Citations

Achieving negative surgical margins is critical for patient outcomes in breast-conserving surgery (BCS), however positive margins require reoperation in 20% to 40% of cases currently. This study explores design criteria and current barriers and facilitators to margin definition and assessment as part of designing an intraoperative tool for margin assessment during BCS. We conducted observations of nine surgeries by four surgeons at a quaternary medical center. We analyzed the data using the Systems Engineering Initiative for Patient Safety (SEIPS) model to identify barriers and facilitators to margin assessment. We identified 38 barriers and 62 facilitators, which we inductively categorized into dimensions. The dimensions included teamwork, information display design, intraoperative tool use, and tissue characteristics. Teamwork was the most frequently observed dimension, followed by information display design and intraoperative tool use. This study provides insights to support the design of workflow-adaptive solutions and improve margin accuracy and surgical performance in breast oncology procedures.

Summary Introduction Postoperative delirium is a common complication following cardiac surgery. Despite its known impact on patient outcomes, effective preventative strategies remain elusive. We aimed to perform a comprehensive Bayesian network meta‐analysis of randomised controlled trials assessing the effect of pharmacological interventions on the incidence of postoperative delirium. Methods Databases were searched from inception to September 2024. Our search was updated in January 2025. Eligible studies included randomised controlled trials reporting the incidence of postoperative delirium in patients having cardiac surgery treated with pharmacological interventions. Bayesian models were used to estimate risk ratios (RR) and mean differences with 95%CrI through Markov chain Monte Carlo. Interventions were ranked using the surface under the cumulative ranking curve. Sensitivity analyses and grading of recommendations, assessment, development and evaluation assessment were conducted to evaluate the robustness and certainty of evidence. Results Seventy‐nine randomised controlled trials comprising 24,827 patients were included, with 29 pharmacological interventions compared. Dexmedetomidine combined with melatonin was the most effective intervention, reducing the incidence of postoperative delirium compared with placebo (risk ratio 0.31, 95%CrI 0.13–0.69; low certainty). Dexmedetomidine with melatonin also significantly decreased intensive care unit stay (2.4 days, 95%CrI ‐3.50–1.10) and hospital stay (1.32 days, 95%CrI ‐2.09 to ‐0.57). Other interventions, including ketamine and risperidone, showed potential efficacy but with low or very low certainty of evidence. Discussion We identified dexmedetomidine with melatonin as the most effective pharmacological strategy for preventing postoperative delirium following cardiac surgery. Whilst these findings highlight potential benefits, the low certainty of evidence underscores the need for more high‐quality primary evidence.

Background/importance Spinal cord stimulation (SCS) is an established therapy for chronic pain conditions when conventional treatments fail. However, global research implementation varies significantly due to patient demographics, healthcare infrastructure, and economic factors, creating disparities in access that directly impact patient care and public health outcomes. Objective To evaluate the global landscape of SCS research by analyzing patient demographics, geographic distribution, funding sources, and pain conditions treated across chronic pain populations aged 18 years and older, with primary focus on associations between geographic regions and patient age demographics. Evidence review We conducted a systematic literature review and meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, searching five major databases through October 2024. Studies from 2000 onward reporting SCS in adults with chronic pain lasting 3 months or longer were included. We included randomized trials, comparative studies, and case series with at least 10 patients, excluding commentaries, reviews, and insurance databases. Findings Analysis of 187 studies revealed heterogeneity in age distributions across geographic regions, with Asian studies showing higher mean ages compared to North America, while European showed lower mean ages. Research concentration was predominantly in high-income regions, with 57% of studies receiving industry funding and significant associations between funding source and geographic origin. Post-surgical pain syndrome-thoracolumbar emerged as the most prevalent condition globally, representing 44.9% of cases. Conclusions Significant associations exist between geographic regions and patient demographics in SCS research, with notable disparities in research concentration highlighting the need for broader investigation in underrepresented areas to optimize global application of this chronic pain management therapy. PROSPERO registration number CRD42025635147.

ABSTRACTBackgroundAchalasia is associated with an increased risk of esophageal cancer; though reported incidence rates vary widely (0.4% to 9.2%) due to differences in demographics, follow‐up duration, and diagnostic methods. This study evaluates the risk of esophageal cancer and Barrett's esophagus (BE) in achalasia using a large national database and a propensity‐matched control cohort.MethodsAchalasia patients were identified utilizing the TriNetX database based on International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes for diagnostic procedures and lower esophageal sphincter (LES) directed therapies, including Heller myotomy, peroral endoscopic myotomy, and pneumatic dilation. A matched control group of celiac disease patients was used. A 1‐year lead time was applied to exclude secondary malignant achalasia. Outcomes included the incidence of esophageal cancer and BE, with subgroup analysis in patients following therapy.ResultsAmong 7863 achalasia patients (mean age 58.0, 51.9% female), the esophageal cancer risk was significantly higher than control (risk ratio 2.87, 95% CI: 1.56–5.27, p < 0.001). The absolute risk was low, with 40 cases (0.51%) over a mean follow‐up of 3.18 years. BE risk was also higher in achalasia (risk ratio 1.54, 95% CI: 1.24–1.90, p < 0.001), with 220 cases (2.80%). Subgroup analysis revealed no significant difference in BE risk between POEM and Heller myotomy (risk ratio 1.0, 95% CI: 0.42–2.40, p > 0.99).DiscussionThe elevated cancer risk in achalasia over a short follow‐up period warrants reconsideration of current endoscopic surveillance guidelines, despite the low absolute risk of esophageal cancer and BE.

Summary Among individuals of European Ancestry (EA), genome‐wide association studies (GWAS) have identified single nucleotide polymorphisms (SNPs) and polygenic risk scores (PRSs) associated with non‐Hodgkin lymphoma (NHL) risk. We evaluated subtype‐specific PRSs, based on established EA‐SNPs, in Israeli Jews (IJ) and Palestinian Arabs (PA) and performed a GWAS in the combined ethnic groups to identify new loci. We included three common pathologically confirmed subtypes: diffuse large B‐cell (DLBCL), follicular (FL) and marginal zone (MZL) lymphomas. Controls were frequency matched to cases by age and sex. Among 752 IJ (201—DLBCL; 130—FL; 54—MZL/367—controls) and 593 PA (203—DLBCL; 41—FL/349‐controls), we computed PRSs weighted by EA‐derived effect estimates and used logistic regression models adjusted for confounders. In the combined ethnic groups of IJ and PA, subtype‐specific PRSs were significantly associated with the corresponding subtype, with a 1.69‐fold, 2.21‐fold and 2.26‐fold risk for DLBCL, FL and MZL, respectively; however, these effect sizes were attenuated compared to those reported in EA and varied by ethnicity. In the GWAS of the combined ethnic groups, two novel SNPs in the 6p21.32 locus were associated with DLBCL risk. Additional GWAS studies are needed among Jewish and Arab populations to improve genetic risk prediction for NHL in these ethnic groups.

ABSTRACT Objective Pre‐eclampsia complicates up to 8% of pregnancies and is associated with increased risk of ischemic cardiac and cerebral disease, which may be prevented through management of cardiovascular risk when early disease stages are detected. This meta‐analysis aimed to determine the prevalence of clinical and subclinical atherosclerosis in women after pre‐eclamptic vs non‐pre‐eclamptic pregnancy with advancing maternal age. Methods A systematic search of the literature was conducted in PubMed, Embase and Web of Science for studies reporting on the prevalence of atherosclerosis in women with a previous pre‐eclamptic pregnancy and those with a previous uncomplicated pregnancy. Any systemic atherosclerosis documented using ultrasound or computed tomography was included. Random‐effects meta‐analysis was used to compute the odds ratio (OR) with 95% CI for the association between pre‐eclampsia and the presence of atherosclerosis. Subgroup analysis was conducted according to average maternal age at evaluation. Results A total of 11 articles were included (13 217 participants). The average maternal age at evaluation ranged from 32 to 60 years. Within this age range, the pooled OR for the presence of atherosclerotic plaque after pre‐eclampsia was 1.57 (95% CI, 1.39–1.78). The pooled OR of developing atherosclerotic plaque after a pre‐eclamptic vs non‐pre‐eclamptic pregnancy increased gradually with advancing maternal age. The OR was not significant in the 30–39‐year‐old group (0.64 (95% CI, 0.10–4.15)), but the odds of finding an atherosclerotic plaque were significantly increased after pre‐eclamptic pregnancy in the 40–49‐year‐old group (OR, 1.59 (95% CI, 1.34–1.89)) and 50–60‐year‐old group (OR, 2.00 (95% CI, 1.30–3.08)). At any given age, the percentage plaque prevalence in formerly pre‐eclamptic women was roughly equal to that seen 10 years later in women with a previous non‐pre‐eclamptic pregnancy. Conclusions Women with a previous pre‐eclamptic pregnancy exhibit atherosclerosis more frequently and approximately 10 years earlier compared with women with a previous non‐pre‐eclamptic pregnancy. Targeted primary prevention is required to reduce morbidity and mortality from premature cardiovascular disease in women after pre‐eclampsia. © 2025 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

ABSTRACT Background High‐power short‐duration (HPSD) ablation has emerged as a promising alternative to conventional power delivery (CPD) for pulmonary vein isolation (PVI) among patients with atrial fibrillation (AF), though its efficacy, procedural efficiency, and safety profile remain uncertain. Aims To evaluate and compare the efficacy, procedural efficiency, and safety of HPSD versus CPD ablation strategies for PVI in patients with AF through a systematic review and meta‐analysis of randomized controlled trials (RCTs). Materials and Methods PubMed, Embase, Cochrane Library, and ClinicalTrials.Gov databases were systematically searched for RCTs comparing HPSD with CPD ablation for PVI in patients with AF. Random‐effects models were used to pool hazard ratios (HR) and risk ratios (RR) with 95% confidence intervals (CI). R version 4.4.2 was used for statistical analysis. Results Eight RCTs with 1094 patients (558 undergoing HPSD and 536 undergoing CPD ablation) were included. No significant differences were found in freedom from arrhythmia during the follow‐up period (HR: 0.77; 95% CI: 0.41–1.45; p = 0.424). AF recurrence did not differ (RR: 0.83; 95% CI: 0.59–1.16; p = 0.268) between groups. HPSD had a significantly shorter procedural (mean difference [MD]: −21.93 min; 95% CI: −31.34, −12.53; p < 0.001) and RF ablation times (MD: −13.87 min; 95% CI: −19.46, −8.27; p < 0.001). No differences were observed in fluoroscopy time and first‐pass isolation for right and left pulmonary veins. There was no difference in esophageal lesion rates, pericardial, or neurological complications, but there was a higher incidence of steam pops in HPSD (RR: 3.42; 95% CI: 1.45–8.09; p = 0.005). Discussion Although HPSD ablation did not significantly improve freedom from arrhythmia or reduce AF recurrence compared to CPD, it demonstrated enhanced procedural efficiency, with shorter procedure and RF ablation times. Despite the higher rate of steam pops, the overall safety profile was similar between both groups. Conclusion High‐power short‐duration ablation for pulmonary vein isolation in atrial fibrillation demonstrated comparable efficacy and safety to conventional power delivery, with the added benefit of shorter procedure and RF ablation times. However, HPSD ablation was associated with increased occurrence of steam pops.

ObjectiveIn the phase 3 head‐to‐head MANDARA study (NCT04157348), benralizumab demonstrated noninferiority to mepolizumab in inducing remission (defined as Birmingham Vasculitis Activity Score [BVAS] of 0 and oral glucocorticoid [OGC] dosage ≤4 mg/day at weeks 36 and 48) in patients with eosinophilic granulomatosis with polyangiitis (EGPA). This analysis investigated a more stringent definition of remission that included discontinuation of OGCs and being relapse‐free.MethodsPatients aged ≥18 years with documented relapsing or refractory EGPA receiving OGCs at ≥7.5 mg/day with or without immunosuppressive therapy for ≥4 weeks before enrollment were randomized (1:1) to benralizumab at 30 mg or mepolizumab at 300 mg subcutaneously every 4 weeks for 52 weeks. The proportion of patients achieving remission off OGCs, defined as BVAS of 0, OGC dose of 0 mg/day (at weeks 36 and 48) and no relapses during the double‐masked period, was assessed.ResultsPatients (n = 140) were randomized to benralizumab (n = 70) or mepolizumab (n = 70). The adjusted percentage of patients with remission off OGCs was 23.5% (n = 16) with benralizumab versus 11.1% (n = 8) with mepolizumab (difference 12.47 [95% confidence interval 0.46–24.48], P = 0.042). Of those who achieved remission off OGCs, 100% of benralizumab‐treated patients and 98.6% of mepolizumab‐treated patients achieved remission within the first 36 weeks of treatment.ConclusionThe administration of anti–interleukin‐5/receptor (IL‐5/R) therapies, benralizumab and mepolizumab, enable discontinuation of OGCs in some patients with EGPA, while avoiding relapses. These findings suggest that adding anti‐IL‐5/R therapy to standard primary treatment for patients with EGPA may improve response.

Abstract Introduction Multiple myeloma (MM) is characterized by the abnormal proliferation of plasma cells, resulting in the overproduction of distinctive monoclonal proteins (M-protein). Suspected MM necessitates screening for M-protein through a combination of serum protein electrophoresis, serum immunofixation (SIFE), and serum free light chain (SFLC) determination. An M-protein appears as a relatively restricted band on agarose gel, where migration in ɑ-2 is rare. Methods A 55-year-old man with pulmonary tuberculosis presented with severe lower back pain. On examination, he appeared chronically ill, with conjunctival pallor. X-rays revealed vertebral compression fractures. The full blood count confirmed anemia; however, serum calcium and creatinine levels did not meet myeloma-defining event criteria. Results The serum protein electrophoresis revealed hypogammaglobulinemia, with the SIFE demonstrating unusual unrestricted κ staining in the ɑ-2 region. A markedly elevated κ SFLC and κ:λ ratio were found. Bone marrow examination demonstrated approximately 90% plasmacytosis. Urine immunofixation revealed a small, restricted κ band disproportionate to the κ SFLC. Notably, matrix-assisted laser desorption/ionization time-of-flight mass spectrometry identified only polyclonal κ SFLC. Discussion Given the absence of a discernible M-protein on SIFE, a small κ restriction on urine immunofixation, and a polyclonal increase in κ SFLCs, the patient’s condition is being managed as an oligosecretory MM.

Importance Cardiovascular (CV) disease is the leading cause of death globally for both men and women, yet women remain historically underrepresented in CV clinical trials, despite facing a disproportionately high burden of morbidity and mortality in many forms of CV disease. Objective To determine the representation of women across a broad range of CV trials. Evidence Review The participation of women in CV trials registered on ClinicalTrials.gov from 2017 to 2023 was systematically determined through the extraction of publicly available information. Data were extracted to identify the country of study, disease type, trial size, clinical intervention, and age of the participants. The proportion of women and the ratio of number of female to male participants (F:M ratio) were calculated for each trial. The women’s participation:prevalence ratio (PPR) was estimated for each trial based on the relative prevalence of the disease by sex in the specified region. Findings A total of 1079 registered CV trials were identified, including 1 396 104 participants, of whom 571 641 (41.0%) were women. The F:M ratio was significantly lower for studies on arrhythmia (median [IQR], 0.5), coronary heart disease (median [IQR], 0.39 [0.33-0.70]), acute coronary syndrome (median [IQR], 0.32 [0.24-0.51]), and heart failure (median [IQR], 0.51 [0.32-0.87]) but higher for obesity (median [IQR], 1.44 [1.08-4.50]) and pulmonary hypertension (median [IQR], 2.86 [1.50-3.97]) trials. The F:M ratio was higher for trials on lifestyle interventions (median [IQR], 1.51 [0.77-3.24]) than for drug trials. PPRs were low for clinical trials on coronary heart disease (median [IQR], 0.66 [0.50-0.86]), acute coronary syndrome (median [IQR], 0.79 [0.51-0.87]), and stroke (median [IQR], 0.74 [0.61-0.95]). Representation of women in CV trials varied by disease state, region, intervention, and sponsor type. Conclusions and Relevance These findings highlight both progress and persistent challenges in representation of women within CV trials. These gaps not only limit the generalizability of trial outcomes but also perpetuate inequities in evidence-based care for women with CV conditions.