Background : Breast cancer and diabetes mellitus are highly prevalent conditions that frequently coexist and share overlapping metabolic risk factors. Their interaction has important clinical implications for cancer risk, treatment, and survivorship. This review synthesizes current evidence on the epidemiologic associations, underlying mechanisms, and clinical outcomes linking these conditions. Findings The strongest and most clinically relevant evidence concerns type 2 diabetes mellitus (T2DM), which accounts for most diabetes cases and is the subtype most consistently linked to breast cancer risk and outcomes. Compared with women without diabetes, women with T2DM have an approximately 20–27% higher risk of developing breast cancer in meta-analyses (RR 1.20, 95% CI 1.12–1.28; SRR 1.27, 95% CI 1.16–1.39), particularly after menopause. Proposed mechanisms include hyperinsulinemia, insulin-like growth factor-1 signaling, chronic inflammation, obesity-related metabolic dysfunction, and altered sex hormone metabolism. Among patients with breast cancer, coexisting diabetes is associated with more advanced stage at diagnosis, greater treatment-related toxicity, and higher infection-related complications compared with no diabetes. Systematic reviews and meta-analyses report a 49–51% higher all-cause mortality risk among breast cancer patients with diabetes compared with those without diabetes (HR 1.49, 95% CI 1.35–1.65; pooled adjusted HR 1.51, 95% CI 1.34–1.70). Breast cancer survivors also have a modestly increased risk of subsequent T2DM compared with cancer-free women, particularly after endocrine therapy and chemotherapy. Conclusion : The coexistence of diabetes and breast cancer is associated with increased morbidity and mortality, driven by shared metabolic pathways and treatment-related factors. Integrated care approaches incorporating metabolic management into oncologic care are essential to improve outcomes. Future Directions Future research should prioritize prospective subtype-specific studies, standardized glucose monitoring during systemic therapy, randomized or pragmatic trials of integrated oncology-diabetes care, and careful evaluation of newer antidiabetic agents as metabolic therapies.
Background Osteoporosis is a major public health concern affecting approximately 1 in 3 women and 1 in 5 men over the age of 50 globally. Hip fractures are a significant complication of osteoporosis and are associated with approximately 20-24% mortality in the year after fracture. While medications can substantially reduce fracture risk, these therapies remain significantly underutilized. This treatment gap is partly driven by confusion among healthcare professionals and patients regarding potential treatment complications. Findings This narrative review provides a practical overview of strategies to maximize benefits and minimize risks of pharmacologic osteoporosis therapies, including calcium/vitamin D, bisphosphonates, denosumab, parathyroid hormone (PTH) analogs, romosozumab, raloxifene, and menopausal hormone therapy (MHT). In addition to reviewing the latest data about therapeutic efficacy and safety, we provide a summary of best practices to mitigate potential side effects. Relevant updates include new data on the efficacy of bisphosphonates in lower risk patients, recommendations for using osteoanabolic agents as first-line for very high fracture risk patients, important considerations regarding multiple vertebral fractures when discontinuing denosumab, as well as cardiovascular safety data and the option of a shortened course for romosozumab. FDA updates are highlighted: removal of the osteosarcoma black-boxed warning for PTH analogs, nuances in the warnings regarding MHT, and addition of a black-boxed warning for severe hypocalcemia with denosumab in chronic kidney disease. Conclusion The benefits of osteoporosis medications in preventing high-morbidity fragility fractures significantly outweigh the small risks of serious complications. It is essential for clinicians to understand the myths and realities of these treatments and to implement mitigation strategies to ensure patient safety. By effectively addressing these issues, healthcare professionals can play a vital role in closing the osteoporosis treatment gap.
Background:Hospital-at-home (HaH) is increasingly used to manage acute conditions like influenza, but data on long-term outcomes remain limited. Objective:To identify clinical predictors of 30- and 90-day adverse outcomes among influenza patients treated at HaH. Methods:We retrospectively analyzed 270 adult patients with laboratory-confirmed influenza managed at HaH over 10 influenza seasons. Outcomes included emergency room (ER) visits, hospital readmissions, and all-cause mortality at 30 and 90 days. Results:At 30 days, 12.4% had ED visits, 5.1% were readmitted, and 3.4% died; at 90 days, these increased to 16.2%, 6.5%, and 6.8%, respectively. Multivariable analysis identified reduced glomerular filtration rate (GFR < 60 mL/min/1.73 m²) at discharge and early ER visits as independent predictors of poor outcomes. Conclusions:Renal impairment and early postdischarge ER use are significant predictors of adverse outcomes in influenza patients managed through HaH. These findings help clinicians optimize risk stratification and follow-up strategies during seasonal influenza peaks.
Introduction Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease frequently requiring emergency care. However, limited data exist on factors influencing hospital admission from the emergency department (ED) in this population. Methods We performed a retrospective analysis of adult SLE-related ED visits in the 2022 Nationwide Emergency Department Sample (NEDS). All analyses incorporated NEDS discharge weights to produce nationally representative estimates. Logistic regression analyses were used to identify factors associated with ED-to-hospital admission in adult SLE patients. Results Of the weight total of 376,776 SLE-related ED visits, 37.7% resulted in hospital admission. Infections, cardiovascular, and renal complications were the most common admitting diagnoses. The strongest associations with hospital admission included bloodstream infection due to central venous catheter (OR 532.10), sepsis (OR 94.65), myocardial infarction (OR 18.27), hypertensive emergency (OR 14.33), combined kidney heart disease (OR 14.26), and acute kidney failure (OR 9.05). Additionally, increasing age and Asian/Pacific Islander race were associated with higher odds of admission, while female sex was associated with lower odds. Conclusion Over one-third of ED visits for SLE patients result in hospitalization, primarily driven by high-acuity conditions. These findings highlight key clinical and demographic factors associated with admission and can inform ED triage decisions and care algorithms for this complex population.
Background Debris flow is a sudden and destructive natural disaster that poses serious threats to human life and property. Much attention has been paid to its environmental and infrastructural impact but the health risks and emergency medical needs associated with debris flow are often overlooked. Objectives This review aims to examine the causes, characteristics, and health implications of debris flow disasters, with a focus on evaluating emergency medical rescue efforts. It seeks to identify current gaps in disaster response and highlight emerging innovations that can enhance medical preparedness and intervention, and inform future research priorities as well as operational planning and policy development. Discussion Existing studies have mainly concentrated on debris flow prediction and prevention, while medical rescue strategies remain underdeveloped. Major challenges include inadequate medical resources, poor coordination among response teams, and technological limitations in affected areas. Nonetheless, promising advancements such as drone-based surveillance, mobile medical units, and portable diagnostic equipment are gradually being integrated into disaster response systems. These innovations offer improved situational awareness and faster deployment of care but require further refinement and integration into national disaster response frameworks. Conclusions Improving medical rescue in debris flow disasters requires a coordinated, multidisciplinary approach. Future efforts should aim to develop scalable, field-ready rescue models that prioritize human health and ensure timely, efficient medical care in debris flow emergencies. These findings also provide operationally oriented evidence to support protocol standardization and policy design for disaster medical response systems.
Aims:To evaluate county-level incidence of diagnosed diabetes and key sociodemographic factors in a high-dimensional, nonlinear setting. Methods:This temporally aggregated observational study used US Centers for Disease Control and Prevention data on county-level incidence of diagnosed diabetes, from 2004 to 2019, and 34 sociodemographic factors from public databases. We defined counties as higher-burden if diabetes incidence was >12.6 per 1000 persons (1 standard deviation [SD] above sample mean). As relationships between sociodemographic factors and diabetes incidence may be nonlinear and involve complex interactions, we trained three machine learning models to estimate incidence (elastic net regression), classify counties as higher-burden (eXtreme Gradient Boosting [XGBoost], support vector machine [SVM]), and identify feature importance. Model performance was evaluated using fivefold cross-validation, with stratified folds for XGBoost and SVM models. Results:Overall, 500 of 3114 counties (16.1%) were of higher-burden. Elastic net regression showed good predictive performance for estimating diabetes incidence (R 2 0.78 [95% CI, 0.75-0.80]). For classification of higher-burden counties, SVM and XGBoost showed high discrimination with AUROC of 0.962 (95% CI, 0.948-0.974) and 0.957 (95% CI, 0.941-0.971), respectively. Sensitivity analyses using alternative definitions of higher-burden counties (mean + 0.75 × SD; mean + 1.25 × SD) yielded comparable results. Across all three models, key county-level features contributing to model predictions were percentages of children living with grandparent householders and of people withLimited English. Conclusions:Machine learning models demonstrated consistent performance in estimating and classifying county-level diabetes incidence, with high discrimination for identifying higher-burden counties. Sociodemographic factors, including children living with grandparent householders, may inform tailored public health interventions.
In this communication, the authors attempted to weave together medical history, public policy, popular culture, comedy, film, and the arts to examine how 'colonoscopy' has entered the public lexicon. The narrative flows from evidence-based screening policy to cultural commentary, while maintaining a thoughtful and balanced tone. The manuscript attempts to highlight legitimate patient anxieties while also acknowledging the medical community's efforts to improve patient experience through advances in preparation, sedation, and technique while never losing sight of reinforcing the value of colorectal cancer screening and shared decision and recognizing that cultural visibility - whether humorous, artistic, or provocative - can serve as a powerful catalyst for patient-provider conversations.
Background: Patient-directed discharge (PDD), also known as discharge against medical advice, is associated with poor outcomes, such as increased hospital readmission and mortality. PDD is 10-20 times more common among persons with opioid use disorder (OUD). This scoping review sought to describe the reported incidence in the fentanyl era and characterize relevant patient level, clinical care level and systems level risk factors that may contribute to this phenomenon. Methods: A comprehensive assessment of the literature was conducted across 4 electronic databases: PubMed, CINAHL, Cochrane Library and Embase. The search strategy was designed to identify articles reporting PDD incidence and OUD in the era of fentanyl and other highly-potent synthetic opioids. Results: PDD incidence varies significantly by population; many studies report PDD rate in 10%-20% range and the incidence rate appears to be increasing over time. Younger patients with co-occurring stimulant use and OUD carry the highest rates of PDD. Studies examining the association between medications for OUD (MOUD) and decreased PDD report mixed findings, which likely reflects the impact of variability in medication selection and timing of administration. Consultation with addiction consult service (ACS) was not consistently associated with decreased PDD. Conclusions: Overall, there is increased rate of PDD in fentanyl era. More work is needed to characterize the relationship between MOUD provision and ACS with incidence of PDD.
Background The Mini-Mental State Examination (MMSE) is commonly used in clinical and research settings to assess cognitive function and scores 27–30 are considered normal. Whether individuals with lower MMSE scores within this normal range are at increased risk for Alzheimer’s disease and related dementias (ADRD) remains unclear. We sought to examine this question in the current study. Methods In the Cardiovascular Health Study (CHS), 4433 community-dwelling adults ≥65 years had MMSE 27–30: MMSE-30 (n=1228), MMSE-29 (n=1353), MMSE-28 (n=1079) and MMSE-27 (n=773). HR (95% CI) for incident ADRD during 23 years of follow-up associated with MMSE-29, MMSE-28, and MMSE-27 were estimated, adjusting for 27 baseline characteristics including activities of daily living (ADL) impairment. ADRD was defined using International Classification of Diseases (ICD) codes. Results Individuals with MMSE-30, MMSE-29, MMSE-28, and MMSE-27 had mean ages of 71.1, 71.9, 72.6, and 73.4 years, and mean ADL impairment scores of 0.06, 0.08, 0.12 and 0.16, respectively (both p <0.001). Overall, 59% were women and 10% African American. ADRD occurred in 8.5%, 11.4%, 12.5% and 13.6% of those with MMSE-30, MMSE-29, MMSE-28, and MMSE-27, respectively. Compared with MMSE-30, HR (95% CI) for incident ADRD for MMSE-29, MMSE-28, and MMSE-27 were 1.48 (1.16–1.90), 1.82 (1.42–2.35) and 2.15 (1.64–2.82), respectively. These associations varied by age, sex, race, education, and self-reported general health. Conclusions These findings suggest that among community-dwelling older adults with normal MMSE, lower scores were associated with impaired ADL and significant, independent, and incrementally higher risk of ADRD.
Background Systematic screening could promote earlier detection and management of age-related hearing loss (ARHL), but there is limited research to support its implementation. This study describes findings from an ARHL screening program, including responses to screening questions and factors associated with responses. Methods A pilot ARHL screening program was launched at 2 Family Medicine and 3 Otolaryngology (ENT) clinics at the Medical University of South Carolina between July 2017 and December 2020. All screening processes, including automatic referrals to audiology clinics, were integrated into the Epic electronic health record. Patients were asked a series of simple screening questions related to perceived hearing loss, current treatment, and desire for a referral to audiology. We report demographic and clinic-level factors associated with responses to each hearing screening question. Results A total of 5360 patients were asked hearing screening questions (65.6% in ENT clinics). Patients’ mean age was 73.0 (SD: 6.7) years, 58.3% were female and 29.0% Black/African American race. Forty-three percent of patients reported hearing loss. Among those, 38% reported not being treated, and among those with reported hearing loss and no treatment, 51% requested a referral to audiology. Demographic and clinic-level factors, including the date and clinic location of screening, were associated with responses to each screening question. Conclusions Simple screening questions asked in outpatient clinical settings can identify patients with perceived hearing loss and who are interested in receiving hearing health care. Demographic and clinic-level factors should be accounted for in research related to the effectiveness of ARHL screening.
Objective:This study describes outcomes of a pilot age-related hearing loss screening program implemented in two Family Medicine and three Otolaryngology (ENT) clinics at the Medical University of South Carolina, in terms of postscreening follow-up and associations of screening with hearing health care use. Methods:Screening questions focused on perceived hearing, treatment, and desire for audiology referral. Hearing health care use, determined by diagnostic and procedural codes, was defined as at least one visit to audiology clinics within 1 year of screening. We used logistic regression models to determine associations of screening with hearing health care use among patients seen in Family Medicine and ENT clinics, separately. Results are presented as odds ratios with corresponding 95% confidence intervals. Key Results:Screened (n = 5360; mean age 73.0 [SD 6.7] years; 58.3% female) and nonscreened patients (n = 4106; mean age 72.0 [SD 6.7] years; 56.4% female) were matched for age and sex. Among patients who requested an audiology referral, 52.4% used hearing health care; of those, 21.5% obtained hearing aids. In a multivariable model, screening (vs not) in Family Medicine was associated with higher odds of hearing health care use (5.36 [1.92, 14.94]). In multivariable models, screening (vs not) in ENT was associated with lower odds of hearing health care use (0.86 [0.76, 0.98]); after excluding patients screened and seen in audiology on the same day, screening was associated with higher odds of hearing health care use (1.44 [1.16, 1.78]). Conclusions:Hearing screening among older adults could facilitate timely identification and management of hearing loss.
Systemic nickel allergy syndrome (SNAS) is characterized by both cutaneous and extracutaneous symptoms following systemic exposure to nickel, most commonly through the ingestion of nickel-containing foods in individuals sensitized to nickel via skin contact. Patients with SNAS present with dermatitis in addition to gastrointestinal, neurologic, and other extracutaneous symptoms. The most widely implemented treatment is the low-nickel diet. The present authors saw a patient with a history of allergic contact dermatitis to nickel experience resolution of hand dermatitis, chronic pain (diagnosed as fibromyalgia), and chronic diarrhea (diagnosed as irritable bowel syndrome) with a low-nickel diet after just 1 month. She was diagnosed with SNAS, and this intriguing case prompted the review that follows.
Background:Cancer Centers offer a comprehensive approach to cancer prevention, diagnosis, and treatment through tertiary services and by providing coordinated, personalized care. We investigated whether this approach results in significantly better patient outcomes at an NCI-designated Comprehensive Cancer Center (NCI-CCC), City of Hope (COH), versus the U.S. Surveillance, Epidemiology, and End Results (SEER) national database. Methods:Patient-level data were abstracted from the COH Cancer Registry and SEER*Stat software, respectively. The cohort included patients diagnosed with incident cancer from 2004 to 2020. Overall survival was analyzed using multivariable Cox proportional hazards models. To reduce confounding from baseline differences, propensity score matching (PSM) methods were employed in a 1:5 ratio between COH and SEER, respectively, using age group at diagnosis category, gender, race, ethnicity, stage (for solid tumors), and diagnosis year. Findings:Patients treated at COH had significantly superior overall survival (OS) compared with those in the SEER cohort across all examined cancer types after multivariable adjustment for key baseline characteristics and in the PSM analyses. Median OS (when reached) was uniformly longer in the COH cohort compared with the SEER cohort in the full population adjusted model and in the PSM analyses. For the PSM analyses: non-small cell lung cancer (NSCLC) hazard ratio (HR) 0.73 (95% confidence interval [CI]: 0.70-0.76), breast cancer HR 0.83 (95% CI: 0.78-0.86), prostate cancer HR 0.62 (95% CI: 0.58-0.65), colorectal cancer HR 0.74 (95% CI: 0.69-0.79), pancreatic cancer HR 0.75 (95% CI: 0.70-0.81), acute myeloid leukemia HR 0.79 (95% CI: 0.75-0.84), acute lymphoid leukemia HR 0.7 (95% CI: 0.69-0.87), and multiple myeloma HR 0.70 (95% CI: 0.66-0.76) (all p <0.001). In addition, notable findings included substantially lower mortality risk for patients with any of the studied advanced solid cancers, including stage IV NSCLC (HR 0.71, 95% CI: 0.67-0.75, p <0.001) and stage IV breast cancer (HR 0.78, 95% CI: 0.69-0.87, p <0.001). Conclusions:Our results revealed patient care at an individual NCI-CCC employing state-of-the-art therapies and modern care is associated with survival benefits for cancer patients. Patients had significantly superior OS in the COH cohort compared with the SEER cohort for most of the analyzed solid tumors assessed for each stage (I-IV) and for 3 major hematologic malignancies assessed by age group.Until randomized comparisons studies are possible and the SEER data becomes more comprehensive, the specific causes of the observed benefit and identifying patients that benefit most may be subject to considerable debate. Additional research can help determine with greater granularity the drivers of the survival benefit and highlight an opportunity to make adjusted survival outcomes more accessible to patients, complementing the data currently available because of price transparency mandates. Such efforts may help ensure that all patients benefit from precision medicine approaches.
Background:Effective management of alcohol withdrawal syndrome during hospitalization is paramount to patient safety and quality care. NYC Health + Hospitals initiated a quality improvement project to pilot an electronic health record (EHR) integrated, nurse-driven CIWA-Ar symptom-triggered protocol, including recommendations for medications for alcohol use disorder (MAUD), in medical and surgical units at 3 public hospitals. Objective:To describe implementation processes and to report related implementation outcomes (appropriateness, feasibility, and adoption) of the updated CIWA-Ar protocol in a safety net hospital setting. Methods:NYC Health + Hospitals implemented a standardized CIWA-Ar symptom-triggered, nurse-driven EHR protocol on March 15, 2022. The protocol included order sets, practice advisories, task lists, and reminders for assessments and orders. We measured nursing perspectives on feasibility and appropriateness at 6 months via a survey. We measured provider adoption as the proportion of admissions with a CIWA-Ar protocol ordered among admissions that triggered a recommendation, and MAUD use as the proportion of admissions with a MAUD order during hospitalization among all patients with a protocol ordered. Results:During 13 months of implementation, providers ordered a CIWA-Ar protocol for 59.1% (n = 887/1500) of recommended admissions. Adoption increased over time from 46.0% in month 1 to 63.2%-78.9% in months 11 to 13 (P = .0004). Most nurses agreed that the protocol was suitable, fitting for medicine, easy to use, and improved clinical care for patients experiencing alcohol withdrawal syndrome. MAUD was ordered in 19.2% of admissions, however, did not change over the course of implementation (P = .249). Conclusions:The CIWA-Ar protocol was appropriate, feasible, and adopted at NYC public hospitals. Quality improvements to ensure protocol fidelity with benzodiazepine dosing and MAUD prescribing are needed.
