General Department of Preventive Medicine

Background Patients with a transient ischemic attack (TIA) or minor stroke have an increased risk of subsequent stroke that persists for at least 10 years. We aimed to identify prognostic factors associated with long-term risk of stroke in this patient group, and estimate their population attribution fraction (PAF).Methods A systematic review was performed of MEDLINE, Embase, and Web of Science for cohort studies including patients with TIA or minor stroke that evaluated factors for subsequent stroke over a follow-up period of ≥1 year. We pooled hazard ratios adjusted for relevant confounders using random-effect meta-analysis and determined the PAF of factors based on their pooled prevalence and adjusted hazard ratio (aHR). We assessed certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach. The study is registered in PROSPERO (CRD42023476551).Results From 14 732 identified citations, we included 28 cohort studies comprising 86 810 patients with TIA or minor stroke (median age, 69 years [IQR, 65-71]; 52-60% male patients). Factors that had high certainty evidence of association with increased long-term risk of stroke included older age (aHR 1.04 per year increase, 95% CI 1.02-1.05), male sex (1.25, 1.15-1.36; PAF 13.0%, 95% CI 7.8-18.7), atrial fibrillation (1.34, 1.18-1.52; 3.8%, 95% CI 0.3-9.9), diabetes mellitus (1.52, 1.32-1.75; 7.7%, 3.1-14.1), hypertension (1.60, 1.31-1.94; 19.3%, 8.4-31.6), ischemic heart disease (1.67, 1.28-2.18; 10.7%, 2.8-22.9), history of stroke or TIA before the index event (1.70, 1.43-2.02; 12.0%, 5.2-21.4), smoking (1.29, 1.05-1.60; 11.2%, 1.0-30.7), ABCD2 score of ≥4 (1.59, 1.31-1.94; 18.0%, 2.9-39.9), presence of acute infarct on neuroimaging (1.97, 1.41-2.74; 19.0%, 5.2-38.9) including diffusion-weighted imaging positive lesions (1.86, 1.02-3.37; 14.0%, 7.0-25.0), minor stroke as index event (1.75, 1.35-2.27 vs TIA; 28.0%, 10.2-47.6), presentation with aphasia or dysarthria (1.45, 1.24-1.69; 19.2%, 0.2-53.1), presentation with paresis (1.45, 1.15-1.84; 22.0%, 3.8-43.4), and etiologic stroke subtypes including cardioembolism (2.16, 1.53-3.05; 14.6%, 3.1-33.5), large artery atherosclerosis (2.19, 1.68-2.86; 13.2%, 5.1-25.5), and small vessel disease (1.69, 1.14-2.49; 16.8%, 5.0-34.3).Conclusions These findings can help identify patients with a particularly enduring risk of stroke who are most likely to benefit from ongoing monitoring and treatment, and facilitate the development and implementation of targeted stroke prevention strategies.

Acute care surgery (ACS) is a specialty that includes trauma, emergency general surgery, and surgical critical care. It has become a vital surgical specialty in the United States, providing surgical services, rescue functions, disaster response, and other important services. Despite its key role in patient care and hospital operations, ACS faces challenges to its sustainability. This overview targets readers who wish to understand the structure and scope of ACS and who work with or manage these practices. The goal is to provide an overview of ACS, its current challenges, and suggestions for developing the specialty. This consensus statement was created by the Acute Care Surgery Workforce Workgroup, which includes representatives from various national surgical organizations. The article combines current ACS models, staffing and compensation practices, and institutional value. It relies on expert agreements and national trends. Several key themes are examined. The value of ACS is shown through better patient outcomes, efficiency, cost savings, and support for institutional missions like disaster preparedness and education. Current ACS programs differ significantly in structure, but two main staffing models exist: traditional (historic) and time delineated. Each model has its own advantages and challenges regarding workload, sustainability, and academic involvement. Regardless of the staffing model, most physician compensation often depends on the measurement of work relative value units. However, these do not fully capture the extent and intensity of ACS work. Additional challenges for the specialty include inconsistencies in terminologies, the absence of board certification, and varying compensation standards. Acute care surgery is a crucial specialty that provides significant value to patients, hospitals, and health care systems. To maintain sustainability and quality, health care leaders need to consider the complexities of ACS practice discussed in this article as well as local demands. Staffing and compensation models should be sustainable and optimize for patient care. Recognizing both clinical and nonclinical contributions of ACS surgeons is essential for resilience and further development of the specialty.

Background Diagnostic error is a major patient safety concern in hospitals, yet most studies have focused on selected high-risk subgroups, leaving the broader general internal medicine inpatient population understudied. Objectives To determine the incidence, contributing factors, resulting harm, and predictors of diagnostic error in medical inpatients.Methods This retrospective cohort study included adults admitted to internal medicine between 01/2022 and 12/2022 at one tertiary and 4 secondary care hospitals in Switzerland. Retrieved admissions were randomly ordered, and electronic medical records were reviewed sequentially by two clinicians using standardized instruments, until reaching a pre-specified target threshold of 50 patients with ≥1 diagnostic error, enabling analysis of five predictors. The primary outcome was the occurrence of a diagnostic error. The secondary outcome was the resulting level of harm. Five pre-specified predictors were analyzed using multivariable logistic regression. Results Of 347 patients (median age 73 [interquartile range, 61-81] years; 140 [40.3%] female), 52 (15%; 95% confidence interval [CI], 11.6%-19.1%) experienced ≥1 diagnostic error, causing harm in 43/52 patients (82.7%; 95% CI 70.3%-90.6%). The most common contributing factors were failures to consider the correct diagnosis (40/52, 76.9%), order appropriate tests (31/52, 59.6%), and act on critical physical exam findings (30/52, 57.7%). Neurocognitive/psychiatric disorders (odds ratio [OR], 2.20; 95% CI, 1.20-4.10) and active cancer (OR, 2.10; 95% CI, 1.01-4.20) independently predicted diagnostic error. Conclusions Diagnostic error is common among adult medical inpatients and causes harm. We identified neurocognitive/psychiatric disorders and active cancer as patient-level predictors of diagnostic error, providing a basis for future studies on targeted interventions.

Sickle cell disease (SCD) is associated with vaso-occlusive episodes (VOEs) that often require inpatient care. Parenteral opioids are recommended as first-line VOE treatment in hospitalized patients. The Current Opioid Misuse Measure (COMM) survey was used to screen for aberrant opioid use in SCD patients hospitalized for VOE. Goals were to estimate the proportion of positive screens and evaluate associations with length of stay (LOS), electronic health record (EHR) data, and Prescription Drug Monitoring Program (PDMP) assessments. SCD patients hospitalized for VOE were approached to complete COMM surveys. Descriptive statistics and multivariate modeling were used to evaluate whether COMM results were associated with LOS or secondary variables. A total of 111 patients were approached and 89 completed surveys. Approximately 6 in 10 (57.3%) respondents screened positive for aberrant opioid use using a sensitive COMM threshold (≥9). A more specific threshold (≥13) identified about 3 in 10 (31.7%) of respondents. Positive COMM screens were more common among younger patients and those with a higher EHR risk index (Epic general risk score). COMM score was positively correlated with LOS (Spearman r =0.25, P =0.025), although this association was nonsignificant in survival models adjusted for sex and age ( P ≥0.081). A high proportion of adults admitted for VOE screened positively using the COMM survey, which is a sensitive indicator of opioid misuse among outpatients. Our findings demonstrate feasibility of inpatient screening using the COMM survey and support further investigation of this tool for SCD patients hospitalized with VOE.

Periodontal disease is associated with inflamed gingival tissues and degradation of the gingival extracellular matrix (ECM), yet the role of mechanical cues is poorly understood. Gingival ECM in periodontal disease showed a loss of fibrillar collagen compared to healthy samples. We hypothesized that ECM softening in periodontal disease contributes to inflammation due to dysregulated gingival fibroblasts (GFs). A mechanically tunable hydrogel model of the gingival ECM was developed to investigate the mechano-immune crosstalk. Stiff collagen-alginate hydrogels matched the rheological properties of gingival biopsies. Human donor GFs encapsulated in these stiff hydrogels showed significantly suppressed toll-like receptor inflammatory responses compared to soft. Stiffness-dependent inflammatory responses of GFs were directed by the non-canonical NFκB pathway and epigenetic nuclear organization. The direct impact of mechanical cues on immune responses was investigated with human donor cells ex vivo by co-culture of human GFs with myeloid cells and in human gingival explants. Myeloid progenitors co-cultured with GFs in stiff hydrogels differentiated into immunomodulatory dendritic cells. Ex vivo crosslinking of human gingival tissue increased stiffness and reduced inflammatory cytokines. Gingival mechano-immune regulation provides a new avenue for biomaterials-based treatments in periodontitis.

ABSTRACTObjectivesNon‐Cyclical mastalgia (NCM) is a chronic breast pain condition in women of reproductive age, often linked to anxiety and reduced quality of life (QoL). Evidence suggests central sensitization (CS) may contribute to NCM, but its clinical significance and management remain unclear.MethodsThis cross‐sectional study included 201 women aged 25 to 65, with 106 NCM patients and 95 healthy controls, to investigate the association between NCM and central sensitization syndromes (CSS). Data collection involved demographic characteristics and assessments using the Central Sensitization Inventory (CSI), Nottingham Health Profile (NHP), Short‐Form McGill Pain Questionnaire (SF‐MPQ), Pain Detect, Leeds Assessment of Neuropathic Symptoms and Signs (LANSS), and Hospital Anxiety and Depression Scale (HADS). The main outcome is to reveal the interrelationship between NCM and CSS.ResultsNCM patients had significantly higher Central Sensitization Inventory‐A (CSI‐A) scores than controls (p < 0.001), with 15.1% surpassing the critical threshold of 40, indicating pronounced CS. NCM patients also had increased NHP‐1, NHP‐2, and HADS‐total scores (p = 0.008, p = 0.003, p = 0.004), reflecting greater distress. Subgroup analyses showed more intense pain (p < 0.001) and sleep disturbances (p = 0.002). CSI‐A scores strongly correlated with SF‐MPQ, LANSS, Pain Detect, and HADS (all p < 0.001). Regression analysis identified pain duration, Pain Detect, and SF‐MPQ sensory scores as key predictors of CSI‐A (p < 0.001).DiscussionNCM shares characteristics with chronic pain syndromes linked to CSS. Multidisciplinary approaches and innovative treatments, such as cognitive therapies combined with integrative approaches may improve outcomes.

To explore the relationship and current status of coping styles, burnout, and hospital patient safety culture in patient suicide incidents. To examine whether nurse second victim coping styles in patient suicide incidents mediate the relationship between hospital patient safety culture and burnout. A cross-sectional study. The collection of information was carried out during the same period of time. The study recruited a sample of 425 nurses, second victims who had experienced patient suicides from 6 tertiary grade A hospitals (Shanxi, China). The General Information Questionnaire, the Coping Styles Scale, the Burnout Scale, and the Hospital Patient Safety Climate Scale were used to gather data. The Pearson correlation analysis was used to study the correlation among the 3, one-way ANOVA or independent samples t tests were used to compare differences in second victim burnout among nurses with different characteristics, and the model 4 in process was employed to establish structural equation modeling and test the influence paths of hospital patient safety culture, coping styles, and burnout. In this study, the patient safety culture score of hospital patients was (134.43±4.84), which was at a medium level; the coping score was (68.70±4.94), which was at a medium level, with positive coping score (23.03±2.94), negative coping score (22.12±2.66), and problem solving score (23.55±3.10), which was at a high level. The burnout score is (71.19±3.83), which is at a high level. Hospital patient safety culture was positively correlated with coping styles ( r =0.458, P <0.001) and negatively correlated with burnout ( r =-0.754, P <0.001), and coping styles were negatively correlated with burnout ( r =-0.356, P <0.001). In the mediation models, the mediating effect of coping styles between hospital patient safety culture and burnout was -0.26, which accounted for 40.63% of the total effect. A good hospital patient safety culture can improve the coping styles of nurse second victims and also reduce the burnout of nurse second victims. Hospital patient safety culture not only has a direct effect on burnout, but also indirectly affects burnout through coping styles, and reduces burnout by improving their coping styles; hospitals and administrators should take a variety of interventions to improve nurse second victims' coping styles and enhance hospital patient safety culture to reduce burnout.