Duke University Hospital

Childhood victimization has lifelong adverse consequences including lower well-being and functional impairments in adulthood. Nonetheless, some victimized individuals appear to fare well, although it remains unclear whether they flourish (i.e., experience overall well-being and optimal functioning). We used data from the nationally representative Environmental Risk (E-Risk) Longitudinal Twin Study, which followed 2,232 children born in 1994-1995 across England and Wales to 18 years of age (93% retention, N = 2,066). Victimization was prospectively assessed between ages 5-12 years, capturing exposure to severe physical abuse, sexual abuse, emotional abuse and neglect, physical neglect, peer bullying, and domestic violence. Flourishing was assessed at age 18 across four domains: social well-being, education and cognition, physical health, and mental well-being. Over a third of the 558 victimized children flourished on at least one measure within all four domains at age 18, with the highest flourishing rates found for perceptions of social support, social status, and sleep quality. Experiencing two or more types of victimization was associated with lower flourishing for perceived social status (adjusted odds ratio [adj.OR] = 0.45, 95% confidence interval [CI] = 0.28, 0.73, p = .001) and faster biological aging (adj.OR = 0.57, 95% CI = 0.35, 0.93, p = .024) compared to single victimization exposure. Victimized girls were more likely to flourish in their educational attainment than boys (adj.OR = 1.61, 95% CI = 1.02, 2.55, p = .042). A substantial proportion of victimized children flourished across multiple domains in early adulthood. Identifying enabling factors could inform promotive interventions.

Left ventricular (LV) dysfunction is a potential cardioembolic source of ischemic stroke, but its role in recurrent stroke risk and treatment response remains unclear. We explore whether LV injury associates with the risk of recurrent stroke and modifies the association between anticoagulation and stroke recurrence using real-world data. We performed a multicenter, retrospective study of Cardiac Abnormalities in Stroke Prevention and Recurrence cohort across 27 US sites. Patients with LV ejection fraction ≥20% were included. LV injury, defined as LV ejection fraction 20% to 40% and wall motion abnormality, was the primary exposure and treatment effect modifier. The treatment of interest was anticoagulant versus antiplatelet therapy. The composite outcome included recurrent stroke, major bleeding, or death. Outcomes were evaluated using unadjusted and inverse probability weighting adjusted Cox proportional hazards models, with treatment effect modification tested by LV injury status. Among 2685 patients enrolled, 2328 with complete data were analyzed (median age, 65 years; 49.8% female; median follow-up, 1.6 years). LV injury was present in 310 patients (13.3%). Overall, 535 events occurred: 258 recurrent ischemic strokes, 28 hemorrhagic strokes, 67 major hemorrhages, and 256 deaths. LV injury was associated with a higher unadjusted risk of the primary outcome (hazard ratio [HR], 1.51 [95% CI, 1.21-1.87]), though nonsignificant after inverse probability weighting adjustment (adjusted HR, 1.29 [95% CI, 0.97-1.70]). In the LV injury subgroup, anticoagulation versus antiplatelet therapy was associated with a lower risk of the primary outcome (adjusted HR, 0.24 [95% CI, 0.10-0.59]), relative to the non-LV injury subgroup (adjusted HR, 1.28 [95% CI, 0.83-1.95]; p[LV-interaction], 0.001). Similar interactions were seen for EF 20% to 40% (versus >40%; adjusted HR, 0.19 [95% CI, 0.04-0.86]; p[LV-interaction], 0.001) and wall motion abnormality (versus no wall motion abnormality; adjusted HR, 0.33 [95% CI, 0.15-0.73]). After cryptogenic stroke, anticoagulation in those with LV injury was associated with lower rates of recurrent stroke, major bleeding, and death. These findings warrant confirmation in a dedicated randomized controlled trial. URL: https://www.clinicaltrials.gov; Unique identifier: NCT06398366.

Surgeons pursuing improvement in the aesthetic outcomes of their cleft lip repairs may benefit from a granular scale evaluating individual objectives of the repair. A working group of 9 surgeons convened to develop an assessment scale for nasolabial aesthetics after unilateral cleft lip repair. The group identified objectives of the repair that could be evaluated using two-dimensional facial photographs. Scale items were developed to appraise success or failure in achieving each objective. Scale items were iteratively tested and refined. The scale was subsequently implemented as part of a Continuing Medical Education course that included self-evaluation and peer-to-peer education, culminating in the formation of individual plans for improvement. Twelve distinct objectives of unilateral cleft lip repair were identified, of which 10 could be evaluated using photographs routinely obtained in clinical practice. A comprehensive scale was developed, incorporating these 10 objectives. Each scale item takes the form of a binary (yes/no) question evaluating a specific aesthetic concept, with accompanying reference images. Intrarater reliability for each item ranged from moderate to substantial (kappa value, 0.57 to 0.81). Interrater reliability ranged from fair to substantial (kappa value, 0.27 to 0.81). When implemented in a Continuing Medical Education course, the scale enabled surgeons to identify specific opportunities for improvement in their repair and specific surgical maneuvers to adopt in pursuit of these improvements. A new scale for evaluating outcomes of unilateral cleft lip repair is presented. The scale provides specific, actionable evaluations for individual objectives of the repair.

The National Residency Match Program considers a successful Couples Match when both parties match, regardless of location. However, there is a dearth of data on Couples Match outcomes compared to normal Match Outcomes. To compare the success rates, geographic preferences, and application preparation between Couples Match and traditional Match applicants within the specialty of internal medicine. An anonymous, cross-sectional, two-part REDCap survey was designed for standard and Couples Match residents. This survey was distributed via email to 437 academic United States internal medicine program directors from 1 October 2022 to 31 December 2023. Questions focused on post-match satisfaction, pre-application priorities, and number of interviews conducted. Around 248 residents completed the survey across the 437 internal medicine residency programs initially contacted. 64% (52/82) of Couples Match participants felt the need to make compromises to ensure dual matching. Compared to standard applicants, Couples Match applicants were significantly less likely to match in their top three ranked programs (89% vs. 67%, P < 0.01). When asked how to rate their perceived stress during the match process on a scale of 1-10, Couples Match respondents reported significantly higher perceived stress than their standard match counterparts (7.85 ± 1.30 vs. 7.13 ± 1.74) (P < 0.001). We found that Couples Match applicants had differing pre-match priorities, significantly less likelihood of matching in their top three programs, and significantly higher perceived levels of stress. Our study highlights the unique needs and stressors of medical students who are applying to internal medicine through the Couples Match. Key messages What is already known on this topic: While the NRMP Couples Match boasts a high overall success rate, little is known about specialty-specific outcomes, applicant satisfaction, or the personal and professional compromises made by couples, particularly within internal medicine. What this study adds: This is the first national study to quantify internal medicine Couples Match outcomes, revealing that these applicants face significantly higher stress, are less likely to match at top-choice programs, and frequently compromise on prestige, geography, and personal priorities to match with their partner. How this study might affect research, practice, or policy: These insights underscore the need for tailored advising, informed program recruitment strategies, and potential policy considerations to better support the unique constraints faced by Couples Match applicants-enhancing both resident well-being and match satisfaction.

Although validated prognostic models exist for men with metastatic castration-resistant prostate cancer (mCRPC), current tools do not incorporate genomic biomarkers such as circulating tumor DNA (ctDNA) aneuploidy or pathogenic genetic alterations (PGAs). This study aimed to estimate the prevalence of PGAs in ctDNA, assess their correlation with ctDNA aneuploidy fraction, and evaluate their association with overall survival (OS). Additionally, we developed and validated a clinical-genetic (CG) model to predict OS. We analyzed ctDNA from 776 patients enrolled in the Alliance phase 3 trial (A031201). PGAs were derived using the AR-ctDETECT assay. The net reclassification improvement (NRI) evaluated the added value of the CG model, and the time-dependent area under the receiver operating characteristic curve (tAUC) assessed the accuracy of the OS model. Feature selection using random survival forest identified gains in androgen receptor (AR), AR enhancer, MYC, RSPO2, CCND1, BRAF, and MET; losses or pathogenic variants in ZBTB16, PTEN, MSH6, PPP2R2A, NKX3-1, ZFHX3, TP53, ZNFR3, RB1, FANCA, CHECK1, APC, and CHD1; and a pathogenic AR variant. The CG model significantly outperformed the clinical model, with an average tAUC of 0.77 (95% confidence interval [CI]: 0.73-0.79) for the CG model compared with the tAUC of 0.72 (95% CI: 0.69-0.75, p=0.01) for the clinical model, and NRI of 0.29 between the models. Patients were categorized by the predicted risk scores into poor-, intermediate-, and low-risk groups with median OS of 19.6, 33.6, and 60.8mo, respectively. Incorporation of PGAs from ctDNA into a CG model improved OS prediction by nearly 30% over a clinical model. This model can classify patients into risk groups and is useful for selecting patients in future mCRPC trials.

CT angiography of the head and neck (CTAHN) is commonly obtained in the emergency department (ED) for patients with acute neurologic symptoms to guide interventions. There are limited data on which clinical characteristics predict these changes. The primary objective of this study was to assess the yield of CTAHN across common neurologic ED presentations and identify patient and clinical factors associated with CTAHN findings that result in acute management change. We performed a retrospective cohort study of 1,445 ED patients at an academic Level 1 trauma center who underwent CTAHN in 2023 for 5 common neurologic presentations: stroke code, headache, dizziness, altered mental status, and vision changes. Multivariable logistic regression models with LASSO variable selection were used to identify predictors of acute management change. Odds ratios (OR), 95% CIs, and p values were reported for each independent predictor. Overall, 216 of 1,445 CTA head and neck sudies (CTAHNs; 14.9%) resulted in acute management change. The highest yield of CTAHN acute management change was for stroke codes (21.2%) and vision changes (14.7%), and the lowest for dizziness (4.0%). For stroke codes, independent predictors included abnormal CT head (OR 2.84, p = 0.0001), focal neurologic deficit (OR 2.2, p = 0.0119), new vs recurring symptoms (OR 2.39, p = 0.0272), maximal symptom severity at onset (OR 3.95, p = 0.0011), and tobacco use (OR 2.02, p = 0.0016). National Institutes of Health Stroke Scale (NIHSS) scores of 10-14 had the highest likelihood of CTAHN acute management change. Previous neurologic disorder was protective (OR 0.66, p = 0.0317). For headache, abnormal CT head (OR 4.98, p = 0.0303) and thunderclap presentation (OR 5.31, p = 0.0276) were associated with CTAHN acute management change. Only univariate trends could be identified for dizziness, altered mental status, and vision changes. CTAHN was most useful in those presenting with vision loss or diplopia, but not cases of blurry vision or positive visual phenomena. Abnormalities on the preceding CT head increased the yield for altered mental status, while CTAHNs were low yield for isolated dizziness. These results highlight specific, obtainable clinical predictors that can guide judicious use of CTAHN in the ED. Recognizing these predictors can inform emergency physicians' and neurologists' clinical judgment, optimize imaging utilization, improve resource allocation, and reduce patient burden.