Citations

Background: Lumbar laminectomy and fusion may be complicated by cerebrospinal fluid (CSF) leaks. Beta-2 transferrin (B2T) is a diagnostic marker for CSF that has been mostly studied in the context of cranial CSF leak, but its accuracy in diagnosing spinal leaks is less certain. Case Description: A 59-year-old male with chronic back pain and lumbar stenosis underwent a multi-level laminectomy and fusion with a watertight repair of incidental durotomy. Postoperatively, he developed a non-healing surgical wound and persistent high drain output with fluid testing positive for B2T. However, the patient had no clinical symptoms or signs of CSF leak and repeated wound exploration showed no leak. The wound became infected and, due to poor healing, the patient underwent a secondary closure with a negative pressure treatment dressing. Multiple intraoperative dressing changes did not disclose a CSF leak despite the fact that a repeat B2T in the wound fluid remained positive. Conclusions: This report describes a case of false-positive B2T in a patient after lumbar spine surgery. This case highlights the fact that a positive B2T measured in spinal wound fluid may not be diagnostic of a CSF leak. Possible sources of false-positive B2T laboratory results are discussed in this paper.

Background: Unicompartmental knee arthroplasty (UKA) is an alternative to total knee arthroplasty for isolated compartment osteoarthritis; however, concerns persist regarding its long-term durability. The purpose of this study was to evaluate revision-free survivorship, risk factors for revision, and clinical outcomes in a large consecutive series of contemporary UKAs. Methods: We retrospectively reviewed consecutive primary UKAs performed from 2000 to 2021 at a single tertiary academic center. Revision-free survivorship was estimated using a Kaplan-Meier analysis, and risk factors for revision were assessed using Cox proportional hazards modeling. Clinical outcomes were assessed using the Knee Society Score (KSS). Results: A total of 2,234 UKAs were included. Fixed-bearing implants were used in 78% of UKAs. Technology assistance was used in 59% of UKAs (fluoroscopy, 43%; robotic assistance, 15%; computer navigation, 1%). The mean patient age was 65 years, the mean body mass index was 31 kg/m 2 , and 49% of UKAs were performed in female patients. Patient race was White in 97% of UKAs, and patient ethnicity was not Hispanic or Latino in 94%. Revision-free survivorship was 92% at 10 years and 85% at 15 years. Overall, 118 UKAs were revised, most commonly through conversion to total knee arthroplasty (97%). The most frequent indications for revision were progression of osteoarthritis in an adjacent compartment (41%), aseptic loosening (23%), unexplained pain (9%), and hardware failure (9%). Factors associated with a lower risk of revision in the univariable analysis included technology assistance (hazard ratio [HR], 0.4; p < 0.01) and high surgeon volume (HR, 0.5; p < 0.01). Mobile-bearing design (HR, 1.9; p < 0.01) was associated with an increased risk of revision in the univariable analysis. The mean KSS improved from 47 preoperatively to 75 at 5 years postoperatively (p < 0.001). Conclusions: In this large consecutive series, UKA demonstrated excellent long-term survivorship, with an approximately 1% annual risk of revision through 15 years. Technology assistance, a fixed-bearing implant design, and high surgeon volume were each associated with a lower risk of revision, underscoring the importance of operative technique and implant selection in achieving durable outcomes. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background Clinicians often care for multilingual patients and generally prefer in-person rather than remote interpretation. However, little is known about the reasons for selecting specific interpretation modalities in intensive care units (ICUs) and acute inpatient care settings. Objective To examine the context and application of in-person interpretation in ICUs and acute care settings. Methods Semistructured interviews of interprofessional stakeholders were conducted to understand the advantages and limitations of in-person and remote interpretation modalities in ICUs and acute care settings. Thematic analysis of the interviews was performed. Results Forty-one interviews were completed. Certain contexts motivated preferences for selecting in-person rather than remote interpretation in ICUs and acute care settings. Three overarching themes were identified: (1) specific types of conversations (eg, goals-of-care, end-of-life, and difficult conversations), (2) additional patient-related communication barriers (eg, hearing problems, delirium), and (3) other considerations related to in-person interpreter expertise (cultural contexts and prebriefing) and barriers to use (eg, delays, difficulty contacting interpreters). Conclusions Acute care clinicians often prefer in-person interpretation owing to factors that are either specific to in-person interpretation or cannot be fully replicated via remote modalities. Acute care clinicians consider conversation complexity, patient factors, and unique benefits versus logistical barriers when considering in-person interpretation. Overall, in-person interpretation provides advantages over alternative modalities for several scenarios to improve the quality of care for patients with non-English language preference in ICUs and acute care settings.

Background: Artificial intelligence (AI) has been utilized as a supplemental tool by patients and providers in the evaluation of common hand pathology. This study evaluated the ability of 3 large language model (LLM)-based AI systems (ChatGPT, Gemini, and Claude) to characterize Dupuytren’s contracture involvement and recommend treatment based solely on patient images. Methods: A heterogeneous set of publicly available images was obtained from open-access databases and literature sources. Images were evaluated by LLMs in independent stateless sessions using a standardized prompt to identify contracture characteristics and recommend treatment. Artificial intelligence outputs were compared with consensus assessments from 3 board-certified hand surgeons. Results: Large language models demonstrated limited accuracy in characterizing Dupuytren’s contracture involvement from patient images. Treatment recommendations were often within 1 ordinal tier of surgeon consensus; however, agreement with surgeons was no greater than chance. No consistent differences in performance were observed among the models. Conclusions: Large language model-based AI systems demonstrated limited capability in the image-based assessment and treatment recommendation of Dupuytren’s contracture. These findings highlight a gap between current LLM performance and surgeon consensus when evaluating Dupuytren’s contracture from single-patient-submitted images. Further research is needed to determine whether the incorporation of standardized clinical information can improve the reliability of AI-assisted treatment recommendations.

Background Nonobstructive hypertrophic cardiomyopathy (HCM) affects approximately one‐third of all patients with HCM and carries substantial morbidity, yet no approved disease‐modifying therapies exist. We conducted a systematic review of prospective interventional studies evaluating pharmacologic therapies in adults with nonobstructive HCM. Methods A systematic search of PubMed, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov was performed through September 2025. Eligible studies included randomized and nonrandomized prospective interventional trials. A narrative synthesis was performed by pharmacologic class and outcome domain. Results Twenty‐nine clinical trials evaluating 9 pharmacologic classes were identified: cardiac myosin inhibitors, cardiac sarcomere modulators, metabolic modulators, angiotensin II receptor blockers, angiotensin receptor‐neprilysin inhibitors, mineralocorticoid receptor antagonists, SGLT2 (sodium‐glucose cotransporter 2) inhibitors, beta blockers, and calcium channel blockers. Cardiac myosin inhibitors demonstrated reductions in left ventricular hypertrophy, improvements in diastolic function, and marked reductions in cardiac biomarkers, although improvements in exercise capacity and symptoms were variable. SGLT2 inhibition showed concordant improvements in diastolic function, atrial remodeling, biomarkers, and functional status in patients with symptomatic nonobstructive HCM and comorbid type 2 diabetes. Angiotensin receptor blockade showed signals of structural remodeling with valsartan and candesartan without consistent functional benefit. Mineralocorticoid receptor antagonism and angiotensin receptor‐neprilysin inhibition demonstrated largely neutral effects. Among metabolic modulators, ninerafaxstat improved ventilatory efficiency and quality of life in patients with greater baseline symptom burden. Conclusions Pharmacologic responsiveness in nonobstructive HCM is variable and appears to be mechanism‐ and disease stage‐dependent. Ongoing trials evaluating cardiac myosin inhibitors, SGLT inhibitors, and novel therapeutic agents including ninerafaxstat and EDG‐7500 will be critical in further defining the therapeutic landscape.

Background: Hyperkinetic biliary dyskinesia, defined as a gallbladder ejection fraction (EF) ≥80% on cholecystokinin (CCK)-stimulated hepatobiliary iminodiacetic acid scans in the setting of biliary-type pain, has been increasingly recognized as a potential functional gallbladder disorder. The clinical significance of this entity and the role of cholecystectomy remain uncertain. Patients and Methods: We conducted a systematic review and meta-analysis of studies reporting outcomes in patients with CCK-hepatobiliary iminodiacetic acid EF ≥80% who underwent cholecystectomy due to non-acute biliary-type pain. Primary outcomes included mean EF, rates of symptom resolution and improvement following cholecystectomy, and prevalence of chronic cholecystitis on pathology. Secondary outcomes included normal histology rates and symptom reproduction with CCK stimulation. All statistical analyses were conducted in R (version 4.5.0) using a random-effects model to obtain pooled estimates. Results: A total of 14 retrospective studies, including 686 patients, were analyzed. The pooled mean gallbladder EF was 90.27% (95% CI: 88.73–91.80, I 2 = 86.6%). Symptom resolution occurred in 83.1% (95% CI: 76.7–89.4, I 2 = 76.8%), and symptom improvement in 91.6% (95% CI: 89.0–94.2, I 2 = 29.7%) of patients following cholecystectomy. Histopathologic analysis revealed chronic cholecystitis in 85.1% (95% CI: 76.9–93.4, I 2 = 90.6%) of surgical specimens, while normal gallbladder histology was rare, observed in only 9.9% (95% CI: 4.6–15.2, I 2 = 83.7%). The pooled risk ratio indicated a 6.70-fold higher likelihood of chronic cholecystitis compared with normal histology (95% CI: 3.69–12.17, I 2 = 65.2%, P = 0.0022). Functional reproduction of symptoms during CCK stimulation was frequent, with a pooled rate of 78.3% (95% CI: 70.4–86.3, I 2 = 35.6%). Egger regression test suggested potential publication bias for the normal histology outcome ( P = 0.0223), but not for symptom resolution ( P = 0.1589). Conclusions: This meta-analysis suggests that a high gallbladder EF in the setting of biliary-type pain could represent clinically relevant hyperkinetic biliary dyskinesia rather than normal physiology. Cholecystectomy appears to provide meaningful symptom relief in appropriately selected patients, and pathologic findings frequently indicate underlying chronic inflammation. Further studies are needed to establish clear diagnostic cutoffs and guide management.

BACKGROUND: The impact of life-course blood pressure (BP) trajectories on later-life focal left ventricular (LV) fibrosis by late gadolinium enhancement (LGE) remains elusive. METHODS: MyoFit46 prospectively recruited ≈500 participants from a 1946 birth cohort for a cardiovascular magnetic resonance scan at 77 years, assessing LV LGE calculated using the 3-SD method or 5-SD method. Systolic BP (SBP) and diastolic BP were recorded at 36, 43, 53, 63, 69, and 77 years. For each participant, annual rates of BP change (steepness) and area under the BP trajectory (cumulative burden) for each age interval were calculated using mixed-effects models. Associations between life-course BPs and LGE were tested using generalized linear models, adjusted for antihypertensives, demographics, lifestyle, and comorbidities. Time-to-event associations between LGE and incident major adverse cardiovascular event (hospitalizations for coronary artery disease, stroke, heart failure, and atrial/ventricular arrhythmias; n=29) were also evaluated. RESULTS: Among 472 participants (54% male), each 10 mm Hg greater individual SBPs at 36 to 69 years were associated with 6% to 11% greater LV LGE calculated using the 3-SD method (all P ≤0.033), whereas each 10 mm Hg sustained greater SBPs on any age interval from 36 to 69 associated with 16% to 24% greater LGE calculated using the 3-SD method at 77(all P ≤0.005), independent of SBP at 77 years. Each 1 mm Hg/y steeper SBP rise during age intervals 36 to 43, 43 to 53, and 53 to 63 was associated with 6% to 12% greater LGE calculated using the 3-SD method at 77 years. LGE presence was associated with greater major adverse cardiovascular event rates (hazard ratio, 2.5 [95% CI, 1.2–5.2]). CONCLUSIONS: Higher life-course BPs, cumulative burden, and steeper increases were associated with greater older-age LV LGE, which was linked to incident major adverse cardiovascular events. BP trajectories, beyond single-point BP measurements, warrant further investigation as tools to guide BP management strategies.

Purpose The purpose of this study was to identify risk factors and evaluate clinical outcomes associated with incidental left common iliac vein compression on CT imaging. Methods This is a retrospective study that reviewed venous-phase abdomen and pelvis CT scans to identify patients with incidental extrinsic compression of the left common iliac vein due to an overlying right common iliac artery. A total of 726 patients were included (364 females, 362 males; mean patient age: 61.9 ± 15.9 years). Board-certified radiologists reviewed all CT scans. Significant left iliac vein compression was defined as >50% luminal narrowing. Results Significant iliac vein compression was identified in 114 (15.7%) patients and was more common in females (19.5%) versus males (11.9%) ( p < 0.01). Patients with iliac vein compression >50% had significantly lower BMI than those without compression (24.8 ± 6.2 vs 28.7 ± 7.2 kg/m 2 , p < 0.01). Patients with incidental left iliac vein compression had a higher rate of prior left lower extremity DVT ( p = 0.02). Conclusion Incidental left common iliac vein compression was present in approximately 16% of patients and was more frequent among females. Compression was associated with lower BMI and more than twice the rate of ipsilateral DVT, despite no prior diagnosis of MTS. These findings suggest that incidental iliac vein compression could have more clinical significance than previously recognized.

PURPOSE Patients with breast cancer requiring postmastectomy radiation therapy (PMRT) often desire breast reconstruction. Reconstructions can be adversely affected by PMRT, and fear of reconstruction complications has discouraged adoption of short-course radiation therapy used after lumpectomy. To fill the evidence gap, we conducted a noninferiority trial of hypofractionated versus conventional PMRT in patients undergoing breast reconstruction. The primary outcome was reconstruction complication rate, a composite of wound healing, readmission, capsular contracture, unplanned reoperation, and reconstruction failure. METHODS Women with unilateral invasive breast cancer with planned immediate or delayed reconstruction and PMRT were randomly assigned (1:1) to 50 Gy (25 fractions/5 weeks) or 42.56 Gy (16 fractions/3 weeks). This study was designed with a noninferiority margin of 10%, assuming a 2-year reconstruction complication rate of 25% with conventional PMRT. Randomization was stratified by immediate versus delayed and autologous versus implant-only reconstruction. RESULTS Between 2018 and 2021, 898 patients enrolled with a median follow-up of 3.9 years; 825 patients were evaluable for the primary end point. The 24-month reconstruction complication rates were 12.3% (52/422) with hypofractionated PMRT and 10.2% (41/403) with conventional PMRT, corresponding to an estimated difference of -2.1% (95% CI, -6.5 to 2.2). The complication rate was higher (regardless of arm) with implant-only versus autologous reconstruction (odds ratio = 1.65). There was no statistically significant difference in 36-month locoregional recurrence rates: 1.5% (95% CI, 0.7 to 3.2) with hypofractionated and 2.2% (95% CI, 1.1 to 4.3) with conventional PMRT. Acute and late toxicity rates were not statistically different. CONCLUSION A 16-fraction course of hypofractionated PMRT is safe and noninferior to conventional PMRT in women undergoing breast reconstruction after mastectomy.