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Convenience, rapport and skill: effective rural hepatitis C treatment, qualitative findings from a mobile harm reduction-informed tele-medicine intervention in Northern New England, 2022-2024
No full textBackground: People who inject drugs (PWID) are at high risk for acquiring and transmitting the hepatitis C virus (HCV). Access to HCV testing and treatment remains limited in rural communities. Mobile healthcare interventions are promising models to reach underserved populations like rural PWID. Understanding the characteristics of effective interventions to engage rural PWID in HCV care can guide design strategies for HCV treatment and elimination in rural areas.
Methods: The Drug Injection Surveillance and Care Enhancement for Rural Northern New England (DISCERNNE) study randomized 150 participants with chronic HCV to examine Mobile Tele-HCV Care (MTC) versus Enhanced Usual Care (EUC). On-the-spot qualitative interviews (n = 34) were conducted with study participants, community providers, and study van staff to understand the context for protocol implementation. For this study, qualitative coding and thematic analyses identified the characteristics of successful HCV treatment engagement among PWID in rural areas.
Results: This successful HCV treatment engagement intervention with out-of-treatment rural PWID had three essential characteristics: convenience, effective rapport, and skilled staff. Convenience factors included dependable and easily accessible locations with drop-in availability that made it easy to make HCV treatment a priority. Rapport with participants through a harm reduction approach engendered respect for autonomy and tailoring the protocol to accommodate the complexities of daily life that PWID face. Skilled staff were flexible across multiple roles including on-site phlebotomy, a notable barrier to rural PWID obtaining HCV treatment, and were competent in caring for PWID.
Conclusions: We identified salient characteristics that contributed to high trust and treatment adherence among a marginalized population of rural PWIDs. Tailored, flexible approaches and specialized skills are required to engage and retain PWID in rural areas.
Trial registration: NCT05466331.
Keywords: Harm reduction; Hepatitis C virus; Injection drug use; Rural health; Tele-medicine
EXPRESS: Nationwide Trends in Pneumonia-Associated Mortality and the Impact of the COVID-19 Pandemic
No full textOutcomes of Pulsed Field Versus Cryoballoon Ablation in Atrial Fibrillation: A Comprehensive Systematic Review and Meta-Analysis
No full textBackground: Catheter-based pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). While cryoballoon ablation (CBA) is a well-validated single-shot thermal technology, pulsed field ablation (PFA) has emerged as a predominantly non-thermal modality that employs high-voltage electric fields to achieve selective myocardial ablation, potentially minimizing collateral damage. However, comparative evidence between PFA and CBA remains limited.
Objectives: To systematically review and compare the efficacy, safety, and procedural efficiency of PFA versus CBA for PVI.
Methods and results: A structured systematic database search was conducted up to August 2025, following PRISMA guidelines. Eighteen studies (n = 5638; 2396 PFA and 3242 CBA) were included including two randomized controlled trials. PFA significantly shortened procedure time (mean difference -13.7 min; 95% CI -16.7 to -10.8; p \u3c 0.001), while fluoroscopy time and radiation dose were similar. Both modalities achieved high acute PVI success (95%-100%). At 12-month follow-up, PFA showed lower arrhythmia recurrence (OR 0.73; 95% CI 0.59-0.90; p = 0.003) with no difference in redo ablation. Overall complications were fewer with PFA (OR 0.53; 95% CI 0.32-0.87; p \u3c 0.001), largely due to reduced phrenic nerve injury, though cardiac tamponade occurred slightly more often in the PFA group. Subgroup analyzes yielded consistent results in paroxysmal AF and when 3D mapping was used.
Conclusion: PFA offers superior procedural efficiency and safety compared with CBA, achieving shorter procedures, fewer complications, and lower arrhythmia recurrence at mid-term follow-up. Larger multicentre randomized trials with standardized protocols and long-term follow-up are needed to confirm these findings and evaluate evolving PFA technologies.
Keywords: atrial fibrillation; cryoballoon ablation; pulmonary vein isolation; pulsed field ablation
Balloon-expandable versus self-expanding valves in severe aortic stenosis with small aortic annulus: an updated meta-analysis
No full textBackground: Balloon-expandable valve (BEV) and self-expanding valve (SEV) are used in transcatheter aortic valve replacement (TAVR). Patients with a small aortic annulus (SAA) make up to one-third of the cases and face higher risks of prosthesis-patient mismatch and high valvular gradients.
Objectives: This meta-analysis aimed to compare balloon-expandable and self-expanding valves used in TAVR in patients with a SAA, focusing on hemodynamic and clinical outcomes.
Methods: We systematically searched Cochrane Central, PubMed, and EMBASE for studies comparing balloon-expandable and self-expanding valves in patients with SAA undergoing TAVR. Random effects models were applied to generate odds ratios (ORs) and mean differences with 95% confidence interval (CI).
Results: Fifteen studies (two randomized controlled trials and 13 propensity-matched studies) with 5149 patients (48.4% balloon-expandable valves) were identified. BEVs were associated with a lower indexed effective orifice area (mean difference: -0.18, 95% CI: -0.25 to -0.10; P \u3c 0.00001) and higher transvalvular mean pressure gradient (mean difference: 4.32, 95% CI: 3.39-5.24; P \u3c 0.00001) and peak pressure gradients (mean difference: 4.87, 95% CI: 1.23-8.51; P = 0.009). Permanent pacemaker implantation (OR: 0.57, 95% CI: 0.44-0.73; P \u3c 0.0001) and major bleeding (OR: 0.67, 95% CI: 0.47-0.96; P = 0.03) were lower in balloon-expandable valves. BEVs increased the odds of any prosthesis-patient mismatch (OR: 2.28, 95% CI: 1.61-3.22; P \u3c 0.00001) and severe prosthesis-patient mismatch (OR: 3.16, 95% CI: 2.19-4.58; P \u3c 0.00001).
Conclusion: In patients with SAA undergoing TAVR, SEVs offer superior hemodynamic performance, whereas BEVs are associated with fewer conduction disturbances and bleeding events. Both valve platforms yielded similar clinical outcomes, underscoring the need for individualized device selection.
Keywords: aortic stenosis; balloon-expandable valve; self-expanding valve; small aortic annulus; transcatheter aortic valve replacement
The effect of standard time to daylight-saving clock transition on sleep and migraine headaches
No full textPatient Perceptions of Palliative Care in Surgery: A Qualitative Study
No full textContext: Despite professional guidelines encouraging integration, palliative care (PC) remains underutilized among surgical patients.
Objectives: We sought to characterize contextual factors influencing PC integration in surgical practice from the patient perspective.
Methods: We used a combination of ethnographic observations and semi-structured interviews with seriously ill older adults to explore perceptions of and behaviors related to PC among patients undergoing surgery.
Results: Across 207 observations and 19 interviews, we identified that patients were either unaware of PC or equated it with end-of-life care, believing that pursuing PC would mean forgoing surgery or efforts at recovery. Patients were nevertheless observed elevating concerns related to PC domains, including social or psychological burdens, during visits with surgeons. When presented with a comprehensive definition of PC, some patients were receptive to increased integration with surgery whereas others preferred that their surgeons contribute only technical expertise.
Conclusions: Our results offer new perspectives on established findings, including that patients equate PC with hospice and end-of-life treatments. While patients in our study endorsed these same attitudes, they also exhibited interest in discussing broad domains of PC with their surgeons, highlighting further opportunities for integration.
Keywords: palliative care; qualitative study; surgery
Temporary Mechanical Circulatory Support and Shock Teams in High-Risk Cardiac Surgery: The Strategic Evolution of Protected Cardiac Surgery
No full textBackground: Protected Cardiac Surgery is a proactive strategy that applies temporary mechanical circulatory support to prevent perioperative low cardiac output syndrome in high-risk cardiac surgery. Rather than escalating vasoactive agents after hemodynamic decline, the approach emphasizes early identification of physiologic vulnerability and timely initiation of support.
Methods: We conducted a structured literature review of peer-reviewed studies published from 2000 to 2024 on temporary mechanical circulatory support in adult cardiac surgery. Fifty-two studies were selected based on relevance to early or prophylactic support, timing of initiation, risk stratification, and systems of care. Clinical insights from multidisciplinary experts also informed the review framework.
Results: Inotropic escalation after hemodynamic deterioration is consistently associated with poor outcomes. High pharmacologic requirements and severe metabolic derangements predict very high mortality, whereas conventional risk scores often fail to identify vulnerable patients. In contrast, early initiation of mechanical support has been associated with lower in-hospital mortality, reduced dependence on vasoactive agents, and improved recovery. Physiologic markers such as filling pressures and lactate levels may provide earlier signals of circulatory decline. Effective implementation also requires institutional coordination, team-based planning, and regional referral systems.
Conclusions: Protected cardiac surgery reframes success in high-risk cardiac surgery by focusing on recovery rather than survival alone. It integrates physiology-guided support with structured planning and system-level readiness to improve outcomes in vulnerable surgical populations
Guideline-Concordant Sedative and Analgesia Use in Critically Ill Patients Receiving Sustained Neuromuscular Blockade
No full textObjectives: Given significant harms of awake paralysis, guidelines recommend combination sedation and analgesia during neuromuscular blockade. In this study, we sought to describe guideline-concordant use of parenteral sedation and analgesia during sustained neuromuscular blockade among adults with critical illness.
Design: Multicenter, retrospective cohort study.
Setting: ICUs in 871 hospitals across the United States.
Patients: Adult patients admitted to an ICU between 2016 and 2022 who received invasive mechanical ventilation and at least one neuromuscular blocking agent (NMBA) on the same calendar day.
Interventions: None.
Measurements and main results: We used charge codes to identify use of parenteral sedatives (propofol, fospropofol, lorazepam, midazolam, diazepam, etomidate, phenobarbital, pentobarbital, and ketamine), and analgesics (fentanyl, hydromorphone, morphine, and ketamine) for each patient-day with neuromuscular blockade, and then categorized patient-days as guideline concordant or not. A total of 363,382 patient-days (among 104,984 hospitalizations) were included in the final cohort. Guideline-concordant sedation and analgesia were used concurrently in 345,660 patient-days (95.1%); only sedation was used in 15,618 patient-days (4.3%), only analgesia was used in 1,348 patient-days (0.4%), and neither sedation nor analgesia was used in 756 patient-days (0.2%). Most included hospitals (856 [98.3%]) used both sedation and analgesia on greater than or equal to 50% of patient-days; however, ten hospitals (1.1%) used only sedation on greater than or equal to 50% of patient-days, and 4 (0.6%) had no predominant sedation and analgesia strategy; however, 42.3% of the variation in guideline-concordant practice was attributable to residual unexplained clustering by hospital after accounting for demographics, severity of illness, and hospital characteristics.
Conclusions: Our findings suggest sedation and analgesia practices with NMBA use in adult ICUs are generally guideline-concordant but require corroboration using more precise, quantitative medication data. Practice variation between hospitals is potentially concerning and warrants further investigation targeting adequacy of sedation and analgesia during NMBA use and assessing the clinical impact of guideline-discordant practices.
Keywords: analgesia; critical illness; intensive care units; neuromuscular blocking agent; sedatives
Ultrasonography of palpable masses in the pediatric head and neck
No full textPalpable soft-tissue masses in the pediatric head and neck are common and encompass a broad differential that includes congenital, infectious, inflammatory, and neoplastic processes. Owing to its ability to characterize lesion morphology, vascularity, and internal architecture without ionizing radiation, ultrasonography (US) remains the primary imaging modality for initial evaluation. This review focuses on pediatric head and neck masses, emphasizing practical US-based assessment and differential diagnosis. Entities discussed include common congenital lesions such as dermoid cysts, thyroglossal duct cysts, and branchial cleft anomalies, salivary gland abnormalities (including sialadenitis, sialolithiasis, ranulas, and salivary tumors), thymic lesions (such as ectopic thymus and thymic cysts), and thyroid abnormalities (including ectopic thyroid tissue, thyroid nodules, and thyroid malignancy).
Keywords: Branchial cleft anomalies; Child; Dermoid cyst; Salivary gland; Thymus; Thyroid; Ultrasonography