JAMA Network Open最新文献

Importance: The polyethylene glycol-based hydrogel spacer (PHS) system temporarily separates the rectum from the prostate in patients undergoing radiotherapy (RT) for prostate cancer (PCa).

Objective: To compare incidence of bowel disorders and related procedures in patients receiving RT with and without PHS.

Design, setting, and participants: This retrospective cohort study used 4 datasets: Medicare 5% Standard Analytic Files, Medicare 100% Standard Analytic Files, Merative MarketScan Commercial Database, and Premier Healthcare Database. Participants included adult patients with PCa undergoing RT from 2015 to 2021.

Exposure: Placement of PHS.

Main outcomes: All-cause bowel disorders and related procedures, identified from diagnosis and procedure codes. Results were compared with age-matched male general population without PCa or RT.

Results: Of 261 906 patients with PCa included in the study, 25 167 (9.6%) received PHS (mean [SD] age, 70.7 [6.5] years) and 236 739 did not (mean [SD] age, 71.1 [7.5] years). One year prior to RT, patients who received PHS had a lower mean (SD) Charlson Comorbidity Index score than those who did not (2.48 [1.08] vs 3.14 [1.95]; P < .001). Stereotactic RT was more common in patients who received PHS (2743 [10.9%] vs 8810 [3.7%]; P < .001), while intensity-modulated RT was less common (12 755 [50.7%] vs 142 402 [60.2%]; P < .001). After 4 years post RT, patients who received PHS had a 25% lower hazard of bowel disorders (hazard ratio [HR], 0.75 [95% CI, 0.72-0.78]; P < .001) and a 46% lower hazard of related procedures (HR, 0.54 [95% CI, 0.47-0.62]; P < .001) than patients who did not receive PHS. Patients without PHS had higher hazard compared with an age-matched general population (disorders: 17.1% [95% CI, 17.3%-17.6%] vs 10.3% [95% CI, 10.1%-10.5%]; HR, 1.35 [95% CI, 1.32-1.37]; P < .001; procedures: 2.0% [95% CI, 1.9%-2.1%] vs 0.7% [95% CI, 0.7%-0.8%]; HR, 1.92 [95% CI, 1.79-2.06]; P < .001), while patients who received PHS did not (disorders: 12.4% vs 10.3%; HR, 1.00 [95% CI, 0.98-1.05]; P = .82; procedures: 1.1% [95% CI, 1.0%-1.3%] vs 0.7% [95% CI, 0.7%-0.8%]; HR, 1.11 [95% CI, 0.96-1.29]; P = .15). Common procedures included colonoscopy, sigmoidoscopy, and rectal resection.

Conclusions and relevance: In this cohort study of patients with PCa receiving RT, those receiving a PHS had a significantly lower incidence of all-cause bowel disorders and related procedures compared with patients who did not receive a PHS over the 4-year follow-up. The incidence among patients with PHS was similar to the general population. These findings are consistent with prior phase 3 trial results, where patients receiving PHS experienced no decline in bowel quality of life.

Importance: The use of hypertonic saline (HTS) vs mannitol in the control of elevated intracranial pressure (ICP) secondary to neurotrauma is debated.

Objective: To compare mortality and functional outcomes of treatment with 3% HTS vs 20% mannitol among children with moderate to severe traumatic brain injury (TBI) at risk of elevated ICP.

Design, setting, and participants: This prospective, multicenter cohort study was conducted between June 1, 2018, and December 31, 2022, at 28 participating pediatric intensive care units in the Pediatric Acute and Critical Care Medicine in Asia Network (PACCMAN) and the Red Colaborativa Pediátrica de Latinoamérica (LARed) in Asia, Latin America, and Europe. The study included children (aged <18 years) with moderate to severe TBI (Glasgow Coma Scale [GCS] score ≤13).

Exposure: Treatment with 3% HTS compared with 20% mannitol.

Main outcomes and measures: Multiple log-binomial regression analysis was performed for mortality, and multiple linear regression analysis was performed for discharge Pediatric Cerebral Performance Category (PCPC) scores and 3-month Glasgow Outcome Scale-Extended Pediatric Version (GOS-E-Peds) scores. Inverse probability of treatment weighting was also performed using the propensity score method to control for baseline imbalance between groups.

Results: This study included 445 children with a median age of 5.0 (IQR, 2.0-11.0) years. More than half of the patients (279 [62.7%]) were boys, and 344 (77.3%) had severe TBI. Overall, 184 children (41.3%) received 3% HTS, 82 (18.4%) received 20% mannitol, 69 (15.5%) received both agents, and 110 (24.7%) received neither agent. The mortality rate was 7.1% (13 of 184 patients) in the HTS group and 11.0% (9 of 82 patients) in the mannitol group (P = .34). After adjusting for age, sex, presence of child abuse, time between injury and hospital arrival, lowest GCS score in the first 24 hours, and presence of extradural hemorrhage, no between-group differences in mortality, hospital discharge PCPC scores, or 3-month GOS-E-Peds scores were observed.

Conclusions and relevance: In this cohort study of children with moderate to severe TBI, the use of HTS was not associated with increased survival or improved functional outcomes compared with mannitol. Future large multicenter randomized clinical trials are required to validate these findings.

Importance: Defensive gun use (DGU) is cited as a rationale for permissive firearm-carrying policies; however, no consensus exists on how frequently DGU occurs.

Objective: To examine the frequency of DGU relative to gun violence exposure (GVE) in a sample of firearm owners drawn from a nationally representative sample of US adults.

Design, setting, and participants: This survey study used data from a cross-sectional, self-reported survey administered via KnowledgePanel, a probability-based panel, between May 15 and May 28, 2024. Eligible participants were adults residing within the US reporting current firearm access who responded to DGU survey items. Data were analyzed from July to September 2024.

Main outcomes and measures: Primary outcomes were 4 forms of DGU: telling a perceived threat about a firearm, showing a firearm to a perceived threat, firing in the vicinity of but not at a perceived threat, and firing at a perceived threat.

Results: Among 12 822 adults invited to participate, 8647 (67.4%) read the informed consent, 8009 (92.6%) consented to participate, and 3000 (37.7%; 532 [51.1%] male; 982 [32.7%] aged ≥60 years) endorsed firearm access and responded to DGU items, including 295 Black, non-Hispanic participants (9.8%); 365 Hispanic participants (12.2%); and 2178 White, non-Hispanic participants (72.6%). DGU was rare, with 91.7% (95% CI, 90.6%-92.7%) of participants reporting no lifetime history of DGU. The most reported form of DGU was showing a firearm to a perceived threat (lifetime: 4.7%; 95% CI, 4.0%-5.5%). Less than 1% of the sample reported any form of past-year DGU. GVE was more pervasive for lifetime (eg, loss of a friend or loved one to firearm suicide: 34.4%; 95% CI, 32.7%-36.1%; hearing gunshots in neighborhood: 51.8%; 95% CI, 50.0%-53.6%) and past-year exposure (eg, loss of a friend or loved one to firearm suicide: 3.2%; 95% CI, 2.6%-3.9%; hearing gunshots in neighborhood: 32.7%; 95% CI, 31.0%-34.4%).

Conclusions and relevance: In this survey of adults with firearm access, DGU was rare relative to GVE. Perceived threats may not necessitate DGU, and given the association between DGU and GVE, the consequences of DGU may be substantial. Narratives centering DGU as a consideration in firearm policies may misstate the risk profile of firearm access.