Intraoperative adverse events among surgeons in Singapore: a multicentre cross-sectional study on impact and support.

BACKGROUND: It is known that many surgeons encounter intraoperative adverse events which can result in Second Victim Syndrome (SVS), with significant detriment to their emotional and physical health. There is, however, a paucity of Asian studies in this space. The present study thus aimed to explore the degree to which the experience of an adverse event is common among surgeons in Singapore, as well as its impact, and factors affecting their responses and perceived support systems. METHODS: A self-administered survey was sent to surgeons at four large tertiary hospitals. The 42-item questionnaire used a systematic closed and open approach, to assess: Personal experience with intraoperative adverse events, emotional, psychological and physical impact of these events and perceived support systems. RESULTS: The response rate was 57.5% (n = 196). Most respondents were male (54.8%), between 35 and 44 years old, and holding the senior consultant position. In the past 12 months alone, 68.9% recalled an adverse event. The emotional impact was significant, including sadness (63.1%), guilt (53.1%) and anxiety (45.4%). Speaking to colleagues was the most helpful support source (66.7%) and almost all surgeons did not receive counselling (93.3%), with the majority deeming it unnecessary (72.2%). Notably, 68.1% of the surgeons had positive takeaways, gaining new insight and improving vigilance towards errors. Both gender and surgeon experience did not affect the likelihood of errors and emotional impact, but more experienced surgeons were less likely to have positive takeaways (p = 0.035). Individuals may become advocates for patient safety, while simultaneously championing the cause of psychological support for others. CONCLUSIONS: Intraoperative adverse events are prevalent and its emotional impact is significant, regardless of the surgeon's experience or gender. While colleagues and peer discussions are a pillar of support, healthcare institutions should do more to address the impact and ensuing consequences.

Scoping review of the second victim syndrome among surgeons: Understanding the impact, responses, and support systems.

BACKGROUND: It is thought that 50% of healthcare providers experience Second Victim Syndrome (SVS) in the course of their practice. The manifestations of SVS varies between individuals, with potential long-lasting emotional effects that impact both the personal lives and professional clinical practice of affected persons. Although surgeons are known to face challenging and high-stress situations in their profession, which can increase their vulnerability to SVS, majority of studies and reviews have focused squarely on nonsurgical physicians. METHODS: This scoping review aimed to consolidate existing studies pertaining to a surgeon's experience with SVS, by broadly examining the prevalence and impact, identifying the types of responses, and evaluating factors that could influence these responses. The scoping review protocol was guided by the framework outlined by Arksey and O'Malley and ensuing recommendations made by Levac and colleagues. Three databases (MEDLINE, EMBASE and Cochrane Library) were searched from inception till March 19, 2023. RESULTS: A total of 13 articles were eligible for thematic analysis based on pre-defined inclusion criteria. Effects of SVS were categorized into Psychological, Physical and Professional impacts, of which Psychological and Professional impacts were particularly significant. Factors affecting the response were categorized into complication type, surgeon factors and support systems. CONCLUSION: SVS adds immense psychological, emotional and physical burden to the individual surgeon. There are key personal, interpersonal and environmental factors that can mitigate or exacerbate the effects of SVS, and greater emphasis needs to be placed on improving availability and access to services to help surgeons at risk of SVS.

Risk of Parkinson's disease in hepatitis B and C populations: a systematic review and meta-analysis.

Parkinson's disease (PD) is a common neurodegenerative disorder, and its association with viral hepatitis has been debated. We performed a meta-analysis to examine the association between PD risk and viral hepatitis. Medline, EMBASE, and the Cochrane library were searched from inception till July 2022. Meta-analysis was conducted using a fixed-effect model with the inverse variance method. Three groups were compared to controls: infection with either hepatitis B or C virus (HBV and HCV, respectively), or coinfection with both viruses. We found 551 records, and six studies comprising of 2,566,947 patients were included in the analysis. PD risk was increased in HCV-infected population (OR 1.10, 95% CI 1.03-1.17, p = 0.005) and (HR 1.37, 95% CI 1.26-1.49, p < 0.001). This increase was not observed for the HBV-infected and HBV-HCV-coinfected coinfection populations. For pooled OR, the risk was significantly lower in HBV-infected (OR 0.79, 95% CI 0.76-0.83, p < 0.001) but not significantly different in HBV-HCV-coinfected populations (OR 0.96, 95% CI 0.82-1.12, p = 0.57). For pooled HR, the risk was significantly higher in both HBV-infected (HR 1.22, 95% CI 1.14-1.31, p < 0.001) and HBV-HCV-coinfected populations (HR 1.29, 95% CI 1.05-1.58, p = 0.013). We found that the risk of PD was increased in the HCV-infected population, but results were inconsistent in those with HBV and HBV-HCV infections. Our findings provide impetus for further clinical and functional studies to unravel the role of the adaptive immune system in PD.

Environmental exposure disparities in ultrafine particles and PM2.5 by urbanicity and socio-demographics in New York state, 2013-2020.

BACKGROUND: The spatiotemporal and demographic disparities in exposure to ultrafine particles (UFP; number concentrations of particulate matter (PM) with diameter ≤0.1 µm), a key subcomponent of fine aerosols (PM2.5; mass concentrations of PM ≤ 2.5 µm), have not been well studied. OBJECTIVE: To quantify and compare the aerosol pollutant exposure disparities for UFP and PM2.5 by socio-demographic factors in New York State (NYS). METHODS: Ambient atmospheric UFP and PM2.5 were quantified using a global three-dimensional model of chemical transport with state-of-the-science aerosol microphysical processes validated extensively with observations. We matched these to U.S. census demographic data for varied spatial scales (state, county, county subdivision) and derived population-weighted aerosol exposure estimates. Aerosol exposure disparities for each demographic and socioeconomic (SES) indicator, with a focus on race-ethnicity and income, were quantified for the period 2013-2020. RESULTS: The average NYS resident was exposed to 4451 #·cm-3 UFP and 7.87 µg·m-3 PM2.5 in 2013-2020, but minority race-ethnicity groups were invariably exposed to greater daily aerosol pollution (UFP: +75.0% & PM2.5: +16.2%). UFP has increased since 2017 and is temporally and seasonally out-of-phase with PM2.5. Race-ethnicity exposure disparities for PM2.5 have declined over time; by -6% from 2013 to 2017 and plateaued thereafter despite its decreasing concentrations. In contrast, these disparities have increased (+12.5-13.5%) for UFP. The aerosol pollution exposure disparities were the highest for low-income minorities and were more amplified for UFP than PM2.5. DISCUSSION: We identified large disparities in aerosol pollution exposure by urbanization level and socio-demographics in NYS residents. Jurisdictions with higher proportions of race-ethnicity minorities, low-income residents, and greater urbanization were disproportionately exposed to higher concentrations of UFP and PM2.5 than other NYS residents. These race-ethnicity exposure disparities were much larger, more disproportionate, and unabating over time for UFP compared to PM2.5 across various income strata and levels of urbanicity.

Local Therapy on Clinically Lymph Node-positive Prostate Cancer: A Systematic Review and Meta-analysis.

CONTEXT: Patients with clinically lymph node-positive (cN1) prostate cancer (PCa) are traditionally regarded to have metastatic disease, and the role of local therapy (LT) in their treatment remains unclear. OBJECTIVE: To evaluate the outcomes of cN1 PCa patients treated with LT, and secondarily to compare between different modalities of LT, including radiotherapy (RT) and radical prostatectomy (RP). EVIDENCE ACQUISITION: A bibliographic search was performed using Medline, Embase, and the Cochrane Library to identify studies comparing the survival outcomes of cN1 PCa patients treated with LT (RT or RP) with those who did not receive any form of LT (observation or androgen deprivation therapy alone). The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations were followed. Survival outcomes of the addition of LT were assessed using a random-effect model. EVIDENCE SYNTHESIS: A total of 8522 patients across eight studies were included. LT significantly improved overall survival (OS) across all time points from 2 to 10 yr compared with patients without LT, most notably providing a durable benefit in 10-yr OS (odds ratio [OR]: 1.49, 95% confidence interval [CI] 1.06-2.10). Both RT and RP were associated with benefits to both OS and recurrence-free survival, with no significant difference in OS between both modalities in medium-term follow-up (4-yr OR: 0.76, 95% CI 0.41-1.40, p = 0.19). CONCLUSIONS: Regardless of modality, the use of LT in cN1 patients improved OS. Future studies should aim to identify patients who could benefit from LT and include more comprehensive survival data including biochemical recurrence. PATIENT SUMMARY: In this study, we evaluated the outcomes of clinically lymph node-positive (cN1) prostate cancer (PCa) patients treated with local therapy (LT) and compared between different modalities of LT, including radiotherapy (RT) and radical prostatectomy (RP). We found that the addition of LT for cN1 PCa patients leads to a significant improvement in survival outcomes, most notably for overall survival, with no significant difference between RT and RP.

Should Procalcitonin Be Included in Acute Cholecystitis Guidelines? A Systematic Review.

Background and Objectives: Acute cholecystitis (AC) is a common surgical emergency. Recent evidence suggests that serum procalcitonin (PCT) is superior to leukocytosis and serum C-reactive protein in the diagnosis and severity stratification of acute infections. This review evaluates the role of PCT in AC diagnosis, severity stratification, and management. Materials and Methods: PubMed, Embase, and Scopus were searched from inception till 21 August 2022 for studies reporting the role of PCT in AC. A qualitative analysis of the existing literature was conducted. Results: Five articles, including 688 patients, were included. PCT ≤ 0.52 ng/mL had fair discriminative ability (Area under the curve (AUC) 0.721, p < 0.001) to differentiate Grade 1 from Grade 2-3 AC, and PCT > 0.8 ng/mL had good discriminatory ability to differentiate Grade 3 from 1-2 AC (AUC 0.813, p < 0.001). PCT cut-off ≥ 1.50 ng/mL predicted difficult laparoscopic cholecystectomy (sensitivity 91.3%, specificity 76.8%). The incidence of open conversion was higher with PCT ≥ 1 ng/mL (32.4% vs. 14.6%, p = 0.013). A PCT value of >0.09 ng/mL could predict major complications (defined as open conversion, mechanical ventilation, and death). Conclusions: Current evidence is plagued by the heterogeneity of small sample studies. Though PCT has some role in assessing severity and predicting difficult cholecystectomy, and postoperative complications in AC patients, more evidence is necessary to validate its use.

What Has Longitudinal 'Omics' Studies Taught Us about Irritable Bowel Syndrome? A Systematic Review.

Irritable bowel syndrome is a prototypical disorder of the brain-gut-microbiome axis, although the underlying pathogenesis and mechanisms remain incompletely understood. With the recent advances in 'omics' technologies, studies have attempted to uncover IBS-specific variations in the host-microbiome profile and function. However, no biomarker has been identified to date. Given the high inter-individual and day-to-day variability of the gut microbiota, and a lack of agreement across the large number of microbiome studies, this review focused on omics studies that had sampling at more than one time point. A systematic literature search was performed using various combinations of the search terms "Irritable Bowel Syndrome" and "Omics" in the Medline, EMBASE, and Cochrane Library up to 1 December 2022. A total of 16 original studies were reviewed. These multi-omics studies have implicated Bacteroides, Faecalibacterium prausnitzii, Ruminococcus spp., and Bifidobacteria in IBS and treatment response, found altered metabolite profiles in serum, faecal, or urinary samples taken from IBS patients compared to the healthy controls, and revealed enrichment in the immune and inflammation-related pathways. They also demonstrated the possible therapeutic mechanisms of diet interventions, for example, synbiotics and low fermentable oligosaccharides, disaccharides, monosaccharides, and polyol (FODMAP) diets on microbial metabolites. However, there was significant heterogeneity among the studies and no uniform characteristics of IBS-related gut microbiota. There is a need to further study these putative mechanisms and also ensure that they can be translated to therapeutic benefits for patients with IBS.

Associations Between Ambient Extreme Heat Exposure and Emergency Department Visits Related to Kidney Disease.

RATIONALE & OBJECTIVE: Extreme heat exposure is associated with multiple diseases. However, our current understanding of the specific impact of extreme heat exposure on kidney disease is limited. STUDY DESIGN: Case-crossover study. SETTING & PARTICIPANTS: 1,114,322 emergency department (ED) visits with a principal diagnosis of kidney disease were identified in New York state, 2005-2013. EXPOSURE: Extreme heat exposure was defined as when the daily temperature exceeded the 90th percentile temperature of that month during the study period in the county. OUTCOME: ED visits with a principal diagnosis of kidney disease and its subtypes (ICD-9 [International Classification of Diseases, Ninth Revision] codes 580-599, 788). ANALYTICAL APPROACH: Extreme heat exposure on the ED visit days was compared with extreme heat exposure on control days using a conditional logistic regression model, controlling for humidity, air pollutants, and holidays. The excess risk of kidney disease was calculated for a week (lag days 0-6) after extreme heat exposure during the warm season (May through September). We also stratified our estimates by sociodemographic characteristics. RESULTS: Extreme heat exposure was associated with a 1.7% (lag day 0) to 3.1% (lag day 2) higher risk of ED visits related to kidney disease; this association was stronger with a greater number of extreme heat exposure days in the previous week. The association with extreme heat exposure lasted for an entire week and was stronger in the transitional months (ie, May and September; excess rates ranged from 1.8% to 5.1%) rather than the summer months (June through August; excess rates ranged from 1.5% to 2.7%). The strength of association was greater among those with ED visits related to acute kidney injury, kidney stones, and urinary tract infections. Age and sex may modify the association between extreme heat exposure and ED visits. LIMITATIONS: Individual exposure to heat-how long people were outside or whether they had access to air conditioning-was unknown. CONCLUSIONS: Extreme heat exposure was significantly associated with a dose-dependent greater risk of ED visits for kidney disease.

The feasibility of reduced-dose radiotherapy in childhood nasopharyngeal carcinoma with favorable response to neoadjuvant chemotherapy.

BACKGROUND: To assess the feasibility of adjusting radiation dose (RD) in childhood NPC with favorable tumor response after neoadjuvant chemotherapy (NAC). PATIENTS AND METHODS: Using an NPC-specific database, children and adolescents (≤18 years) with locoregionally advanced NPC (CA-LANPC) were retrospectively analyzed. Enrolled patients were those who received favorable tumor response after 2-4 cycles of NAC followed by concurrent chemoradiotherapy. Survival outcomes and treatment-related toxicities were compared for the standard RD on primary tumors (PT-RDstandard, 66-72 Gy) and the reduced RD on primary tumors (PT-RDreduced, 60-65.9 Gy). RESULTS: A total of 132 patients were included, and the median follow-up time was 75.2 months (IQR, 53.2-98.7 months) for the entire cohort. The PT-RDreduced group had a significantly decreased incidence of severe mucositis (51.3 % vs 32.1 %; P = 0.034) when compared to the PT-RDstandard group. The total incidence of severe sequela in the PT-RDstandard group were significantly higher than those in the PT-RDreduced group (31.8 % vs 13.7 %; P = 0.029). In the propensity-matched analysis, the PT-RDreduced group resulted in parallel 5-year survival with the PT-RDstandard group from the matched cohort (disease-free survival, 82.7 % vs 80.3 %, P = 0.841; overall survival, 91.7 % vs 91.3 %, P = 0.582; distant metastasis-free survival, 87.5 % vs 82.8 %, P = 0.573; and locoregional relapse-free survival, 95.6 % vs 97.3 %, P = 0.836). In multivariate analysis, the impact of PT-RDreduced on all survival end points remained insignificant. CONCLUSIONS: Chemoradiotherapy with RD at levels of 60-65.9 Gy may be a reasonable strategy for CA-LANPC with favorable tumor response after NAC.

Measuring students' exposure to particulate matter (PM) pollution across microenvironments and seasons using personal air monitors.

Particulate matter (PM) pollution is a significant concern in public health, yet children's exposure is not adequately characterized. This study evaluated PM exposures among primary school-aged children in NYS across different microenvironments. This study helps fill existing knowledge gaps by characterizing PM exposure among this population across seasons and microenvironments. Sixty students were recruited from randomly selected public primary schools representing various socioeconomic statuses. Individual real-time exposure to PM2.5 was measured continuously using AirBeam personal monitors for 48 h. Children were consistently exposed to higher PM2.5 concentrations in the fall (median: fall = 2.84, spring = 2.31, winter = 0.90 µg/m3). At school, 2.19% of PM2.5 measurements exceeded the EPA annual fine particle standard, 12 µg/m3 (winter = 7.38%, fall = 2.39%, spring = 1.38%). In classrooms, PM1-4 concentrations were higher in spring and overnight, while PM7-10 concentrations were higher in fall and school hours. At home, 37.2% of fall measurements exceeded EPA standards (spring = 10.39%, winter = 4.37%). Overall, PM2.5 levels in classrooms and during transportation never rose above the EPA standard for any significant length of time. However, PM2.5 levels routinely exceeded these standards at home, in the fall, and the evening. More extensive studies are needed to confirm these results.

COVID-19 Symptoms and Deaths among Healthcare Workers, United States.

We evaluated whether demographics and COVID-19 symptoms predicted COVID-19 deaths among healthcare workers (HCWs) in the United States by comparing COVID-19 deaths in HCWs with 3 control groups (HCW nondeaths, non-HCW deaths, and non-HCW nondeaths) using a case-control design. We obtained patient-level data of 33 variables reported during January 1, 2020-October 12, 2021, in all US states. We used logistic regression analysis while controlling for confounders. We found that persons who were >50 years of age, male, Black, or Asian experienced significantly more deaths than matched controls. In addition, HCWs who died had higher risks for the most severe clinical indicators. We also found that the most indicative symptoms were preexisting medical conditions, shortness of breath, fever, cough, and gastrointestinal symptoms. In summary, minority, male, and older HCWs had greater risk for COVID-19 death. Severe clinical indicators and specific symptoms may predict COVID-19-related deaths among HCWs.

Identifying joint impacts of sun radiation, temperature, humidity, and rain duration on triggering mental disorders using a high-resolution weather monitoring system.

BACKGROUND: Mental disorders (MDs) are behavioral or mental patterns that cause significant distress or impairment of personal functioning. Previously, temperature has been linked to MDs, but most studies suffered from exposure misclassification due to limited monitoring sites. We aimed to assess whether multiple meteorological factors could jointly trigger MD-related emergency department (ED) visits in warm season, using a highly dense weather monitoring system. METHODS: We conducted a time-stratified, case-crossover study. MDs-related ED visits (primary diagnosis) from May-October 2017-2018 were obtained from New York State (NYS) discharge database. We obtained solar radiation (SR), relative humidity (RH), temperature, heat index (HI), and rainfall from Mesonet, a real-time monitoring system spaced about 17 miles (126 stations) across NYS. We used conditional logistic regression to assess the weather-MD associations. RESULTS: For each interquartile range (IQR) increase, both SR (excess risk (ER): 4.9%, 95% CI: 3.2-6.7%) and RH (ER: 4.0%, 95% CI: 2.6-5.4%) showed the largest risk for MD-related ED visits at lag 0-9 days. While temperature presented a short-term risk (highest ER at lag 0-2 days: 3.7%, 95% CI: 2.5-4.9%), HI increased risk over a two-week period (ER range: 3.7-4.5%), and rainfall hours showed an inverse association with MDs (ER: -0.5%, 95% CI: 0.9-(-0.1)%). Additionally, we observed stronger association of SR, RH, temperature, and HI in September and October. Combination of high SR, RH, and temperature displayed the largest increase in MDs (ER: 7.49%, 95% CI: 3.95-11.15%). The weather-MD association was stronger for psychoactive substance usage, mood disorders, adult behavior disorders, males, Hispanics, African Americans, individuals aged 46-65, or Medicare patients. CONCLUSIONS: Hot and humid weather, especially the joint effect of high sun radiation, temperature and relative humidity showed the highest risk of MD diseases. We found stronger weather-MD associations in summer transitional months, males, and minority groups. These findings also need further confirmation.

Particle surface area, ultrafine particle number concentration, and cardiovascular hospitalizations.

While the health impacts of larger particulate matter, such as PM10 and PM2.5, have been studied extensively, research regarding ultrafine particles (UFPs or PM0.1) and particle surface area concentration (PSC) is lacking. This case-crossover study assessed the associations between exposure to PSC and UFP number concentration (UFPnc) and hospital admissions for cardiovascular diseases (CVDs) in New York State (NYS), 2013-2018. We used a time-stratified case-crossover design to compare the PSC and UFPnc levels between hospitalization days and control days (similar days without admissions) for each CVD case. We utilized NYS hospital discharge data to identify all CVD cases who resided in NYS. UFP simulation data from GEOS-Chem-APM, a state-of-the-art chemical transport model, was used to define PSC and UFPnc. Using a multi-pollutant model and conditional logistic regression, we assessed excess risk (ER)% per inter-quartile change of PSC and UFPnc after controlling for meteorological factors, co-pollutants, and time-varying variables. We found immediate and lasting associations between PSC and overall CVDs (lag0-lag0-6: ERs% (95% CI%) ranges: 0.4 (0.1,0.7) - 0.9 (0.7-1.2), and delayed and prolonged ERs%: 0.1-0.3 (95% CIs: 0.1-0.5) between UFPnc and CVDs (lag0-3-lag0-6). Exposure to larger PSC was associated with immediate ER increases in stroke, hypertension, and ischemic heart diseases (1.1%, 0.7%, 0.8%, respectively, all p < 0.05). The adverse effects of PSC on CVDs were highest among children (5-17 years old), in the fall and winter, and during cold temperatures. In conclusion, we found an immediate, lasting effects of PSC on overall CVDs and a delayed, prolonged impact of UFPnc. PSC was a more sensitive indicator than UFPnc. The PSC effects were higher among certain CVD subtypes, in children, in certain seasons, and during cold days. Further studies are needed to validate our findings and evaluate the long-term effects.

A scoping review of qualitative studies on pre-hospital analgesia administration and practice.

BACKGROUND: Pain is an exceedingly common complaint in the pre-hospital setting. Despite advancements in organizational protocols and guidelines, many emergency medical services (EMS) systems still fail to provide optimal pain management. This scoping review thus aimed to map the body of qualitative literature pertaining to factors influencing pre-hospital analgesia administration and practice in order to clarify concepts and understanding as well as to identify any knowledge gaps. METHODS: The review protocol was guided by the framework outlined by Arksey and O'Malley and ensuing recommendations made by Levac and colleagues. Five databases were searched from inception till October 26, 2021, namely MEDLINE, EMBASE, CINAHL, The Cochrane Library, and Scopus. The search strategy was developed in consultation with a medical information specialist. A total of 5848 records were screened by abstract and title by four independent researchers. 199 records were included for full text review. From these, 15 articles were eligible for thematic analysis based on pre-defined inclusion criteria. RESULTS: Included studies found that practitioner, patient, and environmental factors influenced the administration and practice of pre-hospital analgesia. Key barriers included the difficulty in assessing pain, poor inter-professional relationship, knowledge deficits, stress and anxiety, and miscellaneous factors, such as concerns over drug-seeking behaviours. Some possible solutions were proposed, and pre-hospital EMS systems and healthcare institutions could consider bridging some of these gaps. There was a notable paucity of Asian studies, and a variety of EMS settings with different protocols and workflows were examined, hence systemic factors including guidelines and legislations cannot and should not be generalized across every healthcare system. CONCLUSION: The factors influencing pre-hospital analgesia administration and practice remain incompletely understood. Existing tools and practice guidelines were also inadequate. This scoping review provided an overarching perspective of the extant literature, highlighting some of the significant barriers, enablers, and areas for further research.

Vitamin D supplementation for irritable bowel syndrome: A systematic review and meta-analysis.

BACKGROUND AND AIM: Irritable bowel syndrome (IBS) is a prevalent and complex gastrointestinal disorder characterized by chronic abdominal pain and altered bowel habits. Observational studies have suggested a relationship between serum vitamin D levels and IBS symptoms. This systematic review and meta-analysis aimed to investigate the clinical effects of vitamin D supplementation on IBS symptom severity and quality of life (QoL) measures. METHODS: Medline, Embase, Scopus, Web of Science, and The Cochrane Library databases were systematically searched. Data abstraction and quality assessment were conducted by four authors independently, and discrepancies were resolved through consensus from the senior author. Continuous data were pooled with standardized mean difference (SMD) using the DerSimonian and Laird's random-effects model. Sensitivity analysis by risk of bias and potentially "predatory" publication were performed as well. RESULTS: A total of 685 patients across eight studies were included in the meta-analysis. Vitamin D supplementation significantly improved IBS symptom severity scale scores, with a SMD of -0.77 (95% confidence interval [CI] -1.47 to -0.07, P = 0.04, I2  = 91%). Improvements in IBS-QoL scores were also observed, albeit not statistically significant (SMD 0.54; 95% CI -0.34 to 1.41, P = 0.15, I2  = 87%). However, small sample sizes, a relatively young study population, limited ethnicities, and varied vitamin D dosing strategies across the studies were notable limitations. CONCLUSIONS: Vitamin D supplementation could be part of our clinical armamentarium when managing IBS patients due to the potential efficacy and good safety profile. Further randomized, controlled trials are required to confirm the therapeutic effects.

The independent and synergistic impacts of power outages and floods on hospital admissions for multiple diseases.

Highly destructive disasters such as floods and power outages (PO) are becoming more commonplace in the U.S. Few studies examine the effects of floods and PO on health, and no studies examine the synergistic effects of PO and floods, which are increasingly co-occurring events. We examined the independent and synergistic impacts of PO and floods on cardiovascular diseases, chronic respiratory diseases, respiratory infections, and food-/water-borne diseases (FWBD) in New York State (NYS) from 2002 to 2018. We obtained hospitalization data from the NYS discharge database, PO data from the NYS Department of Public Service, and floods events from NOAA. Distributed lag nonlinear models were used to evaluate the PO/floods-health association while controlling for time-varying confounders. We identified significant increased health risks associated with both the independent effects from PO and floods, and their synergistic effects. Generally, the Rate Ratios (RRs) for the co-occurrence of PO and floods were the highest, followed by PO alone, and then floods alone, especially when PO coverage is >75th percentile of its distribution (1.72% PO coverage). For PO and floods combined, immediate effects (lag 0) were observed for chronic respiratory diseases (RR:1.58, 95%CI: 1.24, 2.00) and FWBD (RR:3.02, 95%CI: 1.60, 5.69), but delayed effects were found for cardiovascular diseases (lag 3, RR:1.13, 95%CI: 1.03, 1.24) and respiratory infections (lag 6, RR:1.85, 95%CI: 1.35, 2.53). The risk association was slightly stronger among females, whites, older adults, and uninsured people but not statistically significant. Improving power system resiliency could be a very effective way to alleviate the burden on hospitals during co-occurring floods. We conclude that PO and floods have independently and jointly led to increased hospitalization for multiple diseases, and more research is needed to confirm our findings.

Impact of cumulative cisplatin dose in childhood nasopharyngeal carcinoma based on neoadjuvant chemotherapy response in the intensity-modulated radiotherapy era: a real-world study.

BACKGROUND: We aimed to comprehensively investigate the optimal cumulative cisplatin dose during concurrent chemoradiotherapy (CC-CCD) for locoregionally advanced nasopharyngeal carcinoma (CA-LANPC) with different tumor responses after neoadjuvant chemotherapy (NAC). METHODS: Patients with CA-LANPC who underwent NAC followed by cisplatin-based concurrent chemoradiotherapy were retrospectively analyzed. Evaluation of tumor response in patients was conducted by Response Evaluation Criteria for Solid Tumor (RECIST) 1.1 after two to four cycles NAC. Multivariate Cox proportional hazards models were used for prognosis. Recursive partitioning analysis (RPA) was conducted to classify participates and predict disease-free survival (DFS). RESULTS: One hundred and thirty-two patients with favorable response after NAC were included. The median CC-CCD was 163 mg/m2 (IQR, 145-194 mg/m2), and 160 mg/m2 was selected as the cutoff point to group patients into low and high CC-CCD groups (< 160 vs. ≥ 160 mg/m2). There was significant improvement in 5-year DFS (91.2% vs. 72.6%; P = 0.003) for patients receiving high CC-CCD compared to those receiving low CC-CCD. Multivariate analysis revealed that CC-CCD, T stage, and Epstein-Barr virus (EBV) DNA were independent prognostic factors for DFS (P < 0.05 for all). Patients were further categorized into two prognostic groups by RPA: the low-risk group (T1-3 disease with regardless of EBV DNA, and T4 disease with EBV DNA < 4000 copy/mL), and the high-risk group (T4 disease with EBV DNA ≥ 4000 copy/mL). Significant 5-year DFS improvement was observed for the high-risk group (P = 0.004) with high CC-CCD. However, DFS improvement was relatively insignificant in the low-risk group (P = 0.073). CONCLUSIONS: CC-CCD was a positive prognostic factor for responders after NAC in CA-LANPC. Furthermore, CC-CCD ≥ 160 mg/m2 could significantly improve DFS in the high-risk group with CA-LANPC, but the benefit of high CC-CCD in the low-risk group needs further study.

Ambient extreme heat exposure in summer and transitional months and emergency department visits and hospital admissions due to pregnancy complications.

Although extreme heat exposure (EHE) was reported to be associated with increased risks of multiple diseases, little is known about the effects of EHE on pregnancy complications. We examined the EHE-pregnancy complications associations by lag days, subtypes, sociodemographic characteristics, and areas in New York State (NYS). We conducted a case-crossover analysis to assess the EHE-pregnancy complications associations in summer (June-August) and transitional months (May and September). All emergency department (ED) visits and hospital admissions due to pregnancy complications (ICD 9 codes: 630-649) from 2005 to 2013 in NYS were included. Daily mean temperature > 90th percentile of the monthly mean temperature in each county was defined as an EHE. We used conditional logistic regression while controlling for other weather factors, air pollutants and holidays to assess the EHE-pregnancy complications associations. EHE was significantly associated with increased ED visits for pregnancy complications in summer (ORs ranged: 1.01-1.04 from lag days 0-5). There was also a significant and stronger association in transitional months (ORs ranged: 1.02-1.06, Lag 0). Furthermore, we found EHE affected multiple subtypes of pregnancy complications, including threatened/spontaneous abortion, renal diseases, infectious diseases, diabetes, and hypertension (ORs range: 1.13-1.90) during transitional months. A significant concentration response effect between the number of consecutive days of EHE and ED visits in summer (P for trend <0.001), ED visits in September (P for trend =0.03), and hospital admission in May (P for trend<0.001) due to pregnancy complications was observed, respectively. African Americans and residents in lower socioeconomic position (SEP) counties were more susceptible to the effects of EHE. In conclusion, we found an immediate and prolonged effect of EHE on pregnancy complications in summer and a stronger, immediate effect in transitional months. These effects were stronger in African Americans and counties with lower SEP. Earlier warnings regarding extreme heat are recommended to decrease pregnancy complications.

Application of data science methods to identify school and home risk factors for asthma and allergy-related symptoms among children in New York.

OBJECTIVES: Few studies have comprehensively assessed multiple environmental exposures affecting children's health. This study applied machine-learning methods to evaluate how indoor environmental conditions at home and school contribute to asthma and allergy-related symptoms. METHODS: We randomly selected 10 public schools representing different socioeconomic statuses in New York State (2017-2019) and distributed questionnaires to students to collect health status and home-and school-environmental exposures. Indoor air quality was measured at school, and ambient particle exposures (PM2.5 and components) were measured using real-time personal monitors for 48 h. We used random forest model to identify the most important risk factors for asthma and allergy-related symptoms, and decision tree for visualizing the inter-relationships among the multiple risk factors with the health outcomes. RESULTS: The top contributing factors identified for asthma were family rhinitis history (relative importance: 10.40%), plant pollen trigger (5.48%); bedroom carpet (3.58%); environmental tobacco smoke (ETS) trigger symptom (2.98%); and ETS exposure (2.56%). For allergy-related symptoms, plant pollen trigger (10.88%), higher paternal education (7.33%), bedroom carpet (5.28%), family rhinitis history (4.78%), and higher maternal education (4.25%) were the strongest contributing factors. Conversely, primary heating with hot water radiator was negatively (-6.86%) associated with asthma symptoms. Younger children (<9 years old) with family history of rhinitis and carpeting in the bedroom were the prominent combined risk factors for asthma. Children jointly exposed to pollen, solvents, and carpeting in their home tended to have greater risks of allergy-related symptoms, even without family history of rhinitis. CONCLUSION: Family rhinitis history, bedroom carpet, and pollen triggers were the most important risk factors for both asthma and allergy-related symptoms. Our new findings included that hot-water radiator was related to reduced asthma symptoms, and the combination of young age, rhinitis history, and bedroom carpeting was related to increased asthma symptoms. Further studies are needed to confirm our findings.

Using Innovative Machine Learning Methods to Screen and Identify Predictors of Congenital Heart Diseases.

Objective: Congenital heart diseases (CHDs) are associated with an extremely heavy global disease burden as the most common category of birth defects. Genetic and environmental factors have been identified as risk factors of CHDs previously. However, high volume clinical indicators have never been considered when predicting CHDs. This study aimed to predict the occurrence of CHDs by considering thousands of variables from self-reported questionnaires and routinely collected clinical laboratory data using machine learning algorithms. Methods: We conducted a birth cohort study at one of the largest cardiac centers in China from 2011 to 2017. All fetuses were screened for CHDs using ultrasound and cases were confirmed by at least two pediatric cardiologists using echocardiogram. A total of 1,127 potential predictors were included to predict CHDs. We used the Explainable Boosting Machine (EBM) for prediction and evaluated the model performance using area under the Receive Operating Characteristics (ROC) curves (AUC). The top predictors were selected according to their contributions and predictive values. Thresholds were calculated for the most significant predictors. Results: Overall, 5,390 mother-child pairs were recruited. Our prediction model achieved an AUC of 76% (69-83%) from out-of-sample predictions. Among the top 35 predictors of CHDs we identified, 34 were from clinical laboratory tests and only one was from the questionnaire (abortion history). Total accuracy, sensitivity, and specificity were 0.65, 0.74, and 0.65, respectively. Maternal serum uric acid (UA), glucose, and coagulation levels were the most consistent and significant predictors of CHDs. According to the thresholds of the predictors identified in our study, which did not reach the current clinical diagnosis criteria, elevated UA (>4.38 mg/dl), shortened activated partial thromboplastin time (<33.33 s), and elevated glucose levels were the most important predictors and were associated with ranges of 1.17-1.54 relative risks of CHDs. We have developed an online predictive tool for CHDs based on our findings that may help screening and prevention of CHDs. Conclusions: Maternal UA, glucose, and coagulation levels were the most consistent and significant predictors of CHDs. Thresholds below the current clinical definition of "abnormal" for these predictors could be used to help develop CHD screening and prevention strategies.