共找到 20 条结果
General anesthesia (GA) is the predominant choice for open inguinal hernia repair but may be associated with a higher risk of postoperative complications, particularly in patients with multiple comorbidities. Spinal anesthesia (SA) is therefore considered as an alternative for high-risk patients. However, its potential benefits in reducing postoperative complications remain unclear. This study aimed to compare 30-day outcomes between SA and GA in high-risk patients undergoing initial open inguinal hernia repair. Patients who underwent initial open inguinal hernia repair were identified in the ACS-NSQIP database from 2005 to 2024. High-risk status was defined as a Modified Frailty Index (mFI) ≥3 and American Society of Anesthesiology (ASA) score ≥3. Exclusion criteria included emergency surgery, ventilator dependency, procedures not performed by general surgeons, cases with concomitant bowel resection, and cases where the primary anesthesia type was neither SA nor GA. A 1:1 propensity-score matching was performed to balance demographics and comorbidities between patients who received SA versus GA, and thirty-day outcomes were then compared. Additionally, a multivariable logistic regression analysis that included all high-risk patients was conducted to evaluate thirty-day outcomes while adjusting for all preoperative variables. A total of 118 high-risk patients underwent open inguinal hernia repair under SA, of whom 106 were successfully propensity-score matched to 106 of the 1,365 patients who received GA. After matching, 30-day mortality rates were comparable between SA and GA (0.94% vs. 0%, p = 1.00), as were rates of organ system complications, including cardiac (0.94% vs. 1.89%, p = 1.00), pulmonary (2.83% vs. 0.94%, p = 0.62), and renal complications (1.89% vs. 0%, p = 0.50). Operative time (63.44 ± 30.61 vs. 65.05 ± 30.74 min, p = 0.70), as well as length of stay for outpatient cases (0.28 ± 0.63 vs. 0.32 ± 0.95 days, p = 0.79) were comparable between SA and GA. All other 30-day outcomes were likewise comparable. Multivariable analysis confirmed that the 30-day outcomes of SA and GA were comparable for all high-risk patients. In high-risk patients undergoing open inguinal hernia repair, this study showed no evidence of a difference in 30-day outcomes between SA and GA; however, given the limited statistical power, these findings should not be interpreted as evidence of equivalence. The choice between SA and GA should therefore be guided by patient-specific factors, surgical complexity, and surgeon and center expertise. Further prospective studies are needed to validate these findings.
The 2023 iteration of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) estimated prevalence, incidence, and health burden for 375 diseases and injuries, including 12 mental disorders. We assess past, current, and emerging trends in the prevalence and burden of mental disorders across sexes and age groups, for 21 regions, 204 countries and territories, and by Socio-demographic Index (SDI) quintile, from 1990 to 2023. Mental disorders included in GBD 2023 were anxiety disorders, major depressive disorder, dysthymia, bipolar disorder, schizophrenia, autism spectrum disorders, conduct disorder, attention-deficit hyperactivity disorder, anorexia nervosa, bulimia nervosa, idiopathic developmental intellectual disability, and a residual category of other mental disorders. A literature review identified epidemiological data for each disorder. These were analysed via a Bayesian meta-regression to estimate prevalence by disorder, sex, age, location, and year. Disorder-specific prevalence was multiplied by disability weights representing the severity of health loss associated with each disorder to estimate years lived with disability (YLDs). Deaths due to anorexia nervosa were assessed with a Cause of Death Ensemble modelling strategy to estimate deaths by sex, age, location, and year, and then multiplied by the standard life expectancy at age of death to estimate years of life lost (YLLs). YLDs equalled disability-adjusted life-years (DALYs) for all mental disorders except anorexia nervosa (the only mental disorder considered as an underlying cause of death in GBD), for which DALYs represented the sum of YLDs and YLLs. We presented prevalence, deaths, YLDs, YLLs, and DALYs as counts, age-specific rates per 100 000 population, and age-standardised rates per 100 000 population. We estimated 1·17 billion (95% uncertainty interval 1·06-1·31) prevalent cases of mental disorders globally in 2023, equivalent to an age-standardised prevalence rate of 14 210·7 cases (12 849·5-15 940·1) per 100 000 population. These estimates represented a 95·5% (75·0-121·2) increase in prevalent cases and 24·2% (11·4-41·4) increase in age-standardised prevalence rate between 1990 and 2023. All mental disorders showed increases in prevalent cases between 1990 and 2023, while notable increases were seen in age-standardised prevalence rates for anxiety disorders, major depressive disorder, dysthymia, anorexia nervosa, bulimia nervosa, schizophrenia, and conduct disorder. There were an estimated 171 million (127-228) DALYs due to mental disorders globally across sex and age in 2023, equivalent to an age-standardised DALY rate of 2070·5 DALYs (1519·1-2750·5) per 100 000 population. Mental disorders contributed to 6·1% (4·8-7·6) of all-cause DALYs in 2023, making them the fifth leading cause of global DALYs (up from 12th in 1990). DALYs were almost entirely composed of YLDs. Mental disorders were the leading cause of YLDs in 2023 (up from second in 1990), explaining 17·3% (14·8-20·6) of all-cause global YLDs. Leading causes of mental disorder DALYs were anxiety disorders (ranked 11th among the 304 diseases and injuries at Level 4 of the GBD cause hierarchy), major depressive disorder (15th), and schizophrenia (41st). Globally in 2023, mental disorder age-standardised DALY rates were higher among females (2239·6 [1643·7-3014·1] per 100 000) than among males (1900·2 [1399·8-2510·8] per 100 000), and peaked in the 15-19 years age group (2617·3 [1850·6-3696·8] per 100 000). All locations showed increased mental disorder DALY rates in 2023 compared with 1990, ranging across countries and territories from 1302·4 (952·7-1683·7) per 100 000 in Viet Nam to 3555·8 (2661·9-4715·0) per 100 000 in the Netherlands. Across SDI quintiles, DALY rates ranged from 1853·0 (1352·1-2469·3) per 100 000 for middle SDI to 2184·1 (1606·1-2890·3) per 100 000 for high SDI. A significant health burden was imposed by mental disorders in all countries and territories in 2023, irrespective of the health resources available. In some instances, this burden has increased over time and is unevenly distributed across populations. Stronger surveillance systems, particularly in low-income and middle-income countries, are required. Additionally, we need more coordinated and inclusive policies to reduce the burden through early treatment and prevention, tailored to sex and age differences across locations. Responding to the mental health needs of our global population, especially those most vulnerable, is an obligation, not a choice. Gates Foundation, Queensland Health, and University of Queensland.
Background and Objectives: The surgical management of displaced scapular fractures remains controversial, particularly regarding the importance of restoring scapular alignment. This study evaluated radiologic restoration and clinical outcomes following posterior fixation of displaced scapular fractures, with a particular focus on correction of lateral border offset (LBO) and angular deformity. Materials and Methods: This retrospective case series included 20 patients who underwent posterior open reduction and internal fixation for displaced scapular fractures between 2017 and 2024 with a minimum follow-up of 12 months. Surgical indications included lateral border offset (LBO) > 20 mm, angular deformity > 30°, or displaced intra-articular fractures with step-off > 3 mm. Radiologic parameters including LBO, angular deformity, and intra-articular step-off were measured using computed tomography before and after surgery. Clinical outcomes were evaluated using shoulder range of motion (ROM), Disabilities of the Arm, Shoulder and Hand (DASH) score, and modified American Shoulder and Elbow Surgeons (ASES) score. Results: Significant postoperative improvement was observed in all radiologic parameters. Mean LBO improved from 18.9 ± 10.7 mm (range, 0-45.5 mm) to 3.1 ± 7.1 mm (range, 0-29.9 mm), angular deformity improved from 28.7° ± 11.3° (range, 10.2-48.1°) to 0.9° ± 3.9° (range, 0-17.8°), and intra-articular step-off improved from 6.4 ± 2.0 mm (range, 3.7-9.7 mm) to 1.8 ± 0.5 mm (range, 1-2.5 mm). At final follow-up, mean forward flexion was 126° ± 34.4° (range, 10-170°) and external rotation was 62.3° ± 20.8° (range, 0-90°). Mean DASH and modified ASES scores were 27.3 ± 17.3 (range, 8.3-74.2) and 71.6 ± 15.0 (range, 25.8-89), respectively. Glenoid involvement was not associated with inferior clinical outcomes, whereas associated ipsilateral upper extremity injuries tended to be related to poorer functional results. Conclusions: Posterior fixation effectively restored scapular alignment and articular congruity in displaced scapular fractures. Restoration of LBO and correction of angular deformity may represent important surgical objectives for correction of glenoid medialization and restoration of normal scapular alignment.
African American and rural-dwelling family caregivers of persons with newly diagnosed advanced cancer perform critical, time-intensive tasks and historically have had limited resources to support their role. To determine the effect of a lay coach-led, early palliative care telehealth intervention (Educate, Nurture, Advise, Before Life Ends [ENABLE] Cornerstone) for African American and rural-dwelling family caregivers of patients with advanced cancer on caregiver and patient outcomes at 24 weeks. This single-blind randomized clinical trial was conducted from January 2020 to May 2025 at outpatient oncology clinics at 2 large cancer centers in the Southeastern US. Participants were African American and rural-dwelling family caregivers aged 21 years or older self-identifying as an unpaid close friend or family member who is involved with the day-to-day medical care of a patient with advanced cancer. The intervention included 6 weekly, 20- to 60-minute psychosocial telephonic sessions facilitated by a trained lay coach plus monthly follow-up. Usual care consisted of mailed pamphlets outlining resources for families at each of the cancer centers. The primary outcome was caregiver distress (anxiety and depressive symptoms as measured by the Hospital Anxiety and Depression Scale [HADS]) at 24 weeks. Secondary outcomes were caregiver and patient quality of life (QOL; measured with the Patient-Reported Outcomes Measurement Information System Global Health Short Form), caregiver burden (Montgomery-Borgatta Caregiver Burden Scale), and patient distress (HADS). Outcomes were assessed using baseline-constrained linear mixed-effects models. A total of 222 family caregivers (mean [SD] age, 55.5 [14.7] years; 169 [76.1%] female; 114 [51.4%] African American; 101 White [45.5%]; 7 other race [3.2%]) and 165 patients (mean [SD] age, 60.7 [12.2] years; 98 [59.4%] female; 79 African American [47.9%]; 84 White [50.9%]; 2 other race [1.2%]) were randomized. At week 24, no relevant between-group differences were observed in caregiver HADS anxiety (mean [SE] baseline-adjusted difference, 0.23 [0.44]; Cohen d = 0.05; 95% CI, -0.14 to 0.24; P = .60) or HADS depressive symptom scores (mean [SE] baseline-adjusted difference, 0.04 [0.41]; Cohen d = 0.01; 95% CI, -0.19 to 0.21; P = .91). For all other outcomes, 24-week differences were of small magnitude and not statistically significant. Exploratory sensitivity analyses of caregivers distressed at baseline indicated improvements in caregiver anxiety (mean [SE] baseline-adjusted difference, -1.21 [0.53]; Cohen d = -0.38; 95% CI, -0.70 to -0.05) and patient mental health QOL (mean [SE] baseline-adjusted difference, 3.00 [1.37]; Cohen d = 0.45; 95% CI, 0.04 to 0.86), but no statistically significant differences in caregiver burden (mean [SE] baseline-adjusted difference, -1.15 [0.69]; Cohen d = -0.32; 95% CI, -0.71 to 0.06) and patient depression (mean [SE] baseline-adjusted difference, -1.30 [0.71]; Cohen d = -0.37; 95% CI, -0.77 to 0.03). This randomized clinical trial of a telehealth intervention for African American and rural-dwelling caregivers of patients with advanced cancer found no differences in caregiver and patient outcomes at 24 weeks. However, an exploratory sensitivity analysis indicated potential improvements in caregiver anxiety and patient mental health QOL. ClinicalTrials.gov Identifier: NCT04318886.
Complex ventral hernias are a surgical challenge associated with high morbidity and healthcare costs. Component separation techniques have improved throughout the years with better outcomes, although the optimal approach remains debated. Robotic surgery has shown promising outcomes as an alternative to open repair, although data in large multicenter studies is still limited. A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Adult patients undergoing component separation for ventral hernia repair were identified using CPT and ICD codes. Outcomes included 30-day surgical, wound, medical, and overall complications, as well as length of stay and readmission. Multivariable logistic regression and propensity score matching were applied to adjust for baseline differences. A total of 6,207 patients were included, from those 4,443 (71.6%) underwent open technique and 1,764 (28.4%) robotic. After propensity matching (n = 5,259), robotic repair was independently associated with significantly lower overall complication rates (4.8% vs. 19.6%, aOR 0.193, 95% CI 0.140-0.265, p < 0.001), including wound (2.2% vs. 10.2%, aOR 0.164, p < 0.001), surgical (2.9% vs. 10.0%, aOR 0.271, p < 0.001), and medical complications (2.0% vs. 7.0%, aOR 0.229, p < 0.001). Robotic surgery was also associated with shorter length of stay (1.34 vs. 3.86 days, p < 0.001) and lower readmission rates (4.4% vs. 9.1%, p < 0.001). Robotic component separation for ventral hernia repair is associated with lower postoperative complication rates, shorter length of stay, and fewer readmissions compared to the open approach. These benefits remained significant after multivariate analysis and propensity score matching, supporting the robotic technique as an effective strategy. Prospective studies are warranted to evaluate long-term outcomes, including recurrence, and to assess cost-effectiveness to optimize evidence-based surgical decision-making.
Minimally invasive surgery (MIS) has become common practice in elective colectomy; however, in emergent settings, this is less common and requires further research on safety and efficacy. The aim of this study was to compare MIS and open approaches for emergency colectomy. Adults who underwent emergency colectomy for diverticular disease, colorectal malignancy or inflammatory bowel disease between 2016 and 2022 were identified in the American College of Surgeons National Surgical Quality Improvement Program. The primary outcome was overall 30-day post-operative major morbidity-a composite outcome that included variables such as mortality and venous thromboembolism. Secondary outcomes were 30-day post-operative mortality, septic complications, wound complications and length of stay (LOS). Multivariable regression models were fit for each outcome. In total, 82,142 patients were identified who underwent emergency colectomy, of which 24,050 patients underwent MIS (29.4%). In total, 27,206 patients (33.1%) experienced the primary outcome of overall in-hospital post-operative morbidity, with significantly more patients in the open group experiencing this outcome (39.3% vs. 18.3%, odds ratio [OR] 0.57, 95% confidence intervals [CI] 0.54-0.59, p < 0.001). MIS patients had significantly lower risk of mortality (OR 0.54, 95% CI 0.48-0.60), septic complications (OR 0.57, 95% CI 0.54-0.61) and wound complications (OR 0.53, 95% CI 0.51-0.56). Post-operative LOS was 2.22 days shorter in the MIS group (95% CI -2.32 to -2.13, p < 0.001). Emergency colectomy via MIS is associated with a decreased risk of post-operative morbidity and mortality as compared to open surgery. While MIS is increasingly prevalent in elective settings, these data illustrate potential benefits in the emergent setting.
To compare the effectiveness of Holosight robot-assisted percutaneous reduction and internal fixation versus reduction and internal fixation via sinus tarsi approach in treatment of calcaneal fractures. A retrospective analysis was conducted on 46 cases (46 feet) of closed intra-articular calcaneal fractures classified as Sanders type Ⅱ or Ⅲ, admitted between June 2022 and June 2025. Among them, 20 patients were treated with Holosight robot-assisted percutaneous reduction and internal fixation (RA group), and 26 with open reduction and internal fixation via sinus tarsi approach (control group). There was no significant difference between groups ( P>0.05) in age, gender, affected side, fracture classification, the interval between fracture and operation, and preoperative visual analogue scale (VAS) score for pain, American Orthopedic Foot and Ankle Association (AOFAS) score, calcaneal morphological parameters (length, width, height, Böhler angle, Gissane angle). The two groups were compared in terms of operation time, intraoperative blood loss, fluoroscopy frequency, screw (guide wire) adjustment times, initial screw (guide wire) implantation success rate, incidence of complications, and the differences in calcaneal morphological parameters, pain and functional outcomes (VAS and AOFAS scores) between pre- and post-operation. Compared with the control group, the RA group had significantly less intraoperative blood loss, fewer fluoroscopy frequency, fewer screw (guide wire) adjustments, higher initial screw (guide wire) implantation success rate, and shorter operation time and hospital stay ( P<0.05). No postoperative complication occurred in RA group, whereas 1 case of superficial incision infection was observed in control group; however, there was no significant difference in the incidence of complications between groups ( P>0.05). All patients were followed up 6-7 months (mean, 6.5 months). X-ray film at last follow-up showed that all fractures healed. At 6 months after operation, the calcaneal morphological parameters and pain and functional indicators all significantly improved when compared with the preoperative values in the two groups ( P<0.05). The changes in VAS score and AOFAS score differed significantly between the two groups ( P<0.05), whereas no significant difference was found in the changes of the other indicators ( P>0.05). Compared with the operation via sinus tarsi approach, Holosight robot-assisted percutaneous reduction and internal fixation for calcaneal fractures demonstrates superior safety and effectiveness, as evidenced by shortened operation and hospital stay, reduced intraoperative blood loss and the fluoroscopy frequency, improved screw placement accuracy, enhanced postoperative functional recovery. 探讨Holosight机器人辅助经皮复位内固定与经跗骨窦入路复位内固定治疗跟骨骨折的疗效差异。. 回顾性分析2022年6月—2025年6月收治且符合选择标准的46例（46足）Sanders Ⅱ、Ⅲ型闭合性关节内跟骨骨折患者临床资料。其中，Holosight机器人辅助经皮复位内固定20例（机器人组），经跗骨窦入路复位内固定26例（对照组）。两组患者年龄、性别、患肢侧别、骨折分型、骨折至手术时间，以及术前疼痛视觉模拟评分（VAS）、美国矫形足踝协会（AOFAS）评分、Gissane角、Böhler角及跟骨长度、宽度、高度，差异均无统计学意义（ P>0.05）。比较两组手术时间、住院时间、术中出血量、术中透视次数、术中螺钉（导针）调整次数及首次植入率、术后并发症发生率，手术前后跟骨长度、宽度、高度以及Gissane角、Böhler角、VAS评分、AOFAS评分的差值（变化值）。. 与对照组相比，机器人组术中出血量、透视次数、螺钉（导针）调整次数减少，螺钉（导针）首次植入率更高，手术时间及住院时间缩短，差异均有统计学意义（ P<0.05）。术后机器人组无并发症发生；对照组发生1例切口浅表感染，并发症发生率组间差异无统计学意义 （P>0.05）。两组患者均获随访，随访时间6～7个月，平均6.5个月。X线片复查示末次随访时两组骨折均愈合良好。术后6个月，两组跟骨长度、宽度、高度及Böhler角、Gissane角、VAS评分与AOFAS评分均较术前改善（ P<0.05）；VAS评分与AOFAS评分变化值组间差异有统计学意义（ P<0.05），其余指标变化值组间差异无统计学意义 （P>0.05）。. 与经跗骨窦入路手术相比，跟骨骨折内固定术中采用Holosight机器人辅助植钉能缩短手术及住院时间、减少术中出血与透视次数、提升植钉精准性，有利于术后功能恢复。.
Octogenarians undergoing surgical management for benign prostatic obstruction (BPO) present unique challenges because of age-related comorbidities and frailty, which may impact perioperative outcomes. This study evaluates 30-day complications in octogenarian patients undergoing laser enucleation of prostate (LEP), robotic simple prostatectomy (RSP), and open simple prostatectomy (OSP) as reported in a large U.S. national database. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for octogenarian patients who underwent BPO surgery from 2010 to 2023. Procedures were categorized using Current Procedural Terminology codes. Outcomes assessed included 30-day complications, readmission, and reoperation. Of 136,991 patients undergoing BPO surgery, 1,798 were octogenarians (LEP = 1,222; RSP = 93; OSP = 483). LEP patients had shorter median operative times (94 vs 123 and 153 minutes, p < 0.0001), shorter hospital stays (1 vs 3-6 days, p < 0.0001), and higher rates of discharge to home (96.8% vs 85.3%, p = 0.016). Transfusions were more frequent after OSP (27.5% vs 3.2%, p < 0.0001). Urinary tract infections were more common following RSP (9.7% vs 3.7-5.8%, p = 0.009). OSP was associated with higher rates of return to the operating room (4.6% vs 1.1-2.3%, p = 0.023) and prolonged hospitalization beyond 30 days (3.4% vs 0-1.5%, p = 0.016). Independent predictors of complications included higher ASA class, dependent functional status, longer operative time, and undergoing OSP vs LEP. LEP demonstrated superior perioperative outcomes with shorter operative times, lower transfusion rates, and a higher likelihood of discharge to home, supporting its preference in octogenarians. RSP provided intermediate outcomes, whereas OSP was associated with the highest morbidity.
Studies have demonstrated lower odds of survival from out-of-hospital cardiac arrest (OHCA) during nighttime hours, but this has not been studied in North America since 2013, and it is unclear what factors might explain this survival difference. To identify whether OHCA survival during nighttime hours remains lower than during daytime hours using contemporary data and whether it can be explained by variable patient physiology or emergency care factors. This cohort study included adults (aged ≥18 years) with OHCA in the Cardiac Arrest Registry for Enhanced Survival from 2013 to 2024. Daytime was defined as 7:00 am to 10:59 pm, and nighttime was defined as 11:00 pm to 6:59 am. Primary outcomes were sustained return of spontaneous circulation (ROSC) and neurologically favorable survival (Cerebral Performance Category score of 2 or more). A multilevel mixed-effects logistic regression model with prehospital agency as a random effect and patient or treatment characteristics as fixed effects was used. A similar analysis of postresuscitation survival was performed among patients with sustained ROSC, adjusting for the time-to-cardiopulmonary resuscitation interval and defibrillation status. A mediation analysis was performed to identify whether the prehospital response interval mediates the association. Of 1 151 845 patients in the registry, 874 415 were eligible and included in the analysis, and the median (IQR) age in the cohort was 64 (52-75) years with 557 515 males (63.8%) and 181 878 Black or African American patients (20.8%), 146 352 Hispanic or Latino patients (16.7%), and 447 646 White patients (51.2%). A minority of OHCA responses occurred at nighttime (241 967 [27.7%]), and the odds of sustained ROSC and neurologically favorable survival were lower at nighttime than daytime (sustained ROSC: 62 548 [25.8%] vs 193 486 [30.6%]; adjusted odds ratio [aOR], 0.85; 95% CI, 0.84-0.86; neurologically favorable survival: 16 234 [6.7%] vs 58 542 [9.3%]; aOR, 0.84; 95% CI, 0.82-0.86). Among those with sustained ROSC, the odds of postresuscitation survival at nighttime were also lower than daytime (aOR, 0.93; 95% CI, 0.90-0.95). The prehospital response interval partially mediated the nighttime survival disadvantage, with approximately 12.6% of the total effect mediated by the response interval. In this cohort study of OHCA, nighttime response was associated with lower adjusted odds of sustained ROSC, neurologically favorable survival, and postresuscitation survival. Emergency care factors accounted for only a portion of the decreased odds of survival at nighttime.
The integration of point-of-care ultrasound (POCUS) into internal medicine (IM) residency training and curriculum remains an area for further development and research. To assess the confidence and barriers to the utilization of POCUS among IM residents in the United States. This cross-sectional, multi-institutional study involved residents from various IM programs across the United States, who were invited to participate in a voluntary online survey on POCUS confidence and utilization between October 30, 2024, and December 3, 2024. Out of 273 respondents (16.2%), 96.3% were IM residents, and 50.2% were female. 34.4%, 41.0%, and 24.5% were postgraduate year (PGY)-1, PGY-2, and PGY-3, respectively. Residents felt least comfortable with and wanted to learn focused cardiac (46.9%) and extended focused assessment with sonography in trauma (45.1%) scans. The top barriers to POCUS utilization were lack of time (55.7%), lack of confidence in interpreting images (42.9%), and limited access to machines (36.3%). Desired interventions included designated elective time for POCUS training (65.6%), ultrasound machines on every floor (55.3%), and formal integration of POCUS training into residency (53.5%). Self-reported confidence also correlated with training level. This is the first national survey to highlight critical gaps in POCUS utilization among IM residents. This study emphasizes the need for targeted POCUS interventions from program leaders, professional societies, and accrediting bodies for IM residents.
To evaluate the effectiveness of a theory-informed, iterative implementation strategy (IS) to improve point-of-care ultrasound (POCUS) documentation compliance among emergency medicine (EM) residents according to American College of Emergency Physicians (ACEP) guidelines in a high-volume emergency department (ED). We conducted a 19-month (December 2023-June 2025) mixed-methods implementation study at a tertiary academic ED in India. The Consolidated Framework for Implementation Research (CFIR) and Expert Recommendations for Implementing Change guided six iterative IS phases, including education, co-design, workflow optimisation and audit/feedback. Participants were EM residents. The primary outcome was the proportion of POCUS examinations achieving ≥80% compliance with ACEP documentation standards. Compliance trends were analysed across phases and summarised using proportions and medians with IQRs. Qualitative data from five focus group discussions were analysed using CFIR to identify barriers, facilitators and mechanisms of change. Quantitative and qualitative findings were integrated using a joint display. We assessed 3074 POCUS examinations. The proportion of scans achieving ≥80% compliance increased from 0% at baseline to 35.1% postimplementation. Median compliance rose from 24% (IQR 17-34) to 69% (IQR 54-84). Compliance followed a nonlinear trajectory. Initial phases showed minimal gains (0%-8.7%) due to workflow barriers. A marked acceleration occurred during IS-5 (22.5%) following the introduction of a user-designed, single multimodal form and gamification. Qualitative analysis demonstrated a shift from initial resistance (CFIR: compatibility, complexity) to normalisation (implementation climate), although technical challenges with image archiving persisted. User-centred co-design and peer engagement were key to the improvement, although persistent infrastructure challenges limited further gains and highlighted the need for informatics-enabled solutions. This study demonstrates that low-cost, context-sensitive strategies can enhance POCUS documentation effectively in high-volume, resource-constrained EDs. A multifaceted, iterative IS guided by theoretical frameworks significantly improved POCUS documentation compliance. User-centred design and participatory engagement were critical mechanisms for sustainable practice change in a resource-variable EM setting. CTRI/2024/03/063671.
Adverse pregnancy outcomes (APOs) confer risk for maternal cardiovascular disease, but the role of APOs in cardiovascular health (CVH) of offspring across the life course is unknown. To examine associations of APO exposure with CVH and early arterial injury among offspring in young adulthood. This longitudinal cohort study used data from the Future of Families and Child Well-Being Study and Future of Families-Cardiovascular Health Among Young Adults study, conducted in 20 US cities from February 1998 to September 2000, with follow-up until September 2023. Participants were mother-child dyads enrolled at the child's birth; offspring were followed up until young adulthood (year 22). Data were analyzed from June 2024 to June 2025. Hypertensive disorders of pregnancy (HDP), gestational diabetes (GD), and preterm birth (PTB), ascertained by pregnancy medical records. Offspring CVH assessed by the American Heart Association's Life's Essential 8 (LE8) score, individual clinical cardiovascular risk factors, and arterial injury assessed by carotid ultrasonography at year 22 after birth. Among 1333 offspring participants (729 [55%] female; mean [SD] age in early adulthood, 22.4 [0.7] years), 128 (10%) had HDP exposure, 67 (5%) had GD exposure, and 137 (10%) had PTB exposure. In analyses adjusted for sociodemographic factors, HDP exposure was associated with higher body mass index (adjusted β, 2.80; 95% CI, 1.07-4.53), higher diastolic blood pressure (adjusted β, 2.29; 95% CI, 0.17-4.41), and higher glycated hemoglobin (HbA1c) level (adjusted β, 0.21; 95% CI, 0.02-0.41) in early adulthood. PTB was associated with higher HbA1c level (adjusted β, 0.29; 95% CI, 0.15-0.43). GD exposure was associated with a lower LE8 blood pressure score (adjusted β, -6.59; 95% CI, -13.95 to -0.16). HDP exposure was associated with higher mean carotid intima-media thickness (adjusted β, 0.02; 95% CI, 0.01-0.03) and lower carotid grayscale median (adjusted β, -3.68; 95% CI, -6.30 to -1.05). Exposure to GD was associated with higher mean carotid intima-media thickness (adjusted β, 0.02; 95% CI, 0.00-0.04). In this longitudinal cohort study of mother-child dyads enrolled at the child's birth, exposure to APOs during gestation, particularly HDP, was associated with suboptimal CVH and arterial injury among offspring in early adulthood. The findings suggest optimizing pregnancy health may support offspring CVH into early adulthood.
This study describes outcomes of a pilot age-related hearing loss screening program implemented in two Family Medicine and three Otolaryngology (ENT) clinics at the Medical University of South Carolina, in terms of postscreening follow-up and associations of screening with hearing health care use. Screening questions focused on perceived hearing, treatment, and desire for audiology referral. Hearing health care use, determined by diagnostic and procedural codes, was defined as at least one visit to audiology clinics within 1 year of screening. We used logistic regression models to determine associations of screening with hearing health care use among patients seen in Family Medicine and ENT clinics, separately. Results are presented as odds ratios with corresponding 95% confidence intervals. Screened (n = 5360; mean age 73.0 [SD 6.7] years; 58.3% female) and nonscreened patients (n = 4106; mean age 72.0 [SD 6.7] years; 56.4% female) were matched for age and sex. Among patients who requested an audiology referral, 52.4% used hearing health care; of those, 21.5% obtained hearing aids. In a multivariable model, screening (vs not) in Family Medicine was associated with higher odds of hearing health care use (5.36 [1.92, 14.94]). In multivariable models, screening (vs not) in ENT was associated with lower odds of hearing health care use (0.86 [0.76, 0.98]); after excluding patients screened and seen in audiology on the same day, screening was associated with higher odds of hearing health care use (1.44 [1.16, 1.78]). Hearing screening among older adults could facilitate timely identification and management of hearing loss.
Disclosure of conflict of interest (COI) is important for surgical societies to minimize bias. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) requires committee members to disclose potential COI to promote full transparency. This study investigates compliance with this requirement and quantifies the actual dollar amounts that ineligible companies, collectively "industry", give to committee members. All SAGES committee members were queried in the Centers for Medicare & Medicaid Services Open Payments database (OPD). The query results for 2023 and 2024 were compared to the actual self-reported disclosure statements submitted to SAGES in the spring of 2025. Due to the nature of the database, only US-based physicians were included. Only payments of $500 or more were recorded. Only committees whose rosters were available online were utilized. Incorrect disclosure was defined as a mismatch between the OPD and the member's disclosure. There were 930 individual committee members and 185 were excluded by OPD. Only 51% (382/745) of OPD queries matched disclosures. Correct disclosure occurred in 104/467 who had disclosable COI. Industry paid over $18,000,000 to committee members; one-third came from Intuitive Surgical. Members who received payments received an average of $38,992. The largest total amount to one individual was over $2,500,000. There was no difference in average payments received or appropriate disclosure rate by committee members on one committee versus those on multiple committees. Chair/co-chairs (n = 114) did not differ from other members (n = 631) in percent of appropriate disclosures (59 vs. 50%). However, chairs/co-chairs did receive larger payments ($37,501 vs. $22,021; p < 0.0035). SAGES has set policies for disclosing COI. Enforcement of these policies is challenging. Many committee members receive large payments from industry; thus the actual dollar amount should also be reported. Full and accurate reporting will allow for full transparency and reduce perception of bias.
Infectious diseases, particularly those caused by members of the genus Ranavirus (Iridoviridae), have caused mass mortality events in amphibian populations worldwide. Frog virus 3 (FV3) infects a wide range of amphibian hosts and results in high mortality. Despite the global prevalence of FV3, its origin and routes of spread remain unclear, largely because of limited genetic data from limited geographic regions. This study aimed to classify the ranaviruses isolated in the Republic of Korea through whole-genome sequencing. We collected amphibian carcasses and both symptomatic and asymptomatic live amphibians. The asymptomatic amphibians were collected from locations with previous infections. Among the 278 amphibian samples collected from 24 locations, 44 were positive for ranavirus according to quantitative PCR (qPCR) analysis. We obtained whole-genome sequences from 5 isolates, all of which were identified as FV3-like ranaviruses and belonged to the Asian FV3 clade in the maximum likelihood phylogenetic tree. By comparative analysis of open reading frames (ORFs) and phylogenomic trees, the Korean isolates were further divided into 2 strains: FV3-Kor_MT (mountain lineage) and FV3-Kor_LL (lowland lineage). Our findings highlight the importance of surveillance of a wide range of amphibian species and facilitate phylogenetic analyses of global FV3-like strains, including newly verified Korean strains.
Left-sided pancreatectomies are increasingly done by minimally invasive surgery (MIS), but variation persists in clinical practice. The implementation of MIS at a population level may identify areas for improvement. The aim of this study was to investigate the implementation of minimally invasive left-sided pancreatic resections at a national level, using population-adjusted resection rates and impact on a composite ideal outcome. All open and laparoscopic left-sided pancreatectomies as recorded in a national quality register, as a nationwide IDEAL stage IV cohort study from 2016 to 2023. Population-adjusted resection rates over time were calculated. Rates of ideal outcome were calculated and risk was expressed as odds ratio with 95% CI. The study period included 817 left-sided pancreatectomies, of which 519 (63.5%) were by minimally invasive access. The temporal age- and sex-adjusted resection rates for open and laparoscopic procedures were stable, but with regional variation in MIS. MIS was associated with shorter hospital stays and increased discharge-to-home rates. Patients selected for laparoscopy were younger, had better performance status and American Society for Anesthesiology risk score, and achieved higher ideal outcomes. In multivariable analysis, achieving an ideal outcome was associated with MIS in nonobese patients with good performance status in the recent time period and with health region. A temporal stability in resection rates and access type within regions demonstrated significant differences in the use of MIS. Although MIS was associated with the selection of younger, nonobese patients and lower rates of malignant lesions, it was also associated with 2-fold higher rates of ideal outcomes.
Robot-assisted minimally invasive esophagectomy (RAMIE) has emerged as an alternative to conventional minimally invasive esophagectomy (MIE) for esophageal cancer, but its short-term perioperative advantages remain uncertain. To compare early postoperative outcomes of RAMIE and MIE in patients with resectable esophageal cancer, this systematic review and meta-analysis was conducted according to PRISMA 2020 guidelines. PubMed was searched for randomized controlled trials, propensity score-matched studies, and retrospective comparative studies published between January 2005 and December 2024. Adult patients undergoing RAMIE or conventional MIE for resectable esophageal cancer were included. Random-effects models were used to pool standardized mean differences and odds ratios with 95% confidence intervals. Study quality was assessed using the MINORS criteria and Cochrane RoB 2 tool. In addition, a post hoc GRADE assessment was carried out for key outcomes to evaluate the certainty of evidence. Forty-one studies involving 13,321 patients were included, of whom 4,327 underwent RAMIE and 8,994 underwent MIE. Compared with MIE, RAMIE was associated with lower blood loss, reduced conversion to open surgery, higher total lymph node yield, greater left recurrent laryngeal nerve lymph node harvest, fewer pulmonary complications, and lower overall postoperative morbidity. ICU stay and hospital stay were also e shorter after RAMIE, whereas operative time was longer. No significant differences were observed in R0 resection, anastomotic leak, recurrent laryngeal nerve palsy, cardiac complications, chyle leak, surgical site infection, or 30- and 90-day mortality. Post hoc GRADE assessment showed that the certainty of evidence was very low across key outcomes, mainly because of the predominance of non-randomized studies, substantial heterogeneity across several pooled analyses, and outcome-specific concerns regarding imprecision and publication bias. RAMIE is safe and may offer some short-term perioperative advantages over conventional MIE without clear evidence of increased major morbidity or short-term mortality. However, the certainty of evidence across key outcomes was very low, and the predominance of nonrandomized studies and substantial heterogeneity across several analyses warrant cautious interpretation. Further adequately powered randomized trials are required.
Minimally invasive surgical techniques have improved outcomes in colorectal surgery, but comparative data on their use in total abdominal colectomy with end ileostomy for inflammatory bowel disease remain limited. This study aimed to compare postoperative outcomes among patients undergoing robotic, laparoscopic, or open total abdominal colectomy for inflammatory bowel disease. We performed a retrospective cohort analysis using propensity score matching to control for baseline differences across patients. Data were obtained from the 2022 American College of Surgeons National Surgical Quality Improvement Program, a national surgical outcomes registry. Adult patients who underwent total abdominal colectomy with end ileostomy for ulcerative colitis or Crohn's disease were included. Patients were treated with robotic-assisted, laparoscopic, or open total abdominal colectomy with end ileostomy. The primary outcome was any postoperative complication within 30 days of surgery. Secondary outcomes included operative time, conversion to open surgery, length of hospital stay, 30-day readmission, and other specific postoperative complications such as surgical site infection and renal insufficiency. A total of 581 matched patients were analyzed, including 83 robotic, 415 laparoscopic, and 83 open cases. There were no significant differences in overall 30-day morbidity across groups. Robotic surgery had significantly longer operative time than laparoscopic but not open surgery. Organ space infections and renal complications were more common in the robotic group compared with laparoscopic. Although robotic surgery was associated with shorter hospital stay, it also had the highest 30-day readmission rate. Robotic total abdominal colectomy demonstrated similar overall morbidity and conversion rates compared with other approaches but was associated with longer operative time, increased complications, and higher readmissions. Further refinement of perioperative protocols and patient selection may improve outcomes.
Lower neighborhood socioeconomic status (nSES) is associated with worse stroke recovery. It remains unclear what factors could be targeted therapeutically to mitigate nSES-associated poststroke recovery differences. To identify the extent with which receipt of hyperacute treatment, neighborhood density of home health services, density of rehabilitation clinics, density of recreation centers, transportation access, and walkability mediate the association between nSES and stroke recovery. The population-based stroke cohort Brain Attack Surveillance in Corpus Christi (BASIC) enrolled individuals between 2009 and 2022 in Nueces County, Texas. Candidate mediators were derived from BASIC, Redfin, or the National Neighborhood Data Archive. Causal mediation analyses were performed. Participants were followed from time of stroke to 90 days after stroke. Participants' census tracts at time of stroke were used to define neighborhoods. Individuals aged 45 years or older with completed baseline and community-dwelling 90-day assessments were included. Data analysis was performed from January 2024 to April 2026. nSES, a validated index of neighborhood deprivation. The primary outcomes were 90-day functional status (activities of daily living [ADL] and instrumental ADL [IADL] questionnaire score), depressive symptom burden (Patient Health Questionnaire [PHQ]-8 Score), and quality of life (Stroke-Specific Quality-of-life questionnaire [SS-QoL] score). Associations between nSES and the outcomes were assessed using generalized estimating equations. Among the 2203 individuals with 90-day outcomes from 77 census tracts, 1044 (47.4%) were female, the median (IQR) acute National Institute of Health Stroke Scale score was 3 (1 to 6), and the median (IQR) age was 66 (57 to 75) years. Higher nSES was associated with better outcomes across all measures (PHQ-8 score, β = -1.21 [95% CI, -1.86 to -0.56]; ADL-IADL score, β = -0.20 [95% CI, -0.27 to -0.13]; SS-QoL score, β = 0.20 [95% CI, 0.11 to 0.29]). Shifting all mediator distributions from low-nSES to high-nSES neighborhoods modestly attenuated the association of nSES with PHQ-8 score by 14.1% (95% CI, -36.3% to 64.5%) and accounted for 15.1% (95% CI, -11.0% to 41.2%) of the association of nSES with ADL-IADL score and 5.6% (95% CI, -25.4% to 36.6%) of the association of nSES with SS-QoL score. However, no evaluated factors were statistically significant mediators. In this cohort study of a biethnic urban population with predominantly mild strokes, higher nSES was associated with better outcomes. These differences were not significantly mediated by hyperacute treatment, postacute care resource density, transportation access, or walkability. Future studies should evaluate to what extent time to hyperacute treatment, postdischarge disposition, poststroke therapy intensity, and other factors may underlie differences in stroke recovery by nSES.
Patients with cancer are routinely prescribed extended-spectrum antibiotics despite overall low multidrug-resistant organism (MDRO) prevalence. Evidence for effective strategies to reduce antibiotic overuse in this population is limited. To evaluate the association of computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO risk estimates with empiric extended-spectrum antibiotic use in patients with cancer. This secondary analysis of the 4 Intelligent Stewardship Prompts to Improve Real-Time Empiric Antibiotic Selection (INSPIRE) cluster randomized clinical trials identified non-critically ill hospitalized adults (aged ≥18 years) with discharge diagnosis codes for hematologic or solid organ malignant tumors in the INSPIRE pneumonia, urinary tract infection (UTI), abdominal, and skin and soft tissue infection (SSTI) trials. Each trial evaluated the effect of CPOE prompts that used real-time patient-specific electronic health record data to estimate MDRO infection risk for patients prescribed extended-spectrum antibiotics during the first 3 hospital days; the prompt recommended standard-spectrum antibiotics when the risk of antibiotic-resistant infection was less than 10%. Extended-spectrum antibiotic days of therapy were evaluated using as-randomized, adjusted difference-in-difference analyses with generalized linear mixed-effects models and clustering by patient, hospital, and period. Days to intensive care unit transfer, hospital length of stay, hospital readmissions, and in-hospital mortality were also assessed. In all trials, 36 861 patients (mean [SD] age, 69.0 [13.6] years; 19 076 [52%] female), including 18 272 baseline and 18 589 intervention patients, had cancer. Extended-spectrum antibiotic days of therapy decreased by 27% (rate ratio [RR], 0.73; 95% CI, 0.67-0.80; P < .001) in the pneumonia trial, 24% (RR, 0.76; 95% CI, 0.68-0.84; P < .001) in the UTI trial, 17% (RR, 0.83; 95% CI, 0.74-0.92; P < .001) in the SSTI trial, and 24% (RR, 0.76; 95% CI, 0.69-0.84; P < .001) in the abdominal infection trial. Pre-post changes in hospital length of stay, intensive care unit transfers, readmissions, and in-hospital mortality were similar in the 2 groups. In this secondary analysis of randomized clinical trials, an antibiotic stewardship bundle that included CPOE prompts recommending standard-spectrum antibiotics for patients at low risk for antimicrobial-resistant infections was associated with reduced extended-spectrum antibiotic use in non-critically ill patients with cancer who were hospitalized with community-acquired pneumonia, UTI, SSTI, or abdominal infection, without observed differences in safety outcomes. The findings support scalable, low-burden strategies to improve antimicrobial use in patients with cancer, a population with limited evidence to guide stewardship. ClinicalTrials.gov Identifiers: NCT05423756, NCT05423743, NCT03697070, NCT03697096.