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Abstract Background Delirium, an acute brain dysfunction, is proposed to be highly prevalent in clinical care and shown to significantly increase the risk of mortality and dementia. Objectives To report on the global prevalence of clinically documented delirium and delirium-related clinical practices in wards caring for paediatric and adult patients in healthcare facilities. Design A prospective, cross-sectional, 39-question survey completed on World Delirium Awareness Day, 15 March 2023. Participants Clinicians or researchers with access to clinical data. Main Outcome and Measure The primary outcome was the prevalence of clinically documented delirium at 8:00 a.m. (4 h) and 8:00 p.m. (±4 h). Secondary outcomes included delirium-related care practices and barriers to use. Descriptive statistics were calculated and multilevel modelling was completed. Results 1664 wards submitted surveys from 44 countries, reporting on delirium assessments at 8:00 a.m. (n = 36 048) and 8:00 p.m. (n = 32 867); 61% reported use of validated delirium assessment tools. At 8:00 a.m., 18% (n = 2788/15 458) and at 8:00 p.m., 17.7% (n = 2454/13 860) were delirium positive. Top prevention measures were pain management (86.7%), mobilisation (81.4%) and adequate fluids (80.4%). Frequently reported pharmacologic interventions were benzodiazepines (52.7%) and haloperidol (46.2%). Top barriers included the shortage of staff (54.3%), lack of time to educate staff (48.6%) and missing knowledge about delirium (38%). Conclusion and Relevance In this study, approximately one out of five patients were reported as delirious. The reported high use of benzodiazepines needs further evaluation as it is not aligned with best-practice recommendations. Findings provide a benchmark for future quality improvement projects and research.

Abstract Background Data on the relative utilization and outcomes of transcatheter aortic valve replacement (TAVR) versus surgical AVR (SAVR) in patients <65 years are limited. Purpose To compare the relative utilization and outcomes of TAVR versus SAVR in patients <65 years in the United States. Methods We queried the National Inpatient Sample (2016-2020) to identify patients <65 years hospitalized for isolated AVR. In-hospital outcomes of TAVR versus SAVR were compared using multivariable regression and propensity-matching analyses. Results Of 74,155 patients aged <65 years hospitalized for isolated AVR, 17,300 (23.3%) underwent isolated TAVR, and 56,855 (76.7%) underwent isolated SAVR. From 2016-2020, the use of TAVR increased, while the use of SAVR decreased in patients <65 years (both ptrend<0.01). Factors independently associated with TAVR selection in patients <65 years included female sex, congestive heart failure, pulmonary disease, renal failure, liver disease, cancer, and prior revascularization. Factors independently associated with SAVR selection included bicuspid aortic valve. After adjustment for baseline characteristics, TAVR was associated with lower odds of in-hospital mortality (adjusted odds ratio [aOR] 0.61, 95% confidence interval [CI] 0.38-0.97), stroke (aOR 0.58, 95% CI 0.38-0.90), acute kidney injury (aOR 0.41, 95% CI 0.34-0.49), and major bleeding (aOR 0.62, 95% CI 0.38-0.96), and higher vascular complications compared with SAVR (aOR 2.39, 95% CI 1.75-3.24). Length of stay was shorter and nonhome discharges were lower with TAVR (all p<0.01). Similar findings were observed in the propensity-matched cohort. Conclusions This nationwide observational analysis showed that TAVR is a feasible treatment option for patients <65 years with lower in-hospital mortality and resource utilization compared with SAVR.Central Illustration

Abstract Background and Objectives Gastric varices (GVs) are associated with a higher risk of uncontrolled bleeding and death when compared with esophageal varices. While endoscopic glue injection therapy has been traditionally used for secondary prophylaxis in GV, data regarding primary prophylaxis continue to emerge. Recently, EUS–guided therapies have been used in GV bleeding. Methods We conducted a comprehensive search of several major databases from inception to June 2022. Our primary goals were to estimate the pooled rates of treatment efficacy, GV obliteration, GV recurrence, and rebleeding with EUS-guided therapy in primary and secondary prophylaxis. Overall adverse events and technical failures were assessed. Random-effects model was used for our meta-analysis, and heterogeneity was assessed using the I 2 % statistics. Results Eighteen studies with 604 patients were included. In primary prophylaxis, pooled rate of GV obliteration was 90.2% (confidence interval [CI], 81.1–95.2; I 2 = 0). With combination EUS–glue and coil therapy, the rate was 95.4% (CI, 86.7%–98.5%; I 2 = 0). Pooled rate of posttherapy GV bleeding was 4.9% (CI, 1.8%–12.4%; I 2 = 0). In secondary prophylaxis, pooled rate of treatment efficacy was 91.9% (CI, 86.8%–95.2%; I 2 = 12). With EUS-glue, EUS-coil, and combination EUS–glue and coil, the rates were 94.3% (CI, 88.9%–97.1%; I 2 = 0), 95.5% (CI, 80.3%–99.1%; I 2 = 0), and 88.7% (CI, 76%–95.1%; I 2 = 14), respectively. Pooled rate of GV obliteration was 83.6% (CI, 71.5%–91.2%; I 2 = 74). With EUS-glue, EUS-coil, and combination EUS–glue and coil, the rates were 84.6% (CI, 75.9%–90.6%; I 2 = 31), 92.3% (CI, 81.1%–97.1%; I 2 = 0), and 84.5% (CI, 50.8%–96.7%; I 2 = 75), respectively. Pooled rates of GV rebleeding and recurrence were 18.1% (CI, 13.1%–24.3%; I 2 = 16) and 20.6% (CI, 9.3%–39.5%; I 2 = 66), respectively. Conclusion Our analysis shows that EUS-guided therapy for GVs is technically feasible and clinically successful in both primary and secondary prophylaxis of GV.

Abstract During the past several decades, medical education research has advanced in many ways. However, the field has struggled somewhat with translating knowledge into practice. The field has tremendous potential to generate insights that may improve educational outcomes, enhance teaching experiences, reduce costs, promote equity, and inform policy. However, the gap between research and practice requires attention and reflection. In this commentary, the authors reflect on ways that medical education researchers can balance relevance and rigor, while discussing a potential path forward. First, medical education research can learn from implementation science, which focuses on adopting and sustaining best practices in real-world settings. Second, gaining a deeper understanding of the complex and dynamic ways that medical education contexts may influence the uptake of research findings into practice would facilitate the translation and mobilization of knowledge into practical settings. Third, moving from unilateral knowledge translation to participatory knowledge mobilization and engaging diverse stakeholders as active participants in the research process can also enhance impact and influence research findings. Overall, for medical education research to effect meaningful change, it must transition from producing generalizable findings to generating context-specific insights and embracing participatory knowledge mobilization. This shift will involve rethinking traditional research approaches and fostering collaboration with knowledge users to cocreate and implement innovative solutions tailored to their unique settings.

ABSTRACT Background Pancreatoduodenectomy (PD) for pancreatic cancer has a profound impact on patients' lives. However, the long‐term financial implications are poorly understood. Objective Assess the financial burden of long‐term survivors who underwent PD. Methods Patients who underwent PD between January 2011 and June 2019 were identified. To evaluate the long‐term financial burden, patients surviving ≥ 3 years post‐resection were prospectively surveyed using the Comprehensive Score for financial Toxicity (COST‐FACIT) and a customized institutionally developed questionnaire. A logistic regression model predicting high financial toxicity was used to identify predictive factors. Results Among 238 eligible patients, 137 (57.6%) responded. Responders had a median age of 66 (59–73) years, with 86.7% identifying as financial prosperous or comfortable. However, 33.3% experienced financial distress due to treatment costs, 27.3% demonstrated high financial toxicity on the COST‐FACIT survey, and 37.2% made sacrifices to afford treatment. Only 8.9% stated that the treatment costs influenced their decisions, and the majority (85.9%) did not discuss financial implications with healthcare providers. Multivariable analysis identified younger age as a risk factor for high financial toxicity. Conclusion One in three long‐term survivors experienced high financial toxicity, with younger age being a predictor. This emphasizes the need for efforts to provide comprehensive support and guidance to patients to navigate their oncological journey.

BACKGROUND AND OBJECTIVES: Stereotactic radiosurgery (SRS) with neoadjuvant embolization is a treatment strategy for brain arteriovenous malformations (AVMs), especially for those with large nidal volume or concomitant aneurysms. The aim of this study was to assess the effects of pre-SRS embolization in AVMs with an associated intracranial aneurysm (IA). METHODS: The International Radiosurgery Research Foundation AVM database from 1987 to 2018 was retrospectively reviewed. SRS-treated AVMs with IAs were included. Patients were categorized into those treated with upfront embolization (E + SRS) vs stand-alone SRS (SRS). Primary end point was a favorable outcome (AVM obliteration + no permanent radiation-induced changes or post-SRS hemorrhage). Secondary outcomes included AVM obliteration, mortality, follow-up modified Rankin Scale, post-SRS hemorrhage, and radiation-induced changes. RESULTS: Forty four AVM patients with associated IAs were included, of which 23 (52.3%) underwent pre-SRS embolization and 21 (47.7%) SRS only. Significant differences between the E + SRS vs SRS groups were found for AVM maximum diameter (1.5 ± 0.5 vs 1.1 ± 0.4 cm 3 , P = .019) and SRS treatment volume (9.3 ± 8.3 vs 4.3 ± 3.3 cm 3 , P = .025). A favorable outcome was achieved in 45.4% of patients in the E + SRS group and 38.1% in the SRS group ( P = .625). Obliteration rates were comparable (56.5% for E + SRS vs 47.6% for SRS, P = .555), whereas a higher mortality rate was found in the SRS group (19.1% vs 0%, P = .048). After adjusting for AVM maximum diameter, SRS treatment volume, and maximum radiation dose, the likelihood of achieving favorable outcome and AVM obliteration did not differ between groups ( P = .475 and P = .820, respectively). CONCLUSION: The likelihood of a favorable outcome and AVM obliteration after SRS with neoadjuvant embolization in AVMs with concomitant IA seems to be comparable with stand-alone SRS, even after adjusting for AVM volume and SRS maximum dose. However, the increased mortality among the stand-alone SRS group and relatively low risk of embolization-related complications suggest that these patients may benefit from a combined treatment approach.

Abstract We conducted this systematic review and meta-analysis to clarify the trend of precocious puberty (PP) incidence after the COVID-19 outbreak and explore potential contributing factors, such as age at presentation and body mass index (BMI) SD score (SDS). Children visiting pediatric endocrinology clinics for the first time for suspected PP were included. We searched databases until February 28, 2023, for studies reporting various indicators of PP incidence before and during the pandemic. Total numbers of events and observations were recorded. A meta-analysis was performed to compare the odds of PP, BMI SDS, and age at presentation between the 2 periods. The dose-response relationships between time points (by number of years away from the pandemic) and PP risk were explored. In summary, a total of 32 studies including 24 200 participants were recruited. The COVID-19 pandemic was associated with the increasing odds of PP among children referred for a suspicious condition (odds ratio = 1.96; 95% CI, 1.56-2.47; I2 = 54%; P < .001). Sensitivity analysis confirmed the robustness of the findings. The BMI SDS did not vary between the 2 periods, whereas age at presentation was lower after the pandemic. Precocious puberty incidence increased more rapidly during the pandemic period than during the prepandemic period. Trial registration: International Prospective Register of Systematic Reviews (PROSPERO; identifier: CRD42023402212)