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Importance: The Southern Community Cohort Study (SCCS) Polypill Trial showed that a cardiovascular polypill (a single pill containing a statin and 3 half-standard dose antihypertensive medications) effectively controls cardiovascular disease (CVD) risk factors in a majority Black race and low-income population. The cost-effectiveness of polypill treatment in this population has not been previously studied., Objective: To determine the cost-effectiveness of the cardiovascular polypill., Design, Setting, and Participants: A discrete-event simulation version of the well-established CVD policy model simulated clinical and economic outcomes of the SCCS Polypill Trial from a health care sector perspective. A time horizon of 10 years was adopted. Polypill treatment was priced at $463 per year in the base-case analysis. Model input data were derived from the National Health and Nutrition Examination Survey, Medical Expenditure Panel Survey, pooled longitudinal cohort studies, the SCCS Polypill Trial, and published literature. Two cohorts were analyzed: an SCCS Polypill Trial-representative cohort of 100 000 individuals and all trial-eligible non-Hispanic Black US adults. Study parameters and model inputs were varied extensively in 1-way and probabilistic sensitivity analysis., Exposures: Polypill treatment or usual care., Main Outcome and Measures: Primary outcomes were direct health care costs (US dollar 2023) and quality-adjusted life-years (QALYs), both discounted 3% annually, and the incremental cost per QALY gained., Results: In the trial-representative cohort of 100 000 individuals (mean [SD] age, 56.9 [5.9] years; 61 807 female [61.8%]), polypill treatment was projected to yield a mean of 1190 (95% uncertainty interval, 287-2159) additional QALYs compared with usual care, at a cost of approximately $10 152 000. Hence, polypill treatment was estimated to cost $8560 per QALY gained compared with usual care and was high value (<$50 000 per QALY gained) in 99% of simulations. Polypill treatment was estimated to be high value when priced at $559 or less per year and cost saving when priced at $443 or less per year. In almost all sensitivity analyses, polypill treatment remained high value. In a secondary analysis of 3 602 427 trial-eligible non-Hispanic Black US adults (mean [SD] age, 55.4 [7.6] years; 2 006 597 female [55.7%]), polypill treatment was high value, with an estimated cost of $13 400 per QALY gained., Conclusions and Relevance: Results of this economic evaluation suggest that polypill treatment could be a high value intervention for a low-income, majority Black population with limited access to health care services. It could additionally reduce health disparities.

Transitions from one EHR to another can be enormously disruptive to care. Nurses are the largest group of EHR users, but nurse experiences with EHR transitions have not been well documented. We sought to understand nurse experiences with an EHR transition at the US Department of Veterans Affairs. We used a mixed methods design, combining a cumulative 26 longitudinal interviews with 317 survey free-text responses and quantitative measures from a repeated cross-sectional survey, all from nurses at one of the first facilities to transition from the Department of Veterans Affairs' homegrown EHR to a commercial system. We conducted inductive/deductive content analysis of qualitative data and paired qualitative findings with descriptive statistics of survey questions. Analyses yielded insights about three key aspects of the transition: (1) EHR functionality: diverse perceived causes of challenges using the new EHR; (2) transition process: barriers and facilitators of nurses' EHR training and technical support; and (3) outcomes: nurse-perceived impacts on safety, quality, nurse satisfaction, and efficiency. Alongside improvements to EHR functionality, findings underscore the need for organizationally informed training and careful alignment between the new EHR and the organization's nursing practices-all of which have been undertaken by Department of Veterans Affairs nurses informed by this and other studies., (Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.)

Patients undergoing dialysis are at risk of osteoporosis and sarcopenia because of mineral and bone disorders or malnutrition. Additionally, maintaining muscle mass is important to prevent osteoporosis. The psoas muscle mass index (PMI) was recently used to evaluate muscle mass. However, few studies have evaluated the association between the PMI and bone mineral density (BMD); therefore, we examined the association between PMI and BMD in the femoral neck (FN) of 80 patients (45 males, age, 71 (60-76) years; dialysis duration, 74 (36-140) months) undergoing hemodialysis. FN-BMD was measured using dual-energy X-ray absorptiometry, and PMI was evaluated using psoas muscle areas on computed tomography. FN-BMD and PMI were significantly higher in males than in females. In a correlation analysis, sex, BMI, serum creatinine levels, HbA1c levels, and PMI were positively correlated with FN-BMD, whereas age, history of bone fracture, difficulty in walking and bone-specific alkaline phosphatase level were negatively correlated. In the multivariate regression analysis using clinical factors significantly correlated to FN-BMD, including PMI, both sex (standardized coefficient: 0.249, p = 0.028) and PMI (standardized coefficient: 0.249, p = 0.038) were extracted. Multivariable linear regression analysis using PMI and traditional osteoporosis factors revealed that PMI was significantly and independently associated with FN-BMD (standardized coefficient: 0.308, p = 0.010). In conclusion, PMI was positively associated with FN-BMD. Attention should be paid to the possibility of decreased BMD with decreased muscle mass., Competing Interests: Declarations. Competing interests: The authors declare no competing interests. Ethics declaration: Studies involving human participants were reviewed and approved by the Institutional Review Board of Minami-Uonuma City Hospital (R3-3). Due to the retrospective nature of the study, the Institutional Review Board of Minami-Uonuma City Hospital waived the need to obtain informed consent., (© 2024. The Author(s).)

Background: Analysis of documented Serious Illness Conversations (SICs) in the inpatient setting can help clinicians align management to address patient and caregiver needs., Methods: We conducted a mixed methods analysis of the first instance of standardized documentation of a SIC within a structured module among hospitalized general medicine patients from 2018 to 2019. Percentage of documentations that included a description of patient or family understanding of the patient's medical condition and use of radio buttons to answer the "prognostic information shared," "hopes," and "worries" modules are reported. Using grounded theory approach, physicians analyzed free text entries to: "What is important to the patient/family?" and "Recommendations or next steps planned.", Results: Out of 5142 patients, 59 patients had a documented SIC. Patient or family understanding of the medical condition(s) was reported in 56 (95%). For "prognostic information shared," the most frequently selected radio buttons were: 49 (83%) incurable disease and 28 (48%) prognosis of weeks to months while those for "hopes" were: 52 (88%) be comfortable and 27 (46%) be at home and for "worries" were: 49 (83%) other physical suffering and 36 (61%) pain. Themes generated from entries to "What's important to patient/family?" included being with loved ones; comfort; mentally and physically present; and reliable care while those for "Recommendations" were coordinating support services; symptom management; and support and communication., Conclusions: SIC content indicated concern about pain and reliable care suggesting the complex, intensive nature of caring for seriously ill patients and the need to consider SICs earlier in the life course of patients., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Importance: Little is known about the safety of midline catheters vs peripherally inserted central catheters (PICCs) for outpatient parenteral antimicrobial therapy (OPAT)., Objective: To compare outcomes from midline catheters vs PICCs for OPAT., Design, Setting, and Participants: This retrospective cohort study included patients who received antimicrobial therapy through a midline catheter or PICC between January 2017 and November 2023 across 69 Michigan hospitals. Because peripherally compatible OPAT was the indication of interest, vancomycin therapy was excluded. Data were analyzed from April to June 2024., Exposures: Insertion of a midline catheter or PICC for OPAT following hospitalization., Main Outcomes and Measures: The primary outcome was major device complications (ie, catheter-related bloodstream infection or catheter-related venous thromboembolism). Secondary outcomes included minor device complications (eg, catheter dislodgement, occlusion, tip migration, infiltration, superficial thrombophlebitis, or exit site concerns) and device failure, defined as catheter removal following device complication. Cox proportional hazards regression models were fit to device type and outcomes, adjusting for patient and device confounders and device dwell., Results: Of 2824 included patients, 1487 (53.5%) were male, and the median (IQR) age was 66.8 (55.9-77.1) years. Of 2824 devices placed for OPAT, 1999 (70.8%) were midline catheters and 825 (29.2%) were PICCs. The median (IQR) dwell time was 12 (8-17) days for midline catheters and 19 (12-27) days for PICCs (P < .001). A major device complication occurred in 44 patients (1.6%) overall, including 16 (0.8%) with midline catheters and 28 (3.4%) with PICCs (P < .001). OPAT delivered via midline catheters was associated with a lower risk of major complications vs PICCs (adjusted hazard ratio [aHR], 0.46; 95% CI, 0.23-0.91). Risks of minor complications and device failure were similar across device types (minor complications: 206 of 1999 [10.3%] vs 114 of 825 [13.8%]; aHR, 1.07; 95% CI, 0.83-1.38; device failure: 191 of 1999 [9.6%] vs 100 of 825 [12.1%]; aHR, 1.26; 95% CI, 0.96-1.65). For device dwell of 14 or fewer days, midline catheters were associated with a lower risk of major complications (12 of 1324 [0.9%] vs 16 of 304 [5.3%]; aHR, 0.29; 95% CI, 0.12-0.68) and similar risk of failure (151 of 1324 [11.4%] vs 52 of 304 [17.1%]; aHR, 0.79; 95% CI, 0.56-1.12) vs PICCs. For dwell longer than 14 days, no significant difference in rates of major complications (4 of 675 [0.6%] vs 12 of 521 [2.3%]; aHR, 0.42; 95% CI, 0.13-1.40) or device failure (40 of 675 [5.9%] vs 48 of 521 [9.2%]; aHR, 1.02; 95% CI, 0.64-1.61) were observed., Conclusions and Relevance: In this study, midline catheters appeared to be safe alternatives to PICCs for OPAT, particularly if infusions were planned for 14 or fewer days.

Introduction: Little is known about how patients make decisions about and prioritize therapies and disease management in eosinophilic esophagitis (EoE). We aimed to systematically identify and characterize patient perspectives and attitudes that influence decision making for EoE management., Methods: To understand the diverse attitudes and values of patients with EoE, we designed a study using the Q-method. We iteratively developed 31 statements related to EoE disease management. Participants sorted statements by ranking from +4 (most agree) to -4 (most disagree). By-person factor analysis, using 2-factor and 3-factor rotation, revealed distinct preference archetypes., Results: Thirty-four adults with EoE (mean age 40.9 years, 51.4% male, 82.9% White) were recruited from gastroenterology and allergy clinics from a single center. We identified 2 treatment-centered archetypes: Medication preference, driven by symptoms and the desire to minimize risk of complications and Natural treatment preference , focusing on identifying trigger foods and diet adherence. Three-factor analysis revealed an additional archetype: Treatment ambivalent, a view of EoE as a mild and episodic (not chronic) disease with low priority to treat. Comparison by factor revealed 54% of those in the natural preference archetype were recategorized as treatment ambivalent , suggesting that they see natural treatment as a less complicated or milder strategy and may be at risk of nonadherence and reduced treatment uptake., Discussion: We identified 3 distinct treatment preference archetypes among individuals with EoE, underscoring the need for personalized treatment strategies, especially for those favoring natural approaches but masking ambivalence, and may be at risk of nonadherence or loss to follow-up., (Copyright © 2024 by The American College of Gastroenterology.)

BACKGROUND Human metapneumovirus (hMPV), classified in the Pneumoviridae family, is primarily known for causing lower respiratory tract infections in children, the elderly, and immunocompromised individuals. However, rare instances have shown that hMPV can also affect other systems, such as the cardiovascular system, leading to conditions like myocarditis. CASE REPORT We describe a 68-year-old man with a medical history of diabetes, hypertension, and liver cirrhosis who presented to the Emergency Department (ED) exhibiting symptoms of fever, cough, and dyspnea. His condition deteriorated rapidly, progressing to septic shock and requiring increased oxygen support, which led to his transfer to the medical intensive care unit (MICU). Diagnostic evaluations, including cardiac echocardiography and coronary angiography (CAG), confirmed the presence of myocarditis while excluding acute myocardial infarction. Despite aggressive interventions, including extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pump (IABP) therapy, the patient's condition worsened, and he died 3 days after admission. Polymerase chain reaction (PCR) testing of a throat swab confirmed hMPV infection, with Klebsiella pneumoniae simultaneously identified via sputum culture. The bacterial susceptibility report indicated that the bacteria were sensitive to piperacillin/tazobactam, which had been administered since the patient arrived at our ED, which suggests that the bacterial infection alone cannot fully explain the patient's condition. CONCLUSIONS Compared to previously reported cases of hMPV-related myocarditis, this case is the first to demonstrate notably adverse outcomes associated with the concurrent presence of bacterial infection. The rapid progression and poor outcome despite aggressive treatment emphasize the need for early diagnosis and management of such co-infections.

Background: Clinical inertia is common when blood pressure (BP) is high in the office. Little is known about the extent of clinical inertia after ambulatory BP monitoring (ABPM)., Methods: This was an electronic health record-based retrospective cohort study of patients with high office BP (≥140/90 mmHg) referred for ABPM at a medical center in New York City between 2016 and 2020. Diagnostic inertia was defined as clinicians not newly diagnosing or treating hypertension in patients with high ABPM (i.e., mean awake BP ≥135/85 mmHg). Therapeutic inertia was defined as clinicians not intensifying treatment for patients with established hypertension after high ABPM. Multilevel modeling was used to assess patient and clinician characteristics associated with inertia., Results: Among 329 patients without prior hypertension, 144 (44%) had high awake BP, and of these, diagnostic inertia occurred in 45 of 144 (31%). Among 239 patients taking antihypertensive medication, 141 (59%) had high awake BP, and of these, therapeutic inertia occurred in 73 of 141 (52%). In multilevel models, male gender (OR 2.81, 95%CI 1.11 - 7.08), lower awake SBP (OR 0.73 per 5 mmHg increase, 95%CI 0.53 - 1.00), and specialist vs primary care clinician type (OR 4.57, 95%CI 1.78 - 11.75) were associated with increased diagnostic inertia. Increasing age (OR 1.16 per 5-year increase, 95%CI 1.00 - 1.28) and lower awake SBP (OR 0.82 per 5 mmHg increase, 95%CI 0.66 - 0.95) were associated with increased therapeutic inertia., Conclusions: Diagnostic and therapeutic inertia were common after ABPM, particularly when awake SBP was near the threshold., (© The Author(s) 2024. Published by Oxford University Press on behalf of American Journal of Hypertension, Ltd. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Lower gastrointestinal perforation (LGP) is an acute abdominal condition associated with a high mortality rate. Timely and accurate diagnosis is crucial. Nevertheless, a diagnostic delay has been estimated to occur in approximately one-third of the cases, and the factors contributing to this delay are yet to be clearly understood. This study aimed to evaluate the diagnostic process for appropriate clinical reasoning and availability of image interpretation in cases of delayed diagnosis of LGP., Methods: A secondary data analysis of a large multicenter retrospective study was conducted. This descriptive study analyzed data from a multicenter, observational study conducted across nine hospitals in Japan from January 2015 to December 2019. Out of 439 LGP cases, we included 138 cases of delayed diagnosis, excluding patients with traumatic or iatrogenic perforations, or those secondary to mesenteric ischemia, appendicitis, or diverticulitis. Clinical history and computed tomography (CT) imaging information were collected for 138 cases. Additionally, information on the clinical course of 50 cases, which were incorrectly diagnosed as gastroenteritis, constipation, or small bowel obstruction, was also collected., Results: In 42 (30.4%) cases of delayed diagnosis of LGP, CT imaging was performed before diagnosis, indicating a missed opportunity for timely diagnosis. Moreover, 33 of the 50 patients initially diagnosed with gastroenteritis, constipation, or small bowel obstruction at the time of initial examination had atypical findings that were not consistent with the initial diagnosis. Of the 138 cases with delayed diagnosis in our study, 67 cases (48.6%) showed problems with either the interpretation of CT scans or with the process of clinical reasoning., Conclusion: Our retrospective study results indicate that approximately half of the cases with delayed diagnosis of LGP were due to problems in interpreting CT images or in clinical reasoning. This finding suggests that clinical reasoning and image interpretation by radiologists are important in improving the diagnostic process for LGP., Competing Interests: Declarations. Ethics approval and consent to participate: This study was approved by the ethical review board of Showa University Koto Toyosu Hospital (No. 20T7044) and conducted in accordance with the Declaration of Helsinki. Written informed consent was waived owing to the retrospective study design by the ethical review board of Showa University Koto Toyosu Hospital. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: There is a perception that income-based disparities are present in most countries but may differ in magnitude. However, there are few international comparisons that describe income-based disparities across countries and none that focus on hip fractures., Objective: To compare treatment patterns and outcomes of high- and low-income older adults hospitalized with hip fracture across six high-income countries., Design: Retrospective serial cross-sectional cohort study., Participants: Adults aged ≥ 66 years hospitalized with hip fracture from 2013 to 2019 in Canada, England, Israel, the Netherlands, Taiwan, and the USA using population-representative patient-level administrative data., Main Measures: Older adults in the top and bottom income quintiles within countries were compared on 30-day and 1-year mortality, treatment approaches, hospital length of stay (LOS), 30-day readmission rates, time to surgery, and discharge disposition., Key Results: Annual age- and sex-standardized incidence rates of hip fracture were higher for low- than for high-income populations in all countries except in the USA. In all countries, adjusted 1-year mortality was lower for high-income than low-income patients, with the largest difference in Israel (- 10.0 percentage points [95% confidence interval [CI], - 15.2 to - 4.8 percentage points]). Across countries, utilization of total hip arthroplasty was 0.1 (95% CI, 0.0-0.2 percentage points) to 6.9 percentage points (95% CI, 4.6-9.2 percentage points) higher among high- vs. low-income populations. With few exceptions, LOS, adjusted 30-day readmission rate, and time to surgery were shorter and lower for high-income patients., Conclusions: Income-based disparities in treatments and outcomes for older adults hospitalized for hip fractures differed in magnitude, but were present in all six high-income countries. Defying our expectations, the USA did not have consistently larger disparities than other countries suggesting that the impacts of poverty exist in vastly different healthcare systems and transcend geopolitical borders., Competing Interests: Declarations:. Conflict of Interest:: The authors declare that they do not have a conflict of interest., (© 2024. The Author(s).)

Background: Time-at-bedside plays a central role in clinical medicine. However, the amount of time Japanese clinical residents spend at patients' bedsides remains unexplored., Objective: To quantify time-at-bedside and examine its association with in-training examination scores during clinical residency in Japan., Design: Nationwide multicenter cross-sectional study., Participants: First- and second-year postgraduate residents who took the General Medicine In-Training Examination at the end of the 2022 academic year., Interventions: Time-at-bedside was defined as the average time per day the residents spend providing care at patients' bedsides during their residency. Time-at-bedside was classified into six categories: C1 (10-20 min per day), C2 (30-50 min per day), C3 (60-80 min per day), C4 (90-110 min per day), C5 (120-140 min per day), and C6 (150 min or more per day). Data on time-at-bedside were collected through an electronic survey conducted immediately after the General Medicine In-Training Examination., Main Measures: The primary outcome was the General Medicine In-Training Examination score. A multi-level analysis examined the association between self-reported time-at-bedside and the General Medicine In-Training Examination score., Key Results: A total of 5344 residents were included in this study. Of these, 2760 were first-year residents, and 2584 were second-year residents. Of the 5334 residents, 66.9% reported spending less than 60 min at a patient's bedside. Compared to the C1, C2 (adjusted score difference [aSD] = 1.1, 95% confidence interval [95% CI] 0.48 to 1.79), C3 (aSD = 1.5, 95% CI 0.75 to 2.20), and C5 (aSD = 2.0, 95 CI 0.62 to 3.38) were positively associated with the General Medicine In-Training Examination score. However, C4 (aSD = 1.1, 95% CI - 0.15 to 2.26) and C6 (aSD = 0, 95% CI - 1.79 to 1.87) were not associated with the General Medicine In-Training Examination score., Conclusion: Self-reported time-at-bedside positively correlates with in-training examination scores among Japanese resident physicians., Competing Interests: Declarations:. Disclosures:: Dr. Nishizaki received an honorarium from JAMEP as a GM-ITE project manager. Dr. Tokuda is the director of JAMEP and received an honorarium as a speaker for the JAMEP lecture. Dr. Shimizu and Dr. Yamamoto received an honorarium from JAMEP as test authors for the GM-ITE. Ethical Approval:: The study and its protocol were approved by the Ethics Review Board of the Japan Organization of Advancing Medical Education Program (JAMEP) (22–9). Patient Consent Statement:: All the participants provided informed consent to participate in this study before the survey. The research consent document stated that the questionnaire results would be anonymized. Conflict of Interest: The authors declare that they do not have a conflict of interest for this article., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: Traumatic brain injury (TBI) is common in people with substance use disorders (SUDs). TBI often results in cognitive deficits which can affect the clinical course of SUD., Case Presentation: Here we present the case of a 34-year-old Spanish-speaking man with severe opioid use disorder and two prior TBIs affecting his cognitive abilities. He was linked to outpatient addiction specialty care at a community health center. After identification of his TBI history, his care team, which included a language-concordant physician and peer recovery coach, worked to develop a treatment plan that accounted for his unique cognitive deficits and behavioral challenges. He was also connected with community resources including a rehabilitation program designed for people with TBI. These individualized aspects of treatment helped to better engage and retain the patient in quality care for his SUD., Conclusions: By identifying TBI history in people with SUDs, the treatment plan can be tailored to accommodate TBI-related deficits. An effective care plan should incorporate not only medical providers, but also resources such as peer recovery supports and TBI-focused rehabilitation programs when and where they are available, with an emphasis on improving functional capacity., Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: Patient provided witnessed and signed consent form for publication of this case report. Institutional (Boston Medical Center) consent form used for this purpose. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: The spleen is a key organ in preventing pneumococcal infection, especially in patients with immunocompromised condition such as those with cancer. Previous studies have shown that a small spleen volume in pneumococcal pneumonia patients is associated with severe disease course. However, it is unknown whether a small spleen increases risk of pneumococcal infection. We investigated the association between spleen volume and risk of pneumococcal infection., Methods: This study was a retrospective cohort study using a nested case-control design and involved adult patients with malignancy who underwent chest and/or abdominal CT scans from January 1, 2008, to September 30, 2020, at a tertiary care center in Japan. Exclusion criteria comprised patients diagnosed with hepatic cirrhosis, leukemia, lymphoma, and/or post-splenectomy. From the cohort group that met all selection criteria (n = 22475), we identified all incident cases of pneumococcal infection (pneumococcal pneumonia and/or invasive pneumococcal diseases) and matched them with four controls by age, sex, and follow-up duration. Odds ratios (ORs) for the association between spleen volume and pneumococcal infection were estimated using conditional logistic regression models adjusted for body surface area, performance status, Charlson comorbidity index, and metastatic cancer., Results: The median spleen volume was 85.8 (interquartile range, 65.8-120.8) cm 3 . Over a median follow-up of 4.95 (interquartile range, 1.54-9.25) years, 60 patients were diagnosed with pneumococcal infection (20 with invasive pneumococcal disease and 40 with pneumonia without invasive pneumococcal disease) and matched with 240 controls. Spleen volume reduction (per 10 cm 3 ) did not increase risk of pneumococcal infection in a crude analysis [OR 1.04 (95% CI 0.98-1.11)]. The outcome remained unchanged in the multivariable analysis (OR 1.01 [95% CI 0.95-1.08])., Conclusions: Small spleen volume did not increase risk of pneumococcal infection in cancer patients., Competing Interests: Declarations. Ethical approval and participation consent: The current study was approved by the ethics committee of the Jichi Medical University Saitama Medical Center (Approval Number: Clinical S20-176). In accordance with Japanese ethical guidelines for medical and health research involving human subjects, the need for written informed consent was waived by the ethics committee of the Jichi Medical University Saitama Medical Center due to retrospective nature of the study. The study was conducted using a non-participation method based on our hospital’s website. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Competing Interests: Disclosures: Disclosure forms are available with the article online.

Background: Studying the association between blood pressure (BP) trajectories during young adulthood and subsequent cardiovascular disease (CVD) risk can provide insights into how long-term BP patterns in early-life influence the development of CVD later in life., Methods: We pooled data from 2 US cohorts (Coronary Artery Risk Development in Young Adults, Framingham Heart Study). We used latent growth curve models to identify distinct BP trajectory groups between ages 18 and 39 years. We then used Cox proportional hazards models to assess the associations between BP trajectories and CVD events (composite of coronary heart disease [CHD], stroke, and heart failure [HF]) after age 40 years., Results: We included 6,579 participants and identified 4 distinct systolic BP (SBP) trajectory groups during young adulthood. During a median follow-up of 18.2 years after age 40 years, 213 CHD, 139 stroke, 120 HF, and 400 composite CVD events occurred. Individuals in an elevated-increasing vs. low-stable SBP trajectory during young adulthood were associated with a higher risk of CVD after adjusting for traditional CVD risk factors, with hazard ratios (95% confidence interval) of 3.25 (1.63, 6.46) for CHD, 3.92 (1.63, 9.43) for stroke, 8.30 (2.97, 23.17) for HF, and 3.91 (2.38, 6.41) for composite CVD outcomes. Adding BP trajectory to BP at baseline improved model discrimination for all outcomes (changes in Harrell's C-index 0.0084-0.0192)., Conclusions: An elevated-increasing BP trajectory during young adulthood is associated with a higher risk of CVD later in life, highlighting the importance of maintaining a low-stable BP trajectory throughout the young adulthood period for prevention of CVD in later life., (© The Author(s) 2024. Published by Oxford University Press on behalf of American Journal of Hypertension, Ltd. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Rationale: Dysanapsis refers to a mismatch between airway tree caliber and lung size arising early in life. Dysanapsis assessed by computed tomography (CT) is evident by early adulthood and associated with chronic obstructive pulmonary disease (COPD) risk later in life. Objectives: By examining the genetic factors associated with CT-assessed dysanapsis, we aimed to elucidate its molecular underpinnings and physiological significance across the lifespan. Methods: We performed a genome-wide association study of CT-assessed dysanapsis in 11,951 adults, including individuals from two population-based and two COPD-enriched studies. We applied colocalization analysis to integrate genome-wide association study and gene expression data from whole blood and lung. Genetic variants associated with dysanapsis were combined into a genetic risk score that was applied to examine association with lung function in children from a population-based birth cohort ( n  = 1,278) and adults from the UKBiobank ( n  = 369,157). Measurements and Main Results: CT-assessed dysanapsis was associated with genetic variants from 21 independent signals in 19 gene regions, implicating HHIP (hedgehog interacting protein), DSP , and NPNT as potential molecular targets based on colocalization of their expression. A higher dysanapsis genetic risk score was associated with obstructive spirometry among 5-year-old children and among adults in the fifth, sixth, and seventh decades of life. Conclusions: CT-assessed dysanapsis is associated with variation in genes previously implicated in lung development, and dysanapsis genetic risk is associated with obstructive lung function from early life through older adulthood. Dysanapsis may represent an endophenotype link between the genetic variations associated with lung function and COPD.

Abstract: Pretransplant detection of KMT2Ar measurable residual disease ≥0.001% by quantitative polymerase chain reaction was associated with significantly inferior posttransplant survival (2-year relapse-free survival 17% vs 59%; P = .001) and increased 2-year cumulative incidence of relapse (75% vs 25%, P = .0004)., (© 2024 American Society of Hematology. Published by Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.)

Background&aims: Non-invasive tests (NITs) for ruling-out clinical significant portal hypertension (CSPH) and high-risk varices (HRV) in patients with primary biliary cholangitis(PBC) and compensated advanced chronic liver disease (cACLD) are lacking. We evaluated NITs in these patients and the influence of cholestasis on their performance., Methods: Consecutive patients from the "Italian PBC registry" and two UK large-volume PBC referral centres with upper endoscopy within 6 months from biochemical evaluation and transient elastography were included. RESIST, Baveno-VI (BVI) and Expanded Baveno-VI (EBVI) criteria for ruling-out HRV were assessed according to alkaline phosphatase levels (ALP)(1.5 ULN). Decision curve analysis (DCA) was performed. Prevalence of any-sized esophageal varices among patients fitting Baveno VII (BVII) criteria was also calculated., Results: The final cohort consisted of 293 patients with cACLD. RESIST criteria were associated with the lowest rate of missed HRV (2.5% vs 9.8% for BVI and 8.9% for EBVI). In patients with ALP levels>1.5 times ULN, BVI and EBVI missed a higher rate of HRV (15.5% and 14.5%, respectively) than RESIST (3.1%). DCA demonstrated the highest net benefit of RESIST criteria for ruling out HRV, regardless ALP levels. Among 75 patients classified as low risk of CSPH according to BVII, 14 (18.7%) showed esophageal varices., Conclusions: Biochemical-based RESIST criteria demonstrate the highest net benefit compared to elastography-based criteria for ruling out HRV. The severity of cholestasis affects NITs performance to rule out HRV and CSPH in patients with PBC and cACLD., (Copyright © 2024. Published by Elsevier Inc.)

Background: Although the pathogenesis of delirium is poorly understood, increasing evidence supports a role for inflammation. Previously, individual inflammatory biomarkers have been associated with delirium. Aggregating biomarkers into an index may provide more information than individual biomarkers in predicting certain health outcomes (eg, mortality); however, inflammatory indices have not yet been examined in delirium., Methods: Four inflammatory markers, C-reactive protein, interleukin-6, soluble tumor necrosis factor alpha receptor-1, and chitinase-3 like protein-1, were measured preoperatively and on postoperative day 2 in 548 adults aged 70+ undergoing major noncardiac surgery (mean age 76.7 [standard deviation 5.2], 58% female, 24% delirium). From these markers, 4 inflammatory indices were considered: (i) quartile summary score, (ii) weighted summary score, (iii) principal component score, and (iv) a well-established inflammatory (least absolute shrinkage and selection operator-derived) index associated with mortality. Delirium was assessed using the Confusion Assessment Method, supplemented by chart review. Generalized linear models with a log-link term were used to determine the association between each inflammatory index and delirium incidence., Results: Among the inflammatory indices, the weighted summary score demonstrated the strongest association with delirium: participants in the weighted summary score quartile (Q)4 had a higher risk of delirium versus participants in Q1, after clinical variable adjustment (relative risk, 95% confidence interval for preoperatively: 3.07, 1.80-5.22; and postoperative day 2: 2.65, 1.63-4.30). The weighted summary score was more strongly associated with delirium than the strongest associated individual inflammatory marker (preoperatively chitinase-3 like protein-1 [relative risk 2.45, 95% confidence interval 1.53-3.92]; postoperative day 2 interleukin-6 [relative risk 2.39, 95% confidence interval 1.50-3.82])., Conclusions: A multi-protein inflammatory index using a weighted summary score provides a slight advantage over individual inflammatory markers in their association with delirium., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Gerontological Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Hospitalizations related to alcohol use disorder (AUD) are common. Yet, few patients receive pharmacotherapy consistent with guideline recommendations. Previous concerns over the potential hepatotoxicity of naltrexone have been disproven and recent studies have shown its safety and efficacy in patients with cirrhosis. Naltrexone is an effective therapy to reduce heavy alcohol consumption, however, lack of knowledge among prescribers inhibits greater uptake. Hospitalization is an opportune time for change-naltrexone can promote the reduction or cessation of unhealthy alcohol consumption, as well as subsequent readmissions or progression of alcohol-related liver disease. Hospitalists should stop avoiding naltrexone in the treatment of AUD., (© 2024 Society of Hospital Medicine.)

Standardized examinations measure progress throughout medical education. Successful completion of the American Board of Internal Medicine Certification Examination (ABIM-CE) benchmarks completion of internal medicine (IM) residency training. Recent declines in initial ABIM-CE pass rates may prompt residency programs to examine strategies to improve learner performance. We synthesized published literature on associations between the United States Medical Licensing Examination (USMLE), in-training examination (ITE), and board preparation to support residents for ABIM-CE. We searched MEDLINE for test performance and preparation strategies for IM board certification during training. Relevant articles published until March 15, 2024, were screened using pre-defined criteria for narrative review, then codified into three domains (USMLE, ITE, curriculum/program strategies). Findings were grouped by theme into considerations for training programs seeking guidance on learning augmentation plans to improve resident performance on ABIM-CE. Themes drawn from articles focused on USMLE include validity in predicting CE performance, noting (1) failing USMLE Step 1 is associated with failing ABIM-CE, (2) any USMLE score < 220 increases failure probability, and (3) a mean USMLE ≥ 250 approximates ~ 100% pass rates on board examination. Inferences from ITE-focused articles support use as a predictive tool; specifically, a score < 35th percentile signals a resident at risk for failing the ABIM-CE while > 70th percentile is predictive of passing. Lastly, inferences from curriculum- and program-focused articles suggest standard contents (conferences) do not correlate with CE passage, while targeted clinical reasoning and remediation plans do. IM residency programs should consider adopting learning augmentation strategies targeted to at-risk residents to support CE passage., Competing Interests: Declarations:. Conflict of Interest:: The authors declare that they do not have a conflict of interest., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Introduction: As health systems strive to screen for and address social determinants of health (SDOH), the role of access to childcare and barriers to healthcare posed by childcare needs remains underexplored. A gap exists in synthesizing existing evidence on the role of access to childcare as a SDOH., Methods: This scoping review aimed to examine and analyze existing literature on the role of childcare needs as a social determinant of access to healthcare. We conducted a structured literature search across PubMed, Scopus, health policy fora, and professional healthcare societies to inclusively aggregate studies across interdisciplinary sources published between January 2000 and June 2023. Two independent reviewers reviewed results to determine inclusions and exclusions. Studies were coded into salient themes utilizing an iterative inductive approach., Results: Among 535 search results, 526 met criteria for eligibility screening. Among 526 eligible studies, 91 studies met inclusion criteria for analysis. Five key themes were identified through data analysis: (1) barriers posed by childcare needs to healthcare appointments, (2) the opportunity for alternative care delivery models to overcome childcare barriers, (3) the effect of childcare needs on participation in medical research, (4) the impact of the COVID-19 pandemic on childcare needs, and (5) the disproportionate burden of childcare experienced by vulnerable populations., Discussion: Childcare needs remain underexplored in existing research. Current evidence demonstrates the relevance of childcare needs as a barrier to healthcare access, however dedicated studies are lacking. Future research is needed to understand mechanisms of childcare barriers in access to healthcare and explore potential interventions., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 McArthur, Tian, Kho, Bhavan, Balasubramanian and Ganguly.)

Background: Patients undergoing colectomy are at risk of numerous major complications. However, existing binary risk stratification models do not predict when a patient may be at highest risks of each complication. Accurate prediction of the timing of complications facilitates targeted, resource-efficient monitoring. We sought to develop and internally validate Cox proportional hazards models to predict time-to-complication of major complications within 30 days after elective colectomy., Methods: We studied a retrospective cohort from the multicentered American College of Surgeons National Surgical Quality Improvement Program procedure-targeted colectomy dataset. Patients aged 18 years or above, who underwent elective colectomy between January 1, 2014 and December 31, 2019 were included. A priori candidate predictors were selected based on variable availability, literature review, and multidisciplinary team consensus. Outcomes were mortality, hospital readmission, myocardial infarction, cerebral vascular events, pneumonia, venous thromboembolism, acute renal failure, and sepsis or septic shock within 30 days after surgery., Results: The cohort consisted of 132145 patients (mean ± SD age, 61 ± 15 years; 52% females). Complication rates ranged between 0.3% (n = 383) for cardiac arrest and acute renal failure to 5.3% (n = 6986) for bleeding requiring transfusion, with readmission rate of 8.6% (n = 11415). We observed distinct temporal patterns for each complication: the median [quartiles] postoperative day of complication diagnosis ranged from 1 [0, 2] days for bleeding requiring transfusion to 12 [6, 18] days for venous thromboembolism. Models for mortality, myocardial infarction, pneumonia, and renal failure showed good discrimination with a concordance > 0.8, while models for readmission, venous thromboembolism, and sepsis performed poorly with a concordance of 0.6 to 0.7. Models exhibited good calibration but ranges were limited to low probability areas., Conclusions: We developed and internally validated time-to-event prediction models for complications after elective colectomy. Once further validated, the models can facilitate tailored monitoring of high risk patients during high risk periods., Trial Registration: Clinicaltrials.gov (NCT05150548; Principal Investigator: Janny Xue Chen Ke, M.D., M.Sc., F.R.C.P.C.; initial posting: November 25, 2021)., Competing Interests: We have read the journal’s policy and the authors of this manuscript have the following declarations. This does not alter our adherence to PLOS ONE policies on sharing data and materials. The funders below did not contribute to this project, and this project has no relation with the projects below. Dr. Janny Ke received salary support as the Clinical Data Lead, St. Paul’s Hospital, Vancouver, BC, Canada, for the project “Reducing Opioid Use for Pain Management” DIGITAL, Canada’s Global Innovation Cluster for digital technologies, and a project consortium from commercial funders (Careteam Technologies Inc, Thrive Health Inc, Excelar Technologies (Connected Displays Inc), Providence Health Care Ventures Inc, and Xerus Inc [now part of Excelar]). Dr. Ke provided paid consulting for commercial funder Careflow Technologies (Connected Displays Inc), funded via Providence Health Care Ventures (Vancouver, BC, Canada). Dr. Ke receives research and salary support for Project "Continuous Connected Patient Care", funded by DIGITAL and a project consortium of commercial funders (Medtronic Canada ULC, Cloud Diagnostics Canada ULC, Excelar Technologies [Connected Displays Inc.], Providence Health Care Ventures Inc, 3D Bridge Solutions Inc, and FluidAI [NERv Technology Inc.]). Dr. Stephan K. W. Schwarz is the Editor-in-Chief of the Canadian Journal of Anesthesia and holds the Dr. Jean Templeton Hugill Chair in Anesthesia, supported by the Dr. Jean Templeton Hugill Endowment for Anesthesia Memorial Fund at The University of British Columbia (Vancouver, BC, Canada). He gratefully receives academic support from the Department of Anesthesia, St. Paul’s Hospital/Providence Health Care (Vancouver, BC, Canada). Dr. Matthias Görges holds a Michael Smith Health Research BC scholar award, is supported by a 2020 BC Children’s Hospital Research Institute External Salary Recognition Award, and was the research lead for the “Reducing Opioid Use for Pain Management” DIGITAL project consortium (see above for commercial funders). Dr. Alana Flexman declares consultant fees from Wolter Kluwer (Up To Date), research salary support from Michael Smith Health Research BC and operational research support from commercial funder Eisai, Inc. There is no other employment, consultancy, patents, products in development, or marketed products from commercial entities., (Copyright: © 2024 Ke et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The administration of the COVID-19 vaccine has been linked to the development of herpes zoster (HZ). However, studies examining the clinical outcomes in COVID-19 vaccination-associated and non-COVID-19 vaccination-associated HZ are lacking., Objective: To investigate the risk of postherpetic neuralgia (PHN) in COVID-19 vaccination associated HZ., Methods: A total of 7200 patients with COVID-19 vaccination-associated HZ and 7200 matched controls were enrolled from the US Collaborative Network in the TriNetX database. The main outcome of this study was the development of PHN. Patients were followed-up from 3 months after HZ until PHN diagnoses, withdrawal from the database, or October 8, 2024., Results: We observed that patients with COVID-19 vaccination-associated HZ had a significantly higher risk of developing PHN as compared to the control group, with hazard ratio of 1.69 (> 3 months), 1.80 (> 6 months), 1.86 (> 1 year), and 1.93 (>2 years), respectively. Additionally, the association remained significant in the stratified analysis, which included sex, age, malignancy status, and initial use of antiviral agents., Conclusion: This study showed that COVID-19 vaccination-associated HZ demonstrated a significantly higher risk of developing PHN., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Chen-Yi Wu has made payments to Ministry of Science and Technology, Taiwan and Taipei Veterans General Hospital., (Copyright © 2024. Published by Elsevier Ltd.)

Background: It remains unclear whether residential segregation impacts on clinical treatment and outcomes for ductal carcinoma in situ (DCIS), a nonobligate precursor to invasive breast cancer (IBC)., Methods: This population-based retrospective cohort study included adult non-Hispanic White and Black women diagnosed with unilateral DCIS between January 1990 and December 2015, followed through December 2016, and identified from the Surveillance, Epidemiology, and End Results dataset. County-level racialized economic segregation was measured using the Index of Concentration at the Extremes. Multilevel logistic regression and Cox proportional hazards regression accounting for county-level clustering were used to estimate the ORs of local treatment and HRs of subsequent IBC and mortality., Results: Of 103,898 cases, mean age was 59.5 years, 12.5% were non-Hispanic Black, 87.5% were non-Hispanic White, 97.5% underwent surgery, 64.5% received radiotherapy following breast-conserving surgery (BCS), 7.1% developed IBC, and 18.6% died from all causes. Among women living in the least versus most privileged counties, we observed higher odds of receiving mastectomy [vs. BCS; OR = 1.51; 95% confidence interval (CI), 1.35-1.69; Ptrend < 0.001] and radiotherapy following BCS(OR = 1.27; 95% CI, 1.07-1.51; Ptrend < 0.01); the risk was higher in subsequent ipsilateral IBC (HR = 1.16; 95% CI, 1.02-1.32; Ptrend = 0.04), not in breast cancer-specific mortality (HR = 1.04; 95% CI, 0.88-1.23; Ptrend = 0.56)., Conclusions: The results provide evidence for disparities in clinical treatment for DCIS and prognostic outcomes among women in racially and economically segregated counties., Impact: Our findings may inform geographically targeted multilevel interventions to reduce breast cancer burden and improve breast cancer care and equity., (©2024 American Association for Cancer Research.)

Importance: Metals are established neurotoxicants, but evidence of their association with cognitive performance at low chronic exposure levels is limited., Objective: To investigate the association of urinary metal levels, individually and as a mixture, with cognitive tests and dementia diagnosis, including effect modification by apolipoprotein ε4 allele (APOE4)., Design, Setting, and Participants: The multicenter prospective cohort Multi-Ethnic Study of Atherosclerosis (MESA) was started from July 2000 to August 2002, with follow-up through 2018. A total of 6303 MESA participants were included. Data analysis was performed from October 12, 2023, to June 13, 2024., Exposure: Urine samples were collected at baseline (2000-2002), and arsenic, cadmium, cobalt, copper, lead, manganese, tungsten, uranium, and zinc levels were measured in 2020-2022., Main Outcomes and Measures: Digit Symbol Coding (DSC) (n = 3819) (possible score range, 0-133), Cognitive Abilities Screening Instrument (CASI) (n = 3918) (possible score range, 0-100), and Digit Span (DS) (n = 4176) (possible score range, 0-30) cognitive tests were administered in 2010-2012; higher scores of each test indicate increasing levels of positive response., Results: A total of 6303 participants were followed up for dementia diagnosis through 2018. The median age at baseline was 60 (IQR, 53-70) years, and 3303 participants (52.4%) were female. The median cognitive scores were 51 (IQR, 38-64) for DSC, 90 (IQR, 84-95) for CASI, and 15 (IQR, 12-18) for DS. There were 559 cases of dementia through the follow-up period. Inverse associations with DSC were identified: mean differences in z scores per IQR increase in metal levels were -0.03 (95% CI, -0.07 to 0.00) for arsenic, -0.05 (95% CI, -0.09 to -0.004) for cobalt, -0.05 (95% CI, -0.07 to -0.02) for copper, -0.04 (95% CI, -0.08 to -0.001) for uranium, and -0.03 (95% CI, -0.06 to -0.01) for zinc. Among 1058 APOE4 carriers, manganese was also inversely associated with DSC. The joint mean difference of DSC comparing percentile 95th with the 25th of the 9-metal mixture was -0.30 (95% CI, -0.47 to -0.14) for APOE4 carriers and -0.10 (95% CI, -0.19 to -0.01) for noncarriers. Arsenic, cadmium, cobalt, copper, tungsten, uranium, and zinc were individually associated with dementia, with hazard ratios per IQR of metal ranging from 1.15 (95% CI, 1.03-1.29) for tungsten to 1.46 (95% CI, 1.06-2.02) for uranium. The joint hazard ratio of dementia comparing percentiles 95th with the 25th of the 9-metal mixture was 1.71 (95% CI, 1.24-3.89), with no significant difference by APOE4 status., Conclusions and Relevance: In this study, participants with higher concentrations of metals in their urine, compared with those with lower concentrations, had worse performance on cognitive tests and greater likelihood of developing dementia. The findings of this multicenter multiethnic cohort study might inform screening and potential interventions for prevention of dementia based on individuals' metal exposure levels and genetic profiles.

Background: Germany is challenged by an increasing shortage in general practice services, especially in non-urban areas. Task shifting from general practitioners (GPs) to other health professionals may improve practice efficiency to address this mismatch., Objectives: Exploring GPs' motives and beliefs towards task shifting in non-urban Germany and identifying potential factors influencing these., Methods: The cross-sectional survey was disseminated by mail in three waves between July 2021 and August 2022 among all GPs in non-urban Baden-Wuerttemberg, Germany. It included items on demographics and practice characteristics as well as 15 Likert-scale items addressing motives and beliefs towards task shifting, based on the Theoretical Domain Framework. Likert-scale items were analysed descriptively, influencing factors on motives and beliefs were identified using multiple linear regression., Results: Response rate was 24.2% (281/1162), with respondents comparable in age and gender to all GPs in Baden-Wuerttemberg. GPs' motives and beliefs towards task shifting are positive overall. The majority expects task shifting to reduce their workload (87.9%) and increase practice efficiency (74.7%). They are open to shift additional tasks to other professionals (69.1%), even in the currently prohibited form of substitution (51.2%). Motives and beliefs were significantly more positive among younger GPs and those participating in the GP-centred care programme., Conclusion: This study describes GPs' motives and beliefs towards task shifting in non-urban Germany. Identifying younger GPs and those participating in the GP-centred care programme as particularly endorsing may help design future interventions aiming to improve efficiency in general practice in non-urban Germany.

Background: Chronic, mildly insufficient sleep is associated with increased cardiometabolic risk, but whether the regulation of thyroid hormones and related growth factors are mechanisms of this association is unclear. We investigated whether 6 wk of mild sleep restriction (SR) alters levels of free thyroxine (FT4), thyroid stimulating hormone (TSH), and fibroblast growth factor-21 (FGF-21), a modulator of FT4, in adults with adequate habitual sleep (AS; 7-9 h/night)., Methods: Healthy adults participated in one of two randomized, crossover studies with identical 6-wk intervention phases: AS and SR (1.5 h/night < AS). Fasted blood samples were collected at baseline and endpoint of each phase. Outcomes were concentrations of FT4, TSH, and FGF-21 (women only). Linear mixed models tested the effects of SR vs AS on the outcomes, adjusting for baseline levels, week, sex, and sex-by-condition interaction., Results: Thirty participants (20 women; 73% racial/ethnic minority; age 21-64 y [M±SD = 36.2 ± 12.8 y]) were included. In the full sample, no effects of SR on FT4 (β±SE = 0.02 ± 0.04, p = 0.654) or TSH (β±SE = -0.02 ± 0.04, p = 0.650) were observed; however, there were sex-by-condition interactions for both FT4 (p-interaction = 0.056) and TSH (p-interaction = 0.049). In sex-stratified analyses, TSH was reduced in SR vs. AS in women (β±SE = -0.11 ± 0.04, p = 0.011, Cohen's f 2  = 0.55) but not men (β±SE = 0.09 ± 0.08, p = 0.261). Among women (n = 17), FGF-21 was not significantly different between conditions (β±SE = 8.51 ± 17.70, p = 0.638)., Conclusion: Prolonged mild SR reduces TSH in women, whereas FT4 and FGF-21 remain unaffected compared with AS. If sustained, disruptions to the thyrotropic axis in women may contribute to their more pronounced cardiometabolic risk in response to SR compared with men., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Catheter-associated urinary tract infections (CAUTIs) are common and costly hospital-acquired infections, yet they are largely preventable. The greatest modifiable risk factor for developing a CAUTI is duration of catheterization, including initial indwelling catheter placement when it may not otherwise be necessary. Alternatives to indwelling urinary catheters, including intermittent straight catheterization and the use of external catheters, should be considered in applicable patients. If an indwelling urinary catheter is required, aseptic insertion technique and maintenance should be performed. Through the use of collaborative, multidisciplinary intervention efforts, CAUTI rates can be successfully reduced., Competing Interests: Disclosures Dr Meddings has reported receiving honoraria from hospitals and professional societies devoted to complication prevention for lectures and teaching related to prevention and value-based purchasing policies involving catheter-associated urinary tract infection and hospital-acquired pressure ulcers. Dr Meddings also serves as an Associated Editor for the Annals of Internal Medicine: Clinical Cases journal., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Delirium and dementia are common causes of cognitive impairment in older adults. They are distinct but interrelated. Delirium, an acute confusional state, has been linked to the chronic and progressive loss of cognitive ability seen in dementia. Individuals with dementia are at higher risk for delirium, and delirium itself is a risk factor for incident dementia. Additionally, delirium in individuals with dementia can hasten underlying cognitive decline. In this review, we summarize recent literature linking these conditions, including epidemiological, clinicopathological, neuroimaging, biomarker, and experimental evidence supporting the intersection between these conditions. Strategies for evaluation and diagnosis that focus on distinguishing delirium from dementia in clinical settings and recommendations for delirium prevention interventions for patients with dementia are presented. We also discuss studies that provide evidence that delirium may be a modifiable risk factor for dementia and consider the impact of delirium prevention interventions on long-term outcomes., Competing Interests: None declared., (Thieme. All rights reserved.)

Shared decision making (SDM) between health care professionals and patients is essential to help patients make well informed choices about lung cancer screening (LCS). Patients who participate in SDM have greater LCS knowledge, reduced decisional conflict, and improved adherence to annual screening compared with patients who do not participate in SDM. SDM tools are acceptable to patients and clinicians. The importance of SDM in LCS is emphasized in recommendations from professional organizations and highlighted as a priority in the 2022 President's Cancer Panel Report. The updated 2022 national coverage determination from the Centers for Medicare & Medicaid Services reaffirms the value of SDM in offering LCS to eligible beneficiaries. The Shared Decision-Making Task Group of the American Cancer Society National Lung Cancer Roundtable undertook a group consensus process to identify priorities for research and implementation related to SDM for LCS and then evaluated current knowledge in these areas. Priority areas included: (1) developing feasible, adaptable SDM training programs for health care professionals; (2) understanding the impact of alternative health system LCS models on SDM practice and outcomes; (3) developing and evaluating new patient decision aids for use with diverse populations and in varied settings; (4) offering conceptual clarity about what constitutes a high-quality decision and developing appropriate quality measures; and (5) studying the use of prediction-augmented screening to support SDM in practice. Gaps in current research in all areas were observed. The authors conclude with a research and implementation agenda to advance the quality and implementation of SDM for persons who might benefit from LCS., (© 2024 American Cancer Society. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Metabolic-associated fatty liver disease (MAFLD) induced-severe hepatic steatosis poses significant health risks. Early prediction of this condition is crucial for prompt intervention. Short-chain fatty acids (SCFAs) and tryptophan are gut metabolites correlated with MAFLD pathogenesis in the gut-liver axis. This study aims to construct prediction models for severe hepatic steatosis by including SCFAs and tryptophan metabolites. This study enrolled 83 participants from the outpatient department in 2023. Physical measurements, serum metabolic and inflammatory markers, metabolites of serum SCFAs and tryptophan were collected. Severe hepatic steatosis was diagnosed using vibration-controlled transient elastography and abdominal sonography. All 40 (48.2%) participants diagnosed with severe hepatic steatosis had MAFLD, while approximately three-quarters of those without severe hepatic steatosis had MAFLD. In comparison to the non-severe hepatic steatosis group, individuals with severe hepatic steatosis exhibited higher levels of waist and arm circumference, serum triglyceride (TG), and lower levels of serum high-density lipoprotein cholesterol (HDL-C) and AST/ALT ratio. They also had higher serum levels of lipopolysaccharide-binding protein, isovaleric acid, and propionic acid, and lower levels of 3-methylvaleric acid, indole-3-propionic acid, and indoxyl sulfate. Models incorporating these markers predicted severe hepatic steatosis. One model additionally included waist circumference and triglyceride-glucose index, while the other incorporated arm circumference and TG/HDL-C ratio. The area under the curve reached 0.958 and 0.938, respectively (p < 0.001). SCFAs and tryptophan metabolites are valuable in predicting severe hepatic steatosis. Further research is needed to investigate the roles of these metabolites in MAFLD., (© 2024 The Author(s). The Kaohsiung Journal of Medical Sciences published by John Wiley & Sons Australia, Ltd on behalf of Kaohsiung Medical University.)

Competing Interests: Conflict of interest The Authors have no conflict of interest to declare.

Background/objectives: Chronic pain is an opioid use disorder (OUD) treatment barrier and associated with poor outcomes in OUD treatment including relapse. Fibromyalgia is a chronic pain condition related to central nervous system substrates that overlap with the brain disease model of OUD. We know of no studies that have looked at non-treatment seeking individuals, to see if fibromyalgia might represent a barrier to OUD treatment. Given many non-treatment-seeking individuals previously attempted recovery before experiencing relapse, and chronic pain is a known precipitant of relapse, fibromyalgia might be a currently unappreciated modifiable factor in OUD relapse and, potentially, a barrier to treatment reengagement among those not currently seeking treatment. This study aimed to determine if fibromyalgia is associated with greater odds of agreeing that 'I have tried to stop using opioids before, but pain caused me to relapse' among non-treatment seeking individuals with OUD., Methods: This cross-sectional study recruited non-treatment-seeking individuals with OUD ( n  = 141) from a syringe service program. Ordinal logistic regression was used to determine if the presence of fibromyalgia increased the odds of agreement with prior pain-precipitated relapse., Results: Fibromyalgia was identified in 35% of study participants and associated with 125% greater odds of strongly agreeing that pain had previously caused them to relapse, even after accounting for relevant covariates, including age, sex, depression, anxiety, OUD severity, and pain severity., Conclusions: This study provides early evidence that the presence of fibromyalgia may be associated with increased odds of pain-precipitated OUD relapse.

Purpose: Exercise offers various clinical benefits to older breast cancer survivors. However, studies report that healthcare providers may not regularly discuss exercise with their patients. We evaluated clinical and sociodemographic determinants of receiving advice about exercise from healthcare providers among older breast cancer survivors (aged ≥65 years)., Methods: We used data from the Surveillance, Epidemiology, and End Results cancer registries linked to the Medicare Health Outcomes Survey (MHOS) from 2008 to 2015. We included female breast cancer survivors, aged ≥65 years, who completed the MHOS survey ≥2 years after a breast cancer diagnosis in a modified Poisson regression to identify clinical and sociodemographic determinants of reportedly receiving advice about exercise from healthcare providers., Results: The sample included 1,836 breast cancer survivors. The median age of the sample was 76 years (range: 72-81). Overall, 10.7% of the survivors were non-Hispanic Black, 10.1% were Hispanic, and 69.3% were non-Hispanic White. Only 52.3% reported receiving advice about exercise from a healthcare provider. Higher body mass index (BMI) and comorbid medical history that included diabetes, cardiovascular, or musculoskeletal disease were each associated with a higher likelihood of receiving exercise advice. Lower education levels, lower BMI, and never having been married were each associated with a lower likelihood of receiving exercise advice., Conclusions: Nearly half of breast cancer survivors aged ≥65 years did not report receiving exercise advice from a healthcare provider, suggesting interventions are needed to improve exercise counseling between providers and survivors, especially with women with lower educational attainment who have never been married., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Introduction: 80 % of Americans wish to die somewhere other than a hospital, and hospice is an essential resource for providing such care. The emergency department (ED) is an important location for identifying patients with end-of-life care needs and providing access to hospice. The objective of this study was to analyze a quality improvement (QI) program designed to increase the number of patients referred directly to hospice from the ED, without the need for an observation stay and without access to in-hospital hospice., Methods: We implemented a QI program in September 2021 consisting of three components: (1) clarification and streamlining of referral workflows, (2) staff/provider education on hospice and workflows, and (3) electronic medical record (EMR) tools to facilitate hospice transitions. The primary outcome was the change in monthly ED-to-hospice cases pre- and post-implementation. We also calculated the monthly incidence rate of ED-to-hospice transfers. The secondary outcome was ED length of stay (LOS)., Results: 202 patients completed ED-to-hospice transfers from January 1, 2019 to February 29, 2024. 98 patients transitioned from the ED to hospice before QI implementation, and 104 patients transitioned after implementation. We observed a slight but insignificant increase in the mean monthly ED-to-hospice cases from 3.16 patients per month pre-implementation to 3.47 patients per month post-implementation (P = 0.46). We found no significant difference in the monthly incidence rate of ED-to-hospice cases before and after implementation (P = 0.78). ED LOS was unaffected (P = 0.21)., Conclusion: In this largest study to date on direct ED-to-hospice discharges, a QI program focused on workflow optimization, education, and EMR modification was insufficient to significantly impact ED-to-hospice discharges. Future efforts to increase hospice transitions from the ED should investigate methods to improve patient identification, the impact of in-hospital hospice programs, and coordination with hospital and community teams to support home-based care for those desiring to remain there., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To prospectively examine the association between device-measured sleep regularity and incidence of type 2 diabetes (T2D) in a population-based sample of adults. We also examined if meeting sleep duration recommendations attenuated or eliminated the effects of irregular sleep on T2D., Research Design and Methods: We conducted a prospective cohort study of adults aged 40-79 years participating in the UK Biobank accelerometer substudy. Participants wore wrist-attached accelerometers for a duration of 7 days, which was used to compute the Sleep Regularity Index (SRI). Participants were categorized as irregular (SRI <71.6), moderately irregular (SRI between 71.6 and 87.3), and regular (SRI >87.3) sleepers. T2D diagnosis was obtained through self-reports and health records., Results: We analyzed data from 73,630 individuals observed for 8 years, without a history of T2D and without an event in the first year of follow-up. Compared with regular sleepers, irregular (hazard ratio [HR] 1.38; 95% CI 1.20-1.59) and moderately irregular sleepers (HR 1.35; 95% CI 1.19-1.53) were at higher risk of T2D incidence. Dose-response analyses treating SRI as a continuous measure showed higher T2D incidence with SRI scores <80. Meeting current sleep duration recommendations did not counteract the adverse effects of irregular (HR 1.35; 95% CI 1.09-1.66) or moderately irregular (HR 1.29; 95% CI 1.08-1.54) sleep on T2D incidence., Conclusions: Moderate and high sleep irregularity were deleteriously associated with T2D risk, even in participants who slept ≥7 h per night. Future sleep interventions will need to pay more attention to consistency in bedtimes and wake-up times, in addition to sleep duration and quality., (© 2024 by the American Diabetes Association.)

Objective: The objective of this study was to examine the changes in adipose tissue lipolytic capacity and insulin signaling in response to shortened sleep duration (SSD) in postmenopausal women., Methods: Adipose tissue from a randomized crossover study of nine healthy postmenopausal women (mean [SD], age: 59 [4] years; BMI: 28.0 [2.6] kg/m 2 ) exposed to four nights of habitual and SSD (60% of habitual sleep) while following a eucaloric diet was examined ex vivo. Tissue lipolytic capacity was determined by measurement of secreted glycerol. Cellular insulin signaling was determined by measuring insulin-mediated changes in Akt phosphorylation. RNA sequencing examined global transcriptional changes., Results: With SSD, basal glycerol secretion was reduced, and isoproterenol-stimulated lipolysis was attenuated. Insulin concentration-dependent increases in phosphorylated Akt observed in samples after habitual sleep were abrogated after SSD. However, insulin-mediated suppression of lipolysis remained unaltered with changes in sleep duration. Increased transcription of genes involved in adipogenesis and fatty acid metabolism was observed after SSD., Conclusions: SSD blunts adrenergic stimulation of lipolysis without altering insulin-mediated suppression of lipolysis in postmenopausal women. These changes in adipose tissue may potentiate fat gain independent of caloric intake. Therefore, interventions promoting sleep may be considered to mitigate abdominal adiposity in postmenopausal women., (© 2024 The Obesity Society.)

Purpose: Although noninvasive tests can be used to predict liver fibrosis, their accuracy is limited for patients with severe obesity and nonalcoholic fatty liver disease (NAFLD). We developed machine learning (ML) models to predict significant liver fibrosis in patients with severe obesity through noninvasive tests., Materials and Methods: This prospective study included 194 patients with severe obesity who underwent wedge liver biopsy and metabolic bariatric surgery at Taipei Medical University Hospital between September 2016 and December 2020. Significant liver fibrosis was defined as a fibrosis score ≥ 2. Patients were randomly divided into a training group (70%) and a validation group (30%). ML models, including support vector machine, random forest, k-nearest neighbor, XGBoost, and logistic regression, were trained to predict significant liver fibrosis, using DM status, AST, ALT, ultrasonographic fibrosis scores, and liver stiffness measurements (LSM). An ensemble model including these ML models was also used for prediction., Results: Among the ML models, the XGBoost model exhibited the highest AUROC of 0.77, with a sensitivity, specificity, and accuracy of 61.5%, 75.8%, and 69.5%, in validation set, while LSM, AST, ALT showed strongest effects on the model. The ensemble model outperformed all ML models in terms of sensitivity, specificity, and accuracy of 73.1%, 90.9%, and 83.1%., Conclusion: For patients with severe obesity and NAFLD, the XGBoost model and the ensemble model exhibit high predictive performance for significant liver fibrosis. These models may be used to screen for significant liver fibrosis in this patient group and monitor treatment response after metabolic bariatric surgery., Competing Interests: Declarations. Ethical Approval: This study was conducted in accordance with the Declaration of Helsinki. The study protocol was approved by the Institutional Review Board of Taipei Medical University (approval no. N201601029). Informed Consent: Written informed consent was obtained from all participants. This clinical trial was registered on ClinicalTrials.gov (identifier no. NCT04059029). Conflict of Interest: The authors have no conflicts of interest to declare., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: The outcomes of carotid revascularization in patients with prior carotid artery stenting (CAS) remain understudied. Prior research has not reported the outcomes after transcarotid artery revascularization (TCAR) in patients with previous CAS. In this study, we compared the peri-operative outcomes of TCAR, transfemoral CAS (tfCAS) and carotid endarterectomy (CEA) in patients with prior ipsilateral CAS using the Vascular Quality Iniatitive., Methods: Using Vascular Quality Initiative data from 2016 to 2023, we identified patients who underwent TCAR, tfCAS, or CEA after prior ipsilateral CAS. We included covariates such as age, race, sex, body mass index, comorbidities (hypertension, diabetes, prior coronary artery disease, prior coronary artery bypass grafting/percutaneous coronary intervention, congestive heart failure, renal dysfunction, smoking, chronic obstructive pulmonary disease, and anemia), symptom status, urgency, ipsilateral stenosis, and contralateral occlusion into a regression model to compute propensity scores for treatment assignment. We then used the propensity scores for inverse probability weighting and weighted logistic regression to compare in-hospital stroke, in-hospital death, stroke/death, postoperative myocardial infarction (MI), stroke/death/MI, 30-day mortality, and cranial nerve injury (CNI) after TCAR, tfCAS, and CEA. We also analyzed trends in the proportions of patients undergoing the three revascularization procedures over time using Cochrane-Armitage trend testing., Results: We identified 2137 patients undergoing revascularization after prior ipsilateral carotid stenting: 668 TCAR patients (31%), 1128 tfCAS patients (53%), and 341 CEA patients (16%). In asymptomatic patients, TCAR was associated with a lower yet not statistically significant in-hospital stroke/death than tfCAS (TCAR vs tfCAS: 0.7% vs 2.0%; adjusted odds ratio [aOR], 0.33; 95% confidence interval [CI], 0.11-1.05; P = .06), and similar odds of stroke/death with CEA (TCAR vs CEA: 0.7% vs 0.9%; aOR, 0.80; 95% CI, 0.16-3.98; P = .8). Compared with CEA, TCAR was associated with lower odds of postoperative MI (0.1% vs 14%; aOR, 0.02; 95% CI, 0.00-0.10; P < .001), stroke/death/MI (0.8% vs 15%; aOR, 0.05; 95% CI, 0.01-0.25; P < .001), and CNI (0.1% vs 3.8%; aOR, 0.04; 95% CI, 0.00-0.30; P = .002) in this patient population. In symptomatic patients, TCAR had an unacceptably elevated in-hospital stroke/death rate of 5.1%, with lower rates of CNI than CEA. We also found an increasing trend in the proportion of patients undergoing TCAR following prior ipsilateral carotid stenting (2016 to 2023: 14% to 41%), with a relative decrease in proportions of tfCAS (61% to 45%) and CEA (25% to 14%) (P < .001)., Conclusions: In asymptomatic patients with prior ipsilateral CAS, TCAR was associated with lower odds of in-hospital stroke/death compared with tfCAS, with comparable stroke/death but lower postoperative MI and CNI rates compared with CEA. In symptomatic patients, TCAR was associated with unacceptably higher in-hospital stroke/death rates. In line with the postprocedure outcomes, there has been a steady increase in the proportion of patients with prior ipsilateral stenting undergoing TCAR over time., Competing Interests: Disclosures None., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Autism spectrum disorder (ASD) poses a significant challenge due to its diverse impact on individuals, emphasizing the need for personalized treatment plans. The financial burden of ASD-related healthcare is substantial, necessitating a comprehensive understanding of its prevalence and evolving trends., Methods: This study aims to analyze the prevalence and trends of ASD, treatment patterns, gender differences, and racial-ethnic disparities in the United States from 2017 to 2020, utilizing nationally representative data from the National Survey of Children's Health (NSCH). The NSCH, a leading annual national survey, provided rich data on child health. A total of 108,142 participants aged 3-17 years were included, with ASD prevalence assessed based on self-reported diagnoses., Results: Between 2017 and 2020, ASD prevalence in children aged 3-17 was 2.94% (95% confidence interval: 2.68-3.18). Significant disparities were observed: older age and male gender correlated with higher prevalence, while family income-to-poverty ratio and insurance coverage influenced prevalence. Racial/ethnic disparities existed, with Hispanics showing the highest prevalence. Treatment trends showed stability overall, but age influenced behavioral and medication interventions. The prevalence remained stable from 2017 to 2020, with variations in age groups and a significant increase among non-Hispanic Whites., Conclusions: This study highlights a higher but stable overall ASD prevalence, with nuanced disparities among different demographic groups. Gender differences persist, emphasizing the need for tailored interventions. Racial-ethnic disparities call for targeted healthcare strategies. The stability in treatment trends underscores the persistent challenge of addressing core ASD symptoms., (© 2024. The Author(s).)

Objectives: The objective of this study was to determine the incidence and types of adverse events (AEs), including preventable and ameliorable AEs, in patients transitioning from the emergency department (ED) to the inpatient setting. A second objective was to examine the risk factors for patients with AEs., Methods: This was a prospective cohort study of patients at risk for AEs in 2 urban academic hospitals from August 2020 to January 2022. Eighty-one eligible patients who were being admitted to any internal medicine or hospitalist service were recruited from the ED of these hospitals by a trained nurse. The nurse conducted a structured interview during admission and referred possible AEs for adjudication. Two blinded trained physicians using a previously established methodology adjudicated AEs., Results: Over 22% of 81 patients experienced AEs from the ED to the inpatient setting. The most common AEs were adverse drug events (42%), followed by management (38%), and diagnostic errors (21%). Of these AEs, 75% were considered preventable. Patients who stayed in the ED longer were more likely to experience an AE (adjusted odds ratio = 1.99, 95% confidence interval = 1.19-3.32, P = 0.01)., Conclusions: AEs were common for patients transitioning from the ED to the inpatient setting. Further research is needed to understand the underlying causes of AEs that occur when patients transition from the ED to the inpatient setting. Understanding the contribution of factors such as length of stay in the ED will significantly help efforts to develop targeted interventions to improve this crucial transition of care., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)