Present Illness Research Articles

November 2024 Medical Image of the Month: A Case of Short Telomeres

No abstract available. Article truncated after 150 words. A 50-year-old woman was referred to our institution for further evaluation of her ILD. Her history of present illness began during the COVID-19 pandemic, when she noticed that she had trouble climbing stairs while wearing a mask. She also had a slowly progressive cough which, at first, she attributed to seasonal allergies. Eventually her symptoms prompted pulmonary function testing at an outside institution, which showed moderately severe restriction with a DLco 40% of predicted. Chest x-ray (Figure 1) and chest CT (Figure 2) demonstrated findings of pulmonary fibrosis. The patient worked as an accountant and was a life-long nonsmoker. No concerning exposure history and no history of any medications associated with pulmonary fibrosis. Her family history is remarkable for a brother diagnosed with IPF at age 49, currently status post lung transplant. Her sister and father were both diagnosed with alpha-1-antitrypsin (both died in their 50’s). The patient also reports …

Elements of dissemination in cryptococcosis.

As healthcare improves and our ability to support patients with compromised immune systems increases, such patients become more vulnerable to microbes in the environment. These include fungal pathogens such as Cryptococcus neoformans, the primary cause of fungal meningitis and a top priority pathogen on the World Health Organization fungal pathogen list. Like many other environmental pathogens, C. neoformans must adapt to and thrive in diverse environments in order to cause disease: (i) the environmental niche, (ii) the lungs following inhalation of infectious particles, (iii) the bloodstream and/or lymphatic system during dissemination, and (iv) the central nervous system (CNS), where it causes a deadly cryptococcal meningoencephalitis. Because CNS infection is the driver of mortality and the presenting illness, understanding the dissemination process from both host and fungal perspectives is important for treating these infections. In this review, we discuss the different stages of dissemination, how fungal cells interact with host cells during disease, and the ability to adapt to different environments within hosts.

Hickam's Dictum: An Analysis of Multiple Diagnoses.

Hickam's dictum ("a patient can have as many diseases as he damn well pleases") has been touted as a counterargument to Ockham's razor, which enjoins clinicians to seek a single, simple, or unifying diagnosis. Yet the phenomenon of multiple diagnoses has not been formally analyzed. We evaluated multiple diagnoses using three methods of inquiry: (1) a review of 83 case reports; (2) a review of 220 cases from the New England Journal of Medicine; and (3) an online survey of providers' intuitions. Eighty-three published case reports claimed to instantiate Hickam's dictum or violate Ockham's razor. All reported a primary diagnosis that explained the presenting illness, and one or more additional diagnoses which could be classified into four categories: (1) an incidentaloma (n = 21; 25.3%); (2) a pre-existing disease (n = 26; 31.3%); (3) a disease causally linked to the primary diagnosis (n = 33, 39.8%); and (4) a causally unrelated second disease contributing to the acute presentation (n = 3, 3.6%). Among 220 cases from the New England Journal of Medicine, all reported a unifying final diagnosis. In an online survey, 265 respondents recruited using social media evaluated four hypothetical cases with multiple diagnoses representing this categorization scheme. A majority of respondents (79%; 95% CI, 74-84%) chose the case representing category 4 - a coincident, causally unrelated second diagnosis - as the most unlikely or surprising diagnostic combination. Multiple diagnoses commonly occur. However, the majority of the multiple diagnoses we analyzed were causally linked, or represented incidentalomas or known pre-existing diseases. These diagnostic combinations were unsurprising to a majority of surveyed providers. We show that multiple diagnoses can be arranged in a framework that considers time, probability, and causation. This framework reconciles the alleged conflict between Hickam's dictum and Ockham's razor and has greater practical and pedagogical utility.

October 2024 Critical Care Case of the Month: Respiratory Failure in a Patient with Ulcerative Colitis

No abstract available. Manuscript truncated after 150 words. History of Present Illness The patient is a 57-year-old woman with a history of ulcerative colitis (UC) complicated by toxic megacolon with subsequent colectomy. She presented to the emergency department with cough, shortness of breath and hypoxemia (87% on RA). PMH, SH • UC with history of toxic megacolon (4 years prior) with a total colectomy • History of a prior episode of respiratory failure a year earlier thought possibly medication induced (ustekinumab, Stelara®) which she was taking for her UC. She was treated with steroids at that time with good response. • Pyoderma gangrenosum of both ankles (attributed to UC). • Anemia of chronic disease. • She is a lifelong non-smoker. • No exposures to toxic dusts, birds, down, humidifiers, mold or other antigens associated with hypersensitivity pneumonitis. Physical Exam • Afebrile, Oxygen saturation 94% on 2 lpm supplemental oxygen. • Chest: crackles noted at left base. • CV regular rhythm, no murmur. Ext: scarring and erythema on …

September 2024 Pulmonary Case of the Month: An Ounce of Prevention Cased a Pound of Disease

No abstract available. Manuscript truncated after 150 words. History of Present Illness: A 55-year-old woman is self-referred for dizziness, fatigue, and difficulty concentrating. She was well until 2 months prior to this visit. She says she feels like she is in a “fog”. She also complains of a “tight chest”. PMH, SH, and FH: She has a past medical history of hypertension and presently takes metoprolol. She has had a tubal ligation and a breast lumpectomy in the past. There is a questionable history of a positive Cardiolite nuclear stress test. She is divorced and lives alone in a small town in Iowa. She does not smoke, drink to excess or used illicit drugs. She has worked assembling bird houses for 20 years. She attributes her problems to a workplace exposure because she seems worse when opens the large shipping containers with the birdhouse parts. Although she worked 20 years previously without problems, her symptoms began 2 months …

Clinical Profile of Leg Symptoms and Reflux in the Legs From Varicose Veins Disease Reported at a Tertiary Healthcare Institute in Jharkhand, India.

Background Varicose veins, affecting 8-10% of the population, are categorized as primary or secondary, depending on the etiology. The aim of thestudy is to assess the clinical profile of leg symptoms and reflux in the legs of varicose veins disease among patients reported in a tertiary hospital. Patients and methods An institution-based cross-sectional exploratory study comprising 56 patients with reflux in legs of varicose veins disease selected through purposive sampling, conducted in the OPD (outpatient department), general surgery, AIIMS (All India Institute of Medical Sciences) Deoghar. The standardized study instrument includes the Aberdeen varicose veins questionnaire, and patients' symptoms and concerns questionnaire, followed by a brief clinical examination based on CEAP (clinical, etiological, anatomical, and pathophysiological)classification and VCSS (venous clinical severity score) for C5/6 and color-flow duplex imaging of both lower limbs. Descriptive and inferential statistics were used for data analysis using IBM SPSS Statistics for Windows, Version 23 (IBM Corp.,Armonk, NY). Results Bilateral presentation of the disease had been seen in 57.1% (n=32) participants, and the common history of present illness reported by participants included swelling along the veins (n=55, 98.2%), pain (n=51, 91.1%), and discoloration (n=33, 58.9%). The clinical grading revealed that most participants, i.e., 87.5% (n=49) had C2 and 75% (n=42) had C3 disease. The majority of participants 96.4% (n=54) suffered from primary varicose veins. Furthermore, all subjects exhibited superficial vein involvement, alongwith one individual having deep vein involvement and a few participants (n=35, 62.5%)having perforators. With this, the majority of participants (n=55, 98.2%) showed reflux pathology. Conclusion Varicose veins typically afflict men in their 40s and 50s who work in positions of extended standing. Limited awareness in the Santhal Pargana division, Jharkhand state, India may result in poor healthcare outcomes. Improving public awareness may help lessen disease-related consequences.

Enhancing medical students' documentation skills: the impact of an assessment and feedback program.

We not only developed a clinical practice program for the assessment and feedback vis-à-vis medical students' medical records but also evaluated the effectiveness of this program via a self-assessment of medical students' competence in writing medical records pre- and post-program. In 2022, 74 third-year medical students were divided into four groups and participated in a 2-week program. The students' medical records were graded on a scale ranging from 1 to 3 daily, and the mean scores for 2 weeks were compared. Pre- and post-program, the students' self-assessment survey was conducted. The mean scores increased from 1.30 in the first week to 2.14 in the second week. The mean score of self-assessment showed significant improvements, increasing from 2.43 to 4.00 for medical record, 2.64 to 4.08 for write present illness, 2.08 to 3.89 for initial orders, 2.35 to 4.34 for signature, and 2.38 to 3.97 for consent (all p<0.001). We found that providing students with real-time assessment and feedback on their medical records increased their skills and confidence in medical records writing.

Disruption and Improvisation: Experiences of Loneliness for People With Chronic Illness.

Chronic illness can disrupt many aspects of life, including identity, social relationships, and anticipated life trajectories. Despite significant scholarship on chronic illness, we know less about the ways in which chronic illness impacts feelings of loneliness and how people with chronic illness deal with loneliness. Drawing on concepts of biographical disruption and liminality and data from walking and photo-elicitation interviews with 14 people, we aimed to explore how people with chronic illness experience loneliness in their everyday lives. Tracing how past and present illness experiences are implicated in the lived experience of loneliness and the strategies people use to manage loneliness, our findings illustrated that being caught in a liminal state where participants struggled to maintain and adapt to a new normality in life with chronic illness was a central thread woven throughout their experience of loneliness. Although participants drew on their personal agency and adopted strategies to account for, manage, and limit disruptions from chronic illness and loneliness, they found that their strategies were not completely effective or satisfactory. Chronic illness and loneliness continue to be largely considered as an individual's problem, limiting opportunities for people with chronic illness who experience loneliness to seek support and social connection. Our research highlighted that chronic illness and loneliness need to be acknowledged as both a personal and collective problem, with multi-level responses that involve individuals, communities, and society.

Madrasa student’s health-related quality of life and its associated factors: a cross-sectional study from Bangladesh

The evidence clearly shows that education greatly impacts people’s well-being. Bangladesh has two main education systems—general and traditional religious schooling. The current study aimed to measure the quality of life of madrasa students and find out the factors influencing it. This was a cross-sectional study on a group of madrasa students in the Mirpur area of Dhaka, Bangladesh. Data were collected using two-stage stratified random sampling between April and May 2022. The final sample size was 373. The health-related quality of life (HRQoL) was calculated using the KIDSCREEN-10 index, and the median split was used to categorize the score into ‘good’ and ‘poor’ categories. A p < 0.05 was considered statistically significant for all statistical tests. Among the participants, most (56%) reported having a good HRQoL. The median age (IQR) of the participants was 10.0 (8.0–12.0) years. Most of the participants were male (91%) and were not orphans (95%). The current study also found that a higher feeling of safety (AOR 3.7; 95% CI 1.3–10.4; p = 0.016) increased the odds of having good HRQoL. However, having a present illness decreased the odds (AOR 0.6; 95% CI 0.4–0.9; p = 0.10) of having a good HRQoL. The key results show that the majority reported a good HRQoL. Promoting students’ physical, mental, and social well-being through health education, anti-bullying initiatives, regular school health screening, and institutional & community involvement can help to improve the overall HRQoL of madrasa students.

Inpatient diabetes management.

Diabetes mellitus is currently approaching epidemic proportions and disproportionately affects patients in the hospital setting. In the United States, individuals living with diabetes represent over 17 million emergency department visits and 8 million admissions annually. The management of these patients in the hospital setting is complex and differs considerably from the outpatient setting. All patients with hyperglycemia should be screened for diabetes, as in-hospital hyperglycemia portends a greater risk for morbidity, mortality, admission to an intensive care unit, and increased hospital length of stay. However, the definition of hyperglycemia, glycemic targets, and strategies to manage hyperglycemia in the inpatient setting can vary greatly depending on the population considered. Moreover, the presenting illness, changing nutritional status, and concurrent hospital medications often necessitate thoughtful consideration to adjustments of home diabetes regimens and/or the initiation of new insulin doses. This review article will examine core concepts and emerging new literature surrounding inpatient diabetes management, including glycemic targets, insulin dosing strategies, noninsulin medications, new diabetes technologies, inpatient diabetes management teams, and discharge planning strategies, to optimize patient safety and satisfaction, clinical outcomes, and even hospital financial health.

A History of Present Illness.

A History of Present Illness.

Value of Transabdominal Sonographic Rectal Diameter in Children with Functional Constipation

Abstract Background Constipation is a common problem worldwide. Since rectal digital examination and abdominal radiography have both limitations, ultrasound is considered an alternative technique, thus the aim of the current study is measurement of rectal diameter among a group of children with functional constipation (FC) in comparison with a healthy control group to determine the diagnostic efficacy of dilated rectal diameter for diagnosis of constipation. Patients and Methods A case control study that was conducted on children aged between 2 and 10 years; 50 were cases with functional constipation who were recruited from gastroenterology department and an equal number of age and sex matched apparently normal and healthy children were included as a control. FC was diagnosed according to the ROME IV criteria. Pelviabdominal ultrasound was done to all cases and controls to assess the rectal transverse diameter after taking detailed history regarding personal history, symptoms and history of present illness, past history and family history. Results Rectal diameter was measured in cases initially on presentation where 80% of the cases had enlarged rectal diameter, and 20% of cases had normal rectal diameter, ranging from 1.6 cm to 4.7 cm with a median of 3.55, while only 8% of controls has enlarged rectal transverse diameter and others were normal (P value &amp;lt;0.001). Conclusion based on our results, it can be concluded that rectal diameter is. significantly enlarged in most cases with constipation.

Ethnicity and outcomes for patients with gastrointestinal disorders attending an emergency department serving a multi-ethnic population

BackgroundEthnic inequalities in acute health acute care are not well researched. We examined how attendee ethnicity influenced outcomes of emergency care in unselected patients presenting with a gastrointestinal (GI) disorder.MethodsA descriptive, retrospective cohort analysis of anonymised patient level data for University Hospitals of Leicester emergency department attendees, from 1 January 2018 to 31 December 2021, receiving a diagnosis of a GI disorder was performed. The primary exposure of interest was self-reported ethnicity, and the two outcomes studied were admission to hospital and whether patients underwent clinical investigations. Confounding variables including sex and age, deprivation index and illness acuity were adjusted for in the analysis. Chi-squared and Kruskal–Wallis tests were used to examine ethnic differences across outcome measures and covariates. Multivariable logistic regression was used to examine associations between ethnicity and outcome measures.ResultsOf 34,337 individuals, median age 43 years, identified as attending the ED with a GI disorder, 68.6% were White. Minority ethnic patients were significantly younger than White patients. Multiple emergency department attendance rates were similar for all ethnicities (overall 18.3%). White patients had the highest median number of investigations (6, IQR 3–7), whereas those from mixed ethnic groups had the lowest (2, IQR 0–6). After adjustment for age, sex, year of attendance, index of multiple deprivation and illness acuity, all ethnic minority groups remained significantly less likely to be investigated for their presenting illness compared to White patients (Asian: aOR 0.80, 95% CI 0.74–0.87; Black: 0.67, 95% CI 0.58–0.79; mixed: 0.71, 95% CI 0.59–0.86; other: 0.79, 95% CI 0.67–0.93; p < 0.0001 for all). Similarly, after adjustment, minority ethnic attendees were also significantly less likely to be admitted to hospital (Asian: aOR 0.63, 95% CI 0.60–0.67; Black: 0.60, 95% CI 0.54–0.68; mixed: 0.60, 95% CI 0.51–0.71; other: 0.61, 95% CI 0.54–0.69; p < 0.0001 for all).ConclusionsSignificant differences in usage patterns and disparities in acute care outcomes for patients of different ethnicities with GI disorders were observed in this study. These differences persisted after adjustment both for confounders and for measures of deprivation and illness acuity and indicate that minority ethnic individuals are less likely to be investigated or admitted to hospital than White patients.

July 2024 Critical Care Case of the Month: Community-Acquired Meningitis

No abstract available. Article truncated after 150 words. History of Present Illness A 62-year-old woman was brought to our emergency department at 0300 with a possible stroke. She was last known well at 2230 the previous evening, when she complained of severe headache and took some acetaminophen before going to bed. Her daughter (who provided all history) noted that the patient awoke about midnight, vomited and took some naproxen. The daughter next heard the patient awake at 0230, and found her back in the bathroom vomiting again, slow to respond, “mumbling” and confused. The daughter was able to get the patient into their car with some difficulty and drove her to the ER. Past Medical History, Social History, Family History Only minimal past medical history was elicited. There was no known trauma, no fever and no recent illnesses. The patient took no prescription medications. She did not have any history of neurological disease and no known history of …

Natural Language Processing-Driven Artificial Intelligence Models for the Diagnosis of Lumbar Disc Herniation with L5 and S1 Radiculopathy: A Preliminary Evaluation

To develop and validate natural language processing-driven artificial intelligence (AI) models for the diagnosis of lumbar disc herniation (LDH) with L5 and S1 radiculopathy using electronic health records (EHRs). EHRs of patients undergoing single-level percutaneous endoscopic lumbar discectomy for the treatment of LDH at the L4/5 or L5/S1 level between June 1, 2013, and December 31, 2021, were collected. The primary outcome was LDH with L5 and S1 radiculopathy, which was defined as nerve root compression recorded in the operative notes. Datasets were created using the history of present illness text and positive symptom text with radiculopathy (L5 or S1), respectively. The datasets were randomly split into a training set and a testing set in a 7:3 ratio. Two machine learning models, the long short-term memory network and Extreme Gradient Boosting, were developed using the training set. Performance evaluation of the models on the testing set was done using measures such as the receiver operating characteristic curve, area under the curve, accuracy, recall, F1-score, and precision. The study included a total of 1681 patients, with 590 patients having L5 radiculopathy and 1091 patients having S1 radiculopathy. Among the 4 models developed, the long short-term memory model based on positive symptom text showed the best discrimination in the testing set, with precision (0.9054), recall (0.9405), accuracy (0.8950), F1-score (0.9226), and area under the curve (0.9485). This study provides preliminary validation of the concept that natural language processing-driven AI models can be used for the diagnosis of lumbar disease using EHRs. This study could pave the way for future research that may develop more comprehensive and clinically impactful AI-driven diagnostic systems.

June 2024 Pulmonary Case of the Month: A Pneumo-Colic Association

No abstract available. Article truncated after 150 words. History of Present Illness: The patient is a 57-year-old woman who presented to the emergency department with increasing cough and shortness of breath over several days. She has a history of ulcerative colitis complicated by toxic megacolon with subsequent colectomy. Past Medical History, Family History and Social History • Ulcerative colitis with history of toxic megacolon (4 years prior), s/p total colectomy • History of recent respiratory failure thought secondary to ustekinumab (Stelara). The respiratory failure responded well to steroid therapy. • She has a history of latent Tb treated with rifampin • Anxiety Medications • Clonazepam 1.0 mg daily at bedtime • Gabapentin 300 mg TID • Pantoprazole 40 mg BID • Prednisone 5 mg daily Physical Examination • Mild-moderate respiratory distress • Afebrile. SpO2 87% on room air. Oxygen saturation 94% on 2 lpm supplemental oxygen. • Chest: crackles noted at left base • Cardiovascular: regular rhythm, no murmur • Extremities: scarring and erythema on both ankles consistent with resolving pyoderma …

Evaluation of Pain Catastrophizing Scale for surgical referral to pain psychology in patients undergoing spinal surgery

BackgroundChronic pain is an issue that affects over 100 million Americans daily. Acceptance and Commitment Therapy (ACT) has been found to be beneficial for patients with chronic pain by focusing provider efforts on teaching coping mechanisms for pain instead of eliminating the pain entirely. Current studies demonstrate that ACT significantly improves post-operative chronic pain scores and outcomes. MethodsThe 200 patients chosen via random generator were collected and presented to (institution) orthopedic spine surgeons along with additional information such as the patients’ history of present illness, Visual Analog Scale (VAS) scores, PROMIS-CAT Pain Interference scores, and status of opiate usage. Surgeons were blinded to the PCS cutoff scores. The (institution) orthopedic spine surgeons then identified which patients they would indicate for ACT and their reasoning. Pre-determined PCS score cut-offs were separately used to determine if a patient was indicated for ACT. ResultsThe effectiveness of this screening tool was based on the frequency at which the surgeons and PCS scores were complimentary. A department epidemiologist assisted in the analysis of the data with the use of a ROC curve. ROC Curve demonstrated an area under the curve of 0.7784 with a Sensitivity of 0.68 and a Specificity of 0.79. The cut point according to Youden's index is 35. The data showed that the PCS is moderately accurate in its ability to distinguish coinciding patients that the [institution] orthopedic spine surgeons referred for ACT. The adjusted cut-point indicates that patients above a PCS of 35 would be referred to ACT by the orthopedic spine surgeons while those below a PCS score of 35 would not be referred. ConclusionsUsing the PCS, a referral with the department pain psychologist would occur by [institution] orthopedic spinal surgeons for patients that are deemed at-risk with a score of at least 35. The goal following this study is to perform future investigations regarding PCS and ACT with patients regarding chronic opioid use and postoperative outcomes. Patients who would be referred for help with chronic pain would be compared to PCS-referred patients and non-referred patients. Pre-operative ACT would be compared to patient outcomes post-operatively. The future aim is to use the cut-offs established in this study for experimental design to evaluate if PCS-referred patients have better pain management post-operatively as compared to the control and previously referred patients. Level of EvidenceLevel III diagnostic study.

ChatGPT4 Outperforms Endoscopists for Determination of Postcolonoscopy Rescreening and Surveillance Recommendations

Large language models including Chat Generative Pretrained Transformers version 4 (ChatGPT4) improve access to artificial intelligence, but their impact on the clinical practice of gastroenterology is undefined. This study compared the accuracy, concordance, and reliability of ChatGPT4 colonoscopy recommendations for colorectal cancer rescreening and surveillance with contemporary guidelines and real-world gastroenterology practice. History of present illness, colonoscopy data, and pathology reports from patients undergoing procedures at 2 large academic centers were entered into ChatGPT4 and it was queried for the next recommended colonoscopy follow-up interval. Using the McNemar test and inter-rater reliability, we compared the recommendations made by ChatGPT4 with the actual surveillance interval provided in the endoscopist's procedure report (gastroenterology practice) and the appropriate US Multisociety Task Force (USMSTF) guidance. The latter was generated for each case by an expert panel using the clinical information and guideline documents as reference. Text input of de-identified data into ChatGPT4 from 505 consecutive patients undergoing colonoscopy between January 1 and April 30, 2023, elicited a successful follow-up recommendation in 99.2% of the queries. ChatGPT4 recommendations were in closer agreement with the USMSTF Panel (85.7%) than gastroenterology practice recommendations with the USMSTF Panel (75.4%) (P < .001). Of the 14.3% discordant recommendations between ChatGPT4 and the USMSTF Panel, recommendations were for later screening in 26 (5.1%) and for earlier screening in 44 (8.7%) cases. The inter-rater reliability was good for ChatGPT4 vs USMSTF Panel (Fleiss κ, 0.786; 95% CI, 0.734-0.838; P < .001). Initial real-world results suggest that ChatGPT4 can define routine colonoscopy screening intervals accurately based on verbatim input of clinical data. Large language models have potential for clinical applications, but further training is needed for broad use.

Improving the Prognostic Evaluation Precision of Hospital Outcomes for Heart Failure Using Admission Notes and Clinical Tabular Data: Multimodal Deep Learning Model.

Clinical notes contain contextualized information beyond structured data related to patients' past and current health status. This study aimed to design a multimodal deep learning approach to improve the evaluation precision of hospital outcomes for heart failure (HF) using admission clinical notes and easily collected tabular data. Data for the development and validation of the multimodal model were retrospectively derived from 3 open-access US databases, including the Medical Information Mart for Intensive Care III v1.4 (MIMIC-III) and MIMIC-IV v1.0, collected from a teaching hospital from 2001 to 2019, and the eICU Collaborative Research Database v1.2, collected from 208 hospitals from 2014 to 2015. The study cohorts consisted of all patients with critical HF. The clinical notes, including chief complaint, history of present illness, physical examination, medical history, and admission medication, as well as clinical variables recorded in electronic health records, were analyzed. We developed a deep learning mortality prediction model for in-hospital patients, which underwent complete internal, prospective, and external evaluation. The Integrated Gradients and SHapley Additive exPlanations (SHAP) methods were used to analyze the importance of risk factors. The study included 9989 (16.4%) patients in the development set, 2497 (14.1%) patients in the internal validation set, 1896 (18.3%) in the prospective validation set, and 7432 (15%) patients in the external validation set. The area under the receiver operating characteristic curve of the models was 0.838 (95% CI 0.827-0.851), 0.849 (95% CI 0.841-0.856), and 0.767 (95% CI 0.762-0.772), for the internal, prospective, and external validation sets, respectively. The area under the receiver operating characteristic curve of the multimodal model outperformed that of the unimodal models in all test sets, and tabular data contributed to higher discrimination. The medical history and physical examination were more useful than other factors in early assessments. The multimodal deep learning model for combining admission notes and clinical tabular data showed promising efficacy as a potentially novel method in evaluating the risk of mortality in patients with HF, providing more accurate and timely decision support.

Regional Inequalities in Oral Frailty and Social Capital.

Oral frailty leads to poor nutritional status, which, in turn, leads to frailty. This cross-sectional study aimed to determine regional differences in the prevalence of oral frailty and to identify factors associated with oral frailty using 3-level multilevel models. This study comprised 165,164 participants aged ≥65 y without long-term care requirements in the Japan Gerontological Evaluation Study. The dependent variable was oral frailty, which was calculated based on age, number of teeth, difficulty in eating tough foods, and choking. The individual-level independent variables included sociodemographics, present illness, social participation, frequency of meeting friends, and social capital. The local district-level independent variable was social capital (n = 1,008) derived from exploratory factor analyses. The municipality-level independent variable was population density (n = 62). Three-level multilevel Poisson regression analysis was performed to calculate the prevalence ratios (PRs). The prevalence of oral frailty in municipalities ranged from 39.9% to 77.6%. Regarding district-level factors, higher civic participation was significantly associated with a lower probability of oral frailty. At the municipality level, the PR of the rural-agricultural area was 1.17 (95% confidence interval, 1.11-1.23) (reference: metropolitan). These results highlight the usefulness of oral frailty prevention measures in encouraging social participation in rural areas. The results of the present study showed regional differences in oral frailty. In particular, rural-agricultural areas show higher prevalence rates of oral frailty than those in metropolitan cities. Promoting measures of social participation among older adults may help prevent oral frailty in rural areas.