Citations

Telesurgery has the potential to overcome geographical barriers in surgical care, encouraging its deployment in areas with sparse surgical expertise. Despite successful in-human experiments and substantial technological progress, the adoption of telesurgery remains slow. In this Review, we analyze the reasons for this slow adoption. First, we identify various contexts for telesurgery and highlight the vastly different requirements for their realization. We then discuss why procedures with high urgency and skill sparsity are particularly suitable for telesurgery. Last, we summarize key research areas essential for further progress. The goal of this Review is to provide the reader with a comprehensive analysis of the current state of telesurgery research and to provide guidance for faster adoption of this exciting technology.

OBJECTIVE The definitive influence of prestroke disability on outcomes in patients with a low Alberta Stroke Program Early CT Score (ASPECTS) treated with endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) due to large-vessel occlusion (LVO) remains unknown. This study aimed to investigate the impact of prestroke disability on outcomes in this specific population. METHODS Data from 32 international centers for AIS-LVO patients with a low ASPECTS who underwent EVT between January 2013 and December 2022 were analyzed retrospectively. Low ASPECTS and prestroke disability were defined as ASPECTS values of 2–5 and prestroke modified Rankin Scale (mRS) score ≥ 2. The primary outcome was a return to the prestroke mRS score at 90 days. Secondary outcomes were independent ambulation (mRS scores of 0–3) or a return to the prestroke mRS score at 90 days, good functional outcome (mRS scores of 0–2) or a return to the prestroke mRS score at 90 days, successful recanalization, and 90-day mortality. Safety outcomes were any intracranial hemorrhage or symptomatic intracranial hemorrhage. A symptomatic intracranial hemorrhage was defined as an intracranial hemorrhage with an associated worsening of ≥ 4 points in the National Institutes of Health Stroke Scale score. Outcomes were compared between patients with and without prestroke disability. RESULTS Of 293 patients, 50 (17.1%) had a prestroke disability. Of 50 patients, 20 (40.0%), 24 (48.0%), and 6 (12.0%) had prestroke mRS scores of 2, 3, and 4, respectively. The primary outcome showed no significant difference between the two groups. Compared with patients without prestroke disability, those with prestroke disability had a significantly smaller proportion of independent ambulation or return to prestroke mRS score (adjusted OR 0.13, 95% CI 0.03–0.53) and good functional outcome or return to prestroke mRS score (adjusted OR 0.21, 95% CI 0.05–0.91). Other secondary and safety outcomes showed no significant difference between the two groups. CONCLUSIONS The present study indicated that prestroke disability was not associated with a return to the prestroke mRS score at 90 days or intracranial hemorrhage. Physicians should not routinely exclude AIS-LVO patients with a low ASPECTS who have prestroke disability from EVT based on prestroke disability alone.

Background To provide recommendations on risk mitigation, diagnosis and treatment of infectious complications associated with the practice of regional anesthesia, acute and chronic pain management. Methods Following board approval, in 2020 the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) commissioned evidence-based guidelines for best practices for infection control. More than 80 research questions were developed and literature searches undertaken by assigned working groups comprising four to five members. Modified US Preventive Services Task Force criteria were used to determine levels of evidence and certainty. Using a modified Delphi method, >50% agreement was needed to accept a recommendation for author review, and >75% agreement for a recommendation to be accepted. The ASRA Pain Medicine Board of Directors reviewed and approved the final guidelines. Results After documenting the incidence and infectious complications associated with regional anesthesia and interventional pain procedures including implanted devices, we made recommendations regarding the role of the anesthesiologist and pain physician in infection control, preoperative patient risk factors and management, sterile technique, equipment use and maintenance, healthcare setting (office, hospital, operating room), surgical technique, postoperative risk reduction, and infection symptoms, diagnosis, and treatment. Consensus recommendations were based on risks associated with different settings and procedures, and keeping in mind each patient’s unique characteristics. Conclusions The recommendations are intended to be multidisciplinary guidelines for clinical care and clinical decision-making in the regional anesthesia and chronic interventional pain practice. The issues addressed are constantly evolving, therefore, consistent updating will be required.

Abstract Approximately 50% of prostate cancer (PCa) patients harbor fusions involving the TMPRSS2 and ERG genes. Despite this, tailored therapies targeting the fused gene, tERG , remain undeveloped. Our study analyzed biopsy samples from two clinical trials assessing the efficacies of androgen receptor (AR) signaling inhibitors (ARSIs). The results revealed that tERG promotes resistance to ARSIs and is associated with elevated levels of the glucocorticoid receptor (GR). Subsequent assays showed that GR directly interacts with tERG, alleviates allosteric autoinhibition and prevents chemotherapy-induced tERG degradation. In PCa models, either inhibiting GR or lowering cortisol levels suppressed tumor growth in tERG-positive models, but not in fusion-negative models. In addition, patient-derived fusion-positive xenografts displayed enhanced sensitivity to combined GR and AR inhibitors. Collectively, these findings highlight TMPRSS2-ERG as a new biomarker and propose that simultaneous inhibition of GR and AR may specifically benefit tERG -positine patients. However, GR stimulatory corticosteroid therapies may not be advisable for this patient subgroup.

Abstract To assess breast imaging fellowship program directors’ perspectives of the outcomes of the first-ever virtual interview season. A 19-question survey was constructed by members of the Fellowship Match Committee of the Society of Breast Imaging and distributed via email to 103 program directors. An initial email with a link to the survey was distributed on May 17, 2023, with 2 reminder emails sent on May 31, 2023, and June 20, 2023. The survey was closed on June 26, 2023. Results were compiled, and a descriptive statistical analysis was performed using Excel. There were 36 total responses yielding a response rate of 35% (36/103). The majority of programs, 61% (22/36), did not fill positions with any internal candidates. Overall, 72% answered that the perception of their fellow’s performance was equal to or higher than those in prior years. Despite the effects of the pandemic on clinical exposure for this cohort, 73% of programs stated that the fellow’s foundational knowledge was equivalent or better. Remarkably, 81% of respondents stated that procedural skills were equivalent or better, and 78% stated that communication skills were equivalent or better. This is the first study to investigate the outcomes of the unexpected pivot to virtual interviews. Despite the lack of preparation for this operational shift, it does not appear to have negatively impacted the program directors’ impressions of their matched fellows.

ABSTRACT Background Patients with erosive oesophagitis, and those with persistent symptomatic non‐erosive gastro‐oesophageal reflux disease, require long‐term maintenance treatment with acid‐suppressing agents. Aim To evaluate the safety of vonoprazan, a potassium‐competitive acid blocker, in an integrated analysis of data from clinical trials in adults. Methods We included 14 clinical trials of vonoprazan conducted in multiple countries. Mean duration of exposure in person‐years to vonoprazan ( n = 5318) was 2068, to comparators lansoprazole ( n = 1925) or esomeprazole ( n = 86) was 751, and to placebo ( n = 779) was 59. We report adverse events, serum gastrin, and liver enzyme levels as the main outcomes. Post‐marketing safety data from December 26, 2014 (date of commercialisation in Japan) to December 25, 2023, are also provided. Results Nasopharyngitis was the only adverse event reported by at least 5.0% of patients (6.94% vonoprazan, 5.07% proton pump inhibitor (PPI), 4.49% placebo). Incidence rates per 100 person‐years for serious adverse events were 10.39 for vonoprazan, 10.65 for PPIs, and 1.69 for placebo. One patient each on vonoprazan and lansoprazole was diagnosed with gastric cancer. Mean serum gastrin levels were higher on vonoprazan than lansoprazole but normalised by 4 weeks after discontinuation. Elevated liver enzyme levels were infrequent and of low magnitude with no differences between vonoprazan and PPIs. There were four deaths; none was considered related to study drug. Conclusions Vonoprazan was well tolerated. Its safety profile from both clinical trial and post‐marketing data were consistent and comparable to that of its PPI comparators with respect to treatment‐emergent adverse events.

OBJECTIVE Endovascular intracranial aneurysm (IA) management has significantly evolved over the last 2 decades. Despite these advancements, the aneurysm recanalization rate after coil embolization remains a concern. Statins have been found to affect vascular repair and remodeling; therefore, the authors hypothesized that patients receiving statin therapy at the time of coil embolization would have lower aneurysm recurrence and retreatment rates compared with patients not receiving statin therapy. METHODS A post hoc analysis was conducted of the primary data from patients enrolled in the Hydrogel Endovascular Aneurysm Treatment Trial focusing on the impact of statin use on the recurrence rates of 3- to 14-mm IAs after endovascular coiling. The primary outcome measured included aneurysm recurrence over 18–24 months using the Raymond-Roy Occlusion Classification. Secondary outcomes included major and minor recurrence rates and retreatment rates. Propensity score matching based on patient and aneurysm characteristics was performed to mitigate selection bias. RESULTS A total of 577 patients with data on statin use were eligible for this analysis. Of these, 178 (30.8%) patients were using statins and 399 (69.2%) were not. After propensity score matching, 156 (39.2%) patients were included in the statin group and 242 (60.8%) in the nonstatin group. The recurrence rate was 3.8% (6/156) in the statin group and 10.7% (26/242) in the nonstatin group (p = 0.013). In a subgroup analysis, statin use significantly reduced recurrence in patients with unruptured aneurysms (1.6% vs 9.7%, p = 0.005), but not in those with ruptured aneurysms (12.5% vs 13.6%, p = 0.876). CONCLUSIONS Statin use was associated with a reduced rate of aneurysm recurrence in patients who underwent endovascular coiling for IAs with a decreased rate of retreatment during the follow-up period. Statins are a relatively low-risk treatment and may be an effective therapy to reduce recanalization of IAs, although further prospective studies are warranted to validate these findings.

Rosai–Dorfman Disease (RDD), also known as sinus histiocytosis with massive lymphadenopathy, is a rare non-Langerhans cell histiocytic neoplasm. Although the disease classically presents as massive painless lymphadenopathy in young adults, RDD can also involve the central nervous system in some patients. CNS lesions, can cause headaches, neurologic deficits, and even neurologic deficits. The imaging appearance of CNS RDD typically mimics that of meningiomas: well-circumscribed dural-based lesions that often have dural tails. However, some imaging clues also exist that might help a radiologist recognize RDD, even before histopathologic confirmation. This radiology-pathology report of a patient with CNS RDD highlights the most pertinent clinical, imaging, and pathologic features of CNS RDD, and discusses what the neuroradiologist needs to know about the disease.