Strengthening the Reporting of Molecular Epidemiology for Infectious Diseases (STROME-ID): an extension of the STROBE statement

Robotic-assisted sleeve gastrectomy: an analysis of cost, peri-operative outcomes and learning curve in a prospective cohort study

Minimally invasive sleeve gastrectomy as a treatment for individuals living with severe obesity remains the most common operation in bariatric and metabolic surgery. With the introduction of robotic-assisted surgery, an increasing proportion of sleeve gastrectomies are performed using the da Vinci robotic surgical platform. To date, the evidence to support or contest this practice is still unclear although meta-analyses have shown safety and feasibility. Here we present a prospective cohort study comparing 101 consecutive patients who had either robotic-assisted or laparoscopic sleeve gastrectomy for obesity. Short-term outcomes, including length of stay and thirty-day complication rates, as well as the total consumable cost for both the laparoscopic and robotic-assisted procedures were collected. We also assessed the learning curve associated with robotic-assisted sleeve gastrectomy. The cohort had similar baseline characteristics in terms of BMI and co-morbidity. The mean operative time, post-operative CRP and complication rates were the same in both groups. Length of stay was statistically shorter for the robotic-assisted cohort in comparison to the laparoscopic cohort; 1.3 days versus 1.9 days, respectively (p < 0.005). The percentage of patients requiring only a single night admission was significantly higher at 82% in the robotic-assisted group, compared to 32% in the laparoscopic group (p < 0.005); in the context of a nurse-led-discharge protocol. Total consumable cost was significantly lower in the robotic group at an average of £2310, compared to £2665 in the laparoscopic group (p < 0.001). The learning curve for the procedure was found to be 26 cases, predominantly driven by the resectional component of the procedure. Robotic-assisted sleeve gastrectomy on the 4th generation da Vinci system utilising robotic advanced energy and Sureform stapling is safe and effective. This cohort study suggests that using the robotic platform is favourable in terms of overall consumable cost and may reduce length of stay. In the context of previous robotic experience, the observed learning curve is relatively short.

Housing Status and Cancer Screening in US Veterans

BACKGROUND

Cancer is a leading cause of death in people experiencing homelessness, who are more commonly diagnosed with late-stage disease and have poorer survival after diagnosis than housed.

OBJECTIVE

To characterize the incidence and timeliness of colorectal and breast cancer screening in a national sample of Veterans.

DESIGN

Retrospective, matched cohort study from 2011 to 2021 in a national sample of Veterans receiving care from the Veterans Health Administration (VA).

PARTICIPANTS

Each Veteran experiencing homelessness was matched to three housed Veterans with the same age, gender, clinic location, and month and year of outpatient clinic appointment.

EXPOSURE

We classified Veterans as homeless if they had any homeless indicator at the matched clinic visit or in the 12 months prior and all others as housed.

MAIN MEASURES

Our primary outcomes were being up to date on screening, receiving a biopsy following a positive screen and timeliness of biopsy. We assessed the association between housing status and our outcomes using conditional Poisson regression models with generalized estimating equations, adjusting for race, ethnicity, marital status, Charlson Comorbidity Index, smoking status, and mental health comorbidities.

KEY RESULTS

Our sample included 2,580,640 Veterans, with 1,935,480 housed and 645,160 experiencing homelessness. Patients experiencing homelessness had a 16% lower adjusted incidence rate ratio (aIRR) of being up to date with colorectal cancer screening when compared to housed (aIRR 0.84, 95%CI 0.83-0.84; p<0.001) and a 13% lower aIRR for breast cancer (aIRR 0.87, 95%CI 0.86-0.88; p<0.001). Following a positive stool-based test, patients experiencing homelessness had a 12% lower aIRR of undergoing diagnostic colonoscopy compared to housed (aIRR 0.88, 95%CI 0.84-0.92; p<0.001). Time to biopsy was similar between groups for both cancer types.

CONCLUSIONS

Veterans experiencing homelessness were less commonly screened for cancer than a matched housed cohort. However, screening rates in this group were higher than in non-Veteran homeless populations. The VA system may offer insights into providing preventative care for this population.

Genetic and Clinical-epidemiologic Profile of hRSV in Pediatric Patients in Southern Brazil: A Four-year Hospital Surveillance Study

BACKGROUND

Respiratory syncytial virus (hRSV) infections primarily cause acute respiratory illness and pediatric hospitalizations. We examined the hRSV molecular epidemiology in a pediatric cohort over a 4-year period and described the interrelationship with clinical data.

METHODS

A cross-sectional study was conducted from 2014 to 2017 on children with acute respiratory illness. Respiratory viruses were detected using a multiplex real-time polymerase chain reaction and molecular typing was performed by nucleotide sequencing.

RESULTS

Three hundred fifty-three children with hRSV were included; 207 (36%) samples were submitted to partial G gene sequencing. A total of 58.3% (n = 120) were males, the median age was 2.3 months (interquartile range 1-4), and 36.4% (n = 75) of the children required intensive care unit assistance. Coinfection was detected in 27 (5.7%) children, mainly hRSV and rhinovirus (14.2%). A total of 95.6% of patients had no comorbidities, and prematurity (4.4%) was more frequent among those with comorbidities. hRSV-B was detected in 109 patients (53%) and hRSV-A in 98 patients (47%), with changes in incidence over the period. All the hRSV-A sequences were classified as ON1-like, with genetic lineage GA2.3.5 forming distinct clusters. hRSV-B sequences were identified as BA-like, comprising 3 genetic lineages, GB5.0.2, GB5.0.4a and GB5.0.5a, with variation over time, and a higher severity was associated with hRSV type B GB5.0.2 and GB5.0.4a lineages compared with the GB5.0.5a.

CONCLUSIONS

Both hRSV subtypes showed similar severity and were not linked to comorbidities. Severe cases were more common in young patients and those infected with GB5.0.2 and GB5.0.4a genotypes. Understanding hRSV's molecular evolution is crucial for tracking new variants and assessing their impact on the effectiveness of emerging vaccines and monoclonal antibodies.

Development, revision, and validation of a Self-Regulated Learning Questionnaire for Chinese undergraduate students

Self-control is a critical aspect of learning, and a key factor for Chinese undergraduates transitioning from high school to university. This study aims to develop a questionnaire based on the existing theory of SRL while emphasizing self-control to better support educational research among Chinese undergraduates. By integrating open-ended surveys, interviews, expert evaluation with the theoretical framework of SRL, we generate 92 items for pilot test on 362 undergraduates in China. Further re-tests involved 409 students for item analysis, factor analysis, reliability, and validity. Item analysis removed 18 items from the pilot-test based on statistical and psychometric criteria, retaining 38 items across 10 factors, explaining 63.71 % of variance. The proposed Chinese-Self-Regulated Learning (C-SRL) Questionnaire showed strong reliability of the total scores ranging from 0.81 to 0.90 and subscales ranging from 0.64 to 0.80. Construct validity was supported by moderate to strong correlations (ranging from 0.51 to 0.59) within the subscales. Confirmatory Factor Analysis (CFA) results revealed that the two-stage, three-factor model fit better than the one-stage model, aligning with the theoretical framework. Additionally, convergent validity was confirmed through significant correlations with self-control and academic achievement, validating the relevance of the proposed questionnaire. The C-SRL Questionnaire, developed using a mixed-method approach, demonstrates strong reliability and validity, making it a valuable tool for studying self-regulation and predicting academic performance among Chinese undergraduates.

Amplitude-Integrated Electroencephalogram in Premature Infants: A Prospective Cohort Study

OBJECTIVE

 The study aimed to interpret and establish patterns of amplitude-integrated electroencephalogram (aEEG) in stable preterm neonates and compare the aEEG among different gestational age groups using three standard classifications.

METHODS

 This prospective cohort study included stable preterm neonates between 240/7 and 366/7 weeks of gestation. aEEG was recorded in the first and second week of life and interpreted using the L. Hellström-Westas, Burdjalov, and Magalhães classification for background pattern, continuity, upper and lower margin amplitude, sleep-wake cycle, bandwidth, and presence of seizures. Subgroup analysis was performed based on ≤30 and >30 weeks' gestation.

RESULTS

 A total of 76 aEEG recordings were analyzed from 45 preterm neonates. In the first week, 60% of the neonates had normal voltage patterns, which increased to 80% in the second week. All infants ≤30 weeks displayed discontinuous wave patterns during the first week, and half transitioned to continuous waves in the second week. The lower margin amplitude increased, and the upper margin amplitude decreased with increased gestational age. Additionally, 65% of neonates had a mature sleep-wake cycle in the second week compared with 22% in the first week. The median (interquartile range) CFM score in the second week was 12 (4.5) compared with 8 (4) in the first week, and the CFM score positively correlated with gestation (Spearman correlation coefficient, 0.8; 95% confidence interval, 0.7-0.86). Magalhães grading in both groups was predominantly normal.

CONCLUSION

 aEEG is predominantly a continuous normal voltage pattern in >30 weeks' gestation and discontinuous in ≤30 weeks' gestation. CFM score correlates positively with advancing gestation gestational age.

Traumatic pancreatic injuries and treatment outcomes: An observational retrospective study from a high-volume tertiary trauma center

INTRODUCTION

This study discusses a tertiary trauma center's experience involving traumatic pancreatic injuries, focusing on identification, management, and complications, aiming to provide a valuable contribution to the literature on pancreatic trauma management.

METHODS

We conducted a five year (2019-2023) retrospective analysis utilizing trauma registry data to identified pancreatic injuries in tier 1 and 2 activations. Pancreatic Organ Injury Scaling (OIS) and overall injury severity (ISS) was assessed using AAST scoring. Data was stratified by mechanism, management, associated injuries, and outcomes.

RESULTS

Thirty-one patients suffering firearm (48.4 ​%), stabbing (16.1 ​%), or blunt injuries (35.5 ​%) were investigated. Firearms correlated with diaphragm (P ​= ​0.047), stomach (P ​= ​0.001) and intrabdominal injury count (P = 0.0042). Robust trends were found between OIS, ISS, complication, mortality and many alike.

CONCLUSION

In penetrating injury, increasing ISS and number of intrabdominal injuries should heighten pancreatic trauma suspicion and lower the threshold for surgical exploration, particularly when involving the diaphragm, stomach, transverse colon or spleen.

U.S. national trends in cervical cancer screening by sexual orientation and race/ethnicity in cisgender women

INTRODUCTION

Changes in up-to-date cervical cancer screening (CCS) over time by sexual orientation and race/ethnicity were estimated to identify trends in screening disparities.

METHODS

This 2024 retrospective, cross-sectional analysis of National Health Interview Survey data (years 2013, 2015, 2019 and 2021) included 40,818 cisgender women aged 21-65 without hysterectomy. Joinpoint analysis was performed to calculate the annual percent change (APC) of up-to-date CCS from 2013 to 2021. Logistic regression (years 2019 and 2021) was used to describe the relationship between up-to-date screening and sexual orientation, race/ethnicity, and the interaction thereof.

RESULTS

The adjusted odds of up-to-date CCS were 22 % lower for lesbian, gay, and/or bisexual (LGB) compared to heterosexual women (OR = 0.78, p = 0.01). Up-to-date CCS fell significantly from 80.50 % in 2013 to 75.00 % in 2021 for heterosexual respondents (APC = -0.97 %, p < 0.01), but was stable across years for LGB respondents. Up-to-date CCS decreased for Hispanic (APC = -1.52, p < 01) and non-Hispanic White only heterosexual women (APC = -0.63, p = 0.02). It also decreased for non-Hispanic Black/African American only LGB women (APC = -2.67, p < 0.01) falling from 85.22 % in 2013 to 67.91 % in 2021. By multiplicative interaction, LGB Hispanic women were more up-to-date than their heterosexual counterparts (p = 0.05).

CONCLUSIONS

In 2021 there were approximately 19.72 million women aged 21-65 who were not up-to-date with CCS. 1.76 million LGB women were not up-to-date for CCS, and a greater proportion of these women identified as non-Hispanic Black/African American. CCS must be improved for all cisgender women, and specific attention should be given to those who identify as LGB and/or Black/African American.

Association between serum bicarbonate and 28-day mortality in critically ill patients with infective endocarditis: a cohort study from MIMIC-IV

The relationship between bicarbonate level and mortality in critically sick patients with infective endocarditis (IE) is currently not well established. The MIMIC-IV database was used to provide data for a retrospective cohort research. Included were patients with IE who were hospitalized to the critical care unit (ICU). Within the first 24 h following ICU admission, the serum bicarbonate was assessed. The 28-day mortality was the end-point result. To evaluate the relationship between the serum bicarbonate and 28-day mortality, multivariable Cox regression was employed. The study included 450 patients with IE in serious condition in the ICU, with a 57.4-year-old average and 64.2% male representation. The 28-day mortality rate stood at 20%. Unadjusted analysis revealed that higher serum bicarbonate levels upon ICU admission were significantly linked to reduced 28-day mortality (hazard ratio [HR], 0.90; 95% confidence interval [CI], 0.85-0.95; p < 0.001). This correlation remained significant after adjusting for potential confounding factors (adjusted HR, 0.94; 95% CI 0.89-0.99; p = 0.028). When categorizing bicarbonate levels, patients in the highest group (T3, ≥ 25 mEq/L) showed a significantly decreased adjusted HR of 0.55 (95% CI 0.33-0.93; p < 0.001) in relation to the control group (T1, ≤ 22 mEq/L) in the final model. Consistent results were observed in subgroup analyses across various groups. In patients with IE in the ICU, elevated serum bicarbonate upon admission was independently linked to a lower 28-day mortality. These findings indicate that serum bicarbonate can serve as a prognostic marker, supporting the process of risk assessment and providing direction for the clinical care of patients with IE.

Kinetic estimated glomerular filtration rate and drug dosing in critically ill patients with acute kidney injury-A prospective observational study

OBJECTIVE

To study the impact of kinetic glomerular filtration rate (kGFR) on clinical decision making and its implications on drug dosing compared to that of estimated GFR (eGFR) using chronic kidney disease epidemiology collaboration (CKD-EPI) equation in critically ill patients with acute kidney injury (AKI) admitted in a tertiary level intensive care unit (ICU).

METHODS

Cross-sectional, prospective, observational study design. All patients admitted to Medical ICU, Fortis Hospital, Bangalore with AKI defined as per AKI network (AKIN) criteria. Patients were recruited after approval from the scientific and institutional ethics committee, with written informed consent. Serum creatinine values at admission and further values were noted. GFR was calculated using both formulas (CKD-EPI and kGFR) and documented at all intervals of creatinine sampling. Drugs requiring renal dose modification along with the dosing were documented. Sample size was calculated after a pilot study and a total of 107 patients were analyzed.

RESULTS

Incidence of AKI was 12.84%. The mean (±SD) eGFR was 37.25 (±29.4) and kGFR was 42.5 (±33.2), (p-value .003). 70 (65.42%) patients required drug dose change when kGFR was used. Dosing changes from Day 1 to Day 5 are 53/104 (50.9%), 39/81 (48.1%), 12/26 (46.1%), 2/9 (28.5%), 1/2 (50%). Predominant dose changes were for antimicrobials: vancomycin (35.7%), acyclovir (23.1%), and meropenem (23%).

DISCUSSION

Drug dosing using different methods of GFR calculation showed a difference in the dosing in 65.42% of patients with AKI. Accounting for change in creatinine over time using kinetic GFR may lead to better drug dosing in critically ill patients with AKI.

CONCLUSION

Our study shows that calculating GFR using kGFR formula instead of CKD-EPI may change drug dosages among patients with AKI admitted in ICU. By replacing conventional GFR estimation formulas with kGFR we may reduce the drug dosing inaccuracies that are currently prevalent in this cohort of patients.

The impact of quantitative platform on candidacy for bronchoscopic lung volume reduction: a multi-center retrospective cohort study

BACKGROUND

Bronchoscopic lung volume reduction (BLVR) can be an effective treatment for highly selected patients with severe emphysema but only half of carefully selected patients derive clinical benefit. Two commercially available platforms exist to help determine candidacy for BLVR via quantitative analysis of computed tomography (CT) scans.

OBJECTIVES

To determine if the two commercially available quantitative platforms identified the same patient population that may benefit from BLVR.

DESIGN

A multicenter, retrospective cohort study.

METHODS

Consecutive patients referred for BLVR between January 1, 2022 and March 31, 2023 at three medical centers in the United States with the same CT scan submitted for quantitative analysis to two commercially available platforms to determine BLVR candidacy were analyzed. The primary outcome of interest was whether quantitative analysis provided different recommendations for individual patients. The recommendation to proceed with BLVR was based on a prespecified algorithm using criteria established in clinical trials for each quantitative platform, respectively.

RESULTS

A total of 83 patients referred for BLVR across three centers were included; patients were a median 67 years old, had a median post bronchodilator FEV1 of 30% predicted (IQR: 25, 38), a median residual volume of 220% predicted (IQR: 185, 268), and 29 (34.9%) received endobronchial valves. A total of 26 patients (31.3%) received different recommendations from the two quantitative platforms.

CONCLUSION

In this cohort of patients evaluated for BLVR across multiple medical centers, nearly a third of patients received different recommendations based on the platform utilized for valve assessment. This suggests that the selection process for BLVR may warrant refinement.

Non-linear relationship between platelet count and 28-day mortality in critically ill patients with infective endocarditis: a retrospective cohort study from MIMIC IV database

Background

The relationship between platelet count and 28-day mortality in critically ill patients with infective endocarditis (IE) is currently not well established.

Objective

This study aims to investigate the impact of platelet count on 28-day mortality in critically ill patients with infective endocarditis.

Methods

A retrospective cohort study was conducted involving 450 participants diagnosed with infective endocarditis and admitted to intensive care units (ICU). Vital signs, laboratory parameters and comorbidity were collected for all participants to analyze the association between platelet count and 28-day mortality. In order to assess the independent association between platelet count and 28-day mortality, we employed multivariable cox hazard regression analyses and smooth curve fitting. A further analysis was conducted using a two-piecewise linear regression model to examine the nonlinear association between platelet count and in-hospital mortality.

Results

A total of 450 critically ill patients with infective endocarditis were included in the study. The mean age was 57.4 years, and 64.2% were male. The overall 28-day mortality rate was 20%. A non-linear relationship was observed between platelet count and 28-day mortality. Two different slopes were identified, with correlations between platelet count and 28-day mortality in patients with IE differing significantly below and above the inflection point, which was approximately 141 K/µl. On the left side of the inflection point, the hazard ratio was 0.990 (hazard ratio: 0.990, 95% confidence interval: 0.982-0.997, p = 0.006). However, on the right side of the inflection point, the hazard ratio increased marginally to 1.0004 (HR: 1.0004, 95% CI: 0.997-1.004, p = 0.825). Notably, the association lacked statistical significance on the right side of the inflection point.

Conclusion

A nonlinear association between platelet count and 28-day mortality was observed in critically ill patients with infective endocarditis. The optimal platelet count associated with the lowest risk of 28-day mortality was above 141 k/µl.

Better Oncological Outcomes After Prostate-specific Membrane Antigen Positron Emission Tomography-guided Salvage Radiotherapy Following Prostatectomy

BACKGROUND AND OBJECTIVE

Up to 50% of patients with prostate cancer experience prostate-specific antigen (PSA) relapse following primary radical prostatectomy (RP). Prostate-specific membrane antigen (PSMA) positron emission tomography (PET) is increasingly being used for staging after RP owing to its high detection rate. Our aim was to compare outcomes for patients who received salvage radiotherapy (sRT) with versus without PSMA PET guidance.

METHODS

In this observational case-control study, the control group consisted of 344 patients from the SAKK09/10 trial (sRT without PSMA PET guidance from 2011 to 2014). The treatment group consisted of 1548 patients from a retrospective multicenter cohort (PSMA PET-guided sRT from July 2013 to 2020). Data were collected up to November 2023. Patients with pN1 status at RP, initial cM1 status, cM1 status on PET, or PSA >0.5 ng/ml were excluded. Patients with detectable PSA after RP who were treated with sRT were eligible. We assessed 3-yr biochemical recurrence-free survival (BRFS) and metastasis-free survival (MFS).

KEY FINDINGS AND LIMITATIONS

The study population of 717 patients comprised a control group (n = 255) with median follow-up of 75 mo and a PSMA PET group (n = 462) with median follow-up of 31 mo. In the PSMA PET cohort, 103 patients (22.3%) had PSMA-positive pelvic lymph nodes (PLNs), 85 (18.4%) received androgen deprivation therapy (ADT), and 104 (22.5%) underwent PLN irradiation. The BRFS rate at 3 yr was 71% (95% confidence interval [CI] 64-78%) for the control group and 77% (95% CI 72-82%) for the PSMA PET group. The PSMA PET group had favorable BRFS at 18-24 mo after sRT (hazard ratio 0.32, 95% CI 0.0.14-0.75; p = 0.01) and a lower rate of lymph node relapse after sRT (standardized mean difference 0.603). The MFS rate at 3 yr was 89.2% (95% CI 84.6-94.1%) for the control group and 91.2% (95% CI 88.1-94.4%) for the PSMA PET group.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Our results suggest a moderate improvement in short-term BRFS if PSMA PET is used to guide sRT. One possible reason is individualized PLN coverage facilitated by PET. MFS was not improved by PSMA PET guidance for sRT.

PATIENTS' SUMMARY

For patients who experience recurrence of prostate cancer after surgical removal of their prostate, salvage radiotherapy (sRT) is a further treatment option. We found that a type of scan called PSMA PET (prostate-specific membrane antigen positron emission tomography) to identify recurrence and guide sRT can improve recurrence-free survival because of better targeting of pelvic lymph nodes that may contain cancer cells.

Association between serum anion gap and 28-day mortality in critically ill patients with infective endocarditis: a retrospective cohort study from MIMIC IV database

BACKGROUND

The relationship between serum anion gap (AG) and 28-day mortality in critically ill patients with infective endocarditis is currently not well established.

OBJECTIVE

This study aims to investigate the impact of serum AG on 28-day mortality in critically ill patients with infective endocarditis.

METHODS

A retrospective cohort study was conducted involving 449 participants diagnosed with infective endocarditis and admitted to intensive care units (ICU). Vital signs, laboratory parameters and comorbidity were collected for all participants to analyze the association between anion gap levels and 28-day mortality.

RESULTS

A total of 449 critically ill patients with infective endocarditis (IE) were included in the study. The mean age was 57 years, and 64% were male. The overall 28-day mortality rate was 20%. A greater AG on admission were significantly associated with increased 28-day mortality in unadjusted analysis (hazard ratio [HR] 1.13; 95% confidence interval [CI] 1.09-1.18; p < 0.001). After adjusting for all confounders, the association remained significant (adjusted HR 1.07; 95% CI 1.02-1.13; p = 0.003). When AG was converted into categorial variables (quartiles), the risk of 28-day mortality in the greatest Q4 group was significantly higher compared with that in the lowest Q1 group (model 4: HR = 2.62, 95%CI: 1.17-5.83, p = 0.019). Subgroup analysis showed consistent results across different groups.

CONCLUSION

A greater AG on admission were independently associated with increased 28-day mortality in critically ill patients with IE. These findings suggest that the AG can serve as a prognostic marker in this population, aiding in risk stratification and guiding clinical management.

Associations of metabolic heterogeneity of obesity with the risk of dementia in middle-aged adults: three prospective studies

BACKGROUND

The associations of different obesity and metabolic phenotypes during midlife with the risk of incident dementia remain unclear. This study aimed to investigate the associations between metabolic heterogeneity of obesity and long-term risk of dementia.

METHODS

We conducted prospective analyses from three cohorts, including the UK Biobank (UKB), Atherosclerosis Risk in Communities (ARIC) study, and Framingham Offspring Study (FOS). Eligible participants were those aged 45-65 years with valid assessments of body mass index (BMI) and metabolic status at the study baseline. Obesity was defined as a BMI of ≥ 30.0 kg/m2, while metabolic abnormality was defined as meeting ≥ 2 of the National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III) criteria. Metabolic heterogeneity of obesity was evaluated based on obesity and metabolic phenotypes and grouped as metabolically normal non-obesity (MNNO), metabolically abnormal non-obesity (MANO), metabolically normal obesity (MNO), and metabolically abnormal obesity (MAO).

RESULTS

Included in this study were 295,823 participants aged 56.3 ± 5.9 years from the UKB, 12,547 participants aged 54.0 ± 5.7 years from the ARIC, and 2,004 participants aged 53.9 ± 5.9 years from the FOS. Over 4,348,208 person-years, a total of 6,190 participants (3,601 in the UKB, 2,405 in the ARIC, and 184 in the FOS) developed incident dementia. In the pooled analysis of three cohorts, metabolic abnormality was associated with a hazard ratio (HR) of 1.41 (95% confidence interval [CI]: 1.10-1.80) for dementia, while obesity was associated with an HR of 1.20 (1.03-1.41). Compared with MNNO, individuals with MANO and MAO had increased risks of dementia (pooled HR: 1.33, 95% CI: 1.04-1.71 for MANO and 1.48, 1.16-1.89 for MAO). However, there was no significant difference in the risk of dementia among MNO (pooled HR: 1.10, 95% CI: 0.98-1.24). In addition, participants who recovered from MANO to MNNO had a lower risk of dementia (pooled HR: 0.79, 95% CI: 0.64-0.97), as compared with stable MANO.

CONCLUSIONS

Metabolic abnormality has a stronger association with dementia than obesity. Metabolically abnormal non-obesity and obesity, but not metabolically normal obesity, are associated with higher risks of incident dementia as compared with metabolically normal non-obesity. Recovering from an abnormal metabolic status to normal reduces the risk of dementia in populations without obesity. Our findings highlight the important role of metabolic status in the development of dementia and recommend the stratified management of obesity based on metabolic status.

Missing School Days Following Sport-Related Concussion in High School Athletes

Importance

Sport-related concussions (SRC) can significantly impact students' attendance and academic performance, highlighting the importance of gradual return-to-learn protocols for recovery. Understanding the association between missed school days and recovery, especially across genders, is vital for effective concussion management in high school athletes.

Objectives

To describe missed school days in high school athletes with SRC and to determine associations between missed school days and authorized clearance to return to competition; secondarily, to determine whether school days missed differed by gender.

Design, Setting, and Participants

Cohort study among student athletes participating in athletics sponsored by the Michigan High School Athletic Association (MHSAA) during academic years 2015 to 2023. SRC was a participant eligibility criterion and was defined as a head injury during participation in a MHSAA-sanctioned event. Data were analyzed from August 2015 to June 2023.

Exposures

Primary exposure was missed school days; additional exposures included gender, year of season, concussion history, event type, sport level, contact level, and athletic trainer involvement.

Main Outcome and Measure

The primary outcome was time to full unrestricted clearance following SRC.

Results

The analysis included a total of 20 934 individuals with SRC (13 869 boys [66.25%]). Gender (χ23 = 167.40; P < .001), season (χ221 = 57.41; P < .001), event type (χ23 = 99.29; P < .001), sport level (χ29 = 68.15; P < .001), contact level (χ26 = 56.73; P < .001), and initial evaluation (χ23 = 147.13; P < .001) were independently associated with missed school days. Athletes took a median (IQR) of 11 (7-16) days to return to full unrestricted clearance. Relative to no missed school days, there was a significant mean increase of 57% (incidence rate ratio, 1.57; 95% CI, 1.52-1.62) in time to full unrestricted clearance for 3 or more missed school days. The estimated mean days to return to sport were 12.15 (95% CI, 12.00-12.30) for 0 missed school days, 12.68 (95% CI, 12.39-12.96) for 1 missed school day, 15.47 (95% CI, 15.06-15.87) for 2 missed school days, and 19.08 (95% CI, 18.55-19.62) for 3 or more missed school days.

Conclusions and Relevance

This cohort study found that high school athletes typically missed 2 or fewer school days after SRC, suggesting that concussion management teams adhered to current recommendations of 24 to 48 hours of initial rest. The dose association, with more missed school days associated with slower return to play, suggests athletes' missing more school days (eg, ≥3) may be associated with severity of concussion and warrant additional support to return to school and/or sport.

Emergency department utilization among adults with epilepsy: A multi-state cross-sectional analysis, 2010-2019

OBJECTIVE

We described patterns and trends in ED use among adults with epilepsy in the United States.

METHODS

Utilizing inpatient and ED discharge data from seven states, we conducted a cross-sectional analysis to identify adult ED visits diagnosed with epilepsy or seizures from 2010 to 2019. Using ED visit counts and estimates of state-level epilepsy prevalence, we calculated ED visit rates overall and by payer, condition, and year.

RESULTS

Our data captured 304,935 ED visits with epilepsy as a primary or secondary diagnosis in 2019. Across the seven states, visit rates ranged between 366 and 726 per 1000 and were higher than rates for adults without epilepsy in all states but one. ED visit rates were highest among Medicare and Medicaid beneficiaries (vs commercial or self-pay). Adults with epilepsy were more likely to be admitted as inpatients. Visits for nervous system disorders were 6.3-8.2 times higher among people with epilepsy, and visits for mental health conditions were 1.2-2.6 times higher. Increases in ED visit rates from 2010 to 2019 among people with epilepsy exceeded increases among adults without by 6.0-27.3 percentage points.

CONCLUSION

Adults with epilepsy visit the ED frequently and visit rates have been increasing over time. These results underscore the importance of identifying factors contributing to ED use and designing tailored interventions to improve ambulatory care quality.

Rotavirus infections and their genotype distribution pre- and post-vaccine introduction in Ethiopia: a systemic review and meta-analysis

BACKGROUND

Rotavirus infections are a significant cause of severe diarrhea and related illness and death in children under five worldwide. Despite the global introduction of vaccinations for rotavirus over a decade ago, rotavirus infections still result in high deaths annually, mainly in low-income countries, including Ethiopia, and need special attention. This system review and meta-analysis aimed to comprehensively explore the positive proportion of rotavirus at pre- and post-vaccine introduction periods and genotype distribution in children under five with diarrhea in Ethiopia.

METHODS

The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Database sources included PubMed, Scopus, EMBASE, and Epistemonikos, focusing on studies published before November 30, 2023. The search targeted rotavirus infection and genotype distribution in Ethiopia before and after the introduction of the Rota vaccine. Data was managed using EndNote 2020 software and stored in an Excel 2010 sheet. A random-effects model determined the pooled estimate of the rotavirus infection rate at 95% confidence intervals. The Q-and I² statistics were used to assess the study heterogeneity, and a funnel plot (Egger test) was used to determine the possibility of publication bias.

RESULTS

The analysis included data from nine studies conducted in different regions of Ethiopia. The overall prevalence of rotavirus infection was significant, with a prevalence rate of approximately 22.63% (1362/6039). The most common genotypes identified before the Rota vacation introduction were G1, G2, G3, G12, P [4], P [6], P [8], P [9], and P [10]. Meanwhile, G3 and P [8] genotypes were particularly prevalent after the Rota vaccine introduction. These findings highlight the importance of implementing preventive measures, such as vaccination, to reduce the burden of rotavirus infection in this population. The identified genotypes provide valuable insights for vaccine development and targeted interventions.

CONCLUSION

This study contributes to the evidence base for public health interventions and strategies to reduce the impact of rotavirus infection in children under five in Ethiopia. Despite the rollout of the Rota vaccination in Ethiopia, rotavirus heterogeneity is still high, and thus, enhancing vaccination and immunization is essential.

Association between the anion gap and mortality in critically ill patients with influenza: A cohort study

Introduction

Influenza is an important global health concern, particularly in critically ill patients. The anion gap, a marker of metabolic acidosis, is associated with mortality in various critical illnesses. However, its association with mortality in critically ill patients with influenza remains unclear. This study investigated the association between the anion gap on admission and 28-day mortality in critically ill patients with influenza.

Methods

A retrospective cohort study was conducted using data from MIMIC-IV database. Patients admitted to the intensive care unit (ICU) with influenza were included. The anion gap was measured within the first 24 h of ICU admission. The primary outcome was the 28-day mortality. The secondary outcomes were 60-day mortality and in-hospital mortality. Multivariable Cox regression was used to assess the association between the anion gap and mortality.

Results

A total of 276 critically ill patients with influenza were included in the study. The mean age was 65 years, and 60 % were male. The overall 28-day mortality was 15.5 %. A greater anion gap on admission was associated with significantly increased 28-day mortality in the unadjusted analysis (hazard ratio [HR], 1.11; 95 % confidence interval [CI], 1.03-1.2; p < 0.001). The association remained significant after adjusting for age, sex, race, and illness severity (adjusted HR, 1.09; 95 % CI, 1.02-1.17; p = 0.017). Subgroup analysis showed consistent results across the different groups.

Conclusion

A greater anion gap on admission was independently associated with increased 28-day mortality in critically ill patients with influenza. These findings suggest that the anion gap can be used as a prognostic marker in patients with influenza, aiding in risk stratification and guiding clinical management.

Prevalence and risk factors of depression in U.S. adults post mass shootings: evidence from population-based surveys of multiple communities

OBJECTIVES

Mass violence incidents (MVIs) involving firearms, commonly referred to as "mass shootings" have become increasingly frequent in the United States. These shootings often result in immediate casualties and have far-reaching psychological impacts on survivors, witnesses, and the broader community. This study aimed to assess the prevalence and risk factors of depression within affected communities.

STUDY DESIGN

Population-based cross-sectional study.

METHODS

Data were collected from six communities affected by MVIs involving firearms that occurred between 2015 and 2020. Participants were randomly selected through address-based sampling, and depression was assessed using Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) diagnostic-level major depressive episode (MDE).

RESULTS

Overall, the MDE prevalence was 17·2% since the MVI, 15·4% in the past year, and 8·2% in the past month. Significant risk factors for MDE since MVIs include high exposure to the incident (adjusted relative risk [aRR] = 1·32, 95% confidence interval [CI]: 19-1·60), being aged 18-29 years (aRR = 2·52, 95% CI: 1·61-3·95), being a woman (aRR = 1·58, 95% CI: 1·27-1·96), having low social support (aRR = 1·80, 95% CI: 1·46-2·22), and experiencing past sexual or physical trauma (aRR = 2·20, 1·52-3·19).

CONCLUSION

Our study reveals a high burden of depression within communities affected by MVIs involving firearm use. Persons with high exposure to the MVIs and certain demographic groups had greater risks for MDE. These findings highlight the long-term mental health burden in communities affected by MVIs and underscore the necessity of providing mental health services in its aftermath.

Use of Muscle Relaxants After Surgery in Traditional Medicare Part D Enrollees

BACKGROUND

Surgeons have come under increased scrutiny for postoperative pain management, particularly for opioid prescribing. To decrease opioid use but still provide pain control, nonopioid medications such as muscle relaxants are being used, which can be harmful in older adults. However, the prevalence of muscle relaxant prescribing, trends in use over time, and risk of prolonged use are unknown.

STUDY DESIGN

Using a 20% representative Medicare sample, we conducted a retrospective analysis of muscle relaxant prescribing to patients ≥ 65 years of age. We merged patient data from Medicare Carrier, MedPAR, and Outpatient Files with Medicare Part D for the years 2013-2018. A total of 14 surgical procedures were included to represent a wide range of anatomic regions and specialties.

RESULTS

The study cohort included 543,929 patients. Of the cohort, 8111 (1.5%) received a new muscle relaxant prescription at discharge. Spine procedures accounted for 12% of all procedures but 56% of postoperative prescribing. Overall, the rate of prescribing increased over the time period (1.4-2.0%, p < 0.001), with increases in prescribing primarily in the spine (7-9.6%, p < 0.0001) and orthopedic procedure groups (0.9-1.4%, p < 0.0001). Of patients discharged with a new muscle relaxant prescription, 10.7% had prolonged use.

CONCLUSIONS

The use of muscle relaxants in the postoperative period for older adults is low, but increasing over time, especially in ortho and spine procedures. While pain control after surgery is crucial, surgeons should carefully consider the risks of muscle relaxant use, especially for older adults who are at higher risk for medication-related problems.

Youth Suicide and Preceding Mental Health Diagnosis

Importance

Suicide is a leading cause of death among US youths, and mental health disorders are a known factor associated with increased suicide risk. Knowledge about potential sociodemographic differences in documented mental health diagnoses may guide prevention efforts.

Objective

To examine the association of documented mental health diagnosis with (1) sociodemographic and clinical characteristics, (2) precipitating circumstances, and (3) mechanism among youth suicide decedents.

Design, Setting, and Participants

This retrospective, cross-sectional study of youth suicide decedents aged 10 to 24 years used data from the Centers for Disease Control and Prevention National Violent Death Reporting System from 2010 to 2021. Data analysis was conducted from January to November 2023.

Exposures

Sociodemographic characteristics, clinical characteristics, precipitating circumstances, and suicide mechanism.

Main Outcomes and Measures

The primary outcome was previously documented presence of a mental health diagnosis. Associations were evaluated by multivariable logistic regression.

Results

Among 40 618 youth suicide decedents (23 602 aged 20 to 24 years [58.1%]; 32 167 male [79.2%]; 1190 American Indian or Alaska Native [2.9%]; 1680 Asian, Native Hawaiian, or Other Pacific Islander [4.2%]; 5118 Black [12.7%]; 5334 Hispanic [13.2%]; 35 034 non-Hispanic; 30 756 White [76.1%]), 16 426 (40.4%) had a documented mental health diagnosis and 19 027 (46.8%) died by firearms. The adjusted odds of having a mental health diagnosis were lower among youths who were American Indian or Alaska Native (adjusted odds ratio [aOR], 0.45; 95% CI, 0.39-0.51); Asian, Native Hawaiian, or Other Pacific Islander (aOR, 0.58; 95% CI, 0.52-0.64); and Black (aOR, 0.62; 95% CI, 0.58-0.66) compared with White youths; lower among Hispanic youths (aOR, 0.76; 95% CI, 0.72-0.82) compared with non-Hispanic youths; lower among youths aged 10 to 14 years (aOR, 0.70; 95% CI, 0.65-0.76) compared with youths aged 20 to 24 years; and higher for females (aOR, 1.64; 95% CI, 1.56-1.73) than males. A mental health diagnosis was documented for 6308 of 19 027 youths who died by firearms (33.2%); 1691 of 2743 youths who died by poisonings (61.6%); 7017 of 15 331 youths who died by hanging, strangulation, or suffocation (45.8%); and 1407 of 3181 youths who died by other mechanisms (44.2%). Compared with firearm suicides, the adjusted odds of having a documented mental health diagnosis were higher for suicides by poisoning (aOR, 1.70; 95% CI, 1.62-1.78); hanging, strangulation, and suffocation (aOR, 2.78; 95% CI, 2.55-3.03); and other mechanisms (aOR, 1.59; 95% CI, 1.47-1.72).

Conclusions and Relevance

In this cross-sectional study, 3 of 5 youth suicide decedents did not have a documented preceding mental health diagnosis; the odds of having a mental health diagnosis were lower among racially and ethnically minoritized youths than White youths and among firearm suicides compared with other mechanisms. These findings underscore the need for equitable identification of mental health needs and universal lethal means counseling as strategies to prevent youth suicide.

Impact of health insurance on the use of oral health services in the Peruvian population 2015-2019

BACKGROUND

The high treatment cost of oral diseases is a barrier for accessing oral health services (OHS), particularly in low-income countries. Therefore, this study aimed to evaluate the impact of health insurance on the use of OHS in the Peruvian population from 2015 to 2019.

METHODS

We conducted a prospective, longitudinal study of secondary data using the National Household Survey (ENAHO) 2015-2019 panel databases, which collected information from the same participants during each of the five years. The dependent variable was the use of OHS in the three months prior to the survey (yes/no). The independent variable was health insurance affiliation (four years or less/all five years). Both were measured by survey questions. Generalized estimating equation (GEE) Poisson regression models with robust standard errors were used to estimate the relative risk (RR) associated with use of OHS.

RESULTS

We included 4064 individuals distributed in 1847 households, who responded to the survey during each of the five years. The adjusted GEE model showed that those who had health insurance during all five years without interruption were more likely to attend OHS than those who had insurance for four years or less (adjusted relative risk [aRR]: 1.30; 95%CI: 1.13-1.50). In addition, we carried out a sensitivity analysis by recategorizing the independent variable into three categories (never/some years/ all five years), which also showed (aRR: 1.45; 95%CI: 1.11-1.89) that participants with health insurance during all five years were more likely to have used OHS than those who never had insurance.

CONCLUSION

Therefore, in the Peruvian context, health insurance affiliation was associated with greater use of OHS. The panel data used derives from a subsample of consecutive nationally representative samples, which may have led to a loss of representativeness. Furthermore, the data was collected between 2015 and 2019, prior to the onset of the COVID-19 pandemic, and insurance conditions may have changed.

Molecular epidemiology and risk factors associated with BK and JC polyomavirus urinary shedding after kidney allograft

Polyomaviruses BK (BKPyV) and JC (JCPyV), belonging to the Polyomaviridae, are responsible for human pathologies. In kidney transplant recipients, BKPyV replication can lead to irreversible nephron damage whereas JCPyV replication remains asymptomatic. Concomitant replication is rare and potential competition between the infections has been described. The aim of this retrospective case-control study was to describe the molecular epidemiology and risk factors associated with BKPyV and JCPyV replication in a cohort of kidney transplant recipients. In total, 655 urine samples from 460 patients were tested for BKPyV and JCPyV DNA. Positive samples were submitted to strain genotyping. Demographic and clinical characteristics were also compared. Isolated JCPyV and BKPyV was found in 16.5% and 23.3% of patients, respectively; co-replication was rare (3.9%). BKPyV strains Ib-2, Ib-1, and IVc-2 were the most prevalent. JCPyV strains mostly belonged to genotypes 4 and 1B. During follow-up, JCPyV shedding significantly reduced the risk of BKPyV DNAuria, with an odds ratio of 0.57 (95% confidence interval: 0.35-0.99), and was associated with better prognosis than BKPyV replication, based on the estimated glomerular filtration rate. Molecular epidemiology of BKPyV and JCPyV strains in our region was similar to previous studies. This study suggests that JCPyV is benign and appears to limit damaging BKPyV replication. JCPyV DNAuria screening could thus be a useful strategy to predict BKPyV-related outcomes.

Understanding the potential role of whole genome sequencing (WGS) in managing patients with gonorrhoea: A systematic review of WGS use on human pathogens in individual patient care

OBJECTIVES

The utility of whole genome sequencing (WGS) to inform sexually transmitted infection (STI) patient management is unclear. Timely WGS data might support clinical management of STIs by characterising epidemiological links and antimicrobial resistance profiles. We conducted a systematic review of clinical application of WGS to any human pathogen that may be transposable to gonorrhoea.

METHODS

We searched six databases for articles published between 01/01/2010-06/02/2023 that reported on real/near real-time human pathogen WGS to inform clinical intervention. All article types from all settings were included. Findings were analysed using narrative synthesis.

RESULTS

We identified 12,179 articles, of which eight reported applications to inform tuberculosis (n = 7) and gonorrhoea (n = 1) clinical patient management. WGS data were successfully used as an adjunct to clinical and epidemiological data to enhance contact-tracing (n = 2), inform antimicrobial therapy (n = 5) and identify cross-contamination (n = 1). WGS identified gonorrhoea transmission chains that were not established via partner notification. Future applications could include insights into pathogen exposure detected within sexual networks for targeted patient management.

CONCLUSIONS

While there was some evidence of WGS use to provide individualised tuberculosis and gonorrhoea treatment, the eight identified studies contained few participants. Future research should focus on testing WGS intervention effectiveness and examining ethical considerations of STI WGS use.

Association of Race and Ethnicity With Postoperative Gabapentinoid and Opioid Prescribing Trends for Older Adults

BACKGROUND

Disparities in opioid prescribing by race/ethnicity have been described in many healthcare settings, with White patients being more likely to receive an opioid prescription than other races studied. As surgeons increase prescribing of nonopioid medications in response to the opioid epidemic, it is unknown whether postoperative prescribing disparities also exist for these medications, specifically gabapentinoids.

METHODS

We conducted a retrospective cohort study using a 20% Medicare sample for 2013-2018. We included patients ≥66 years without prior gabapentinoid use who underwent one of 14 common surgical procedures. The primary outcome was the proportion of patients prescribed gabapentinoids at discharge among racial and ethnic groups. Secondary outcomes were days' supply of gabapentinoids, opioid prescribing at discharge, and oral morphine equivalent (OME) of opioid prescriptions. Trends over time were constructed by analyzing proportion of postoperative prescribing of gabapentinoids and opioids for each year. For trends by year by racial/ethnic groups, we ran a multivariable logistic regression with an interaction term of procedure year and racial/ethnic group.

RESULTS

Of the 494,922 patients in the cohort (54% female, 86% White, 5% Black, 5% Hispanic, mean age 73.7 years), 3.7% received a new gabapentinoid prescription. Gabapentinoid prescribing increased over time for all groups and did not differ significantly among groups (P = 0.13). Opioid prescribing also increased, with higher proportion of prescribing to White patients than to Black and Hispanic patients in every year except 2014.

CONCLUSIONS

We found no significant prescribing variation of gabapentinoids in the postoperative period between racial/ethnic groups. Importantly, we found that despite national attention to disparities in opioid prescribing, variation continues to persist in postoperative opioid prescribing, with a higher proportion of White patients being prescribed opioids, a difference that persisted over time.

Does Single Dose Epinephrine Improve Outcomes for Patients with Out-of-Hospital Cardiac Arrest and Bystander CPR or a Shockable Rhythm?

BACKGROUND

A single dose epinephrine protocol (SDEP) for out-of-hospital cardiac arrest (OHCA) achieves similar survival to hospital discharge (SHD) rates as a multidose epinephrine protocol (MDEP). However, it is unknown if a SDEP improves SHD rates among patients with a shockable rhythm or those receiving bystander cardiopulmonary resuscitation (CPR).

METHODS

This pre-post study, spanning 11/01/2016-10/29/2019 at 5 North Carolina EMS systems, compared pre-implementation MDEP and post-implementation SDEP in patients ≥18 years old with non-traumatic OHCA. Data on initial rhythm type, performance of bystander CPR, and the primary outcome of SHD were sourced from the Cardiac Arrest Registry to Enhance Survival. We compared SDEP vs MDEP performance in each rhythm (shockable and non-shockable) and CPR (bystander CPR or no bystander CPR) subgroup using Generalized Estimating Equations to account for clustering among EMS systems and to adjust for age, sex, race, witnessed arrest, arrest location, AED availability, EMS response interval, and presence of a shockable rhythm or receiving bystander CPR. The interaction of SDEP implementation with rhythm type and bystander CPR was evaluated.

RESULTS

Of 1690 patients accrued (899 MDEP, 791 SDEP), 19.2% (324/1690) had shockable rhythms and 38.9% (658/1690) received bystander CPR. After adjusting for confounders, SHD was increased after SDEP implementation among patients with bystander CPR (aOR 1.61, 95%CI 1.03-2.53). However, SHD was similar in the SDEP cohort vs MDEP cohort among patients without bystander CPR (aOR 0.81, 95%CI 0.60-1.09), with a shockable rhythm (aOR 0.96, 95%CI 0.48-1.91), and with a non-shockable rhythm (aOR 1.26, 95%CI 0.89-1.77). In the adjusted model, the interaction between SDEP implementation and bystander CPR was significant for SHD (p = 0.002).

CONCLUSION

Adjusting for confounders, the SDEP increased SHD in patients who received bystander CPR and there was a significant interaction between SDEP and bystander CPR. Single dose epinephrine protocol and MDEP had similar SHD rates regardless of rhythm type.

A retrospective analysis of mission reports in the national Swedish Police Registry on mountain rescue 2018-2022: here be snowmobiles

BACKGROUND

Increasing mountain activity and decreasing participant preparedness, as well as climate change, suggest needs to tailor mountain rescue. In Sweden, previous medical research of these services are lacking. The aim of the study is to describe Swedish mountain rescue missions as a basis for future studies, public education, resource allocation, and rescuer training.

METHODS

Retrospective analysis of all mission reports in the national Swedish Police Registry on Mountain Rescue 2018-2022 (n = 1543). Outcome measures were frequencies and characteristics of missions, casualties, fatalities, traumatic injuries, medical conditions, and incident mechanisms.

RESULTS

Jämtland county had the highest proportion of missions (38%), followed by Norrbotten county (36%). 2% of missions involved ≥ 4 casualties, and 44% involved ≥ 4 mountain rescuers. Helicopter use was recorded in 59% of missions. Non-Swedish citizens were rescued in 12% of missions. 37% of casualties were females. 14% of casualties were ≥ 66 or ≤ 12 years of age. Of a total 39 fatalities, cardiac event (n = 14) was the most frequent cause of death, followed by trauma (n = 10) and drowning (n = 8). There was one avalanche fatality. 8 fatalities were related to snowmobiling, and of the total 1543 missions, 309 (20%) were addressing snowmobiling incidents. Of non-fatal casualties, 431 involved a medical condition, of which 90 (21%) suffered hypothermia and 73 (17%) cardiovascular illness.

CONCLUSIONS

These baseline data suggest snowmobiling, cardiac events, drownings, multi-casualty incidents, and backcountry internal medicine merit future study and intervention.

Factors Related to the Willingness of People with Mental Health Illnesses Living in Group Homes to Disclose Their Illness to Supporters during Disaster Evacuation: A Cross-Sectional Study

Severe heavy rains caused by linear precipitation systems are occurring more frequently in Japan owing to climate change, and residents are being asked to evacuate more often. The purpose of this study was to identify factors associated with the willingness of people with mental health illness (PMHI) in group homes to disclose their illness when being evacuated. Participants were PMHI living in group homes in Japan. We conducted an original anonymous self-administered questionnaire based on previous research. Valid data from 119 people were analyzed. Factors associated with the willingness to disclose illness to supporters upon evacuation were "I can imagine living in a public shelter" (Odds Ratio [OR] 4.50, 95% Confidence Interval [CI]: 1.78-11.43), and "I socialize with neighbors" (OR 5.63, 95% CI: 1.74-18.22). Managers of group homes should encourage PMHI to imagine life in an evacuation zone by increasing opportunities for disaster training and for interaction with local residents. People who are less likely to socialize with neighbors should be especially careful, as they may not be able to disclose their illness, and those who support evacuees should pay special attention to these people.

Evolutionary relationship between antimitochondrial antibody positivity and primary biliary cholangitis in Taiwan: a 16-year hospital cohort study

Background

How antimitochondrial antibody (AMA)-positive patients evolve to have primary biliary cholangitis (PBC) in viral hepatitis-endemic areas is unknown.

Objectives

We aimed to investigate this evolution in Taiwan.

Design/methods

A 16-year medical center-based cohort study of 2,095,628 subjects was conducted in Taiwan, an Asian country endemic to viral hepatitis. AMA-positive subjects were those with positive AMA with alkaline phosphatase (ALP) ⩽1.5 times the upper limit of normal (ULN), and PBC was defined as positive AMA with ALP >1.5 × ULN.

Results

AMA-positive subjects had a lower average age- and sex-adjusted prevalence than PBC patients (4.68/105 versus 11.61/105, p = 0.0002), but their incidence was comparable (0.99/105 versus 1.12/105, p = 0.36). The former group had a borderline significantly lower mean age (56.59 years versus 58.10 years, p = 0.06) and a lower female-to-male ratio (2.85:1 versus 5.44:1, p < 0.0001). Both AMA-positive subjects (prevalence change: 20.0%, p < 0.01; incidence change: -9.2%, p < 0.01) and PBC patients (prevalence change: 14.6%, p < 0.01; incidence change: -4.7%, p < 0.01) prevalence rate increased but the incidence rate decreased. Among the 423 AMA-positive subjects, 77 (18.2%) developed PBC, for a mean duration of 1.757 years. Compared with AMA-positive subjects, PBC patients had similar concurrent chronic hepatitis B (CHB) rates (2.7% versus 4.3%, p = 0.197) but lower chronic hepatitis C (CHC) rates (3.69% versus 15.60%, p < 0.01).

Conclusion

PBC was more prevalent than AMA-positive subjects, and PBC patients had a higher female-to-male ratio than AMA-positive subjects, of whom 18.2% developed PBC (mean lag: 1.757 years). Upward trends in prevalence rates and downward trends in incidence rates were noted for both AMA-positive subjects and PBC. CHB was rare, CHC was more prevalent among PBC patients than the general population, and CHC was less prevalent among PBC than among AMA-positive subjects.

Do-Not-Resuscitate Orders by COVID-19 Status Throughout the First Year of the COVID-19 Pandemic

BACKGROUND

At the beginning of the COVID-19 pandemic, whether performing CPR on patients with COVID-19 would be effective or increase COVID-19 transmission to health care workers was unclear.

RESEARCH QUESTION

Did the prevalence of do-not-resuscitate (DNR) orders by COVID-19 status change over the first year of the pandemic as risks such as COVID-19 transmission to health care workers improved?

STUDY DESIGN AND METHODS

This cross-sectional study assessed DNR orders for all adult patients admitted to ICUs at two academic medical centers in Chicago, IL, between April 2020 and April 2021. DNR orders by COVID-19 status were assessed using risk-adjusted mixed-effects logistic regression and propensity score matching by patient severity of illness.

RESULTS

The study population of 3,070 critically ill patients were 46% Black, 53% male, with median age (interquartile range [IQR]) 63 (50-73) years. Eighteen percent were COVID-19 positive and 27% had a DNR order. Black and Latinx patients had higher absolute rates of DNR orders than White patients (30% vs 29% vs 23%; P = .006). After adjustment for patient characteristics, illness severity, and hospital location, DNR orders were more likely in patients with COVID-19 in the nonpropensity score-matched (n = 3,070; aOR, 2.01; 95% CI, 1.64-2.38) and propensity score-matched (n = 1,118; aOR, 1.91; 95% CI, 1.45-2.52) cohorts. The prevalence of DNR orders remained higher for patients with COVID-19 than patients without COVID-19 during all months of the study period (difference in prevalence over time, P = .751).

INTERPRETATION

In this multihospital study, DNR orders remained persistently higher for patients with COVID-19 vs patients without COVID-19 with similar severity of illness during the first year of the pandemic. The specific reasons why DNR orders remained persistently elevated for patients with COVID-19 should be assessed in future studies, because these changes may continue to affect COVID-19 patient care and outcomes.

Global Streptococcus pyogenes strain diversity, disease associations, and implications for vaccine development: a systematic review

The high strain diversity of Streptococcus pyogenes serves as a major obstacle to vaccine development against this leading global pathogen. We did a systematic review of studies in PubMed, MEDLINE, and Embase that reported the global distribution of S pyogenes emm-types and emm-clusters from Jan 1, 1990, to Feb 23, 2023. 212 datasets were included from 55 countries, encompassing 74 468 bacterial isolates belonging to 211 emm-types. Globally, an inverse correlation was observed between strain diversity and the UNDP Human Development Index (HDI; r=-0·72; p<0·0001), which remained consistent upon subanalysis by global region and site of infection. Greater strain diversity was associated with a lower HDI, suggesting the role of social determinants in diseases caused by S pyogenes. We used a population-weighted analysis to adjust for the disproportionate number of epidemiological studies from high-income countries and identified 15 key representative isolates as vaccine targets. Strong strain type associations were observed between the site of infection (invasive, skin, and throat) and several streptococcal lineages. In conclusion, the development of a truly global vaccine to reduce the immense burden of diseases caused by S pyogenes should consider the multidimensional diversity of the pathogen, including its social and environmental context, and not merely its geographical distribution.

Using molecular methods to delineate norovirus outbreaks: a systematic review

Noroviruses are among the major causative agents of human acute gastroenteritis, and the nature of norovirus outbreaks can differ considerably. The number of single-nucleotide polymorphisms (SNPs) between strains is used to assess their relationships. There is currently no universally accepted cutoff value for clustering strains that define an outbreak or linking the individuals involved. This study was conducted to estimate the threshold value of genomic variations among related strains within norovirus outbreaks. We carried out a literature search in the PubMed and Web of Science databases. SNP rates were defined as the number of SNPs/sequence length (bp) × 100%. The Mann-Whitney U-test was used in comparisons of the distribution of SNP rates for different sequence regions, genogroups (GI and GII), transmission routes, and sequencing methods. A total of 25 articles reporting on 108 norovirus outbreaks were included. In 99.1% of the outbreaks, the SNP rates were below 0.50%, and in 89.8%, the SNP rates were under 0.20%. Outbreak strains showed higher SNP rates when the P2 domain was used for sequence analysis (Z = -2.652, p = 0.008) and when an NGS method was used (Z = -3.686, p < 0.001). Outbreaks caused by different norovirus genotypes showed no significant difference in SNP rates. Compared with person-to-person outbreaks, SNP rates were lower in common-source outbreaks, but no significant difference was found when differences in sequencing methods were taken into consideraton. SNP rates under 0.20% and 0.50% could be considered as the rigorous and relaxed threshold, respectively, of strain similarity within a norovirus outbreak. More data are needed to evaluate differences within and between various norovirus outbreaks.

Incidence of Pediatric Urinary Tract Infections Before and During the COVID-19 Pandemic

IMPORTANCE

Urinary tract infection (UTI) is common in children, but the population incidence is largely unknown. Controversy surrounds the optimal diagnostic criteria and how to balance the risks of undertreatment and overtreatment. Changes in health care use during the COVID-19 pandemic created a natural experiment to examine health care use and UTI diagnosis and outcomes.

OBJECTIVES

To examine the population incidence of UTI in children and assess the changes of the COVID-19 pandemic regarding UTI diagnoses and measures of UTI severity.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective observational cohort study used US commercial claims data from privately insured patients aged 0 to 17 years from January 1, 2016, to December 31, 2021.

EXPOSURE

Time periods included prepandemic (January 1, 2016, to February 29, 2020), early pandemic (April 1 to June 30, 2020), and midpandemic (July 1, 2020, to December 31, 2021).

MAIN OUTCOMES AND MEASURES

The primary outcome was the incidence of UTI, defined as having a UTI diagnosis code with an accompanying antibiotic prescription. Balancing measures included measures of UTI severity, including hospitalizations and intensive care unit admissions. Trends were evaluated using an interrupted time-series analysis.

RESULTS

The cohort included 13 221 117 enrollees aged 0 to 17 years, with males representing 6 744 250 (51.0%) of the population. The mean incidence of UTI diagnoses was 1.300 (95% CI, 1.296-1.304) UTIs per 100 patient-years. The UTI incidence was 0.86 per 100 patient-years at age 0 to 1 year, 1.58 per 100 patient-years at 2 to 5 years, 1.24 per 100 patient-years at 6 to 11 years, and 1.37 per 100 patient-years at 12 to 17 years, and was higher in females vs males (2.48 [95% CI, 2.46-2.50] vs 0.180 [95% CI, 0.178-0.182] per 100 patient-years). Compared with prepandemic trends, UTIs decreased in the early pandemic: -33.1% (95% CI, -39.4% to -26.1%) for all children and -52.1% (95% CI, -62.1% to -39.5%) in a subgroup of infants aged 60 days or younger. However, all measures of UTI severity decreased or were not significantly different. The UTI incidence returned to near prepandemic rates (-4.3%; 95% CI, -32.0% to 34.6% for all children) after the first 3 months of the pandemic.

CONCLUSIONS AND RELEVANCE

In this cohort study, UTI diagnosis decreased during the early pandemic period without an increase in measures of disease severity, suggesting that reduced overdiagnosis and/or reduced misdiagnosis may be an explanatory factor.

The effect of Medicaid expansion on female gynecologic cancer-related inpatient admissions

BACKGROUND

Mortality rate of female gynecologic cancer is higher among individuals without affordable health insurance.

OBJECTIVES

We determined the impact of Medicaid expansion on the number of female gynecologic-related cancer inpatient admissions in Virginia (VA) relative to North Carolina (NC), the latter of which did not expand Medicaid.

DESIGN

This quasi-experimental study was restricted to women between 18 and 64 years old admitted to general, acute, and short-term hospitals with gynecologic cancer.

METHODS

We used Poisson fixed-effect event study regression to examine differences in the predicted number of female gynecologic-related cancer admissions in the quarters before and after Medicaid expansion (implemented in January 2019) in VA, compared to the same period in NC.

RESULTS

Even though not significant, the predicted number of female gynecologic cancer-related inpatient admissions in VA increased by 4.8%, 4.9%, and 5.5% in the second, third, and fourth quarter of 2019, respectively, compared to the first quarter of 2019.

CONCLUSION

Medicaid expansion in VA increased access to health services for Medicaid members, possibly due to initial pent-up demand among uninsured individuals.

Extracorporeal Membrane Oxygenation for Cardiac Arrest: Does Age Matter?

OBJECTIVES

The impact of age on hospital survival for patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) for cardiac arrest (CA) is unknown. We sought to characterize the association between older age and hospital survival after ECPR, using a large international database.

DESIGN

Retrospective analysis of the Extracorporeal Life Support Organization registry.

PATIENTS

Patients 18 years old or older who underwent ECPR for CA between December 1, 2016, and October 31, 2020.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was adjusted odds ratio (aOR) of death after ECPR, analyzed by age group (18-49, 50-64, 65-74, and > 75 yr). A total of 5,120 patients met inclusion criteria. The median age was 57 years (interquartile range, 46-66 yr). There was a significantly lower aOR of survival for those 65-74 (0.68l 95% CI, 0.57-0.81) or those greater than 75 (0.54; 95% CI, 0.41-0.69), compared with 18-49. Patients 50-64 had a significantly higher aOR of survival compared with those 65-74 and greater than 75; however, there was no difference in survival between the two youngest groups (aOR, 0.91; 95% CI, 0.79-1.05). A sensitivity analysis using alternative age categories (18-64, 65-69, 70-74, and ≥ 75) demonstrated decreased odds of survival for age greater than or equal to 65 compared with patients younger than 65 (for age 65-69: odds ratio [OR], 0.71; 95% CI, 0.59-0.86; for age 70-74: OR, 0.84; 95% CI, 0.67-1.04; and for age ≥ 75: OR, 0.64; 95% CI, 0.50-0.81).

CONCLUSIONS

This investigation represents the largest analysis of the relationship of older age on ECPR outcomes. We found that the odds of hospital survival for patients with CA treated with ECPR diminishes with increasing age, with significantly decreased odds of survival after age 65, despite controlling for illness severity and comorbidities. However, findings from this observational data have significant limitations and further studies are needed to evaluate these findings prospectively.

Investigating the impact of condomless vaginal intercourse and lubricant use on the vaginal metabolome: a pre-post observational study

OBJECTIVE

The vaginal metabolome is a significant factor in the vaginal microenvironment, and data are emerging on its independent role in urogenital health. Condomless vaginal intercourse and personal lubricant use are common practices that may affect the vaginal metabolome. The aim of the present study is to describe the associations between condomless intercourse and lubricant use on the vaginal metabolome.

METHODS

This study used archived mid-vaginal swabs from a 10-week observational cohort of reproductive age women who self-collected samples and recorded behavioural diaries daily. Cases and controls were defined as participants who self-reported condomless vaginal intercourse with or without lubricant use, respectively. Samples were drawn prior to and following condomless vaginal intercourse. Twenty-two case participants were race/ethnicity matched to 22 control participants. Mid-vaginal swabs were subjected to 16S rRNA gene amplicon sequencing and untargeted ultrahigh performance liquid chromatography tandem mass spectroscopy metabolomics. Bayesian mixed-effects regression (unadjusted and adjusted for the vaginal microbiota) was used to evaluate differences in metabolite concentration associated with vaginal intercourse and lubricant use.

RESULTS

Both condomless penile-vaginal intercourse and lubricant use were independently associated with higher (up to 8.3-fold) concentrations of metabolites indicative of epithelial damage (eg, sarcosine) and many host-produced antioxidants. Lubricant use was significantly associated with increases in lipids related to cellular damage, host-produced sphingolipids (antimicrobials), antioxidants and salicylate, a cooling agent common to lubricants, in a study design which controls for the independent effect of intercourse. Metabolites involved in oxidative stress and salicylate were strongly correlated with several molecular bacterial vaginosis-associated bacteria.

CONCLUSIONS

This study provides important foundational data on how condomless vaginal-penile intercourse and lubricant use affect the vaginal metabolome and may affect the protective mechanisms in the vaginal microenvironment.

Proctored adoption of robotic hiatus hernia surgery: outcomes and learning curves in a high-volume UK centre

BACKGROUND

The adoption of new surgical technologies is inevitably accompanied by a learning curve. With the increasing adoption of robotic techniques in benign foregut surgery, it is imperative to define optimal learning pathways, to ensure a clinically safe introduction of such a technique. The aim of this study was to assess the learning curve for robotic hiatal hernia repair with a pre-defined adoption process and proctoring.

METHODS

The learning curve was assessed in four surgeons in a high-volume tertiary referral centre, performing over a 100 hiatal hernia repairs annually. The robotic adoption process included simulation-based training and a multi-day wet lab-based course, followed by robotic operations proctored by robotic upper GI experts. CUSUM analysis was performed to assess changes in operating time in sequential cases.

RESULTS

Each surgeon (A, B, C and D) performed between 22 and 32 cases, including a total of 109 patients. Overall, 40 cases were identified as 'complex' (36.7%), including 16 revisional cases (16/109, 14.7%). With CUSUM analysis inflection points for operating time were seen after 7 (surgeon B) to 15 cases (surgeon B).

CONCLUSION

The learning curve for robotic laparoscopic fundoplication may be as little as 7-15 cases in the setting of a clearly organized learning pathway with proctoring. By integrating these organized learning pathways learning curves may be shortened, ensuring patient safety, preventing detrimental outcomes due to longer learning curves, and accelerating adoption and integration of novel surgical techniques.

Health-promoting work schedules among nurses and nurse assistants in France: results from nationwide AMADEUS survey

BACKGROUND

The study aimed to investigate the relationship between different work schedules and self-reported working conditions and health risk behaviours among nurses and nurse assistants (NNA) in France. It hypothesized that work schedules, particularly long shifts, could impact work-life balance, workload, stress levels, burnout, and smoking habits. NNA had the option to work either with a 7-hour schedule, 5 days per week, or with long work schedules consisting of ten to twelve-hour shifts, three days per week. These schedules could potentially influence various aspects of their professional lives.

METHODS

The survey followed the guidelines of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement and was administered to NNA working in public and private national healthcare facilities in France. The researchers used the Job Content Questionnaire to assess the work environment and the French version of the 22-item Maslach Burnout Inventory (MBI) scale to measure burnout.

RESULTS

A total of 3,133 NNA participated in the study, including 2,369 nurses (75.6%) and 764 nurse assistants (24.4%). Among them, 1,811 individuals (57.8%) followed a 7-hour work schedule, while 1,322 individuals (42.2%) had a long work schedule. Multivariate analyses revealed that NNA working with long schedules reported higher psychological demands, more frequent burnout, a higher number of daily smoked cigarettes, and greater coffee consumption. These findings were independent of other factors such as sector of employment, type of healthcare facility, job status, work schedules, night shifts, department specialty, age, and family responsibilities.

CONCLUSIONS

While some NNA may choose long schedules to have more days off, those working with these schedules experience greater work-related burdens and engage in worse health risk behaviours as a coping mechanism. It emphasizes the importance of considering health-promoting work schedules to address the high psychological demands and burnout experienced by NNA with long schedules. Implementing changes in work schedules could potentially improve the overall well-being and job satisfaction of these healthcare professionals.

Secondary vectors of Zika Virus, a systematic review of laboratory vector competence studies

BACKGROUND

After the unprecedented Zika virus (ZIKV) outbreak in the western hemisphere from 2015-2018, Aedes aegypti and Ae. albopictus are now well established primary and secondary ZIKV vectors, respectively. Consensus about identification and importance of other secondary ZIKV vectors remain. This systematic review aims to provide a list of vector species capable of transmitting ZIKV by reviewing evidence from laboratory vector competence (VC) studies and to identify key knowledge gaps and issues within the ZIKV VC literature.

METHODS

A search was performed until 15th March 2022 on the Cochrane Library, Lilacs, PubMed, Web of Science, WHOLIS and Google Scholar. The search strings included three general categories: 1) "ZIKA"; 2) "vector"; 3) "competence", "transmission", "isolation", or "feeding behavior" and their combinations. Inclusion and exclusion criteria has been predefined and quality of included articles was assessed by STROBE and STROME-ID criteria.

FINDINGS

From 8,986 articles retrieved, 2,349 non-duplicates were screened by title and abstracts,103 evaluated using the full text, and 45 included in this analysis. Main findings are 1) secondary vectors of interest include Ae. japonicus, Ae. detritus, and Ae. vexans at higher temperature 2) Culex quinquefasciatus was not found to be a competent vector of ZIKV, 3) considerable heterogeneity in VC, depending on the local mosquito strain and virus used in testing was observed. Critical issues or gaps identified included 1) inconsistent definitions of VC parameters across the literature; 2) equivalency of using different mosquito body parts to evaluate VC parameters for infection (mosquito bodies versus midguts), dissemination (heads, legs or wings versus salivary glands), and transmission (detection or virus amplification in saliva, FTA cards, transmission to neonatal mice); 3) articles that fail to use infectious virus assays to confirm the presence of live virus; 4) need for more studies using murine models with immunocompromised mice to infect mosquitoes.

CONCLUSION

Recent, large collaborative multi-country projects to conduct large scale evaluations of specific mosquito species represent the most appropriate approach to establish VC of mosquito species.

Disparities in Unilateral Do Not Resuscitate Order Use During the COVID-19 Pandemic

OBJECTIVES

A unilateral do-not-resuscitate (UDNR) order is a do-not-resuscitate order placed using clinician judgment which does not require consent from a patient or surrogate. This study assessed how UDNR orders were used during the COVID-19 pandemic.

DESIGN

We analyzed a retrospective cross-sectional study of UDNR use at two academic medical centers between April 2020 and April 2021.

SETTING

Two academic medical centers in the Chicago metropolitan area.

PATIENTS

Patients admitted to an ICU between April 2020 and April 2021 who received vasopressor or inotropic medications to select for patients with high severity of illness.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The 1,473 patients meeting inclusion criteria were 53% male, median age 64 (interquartile range, 54-73), and 38% died during admission or were discharged to hospice. Clinicians placed do not resuscitate orders for 41% of patients ( n = 604/1,473) and UDNR orders for 3% of patients ( n = 51/1,473). The absolute rate of UDNR orders was higher for patients who were primary Spanish speaking (10% Spanish vs 3% English; p ≤ 0.0001), were Hispanic or Latinx (7% Hispanic/Latinx vs 3% Black vs 2% White; p = 0.003), positive for COVID-19 (9% vs 3%; p ≤ 0.0001), or were intubated (5% vs 1%; p = 0.001). In the base multivariable logistic regression model including age, race/ethnicity, primary language spoken, and hospital location, Black race (adjusted odds ratio [aOR], 2.5; 95% CI, 1.3-4.9) and primary Spanish language (aOR, 4.4; 95% CI, 2.1-9.4) had higher odds of UDNR. After adjusting the base model for severity of illness, primary Spanish language remained associated with higher odds of UDNR order (aOR, 2.8; 95% CI, 1.7-4.7).

CONCLUSIONS

In this multihospital study, UDNR orders were used more often for primary Spanish-speaking patients during the COVID-19 pandemic, which may be related to communication barriers Spanish-speaking patients and families experience. Further study is needed to assess UDNR use across hospitals and enact interventions to improve potential disparities.

Are European clinical trial funders policies on clinical trial registration and reporting improving? A cross-sectional study

Objectives

Assess the extent to which the clinical trial registration and reporting policies of 25 of the world's largest public and philanthropic medical research funders meet best practice benchmarks as stipulated by the 2017 WHO Joint Statement, and document changes in the policies and monitoring systems of 19 European funders over the past year.

Design Setting Participants

Cross-sectional study, based on assessments of each funder's publicly available documentation plus validation of results by funders. Our cohort includes 25 of the largest medical research funders in Europe, Oceania, South Asia, and Canada.

Interventions

Scoring all 25 funders using an 11-item assessment tool based on WHO best practice benchmarks, grouped into three primary categories: trial registries, academic publication, and monitoring, plus validation of results by funders.

Main outcome measures

How many of the 11 WHO best practice items each of the 25 funders has put into place, and changes in the performance of 19 previously assessed funders over the preceding year.

Results

The 25 funders we assessed had put into place an average of 5/11 (49%) WHO best practices. Only 6/25 funders (24%) took the PI's past reporting record into account during grant application reviews. Funders' performance varied widely from 0/11 to 11/11 WHO best practices adopted. Of the 19 funders for which 2021(2) baseline data was available, 10/19 (53%) had strengthened their policies over the preceding year.

Conclusions

Most medical research funders need to do more to curb research waste and publication bias by strengthening their clinical trial policies.

The Principles of SARS-CoV-2 Intervariant Competition Are Exemplified in the Pre-Omicron Era of the Colombian Epidemic

The first 18 months of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in Colombia were characterized by three epidemic waves. During the third wave, from March through August 2021, intervariant competition resulted in Mu replacing Alpha and Gamma. We employed Bayesian phylodynamic inference and epidemiological modeling to characterize the variants in the country during this period of competition. Phylogeographic analysis indicated that Mu did not emerge in Colombia but acquired increased fitness there through local transmission and diversification, contributing to its export to North America and Europe. Despite not having the highest transmissibility, Mu's genetic composition and ability to evade preexisting immunity facilitated its domination of the Colombian epidemic landscape. Our results support previous modeling studies demonstrating that both intrinsic factors (transmissibility and genetic diversity) and extrinsic factors (time of introduction and acquired immunity) influence the outcome of intervariant competition. This analysis will help set practical expectations about the inevitable emergences of new variants and their trajectories. IMPORTANCE Before the appearance of the Omicron variant in late 2021, numerous SARS-CoV-2 variants emerged, were established, and declined, often with different outcomes in different geographic areas. In this study, we considered the trajectory of the Mu variant, which only successfully dominated the epidemic landscape of a single country: Colombia. We demonstrate that Mu competed successfully there due to its early and opportune introduction time in late 2020, combined with its ability to evade immunity granted by prior infection or the first generation of vaccines. Mu likely did not effectively spread outside of Colombia because other immune-evading variants, such as Delta, had arrived in those locales and established themselves first. On the other hand, Mu's early spread within Colombia may have prevented the successful establishment of Delta there. Our analysis highlights the geographic heterogeneity of early SARS-CoV-2 variant spread and helps to reframe the expectations for the competition behaviors of future variants.

Foreign Body Aspiration in Children-Retrospective Study and Management Novelties

Foreign body aspiration (FBA) is a frequent diagnosis in children. In the absence of other lung conditions, such as asthma or chronic pulmonary infections, this manifests as a sudden onset of cough, dyspnea, and wheezing. The differential diagnosis is based on a scoring system which takes into account the clinical picture as well as the radiologic aspects. The treatment that is considered the gold-standard for FBA in children remains to be rigid fibronchoscopy, however it comes with several potentially crucial local complications such as airway edema, bleeding, and bronchospasm, along inherent issues due to general anesthesia. Material and methods: Our study is a retrospective study analyzing the medical files of the cases from our hospital over the span of 9 years. The study group consisted of 242 patients aged 0-16 years diagnosed with foreign body aspiration in the Emergency Clinical Hospital for Children "Sfânta Maria" Iași, between January 2010-January 2018. Clinical and imaging data were extracted from the patients' observation sheets. Results: In our cohort, the distribution of children with foreign body aspiration was uneven, with the highest incidence being reported in children from rural areas (70% of cases), whereas the most affected age group was 1-3 years, amounting to 79% of all cases. The main symptoms which led to emergency admittance were coughing (33%) and dyspnea (22%). The most important factors that determined the unequal distribution were socio-economic status, which relates to a lack of adequate supervision by parents, as well as the consumption of food inappropriate for their age. Conclusions: Foreign body aspiration is a major medical emergency that may be associated with dramatic clinical manifestations. Several scoring algorithms designed to establish the need for bronchoscopy have been proposed, taking into account both the clinical and radiological results. The issue with asymptomatic or mild symptomatic cases, as well as difficulties managing cases with radiolucent foreign bodies, remains a challenge.

Prevalence of venous thromboembolism in patients undergoing diagnostic venous ultrasound during the first SARS-CoV-2 pandemic

Background: Venous thromboembolism appears to be associated with severe COVID-19 infection than in those without it. However, this varies considerably depending on the cohort studied. The aims of this single-centre, multi-site retrospective cross-sectional study were to assess the number of all venous scans performed in the first month of pandemic in a large university teaching hospital, to evaluate the incidence of deep venous thrombosis (DVT), and assess the predictive ability of the clinical information available on the electronic patient record in planning work-up for DVT and prioritising ultrasound scans. Patients and methods: All consecutive patients undergoing venous ultrasound for suspected acute DVT between 1st of March and 30th of April 2020 were considered. Primary outcome was the proportion of scans positive for DVT; the secondary outcomes included association of a positive SARS-CoV-2 PCR test, demographic, clinical factors, and Wells scores. Results: 819 ultrasound scans were performed on 762 patients across the Trust in March and April 2020. This number was comparable to the corresponding pre-pandemic cohort from 2019. The overall prevalence of DVT in the studied cohort was 16.1% and was higher than before the pandemic (11.5%, p=.047). Clinical symptoms consistent with COVID-19, irrespective of the SARS-CoV-2 PCR test result (positive_COVID_PCR OR 4.97, 95%CI 2.31-10.62, p<.001; negative_COVID_PCR OR 1.97, 95%CI 1.12-3.39, p=.016), a history of AF (OR 0.20, 95%CI 0.03-0.73, p=.037), and personal history of venous thromboembolism (VTE) (OR 1.95, 95%CI 1.13-3.31, p=.014), were independently associated with the diagnosis of DVT on ultrasound scan. Wells score was not associated with the incidence of DVT. Conclusions: Amongst those referred for the DVT scan, SARS-CoV-2 PCR test was associated with an increased risk of VTE and should be taken into consideration when planning DVT work-up and prioritising diagnostic imaging. We postulate that the threshold for imaging should possibly be lower.

PROBE 2023 guidelines for reporting observational studies in Endodontics: A consensus-based development study

Observational studies are non-interventional studies that establish the prevalence and incidence of conditions or diseases in populations or analyse the relationship between health status and other variables. They also facilitate the development of specific research questions for future randomized trials or to answer important scientific questions when trials are not possible to carry out. This article outlines the previously documented consensus-based approach by which the Preferred Reporting items for Observational studies in Endodontics (PROBE) 2023 guidelines were developed. A steering committee of nine members was formed, including the project leaders (PD, VN). The steering committee developed an initial checklist by combining and adapting items from the STrengthening the Reporting of Observational studies in Epidemiology (STROBE) checklist and the Clinical and Laboratory Images in Publications (CLIP) principles, as well as adding several new items specifically for the specialty of Endodontics. The steering committee then established a PROBE Delphi Group (PDG) and a PROBE Online Meeting Group (POMG) to obtain expert input and feedback on the preliminary draft checklist. The PDG members participated in an online Delphi process to reach consensus on the clarity and suitability of the items present in the PROBE checklist. The POMG then held detailed discussions on the PROBE checklist generated through the online Delphi process. This online meeting was held via the Zoom platform on 7th October 2022. Following this meeting, the steering committee revised the PROBE checklist, which was piloted by several authors when preparing a manuscript describing an observational study for publication. The PROBE 2023 checklist consists of 11 sections and 58 items. Authors are now encouraged to adopt the PROBE 2023 guidelines, which will improve the overall reporting quality of observational studies in Endodontics. The PROBE 2023 checklist is freely available and can be downloaded from the PRIDE website (https://pride-endodonticguidelines.org/probe/).