Citations

ABSTRACT Rationale Longer duration of epilepsy before surgery is a predictor of poor outcome. While referral delays of surgical candidates are well documented, factors causing delay during the presurgical evaluation remain unclear and may vary depending on institutional characteristics. By benchmarking the duration of presurgical evaluation across multiple centers and identifying patient and evaluation characteristics contributing to duration, we can ascertain best practices and address modifiable contributors to reduce delays. Methods We queried the Pediatric Epilepsy Research Consortium Surgery Database, a prospective, observational multicenter study enrolling children 0–18 years at 27 US pediatric epilepsy centers, for all patients undergoing initial presurgical evaluation for drug‐resistant epilepsy (DRE). We included patients with completed evaluations and data on duration from initiation of presurgical evaluation to final surgical decision. We compared patient characteristics and evaluation components between those with long duration evaluations (> 75% quartile) and those with short evaluations (< 25% quartile). Akaike information criteria selection identified variables associated with longer duration. From these, we developed a logistic prediction model for evaluation duration, using a random 80/20 training/testing split of the entire cohort. The model was tested among institutions with ≥ 10 patients in the cohort to assess its accuracy in predicting long durations. Linear models for each site assessed each variable's impact on duration. Variables with < 10% of the patient population at each site were excluded. Beta values were compared to identify intra‐ and inter‐institution variability and to delineate institutions with the shortest added duration for each variable. Results Of 2318 patients undergoing surgical evaluation, 1655 (71%) from 23 sites had complete data. Median evaluation duration was 8 weeks (interquartile range 3–22); 453 (27%) were short‐duration evaluations and 414 (25%) were long‐duration evaluations. Multiple patient and evaluation characteristics were associated with duration (Table 1). Table 6 provides the average duration each variable contributes to evaluation by site, highlighting the shortest durations compared with other groups. Conclusions Duration of presurgical evaluation for DRE can be accurately modeled using multiple patient characteristics and testing strategies commonly employed in epilepsy surgery evaluations. This predictive model can not only estimate evaluation duration but also identify opportunities to improve systemic efficiency. Institution‐level modeling identifies specific program strengths, providing an opportunity to learn from successful processes. Subsequent research will focus on institutional process mapping to better understand systemic practices that lead to improved efficiencies, then sharing these processes across the consortium to shorten evaluation durations.

Background Percutaneous left atrial appendage occlusion (LAAO) is an alternative to long‐term anticoagulation for preventing ischemic stroke in patients with atrial fibrillation. There are limited long‐term outcomes data for “real‐world” patients undergoing LAAO. Methods We performed a retrospective cohort study using the National Cardiovascular Data Registry LAAO registry from January 1, 2016, through December 31, 2019. We linked LAAO data to inpatient Medicare fee‐for‐service claims data using probabilistic matching to establish a cohort of patients 65 years and older undergoing LAAO with a WATCHMAN device. The primary outcomes were any stroke and all‐cause mortality. Results A total of 34 975 patients with a mean±SD CHA 2 DS 2 ‐VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, previous stroke or transient ischemic attack, vascular disease, age 65 to 74 years, and sex category) score of 4.7±1.4 were included. The median follow‐up was 2.8 years (interquartile range, 2.2–3.7 years). The cumulative incidence of any stroke was 1.57 per 100 person‐years (95% CI, 1.45–1.70), with a 1‐year and 5‐year any stroke estimate of 1.70% (95% CI, 1.57–1.84%) and 5.70% (95% CI, 5.37–6.05%), respectively. The cumulative incidence of ischemic stroke was 1.36 per 100 person‐years (95% CI, 1.25–1.48), with a 1‐year and 5‐year ischemic stroke estimate of 1.42% (95% CI, 1.30–1.54%) and 5.03% (95% CI, 4.71–5.36%), respectively. The cumulative incidence of death was 10.82 per 100 person‐years (95% CI, 10.49–11.13), with a 5‐year mortality estimate of 44.34% (95% CI, 43.35–45.23%). Conclusions Long‐term stroke rates in a large nationally representative cohort of Medicare patients following LAAO were low and durably consistent during long‐term follow‐up despite a high thromboembolic risk. High mortality rates in this elderly population underscore the importance of incorporating patient values and preferences when considering LAAO.

Abstract Background: Congenital peritoneal encapsulation (cocoon deformity) is a rare variant of intestinal malrotation. Objectives: To characterize the clinical presentation and outcomes in patients undergoing surgery for intestinal malrotation with cocoon deformity. Design: Retrospective review. Settings: A large tertiary care center, from January 2003 to December 2022. Patients and Methods: All patients who underwent surgery for intestinal malrotation with cocoon deformity were included. Sample Size: Nine patients were identified. Main Outcome Measures: Patient demographics and operative outcomes. Results: Most patients were female (88.9%), with a median age of 37 years (interquartile range [IQR], 19–53). Most were symptomatic upon diagnosis (88.9%), with abdominal pain (77.8%) being the most common symptom. One patient presented acutely, requiring immediate surgical intervention. Computed tomography was the most frequently used modality to establish a diagnosis of intestinal malrotation. A laparoscopic Ladd procedure was attempted in all patients, with three requiring conversion to open surgery. The median operative time was 119 min (IQR, 96.5–202), with a median estimated blood loss of 25 mL (IQR, 15–125). The median length of hospital stay was 2 days (IQR, 1.5–7). The most common postoperative complications were ileus ( n = 3, 33.3%) and 30-day readmission ( n = 3, 33.3%). Most patients experienced partial or complete resolution of symptoms ( n = 7, 77.8%) and no patients required reoperation. The median follow-up duration was 71.8 months (IQR, 21.3–138.7). Conclusions: The laparoscopic Ladd procedure with excision of the cocoon deformity can be performed safely and is associated with significant improvement in preoperative symptoms. Limitations: Cocoon deformity was not diagnosed preoperatively, and there is currently no gold standard imaging modality for its detection.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, contributing to significant morbidity and mortality worldwide. The relationship between physical exercise and AF is complex, with studies showing both beneficial and potentially adverse effects. Moreover, evidence suggests a U-shaped association between exercise intensity and AF risk. Moderate exercise has been shown to reduce AF burden by improving cardiovascular risk factors, enhancing autonomic regulation, and mitigating atrial fibrosis. In contrast, excessively high-intensity endurance exercise may increase AF risk, particularly in young athletes, due to atrial stretching, dilation, fibrosis, autonomic imbalances, and heightened inflammation. The current guidelines emphasize exercise as a core lifestyle intervention for AF management, recommending moderate-intensity aerobic activity for optimal outcomes. This review examines the current evidence on the effects of exercise on AF, identifies knowledge gaps, and proposes potential future research directions.

Abstract Purpose We examined barriers and facilitators to colorectal cancer (CRC) screening among Alaska Native individuals who had never been screened or were not up to date with screening guidelines. Methods As part of a larger study investigating the use of the multitarget stool DNA test in rural Alaska communities, we conducted focus groups and in‐depth interviews with 28 never screened or not up‐to‐date Alaska Native people in two remote communities between November 2022 and July 2023. Participants shared their barriers to CRC screening and offered suggestions to improve programs to better reach those who are guideline discordant. Findings General screening barriers included lack of knowledge, fear of discovering you have cancer, and cultural health beliefs. Colonoscopy‐specific barriers included embarrassment from knowing the local medical staff, having rectal area viewed or touched, fear of pain and injury, difficulty scheduling a procedure due to traditional food gathering activities, lack of provider referrals/reminders, and the high cost of air travel required to get to a colonoscopy facility. Stool DNA‐specific concerns included not feeling that it was as good as colonoscopy, lack of privacy to do the test, and hesitancy collecting stool samples. Suggestions for increasing screening rates included increasing access via paid air transportation, using local indigenous languages, improving provider relationships and reminder systems, and providing CRC and screening education using trusted messengers. Conclusions This was the first exploration of the perceptions of CRC screening among guideline discordant Alaska Native people. Identified themes can be used to improve screening program outreach effectiveness in the future.

ABSTRACT Objective We sought to characterize patients presenting to emergency departments (EDs) with abdominal pain and to validate risk categories defined by the Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE‐2) for low‐risk recurrent abdominal pain. Methods We conducted a retrospective cohort study of patients presenting with abdominal pain between November 2019 and November 2023 across 21 EDs in Arizona, the Midwest, and Florida. Patients were categorized per GRACE‐2 into recurrent and non‐recurrent pain as well as low‐ and high‐risk groups. Primary outcomes included 72‐h returns and mortality at 30 and 90 days. Results The study included 162,494 visits (112,896 unique patients; median age 46 years; 61.2% female). Among these, 4.3% had low‐risk recurrent abdominal pain. Patients with recurrent and non‐recurrent low‐risk pain had similar ED length of stay and discharge rates to each other, compared to patients with high‐risk pain who had longer length of stay and lower discharge rates. At 30 days after the ED encounter, patients with low‐risk recurrent abdominal pain had similar mortality to patients with low‐risk non‐recurrent pain (0.4% vs. 0.3%; adjusted RR = 1.31, 95% CI: 0.85–2.03), while they had significantly lower mortality than patients with high‐risk recurrent abdominal pain (0.4% vs. 2.3; adjusted RR = 3.14, 95% CI: 2.02–4.89). Conclusions This study highlights the heterogeneity in patients presenting to the ED with abdominal pain. Among these patients, those with low‐risk recurrent pain demonstrated similar lengths of stay, discharges, and mortality rates to those with low‐risk non‐recurrent pain and less favorable lengths of stay, discharges, and mortality rates compared to those with any high‐risk features. These findings suggest that low‐ and high‐risk features may be more useful than recurrent or non‐recurrent pain in identifying patients who could benefit from more robust ED evaluations.

Limited studies have explored the effects of individual and environmental factors on sleep disturbance in individuals with inflammatory bowel disease (IBD), which is vital for informing future sleep interventions. Thus, the purpose of this study was to explore the possible mediated effects of potential precipitating and/or perpetuating factors on the relationship between sleep disturbance and symptoms in adults with IBD. This is a correlational study of adults with IBD recruited from ResearchMatch. Survey questions asked about demographics, clinical characteristics, sleep hygiene, sleep beliefs and attitudes, sleep environment, sleep control, and symptoms (sleep disturbance, abdominal pain, anxiety, depression, fatigue). Data analysis included descriptive statistics, Pearson correlations, and mediation analysis. We included 250 adults with IBD ( M = 37.9 years old, 64.8% female, 72.4% white). Fifty-four percent of the sample self-reported having a diagnosed sleep disorder. Sleep hygiene and sleep beliefs and attitudes significantly mediated the relationship between sleep disturbance and symptoms (i.e., fatigue, depression, anxiety, and abdominal pain). Whereas the sleep environment and sleep control did not significantly mediate the relationship between sleep disturbance and symptoms. Individuals with IBD experience sleep disturbances, alongside symptoms of anxiety, depression, abdominal pain, and fatigue. Mediation analysis identified sleep hygiene and sleep beliefs, and attitudes as partial mediators. Considering cognitive-behavioral therapy for insomnia is recommended for restructuring these mediating factors. Participants also faced moderate environmental disturbances, suggesting a need for further investigation in this population.