent EVAR for AAA between 2013 and 2023 at the First Affiliated Hospital of Guangxi Medical University were examined. Patients were followed up and categorized into ELO and non-ELO groups. The groups were made comparable using propensity score matching. A prediction model was constructed using Lasso regression analysis.

RESULTS

The study included 425 AAA patients. After propensity score matching, the analysis involved 23 patients with ELO and 69 patients without ELO. All patients with the stent positioned distally in the external iliac artery were exclusively in the ELO group, indicating that the stent position variable perfectly predicted the outcome within our matched cohort. A predictive model was constructed using Lasso regression analysis, incorporating 3 variables: double iliac sign, surgical approaches, and iliac artery stent oversizing. Validation of the predictive model using the Hosmer-Lemeshow test demonstrated its excellent predictive capability, achieving an area under the curve of 0.91.

CONCLUSION

Double iliac sign, open surgical approaches, and iliac artery stent oversizing (>50%) emerged as independent risk factors for ELO occurrence in AAA patients undergoing EVAR. The position of the stent in the external iliac artery independently predicts ELO and directly indicates a high-risk situation. Our predictive model aids in risk stratification and clinical decision-making, thereby improving patient outcomes.

Covariates in studies examining longitudinal relationships between substance use and mental health problems among youth: A meta-epidemiologic review

INTRODUCTION

This meta-epidemiological review examines covariate selection and reporting practices in observational studies analyzing longitudinal relationships between youth substance use and mental health problems (internalizing and externalizing).

METHODS

Sixty-nine studies published in high-impact journals from 2018 to 2023 were included. Studies were included if they explored prospective relationships between substance use and mental health among youth (12-25 years) and used repeated measures designs. Data extraction focused on study characteristics, covariates and their selection methods, and reporting practices.

RESULTS

There were 574 covariates included across studies; 33 were included as moderators and 18 were included as mediators. At the study level, the most common covariate domains included demographics (90 % of included studies had at least one demographic, mostly sex), substance-related variables (67 %; mostly alcohol or smoking), internalizing symptoms (39 %; mostly depression), family-related variables (29 %; mostly parental substance use or mental illness), and externalizing symptoms (19 %; mostly conduct). 93 % of studies had unique sets of lower-order covariates. Across all studies (n = 69), only 35 % provided details for how, and why, all covariates were selected with only 12 % reporting selecting covariates a priori, and none being pre-registered. Only 60 % mentioned confounding and only 13 % mentioned risk of confounding in their conclusions.

CONCLUSIONS

The findings highlight the need for improved covariate selection and reporting practices. Establishing a core set of covariates and adhering to standardized reporting guidelines would enhance the comparability and reliability of research findings in this field. Researchers can use this review to identify and justify the inclusion and exclusion of commonly reported covariates when analyzing relationships between youth substance use and mental health problems.