JAMA Network Open最新文献

Importance: Screening for adverse social determinants of health (SDOH) in the emergency department (ED) may help reduce health disparities in underserved populations.

Objective: To understand barriers and facilitators to screening, documenting, and addressing adverse SDOH in a diverse sample of US EDs.

Design, setting, and participants: This qualitative study used in-depth interviews with leaders of a purposive sample of EDs across urban, rural, academic, and community settings who self-reported screening for adverse SDOH on a prior National Emergency Department Inventory (NEDI) USA survey. EDs that completed the 2022 NEDI-USA survey and reported adverse SDOH screening were eligible for recruitment. Eligible participants were interviewed in April to September 2023. Inductive thematic analysis was conducted from September 2023 to January 2024 to identify themes and concepts.

Main outcomes and measures: Themes and concepts related to ED practices for adverse SDOH screening and referral.

Results: From 77 eligible EDs, 27 leaders agreed to be interviewed, (18 [66.7%] female; mean [range] age, 44 [30 to 63] years; mean [range] time in current role, 3.25 [<1 to 12] years). Participants worked in a variety of leadership roles (eg, chair or medical, nursing, or operations director). Findings centered around heterogeneity in ED adverse SDOH screening and documentation practices; skepticism of utility of ED adverse SDOH screening and referral; drivers of ED adverse SDOH screening, such as regulatory mandates for the expansion of adverse SDOH screening; resource, staffing, and time constraints in adverse SDOH screening and linkage to services processes; and recommendations and suggestions for improving the implementation of ED adverse SDOH screening, such as tailoring validated tools to the ED context and ED stakeholder engagement in designing the screening process. Other suggestions included having additional dedicated screening staff, particularly social workers, and strengthening relationships with existing non-ED SDOH initiatives and community resources dedicated to addressing adverse SDOH.

Conclusions and relevance: This qualitative study of US EDs describes an overview of practices and challenges surrounding adverse SDOH screening and identified novel solutions and areas where more research is needed for the successful implementation of adverse SDOH screening in the ED setting. At the policy level, regulatory mandates instituting adverse SDOH screening should include provisions for funding to support patient needs identified by screening. Additional research on development and implementation of ED adverse SDOH screening programs is needed.

Importance: Evidence suggests that trauma-related mortality and morbidities may follow a multiphasic pattern, with outcomes extending beyond hospital discharge.

Objectives: To determine the incidence of having new mental health conditions after the first (or index) trauma admission and their association with long-term health outcomes.

Design, setting, and participants: This population-based, linked-data cohort study was conducted between January 1994 and September 2020, with data analyzed in April 2024. Participants were adult patients with trauma admitted to 1 of the 5 adult trauma hospitals in Western Australia. All patients with major trauma with an Injury Severity Score (ISS) greater than 15 were included. For each patient with major trauma, 2 patients with trauma with a lower ISS (<16) were randomly selected.

Exposure: A new mental health condition recorded in either subsequent public or private hospitalizations after trauma admission.

Main outcomes and measures: The primary outcomes were the associations between new mental health conditions after trauma and subsequent risks of trauma readmission, suicide, and all-cause mortality, as determined by Cox proportional hazards regression. Logistic regression was used to determine which factors were associated with developing a new mental health condition after trauma.

Results: Of 29 191 patients (median [IQR] age, 42 [27-65] years; 19 383 male [66.4%]; median [IQR] ISS, 9 [5-16]; 9405 with ISS >15 and 19 786 with ISS <16) considered, 2233 (7.6%) had a mental health condition before their trauma admissions. The median (IQR) follow-up time after the index trauma admission was 99.8 (61.2-148.5) months. Of 26 958 patients without a prior mental health condition, 3299 (11.3%) developed a mental health condition subsequently, including drug dependence (2391 patients [8.2%], with 419 patients [1.4%] experiencing opioid dependence) and neurotic disorders (1574 patients [5.4%]), including posttraumatic stress disorder. Developing a new mental health condition after trauma was associated with subsequent trauma readmissions (adjusted hazard ratio [aHR], 1.30; 95% CI, 1.23-1.37; P < .001), suicides (aHR, 3.14; 95% CI, 2.00-4.91; P < .001), and all-cause mortality (aHR, 1.24; 95% CI, 1.12-1.38; P < .001). Younger age, unemployment, being single or divorced (vs married), Indigenous ethnicity, and a lower socioeconomic status were all associated with developing a new mental health condition after the first trauma admission.

Conclusions and relevance: This cohort study of 29 191 patients with trauma found that mental health conditions after trauma were common and associated with an increased risk of adverse long-term outcomes, indicating that mental health follow-up of patients with trauma, particularly those from vulnerable subgroups, may be warranted.

Importance: Sexual dysfunction is a common adverse effect of prostate cancer treatment, and current management strategies do not adequately address physical and psychological causes. Exercise is a potential therapy in the management of sexual dysfunction.

Objective: To investigate the effects of supervised, clinic-based, resistance and aerobic exercise with and without a brief psychosexual education and self-management intervention (PESM) on sexual function in men with prostate cancer compared with usual care.

Design, setting, and participants: A 3-arm, parallel-group, single-center randomized clinical trial was undertaken at university-affiliated exercise clinics between July 24, 2014, and August 22, 2019. Eligible participants were men with prostate cancer who had previously undergone or were currently undergoing treatment and were concerned about sexual dysfunction. Data analysis was undertaken October 8 to December 23, 2024.

Interventions: Participants were randomized to (1) 6 months of supervised, group-based resistance and aerobic exercise (n = 39 [34.8%]), (2) the same exercise program plus PESM (n = 36 [32.1%]), or (3) usual care (n = 37 [33.0%]). Exercise was to be undertaken 3 days per week.

Main outcomes and measures: The primary outcome was sexual function assessed with the International Index of Erectile Function (IIEF). Secondary outcomes included body composition, physical function, and muscle strength. Analyses were undertaken using an intention-to-treat approach.

Results: In total, 112 participants (mean [SD] age, 66.3 [7.1] years) were randomized. Mean adjusted difference in IIEF score at 6 months favored exercise compared with usual care (3.5; 95% CI, 0.3-6.6; P = .04). The mean adjusted difference for intercourse satisfaction was not significant (1.7; 95% CI, 0.1-3.2; P = .05). PESM did not result in additional improvements. Compared with usual care, exercise also significantly improved fat mass (mean adjusted difference, -0.9 kg; 95% CI, -1.8 to -0.1 kg; P = .02), chair rise performance (mean adjusted difference, -1.8 seconds; 95% CI, -3.2 to -0.5 seconds; P = .002), and upper (mean adjusted difference, 9.4 kg; 95% CI, 6.9-11.9 kg; P < .001) and lower (mean adjusted difference, 17.9 kg; 95% CI, 7.6-28.2 kg; P < .001) body muscle strength.

Conclusions and relevance: In this randomized clinical trial of supervised exercise, erectile function in patients with prostate cancer was improved. PESM resulted in no additional improvements. Patients with prostate cancer should be offered exercise following treatment as a potential rehabilitation measure.

Trial registration: ANZCTR Identifier: ACTRN12613001179729.

Importance: Previously published literature found that 28.6% of surgical residents have or are expecting children, yet little information exists regarding the financial demands of childcare during residency.

Objective: To evaluate surgical residents' net financial balance after childcare costs at various postgraduate years and child ages.

Design, setting, and participants: This cross-sectional study, conducted from June 14 to August 2, 2024, examined surgical residency programs across the US using publicly available data. Programs were categorized into US regions based on the Association of American Medical Colleges classifications: Northeast, Midwest, South, and West. Childcare costs were obtained from the National Database of Childcare Prices, and annual expenditure data came from the Bureau of Labor Statistics.

Main outcomes and measures: The primary outcome was residents' net income by year of residency, calculated using salaries and expenditures. To compare costs by region and child age, net income was determined by subtracting mean expenditures and childcare costs from residency salaries. Calculations were validated using the Massachusetts Institute of Technology Living Wage Calculator.

Results: Of 351 US surgical residency programs, 295 with publicly available salaries for postgraduate years 1 through 5 met inclusion criteria. A total of 290 programs (98.3%) showed a negative net income when expenditures and childcare costs were deducted. This finding held true across all child age groups and US regions. The West had the most negative mean net income (-$18 852 [range, -$35 726 to $766]), followed by the Northeast (-$15 878 [range, -$37 310 to $3589]), Midwest (-$12 067 [range, -$26 111 to $1614]), and South (-$8636 [range, -$18 740 to $4826]). Parents of school-aged children in the South had the lowest mean negative net income (-$8453 [range, -$16 377 to $3417]), while parents of infants in the West had the highest mean negative net income (-$21 278 [range, -$35 726 to -$5112]).

Conclusions and relevance: This cross-sectional study of surgical residents' net income found that, after accounting for mean annual expenditures and childcare costs, a surgical resident's salary was insufficient to cover living expenses and childcare costs for single resident parents. This financial obstacle may deter individuals from pursuing surgical residency or from starting families as surgical residents.