搜索结果：American

Recently, the 2026 American Heart Association (AHA)/American College of Cardiology (ACC)/American College of Chest Physicians/American College of Chest Physicians/Society for Cardiovascular Angiography and Interventions/Society of Hospital Medicine/Society of Interventional Radiology/Society of Vascular Medicine/Society for Vascular Nursing Guideline for Evaluation and Management of Acute Pulmonary Embolism in Adults (AHA/ACC Acute PE Guideline) has been published. We aimed to critically evaluate the most significant sections of the guidelines. The new risk classification provides granularity, although the new categories require validation. We concur with the guidelines' recommendations regarding the use of low-molecular-weight heparins (parenteral treatment) and direct oral anticoagulants (oral treatment) as the preferred anticoagulants for the vast majority of patients with acute PE. Finally, the guidelines suggest reperfusion therapies for scenarios that currently lack robust scientific evidence; therefore, the results of ongoing clinical trials must be awaited to determine their precise indications.

We assessed sex-specific disparities in HCC risk according to detailed race/ethnicity with a multi-institutional, electronic health record (EHR)-based cohort. We linked an EHR-based cohort of adult patients at Sutter Health, Kaiser Permanente Hawai'i, and San Francisco Health Network from 2000 to 2016/2017 to population-based cancer registry data for incident HCC. Race and ethnicity data were operationalized into 17 detailed categories. We used sex-stratified Cox regression to assess racial/ethnic disparities in HCC. A secondary analysis explored cirrhosis-stratified disparities, with cirrhosis defined as occurrence of one or more ICD-9/ICD-10 codes indicating cirrhosis or complication thereof. Among 4,248,553 patients, 2,916 developed HCC. Vietnamese American females (HR=5.5; 95% CI=2.3, 13.2) and males (HR=5.4; 95% CI=3.1, 9.6) had highest HCC risk compared to non-Hispanic (NH) White counterparts. For both sexes, those who were Native Hawaiian, Chinese or Korean American, had another single Asian ethnicity or multiple Asian ethnicities, or were Black or Hispanic had greater HCC risk than NH White. Filipino and Japanese American females and males who were American Indian/Alaska Native or had multiple races/ethnicities also had greater risk. Exploratory analyses showed that, for both sexes, racial/ethnic disparities were mitigated within the context of EHR-documented cirrhosis but not without. Our innovative use of EHR data on race and ethnicity advances disparities research methodology, yielding findings on HCC disparities not apparent with broad categories. More persistent racial/ethnic disparities among those without EHR-documented cirrhosis suggest racial/ethnic differences in coordinated hepatitis screening and treatment, cirrhosis recognition/documentation, or healthcare delivery and thus informs efforts to reduce HCC disparities.

In the past 3 years key recommendations for the management of systemic sclerosis (SSc) have been published, including updated EULAR recommendations and British Society for Rheumatology (BSR) guidelines. These recommendations are generally aligned but also reflect differences in the methodology and scope of the responsible organizations. For both EULAR and BSR, the methodology is robust and aligns with recommendations and guidelines developed for other rheumatic conditions and produced by other specialist societies. Advances in treatment and a growing evidence base for management of interstitial lung disease (ILD), a frequent complication of SSc, have informed additional relevant recommendations that include SSc-ILD. Some of these cover a broad range of ILDs that occur across systemic autoimmune rheumatic diseases, including those developed by the ACR-American College of Chest Physicians and the 2025 European Respiratory Society-EULAR clinical-practice guidelines. The American Thoracic Society has also developed recommendations for SSc-ILD. Taken together, a comparison of these published guidelines provides an overview of best practice evidence-based management that is supported by expert opinion and relevant stakeholders. By considering the overlap and similarity in recommendations and highlighting differences in approach and scope, this article helps readers to navigate an evolving treatment landscape of SSc.

Percutaneous nephrolithotomy (PCNL) is associated with significant postoperative pain. Ultrasound-guided erector spinae plane block (ESPB) and anterior quadratus lumborum block (QLB) are increasingly used for analgesia; however, direct comparative evidence in PCNL remains limited. This randomized controlled study compared their analgesic efficacy following unilateral PCNL. Eighty-four adult patients (American Society of Anaesthesiologists I-III) were randomized to receive ESPB or anterior QLB. Three patients in each group had block failure. The primary outcome was time to first rescue analgesia. Secondary outcomes included Numeric Rating Scale (NRS) pain scores at rest and during movement at 1, 2, 6, 12, and 24 h, total tramadol consumption, complications, time to ambulation, and length of hospital stay. Time to first rescue analgesia was significantly longer in Group E compared to Group Q (406.15 ± 161.97 min vs. 326.15 ± 155.61 min; mean difference 80 min; 95% CI 9-151; P = 0.022; Cohen's d = 0.50). At 2 h, fewer patients in Group E required rescue analgesia (7.7% vs. 25.6%; P = 0.033). NRS scores at rest and during movement were comparable at all time points. Total tramadol consumption over 24 h was similar; however, fewer patients in Group E required tramadol at 12 h (23.1 vs. 43.6%; P = 0.049). Complication rates, ambulation time, and length of hospital stay were comparable. Both ESPB and anterior QLB provide effective postoperative analgesia after PCNL. ESPB offers moderate effect size prolongation in time to first rescue analgesia, suggesting a modest early postoperative analgesic advantage without increased complications.

This case report aimed to describe the medium-term results of the cortical lamina and fibrin sealant for horizontal bone augmentation at implant sites. A 62-year-old female American Society of Anesthesiologists I patient was treated with guided implant placement in the #3-#5 area. A mixture of collagenated xenogenic bone granules (OsteoBiol Gen-Os and OsteoBiol Apatos, Tecnoss, Giaveno, Italy) and fibrin sealant (Tisseel, Baxter Healthcare Corporation, Deerfield, IL) was carefully positioned in a single block with slight pressure on the recipient area. The xenogenic collagenated cortical lamina (OsteoBiol Lamina, Tecnoss) was shaped and placed over the augmented area. Fibrin sealant was also applied over the bone grafts to improve the lamina adhesion. After 5 months, a biopsy sample from the augmented area was harvested. The histological analysis showed newly formed bone in proximity to collagenated granules without a clear distinction. Signs of bone maturation were also noted. The 3D superimposition of the cone-beam computerized tomography scans showed that the bone volume at augmented sites remained stable during the 5-month healing period. Final prostheses were delivered 6 months after the second stage surgery with positive esthetic and functional results. The proposed technique demonstrated favorable outcomes in bone augmentation and stability.

The American Heart Association Predicting Risk of Cardiovascular Disease EVENT (PREVENT) equations were developed from observational research cohorts and electronic health record data and provide sex-specific risk estimates for cardiovascular disease (CVD), atherosclerotic CVD (ASCVD), and heart failure (HF). External validation in large contemporary samples across multiple health systems in the United States is needed. We assembled a national electronic health record-based cohort of US adults with individual-level patient data pooled from a collective of 30 health systems (Truveta) to externally validate the outcome-specific 10-year PREVENT equations (PREVENT-CVD, PREVENT-ASCVD, and PREVENT-HF). We included patients aged 30 to 79 years without a history of prior CVD and with an ambulatory encounter in the electronic health record between 2013 and 2018. The outcomes were defined as total CVD (composite of ASCVD and HF), ASCVD, and HF through December 2024 using diagnosis codes. Model performance of the outcome-specific PREVENT base equations was assessed with the Harrell C statistic and calibration slope, stratified by sex. Of the 680 864 adults included, the mean (SD) age was 55 (13) years, and 56% were female. Over a mean (SD) follow-up of 6.8 (2.3) years, there were 29 535 incident CVD events, 19 280 incident ASCVD events, and 16 824 incident HF events. The median (interquartile range) 10-year predicted risk of PREVENT-CVD among women was 3.6% (1.3%-8.8%), and among men was 5.8% (2.5%-11.7%). The C statistic (95% CI) was 0.788 (0.786-0.790), and the calibration slope (95% CI) was 0.98 (0.95-1.01) for PREVENT-CVD. PREVENT-ASCVD and PREVENT-HF demonstrated similar C statistics (0.774 [0.771-0.777] and 0.824 [0.820-0.828]) and calibration slopes (1.07 [1.04-1.10] and 1.01 [0.97-1.04]) for prediction of the 10-year risk of ASCVD and HF, respectively. The PREVENT equations accurately and precisely estimate the 10-year risk of CVD, ASCVD, and HF in a large sample of US adults. These findings support the generalizability of the PREVENT equations to inform guideline-recommended risk assessment and preventive efforts.

To compare changes in oral health-related quality of life (OHRQoL) and subjective food intake ability (key food intake ability [KFIA]) among different Class II camouflage strategies and to assess posterior occlusal contact types in Class II molar finishing. Records from 62 patients with Class II malocclusion were categorized into nonextraction, maxillary premolar extraction (ME), and maxillomandibular premolar extraction (MME). The Oral Health Impact Profile-14 (OHIP-14) and KFIA were administered before and after treatment. The American Board of Orthodontics Discrepancy Index and Objective Grading System (OGS) were also evaluated. The primary outcomes were group &#xd7; time interactions in OHIP-14 and KFIA; the secondary outcome was posterior disclusion in ME cases. Baseline characteristics were similar, except for greater initial overjet and overbite in ME (P < .05). KFIA remained stable after treatment in all groups (P &#x2265; .05). OHIP-14 improved significantly in total score and psychological discomfort for all patients, with additional improvement in the handicap domain in the MME group; however, no significant group &#xd7; time interactions were found. Baseline OHIP-14 was the only predictor of posttreatment OHRQoL (P < .001). OGS outcomes were comparable; however, digital analysis showed second-molar posterior disclusion in 10% of ME cases. Class II camouflage treatment improved psychosocial aspects of OHRQoL regardless of extraction pattern; in contrast, subjective masticatory function remained unchanged. Baseline OHRQoL, rather than extraction type or case complexity, predicted final OHRQoL. Posterior occlusal assessment beyond OGS criteria may be useful in ME cases.

Study the treatment gap of guideline-indicated therapies in people with T2D and atherosclerotic cardiovascular disease (ASCVD) or heart failure (HF) or chronic kidney disease (CKD). We extracted prescription history from 2005 to 2025 from a national dataset, a community-based health system, and an academic center. We assessed treatment gap (current and ever) within four subgroups defined using American Diabetes Association Standards of Care indications for SGLT2i and GLP-1RA use. We identified 6,951,624 people in the national dataset, 58,390 people at the community-based health system, and 15,235 people at the academic center. The current treatment gaps among people with ASCVD (without HF or CKD) were 72%, 67%, and 49%; with ASCVD and HF or CKD3 were 73%, 71%, and 55%; with CKD3 or HF without ASCVD were 75%, 71%, and 65%; with CKD4/5 were 87%, 89%, and 74% within the national dataset, community-based health system, and academic health system, respectively. The ever-prescription rates ranged from 23% to 39%, 30%-47%, 42%-64% within the national dataset, community-based health system, and academic center, respectively. Over half the population never received an indicated cardio-kidney protective prescription, and two-thirds lack a current prescription. These gaps were substantial across all systems; however, lowest at the academic center.

Despite being an important social determinant of health (SDOH), independent association of housing with emergency department (ED) utilization is not well characterized. This study evaluated whether a previously validated ZIP code-level multidimensional housing index is associated with 30-day ED readmission in Maryland. We conducted a retrospective analysis of Maryland ED visits from 2019 to 2023, linked to the American Community Survey housing estimates. The primary outcome was 30-day ED readmission. The variable of interest was a validated ZIP code-level housing index reflecting housing value, quality, occupancy, facilities, transportation access, and cost burden. Multivariable logistic regression was used to adjust for age, sex, race, Elixhauser comorbidity score, and procedure category. Mixed-effects logistic regression with ZIP code random intercepts assessed geographic clustering. Predictive performance was evaluated using 100 repeated 50/50 train-test splits. In 2019, higher housing index was strongly associated with lower odds of readmission in adjusted models (odds ratio [OR] 0.33, 95% CI 0.32-0.34; P < 0.0001), with comparable results generated by the mixed-effects models (OR 0.32, 95% CI 0.29-0.37). This protective association was consistent across all study years. Adding the housing index modestly improved predicting ED readmission in 2019, increasing area under the curve (AUC) from 0.5703 to 0.5888. As a key SDOH, community-level housing conditions were independently associated with reduced 30-day ED readmission. Housing-specific indices may enhance population health risk stratification and inform targeted interventions.

Systemic lupus erythematosus (SLE) is a prevalent autoimmune disease affecting up to a quarter million Americans. Lupus nephritis (LN) is an immune complex glomerulonephritis that occurs when circulating immune complexes deposit in the kidney and is a common sequela of SLE. LN serves as a marker of disease severity and contributes significantly to mortality in SLE. Despite growing access to novel therapies, the disease burden remains high, and the gap between real-life challenges and clinical trial success persists. Our study is an effort to bridge the gap by examining factors such as diverse choice of immunosuppression, socioeconomic constraints, and adherence outside the carefully calibrated environment of clinical trials. We conducted a retrospective review of patients with biopsy proven LN to evaluate prognostic factors and treatment related complications at a tertiary hospital with patients selected from biopsy records obtained from January 2015 through December 2023. A total of 66 patients met inclusion criteria and were included in the final analysis of the cohort. Patients with findings other than confirmed LN and kidney transplant recipients were excluded. Longitudinal data were collected at 6 months, 12 months, 2 years, and 5 years after biopsy, and response to treatment was defined using Kidney Disease Improving Global Outcomes (KDIGO) 2024 clinical practice guidelines for LN. Of the 163 kidney biopsy reports reviewed from January 2015 through December 2023, 66 were confirmed as LN and included in the analysis. The median age at biopsy was 35 years, 76% were women, and 62% were African American. At 6 months, 50% of Class I and II LN, 49% of Class III, IV, III + V and IV + V LN, and 83% of Class V LN had no response to treatment, without significant differences between classes or in terms of partial vs. complete response. At 12 months, 55% of Class I and II, 50% of Class III, IV, III + V, and IV + V, and 87% of Class V LN had no response to treatment, with a significant difference (p = 0.04) between classes in terms of rate of response, but not in terms of partial vs. complete response. Notable complications were advancement to ESRD in 11 patients (17%), infections that required hospital admission in 27 patients (41%), and death in 9 patients (14%) in the study period. Our study provides practical and real-world data on management of LN. In patients with SLE, LN is associated with significant morbidity and mortality. Management continues to pose a unique challenge despite developing therapies. Sustained remission is often dependent on a complex interplay of individualized care, patient adherence, and socioeconomic factors. There is a need for increased awareness of LN as early biopsy, prompt initiation and continuation of treatment positively impacts outcomes.

Laryngeal cancer (LC) represents one-third of all head and neck cancers, with global deaths rising by 36.7% between 1990 and 2021. Although mortality has declined over the past two decades, recent data indicate a potential slowdown in this progress. This study evaluated temporal trends in laryngeal cancer mortality in the United States. LC mortality data from 1999 to 2024 were obtained from the CDC WONDER database. Age-adjusted mortality rates (AAMRs) per 100,000 population and annual percentage changes (APCs) with 95% confidence intervals (CIs) were calculated using Joinpoint regression analysis to assess temporal trends. Between 1999 and 2024, 129,275 LC-related deaths were recorded in the United States. The overall age-adjusted mortality rate (AAMR) declined from 3.76 to 2.25 per 100,000, with a significant decrease from 1999-2016 (APC: -2.75%; 95% CI, -2.92 to -2.58; p&#xa0;<&#xa0;0.001), followed by a non-significant change from 2016-2024 (APC: -0.38%; 95% CI, -0.87 to 0.11; p&#xa0;=&#xa0;0.12). Mortality was consistently higher in males than females, declining from 7.00 to 3.94 and 1.40 to 0.85 per 100,000, respectively. In 1999-2020 analyses, NH-Black individuals had the highest mortality, followed by NH-American Indian or Alaska Native and NH-White populations, with significant declines across all racial/ethnic groups (p&#xa0;<&#xa0;0.001). Highest state-level AAMRs were observed in Kentucky, West Virginia, Louisiana, Tennessee, Ohio, and the District of Columbia (reported separately as a federal district). Mortality declined across all age groups and was consistently higher in non-metropolitan than metropolitan areas (all trend tests p&#xa0;<&#xa0;0.05). LC mortality in the United States has declined since 1999, but the rate of decline has slowed in recent years. Marked disparities persist by sex, race/ethnicity, age, and geographic region, with higher mortality in males, NH-Black individuals, older adults, and non-metropolitan areas. These findings underscore the need for continued surveillance and targeted interventions.

Background and objectives Partial nephrectomy (PN) is the gold standard for small renal tumors, preserving nephrons without compromising oncologic outcomes. However, PN carries a higher complication rate, with postoperative bleeding being a notable risk. Despite its significance, data on transfusion risk factors remain limited. This study identifies variables associated with perioperative transfusion in patients undergoing PN. Methods A retrospective cohort study was conducted using the 2019-2020 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Patients undergoing PN were identified and stratified by transfusion status. Preoperative, perioperative, and postoperative variables were analyzed using univariate and multivariate logistic regression models. Results Among 892 PN patients, 116 (13.0%) required transfusion. Transfused patients were older (p=0.026) and had higher rates of disseminated cancer (p=0.020), weight loss (p=0.036), bleeding disorders (p=0.025), and prior pelvic surgeries (p=0.014). Perioperative factors included longer operative times (p<0.001), concomitant procedures (p<0.001), and unplanned reoperations (p<0.001). Multivariate analysis identified concomitant procedures (OR: 2.27, p<0.001), prior chemotherapy (OR: 4.89, p=0.001), and unplanned reoperation (OR: 6.16, p<0.001) as significant predictors. Transfusion increased the odds of composite complications (OR: 1.20, p=0.041). Conclusions Preoperative and perioperative factors influence transfusion risk, which in turn increases complication rates. Careful preoperative assessment and surgical planning can minimize transfusion-related morbidity. Restrictive transfusion strategies and optimized patient selection may improve outcomes.

Breast cancer is one of the leading health problems in the world, and the challenge lies in the fact that its diagnosis at the earliest possible and accurate rate is the main factor to guarantee a successful patient outcome. The traditional deep learning (DL) frameworks usually utilize data from a single modality at a time and, therefore, are not capable of addressing the complexity and heterogeneity of the disease, particularly when data are unavailable or incomplete. To address these constraints, a multimodal breast cancer diagnosis model is presented that consists of attention-based transformers to achieve efficient modality specific feature extraction, the modified mantissa search (MMS) algorithm to remove irrelevant features, and the American zebra optimization (AZO) algorithm to dynamically and efficiently combine features. Final classification is then performed using a lightweight convolutional neural network (LCNN) to avoid compromising diagnostic accuracy. The proposed model is highly generalizable and resilient to missing modalities, achieving 98.958, 97.37, and 99.438% accuracy on Mammographic Image Analysis Society (MIAS), BreakHis, and combined multimodal datasets, respectively. These findings reveal their usefulness and strength in clinical diagnostic cases with a variety of imaging data.

The US continues to lag in health outcomes and equity. In Part 1 of this review, we identified a persistent "Action Gap" as a failure of physician professionalism as defined in the Physician Charter. Competency-Based Medical Education identifies professionalism as an opportunity to reconnect ethical foundations to medical training. Role models like internist Jean Cowsert, MD (1925-1967) and a 7-member Black "Medical Intelligence Group", illustrate how professionalism can transcend rhetoric and become action. Cowsert helped lead hospital desegregation during the implementation of Medicare following the passage of the Civil Rights Act of 1964. She provided information to federal officials investigating hospital noncompliance with federal desegregation mandates. Days after her identity was compromised, she was shot dead. The circumstances were recently reviewed by the Department of Justice under the Emmett Till Crime Act. Cowsert's story, the work of Mobile civil rights leader John LeFlore and his "Medical Intelligence Group", demonstrate how physicians and healthcare advocates bridged the gap between ethics and action during one of the most turbulent periods in American medical history. Their example is relevant to modern debates regarding professionalism.