Emergency Department Presentation of Retinal Artery Occlusion

Purpose: To determine how frequently patients who present to an emergency department (ED) with a retinal artery occlusion (RAO) undergo brain imaging and cardiovascular testing and are hospitalized.

Design: Retrospective cross-sectional study.

Participants: Patients who presented to an ED with an RAO in the National Emergency Department Sample (NEDS), a nationally representative United States database.

Methods: The NEDS was queried to identify patients who presented to an ED with the primary diagnosis of RAO between 2006 and 2014. Patient and hospital characteristics were evaluated, and a multivariable regression was performed to determine predictors of hospitalization. Testing was categorized into 3 groups: (1) brain imaging performed using computed tomography or magnetic resonance; (2) carotid imaging performed using ultrasound, computed tomography, or magnetic resonance; and (3) cardiac testing performed using electrocardiogram or echocardiogram. The number of tests performed for each category was recorded.

Main outcome measures: Proportions of patients undergoing brain imaging, carotid imaging, or cardiac testing. Rate and predictors of hospitalization.

Results: Among 259 343 582 ED visits, 2802 had a primary diagnosis of RAO. Patients were mostly aged ≥65 years (59%) and male (54%). Hypertension (59%), dyslipidemia (36%), and diabetes (20%) were the most common preexisting cardiovascular diseases. Brain imaging, carotid imaging, and cardiac testing were performed in 20.3%, 7.1%, and 23.8% of the patients, respectively; at least 1 test from each of these 3 categories was performed in 4.1% of the patients. Half of the patients were hospitalized. Factors that increased the chances of hospitalization included the following (P < 0.05): age of <45 years; female sex; a history of smoking; presenting to a metropolitan hospital and having giant cell arteritis, carotid artery disease, atrial fibrillation, cardiac valve disease, obesity, dyslipidemia, hypertension, diabetes, and chronic ischemic heart disease.

Conclusions: Most patients who presented to an ED with an RAO did not receive emergency brain imaging, carotid imaging, or basic cardiac testing. A multidisciplinary approach is needed to raise awareness that RAOs should be treated as a precursor of stroke or a stroke equivalent.https://pubmed.ncbi.nlm.nih.gov/34742898/

Global uptake of fertility preservation by women undergoing cancer treatment: An unmet need in low to high-income countries

Although the incidence of cancers is on the rise globally, mortality has continued to decrease due to advances in early detection and treatment. Cancer treatments such as chemotherapy and radiotherapy can impact the reproductive capacity of survivors by inducing premature ovarian failure and subsequent infertility causing significant psychological distress with decreased quality of life. Despite the increasing need for fertility preservation services for the rising number of cancer survivors and the recent advances in assisted reproductive technology, many women with cancers in low, middle, and to a lesser extent, high-income countries have no access to these services. This article, therefore, presents an overview of the effect of cancer treatment on fertility, options of fertility preservation, and factors influencing fertility preservation utilization by women who had a cancer diagnosis. In addition, we discuss the availability, practices, and outcomes of fertility preservation services in low, middle, and high-income countries and highlight pragmatic steps to improving access to oncofertility care for women with cancers globally.https://pubmed.ncbi.nlm.nih.gov/35605436/

Predictors of Completed Suicides Among Emergency Department Visits for Attempted Suicides

Background: The objective of this study was to identify predictors of mortality among patients presenting to the emergency department (ED) with attempted suicides.

Methods: We analyzed data on emergency department (ED) visits for attempted suicides from the Nationwide Emergency Department Sample (NEDS) database from January 2010 to December 2017. The predictors of mortality were determined in multivariate analysis including age, sex, insurance, annual income, region of the country, mechanism of injury, mental health conditions (schizophrenia; depression; and anxiety, bipolar, and personality disorders), chronic illnesses (hypertension, diabetes, obesity, and dementia), and social risk factors such as alcohol addiction, smoking, and substance abuse.

Results: From 2010 to 2017, there were 979,383 ED visits for attempted suicides in the NEDS database. Among these patients, 10,301 (1.1%) died. Of these completed suicides, 73.9% were male with the median age of 43 years (IQR, 30) while the unsuccessful suicide attempt group had a median age of 30 years (IQR, 24) and were 42.7% male. The most common mechanisms of suicide attempt were poisoning (58.8%) and cut injury (25.6%). Gunshot was the most lethal mechanism accounting 40.3% of the completed suicides despite representing 1.3% of the attempts who came to ED. After controlling for common risk factors for attempted suicide, significant predictors of completed suicide include higher income status, uninsured status, male sex, and higher age.

Discussion: Among US patients presenting to the ED following attempted suicide, factors associated with suicide completion include increasing age, male sex, higher income, gunshot injuries, and uninsured status.https://pubmed.ncbi.nlm.nih.gov/36853915/

Racial Disparities in Survival Among Non-Hodgkin Lymphoma Patients: An Analysis of the SEER Database (2007-2015)

Introduction Although disparities in cancer survival exist across different races/ethnicity, the underlying factors are not fully understood. Aim To identify the interaction between race/ethnicity and insurance type and how this influences survival among non-Hodgkins lymphoma (NHL) patients. Methods We utilized the SEER (Surveillance, Epidemiology, and End Results) Registry to identify patients with a primary diagnosis of NHL from 2007 to 2015. Our primary outcome of interest was the hazard of death following a diagnosis of NHL. In addition, we utilized the Cox regression model to explore the interaction between race and insurance type and how this influences survival among NHL patients. Results There were 44,609 patients with NHL who fulfilled the study criteria. The mean age at diagnosis was 50.9 ± 10.8 years, with a mean survival of 49.8± 34.5 months. Among these patients, 64.8% were non-Hispanic Whites, 16% were Hispanics, and 10.8% were Blacks. In addition, 76.5% of the study population had private insurance, 16.6% had public insurance, and 6.9% were uninsured. Blacks had the worst survival (HR=1.66; 95% = 1.55-1.78). Patients on private insurance had better survival compared to those with public insurance (HR=2.11; 95% CI=2.00-2.24) Conclusion The racial and socioeconomic disparity in survival outcomes among patients with NHL persisted despite controlling for treatment modalities, age, and disease stage.https://pubmed.ncbi.nlm.nih.gov/35836466/

Intimate Partner Violence: An Independent Predictor of Emergency Department Visits for Attempted Suicides and Self-inflicted Injuries among American Women

Introduction: Intimate Partner Violence (IPV) is becoming a significant public health issue and has been associated with adverse health outcomes such as mental health disorders, medical conditions, and devastating lifestyle behaviors. The lifetime cost estimated with IPV has been estimated to be $3.6 trillion. Intimate partner violence (IPV) has been associated with attempted suicide and self-inflicted injuries.

Aim: To determine if IPV is an independent predictor of attempted suicides and self-inflicted injuries among American women.

Methods: We analyzed data on emergency department visits for attempted suicides and self-inflicted injuries from the National Emergency Sample database from January 2016 to December 2017. In a multivariate analysis, we determined the association between IPV and attempted suicides and self-inflicted injuries, controlling for covariates such as schizophrenia and other psychotic symptoms, anxiety disorders, depression, bipolar disorder, dementia, alcohol and substance abuse disorder, hospital region, insurance, and annual income. Samples were weighed to generate nationally representative estimates.

Results: We identified 64,152 women who visited the ED on account of attempted suicide and self-inflicted injuries between January 2016 and December 2017. Among this population, 0.19% have a background history of IPV. IPV increased the risk of attempted suicides/ self-inflicted injuries by 4 folds (OR= 4.34, 95% CI 1.56-12.13, p < 0.01).

Conclusion: Intimate partner violence is an independent predictor of increased risk of attempted suicides and self-inflicted injuries.https://hphr.org/62-article-akinyemi/

Postoperative atrial fibrillation following non-cardiac surgery: Predictors and risk of mortality

Background: Postoperative atrial fibrillation (POAF) is a major complication that follows both cardiac and non-cardiac procedures. Many studies have explored POAF after cardiac procedures, however POAF following non-cardiac procedures has been understudied.

Methods: National Inpatient Sample database was utilized to conduct a retrospective study of hospitalizations with diagnosis of POAF following non-cardiac procedures between 2010 and 2015.

Results: 294,112 patients met the inclusion criteria. Advanced age, male gender, colonic resections, coagulopathy, fluid and electrolyte disorders and history of congestive heart failure are major predictors of POAF and in-hospital mortality. Race, type of insurance, income quartile and weekend admissions are independent determinants of mortality following POAF.

Conclusions: Development of POAF and mortality is dependent upon a wide range of factors not limited to age and medical comorbidities. Although a patient may be at an increased risk for POAF this does not mean they are at an increased risk for mortality.https://www.sciencedirect.com/science/article/abs/pii/S0002961022004573

Color or money?: The impact of socioeconomic status and race/ethnicity on breast cancer mortality

Background: Although the incidence of breast cancer is highest in White women, Black women die at a higher rate. Our aim was to compare the relative association between race/ethnicity and socioeconomic status on breast cancer mortality.

Methods: We identified female breast cancer patients diagnosed between 2007 - 2011 and followed through 2016 in the SEER database. Patients were grouped into socioeconomic quartiles by a prosperity index. The primary outcome of interest was 5-year cancer-specific survival.

Results: A total of 286,520 patients were included. Five-year survival was worst for Black women compared to other races/ethnicities in each socioeconomic quartile. When compared to White women in the lowest quartile, Black women in the lowest quartile, 2nd quartile, and 3rd quartile experienced the lowest 5-year survival rates (Hazard ratio 1.33, 1.23, 1.20; P < 0.01).

Conclusion: Regarding cancer mortality, only in the most prosperous quartile do Black women achieve a similar outcome to the poorest quartile White women.https://www.sciencedirect.com/science/article/abs/pii/S0002961022004561

Retina Fellowship Match Outcomes and Trends in Program Characteristics

https://www.sciencedirect.com/science/article/abs/pii/S2468653022003141?via%3Dihub

Increasing Pre-pregnancy Body Mass Index and Pregnancy Outcomes in the United States

Introduction: As many Americans are becoming overweight or obese, increased body mass index (BMI) is fast becoming normalized. There is a need for more research that highlights the association between pre-pregnancy obesity and adverse pregnancy outcomes.

Aim: To determine the association between increasing pre-pregnancy BMI and adverse pregnancy outcomes.

Methods: We utilized the United States Vital Statistics records to collate data on all childbirths in the United States between 2015 and 2019. We determined the association between increasing pre-pregnancy BMI and adverse pregnancy outcomes using multivariate analysis. Neonatal outcomes measures include the five-minute Apgar score, neonatal unit admission, neonates receiving assisted ventilation > six hours, neonatal antibiotics use, and neonatal seizures. Maternal outcomes include cesarean section rate, mothers requiring blood transfusion, unplanned hysterectomy, and intensive care unit admission. In addition, we controlled for maternal parameters such as race/ethnicity, age, insurance type, and pre-existing conditions such as chronic hypertension and prediabetes. Other covariates include paternal race, age and education level, gestational diabetes mellitus, induction of labor, weight gain during pregnancy, gestational age at delivery, and delivery weight.

Results: We studied 15,627,572 deliveries in the US Vital Statistics records between 2015 and 2019. Among these women, 3.36% were underweight, 43.19% were with a normal BMI, 26.34% were overweight, 14.73% were in the obese class I, 7.23% were in the obese class II, and 5.14% were in the obese class III. Increasing pre-pregnancy BMI was associated with significant adverse outcomes across all measures of maternal and neonatal outcomes.

Conclusion: A strong association exists between increasing pre-pregnancy BMI and adverse maternal and neonatal outcomes. The higher risk of adverse pregnancy outcomes among overweight and obese women remained even after controlling for other traditional risk factors of adverse maternal and neonatal outcomes.

Keywords: cesarean section; classes of obesity; gestational weight gain; macrosomia; obesity prevention; perinatal outcomes; pre-pregnancy body mass index; pregnancy outcomes.https://pubmed.ncbi.nlm.nih.gov/36196279/

The Distressed Communities Index: A Measure of Community-Level Economic Deprivation and Rate of Firearm Injuries in Maryland

Background: This study aimed to investigate the relationship between community-level economic deprivation, as measured by the Distressed Communities Index (DCI) and ED visits on account of firearm injuries (assaults and unintentional).

Methods: A retrospective analysis was conducted using the Maryland State Emergency Department Databases (SEDD) from January 2019 to December 2020 to explore the association between the DCI and ED visits because of firearm injuries (assaults and unintentional). The DCI utilizes 7 variables, based on zip codes, generating 5 levels of socioeconomic distress (prosperous, comfortable, mid-tier, at-risk, and distressed). In a multivariate analysis, we adjusted for age, sex, mental conditions, alcohol addiction, substance abuse, smoking, race/ethnicity, insurance type, and median income.

Results: Of the 2725 ED visits for firearm injuries, 84.5% were Black and 88.5% male. The median age was 27 (21-35) years, and the mortality rate was 17.7%. A statistically significant association was found between economic deprivation and ED visits for firearm injuries. Compared to prosperous communities, the odds ratios (ORs) were comfortable (OR = 1.33, 95% CI 1.04-1.71, P = .03), mid-tier (OR = 1.69, 95% CI 1.33-2.15, P < .001), at-risk (OR = 1.53, 95% CI 1.17-1.99, P < .001), and distressed (OR = 2.65, 95% CI 2.11-3.33, P < .001).

Discussion: The study highlights the significant association between community-level economic deprivation, as measured by the Distressed Communities Index, and the incidence of firearm injuries in Maryland. The findings underscore the importance of addressing socioeconomic disparities and implementing targeted interventions to reduce firearm-related injuries in economically distressed communities.https://pubmed.ncbi.nlm.nih.gov/37486307/

Examining the Association between Neighborhood Socioeconomic Deprivation and Cesarean Section Rates among Women Diagnosed with Gestational Diabetes Mellitus—A Retrospective Analysis of the Maryland State Inpatient Database

Introduction: The rising cesarean section (CS) rates in patients with Gestational Diabetes Mellitus (GDM) may be influenced by social determinants of health, including neighborhood socioeconomic deprivation. Recent research has highlighted the association between higher levels of neighborhood socioeconomic deprivation and increased rates of CS among women with GDM. Understanding this relationship is crucial for addressing health disparities and improving maternal and infant health outcomes in disadvantaged communities.

Objective: To determine the association between neighborhood socioeconomic deprivation (DCI) and incidences of cesarean section among women with GDM in Maryland.

Methodology: DCI and CS rates among women with GDM. We adjusted for potential confounding variables, including age, day of admission, insurance type, race/ethnicity, and income, in our final multivariate analysis.

Results: In our study period, we identified 17,326 cases of GDM, with a CS rate of 44.3%. We found a significant correlation between the level of socioeconomic deprivation in the neighborhood and the rate of CS among women with GDM. Women with GDM residing in the poorest communities had the highest odds of CS. Prosperous, reference, Comfortable, (OR=1.08, 95% CI 0.98-1.20, p=0.13), Mid-tier, (OR=1.14, 95% CI 1.02-1.26, p=0.02), At-Risk, (OR= 1.17, 95% CI 1.02-1.34, p=0.03), and Distressed, (OR=1.29, 95% CI 1.11-1.50, p=0.001).

Conclusion: Women with GDM residing in areas with the poorest communities have the highest incidence of CS, irrespective of other risk factors.https://doi.org/10.2337/db23-185-LB

Influence of Race/Ethnicity and Household Median Income on Penile Cancer Mortality

Introduction: Penile cancer, while relatively rare in developed nations, presents substantial disparities in outcomes among different demographic groups. Previous research has shown race/ethnicity and socioeconomic status, often proxied by household median income, to be critical determinants of health outcomes across various diseases.

Objective: This study examines the association of race/ethnicity and household median income with survival among penile cancer patients in the United States.

Methods: We utilized the Surveillance, Epidemiology, and End Results (SEER) Registry to identify patients with a primary diagnosis of penile malignancies from 2000 to 2019. Our primary outcome of interest was the hazard of death following a diagnosis of penile cancer. We utilized the Cox regression model to explore the association between race/ethnicity and median household income and how this influences survival among these patients. We adjusted for patients' characteristics, disease stage at presentation, and treatment modalities.

Result: Of the 6,520 penile cancer patients identified, 5,242 (80.4%) had primary malignancies. The distribution of patients was as follows: 64.1% non-Hispanic Whites, 8.9% non-Hispanic Blacks, 20.8% Hispanics, and 6.2% from other racial/ethnic groups. The median diagnosis age was 66 years (interquartile range: 56-74). Survival rates at 5, 10, and 15 years showed racial disparities: 76.4%, 72.5%, and 69.7% for non-Hispanic Whites; 70.6%, 64.1%, and 61.1% for non-Hispanic Blacks; and 70.5%, 67.4%, and 65.6% for Hispanics. Multivariate Cox regression revealed worst survival for Black (HR=1.40; 95% CI=1.08-1.81, p=0.01) and Hispanic patients (HR=1.24; 95% CI=1.01-1.52, p=0.04). No association was found between median household income and survival. Interaction analysis indicated that the poorest Black men had worse outcomes than the poorest Whites did (HR=2.08; 95% CI=1.27-3.41, p=0.003).

Conclusion: Survival rates for non-Hispanic Black and Hispanic patients are significantly lower than those for non-Hispanic Whites. Furthermore, survival is worse for low-income Black patients than their White counterparts in the same income bracket.https://www.cureus.com/articles/163757-influence-of-raceethnicity-and-household-median-income-on-penile-cancer-mortality#!/

Association Between Obesity and Self-Reported Depression Among Female University Students in the United States

Aim: To determine the relationship between obesity and depression among female undergraduate students at Western Illinois University (WIU), Macomb, Illinois.

Methods: A cross-sectional study using self-reported questionnaires were conducted between August 15, 2019, and December 15, 2019. A cohort of 434 female undergraduate students was retrieved from the study. We determined the association between self-reported diagnosis of depression within the last year and body mass index (BMI) among female students.

Results: The prevalence of depression among female undergraduates at WIU was 33.2%. Obese and overweight female undergraduate students had a higher likelihood of being diagnosed with depression than students with normal BMI (reference), overweight (OR= 1.91; 95% CI 1.11-3.31), obese (OR= 2.20; 95% CI 1.30-3.80). Latino and black students were less likely to report depression than white students, Latino (OR=0.37 95% CI 0.15-0.92), and Black (OR= 0.40; 95% CI 0.18-0.86). There was also a positive association between chronic back pain and development of the diagnosis of depression, (OR=2.26; 95% CI 1.45-3.52).

Conclusion: Depression among female undergraduate students is very common in the USA. Obese and overweight female students are more likely to be depressed than students with normal BMI. There is a need for urgent public health interventions to reduce the obesity rate among university students.https://pubmed.ncbi.nlm.nih.gov/36514672/

Screening for Gestational Diabetes Mellitus: Is There a Need for Early Screening for All Women in Developing Countries?

Background: Gestational diabetes mellitus (GDM) is associated with significant adverse pregnancy outcomes. Early diagnosis and treatment have been proven to reduce adverse pregnancy outcomes among women diagnosed with GDM. Current guidelines recommend routine screening for GDM at 24-28 weeks of pregnancy, with early screening offered to those considered high risk. However, risk stratification may not always be helpful for those who would benefit from early screening, especially in non-Western settings.

Aim: To determine the need for early screening for GDM among pregnant women attending antenatal clinics in two tertiary hospitals in Nigeria.

Methods: We conducted a cross-sectional study from December 2016 to May 2017. We identified women who presented at the antenatal clinics of the Federal Teaching Hospital Ido-Ekiti and Ekiti State University Teaching Hospital, Ado Ekiti. A total of 270 women who fulfilled the study inclusion criteria were enrolled. The 75 g oral glucose tolerance test was used to screen participants for GDM before 24 weeks and between 24 and 28 weeks for those who screened negative before 24 weeks. Pearson's chi-square test, Fisher's exact test, independent t-test, and Mann-Whitney U test were utilized in the final analysis.

Results: The median age of the women in the study was 30 (interquartile range: 27-32) years. Of our study participants, 40 (14.8%) were obese, 27 (10%) had a history of diabetes mellitus in a first-degree relative, and three (1.1%) women had a previous history of GDM. Twenty-one women (7.8%) were diagnosed with GDM, and six (28.6%) were diagnosed before 24 weeks. Women diagnosed with GDM before 24 weeks were older (37 years; interquartile range: 34-37) and more likely to be obese (80.0%). A significant number of these women also had identifiable risk factors for GDM: previous GDM (20.0%), family history of diabetes mellitus in a first-degree relative (80.0%), prior delivery of fetal macrosomia (60.0%), and previous history of congenital fetal anomaly (20.0%).

Conclusion: The findings from the present study did not justify universal screening for GDM in all pregnant women. Patients diagnosed before the 24-28 weeks of universal screening are more likely to have significant risk factors for GDM and, therefore, would have been selected for screening based on the risk factor screening.https://pubmed.ncbi.nlm.nih.gov/37007361/

Factors associated with suicide/self-inflicted injuries among women aged 18–65 years in the United States: A 13-year retrospective analysis of the National Inpatient Sample database

Background: Suicide is a significant cause of mortality in the United States, accounting for 14.5 deaths/100,000. Although there are data on gender disparity in suicide/self-inflicted injury rates in the United States, few studies have examined the factors associated with suicide/self-inflicted injury in females.

Objective: To determine factors associated with suicide/self-inflicted injuries among women aged 18–65 years in the United States.

Methods: Hospitalizations for suicide or self-inflicted injuries were identified using the National Inpatient Sample database from 2003–2015 using sample weights to generate national estimates. Independent predictors of suicide/self-inflicted injuries were identified using multivariable regression models. Interaction term analysis to identify the interaction between race/ethnicity and income were conducted.

Results: There were 1,031,693 adult women hospitalizations in the U.S. with a primary diagnosis of suicide/self-inflicted injury in the study period. The highest suicide/self-inflicted injury risk was among women aged 31-45years (OR = 1.23, CI = 1.19–1.27, p < 0.05). Blacks in the highest income strata had a 20% increase in the odds of suicide/self-inflicted injury compared to Whites in the lowest socioeconomic strata (OR = 1.20, CI = 1.05–1.37, p <0.05). Intimate partner violence increased suicide/self-inflicted injury risk 6-fold (OR = 5.77, CI = 5.01–6.65, p < 0.05).

Conclusion: Suicide risk is among women aged 31–45 years, higher earning Black women, intimate partner violence victims, uninsured, and current smokers. Interventions and policies that reduce smoking, prevents intimate partner violence, addresses racial discrimination and bias, and provides universal health coverage are needed to prevent excess mortality from suicide deaths.https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0287141

Determinants of Neonatal Mortality in the United States

Introduction: Despite a notable reduction in infant mortality over recent decades, the United States, with a rate of 5.8 deaths per 1,000 live births, still ranks unfavorably compared to other developed countries. This improvement appears inadequate when contrasted with the country's healthcare spending, the highest among developed nations. A significant proportion of this infant mortality rate can be attributed to neonatal fatalities.

Objective: The present study aimed to determine the risk factors associated with neonatal deaths in the United States.

Method: Using the United States Vital Statistics records, we conducted a retrospective study on childbirths between 2015 and 2019 to identify risk factors for neonatal mortality. Our final multivariate analysis included maternal parameters like age, insurance type, education level, cesarean section rate, pregnancy inductions and augmentations, weight gain during pregnancy, birth weight, number of prenatal visits, pre-existing conditions like chronic hypertension and prediabetes, and pregnancy complications like gestational diabetes mellitus (GDM). These variables were incorporated to enhance our model's sensitivity and specificity.

Result: There were 51,174 neonatal mortalities. Mothers with augmentation of labor had a 25% reduction in neonatal mortalities (NM) (OR=0.75; 95% CI 0.72-0.79), while labor induction was associated with a 31% reduction in NM (OR=0.69; 95% CI 0.66-0.72). Women above 40 years had a 29% increase in NM rate (OR=1.29;95% CI 1.15-1.44). Women without prenatal care have a 22% increase in the risk of NM (OR=1.22; 95% CI 1.14-1.30). The present model has a 60.7% sensitivity and a 99.9% specificity.

Conclusion: In the present study, significant interventions such as labor induction, augmentation, and prenatal care were associated with improved neonatal outcomes. These findings could serve as an algorithm for improving neonatal outcomes in the United States. https://pubmed.ncbi.nlm.nih.gov/37674952/

The impact of the affordable care act on access to bariatric surgery in Maryland

Introduction: This study aims to investigate the influence of the Affordable Care Act (ACA) on the utilization of Roux-en-Y gastric bypass (RYGB) procedures in Maryland.

Methods: Using the Maryland State Inpatient Database, this retrospective study compared all patients undergoing RYGB during the pre-ACA (2007–2009) and post-ACA (2018–2020) periods, including patient demographic factors, pre-existing conditions, and socioeconomic factors.

Results: A total of 16,494 RYGB procedures were performed during the study period, of which 12,089 (73.3 ​%) were post-ACA. This was a 179.2 ​% increase in patients undergoing RYGB post-ACA; nearly triple that of the pre-ACA period. There was a significant decrease in uninsured patients (5.6 ​%–1.5 ​%, p ​< ​0.01) an increase in Black patients (32.1 ​%–46.8 ​%, p ​< ​0.01) and Medicaid beneficiaries (6.0 ​% pre-ACA to 17.8 ​% post-ACA, p ​< ​0.01). There were significant reductions in adverse outcomes (long hospital stays, hemorrhage, GIT leaks, and mortality) across all insurance types (all p ​< ​0.01).

Conclusion: The ACA increased access to RYGB procedures, especially in Black and Medicaid recipients in Maryland, enhancing healthcare across all insurance types. https://www.americanjournalofsurgery.com/article/S0002-9610(23)00667-0/fulltext

Neovascular Age-Related Macular Degeneration in a Predominantly Black Population

BACKGROUND AND OBJECTIVE:We intend to study the characteristics and outcomes of an understudied patient population with neovascular age-related macular degeneration (nAMD).

PATIENTS AND METHODS:This retrospective study evaluated presenting features and outcomes in a predominantly Black patient population with nAMD. A multivariate regression explored baseline characteristics predictive of 1-year vision.

RESULTS:Sixty-three eyes were included. The median (interquartile range) baseline vision was 20/300 (20/80 to counting fingers). Patients' baseline optical coherence tomography findings showed a mean central subfield thickness of 336 µm; 80% (n = 35) and 41% (n = 18) had fluid and central scarring, respectively. The primary predictor for vision at year-one was baseline vision (P = 0.03, 95% CI: 0.04 to 0.91). All of those who gained ≥ 3 lines of vision lacked central scarring at baseline.

CONCLUSION:Further studies are needed to investigate how to improve earlier detection and treatment of nAMD in this patient populationhttps://journals.healio.com/doi/10.3928/23258160-20230927-01

Self-Regulation, Dietary Habits, and Obesity Trends Among Female College Students

Introduction: Dietary habits and self-regulation are crucial in weight management, particularly among female college students. These students, navigating transitional life stages and academic stressors, often grapple with making healthy food choices. Understanding their self-confidence in resisting overeating and unhealthy foods can shed light on obesity trends within this demographic.

Objective: We determine the association between self-reported individual-level confidence in resisting the urge to overeat or choose less healthy food options and obesity among female college students.

Methods: From August 10 to October 20, 2019, a cross-sectional survey was conducted among female students at Western Illinois University. Using a Likert scale, we gauged self-reported confidence in resisting overeating or unhealthy food choices. Responses were numerically scored (5-55), with higher scores indicating greater confidence. These scores were integrated into a multivariate analysis, investigating associations with obesity and depression risks, adjusted for age, race, and academic year.

Results: Of 375 female students meeting the criteria, the racial breakdown was 60.8% white, 21.9% black, 8.3% Hispanic, and 9.1% other. Age 18-21 covered 66.2%. BMIs were 44.0% normal, 21.9% overweight, and 30.1% obese. Depression was clinically diagnosed in 23.2%. The median dietary score was 34 (IQR 31-39).Every dietary score unit increase reduced the risk of being underweight by 3.9% (RR=0.96, 95% CI 0.89-1.04, P=0.31), overweight by 4.5% (RR=0.96, 95% CI 0.92-0.99, P=0.022), and obese by 5.7% (RR=0.94, 95% CI 0.91-0.98, P=0.004) relative to normal BMI. Significant predictors of self-reported depression include being underweight or obese, being White, and having a family history of obesity.

Conclusion: In this cohort of college students in Macomb, female students with stringent dietary practices are less prone to overweight or obesity.https://hphr.org/64-article-salihu/

The Association between Community-Level Economic Deprivation and Incidences of Emergency Department Visits on Account of Attempted Suicides in Maryland

Background: Suicide is a major cause of mortality in the United States, accounting for 14.5 deaths per 100,000 population. Many emergency department (ED) visits in the United States are due to attempted suicides. Suicide attempts predict subsequent completed suicides. Socioeconomic factors, such as community-level socioeconomic deprivation, significantly affect many traditional risk factors for attempted suicides and suicides.

Aim: To determine the association between community-level socioeconomic deprivation and ED visits for attempted suicide in Maryland.

Methods: A retrospective analysis of attempted suicides in the Maryland State Emergency Department Database from January 2019 to December 2022. Community-level socioeconomic deprivation was measured using the Distress Community Index (DCI). Multivariate regression analyses were conducted to identify the association between DCI and attempted suicides/selfharm.

Results: There were 3,564,987 ED visits reported in the study period, with DCI data available for 3,236,568 ED visits; 86.8% were younger than 45 years, 64.8% were females, and 54.6% non-Hispanic Whites. Over the study period, the proportion of ED visits due to attempted suicide was 0.3%. In the multivariate logistic regression, compared to prosperous zones, those in comfortable (OR=0.80,95% CI: 0.73-0.88, p<0.01), Mid-Tier (OR=0.76, 95%CI:0.67-0.86, p<0.01), p<0.01) and Distressed zones (OR=0.53; 95%CI:0.42-0.66, p<0.01) were less likely to visit the ED for attempted suicide.

Conclusion: Prosperous communities had the highest rate of attempted suicides, with the risk of attempted suicide increasing as individuals move from the least prosperous to more prosperous areas.https://www.frontiersin.org/articles/10.3389/fpubh.2024.1353283/abstract

Retina Fellowship Match Outcomes and Trends in Program Characteristics

Each year, aspiring ophthalmology residents submit their applications to the San Francisco Match (SFM) with the hopes of becoming a retina specialist. Although a detailed analysis of the ophthalmology residency match and in-depth subspecialty analysis for other ophthalmology fellowships are available, similar studies to serve as a resource for applicants and their advisors preparing for the retina match are lacking. Therefore, we queried the SFM database to study applicant characteristics and match outcomes for all applicants for the 2019 retina fellowship match. Additionally, we studied fellowship program characteristics over the last decade to identify trends in fellowship offerings.https://www.ophthalmologyretina.org/article/S2468-6530(22)00314-1/fulltext

Utilization and Outcomes of Roux-en-Y Gastric Bypass Surgery Following the Affordable Care Act in the United States

Background: The passage of the Affordable Care Act (ACA) in 2010 marked a pivotal moment in American health care policy, significantly expanding access to health care services. This study aims to explore the relationship between the ACA and the utilization and outcomes of Roux-en-Y Gastric Bypass (RYGB) surgery.

Methods: Using data from the National Inpatient Sample (NIS) Database, this retrospective study compares the pre-ACA period (2007-2009) with the post-ACA period (2017-2019), encompassing patients who had RYGB. Multivariable logistic analysis was done accounting for patient's characteristics, comorbidities, and hospital type.

Results: In the combined periods, there were 158 186 RYGB procedures performed, with 30.0% transpiring in pre-ACA and 70.0% in the post-ACA. Post-ACA, the proportion of uninsured patients decreased from 4.8% to 3.6% (P < .05), while Black patients increased from 12.5% to 18.5% (P < .05). Medicaid-insured patients increased from 6.8% to 18.1% (P < .05), and patients in the poorest income quartile increased from 20% to 26% (P < .05). Patients in the post-ACA period were less likely to have longer hospital stays (OR = .16: 95% CI .16-.17, P < .01), in-hospital mortality (OR = .29: 95% CI .18-.46, P < .01), surgical site infection (OR = .25: 95% CI .21-.29, P < .01), postop hemorrhage (OR = .24: 95% CI .21-.28, P < .01), and anastomotic leak (OR = .14: 95% CI .10-.18, P < .01) than those in the pre-ACA period.

Discussion: Following the implementation of the ACA, utilization of bariatric surgery significantly increased, especially among Black patients, Medicaid beneficiaries, and low-income patients. Moreover, despite the inclusion of more high-risk surgical patients in the post-ACA period, there were better outcomes after surgery.https://pubmed.ncbi.nlm.nih.gov/38214232/

Causal Effects of the Affordable Care Act (ACA) Implementation on Non-Hodgkin's Lymphoma Survival: A Difference-in-Differences Analysis

Introduction: Non-Hodgkin's Lymphoma (NHL) accounts for a substantial number of cancer cases in the United States, with a significant prevalence and mortality rate. The implementation of the Affordable Care Act (ACA) has the potential to impact cancer-specific survival among NHL patients by improving access to healthcare services and treatments.

Objective: This study aims to assess the impact of the implementation of the ACA on cancer-specific survival among patients diagnosed with NHL.

Methodology: In this retrospective analysis, we leveraged data from the Surveillance, Epidemiology, and End Results (SEER) registry to assess the impact of the ACA on cancer-specific survival among NHL patients. The study covered the years 2000-2020, divided into pre-ACA (2000-2013) and post-ACA (2017-2020) periods, with a three-year washout (2014-2016). Using a Difference-in-Differences approach, we compared Georgia (a non-expansion state) to New Jersey (an expansion state since 2014). We adjusted for patient demographics, income, metropolitan status, disease stage, and treatment modalities.

Results: Among 74,762 patients, 56.2% were in New Jersey (42,005), while 43.8% were in Georgia (32,757). The pre-ACA period included 32,851 patients (51.7% in Georgia and 56.7% in New Jersey), and 27,447 patients were in the post-ACA period (48.3% in Georgia and 43.4% in New Jersey). The post-ACA period exhibited a 34% survival improvement (OR=0.66, 95% CI 0.58-0.75). ACA implementation was associated with a 16% survival boost among NHL patients in New Jersey (OR=0.84, 95% CI 0.74-0.95). Other factors linked to improved survival included surgery (OR=0.86, 95% CI 0.81-0.91), radiotherapy (OR=0.77, 95% CI 0.72-0.82), and married status (OR=0.67, 95% CI 0.64-0.71).

Conclusion: The study underscores the ACA's potential positive impact on cancer-specific survival among NHL patients, emphasizing the importance of healthcare policy interventions in improving patient outcomes.https://pubmed.ncbi.nlm.nih.gov/38249651/

The association between community-level economic deprivation and incidences of emergency department visits on account of attempted suicides in Maryland

Background: Suicide is a major cause of mortality in the United States, accounting for 14.5 deaths per 100,000 population. Many emergency department (ED) visits in the United States are due to attempted suicides. Suicide attempts predict subsequent completed suicides. Socioeconomic factors, such as community-level socioeconomic deprivation, significantly affect many traditional risk factors for attempted suicides and suicides.

Aim: To determine the association between community-level socioeconomic deprivation and ED visits for attempted suicide in Maryland.

Methods: A retrospective analysis of attempted suicides in the Maryland State Emergency Department Database from January 2018 to December 2020. Community-level socioeconomic deprivation was measured using the Distress Community Index (DCI). Multivariate regression analyses were conducted to identify the association between DCI and attempted suicides/self-harm.

Results: There were 3,564,987 ED visits reported in the study period, with DCI data available for 3,236,568 ED visits; 86.8% were younger than 45 years, 64.8% were females, and 54.6% non-Hispanic Whites. Over the study period, the proportion of ED visits due to attempted suicide was 0.3%. In the multivariate logistic regression, compared to prosperous zones, those in comfortable (OR = 0.80, 95% CI: 0.73-0.88, p < 0.01), Mid-Tier (OR = 0.76, 95%CI:0.67-0.86, p < 0.01), At-Risk (OR = 0.77; 95%CI: 0.65-0.92, p < 0.01) and Distressed zones (OR = 0.53; 95% CI:0.42-0.66, p < 0.01) were less likely to visit the ED for attempted suicide.

Conclusion: Prosperous communities had the highest rate of attempted suicides, with the risk of attempted suicide increasing as individuals move from the least prosperous to more prosperoushttps://pubmed.ncbi.nlm.nih.gov/38384877/

Impact of Medicaid expansion on pregnancy outcomes among women with gestational diabetes

Introduction: The Affordable Care Act (ACA) aims to broaden health care access and significantly impacts obstetric practices. Yet, its effect on maternal and neonatal outcomes among women with gestational diabetes across diverse demographics is underexplored.

Objective: This study examines the impact of the implementation of the ACA on maternal and neonatal health in Maryland with ACA implementation and Georgia without ACA implementation.

Methodology: We used data from the Maryland State Inpatient Database and US Vital Statistics System to assess the ACA's influence on maternal and neonatal outcomes in Maryland, with Georgia serving as a nonexpansion control state. Outcomes compared include cesarean section (CS) rates, low Apgar scores, neonatal intensive care unit (NICU) admissions, and assisted ventilation 7 h postdelivery. We adjusted for factors including women's age, race, insurance type, preexisting conditions, prior CS, prepregnancy obesity, weight gain during pregnancy, birth weight, labor events, and antenatal practices.

Results: The study included 52 479 women: 55.8% from Georgia and 44.2% from Maryland. Post-ACA, CS rates were 45.1% in Maryland versus 48.2% in Georgia (P = 0.000). Maryland demonstrated better outcomes, including lower rates of low Agar scores (odds ratio [OR], 0.74 [95% confidence interval (CI), 0.63-0.86]), assisted ventilation (OR, 0.79 [95% CI, 0.71-0.82]), and NICU admissions (OR, 0.76 [95% CI, 0.71-0.82]), but no significant change in CS rates (OR, 0.96 [95% CI, 0.92-1.01]).

Conclusion: After ACA implementation, Maryland showed improved maternal and neonatal outcomes compared with Georgia, a nonexpansion state.https://pubmed.ncbi.nlm.nih.gov/38445784/

Impact of the Kidney Allocation Revision on Access to Kidney Transplantation and Outcomes in the United States

Background: The 2014 Kidney Allocation System (KAS) revision aimed to enhance equity in organ allocation and improve patient outcomes. This study assesses the impacts of the KAS revision on renal transplantation demographics and outcomes in the United States.

Methods: We conducted a retrospective study utilizing the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients (OPTN/SRTR) database from 1998 to 2022. We compared recipient and donor characteristics, and outcomes (graft failure and recipient survival) pre- and post-KAS revision.

Results: Post-KAS, recipients were significantly older (53 vs 48, P < .001) with an increase in Medicaid beneficiaries (7.3% vs 5.5%, P < .001). Despite increased graft survival, HR = .91 (95% CI 0.80-.92, P < .001), overall recipient survival decreased, HR = 1.06 (95% CI 1.04-1.09, P < .001). KAS revision led to greater racial diversity among recipients and donors, enhancing equity in organ allocation. However, disparities persist in graft failure rates and recipient survival across racial groups.

Discussion: The 2014 Kidney Allocation System revision has led to important changes in the renal transplantation landscape. While progress has been made towards increasing racial equity in organ allocation, further refinements are needed to address ongoing disparities. Recognizing the changing patient profiles and socio-economic factors will be crucial in shaping future policy modifications.https://pubmed.ncbi.nlm.nih.gov/38531806/

Impact of the Affordable Care Act on Revascularization Versus Amputation in Patients Presenting With Chronic Limb-Threatening Ischemia in Maryland

Introduction: The Affordable Care Act (ACA) aimed to expand Medicaid, enhance health care quality and efficiency, and address health disparities. These goals have potentially influenced medical care, notably revascularization rates in patients presenting with chronic limb-threatening ischemia (CLTI). This study examines the effect of the ACA on revascularization vs amputation rates in patients presenting with CTLI in Maryland.

Methods: This was a retrospective analysis of the Maryland State Inpatient Database comparing the rate of revascularization to rate of major amputation in patients presenting with CLTI over 2 periods: pre-ACA (2007-2009) and post-ACA (2018-2020). In this study, we included patients presenting with CLTI and underwent a major amputation or revascularization during that same admission. Using regression analysis, we estimated the odds of revascularization vs amputation pre- and post-ACA implementation, adjusting for pertinent variables.

Result: During the study period, 12,131 CLTI patients were treated. Post-ACA, revascularization rate increased from 43.9% to 77.4% among patients presenting with CLTI. This was associated with a concomitant decrease in the proportion of CLTI patients undergoing major amputation from 56.1% to 22.6%. In the multivariate analysis, there was a 4-fold odds of revascularization among patients with CLTI compared to amputation (OR = 4.73, 95% CI 4.34-5.16) post-ACA. This pattern was seen across all insurance groups.

Conclusion: The post-ACA period in Maryland was associated with an increased revascularization rate for patients presenting with CLTI with overall benefits across all insurance types.https://pubmed.ncbi.nlm.nih.gov/38822765/

The relationship between neighborhood economic deprivation and asthma-associated emergency department visits in Maryland

Background: Asthma represents a substantial public health challenge in the United States, affecting over 25 million adults. This study investigates the impact of neighborhood economic deprivation on asthma-associated Emergency Department (ED) visits in Maryland, using the Distressed Communities Index (DCI) for analysis.

Methods: A retrospective analysis of Maryland's Emergency Department Databases from January 2018 to December 2020 was conducted, focusing on asthma-associated ED visits.

Results: The study involved 185,317 ED visits, majority of which were females (56.3%) and non-Hispanic whites (65.2%). A significant association was found between increased neighborhood socioeconomic deprivation and asthma-related ED visits. The poorest neighborhoods showed the highest rates of such visits. Compared to prosperous areas, neighborhoods classified from Comfortable to Distressed had progressively higher odds for asthma-related ED visits (Comfortable: OR = 1.14, Distressed OR = 1.65). Other significant asthma predictors included obesity, female gender, tobacco smoking, and older age.

Conclusion: There is a substantive association between higher asthma-related ED visits and high neighborhood economic deprivation, underscoring the impact of socioeconomic factors on health outcomes.

Public health implications: Addressing healthcare disparities and improving access to care in economically distressed neighborhoods is crucial. Targeted interventions, such as community health clinics and asthma education programs, can help mitigate the impact of neighborhood disadvantage.https://www.frontiersin.org/articles/10.3389/falgy.2024.1381184/full

Trends in Suicides and Homicides in 21st Century America

BACKGROUND: Violent deaths, including suicides and homicides, pose a significant public health challenge in the United States. Understanding the trends and identifying associated risk factors is crucial for targeted intervention strategies.

AIM: To examine the trends in suicides and homicides over the past two decades and identify demographic and contextual predictors using the Center for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System online database.

METHODS: A retrospective analysis of mortality records from 2000 to 2020 was conducted, utilizing multivariate regression analyses. Covariates included age, race, sex, education, mental health conditions, and time period. Age-adjusted rates were employed to assess trends.

RESULTS: Over the 20 years, there was an upward trajectory in suicide rates, increasing from approximately 10/100,000 to over 14/100,000 individuals, which is a notable increase among American Indians (100.8% increase) and individuals aged 25 years and younger (45.3% increase). Homicide rates, while relatively stable, exhibited a significant increase in 2019-2020, with African Americans consistently having the highest rates and a significant increase among American Indians (73.2% increase). In the multivariate regression analysis, Individuals with advanced education (OR= 1.74, 95% CI= 1.70 - 1.78), depression (OR = 13.47, 95% CI = 13.04 - 13.91), and bipolar disorder (OR = 2.65, 95% CI = 2.44 - 2.88) had higher odds of suicide. Risk factors for homicide include African Americans (OR = 4.15, 95% CI = 4.08 - 4.23), Latinx (OR = 2.31, 95% CI = 2.26 - 2.37), people aged 25 years and younger, and those with lower educational attainment.

CONCLUSIONhttps://assets.cureus.com/uploads/original_article/pdf/253692/20240524-29207-5qfwth.pdf: This study highlights the changing demographic pattern in suicides and homicides in the United States and the need for targeted public health responses. Means restriction, universal suicide screening, addressing mental health stigma, and implementing broad interventions that modify societ

Impact of the Implementation of the Affordability Care Act on Gastric Cancer Survival Rates

Background: Violent deaths, including suicides and homicides, pose a significant public health challenge in the United States. Understanding the trends and identifying associated risk factors is crucial for targeted intervention strategies.

Aim: To examine the trends in suicides and homicides over the past two decades and identify demographic and contextual predictors using the Center for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System online database.

Methods: A retrospective analysis of mortality records from 2000 to 2020 was conducted, utilizing multivariate regression analyses. Covariates included age, race, sex, education, mental health conditions, and time period. Age-adjusted rates were employed to assess trends.

Results: Over the 20 years, there was an upward trajectory in suicide rates, increasing from approximately 10/100,000 to over 14/100,000 individuals, which is a notable increase among American Indians (100.8% increase) and individuals aged 25 years and younger (45.3% increase). Homicide rates, while relatively stable, exhibited a significant increase in 2019-2020, with African Americans consistently having the highest rates and a significant increase among American Indians (73.2% increase). In the multivariate regression analysis, Individuals with advanced education (OR= 1.74, 95% CI= 1.70 - 1.78), depression (OR = 13.47, 95% CI = 13.04 - 13.91), and bipolar disorder (OR = 2.65, 95% CI = 2.44 - 2.88) had higher odds of suicide. Risk factors for homicide include African Americans (OR = 4.15, 95% CI = 4.08 - 4.23), Latinx (OR = 2.31, 95% CI = 2.26 - 2.37), people aged 25 years and younger, and those with lower educational attainment.

Conclusion: This study highlights the changing demographic pattern in suicides and homicides in the United States and the need for targeted public health responses. Means restriction, universal suicide screening, addressing mental health stigma, and implementing broad interventions that modify societal attitudes toward suicide and homicides are essential components of a comprehensive strategy.https://pubmed.ncbi.nlm.nih.gov/38910703/

The relationship between neighborhood economic deprivation and community-acquired pneumonia related admissions in Maryland

Introduction: Community-acquired pneumonia (CAP) is a major health concern in the United States (US), with its incidence, severity, and outcomes influenced by social determinants of health, including socioeconomic status. The impact of neighborhood socioeconomic status, as measured by the Distressed Communities Index (DCI), on CAP-related admissions remains understudied in the literature.

Objective: To determine the independent association between DCI and CAP-related admissions in Maryland.

Methods: We conducted a retrospective study using the Maryland State Inpatient Database (SID) to collate data on CAP-related admissions from January 2018 to December 2020. The study included adults aged 18–85 years. We explored the independent association between community-level economic deprivation based on DCI quintiles and CAP-related admissions, adjusting for significant covariates.

Results: In the study period, 61,467 cases of CAP-related admissions were identified. The patients were predominantly White (49.7%) and female (52.4%), with 48.6% being over 65 years old. A substantive association was found between the DCI and CAP-related admissions. Compared to prosperous neighborhoods, patients living in economically deprived communities had 43% increased odds of CAP-related admissions.

Conclusion: Residents of the poorest neighborhoods in Maryland have the highest risk of CAP-related admissions, emphasizing the need to develop effective public health strategies beneficial to the at-risk patient population.https://doi.org/10.3389/fpubh.2024.1412671

Comparative impact of the affordable care act on breast cancer outcomes among women in two US states

Introduction: Since the implementation of the Patient Protection and Affordable Care Act (ACA) and Medicaid expansion, states that adopted the policy have seen reduced uninsured rates. However, it is unclear whether increased healthcare access, particularly for minority and socioeconomically disadvantaged groups, has translated into measurable improvements in health outcomes.

Objective: Our study aims to evaluate the impact of the ACA and Medicaid expansion on breast cancer outcomes in Louisiana, which has implemented the policy, compared to Georgia, which has not, as of 2024.

Methodology: We conducted a retrospective study using SEER registry data from January 2011 to December 2021, including women aged 18-64 diagnosed with breast cancer. The impact of the ACA and Medicaid expansion on cancer-specific survival (CSS), overall survival (OS), and stage at presentation was evaluated. The cohort was divided into pre-ACA (2011-2015) and post-ACA (2017-2021) periods, with a one-year washout (2016). A difference-in-difference (DID) approach compared outcomes between Louisiana and Georgia.

Results: The study analyzed 62,381 women with breast cancer, with 32,220 cases in the pre-ACA period (51.7%) and 30,161 in the post-ACA period (48.3%). In Georgia, 43,279 women were included (52.3% pre-ACA vs. 47.7% post-ACA), while Louisiana had 19,102 women (50.1% pre-ACA vs. 49.9% post-ACA). Medicaid expansion in Louisiana was associated with a 0.26 percentage point reduction in overall deaths (95% CI: -10.9 to 10.4) and a 5.97 percentage point reduction in cancer-specific mortality (95% CI: -26.1 to 14.2). There was also no significant difference in disease stage at presentation compared to Georgia.

Conclusion: This study found no significant differences in overall mortality, cancer-specific mortality, or disease stage at presentation among women with breast cancer in Louisiana, which implemented Medicaid expansion in 2016, compared to Georgia, which has not expanded Medicaid. https://doi.org/10.3389/fonc.2024.1460714