JAMA Network Open最新文献

Importance: With blood-based phosphorylated tau biomarkers soon to be used for diagnosis of Alzheimer disease, analyzing tau levels in other conditions could enhance biomarker interpretability. Moreover, mechanisms of tau release into circulation remain unclear.

Objective: To evaluate concentrations of phosphorylated and nonphosphorylated tau variants in the blood of patients with multiple traumatic injuries on days 0, 1, 5, and 10 and investigate biological processes driving tau release.

Design, setting, and participants: This multiple-trauma cohort (injury severity score, ≥18) included 45 severely injured patients with (n = 27) and without (n = 18) moderate-to-severe traumatic brain injury on emergency computed tomographic imaging. Controls consisted of 24 healthy volunteers. Participants were recruited from December 1, 2013, to October 31, 2022. Blood samples were analyzed for brain-derived tau (BD-tau), total tau (t-tau), and phosphorylated tau 217 (p-tau217) and 231 (p-tau231) levels. Associations among tau concentrations, clinical data, and outcome (eg, Glasgow Coma Scale [GCS] score) were assessed. Data were analyzed from March 1, 2023, to September 30, 2024.

Exposures: Serum BD-tau, t-tau, p-tau217, and p-tau231 levels.

Results: A total of 214 serum samples were analyzed. Median age of the 45 patients was 48 (IQR, 33-60) years (35 [77.8%] male); median age of the 24 controls, 43 (IQR, 28-50) years (16 [66.7%] male). Median serum levels of tau variants were increased in patients with multiple traumatic injuries at day 0 compared with controls (t-tau: 43 [IQR, 21-95] vs 3 [IQR, 3-5] pg/mL; BD-tau: 78 [IQR, 30-343] vs 2 [IQR, 2-3] pg/mL; p-tau231: 61 [IQR, 21-79] vs 2 [IQR, 1-3] pg/mL; all, P < .001). Only median BD-tau levels remained elevated until day 10 (day 1, 25 [IQR, 14-69] pg/mL; day 5, 9 [IQR, 4-15] pg/mL; day 10, 8 [IQR, 4-18] pg/mL). Median tau levels at admission were higher in patients with lower GCS scores (BD-tau: 107 [ IQR, 59-838] vs 33 [IQR, 24-78] pg/mL [P = .01]; p-tau231: 76 [IQR, 36-114] vs 28 [IQR, 9-63] pg/mL [P = .02]). Elevated median tau levels were also observed in patients with hemorrhagic shock vs those without shock (eg, BD-tau on day 0: 113 [IQR, 78-378] vs 31 [IQR, 24-61] pg/mL; P = .002) and in nonsurvivors vs survivors with uncomplicated courses (eg, BD-tau on day 1: 92 [IQR, 22-527] vs 16 [IQR, 7-23] pg/mL; P = .009).

Conclusions and relevance: In this exploratory study among a cohort of patients with multiple traumatic injuries, levels of tau variants reflected both direct and indirect neurological injury, with BD-tau showing the most persistent elevation in the acute phase.

Importance: The requirement for in-person, often daily, attendance at opioid treatment programs (OTPs) makes travel times a barrier to methadone treatment. Research on methadone accessibility has primarily focused on travel via personal vehicle, and there is uncertainty about public transit travel time to methadone treatment.

Objective: To estimate travel time via personal vehicle vs public transit to methadone treatment in the state of Connecticut.

Design, setting, and participants: This cross-sectional study included geospatial analysis of median travel time to nearest OTP via personal vehicle and public transit from all census block groups (CBGs). This study took place in the state of Connecticut in 2023. Participants were all CBGs in Connecticut.

Exposures: Participants were characterized by racial and ethnic demographics; household income; car ownership; urban, suburban, or rural designations; and per-capita opioid overdose deaths.

Main outcomes and measures: The primary outcome was the median travel time to nearest OTP by via personal vehicle and public transit. Spatial error models using k-nearest neighbor spatial weight matrices were estimated to assess the associations between sociodemographic characteristics and travel times for each transportation mode (personal vehicle vs public transit) at the CBG level.

Results: From the centroids of the 2702 CBGs in Connecticut, the median (IQR) travel time to the closest OTP was 11.0 (7.5-16.3) minutes by personal vehicle and 41.7 (31.0-49.5) minutes via public transit, with 1431 CBGs (53%) lacking access to public transit or having high public transit times (>60 minutes or no trip available). Travel times via public transit increased along the urban-rural gradient and across CBGs with an increasing percentage of non-Hispanic White residents. Median (IQR) travel times to an OTP from the 489 CBGs with the highest per-capita overdose death rates were 8.2 (5.9-11.7) minutes by personal vehicle and 37.6 (27.8-48.5) minutes by public transit, with 166 (34%) lacking public transit access.

Conclusions and relevance: The findings of this cross-sectional study of barriers to access to methadone treatment suggest that areas with high overdose death rates, low car ownership, and high public transit travel times should be targets for interventions (eg, mobile services or greater use of take-home doses for patients) to lower travel-based barriers to methadone. Current federal statutes and regulations governing methadone provision are the greatest barrier, as they directly require often daily transit to opioid treatment clinics. Reducing this barrier requires policy changes.

Importance: Australia is leading the world in efforts to reduce tobacco use by implementing high cigarette taxes and restrictive regulations on nicotine vaping products. However, concerns have emerged that these policies may unintentionally drive the expansion of illicit tobacco and vaping markets, potentially undermining public health gains.

Objectives: To assess spatial and temporal changes in total nicotine, tobacco-derived nicotine, and illicit tobacco use across Australian regions of different remoteness from 2017 to 2023.

Design, setting, and participants: This longitudinal, cross-sectional wastewater study was performed from April 2017 to April 2023. Wastewater samples were collected from as many as 55 wastewater treatment plants (WWTPs) in Australia, including 3 remoteness levels: major cities, inner regional, and outer regional to remote areas. The selected WWTPs serve more than 50% of the Australian population.

Main outcomes and measures: Nicotine metabolites (cotinine and hydroxycotinine) and the tobacco-specific alkaloid (anabasine) were analyzed in wastewater samples using a validated liquid-chromatography tandem mass spectrometry method. Total nicotine and tobacco-derived nicotine consumption were back-estimated. Illicit tobacco use was identified in combination with the tobacco sales data.

Results: Wastewater samples collected across Australia, representing 14 million people, were analyzed for back-estimation. Total nicotine consumption declined fastest in outer regional to remote areas (-2.2% annually; 95% CI, -3.2% to -1.1%), followed by inner regional areas (-1.4% annually; 95% CI, -2.1% to -0.8%), and remained stable in major cities. By comparison, tobacco-derived nicotine consumption decreased faster in major cities (-5.0% annually; 95% CI, -8.3% to -1.9%) and inner regional areas (-9.8% annually; 95% CI, -12.5% to -7.3%) than in the outer regional to remote areas (-2.3% annually; 95% CI, -6.0% to 1.8%). Illicit tobacco use was estimated to have increased from 1350 to 3400 tons from 2017 to 2023.

Conclusions and relevance: In this cross-sectional study of wastewater surveillance in Australia, different trends of tobacco use were observed across regions, accompanied by increasing use of illicit tobacco and vaping products. These findings provide evidence for future tobacco and vaping control policies. Ongoing wastewater monitoring is essential for evaluating new tobacco and vaping product control measures implemented in 2024.

Importance: Current interpretation services for Deaf patients who use sign language are often ineffective or unacceptable. In-person interpretation is frequently unavailable, and while video remote interpreting (VRI) remains underused, its scalability may be a solution given interpreter shortages and cost barriers. Existing research focuses on user and interpreter preferences, leaving a critical gap in understanding how interpretation formats affect communication quality.

Objective: To evaluate the effectiveness of VRI in improving communication outcomes between Deaf patients and physicians compared with usual communication tools, such as self-arranging interpretation, lip-reading, note-taking, and the use of images.

Design, setting, and participants: This randomized clinical trial was conducted in Colombia at a public hospital from August 2023 to October 2024, involving Deaf adults who use Colombian Sign Language as their primary language. Participants were randomly assigned to either the control or intervention group. The data were analyzed between January and May 2025.

Interventions: Patients were divided into 2 groups: an intervention group that received a medical appointment via VRI and a control group that received one via the current standard of communication. Both the Deaf participants and the health care professionals were blinded to the allocation.

Main outcomes and measures: An assessment of communication using the Doctor-Patient Communication scale.

Results: Data were collected from 210 Deaf participants, including 123 (58.6%) women and 87 (41.4%) men, with a mean (SD) age of 42 (13) years (range, 18-84 years). Overall, 108 participants (51.4%) reported using VRI. The intervention revealed that having VRI did not always result in improved communication between Deaf individuals and physicians. While those using VRI were more likely to report positive outcomes in certain areas, such as being encouraged to express themselves (odds ratio, 1.90; 95% CI, 1.13-3.18; P = .02), there was no difference in other areas, such as understanding the doctor (OR, 1.33; 95% CI, 0.79-2.23; P = .28).

Conclusions and relevance: In this randomized clinical trial of VRI in the health care context, some aspects of clinical communication were improved, but others were not. This suggests that critical preconditions have to be met for this technology to achieve its intended impact.

Trial registration: ClinicalTrials.gov Identifier: NCT05966623.

Importance: Predischarge car seat tolerance screening (CSTS) has been recommended by the American Academy of Pediatrics since 1991 for preterm and at-risk full-term-born infants. However, it remains unclear whether routine CSTS prevents adverse outcomes after discharge.

Objective: To estimate the frequency of failed CSTS and its association with adverse postdischarge outcomes.

Data sources: PubMed, Embase, and Web of Science were searched for English-language studies published before June 2025.

Study selection: Randomized trials, nonrandomized intervention studies (utilizing a comparison group discharged without CSTS), and single-group observational studies were eligible.

Data extraction and synthesis: Data were extracted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guideline by 2 reviewers. Study quality was assessed using the Risk of Bias in Nonrandomized Studies tool.

Main outcomes and measures: Outcomes were 30-day readmission, mortality, and predischarge length of stay for intervention studies, and first and subsequent CSTS failure rates for single-group studies. Random-effects models were used to pool data, and generalized linear mixed models were used to estimate pooled treatment effects from 2-group studies and CSTS failure event rates from all included studies.

Results: A total of 21 studies were included. No randomized trials were identified. Three nonrandomized intervention studies (54 358 participants; 27 786 participants without CSTS) reported postdischarge outcomes. There was no difference in 30-day mortality (2 studies; not pooled due to 0 events), 30-day readmissions (odds ratio, 1.05; 95% CI, 0.86-1.28; 3 studies; 54 559 participants), or combined 30-day mortality or readmission (odds ratio, 1.17; 95% CI, 0.95-1.43; 2 studies; 49 420 participants) among infants receiving predischarge CSTS compared with those that did not. Pooled analysis estimated 8.62 (95% CI, 6.42-11.47) first-test failures per 100 patients (21 studies; 39 052 participants) and 24.40 (95% CI, 6.44-34.64) repeat-test failures per 100 patients (11 studies; 912 participants).

Conclusions and relevance: In this systematic review and meta-analysis of predischarge CSTS for preterm and at-risk full-term-born infants, CSTS was not associated with a reduction in postdischarge readmission or mortality. These findings call into question whether routine CSTS before discharge improves outcomes in preterm or at-risk full-term infants.

Importance: Rates of posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) are high among paramedics.

Objective: To evaluate the efficacy of a cognitive resilience training program for reducing the development of PTSD and MDD among early career paramedics compared with psychoeducation and standard practice.

Design, setting, and participants: This randomized clinical trial of paramedics training at 15 universities across England was conducted between October 2017 to October 2022 with 12-month follow-up. Data were analyzed from December 2023 to July 2025.

Intervention: Participants were randomized to receive internet-delivered cognitive training in resilience (iCT-R), psychoeducation, or standard practice. iCT-R, a guided online intervention that utilizes cognitive therapy tools to target predictors of PTSD and MDD identified in prospective research with paramedics, consisted of 6 modules delivered over 6 weeks with 6-monthly top-up sessions delivered by email. Internet-delivered psychoeducation, a supported online psychoeducation intervention, consisted of 6 topics (1 topic per week) with 6-monthly top-up sessions delivered by email. Standard practice was training as usual.

Main outcomes and measures: The primary outcome was rate of PTSD and MDD at 1-year follow-up, assessed by independent assessors blinded to intervention using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). Secondary outcomes included measures of PTSD and depression symptom severity, resilience, rumination, anxiety, psychological distress, and well-being. Intent-to-treat analyses were conducted, with the primary outcome analyzed using mixed-effects logistic regression.

Results: Of 570 student paramedics enrolled (372 female [65.3%]; mean [SD] age, 23.67 [6.88] years), 195 were randomized to iCT-R, 197 to psychoeducation, and 178 to standard practice. For participants randomized to iCT-R, the odds of meeting criteria for PTSD or MDD at 12 months were significantly lower compared with psychoeducation (odds ratio [OR], 0.20; 95% CI, 0.05-0.73) and standard practice (OR, 0.25; 95% CI, 0.07-0.97). Providing iCT-R training to 18 to 24 paramedic trainees (number needed to treat) would prevent 1 case of PTSD or MDD.

Conclusions and relevance: In this randomized clinical trial, participants receiving iCT-R were approximately 5 times less likely to develop PTSD or MDD at 1-year follow-up compared with psychoeducation and 4 times less likely when compared with standard practice. These findings suggest that iCT-R appears to decrease the likelihood of developing PTSD and MDD in early career paramedics.

Trial registration: isrctn.org Identifier: ISRCTN16493616.