The evidence linking blood pressure (BP) variability (BPV) to longitudinal lung function decline remains unclear. This cohort study aims to reveal the association between BPV and lung function decline among population over 45 years old. Participants were from the Health and Retirement Study (HRS) and the China Health and Retirement Longitudinal Study (CHARLS). Lung function was assessed by peak expiratory flow (PEF), and was standardized using Z-score transformation. Variation independent of mean (VIM) was mainly used to assess BPV. A linear mixed model was conducted. Subgroup analyses across age, sex, body mass index (BMI), and hypertension status were employed. A meta-analysis was performed to pool results, with heterogeneity reported. A total of 6,930 and 5,119 eligible participants from HRS and CHARLS were included, respectively. With increment of VIM, participants' PEF decreased. Pooled analysis revealed that increased BPV was significantly associated with faster lung function decline [β for systolic BP: -0.224, 95% confidence interval (CI): -0.323 to -0.126; β for diastolic BP: -0.08, 95% CI: -0.011 to -0.005]. Compared with participants in the lowest tertile of VIM, those in the middle and highest tertiles showed greater declines. Subgroup analysis demonstrated that sex modified this association, with a more pronounced effect observed in males (pooled β for systolic BP: -0.347, 95% CI: -0.669 to -0.025; pooled β for diastolic BP: -0.012, 95% CI: -0.019 to -0.005). BPV is significantly associated with lung function decline in middle-aged and older adults, and this association is more pronounced in males. More early intervention for individuals with higher BPV is needed, particularly for males.
Rotavirus is a major cause of acute gastroenteritis in children. This study assessed the frequency and clinical characteristics of rotavirus infection in children under five years old. This cross-sectional study was conducted in 2020 on children with acute gastroenteritis. Clinical and demographic data were collected, dehydration severity was assessed by a pediatrician, and stool samples obtained within 48 hours of admission were tested for rotavirus antigen using ELISA. A total of 301 children with acute gastroenteritis were included. Rotavirus antigen was detected in 34.6% of cases. Vomiting (81.2%) and diarrhea (96.1%) were significantly common among rotavirus-positive children (p = 0.01). Severe dehydration (>10%) and the need for parenteral rehydration were observed more frequently among rotavirus-positive children compared with rotavirus-negative cases (20.9% vs. 9.2%, p = 0.02 and 91.1% vs. 78.1%, p = 0.01, respectively). However, these findings should be interpreted cautiously, as clinical severity may also have been influenced by other demographic and clinical factors. Rotavirus was detected in a considerable proportion of children with acute gastroenteritis in southern Iran. Rotavirus-positive cases showed more frequent severe dehydration, although this finding should be interpreted cautiously. Early assessment and supportive care remain important.
Advanced age is often associated with increased technical difficulty during lung resection; however, the mechanisms underlying age-related operative burden during segmentectomy remain unclear. This study aimed to evaluate age-related differences in pleural adhesion, operative complexity, and perioperative outcomes in patients undergoing uniportal video-assisted thoracoscopic surgery (VATS) segmentectomy for lung cancer. Consecutive patients who underwent uniportal VATS segmentectomy were retrospectively reviewed. Patients were stratified into two groups according to age (<70 vs. ≥70 years). Baseline characteristics, radiologic and operative findings, pleural adhesion status, and postoperative outcomes were compared between the groups. Pleural adhesion was categorized as absent, partial, or whole. Continuous variables were compared using the Student's t-test or Wilcoxon rank-sum test, as appropriate. Multivariable logistic regression was performed to identify independent predictors of pleural adhesion. A total of 814 patients were included, of whom 683 were aged <70 years and 131 were aged ≥70 years. Pleural adhesion was significantly more frequent in patients aged ≥70 years than in those aged <70 years (26.7% vs. 8.8%, P<0.001), and whole pleural adhesion was also more common in the elderly group (5.3% vs. 1.8%, P=0.02). In multivariable analysis, age remained independently associated with pleural adhesion (adjusted OR 1.11 per year increase, 95% CI: 1.08-1.14, P<0.001). Patients aged ≥70 years demonstrated greater operative burden, with longer operative time (median 91 vs. 89 minutes, P=0.002) and longer postoperative chest tube duration {median [interquartile range]: 1 [1-3] vs. 1 [1-1] days, P<0.001}. The incidence of postoperative complications was significantly higher in the elderly group (12.2% vs. 3.8%, P<0.001), including a higher rate of prolonged air leak. Surgical margin distance was comparable between the two groups. Elderly patients undergoing uniportal VATS segmentectomy exhibited a significantly higher incidence of pleural adhesion and were associated with longer operative time and postoperative drainage, as well as higher complication rates. Nevertheless, acceptable postoperative outcomes can be achieved, supporting the feasibility of segmentectomy in carefully selected elderly patients.
Uterine fibroids are highly prevalent globally. However, evidence on the effects of menopausal hormone therapy (MHT) on fibroid growth during menopausal transition remains limited. This study explores the association between MHT and the size of uterine fibroids in women during the menopausal transition. This retrospective observational study enrolled women during menopausal transition with uterine fibroids who received sequential menopausal hormone therapy (estradiol combined with dydrogesterone) at Nanjing Women and Children's Healthcare Hospital from January 2016 to August 2023. Serial ultrasound examinations were performed to dynamically monitor changes in fibroid cross-sectional area during follow-up. A linear mixed-effects model was applied to explore the long-term impact of menopausal hormone therapy on fibroid size alterations over time. Furthermore, all adverse events occurring during hormone therapy were systematically recorded and summarized. A total of 83 patients were enrolled, with a maximum follow-up of 5 years post-treatment. Although statistically significant differences from baseline in fibroid cross-sectional area were observed during the first four years of follow-up, these changes were marginal and clinically unremarkable and undetectable at year 5. Most adverse events were transient and resolved spontaneously. The incidence rates of unexpected bleeding, breast discomfort and gastrointestinal symptoms were 18.07%, 10.84% and 2.41%, respectively. Findings suggest that women during menopausal transition that receiving MHT may experience transient, minor changes in fibroid size. These changes are not considered clinically meaningful, and MHT exhibits an overall favorable safety profile for this group. With regular surveillance and use of the lowest effective dose, MHT represents a safe and practical therapeutic choice. Additional prospective investigations are needed to characterize the long-term dynamic changes of fibroids associated with MHT. Uterine fibroids are the most common gynecological tumors in women worldwide. This retrospective study examined the association between MHT and fibroid size changes in women undergoing menopausal transition. A total of 83 patients received sequential MHT (estradiol plus dydrogesterone). Over 5 years of follow-up, a dynamic change in fibroid cross-sectional area was observed. Specifically, statistically significant differences from baseline were observed in the first four years and resolved by the fifth year. Given the modest magnitude of these variations, the effects of MHT on uterine fibroids are clinically acceptable. Most reported adverse events were transient and resolved without intervention. With appropriate monitoring and adherence to the lowest effective dose principle, MHT is a feasible option for women initiating MHT during the menopausal transition. Further prospective studies are needed to validate this dynamic change pattern and its clinical implications.
Robotic mitral valve (MV) repair has evolved as a minimally invasive surgical approach for mitral regurgitation (MR). However, evidence regarding its safety and clinical outcomes in octogenarians remains limited. This study was performed to evaluate the feasibility and early outcomes of robotic MV repair in octogenarians compared with younger patients. We retrospectively reviewed consecutive patients who underwent totally endoscopic robotic MV repair for MR between September 2019 and September 2024 at Osaka Metropolitan University Graduate School of Medicine. Both degenerative and functional MR were included. Patients were divided into two groups according to age: octogenarians (≥80 years) and younger patients (≤65 years). Preoperative characteristics, operative findings, and postoperative outcomes were compared. Postoperative physical function in older patients was evaluated using the Short Physical Performance Battery (SPPB). Among 170 robotic MV repair cases, 16 patients were aged ≥80 years and 101 patients were aged ≤65 years. Older patients had a higher prevalence of hypertension [14 (88%) vs. 51 (50%); P=0.006], dyslipidemia [6 (38%) vs. 14 (14%); P=0.03], respiratory disorders [4 (25%) vs. 2 (2%); P=0.003], and atrial fibrillation [9 (56%) vs. 13 (13%); P<0.001]. Preoperative echocardiography showed severe MR in all patients, and 10 older patients (63%) had more than moderate tricuspid regurgitation (TR). Concomitant procedures, including tricuspid valve repair [7 (44%) vs. 10 (10%); P=0.002], Maze procedure [7 (44%) vs. 10 (10%); P=0.002] and left atrial appendage closure [8 (50%) vs. 9 (9%); P<0.001], were performed more frequently in octogenarians. Echocardiography at 1 week after surgery and at the 1-year follow-up showed that MR and TR were reduced to no more than mild in all older patients. Comparison of preoperative and postoperative SPPB scores showed no significant differences in any component (balance, gait speed, or chair stand), and all older patients were discharged home without major complications. Robotic MV repair in carefully selected octogenarians was feasible and associated with favorable early clinical outcomes. Concomitant procedures could be safely performed without deterioration of postoperative physical performance. Robotic MV surgery may represent a reasonable treatment option for older patients.
Marfan syndrome (MFS) is a heritable connective tissue disorder associated with a heightened risk of acute type A aortic dissection (ATAAD). The long-term impact of MFS on outcomes following total arch replacement with frozen elephant trunk (TAR with FET) remains poorly characterized. This study aimed to evaluate this impact in a large cohort from a single high-volume aortic center. Patients with ATAAD who underwent TAR with FET at Fuwai Hospital (2010-2018) were categorized into MFS and non-MFS groups. Long-term follow-up was complete for all surviving patients, with a median follow-up of 6.08 years (terminating in December 2023). Clinical characteristics and long-term follow-up outcomes were analyzed, with primary endpoints including survival, reoperation rates, and functional status. Multivariable logistic regression and competing risks Cox regression models were employed to identify independent predictors of outcomes. Among 1,086 patients with a mean age of 46.6 years (104 MFS, 982 non-MFS), Marfan patients were significantly younger (36.1 vs. 47.7 years, P<0.001) with higher rates of previous cardiovascular surgery (11.5% vs. 2.2%, P<0.001) and root replacement (76.0% vs. 22.7%, P<0.001). Overall operative mortality was 7.4% (80/1,086) with no significant between-group difference. At median follow-up of 6.08 years, 10-year survival was 80.6% and comparable between groups (P=0.22). Over 90% of survivors maintained complete self-care ability. Among 67 total reoperations, 25 occurred in Marfan patients. MFS remained an independent risk factor for reoperation (hazard ratio 2.06, 95% confidence interval: 1.18-3.59, P=0.01). While MFS does not compromise long-term survival in ATAAD patients undergoing TAR with FET, significantly elevated reoperation rates necessitate specialized long-term surveillance.
Lung transplantation (LT) remains a life-saving intervention for patients with end-stage lung disease, but recipient age continues to be a key determinant of long-term outcomes. As the candidate population ages and allocation policies shift, understanding how age and donor-recipient variables impact survival is increasingly critical. This study aimed to evaluate the association between recipient age and long-term survival after LT, and to characterize age-specific differences in mortality risk factors in a national cohort. We conducted a retrospective cohort study of 30,494 adult LT recipients using data from the Scientific Registry of Transplant Recipients (SRTR) from 2006 to 2022. Recipients were stratified by age at transplant into three groups: 18-64, 65-69, and ≥70 years. Primary outcome was all-cause mortality; secondary outcomes included graft dysfunction, rejection rates, and cause of death. Kaplan-Meier and Cox proportional hazards models were used to evaluate survival risk factors. Survival declined progressively with increasing age, with recipients aged ≥70 years showing significantly lower 5-year survival. Multivariable analysis identified treated rejection, low body mass index (BMI), pre-transplant intensive care unit (ICU) stay, and post-transplant dialysis as independent predictors of mortality. The impact of risk factors varied by age: rejection had less effect in older recipients, extracorporeal membrane oxygenation (ECMO) predicted mortality only in younger patients, and dialysis was significant mainly in the 65-69 years group. Importantly, donor age and sex did not significantly affect survival. Advanced recipient age is independently associated with reduced long-term survival after LT, and this association persists after adjustment for donor and procedural factors. The relative importance of risk predictors varies across age groups, highlighting distinct, age-dependent risk profiles that may inform candidate selection and counselling. Together, these findings underscore the need to further refine selection strategies to support the ethical and effective allocation of scarce donor lungs.
Electronic cigarette (e-cig) use (vaping) has been associated with dysregulation of genes and molecular pathways in epithelial tissues. However, the relative contributions of dose and product characteristics to vaping-associated transcriptomic alterations have not been systematically evaluated. We performed RNA-sequencing of oral epithelial cells from e-cig users (vapers), cigarette smokers, and non-users. Differential gene expression was assessed using covariate-adjusted limma-voom modeling with false discovery rate control. We evaluated the extent to which exposure-specific dose metrics (including cumulative e-liquid, cumulative e-nicotine, years vaped, and plasma cotinine for vaping, and pack-years and plasma cotinine for smoking) explained transcriptional changes. Among vapers, we additionally examined whether device generation and flavor type contributed to variation in gene expression. Both vaping and smoking were associated with transcriptomic dysregulation relative to non-users, with partial overlap in differentially expressed genes (DEGs). Functional enrichment analyses revealed disruption of shared cancer- and signaling pathways, including RHO GTPase Cycle, as well as perturbation of pathways specific to vapers or smokers. Among vapers, 27.6% of DEGs showed concordant behavior across all dose metrics, indicating heterogeneous dose-response patterns for the remaining DEGs. Device generation and flavor type explained additional, largely non-overlapping components of gene expression variability. A much higher proportion of smoking-associated DEGs (54.1%) was consistently affected across dose metrics, reflecting more unified dose-dependent responses. These findings suggest that vaping-associated transcriptional dysregulation reflects combined influences of dose and product characteristics, highlighting structural differences in molecular perturbations between vaping and smoking. Incorporating multidimensional exposure metrics and product features into regulatory evaluation may better capture the biological complexity of e-cig exposure, thus informing clinical, public health practice, and regulatory decisions.
Bronchodilator responsiveness (BDR) is a common indicator in chronic obstructive pulmonary disease (COPD), but its clinical relevance remains controversial. Traditional spirometry may fail to detect small airway reversibility, which can be captured by maximum mid-expiratory flow (MMEF). The clinical significance of combined-BDR (integrating spirometric indices and MMEF) in guiding phenotype-based and individualized COPD management under current Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations remains unclear. This study aimed to investigate the clinical significance of combined-BDR in patients with COPD. In this single-center prospective study, a total of 137 patients with stable COPD were enrolled [post-bronchodilator forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) <0.70, age ≥40 years, smoking ≥10 pack-years]. Combined-BDR was defined as ≥12% and ≥200 mL increase in FEV1 or FVC and/or ≥30% increase in MMEF post-bronchodilator. Symptoms [COPD Assessment Test (CAT), modified Medical Research Council (mMRC) dyspnea scale, and St. George's Respiratory Questionnaire for COPD (SGRQ-C)], lung function, and moderate-to-severe exacerbations were assessed at baseline and 12 months. Multivariable regression and linear mixed-effects models were used to evaluate the associations between combined-BDR and clinical outcomes. Of 137 patients, 49 (35.8%) exhibited Combined-BDR, while 88 (64.2%) did not. Baseline demographic characteristics, including age, sex, body mass index (BMI), smoking status, and fractional exhaled nitric oxide (FeNO) levels, were comparable between the two groups. Patients with combined-BDR had significantly higher mMRC scores (P<0.01), CAT total scores (11.73±6.29 vs. 9.26±5.71, P=0.02), and lower baseline FEV1 (1.32±0.45 vs. 1.78±0.72 L, P<0.001). Over 12 months, patients with combined-BDR demonstrated greater improvements in pre-bronchodilator FEV1 [adjusted mean difference 0.12 L, 95% confidence interval (CI): 0.02-0.21, P=0.02] and FVC (adjusted mean difference 0.22 L, 95% CI: 0.04-0.39, P=0.02). Combined-BDR identifies a distinct COPD phenotype characterized by a higher baseline symptom burden but greater functional improvement following inhaled therapy, highlighting its potential value for phenotype-guided and individualized disease management.
Early diagnosis of invasive fungal diseases (IFD) remains a major clinical challenge due to pathogen diversity and nonspecific symptoms. This study used metagenomic next-generation sequencing (mNGS) technology to comprehensively characterize fungal profiles across various clinical specimens and the demographic characteristics (sex and age) of the patient population. The results provide laboratory evidence to support the diagnosis and treatment of fungal infections. A total of 11,161 mNGS reports from clinical specimens collected at the Renmin Hospital of Wuhan University between March 2022 to August 2024 were retrospectively analyzed. Fungal spectra and patient demographics were comprehensively profiled and compared across different specimen types. The highest fungal detection rate was observed in bronchoalveolar lavage fluid (36.85%, 1,985/5,387), followed by urine (22.76%, 264/1,160), blood (13.38%, 380/2,840), pleural and peritoneal fluid (12.91%, 174/1,348), cerebrospinal fluid (CSF) (13.82%, 17/123), and wound exudates (12.87%, 39/303). Candida species were the most frequently detected fungi across all specimen types except CSF, wherein Aspergillus predominated. Overall fungal detection rates were significantly higher in male patients than in female patients (26.76% vs. 23.84%, P < 0.01) and in individuals aged > 60 years compared with those aged ≤ 60 years (33.04% vs. 20.02%, P < 0.001), although this trend varied by specimen type. Multivariate logistic regression analysis confirmed that male sex (adjusted odds ratio [aOR]=0.893,95% confidence interval: 0.824-0.967, P = 0.006) and advanced age (≥80 years: aOR=14.77,95% confidence interval: 12.08-18.06, compared with minors) were independent risk factors for fungal detection. Among fungal-positive specimens, 68.28% (1,952/2,859) were co-detected with bacteria, and 15.63% (447/2,859) showed polyfungal detection (≥ 2 fungal species). In conclusion, our findings highlight the predominance of Candida and Aspergillus, identify elderly male patients as a high-risk population, and underscore the high frequency of bacterial-fungal co-detection. Overall, Clinicians should combine mNGS results with imaging, conventional fungal tests (G/GM assays, culture), and clinical presentation for a more accurate diagnosis of IFD.
Although trauma has been widely documented as a key risk factor for substance use among military personnel, there is a notable paucity of research on the factors that may mitigate trauma-related substance use in this population. The present study examined the moderating role of organizational trust in the relationship between psychological trauma and substance use among military personnel in Nigeria. Using a cross-sectional design, 250 military personnel aged between 26 and 60 years (mean age = 34.99 years, SD = 9.23; males = 187 [74.8%], females = 63 [25.2%]) were conveniently sampled from a military formation in South-eastern Nigeria. Participants completed relevant measures. Results indicated that psychological trauma was positively associated with substance use, whereas, organizational trust had a negative relationship with substance use, and also moderated the relationship between psychological trauma and substance use. Specifically, individuals with higher levels of organizational trust reported fewer issues with substance use due to their trauma, suggesting that the presence of organizational trust mitigated the impact of psychological trauma on the use of substance among military personnel. Thus interventions designed to reduce the negative impacts of psychological trauma should focus on fostering and reinforcing a sense of trust in the military while taking into consideration individual characteristics and experiences of military personnel in order to maximize the effectiveness of the intervention.
Respiratory syncytial virus is the most common virus causing acute respiratory infections in children under 5 years old. We aimed to investigate the prevalence and circulating strains of RSV in hospitalized children in Isfahan. Between January and May 2024, children under 5 years of age were enrolled in this study. Nasal swabs were collected from 100 children with acute respiratory infections admitted to the referral pediatric ward at Imam Hossein Children's Hospital in Isfahan, Iran. The prevalence of circulating RSV was investigated using the RSV qPCR detection kit. The virus type was identified by RT-PCR using type A- and B-specific primers. A total of 51 (51%) samples tested positive for RSV. Among them, typing was done in 33 specimens, of which 66.6% (22/33 cases) were assigned as subtype B and 33.3% (11/33 cases) as subtype A. Infants under 6 months were most severely affected by RSV (47.1%, 24/51). RSV-positive samples peaked in February (43.1%), followed by January (29.4%). The results of the current study revealed a high prevalence of RSV and co-circulation of subtypes A and B, with subtype B more prevalent among children. This highlights the importance of ongoing surveillance of RSV.
Connective tissue disease-associated interstitial lung disease (CTD-ILD) is a severe complication, yet early objective detection of pulmonary structural and microvascular alterations remains challenging. This study aimed to quantitatively compare pulmonary structural alterations between connective tissue disease (CTD) patients with and without interstitial lung disease (ILD) and to identify independent computed tomography (CT)-derived discriminators for ILD diagnosis by means of quantitative computed tomography (QCT). Fifty-one CTD patients with ILD (median age, 51 years; 66.7% female) and thirty-three CTD patients without ILD (median age, 33 years; 69.7% female) who underwent paired inspiratory and expiratory non-contrast chest computed tomography (CT) scans and pulmonary function testing were retrospectively collected. The lung density, functional small airway and pulmonary vessel parameters were analyzed using computer software. Differences in these CT quantitative parameters between the patients with CTD-ILD and those with CTD without ILD were compared using Mann-Whitney U tests. Furthermore, univariable and multivariable logistic regression analyses were used to establish nomograms to identify the independent predictors associated with the presence of ILD in patients with CTD. The calibration curve evaluates the predictive accuracy, while the decision curve analysis (DCA) evaluates clinical applicability. The forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), diffusing capacity of the lungs for carbon monoxide corrected for alveolar volume (DLCO/VA) and diffusing capacity of the lungs for carbon monoxide (DLCO) of the CTD with ILD group were significantly lower than those of the CTD without ILD group (all P<0.05). CTD with ILD group had higher percentages of high-attenuation area on inspiratory and expiratory CT (HAA%-IN and HAA%-EXP) (both P<0.05), and lower percentage of low-attenuation area on expiratory CT (LAA%-EXP), functional air trapping (fAT) volume, functional small airway disease (fSAD) volume and fSAD volume ratio (all P<0.001). Additionally, pulmonary vascular parameters including No. vessels, No. vessels cross-sectional area (CSA) <5 mm2 at 6, 12 and 24 mm depth from the pleural surface, BV1, BV5, BV10 and total blood volume (TBV) were significantly decreased in CTD-ILD patients (all P<0.001). Multivariate Ridge regression identified age, sex, DLCO%, FEV1%, EXP HAA%, fSAD ratio, and No. vessels_12mm as independent diagnostic predictors associated with the presence of ILD (all P<0.05). The combined diagnostic model achieved an area under the curve (AUC) of 0.963 [95% confidence interval (CI): 0.920-0.998], with an accuracy of 0.893, sensitivity of 0.941 and specificity of 0.818. The calibration curve demonstrated high consistency between predicted probabilities and actual outcomes. QCT can serve as a crucial and highly promising imaging biomarker for the diagnosis and assessment of CTD-ILD.
The mortality rate among patients in the intensive care units (ICUs) with severe community-acquired pneumonia (CAP) is high. Identification of severe CAP early in the course and transferring to appropriate setting seem favorable. This study aimed to identify clinical characteristics and the risk factors associated with mortality of severe CAP in the ICU (ICU-CAP). A multi-center, prospective study was conducted at 11 teaching hospitals in China from December 2017 to October 2021. Patients who met the inclusion criteria were assigned to the ICU group and the non-ICU group according to whether they were admitted to the ICU. A total of 170 patients with severe CAP were included, 111 patients were admitted to the ICU and 59 patients were admitted to the ward. Among patients in the ICU, 91.9% of patients were with respiratory failure, 65.8% of patients with consciousness disturbance, 23.4% were in shock state, and 73.0% (81/111) of patients had at least one comorbidity. In-hospital mortality for ICU-CAP was 34.2% (38/111), 28-day mortality was 27.9% (31/111), and 7-day mortality was 10.8% (12/111). Mortality in patients with pneumonia severity index class V (PSI-V) was 40.0% (18/45), mortality in patients with invasive mechanical ventilation was 40.2% (33/82). In the ICU subgroup, invasive mechanical ventilation [odds ratio (OR) =3.35; 95% confidence interval (CI): 1.14-9.81; P=0.02] and age ≥60 years (OR =2.64; 95% CI: 1.07-6.53; P=0.03) were independently associated with in-hospital mortality. In this multicenter prospective cohort, severe CAP patients admitted to the ICU exhibited substantial disease severity, with high rates of treatment failure and mortality. Invasive mechanical ventilation and age ≥60 years were associated with in-hospital mortality in the ICU subgroup.
Virtual-assisted lung mapping (VAL-MAP) is a preoperative bronchoscopic multi-spot dye-marking technique that utilizes virtual bronchoscopy images to aid in the resection of pulmonary nodules that are difficult to identify intraoperatively. In this study, we compared the long-term oncologic outcomes of VAL-MAP with those of historical computed tomography (CT)-guided percutaneous marking. This retrospective observational study included 213 consecutive patients who underwent curative pulmonary resection from 1998 to 2018 at our institute. Patients who underwent VAL-MAP were compared with those who underwent CT-guided localization. The local recurrence rate and local recurrence-free survival were evaluated. In total, 163 patients underwent sublobar pulmonary resection. Age and surgical procedure were significantly different between the VAL-MAP and CT-guided localization groups. The local recurrence rate was significantly lower in the VAL-MAP group than in the CT-guided localization group [2.9% vs. 11.1% at 5 years; subdistribution hazard ratio (HR) =0.22; 95% confidence interval (CI): 0.06-0.82; P=0.02]. Local recurrence occurred in three patients with metastatic lung tumors and in no patients with primary lung cancer in the VAL-MAP group. Among patients with metastatic lung tumors undergoing sublobar resection, VAL-MAP was associated with a lower local recurrence rate (subdistribution HR =0.23; 95% CI: 0.06-0.92; P=0.03) and higher local recurrence-free survival rate (65.5% vs. 36.4% at 5 years; P=0.04) compared with historical CT-guided localization. VAL-MAP demonstrated favorable long-term outcomes for both local recurrence and local recurrence-free survival compared with CT-guided percutaneous marking.
Many adults with posttraumatic stress disorder (PTSD) related to childhood interpersonal trauma (CIT) face substantial barriers to care and limited access to trauma-specific treatment. We evaluated the efficacy of the Trauma PORTAL (Providing Online tRauma Therapy using an Asynchronous Learning platform), a trauma-focused hybrid therapy integrating self-paced psychoeducational and skills-based modules and virtual therapist-led group sessions, to reduce PTSD symptoms in adults with a history of CIT. This randomised, assessor-masked, controlled, parallel-group trial was conducted at a single site in Ontario, Canada. Participants (≥18 years) with a history of CIT were recruited within an ambulatory urban hospital and met criteria for PTSD based on the Mini-International Neuropsychiatric Interview (MINI). Participants were randomly assigned (1:1) to Trauma PORTAL (intervention; eight online modules and eight optional weekly 1-h virtual group sessions facilitated by two trauma therapists) or treatment as usual (control). The primary outcome was severity of PTSD symptoms assessed at 8 weeks relative to baseline, measured by self-report on the PTSD Checklist for DSM-5 (PCL-5). Outcomes were analysed in the intention-to-treat population using a linear mixed-effects model. Secondary outcomes included clinician-rated PTSD severity using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), emotion regulation, depression, anxiety, stress, and self-compassion. Individuals with lived experience of CIT were involved in the development of the Trauma PORTAL intervention, but not in the design of this trial. The trial was registered with ClinicalTrials.gov (NCT05670405). Between November 7, 2022, and October 6, 2023, 328 participants were screened for eligibility, and of these 183 (56%) provided consent and were enrolled. After 2 were lost to follow-up, 181 participants were randomly assigned to Trauma PORTAL (91 [50%]) or control (90 [50%]). At baseline, 147 (81%) participants were women, mean age was 40.8 years (SD 11.5), and 119 (66%) were White. Trauma PORTAL was superior to control in reducing PTSD symptoms, showing an adjusted mean difference (aMD) on the PCL-5 at week 8 of -7.08 (95% CI -11.55 to -2.61), corresponding to a moderate effect size (d = 0.44 [95% CI 0.12-0.76]). This effect was maintained at week 16 (aMD -7.00, 95% CI -11.83 to -2.18). No adverse events were reported. Trauma PORTAL reduced PTSD symptoms more than treatment as usual, supporting its potential as an effective and acceptable hybrid psychoeducation and skills-based therapy that may help expand access to trauma-focused care for adults with CIT. Further evaluation against established treatments is warranted. This project was supported by the WCHAMSG (Women's College Hospital Alternative Medical Staff Group) Innovation Fund of the Alternative Funding Plan for the Academic Health Sciences Centres of Ontario, and the Department of Psychiatry, Women's College Hospital.
Medical education curricula may reinforce health inequities and bias, impacting clinical care. Interventions are needed to address these unintended consequences that contribute to health disparities. The Departmental Anti-Racism and Equity (DARE) educational initiative has been shown to improve the health equity-related content of residency educational conferences. This study evaluates the impact of DARE in sustaining equity-related content in medical education overtime. DARE was implemented in an internal medicine residency program's noon conferences in academic year 2021-2022 (AY22). A standardized rubric was used to evaluate lectures with the same topic and speaker pre-intervention (AY21), post-intervention (AY22), and 3 years post-intervention (AY25) to see if rubric scores for each session changed over time. Mean rubric scores across lectures were compared between AYs. The weighted rubric score was used to normalize total rubric scores between -1 and +1 (total score/number of rubric components scored) to account for different number of rubric components between conferences. All lectures with the same topic and speaker in AY21, AY22, and AY25 were evaluated. The weighted rubric score significantly improved from AY21 to AY22 in this subset of conferences (0.07 to 0.34 [+0.27]; P=.002; possible scores -1 to 1). Weighted rubric score remained higher in AY25 compared to AY21 (0.06 to 0.25 [+0.19]; P=.08) but was no longer statistically significant. The decrease in weighted score between AY22 and AY25 was also not statistically significant ([-0.06]; t9=-0.86; P=.41). Improvement in the health equity-related content of medical education curricula appeared to continue but was diminished 3 years after DARE.
Delirium is common and serious among older adults in emergency departments (EDs) yet screening often falls short of national expectations. This study evaluated current delirium screening practices in a metropolitan ED and identified barriers and enablers to implementing screening in line with the Australian Delirium Clinical Care Standard. A mixed-methods quality assurance study was conducted in The Prince Charles Hospital ED. A retrospective audit of 238 medical records for patients aged ≥ 65 years examined the frequency of delirium screening and associated clinical or operational factors. Semi-structured interviews with nine staff members explored perceptions, experiences and decision-making processes related to screening. Deductive framework analysis guided integration of quantitative and qualitative data. Of eligible patients, 4.2% were screened, with most assessments completed by specialist teams during weekday hours. Screened patients had longer ED stays, although this finding should be interpreted as exploratory. Nurses recognised major delirium risk factors but described screening as reactive rather than routine. Reported barriers included time pressures, environmental limitations, lack of digital integration and uncertainty about role responsibilities. Awareness of the Australian Delirium Clinical Care Standard was limited, contributing to inconsistent practice. Despite baseline knowledge of delirium risk, ED screening remains inconsistent and specialist-dependent. Strengthening adherence to national standards requires embedding screening into routine nursing workflows through clearer role delineation and the integration of prompts to support systematic assessment for all older patients.
Obsessive-compulsive disorder (OCD) is a chronic psychiatric disorder commonly treated with selective serotonin reuptake inhibitors (SSRIs) and, in more severe or resistant cases, clomipramine. Clomiphene citrate, a selective estrogen receptor (ER) modulator primarily used for infertility, is not indicated for psychiatric disorders but may influence neuroendocrine and serotonergic pathways. This case describes an unexpected improvement in OCD symptoms following the accidental prescription of clomiphene instead of clomipramine. A 50-year-old woman with a longstanding history of anxiety and recurrent major depressive disorder (MDD) developed OCD symptoms after childbirth during her second pregnancy. Her symptoms previously responded well to sertraline, clonazepam, and clomipramine. After ~15 years of relative stability, clomipramine was discontinued because of anticholinergic side effects, resulting in relapse of obsessive-compulsive symptoms. A 3-month trial of sertraline 200 mg/day was ineffective. When clomipramine was intended to be restarted, a prescribing error led to clomiphene 25 mg/day being dispensed instead. The patient took clomiphene together with sertraline 100 mg/day and clonazepam 2 mg/night for 12 weeks. During this period, she experienced a dramatic and complete remission of her obsessive-compulsive symptoms, with an estimated reduction in Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score from 23 to ~7. No adverse effects were identified. After the error was recognized, clomiphene was discontinued, the incident was reported, and clomipramine was reintroduced, although the same degree of improvement was not reproduced. This case raises a speculative but clinically important hypothesis regarding the possible role of hormonal modulation in a subgroup of hormonally sensitive patients with OCD. However, causality cannot be established because hormonal measurements were unavailable and alternative explanations, including placebo effects, spontaneous symptom fluctuation, and concomitant medication effects, remain possible. Future studies should longitudinally assess OCD symptom changes during hormonally sensitive periods, ideally in conjunction with standardized clinical measures and hormonal biomarkers. The case also underscores the ethical and patient-safety importance of preventing medication errors.
Kienböck disease is a rare entity in pediatric and adolescent patients. The available published literature is limited primarily to case series and case reports. A trial of conservative treatment with rigid immobilization has been described as the standard of care in these cases. Our aim was to examine the body of literature regarding Kienböck disease in patients under 18 years of age to determine the quality of current evidence and whether concrete conclusions could be drawn regarding management and outcomes. Literature searches were run in the databases PubMed, Scopus, and Cochrane Library with keywords for terms such as osteonecrosis, lunate, and Kienböck disease. The results underwent deduplication followed by title screening, abstract screening, and full-text screening. From the resulting studies, data were extracted regarding patient presentation and diagnosis, interventions, and reported outcomes. Five hundred twenty-seven studies were screened after removal of duplicates. Further review yielded 69 studies published from 1976 to 2023 with data specific to pediatric and adolescent Kienböck disease. In total, 57 studies detailed operative intervention in 142 patients. Sixteen studies reported isolated conservative management in 26 patients. Surgical procedures were highly variable, with radial shortening osteotomy being the most prevalent. Reported outcomes were similarly inconsistent, with pain and range of motion most documented. Publications regarding pediatric and adolescent Kienböck disease are limited primarily to case reports and case series with highly variable data collection regarding patient presentation, interventions, and outcome measures. Although conservative management with immobilization has been reported as the gold standard treatment for this condition, most literature reports operatively treated cases. A prospective investigation is needed to delineate the appropriate management and expected outcomes of pediatric and adolescent Kienböck disease. Differential diagnosis/symptom prevalence study 3a.