Citations

Abstract Introduction The effectiveness of temporary uterine artery ligation (TUAL) in reducing blood loss during laparoscopic myomectomy (LM) is uncertain, despite increased use as an adjunct to improve surgical safety. This study aims to evaluate the safety and efficacy of TUAL in LM for the management of uterine myomas. Material and Methods We conducted a systematic review and meta‐analysis of comparative studies evaluating LM with and without TUAL. Electronic databases were searched up to October 7, 2024. Eligible studies were randomized controlled trials or observational comparative studies published in English that reported at least one primary outcome. The primary outcomes were intraoperative estimated blood loss and perioperative change in hemoglobin. Secondary outcomes included operative time, number and size of myomas removed, length of hospital stay, recurrence, and complication rates. Data extraction and analysis were performed using a random‐effects model. This review was registered prospectively with PROSPERO (CRD42024595684). Results Seven studies met the inclusion criteria, comprising five randomized controlled trials and two retrospective case–control studies, with a total of 857 women (352 undergoing LM with TUAL and 505 undergoing LM alone). TUAL was associated with a reduction in intraoperative estimated blood loss (mean difference [MD]: −84.7 mL; 95% Cl: −89.0; −80.0) and postoperative reduction in hemoglobin level (MD: −0.4 g/dL; 95% Cl: −0.7; −0.2) compared with LM without TUAL. However, TUAL was associated with increased operative time (MD: 16.5 min; 95% Cl: 3.4; 29.6). Conclusions TUAL appears to be a possible adjunct to LM for selected patients in the management of uterine myomas. Our study demonstrated that TUAL with LM could be associated with a reduction in estimated blood loss, despite an increase in operative time. Nonetheless, further studies with a larger sample size and long‐term follow‐up, as well as stratification of outcomes based on ligation technique, are warranted to elucidate the benefits of TUAL.

Background: Rheumatic heart disease (RHD) remains a prevalent cause of valvular heart pathology worldwide, especially in younger populations of low- and middle-income countries. Tricuspid valve (TV) involvement in RHD is usually secondary to left-sided valvular lesions and is often underdiagnosed, since two-dimensional echocardiography (2DE) has limited ability to visualize the complex tricuspid anatomy. Compared with 2DE, three-dimensional echocardiography (3DE) provides an en face visualization of the tricuspid valve, enabling direct planimetric measurements and detailed commissural assessment, and offers advantages for evaluating complex valvular heart disease (VHD). Thus, this study aimed to assess baseline characteristics and valvular morphology in patients with rheumatic tricuspid valve disease using 3DE. Methods: A prospective cohort single-center study conducted between April 2022 and April 2023 included 34 patients with rheumatic TV involvement. Baseline demographics, morphological features, and hemodynamic parameters were assessed using transthoracic 3DE. Results: The mean age of included patients was 45.5 ± 9.1 years, and 88.2% were female. Most patients had associated left-sided valvular involvement (mitral or combined mitral and aortic). Commissural fusion (50%), leaflet thickening (82.4%), restricted mobility (85.3%), and coaptation loss (58.8%) were predominantly noted. The mean diastolic TV gradient was 3.9 ± 3.4 mmHg, planimetry area 3.3 ± 1.7 cm2, and estimated pulmonary artery systolic pressure 43.3 ± 19.5 mmHg. Mean right ventricular (RV) global longitudinal strain was –23.6 ± 6.1%. Conclusion: Rheumatic TV involvement is characterized by commissural fusion, leaflet thickening, and coaptation loss, highlighting the diagnostic value of 3DE in identifying morphological patterns that may guide intervention planning.

ABSTRACT We report on the 2025 International ICU Diary Conference that provided a comprehensive update on current knowledge, innovations and global practices related to ICU diaries. Held in a 6‐week online format, the event featured 23 speakers and was attended by mean 69.7 (SD 20.5) participants per session. Topics included development of ICU diaries, use in special settings, digital diaries, survivors' and families' experiences, Post‐Intensive‐Care Syndrome and follow‐up and implementation projects. Highlights were innovative solutions for digital diaries and the report of persons with lived and living experiences with diaries, changing the focus on humanising critical care. Relevance for Practice ICU diaries support patient‐ and family‐centred care and should be implemented more widely across healthcare systems. Their successful adoption requires contextual adaptation and policy support, with future development likely to be shaped by the increasing use of digital ICU diaries.

Abstract Background Robotic left pancreatectomy (RLP) is increasingly adopted worldwide. Current guidelines suggest a learning curve of 21 cases, yet its impact on major morbidity and oncological quality remains uncertain. Methods A retrospective multicentre international study was undertaken across 10 centres in the UK, Spain, Germany, the USA, and Australia (2014–2025). Consecutive patients undergoing RLP were categorised into competency (first 21 cases per centre) or proficiency phase (>21). The primary outcome was major morbidity (Clavien–Dindo grade ≥ IIIa), and secondary outcome was the R1-margin rate. Mixed-effects logistic regression and risk-adjusted cumulative sum (RA-CUSUM) analyses were performed. Results 521 patients underwent RLP, including 200 (38.4%) in the competency phase and 321 (61.6%) in the proficiency phase. Median age was 63 years (IQR 54–73), and 56.4% were female. Rates of major morbidity were similar between phases (14.5% versus 14.0%, P = 0.981), as were R1 margin rates (21.6% versus 19.7%, P = 0.092). Independent predictors of major morbidity included male sex (OR 1.76, P = 0.037), preoperative pancreatitis (OR 2.23, P = 0.031), and multivisceral resection (OR 2.29, P = 0.034). Among patients with adenocarcinoma (n = 110), prolonged operative time (OR 1.39 per hour, P = 0.004) and nodal positivity (OR 2.62, P = 0.047) predicted R1 resection, while learning phase was not associated with margin status. RA-CUSUM demonstrated no excess morbidity over time in any centre. Conclusions In this first multicentre international analysis, the learning phase of RLP did not increase the risk of major morbidity or compromise oncological quality. These findings support the safe global adoption of RLP with appropriate training and case selection.

Abstract Background Minimally invasive left-sided pancreatectomy (MIS-LP) is increasingly adopted for pancreatic neuroendocrine tumours (PNETs), yet its oncological safety compared with open surgery (O-LP) remains debated. Robust population-level evidence is required to guide practice. Methods Patients ≥65 years with grade 1–2 PNETs undergoing left pancreatectomy were identified from the SEER-Medicare database (2010–2019). Overall and cancer-specific survival outcomes were analysed using multilevel Cox regression after propensity-score matching (PSM). Landmark analysis from 6 months excluded early postoperative deaths. Results 772 patients were included: 257 (33%) MIS-LP and 515 (67%) O-LP. Median age was 71 years; 87% had grade 1 and 13% grade 2 tumours. Before matching, MIS-LP patients had lower comorbidity (median Charlson Index 2 versus 3, P = 0.011) and fewer with metastatic disease (2.0% versus 5.7%, P = 0.019). After PSM (MIS-LP n = 248; O-LP n = 441), 5-year overall survival was higher with MIS-LP (88.1% versus 84.5%, P = 0.03), while 5-year cancer-specific survival was similar (95.2% versus 93.5%, P = 0.11). O-LP was associated with increased risk of death (HR 1.75, 95% c.i. 1.05–2.91, P = 0.030), though not cancer-specific death (HR 1.97, 95% c.i. 0.86–4.54, P = 0.110). Notably, all 90-day mortalities (n = 15, 1.9%) occurred in the O-LP group. In landmark analysis beyond 6 months, surgical approach was no longer predictive of OS or CSS. Conclusions MIS-LP confers an early survival advantage, driven by reduced perioperative mortality, without compromising long-term oncological outcomes. As the largest population-based analysis in this setting, these findings support MIS-LP as the standard surgical approach for older patients with low- to intermediate-grade PNETs.

Importance Adjuvant chemotherapy regimens may be administered after pancreatic resection for adenocarcinoma arising from intraductal papillary mucinous neoplasms (A-IPMNs), although the evidence supporting their use is limited. Objective To evaluate the survival benefit associated with contemporary adjuvant chemotherapy regimens after resection in A-IPMNs between 2017 and 2023. Design, Setting, and Participants This retrospective cohort study was an international, multicenter study with 69 participating centers across Europe, North America, South America, and the Asia-Pacific region. Patients undergoing resection for A-IPMNs were included. Data were analyzed from May to August 2025. Intervention Contemporary adjuvant chemotherapy regimens, such as gemcitabine-capecitabine (GemCap); 5-fluorouracil, leucovorin, oxaliplatin, and irinotecan (FOLFIRINOX), modified FOLFIRINOX (mFOLFIRINOX), and S-1. Main Outcome and Measure Overall survival (months). Results Among 1321 patients (median [IQR] age 70 [63 to 76] years; 713 males [54.0%] and 608 females [46.0%]), 781 patients (59.1%) received adjuvant chemotherapy, while in 181 patients (13.7%) it was omitted due to poor patient fitness. Of patients who received adjuvant chemotherapy, 568 patients (72.6%) received contemporary regimens, including GemCap (232 patients [29.7%]), FOLFIRINOX (176 patients [22.5%]), mFOLFIRINOX (71 patients [9.1%]), and S-1 (70 patients [9.0%]). The median (IQR) follow-up for the cohort was 64.2 (40.4 to 85.0) months, and the median overall survival was 73.8 months (95% CI, 66.4 to 81.9 months). After 90-day landmark analysis and exclusion of patients ineligible for chemotherapy, adjuvant chemotherapy vs no adjuvant chemotherapy (propensity score–matched populations, 243:243 patients) was not associated with improved overall survival (median, 82.3 months; 95% CI, 78.2 months to not applicable [NA] vs not reached; 95% CI, 75.3 months to NA; P = .58). Contemporary regimens vs no adjuvant chemotherapy (propensity score–matched populations, 309:309 patients) was not associated with longer survival, and a mean survival benefit greater than 4.2 months over 5 years was excluded (difference in restricted mean survival, 1.26 months; 95%, −1.72 to 4.24 months). Treatment outcomes did not vary by chemotherapy regimen or disease characteristic (eg, N stage or carbohydrate antigen 19-9 level). Conclusions and Relevance In this study, contemporary adjuvant chemotherapy was not associated with improved overall survival in A-IPMNs, and a randomized clinical trial is indicated.

Abstract Objectives Minimally invasive cardiac surgery (MICS) offers significant advantages over conventional sternotomy, including reduced trauma and faster recovery. Preoperative planning is crucial, with computed tomography (CT) emerging as an essential imaging tool. This systematic review aims to evaluate CT’s role in MICS planning, focusing on imaging protocols, surgical guidance, and patient outcomes. Methods This study included studies published between January 2003 and January 2025 that examined the role of CT imaging in planning minimally invasive valvular heart surgery. A comprehensive search was conducted in Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Excerpta Medica Database (EMBASE) using predefined keywords and medical subject headings (MeSH) terms related to CT imaging, angiography, minimally invasive surgery, robotic surgery, aortic valve surgery, and mitral valve surgery. Results Initial search found 378 studies, and 17 studies were included in the review. The studies highlight CT’s value in assessing surgical feasibility, vascular access, and risk stratification. CT aids in selecting arterial cannulation sites, guiding aortic occlusion strategies, and optimizing port placement. It also identifies contraindications, such as extensive atherosclerosis and anatomical abnormalities, that may necessitate sternotomy. Conclusions Current evidence underscores CT’s critical role in optimizing MICS planning and enhancing patient safety.

Abstract Background Current risk assessment tools for guiding direct oral anticoagulant (DOAC) therapy for patients with atrial fibrillation (AF) based on clinical risk factors demonstrate modest predictive performance limiting clinical impact. Additionally, while guidelines recommend periodic reassessment of risk over time, there remains an absence of modelling solutions for capturing evolving risk in AF patients. Methods Using UK electronic health records, we developed and validated the Transformer-based Risk assessment survival model (TRisk), an artificial intelligence model that predicts 12-month thromboembolic and bleeding events in AF patients by leveraging temporal patient journeys up to baseline. A cohort of 411,850 prevalent non-valvular AF patients aged ≥18 years between 2010 and 2020 was identified from 1,442 English general practices. Practices were randomly allocated to derivation (n=1,079) and external validation (n=363) cohorts. TRisk was compared with CHA 2 DS 2 -VASc and CHA 2 DS 2 -VA for thromboembolic event prediction, and HAS-BLED and ORBIT for bleeding prediction, with subgroup analyses by sex, age, and baseline characteristics. A second validation of TRisk was also performed on 16,218 US AF patients between 2010 and 2023. A decision model compared outcomes and healthcare costs for TRisk versus standard care. Findings TRisk achieved higher discrimination for thromboembolic event prediction (C-index: 0.82; 95% confidence interval [CI]: [0.81, 0.83]) as compared to CHA 2 DS 2 -VASc (0.71 [0.70, 0.73]) in UK validation. Application of TRisk to US data yielded similar C-index: 0.82 (0.80, 0.84). For bleeding prediction, TRisk (C-index: 0.70 [0.69–0.71]) outperformed both HAS-BLED (0.63; [0.61, 0.64]) and ORBIT (0.64; [0.63, 0.65]), with comparable US results (0.71; [0.69, 0.74]). The model remained well-calibrated across both populations and performed equitably across subgroups, including by race and during the COVID-19 pandemic. Impact analyses showed TRisk could reduce DOAC prescriptions by 8% in the UK and 7% in the US relative to guideline-recommended approaches, while preventing at least as many thromboembolic events. This refined approach would generate annual healthcare savings of £5.5 million and $456.2 million in the UK and US respectively among patients initiating DOACs, rising to £48.6 million and $1.8 billion when extended to all AF patients on DOACs. Interpretation TRisk enabled more precise prediction for both thromboembolic and bleeding events across AF populations in UK and US compared to established clinical scoring systems. Incorporating TRisk into routine AF care would result in substantial cost savings without compromising the identification of true high-risk patients. Funding None

OBJECTIVE: A definition of refractory septic shock is necessary to guide diagnosis, management, prognostication, research, and future guidelines for this most severe form of the disease. We sought to achieve consensus on clinical criteria that would be used to define refractory septic shock. DESIGN: Review of literature, expert panel position statements, and Delphi rounds with an international expert group. SETTING: Consensus was defined as having at least 75% of panellists in agreement or disagreement on the three highest or lowest levels of a 7-point Likert scale or based on responses to single- or multiple-choice questions, respectively. SUBJECTS: A panel of multinational, multiprofessional and multidisciplinary critical care experts assembled by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine (57 invitations and 56 participants). MEASUREMENTS AND MAIN RESULTS: A five-round Delphi process was conducted for consensus and stability. The steering committee proposed 34 statements, and five of them were rejected by panel experts after round 2. Among 29 statements selected from eight domains, consensus was reached for 13. The panel agreed on the need for a comprehensive consensus set of clinical criteria for refractory septic shock. Markers of organ dysfunction (75%, 2 rounds), tissue perfusion (91.1%, 2 rounds) including lactate (94.6%, 2 rounds) and capillary refill time (76.8%, 2 rounds), assessment of fluid-responsiveness after initial resuscitation (92.9%, 5 rounds), and use of vasoactive drugs at norepinephrine equivalents greater than 0.5 µg/kg/min (75.0%, 3 rounds), were selected as clinical criteria of refractory septic shock. The use of critical care ultrasound (CCUS) (92.9%, 3 rounds) was the single diagnostic modality that reached a consensus-based agreement. CONCLUSIONS: A consensus for 13 criteria to frame the definition of refractory septic shock was reached. Refractory septic shock is characterised by persistently elevated lactate concentrations and or prolonged capillary refill time in patients with septic shock who are fluid unresponsive, require a norepinephrine base equivalent dose greater than 0.5 micrograms per kilogram per minute, and undergo CCUS assessment when mixed shock is suspected.