Outcomes Of Interest Research Articles

EUS-guided Drainage of Pancreatic Fluid Collections Using Lumen Apposing Metal Stents With or Without Coaxial Plastic Stents: A Systematic Review and Meta-analysis.

Co-axial plastic double pigtail stents (DPSs) are commonly placed through lumen apposing metal stents (LAMS) in patients with pancreatic fluid collections (PFCs) to decrease the risk of adverse events. In this meta-analysis, we have compared the outcomes of LAMS plus co-axial DPS versus LAMS alone in patients with PFCs. We reviewed several databases to identify the studies that compared outcomes of LAMS with DPS to LAMS without DPS in the treatment of PFCs. Our outcomes of interest were overall adverse events, clinical success and individual adverse events such as stent (LAMS) migration, stent occlusion, bleeding, and infection. We calculated pooled risk ratios (RR) with 95% confidence intervals (CIs) for the analysis of outcomes. We used a random effects model to analyze the data. Heterogeneity was assessed using the I2 statistic. We included 10 studies with 685 patients. Rate of overall adverse events was significantly lower in the LAMS+DPS group compared with LAMS alone, RR (95% CI) 0.58 (0.40, 0.87). There was no significant difference in the rate of clinical success between groups, RR (95% CI) 1.03 (0.94, 1.13). We found no significant difference in rate of stent occlusion between groups. Rate of infection was significantly lower in LAMS+DPS group, RR (95% CI) 0.46 (0.24, 0.85). There was no significant difference in rate of bleeding and stent (LAMS) migration between groups. Addition of co-axial DPS to LAMS decreases the risk of adverse events in patients with PFCs and should be considered in all patients with PFCs.

Data‐driven prediction of prolonged air leak after video‐assisted thoracoscopic surgery for lung cancer: Development and validation of machine‐learning‐based models using real‐world data through the ePath system

AbstractIntroductionThe reliability of data‐driven predictions in real‐world scenarios remains uncertain. This study aimed to develop and validate a machine‐learning‐based model for predicting clinical outcomes using real‐world data from an electronic clinical pathway (ePath) system.MethodsAll available data were collected from patients with lung cancer who underwent video‐assisted thoracoscopic surgery at two independent hospitals utilizing the ePath system. The primary clinical outcome of interest was prolonged air leak (PAL), defined as drainage removal more than 2 days post‐surgery. Data‐driven prediction models were developed in a cohort of 314 patients from a university hospital applying sparse linear regression models (least absolute shrinkage and selection operator, ridge, and elastic net) and decision tree ensemble models (random forest and extreme gradient boosting). Model performance was then validated in a cohort of 154 patients from a tertiary hospital using the area under the receiver operating characteristic curve (AUROC) and calibration plots.ResultsTo mitigate bias, variables with missing data related to PAL or those with high rates of missing data were excluded from the dataset. Fivefold cross‐validation indicated improved AUROCs when utilizing key variables, even post‐imputation of missing data. Dichotomizing continuous variables enhanced performance, particularly when fewer variables were employed in the decision tree ensemble models. Consequently, regression models incorporating seven key variables in complete case analysis demonstrated superior discriminatory ability for both internal (AUROCs: 0.77–0.84) and external cohorts (AUROCs: 0.75–0.84). These models exhibited satisfactory calibration in both cohorts.ConclusionsThe data‐driven prediction model implementing the ePath system exhibited adequate performance in predicting PAL post‐video‐assisted thoracoscopic surgery, optimizing variables and considering population characteristics in a real‐world setting.

Comparison of two modeling approaches for the identification of predictors of complications in children with cerebral palsy following spine surgery

BackgroundChildren with non-ambulatory cerebral palsy (CP) frequently develop progressive neuromuscular scoliosis and require surgical intervention. Due to their comorbidities, they are at high risk for developing peri- and post-operative complications. The objectives of this study were to compare stepwise and LASSO variable selection techniques for consistency in identifying predictors when modelling these post-operative complications and to identify potential predictors of respiratory complications and infections following spine surgery among children with CP.MethodsIn this retrospective cohort study, a large administrative claims database was queried to identify children who met the following criteria: 1) ≤ 25 years old, 2) diagnosis of CP, 3) underwent surgery during the study period, 4) had ≥ 12-months pre-operative, and 5) ≥ 3-months post-operative continuous health plan enrollment. Outcome measures included the development of a post-operative respiratory complication (e.g., pneumonia, aspiration pneumonia, atelectasis, pleural effusion, pneumothorax, pulmonary edema) or an infection (e.g., surgical site infection, urinary tract infection, meningitis, peritonitis, sepsis, or septicemia) within 3 months of surgery. Codes were used to identify CP, surgical procedures, medical comorbidities and the development of post-operative respiratory complications and infections. Two approaches to variable selection, stepwise and LASSO, were compared to determine which potential predictors of respiratory complications and infection development would be identified using each approach.ResultsThe sample included 220 children. During the 3-month follow-up, 21.8% (n = 48) developed a respiratory complication and 12.7% (n = 28) developed an infection. The prevalence of 11 variables including age, sex and 9 comorbidities were initially considered to be potential predictors based on the intended outcome of interest. Model discrimination utilizing LASSO for variable selection was slightly improved over the stepwise regression approach. LASSO resulted in retention of additional comorbidities that may have meaningful associations to consider for future studies, including gastrointestinal issues, bladder dysfunction, epilepsy, anemia and coagulation deficiency.ConclusionsPotential predictors of the development of post-operative complications were identified in this study and while identified predictors were similar using stepwise and LASSO regression approaches, model discrimination was slightly improved with LASSO. Findings will be used to inform future research processes determining which variables to consider for developing risk prediction models.

Effectiveness of robotic rehabilitation for gait and balance in people with multiple sclerosis: a systematic review.

This review investigated the effectiveness of robotic-assisted gait training (RAGT) in improving gait and balance performance in adults with multiple sclerosis (MS). Databases and registers were searched from inception to December 2023 to identify randomized controlled trials (RCTs) that analyzed the effects of RAGT on gait speed, function, balance, fatigue, and adverse events. Three reviewers screened studies for eligibility and extracted key information such as participants and intervention characteristics, as well as outcomes of interest. The reviewers assessed the risk of bias of included studies using Cochrane Risk of Bias tool. From the 948 records identified, 8 RCTs were included, involving 335 participants. The studies have demonstrated significant heterogeneity in patient characteristics, intervention protocols, and outcomes measured. The risk of bias assessment revealed concerns, mainly in terms of performance and detection bias. The evidence is uncertain on the effectiveness of RAGT on balance and gait in people with MS, but a multimodal rehabilitation approach, including RAGT, should be encouraged. No serious adverse events seem to be associated with RAGT, suggesting that these interventions are generally safe for use in people with MS. Further studies of higher methodological quality should be led to confirm these positive results.

Examining Disparities in Regional Anesthesia Utilization, Opioid Prescriptions, and Pain Scores Among Patients Who Received Primary or Revision Total Knee Arthroplasty at a Veterans Affairs Medical Center: A Retrospective Cohort Study.

Total knee arthroplasty (TKA) is one of the most performed surgical operations in the United States. Managing postoperative pain after TKA is of vital importance, as it is positively associated with outcome measures related to recovery of function and quality of life. Two commonly used methods to control postoperative pain are regional anesthesia (RA), consisting of a single or a combination of peripheral nerve and epidural blocks, and pain medication, such as opioids. Our retrospective analysis sought to better understand whether revision versus primary TKA impacted previously discovered disparities in perioperative pain management and use of RA at the Atlanta Veterans Affairs Health Care System (AVAHCS). Before data collection, we hypothesized that revision TKA would have a higher proportion of Black and older patients and that revision TKA patients would have lower postoperative pain scores. This was a retrospective analysis of AVAHCS patients who underwent elective unilateral primary or revision TKA surgery between 2014 and 2020. After application of our exclusion criteria, data from 562 patients were analyzed. Data collected included demographics information, type of RA used, and pain scores. Statistical analyses included chi-square test, t-tests, multiple logistic regression, and multiple linear regression, as appropriate to the outcomes of interest. Revision TKA patients were more likely to be Black (P = .018) and younger (P = .023 for <50 years of age group, P = .006 for 50 to 64 years of age compared to the >65 years group). Black patients, compared to White patients, had significantly higher pain scores at baseline (P = .0086) and at 24 hours postsurgery (P = .0037). Older patients (≥50 years old) had significantly higher baseline pain scores (P = .021 for the 50 to 64 years group, P < .01 for the >65 years group) and significantly lower first postanesthesia care unit pain scores (P < .05). Black race (P < .01) and age > 65 years (P < .01) were associated with a significant decrease in total oral morphine equivalents (OME) prescribed at discharge. None of the predictor variables-race, age, type of surgery (primary versus revision), baseline, and first postanesthesia care unit pain scores-were significantly associated with the use of RA in our cohort. Sociodemographic disparities in pain management have been reported in all healthcare systems, including the VAHCS. This moderately sized retrospective study, conducted at a single veterans affairs site, yielded several noteworthy findings. One finding of particular interest was that, despite Black patients reporting higher baseline and 24-hour postoperative pain scores, they were prescribed fewer opioids at discharge. Our results highlight the presence of clinically significant disparities in perioperative TKA pain management, emphasizing the need for continuous investigation and focused mitigation efforts among Veterans.

Caregivers on point: a randomized treatment–control prevention trial for foster and kinship caregivers to reduce behavior challenges among children in foster care

BackgroundChildren in foster care who are newly placed with licensed or kinship caregivers are often vulnerable to increased behavior problems associated with trauma and social disruptions. When those issues are not addressed, children are susceptible to placement disruptions that exacerbate behavior problems. Few preventive interventions are available for foster and kinship caregivers, and none are designed to be delivered at the time of a child’s placement into the home. This study aims to examine the impact of the Chicago Parent Program adapted and customized for foster and kinship caregivers (CPP-FC), locally branded as Caregivers on Point, on caregiver stress, parenting confidence and strategies, children’s behaviors, and placement stability.MethodsCaregivers (N = 300) are being recruited from a specialized foster care clinic that sees children and caregivers within five business days of a new placement. Upon completing baseline surveys and behavioral observation, caregiver-child dyads are randomized to receive CPP-FC (n = 150) or usual care (n = 150). Those in the treatment condition will complete 11 weekly sessions addressing child behavior management and caregiving approaches. A booster session will occur one month after the weekly sessions conclude. A mid-point assessment and behavioral observation will be collected four months after the baseline assessment for all participants, coinciding with the completion of the CPP-FC programming. At 6 months post-baseline, an end-of-study assessment will be collected. Administrative data will be extracted from the child welfare record to determine placement stability for the 12 months following enrolment. The primary outcome of interest is child behavior, indicated by changes in caregiver reports and objective ratings of behavior from observations, where raters are blinded to the treatment arm and timing of data collection. Secondary outcomes include placement stability and changes in caregiver stress and confidence in managing children’s behavior.DiscussionIf found to be effective, CPP-FC would be helpful for families involved with child welfare. It could be delivered by child welfare agencies, licensing and kinship navigator agencies, and foster care clinics and may be eligible for government reimbursement as a preventive intervention for children in foster care.Trial registrationThis study was prospectively registered with ClinicalTrials.gov, NCT06170047.

Surgical Experience and Functional Outcomes after Laparoscopic and Robot-Assisted Partial Nephrectomy: Results from a Multi-Institutional Collaboration

Background: In patients treated with partial nephrectomy, prior evidence showed that peri-operative outcomes, such as complications and ischemia time, improved as a function of the surgical experience of the surgeon, but data on functional outcomes after surgery are still scarce. Methods: We retrospectively analyzed data of 4011 patients with a single, unilateral cT1a-b renal mass treated with laparoscopic or robot-assisted partial nephrectomy. The operations were performed by 119 surgeons at 22 participating institutions between 1997 and 2022. Multivariable models investigated the association between surgical experience (number of prior operations) and acute kidney injury (AKI) and recovery of at least 90% of baseline estimated glomerular filtration rate (eGFR) 1 yr after partial nephrectomy. The adjustment for case mix included age, Body Mass Index, preoperative serum creatinine, clinical T stage, PADUA score, warm ischemia time, pathologic tumor size, and year of surgery. Results: A total of 753 (19%) and 3258 (81%) patients underwent laparoscopic and robot-assisted partial nephrectomy, respectively. Overall, 37 (31%) and 55 (46%) surgeons contributed only to laparoscopic and robotic learning curves, respectively, whereas 27 (23%) contributed to the learning curves of both approaches. In the laparoscopic group, 8% and 55% of patients developed AKI and recovered at least 90% of their baseline eGFR, respectively. After adjusting for confounders, we did not find evidence of an association between surgical experience and AKI after laparoscopic partial nephrectomy (odds ratio [OR]: 0.9992; 95% confidence interval [CI]: 0.9963, 1.0022; p = 0.6). Similar results were found when 1-year renal function was the outcome of interest (OR: 0.9996; 95% CI: 0.9988, 1.0005; p = 0.5). Among patients who underwent robot-assisted partial nephrectomy, AKI occurred in 11% of patients, whereas 54% recovered at least 90% of their baseline eGFR. On multivariable analyses, the relationship between surgical experience and AKI after surgery was not statistically significant (OR: 1.0015; 95% CI: 0.9992, 1.0037; p = 0.2), with similar results when the outcome of interest was renal function one year after surgery (OR: 1.0001; 95% CI: 0.9980, 1.0022; p = 0.9). Virtually the same findings were found on sensitivity analyses. Conclusions: In patients treated with laparoscopic or robot-assisted partial nephrectomy, our data suggest that the surgical experience of the operating surgeon might not be a key determinant of functional recovery after surgery. This raises questions about the use of serum markers to assess functional recovery in patients with two kidneys and opens the discussion on what are the key steps of the procedure that allowed surgeons to achieve optimal outcomes since their initial cases.

Vegetarian diet and pregnancy outcome

ObjectiveVegetarian diets are becoming increasingly popular. Our aim was to evaluate the association of a vegetarian diet with pregnancy, labor, and newborn’s outcome. Study designThis retrospective case-control study included 150 women on a vegetarian diet and 300 omnivores. The data were collected from Tampere University Hospital pregnancy database from January 2015 to April 2021. Diet was a self-reported variable. Outcomes of interest were compared between the groups. The frequency of small-for-gestational age (SGA) newborns and low birth weight were primary outcomes. Other parameters concerning pregnancy, labor, and newborn served as secondary outcomes. ResultsThe rate of SGA at the 10 % cutoff was lower in the vegetarian group. Based on a definition of two standard deviations, SGA did not differ between the vegetarian diet group and the control group. The median birthweight was significantly higher in the vegetarian group. Gestational diabetes (GDM) was more common in the vegetarian group, however the numbers of large for gestational age (LGA) newborns were comparable between the study groups. Labor induction was more common, and the second stage of labor was longer in the vegetarian group. Preterm births (< 32+0 and < 37+0 gestational weeks) were more common in the control group. No differences were found in the mean umbilical artery pH value, 1- and 5- minutes Apgar scores or the number of newborns transferred to the neonatal intensive care unit and neonatal ward. The proportions of hypertensive disorders in pregnancy did not differ between the groups. ConclusionAccording to our results, a vegetarian diet may be considered safe during pregnancy. It was not associated with an increased risk of pregnancy- or neonatal complications.

Leg Cycle Ergometry in Critically Ill Patients - An Updated Systematic Review and Meta-Analysis.

Cycle ergometry is a rehabilitation strategy used in the intensive care unit (ICU) which may help mitigate post-ICU impairments. We aimed to systematically review and summarize evidence examining the efficacy and safety of cycle ergometry in the ICU. We included randomized controlled trials (RCTs) of critically ill adults with any diagnosis admitted to the ICU for >24 hours, comparing cycling interventions to control (no cycling). The primary outcome was physical function, using a hierarchical approach to standardize this outcome across trials. We performed random-effects meta-analyses and assessed the certainty of effect estimates using the Grading of Recommendations Assessment, Development, and Evaluation approach. We included 33 RCTs that enrolled 3274 patients. Cycling may improve physical function at ICU discharge (12 RCTs, 1291 patients, standardized mean difference [SMD], 0.33 [95% confidence interval (CI), 0.05 to 0.62], low certainty) and posthospital discharge (8 RCTs, 865 patients, SMD, 0.23, [95% CI, 0.04 to 0.42], low certainty). Cycling may decrease ICU length of stay (29 RCTs, 2575 patients, mean difference [MD], 1.06 days fewer [95% CI, 0.33 to 1.80 days fewer], low certainty) and probably decreases hospital length of stay (22 RCTs, 2060 patients, MD, 1.48 days fewer [95% CI, 0.47 to 2.49 days fewer], moderate certainty). Cycling may have no effect on ICU mortality (17 RCTs, 2039 patients, risk ratio, 12 fewer deaths per 1000 [95% CI, 43 fewer to 23 more], low certainty). The pooled rate of adverse events in the intervention group was 1% (11 RCTs, 4623 sessions, [95% CI, 0 to 2%], low certainty) and in the comparison group, 2% (6 RCTs, 3365 sessions, [95% CI, 0 to 5%], low certainty). In this meta-analysis, we found that cycling with critically ill patients may improve physical function at ICU discharge and after hospital discharge, may reduce ICU length of stay, and probably reduces hospital length of stay, with no effect on other outcomes including mortality. We observed low to very low certainty of evidence for all but one outcome of interest. Adverse events were uncommon. (PROSPERO number, CRD 42018092132.).

Cross-Sectional Analysis of Patients Referred to a Tertiary Lymphatic Surgery Center.

Secondary lymphedema has become an increasingly common reason for referral to plastic surgery. Understanding referral patterns for lymphedema patients is crucial to optimizing care. Patients referred to plastic surgery for lymphedema at a lymphatic surgery center between January 2016 and 2023 were identified. Primary outcomes of interest included clinical lymphedema staging and characteristics, patient demographics, and referral sources. Secondary outcomes were prior lymphedema treatment, agreement between referring provider and plastic surgeon's diagnosis, and patient disposition after surgical evaluation. Descriptive statistics and multivariate logistic regression analysis were performed. A total of 285 patients with extremity edema were referred to plastic surgery; 60.0% of patients had prior malignancy, 45.6% of patients had undergone a prior lymph node procedure, and 40% had received radiation, while 56.8% of patients had previously seen occupational therapy. Body mass index (BMI, OR 1.09, p = 0.013), age (OR 1.25, p = 0.005), and prior physical oroccupational therapy (OR 1.23, p = 0.011) were associated with later stages of lymphedema upon presentation, while prior radiation (OR 0.79, p = 0.006) and malignancy (OR 0.85, p = 0.034) were associated with earlier stages of lymphedema. Self-referral (27.4%), primary care (17.9%), and medical oncology (14.7%) were the most common referral sources. Lymphedema was confirmed in 68.1% of referrals, and 28.5% of these patients proceeded to surgery. Patients were more likely to be operative candidates if referred by primary care (RR 2.1, p = 0.006) or occupational therapy (RR 4.6, p = 0.010). Referred patients ultimately undergo lymphedema surgery at relatively low rates, indicating that most referred patients are not ideal surgical candidates. Optimizing referral patterns through multidisciplinary education may enhance the referral process and improve access to lymphedema surgery.

Respiratory phenotype and health care utilization patterns by adults with sickle cell disease

AbstractAdults with sickle cell disease (SCD) and asthma have increased mortality and health care utilization; however, there are individuals with respiratory symptoms (including cough and wheeze) without asthma. These individuals may have similar patterns of increased mortality and health care utilization. To characterize the association between respiratory phenotype and health care utilization by adults with SCD. Cross-sectional study of adults with SCD presenting for emergency and inpatient hospital care from 2012 to 2014 in Florida, Iowa, and New York using state-level health care utilization databases. Outcomes of interest include all-cause, SCD-related, painful episode, and acute chest syndrome–related care. Respiratory phenotype was defined as SCD + asthma, SCD + respiratory symptoms, and SCD + none. We built multivariable logistic regression and negative binomial regression models to evaluate the association adjusting for demographics, social determinant of health proxies, year of care, and state. Of 29 952 identified individuals, 3.4% had intermittent respiratory symptoms, and a larger proportion (15.6%) had asthma. There was a high rate of inpatient hospitalizations (43%) and ED visits (60%). Individuals with asthma had a higher annual risk of inpatient hospitalizations (48% vs 37%) but lower annual risk of an ED visit (62% vs 86%) than individuals with intermittent respiratory symptoms. The pattern of increased health care utilization among individuals with intermittent respiratory symptoms was consistent across each utilization type. In this large cohort of adults with SCD, we identified some with intermittent respiratory symptoms who had significantly increased health care utilization. This warrants further evaluation to understand potential etiologies and interventions.

Effect Modification by Obesity on Nonsurgical Periodontal Treatment.

Obesity is associated with increased periodontal disease prevalence and incidence. This retrospective cohort study examined whether body mass index (BMI) is an effect modifier of periodontal treatment outcomes in patients attending an urban dental school clinic. Data were extracted from electronic health records of 344 patients at a large urban dental school clinic who had at least 1 tooth with a probing pocket depth (PD) ≥5 mm at baseline and who subsequently received nonsurgical periodontal treatment. BMI was computed from self-reported weight and height and categorized as obese (≥30 kg/m2), overweight (25-29.9 kg/m2), or healthy (18-24.9 kg/m2). The primary treatment outcome of interest was defined as having no teeth with PD ≥5 mm in a quadrant on follow-up after nonsurgical periodontal therapy. That outcome was considered to represent treatment success in this study. Secondary outcomes included changes in mean PD and clinical attachment loss (CAL). Analyses included 879 treated quadrants among 344 patients (185 males, 159 females; mean age 49 ± 12 y at baseline; mean posttreatment follow-up of 6 ± 2 mo). Clinical outcomes in patients who were overweight or obese were compared to healthy-weight patients using generalized linear models for binary or continuous outcomes, accounting for clustering within patients. Covariates were age, gender, tobacco use, history of diabetes, insurance type, and number of baseline sites ≥5 mm. Obesity was associated with a significantly lower likelihood of successful nonsurgical treatment (odds ratio = 0.47; 95% confidence interval, 0.25-0.88) than healthy weight. Being overweight was not associated with treatment success. Posttreatment reductions in the percentage of sites with pockets ≥5 mm and CAL ≥5 mm were greater in patients with healthy weight as compared to those either overweight or obese. However, posttreatment changes in mean PD and CAL did not differ among the BMI groups. Obesity adversely modifies the effectiveness of nonsurgical periodontal treatment among dental school clinic patients. The results of this study may be used by dental providers to better understand and manage periodontal therapy in patients with obesity. Furthermore, patients will be better informed about their therapeutic options and outcome success.

Selected Acute Safety Events Following the Use of Nirmatrelvir/Ritonavir or Molnupiravir for COVID-19: A Nationwide Cohort Study in South Korea.

There had been concerns about the acute complications during or shortly after coronavirus disease 2019 (COVID-19) treatment with nirmatrelvir/ritonavir (NMVr) and molnupiravir (MOL). This study aimed to compare the risks of selected acute safety events in patients treated with or without NMVr or MOL using the COVID-19 oral treatment safety assessment data, constructed through the linkage of nationwide databases: National COVID-19 registry, Real-time Prescription Surveillance, and National Health Insurance data. We identified all adults diagnosed with COVID-19 between January and November 2022, and then constructed two cohorts by matching up to four patients without antiviral treatment records to NMVr or MOL users using propensity score matching. Outcomes of interest were incident-selected cardiac (i.e., atrial fibrillation, other arrhythmia, bradycardia), neurological (i.e., seizure, neuropathy, encephalomyelitis), and miscellaneous (i.e., acute pancreatitis, acute liver injury, dysgeusia) events. A total of 739,935 NMVr users were matched with 2,951,690 comparators and 150,431 MOL users with 759,521 comparators. NMVr users were at lower risk for developing selected cardiac events (hazard ratio 0.74 [95% CI 0.65-0.87] for atrial fibrillation, 0.81 [0.65-0.99] for other arrhythmia, and 0.82 [0.70-0.96] for bradycardia) and dysgeusia (0.58 [0.45-0.74]). For MOL users, the risk was lower for atrial fibrillation (0.72 [0.53-0.96]) and dysgeusia (0.34 [0.18-0.65]). Overall, there were no increased risks of acute complications during and shortly after treatment with oral COVID-19 antivirals. Rather, the findings underscore their effectiveness in attenuating the risk of potential acute sequelae of COVID-19.

High Post-Kidney Transplant Serum Uric Acid Levels Are Associated with Detrimental Outcomes.

The potential effects of post-transplant serum uric acid (SUA) levels and outcomes pose a variety of risks among kidney transplant (KTR) recipients. The association between post-transplant SUA and major detrimental outcomes among KTRs remains uncertain. We evaluated all adult kidney transplant recipients (KTRs) transplanted between 1/1/2000 and 12/31/2019. Recipients were included if they had a functioning allograft without any cardiovascular events (CVE) before their earliest SUA measurement within 5-13 months post-transplant.Survival analyses were performed regarding CVEs, CVE-related mortality, death-censored graft failure (DCGF), and uncensored graft failure, within 10 years after transplantation. A total of 3808 eligible KTRs were followed for a median of 7.5 years after transplantation. Recipients with post-transplant SUA > 6.8 mg/dl had significantly higher risk of congestive heart failure (CHF) than those with SUA <6 mg/dl (adjusted hazard ratio [aHR] = 1.55, 95% CI: 1.10-2.19; p = 0.01); uncensored graft failure (aHR = 1.18, 95% CI: 1.02-1.36; p = 0.03), and DCGF (aHR = 1.28, 95% CI: 1.01-1.61; p = 0.04), after adjustment for multiple variables, including kidney graft function. No statistically significant association was found between SUA levels and other CVEs. There was no statistically significant risk for other outcomes of interest when comparing SUA < 6 mg/dl versus 6-6.8 mg/dl. Elevated early post-transplant SUA levels were associated with detrimental post-transplant outcomes, leading to increased morbidity and mortality through CHF, graft failure, and overall death.

Detection of atrial fibrillation after stroke due to large or small vessel disease: systematic review and meta-analysis.

Emerging evidence indicates a frequent occurrence of atrial fibrillation (AF) detection among patients with established causes of ischemic stroke unrelated to AF. This systematic review and meta-analysis aimed to evaluate AF detection rates in stroke patients with large or small vessel disease, considering the AF detection modality and duration of cardiac rhythm monitoring. We conducted a comprehensive search of PubMed and Scopus databases up to March 2, 2024, to identify randomized controlled trials, non-randomized prospective studies, and retrospective studies assessing the frequency of AF detection in stroke patients with large or small vessel disease. The primary outcome of interest was the rate of AF detection. We utilized inverse-variance weights to produce the pooled prevalence (effect size-ES) and 95% confidence interval (CI) of patients diagnosed with post-stroke AF. In the analysis of 14 eligible studies encompassing 4,334 patients, AF was identified in 154 out of 2,082 patients with strokes attributed to small or large-vessel disease, yielding a pooled prevalence of 6.27% (ES; 95% confidence interval [CI]: 3.18-10.17, I2=87.83%). Among patients with large-vessel disease strokes, AF was diagnosed in 79 out of 1,042 patients, accounting for a pooled prevalence of 5.07% (ES;95% CI: 1.30-10.33, I2=77.05%). Similarly, among those with small-vessel disease strokes, AF was detected in 75 out of 1,040 patients, with a pooled prevalence of 5.03% (ES; 95% CI: 1.96-9.06, I2=78.05%). AF is often found in ischemic stroke patients with large or small-vessel disease. Detection rates increase with longer cardiac rhythm monitoring. The safety and benefits of oral anticoagulation for these AF episodes are uncertain.

Outcomes After Early Pregnancy Loss Management With Mifepristone Plus Misoprostol vs Misoprostol Alone

Medication management of early pregnancy loss (EPL), or miscarriage, typically involves the administration of misoprostol with or without pretreatment with mifepristone. Combination treatment with mifepristone plus misoprostol is more effective than misoprostol alone but is underutilized in the US. To describe differences in clinical outcomes after EPL management with mifepristone plus misoprostol vs misoprostol alone using commercial claims data. This retrospective cohort study used national insurance claims data from the IBM MarketScan Research Database. Participants included pregnant people (aged 15-49 years) with private insurance who presented with an initial EPL diagnosis between October 1, 2015, and December 31, 2022. The primary exposure was the medication used to manage EPL (ie, mifepristone plus misoprostol or misoprostol alone). Other exposures of interest included demographic characteristics and location of service. The primary outcome was subsequent procedural management (eg, uterine aspiration) after EPL diagnosis and medication management. Other outcomes of interest included return visits, hospitalizations, and complications occurring in the subsequent 6 weeks. Descriptive statistics and bivariate analyses were used, and a multivariable logistic regression model was created to examine factors associated with subsequent procedural management. This study included 31 977 patients (mean [SD] age, 32.7 [5.6] years) with claims for EPL who received medication management. Of these patients, 3.0% received mifepristone plus misoprostol and 97.0% received misoprostol alone. Patients who received misoprostol with pretreatment with mifepristone were less likely to have subsequent uterine aspiration (10.5% vs 14.0%; P = .002), and they were also less likely to have subsequent emergency department (ED) visits for EPL (3.5% vs 7.9%; P < .001). In multivariable analysis, use of mifepristone plus misoprostol was associated with decreased odds of subsequent procedural management (adjusted odds ratio, 0.71 [95% CI, 0.57-0.87]). The findings of this study suggest that mifepristone is underutilized for the medication management of EPL, but its use is associated with a lower need for subsequent uterine aspiration and a decrease in the number of subsequent visits to an ED. Increasing access to mifepristone for EPL management may decrease health care utilization and expenditures.

Meningkatkan Hasil Belajar Pak dengan Metode PBL Berbantuan E-LKPD

Education is a systematic process that aims to develop the potential, knowledge, skills, attitudes, and character of individuals, so that they can become individuals who are useful in their personal, social, and work lives. The main goal of education is to prepare individuals to face life's challenges, contribute to society, and achieve complete self-development. Education plays an important role in shaping civilization and encouraging the progress of a nation. The quality of learning in schools is largely determined by two main factors, namely student learning motivation and teacher teaching creativity. However, at SDN 091448 Saribujawa, Catholic Religious Education learning often faces obstacles, such as the use of monotonous teaching methods, which have an impact on low student interest and learning outcomes. This study aims to improve student activity and learning outcomes through the application of the Problem-Based Learning Model (PBL) in grade V students of SDN 091448 Saribujawa, with a focus on how PBL can improve learning outcomes and students' self-understanding as developing individuals. The implementation of PBL supported by technology in the learning process has succeeded in increasing student motivation and their learning outcomes, as indicated by the increase in the average value from cycle I to cycle II. In addition, there was a significant improvement in student attitude indicators, such as cooperation, responsibility, and independence.

Peningkatan Hasil Belajar Peserta Didik Kelas VIII SMP Negeri 2 Tarabintang melalui Metode Pembelajaran Problem Based Learning

This study aims to improve the learning outcomes of eighth-grade students at SMP Negeri 2 Tarabintang in the subjects of Catholic Religious Education and Ethics through the implementation of the Problem-Based Learning (PBL) model. This method was chosen as a solution to the low interest and learning outcomes of students, especially in understanding the material of the Church as a Sign and Means of Salvation. This study employs a Classroom Action Research (CAR) approach conducted in two cycles. Each cycle involves the stages of planning, action implementation, observation, and reflection. The results of the study indicate that the implementation of the PBL model successfully improved students' learning outcomes in the cognitive, affective, and psychomotor aspects. In the first cycle, the average value of student test results reached 76, which increased to 85 in the second cycle. In addition, students' active participation in group discussions increased significantly, as seen from the observation results that showed an increase in students' ability to identify problems, provide alternative solutions, and appreciate the perspectives of others. In conclusion, the implementation of the Problem-Based Learning (PBL) model has proven effective in improving students' learning outcomes, both in terms of knowledge and social skills. The application of this model not only increases students' understanding of the material taught but also enhances students' active participation and motivation to learn. It is recommended that teachers continue to apply this method in teaching, especially in subjects that require active student involvement in problem-solving.

UroARC: A novel surgical risk calculator for older adults undergoing pelvic organ prolapse and stress urinary incontinence surgery.

Surgeries for pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are commonly performed in older adults, many of whom are also frail. A surgical risk calculator for older adults undergoing POP/SUI surgeries that incorporates frailty, a factor known to increase the risk of surgical complications, would be helpful for preoperative counseling but currently does not exist. Medicare Carrier, Outpatient, and MedPAR files were examined for beneficiaries undergoing POP and SUI surgery between 2014 and 2016. A total of 15 POP/SUI categories were examined. The Claims-Based Frailty Index (CFI), a validated measure of frailty in Medicare data, and Charlson Comorbidity Index were deconstructed into their individual variables, and individual variables were entered into stepwise logistic regression models to determine which variables were most highly predictive of 30-day complications and 1-year mortality. To verify the prognostic accuracy for each model for surgical complications of interest, calibration curves and tests of model fit, including C-statistic, Brier scores, and Spiegelhalter p values, were determined. In total, 108 479 beneficiaries were included. Among these, 4.7% had CFI scores consistent with mild to severe frailty (CFI≥0.25). A total of 13 prognostic variable categories were found to be most highly predictive of postoperative complications. Calibration curves for each outcome of interest showed models were well-fit. Most models demonstrated high c-statistic values (≥0.7) and high Spiegelhalter p values (≥0.9), indicating good model calibration and excellent discrimination, and low Brier scores (<0.02), indicating high model accuracy. Urologic surgery for older Adults Risk Calculator serves as a novel surgical risk calculator that is readily accessible to both patients and clinicians that specifically factors in components of frailty. Furthermore, this calculator accounts for the heterogeneity of an aging population and can assist in individualized surgical decision-making for these common procedures.

Discordance Between Clinician and Person-With-Diabetes Perceptions Regarding Technology Barriers and Benefits.

The quality of clinician-patient relationship is integral to patient health and well-being. This article is a narrative review of published literature on concordance between clinician and patient perspectives on barriers to diabetes technology use. The goals of this manuscript were to review published literature on concordance and to provide practical recommendations for clinicians and researchers. In this review, we discuss the qualitative and quantitative methods that can be applied to measure clinician and patient concordance. There is variability in how concordance is defined, with some studies using questionnaires related to working alliance, while others use a dichotomous variable. We also explore the impact of concordance and discordance on diabetes care, barriers to technology adoption, and disparities in technology use. Published literature has emphasized that physicians may not be aware of their patients' perspectives and values. Discordance between clinicians and patients can be a barrier to diabetes management and technology use. Future directions for research in diabetes technology including strategies for recruiting and retaining representative samples, are discussed. Recommendations are given for clinical care, including shared decision-making frameworks, establishing social support groups optimizing clinician-patient communication, and using patient-reported outcomes to measure patient perspectives on outcomes of interest.