Citations

Living donor liver transplantation (LDLT) is an established therapy with curative intent for pediatric and adult patients with acute liver failure and end-stage liver disease. Donor safety remains paramount and commences during preoperative evaluation and assessment. Given the importance of the topic, the International Liver Transplantation Society and International Living Donor Liver Transplantation Group consensus conference on Living Liver Donor Safety was convened in March 2025 (Toronto, Canada). Recommendations were based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for assessment of recommendations, and the Danish model of consensus was followed. This report presents 28 recommendations from the working group focused on addressing clinically relevant questions related to the preoperative aspects of living donor safety including assessment of donor acceptability (age, body mass index and hepatic steatosis; medical conditions and contraindications), medical and surgical workup (liver function and procoagulant workup; anatomical considerations and safe remnant), and psychosocial evaluation (timing and team; underlying conditions; non-directed, paired, and anonymous directed donors; urgent living donor workups for acute liver failure).

BACKGROUND: The Ventral Rectopexy International Expert Panel recently published a consensus update on ventral rectopexy. The ability of large language models to synthesize the literature on ventral rectopexy without an explicit knowledge base was studied before the publication of the consensus. OBJECTIVE: To compare the responses and citations of different large language models on ventral rectopexy using the expert panel consensus as the reference standard. DESIGN: ChatGPT-4o, Gemini 1.5 Pro, and OpenEvidence were compared on content appropriateness (1 = inappropriate to 5 = appropriate), readability (Flesch reading ease), response length, citation fabrication, and citation quality per Oxford Levels of Evidence. The most content-appropriate chatbot response selected by the expert panel was de-identified and presented alongside the consensus text to 15 colorectal surgeons who attempted to identify the chatbot-generated text. SETTINGS: Questions were submitted from September 18 to 19, 2024. Analysis was performed before the online publication of the consensus on January 30, 2025. MAIN OUTCOME MEASURES: The main outcome measures included content appropriateness, fabricated citation rate, citation quality, and the accuracy of identifying human versus chatbot text by colorectal surgeons. RESULTS: OpenEvidence ranked highest for content appropriateness (mean 3.5/5), above Gemini (3.0/5) and ChatGPT (2.8/5; p < 0.001). ChatGPT was most verbose with the highest readability scores ( p = 0.021). ChatGPT fabricated 53% of citations; Gemini fabricated 12%; OpenEvidence fabricated 0% ( p < 0.001). All OpenEvidence citations were peer reviewed, with 40 of 117 (34%) citing level I to III studies compared with 46 of 94 (49%) of the references cited in the consensus ( p = 0.043). Chatbot-generated responses were identified with 28 of 51 (55%) accuracy. LIMITATIONS: Reproducibility may be affected due to the nature of large language models and the availability of the consensus after publication. CONCLUSIONS: OpenEvidence outperformed Gemini 1.5 Pro and ChatGPT-4o in content appropriateness and peer-reviewed citation quantity and quality. Chatbot-generated text was indistinguishable from expert-authored consensus to subject matter experts. Large language models, as an early-stage research tool, may be viable for future consensus working groups, provided transparent disclosure and rigorous oversight. See Video Abstract . ¿PUEDEN LOS MODELOS LINGÜÍSTICOS DE GRAN TAMAÑO SER UNA HERRAMIENTA VIABLE PARA LOS GRUPOS DE TRABAJO DE CONSENSO? LA EXPERIENCIA DEL GRUPO DE CONSENSO DE EXPERTOS EN RECTOPEXIA VENTRAL ANTECEDENTES: El Panel Internacional de Expertos en Rectopexia Ventral publicó recientemente una actualización consensuada sobre la rectopexia ventral. Antes de la publicación del consenso, se estudió la capacidad de los grandes modelos lingüísticos para sintetizar la bibliografía sobre la rectopexia ventral sin una base de conocimientos explícita. Objetivo: Comparar las respuestas y citas de diferentes grandes modelos lingüísticos sobre la rectopexia ventral utilizando el consenso del panel de expertos como estándar de referencia. DISEÑO: Se compararon ChatGPT-4o, Gemini 1.5 Pro y OpenEvidence en cuanto a la idoneidad del contenido (1 = inadecuado a 5 = adecuado), la legibilidad (índice de legibilidad de Flesch), la longitud de la respuesta, la fabricación de citas y la calidad de las citas según los niveles de evidencia de Oxford. La respuesta del chatbot más adecuada en cuanto al contenido seleccionada por el panel de expertos se anonimizó y se presentó junto con el texto del consenso a 15 cirujanos colorrectales que intentaron identificar el texto generado por el chatbot. ENTORNO: Las preguntas se enviaron los días 18 y 19 de septiembre de 2024. El análisis se realizó antes de la publicación del consenso en línea el 30 de enero de 2025. PRINCIPALES MEDIDAS DE RESULTADOS: Adecuación del contenido, tasa de citas inventadas, calidad de las citas, precisión en la identificación del texto humano frente al del chatbot por parte de los cirujanos colorrectales. RESULTADOS: OpenEvidence obtuvo la puntuación más alta en cuanto a la adecuación del contenido (media de 3,5/5), por encima de Gemini (3,0/5) y ChatGPT (2,8/5) (p<0,001). ChatGPT fue el más prolijo, con las puntuaciones más altas en legibilidad (p = 0,021). ChatGPT inventó el 53% de las citas; Gemini inventó el 12 %; OpenEvidence inventó el 0 % (p < 0,001). Todas las citas de OpenEvidence fueron revisadas por pares, con 40/117 (34 %) que citaban estudios de nivel I-III frente a 46/94 (49 %) de las referencias citadas en el consenso (p = 0,043). Las respuestas generadas por el chatbot se identificaron con una precisión del 28/51 (55 %). LIMITACIONES: Reproducibilidad debido a la naturaleza de los modelos de lenguaje grandes y a la disponibilidad del consenso tras la publicación. CONCLUSIONES: OpenEvidence superó a Gemini 1.5 Pro y ChatGPT-4o en cuanto a la idoneidad del contenido y la cantidad y calidad de las citas revisadas por pares. El texto generado por el chatbot era indistinguible del consenso redactado por expertos para los expertos en la materia. Los modelos de lenguaje grandes como herramienta de investigación en fase inicial pueden ser viables para futuros grupos de trabajo de consenso, siempre que se garantice una divulgación transparente y una supervisión rigurosa. ( AI-generated translation )

The success of living donor liver transplantation (LDLT) has bridged the growing gap between organ demand and availability in patients with liver failure or liver cancer. Safety of the living liver donor (LLD) is paramount, and astute intraoperative management plays a critical role in ensuring optimal outcomes for them. Given that intraoperative surgical and anesthesia practices vary widely across centers, the International Liver Transplantation Society (ILTS) and the International Living Donor Liver Transplantation Group (iLDLT Group) convened a global consensus conference in Toronto in March 2025 to develop guidelines for intraoperative management of the LLD. This manuscript details the recommendations on intraoperative considerations for the safety of LLD developed by Working Group II of the Consensus Scientific Committee, using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for assessment of recommendations, and the Danish model of consensus. Working Group II focused on intraoperative monitoring, fluid and ventilation strategies, surgical techniques for vascular and biliary division, surgeon and center-specific experience, and intraoperative crises planning. These guidelines aim to support both established and emerging LDLT teams to ensure high-quality and safe intraoperative care for the LLD.

Nutritional supplement use is common among athletes aiming to enhance performance, recovery, and health. However, variable regulatory frameworks and limited safety oversight create risks for inadvertent doping violations. This article provides a global overview of supplement use, relevant authorities, legislation, and safety measures, with a focus on third-party testing (TPT) as a risk-mitigation strategy. Data from six global regions—Africa, Asia, Australia/New Zealand, Europe, Latin America, and North America—were synthesized from peer-reviewed studies, governmental sources, and regional expert contributions. Reported supplement use ranged from 7% to 100% among athletes (variability within regions), with protein powders, vitamins/minerals, creatine, caffeine, and sports drinks being most prevalent. High-risk products (potential anti-doping rule violations), including certain herbal blends, preworkouts, and weight-management supplements, were reported across all regions. While some countries have robust regulatory systems, most lack harmonized or enforceable safety frameworks. TPT programs, which independently verify products for prohibited substances, remain concentrated in the global northwest (Europe, North America, and Australia/New Zealand); awareness and use of TPT certification vary widely, and even in regions with established systems, athlete adherence is inconsistent. Barriers to low-risk supplement use are limited TPT availability, cost, differences in labeling (including language), and cultural factors. Firsthand experiences and perceptions highlight widespread misconceptions about supplement safety and certification. The authors recommend expanded athlete and team-around-the-athlete education, improved global access to TPT low-risk supplements, and policy initiatives to harmonize safety standards. This work emphasizes the need for coordinated international efforts to protect athlete health and integrity while allowing access to evidence-based supplementation.

Abstract Objectives Patient education is increasingly acknowledged as an important aspect of the management of systemic lupus erythematosus (SLE). The aim of the study was to develop the SLE Knowledge Assessment score (SLAKE), a digital multilingual self-assessment tool designed to quantify essential SLE knowledge. Methods International healthcare professionals (HCPs) and patient representatives engaged in a multi-step process to: identify essential SLE knowledge domains, select key domains via rating, and generate an item bank of 394 questions across 11 domains, which was then adapted into 19 languages. For validation, participants completed 44 questions (including 33 randomly selected), with scores calculated for total knowledge and the 11 specific domains. Statistical analyses examined associations between scores and demographic, clinical, and educational variables. Results SLAKE was used by 1182 SLE participants (1120 [94.8%] women, median age: 45 years [IQR: 35–54 years]), with a median SLE duration of 10 years (IQR: 4–20 years). The median SLAKE score was 37 (IQR: 34–40) of a maximum of 44 points while the median score across the 11 SLAKE domains ranged between 3 and 4 over a maximum of 4 points. There was a significant positive association between SLAKE score and SLE duration (p= 0.006), previous participation to a patient education course or a patient training for lupus (p&lt; 0.0001) and the education level (p&lt; 0.0001) but not with age (p= 0.48) or gender (p= 0.39). Conclusion SLAKE is a valid, multilingual, digital self-assessment tool that effectively measures essential SLE knowledge. Its randomized question bank and domain-specific scoring enable targeted education, ultimately supporting better disease management.

Abstract Background In advanced-stage classical Hodgkin lymphoma (cHL), achieving a negative interim PET (iPET) after two cycles of ABVD is generally considered a favorable prognostic marker. Most patients with early metabolic response proceed to complete therapy without residual disease. However, a subset of patients experience discordant end-of-treatment (EOT) findings, with evidence of the disease despite an initial complete response. This study aimed to identify baseline clinical features that might help predict this unexpected outcome.Methods A retrospective review was conducted of 122 patients with stage III or IV cHL treated at our institution between 2016 and 2024. All patients achieved complete metabolic response (Deauville score ≤3) on iPET following two cycles of ABVD. Clinical and laboratory data, including IPS score, bone marrow, and extranodal involvement, were collected. The primary outcome was residual disease identified at EOT-PET. Logistic regression was used to identify predictive factors. Disease-free survival (DFS) was estimated using Kaplan-Meier analysis.Results Of the 122 patients with negative iPET scans, 21 (17.2%) were found to have residual uptake on EOT-PET. The median age was 28 years; 63% were male, and 70.5% had nodular sclerosis subtype. Most patients (69.7%) had stage IV disease. In univariate analysis, no baseline variable- including IPS score, bone marrow involvement, extranodal disease, or B symptoms- was significantly associated with residual PET positivity. However, in multivariate analysis, stage IV disease emerged as an independent predictor, with a statistically significant association with residual disease at EOT (OR 3.32; 95% CI, 0.97–11.37; p = 0.041). The median follow-up was 28.8 months. The median DFS was not reached, and the estimated two-year DFS was 83%.Conclusions While early metabolic remission on interim PET is reassuring, a notable proportion of patients still demonstrate residual disease by the end of therapy. Stage IV disease was independently associated with this outcome when adjusted for other variables. No significant associations were identified with IPS score, bone marrow, or extranodal involvement. These findings suggest that relying solely on interim PET may overlook residual risk in a subset of patients, particularly those with extensive disease burden at baseline.

Abstract Background: Haploidentical allogeneic stem cell transplantation (haplo-SCT) has been a transformative option for patients lacking matched donors. Post-transplant cyclophosphamide (PTCy) at 100 mg/kg total dose (50 mg/kg on Day +3 and +4) is a standard for graft-versus-host diseases (GvHD) prophylaxis. Efforts to decrease toxicity while maintaining efficacy have informed pursuits of dose de-escalation. However, data regarding the efficacy and safety of reduced-dose PTCy (&lt;100 mg/kg) remain scattered and variably reported. Methods: We performed a systematic review registered on PROSPERO (CRD420250650291) and conducted per PRISMA guidelines. Six databases (Medline, Embase, Web of Science, Scopus, Cinahl, Cochrane) were searched initially up to May 2024. An updated search was conducted to include studies till June 2025. Eligible studies included prospective or retrospective cohorts or randomized trials evaluating low-dose PTCy in haplo-SCT recipients reporting on acute/chronic GvHD, overall survival (OS), relapse-free survival (RFS), immune reconstitution, or complications such as hemorrhagic cystitis or infections. Non-comparative studies, reviews, and abstracts were excluded. Data was extracted independently by two reviewers, and risk-of-bias (ROB) was assessed using ROBINS-I and Cochrane RoB-2 tools. Results: Thirty-three studies, including 31 observational studies and 2 randomized controlled trials (RCTs), encompassing over 2500 patients, met our eligibility criteria. Most studies originated from Asia, with smaller contributions from Europe, the United States, India and Latin America. Low-dose PTCy regimens ranged from 14.5 to 80 mg/kg, commonly administered as 50 mg/kg ×1 on day +3 or 40 mg/kg ×2 on days +3 and +4. Comparators included standard-dose PTCy (100 mg/kg), ATG-based prophylaxis, or other regimens. Median follow-up ranged from 4 months to over 5 years. Acute GvHD (grades II–IV) rates in low-dose PTCy arms ranged from 9% to 34%. Most observational data showed comparable or reduced incidence of aGvHD compared to controls. Chronic GvHD outcomes varied from 8-46% and showed no clear benefit of dose reduction in most studies.Two-year OS ranged widely from 47% to 100%, with some observational studies favoring low-dose PTCy but others showing no survival advantage. RFS was similarly variable. Hemorrhagic cystitis occurred in 3–33% of patients, with no clear dose-dependent pattern. Infections were inconsistently reported, but, when data were available, viral infections, including BK virus, CMV, and EBV reactivation, were common, with no consistent dose-dependent trend. Median time to immune reconstitution was slightly shorter in some cohorts, but clinical relevance remains uncertain. Two studies reported significantly reduced incidence of cardiac complications with lower PTCy exposure. One randomized controlled trial comparing 80 mg/kg PTCy + ATG with the Beijing Protocol reported significantly reduced aGvHD (11.5% vs. 39.3%, p=0.001) and better OS (75.4% vs. 54.1%, p = 0.021) and RFS ((72.7% vs. 55.0%, p = 0.044)) in the experimental arm. In contrast, the only other randomized study used ultra-low-dose PTCy (14.5 mg/kg ×2) vs. ATG and found no significant difference in acute GvHD (18.2% vs. 18.2%, p=0.996) or survival and was stopped early because of futility. Both RCTs showed comparable rates of cGvHD, toxicity, and immune reconstitution.Importantly, 87% of observational studies had a serious or critical ROB. Both RCTs had some concerns of bias due to inadequate allocation concealment and open-label design but were otherwise at low ROB. Conclusions: Low-dose PTCy for GvHD prophylaxis in haplo-SCT carries comparable or lower rates of acute GvHD, similar chronic GvHD incidence, and non-inferior survival outcomes in many studies. Marked heterogeneity in regimens, patient populations, high ROB, and selective reporting preclude definitive conclusions. Randomized trials must focus on identifying subgroups benefiting from de-escalated PTCy. Until then, low-dose PTCy remains a promising but investigational alternative in haploidentical transplantation.

Ventricular arrhythmias after electrical cardioversion for AF are rare. Most of these arrhythmias are related to QT prolongation, resulting from marked and sudden slowing of heart rates, treatment with Class III antiarrhythmic drugs or other QT-prolonging medications, and the ventricular repolarisation remodelling effect of electrical cardioversion. A case of polymorphic ventricular tachycardia post-cardioversion of rapid AF in a patient with tachycardia-induced cardiomyopathy and the use of amiodarone is reported.

Abstract Introduction Penile augmentation or penis enlargement surgery refers to any technique aimed at enhancing penile length or girth. These male enhancement surgical techniques can increase total penile length, either flaccid or erect, while others add to the penile shaft’s girth and/or glans size. Proposed strategies include physical methods such as various penile exercises, mechanical traction devices, and medical therapy, while surgical interventions include cosmetic and phallic reconstructive techniques and use of fillers, sleeves, grafts, and flaps to augment penile size. Objectives The International Consultation on Sexual Medicine (ICSM) consensus statements provide evidence-based recommendations and aim to guide a clinical framework in penile aesthetic and augmentation. Methods A comprehensive literature search was conducted to identify published literature relevant to penile augmentation or enhancement. Preliminary consensus was presented to the delegates attending the 5th ICSM meeting, and feedback was incorporated into the final document. Results Twenty new recommendations are provided with corresponding levels of evidence and grades of recommendation. Conclusions Due to the controversies and lack of longer-term data regarding penile augmentation and cosmetic procedures, comprehensive assessments and careful patient counseling weighing the pros and cons, as well as potential complications, are mandatory before embarking on any treatment. Surgeons should be experienced in anatomy and various surgical techniques, and it is important to individualize surgical options based on patient condition(s) and needs, surgeon expertise, and local resources.

Abstract Introduction There is no ideal treatment for Peyronie’s Disease (PD) since every patient has different needs with varying perceived risks versus benefits of individual treatment options, coupled with the degree of impact relating to PD on sexual function and beyond. Objectives The 5th International Consultation on Sexual Medicine (ICSM) guideline on PD provides an update to the previous ICSM with an aim to provide a clinical framework and best-evidenced consensus recommendations to assist clinicians in managing PD. Methodology Available literature was reviewed, and a modified Delphi consensus was undertaken by leading sexual medicine experts to achieve a set of Quality of Evidence and strength of recommendations. This guideline was developed as an authoritative best-evidenced consensus incorporating state-of-the-art knowledge and contemporary literature. Results A total of thirty-one recommendations were made on PD guidelines. New updates to the 4th ICSM on PD have been made in definition, pathophysiology, and treatment strategies. The presence of penile pain with erection could occur in the chronic phase due to torque or stretch on the penile scar and surrounding tissue. Oral therapy works best during the acute phase and should be provided concurrently with other treatment modalities. Penile traction therapy can reduce penile deformity as monotherapy or may be offered as part of a multimodal therapy approach. There is no convincing evidence supporting cellular-based therapy. The type of plication procedure used depends on the surgeon and patient preference, although excision of the tunica followed by plication may have a higher complication rate. There is currently no ideal graft, and graft contracture can occur postoperatively. Adjunctive procedures such as penile modeling, tunical plication, plaque incision/excision and grafting can be performed when penile deformity and/or penile curvature persist following penile prosthesis implantation. Conclusions The management of PD should be individualized based on the patient’s needs and preferences while balancing the benefits and risks of each treatment option.