Citations

The growing population of older cancer survivors faces an elevated risk of accelerated cognitive decline due to the combined effects of aging and cancer-related cognitive impairment. Loneliness and social isolation have also been linked to poorer cognitive outcomes and increased risk of Alzheimer’s Disease and Related Dementias (ADRD). At the same time, regular physical activity and social support interventions may improve cognitive function and reduce risk of cognitive decline. Despite these parallel lines of evidence, few interventions have addressed these modifiable risk factors simultaneously, particularly among older cancer survivors. In this perspective, we propose that group-based exercise may provide synergistic benefits for cognitive health by addressing both physical activity and social engagement. We present a conceptual model in which participation in group exercise promotes exercise-induced neurobiological adaptations that support cognitive function while simultaneously enhancing social connectedness. These processes may reduce loneliness and social isolation, promoting cognitive engagement. We also highlight key considerations for future research, including the potential for virtual or remotely delivered group exercise to increase accessibility, the importance of group dynamics in fostering social support, and the need to incorporate validated measures of loneliness, social isolation, and cognitive function in intervention studies.

ABSTRACT Background Predictors of complications and length of stay (LOS) in patients requiring brief inpatient stays after total thyroidectomy remain poorly understood. We identify preoperative risk factors for complications, differentiate predictors of overnight versus two‐day stays and estimate associated hospital costs. Methods The National Inpatient Sample for 2016–2021 was used to analyse adult patients undergoing total thyroidectomy with LOS = 1 or 2 days. Multivariate regressions identified predictors of complications and LOS. Costs were transformed logarithmically. Results Of 26 560 patients, 70% had an overnight stay. Two‐day stays were associated with higher complication rates, comorbidity index, neck dissection and increased cost. Hispanic and Asian or Pacific Islander race, comorbidity and surgery in a rural hospital increased the risk of any thyroidectomy‐specific complication. Two‐day stays had a 29% higher cost than overnight stays. Conclusions Preoperative characteristics can help predict complications and LOS following total thyroidectomy. Risk stratification supports cost‐effective, patient‐centred care planning.

Abstract Background Machine learning models for chest X‐ray (CXR)‐based tuberculosis (TB) detection often suffer from performance drops when deployed across institutions due to domain shifts caused by differences in patient populations, imaging protocols, and equipment. Domain adaptation has been widely studied to address the problem, but privacy regulations restrict data sharing, making conventional approaches infeasible. Purpose We aim to enhance TB detection performance when a detector model is shared across multiple clinical sites without accessing any source data or statistics. This problem is related to source‐free domain adaptation (SFDA) but requires special designs for imbalanced binary classification. Methods We propose two methods for TB detection, which are based on Source HypOthesis Transfer (SHOT) and SFDA via source Distribution Estimation (SFDA‐DE), respectively. As the main ideas of our methods, we propose ranking‐based pseudo‐labeling and selective fine‐tuning of network layers to address severe class imbalance and prevent overfitting. Results On six unseen target domains with high class imbalance, our proposed SFDA methods significantly improved the average F1 score and AUROC compared to non‐adapted models, all without accessing source data during adaptation. Conclusions Our methods offer a privacy‐preserving and effective strategy to improve the generalization of TB detection models across institutions, addressing domain shifts while complying with data‐sharing restrictions.

ABSTRACT Objective Management of vestibular schwannoma (VS) remains controversial. Very small VSs represent a pivotal group: on one hand, they pose the least risk to the patient from the perspective of being small; yet, not recommending treatment may result in missing a critical window for achieving the best outcome. This debate fundamentally hinges on whether treatment improves upon the natural history of the disease. There is an unproven assumption that very small tumors behave similarly to the broader observed population. To address this central question, we conducted a multicenter retrospective review to compare the natural history of tumor growth and hearing for patients with very small VS (1–3 mm) with a referent cohort with larger tumors. Methods All patients diagnosed with sporadic VS 1–3 mm were reviewed at 3 large skull base referral centers and compared with a referent cohort of patients with tumors > 3 mm. Tumor growth‐free survival rates, treatment‐free survival rates, and rates of maintenance of class A, B, or C hearing were estimated using the Kaplan–Meier method. Results In total, 123 patients with very small VS and a referent cohort of 326 patients were studied. Seventeen patients with very small VS experienced tumor growth at a median of 3.2 years after diagnosis (IQR 2.6–5.1), demonstrating a median growth rate of 1.0 mm per year (IQR 0.9–1.8). In comparison, 167 of the patients in the referent cohort experienced tumor growth at a median of 1.7 years after diagnosis (IQR 0.8–3.1). Tumor growth‐free survival rates (95% CI, number still at risk) at 5 years after diagnosis for the 2 cohorts were 84% (75–93, 39) and 45% (40–52, 100), respectively ( p < 0.001). Six patients with very small VS underwent treatment after tumor growth at a median of 3.2 years after diagnosis (IQR 3.2–3.8), compared with 138 patients in the referent cohort at a median of 2.2 years after diagnosis (IQR 1.4–3.6). Treatment‐free survival rates (95% CI, number still at risk) at 5 years after diagnosis for the 2 cohorts were 92% (86–98, 55) and 54% (49–61, 125), respectively ( p < 0.001). Among the 105 patients with very small VS and class A, B, or C hearing at diagnosis, 3 progressed to class D. Comparatively, among the 225 patients in the referent cohort with class A, B, or C hearing at diagnosis, 70 progressed to class D at a median of 2.6 years after diagnosis (IQR 1.0–4.8). Rates of maintenance of class A, B, or C hearing (95% CI, number still at risk) at 5 years after diagnosis were 96% (92–100, 28) for patients with very small VS and 65% (57–73, 70) for the referent cohort ( p < 0.001). Conclusions The natural history of tumor growth and hearing for very small VS diverges favorably from the cumulative natural history data and provides a more appropriate benchmark to compare clinical outcomes of upfront surgery or radiosurgery for this population. At 5 years after diagnosis, 96% of very small VS maintained class A, B, or C hearing and only 8% received treatment for growth within this multicenter cohort. Cumulatively, these data substantiate initial wait‐and‐scan management via size threshold surveillance in this population. Level of Evidence 3.

Abstract Background Whether outcomes of germline BRCA1/2 (gBRCA1/2)-associated breast cancer differ compared with sporadic tumors is controversial. We explored the impact of gBRCA1/2 pathogenic variant (PV) status beyond established prognostic features. Methods We conducted 2 retrospective, matched cohort studies comparing gBRCA1/2 PV carriers and noncarriers with HER2-negative, stage I-III breast cancer (Clinical Outcomes Quality Database [COQD] cohort: 185 carriers, 555 noncarriers; Young Women’s Breast Cancer Study [YWS] cohort: 113 carriers, 226 noncarriers). Matching factors were age, stage, hormone receptor status, and year of diagnosis. Clinicopathological features, treatments, and survival outcomes were compared between carriers and noncarriers. Results Most patients in COQD had stage I-II disease (87.2%), and more carriers than noncarriers had genetic testing before diagnosis (33% vs 5.6%, P &lt; .001). In YWS, 22.7% of patients had stage III tumors, and few were tested before diagnosis (14.8% of carriers vs 1.7% of noncarriers; P &lt; .001). Carriers in COQD received chemotherapy more often than noncarriers (81.1 vs 67.0%, P &lt; .001), including platinum (P = .010); the proportion was similar for carriers and noncarriers in YWS. After adjusting for chemotherapy, relapse-free survival was longer in carriers than noncarriers in COQD (adjusted hazard ratio = 0.48 [95% CI = 0.26 to 0.87], P = .016), and a favorable trend was observed for other survival outcomes in both cohorts. Triple-negative tumors appeared to drive the differences. Conclusions We observed a trend toward improved outcomes in gBRCA1/2 PV carriers compared with noncarriers. These findings suggest that carriers should not receive more aggressive treatment solely based on their germline mutation status. Prospective clinical trials in this population are warranted.

Abstract Introduction Transthoracic echocardiography (TTE) identifies a hypercontractile phenotype (HP) in chronic coronary syndromes (CCS), characterized by elevated resting left ventricular (LV) elastance (force = systolic blood pressure/end-systolic volume). To evaluate the prognostic significance and functional correlates of HP. Methods In a prospective multicentre study, 10 677 patients with CCS underwent resting TTE to assess LV ejection fraction (EF), stroke volume, and force by quantitative volumetric echocardiography. All patients were followed for the endpoint of all-cause mortality. In a subset of 5834 patients, stress echocardiography (exercise or dobutamine) was performed for LV contractile reserve and heart rate reserve. Results Patients were stratified into Force quintiles (Q1–Q5). Patients with hypercontractile phenotype exhibited lower stroke volume at rest (Q5 = 34.8 ± 12.3 vs Q1–Q4 = 57.4 ± 19.1 mL; P &lt; .01) and higher EF at rest (Q5 = 64.8 ± 6.9% vs Q1–Q4 = 58.1 ± 8.7%, P &lt; .01). During a median follow-up of 24 months (interquartile range = 12–40 months), 509 deaths occurred. The exposure-adjusted death rate was lowest in Q3 (3.53–4.51 mmHg/mL; 1.03 per 100 person/years) and higher in Q1 (≤2.62 mmHg/mL, 2.88), Q2 (2.63–3.52 mmHg/mL, 1.86), Q4 (4.52–6.11 mmHg/mL, 1.56), and Q5 (HP, &gt;6.11 mmHg/mL; 1.88; P &lt; .0001 vs Q1 and Q3). Multivariable analysis identified HP (Q5; HR 1.531 vs Q3, 95% CI 1.116–2.099; P = .006) and EF (HR 0.963, 95% CI 0.953–0.972; P &lt; .0001) as independent predictors of death. During exercise or dobutamine stress, HP showed reduced LV contractile reserve (ΔEF: Q5 = 4.3 ± 9.4% vs Q1–Q4 = 7.0 ± 9.3%; P &lt; .001) and blunted heart rate reserve (Q5 = 1.77 ± 0.33 vs Q1–Q4 = 1.85 ± 0.39; P &lt; .01). All patients with force-based LV contractile reserve &gt;4.1 (present in 185, 3.2% of the population) survived. Conclusion Patients with CCS with HP assessed by resting TTE demonstrate higher mortality and multilayered functional impairment, including reduced LV contractile and chronotropic reserves. Hypercontractile phenotype improved the prediction of mortality by EF. A ‘stronger’ heart is, in fact, functionally and prognostically weaker.

Background Bedside percutaneous dilatational tracheostomy is a commonly performed procedure in the Intensive Care Unit with a steep learning curve. Checklists and standardized protocols have been established as essential tools for mitigating medical error and enhancing patient safety during critical care procedures. Research Question To assess the feasibility and safety profile of a percutaneous tracheostomy protocol, performed by pulmonary and critical care fellows, which integrates a multi-component checklist, tracheal ultrasound and a unique dual-visualization technique for endotracheal tube management. Study Design and Methods We conducted a retrospective review of all patients (n = 49) who underwent bedside percutaneous tracheostomy using a standardized protocol between November 1, 2022, and October 31, 2024. Key components of the protocol included rigorous pre-procedure assessment with standard tracheal ultrasound stations, a mandatory checklist, and endotracheal tube retraction under dual video laryngoscopy and bronchoscopy. Outcomes analyzed included major bleeding, site infection, and airway complications. Results A total of 49 percutaneous tracheostomy procedures were successfully performed over the 24-month period. No major bleeding episodes or pressure ulcers were identified. There was a single complication involving loss of airway due to endotracheal tube balloon rupture. Critically, the patient was rapidly re-intubated without any hypoxemia or hemodynamic instability, which may be attributed to the immediate availability and use of the dual-visualization safeguard. Interpretation The implementation of this protocolized, checklist-driven approach to bedside percutaneous tracheostomy is feasible and safe within the framework of a pulmonary and critical care fellowship training model. The use of a novel dual-visualization technique (video laryngoscopy and bronchoscopy) during endotracheal tube retraction serves as a robust fail-safe, which may enhance patient safety during airway-compromised events.

Introduction We present a case of acute limb ischemia (ALI) in a morbidly obese patient with prior femoro-popliteal artery PTFE bypass occlusion successfully treated with a hybrid femoral-to-posterior tibial artery bypass utilizing the previously occluded graft. Case Report A 69-year-old morbidly obese woman presented with acute left leg pain and numbness with preserved motor function. Computed tomography angiography (CTA) demonstrates chronic superficial femoral artery and femoro-popliteal PTFE bypass occlusion with a new native popliteal artery thrombosis and loss of tibial runoffs. After systemic heparinization, the leg was revascularized through a small medial thigh incision and a jump PTFE bypass to the posterior tibial artery. The previously occluded femoro-popliteal artery bypass was accessed to re-establish proximal flow through a retrograde endovascular construction using a 7 mm by 25 cm Viabahn (Gore, Flagstaff, AZ) stent. This stent was used as a bridge with distal deployment within a new 6 mm PTFE graft, which was then anastomosed in an end to side fashion to a Linton patch of the posterior tibial artery. There were no postoperative complications, and the ankle-brachial-index was measured to be 0.98 with a CTA with runoffs confirming bypass patency. Discussion ALI in the setting of a prior bypass occlusion in a morbidly obese patient reflects the typical contemporary patient and disease complexity, which demands corrective revascularization with appropriate mitigation/prevention of other postoperative complications. A limited thigh exposure to access a previously occluded bypass can successfully restore in-line flow in these high-risk patients. Conclusion Hybrid lower extremity revascularization is an alternative surgical modality to restore in-line flow to a lower extremity as a limb salvage option while avoiding groin re-exploration in a previously accessed groin for bypass construction in a morbidly obese patient.