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Comparing Perspectives About the Informed Consent Conversation for Laparoscopic Cholecystectomy
No full textIntroduction: Cholecystectomy is one of the most common operations performed. However, there is no consensus regarding the baseline level of detail to be communicated to patients to constitute truly informed consent. The purpose of this study is to compare attending to resident perspectives of the details deemed essential to the informed consent conversation surrounding laparoscopic cholecystectomy.
Methods: Attending surgeons performing laparoscopic cholecystectomies (n = 60) and general surgery residents (n = 105) from three institutions were invited to participate in this study. An electronic survey was distributed to all surgeons assessing the background knowledge, risks, benefits, alternative options, and postoperative expectations that surgeons believe should be routinely communicated to patients undergoing laparoscopic cholecystectomy for gallstone disease.
Results: Response rates were 57.4% and 38.1% for attending surgeons and residents, respectively. There were no differences of opinions regarding discussing the risks of bleeding, infection, bile leak, retained stones, bowel injury, potential need for intraoperative cholangiogram, or conversion to an open operation. Seventy-four percent of attendings reported that the potential need for postoperative endoscopic retrograde cholangiopancreatography should be discussed compared to 37.5% of residents (P = 0.001). All attending surgeons believe biliary tree injury should be communicated as a surgical risk compared to 85% of residents (P = 0.017).
Conclusions: This study identifies gaps in resident understanding of what is essential to communicate to patients prior to cholecystectomy compared to experienced surgeons. These results suggest areas for improvement in resident comprehension of the importance of discussing the risk of bile duct injury and in the role of endoscopic retrograde cholangiopancreatography for patients with benign biliary disease. The findings of this study advocate for structured and deliberate training programs focused on the informed consent process.
Keywords: Education; Informed consent; Laparoscopic cholecystectomy; Medical education; Residency; Surgical education
Applying design thinking to identify strategies for enacting evidence-based policymaking supporting Standard Time
No full textStudy objectives: The transition from Standard Time (ST) to Daylight Saving Time (DST) is associated with health, safety, economic, and other risks, and there is broad public support to do away with the change. However, most legislators have proposed permanent DST (pDST), contrary to medical and scientific recommendations. There is an urgent need to garner public support for legislation that would enact permanent standard time (pST), not pDST.
Methods: We employed a method called Design Thinking to uncover opportunities to design public communication strategies that garner public opinion supporting pST. As a first step, we recruited a multidisciplinary group (n=19) of individuals with diverse expertise (e.g., sleep/circadian rhythms, design, policy/legislation). Attendees gave talks on their area of expertise then broke into groups to discuss why pDST is viewed positively by the public and data informing the medical and scientific endorsement for pST over pDST. During each activity, participant wrote down their reactions on sticky notes. Sticky notes were analyzed qualitatively to identify the primary themes. Finally, participants were instructed to create news headlines declaring a hypothetical future event in which pST was enacted.
Results: The reaction exercise generated 72 sticky notes. Themes regarding why pDST is viewed favorably included perception of longer days, social connections, freedom, and summer. Themes relating to the reasons pST should be preferred included better health and sleep, improved alertness, and learning/productivity. Participants identified potential 11 headlines, many of which emphasized health or cost savings associated with pST.
Conclusions: Design Thinking is an under-explored but effective tool for uncovering potential barriers and brainstorming approaches for engendering support of evidence-based pST legislation.
Keywords: circadian; daylight saving; design thinking; health; public policy; sleep
Gestational vitamin D concentration and child cognitive development: a longitudinal cohort study in the Environmental influences on Child Health Outcomes Program
No full textBackground: Low vitamin D concentrations are common-especially among those with darker pigmented skin-and are frequently observed during pregnancy. Given its important role in brain development, inadequate gestational vitamin D may impair child cognitive development.
Objectives: We aimed to evaluate associations of gestational vitamin D concentrations with childhood cognitive scores, explore whether this relationship differs by self-reported race, and examine sensitive exposure windows within pregnancy.
Methods: This prospective cohort study included 912 mother-child dyads (37.3% Black, 52.3% White) from the Environmental influences on Child Health Outcomes program. 25-hydroxyvitamin D [25(OH)D] concentrations were measured in prenatal or cord blood collected between 4 and 42 wk gestation (median: 23 wk). Children\u27s cognition was assessed at ages 7-12 y using the NIH Toolbox Cognition Battery. Relationships of 25(OH)D and cognitive scores were examined using mixed-effects linear models adjusted for confounders. Potential sensitive periods were explored by estimating population 25(OH)D patterns across gestation for varying levels of the cognitive outcomes.
Results: Mean gestational 25(OH)D was 23.8 ng/mL (SD: 10.0 ng/mL). Each 10-ng/mL increase was associated with greater overall (β: 1.11; 95% CI: 0.08, 2.14) and fluid cognition scores (β: 1.21; 95% CI: 0.07, 2.34), but not crystallized cognition. Although these associations were not significantly modified by self-reported race, associations appeared stronger in children of Black mothers (β: 2.99; 95% CI: 0.82, 5.16) than those in non-Black mothers (β: 0.43; 95% CI: -0.93, 1.78) for fluid cognition. Early pregnancy may be a critical exposure period, evidenced by the greatest divergence in the pattern of 25(OH)D during this period between the mothers of children in the 90th and those in the 10th percentiles of cognitive outcomes.
Conclusions: Gestational 25(OH)D concentrations were positively associated with cognitive scores, especially in children of Black mothers. Given higher deficiency risk among Black women, vitamin D repletion before or in early pregnancy may be an important strategy for reducing racial disparities in child neurodevelopment.
Keywords: childhood cognitive development; fluid cognition; prenatal nutrition; racial health disparities; vitamin D
Corrigendum to Mediational analysis of severe retinal injury causation in children with acute closed head injury [Child Abuse & Neglect (2025) Vol. 167, Page 107539, https://doi.org/10.1016/j.chiabu.2025.107539]
No full textThe impact of intravascular imaging on percutaneous coronary intervention outcomes in acute myocardial infarction: a systematic review and meta-analysis
No full textBackground: Intravascular imaging (IVI) facilitates optimal outcomes in percutaneous coronary intervention (PCI). Focused data on the impact of IVI on outcomes of PCI in acute myocardial infarction (AMI), in particular, are scarce.
Methods: A systematic search of the PubMed, EMBASE, Medline, and Cochrane databases was conducted from their inception to 1 December 2024 for studies comparing IVI to coronary angiography alone to guide PCI in AMI. Outcomes of interest included all-cause mortality (primary), cardiac mortality, major adverse cardiovascular events (MACE), recurrent myocardial infarction, target vessel revascularization (TVR), stent thrombosis, and target lesion revascularization (TLR). Random effects models were used to calculate relative risks (RRs) with 95% confidence intervals (CIs).
Results: Fourteen studies (43 547 patients) met inclusion criteria; nine studies reported all-cause mortality. Among patients with AMI, compared with coronary angiography alone, patients with IVI-guided PCI had lower all-cause mortality (RR: 0.76, 95% CI: 0.64-0.89; P \u3c 0.01). IVI had less cardiac death (RR: 0.71, 95% CI: 0.59-0.86; P \u3c 0.01), MACE (RR: 0.85, 95% CI: 0.77-0.94; P \u3c 0.01), recurrent MI (RR: 0.84, 95% CI: 0.71-99; P = 0.04), TVR (RR: 0.79, 95% CI: 0.70-0.89; P \u3c 0.01), and stent thrombosis (RR: 0.69, 95% CI: 0.53-0.90; P = 0.01). TLR was not significantly different between IVI and coronary angiography alone.
Conclusion: Among patients with AMI, IVI-guided PCI is associated with improved clinical outcomes compared with coronary angiography alone. Further high-quality randomized trials are needed to clarify the magnitude of benefit.
Keywords: acute myocardial infarction; intravascular imaging; intravascular ultrasound; optical coherence tomography; percutaneous coronary intervention
Pediatric rare earth magnet ingestion: Defining progression in serial abdominal imaging
No full textIntroduction: Ingestion of rare earth magnets (REMs) results in significant morbidity and mortality in children, thus patients are frequently admitted to monitor REM progression. Short of peritonitis, unsuccessful or successful progression of REMs is ill-defined. Our goal was to determine if REM midline crossing on serial films was associated with decreased risk of surgical intervention.
Methods: A retrospective cohort study was conducted of patients less than 18 years old admitted to a children\u27s hospital following REM ingestion from 1/1/2013-9/30/2024. Symptoms, serial radiograph findings, and management data were collected. Continuous measures are calculated as mean/standard deviation(SD) when normally distributed and median/percentile if skewed. Categorical measures are shown as frequencies/percentages.
Results: In total, 31 patients were included. Mean(SD) age was 8.2(4.0) years, ranging 3-14 years, with a male predominance of 1.6:1(61.3%). For 77.4%, time of ingestion was known. Mean(SD) time to presentation was 10.7(18.8) hours, ranging 0.5-78.5 hours. The mean(SD) number of ingested REMs was 6(11), ranging 2-68. In 41.9% of cases, REMs were ingested simultaneously. In 58.1%, synchronicity was uncertain. 19 patients(59.4%) had an intervention: 16 endoscopies, 3 surgical. 5 patients required a second intervention: 1 lower endoscopy, 4 surgical. Patients with at least one midline crossing of REMs were less likely to require surgery(16.7%, 81.8%) with a relative risk of 0.044 (95%CI 0.004-0.49)(p\u3c 0.001).
Conclusion: Midline REM crossing provided an indicator of progression through the gastrointestinal tract with a higher likelihood of passage without surgery. In our series, no patients required surgery if REMs were observed to cross midline more than once.
Keywords: foreign body; ingestion; magnet; pediatric; pediatric surgery; radiograph; rare earth metal
Sex differences in in-hospital outcomes in hypertrophic cardiomyopathy: A nationwide analysis
No full textBackground: Hypertrophic cardiomyopathy (HCM) is the most common inherited cardiomyopathy. HCM is associated with heart failure (HF), arrhythmia, and acute coronary syndrome (ACS). The influence of sex on in-hospital outcomes in HCM is unknown. We conducted a nationwide analysis to compare outcomes between women and men with HCM hospitalized for HF, arrhythmias, or ACS.
Methods: This retrospective cohort analysis of the 2022 National Inpatient Sample (NIS) identified adults hospitalized with acute HF, arrhythmia, or ACS plus a secondary diagnosis of HCM. The primary outcome was in-hospital mortality. Secondary outcomes included length of stay (LOS) and total hospital charges. Multivariable logistic and linear regression models were used to adjust for demographics and comorbidities.
Results: Among 5,089 HCM admissions (51.1 % female; mean age 65.9 years), women were older (68.9 vs. 62.1 years) and more often admitted for acute HF. Arrhythmia presentations were similarly common in both sexes, and men more frequently had ACS. In-hospital mortality was 1.7 % and did not differ by sex after adjustment (adjusted odds ratio 1.3, p = 0.63). Mean LOS was 4.3 days and was similar between sexes. Total hospitalization charges showed no significant sex difference for HF or ACS, but men incurred higher charges for arrhythmias.
Conclusions: In this nationwide analysis, sex was not an independent predictor of in-hospital mortality or LOS among admissions with HCM and acute cardiovascular events. Resource utilization was broadly comparable except for arrhythmia admissions, where charges were substantially higher in men. Differences in hospital charges suggest that differences in management may exist.
Keywords: Cardiovascular events; Hypertrophic cardiomyopathy; In-hospital outcomes; Sex differences; Women
Childhood adversity is associated with longitudinal white matter changes after adulthood trauma
No full textBackground: Childhood adversity is associated with susceptibility to posttraumatic stress disorder (PTSD) in adulthood. PTSD and childhood adversity are linked to white matter microstructure, yet the role of white matter as a potential neural mechanism connecting childhood adversity to PTSD remains unclear. The present study investigated the potential moderating role of previous childhood adversity on longitudinal changes in white matter microstructure and posttraumatic stress symptoms following a recent traumatic event in adulthood.
Methods: As part of the AURORA Study, 114 recent trauma survivors completed diffusion weighted imaging at 2-weeks and 6-months after exposure. Participants reported on prior childhood adversity and PTSD symptoms at 2-weeks, 6-months, and 12-months post-trauma. We performed both region-of-interest (ROI) using fractional anisotropy (FA) and whole-brain correlational tractography using quantitative anisotropy (QA) analyses to index associations between white matter microstructure changes and prior adversity.
Results: ROI-based analyses did not identify significant associations between childhood adversity and changes in FA. Whole-brain correlational tractography revealed that greater childhood adversity moderated the QA changes within threat and visual processing tracts including the cingulum bundle and inferior fronto-occipital fasciculus (IFOF). QA changes within cingulum bundle and IFOF were associated with changes in PTSD symptoms between 2-weeks and 6-months.
Conclusions: Our findings suggest temporal variability in threat and visual white matter tracts may be a potential neural pathway through which childhood adversity confers risk to PTSD symptoms after adulthood trauma. Future studies should take the temporal properties of white matter into consideration to better understand the neurobiology of childhood adversity and PTSD.
Keywords: Childhood Adversity; Diffusion Tensor Imaging; PTSD; White Matter
Reply to: In response: The core competencies in hospital medicine: Procedures 2025 update
No full textClinical validation of an AI-based blood testing device for diagnosis and prognosis of acute infection and sepsis
No full textLack of reliable diagnostics for the presence, type and severity of infection in patients presenting to emergency departments with non-specific symptoms poses considerable challenges. We developed TriVerity, which uses isothermal amplification of 29 mRNAs and machine learning algorithms on the Myrna instrument to determine likelihoods of bacterial infection, viral infection and need for critical care interventions within 7 days. To validate TriVerity, the SEPSIS-SHIELD study enrolled 1,222 patients with clinically adjudicated infection status and need for critical care intervention within 7 days as endpoints. The TriVerity Bacterial and Viral scores had higher accuracy than C-reactive protein, procalcitonin or white blood cell count for the diagnosis of bacterial infection with area under the receiver operating characteristic (AUROC) of 0.83, and viral infection (AUROC = 0.91). The TriVerity Severity score had an AUROC of 0.78 for predicting illness severity and allowed reclassification of risk for critical care interventions compared to clinical assessment (quick Sequential Organ Failure Assessment) alone. Each of the three scores had rule-in specificity \u3e92% and rule-out sensitivity \u3e95%. Comparison of antibiotics administration at presentation with post-follow-up adjudication found that TriVerity could potentially reduce false positives and false negatives for inappropriate antibiotics use by 60-70%. Further clinical testing in an interventional setting is needed to prove actionability and clinical benefit of TriVerity