Liver cancer is a major public health issue in five East Asian countries, with metabolic factors becoming primary drivers. Based on the Global Burden of Disease (GBD) 2023 database, we extracted the total number and age-standardized mortality rates, years lived with disability (YLDs), years of life lost (YLLs) and disability-adjusted life years (DALYs) related to liver cancer attributable to metabolic risks (LC-MR). We analyzed the disease burden of LC-MR and trends across five East Asian countries from 1990 to 2023, examining patterns by sex and age as well as key drivers across different nations, and projected future trends through 2053. In 2023, Mongolia exhibited the highest age-standardized rates for LC-MR, while China ranked first in the total absolute number of cases. From 1990 to 2023, the overall disease burden showed a downward trend in Japan and Republic of Korea, whereas an upward trend was observed in Mongolia, Democratic People's Republic of Korea, and China. Significant sex and age disparities were observed across all countries in that males bore a higher burden and the burden generally shifted towards the elderly population. Decomposition analysis revealed that the changes in disease burden in Japan and Republic of Korea were primarily driven by population ageing, whereas the main drivering factors were epidemiological changes and population growth in Mongolia and Democratic People's Republic of Korea. Projections of disease burden for 2053 indicate that the disparities among countries would further widen. Therefore, strengthening metabolic risk interventions and implementing targeted prevention strategies for high-risk populations, especially the aging population, is crucial for reducing the regional burden of LC-MR, given the risk disparities across different countries.
Influenza seasons may be associated with increased anxiety-related expressions on social media. Social media can reflect population-level emotional expression patterns in real time. The aim of the study is to characterize diurnal and full-season dynamics of anxiety-related language during the 2023-2024 influenza season in China and its association with influenza activity. We retrieved Sina Weibo posts in February 2025 covering September 4, 2023, to April 28, 2024. Posts containing Diagnostic and Statistical Manual of Mental Disorders (DSM)-based anxiety terms were cleaned and deduplicated (N=169,728 → 106,440). We first linked weekly influenza incidence with anxiety-related postings. Then, we plotted diurnal patterns by epidemiologic phase, conducted supplementary within-sample hourly normalization analyses, and modeled longitudinal symptom trajectories using ARIMA (autoregressive integrated moving average) and supplementary ARIMAX (autoregressive integrated moving average with exogenous regressors) time-series models. Anxiety-related posts closely followed influenza activity, surging during the outbreak and peak phases and remaining elevated even after influenza declined. Initial Spearman correlation analyses showed significant negative associations for irritability (r=-0.413; P=.02) and restlessness or feeling keyed up or on edge (r=-0.396; P=.02). However, supplementary ARIMAX analyses further revealed that being easily fatigued and difficulty concentrating or mind going blank exhibited more stable positive temporal associations with influenza activity after controlling for autocorrelation and lagged effects. Diurnal patterns shifted across stages, showing mild early-evening variation during the outbreak, clear morning peaks with secondary afternoon and evening rises during prevalence and decline, and morning-afternoon concentration in the end stage. Supplementary within-sample hourly normalization analyses showed that the major diurnal structures remained generally stable after normalization. ARIMA time-series analysis revealed that irritability and being easily fatigued consistently dominated the discussions, whereas others remained at relatively low levels. Out-of-sample forecasting based on a chronological 80% training and 20% testing split suggested generally stable short-term trajectories, with being easily fatigued showing a slight increase. This study demonstrates how social media can capture diurnal and seasonal fluctuations of anxiety symptoms associated with influenza activity, advancing understanding of affective dynamics in population health.
Emergency medicine has experienced growth as a research discipline, with psychiatric emergencies representing an area of expansion. The increasing volume of psychiatric presentations to emergency departments necessitates analysis of scientific output in this domain. This study examines publication trends, geographic distribution, and thematic priorities in psychiatric emergency medicine research over the past decade. We conducted a bibliometric analysis of articles published between January 2014 and December 2023. Data were extracted from the Web of Science Core Collection database using the search terms "Emergency Medicine" AND "Psychiatry." Analysis included publication trends, geographic distribution, journal metrics according to Bradford Law, keyword frequency analysis, and thematic mapping. Statistical analyses employed IBM SPSS Statistics 25 and bibliometric software. The analysis identified 862 publications authored by 5111 individuals from 67 countries. Annual publication volume increased from 52 articles in 2014 to 126 articles in 2023. The United States contributed 488 publications (56.7%), followed by Turkey (46 publications, 5.3%), Canada (44, 5.1%), Australia (40, 4.7%), and Iran (33, 3.8%). Four core journals accounted for 37.0% of publications: American Journal of Emergency Medicine (117 articles), Pediatric Emergency Care (75), Academic Emergency Medicine (66), and Journal of Emergency Medicine (61). Mean citation rate was 11.5 per article. Keyword analysis identified 6 primary research themes: pediatric psychiatric emergencies, substance use, suicide and self-harm, consultation models, emergency department management, and geriatric psychiatric emergencies. Temporal analysis revealed increased research focus on vulnerable populations including children and older adults after 2017. Psychiatric emergency medicine research demonstrated consistent growth over the decade studied. Publication output was concentrated geographically, with limited international collaboration. Research priorities evolved toward pediatric and geriatric populations. Findings provide insight into current research landscape and may inform future research directions and resource allocation in psychiatric emergency care.
The H9N2 subtype of avian influenza A virus has been endemic in poultry populations across Asia and the Middle East, posing ongoing economic and public health concerns. Since their initial detection in Pakistan in the 1990s, H9N2 viruses have caused repeated outbreaks in commercial poultry, leading to substantial economic losses and raising concerns about zoonotic transmission. To characterize the recent genetic evolution and zoonotic potential of circulating strains, five H9N2 isolates were obtained from poultry in Pakistan between January and March 2023. Phylogenetic analysis of the haemagglutinin gene revealed that all five isolates belong to the G5.3.2, formerly known as B2, sub-lineage of the G1 Eurasian lineage, in accordance with the revised global classification system for H9 viruses. Comparative genomic analysis confirmed that all eight gene segments were closely related to previously reported Pakistani strains, with no evidence of recent reassortment, suggesting localized persistence and ongoing genetic drift. Notably, several mammalian-adaptive mutations were identified in internal gene segments of the isolates, suggesting a potential risk of cross-species transmission. In addition, all five isolates exhibited dual receptor-binding characteristics, recognizing both α2,3-linked (avian-type) and α2,6-linked (human-type) sialic acid glycans, with a stronger affinity for α2,6-linked glycans. These findings underscore the need for continuous surveillance and risk assessment of H9N2 viruses circulating in Pakistan.
The aim of this study was to assess the impact of standardized benzathine penicillin therapy on adverse pregnancy outcomes in high-titer toluidine red unheated serum test (TRUST) positive (≥ 1:16) syphilis cases and refine prevention of mother-to-child transmission (PMTCT) strategies. This retrospective cohort study analyzed 2,229 pregnant women with syphilis from the National PMTCT System of Taizhou City (2013-2023). Standardized treatment was defined as 3 weekly intramuscular benzathine penicillin doses (2.4 MU each). Multivariable logistic regression adjusted for gestational age, maternal age, and comorbidities was used to analyze the outcomes. A total of 1,651 women (74.1%) received standardized therapy and the risk of adverse pregnancy outcomes was significantly lower in this group compared to those with non-standardized treatment: perinatal death (0.55% vs. 2.60%), congenital syphilis (0.24% vs. 2.60%), preterm birth/low birth weight (7.81% vs. 16.78%), and total adverse outcomes (8.60% vs. 38.75%) (all p < 0.001). Adjusted analysis demonstrated 58% risk reduction with standardized treatment (aOR = 0.42, 95% CI: 0.31-0.57, p < 0.001). Early initiation (≤ 20 weeks) enhanced efficacy (aOR = 2.12, 95% CI: 1.45-3.10, p < 0.001), with married (aOR = 2.41) and educated women (aOR = 1.89) showing higher adherence. Standardized penicillin regimens significantly mitigate adverse pregnancy outcomes by 58%, emphasizing early diagnosis, timely treatment, and targeted patient education for PMTCT success. Marital status and education level were independently associated with treatment adherence.
Hemorrhagic fever with renal syndrome (HFRS) is a serious viral disease in mainland China, and Shaanxi Province is one of the most severely affected areas. In order to reduce HFRS incidence, an inactivated bivalent vaccine against Hantaan virus (HTNV) and Seoul virus (SEOV) infections was developed and used in China since the 1990s. Descriptive epidemiological methods were used to analyze the spatial, temporal, and population distribution of HFRS along with changes in age distribution in Shaanxi Province from January 2004 to December 2023. A total of 34,265 HFRS human cases were reported in Shaanxi Province, including 25,737 males and 8,528 females. HFRS cases were geographically concentrated in the Guanzhong Plain. The local incidence of HFRS fluctuated remarkably over the past 20 years. The primary peak was from October to January. The proportion of HFRS cases in the 15-60 years age group showed a decreasing trend. However, the proportion of HFRS cases among the > 60 years age group increased by 150.94%, rising from 11.68% to 29.31%. Data from a 20-year surveillance study shows that the proportion of HFRS cases in individuals over 60 years of age has increased significantly, which may potentially be due to vaccine coverage limitations. The results can be used to adjust the prevention and control measures of HFRS and to consider age-expanded vaccination strategies.
Portal hypertension is a central driver of morbidity and mortality in advanced chronic liver disease, yet its contribution to death is frequently underestimated owing to underreporting on death certificates. Population-level data on portal hypertension-related mortality trends and disparities in the United States remain limited. We conducted a retrospective, population-based mortality study using the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research Multiple Cause of Death database, identifying deaths with International Statistical Classification of Diseases and Related Health Problems, 10th Revision code K76.6 listed in any cause-of-death field from 1999 to 2023. Crude and age-adjusted mortality rates per 100,000 population were calculated and stratified by sex, U.S. Census region, race/ethnicity, and urban-rural status (the latter restricted to 1999-2020 due to data availability). Temporal trends were assessed using Joinpoint regression, with annual percent change (APC) reported as the primary trend metric and 95% confidence intervals presented for all estimates. A total of 34,551 portal hypertension-related deaths were identified. Overall age-adjusted mortality rates declined sharply from 1999 to 2002 (APC - 12.85%), plateaued for more than a decade, and rose thereafter. Mortality increased significantly in women after 2009 (APC + 6.69%) and in men after 2013 (APC + 6.18%). Among racial and ethnic groups, Hispanic or Latino individuals consistently demonstrated the highest mortality burden throughout the study period, followed by White individuals, whereas Black or African American individuals exhibited comparatively lower but significantly rising rates from 2006 onward. White individuals demonstrated the steepest recent acceleration, with a significant increase after 2014 (APC + 8.51%). Regionally, the South experienced the steepest post-2013 increase, while the Northeast retained the lowest absolute rates despite a significant rise after 2014. Urban populations showed early improvement through 2014 followed by rising mortality, whereas rural populations experienced a later but steeper rise beginning around 2013, with widening urban-rural disparities over time. Portal hypertension-related mortality has risen significantly since the mid-2010s across all demographic and geographic subgroups, with disproportionate burdens among Hispanic individuals, men, rural populations, and residents of the Southern United States. These findings highlight the urgent need for targeted prevention strategies, equitable access to hepatology care, and aggressive management of metabolic and alcohol-related risk factors to reverse this trajectory.
Characterize how the rates of induced abortion differ by clinical and social patient characteristics. Retrospective cohort analysis of pregnancies (2012-2023) in an integrated healthcare delivery system. We present the association of induced abortion by social and clinical factors; we calculated prevalence ratios (PR) from modified log-Poisson models, adjusted for all other covariates considered. The likelihood of abortion was lower among individuals ≥40 years, individuals with obesity, Spanish speakers, and greater neighborhood deprivation; and higher for public insurance, Black race, and multiparous pregnancies. There are substantial differences in the utilization of abortion services by social and clinical factors.
Respiratory syncytial virus (RSV) is highly prevalent as a cause of acute respiratory tract infection. Detection of RSV using nucleic acid amplification tests provides rapid results that can help physicians manage patients with acute respiratory symptoms and avoid unnecessary antibiotics. This study aimed to report the positivity rate of RSV among patients with acute respiratory symptoms. Nasopharyngeal swab specimens were obtained from primary healthcare facilities and hospital outpatient clinics from January 2023 to June 2024. The specimens were processed using the multiplex QIAStat-Dx Respiratory SARS-CoV-2 Panel (QIAGEN GmbH, Hilden, Germany). A total of 1339 tests were performed and RSV was positive in 10.3% of tested patients (138/1339). Regarding the monthly positivity rate, the highest rate of RSV positivity was in November 2023, followed by January 2023, and March 2023. This study shows a moderate RSV positivity rate in outpatient settings and suggests a seasonal trend, with higher circulation during the rainy season. These findings highlight the value of RSV surveillance for guiding clinical and public health responses in tropical regions.
Accurate mapping of winter wheat is essential for food security, agricultural management, and climate adaptation strategies. We present a multi-source, phenology-aware approach for identifying winter wheat in the arid oasis agricultural landscape of Changji City (northern Xinjiang) using Sentinel-1 C-band SAR and Sentinel-2 surface reflectance imagery acquired during key growth stages in 2023. We constructed a comprehensive six-category feature set-polarimetric, textural, spectral, vegetation indices, normalized-difference indices, and temporal-difference features-and designed eleven feature-combination schemes for comparative evaluation. A Random Forest-based forward sequential feature selection (RF-FS) procedure was used to identify the most informative predictors. From an initial 171 features, RF-FS selected 27 key variables (an 84.4% reduction), dominated by SWIR bands (B11/B12), a phenology index (NDPI), and SAR polarimetric combinations; moisture-sensitive features comprised 40.7% of the selected subset. The optimized model achieved an overall accuracy (OA) of 94.60% and a Kappa coefficient of 0.9338 (producer's accuracy [PA] = 100%). Temporal analysis indicates that April and May contributed the most discriminative information, corresponding to rapid biomass accumulation and the jointing-heading stages. Applying the optimized classifier yielded an estimated 2023 winter wheat area of approximately 93.39 km2 for Changji, with a relative error of 7.79% compared to statistical records. The results validate a "multi-source synergy, phenology-driven, moisture-sensitive" framework for efficient winter wheat mapping in arid desert-oasis mosaics and provide an operational basis for crop structure monitoring and agricultural risk assessment.
Molecular classification has refined risk stratification in endometrial cancer and is now incorporated into the 2023 International Federation of Gynecology and Obstetrics (FIGO) staging system. However, prospective real-world data on its impact on multidisciplinary tumor board (MDT) decision making remain limited. We evaluated the impact of molecular information on adjuvant treatment recommendations in stage I to II endometrial cancer. This prospective observational study included patients with surgically treated FIGO 2023 stage I to II endometrial carcinoma discussed at MDT between February 2024 and December 2025. Clinicopathologic risk stratification was performed using the ESGO-ESTRO-ESP 2016 criteria. Molecular classification was determined using POLE sequencing and immunohistochemistry for mismatch repair (MMR) and TP53. Estrogen receptor status was not assessed, as no specific molecular profile (NSMP) subclassification was part of the operative framework during the study period. MDT recommendations were recorded before and after the integration of molecular results. A total of 122 patients were included. Molecular subtypes were NSMP in 55 (45.1%), MMR-deficient in 41 (33.6%), TP53-abnormal in 24 (19.7%), and POLE-mutated in two (1.6%). Integration of molecular classification changed MDT recommendations in 25 cases (20.5%), with escalation in 15 (12.3%) and de-escalation in 10 (8.2%). Therapy modification was most frequent in TP53-abnormal tumors (62.5%) compared with other subgroups (10.2%; odds ratio, 14.7 [95% CI, 5.1 to 42.1]; P < .001). No treatment changes were observed in NSMP or POLE-mutated tumors. The net incremental treatment cost was ₹11.8 lakh across the cohort; including molecular testing, the overall incremental cost was ₹34,672 per patient (∼$418 US dollars). Integration of molecular classification modified adjuvant treatment in approximately one fifth of patients. Changes were biologically consistent, supporting the feasibility and clinical utility of molecularly integrated MDT decision making in early-stage endometrial cancer even in resource-constrained settings.
High-risk medical devices approved through the US Food and Drug Administration (FDA) premarket approval (PMA) pathway may be supported by limited premarket clinical evidence, leaving uncertainties about safety. Whether device, premarket clinical evidence, or regulatory characteristics are associated with subsequent device recalls is unknown. To examine the association between device, premarket clinical evidence, and regulatory characteristics and serious recalls among high-risk therapeutic devices. This cross-sectional study reviewed 193 high-risk therapeutic medical devices approved through the FDA's PMA pathway between January 1, 2014, and December 31, 2023. Data were analyzed between August 2025 and December 2025. Device characteristics, premarket pivotal clinical study characteristics, and regulatory characteristics. The main outcome was occurrence of serious recall (Class I or II) and Class I (highest severity) recall. From 2014 to 2023, the FDA approved 193 original high-risk therapeutic medical devices through the PMA pathway. As of July 31, 2025, a total of 68 (35.2%) were subject to at least 1 serious recall, with a median (IQR) of 2.6 (1.5-4.6) years from approval to first recall; 20 (10.4%) devices were subject to at least 1 Class I recall. Life-supporting or life-sustaining devices more often had serious recalls (28 of 60 [46.7%] vs 40 of 133 [30.1%]; P = .02) and Class I recalls (14 of 60 [23.3%] vs 6 of 133 [4.5%]; P < .001) than non-life-supporting and life-sustaining devices. Cardiovascular devices more often had Class I recalls than noncardiovascular devices (16 of 99 [16.2%] vs 4 of 94 [4.3%]; P = .004). Class I recalls differed by pivotal study design: single-arm with no controls, 3 of 9 (33.3%); single-arm with nonconcurrent controls, 11 of 89 (12.4%); and multiple-arm with concurrent controls, 6 of 95 (6.3%) (P = .03). Devices with required postapproval studies had more serious recalls (56 of 140 [40.0%] vs 12 of 53 [22.6%]; P = .04) than those without. Other characteristics were not associated with recall likelihood. In this cross-sectional study, more than one-third of high-risk therapeutic medical devices were subject to serious recalls. Because device, premarket clinical evidence, and regulatory characteristics were not consistently associated with serious recalls, robust postmarket surveillance is needed to ensure patient safety.
Point-of-care ultrasound (POCUS) is integral to obstetrics and gynecology (OBGYN), offering bedside diagnostic and therapeutic advantages. Despite its widespread adoption, accurate documentation and billing remain challenging due to inconsistent workflows, variable free-text note quality, and inefficiencies within electronic health record (EHR) systems. These barriers often result in missed procedural charges and hinder operational, educational, and reimbursement efforts. This study leveraged machine learning (ML) to automatically identify POCUS procedures within clinical notes and assessed the effect of implementing standardized procedure documentation (ProcDoc) templates on billing capture accuracy and efficiency. We conducted a multipart retrospective cohort study at a large academic medical center using EHRs from January 2018 to August 2024 across 11 OBGYN clinic sites. ML models (LightGBM [light gradient boosting machine] and BioClinBERT [biomedical and clinical bidirectional encoder representations from transformers]) were trained on clinical encounter notes to classify POCUS procedures and validated against Current Procedural Terminology (CPT) manual code assignments. In February 2023, a standardized ProcDoc smart form was introduced to streamline POCUS documentation and automatically trigger CPT billing codes. Preintervention and postintervention periods were compared using ML metrics and manual billing audits. Outcomes included model accuracy, recall, precision, adoption rates, improvement in billing recapture, and usage of ProcDoc templates. A total of 559,029 encounters from 109,776 unique patients were analyzed. The BioClinBERT model (accuracy 0.97; F1-score 0.55-0.63) demonstrated a robust ability to identify documented and missed procedures in free-text clinical notes. ProcDoc adoption reached 75.1% within 12 months, supported by comprehensive staff education. Billing recapture-the proportion of charges missed by providers but later identified-dropped from 10.0% preintervention to 2.4% postintervention, primarily arising from the shift toward auto-capturing documentation (odds ratio 0.22, 95% CI 0.17-0.30; P<.001), with overall POCUS billing slightly increased (+0.6%). Most postintervention CPT codes (1812/2404, 75.4%) originated from ProcDoc templates, confirming improved workflow efficiency and reduced manual audit burden. Model analysis and billing metrics demonstrated that improvements were associated with workflow changes and not an increase in procedure frequency. ML modeling proved effective for extracting POCUS procedures from clinical documentation and serving as an evaluation tool for workflow interventions. Standardized documentation with ProcDoc significantly enhanced charge capture accuracy and reduced dependence on manual chart reviews and billing reconciliation. This approach highlights the use of ML as a retrospective auditing and evaluation tool for assessing clinical workflow interventions. Broader application of similar strategies could address documentation inefficiencies and promote sustainability across health care settings.
Scholars have not conventionally examined the COVID-19 pandemic and immigration enforcement together or as having similar dimensions. We use the framework of cascading crisis to assess the impact of the cascading pandemic-immigration enforcement crisis on Latine immigrants' health from the perspectives of community health workers (CHWs) deeply embedded in immigrant communities. This qualitative study was carried out in a large metropolitan region across two phases: December 2024-January 2025 (focused on the pandemic period, January 2020-May 2023) and April-May 2025 (focused after the official end of the public health emergency in May 2023). We conducted 41 semi-structured interviews with CHWs recruited from four local organizations and analyzed data using thematic analysis. We identified three themes highlighting how CHWs described immigration enforcement as an extension of the pandemic: immigrants' lockdown mentality and decreased access to services, elevated distrust of the government, and barriers with information-sharing. Although CHWs effectively forged trust-building strategies during the pandemic that carried forward beyond its official end, this trust is now being undermined. In response, CHWs have had to innovate to adapt to immigrants' new circumstances and reaffirm trust. A multi-faceted approach to addressing the pandemic-immigration enforcement cascading crisis will be necessary, including health care professional advocacy, health care delivery innovation, the passage of inclusionary state-local policies, and alternate models of community care.
Recurrence after surgical treatment of chronic subdural hematoma (CSDH) remains insufficiently understood. Microvascular pathology of the CSDH membrane is a suspected driver of this recurrence, supported by reduced recurrence following middle meningeal artery embolization. Given the known differences in clotting propensity among ABO blood groups and the frequent use of antiplatelet and/or anticoagulant therapy (AAT) in the CSDH population, this study aimed to investigate the impact of ABO blood groups on postoperative recurrence risk. The authors conducted a retrospective analysis of patients with symptomatic CSDH who underwent surgery at their institution between June 2012 and December 2023. Prior AAT was discontinued at hospital admission and reinitiated 3 weeks postoperatively, if CSDH resolution was complete. Recurrence was defined as an episode of radiological hematoma progression, with or without the development of symptoms, that required reoperation. A total of 756 patients with surgically treated CSDH (mean age 75.1 [SD 11.9] years, female-to-male ratio 1:2.1) were included. In patients without prior AAT use (n = 360), univariate analysis showed that non-O blood groups had significantly higher recurrence rates than blood group O (19.4% vs 8.7%, p = 0.006). Multivariate analysis confirmed non-O (p = 0.002, adjusted odds ratio [aOR] 3.5), and particularly A (p < 0.001, aOR 5.1), blood groups were independent predictors of recurrence. Comparing patients with prior acetylsalicylic acid (aspirin) use (n = 190) with those without prior AAT use, univariate analysis revealed that prior aspirin therapy was associated with a significantly lower recurrence rate among non-O (6.9% vs 19.4%, p = 0.002), and particularly A (8% vs 21%, p = 0.011), blood groups. Multivariate analysis identified prior aspirin use in non-O (p = 0.004, aOR 0.284), and particularly A (p = 0.015, aOR 0.324), blood groups as an independent predictor of reduced recurrence. This large-scale study demonstrated that non-O blood groups, and particularly A blood groups, are independent predictors of increased CSDH recurrence in patients without prior AAT use. These findings support the development of a scoring system based on blood groups, particularly for patients with groups A and O, to improve recurrence risk stratification and to tailor treatment plans. In contrast, prior aspirin use in these groups was an independent predictor of markedly reduced recurrence rates, comparable to those of blood group O.
To analyze discharge planning for older adults hospitalized due to fractures resulting from same-level falls, combining the investigation of associations between sociodemographic and clinical variables with a qualitative exploration of the processes and perceptions involved. A mixed-methods study conducted in a public hospital in the interior of Bahia and in home settings. A total of 142 medical records of older adults hospitalized for fractures (September 2022 to August 2023) were analyzed, and interviews were conducted with 16 participants after discharge. Quantitative data were analyzed using descriptive statistics and Pearson's chi-square test (p < 0.05), while qualitative data were analyzed through content analysis. Only 17 medical records included discharge instructions, which were generic and restricted to clinical aspects. Interviews revealed a predominance of lack of guidance on fall prevention and reports of ptophobia after discharge, leading to activity restriction and social isolation. An association was found between lower limb fractures and female sex, as well as the presence of two to three comorbidities; individuals aged 60 to 79 years showed a higher occurrence of upper limb fractures. The findings point to the urgent need for structured, individualized, and multidisciplinary long-term planning. Nurse-led protocols that include guidance on fall prevention and psychosocial support are essential to prevent ptophobia and activity restriction, ensuring safe hospital-to-home transitions for older adults who have sustained fractures resulting from same-level falls.
Tracheostomy insertion is common in patients requiring prolonged mechanical ventilation (MV), with cuff deflation and voice restoration a critical step in the weaning process. However, the optimal timing for cuff deflation and its impact on clinical outcomes remain unclear. This study aims to examine local tracheostomy cuff deflation practices and assess associations with outcomes in patients requiring prolonged MV. A retrospective study was conducted at a large UK ICU between November 2021 and October 2023, which included patients without significant neurological injury requiring tracheostomy insertion for prolonged MV (defined as WIND 3). Data were extracted from electronic health records for patient demographics and outcomes including weaning milestones; physical, cognitive, and psychological outcomes; ICU and hospital length of stay (LOS); ventilator-acquired pneumonia (VAP); and mortality. These were compared across subgroups defined based on the time from tracheostomy to cuff deflation, namely 0-5, 6-10, and >10 days; patients who died prior to achieving this were included in the latter subgroup. The 157 included patients comprised those with tracheostomy to cuff deflation of 0-5 days (N = 58), 6-10 days (N = 54) and >10 days/death (N = 45). Patient characteristics at ICU admission were not found to differ significantly between these groups. Delayed cuff deflation was associated with prolonged MV (p < 0.001); delayed weaning milestones, including decannulation (p < 0.001); higher rates of VAP (p = 0.010); increased ICU LOS (p < 0.001) and mortality (p < 0.001); and greater levels of anxiety (p = 0.040) and psychological distress (p = 0.046) at ICU discharge. Delayed tracheostomy cuff deflation maybe associated with inferior clinical and patient outcomes. Further research examining the relationship between cuff deflation timing and clinical outcomes is warranted.
Prolonged empirical antibiotic exposure in neonates is associated with adverse outcomes and antimicrobial resistance. Serial C-reactive protein (CRP) and procalcitonin (PCT) measurements may support earlier discontinuation, but neonatal protocols remain heterogeneous. To map evidence on CRP- and/or PCT-guided antibiotic-duration strategies in neonatal sepsis and summarize their effects on antibiotic exposure and safety. Following Joanna Briggs Institute guidance and PRISMA-ScR, PubMed/MEDLINE, Embase, Web of Science and the Cochrane Library were searched from inception to December 2023. Peer-reviewed English-language studies of neonates aged 0-28 days with suspected, probable or culture-proven early- or late-onset sepsis were included when serial CRP and/or PCT formed part of an explicit antibiotic-stopping strategy. Two reviewers independently screened records and charted study characteristics, protocols and outcomes. Fifteen studies involving 4755 neonates were included: five randomized trials, six cohort studies, two prospective observational studies and two systematic reviews with meta-analyses. Seven studies evaluated CRP-guided discontinuation, six evaluated PCT-guided strategies and four used combined approaches. Biomarker-guided care reduced mean antibiotic duration from 7.3 to 4.5 days, a mean reduction of 2.8 days (38.6%). Reductions were directionally consistent and appeared greater in early-onset than late-onset sepsis. Thirteen studies reported treatment failure and 14 reported mortality; neither outcome showed an apparent increase with biomarker-guided discontinuation. Antimicrobial-resistance, ecological and cost outcomes were infrequently reported. CRP- and/or PCT-guided stopping strategies may reduce antibiotic exposure in neonatal sepsis without an apparent increase in treatment failure or mortality. Standardized protocols and further implementation, cost-effectiveness and resistance-focused research are needed, particularly in resource-limited settings and extremely preterm infants.
The interaction between nasopharyngeal pneumococcal carriage (NPC) and respiratory viral infections (RVI) is poorly understood. This study aimed to investigate the prevalence and epidemiology of NPC, and its correlation with RVI. This retrospective study included patients aged < 18 years who presented with RVI symptoms between 1 February and 30 June 2023. Naso-oropharyngeal swabs were tested using quantitative polymerase chain reaction (PCR) for Streptococcus pneumoniae and respiratory viruses. Patients were grouped by NPC status and compared for viral detection, and clinical and demographic characteristics. NPC was detected in 15.7% (n = 1,185) of the 7,522 samples analyzed. The mean age was 56.5 ± 49.3 months, being significantly lower in NPC-positive patients (p < 0.001). Most (82%) were fully vaccinated against pneumococcus; 16% had underlying conditions. The most frequent viruses were adenovirus (17.2%), influenza B (9.0%), severe acute respiratory syndrome coronavirus 2 (5.3%), respiratory syncytial virus (4.9%), and influenza A (2.8%). Adenovirus (19.7%) and influenza B (11.0%) were significantly more frequent in NPC-positive patients than in NPC-negative patients (p < 0.001 for both). Overall, 20.5% were hospitalized, and 2.4% required intensive care. Intensive care admission was higher among NPC-positive patients, whereas mortality did not differ. NPC was epidemiologically associated with the detection of certain respiratory viruses, particularly adenovirus and influenza B. Given the retrospective design and lack of pneumococcal serotype data, these findings should be interpreted as associations rather than evidence of causality. Further prospective studies are warranted to clarify the bacterial-viral interactions and their clinical relevance.
Fracture risk increases along the progression of chronic kidney disease (CKD) to become several-fold higher in patients with CKD G4-5D as compared to the kidney-healthy background population matched for age and sex. In 2023, Kidney Disease Improving Global Outcomes (KDIGO) introduced the term CKD-associated osteoporosis to acknowledge and emphasize the overlap in diagnostic workup and therapeutic choices when treating bone fragility in CKD versus other conditions of osteoporosis, while maintaining the need to individualise the treatment plan with knowledge of CKD. Although evidence-based practice guidelines promote management strategies that are widely accepted in postmenopausal women and elderly men, there is a clear need to perform randomized controlled trials to confirm or disprove the benefits of therapy in the setting of advanced CKD. Lifestyle modification, as a 'low risk/potentially high return' intervention, should be considered in all patients. Current evidence furthermore supports a sequential approach to treatment, where mineral metabolism should be optimised, including parathyroid hormone targeting therapy, before initiating bone targeting drugs. We review the current standards of treatment and discuss novel developments in the pathophysiology, diagnosis, outcome prediction and management of CKD-associated osteoporosis and propose a pragmatic treatment algorithm, pending more definite evidence from appropriately designed and powered clinical trials.