National Study Research Articles

44 Spotting the clotting: a 3-year national surveillance study of paediatric pulmonary thromboembolism

Abstract Background Pulmonary thromboembolism (PE) is a rare event in the paediatric population but can be acutely life-threatening and result in chronic complications. Awareness of contemporary patterns of clinical presentation, diagnostic modalities, and management may aid clinicians in ensuring that patients are promptly identified and treated. Objectives To describe the risk factors, symptoms, diagnostic modalities, therapeutic interventions, and short-term outcomes in paediatric patients (neonate up to 18 years) with PE through national surveillance. Design/Methods Between January 2020 and December 2022, monthly surveillance was conducted with over 2,800 paediatricians and sub-specialists through the Canadian Paediatric Surveillance Program. Voluntary reporting of cases meeting a standardized definition of PE was followed up with a detailed questionnaire. Results 58 confirmed cases were reported; 33 (57%) were females age 15 to 18 years. Detailed information was available for 31 (53%) of 58 cases. At least 1 risk factor was identified in 28 (90%) cases and 12 (39%) patients had 2 or more risk factors. The most common risk factors were oral contraceptive use (n=10 of 31; 32%) and obesity (n=9 of 31; 29%). Presentation was symptomatic in 28 (90%) cases; 24 (77%) patients presented with 2 or more symptoms. The most common symptoms were chest pain (n=18; 58%), dyspnea (n=13; 42%) and tachycardia (n=13; 42%). The most common diagnostic modality utilized was computed tomography pulmonary angiography (n=25; 81%). Initiation of systemic anticoagulation was reported for 24 (77%) of 31 cases; thrombolysis and surgical interventions were uncommon (< 5 cases). Treatment complications were common (n=8; 29%). Mortality was reported, but in fewer than 5 cases. Conclusion PE in children often presents with non-specific symptoms, but usually occurs in patients with known risk factors. Clinicians should maintain a high index of suspicion in symptomatic patients, particularly those with risk factors and in cases when other diagnoses that may explain symptoms have been excluded. Anticoagulation is the mainstay of treatment; complications can occur. Prompt recognition and management presumably reduce morbidity and mortality, but this cannot be inferred from our data.

42 Clinical features and severity of COVID-19 with respiratory virus coinfections versus SARS-CoV-2 monoinfection in hospitalized children: A Canadian national surveillance study

Abstract Background The co-circulation of SARS-CoV-2 alongside other respiratory viruses has led to the risk of coinfections, potentially intensifying the severity of cases, especially in children. Objectives This study examined the epidemiology, clinical characteristics, and outcomes of SARS-CoV-2 respiratory virus coinfections in comparison to SARS-CoV-2 monoinfections in hospitalized children. Design/Methods A nationwide surveillance study was conducted to assess paediatric COVID-19-related hospitalizations across Canada from April 2020 to May 2022. Data were captured through two datasets covering ~90% of all Canadian tertiary-care paediatric beds: The Canadian Paediatric Surveillance Program and the Canadian Immunization Monitoring Program, ACTive. Coinfections were defined as the simultaneous detection of SARS-CoV-2 and ≥1 other respiratory virus. Severe infection was defined as intensive care, ventilatory, or hemodynamic support needs, organ systems complications, or death. Variables and outcomes were summarized and compared, and risk ratios were computed using Poisson regression, adjusting for age, gender, comorbid conditions, SARS-CoV-2 lineage, and vaccination status. Results Out of 1501 COVID-19-related hospitalizations, 163 (10.9%) had documented coinfections with 44/163 [27%] involving SARS-COV-2 plus ≥2 other respiratory viruses. The majority of SARS-CoV-2 monoinfections (1176/1501, 87.9%) and coinfections (139/163, 85.3%) belonged to the Omicron era (Figure A). RSV (66/163, 40.5%) and Enterovirus/rhinovirus (61/163, 37.4%) coinfections were the most common. Coinfection cases were significantly younger than monoinfection cases (median age 1.2 [IQR:0.3-3.3] vs 1.6 [IQR:0.3-7.0] years, p=0.04). Overall, severe disease was more common among cases with any coinfection (38.0%) than SARS-CoV-2 monoinfection (25.7%; adjusted risk ratio 1.45, 95% confidence interval 1.17-1.80) (Figure B). In particular, we observed that severe outcomes were significantly higher in SARS-CoV-2 coinfections compared to monoinfections during the Omicron era (Figure C-D). Overall, 26/61 (42.6%) Enterovirus/Rhinovirus and 20/66 (30.3%) RSV coinfections were associated with severe outcomes. Conclusion Children with documented coinfections had more severe respiratory disease compared to SARS-COV-2 monoinfections. However, children with severe COVID-19 may have been more likely tested for multiple viruses, leading to a risk of underestimation of coinfections among children with milder disease. Further work is needed to assess how different virus coinfections may affect children and which, if any, may be a predominant driver of disease severity. 1Severe disease was defined as intensive care, ventilatory, or hemodynamic support requirements, organ system complications, or death. 2Lineage was first assigned based on available genetic sequencing data. If missing, lineage was imputed based on the dominant circulating lineage at the provincial level according to the GISAID database.

The Socialization of Meritocracy and Market Justice Preferences at School

Previous research has shown that schools often justify student performance differences using meritocratic ideals. One potential consequence of such ideals is the legitimization of outcome inequalities across various spheres, including those traditionally associated with equality and redistribution. In this study, we argue that the promotion of meritocratic values during school age can shape students’ beliefs about meritocracy and influence their views on market-based access to health, pensions, and education. Using data from the 2017 National Study of Civic Education in Chile, which includes 5047 eighth-grade students from 231 schools, we estimated a series of multilevel models (lme4 library, R version 4.1.3) to test our hypotheses. Our findings show that a significant proportion of Chilean students agree with market justice principles—more so than adults. Most students endorse meritocratic views, particularly the notion that effort should be rewarded, which strongly correlates with market justice preferences: students who believe in meritocracy are more likely to justify inequalities based on financial capacity. At the school level, market justice preferences are higher in high-status schools but lower in schools with higher academic achievement. Furthermore, the conditional influence of meritocratic beliefs diminishes in schools with higher socioeconomic status and performance levels. These results suggest that the association between meritocratic beliefs and market justice preferences is already established at school age and is shaped by the school environment.

Composite dietary antioxidant index and abdominal aortic calcification: a national cross-sectional study

PurposeThe Composite Dietary Antioxidant Index (CDAI) is a novel, inclusive measure for evaluating the antioxidant potential of diets. We aim to explore the link between the CDAI and abdominal aortic calcification (AAC) in U.S. adults aged ≥ 40 years.MethodsThis cross-sectional study collected dietary and AAC data for individuals aged ≥ 40 years from the 2013–2014 National Health and Nutrition Examination Survey (NHANES) database. The CDAI was calculated using six dietary antioxidants. AAC was evaluated using a semi-quantitative scoring system known as AAC-24, with an AAC score greater than 6 as severe AAC (SAAC). To examine the association between CDAI and AAC, including SAAC, liner/logistic regression analyses and smooth curve fitting were applied.ResultsA total of 2,640 participants were included in this study, and significant decreases in AAC score and SAAC prevalence were observed with ascending CDAI levels (P < 0.01). After adjusting for confounding factors, a clear link was established between the CDAI and both AAC score (β = -0.083, 95% CI -0.144–0.022, P = 0.008) and SAAC (OR = 0.883, 95% CI 0.806–0.968, P = 0.008), respectively. Further smooth curve fitting indicated a negative correlation between CDAI and both AAC score and SAAC.ConclusionsDietary antioxidant consumption, as quantified by the CDAI, shows an inverse relationship with AAC risk. Additional longitudinal and intervention studies are essential.

Promoting sustainability literacy for students in Thai higher education institution: a case of Siam University

PurposeThe objectives of this study were (1) to explore and analyze sustainability literacy of undergraduate students and (2) to propose guidelines for promoting sustainability literacy of the undergraduate students at Siam University, Bangkok, Thailand.Design/methodology/approachA 5-point rating scale survey questionnaire was used to collect data from 235 students registered in General Education courses in Semester 2 of academic year 2022. The analyzed data was presented to a focus group discussion, conducted with 19 internal and external stakeholders, as a basis to propose guidelines for promoting sustainability literacy.FindingsThe students perceived that they had better knowledge about sustainable development and sustainable development goals (SDGs) and that their knowledge about and degree of participation in SDGs-related activities were at high level. Intrapersonal competence was rated as their highest sustainability competence, followed by futures-thinking, and systems-thinking. The focus-group suggested that competency-based GE curriculum should be used as a platform to enhance sustainability literacy. Guidelines concerning learning outcomes, learning content, learning culture, learning with technology, and learning assessment were then proposed.Research limitations/implicationsThe study’s methodological limitations include the use of purposive sample case of the Siam University and self-perceiving assessment survey instrument for the data collection that provide sufficient insights on the present state and problems concerning sustainability literacy of university students.Practical implicationsSustainability is one of the national pillars in Thailand 20 years strategy (2018–2037). Hence, the government encourages all educational institutions, including universities to transform themselves toward this goal. Siam University has used education program as a vehicle to meet this aspiration. Lesson learnt from the study will not only benefit the university per se but will be valuable for practices in other universities. In addition, findings and implications from the study will help accelerate the transformation of Thai higher education institutions toward sustainable universities.Social implicationsSustainability has been promoted in education and social context. Siam University is recognized as a leading university in promoting campus and community sustainability through our “living learning lab” approach. We have used social living labs for teaching and learning activities for years. Partnerships among academia, private and public sectors, as well as community members will benefit from this research.Originality/valueThe study explores the scholarly topic of significant social importance and implications in the Thai context. The present study on sustainability literacy opens a path for further research and cross-institutional and national comparative studies on the issue.

Polymer Everolimus-Eluting Stent as Bailout Stenting for Below-the-Knee Artery Repair in Patients with Critical Limb-Threatening Ischemia: A Real-World National Registry.

Percutaneous old balloon angioplasty is still the preferred treatment for the treatment of below-the-knee (BTK) arteries in chronic limb-threatening ischemia (CLTI). In the case of a suboptimal angioplasty result, a bailout stenting is required. So far, few data are available to assess the outcomes of bailout stenting after BTK angioplasty. This study aims to investigate the 1-year efficacy and safety after implantation of a polymer everolimus-eluting stent (PEES) as bailout stenting for BTK repair in patients with CLTI in a real-world setting. This was a national multicenter prospective observational study. Patients with CLTI (Rutherford 4 to 6) BTK lesions (including P3) and requiring a bailout PEES due to dissection, thrombosis, or residual stenosis ≥30% after angioplasty were included. The freedom of a major adverse limb event at 12 months of the target limb was the primary endpoint. XIENCE assessed 106 limbs (CLTI, 96.2%; chronic total occlusion, 2.8%) in 106 patients (mean age 77.1 years; males, 71.7%; diabetes mellitus, 66.9%; chronic kidney failure, 36.8%) with CLTI undergoing PEES stenting as a bailout for BTK lesions. Bailout stenting was required after 75.5% and 26.4% of residual stenosis and dissection, respectively. The mean diameter and length of the PEES were 3 mm and 3.4 ± 0.5 cm, respectively. At 1 year, the freedom of a major adverse limb event was 79.6% (95% CI, 71.5%-88.7%), the major amputation rate was 6.2% (95% CI, 1.3%-11%), and the target revascularization rate was 14.9% (95% CI, 6.5%-22.5%). In CLTI patients with BTK lesions, PEES stenting showed safety and efficacy as bailout stenting for BTK arterial lesions. This confirms the need for PEES stenting in a real-world practice. The XIENCE study introduces the PEES as an effective bailout stenting option for patients with CLTI undergoing BTK revascularization, particularly for lesions under 4 cm. The study focuses on real-world cases where POBA alone is insufficient, demonstrating that PEES significantly improves outcomes by enhancing limb salvage and reducing the need for major amputations. For clinicians, this innovation offers a precise, size-adaptable solution, especially in cases where bailout stenting is required for short, focal lesions, improving both clinical and procedural results.

Reducing research participant disparities through use of a co-developed video intervention: A cohort nested pre-post study

Background Evidence on effective approaches for the recruitment of diverse populations remains limited. This study aimed to assess whether a co-developed study information video would improve participant ethnic diversity within a paediatric study cohort. Methods Pre-post study nested within the Uveitis in childhood prospective national inception cohort study, UNICORNS. Intervention of interest: study information and recruitment video with format and content co-developed with a patient expert group. Outcome of interest: the proportion of families from ethnic minority groups, and of families with primary caregivers without a higher educational degree who were recruited to the study, and the proportion of families who engaged in study activities (returned patient reported outcome metrics following recruitment) pre and post intervention implementation. Results During the study period, 191 children were recruited to UNICORNS (110 pre-intervention era, 81 post-intervention era). A larger proportion of families recruited in the post-intervention era were of an ethnic minority background (36% versus 20%, Fisher’s exact test p=0.02). A larger proportion of families returned self-descriptions of their sociodemographic background (100% versus 87%, Fisher’s exact test p=0.0003) and a larger proportion returned study specific patient reported outcome measures (70% versus 55%, Fisher’s exact test p=0.003). Conclusion Co-created digital research information resources can be an effective tool for ensuring better representation in research studies and may also support participant engagement overall. Our reported methods and findings should support other researchers in developing patient-centred and patient co-developed strategies and tools for the purposes of equitable access to medical research.

Suicide in people prescribed opioid-agonist therapy in Scotland, United Kingdom, 2011-2020: A national retrospective cohort study.

Opioid dependence is associated with an increased risk of suicide. Drug-related mortality among people with opioid dependence in Scotland has more than tripled since 2010; less is known about changes in suicide risk. We aimed to determine if opioid agonist therapy (OAT) in Scotland is protective against suicide and to measure trends in suicide rates in those with opioid dependence over time. Retrospective cohort study. Scotland, UK. 46 453 individuals in Scotland who received at least one prescription for OAT between 2011 and 2020 with over 304 000 person-years (pys) of follow-up. We calculated standardised mortality ratios (SMR) using the age- and sex-specific suicide rates in Scotland for years 2011-2020. We fitted multivariable competing-risk regression models to estimate suicide rates by OAT exposure and to estimate trends over time, adjusting for potential confounders. There were 575 deaths classed as suicide among the cohort and the overall suicide rate was 1.89 (95% confidence interval [CI] = 1.74-2.05) per 1000 pys. Age and sex SMR for suicide was 7.05 times (95% CI = 6.50-7.65) higher than in the general population. After adjustment, OAT was shown to be highly protective against suicide, with rates more than three times greater (adjusted hazard ratio: 3.07; 95% CI = 2.60-3.62) off OAT compared with on OAT. Suicide rates decreased over time, falling from 2.57 (95% CI = 2.19-3.02) per 1000 pys in 2011-12 to 1.48 (95% CI = 1.21-1.82) in 2019-20. People with opioid dependence in Scotland appear to have a greater risk of suicide than the general population. Treatment is protective, with rates of suicide lower among those on opioid agonist therapy. Suicide rates have decreased over time, during a period in which drug-related death rates in Scotland have risen to globally high levels.

Real-world effectiveness and safety of CT-P13, an infliximab biosimilar, for inflammatory bowel diseases: A prospective national observational cohort study (ReFLECT study)

BackgroundReFLECT was a French, prospective, multicenter, observational cohort study evaluating the effectiveness and safety of the infliximab (IFX) biosimilar CT-P13 in a real-world setting. Here, we describe the results for adults with inflammatory bowel disease (IBD). MethodsEligible patients with IBD were recruited and received intravenous CT-P13 induction and/or maintenance therapy; patients were either naive to IFX (IFX-naive) or previously treated with IFX originator or another IFX biosimilar (IFX-switched). The primary objective was CT-P13 persistence, which was measured as a time-dependent variable during a two-year follow-up period with four prespecified visits. Safety was assessed. ResultsThe adult IBD population comprised 530 patients with Crohn's disease (CD), including 327 categorized as IFX-naive, 188 as IFX-switched, 11 as other (i.e., previously received IFX but received another treatment before switching to CT-P13), and 4 with missing data; and 221 patients with ulcerative colitis (UC), including 152 categorized as IFX-naive, 59 as IFX-switched, 8 as other, and 2 with missing data. After two years of follow-up, the rates of CT-P13 persistence were 71.7 % (95 % CI: 66.7, 77.0) and 63.7 % (55.3, 73.3) in patients with CD and UC, respectively. CT-P13 persistence was greater for IFX-switched patients than for IFX-naive patients (CD: 83.7 % [95 % CI: 78.0, 89.9] vs 65.7 % [58.6, 73.7]; UC: 91.2 % [81.7, 100.0] vs 53.4 % [43.0, 66.2]). The main reason for CT-P13 discontinuation was loss of response (CD/UC) in both IFX-naive (14.7 %/21.7 %) and IFX-switched (7.4 %/5.1 %) groups. Among patients (CD and UC, respectively), 51.3 % and 45.2 % reported ≥1 adverse event (AE), and 13.2 % and 12.7 % reported serious AEs, respectively. ConclusionAfter two years of follow-up, the effectiveness of intravenous CT-P13 was maintained in >80 % of IFX-switched patients. CT-P13 induced effective therapeutic maintenance in IFX-naive patients. CT-P13 had an acceptable safety profile. Trial registrationClinicalTrials.gov identifier: NCT02925338

Cardiometabolic index and the risk of new-onset chronic diseases: results of a national prospective longitudinal study

BackgroundThe cardiometabolic index (CMI) has emerged as a novel marker for evaluating the distribution and dysfunction of visceral adipose tissue, yet its correlation with numerous diseases, particularly new-onset chronic conditions, remains underexplored. Therefore, we aim to explore the association of cardiometabolic index (CMI) and new-onset chronic diseases.MethodsThe analysis utilized data from the China Health and Retirement Longitudinal Study, with a baseline in 2011 and follow-ups biennially until 2020. Fourteen new-onset chronic diseases were diagnosed based on self-report, and separate cohorts were created for each disease. CMI was calculated as triglycerides/high-density lipoprotein cholesterol multiplied by the waist-to-height ratio. Cox proportional hazards models were used to assess the association between CMI and new-onset chronic diseases, while restricted cubic spline (RCS) models were employed to explore potential nonlinear effects. Additional and sensitivity analyses included Kaplan-Meier survival curves, subgroup analyses, multiple imputations, and exclude outcome events at the first follow-up.ResultsHigher levels of CMI were associated with an increased risk of new-onset hypertension (HR=1.05, 95% CI=1.04-1.06, P&amp;lt;0.001), diabetes (HR=1.08, 95% CI=1.06-1.09, P&amp;lt;0.001), dyslipidemia (HR=1.07, 95% CI=1.06-1.09, P&amp;lt;0.001), liver disease (HR=1.05, 95% CI=1.03-1.07, P&amp;lt;0.003), and stroke (HR=1.04, 95% CI=1.02-1.06, P&amp;lt;0.001), although the association with stroke was not significant after adjusting for confounders (HR=1.02, 95% CI=1.00-1.05, P=0.054). Participants in the highest quartile of CMI had a significantly higher risk of these diseases compared to those in the lowest quartile. RCS analyses showed a significant nonlinear relationship between CMI and the risk of these diseases above.ConclusionsCMI showed a significant positive association with the risk of new-onset chronic diseases such as hypertension, diabetes, dyslipidemia, and liver disease. Future applications of CMI hold promise as an effective marker for early identification of chronic disease risk.

Lynch syndrome diagnostic testing pathways in endometrial cancers: a nationwide English registry-based study

BackgroundFor female patients with Lynch syndrome (LS), endometrial cancer (EC) is often their first cancer diagnosis. A testing pathway of somatic tumour testing triage followed by germline mismatch repair (MMR)...

Use of Preferred Source of Contraception Among Users of the Pill, Patch, and Ring in the US

Individuals who use contraceptive pills, patches, and rings must frequently interact with the health care system for continued and consistent use. As options for obtaining these methods expand, better understanding contraceptive users' preferences for source of contraception can help facilitate access. To describe use of preferred source of contraception and to understand associations between prior reproductive health care experiences and preference for traditional in-person sources vs alternative sources. This was a cross-sectional nationally representative survey study fielded in the US in 2022 through NORC's population-based AmeriSpeak panel. Eligible panelists were assigned female sex at birth, aged 15 to 44 years, not infecund, and not personally using permanent contraception. Of the screened panelists, 3150 were eligible; 3059 completed the survey (97%). The analysis sample included 595 individuals who currently used a pill, patch, or ring contraceptive. Data were analyzed from January 25, 2023, to August 15, 2024. Primary outcomes were use of any preferred source and use of most preferred source when most recently obtaining contraception. Sources included in-person care, telehealth, pharmacist-prescribed, online service, and over the counter. A binary variable captured whether respondents most preferred traditional, in-person contraceptive care vs an alternative approach. Prior reproductive health care experiences included missing a pill, patch, or ring because they couldn't obtain it on-time and receipt of person-centered contraceptive counseling at most recent contraceptive visit. Sociodemographic characteristics and responses are presented as unweighted numbers with weighted prevalences. In this study, 581 of 595 unweighted respondents (weighted prevalence, 95.9%) of the analytic sample identified as female, 256 unweighted respondents (weighted prevalence, 64.4%) were ages 15 to 29 years, and 448 unweighted respondents (weighted prevalence, 73.8%) had most recently obtained their contraception in-person. Only 197 unweighted respondents (weighted prevalence, 35.6%) selected in-person care as their most preferred source. Additionally, 296 unweighted respondents (weighted prevalence, 49.7%) had most recently obtained their method through any preferred source, and 227 unweighted respondents (weighted prevalence, 39.8%) had obtained it through their most preferred source. In adjusted regression analyses, respondents who previously reported being unable to get their method on time (adjusted odds ratio [aOR], 2.57; 95% CI, 1.36-4.87) had higher odds of preferring an alternative source vs traditional in-person care. Those who recently received person-centered contraceptive counseling (aOR, 0.59; 95% CI, 0.35-0.98) had lower odds of preferring an alternative source. In this national study of individuals who used the pill, patch, and ring, most preferred alternative sources to obtain their contraception, and only half had most recently used a preferred source. These findings suggest that expansion of alternative contraceptive sources can better meet the needs of contraceptive users and support reproductive autonomy.

Transgender and gender-diverse identity in patients with eating disorders: A national cross-sectional study.

This national study aimed to estimate the prevalence of the transgender and gender-diverse identity and to assess the level of gender congruence, body dissatisfaction and quality of life among patients with eating disorders in Denmark. Patients with eating disorders were compared to a matched non-clinical comparison group. The survey included the Eating Disorder Examination Questionnaire and assessment of body dissatisfaction, gender congruence and quality of life. In total 568 patients with eating disorders and 538 individuals from the non-clinical comparison group were included. The prevalence of individuals identifying as transgender or gender-diverse was 4.50% (n=20) among patients with eating disorders, and 6.23% (n=23) in the non-clinical comparison group (p-value=0.276). The transgender and gender-diverse individuals with eating disorders showed no statistically significant differences in eating disorder symptomatology compared to the cisgender individuals with eating disorders; however, they reported significantly more body dissatisfaction, less gender congruence and lower quality of life. The prevalence of transgender and gender-diverse individuals did not differ between patients with eating disorders and the non-clinical comparison group; however, transgender and gender-diverse individuals with eating disorders may be characterised by pronounced body dissatisfaction and low quality of life.

Frailty and its association with readmissions in patients with rheumatoid arthritis: A national readmissions database study.

It remains unknown whether frailty status confers an increased risk of readmission in patients with rheumatoid arthritis (RA). From the 2018 Nationwide Readmissions Database (NRD), we identified adult patients (age ≥ 18years) admitted with a diagnosis of RA between January to June 2018. Utilizing validated Hospital Frailty Score, patients' frailty risk score was calculated at the time of index admission and categorized into frail (score ≥ 5) and non-frail (score < 5) groups. Our primary outcomes of interest were (1) 180- day readmission rate (2) inpatient mortality; secondary outcomes included prolonged length of stay, LOS (LOS ≥ 7days), and costs of hospitalization. Multivariable Cox proportional hazard analysis was performed to evaluate the independent effect of frailty adjusting for confounding variables. 133,187 patients met inclusion criteria, with mean age 67.7years, of whom 64,131 (48.1%) patients were categorized as frail. The rate of readmission was significantly higher in the frail (56.60%) compared to the non-frail group (30.61%). At index hospitalization, frail patients also had significantly higher inpatient mortality compared to non-frail patients (3.36% vs 0.39%, p < 0.005), longer LOS (26.24% vs 7.82%, p < 0.005). On multivariate analysis frailty was independently associated with a 9% increased risk of readmission (adjusted hazard ratio, 1.09; 95% confidence interval, 1.08 - 1.11). People with RA who are frail have higher rates of readmission than those who are not frail. These findings are crucial in identifying at-risk patients with RA and in discharge planning after hospitalization. Key Points • People with RA who are frail have higher rates of readmission than those who are not frail. • Frail RA patients are also at higher risk of hospitalization-related adverse outcomes, including inpatient mortality and longer hospital stay. • Sepsis is the most common cause for readmission identified in frail patients with RA. • These findings suggest that frailty may be a useful metric in identifying patients with RA at an increased risk of adverse health outcomes.

Maternal Fasting Plasma Glucose, Age and Body Mass Index as Prediction of Gestational Diabetes Mellitus in Iran

Background: Gestational diabetes mellitus (GDM) is a common complication of pregnancy that can lead to adverse outcomes. In this retrospective cohort study, maternal fasting blood sugar (FBS) in the second trimester of pregnancy, body mass index (BMI), and age were assessed as potential screening indicators of later GDM. Methods: The study population included information on 4007 Iranian pregnant women documented by the Integrated Health Record System (SIB) record system (2019-2020). Results: In the adjusted analysis, FBS maintained a significant relationship with GDM (P ≤0.001). In the simple ROC analysis, the AUC (SE) of FBS for the prediction of GDM was 0.905(0.09), and considering the cut-off point as 85.95, sensitivity (Se) and specificity (Sp) were equal to 0.81 and 0.71, respectively, but by stillbirth, abortion, prematurity, neonatal weight, height, and head circumference not obtained acceptable AUC (≥.60) for detection of FBS cut-off point. The cut-off point of FBS in the presence of maternal age (AUC&gt;0.6) and BMI (AUC&gt;0.6) by GDM was 83.75(Se= 86.4%, Sp= 80.0%). Conclusion: Based on the evidence presented, maternal weight and BMI are important in predicting hyperglycemia leading to GDM. It is necessary to conduct more precise national studies to standardize the FBS cut-off point by controlling age and BMI variables.

When bigger looks better: CLASS results in public Montessori preschool classrooms

The CLASS-PreK instrument is widely used to evaluate early childhood classrooms, but how classrooms using Montessori, the world's most common alternative education system, fare on CLASS is understudied. Because CLASS focuses largely on teacher-child interactions as the situs of learning, but in Montessori theory, child-environment interactions are considered more primary, Montessori classrooms may score systematically lower than conventional classrooms on CLASS. CLASS also collects format, content, and demographic information that could illuminate how Montessori classrooms compare to other classrooms. Here we used data from the first national study of public Montessori preschool to examine CLASS data in Montessori preschool classrooms as compared to a lottery-control-selected set of business-as-usual ones. Montessori classrooms (n = 54) had 50% more children on average, and significantly higher child:adult ratios (roughly 9 vs. 6) than a set of intentionally stratified control classrooms (n = 19 of 128), and CLASS scores did not differ across classroom types. Children in Montessori classrooms were observed in whole group activities during fewer cycles and in freely chosen activities during more cycles; also children were observed engaging with math content during more cycles in Montessori than in control classrooms. Counterintuitively, but consistent with Montessori theory, Montessori classrooms with larger class sizes (up to 26) had higher Emotional Support and Classroom Organization domain scores, and those with higher child:adult ratios (up to 13:1) trended towards higher Instructional Support domain scores.

Correlating Climate Conditions with Pseudomonas aeruginosa Prevalence in Diabetic Foot Infections within the United States

Abstract Background The 2023 ‘International Working Group on the Diabetic Foot/Infectious Disease Society of America Guidelines on the Diagnosis and Treatment of Diabetes-Related Foot Infections’ (DFI) provides recommendations for Pseudomonas coverage based on the climate region. Methods This was a retrospective national study of Veterans between 1/1/2010 – 3/23/2024 with diabetes mellitus and a culture below the malleolus wound. Prevalence of Pseudomonas was categorized based on climate zones according to the International Energy Conservation Code. Multi-variable logistic regression was used to determine odds ratios and 97.5% Confidence Intervals. Results The prevalence of Pseudomonas significantly varied between US climates. Pseudomonas was most prevalent within the Hot Humid climate, where it was isolated in 11.6% of DFI cultures. Pseudomonas was least prevalent within the Very Cold climate, where it was isolated in 6.2% of cultures. In the multivariable logistic regression model, hot and humid climates were associated with an odds of P. aeruginosa of 1.92 97.5%CI (1.69-2.20); a hot, dry of 1.65 97.5%CI (1.44-1.90), and humid climate zone was associated with an odds of 1.65 97.5%CI (1.45-1.89). A lower Charlson Comorbidity Index, inpatient admission, recent antipseudomonal antibiotic use, and swabs were less likely to have Pseudomonas. Recent admission increased the odds of P. aeruginosa OR 1.34 97.5%CI (1.27-1.41). History of P. aeruginosa was associated with an increase in P. aeruginosa; OR 8.90 97.5%CI (8.29-9.56). Conclusions The prevalence of DFI organisms varies within different US climates. Utilization of local climate information may allow for more accurate and targeted empiric antibiotic selection when treating DFIs.

Medical students' perception of mobile learning during COVID-19 in Iran: A national study.

Mobile learning has gained significant attention in medical education in recent years. The COVID-19 crisis has further accelerated its adoption. A lack of research on student perceptions of mobile learning during pandemics limits strategies for maintaining education during these times. This study examines the perceptions of medical students in Iran regarding the mobile learning during COVID-19. It is imperative that these perceptions are understood to optimize mobile learning effectiveness in medical education during disruptions. A cross-sectional study was done in 2022 among 785 medical students in Iran who spent summer semester. Convenience sampling was used to select the sample. We used Biswas et al.'s scale for measuring medical students' perceptions of mobile learning during pandemics. Face and content validity was determined by qualitative methods. Internal consistency was measured with Cronbach's Alpha (0.79). Data was collected through an online questionnaire. To analyze the data, descriptive and analytical statistics were conducted with SPSS software at a significance level of p<0.05. In total, 1,200 medical students were asked to complete the survey, and 785 responded, resulting in a 65.4% response rate. Mobile learning has been embraced by majority of medical students, with Android devices being used the most frequently. They also have frequent access to the internet, and they rely on a wide range of apps and platforms for academic purposes. Students perceive mobile devices to be highly advantageous for improving subject knowledge (Mean = 4.71±0.58), accessing study materials (Mean = 4.44±0.75), and providing flexible learning opportunities (Mean = 4.40±0.79). Despite this, participants were less confident about the ability of mobile devices to assist with specific study problems (Mean = 3.12 ± 1.28), facilitate class discussions (Mean = 3.33 ± 1.38), and overcome screen size limitations (Mean = 3.32 ± 1.38). Medical students in Iran have widely adopted mobile learning and perceive it as beneficial for acquiring knowledge, accessing material, and being flexible during COVID-19. M-learning's effectiveness in specific learning activities must be investigated in further research, and concerns regarding problem-solving, discussion facilitation, and screen size limitations should be addressed.

Most babies born at a French hospital before 26 weeks survived with good outcomes.

The aim of this French study was to determine the neonatal morbidity, mortality and neurodevelopmental outcomes when infants born at the limit of viability reached 2 years of corrected age. We then compared the results with national and international cohorts. This study focused on 294 French infants born from 22 to 25 weeks of gestation in a single tertiary perinatal centre from January 2010 to December 2019. We used data on neonatal mortality and morbidity to calculate the survival rates of infants without moderate to severe neurodevelopmental and sensory deficits at 2 years of corrected age. These outcomes were compared with data from contemporary epidemiological studies of similar populations. Nearly two-thirds (60.5%) of the infants survived to discharge, with varying rates based on their gestational ages, and 57.3% had no severe neonatal morbidity. The vast majority (90.4%) of the 166 alive and available at 2 years of corrected age were free of moderate to severe neurodevelopmental impairment. Our survival rates exceeded a national French cohort study, but were closely aligned with international cohorts. These findings highlight the importance of incorporating local data into ethical decision-making about life-saving treatment for infants at the limit of viability.

Identifying measures for understanding and addressing county-level disparities in adolescent HPV vaccination coverage in North Carolina.

HPV vaccination coverage is characterized by geographic disparities in the US, with national studies finding lower coverage in rural versus nonrural areas. To direct quality improvement efforts in North Carolina, we sought to understand how different rurality measures characterize these disparities. We used separate negative binomial regression models to test associations between 5 dichotomized county-level rurality measures and HPV vaccination coverage (≥1 dose) among North Carolina adolescents, ages 11-12 (n=326,345). Rurality measures were derived from: Office of Management and Budget's Metropolitan Statistical Areas, Rural-Urban Continuum Codes, Index of Relative Rurality, US Census Bureau classifications, and North Carolina Rural Center classifications. Models controlled for Social Vulnerability Index (SVI) percentile and rate of pediatricians per county. Vaccination data came from the North Carolina Immunization Registry. HPV vaccination coverage was 29% across North Carolina's 100 counties (range: 13%, 46%). Agreement between rurality measures ranged from 54% to 93% of counties. In adjusted analyses, none of the 5 rurality measures correlated with HPV vaccination coverage, but higher SVI and higher rate of pediatricians were positively associated with coverage (p< 0.01). Exploratory moderation analyses suggested regional variation in the relationship between rurality and coverage, with a positive association in one region, a negative association in one region, and no association in four regions. County-level rurality measures did not identify disparities in HPV vaccination coverage in North Carolina. Measures related to social vulnerability and access to pediatricians may be better suited for understanding and addressing the state's substantial county-level vaccination disparities.