JAMA Network Open最新文献

Importance: Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Hypotension in patients with TBI is associated with poorer outcomes. A comprehensive review examining adverse outcomes of hypotension in patients with TBI is needed.

Objective: To investigate the mortality and incidence of hypotension in patients with TBI.

Data sources: A search of studies published before April 2024 was conducted using MEDLINE, MEDLINE In Process, ePubs, Embase, Classic+Embase, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews for primary research articles in English, including randomized control trials, quasirandomized studies, prospective cohorts, retrospective studies, longitudinal studies, and cross-sectional surveys.

Study selection: Inclusion criteria were patients aged at least 10 years with moderate to severe TBI with hypotension. The exclusion criteria were mild TBI (due to the differences in management principles from moderate to severe TBI). Data were screened using Covidence software with multiple reviewers.

Data extraction and synthesis: This meta-analysis conforms to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guidelines for assessing data quality and validity. Primary outcomes (unadjusted and adjusted odds ratios [ORs]) were calculated using a random-effect model with 95% CIs. Incidence of hypotension was derived using logit transformation.

Main outcomes and measures: Main outcomes were association of hypotension with death and/or vegetative state within 6 months and incidence of hypotension. Vegetative state was not reported due to lack of data from included studies. Hypothesis testing occurred before data collection.

Results: The search strategy identified 17 676 unique articles. The final review included 51 studies (384 329 patients). Pooled analysis of found a significant increase in mortality in patients with hypotension and moderate to severe TBI (crude OR, 3.82; 95% CI, 3.04-4.81; P < .001; I2 = 96.98%; adjusted OR, 2.22; 95% CI, 1.96-2.51; P < .001; I2 = 92.21%). The overall hypotension incidence was 18% (95% CI, 12%-26%) (P < .001; I2 = 99.84%).

Conclusions and relevance: This meta-analysis of nearly 400 000 patients with TBI found a significant association of greater than 2-fold odds of mortality in patients with hypotension and TBI. This comprehensive analysis can guide future management recommendations, specifically with respect to blood pressure threshold management to reduce deaths when treating patients with TBI.

Importance: The National Comprehensive Cancer Network (NCCN) guidelines for non-small cell lung cancer suggest that RNA next-generation sequencing (NGS) may improve the detection of fusions and splicing variants compared with DNA-NGS alone. However, there is limited adoption of RNA-NGS in routine oncology clinical care today.

Objective: To analyze clinical evidence from a diverse cohort of patients with advanced lung adenocarcinoma and compare the detection of NCCN-recommended actionable structural variants (aSVs; fusions and splicing variants) via concurrent DNA and RNA-NGS vs DNA-NGS alone.

Design, setting, and participants: This multisite, retrospective cohort study examined patients sequenced between February 2021 and October 2023 within the deidentified, Tempus multimodal database, consisting of linked molecular and clinical data. Participants included patients with advanced lung adenocarcinoma and sufficient tissue sample quantities for both RNA-NGS and DNA-NGS testing.

Exposures: Received results from RNA-NGS and DNA-NGS solid-tissue profiling assays.

Main outcomes and measures: Detection rates of NCCN guideline-based structural variants (ALK, ROS1, RET and NTRK1/2/3 fusions, as well as MET exon 14 skipping splicing alterations) found uniquely by RNA-NGS.

Results: In the evaluable cohort of 5570 patients, median (IQR) age was 67.8 (61.3-75.4) years, and 2989 patients (53.7%) were female. The prevalence of actionable structural variants detected by either RNA-NGS or DNA-NGS was 8.8% (n = 491), with 86.7% (n = 426) of these detected by DNA-NGS. Concurrent RNA-NGS and DNA-NGS identified 15.3% more patients harboring aSVs compared with DNA-NGS alone (491 vs 426 patients, respectively), including 14.3% more patients harboring actionable fusions (376 vs 329 patients) and 18.6% more patients harboring MET exon 14 skipping alterations (115 vs 97 patients). There was no significant association between the assay used for aSV detection and aSV-targeted therapeutic adoption or clinical outcome. Emerging structural variants (eSVs) were found to have a combined prevalence to be 0.7%, with only 47.5% of eSVs detected by DNA-NGS.

Conclusions and relevance: In this cohort study, the detection of structural variants via concurrent RNA-NGS and DNA-NGS was higher across multiple NCCN-guideline recommended biomarkers compared with DNA-NGS alone, suggesting that RNA-NGS should be routinely implemented in the care of patients with advanced NSCLC.

Importance: Meal timing strategies, such as time-restricted eating (TRE), reducing meal frequency, or altering calorie distribution across the day, have gained interest for their potential to enhance weight loss and metabolic health, particularly in managing chronic diseases, yet their long-term benefits are not known.

Objective: To evaluate the association between meal timing strategies (≥12 weeks) and anthropometric and metabolic indicators.

Data sources: Medline, Embase, CINAHL, and Cochrane CENTRAL were searched from inception to October 17, 2023.

Study selection: Randomized clinical trials, regardless of language and publication date, involving adults 18 years and older, evaluating within-day meal timing patterns for 12 or more weeks, and reporting anthropometric measures were included. Studies were excluded if participants had eating disorders, prior significant weight change, underwent bariatric surgery, were pregnant, or if controlled variables differed between groups.

Data extraction and synthesis: Study quality was determined via Risk of Bias 2.0 tool. Data were extracted independently by multiple reviewers. Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used. Meta-analysis was performed using random-effects model on pooled continuous outcomes with 2 or more studies.

Main outcome and measures: Weight change in kilograms, reported as between-group mean difference with 95% CIs.

Results: Sixty-nine reports of 29 randomized clinical trials including 2485 individuals (1703 [69%] female; mean [SD] age, 44 [9.5] years; and mean [SD] body mass index, 33 [3.5]) were included. Study interventions included TRE (17 studies), meal frequency (8 studies), and calorie distribution (4 studies). There were some concerns of risk of bias for 7 studies and high concerns for 22 studies. Statistically significant weight change was observed in TRE when compared with control (-1.37 kg; 95% CI, -1.99 to -0.75 kg). Lower meal frequency and earlier caloric distribution were also both associated with greater change (-1.85 kg; 95% CI, -3.55 to -0.13 kg; and -1.75 kg; 95% CI, -2.37 to -1.13 kg, respectively).

Conclusions and relevance: The findings of this meta-analysis suggest that TRE, lower meal frequency, and earlier caloric distribution in the day may reduce weight compared with standard care and/or nutritional advice; however, the effect sizes found were small and of uncertain clinical importance. High heterogeneity and risk of bias among included studies led to concerns about the certainty of the underpinning evidence. Further research, including trials with larger sample sizes, standardized interventions with prescribed or matched energy intake, and longer follow-up, are needed.

Importance: The rising suicide rates in the US emphasize the need for effective prevention. While telehealth has transformed access to mental health care, the impact of telehealth on suicide outcomes is unknown.

Objective: To evaluate the association of virtual mental health services with individual-level suicide-related events (SREs).

Design, setting, and participants: This retrospective cohort study using broadband access as an instrumental variable assessed a national sample of Veterans Health Administration patients who received mental health care between March 1, 2020, and December 31, 2021. Participants were recently separated (ie, discharged or released from active duty) veterans who completed their active duty service between March 1, 2019, and December 31, 2020, and who received at least 2 outpatient or inpatient diagnoses related to major depressive disorder, substance use disorder, or posttraumatic stress disorder within the year before their most recent separation date. Data were analyzed May 1 to October 31, 2023.

Exposure: Percentage of a patient's total mental health visits that were conducted virtually by psychiatrists, psychologists, or social workers within a calendar month.

Main outcomes and measures: Binary measure indicating whether the patient had experienced an SRE (defined as a nonfatal suicide attempt, intentional self-harm, or suicide death) in a specific month and year as evaluated an instrumental variable probit model.

Results: The sample included 66 387 data points from 16 236 unique recently separated veterans. Among these entries, 44 766 were for male veterans (67.4%), the mean (SD) age across the sample was 32.9 (8.9) years, and the sample was representative of the US veteran population. There were 929 SREs (1.4%). Virtual mental health visits comprised a mean (SD) of 44.6% (46.1%) of all mental health visits. In instrumental variable probit analyses accounting for factors simultaneously associated with use of virtual mental health care and SRE risk, a 1% increase in the probability of virtual mental health visits was associated with a 2.5% decrease in SREs.

Conclusions and relevance: Findings from this cohort study using a retrospective quasi-experimental design found that an increase in virtual mental health visits relative to total visits was associated with a statistically significant decrease in SREs, suggesting that providing virtual mental health services may reduce suicide-related outcomes.

Importance: The US Department of Veterans Affairs (VA) partners with community organizations (grantees) across the US to provide temporary financial assistance (TFA) to vulnerable veterans through the Supportive Services for Veteran Families (SSVF) program. The goal of TFA for housing-related expenses is to prevent homelessness or to quickly house those who have become homeless.

Objective: To assess the cost-effectiveness of the SSVF program with TFA vs without TFA as an intervention for veterans who are experiencing housing insecurity.

Design, setting, and participants: This study used a Markov simulation model to compare cost and housing outcomes in a hypothetical cohort of veterans enrolled in the SSVF program. Enrollees who are homeless receive rapid rehousing services, while those who are at risk of becoming homeless receive homelessness prevention services.

Exposure: The SSVF program with TFA for veterans who are experiencing housing insecurity.

Main outcomes and measures: The effectiveness measure was the incremental cost-effectiveness ratio (ICER) with quality-adjusted life-years (QALYs). The model was parameterized using a combination of inputs taken from published literature and internal VA data. The model had a 2-year time horizon and a 1-day cycle length. In addition, probabilistic sensitivity analyses were conducted using 10 000 Monte Carlo simulations.

Results: The base case analyses found that the SSVF program with TFA was more costly ($35 814 vs $32 562) and yielded more QALYs (1.541 vs 1.398) than the SSVF program without TFA. The resulting ICER was $22 676 per QALY, indicating that TFA is the preferred strategy at a willingness-to-pay threshold of $150 000 per QALY. This ICER was $19 114 per QALY for veterans in the rapid rehousing component of the SSVF program and $29 751 per QALY for those in the homelessness prevention component of the SSVF program. At a willingness-to-pay threshold of $150 000 per QALY, probabilistic sensitivity analyses showed that TFA was cost-effective in 8972 of the 10 000 Monte Carlo simulations (89.7%) for rapid rehousing and in 8796 of the 10 000 Monte Carlo simulations (88.0%) for homelessness prevention only.

Conclusions and relevance: This economic evaluation suggests that TFA is a cost-effective approach (ie, yields improved health benefits at a reasonable cost) for addressing housing insecurity for veterans enrolling in the SSVF program. Future research could examine the cost effectiveness of large, nationwide housing interventions such as this one among subpopulations of veterans such as those with certain comorbidities including severe mental illness or substance use disorders, those with chronic diseases, or those experiencing long-term housing instability vs acute loss of housing.