JAMA Network Open最新文献

{"title":"Surgical Site Infections, Risk Factors, and Outcomes After Liver Transplant.","authors":"Peter W Schreiber, Linard D Hoessly, Katia Boggian, Dionysios Neofytos, Christian van Delden, Adrian Egli, Michael Dickenmann, Cédric Hirzel, Oriol Manuel, Michael Koller, Simona Rossi, Vanessa Banz, Philippe Compagnon, Philipp Dutkowski, Andreas E Kremer, Annalisa Berzigotti, Julien Vionnet, Nicolas Goossens, David Semela, Patrizia Künzler-Heule, Christine Bernsmeier, Stefan P Kuster, Susanne Stampf, Nicolas J Mueller","doi":"10.1001/jamanetworkopen.2025.1333","DOIUrl":"10.1001/jamanetworkopen.2025.1333","url":null,"abstract":"<p><strong>Importance: </strong>Surgical site infections (SSIs) are one of the most common health care-associated infections. Surgical site infections can have harmful effects in liver transplant (LT) recipients.</p><p><strong>Objective: </strong>To assess the incidence of SSI after LT and identify risk factors associated with SSIs and whether SSIs are associated with death and graft loss.</p><p><strong>Design, setting, and participants: </strong>A multicenter cohort study encompassing data on LT performed at all Swiss transplant centers between May 1, 2008, and September 30, 2020, was conducted. Data analyses were performed in 2023.</p><p><strong>Exposure: </strong>Liver transplant.</p><p><strong>Main outcomes and measures: </strong>Frequency of SSIs within 90 days after transplant, risk factors associated with SSIs, and association of SSIs with 1-year death or graft loss. Surgical site infections were defined according to Centers for Disease Control and Prevention criteria with SSIs occurring within 90 days after LT. For association with posttransplant outcomes, 1-year follow-up data were analyzed.</p><p><strong>Results: </strong>Among 1333 LT recipients in the Swiss Transplant Cohort Study, 1158 adults were included in analyses. Median age was 57.2 (IQR, 49.3-62.8) years and 792 were men (68.4%). Seventy patients (6.0%) had an SSI. Most SSIs were deep incisional (9 [12.8%]) or organ-space infections (54 [77.1%]). In most SSIs (56 [80.0%]), bacteria were detected, most frequently Enterococcus spp (36 of 75 [48.0%]) and Escherichia coli (12 of 75 [16.0%]). In multivariable analysis, prior liver transplant (odds ratio [OR] 4.01; 95% CI, 1.44-11.18; P = .008) and living liver donation (OR, 4.08; 95% CI, 1.37-12.16; P = .01) were independent risk factors associated with SSIs. Surgical site infections were independently associated with graft loss and/or death (hazard ratio [HR], 3.24; 95% CI, 1.82-5.79; P < .001); this association was observed in separate analyses on graft loss (HR, 2.97; 95% CI, 1.32-6.68; P = .02) and death (HR, 3.25; 95% CI, 1.44-7.35; P = .01).</p><p><strong>Conclusions and relevance: </strong>The findings of this study suggest that prior liver transplant and living liver donation are independent risk factors associated with SSIs and that SSIs are independently associated with graft loss and/or death, highlighting the relevance of this health care-associated infection.</p>","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":"8 3","pages":"e251333"},"PeriodicalIF":10.5,"publicationDate":"2025-03-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11929024/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143673946","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Complex Sepsis Presentations, SEP-1 Compliance, and Outcomes.","authors":"Chanu Rhee, Sarah E Train, Michael R Filbin, Steven T Park, Nicholas M Mohr, Anne Zepeski, Brett A Faine, David J Roach, Emily Porter, Claire N Shappell, Kamryn Plechot, Laura DelloStritto, Tingting Yu, Michael Klompas","doi":"10.1001/jamanetworkopen.2025.1100","DOIUrl":"10.1001/jamanetworkopen.2025.1100","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Importance: &lt;/strong&gt;The Centers for Medicare & Medicaid Services Severe Sepsis and Septic Shock Management Bundle (SEP-1) is supported by observational studies that report SEP-1 compliance is associated with lower mortality. Most studies, however, adjusted for limited confounders and provided little insight into why bundle-compliant care was not provided.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Objectives: &lt;/strong&gt;To identify the clinical factors that complicate the diagnosis and management of sepsis and assess their association with SEP-1 compliance and mortality.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Design, setting, and participants: &lt;/strong&gt;This retrospective cohort study was conducted among 590 adults with sepsis in the emergency department of 4 academic hospitals from January 1, 2019, to December 31, 2022. Patients' medical records were reviewed between September 2022 and December 2023.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Main outcomes and measures: &lt;/strong&gt;Study outcomes were (1) characteristics of patients who received SEP-1-compliant care vs characteristics of patients who received noncompliant care and (2) association between SEP-1 compliance and hospital mortality using multivariable models to adjust for successively more potential confounders (first demographics and comorbidities, then infection source, then severity of illness, and then clinical markers of complexity).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;Of 590 patients with sepsis (median age, 65 years [IQR, 53-77 years]; 329 men [55.8%]), 335 (56.8%) received SEP-1-compliant care, and 225 (43.2%) received noncompliant care. Compared with patients in the compliant group, patients in the noncompliant group were more likely to be 65 years or older (142 [55.7%] vs 158 [47.2%]; odds ratio [OR], 1.41 [95% CI, 1.01-1.95]), to have multiple comorbidities (Elixhauser score &gt;20: 99 [38.8%] vs 99 [29.6%]; OR, 1.51 [95% CI, 1.07-2.13]), and to have a higher incidence of septic shock (107 [42.0%] vs 107 [31.9%]; OR, 1.54 [95% CI, 1.10-2.16]), kidney dysfunction (87 [34.1%] vs 80 [23.9%]; OR, 1.65 [95% CI, 1.15-2.37]), and thrombocytopenia (43 [16.9%] vs 37 [11.0%]; OR, 1.16 [95% CI, 1.02-2.62]) on presentation. Compared with patients in the compliant group, those in the noncompliant group also had more nonfebrile presentations (136 [53.3%] vs 121 [36.1%]; OR, 2.02 [95% CI, 1.45-2.82]), impaired mental status (92 [36.1%] vs 94 [28.1%]; OR, 1.45 [95% CI, 1.02-2.05]), need for bedside procedures (57 [22.4%] vs 41 [12.2%]; OR, 2.06 [95% CI, 1.33-3.21]), acute concurrent noninfectious illnesses (140 [54.9%] vs 151 [45.1%]; OR, 1.48 [95% CI, 1.07-2.06]), and noninfectious illness as the primary factor associated with their presentation (84 [32.9%] vs 71 [21.2%]; OR, 1.82 [95% CI, 1.08-3.08]). SEP-1 compliance was associated with lower crude mortality rates compared with noncompliance (40 [11.9%] vs 41 [16.1%]; unadjusted OR, 0.60 [95% CI, 0.37-0.98]), but there was no statistically significant difference between groups after successively adjusting for demograp","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":"8 3","pages":"e251100"},"PeriodicalIF":10.5,"publicationDate":"2025-03-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11923707/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143657243","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Optimal Recovery Following Pediatric Concussion.","authors":"Miriam H Beauchamp, Ken Tang, Andrée-Anne Ledoux, Ashley D Harris, Kristina A Kowalski, William R Craig, Jocelyn Gravel, Quynh Doan, Stephen B Freedman, Roger L Zemek, Keith Owen Yeates","doi":"10.1001/jamanetworkopen.2025.1092","DOIUrl":"10.1001/jamanetworkopen.2025.1092","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Importance: &lt;/strong&gt;Pediatric concussion affects millions and results in heterogeneous outcomes and recovery trajectories. Given favorable outcome for most children, it is useful to understand characteristics of positive outcome to promote full recovery in all children.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Objective: &lt;/strong&gt;To document the timeframe of recovery to optimal functioning, defined comprehensively across motor-physical, cognitive, socioemotional, and resilience-support domains, after concussion among children ages 8 to 16 years.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Design, setting, and participants: &lt;/strong&gt;For this prospective cohort study, children ages 8 to 16.99 years with a concussion or orthopedic injury (OI) were recruited between September 2016 and July 2019 from 5 Pediatric Emergency Research Canada emergency departments and assessed approximately 10 days, 3 months, and 6 months after their injury. Data were analyzed from January 29, 2024, to January 11, 2025.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Exposure: &lt;/strong&gt;Concussion.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Main outcomes and measures: &lt;/strong&gt;Participants completed self-report and direct assessment measures of postconcussive symptoms, physical activity and function, balance, cognitive function, quality of life, resilience, and social support. The main outcome was optimal functioning, which was derived from 11 variables and criteria indicative of absence of impairment and average or above functioning in each domain (overall score, 0-11; higher score indicates better function). A longitudinal, multivariable, cumulative probability ordinal regression model was fitted to examine factors associated with optimal functioning.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;A total of 967 children (median [IQR] age, 12.3 [10.5-14.3] years; 562 [58.1%] male) were enrolled, including 633 children with a concussion and 334 children with an OI. The median (IQR) optimal functioning scores for the OI group were 6.0 (4.0-8.0) at 10 days, 7.0 (5.0-9.0) at 3 months, and 7 (5.0-9.0) at 6 months, compared with 4.0 (2.0-6.0) at 10 days, 6.0 (4.0-9.0) at 3 months, and 7.0 (4.0-9.0) at 6 months in the concussion group. The 3 main variables (time, sex, and group) were significantly associated with optimal functioning, as were all 2-way interactions. Time was the strongest factor associated with optimal functioning (Wald χ258 = 485.11; P &lt; .001), followed by group (Wald χ26 = 95.10; P &lt; .001), and sex (Wald χ26 = 23.19; P &lt; .001). At the 10-day follow-up, concussion was associated with lower optimal functioning than OI among females (odds ratio [OR],  0.24 [95% CI, 0.16-0.36]) and males (OR, 0.37 [95% CI, 0.26-0.53]). This difference persisted for females at 3 months (OR, 0.57 [95% CI, 0.35-0.93]) but not for males. Optimal functioning was comparable at 6 months.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions and relevance: &lt;/strong&gt;In this prospective cohort study of children with concussion, achieving optimal functioning levels across physical, cognitive, socioemotional, and resilience domains took 3 mo","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":"8 3","pages":"e251092"},"PeriodicalIF":10.5,"publicationDate":"2025-03-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11923687/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143657340","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Sleep Interruptions Among Older Adults Admitted to the Hospital.","authors":"Adrian D Haimovich, Suzanne M Bertisch, Venkat Jegadeesan, Jennifer P Stevens, Mara A Schonberg, Sarah D Berry","doi":"10.1001/jamanetworkopen.2025.1131","DOIUrl":"10.1001/jamanetworkopen.2025.1131","url":null,"abstract":"","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":"8 3","pages":"e251131"},"PeriodicalIF":10.5,"publicationDate":"2025-03-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11923702/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143657456","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Treatment Maneuvers in Cupulolithiasis of the Posterior Canal Benign Paroxysmal Positional Vertigo: A Randomized Clinical Trial.","authors":"Eun Hye Oh, Jae-Hwan Choi, Hyun Sung Kim, Seo Young Choi, Hyun Ah Kim, Hyung Lee, In Soo Moon, Ji-Yun Park, Byeol-A Yoon, Sang Ho Kim, Jeong-Yeon Kim, Hyo Jung Kim, Kwang-Dong Choi","doi":"10.1001/jamanetworkopen.2025.0972","DOIUrl":"10.1001/jamanetworkopen.2025.0972","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Importance: &lt;/strong&gt;Head-shaking and mastoid oscillation maneuvers effectively treat cupulolithiasis of horizontal canal benign paroxysmal positional vertigo. However, to date there are no validated treatments for cupulolithiasis of posterior canal benign paroxysmal positional vertigo (PC-BPPV-cu).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Objective: &lt;/strong&gt;To determine the immediate and short-term therapeutic efficacy of head-shaking and mastoid oscillation maneuvers in PC-BPPV-cu.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Design, setting, and participants: &lt;/strong&gt;This double-blind randomized clinical trial was conducted at 6 referral-based university hospitals in South Korea between November 1, 2019, and April 30, 2023. The inclusion criteria consisted of (1) repetitive episodes of positional vertigo or dizziness; (2) positional nystagmus beating torsionally with the upper pole of the eye to the lower ear and vertically upward (to the forehead) and lasting longer than 1 minute, which was evoked by Dix-Hallpike or half Dix-Hallpike maneuver; and (3) absence of accompanying neurologic symptoms or signs suggesting central nervous system disorders. Patients were excluded who declined to participate or had cervical spine problems, multicanal BPPV, or cognitive dysfunction.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Interventions: &lt;/strong&gt;Patients were randomly assigned to the head-shaking, mastoid oscillation, or sham maneuver groups. After a maximum of 2 trials of each maneuver, therapeutic response was assessed within 30 minutes and the following day.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Main outcomes and measures: &lt;/strong&gt;The primary outcome was the short-term resolution rate of positional vertigo and nystagmus the following day. The secondary outcome was the immediate efficacy of 2 trials of each maneuver within 30 minutes.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;A total of 159 patients were included in the analysis (108 [67.9%] women; mean [SD] age, 65.4 [10.5] years). Fifty-three participants were randomized to the head-shaking group (mean [SD] age, 64.0 [11.2] years; 33 [62.3%] women), 53 to the mastoid oscillation group (mean [SD], age, 66.5 [11.1] years; 41 [77.4%] women), and 53 to the control group (mean [SD] age, 65.6 [9.2] years; 34 [64.2%] women). A total of 142 patients (89.3%) completed the assessment the following day. In the intention-to-treat analysis, 20 patients in the head-shaking group (37.7%), 14 in the mastoid oscillation group (26.4%), and 7 in the control group (13.2%) showed the resolution of vertigo and nystagmus the following day (χ2 = 8.40; odds ratio, 2.86; 95% CI, 1.32-6.18; P = .004; α = .0167). For the secondary outcome (the immediate effectiveness of 2 trials of each maneuver compared with sham within 30 minutes), no significant difference was detected (6 of 53 [11.3%] vs 4 of 53 [7.5%] vs 2 of 53 [3.8%]; P = .34; α = .05).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions and relevance: &lt;/strong&gt;In this randomized clinical trial, the head-shaking maneuver was effective in the treatment of PC-BPPV-cu.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Trial registration","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":"8 3","pages":"e250972"},"PeriodicalIF":10.5,"publicationDate":"2025-03-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11923721/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143657457","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Midline Venous Catheter vs Peripherally Inserted Central Catheter for Intravenous Therapy: A Randomized Clinical Trial.","authors":"Ahmed Bentridi, Marie-France Giroux, Gilles Soulez, Louis Bouchard, Pierre Perreault, Audrey Chouinard, Marc Dorais, Ricardo Do Amaral, Pascaline Bernier, Eric Therasse","doi":"10.1001/jamanetworkopen.2025.1258","DOIUrl":"10.1001/jamanetworkopen.2025.1258","url":null,"abstract":"<p><strong>Importance: </strong>Peripherally inserted central catheters (PICCs) are frequently used for peripheral intravenous therapy (IVT) that could be administered through a peripheral midline venous catheter (MVC).</p><p><strong>Objective: </strong>To assess the noninferiority of MVCs compared with PICCs as a reliable vascular access for peripheral IVT and blood draws for IVT that does not require a central VC.</p><p><strong>Design, setting, and participants: </strong>This randomized clinical trial was conducted in a single tertiary care center from September 2018 to March 2022. Participants were all consecutive adult patients who were referred for PICC and eligible for MVC. Patients likely to require a central VC (those in the critical care unit, those with kidney failure, or those requiring a multilumen VC) were excluded. Analyses were based on the evaluable population.</p><p><strong>Interventions: </strong>Participants were randomized 1:1 to either MVC or PICC. For the MVC group, a 20-cm-long, 4F (French), single-lumen MVC without a valve was used without fluoroscopic assistance. For the PICC group, a 4F, single-lumen PICC without a valve was positioned under fluoroscopy at the cavoatrial junction.</p><p><strong>Main outcomes and measures: </strong>The primary outcome was the percentage of patients without VC-related adverse events or dysfunctions requiring medical intervention during follow-up. A noninferiority test was performed to compare the proportion of adverse events or dysfunctions between the MVC and PICC groups. A noninferiority margin was set at 10% and a 5% 1-sided significance level.</p><p><strong>Results: </strong>Of the 6821 patients referred to the tertiary care center for PICC insertion, 294 (180 males [61.2%]; median [IQR] age, 56.3 [38.2-66.7] years) were randomized to receive MVCs (n = 146) or PICCs (n = 148); 135 and 137 participants, respectively, were included in data analysis after exclusion of those who did not complete follow-up. Ninety of 135 patients (66.7%) in the MVC group and 128 of 137 (93.4%) in the PICC group were without VC-related adverse event or dysfunction. The noninferiority of MVC could not be demonstrated (P > .99 for noninferiority).</p><p><strong>Conclusions and relevance: </strong>In this randomized clinical trial, MVCs were associated with a significantly higher percentage of patients with VC-related adverse events or dysfunctions and could not be demonstrated as a noninferior alternative to PICCs.</p><p><strong>Trial registration: </strong>ClinicalTrials.gov Identifier: NCT03502980.</p>","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":"8 3","pages":"e251258"},"PeriodicalIF":10.5,"publicationDate":"2025-03-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11926630/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143663516","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Hospice Use Among Medicare Beneficiaries With Parkinson Disease and Dementia With Lewy Bodies.","authors":"Meredith Bock, Siqi Gan, Melissa Aldridge, Krista L Harrison, Kristine Yaffe, Alexander K Smith, John Boscardin, Lauren J Hunt","doi":"10.1001/jamanetworkopen.2025.0014","DOIUrl":"10.1001/jamanetworkopen.2025.0014","url":null,"abstract":"<p><strong>Importance: </strong>Neurodegenerative disorders are now the most common reason that Medicare beneficiaries enroll in hospice for end-of-life care. People with all-cause dementia have high rates of suboptimal hospice use, but little is known about hospice use patterns in Lewy body disease, which includes both Parkinson disease (PD) and dementia with Lewy bodies (DLB).</p><p><strong>Objective: </strong>To compare patient characteristics, hospice agency characteristics, and patterns of use for beneficiaries with PD and DLB vs Alzheimer disease (AD).</p><p><strong>Design, setting, and participants: </strong>A retrospective cohort study including a 100% sample of national 2010-2020 calendar year Medicare data on hospice enrollees was performed. Data analysis was conducted from November 2023 to May 2024.</p><p><strong>Exposures: </strong>A diagnosis of PD or DLB, compared with AD as the reference group.</p><p><strong>Main outcomes and measures: </strong>Proportion of enrollees with short stays (<7 days), proportion with long stays (>180 days), proportion disenrolled for any reason before death, and disenrollment by type.</p><p><strong>Results: </strong>Of 11 327 324 Medicare beneficiaries enrolled in hospice between 2010 and 2020 who met eligibility criteria (mean [SD] age, 85.2 [7.5] years; 781 763 [63.0%] female), there were 958 182 (8.4%) with a primary diagnosis of AD, 232 864 (2.1%) with PD, and 49 340 (0.4%) with DLB. People with PD were more likely to experience a long stay (odds ratio [OR], 1.15; 95% CI, 1.13-1.16) compared with AD, whereas the odds for those with DLB were not increased. However, people with either PD or DLB were less likely to be disenrolled for extended prognosis compared with AD (OR for DLB, 0.82; 95% CI, 0.79-0.85; OR for PD, 0.86; 95% CI, 0.85-0.88). People with PD were more likely to revoke hospice (OR, 1.29; 95% CI, 1.27-1.32) compared with AD.</p><p><strong>Conclusions and relevance: </strong>In this cohort study of Medicare beneficiaries, hospice use patterns differed by dementia subtype. Higher likelihood of hospice revocation in PD raises important questions about unmet needs and highlights the need for more research around the experience of the end of life in this growing population.</p>","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":"8 3","pages":"e250014"},"PeriodicalIF":10.5,"publicationDate":"2025-03-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11880951/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143542096","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Hospital-Physician Integration and Cardiac Rehabilitation Following Major Cardiovascular Events.","authors":"Ngoc H Thai, Brady Post, Gary Young, Md Noor-E-Alam","doi":"10.1001/jamanetworkopen.2024.62580","DOIUrl":"10.1001/jamanetworkopen.2024.62580","url":null,"abstract":"<p><strong>Importance: </strong>Cardiac rehabilitation (CR) is a medically supervised program designed to improve heart health after a cardiac event. Despite its demonstrated clinical benefits, CR participation among eligible patients remains poor due to low referral rates and individual barriers to care.</p><p><strong>Objectives: </strong>To evaluate CR participation by patients who receive care from hospital-integrated physicians compared with independent physicians, and subsequently, to examine CR and recurrent cardiac hospitalizations.</p><p><strong>Design, setting, and participants: </strong>This retrospective cohort study evaluated Medicare Part A and Part B claims data from calendar years 2016 to 2019. All analyses were conducted between January 1 and April 30, 2024. Patients were included if they had a qualifying event for CR between 2017 and 2018, and qualifying events were identified using diagnosis codes on inpatient claims and procedure codes on outpatient and carrier claims. Eligible patients also had to continuously enroll in fee-for-service Medicare for 12 months or more before and after the index event. Physicians' integration status and patients' CR participation were determined during the 12-month follow-up period. The study covariates were ascertained during the 12 months before the index event.</p><p><strong>Exposure: </strong>Hospital-integration status of the treating physician during follow-up.</p><p><strong>Main outcomes and measures: </strong>Postindex CR participation was determined by qualifying procedure codes on outpatient and carrier claims.</p><p><strong>Results: </strong>The study consisted of 28 596 Medicare patients eligible for CR. Their mean (SD) age was 74.0 (9.6) years; 16 839 (58.9%) were male. A total of 9037 patients (31.6%) were treated by a hospital-integrated physician, of which 2995 (33.1%) received CR during follow-up. Logistic regression via propensity score weighting showed that having a hospital-integrated physician was associated with an 11% increase in the odds of receiving CR (odds ratio [OR], 1.11; 95% CI, 1.05-1.18). Additionally, CR participation was associated with a 14% decrease in the odds of recurrent cardiovascular-related hospitalizations (OR, 0.86; 95% CI, 0.81-0.91).</p><p><strong>Conclusions and relevance: </strong>The findings of this cohort study suggest that hospital integration has the potential to facilitate greater CR participation and improve heart care. Several factors may help explain this positive association, including enhanced care coordination and value-based payment policies. Further research is needed to assess the association of integration with other appropriate high-quality care activities.</p>","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":"8 3","pages":"e2462580"},"PeriodicalIF":10.5,"publicationDate":"2025-03-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11877175/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143542104","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Risk Factors for Health Care-Associated Bloodstream Infections in NICUs.","authors":"Julia Johnson, Sudhir Malwade, Sharad Agarkhedkar, Bharat Randive, Uday C Rajput, Chhaya Valvi, Aarti Kinikar, Tushar B Parikh, Umesh Vaidya, Abhay Kadam, Basma Ouddi, Rachel M Smith, Matthew Westercamp, Vidya Mave, Christina Schumacher, Susan E Coffin, Matthew L Robinson, Amita Gupta, Yukari C Manabe, Aaron M Milstone","doi":"10.1001/jamanetworkopen.2025.1821","DOIUrl":"10.1001/jamanetworkopen.2025.1821","url":null,"abstract":"<p><strong>Importance: </strong>Neonates requiring intensive care are at high risk of health care-associated infections. In neonatal intensive care units (NICUs) in low-resource settings, the identification of modifiable risk factors can inform targeted prevention strategies to reduce the global burden of neonatal morbidity and mortality.</p><p><strong>Objective: </strong>To describe the incidence of and the risk factors associated with health care-associated bloodstream infections (BSIs) in NICUs in Pune, India.</p><p><strong>Design, setting, and participants: </strong>This multicenter prospective cohort study enrolled all neonates admitted to 3 NICUs in Pune, India, from May 1, 2017, to July 31, 2019. Neonates were followed up from admission until discharge, transfer, or death. This secondary data analysis included neonates admitted for 3 days or more and was completed on January 31, 2024.</p><p><strong>Main outcomes and measures: </strong>The primary outcome was health care-associated BSIs, defined as a positive blood culture on or after admission day 3. Summary statistics, incidence of health care-associated BSIs, and hazard rate by characteristics of interest were generated. Among neonates admitted for 7 days or longer, the association between antibiotic exposure and infection risk was assessed.</p><p><strong>Results: </strong>A total of 6410 neonates were admitted for 3 days or longer. The median gestational age was 34 weeks (IQR, 32-37 weeks), and 3560 (55.5%) were male. The incidence of health care-associated BSIs was 6.09 per 1000 patient-days. Most isolates were gram-negative organisms (n = 273 [66.3%]), of which 85.5% (202 of 236 isolates tested) were resistant to third- or fourth-generation cephalosporins and 44.8% (117 of 261 isolates tested) were resistant to carbapenems. The hazard rate of health care-associated BSIs was higher among neonates with central venous catheters, respiratory support, or urinary catheters within 3 days preceding infection. Of 3229 neonates admitted for 7 days or longer, 190 (5.8%) had health care-associated BSIs on or after hospital day 7, with an incidence of 3.22 per 1000 patient-days. Antibiotic exposure during the first week of admission was associated with a nearly 3-fold increase in the risk of health care-associated BSIs (adjusted hazard ratio, 2.82 [95% CI, 1.26-6.32]).</p><p><strong>Conclusions and relevance: </strong>In this cohort study of 6410 neonates admitted to 3 NICUs in Pune, India, the risk of health care-associated BSIs was associated with the presence of indwelling devices and prior antibiotic exposure. Future efforts should focus on mitigating the risks associated with indwelling devices and strengthening infection prevention and control and antimicrobial stewardship programs to prevent health care-associated infections.</p>","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":"8 3","pages":"e251821"},"PeriodicalIF":10.5,"publicationDate":"2025-03-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11937935/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143700430","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Suicide Risk and Living Alone With Depression or Anxiety.","authors":"Daa Un Moon, Hyewon Kim, Jin-Hyung Jung, Kyungdo Han, Hong Jin Jeon","doi":"10.1001/jamanetworkopen.2025.1227","DOIUrl":"10.1001/jamanetworkopen.2025.1227","url":null,"abstract":"<p><strong>Importance: </strong>Living alone and mental health disorders, including depression and anxiety, are associated with high suicide risk, but their combined impact remains underexplored.</p><p><strong>Objective: </strong>To examine the association of living arrangements and depression or anxiety with suicide risk.</p><p><strong>Design, setting, and participants: </strong>This population-based cohort study used data from the Korean National Health Insurance Service database from January 1, 2009, to December 31, 2021, that included adults aged 20 years or older who participated in the General Health Screening Program in Korea in 2009. Individuals with incomplete data and those who died by suicide within the first year were excluded to minimize the possibility of reverse causation. Data were analyzed from December 28, 2023, to December 27, 2024.</p><p><strong>Exposures: </strong>Living arrangements, categorized as living alone (≥5 years) or living with others, and depression and anxiety, determined using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes.</p><p><strong>Main outcomes and measures: </strong>The primary outcome was death by suicide, identified through national death records. Multivariable Cox proportional hazards regression models were used to estimate adjusted hazard ratios (AHRs) and 95% CIs for suicide risk.</p><p><strong>Results: </strong>The study included 3 764 279 adults (mean [SD] age, 47.2 [14.0] years; 55.8% male). Of these individuals, 112 460 (3.0%) had depression, 232 305 (6.2%) had anxiety, and 319 993 (8.5%) lived alone. Compared with individuals who had neither depression nor anxiety nor lived alone, individuals living alone with both depression and anxiety exhibited a 558% increased risk of suicide (AHR, 6.58 [95% CI, 4.86-8.92]). Living alone with depression was associated with a 290% increased risk (AHR, 3.91 [95% CI, 2.96-5.16]), and living alone with anxiety was associated with a 90% increased risk (AHR, 1.90 [95% CI, 1.48-2.43]). The AHRs were higher for the association between living alone and suicide among middle-aged individuals (aged 40 to 64 years) and men compared with other demographic groups.</p><p><strong>Conclusions and relevance: </strong>In this cohort study of 3 764 279 individuals, living alone with depression or anxiety was associated with an increased risk of suicide, particularly among middle-aged individuals and men. These findings underscore the importance of preventing mental illness, such as depression and anxiety, while addressing living arrangements as a critical factor in suicide risk assessments for individuals with these conditions.</p>","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":"8 3","pages":"e251227"},"PeriodicalIF":10.5,"publicationDate":"2025-03-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11947838/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143709166","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}