bluuebunny/crossref_metadata_2025 huggingface dataset:
Recent advances in immunometabolism in rheumatic diseases
Authors: Hisada Ryo , Kono Michihito
Published: November 2024

Purpose of review

Aberrant autoreactive innate and adaptive immune responses cause systemic autoimmune diseases. Autoimmunity has been linked to abnormal metabolic states, and immunometabolism has emerged as a critical field in understanding the pathogenesis of rheumatic diseases. We aimed to explore the latest research on metabolic reprogramming in various immune cell types, including T cells, B cells, neutrophils, dendritic cells, monocytes, and macrophages, in the context of rheumatic diseases.

Recent findings

Each immune cell utilizes preferred metabolic pathways, and the cell activation dramatically modifies metabolic status. The inhibition of these pathways alters cell survival, differentiation, proliferation, and cytokine production – all of which contribute to rheumatic disease progression.

Targeting metabolic pathways or introducing anti-inflammatory metabolites, such as itaconate, could be novel therapeutic strategies for rheumatic diseases. Further research should focus on strategies for translating basic research findings to bedside applications.
Influence of Preoperative Disability on Outcomes Following Primary Surgical Treatment of Cervical Disc Herniation
Authors: Khosla Ishan , Anwar Fatima N. , Roca Andrea M. , Loya Alexandra C. , Medakkar Srinath S. , Kaul Aayush , Wolf Jacob C. , Federico Vincent P. , Sayari Arash J. , Lopez Gregory D. , Singh Kern
Published: November 2024

Study Design:

Retrospective review.

Objective:

To evaluate how preoperative disability influences patient-reported outcomes (PROs) following primary surgical intervention for cervical herniated disc.

Summary of Background Data:

The effect of baseline disability has been evaluated for various spinal surgeries, but not specifically for primary cervical herniated disc.

Methods:

A prospectively maintained single surgeon database was retrospectively reviewed to identify patients who underwent primary cervical spine surgery for herniated nucleus pulposus. Demographics, perioperative data, and baseline/postoperative PROs were collected including Neck Disability Index (NDI), Visual Analog Scale-Arm/Neck (VAS-A/N), 12-Item Short Form Mental/Physical Component Scores (SF-12 MCS/PCS), Patient-Reported Outcome Measure Information System-Physical Function (PROMIS-PF), and 9-Item Patient-Health Questionnaire (PHQ-9). Baseline NDI <50/≥50 defined 2 cohorts. ΔPROs were determined at 6-week postoperatively/final follow-up (average 11.8±7.7 postoperative months). Overall rates of minimal clinically important difference (MCID) achievement were determined for each PRO. Perioperative characteristics/demographics/baseline PROs were compared with χ2 tests (categorical variables)/the Student t test (continuous variables). Intercohort postoperative PROs/ΔPROs/MCID attainment rates were compared with multivariate linear regression (continuous variables)/multivariate logistic regression (categorical variables) accounting for differences in insurance type.

Results:

Of 190 patients, there were 69 in the NDI ≥50 group. Patients with NDI ≥50 were more likely to have workers’ compensation, or Medicare/Medicaid insurance (P<0.001) and report worse baseline PROs (P≤0.001, all). After controlling for insurance type, NDI ≥50 patients continued to report worse PROs at 6 weeks/final follow-up (P≤0.037, all), except PROMIS-PF at 6 weeks postoperatively. NDI ≥50 patients reported greater NDI improvements at 6 weeks (P=0.007) and final follow-up (P<0.001). NDI ≥50 patients experienced higher overall MCID achievement rates for PHQ-9/NDI (P≤0.015, both).

Conclusions:

NDI ≥50 patients reported worse baseline mental/physical health and neck/arm pain and continued to report inferior postoperative outcomes including disability. Despite inferior absolute outcomes, NDI ≥50 patients reported greater improvements/achievement of clinically significant differences in disability through final follow-up. Further, these patients were more likely to experience clinically significant improvements in depressive burden.
Septic Shock Requiring Three Vasopressors: Patient Demographics and Outcomes
Authors: Kwak Gloria H. , Madushani Rajapaksha W. M. A. , Adhikari Lasith , Yan April Y. , Rosenthal Eric S. , Sebbane Kahina , Yanes Zahia , Restrepo David , Wong Adrian , Celi Leo A. , Kistler Emmett A.
Published: November 2024

OBJECTIVES:

Septic shock is a common condition necessitating timely management including hemodynamic support with vasopressors. Despite the high prevalence and mortality, there is limited data characterizing patients who require three or more vasopressors. We sought to define the demographics, outcomes, and prognostic determinants associated with septic shock requiring three or more vasopressors.

DESIGN:

This is a multicenter retrospective cohort of two ICU databases, Medical Information Mart for Intensive Care IV (MIMIC-IV) and electronic ICU-Clinical Research Database, which include over 400,000 patients admitted to 342 ICUs.

PATIENTS:

Inclusion criteria entailed patients who were: 1) age 18 years old and older, 2) admitted to any ICU, 3) administered at least three vasopressors for at least 2 hours at any time during their ICU stay, and 4) identified to have sepsis based on the Sepsis-3 criteria.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

A total of 3447 patients met inclusion criteria. The median age was 67 years, 60.5% were male, and 96.6% had full code orders at the time of the third vasopressor initiation. Septic shock requiring three or more vasopressors was associated with 57.6% in-hospital mortality. Code status changes occurred in 23.9% of patients following initiation of a third vasopressor. Elevated lactate upon ICU admission (odds ratio [95% CI], 2.79 [2.73–2.85]), increased duration of time between ICU admission and third vasopressor initiation (1.78 [1.69–1.87]), increased serum creatinine (1.61 [1.59–1.62]), and age above 60 years (1.47 [1.41–1.54]) were independently associated with an increased risk of mortality based on analysis of the MIMIC-IV database. Non-White race and Richmond Agitation-Sedation Scale scores were not associated with mortality.

CONCLUSIONS:

Septic shock requiring three vasopressors is associated with exceptionally high mortality. Knowledge of patients at highest risk of mortality in this population may inform management and expectations conveyed in shared decision-making.
Continuous peri-operative glucose monitoring in noncardiac surgery
Authors: Putzu Alessandro , Grange Elliot , Schorer Raoul , Schiffer Eduardo , Gariani Karim
Published: November 2024

BACKGROUND

Glucose management is an important component of peri-operative care. The usefulness of continuous glucose monitoring (CGM) in noncardiac surgery is uncertain.

OBJECTIVE

To systematically assess the glycaemic profile and clinical outcome of patients equipped with a CGM device during the peri-operative period in noncardiac surgery.

DESIGN

Systematic review.

DATA SOURCES

Electronic databases were systematically searched up to July 2024.

ELIGIBILITY CRITERIA

Any studies performed in the peri-operative setting using a CGM device were included. Closed-loop systems also administering insulin were excluded. Analyses were stratified according to diabetes mellitus status and covered intra-operative and postoperative data. Outcomes included glycaemic profile (normal range 3.9 to 10.0 mmol l−1), complications, adverse events, and device dysfunction.

RESULTS

Twenty-six studies (1016 patients) were included. Twenty-four studies were not randomised, and six used a control arm for comparison. In bariatric surgery, diabetes mellitus patients had a mean ± SD glucose of 5.6 ± 0.5 mmol l−1, with 15.4 ± 8.6% time below range, 75.3 ± 5.5% in range and 9.6 ± 6.7% above range. During major surgery, diabetes mellitus patients showed a mean glucose of 9.6 ± 1.1 mmol l−1, with 9.5 ± 9.1% of time below range, 56.3 ± 13.5% in range and 30.6 ± 13.9% above range. In comparison, nondiabetes mellitus patients had a mean glucose of 6.4 ± 0.6 mmol l−1, with 6.7 ± 8.4% time below range, 84.6 ± 15.5% in range and 11.2 ± 4.9% above range. Peri-operative complications were reported in only one comparative study and were similar in CGM and control groups. Device-related adverse events were rare and underreported. In 9.21% of cases, the devices experienced dysfunctions such as accidental removal and issues with sensors or readers.

CONCLUSION

Due to the limited number of controlled studies, the impact of CGM on postoperative glycaemic control and complications compared with point-of-care testing remains unknown. Variability in postoperative glycaemic profiles and a device dysfunction rate of 1 in 10 suggest CGM should be investigated in a targeted surgical group.
A novel cricoid pressure sensor device enhances the efficacy of oesophageal occlusion during Sellick's manoeuvre
Authors: Mishra Abhilasha , Ashok Vighnesh , Puri Goverdhan D. , Kumar Neelesh , Mathew Preethy J.
Published: November 2024

BACKGROUND

The inability to measure the force applied during cricoid pressure is an important limitation in clinical practice. We developed a novel device to measure this force and provide real-time feedback to the operator.

OBJECTIVES

To test the hypothesis of superior oesophageal occlusion during cricoid pressure when guided by the novel device as compared with conventional practice.

DESIGN

A prospective randomised controlled trial.

SETTING

Tertiary University Hospital, May to December 2021.

PATIENTS

Sixty-five ASA I/II adult patients of either sex scheduled for elective surgery under general anaesthesia requiring tracheal intubation. Patients with comorbidities involving the neck, those at risk of pulmonary aspiration, anticipated difficult airway and BMI at least 35 kg  m−2 were excluded.

INTERVENTION

Operators applied cricoid pressure with their fingers in both groups. Participants were randomised into ‘feedback group’ where the operator adjusted this force based on the force measured by the novel device, and ‘control group’ where the force measured by the device was shielded from the operator.

MAIN OUTCOME MEASURES

The primary outcome was the rate of occlusion of oesophageal opening assessed by whether a 12 CH orogastric tube could be inserted into the oesophageal entrance during videolaryngoscopy. Secondary outcomes included the magnitudes of force measured during cricoid pressure, oesophageal diameter measured ultrasonographically during cricoid pressure and intubation parameters.

RESULTS

Sixty-four patients completed the study. The oesophageal opening was occluded in significantly more patients in the feedback group compared with the control group (94 vs. 6%; P = 0.001). The mean ± SD force (N) applied was significantly better and consistent at all time points in the feedback group compared to the control group (22.65 ± 7.81 vs. 14.57 ± 11.13, P < 0.001). The median [IQR] anteroposterior diameter of the oesophagus during cricoid pressure was less in the feedback group compared to the control group (0.49 [0.36 to 0.56] vs. 0.57 [0.48 to 0.65], P = 0.006).

CONCLUSIONS

The use of the novel sensor device achieved a significantly high rate of oesophageal occlusion during application of cricoid pressure.

TRIAL REGISTRATION

Clinical Trial Registry of India (CTRI/2021/05/033484).
The Burden of Plastic Surgery in Rural Kenya: The Kapsowar Hospital Experience
Authors: Rhodes Isaiah J. , Arbuiso Sophia , Zhang Ashley , Alston Chase C. , Medina Samuel J. , Liao Matthew , Nthumba Joseph , Chesang Patricia , Hayden Giles , Rhodes William R. , Otterburn David M.
Published: November 2024

Purpose:

Both governmental and nongovernmental training programs are expanding efforts to train the next generation of plastic surgeons who will work in low- and middle-income countries (LMICs). Sufficient training is dependent on acquiring the appropriate skillset for these contexts. Few studies have characterized the spectrum of practice of plastic surgeons in LMICs and their relative disparity.

Methods:

We performed a retrospective review on all patients who received plastic surgery at a single institution in rural western Kenya from 2021 to 2023. Data such as diagnoses, procedures, and home village/town of residence were collected. Patient home location was geomapped using an open-access distance matrix application programming interface to estimate travel time based on terrain and road quality, assuming patient access to a private vehicle and ideal traveling conditions. Descriptive statistics were performed.

Results:

A total of 296 patients received surgery. Common procedures included treatment of cleft lip/palate (CLP), burn reconstruction, and reconstruction for benign tumors of the head and neck. The average distance to treatment was 159.2 minutes. Increased travel time was not associated with time to CLP repair (P > 0.05). Increased travel time was associated with delayed treatment for burns (P = 0.005), maxillofacial trauma (P = 0.032), and hand trauma (P = 0.016).

Conclusions:

Training programs for plastic surgeons in LMICs should ensure competency in CLP, flaps, burn reconstruction, and head and neck reconstruction. Our novel use of an application programming interface indicates that international partnerships have been more successful in decreasing treatment delays for CLP patients, but not other reconstructive procedure patients. Expanded commitment from international partners to address these reconstructive burdens in LMICs is warranted.
Role of the Pectoralis Major Muscle Flap in the Multidisciplinary Treatment of Esophageal Cancer
Authors: Barter Lauren , Forner David , French Daniel G. , Ednie Alexander , Darling Gail E. , Rigby Matthew H.
Published: November 2024

Background:

Management of esophageal cancer is complex. Esophagectomy is associated with risk of significant complications. In this case series, we share the experience of our multidisciplinary team of thoracic surgeons and otolaryngologists in managing complications arising in the surgical treatment of esophageal cancer with the assistance of regional tissue transfer in the form of the pectoralis major flap.

Methods:

We present a case series highlighting 3 patients who underwent esophagectomy who experienced significant anastomotic or conduit complications which were managed with a pectoralis muscle flap.

Results:

Complications included tracheoesophageal fistula, refractory stenosis, and gastric conduit necrosis. Using a pectoralis major muscle flap with both myocutaneous and myofascial transfers was key to successful management. In the first patient, esophageal stent erosion after posterior tracheal wall dissection resulted in a tracheoesophageal fistula reconstructed through interposition of a myofascial flap. In the second patient, a tubed myocutaneous flap was interposed between the remnant gastric conduit and cervical esophagus to manage a posttreatment stenosis following resection of the stenosed segment. Finally, a myofascial flap was utilized to bolster a colonic interposition flap after initial necrosis of a gastric conduit that necessitated the creation of a temporary pharyngocutaneous fistula and subsequent colon interposition.

Conclusions:

Multidisciplinary care and collaboration are integral components for optimization of patient outcomes. In this case series, otolaryngology and thoracic surgery utilized multiple tools within their armamentarium to manage complications associated with the surgical management of esophageal cancer.
Simultaneous Use of the Anterior Interosseous Nerve as Both a Target and Donor Nerve in Radial to Median Nerve Transfers
Authors: Kobraei Edward M.
Published: November 2024

Nerve transfers play a crucial role in the management of nerve injuries. I present a case where a young weightlifter had a devastating high median nerve injury resulting in absent thumb flexor pollicis longus function and absent flexor digitorum superficialis (FDS) and flexor digitorum profundus function of the index finger. An extensor carpi radialis brevis branch of the radial nerve was transferred to the anterior interosseous nerve (AIN), and the distal AIN was then mobilized and reflected from distal to proximal to supply a second nerve transfer to an FDS-index branch of the median nerve. In this configuration, the AIN served as both the target motor nerve for the first transfer and the donor nerve for the second transfer. The use of the AIN in this manner had the effect of minimizing donor morbidity (only 1 functioning donor nerve sacrificed) while also delivering an additional donor nerve to a target in an anatomically distinct area, avoiding sacrifice of additional donors or use of nerve grafts. The patient had full recovery of flexor pollicis longus function and flexor digitorum profundus index function at 10 months, as well as full recovery of FDS function of the index finger at 1.5 years postoperatively.
Cleft Lip and Palate Correction: The Utah Protocol
Authors: Battistini Andrea , Marquez Jessica Lee , Scaife Jack , Collar Lucia , Kim Erinn , Johns Dana , Yamashiro Duane , Gociman Barbu
Published: November 2024

Background:

Cleft repair remains a contentious issue in craniofacial surgery, especially regarding the optimal timing and techniques. This study aims to present our institutions’ current protocol for cleft lip and palate repair, including alveolar bone grafting (ABG).

Methods:

A total of 17 patients (20 clefts) treated with the latest protocol from 2016 to 2023 were evaluated. Demographic and clinical data were obtained from electronic charts. The protocol includes lip repair at 3 months, soft palate repair at 1 year, and hard palate closure with concurrent ABG at 2 years.

Results:

Mean graft height and thickness scores were 2.3 and 2.2, respectively. Three clefts showed scores marginally below the threshold for thickness, potentially requiring regrafting. Malocclusion was minimal with no significant crossbites or velopharyngeal insufficiency.

Conclusions:

Our modified protocol, emphasizing early hard palate closure with ABG, yields satisfactory outcomes in terms of graft height and thickness. Although long-term follow-up is warranted, our approach seems safe and efficient, potentially improving outcomes compared with traditional methods.
Pharmacologically enabling the degradation of NaV1.8 channels to reduce neuropathic pain
Authors: Martin Molly K. , Rodriguez Raider , Guerrero Giselle , Sheehan Garrett D. , Powell Rasheen , Klein Amanda H. , Bhattacharjee Arin
Published: November 2024

In phase II clinical trials, NaV1.8 channels were identified as viable targets to treat acute pain. Results were modest, however, and NaV1.8 pore blockers must be given systemically, potentially leading to adverse effects, especially during prolonged use. A local, long-lasting approach is desirable, yet local anesthetics are neither specific nor long-lasting. In lieu of a pore blocker approach, we show a pharmacological method targeting the scaffolding and degradation of NaV1.8 channels, which attenuated neuropathic pain behavior in mice. NaV1.8 channels interact with the WW domain–containing scaffold protein called Magi-1. WW domains are typically found in ubiquitin ligases, and NaV1.8 channels are susceptible to degradation by ubiquitin ligases. Here, we show NaV1.8 and MAGI-1 colocalized in human tissues. We demonstrate that a lipidated peptide derived from the NaV1.8 WW binding domain, at sub-micromolar concentrations, inhibited rodent dorsal root ganglion neuronal firing. The peptide reduced NaV1.8 channel immunoreactivity and tetrodotoxin-resistant currents in human dorsal root ganglion neurons. We found that the lipidated peptide attenuated neuropathic pain behaviors in mice for multiple weeks after a single injection. Our results reveal that the NaV1.8-targeted lipidated peptide provides local and sustained analgesia, serving as a viable alternative to NaV1.8 pore blockers.
Patient Preferences for Surgical Treatments for Benign Prostatic Hyperplasia: A Discrete Choice Experiment
Authors: Vennedey Vera , Holling Heinz , Steiner Thomas , Schrader Mark , Grossmann Heiko , Hoenig Christian
Published: November 2024

Purpose:

When symptoms of benign prostatic hyperplasia cannot or can no longer be treated by conservative treatment options adequately, various surgical treatment options are available. Different risks and benefits are associated with each type of surgery; the optimal choice depends on the patient's preference. This study analyzes patients' preferences and investigates patient characteristics that might influence patient preferences in Germany.

Materials and Methods:

We conducted an online discrete choice experiment based on 9 treatment attributes related to risks (probability of ejaculatory dysfunction, permanent incontinence, needing surgery again, and erectile dysfunction) and efficacy (frequency of daytime and nighttime urination, urgency and duration of urination, and time until symptoms improve) of surgeries. To estimate preferences, we applied a mixed-logit model. Subgroup analyses based on patients' characteristics were conducted.

Results:

Three hundred thirty participants completed the discrete choice experiment. Overall, participants preferred a lower risk of ejaculatory dysfunction, lower urgency and duration of urination, lower probability of permanent incontinence, lower frequency of nighttime and daytime urination, and lower probability of needing another surgery. Moreover, a faster onset of overall symptom reduction was preferred. Several patient characteristics especially characteristics related to a patient's sexual life seem to influence patients' preferences.

Conclusions:

Significant preference heterogeneity could be observed in this study, and subgroup analyses suggest differences in preferences in relation to patients' characteristics. These findings highlight the need for individualized treatment decisions. Physicians should evaluate patients' clinical but also inquire about a patient's personal situation and preferences to select the optimal treatment in collaboration with the individual patient.
ICU nutrition research: did the evidence get better? Remaining sources of bias
Authors: Koretz Ronald L.
Published: November 2024

Purpose of review

To assess the quality of recently published (18 months from date of article request) randomized trials/systematic reviews of such trials that addressed the use of nutritional support in critically ill patients.

Recent findings

Eligible papers were published between October 1, 2022 and April 7, 2024, only enrolled adults, described a comparison of a nutritional intervention to something else, and reported a clinically relevant outcome. Thirteen randomized trials and four systematic reviews of randomized trials were identified. Quality was assessed by determining the risks of bias of each trial. Two of these trials were at low risk of bias, six were rated as having some concern(s) about bias, and five were at high risk of bias. The four systematic reviews included 55 randomized trials; four were at low risk, 31 had some concerns, and 20 were at high risk. No randomized trial comparing nutritional support to a true control (no nutritional support) was identified in this search; seven older trials, all small and containing risks of bias, failed to demonstrate any consistent differences in clinical outcomes.

The quality of the trials underlying the use of nutritional support in the intensive care unit is not very high.
A nonlinear relationship between dietary inflammatory index and stroke among US adults with metabolic dysfunction-associated steatotic liver disease
Authors: Guo Renwei , Du Juan
Published: November 2024

Background

Some studies have found that high dietary inflammatory index (DII) increases stroke risk, but previous studies have mostly been conducted in the general population, and the exact relationship between DII and stroke in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) is not clear.

Methods

This cross-sectional study utilized data from the National Health and Nutrition Examination Survey (2009–2016) to investigate the association between the DII and stroke. DII was computed according to established methods. Participants were categorized into tertiles of DII (Q1–Q3). Multivariate weighted logistic regression analysis, smooth curve fitting, and subgroup analysis were employed to explore this relationship. Subgroup analyses were conducted based on demographic and clinical variables.

Results

A total of 2426 individuals were enrolled in our study. The overall prevalence of stroke in the study population was 4.66%. The smooth curve fitting analysis indicated a J-shaped relationship between DII and stroke among individuals with MASLD. In multivariate weighted logistic regression analysis, the odds ratio (OR) of DII is 1.17 (95% CI: 1.03–1.38) for stroke, with a turning point of 1.89. After the turning point, the OR (95% CI) was 1.22 (1.08–2.56). In subgroup analysis, DII still increased the risk of stroke independently.

Conclusion

Our study highlighted a J-shaped association between DII and stroke in adults with MASLD from USA.
Healthcare utilisation patterns and drivers amongst inflammatory bowel disease patients in the outpatient clinic
Authors: Koppelman Lola J.M. , Maljaars P.W. Jeroen , Voorneveld Philip W. , van der Meulen-de Jong Andrea E.
Published: November 2024

Objective

Inflammatory bowel disease (IBD), encompassing Crohn’s disease and ulcerative colitis, impose an escalating burden on healthcare systems globally, with a rising prevalence contributing to increased costs. This study explored healthcare utilisation patterns and its drivers amongst IBD patients in an outpatient clinic.

Methods

A longitudinal cohort study was conducted at a Dutch academic teaching hospital. IBD patients (n = 180) were followed for 1 year and were categorised based on disease activity and consultation frequency. Healthcare utilisation was assessed through consultations and laboratory tests. Patient-reported outcomes and biochemical disease activity were measured, and subsequently the reasons for consultations were analysed.

Results

The frequency of outpatient healthcare utilisation exceeded the recommended IBD care guidelines by two-fold. Comorbidities were the leading reason for consultations (40.4%), followed by remission induction, medication changes and pending test results. Moreover, clinical disease activity, reported problems with self-care, daily activities and pain were predictive of an increase in annual consultations.

Conclusion

This study identified factors influencing healthcare utilisation in IBD outpatients. Personalised care pathways using eHealth technologies have the potential to reduce unnecessary consultations and optimise resource allocation.
Specific, Measurable, Action-Oriented, Realistic, and Timed Goals and the Personal Health Inventory in a Wellness Group for Veterans With GWI
Authors: McQuade Maria , Polizzi Craig P. , Katz Emma , Ting Maria , Busser Cameron , Paszkiewicz Matthew , Mori DeAnna L. , Niles Barbara L.
Published: November 2024

Background:

Interventions based on the Veterans Health Administration’s (VHA) Whole Health (WH) initiative may be beneficial for veterans with Gulf War Illness (GWI) through specific, measurable, action-oriented, realistic, and timed (SMART) goal setting and monitoring of perceived goal attainment with the Personal Health Inventory (PHI).

Objectives:

This secondary analysis of 2 randomized controlled trials focused on (1) categorizing SMART goals set during a wellness intervention based on the VHA’s WH approach to identify goals most relevant for veterans with GWI and chronic pain and (2) descriptively examining the PHI over a course of treatment to assess its preliminary sensitivity to change. Also, changes in PHI for those who engaged in the intervention in-person versus remotely were compared.

Subjects:

Participants were 49 veterans with GWI and chronic pain who received a 12-week, 24-session group wellness intervention delivered in-person or remotely due to the COVID-19 pandemic.

Results:

SMART goal themes mapped onto the 8 areas of self-care presented in the WH program’s circle of health with high categorical adherence. Most participants set goals in categories for working the body, food and drink, and personal development. The wellness intervention was related to improvements in perceived goal attainment as measured by the PHI in both in-person and remote participants, which indicates that the PHI may be sensitive to change over time.

Conclusions:

These preliminary findings set the stage for future research on wellness interventions for veterans with GWI and chronic pain and the measurement of whole-person outcomes.
Assessing Whole-Person Outcomes During Routine Clinical Care
Authors: Parr Nicholas J. , Young Sarah , Baltich Nelson Becky
Published: November 2024

Objective:

To identify and describe research conducted on the implementation, validity, and utility of whole-person outcome measures administered during routine inpatient or outpatient care.

Background:

Incorporating information about patients’ overall health, health-related quality of life, and global well-being into health care delivery has the potential to increase referral rates, enhance doctor-patient communication, and improve the detection of untreated symptoms. Assessment of these whole-person outcomes during routine clinical care is of broad interest to health care providers and health systems.

Methods:

We employed a scoping review design and searched Ovid MEDLINE, APA PsycINFO, and CINAHL for relevant English-language primary studies and systematic reviews published through November 13, 2023. Screening for inclusion and data abstraction were conducted by 1 investigator then checked by another. Study risks of bias and the strength of available evidence were not assessed.

Results:

Of 1327 potentially relevant publications, 44 primary studies and 5 systematic reviews met eligibility criteria. Assessment of global well-being was comparatively less researched than overall health or health-related quality of life. Available research provided a range of perspectives on the performance, feasibility, acceptability, implementation, and clinical utility of whole-person outcome measures. No studies reported change in patient health or disease outcomes attributed to whole person outcome assessment (directly or through changes to care delivery).

Conclusions:

Currently available evidence provides insights about the performance and implementation of whole-person outcome measures during routine clinical care, but no studies are available that examine the impact of assessing whole-person outcomes on clinical or patient outcomes.
A Perspective on the Measurement of Whole Person Health
Authors: Herman Patricia M. , Rodriguez Anthony , Edelen Maria Orlando , DiGuiseppi Graham , Zeng Chengbo , Coulter Ian D. , Hays Ron D.
Published: November 2024

There is growing interest in moving away from a reductionistic view of the person and the health services they need to focus on improving the health of the whole person. However, there needs to be agreement about what this focus entails and how to measure its achievement. From this perspective, we offer suggestions for moving the measurement discussion forward. Our key suggestion is to separate the measurement of whole person health (WPH)—that is, the end goal or ultimate outcome we want to improve and/or maintain—from the measurement of WPH determinants—that is, the things that can be intervened upon to maximize WPH. We also offer some next steps toward developing a measure of WPH.
Cultural Transformation of the International Statistical Classification of Diseases and Related Health Problems’ Guidelines Needed to Effectively Measure Well-Being
Authors: Hooshyar Dina , Bruton Maria
Published: November 2024

A cultural transformation is underway at the Veterans Health Administration and other health care systems to address the well-being of the whole person and not just their disease states. A part of this evolution is to develop a measurement paradigm because the existing ones are generally disease-specific; however, the International Statistical Classification of Diseases and Related Health Problems (ICD)-10th Revision-Clinical Modification does include codes for social determinants of health (SDOH). The ICD coding system is an internationally recognized system to identify and classify diseases, injuries, health encounters, and inpatient procedures. Medical and social service providers, researchers, health information managers, public health and health care system professionals, policymakers, and coders use these codes to conduct surveillance, such as on the existence of diseases and their outcomes, health care utilization, and health care–associated adverse events, and for billing and claims reimbursement. The ICD coding system has been the backbone of health care systems’ clinical documentation and coding practices on an international level since 1909. Clinical documentation and coding have an immense influence on what can be measured in medical records. The current ICD guidance needs to undergo a cultural transformation to have parity between codes for medical and nonmedical conditions, such as supporting the standard use of SDOH as primary diagnoses for outpatient encounters, expanding its list of SDOH codes, and incorporating a wellness perspective. Developing a measurement paradigm that assesses the well-being of the whole person must involve in tandem revising the ICD coding system to include this same perspective.
Prioritizing Veteran Social Well-Being
Authors: Britch Ryan , Richards Kaitlin , Williams Kayla , Wolfe Hill L.
Published: November 2024

The Department of Veteran Affairs (VA) has an increased interest in addressing the well-being and whole health of Veterans. In March of 2023, the VA convened a conference to discuss whole-person outcomes of relevance for Veterans in clinical, research, and population health areas. Based upon perceptions from conference participants who are Veteran community members, the aim of this manuscript is to offer a Veteran community perspective on the importance of prioritizing social well-being as part of VA Whole Health programming. Through the involvement of Veterans, their caregivers and their families, the VA can offer a more culturally relevant model of holistic care that promotes social belonging, connectedness, and support for all Veterans.
Health and Well-Being
Authors: Langevin Helene M.
Published: November 2024

The concepts of health and well-being are deeply intertwined and interdependent. Situating both health and well-being within a unified framework is important to ensure their inclusion in the full spectrum of health research and to achieve the crucial task of building a body of basic, translational, and clinical studies to guide the implementation of whole-person health care. This commentary proposes such a framework where an individual’s own assessment of their physical, emotional, and spiritual well-being complements objective measures of their physical and psychological function and where social, environmental, economic, educational, and vocational well-being are located within positive determinants of health.
Is the PHQ-2 a Good Measure to Inform Providers About Patient Well-Being and Functioning? Data From the Veterans Health and Life Survey
Authors: Reed David E. , Engel Charles C. , Coggeshall Scott , Michel Martha , Etingen Bella , Bolton Rendelle E. , Kroenke Kurt , Bokhour Barbara G. , Zeliadt Steven B.
Published: November 2024

Background:

Health care systems are increasingly focused on assessing patient well-being and functioning. The objective of the current analysis was to evaluate a pragmatic question: to what extent and in what way can the PHQ-2, a routinely collected screening measure, be used to help clinicians and a learning health system understand the well-being and functioning of its beneficiaries?

Methods:

The current analysis focused on 2872 Veterans who completed a large-scale longitudinal survey about health and wellness for whom we were able to link survey responses to PHQ-2 scores recorded in their electronic health records (EHR). Regression analyses examined the cross-sectional and longitudinal associations between PHQ-2 scores recorded in the EHR and measures of well-being (life satisfaction, purpose in life, and social health) and functioning (pain severity and interference, physical and mental health, and perceived stress).

Results:

Veterans were aged 65 years on average (11% women). PHQ-2 scores were correlated cross-sectionally with all well-being and functioning measures; however, there was minimal variance accounted for. Changes in the PHQ-2 over time were associated with 3 measures: purpose in life (b = −0.19; 95% CI: −0.34, −0.04), mental health functioning (b = −0.29, 95% CI: −0.54, −0.04), and perceived stress (b = 0.13; 95% CI: 0.02, 0.24).

Conclusions:

The PHQ-2 was minimally associated with patient well-being and functioning, with more work needed on how the PHQ-2 may be used in large health care settings within the context of VA Whole Health. Assessment of well-being is critical as VA’s Whole Health transformation continues, and identifying strategies for well-being measurement is an integral next step.
Planned Home Births in the United States Have Outcomes Comparable to Planned Birth Center Births for Low-Risk Birthing Individuals
Authors: Bovbjerg Marit L. , Cheyney Melissa , Hoehn-Velasco Lauren , Jolles Diana , Brown Jennifer , Stapleton Jennifer , Everson Courtney , Stapleton Susan , Vedam Saraswathi
Published: November 2024

Objective:

There are lingering concerns in the United States about home birth. We used 2 large (n = 50,043; n = 62,984), national community birth registries to compare maternal and neonatal outcomes for planned home versus planned birth center births.

Methods:

To compare outcomes by intended birth site, we used logistic regressions, controlling for demographic and pregnancy risk variables. Maternal outcomes included intrapartum or postpartum transfer to hospital, hospitalization, cesarean, and hemorrhage; neonatal outcomes included neonatal transfer, hospitalization, neonatal intensive care unit admission, and intrapartum or neonatal death. Analyses were conducted twice, once in each dataset.

Results:

Individuals who planned home births had a lower incidence of all types of transfers, compared with those who planned birth center births, but in one dataset only, experienced more cesareans [adjusted odds ratio (95% CI): 1.32 (1.02–1.70); 0.95 (0.88–1.03)]. Planned home birth was associated with lower adjusted odds of maternal hospitalization in one dataset but not the other [0.97 (0.54–1.74); 0.85 (0.76–0.95)], and was not associated with hemorrhage. Neonatal outcomes likewise were either not associated with a planned birthplace or suggested home birth was safer: hospitalization [0.77 (0.53–1.11), 0.90 (0.82–0.98)], neonatal intensive care unit admission [0.54 (0.28–1.00), 0.97 (0.86–1.10)]. There was no observable association with intrapartum or neonatal death: 1.07 (0.68–1.67; only calculated once because of small numbers of events).

Conclusions:

Planned home births are as safe as planned birth center births for low-risk pregnancies. Current guidelines advising against planned home births are not supported by these data.
Measuring the Well-Being of the Whole Person in Clinical Care, Health Research, and Population Health Evaluation
Authors: Vogt Dawne , Kligler Benjamin , Darchuk Kathleen , Elbogen Eric , List Justin M. , McMullen Tara , Murphy Jennifer L. , Bokhour Barbara
Published: November 2024

Objectives:

In 2023, the U.S. Veterans Health Administration convened a State of the Art meeting to evaluate the existing evidence and make recommendations for measuring the well-being of the whole person in clinical care, health research, and population health evaluation. In this article, we describe findings and recommendations concerning each of these health care system functions, as well as key takeaways from the meeting as a whole.

Background:

There has been a growing call for health care organizations to expand their focus beyond disease-based concepts to consider both positive aspects of health and indicators of well-being that extend beyond the health domain. Yet, knowledge remains limited regarding how best to integrate these types of measurements in clinical care, health research, and population health evaluation efforts.

Method:

State of the Art activities were organized into 3 workstreams, each focused on a core health care system function (clinical care, health research, and population health evaluation). Drawing from existing literature on the measurement of the well-being of the whole person in the assigned health care function, workgroups evaluated the existing state of knowledge and made recommendations for future work on well-being measurement in the health care setting.

Results:

Cross-cutting themes included: (1) difficulty evaluating the current state of knowledge due to varied use of terminology in this literature; (2) appreciation for the value of well-being measurement in each health care function; (3) need for additional research on the use and benefits of well-being measures, including their role as predictors and moderators of health and health care outcomes; (4) importance of ensuring that measures are applicable for diverse patient groups and adequately reflect the “patient voice;” and (5) need for additional leadership investment and resource allocation to support use of these measures in the health care setting.

Conclusions:

Knowledge from this meeting can be applied to enhance the use and application of measurement of well-being to improve patients’ health and health care outcomes.
Pain and small fiber pathology in men with fibromyalgia syndrome
Authors: Feulner Betty , Gross Franziska , Evdokimov Dimitar , Malik Rayaz A. , Kampik Daniel , Üçeyler Nurcan
Published: November 2024

Introduction:

Small fiber pathology may be involved in the pathophysiology of pain in women with fibromyalgia syndrome (FMS).

Objectives:

This prospective single-center case-control study provides detailed pain phenotyping and small fiber pathology data in a cohort of men with FMS on a morphological and functional level.

Methods:

Forty-two men with FMS underwent a comprehensive pain-related interview and neurological examination, a questionnaire and neurophysiological assessment, and specialized small fiber tests: skin punch biopsy, quantitative sensory testing including C-tactile afferents, and corneal confocal microscopy. Data were compared with those of healthy male controls.

Results:

Men with FMS reported generalized and permanent pain with additional pain attacks and a mostly pressing pain character. Intraepidermal nerve fiber density was reduced at ≥1 biopsy site in 35 of 42 (83%) men with FMS (controls: 32/65, 49%). Compared with male controls, men with FMS had elevated cold (P < 0.05) and warm detection thresholds (P < 0.001) and an increased mechanical pain threshold (P < 0.05) as well as an impairment of C-tactile afferents (P < 0.05). Corneal nerve fiber density was lower in male patients with FMS vs healthy men (P < 0.01). Male FMS patients with pathological skin innervation at ≥1 biopsy site compared with those with normal skin innervation had a higher clinical Widespread Pain Index (P < 0.05) indicating an association between the severity of cutaneous denervation and symptom load.

Conclusion:

We show a distinct pain phenotype and small nerve fiber dysfunction and pathology in male patients with FMS. These findings may have implications for the diagnosis and management of men with FMS.
Unexpected Pathology During Pelvic Organ Prolapse Repair in an Urban Population
Authors: Gandelsman-Ginis Johanna , Bentley Stephanie , Khan Fareesa , Brincat Cynthia , O’Shea Michele
Published: November 2024

Importance

This study quantifies the occult pathology risk among our urogynecologic patient population and highlights the importance of preoperative counseling, particularly in patients who have been underrepresented in prior studies.

Objective

The aim of the study was to estimate unexpected gynecologic pathology incidence among a low-risk, racially, and ethnically representative patient population undergoing surgery for symptomatic pelvic organ (POP) prolapse.

Study Design

This was a retrospective study of patients undergoing hysterectomy for POP at an urban academic medical center. Patients with abnormal preoperative pathologic evaluation were excluded. Data were abstracted from the electronic health record, including demographic and clinical history, preoperative laboratory evaluation, and clinical risk factors for gynecologic malignancy.

Results

Two hundred ninety-nine nononcologic patients who underwent POP repair with hysterectomy were assessed. Thirty-six percent of patients identified as Hispanic, 17% as non-Hispanic Black, and 38% as non-Hispanic White. Twenty-three percent of patients reported abnormal uterine bleeding, 36% underwent a preoperative ultrasound examination, and 15% underwent endometrial biopsy. Two patients (0.9%) were diagnosed with endometrial carcinoma. Two patients (0.9%) were diagnosed with cervical dysplasia. No patients with concurrent oophorectomy or salpingectomy had ovarian or tubal pathology. The overall incidence of unexpected gynecologic pathology at the time of hysterectomy for prolapse was 1.7%.

Conclusions

The rate of endometrial cancer in our cohort is on the higher end of previously published data, although absolute rates of unanticipated malignancy remain low. Future studies should examine the pathological findings of larger, racially, and ethnically diverse cohorts of patients undergoing POP surgery with hysterectomy, which can aid in providing relevant estimates for preoperative counseling.
The Impact of Smoking on Sacrocolpopexy Perioperative Outcomes: An Observational Study
Authors: Saleeb Monica S. , Wang Rui , Sappenfield Elisabeth C.
Published: November 2024

Importance

Tobacco smoke is a modifiable risk factor that surgeons discuss with patients prior to undergoing sacrocolpopexy or mesh revision surgery.

Objective

The aim of the study was to investigate the effect of smoking on perioperative outcomes after sacrocolpopexy for pelvic organ prolapse and mesh revision repair.

Study Design

This was a retrospective cohort study of data obtained from the National Surgical Quality Improvement Project’s database. Women who underwent surgery for pelvic organ prolapse via abdominal sacrocolpopexy (ASCP) or minimally invasive sacrocolpopexy (MISCP) or prolapse mesh revision surgery from 2011 to 2021 were identified and compared based on current tobacco use. Demographic, medical, and surgical history, as well as intraoperative and 30-day perioperative outcomes, were compared. Multivariate analysis was performed.

Results

Overall, 21,980 women underwent MISCP (8.60% smokers) and 3,775 underwent ASCP (8.74% smokers). Postoperative wound infections were more common after sacrocolpopexy in patients who smoked. Readmission after MISCP was more common in smokers. The composite perioperative morbidity score was different between smokers and nonsmokers for MISCP (P = 0.001) and ASCP (P = 0.002). Multivariate analyses of MISCP outcomes found an association between smoking and wound infection, readmission, and composite score. Multivariate analyses of ASCP outcomes found an association between smoking and wound infection. Overall 2,160 patients underwent mesh removal by any modality (16.57% smokers), and no difference in perioperative outcomes between smokers and nonsmokers for mesh removal was found.

Conclusions

An association was found between tobacco smoking and wound infection as well as other postoperative complications. Tobacco use prior to a mesh excision procedure does not appear to increase perioperative outcomes.