While the United States of America (USA) faces a substantial substance use disorder (SUD) burden on a global scale, relatively little is known about the current trends and future trajectories at both national and state levels. Using the Global Burden of Disease Study 2023, we examined estimates of prevalence and disability-adjusted life years (DALYs) for SUDs in the USA, including alcohol use disorders (AUDs) and drug use disorders (DUDs), across all 50 states and Washington, DC, from 1990 to 2023 and forecasted trends to 2050. In 2023, the USA had the highest age-standardized prevalence of SUDs across the globe. Overall, age-standardized SUD prevalence increased from 4,664.6 (95% uncertainty interval, 4,076.4-5,333.3) estimated rates per 100,000 people in 1990 to 6,430.1 (5,871.7-7,056.3) per 100,000 people in 2023, representing an increase of 37.9%. At the state level in 2023, broader geographical variations were observed in terms of estimated age-standardized DALYs for SUDs. At both the national and state levels, the age-standardized prevalence and burden of DUDs have outpaced and surpassed the increase in AUDs over time. By 2050, if existing trends continue, the age-standardized prevalence of SUDs is projected to rise to 8,956.0 (7,478.8-10,118.4) per 100,000 people, driven primarily by increasing age-standardized prevalence of DUDs, while age-standardized prevalence of AUDs is predicted to increase slightly. These findings suggest that current interventions have been insufficient to curb the SUD crisis. Without urgent, evidence-based reforms, the SUD burden will continue to increase and deepen health disparities across the USA. This work was funded by the Gates Foundation.
暂无摘要（点击查看详情）
In 1988, plastic surgeon Lee Dellon in Annals of Plastic Surgery hypothesized that there was "A Cause for Optimism in Diabetic Neuropathy". He noted that entrapment neuropathy is common in diabetic peripheral neuropathy (DPN) and explained that multiple sites of local nerve entrapment can also produce the classically described clinical picture of progressive and irreversible 'length dependent axonopathy'. This observation has justified for him the use of nerve decompression (ND) surgery for beneficial treatment of DPN pain, diabetic foot ulcer (DFU), ulcer recurrences and their subsequent complications. Subsequent observational and controlled reports have consistently demonstrated post-operative benefit for these problems, but ND has not yet been widely adopted. The lack of an etiologic explanation of the physiology changes which would allow surgery to modify the metabolic disturbances of diabetes has likely been involved in such hesitance. Recent explanations that glycolysis is altered in diabetes through intensified polyol metabolism which produces swollen nerves, local peripheral entrapments and compression neuropathy now provide plausible associations of hyperglycemia with epidermal hypoxia and nutrition deficit. Recognition that nerve enlargements can create secondary fibro-osseous compressions explains the well-known association of diabetes and compression syndromes. Peripheral nerve entrapments damage small c-fibers and produce sympathetic autonomic as well as sensorimotor dysfunction. This explains the diminished skin microcirculation, epidermal hypoxia and nutrition deficit seen in diabetes, DPN, DFU and Charcot neuroarthropathy. Laboratory and clinical evidence has demonstrated that ND in diabetes rejuvenates at least two sympathetically commanded skin microcirculation processes and explains how surgery is producing beneficial results. This article recapitulates the literature which clarifies the processes by which ND surgery can modify painful DPN, DFU occurrence, ulcer healing, DFU recurrence risk, amputations after DFU healing, and bilateral pain relief after unilateral surgery.
This study aimed to examine characteristics of manipulation performed by experienced surgeons in robotic surgery by analyzing log data obtained from the Japanese surgical robot hinotori. Twelve gastrointestinal surgeons performed four tasks (transportation, dissection, single suturing, and continuous suturing), four times each. In total, 24 trials performed by six experienced surgeons were classified as the experienced (E) group, and 24 trials conducted by six less-experienced surgeons were classified as the less-experienced (L) group. Forceps log data were collected using the Medicaroid Intelligent Network, a hinotori network support system. Data on parameters such as instrument travel distance, velocity, acceleration, jerk, normalized mean squared jerk, wrist articulation counts, and scope manipulation characteristics were extracted and compared between the E and L groups. In all tasks, the E group had significantly shorter task durations than the L group. The E group also exhibited higher average velocity, acceleration, jerk, and normalized mean squared jerk values in several tasks, particularly showing shorter travel distances with the right instrument (Arm3) and faster, more dynamically modulated movements with the left instrument (Arm1). Further, compared with the L group, the E group had a significantly longer camera movement per scope pedal press and significantly fewer wrist articulations in the suturing tasks. Experienced manipulation in robotic surgery is characterized by shorter instrument travel distances, intentional modulation of movement speed, and minimal wrist articulation. Quantitative evaluation of operative characteristics using log data can contribute to future applications in surgical training and skill assessment.
To evaluate national trends and clinical outcomes of donation after circulatory death (DCD) simultaneous liver-kidney transplantation (SLKT) in the US, particularly in the modern era following adoption of machine perfusion (MP) and normothermic regional perfusion (NRP). Utilization of DCD donors for liver transplantation has increased substantially in the US, and MP and NRP were reported to reduce complications, including reperfusion syndrome and early allograft dysfunction. However, national trends and outcomes of DCD-SLKT in the contemporary era of organ perfusion have not been characterized. Using UNOS STAR files, we analyzed 10.687 adult primary SLKT performed between 2000 and 2025. Outcomes of DCD and donation after brain death (DBD) SLKT during 2020-2025 were compared using propensity score matching (PSM) to adjust for donor and recipient characteristics. Kaplan-Meier methods were used to assess graft/patient survival. The utilization of DCD-SLKT increased markedly after 2018, accounting for 29.3% of all SLKT cases in 2024. In 2024, liver MP, kidney MP, and NRP were used in 58.1%, 82.9%, and 40.1% of DCD-SLKT cases. Before matching, recipients in the DBD-SLKT group more frequently required dialysis at transplantation (69.1% vs 54.2%) and were hospitalized preoperatively (51.0% vs 17.2%), and had higher MELD scores (30 vs 23) during 2020-2025. Median follow-up was shorter in DCD-SLKT (706 vs 364 days), reflecting the more recent adoption of DCD transplantation. Liver graft/patient survival were comparable between DCD- and DBD-SLKT regardless of PSM. Utilization of DCD donors for SLKT has increased substantially in parallel with the expanding use of MP and NRP, with graft/patient outcomes comparable to those of DBD-SLKT regardless of PSM. However, DBD-SLKT recipients had higher baseline preoperative risk. These support broader adoption of DCD donors for SLKT in appropriately selected recipients.
To assess radiographic progression in patients with early rheumatoid arthritis (RA) and poor prognostic factors treated with certolizumab pegol (CZP)+methotrexate (MTX) versus placebo (PBO)+MTX, stratified by rheumatoid factor (RF) level. In a pooled, post-hoc analysis of phase 3 randomized trials (C-EARLY [NCT01519791] and C-OPERA [NCT01451203], patients were stratified by baseline RF level (low: <200 IU/mL; high: ≥200IU/mL). Change from baseline (Δ) in modified Total Sharp Score (mTSS) and components, predicted risk of RP, and disease activity are reported up to Week (Wk)52. Eight hundred and thirteen CZP+MTX-randomized (low RF: n=571; high RF: n=242) and 367 PBO+MTX-randomized (low RF: n=242; high RF: n=125) patients were included. Baseline characteristics were similar between treatments; however, patients with high RF had more severe disease. The proportion of patients with clinically meaningful radiographic worsening (ΔmTSS >5) at Wk24 was more comparable between patients with high and low RF levels randomized to CZP+MTX (low RF: 1.0% vs high RF: 0.0%) and was numerically lower than with PBO+MTX (2.8% vs 6.5%) and this pattern was maintained through Wk52. Clinical outcomes were generally favorable with PBO+MTX, but better with CZP+MTX. In MTX-naïve patients with early RA, radiographic progression was more similar between CZP+MTX-treated patients with high and low RF levels, and consistently numerically lower, than PBO+MTX-treated patients. Irrespective of RF level, CZP+MTX better attenuated than MTX alone and was associated with more favorable clinical outcomes. Our findings suggest that RF level does not adversely influence radiographic response to CZP+MTX.
Older adults represent an increasing proportion of intensive care unit admissions, but the relationship between country-level human development and outcomes after critical illness remains incompletely understood. We conducted a secondary analysis of three prospective multicentre registries, VIP1, VIP2, and COVIP, including acutely admitted older ICU patients with available Clinical Frailty Scale assessment, country-level Human Development Index (HDI), and 30-day vital status. VIP1 and VIP2 enrolled patients aged ≥80 years, whereas COVIP enrolled patients aged ≥70 years. The primary exposure was exceptionally high human development, defined as HDI ≥ 0.90 versus <0.90. The primary outcome was 30-day mortality. Associations were assessed using logistic regression with robust standard errors clustered by country, adjusting for age, sex, SOFA score, frailty, admission diagnosis, organ support modalities, and treatment-limitation decisions. Exploratory mediation analyses examined selected ICU management variables as potential pathways linking HDI to mortality. Among 9920 patients included in the primary analysis, 8324 (83.9%) were treated in countries with HDI ≥ 0.90 and 1596 (16.1%) in countries with HDI < 0.90. Thirty-day mortality was lower in high-HDI countries than in lower-HDI countries (40.0% vs. 53.3%). In unadjusted analysis, HDI ≥ 0.90 was associated with lower 30-day mortality (OR 0.58; 95% CI 0.38-0.90; P = 0.016). This association persisted after multivariable adjustment (adjusted OR 0.49; 95% CI 0.31-0.80; P = 0.004) and was similar after additional adjustment for study cohort (aOR 0.49; 95% CI 0.31-0.77; P = 0.002) and ICU bed capacity (aOR 0.50; 95% CI 0.29-0.86; P = 0.013). When modelled continuously, higher HDI was associated with lower mortality after full adjustment (OR 0.33 per 0.10-unit increase; 95% CI 0.19-0.56; P < 0.001). Exploratory mediation analyses suggested that lower use of invasive mechanical ventilation in high-HDI countries may partially contribute to the observed association (NIE OR 0.86; 95% CI 0.83-0.89). Mediation analyses involving treatment-limitation decisions were more difficult to interpret because these decisions are closely linked to prognosis, clinical trajectory, and end-of-life practice. In this large European cohort of older critically ill patients, treatment in countries with exceptionally high human development was associated with lower 30-day mortality. The association persisted after adjustment for patient-level severity, frailty, treatment limitation, organ support, study cohort, and ICU bed capacity. These findings suggest that country-level development and ICU management patterns, particularly invasive ventilation practices, may contribute to outcome differences. Because this was an observational secondary analysis using country-level exposure data, causal interpretation should remain cautious.
暂无摘要（点击查看详情）
Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have reshaped the clinical approach to managing obesity and type 2 diabetes. As approved indications have expanded, use of GLP-1RAs has increased rapidly in the United States. Although randomized trials demonstrate strong efficacy, many questions remain about their optimal use in clinical practice. Real-world data (RWD) from electronic health records, registries, insurance claims, and other sources offer a promising avenue to address these questions. However, concerns about data quality, selection bias, and incomplete ascertainment of medication use and outcomes pose significant challenges to the validity of the resulting evidence. In May 2025, the National Institute of Diabetes and Digestive and Kidney Diseases convened experts from regulatory agencies, payer organizations, and academia to explore these challenges. This second of 2 synopsis articles on the workshop summarizes the discussion around the strengths and limitations of various RWD sources and methodological approaches to strengthen causal inference and generalizability. Presenters highlighted pragmatic clinical trials and target trial emulation as strategies to generate stronger real-world evidence (RWE) that is relevant to both clinical practice and policy. The workshop underscored that careful attention to study design, data limitations, and analytic approach is essential to yield RWE that informs clinicians, patients, payers, and policymakers.
Minimally invasive anatomic liver resection (AR) is technically demanding, and the efficacy of robotic surgery in AR remains unestablished. This systematic review aims through a meta-analysis to compare surgical outcomes between robotic (RAR) and conventional laparoscopic (LAR) AR. A systematic literature search of relevant studies published between 2001 and 2024 in PubMed/MEDLINE, Embase and Cochrane Library was carried out, and 15 studies were selected. Meta-analysis was performed to compare perioperative outcomes between RAR and LAR. A total of 4171 patients comprising 2042 RAR and 2129 LAR patients who underwent major hepatectomy or liver parenchyma-sparing AR (PSAR) were included. All included studies were retrospective comparative studies, including eight using propensity score-matched analysis. Meta-analysis demonstrated that as primary outcomes, the 30-day and 90-day mortalities and postoperative overall morbidity were comparable between RAR and LAR, while RAR had significantly less morbidity≥Clavien-Dindo grade II and a lower rate of open conversion. As secondary outcomes, compared to LAR, RAR showed significantly less blood loss and shorter postoperative hospital stay, while RAR had a higher rate of postoperative 30-day readmission. Operative time, blood transfusion, Pringle maneuver, R0 resection, and reoperation were comparable. Subgroup meta-analyses showed a lower rate of blood transfusion in robotic PSAR and a lower rate of open conversion in RAR in the right cranial regions. This large-scale meta-analysis of minimally invasive AR suggests that RAR can confer comparable or partly better perioperative outcomes as compared to LAR, indicating potential advantages of the robotic approach to AR.
Posthepatectomy liver failure (PHLF) is a serious complication of major hepatectomy and is closely related to perioperative mortality. Whether or not indocyanine green (ICG) is used to measure liver function varies by country. Using machine learning, we aimed to develop two highly accurate, user-friendly models for predicting PHLF depending on whether ICG data were used. This was a retrospective, three-center study. SHapley Additive exPlanations (SHAP) evaluated the feature importance of Random Forest (RF) analysis. SHAP quantitatively assessed the impact of each feature on model predictions and identified the three most important features in both ICG-used and ICG-unused models. A Decision Tree (DT) model was constructed using two of these three key features to enhance clinical interpretability. PHLF was defined as Grade B or C according to the International Study Group of Liver Surgery. Feature importance was calculated using the SHAP analysis, in the ICG-used model the ICG clearance rate (ICGK) multiplied by the percentage of remaining liver measured by CT volumetry (ICGK-F), CRP, and operative procedure were identified as the three highest factors, whereas the predicted liver resection rate, CRP, and total bilirubin were identified as the most important features in the ICG-unused model. In the constructed DT model, we categorized the cases into negative and positive, and the negative cases were further classified into three categories based on their risks. These models may offer a simple and practical approach for predicting the risk of PHLF and hold promise for future clinical application.
Emergency cholecystectomy for acute cholecystitis remains controversial in patients classified as high risk by the Tokyo Guidelines 2018 (TG18), although surgery is often unavoidable in real-world emergency settings. The perioperative risk profile of this TG18 non-recommended population remains insufficiently defined. The objective of this study was to examine perioperative outcomes in patients undergoing emergency cholecystectomy against TG18 recommendations, while also exploring clinical factors associated with actual operative risk. This retrospective cohort study included 252 consecutive patients who underwent emergency cholecystectomy for acute cholecystitis between 2018 and 2025. Patients were stratified into TG18 emergency-surgery-recommended and non-recommended groups. Perioperative outcomes were compared, and independent risk factors of major postoperative complications, defined as Clavien-Dindo grade≥III events, were evaluated. Major postoperative complications occurred in 11.9% of patients and were significantly more frequent in the TG18 non-recommended group than in the recommended group (18.0% vs. 2.9%, p < 0.001). In multivariable analysis, American Society of Anesthesiologists physical status classification ≥ 3 and preoperative shock status were independent predictors of major postoperative complications, whereas age and Charlson Comorbidity Index were not. Exploratory stratification of the non-recommended cohort demonstrated substantial heterogeneity in risk, with comparatively low complication rates observed in patients without physiological instability. Emergency cholecystectomy may be feasible in carefully selected TG18 non-recommended patients. Perioperative risk appears to be driven by physiological instability rather than chronological age or comorbidity burden, supporting a more individualized approach to surgical decision-making.
Italy is a major hub for migration routes. Disparities in health management across different geographic regions, particularly among individuals with type 2 diabetes mellitus (T2D), are well recognized, yet comprehensive data on the quality of T2D care in migrant populations remain limited. Quality indicators of T2D care were analyzed for foreign patients compared with European patients using the 2022 AMD Annals database. The Italian National Institute of Statistics classification defined geographic origins. Data on country of origin were available for 179,536 T2D patients, with 19.3% being foreign, mainly from North Africa, Central and Eastern Europe, Central and South Asia, Central and South America.Foreign T2D patients were generally younger, resulting in shorter disease duration. While annual screening rates for risk factors and major complications were as European subjects, critical gaps were noted in microalbuminuria and retinopathy assessments. Treatment intensity was lower for patients from North and West Africa and Central and South Asia, though the use of innovative therapies like GLP-1RAs and SGLT2i was comparable to European patients. The overall quality of care, measured by the Q-score, was lowest in West African patients (26.4 ± 9.1 vs. 29.1 ± 8.0), while 51.6% of those from Central and South Asia had satisfactory care quality (Q-score > 25). Study showed differences in age, disease duration, and treatment among patients from various geographic regions, while indicating equitable access to therapies and comparable overall quality of care. These findings may inform management strategies to improve T2D care for migrant populations.
Intimate partner violence (IPV) is a significant problem; however, researchers and clinicians have not paid much attention. To assess the prevalence of IPV among married rural women and its correlates. This cross-sectional study was conducted in a rural area. All the eligible females were assessed on the Intimate Partner Violence Questionnaire (IPVQ), Generalised Anxiety Disorder Questionnaire-7 (GAD-7) and Patient Health Questionnaire (PHQ)-9. 169 females included with the mean age of 35.8 years. The prevalence of lifetime experience of IPV was 29.0%. Controlling behaviour was most common, followed by physical violence, threatening behaviour and sexual behaviour. About one-fourth (26%) had depres-sion, and a little less than one-third (30.8%) had an anxiety disorder. Severity of depression and anxiety had a significant posi-tive correlation with IPV and other domains of IPV. Those participants whose husbands were consuming alcohol or other illicit drugs and were from a lower socio-economic status reported a significantly higher experience of IPV. The stakeholders, such as community health organisations, Ministry of Family and Healthcare organisations and others, should work in collaboration with a non-govern-mental organisation in a coordinated and planned manner and can take a pivotal role in research, prevention of IPV and other psychiatric problems among rural females.
Despite calls to publish negative studies in prominent medical journals, greater submission and acceptance of positive results remains an issue. We aimed to quantify the degree to which high-impact general medical journals publish negative study results. We searched MEDLINE/PubMed for all randomized controlled trials published in five high-impact general medicine journals: Annals of Internal Medicine, the British Medical Journal (BMJ), the Journal of the American Medical Association (JAMA), the Lancet, and the New England Journal of Medicine (NEJM). Our search spanned a 10-year period from 2014 to 2023, which included data from before and after the emergence of the COVID-19 global pandemic. We performed single-author data extraction via abstract review to determine study positivity, defined as statistical significance for the primary outcome, flagging abstracts for secondary review if positivity was not clear. Two authors reviewed all flagged abstracts. We calculated the proportion of negative studies (i.e., not meeting statistical significance for the primary outcome) overall, by journal, and by publication year. We used logistic regression to model the odds of a study reporting a negative result by journal and year. Our search yielded 3722 individual citations, with screening resulting in 3600 randomized controlled trials for review, with 31% of studies reporting negative results. The proportion of negative studies varied, ranging from 22% in the Lancet to 51% in BMJ and JAMA. The proportion of negative studies remained consistent over time. High-impact general medical journals vary widely in the percentage of negative studies that they publish but did not change over time, even during and after a global pandemic. Further study is needed to determine factors influencing this phenomenon and what can be done to minimize publication bias.
Background: Maternal and child outcomes in Sierra Leone continue to reflect rural-urban inequities in access to care and timely healthcare-seeking. Understanding how predisposing, enabling, and illness-level determinants interact across settings is essential for explaining these disparities. Objectives: To examine how predisposing, enabling, and illness-level factors influence maternal and child healthcare-seeking decisions in Bo District, and to quantify rural-urban differences in these determinants. Methods: We conducted a facility-based cross-sectional study among 500 women attending antenatal, postnatal, or child health services at an urban tertiary hospital and a rural maternity facility. Descriptive statistics summarized participant characteristics. Rural-urban differences were assessed using Pearson's chi-square tests, odds ratios with 95% confidence intervals, Mann-Whitney U tests for ordinal outcomes, and Cramér's V to estimate effect sizes. Findings: Predisposing influences on maternal healthcare-seeking were ubiquitous (97.4%), with knowledge and health awareness most frequently reported. Predisposing influences didn't differ by residence; however, cultural factors were significantly prominent among rural women (p = 0.004; Cramér's V = 0.14). Enabling factors showed the strongest rural-urban differentiation, with small-to-moderate effect sizes. Urban respondents more often reported health insurance coverage, financial stability, proximity to facilities, and transportation availability, whereas rural respondents more frequently reported traditional social, language, and communication support, perceived infrastructure adequacy, preventive service availability, and community engagement. Pregnancy-/childbirth-related complications were common (68.2%) and didn't differ by residence; however, the perceived influence of illness on care-seeking differed significantly between settings (p < 0.001; Cramér's V ≈ 0.21). For childcare-seeking, knowledge and awareness were foundational across settings, while financial protection and prior healthcare experience exerted greater influence among urban caregivers. Conclusions: Rural-urban differences in maternal and child healthcare-seeking in Bo District appear driven less by awareness or illness occurrence and more by context-specific enabling conditions and differences in how illness is interpreted and acted upon.
暂无摘要（点击查看详情）
Feeding enterostomy is commonly created during minimally invasive esophagectomy (MIE); however, its short-term impact remains unclear. We analyzed 19 054 patients who underwent MIE for esophageal or esophagogastric junction cancer during 2019-2022. Inverse probability of treatment weighting was applied to balance baseline characteristics, and G-computation was used to estimate adjusted risks and means and their differences. A secondary analysis was performed to compare gastrostomy and jejunostomy in retrosternal cases. Of 19 054 patients, 4599 (24.1%) received a feeding enterostomy. After adjustment, the primary outcome, postoperative bowel obstruction, did not differ significantly between enterostomy group and no-enterostomy group (+0.2%, p = 0.132). The enterostomy group demonstrated higher rates of reoperation (+2.5%, p < 0.001) and respiratory complications, including pneumonia (+2.5%, p < 0.001) and prolonged ventilation (+0.9%, p = 0.012), than the no-enterostomy group. Conversely, delayed gastric emptying (-0.9%, p < 0.001) and deep vein thrombosis (-0.4%, p = 0.028) occurred less frequently. Among 2723 patients who underwent retrosternal reconstruction with feeding enterostomy, jejunostomy was associated with a shorter operative time (-11.2 min, p = 0.025), whereas gastrostomy was associated with a 2.3-day shorter hospital stay than jejunostomy (p = 0.022). Bowel-related events were rare, and adjusted comparisons for these outcomes were not performed. Feeding enterostomy during MIE may confer benefits (e.g., reduced delayed gastric emptying and deep vein thrombosis) but is also associated with increased postoperative complications. Routine or uniform placement of a feeding enterostomy should be avoided, and gastrostomy may be preferable in retrosternal reconstruction.