Citations

Abstract Prostate cancer is the most common cancer in two thirds of the world, with an expected doubling in both incidence and mortality in the next two decades. No strong environmental associations exist for the development of prostate cancer; therefore, lifestyle measures are unlikely to mitigate this increasing burden. The last three decades have seen rapid developments in the diagnostic and therapeutic landscape of prostate cancer, including multiparametric magnetic resonance imaging, positron emission tomography, robotic surgery, image‐guided hypofractionated and stereotactic radiotherapy, novel anti‐androgens and radioligand therapies. Prostate cancer is unique in that not everyone with a diagnosis needs treatment, and active surveillance is the preferred option for some. This review discusses the contemporary management of all stages of prostate cancer in the light of these modern developments, enabling holistic individualization of treatment, and describes the promise of future research to further improve outcomes.

ABSTRACTIntroductionEsophageal dysmotility following metabolic bariatric surgery (MBS) may relate to decreased gastric compliance. We investigated high‐resolution esophageal manometry (HRM) and secondary peristalsis assessed by functional lumen imaging probe (FLIP) and their association with intragastric pressure after MBS.MethodsPatients undergoing HRM, FLIP, and barium esophagram (BE) after MBS were included. HRM metrics and proximal intragastric pressure at baseline (IGP baseline), during wet swallow‐induced esophagogastric junction relaxation (IGP EGJ opening), and following wet swallow‐induced esophagogastric junction opening with subsequent closure (IGP post EGJ closure) were measured. Contractile response was assessed during FLIP.ResultsForty patients (26 Roux en Y gastric bypass, 14 sleeve gastrectomy) with FLIP a median of 4 years after MBS, were identified. HRM was normal or consistent with ineffective esophageal motility (IEM) in 33 (82.5%) patients, while the contractile response on FLIP was abnormal (disordered/impaired, absent, or spastic reactive) in 28 (70%). Delayed emptying on BE was numerically more frequent with abnormal FLIP (6% vs. 0%, p = 0.08). IGP post‐EGJ closure (median 21.8 vs. 15 mmHg, p = 0.03) and ∆ IGP post‐EGJ closure—IGP baseline (median 4 vs. 0 mmHg, p = 0.02) were greater and predictive of abnormal contractility on FLIP (OR 1.11, 95% CI 1.00–1.2, p = 0.03 and OR 1.6, 95% CI 1.07–2.39, p = 0.003, respectively).DiscussionAbnormal contractility on FLIP, reflecting disordered secondary peristalsis, frequently occurs despite normal HRM findings after MBS. Secondary peristalsis may be associated with reduced gastric compliance, reflected by elevated proximal intragastric pressure. FLIP contractility could serve as an early marker for post‐MBS esophageal dysfunction.

AbstractInsomnia is highly prevalent in clinical practice and can present independently or alongside other medical and mental health disorders. Insomnia is a risk factor for the development and exacerbation of medical and mental health conditions. Behavioral and pharmacological treatments for insomnia are available. In this article, we review important mechanisms associated with insomnia including the hyperarousal model of insomnia and the neurobiology of insomnia. We then review the treatment approaches and management strategies for insomnia including cognitive behavioral therapy for insomnia, transcranial magnetic stimulation, pharmacologic treatment, and adjunctive treatments for insomnia.

Abstract Aim Develop an AI-generated Global Surgery podcast series tailored to healthcare professionals’ needs in specific countries, focussing on Uganda as a pilot. This precision education model addresses disparities in global surgical education, historically driven by high-income countries (HICs). Podcasts were chosen for their scalability, accessibility, and self-directed learning. Method Building on prior data from our international trainee-based needs assessment (145 survey respondents from 18 countries; 94 from Low-and-Middle-Income-Countries, LMICs; 51 from High-Income-Countries, HICs). Generative AI (ChatGPT 4.0, OpenAI) and prompt engineering were used to develop a global surgery curriculum from survey data from Ugandan respondents (selected because Uganda had one of the highest response rates, n=31). The resultant curriculum was then adapted into a podcast format featuring country-specific themes using NotebookLM (Google), using a format of exercises, case studies, and expert interviews. Results The preliminary outputs of the survey and podcasts highlight diverse country-specific priorities; for HICs these include access to resources, research opportunities, and infrastructure development; for LMICs they emphasise the burden of surgical disease, use of local case studies, and foundational concepts in global surgery. Conclusions By tailoring content to regional needs and leveraging storytelling to foster engagement, podcasts can complement traditional curricula to address gaps in access and relevance. Limitations include current AI-generative software offering only US accents, which may not suit learners elsewhere, reflecting concerns about HICs bias in AI-generated content. Future research will validate the podcasts through focus groups with Ugandan surgical trainees, and explore speech-processing for regional accents, or blending human voice with AI-generated transcripts.

Abstract BACKGROUND Postpartum preeclampsia (PPPE) is a maternal condition characterized by de novo hypertension in the postpartum period with end-organ damage. We investigated the use of perinatal immune changes, through routine complete blood count (CBC), to identify high-risk individuals before PPPE development. METHODS We performed a retrospective matched case-control study of 100 individuals with PPPE, 200 term pregnancies (Ctrl) and 200 antenatal preeclampsia (PE). Detailed demographic, obstetrical, and laboratory data were retrieved from medical records. Statistical analysis was performed using one-way ANOVA, multivariate regression, and paired or unpaired t-tests, as appropriate. RESULTS Individuals who developed PPPE were significantly older and predominantly Black vs Ctrl and PE. Both PE and PPPE had higher pre-pregnancy BMI and increased personal and family history of hypertension/PE vs Ctrl (P < 0.001). Before delivery, individuals who later developed PPPE, had lower total leukocyte counts vs Ctrl (9.61 vs 10.75 × 109/L, P < 0.05) whereas monocytes percentage was elevated (8.07 vs 7.27%, P < 0.01). Comparing the postpartum/antenatal ratio in-between each condition revealed elevated leukocyte ratio in PPPE vs Ctrl (P < 0.001). The Neutrophils ratio was also increased, whereas lymphocytes and monocytes were decreased in PPPE vs both Ctrl and PE. After adjusting for race, maternal age, pre-pregnancy BMI, personal history of PE/HT, and diabetes mellitus, perinatal immune changes were still significantly associated with PPPE. CONCLUSIONS Globally, perinatal immune changes were observed in individuals with a seemingly uncomplicated pregnancy prior to the development of PPPE. This strongly supports that such changes could be used to identify high-risk individuals prior to disease onset.

PURPOSE Doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) chemotherapy is used commonly for pediatric Hodgkin lymphoma (pHL) in low- and middle-income countries. The role of radiotherapy (RT) after ABVD in pHL is uncertain. MATERIALS AND METHODS We conducted a systematic review to explore the use of ABVD with or without RT in pHL. Key clinical questions included the number of cycles of ABVD, indications for and dose of RT, and outcomes by risk group. A search was performed in PubMed. Articles reporting survival outcomes by risk group were included. RESULTS Of 97 articles identified in the literature search, nine met inclusion criteria. Chemotherapy consisted of four to six cycles in limited disease and mostly six cycles in advanced disease. Three studies used RT for all patients within a specified risk group. Six studies dictated an adapted RT approach, with 3%-43% of the patients receiving RT for bulky adenopathy, slow early response (SER), and/or incomplete response. Radiation doses ranged between 20 and 36 Gy. The progression-free survival and overall survival at 4-10 years ranged from 84% to 100% and 93%-100% in limited disease and 50%-84.4% and 75%-95.3% in advanced disease, respectively. Studies did not directly assess the impact of certain chemotherapy or RT strategies. Recommendations were made after reviewing outcomes with particular approaches. CONCLUSION Four cycles of ABVD are recommended for limited disease, and six cycles of ABVD are recommended for advanced disease. In both limited and advanced diseases, RT is recommended with a dose of 20-21 Gy only to sites of bulky and/or SER, with a boost of up to 36 Gy to sites of incomplete response. This approach could spare radiation for at least half of the patients with limited disease and one third of advanced disease.

Abstract Background Primary aldosteronism (PA) is a common treatable cause of hypertension. When caused by unilateral adrenal disease, it is potentially curable by adrenalectomy. However, specialized tests and other factors may delay definitive treatment. We assessed the time to adrenalectomy (TTA) for patients worldwide. Methods We conducted an international, multicentre retrospective study involving 39 centres from 15 countries to determine the total time taken from the first presentation to adrenalectomy and the intervals between each stage (screening, confirmatory, subtyping, and adrenalectomy). We included patients with PA who underwent adrenalectomy from January 1, 2018, to October 30, 2022. Post-adrenalectomy outcomes were evaluated using the Primary Aldosteronism Surgery Outcome criteria. We performed multivariable quantile and linear regression to identify characteristics associated with longer TTA. Results We included 861 patients, mean age 49.3 ± 11.1 years, and 44.5% were women. Overall median TTA was 13.5 months, IQR: 6.6-24.5. Median intervals were 0.1 months (screening), 1.0 months (confirmatory), 4.1 months (subtyping), and 4.3 months (adrenalectomy). On multivariable analysis, median TTA was increased by 5.4 months for each additional adrenal vein sampling (AVS) procedure. Other factors associated with longer TTA included adrenalectomy post-COVID-19, younger age, and additional screening tests. Compared with countries with routine AVS, those without AVS had a shorter TTA (6.1 vs 15.1 months, P < .001), but greater likelihood of absent/partial biochemical success post-adrenalectomy (27.4% vs 12.4%, P < .001). Conclusion Primary aldosteronism management is time-consuming worldwide, especially for subtyping tests and adrenalectomy. While omitting AVS reduces overall time, patients are less likely to achieve biochemical cure post-adrenalectomy.