Objectives: The objective of this study was to develop machine learning models to predict health insurance claim costs among older adults in Indonesia. Methods: This study utilized secondary data from the Indonesian National Health Insurance program (Jaminan Kesehatan Nasional [JKN]) spanning 2017 to 2023. Three modeling techniques—linear regression, random forest, and XGBoost—were employed to predict individual claim costs. Model performance was assessed using the root mean square error (RMSE), coefficient of determination (R2), and mean absolute error (MAE). Additionally, variable importance analysis was conducted to identify key predictors. Results: XGBoost with 500 boosting rounds yielded the best performance, with an RMSE of 11 360 283, an R2 of 0.81, and an MAE of 4 485 917, outperforming both linear regression (RMSE, 13 710 035; R2=0.72) and random forest (RMSE, 12 434 238; R2=0.78). Notably, outpatient care was identified as the most consistent predictor across all models. Other significant predictors included length of stay (LOS), diagnosis type (International Classification of Diseases, 10th revision chapter), facility type, facility classification, and severity of illness, particularly for moderate cases. Although LOS and diagnosis type were important predictors, these findings should be interpreted in the context of Indonesia’s fixed Indonesian Case-Based Groups payment system. Conclusions XGBoost provides reliable predictions of claim costs among older adults, capturing clinical, utilization, and structural drivers. These findings can inform targeted interventions, improve chronic disease management, optimize the referral system, and support integration of predictive tools into JKN to enhance responsiveness and promote sustainable, equitable financing.

Introduction: A significant proportion of severe asthma patients require oral corticosteroids (OCS) to maintain symptom control. Prolonged OCS predisposes patients to hypothalamicpituitary-adrenal axis suppression which can be lifethreatening. Biologic therapies are effective steroid-sparing options suitable for select severe asthma patients. We evaluated steroid tapering outcomes and adrenal function during biologic therapy in a tertiary severe asthma clinic. Results: A total of 43 patients were included. Median age was 66 years (interquartile range [IQR] 60–74), and 65% were male. Mepolizumab was the most used (17 patients), followed by benralizumab (15), tezepelumab (6), dupilumab (4), and omalizumab (1). Median baseline prednisolone dose was 10 mg (IQR 5–10). Median lowest dose achieved was 3 mg (IQR 0–3), sustained for at least 4 weeks in 90.7% of patients. Median reduction in prednisolone dose was 5 mg (IQR 5–7.25). In all, 42% of patients successfully discontinued maintenance steroids. Adrenal function was assessed using morning serum cortisol (n = 37) and/or SST (n = 28). Evidence of adrenal insufficiency was identified in 19 patients (44%), including 15 patients with failed SST and four with low morning cortisol suggestive of adrenal suppression. Morning serum cortisol was indeterminate in four patients. A total of 17 patients were referred to endocrinology. During steroid tapering, 11 asthma-related hospital admissions and eight emergency department presentations occurred, involving 10 patients. Conclusion Biologics facilitate the reduction of the OCS burden in severe asthma. Tertiary adrenal suppression is common during steroid tapering and requires prompt biochemical assessment and endocrinology referral. Structured monitoring of adrenal function is essential during biologicfacilitated steroid tapering in routine clinical practice.
Biological Products ; Steroids ; Asthma

This study was to survey the relationship between semen values and demographics, comorbidities, and recreational substance use in a large cohort of adult men at the University of Chicago Medical Center Department of Urology (Chicago, IL, USA). We performed an analysis from January 2013 to December 2023 of semen samples obtained from adult patients at our institution and collected their demographics, comorbid medical conditions, and recreational substance use information. Patients were divided into categories of normozoospermia, oligozoospermia, and azoospermia on the basis of the 5 th version of the World Health Organization (WHO) guidelines. Data were analyzed by univariate linear and logistic regression models, after which statistically significant variables were placed into multivariable models. Azoospermia and oligozoospermia were both associated with Caucasian or Black, Indigenous, and People of Color (BIPOC) race (both P < 0.001), increasing age ( P = 0.005 and P < 0.001, respectively), anemia ( P < 0.001 and P = 0.02, respectively), lifetime tobacco use (both P < 0.001), lifetime alcohol use ( P = 0.02 and P < 0.001, respectively), and lifetime use of at least two recreational substances ( P < 0.001 and P = 0.003, respectively) in multivariable models. Oligospermia was additionally associated with benign prostatic hyperplasia (BPH; P = 0.003) in multivariable models. This study suggests that at-risk populations may benefit from additional early screening and workup for infertility.
Humans ; Male ; Adult ; Longitudinal Studies ; Middle Aged ; Semen Analysis ; Life Style ; Oligospermia/epidemiology* ; Azoospermia/epidemiology* ; Comorbidity ; Midwestern United States/epidemiology* ; Young Adult

Penile emergencies are uncommon and can be categorized as having infectious, vascular, traumatic, or multifactorial etiologies. To facilitate early diagnosis and treatment during emergency, US and color Doppler imaging are imperative. US depicts hypoechoic collections regardless of the presence of air foci in infections like abscess and Fournier’s gangrene.Color Doppler imaging is conducted to evaluate vascular conditions such as penile Mondor disease (PMD) and priapism. PMD is indicated by the absence of color flow and non-compressibility of dorsal penile vein. Priapism can be categorized based on cavernosal artery flow: high flow and low flow. In traumatic injuries like penile fracture, US reveals breach in tunica albuginea with hematoma. Peyronie’s disease can be multifactorial in origin and the imaging is commonly visualized as thickening of the tunica albuginea and echogenic calcified plaques. Urethral injuries are urethral discontinuity with adjacent collection. Urethral calculus is visualized as echogenic focus with posterior acoustic shadowing. Therefore, effective collaboration between radiologists and urologists is required for appropriate initial diagnosis and prompt treatment.

Purpose: Breast cancer is one of the most common cancers globally, with an increasing incidence rate. It is a heterogeneous disease, and early metastasis remains a challenge. Tumor budding, defined as single tumor cells or small clusters at the invasive front, has been suggested as a prognostic marker in various cancers, including breast cancer. This study aims to evaluate tumor budding in invasive breast carcinoma using the International Tumor Budding Consensus Conference (ITBCC) scoring system and explore its association with pathological characteristics and prognosis. Methods: A retrospective study was conducted on 100 mastectomy specimens of histopathologically confirmed invasive breast carcinoma, excluding cases that underwent chemotherapy or radiotherapy. Tumor budding was classified as low, intermediate, or high based on the ITBCC scoring method, and associations with clinicopathological features were analyzed using appropriate statistical tests. Results: Tumor budding was classified as high in 52% of cases. A significant association was found between high tumor budding and higher tumor grade (P<0.001), negative estrogen receptor and progesterone receptor status (P<0.001), positive HER2neu status (P=0.003), and high Ki-67 levels (P<0.001). High tumor budding was also linked to higher T stage, and dermal lymphovascular invasion (P=0.001). Our findings support previous studies showing that high tumor budding is associated with poor prognostic factors such as higher tumor grade, negative hormone receptor status, and higher T stage. Conclusion Tumor budding is a potential prognostic marker in breast cancer, associated with more aggressive tumor characteristics.

Background/Aims: Self-expanding metallic stents (SEMS) are an alternative to emergency surgery (ES) for malignant colorectal obstruction. This study aimed to compare surgical outcomes between SEMS as a bridge to surgery (BTS) and ES in patients with malignant colorectal obstruction. Methods: A comprehensive database search was conducted until October 2023 to compare outcomes between SEMS as a BTS and ES. A subgroup analysis of results by malignancy site was performed. Results: We analyzed 57 studies, including 7,223 patients over a mean duration of 35.4 months. SEMS as a BTS showed clinical and technical success rates of 88.0% (95% confidence interval [CI], 86.1%–90.1%; I2=68%) and 91.6% (95% CI, 89.7%–93.7%; I2=66%), respectively. SEMS as a BTS revealed reduced postoperative adverse events (odds ratio [OR], 0.51; 95% CI, 0.41–0.63; I2=70%; p<0.001) and 30-day mortality (OR, 0.52; 95% CI, 0.37–0.72; I2=10%; p<0.001) compared to ES. Subgroup analysis showed postoperative mortality of 5% and 1.5% for left- and right-sided malignancies, respectively. Adverse events were 15% and 33% for the right and left colon, respectively. Conclusions SEMS as a BTS demonstrated a higher success rate, fewer postoperative adverse events, and a reduced 30-day mortality rate than ES, supporting its use as the preferred initial intervention for right- and left-sided obstructions and indicating broader clinical adoption.

Background/Aims: The irregular Z-line, defined as a segment of columnar mucosa less than 1 cm in the distal esophagus, is often biopsied despite guidelines advising against it due to a low risk of progression to esophageal adenocarcinoma (EAC). However, the clinical significance of an irregular Z-line remains unclear. This meta-analysis examines the prevalence of Barrett’s esophagus, dysplasia, and EAC in patients with an irregular Z-line. Methods: We searched Medline, Embase, and Scopus databases up to October 2023 for studies on the prevalence of Barrett’s esophagus, dysplasia, and EAC in these patients. A random-effects model was used for meta-analysis, and heterogeneity was assessed using I2 statistics. Results: Nine studies involving 17,637 patients were analyzed. Among those with an irregular Z-line, the prevalence of intestinal metaplasia was 29.4%. In patients with intestinal metaplasia, dysplasia was found in 6.2%, low-grade dysplasia in 5.9%, high-grade dysplasia in 1.6%, and EAC in 1.5%. These rates were higher compared to those without intestinal metaplasia. Conclusions Patients with an irregular Z-line and intestinal metaplasia may be at higher risk and could benefit from endoscopic surveillance. Further studies are needed to determine the necessity of biopsying irregular Z-lines.

Purpose: Breast cancer is one of the most common cancers globally, with an increasing incidence rate. It is a heterogeneous disease, and early metastasis remains a challenge. Tumor budding, defined as single tumor cells or small clusters at the invasive front, has been suggested as a prognostic marker in various cancers, including breast cancer. This study aims to evaluate tumor budding in invasive breast carcinoma using the International Tumor Budding Consensus Conference (ITBCC) scoring system and explore its association with pathological characteristics and prognosis. Methods: A retrospective study was conducted on 100 mastectomy specimens of histopathologically confirmed invasive breast carcinoma, excluding cases that underwent chemotherapy or radiotherapy. Tumor budding was classified as low, intermediate, or high based on the ITBCC scoring method, and associations with clinicopathological features were analyzed using appropriate statistical tests. Results: Tumor budding was classified as high in 52% of cases. A significant association was found between high tumor budding and higher tumor grade (P<0.001), negative estrogen receptor and progesterone receptor status (P<0.001), positive HER2neu status (P=0.003), and high Ki-67 levels (P<0.001). High tumor budding was also linked to higher T stage, and dermal lymphovascular invasion (P=0.001). Our findings support previous studies showing that high tumor budding is associated with poor prognostic factors such as higher tumor grade, negative hormone receptor status, and higher T stage. Conclusion Tumor budding is a potential prognostic marker in breast cancer, associated with more aggressive tumor characteristics.

Background/Aims: Self-expanding metallic stents (SEMS) are an alternative to emergency surgery (ES) for malignant colorectal obstruction. This study aimed to compare surgical outcomes between SEMS as a bridge to surgery (BTS) and ES in patients with malignant colorectal obstruction. Methods: A comprehensive database search was conducted until October 2023 to compare outcomes between SEMS as a BTS and ES. A subgroup analysis of results by malignancy site was performed. Results: We analyzed 57 studies, including 7,223 patients over a mean duration of 35.4 months. SEMS as a BTS showed clinical and technical success rates of 88.0% (95% confidence interval [CI], 86.1%–90.1%; I2=68%) and 91.6% (95% CI, 89.7%–93.7%; I2=66%), respectively. SEMS as a BTS revealed reduced postoperative adverse events (odds ratio [OR], 0.51; 95% CI, 0.41–0.63; I2=70%; p<0.001) and 30-day mortality (OR, 0.52; 95% CI, 0.37–0.72; I2=10%; p<0.001) compared to ES. Subgroup analysis showed postoperative mortality of 5% and 1.5% for left- and right-sided malignancies, respectively. Adverse events were 15% and 33% for the right and left colon, respectively. Conclusions SEMS as a BTS demonstrated a higher success rate, fewer postoperative adverse events, and a reduced 30-day mortality rate than ES, supporting its use as the preferred initial intervention for right- and left-sided obstructions and indicating broader clinical adoption.

Background/Aims: The irregular Z-line, defined as a segment of columnar mucosa less than 1 cm in the distal esophagus, is often biopsied despite guidelines advising against it due to a low risk of progression to esophageal adenocarcinoma (EAC). However, the clinical significance of an irregular Z-line remains unclear. This meta-analysis examines the prevalence of Barrett’s esophagus, dysplasia, and EAC in patients with an irregular Z-line. Methods: We searched Medline, Embase, and Scopus databases up to October 2023 for studies on the prevalence of Barrett’s esophagus, dysplasia, and EAC in these patients. A random-effects model was used for meta-analysis, and heterogeneity was assessed using I2 statistics. Results: Nine studies involving 17,637 patients were analyzed. Among those with an irregular Z-line, the prevalence of intestinal metaplasia was 29.4%. In patients with intestinal metaplasia, dysplasia was found in 6.2%, low-grade dysplasia in 5.9%, high-grade dysplasia in 1.6%, and EAC in 1.5%. These rates were higher compared to those without intestinal metaplasia. Conclusions Patients with an irregular Z-line and intestinal metaplasia may be at higher risk and could benefit from endoscopic surveillance. Further studies are needed to determine the necessity of biopsying irregular Z-lines.