Citations

Objectives: To characterize the anatomic distribution, surgical management, perioperative outcomes, and early oncologic results of sinonasal glomangiopericytoma (SN-GPC) within a large single-institution cohort. Design: Multi-site, single-institution retrospective cohort study. Setting: Three tertiary care sites of a single academic medical center (Rochester, MN; Phoenix/Scottsdale, AZ; Jacksonville, FL). Participants: Twenty adults (≥18 years) with pathologically confirmed SN-GPC identified between September 2018 and August 2025. Main Outcome Measures: Tumor anatomic subsite, surgical approach, estimated blood loss, margin status, perioperative complications, and recurrence at follow-up. Results: Mean patient age was 66.4 ± 11 years (65% male). Tumors arose predominantly from the nasal cavity (95%), with 65% originating from the posterior-superior nasal septum near the olfactory cleft and 25% from the anterior-superior septum. Hypertension was the most common comorbidity (85%). All 18 definitively treated patients underwent endoscopic endonasal resection without preoperative embolization or conversion to open surgery. Mean estimated blood loss was 72.6 mL. Negative margins were achieved in 83% of cases. One intraoperative cerebrospinal fluid leak occurred and was repaired primarily. At mean follow-up of 18 months, no recurrences were observed regardless of margin status. No patient received adjuvant therapy. Conclusions: SN-GPC demonstrates a strong predilection for the septal olfactory cleft region. Endoscopic resection without preoperative embolization is safe and effective. The indolent behavior of this tumor supports observation as an acceptable strategy for select patients with positive margins at high-risk skull base locations. Keywords: glomangiopericytoma, sinonasal tumor, hemangiopericytoma, endoscopic resection, nasal cavity, skull base, olfactory cleft, mesenchymal tumor, nasal septum

ABSTRACT Background Evaluating fairness in artificial intelligence (AI) is essential before clinical implementation to prevent unintended harm across diverse patient populations. This study assesses performance differences of an image-based surgical site infection (SSI) detection model across age, gender, geography, race, and skin color. Methods Model development/validation study using retrospective, multicenter data across surgical subspecialties from adults who submitted an image of their incision via the electronic health record within 30 days of their procedure between 2019-2024. Area under receiver operating curve (AUROC) was compared by age (<55 vs. ≥55 years old), gender (male vs. female), geography (Rochester, Minnesota vs. Jacksonville, Florida vs. Scottsdale, Arizona vs. regional Minnesota/Wisconsin areas), race (White/Caucasian vs. non-White/Caucasian), and skin color (Fitpatrick I-III vs. IV-VI and Monk A-E vs. F-J). Results Training data contained 13,702 images from 4,274 patients between 2019-2022 (50.1% ≥55 years old; 63.2% female; 91.6% White/Caucasian; 58.5% Rochester, 17.3% Florida, 10.5% Arizona; 96.3% light skin tone), of which 1,348 images (9.8%) had an SSI. No differences in SSI detection existed for age, gender, race, or skin color (AUROC 0.83-0.87, p>0.09), however geographical differences were significant: lowest AUROC 0.83 (95% CI 0.77-0.88) vs. highest AUROC 0.87 (95% CI 0.84-0.89, p=0.01). Temporal validation using 4,242 images from 1,353 patients between 2022-2023 showed intact fairness across subgroups (ΔAUROC ≤0.06) except geography (ΔAUROC ≤0.16). Conclusions The model behaved fairly across age, gender, race, and skin color, however geographical differences persisted. These findings have practical implications underscoring the importance of evaluating bias in clinical AI before deployment.

ABSTRACT Introduction Patients often receive propofol for sedation and clevidipine for hypertension in the intensive care unit. Both agents are formulated as a lipid emulsion, which may increase the risk of hypertriglyceridemia and acute pancreatitis with their coadministration. We aimed to determine the incidence of hypertriglyceridemia and acute pancreatitis with concurrent administration of propofol and clevidipine and identify patient risk factors for hypertriglyceridemia. Methods This was a multicenter retrospective study of adult patients (≥ 18 years old) receiving concurrent propofol and clevidipine infusions for ≥ 6 h. The primary outcome was the frequency of triglyceride levels greater than 400 mg/dL and acute pancreatitis. The secondary outcome was risk factors associated with hypertriglyceridemia during concurrent propofol and clevidipine infusions until both infusions had been discontinued. Univariable and multivariable logistic regression analyses were used to assess risk factors of hypertriglyceridemia in patients receiving concurrent propofol and clevidipine infusions. Results Across 1,226 patients, the median duration of infusion overlap was 12.4 [interquartile range (IQR) 8.3, 22.7] hours. The mean age of the cohort was 59.6 [standard deviation (SD) 14.9] years, and 59.4% were male. Assuming those without a triglyceride level drawn did not have hypertriglyceridemia, hypertriglyceridemia after initiation of propofol and clevidipine infusion was found in 7.7% [95% confidence interval (CI) 6.3% to 9.3%] of the entire cohort. Twenty‐six patients (2.1%) had a diagnosis of pancreatitis after initiation of lipid infusions, of which 12 cases were possibly infusion‐related, and one case was likely infusion‐related. After calculating the Naranjo Scale, all 13 cases of pancreatitis were possibly related to propofol or clevidipine infusions. Based on a multivariable logistic regression of those with a triglyceride level available, risk factors for hypertriglyceridemia included pancreatitis within the past 5 years [adjusted odds ratio (aOR) 2.77, 95% CI, 1.23 to 6.23] and statin use (aOR 1.94, 95% CI, 1.13 to 3.34). Conclusions In our cohort of patients receiving concurrent propofol and clevidipine, the frequency of hypertriglyceridemia and acute pancreatitis was low. Further comparative studies are warranted to assess the risk of pancreatitis with the addition of clevidipine to propofol.

Importance Elevated low-density lipoprotein cholesterol (LDL-C) is a modifiable risk factor for cardiovascular disease, the leading cause of premature death worldwide. Assessing the LDL-C–related burden is critical for guiding prevention and treatment strategies. Objectives To estimate the global, regional, and national burden of ischemic heart disease and ischemic stroke attributable to elevated LDL-C (relative to 35-54 mg/dL) from 1990 to 2023 and to quantify the contributions of population growth, aging, risk-deleted burden, and exposure changes to burden trends. Design, Setting, and Population This comparative risk assessment, part of the Global Burden of Disease Study 2023, estimated population-level LDL-C exposure and associated health loss in 204 countries and territories. Mean LDL-C levels were estimated using spatiotemporal gaussian process regression based on 806 studies across 161 countries. Relative risks were derived from meta-analyses of 38 randomized clinical trials. Population-attributable fractions for deaths and disability-adjusted life-years (DALYs) were estimated by age and sex for adults aged 25 years or older from 1990 to 2023, with 95% uncertainty intervals. Exposure Population-level LDL-C concentrations. Main Outcomes and Measures Population-attributable fractions, counts, and rates (all ages and age standardized per 100 000) of LDL-C–attributable deaths and DALYs from ischemic heart disease and ischemic stroke, with uncertainty intervals. Results In 2023, elevated LDL-C accounted for 3.6 million deaths (95% uncertainty interval, 2.2-5.4 million; 6.0% of global mortality) and 90.7 million DALYs (95% uncertainty interval, 58.9-123.3 million; 3.2% of DALYs). Although global all-ages rates remained stable, age-standardized death and DALY rates decreased by 45.6% and 39.5%, respectively, since 1990. In 2023, age-standardized LDL-C–attributable DALY rates were highest in Eastern Europe and lowest in high-income Asia-Pacific. One-third of the global LDL-C burden occurred in India and China. Population growth and aging drove the increasing burden, with notable regional disparities in LDL-C exposure and risk-deleted DALY rates shifting toward middle-sociodemographic settings. Conclusions and Relevance Despite declining age-standardized rates, the absolute LDL-C burden has increased since 1990 due to demographic changes and has shifted toward middle-sociodemographic countries. Measurement and surveillance gaps persist. Strengthened prevention, diagnosis, and treatment access strategies are essential to mitigate the health burden of LDL-C.

Abstract Objective This study evaluated sequential multi-site fine-tuning of large language models (LLMs), simulating incremental deployment across institutions for extracting mobility functional status from unstructured clinical notes. Materials and Methods We assembled a corpus of 600 clinical notes from 3 institutions, yielding 3810 annotated note sections (1200 training; 2610 testing). Building upon our previously established LLM mobility extraction pipeline, which utilized optimized prompt engineering, we applied parameter-efficient low-rank adaptation (LoRA) fine-tuning. We evaluated sequential multi-site fine-tuning, where the model is trained locally and only the updated LoRA weights are transferred to the next site. We compared this against joint fine-tuning, which requires pooling all multi-site patient data centrally before training. Performance was measured by micro F1-scores for 2 distinct subtasks: mobility extraction and impairment classification. Results Sequential multi-site fine-tuning yielded comparable results to centralized joint fine-tuning for mobility extraction (F1, 0.861 vs 0.894) and impairment classification (F1, 0.912 vs 0.900). Both sequential and joint fine-tuning outperformed an untuned 70B model. Additionally, single-site LoRA models showed robust cross-site generalization. Discussion Sequential multi-site fine-tuning offers a resource-friendly approach to adapt LLMs to clinical environments. By retaining previously acquired knowledge without severe interference, this strategy allows for local fine-tuning at each institution without the need to pool or share sensitive patient data required for joint fine-tuning. Conclusion Sequential multi-site fine-tuning provides a viable solution for the scalable, incremental deployment of LLMs across institutions, showing promising generalizability for clinical information extraction from electronic health record narratives.

BACKGROUND: Randomized trials comparing radial and femoral access report access site crossover rates of 3% to 9% for radial access and 1% to 3% for femoral access. However, contemporary real-world crossover rates are not well characterized. The aim was to evaluate contemporary trends and predictors of vascular access site crossover during percutaneous coronary intervention (PCI). METHODS: We analyzed index PCI procedures recorded in the National Cardiovascular Data Registry CathPCI Registry from 2018 to 2024. Access site crossover was identified using documented access data, with radial-to-femoral crossover inferred when the final successful access site was femoral. Temporal trends and clinical predictors of crossover were examined. Operator experience was assessed using cumulative total and radial PCI volumes from 2011 to 2024 as captured in CathPCI Registry versions 4 and 5. RESULTS: Among 3 861 790 index PCIs, 192 902 (5.0%) involved access site crossover, with a modest increase over time. Radial-to-femoral crossover accounted for 81.2% of crossover events. Factors independently associated with crossover included older age, female sex, higher body mass index, and peripheral vascular disease. Operators with the lowest total PCI volume and the lowest radial PCI volume experienced the highest crossover rates. Notably, operators with low radial PCI volume demonstrated a substantial decline in radial-to-femoral crossover over the study period. CONCLUSIONS: In contemporary clinical practice, access site crossover rates are consistent with those reported in randomized trials. Although crossover occurs more frequently among lower-volume operators, rates decline with increasing operator experience, supporting the presence of a radial access learning curve and improvement in procedural performance over time.

Background: We describe an investigation of a cluster of eight Corynebacterium amycolatum sternal surgical site infections (SSIs) that occurred among cardiac surgery patients from February to October 2025. Although C. amycolatum is a member of the skin microbiota, clinically significant infections caused by this organism may occur in cardiac surgery patients. Methods: The investigation included retrospective reviews of SSIs, clinical cultures and medical records, surgical observations, and operating room (OR) assessment. Line lists of surgical case criteria and infection prevention practices were created to assess common factors among cases (e.g., staffing, instrumentation, equipment, skin preparation and antisepsis, nasal decolonization, antibiotic protocols, and closure). Whole genome sequencing of isolates was performed and analyzed using SNIPPY for single-nucleotide polymorphism (SNP)-based phylogenetic analysis. Results: Phylogenetic analysis indicated isolates from five of eight case patients who had cardiac surgeries occurring over a six-week period from February to April 2025 were genetically related (?7 SNPs across the genome), suggesting a common source of infection. These five isolates were ceftriaxone, meropenem, and penicillin resistant. The other three case patient isolates were unrelated (<3181 to <15,000 SNPs); two were ceftriaxone, meropenem and penicillin resistant (one also doxycycline intermediate resistant), and the third penicillin resistant. Use of sternal tape for closure was identified as a recent practice change. Four of five genetically related cases involved the same surgeons and suture tape for sternal closure (wire for all other cases). Sternal tape was discontinued with three cases occurring afterwards. Seven patients completed chlorhexidine gluconate bathing and nasal decolonization. Hair was removed in the OR with reusable surgical clippers. All received the same skin antiseptic, and antibiotic prophylaxis was appropriate. No trends were identified in instrument or equipment use. Broad infection control measures were implemented, including surgical clipper replacement, OR cleaning and ultraviolet light disinfection, headlamp cleaning, and environmental repairs. Leadership was engaged through frequent meetings and audits. Infection control practices such as minimizing OR traffic, double gloving, glove changes, and strict adherence to hand hygiene and attire were reinforced. Two of eight cases occurred after these recommendations were completed but were not genetically related to the primary cluster. Conclusion: We describe a cluster of invasive C. amycolatum sternotomy SSIs. Only two genetically unrelated cases of C. amycolatum occurred following infection control investigation and interventions, underscoring the effectiveness of a comprehensive, multidisciplinary approach. This organism has rarely been reported as a cause of SSIs and may be an emerging pathogen.

Exposure of airway epithelia to environmental allergens or nanoparticles invokes a novel genome-protective physiological response to oxidative stress. Fragments of double-stranded genomic DNA released into the airway lumen originate from repetitive, transcriptionally active, and fragile sites within the genome. Exporting DNA with high repetitive content potentially aids cell survival through the preservation of genome integrity and fidelity during the repair process.