Daily Visits Research Articles

Rhegmatogenous Retinal Detachment with Giant Retinal Tear: Case Series and Literature Review.

Background/Objectives: This paper reviews three cases of rhegmatogenous retinal detachment (RRD) with giant retinal tear (GRT), focusing on surgical management and outcomes, and synthesizes the current literature on the subject. Methods: We retrospectively analyzed three cases of male patients diagnosed with RRD with GRT at our hospital from April 2022 to November 2023. The patients, aged 57, 66, and 60, underwent surgical interventions, with postoperative follow-up extending up to six months. All patients underwent pars plana vitrectomy (PPV), endolaser photocoagulation, fluid-air exchange, and intravitreal gas injection (perfluoropropane (C3F8) 14%) in each case. Surgeries were performed within four days of the patients' initial visits. Outcome measures included visual acuity improvement, intraocular pressure stabilization, and retinal reattachment rates. Complications in the patients were also evaluated. Results: The patient who had not previously undergone cataract surgery (Case 1) had it concurrently with the retinal surgery. Four months after the initial surgery, Case 3 developed a secondary epiretinal membrane (ERM) and subsequently underwent ERM removal surgery. Postoperative care involved the tailored use of anti-inflammatory medications and frequent monitoring to mitigate complications such as proliferative vitreoretinopathy, epiretinal membrane formation, and redetachment. Conclusions: While limited by the small sample size, this report underscores the potential benefits of prompt surgical intervention, meticulous postoperative care, and proactive management of complications in RRD with GRT. Insights from these cases, supported by multiple literature reviews, may inform treatment strategies and highlight areas for further research in larger, more diverse patient populations.

Physician Follow-Up of Pediatric and Young Adult Emergency Department Visits for Substance Use in Ontario, Canada

PurposeTo study the proportion and predictors of outpatient physician follow-up within 60 days of substance-related emergency department (ED) visits for Ontario youth. MethodsWe examined administrative data on substance-related ED visits before and during the COVID-19 pandemic among youths aged 10–24 years in Ontario, Canada. Substance-related visits were identified using International Classification of Diseases-10-CA codes. We described demographic characteristics, receipt of mental health services in the year before the ED visit, disposition from the ED, and follow-up services within 60 days of the ED visit. ResultsBetween April 1, 2017, and May 31, 2021, 64,236 youth had at least one ED visit for substance use. Visits for alcohol were the most common (49%), followed by cannabis (32.3%). ED visits for all substances were more prevalent during the pandemic than prepandemic, except visits for alcohol. The receipt of follow-up physician care for substance use was low (33.2% prepandemic) but increased during the pandemic (41.7%; adjusted odds ratio 1.34, 95% CI 1.28, 1.39) and varied between substances. Mental health service history in the year before the substance-related ED visit had the strongest association with receipt of follow-up physician care within 60 days (adjusted odds ratio 6.86, 95% CI 6.57, 7.17). DiscussionYouth frequently do not receive physician follow-ups within two months of the substance-related ED visit, although higher follow-up proportions were seen during the pandemic after the implementation of virtual care. Further research is required to understand why follow-up is low and to examine interventions that can increase connection to care.

Long-term prevention of hereditary angioedema attacks with lanadelumab in adolescents

BackgroundLanadelumab was well tolerated and effective in preventing hereditary angioedema (HAE) attacks in the phase 3, double-blind, placebo-controlled Hereditary angioEdema Long-term Prophylaxis (HELP) study and subsequent HELP open-label extension (OLE) study (NCT02741596). ObjectiveTo evaluate outcomes from HELP OLE for adolescent patients aged 12 to 17 years. MethodsThe HELP OLE study comprised patients who completed the HELP study (rollovers) and new eligible (lanadelumab-naive) patients. Rollovers received a single dose of lanadelumab 300 mg at the last HELP study visit (day 0). Treatment was then paused until patients experienced their first investigator-confirmed HAE attack, after which lanadelumab 300 mg was administered every 2 weeks for up to 33 months (4 wk/mo). Lanadelumab-naive patients received lanadelumab 300 mg every 2 weeks from day 0. Patient-reported outcomes included Angioedema Quality of Life Questionnaire. Safety was monitored throughout the study. ResultsThe subgroup analysis included 21 patients (8 rollovers and 13 lanadelumab-naive patients); 95.2% completed at least 30 months in the study. The mean (SD) monthly attack rates decreased from 1.58 (1.0) at baseline to 0.11 (0.2) during treatment (mean, 94.7% reduction). A total of 8 (38.1%) patients were attack-free during treatment and, on average, 99.1% of days were attack-free (mean, 27.7 d/mo). Patients reported a mean (SD) Angioedema Quality of Life Questionnaire total score of 27.5 (17.5) at baseline vs 7.5 (13.2) at the end of the study. There were 12 (57.1%) patients who reported treatment-related treatment-emergent adverse events; however, there were no treatment-related serious adverse events. ConclusionLanadelumab provided long-term efficacy in preventing HAE attacks, was associated with clinically meaningful improvements in health-related quality of life and high levels of treatment satisfaction, and was well tolerated in adolescent patients. Trial RegistrationClinicalTrials.gov Identifier: NCT02741596.

Bioequivalence and Safety of Bilastine 20 mg Orodispersible Tablets and Conventional Tablets: A Randomized, Single-Dose, Two-Period Crossover Study in Healthy Volunteers Under Fasting Conditions.

Orodispersible tablets (ODT) rapidly dissolve in the oral cavity and can improve patient's convenience. This pharmacokinetic study assessed the bioequivalence of a novel 20 mg ODT formulation of bilastine compared with bilastine 20 mg tablets in healthy volunteers under fasting conditions. A phase I, single-center, open-label, two-period, two-sequence crossover randomized clinical trial was conducted. The study comprised two periods, in which participants were administered a single oral dose of bilastine 20 mg in the form of ODT as the test product, or conventional tablets as the reference product, and a washout of 7 days between each period. Blood samples were collected for up to 72 h. Bioequivalence was established if the 90% confidence intervals of the Cmax and AUC0-t were within the acceptance range (80-125%). Safety was evaluated at the follow-up visit (days 4-7 after the second dose) and throughout the study. A total of 42 healthy volunteers were randomized, and 41 completed the study. Pharmacokinetic parameters were comparable for both formulations after a single dose of 20 mg. Bilastine ODT and conventional tablets were bioequivalent as the 90% confidence intervals of the test over reference ratios were within the predefined range (80-125%). Both formulations were well tolerated and showed a similar safety profile. Bilastine ODT was bioequivalent to the reference treatment formulated as conventional tablets when administered as a single oral dose of 20 mg under fasting conditions. Both formulations showed a similar tolerability and safety profile, with no serious adverse events or significant analytical alterations reported. 2019-004071-39. Date of authorization: 10 December 2019.

Assessing how frailty and healthcare delays mediate the association between sexual and gender minority status and healthcare utilization in the All of Us Research Program.

To understand how frailty and healthcare delays differentially mediate the association between sexual and gender minority older adults (OSGM) status and healthcare utilization. Data from the All of Us Research Program participants ≥50 years old were analyzed using marginal structural modelling to assess if frailty or healthcare delays mediated OSGM status and healthcare utilization. OSGM status, healthcare delays, and frailty were assessed using survey data. Electronic health record (EHR) data was used to measure the number of medical visits or mental health (MH) visit days, following 12 months from the calculated All of Us Frailty Index. Analyses adjusted for age, race and ethnicity, income, HIV, marital status ± general MH (only MH analyses). Compared to non-OSGM, OSGM adults have higher rates of medical visits (adjusted rate ratio [aRR]: 1.14; 95% CI: 1.03, 1.24) and MH visits (aRR: 1.85; 95% CI: 1.07, 2.91). Frailty mediated the association between OSGM status medical visits (Controlled direct effect [Rcde] aRR: 1.03, 95% CI [0.87, 1.22]), but not MH visits (Rcde aRR: 0.37 [95% CI: 0.06, 1.47]). Delays mediated the association between OSGM status and MH visit days (Rcde aRR: 2.27, 95% CI [1.15, 3.76]), but not medical visits (Rcde aRR: 1.06 [95% CI: 0.97, 1.17]). Frailty represents a need for medical care among OSGM adults, highlighting the importance of addressing it to improve health and healthcare utilization disparities. In contrast, healthcare delays are a barrier to MH care, underscoring the necessity of targeted strategies to ensure timely MH care for OSGM adults.

Electronic Health Record–Based Nudge Intervention and Axillary Surgery in Older Women With Breast Cancer

Choosing Wisely recommendations advocate against routine use of axillary staging in older women with early-stage, clinically node-negative (cN0), hormone receptor-positive (HR+), and HER2-negative breast cancer. However, rates of sentinel lymph node biopsy (SLNB) in this population remain persistently high. To evaluate whether an electronic health record (EHR)-based nudge intervention targeting surgeons in their first outpatient visit with patients meeting Choosing Wisely criteria decreases rates of SLNB. This nonrandomized controlled trial was a hybrid type 1 effectiveness-implementation study with subsequent postintervention semistructured interviews and lasted from October 2021 to October 2023. Data came from EHRs at 8 outpatient clinics within an integrated health care system; participants included 7 breast surgical oncologists. Data were collected for female patients meeting Choosing Wisely criteria for omission of SLNB (aged ≥70 years with cT1 and cT2, cN0, HR+/HER2- breast cancer). The study included a 12-month preintervention control period; baseline surveys assessing perceived acceptability, appropriateness, and feasibility of the designed intervention; and a 12-month intervention period. A column nudge was embedded into the surgeon's schedule in the EHR identifying patients meeting Choosing Wisely criteria for potential SLNB omission. The primary outcome was rate of SLNB following nudge deployment into the EHR. Similar baseline demographic and tumor characteristics were observed before (control period, n = 194) and after (intervention period, n = 193) nudge deployment. Patients in both the control and intervention period had a median (IQR) age of 75 (72-79) years. Compared with the control period, unadjusted rates of SLNB decreased by 23.1 percentage points (46.9% SLNB rate prenudge to 23.8% after; 95% CI, -32.9 to -13.8) in the intervention period. An interrupted time series model showed a reduction in the rate of SLNB following nudge deployment (adjusted odds ratio, 0.26; 95% CI, 0.07 to 0.90; P = .03). The participating surgeons scored the intervention highly on acceptability, appropriateness, and feasibility. Dominant themes from semistructured interviews indicated that the intervention helped remind the surgeons of potential Choosing Wisely applicability without the need for additional clicks or actions on the day of the patient visit, which facilitated use. This study showed that a nudge intervention in the EHR significantly decreased low-value axillary surgery in older women with early-stage, cN0, HR+/HER2- breast cancer. This user-friendly and easily implementable EHR-based intervention could be a beneficial approach for decreasing low-value care in other practice settings or patient populations. ClinicalTrials.gov Identifier: NCT06006910.

Summer scour syndrome in weaned dairy calves: case series

BackgroundSummer scour syndrome (SSS) is a recently identified pathological condition affecting weaned dairy and dairy-beef calves during their first grazing season in Ireland. The syndrome is characterised by diarrhoea, weight loss, weakness, and can ultimately lead to death in some calves. Oral and oesophageal ulcerations are present in some cases. This study aimed to characterise a series of SSS cases in weaned dairy-bred calves on Irish commercial farms.ResultsFive farms with calves having unexplained diarrhoea at grass were referred by private veterinary practitioners (PVP) following preliminary testing to exclude coccidiosis and parasitic gastroenteritis. Farms were visited within 2 to 5 days following PVP’s referrals, or 2 days to 3 weeks relative to the onset of clinical signs. Farm management data, grass and concentrate samples, and biological samples from 46 calves (8 to 10 calves/farm) displaying clinical signs were collected. Two farms were subsequently found positive for coccidiosis and/or had chronic pneumonia problems after a thorough herd investigation and were designated as non-case farms (NCF). The remaining three farms were deemed typical SSS outbreaks (case farms; CF). Mean rumen fluid pH per farm ranged from 6.67 to 7.09 on CF, and 6.43–6.88 on NCF. Mean rumen fluid ammonia concentrations ranged from 17.6 to 29.6 mg/L and 17.2–45.0 mg/L on CF and NCF, respectively. Corresponding blood ammonia concentrations ranged from 129 to 223 µmol/L and 22–25 µmol/L. Mean blood copper and molybdenum concentrations were within normal range on all farms. Grass crude protein concentrations on the paddocks where the calves had grazed, and were currently grazing on the day of visit ranged from 137 to 148 g/kg DM and 106–177 g/kg DM, respectively on CF, and 160–200 g/kg DM and 151–186 g/kg DM, respectively on NCF. On CF, inorganic nitrogen fertiliser was applied 1 to 3 weeks pre-grazing, whereas on the two NCF, inorganic nitrogen fertiliser was applied 2 to 3 weeks pre-grazing on one farm and no fertiliser was applied on the other.ConclusionThese findings suggest that copper or molybdenum toxicity, and ruminal acidosis are not the primary causes of SSS. High blood ammonia concentrations and the timing and level of inorganic nitrogen fertiliser application to paddocks pre-grazing, warrant further investigation.

Association between summertime emergency department visits and maximum daily heat index in rural and non-rural areas of Virginia (2015–2022)

There is growing evidence that high ambient temperatures are associated with a range of adverse health outcomes. Further evidence suggests differences in rural versus non-rural populations' vulnerability to heat-related adverse health outcomes. The current project aims to 1) refine estimated associations between maximum daily heat index (HI) and emergency department (ED) visits in regions of Virginia, and 2) compare associations between maximum daily HI and ED visits in rural versus non-rural areas of Virginia and within those areas, for persons 65 years of age and older versus those younger than 65 years. Our study utilized 16,873,213 healthcare visits from Virginia facilities reporting to the Virginia Department of Health syndromic surveillance system between May and September 2015–2022. Federal Office of Rural Health Policy defined rural areas were assigned to patient home ZIP code. The estimated daily maximum HI at which ED visits begin to rise varies between 25 °C and 33 °C across climate zones and regions of Virginia. Across all regions, estimated ED visits attributable to days with maximum HI above 25.7 °C were higher in rural areas (3.7%, 95% CI: 3.5%, 3.9%) versus in non-rural areas (3.1%, 95% CIs: 3.0%, 3.2%). Patients aged 0–64 years had a higher estimated heat attributable fraction of ED visits (4.2%, 95% CI: 4.0%, 4.3%) than patients 65 years and older (3.1%, 95% CI: 2.9%, 3.4%). Rural patients older than 65 have a higher estimated fraction of heat attributable ED visits (2.7%, 95% CI: 2.2%, 3.1%) compared to non-rural patients 65 years and older (1.5%, 95% CI: 1.3%, 1.8%). State-level syndromic surveillance data can be used to optimize heat warning messaging based on expected changes in healthcare visits given a set of meteorological variables, and can be further refined based on climate, rurality and age.

High Demand for Psychological Support in Patients Who Have Periprosthetic Hip and Knee Joint Infections: An Analysis of 13,976 Patients

BackgroundThere is only sparse knowledge on the psychological burden of patients who have periprosthetic joint infections. The aim of our study was to assess the need for psychological support following total joint arthroplasty of the hip and knee. A special focus was set on patients who had aseptic and septic complications. MethodsA total of 13,976 patients who underwent total hip (n = 6,926) or total knee arthroplasty (n = 7,050) between January 1, 2012 and December 31, 2019 at a single institution were retrospectively evaluated for the postoperative need for a psychological consultation. Data were collected on age, sex, type of surgery, and indications for revision procedures. The need for a psychological consultation was assessed during the daily postoperative visits, which were further coordinated by 2 institutional psychologists. ResultsThe average age was 68 years (range, 12 to 100), and there were 63.5% women. The overall rate of psychological consultations was 1.7%. Patients who had a septic indication for revision surgery had an 18.7-fold higher rate of postoperative psychological consultations compared to patients following primary surgery and a 5.4-fold higher rate compared to patients who had an aseptic indication. In detail, this rate was 1.0% in the primary subgroup, compared to 7.7% following revision arthroplasty (P < .001). In the revision subgroup, the rate was 17.9% for septic and 3.3% for aseptic revision arthroplasty cases (P < .001). Postoperative psychological consultations were twice as frequent in women (2.1%) compared to men (1.0%), P < .001. ConclusionsThe present study raises awareness of the markedly high psychological burden in revision arthroplasty cases, in the view of the high estimated number of unknown cases. There is a significant correlation between periprosthetic joint infectionsand the postoperative need for a psychological consultation, with women being at an even higher risk. Health care providers should aim at offering psychological support for patients who have a septic complication, with affected patients being at risk for psychological stress. Level of EvidenceIV.

Limitations of Patient-Controlled Epidural Analgesia Following Abdominoplasty.

Effective postoperative pain management is essential for patient satisfaction and an uneventful postoperative course, particularly in body contouring procedures. Systemic analgesic regimens can be supported by regional procedures, such as the transverse abdominis plane (TAP) block, but these have a limited duration of action. In contrast, thoracic epidural analgesia offers the possibility of a longer-lasting, individualized regional anesthesia administered by a patient-controlled analgesia pump. The aim of this study was to investigate the effects of a patient-controlled epidural analgesia to better classify the clinical value of this procedure in abdominoplasties. This work reviewed the digital medical charts of patients who underwent selective abdominoplasty without combined surgical procedures between September 2018 and August 2022. Evaluated data comprise the postoperative analgesia regimen, including on-demand medication, mobilization time, inpatient length of stay, and clinical outcome. The patients were grouped by the presence of a thoracic epidural catheter. This catheter was placed before anesthetic induction and a saturation dose was preoperatively applied. Postoperative PCEA patients received a basal rate and could independently administer boluses. Basal rate was individually adjusted during daily additional pain visits. The study cohort included 112 patients. Significant differences in the demand for supportive nonepidural opiate medication were shown between the patient-controlled epidural analgesia (PCEA) group (n = 57) and the non-PCEA group (n = 55), depending on the time after surgery. PCEA patients demanded less medication during the early postoperative days (POD 0: PCEA 0.13 (±0.99) mg vs non-PCEA 2.59 (±4.55) mg, P = 0.001; POD 1: PCEA 0.79 mg (±3.06) vs non-PCEA 2.73 (±3.98) mg, P = 0.005), but they required more during the later postoperative phase (POD 3: PCEA 2.76 (±5.60) mg vs non-PCEA 0.61 (±2.01) mg, P = 0.008; POD 4: PCEA 1.64 (±3.82) mg vs non-PCEA 0.07 (±2.01) mg, P = 0.003). In addition, PCEA patients achieved full mobilization later (PCEA 2.67 (±0.82) days vs non-PCEA 1.78 (±1.09) days, P = 0.001) and were discharged later (PCEA 4.84 (±1.23) days vs non-PCEA 4.31 (±1.37) days, P = 0.005). Because the postoperative benefits of PCEA are limited to potent analgesia immediately after abdominoplasty, less cumbersome, time-limited regional anesthesia procedures (such as TAP block) appear not only adequate but also more effective.

O-318 Decline of βhCG concentrations following pregnancy loss: exploring contributing factors

Abstract Study question Which factors impact βhCG decline after a pregnancy loss, thereby inhibiting return of menstrual cycle? Summary answer In pregnancy loss, decline in βhCG levels are influenced by gestational age, BMI, previous losses, and treatment method, impacting menstrual cycle resumption. What is known already Despite one in four pregnancies ending as a pregnancy loss, there is limited knowledge about when to expect reproductive recovery including the decline in βhCG. The placentally produced hormone βhCG binds to luteinizing hormone/hCG-receptors, which, through negative feedback in the pituitary, decreases release of gonadotropins. This limits chances of ovulation, thus inhibiting the onset of menstrual bleeding, however with great individual variability. Therefore, there is an unmet need for a more individualized understanding of the impact of maternal factors on the decline in βhCG concentrations and the relationship between βhCG and reproductive recovery after a pregnancy loss. Study design, size, duration The Copenhagen Pregnancy Loss study (COPL) is a prospective cohort focusing on pregnancy loss. Participants/materials, setting, methods Inclusion criteria required diagnosis of missed, spontaneous or anembryonic miscarriage and hCG results from both day of inclusion and follow-up visit 4-8 weeks later. Primary objective end points were serum-hCG on day of the diagnosis of pregnancy loss and at follow-up. Secondary end points from the follow-up visit included information on return of menstruation. Per laboratory protocol, βhCG &amp;gt; = 5 IU/L is indicative of pregnancy. Analysis was done using a multivariable Bayesian ordinal regression model. Main results and the role of chance Preliminary results, to be updated for presentation at ESHRE 2024: 1,306 women were included in this study between November 2020 - January 2024. Follow-up visits were conducted 6 weeks after pregnancy loss (IQR: 5.6-7.0 weeks). At follow-up, 199 (18.0%) women still had elevated concentrations of βhCG. At the time of pregnancy loss, gestational age (OR: 0.97, 95% CI 0.96-0.98), BMI (OR: 0.98, 95% CI 0.96-0.99), and number of prior pregnancy losses (OR: 1.09, 95% CI 1.01-1.18) were associated with βhCG. βhCG concentration, measured at the follow-up, was strongly influenced by the choice of treatment method, including surgical (OR: 2.74, 95% CI 1.76-4.26) and medical (OR: 1.69, 95% CI 1.11-2.56), compared to spontaneous. Furthermore, Age (OR: 1.02, 95% CI 1.00-1.04) and gestational age (OR: 1.01, 95% CI 1.00-1.01) also affected the decline. βhCG levels at follow-up were correlated with return of menstrual bleeding OR: 0.98, 95% CI 0.96-0.99). Of the women with βhCG levels exceeding 5 IU/L, 145 out of 199 (72.9%) reported the resumption of their menstrual cycle. Among those with βhCG levels above 25 IU/L, 17 out of 33 (52%) reported menstrual cycle return. Limitations, reasons for caution Analysis depicted total-hCG concentrations (intact hCG + free ß-subunit) without distinguishing between the various hCG isoforms. The cohort was gathered at a hospital, reflecting that setting. Wider implications of the findings Our findings are the first step towards a more personalised approach for patients facing pregnancy loss, aiding with counselling and planning of reproductive prospects, including IVF. The evident ßhCG-induced negative feedback, coupled with menstrual bleeding in women with elevated ßhCG, highlights system complexity and hints at additional unidentified factors. Trial registration number not applicable

Association between short-term ozone exposure and allergic conjunctivitis in China: A multi-city case-crossover study

Short-term exposure to ozone has been linked to multiple allergic diseases, but the relationship between ozone exposure and allergic conjunctivitis (AC) remains unclear. This study aimed to investigate the association between short-term exposure to ozone and the risk of AC. We conducted a time-stratified case-crossover study across five Chinese cities from 2014 to 2022. Daily outpatient visit records for AC were identified in five hospitals using either the diagnosis name or ICD-10 code H10.1. Data on air pollution and meteorological conditions were also collected. We first examined the city-specific association between short-term ozone exposure and AC using conditional logistic regression. A random-effects meta-analysis was then conducted to obtain overall estimates. During the study period, 130,093 outpatient visits for AC occurred, with 58.8% (76,482) being male and 41.2% (53,611) female. A one-standard-deviation (SD) increase in ozone was associated with an 8.3% increase (95% CI: 3.8%, 13.0%) in AC outpatient visits. Similar positive associations were observed when adjusting for other pollutants (PM2.5, CO, SO2 and NO2) in two-pollutant and multi-pollutant models. Furthermore, the positive association remained consistent when using mixed-effects regression models or further adjusting for meteorological conditions. In addition, no effect modification of the AC-ozone association by sex, age and season was apparent. This study provides evidence supporting a positive association between short-term ozone exposure and AC risk in China. This highlights the potential value of mitigating ozone pollution to reduce the risk of ocular surface disorders.

Short-term effects of low-level PM2.5, PM10, O3, and tropical meteorological conditions on emergency department visits for respiratory diseases in Haikou, China

Objective: To assess the correlation between atmospheric pollutants, meteorological factors, and emergency department visits for respiratory diseases in Haikou City. Methods: Daily data on atmospheric pollutants, meteorological factors, and emergency department visits for respiratory diseases in Haikou City from 2018 to 2021 were collected. The Spearman rank correlation test was used to analyze the correlation, and a distributed lag non-linear model was employed to analyze the health effects and lag impacts of environmental factors. Subgroup analyses were conducted based on sex and age. Results: According to the criteria of International Classification of Diseases (ICD-10: J00-J99), a total of 221 913 cases were included, accounting for 21.3% of the total emergency department visits in Haikou City. For every 1 °C increase in temperature, the risk of emergency department visits increased by 1.029% (95% CI 1.016%-1.042%). Relative humidity greater than 80% reduced the risk of visits, while higher atmospheric pressure (&gt;1 010 hpa) also decreased the likelihood of daily emergency department visits. Higher concentrations of PM25 (30-50 μg/m3), PM10 (&gt;60 μg/m3), and O3 (75-125 μg/m3) were associated with increased visits. Higher temperatures (&gt;25 °C) have a greater impact on females and children aged 0-14 years, while males are more sensitive to low atmospheric pressure. Individuals aged 65 and above exhibited increased sensitivity to O3 concentration, and the effects of PM2.5, PM10, and O3 are more pronounced in individuals over 14 years old. Conclusions: Short-term exposure to high temperatures, particulate matter pollutants (PM25 and PM10), and ozone (O3) is associated with increased emergency department visits for respiratory diseases.

The Success of Mifepristone and Misoprostol in the Management of Early Pregnancy Loss at a Community Hospital: A Prospective Study

ObjectivesThis prospective single-arm study was conducted to understand the expulsion rate of the gestational sac in the management of early pregnancy loss (EPL). MethodsWe recruited 441 participants; 188 met the eligibility criteria. Participants were 18 years of age and older who experienced a confirmed EPL (<12 weeks gestational age) defined by an intrauterine pregnancy with a non-viable embryonic or anembryonic gestational sac with no fetal heart activity. Participants were given 200 mg of mifepristone pre-treatment orally followed by 2 doses of misoprostol 800 μg vaginally after 24 and 48 hours. Participants were seen in follow-up on day 14 to confirm the absence of a gestational sac, classified as treatment success. For failed treatment (defined by retained gestational sac), we offered expectant management or a third dose of misoprostol and/or dilatation and curettage. We followed all participants for 30 days. We collected data on overtreatment for retained products of conception and hospital admissions for adverse events. ResultsOverall, 181 participants followed the protocol and 169 (93.3%) participants had a complete expulsion of the gestational sac by the second visit (day 14). Twelve (6.6%) failed the treatment and 1 had an adverse event of heavy vaginal bleeding requiring dilatation and curettage. Despite the expulsion of the gestational sac, 29 cases (17.1%) at subsequent follow-up were diagnosed as retained products of conception based on ultrasound assessment of thickened endometrium. ConclusionsPretreatment with mifepristone followed by 2 doses of misoprostol with a 14-day follow-up resulted in a high expulsion rate and is a safe management option for EPL.

Novel Autologous Dendritic Cell Therapy AVT001 for Type 1 Diabetes

BackgroundCD8+ T regulatory (Treg) cells that recognize the nonclassical class 1b molecule Qa-1/human leukocyte antigen E (Q/E CD8+ Treg cells) are important in maintaining self-tolerance. We sought to investigate the role that these T cells play in type 1 diabetes (T1D) pathogenesis and whether an intervention targeting this mechanism may delay T1D progression.MethodsWe conducted a phase 1/2, randomized, double-blind, placebo-controlled trial of the autologous dendritic cell therapy AVT001 that included participants at least 16 years of age, within 1 year of T1D diagnosis, and with ex vivo evidence of a defect in Q/E CD8+ Treg function. Patients were randomly assigned in a 2:1 ratio to AVT001 or placebo, which was administered in three monthly intravenous infusions. The primary end point was safety; efficacy end points included changes from baseline in C-peptide area under the curve (AUC) during a 4-hour mixed meal, hemoglobin A1c (HbA1c), and insulin dose.ResultsSixteen patients received AVT001, and nine received placebo. Similar rates and severity of adverse events were observed in both groups. None of the patients in the AVT001 group had serious adverse events through visit day 360. Compared with placebo, treatment with ATV001 was associated with less decline from baseline log-transformed C-peptide AUC (nmol/l), with the treatment effect between AVT001 and placebo at day 150 of 0.09 (95% confidence interval [CI], 0.03 to 0.15) and at day 360 of 0.10 (95% CI, 0.04 to 0.15). No clear differences in change in HbA1c and insulin dose from baseline were observed between groups. Estimated treatment effects of AVT001 versus placebo at day 360 were −0.17% (95% CI, −0.60 to 0.26%) for HbA1c and −0.06 U/kg/day (95% CI, −0.14 to 0.02) for daily insulin dose.ConclusionsIn this phase 1/2 trial, AVT001 did not result in dose-limiting adverse events. Potential signals of efficacy observed here warrant further evaluation in a fully powered trial. (Funded by Avotres Inc. and the Division of Diabetes, Endocrinology, and Metabolic Diseases; ClinicalTrials.gov number, NCT03895996.)

Establishment level information as proxies for demand, congestion and social interaction

Using cell phone location data linked to store level transactions from a large grocery store chain, this paper finds that the relationship between the number of daily transactions and daily cell phone visits varies within store, across time. More interestingly, this relationship depends on the racial composition and income of the store's market. These results provide guidance, both in terms of estimation strategy and policy implications, to empirical researchers using establishment level cell phone and transaction information as a proxy for business activity, congestion, and social distancing. To demonstrates this policy relevance, we use within-store variation over time and estimate that the measured effect of COVID-19 policies on social distancing depends on whether cell phone location or transactions is used as the proxy.

Switching from cigarettes to IQOS: the relative importance of IQOS-associated reward, reinforcement and abstinence relief

IntroductionThis study investigated whether IQOS, a heated tobacco product, can fully substitute for combustible cigarettes and the factors that promote substitution.MethodsAdults who smoked cigarettes daily (N=90; 21–65 years) completed a...

A strategy for estimating radiation dose to the blood in outpatient settings in differentiated thyroid cancer therapy with 131I-NaI.

Although standard operational procedures for pre-therapeutic dosimetry already exist for the determination of the maximum safe activity to treat differentiated thyroid cancer patients, empiric activity administration of 131I is still the most frequent way of treatment. In this way, the absorbed dose to the blood/bone marrow remains unknown. In this work, we present a strategy to estimate radiation dose to the blood in an outpatient setting. A mobile application was developed, which together with an off-the-shelf compact semiconductor radiation detector allows the determination of whole-body time-integrated activity coefficients. The methodology was tested in a cohort of 79 differentiated cancer patients who received therapeutic 131I activities. Post-therapeutic whole-body time-integrated activity coefficients were compared against pre-therapeutic estimates in a subset of 13 patients. The 95% limits of agreement between pre whole-body and post whole-body time integrated activity coefficients were [-14.4; 6.6] h when considering outliers and [-6.2; 3.6] h without outliers. A high dispersion in blood dose coefficients was found, with a four-fold difference between the highest and lower values. Blood doses were significantly higher for patients treated with dosimetrically guided activities than for empirical activities (median dose=118vs. 49cGy, respectively). Blood dose coefficients were significantly lower for patients prepared with recombinant human thyroid stimulating hormone (rhTSH) than for patients prepared with thyroid hormone withdrawal. A low correlation between blood dose and administered activity was found in empirically treated patients (R2=0.26). We successfully implemented a post-therapeutic internal dosimetry methodology for differentiated thyroid cancer therapy with 131I, which allows to estimate dose to the blood from outpatient measurements with mobile devices. The proposed methodology avoids the need of daily visits to the nuclear medicine department, thus reducing the burden for the patient and for the staff.

Telemedicine and Resource Utilization in Pulmonary Clinic

BackgroundTelemedicine use increased with the Covid-19 pandemic. The impact of telemedicine on resource use in pulmonary clinics is unknown.MethodsThis retrospective cohort study identified adults with pulmonary clinic visits at the University of Miami Hospital and Clinics (January 2018-December 2021). The primary exposure was telemedicine versus in-person visits. Standard statistics were used to describe the cohort and compare patients stratified by visit type. Multivariable logistic regression models evaluated the association of telemedicine with resource use (primarily, computed tomography [CT] orders placed within 7 days of visit).Results21,744 clinic visits were included: 5,480 (25.2%) telemedicine and 16,264 (74.8%) in-person. In both, the majority were < 65-years-old, female, and identified as Hispanic white. Patients seen with telemedicine had increased odds of having CT scans ordered within 7 days (adjusted odds ratio [aOR] 1.34, [95% confidence interval 1.04–1.74]); and decreased odds of chest x-rays (aOR 0.37 [0.23–0.57]). Telemedicine increased odds of contact of any kind with our healthcare system within 30-days (aOR 1.56 [1.29–1.88]) and 90-days (aOR 1.39 [1.17–1.64]). Specifically, telemedicine visits had decreased odds of emergency department visits and hospitalizations (30 days: aOR 0.54 [0.38–0.76]; 90 days: aOR 0.68 [0.52–0.89]), but increased odds of phone calls and electronic health record inbox messages (30 days: aOR 3.44 [2.73–4.35]; 90 days: aOR 3.58 [2.95–4.35]).ConclusionsTelemedicine was associated with an increased odds of chest CT order with a concomitant decreased odds of chest x-ray order. Increased contact with the healthcare system with telemedicine may represent a larger time burden for outpatient clinicians.

Assessing the Environmental and Downstream Human Health Impacts of Decentralizing Cancer Care

Greenhouse gas (GHG) emissions from health care are substantial and disproportionately harm persons with cancer. Emissions from a central component of oncology care, outpatient clinician visits, are not well described, nor are the reductions in emissions and human harms that could be obtained through decentralizing this aspect of cancer care (ie, telemedicine and local clinician care when possible). To assess potential reductions in GHG emissions and downstream health harms associated with telemedicine and fully decentralized cancer care. This population-based cohort study and counterfactual analyses using life cycle assessment methods analyzed persons receiving cancer care at Dana-Farber Cancer Institute between May 2015 and December 2020 as well as persons diagnosed with cancer over the same period from the Cancer in North America (CiNA) public dataset. Data were analyzed from October 2023 to April 2024. The adjusted per-visit day difference in GHG emissions in kilograms of carbon dioxide (CO2) equivalents between 2 periods: an in-person care model period (May 2015 to February 2020; preperiod) and a telemedicine period (March to December 2020; postperiod), and the annual decrease in disability-adjusted life-years in a counterfactual model where care during the preperiod was maximally decentralized nationwide. Of 123 890 included patients, 73 988 (59.7%) were female, and the median (IQR) age at first diagnosis was 59 (48-68) years. Patients were seen over 1.6 million visit days. In mixed-effects log-linear regression, the mean absolute reduction in per-visit day CO2 equivalent emissions between the preperiod and postperiod was 36.4 kg (95% CI, 36.2-36.6), a reduction of 81.3% (95% CI, 80.8-81.7) compared with the baseline model. In a counterfactual decentralized care model of the preperiod, there was a relative emissions reduction of 33.1% (95% CI, 32.9-33.3). When demographically matched to 10.3 million persons in the CiNA dataset, decentralized care would have reduced national emissions by 75.3 million kg of CO2 equivalents annually; this corresponded to an estimated annual reduction of 15.0 to 47.7 disability-adjusted life-years. This cohort study found that using decentralization through telemedicine and local care may substantially reduce cancer care's GHG emissions; this corresponds to small reductions in human mortality.