Citations

Abstract Background Pregnancy-related acute kidney injury (PrAKI) is an uncommon but serious complication associated with adverse maternal and neonatal outcomes, with limited data in high-resource settings. Methods We conducted a retrospective cohort study of 29 586 deliveries at Mayo Clinic hospitals between 2017 and 2022. PrAKI was defined using Kidney Disease Improving Global Outcomes (KDIGO) creatinine criteria. Maternal characteristics, nephrotoxin exposure, clinical interventions, and neonatal outcomes were compared between patients with and without PrAKI. Results PrAKI occurred in 341 patients (1.15%). Compared with controls, PrAKI was associated with higher rates of chronic hypertension (28.7% vs 5.2%), cesarean delivery (68.5% vs 35.1%), intensive care unit (ICU) admission (59.1% vs 6.2%), and nephrotoxin exposure (58.7% vs 31.6%) (all P < .0001). Dialysis was required in 7.1% of patients with PrAKI, with 1.17% remaining dependent at discharge and 0.88% at 30 and 90 days; no control patients required dialysis. Neonates of mothers with PrAKI had higher rates of prematurity and neonatal ICU (NICU) admission (48.7% vs 9.8%; P < .0001). Maternal mortality was rare. Conclusions PrAKI is a marker of severe maternal illness and is associated with adverse maternal and neonatal outcomes. Although most patients recover kidney function, a subset develop persistent dysfunction. Early identification, cautious use of nephrotoxic medications, and structured postpartum follow-up are essential.

Despite advances in imaging, instrumentation, surgical techniques, and postoperative care, outcomes for certain peripheral nerve procedures remain consistently disappointing. In this article, we describe five surgical scenarios--adult pan-brachial plexus injuries, peroneal nerve injury after knee dislocation, sciatic nerve injury after total hip arthroplasty, radiation-induced brachial plexopathy, and lower trunk injury after cardiac surgery--that, in our experience and review of the literature, frequently lead to limited and consistently poor functional recovery after nerve surgery. These challenging cases reflect not only technical and anatomical complexity but the profound biological limitations of nerve regeneration in specific contexts. By critically analyzing these five procedures, we aim to promote more realistic patient counseling, support timely and individualized decision-making, and foster a more nuanced understanding of when and what type of surgical intervention may or may not be beneficial.

Abstract Carpal fractures are uncommon, representing a small proportion of hand fractures. This study aimed to determine the incidence, injury mechanisms, treatment patterns, and complication rates of carpal fractures in Olmsted County, Minnesota, United States. A retrospective review was performed using the Rochester Epidemiology Project registry to identify carpal fractures between 2013 and 2023. Fractures were confirmed by radiographs, computed tomography, or radiology reports. Demographic data, injury mechanism, fracture laterality, and fracture characteristics were recorded. A total of 699 carpal fractures were identified. Most patients were men (57%) with a mean age of 43 years. The most common fracture was the scaphoid (44%), followed by the triquetrum (31%), hamate (9%), and trapezium (3%). The overall incidence was 53.6 per 100,000 person-years. Concomitant wrist fractures occurred in 22%, and multiple ipsilateral carpal fractures in 4.6%. Patients with triquetrum fractures had the highest mean age (54 years) and low surgical rates (2%), whereas hamate and trapezoid fractures occurred at younger ages (39 and 38 years) and had the highest surgical rates (28 and 33%, respectively). The most common injury mechanism was a fall onto an outstretched hand (n = 438). Overall, 14% (n = 98) of patients underwent surgery, of whom 77% were men. The highest nonunion rate was seen in hamate fractures (10.9%), followed by scaphoid waist and proximal pole fractures (10.5%). Nonscaphoid carpal fractures occur more frequently than previously reported and demonstrate variable age distribution, treatment rates, and nonunion risks. Understanding these patterns can improve diagnosis, guide treatment planning, and inform patient expectations. IV.

Abstract Background Even for experienced operators, endovascular treatment of unruptured intracranial aneurysms involves intraoperative uncertainty that may lead to adjustments in strategy, prolong the procedure, and potentially cause inefficiency and device waste. This study aimed to evaluate whether pre-procedural testing (PPT) of endovascular treatment using patient-specific models was associated with increased operator confidence and perceived clinical utility, including improvements in procedural efficiency and reduced resource waste. Methods We enrolled a cohort of patients who underwent PPT before endovascular treatment for complex unruptured intracranial aneurysms and compared their outcomes with a control group treated without PPT. The primary outcome was the Training Fidelity Score, a composite of three operator-reported Likert items defined a priori. Secondary outcomes included perceived clinical utility, intraoperative strategy changes, procedural time, radiation exposure, device waste and safety. Results A total of 85 patients met the inclusion criteria (PPT=40; control=45). The Training Fidelity Score was high across the PPT group (median, 4.33/5). Perceived clinical utility was high and further increased significantly after the procedure. A significant reduction was observed in intraoperative strategy changes, with no changes recorded in the PPT group, compared to 6/45 in the control group (RR 0.09; p=0.027). Reductions in treatment time, radiation exposure and device waste were also noted. Conclusion PPT using patient-specific models was associated with increased operator confidence, fewer intraoperative strategy changes, improved procedural efficiency, and reduced device waste without compromising safety. These findings support its use in pre-interventional preparation, but require prospective multicenter validation.

PURPOSE 177Lu-PSMA-617 (LuPSMA) is an approved prostate-specific membrane antigen (PSMA)–targeted radiopharmaceutical therapy for men with metastatic castration-resistant prostate cancer (mCRPC). Older patients, particularly octogenarians, represent a substantial proportion of men with mCRPC but have been traditionally underrepresented in key registrational trials of LuPSMA. METHODS This retrospective multi-institutional study evaluated patients age 80 years and older with mCRPC after chemotherapy treated with ≥1 cycle of LuPSMA from August 2022 to December 2024. Clinical and demographic data were abstracted from electronic medical records. Outcomes included prostate specific antigen (PSA) response (PSA50 and PSA90), progression-free survival (PFS), overall survival (OS), and toxicities. Kaplan-Meier methods estimated PFS/OS; descriptive statistics summarized baseline and safety data. RESULTS Ninety-five patients (median age, 83 years) were included, of whom 36 (38%) and 21 (22%) had a history of cardiac disease or chronic kidney disease, respectively. Median follow-up was 24.1 months (IQR, 6.7-28.1). Patients received a median of five cycles of LuPSMA. Fifty-two (57%) and 21 (23%) patients achieved a PSA50 and PSA90, respectively. Median PFS and OS were 7.3 months (95% CI, 6.4 to 8.7) and 13.5 months (95% CI, 9.7 to 18.8), respectively. Grade ≥3 hematologic toxicities included anemia (n = 19; 20%) and thrombocytopenia (n = 4, 4%); grade ≥3 acute kidney injury occurred in one patient. Fourteen (15%) patients had dose delays, seven (7%) required reductions, and 10 (11%) discontinued therapy due to toxicity. Thirty-seven patients (39%) were hospitalized during therapy, with intensive care unit-level care required in two patients (2%), and there was one treatment-related death. CONCLUSION LuPSMA had comparable outcomes in octogenarians with mCRPC to patients on registrational trials, although 2/5 of patients required hospitalization during therapy. These findings support the feasibility and efficacy of LuPSMA in well-selected older men with mCRPC and suggest a role for closer monitoring of older patients.

Triple-negative breast cancer (TNBC) is an aggressive breast cancer subtype characterized by lack of estrogen receptor expression, progesterone receptor expression, and human epidermal growth factor 2 overexpression/amplification. Given its generally aggressive biology, current guidelines recommend systemic therapy for most patients, with anthracycline- and taxane-based regimens being historically preferred. However, the clinical outcomes of patients with stage I TNBC and the benefit (or lack thereof) of (neo)adjuvant chemotherapy have not been prospectively evaluated as this population has largely been excluded from prospective randomized clinical trials. As such, management decisions for stage I TNBC are typically extrapolated from trials enrolling patients with stage II or III TNBC or based on retrospective analyses. Currently, the primary factor influencing systemic therapy decisions is the anatomic stage, without other biomarkers clinically used to guide systemic therapy. This review summarizes the existing evidence supporting current and emerging systemic therapy strategies for stage I TNBC, with a special focus on treatment de-escalation and promising biomarkers that can advance personalized treatment selection.

BACKGROUND: Radiofrequency (RF) ablation of premature ventricular complexes (PVCs) originating from the left ventricular summit may be unsuccessful, highlighting the need for alternative approaches. We aimed to assess the efficacy and safety of a novel dual-modality focal catheter in treating left ventricular summit PVCs in patients who had failed previous RF ablation. METHODS: Patients were prospectively enrolled and underwent a redo ablation procedure using an irrigated, contact-force sensing, dual-modality focal catheter (TactiFlex Duo, Abbott) under compassionate use indication. The ablation strategy, including the choice of energy modality (monopolar pulsed field [PF], RF, or both), was left to the operator’s discretion. Safety assessments included serial biomarkers, renal function, and CMR within 36 hours. Efficacy was defined as ≥80% reduction in PVC burden with symptom resolution at 3-month follow-up. RESULTS: Six consecutive patients (4 men; mean age, 53.8±15 years) with symptomatic left ventricular summit PVCs and a prior failed RF ablation (range, 1–2) were prospectively enrolled. All PVCs had an inferior axis, with a left bundle V1 morphology observed in 4 of 6 cases (mean burden, 30.1±5.3%). Acute suppression of PVCs was achieved in all cases. Acute suppression with a single PF application in the great cardiac vein-anterior interventricular vein occurred in 2 patients, while 3 patients required additional RF, PF, or combined RF+PF applications at adjacent sites. One patient with an inaccessible great cardiac vein-anterior interventricular vein was successfully treated in the left ventricular outflow tract with RF+PF application. Transient, reversible left anterior descending vasospasm was observed during PF delivery in 2 of 5 cases that underwent PF application adjacent to a coronary artery, despite pretreatment with intracoronary nitroglycerin without ECG or hemodynamic sequelae. All patients had durable suppression of PVCs at follow-up. CONCLUSIONS: In its first human application, dual-modality ablation was feasible and effective for refractory left ventricular summit PVCs. Transient coronary vasospasm occurred, though it was reversible and without acute clinical consequences.