JAMA Network Open最新文献

Importance: Human fetal tissue is essential for biomedical research, providing unparalleled insights into human development and disease.

Objective: To assess changes in parental decisions to donate fetal tissue following termination of pregnancy after the introduction of the Dutch Fetal Biobank (DFB) and to identify factors associated with consent to donate.

Design, setting, and participants: This cohort study collected data from all individuals assigned female at birth (hereafter referred to as participants) who underwent a termination of pregnancy at the Amsterdam University Medical Center from January 1, 2008, to December 31, 2022. No exclusion criteria were applied.

Exposure: Introduction of the DFB on September 1, 2017, which offers the option to donate fetal tissue after pregnancy termination.

Main outcome and measure: Rates of fetal tissue donation before and after DFB introduction and associations between patient characteristics (maternal age, race and ethnicity, socioeconomic status, gestational age, and reason for termination) and consent to donation were assessed using multivariable binary logistic regression modeling.

Results: Of a total of 1272 participants (mean [SD] age, 33.0 [5.4] years), 576 (45.3%) were nulliparous. The mean (SD) gestational age at termination was 18 weeks 3 days (26 days), and reasons for termination were primarily because of structural defects (567 participants [44.6%]), with only a small portion (58 participants [4.6%]) terminating for social reasons (eg, unwanted or unplanned pregnancy). Fetal tissue donations increased from 1.2% (8 donations among 663 terminations) before the DFB introduction to 21.7% (132 donations among 609 terminations) after its introduction. This rise was primarily due to a shift from collective cremation to donation, while individual cremation or burial rates remained stable. The consent rate was 30.3% (132 of 436) for participants informed about the donation option. No significant demographic differences were found between participants who consented and those who did not, except for gestational age; consent rates decreased with advanced gestational age (odds ratio per week, 0.88; 95% CI, 0.83-0.94). Higher consent rates were observed for terminations due to social reasons (odds ratio, 3.56; 95% CI, 1.40-9.10).

Conclusions and relevance: These findings suggest that a substantial proportion of individuals may be willing to donate fetal tissue for biomedical research after pregnancy termination. Integrating donation options in posttermination counseling respects patient autonomy and could ethically increase tissue availability for research. Expanding biobanks and fostering international collaboration is crucial for standardizing practices and ensuring equitable research benefits.

Importance: Little is known about the impact of different anesthetic agents used for routine magnetic resonance imaging (MRI) sedation on pulmonary function in children.

Objective: To compare the incidence of pulmonary atelectasis after MRI sedation with propofol vs propofol-ketamine.

Design, setting, and participants: This double-masked randomized clinical trial screened 117 consecutive pediatric patients aged 3 to 12 years with American Society of Anesthesiologists physical status I to II undergoing elective MRI under deep sedation from November 2, 2022, to April 28, 2023, at a tertiary referral center. Four patients met the exclusion criteria, and 5 patients refused to participate. The participants and outcome assessors were masked to the group allocation.

Interventions: During the MRI, the propofol group received 0.2 mL/kg of 1% propofol and 2 mL of 0.9% saline followed by a continuous infusion of propofol (200 μg/kg/min) and 0.9% saline (0.04 mL/kg/min). The propofol-ketamine group received 0.2 mL/kg of 0.5% propofol and 1 mg/kg of ketamine followed by a continuous infusion of propofol (100 μg/kg/min) and ketamine (20 μg/kg/min).

Main outcome and measure: The incidence of atelectasis assessed by lung ultrasonography examination.

Results: A total of 107 children (median [IQR] age, 5 [4-6] years; 62 male [57.9%]), with 54 in the propofol group and 53 in the propofol-ketamine group, were analyzed in this study. Notably, 48 (88.9%) and 31 (58.5%) patients had atelectasis in the propofol and propofol-ketamine groups, respectively (relative risk, 0.7; 95% CI, 0.5-0.8; P < .001). The incidence of desaturation and interruption of the MRI due to airway intervention or spontaneous movement did not significantly differ between the groups. The propofol-ketamine group showed a faster emergence time than the propofol group (15 [9-23] vs 25 [22-27] minutes in the propofol-ketamine vs propofol group; median difference in time, 9.0 minutes; 95% CI, 6.0-12.0 minutes; P < .001). No patient was withdrawn from the trial due to adverse effects.

Conclusions and relevance: In this randomized clinical trial, the propofol-ketamine combination reduced sedation-induced atelectasis while allowing for faster emergence compared with propofol alone.

Trial registration: cris.nih.go.kr Identifier: KCT0007699.

Importance: The COVID-19 pandemic has placed a burden on the health of many people, including significant disparities in American Indian and Alaska Native communities.

Objective: This study examines the associations between coping behaviors, social support, and emotional health among American Indian and Alaska Native peoples during the COVID-19 pandemic.

Design, setting, and participants: This cross-sectional study included survey data collected from November 2021 to May 2022 from American Indian and Alaska Native adults aged 18 years or older without dementia or other serious cognitive impairments who were seen at 6 urban health organizations primarily in urban settings (in New Mexico, Alaska, Colorado, Minnesota, Utah, and Kansas) in the year prior to the survey.

Exposures: Exposures of interest included avoidant and direct problem-solving coping behaviors and functional and emotional social support.

Main outcome and measures: The study outcome was self-reported change in emotional health since COVID-19 pandemic onset. Poisson regression was used to model adjusted multivariate associations. Data were weighted to account for age, nonresponse, and disproportionate representation by clinic population.

Results: A total of 1164 participants were included in the analysis, with a mean (SD) age of 42.5 (13.4) years; 830 (61%, weighted sample percentage) were female. Since COVID-19 pandemic onset, 465 patients (39% weighted) reported worsened emotional health. Problem-solving coping mean (SD) utilization score was 2.5 (0.5), avoidant coping mean (SD) utilization score was 2.3 (0.5), mean (SD) functional social support score was 11.4 (2.9), and 219 participants (18% weighted) reported that emotional support was always available. Using problem-solving coping skills was associated with better emotional health (adjusted prevalence ratio [APR], 0.66 [95% CI, 0.54-0.81] for highest vs lowest tertile), as was always (vs never or rarely) getting emotional support (APR, 0.40; 95% CI, 0.30-0.55) and having more functional support (APR, 0.90 [95% CI, 0.87-0.92] per 1-unit increase in functional social support). In examination of psychological resilience potentially modifying primary exposure associations, no interactions were statistically significant.

Conclusions and relevance: In this cross-sectional study of urban American Indian and Alaska Native peoples, problem-solving coping skills and more social support were associated with better emotional health during the COVID-19 pandemic. These findings can be used to identify strengths-based approaches to support community emotional health during social upheavals.

Importance: The rapidly growing population of older adults and their concomitant high prevalence of chronic health conditions require an increased supply in the specialized geriatric workforce to meet increasing health care demands. Understanding trends and geographic disparities in the supply of the geriatric workforce is essential for developing effective policies.

Objectives: To examine temporal and geographic trends in the supply of geriatric physicians (GMDs) and geriatric nurse practitioners (GNPs) from 2010 to 2020 and to assess potential disparities between metropolitan and nonmetropolitan counties.

Design, setting, and participants: This repeated cross-sectional study used annual county-level data from 2010 to 2020, encompassing all counties in the 50 US states and Washington, DC. Statistical analysis was performed from June 2023 to March 2024.

Main outcomes and measures: The primary outcomes were the numbers of GMDs, GNPs, and the combined number of GMDs and GNPs per 100 000 older adults. The secondary outcome included the proportion of counties with or without any GMDs or GNPs.

Results: From 2010 to 2020, the national per capita supply of GMDs decreased by 12.7%, from 13.4 per 100 000 older adults in 2010 to 11.7 per 100 000 older adults in 2020, while GNPs increased by 125.0%, from 4.4 per 100 000 older adults in 2010 to 9.9 per 100 000 older adults in 2020. The combined GMD and GNP workforce increased by 21.3%, from 17.8 per 100 000 older adults in 2010 to 21.6 per 100 000 older adults in 2020. The distributions of older adults, GMDs, and GNPs closely resembled the distribution of metropolitan and nonmetropolitan counties, with GMDs and GNPs highly concentrated in metropolitan counties where the number of older adults was greatest. Throughout the study period, 63.9% of counties (2008 of 3142 in 2010-2019; 2009 of 3143 in 2020), predominantly small and nonmetropolitan counties, had no GMDs or GNPs, which was associated with the disparities between metropolitan and nonmetropolitan counties.

Conclusions and relevance: This repeated cross-sectional study found that from 2010 to 2020, the overall national supply of GMDs and GNPs kept pace with the growth of the older population, largely due to the rapid growth in the number of GNPs. However, significant geographic disparities persisted, particularly in small and nonmetropolitan counties. Future efforts should focus on increasing the availability of GMDs and GNPs in underserved small and nonmetropolitan counties to ensure equitable access to geriatric care.

Importance: Home treatment (HT) has been associated with fewer inpatient treatment (IT) readmission days but lacks evidence on reducing combined psychiatric hospital service use (IT, HT, day clinic).

Objective: To assess the association of intensive home treatment (IHT) compared with IT regarding readmission rate, social outcomes, and clinical outcomes.

Design, setting, and participants: This quasi-experimental, nonrandomized trial was conducted from 2020 to 2022 in 10 psychiatric hospitals in Germany. Propensity score (PS) matching was used to compare both treatment models at the 12-month follow-up using standardized instruments and routine hospital data. All patients were screened until the target sample size was reached, based on these criteria: stable residence with privacy for sessions, no child welfare risk, primary diagnosis within International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes F0X to F6X, residence in the catchment area, no commitment order, no acute suicidality or severe aggression requiring hospitalization, capacity to consent, not participating in other interventional studies, sufficient German language skills, no substantial cognitive deficits or intellectual impairment, and no more than 7 days in IHT or IT before recruitment. Statistical analysis was performed from February to November 2023.

Intervention: IHT provided daily acute psychiatric treatment at home, while IT was psychiatric inpatient treatment as usual. The mean treatment duration of the index treatment was 37.2 days for IHT and 28.2 days for IT.

Main outcomes and measures: The inpatient readmission rate was the primary outcome. Secondary outcomes were combined readmission rate, total inpatient days, job integration, quality of life, psychosocial functioning, symptom severity, and recovery.

Results: Of 1396 individuals, 200 patients receiving IHT and 200 patients receiving IT were included (264 female [65%]; mean [SD] age, 45.45 [15.83] years [range, 18-88 years]). Baseline sociodemographic and psychometric characteristics did not differ significantly between the groups. At 12-month follow-up, patients in the IHT group had lower inpatient readmission rate (IHT vs IT: 31.12% vs 49.74% IT; mean difference, 18% [95% CI, 9%-28%; P < .001), combined readmission rate (mean difference, 13% [95% CI, 4%-24%; P < .001), and fewer inpatient days (mean difference, 6.82 days; P < .001) than the IT group.

Conclusions and relevance: This nonrandomized clinical trial found that patients receiving IHT had a lower likelihood of utilizing hospital-based psychiatric services and spent fewer inpatient days, suggesting that IHT is a viable alternative to IT.

Trial registration: ClinicalTrials.gov Identifier: NCT04745507.