The use of antiseizure medication (ASM) polytherapy has become increasingly common. However, it is known that there is an elevated risk of major congenital malformations (MCMs) in newborns after maternal use of select ASMs. This study characterizes the risk of MCMs in infants born to women using common ASM polytherapies during the first trimester. The study population was pregnant women enrolled in the North American AED Pregnancy Registry between 1997 and 2024. Phone interviews at enrollment, 7 months' gestation, and postpartum collected data on ASM use and maternal characteristics. ASM monotherapy or polytherapy exposure is defined by ASM or ASM combination use during the first 12 weeks of pregnancy. MCMs were confirmed by medical records and adjudicated by a blinded teratologist. The risk of MCMs was calculated among infants exposed to a specific ASM polytherapy during the first trimester of pregnancy and those exposed to lamotrigine (LTG) monotherapy. RRs and 95% CIs were estimated using logistic regression. In a population of 15,318 pregnant women taking ASM at conception, 2,348 (15.3%) used 2 or more ASMs during the first trimester, with 796 polytherapy-exposed pregnancies eligible for analysis (mean age 30 years). The most common monotherapy was lamotrigine (LTG) (n = 2,582, mean age 31 years). The most common polytherapy combination was levetiracetam-lamotrigine (LEV-LTG) (38.4%). Indication of analyzed ASM polytherapy use was largely epilepsy (98.5%). The prevalence of MCMs was 2.0% for the reference LTG monotherapy group. Compared with LTG monotherapy, the adjusted RR of MCM was 1.63 (95% CI 0.69-3.40) for levetiracetam-LTG, 0.78 (0.04-3.78) for levetiracetam-carbamazepine, 0.99 (0.05-5.29) for levetiracetam-lacosamide, 1.40 (0.22-4.97) for levetiracetam-topiramate, 1.21 (0.07-6.22) for levetiracetam-zonisamide, 3.25 (0.74-9.98) for LTG-carbamazepine, 4.54 (1.61-11.07) for LTG-topiramate, and 3.22 (0.74-9.79) for LTG-zonisamide. Among infants exposed to any ASM polytherapy, the most common MCMs were hypospadias (5 cases), ventricular septal defect (5 cases), and cleft lip/palate (4 cases). All cleft lip/palate cases occurred in combinations with either topiramate or zonisamide. Our findings suggest an increased risk of MCM associated with LTG-topiramate duotherapy compared with LTG monotherapy. Relative risk estimates were too imprecise for us to conclude on the teratogenicity of other analyzed polytherapy combinations.

Migraine has been linked to an increased risk of glaucoma, and our study aims to assess the temporal association between calcitonin gene-related peptide inhibitors (CGRPi) and the risks of glaucoma in individuals with migraine. This multinational retrospective cohort study included adults diagnosed with migraine who received migraine preventive medications in 2018-2024. Participants were categorized into the CGRPi group (erenumab, fremanezumab, galcanezumab, eptinezumab, atogepant, or rimegepant) and non-CGRPi group (valproate, topiramate, flunarizine, candesartan, lisinopril, metoprolol, propranolol, nadolol, amitriptyline, and venlafaxine). Crossovers were not allowed, and the non-CGRPi group included only individuals who never used CGRPi. The CGRPi and non-CGRPi groups were propensity score matched in a 1:1 ratio and were followed for up to 3 years to monitor the occurrence of incident glaucoma. The Cox proportional hazards model was used to compare the risk of glaucoma between CGRPi and non-CGRPi users, with results reported as hazard ratios (HRs) and 95% CIs. A total of 73,644 individuals were included in the final analysis. Compared with non-CGRPi users, CGRPi users experience a lower risk of glaucoma development (HR 0.75; 95% CI 0.61-0.92) within 3 years since its first prescription. Individuals using CGRPi also exhibit a reduced risk of glaucoma compared with those using topiramate (HR 0.73; 95% CI 0.59-0.90), valproate (HR 0.54; 95% CI 0.35-0.83), propranolol (HR 0.76; 95% CI 0.59-0.98), metoprolol (HR 0.76; 95% CI 0.59-0.98), lisinopril (HR 0.49; 95% CI 0.38-0.62), amitriptyline (HR 0.69; 95% CI 0.54-0.89), and venlafaxine (HR 0.68; 95% CI 0.50-0.91). In the analysis that further classified participants based on the specific CGRPi used, only users of monoclonal antibody CGRPi show a reduced risk of glaucoma compared with non-CGRPi users (HR 0.77; 95% CI 0.61-0.98). The reduced risk of glaucoma associated with CGRPi is also observed in older adults, women, and those with chronic migraine or migraine without aura. Among adults with migraine receiving preventive treatment, systemic use of CGRPi, particularly monoclonal antibody CGRPi, is associated with a reduced risk of glaucoma compared with the use of other migraine preventive medications. This is a Class II study demonstrating that CGRPi users with migraine have a lower risk of incident glaucoma when compared with non-CGRPi users with migraine.

To describe the proposed mechanism of action of shock wave therapy and discuss treatment considerations and guidelines for use in equine and canine practice. Client-owned animals with owner consent. Shock wave therapy is proposed to stimulate healing by generating forces that cause cells to undergo microtrauma and release anti-inflammatory cytokines and growth factors into the treated tissues. While the 4 types of shock wave therapies are discussed, electrohydraulic and piezoelectric are described in detail, as they are most utilized in veterinary medicine for the treatment of tendon and ligament injuries, osteoarthritis, and nonunion fractures. The dose that is applied per patient is relative to the selected settings of depth, energy level, and number of pulses delivered. It is important to recognize that the highest energy deposition and greatest biological effects are seen at anatomic regions of differing tissue types such as bone and soft tissue interfaces; thus, shock wave is particularly useful at areas of enthesopathy. Because of the mechanism of action, the use of anti-inflammatory medications and/or cryotherapy around shock wave treatment times should be avoided. Additionally, because of the potent analgesic effects of shock wave for the first 48 hours after treatment, rest is recommended to prevent any further damage to the tissues. Competition rules surrounding the use of shock wave must also be followed and discussed with owners. Shock wave therapy is an accessible and useful modality for the treatment of tendon and ligament injuries, osteoarthritis, and nonunion fractures.

Eating behavior problems in children with epilepsy (6-16years): A cross-sectional comparative study.

Stress, coping, and sleep quality are determinants of well-being in health professions education. Despite their importance, little is known about how these constructs interact among different academic roles. This study examined stress, coping, and sleep quality among members of a college of pharmacy, identified predictors of sleep quality, and explored the role of medication use. A cross-sectional, mixedmethod survey was employed. Measures included self-reported medication use and validated Perceived Stress Scale, Toulouse Coping Scale, and Brief Pittsburgh Sleep Quality Index. Correlation, multiple linear regression, and content analysis were conducted. Findings were integrated using a joint display. Of 147 responses, most were female (77.6%), White (56.3%), and pharmacy students (49.6%). Participants reported moderate stress (M=18.2±5.7), moderate coping (M=30.2±3.9), and poor sleep quality (M=5.2±3.1). Stress was inversely correlated with coping (r=-0.21, p=0.009) and positively correlated with poor sleep (r=0.24, p=0.004). Prescription and OTC medication use were associated with higher stress and lower coping (p<0.05), while OTC medication use predicted poorer sleep quality (p<0.001). Stress predicted poorer sleep (β=0.15, p=0.002). Qualitative themes showed workload and emotional strain as stressors, while exercise and social support were key coping strategies. Moderate stress and coping, and poor sleep, were observed, with stress predicting poor sleep. Interventions that integrate stress management, adaptive coping, and sleep hygiene may enhance well-being, academic success, and professional sustainability.

Chronic pain and posttraumatic stress disorder (PTSD) are common in Veterans, commonly co-occurring, and are associated with pain medication use. Our primary aim in this study was to explore the relationship between sleep heart rate (HR) and respiratory sinus arrhythmia (RSA) on next-day prescription pain medication use in Veterans with PTSD. Seventy-eight male US military Veterans attending an inpatient treatment program for service-related PTSD were observed over an average of 78 nights. Sleep HR and RSA were recorded using mattress actigraphy, and daily pain medication prescription was obtained from electronic health record. Binary logistic mixed-effects regression models were used to test the associations between sleep HR and RSA on next-day pain medication prescription. These revealed that higher sleep HR was predictive of higher rates of next-day pain medication prescriptions; however, sleep RSA was not. An analysis disaggregating between- and within-persons effects associating sleep HR and next-day pain prescription found evidence of the former but not the latter. These results replicate and extend those of Dudarev et al. (2024) in demonstrating a positive relationship between sleep HR and next-day pain in a new population, Veterans with deployment-related PTSD. They support a role of autonomic arousal in subjective pain and medication-seeking and suggest that hyperarousal may mediate the excess vulnerability of persons with PTSD to pain medication use.

Atypical femur fractures (AFF) are rare stress fractures linked to long-term bisphosphonate (BP) use. However, since some patients develop AFF without BP exposure (BP-naïve), additional mechanisms have been proposed. In this study, we tested medication use, clinical characteristics, and femoral geometry. We started with a hypothesis that BP-naïve patients would have additional risk factors in these areas compared with BP-users. We included 172 patients aged ≥55yr who sustained AFF in Sweden between 2008 and 2010. Among them, 134 had used BPs prior to the fracture and 38 had not. All fractures met the 2014 ASBMR major criteria for AFF. Data on medication use, comorbidities, and demographics were extracted from national registers, and radiographs were reviewed to assess femoral geometry. All statistical models were adjusted for sex and age. We found that among BP-naïve patients, male sex was more common (21.1%) than among BP-users (3.0%). Additionally, BP-naïve patients were less likely to use calcium supplementation (23.7% vs 90.3%, OR 0.04, 95% CI 0.01-0.10), corticosteroids (13.2% vs 35.8%, OR 0.18, 95% CI 0.05-0.52), proton pump inhibitors (23.7% vs 41.8%, OR 0.36, 95% CI 0.14-0.85), and beta-blockers (28.9% vs 47.0%, OR 0.43, 95% CI 0.18-0.97). Moreover, BP-naïve patients had fewer diagnosed bone disorders, including osteoporosis (5.3% vs 34.3%, OR 0.10, 95% CI 0.02-0.38). Bisphosphonate-naïve patients did have a higher lateral-to-medial cortical thickness ratio (1.00 vs 0.90, p < .01); however, other geometric differences were minor and did not support the hypothesis. The absence of identifiable mechanisms for stress fracture formation suggests that future research should test factors not captured in registry data or femoral geometry. Possibly, physical activity levels or subtle bone metabolic conditions may be contributing to the pathogenesis of AFF, particularly in BP-naïve individuals.

Hypothyroidism is a medical disorder of thyroid hormone deficiency which can manifest with a range of somatic and psychological disturbances. This case highlights the rarer manifestation of psychotic symptoms in a patient with hypothyroidism which is known to typically manifest with depressive and/or anxious psychiatric symptomatology. The following report discusses a case of a young adult married house-wife from a semiurban setting presented with history of irritability, aggressive and odd behaviours, hearing voices, suspiciousness with irregular sleep in an on/off manner for 10 days duration coinciding with a period of irregularity in her hypothyroid medication use. Upon mental status examination signs of poor self-care, gaze avoidance, increased psychomotor activity and speech rates were noted alongside referential and persecutory delusions and beckoning secondary auditory hallucinations. Insight of grade 3 and poor judgement. The patient was assessed by serial applications of the Brief Psychiatric Rating Scale (BPRS) showing an improvement from across the span of four days of re-initiation of long-term thyroid medication under the cover of short-term antipsychotics and psychotherapy. This case exemplifies the acute nature of psychotic symptoms that can manifest in hypothyroidism, with some instances having psychotic features as the presenting complaints. Maintaining a high index of suspicion to enable early identification is important. An improvement in patient’s condition was noted in response to thyroid level assessment and reinforcement of medication use. Appropriate psychopharmacological and psychotherapeutic interventions contributed to the patient’s acute improvement which highlights the need for discussing such cases.

The widespread use of psychotropic medication in long-term care, especially antipsychotics for managing dementia-related behaviours, is controversial due to serious side effects, significant risks, and increased mortality rates. While prescribing authority lies with physicians, nurses often demand treatment and administer as-needed medications at their discretion. This study discusses the ongoing reliance on antipsychotics within the context of structural tensions between person-centred nursing values, multiple professional responsibilities, and resource constraints in long-term care facilities. Drawing on in-depth qualitative interviews with 15 nurses across seven German nursing homes, the study reveals diverse ways in which nursing staff navigate the use of psychotropic medication in dementia care. While nurses' self-descriptions and explicit ethos are framed in humanistic terms – addressing individual needs, promoting health and preserving functional capacities of those in need of care – they also feel responsible for protecting other residents and maintaining organisational stability in the care facilities. While some nurses still try to uphold their person-centred care ethos, seek to resist the rationing of care, and strongly oppose excessive sedation, others set aside their compassionate nursing values in everyday care and rationalise psychotropic medication for managing dementia-related behaviours as a matter of organisational necessity. Moving beyond individualised explanations for the overuse of psychotropic drugs, this study discusses the practices of pharmacological behaviour control as part of a pharmaceuticalisation of dementia care and as emblematic of the broader social-political governance of ageing and dementia. • Explores nurses' perspectives on psychotropic medication in dementia care. • Analyses antipsychotic use amid the economisation of long-term care systems. • Reveals tensions between nursing values, multiple role responsibilities and limited resources. • Conceptualises drug overuse as part of the pharmaceuticalisation of dementia. • Examines psychotropic behavioural control within the socio-political governance of ageing.

The prodromal phase of migraine is highly prevalent and can be very disabling. In this review, we seek to understand the clinical features of prodrome and its underlying pathophysiology. Our aim is to assess the impact of early treatment of migraine during the prodromal phase. A recent phase 3 trial showed ubrogepant is effective at preventing migraine during the prodromal phase. Further studies have shown it is effective in reducing disabling symptoms of the prodrome itself and positive patient reported outcomes. The prodromal phase of migraine presents the earliest opportunity to treat migraine and prevent disability. Studies have shown that the use of medications during this phase of migraine to be effective with recent studies showing ubrogepant is effective when used during prodrome.

Patterns of opioid and sedative use in adult ICUs: Insights from the ALERT-ICU study on iatrogenic withdrawal syndrome.

Infection enteritis is associated with the development of irritable bowel syndrome (IBS) and functional dyspepsia. This study aimed to examine the long-term risk of IBS and functional dyspepsia, and associated health care utilisation following infection enteritis. We conducted a retrospective cohort study using TriNetX U.S. Network. Adults with infection enteritis were identified and matched to controls, balancing demographics and comorbidities. Primary outcomes were the risk of incident IBS and functional dyspepsia diagnoses at 1, 5, and 10 years. Secondary outcomes were rates of IBS- and functional dyspepsia-related medications, endoscopy, abdominal imaging, and hospitalizations. Pathogen-specific and multivariate analyses were performed to assess variations in IBS risk. After matching, 202,244 patients were identified in each study cohort. At 1year of follow-up, the infection enteritis cohort had higher rates of IBS (RR = 2.35; 95% CI: 2.14-2.59), functional dyspepsia (RR = 2.02; 95% CI: 1.84-2.22), use of IBS-related medications (RR = 1.29; 95% CI: 1.26-1.31), functional dyspepsia-related medications (RR = 1.56; 95% CI: 1.55-1.59), abdominal imaging (RR = 2.42; 95% CI: 2.29-2.54), and Oesophagogastroduodenoscopy/colonoscopy (RR = 1.57; 95% CI: 1.50-1.65). These risks remained significantly higher in the IE cohort at 5 and 10 years. Salmonella/Shigella (RR = 6.48), and Giardia lamblia (RR = 5.05) had the highest risk of developing incident IBS. Infection enteritis was associated with increased risk of IBS and functional dyspepsia, rates of related medication use, and greater healthcare utilisation.

Brain aging in bipolar disorder using a neuroimaging and machine learning-derived metric: Findings from the ENIGMA BD Working Group.

Evaluating the efficacy of large language models in predicting intensive care unit admission needs.

False-positive iFOBT in colorectal cancer screening: Association with prescription drug use in The Malaysian Cohort.

Medical innovations have extended patient lifespans while also increasing the clinical complexity associated with aging and chronic conditions. As patients live longer, surgeons may encounter an array of perioperative challenges including patients with multiple comorbidities. Consequently, surgical teams must manage bleeding risks while balancing potential thromboembolic complications. This retrospective observational study evaluated trends in perioperative bleeding management and associated surgical care challenges over 22 years, utilizing data from the Premier Perspective Hospital Database. The analysis included 13,358,404 adult surgical patients, examining patient complexity via Charlson Comorbidity Index (CCI), preoperative anticoagulant/antiplatelet usage, and topical hemostatic agent (THA) utilization. Patient complexity, as indicated by CCI, significantly increased annually across all surgical types, with the greatest increase in cardiovascular surgery (0.029/year). Overall preoperative use of anticoagulants and antiplatelets rose by 0.5 % per year, with marked variations across surgical cohorts. Notably, general surgery exhibited the highest annual increase (2.0 %), while knee and hip replacements showed a decline in anticoagulant/antiplatelet use. Overall, use of THA strategies increased by 0.56 % annually, particularly in neurosurgery, spinal, and cardiovascular procedures. Multivariate analysis demonstrated significant associations between patient complexity, anticoagulant/antiplatelet use, and higher use of THA strategies across various surgical disciplines. Elective surgeries were more likely to be associated with THA charges than emergent or urgent procedures. This large retrospective analysis describes evolving patient complexity, antithrombotic medication use, and associated use of THA strategies across surgical specialties over two decades. These findings characterize practice patterns and may inform future hypothesis-driven studies evaluating the clinical role of THAs in different surgical contexts.

From health check-ups to "City sewage health scan": Multidimensional chemical analysis for wastewater-based epidemiology in Hong Kong.

Diabetic nephropathy (DN) remains a major complication of type 2 diabetes mellitus (T2D). Conventional markers such as albuminuria and HbA1c have limited value for early prediction. Plasma glycated CD59 (gCD59), a complement-regulatory protein modified under chronic hyperglycaemia, has emerged as a potential biomarker. This study examined the association of plasma gCD59 with renal function, tubular injury, inflammation, endothelial dysfunction, and complement activation in T2D. A total of 320 adults with T2D were enrolled and classified into microalbuminuria and normoalbuminuria groups (n = 160 each). Plasma gCD59, eGFR, urinary NGAL and KIM-1 (mg/g creatinine), hs-CRP, sICAM-1, sVCAM-1, ApoB, and soluble membrane attack complex (sMAC, ng/mL) were assessed. Hierarchical multivariable logistic regression was performed with sequential adjustment for demographics, diabetes duration, blood pressure, and medication use. Patients with microalbuminuria had higher plasma gCD59, NGAL, KIM-1, hs-CRP, sICAM-1/sVCAM-1, ApoB, and sMAC levels, along with lower eGFR (all p < 0.01). Plasma gCD59 correlated with sMAC (r = 0.62), NGAL/KIM-1 (r = 0.58), and HbA1c (r = 0.55). In fully adjusted regression (Model 3), plasma gCD59 (OR: 2.72, 95% CI:1.84-4.03), urinary NGAL (OR:1.57, 95% CI:1.09-2.25), and sMAC (OR:2.31, 95% CI:1.49-3.58) remained independent predictors of microalbuminuria. Plasma gCD59 showed strong associations with complement activation, tubular injury, and albuminuria in T2D. When combined with tubular and complement markers, gCD59 may improve early stratification of DN risk. Prospective studies are required to determine temporal and causal relationships and to validate its clinical utility.

Previous retrospective studies involving mixed intensive care unit (ICU) populations found antipsychotic continuation rates ranging from 21% to 61% at hospital discharge. Surgical ICU admission was cited as a risk factor for antipsychotic continuation, although data in the trauma population are limited. The purpose of this study was to evaluate the number of critically ill trauma patients with escalated psychotropic medications in the surgical ICU and the rate of continuation at ICU transfer and hospital discharge. This single-center, retrospective, Institutional Review Board (IRB)-approved study examined adult trauma patients admitted to the surgical ICU at an urban Level 1 Trauma and Academic Medical Center from December 1, 2021, to May 31, 2023. Patients were excluded if they had a history of select psychiatric disorders or were in the ICU for less than 48 hours. Prior psychotropic medication use was noted, and escalation was defined as a new or increased dose of psychotropic medication. The incidence of delirium and agitation was recorded to assess the indication for psychotropic medication escalation. The primary and secondary outcomes were the percentage of patients with escalated psychotropic medications in the ICU who were continued on therapy at the time of ICU transfer and hospital discharge, respectively. Four hundred and twenty-four patients admitted to the surgical ICU were included; 51.4% were escalated on a psychotropic medication while in the ICU. Nearly 35% and 31.8% of the overall population were continued on psychotropic medication at ICU and hospital discharge, respectively. Of patients on psychotropic medication at hospital discharge, 55.6% were discharged to acute rehabilitation, 28.9% to home, and 13.3% to long-term care. Escalation of psychotropic medications was common in trauma patients admitted to the surgical ICU. Further investigation into the appropriateness of psychotropic medication prescription during care transitions is needed.

Impact of Self-Reported Patient-Provider Communication on the Use of High- and Low-Value Care Among U.S. Adults.