Citations

Purpose of review Pain during cesarean delivery (PDCD) has been overlooked and underreported and is associated with a traumatic birth experience and long-term morbidity. We review the studies reporting on PDCD and summarize available guidance providing roadmaps for anesthesiologists caring for patients during cesarean delivery. Recent findings PDCD is a patient-reported outcome and should not be defined by interventions mitigating insufficient neuraxial anesthesia, such as supplemental analgesic medication or general anesthesia. Depending on the cohorts studied and definitions used, current reported rates of PDCD range between 2 and 36%. Preoperative patient counseling, risk stratification, and testing of neuraxial block are mitigating strategies; ultimately, if pain occurs, it should be managed skillfully applying shared decision-making with a supportive follow-up to reduce psychological trauma. Statements from three international organizations offer guidance to prevent and treat PDCD. Summary This review provides strategies to mitigate the occurrence of PDCD, with targeted approaches to better prevent and manage PDCD.

INTRODUCTION: Current guidelines recommend endoscopic surveillance of Barrett's esophagus (BE) but do not account for competing mortality unrelated to esophageal cancer (EC). We conducted a systematic review and meta-analysis to estimate EC and non-EC mortality risk in BE patients. METHODS: We searched multiple databases for studies reporting mortality in BE. We included population-based studies providing standardized mortality ratio (SMR). The primary outcome was SMR from all causes and EC and non-EC etiologies. SMR was calculated by dividing the observed mortality over the expected mortality. Logarithmic form of SMRs was pooled using random-effects model. RESULTS: Our search yielded 2,826 articles, of which 7 studies (n = 34,454) were included. All-cause mortality was elevated in BE patients compared with population controls (pooled SMR 1.24, 95% confident interval [CI] 1.01–1.53) driven in part by increased EC mortality risk (SMR 8.98, 95 CI 5.12–15.77). The mortality risk was still increased but attenuated after excluding EC mortality (SMR 1.21, 95% CI 1–1.46). There was no increased mortality risk of non-EC malignancies (SMR 1.22, 95% CI 0.82–1.82) or mortality due to noncancer etiologies (SMR 1.13, 95% CI 0.90–1.43). Death due to cardiovascular diseases was higher in BE (SMR 1.16, 95% CI 1.02–1.33). BE patients were 10 times more likely to die from noncancer etiologies than EC (risk ratio 10.71, 95% CI 5.98–19.16). Subgroup analysis of studies that excluded prevalent EC at baseline (3 studies) also showed increased all-cause (SMR 1.12, 95% CI 1.07–1.18) and EC mortality (SMR 4.7, 95% CI 3.58–6.17) among BE patients. DISCUSSION: BE patients exhibit a higher all-cause mortality, driven in part by risk of EC mortality. A personalized approach to surveillance, mitigating risk of EC while recognizing the broader mortality risks, is warranted.

Abstract Background: Acute coronary syndrome (ACS) remains a major cause of mortality worldwide, with India reporting approximately three million cases annually. This study aims to assess the demographics, risk factors, and treatment patterns of ACS patients in Central India while exploring challenges related to pre-hospital delays and financial constraints. Materials and Methods: A cross-sectional, questionnaire-based study was conducted at a tertiary care hospital. Data from patients with ACS were collected through face-to-face interviews using a self-designed, semi-structured, open-ended questionnaire. Results: Among the 90 participants, 86.6% were diagnosed with an acute ST-segment elevation myocardial infarction (STEMI), with a male predominance (81.1%). Common risk factors included smoking, diabetes, hypertension, and a history of cardiovascular events. The primary reasons for delays in seeking medical care were a lack of recognition of symptom severity (37%), prolonged travel times (21%), and unavailability of suitable transportation (21%). Chest pain was the most frequently reported initial symptom (73.3%), with symptom onset occurring most often in the morning (43.3%). Males were more likely to experience anterior wall MI, while females predominantly presented with inferior or posterior wall MI. Emergency medical service (EMS) utilization was low, with most patients relying on personal vehicles for transportation. Additionally, rural patients required at least one additional hospital visit before reaching the tertiary care center compared to their urban counterparts. Thrombolysis was the primary treatment modality, administered to 76.67% of participants, with an average door-to-needle time of 78 ± 63 min. Conclusion: Multiple hospital referrals and inadequate EMS utilization hinder optimal ACS management. This study underscores the need for a streamlined referral process, enhanced EMS infrastructure, reduced door-to-needle time, and targeted interventions to mitigate financial barriers to ACS care in India.

Objective: This study aims to identify the perceived barriers and factors contributing to the slow adoption of robotic technology among coronary surgeons. Methods: We administered an anonymous online survey during the 2023 Society for Thoracic Surgeons (STS) Coronary Conference and included questions about factors associated with the lack of, or slow adoption of, robotics in coronary artery bypass surgery. Results: A total of 75 coronary surgeons completed the anonymous online survey. Of these respondents, 30 surgeons (39.4%) reported having more than 15 years of experience as independent coronary surgeons. Among the 71 surgeons (95%) who were not using robotic technology, the barriers to adoption (from most important to less important) were lack of skill or experience with robotic technology (mean score, 2.56 ± 1.84), followed by the lack of referral of patients with hybrid or single-vessel disease from cardiologists (2.81 ± 1.76), the need for more support and learning opportunities (e.g., hands-on courses, online courses; 3.44 ± 1.98), and more data to support the efficacy and safety of robotic coronary surgery (3.63 ± 2.22). Moreover, 38 surgeons (50%) expressed a willingness to consider robotic coronary surgery if industry provided appropriate devices such as stabilizers and automated anastomotic devices. Finally, 53 surgeons (69.7%) reported being unaware of the Thoracic Surgery Foundation and STS Advanced Robotic Cardiac Surgery Fellowship award with a coronary track. Conclusions: The findings from this survey identify the barriers to adopting robotic technology in coronary surgery. Addressing these barriers through targeted interventions could foster wider acceptance and use of robotic technology in coronary bypass surgery.

Objective: Cervical artery dissection (CeAD) was previously thought to be more common in men, but recent epidemiology studies show a disproportionate increase in the incidence of CeAD in women. In addition to sex-based differences in clinical presentation, there are unique biological risk factors for CeAD in women. Identifying risk factors for ischemic stroke in CeAD is crucial in individualizing treatment options. Herein, we utilized an inpatient cohort to investigate whether noncancerous gynecologic conditions or pregnancy are risk factors for ischemic stroke in CeAD. Methods: The National Inpatient Sample was queried from 2016 to 2020 for patients diagnosed with CeAD using the International Classification of Diseases, 10th edition, correction of the mean codes. Diagnoses of pregnancy/puerperium and noncancerous gynecologic conditions were identified. Among CeAD admissions, acute ischemic stroke (AIS) was also identified. Hierarchical, multivariable regression, adjusted for patient demographics and medical comorbidities, was conducted to assess factors associated with AIS. Results: A total of 34,925 women with CeAD were identified. Of these women, 2.1% were pregnant or up to six weeks postpartum, 1.3% had a noncancerous gynecologic condition, and 0.09% had both active pregnancy/puerperium and a noncancerous gynecologic condition. Noncancerous gynecologic conditions (odds ratio = 1.86, P = 0.012) were found to be an independent risk factor for AIS in CeAD but not active pregnancy/puerperium (odds ratio = 0.84, P = 0.34). Conclusion: In this national inpatient sample of female patients with CeAD, the presence of noncancerous gynecologic conditions is associated with an increased risk of AIS. Further studies are needed to validate this observation and help guide the best antithrombotic treatment decisions in this patient population.

ABSTRACT HLA‐B*07:528 differs from HLA‐B*07:02:01:26 by one nucleotide substitution in codon 286 (GGC>GAC) in exon 5.

Background and Objectives: Stroke is a leading cause of disability worldwide. Recent studies have suggested the feasibility and potential utility of remotely supervised transcranial direct current stimulation (RS-tDCS) to improve different types of impairments in various neurological conditions. This scoping review provides a critical appraisal of RS-tDCS as an adjunct therapy to enhance recovery after stroke. Materials and Methods: A comprehensive literature review was systematically conducted using PubMed through Nested Knowledge software. A supplementary search was conducted in Google Scholar. Two independent authors screened and identified related studies investigating RS-tDCS in patients with stroke from inception to February 2025. Results: Studies showed that RS-tDCS was safe, with only mild side effects. Additionally, it was feasible, with high adherence rates likely due to ease of use. Regarding efficacy, RS-tDCS preliminarily yielded improvements in upper- and lower-limb motor functions and increased language and cognitive performance. However, the studies were underpowered and heterogeneous, limiting generalization of findings. Conclusions: RS-tDCS is safe and feasible, affording beneficial effects in the motor, language, and cognitive functions of patients with post-stroke impairments. RS-tDCS has the potential to improve access and reduce disparities for post-stroke experimental treatments. However, adequately powered randomized trials are needed to further investigate the efficacy.

Background/Objectives: Pediatric rhabdomyosarcoma is a rare and poorly understood disease. Patients and parents can have varying experiences including barriers to care, time to treatment, and treatments offered. Here, we report on patient experiences regarding their care of pediatric rhabdomyosarcoma. Methods: Two separate online parent support groups were invited to participate in a survey. The survey included questions that sought to collect patient demographics, history of rhabdomyosarcoma, treatment timelines, and barriers to care. Results: A total of 215 surveys were completed. The average time from diagnosis to treatment was 12 days (SD = 14). Only 26% were offered fertility preservation prior to treatment. For patients with recurrence, an average of 75 days passed between detection of recurrence and treatment re-initiation. Patients traveled to centers with a dedicated sarcoma program in 52% of the cases. A total of 42% of parents sought a second opinion. Of those, the majority had to wait between one week and one month to be seen by another expert. Conclusions: The data collected from the survey suggests there are several opportunities to improve care among patients with pediatric rhabdomyosarcoma. Many patients may benefit from more efficient rhabdomyosarcoma referral networks, delivering patients to experts who can quickly begin multidisciplinary treatment.