Citations

Abstract Dysphagia is defined as a subjective sensation of difficulty swallowing and can result from oropharyngeal or esophageal etiologies based upon patient symptoms. Dysphagia affects approximately 16% of adults in the general population, with prevalence increasing with age. Esophagogastroduodenuoscopy (EGD) is initially performed to assess for structural abnormalities resulting in esophageal dysphagia. However, if EGD reveals no pathologic abnormalities, high-resolution manometry (HRM) and barium esophagography are performed in order to assess for underlying causes of dysmotility. Esophageal motility disorders (EMDs) are an underrecognized cause of dysphagia and can be characterized by impaired esophageal peristalsis or lower esophageal sphincter dysfunction. High-resolution manometry (HRM) measures key metrics such as integrated relaxation pressure (IRP), which is the deglutitive relaxation across the LES, and metrics of esophageal body peristalsis based on distal contractile integral (DCI) and distal latency (DL). The Chicago Classification version 4 (CCv4.0), published in 2021, provides a standardized classification scheme for differentiating EMDs using metrics from HRM. Additionally, barium esophagography has remained an important adjunctive diagnostic modality, as this may identify strictures, neoplasms, or hiatal hernias, but can also identify major motility disorders such as achalasia and distal esophageal spasm. The combined use of HRM with timed barium esophagram can enhance the diagnostic accuracy of EMDs, particularly when HRM demonstrates inconclusive findings. Therefore, radiologists should be familiar with how imaging findings from barium esophagram integrate with findings noted on HRM. The aim of this review is to highlight the findings of EMDs noted on HRM in conjunction with barium esophagography, thereby illustrating characteristic patterns of primary and secondary EMDs.

PURPOSE BRCA carriers face high risks of developing both breast and ovarian/fallopian tube cancers (hereafter referred to as ovarian ). Among BRCA carriers with ovarian cancer, it is not clear whether the risk of breast cancer is sufficiently high that risk-reducing mastectomy should be offered. This study aimed to assess the risk of breast cancer BRCA carriers after a diagnosis of ovarian cancer. METHODS We included women with a pathogenic/likely pathogenic variant in BRCA1 or BRCA2 , a diagnosis of ovarian cancer, and no other cancer history and no risk-reducing bilateral mastectomy. Women were followed for incident breast cancer from the date of ovarian cancer diagnosis or the date of baseline questionnaire, whichever came last. The 5-, 10-, and 15-year cumulative risks of breast cancer were compared for women with ovarian cancer and an age-matched set of control women without ovarian cancer. RESULTS A total of 960 participants with ovarian cancer were identified (814 BRCA1 and 146 BRCA2 carriers). After a mean follow-up of 4.9 years, 41 women (4.3%) developed breast cancer, at a mean age at diagnosis of 57.5 years (range, 39-74). Actuarial cumulative breast cancer risks after ovarian cancer were 4.4%, 8.9%, and 11.5% at 5, 10, and 15 years, respectively. Only three breast cancer–related deaths occurred. Among 741 age-matched BRCA carriers without ovarian cancer, actuarial cumulative risks of breast cancer were 20.9%, 38.6%, and 47.2% at 5, 10, and 15 years, respectively. The hazard ratio for breast cancer, after an ovarian cancer diagnosis, compared with no ovarian cancer, was 0.18 ([95% CI, 0.12 to 0.27]; P < .0001). CONCLUSION After ovarian cancer, BRCA carriers have a relatively low risk of breast cancer. Risk-reducing mastectomy should not be recommended routinely, but might be considered for long-term survivors. Magnetic resonance imaging surveillance and/or mammography is a realistic alternative.

Abstract Introduction Combat casualty care requires standardized proficiency criteria to ensure readiness in austere environments, yet gaps persist in defining performance thresholds for critical trauma skills. The Combat Medical Skills Sustainment Consortium (CMSSC), a novel military-civilian collaboration, aimed to validate competency thresholds for 21 Department of Defense-identified trauma skills. Materials and Methods A prospective cohort study (2022-2025) enrolled 1,495 military and civilian personnel across five academic centers, stratified by experience (novice, intermediate, expert). Skills, including cricothyroidotomy, whole blood transfusion, and ultrasound-guided vascular access, were assessed using validated checklists in Role 2-congruent simulations. Statistical analysis compared checklist performance against participant experience with a priori checklist scores estimated at 40% (novices) and 90% (experts). Results Competency thresholds were established, ranging from 77% (mechanical ventilation) to 100% (handoff). Experts achieved 85%-98% proficiency across most skills, with novices at 34%-97%. A ceiling effect was observed for less complex skills consistent with the power law of practice. Conclusion The Combat Medical Skills Sustainment Consortium validated standardized assessment tools, with potential to address readiness gaps through military-civilian synergy. Findings support consortium-guided curriculum development and highlight the need for longitudinal skill decay studies. Impact This study sets a benchmark for trauma care skills assessment, facilitating rapid adoption across military and civilian settings.

ABSTRACT Background Acute kidney injury (AKI) in hospitalised children is a major complication associated with significant morbidity and mortality. The integration of artificial intelligence (AI)/machine learning (ML) models may enable early detection and risk stratification. This systematic review evaluates the performance of AI/ML models for predicting paediatric AKI across clinical settings. Methods We systematically searched PubMed, Embase, and Web of Science for studies applying AI/ML models to predict AKI in paediatric populations. Studies reporting performance metrics such as the area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and F1 score were included. Results Among 470 records identified, 11 studies met the inclusion criteria, with 14 AI/ML models used. The overall sample size included 33 949 paediatric patients with an AKI proportion of 12.5%. Meta-analyses of the AUC were conducted on neural network, gradient boosting, and logistic regression. Gradient boosting had the highest pooled AUC of 0.873 (95% confidence interval 0.836–0.909). Random forest demonstrated the highest median sensitivity (0.821), specificity (0.942), PPV (0.860), NPV (0.935), and accuracy (0.821); however, these metrics could not be pooled due to inconsistent reporting and limited validation. Conclusion Gradient boosting, random forest, and logistic regression demonstrated reasonable predictive performance for paediatric AKI prediction within specific clinical contexts. However, small sample size, heterogeneity, lack of testing/validation cohorts, insufficient data, and inconsistent patient populations and AKI diagnostic criteria restrict generalisability.

Background: To compare oncologic and postoperative outcomes in patients with scalp squamous cell carcinoma with periosteal, but not gross calvarial, involvement, treated with margin-clearing excision including either calvarial burring or periosteal excision alone. Study Design: Retrospective cohort study. Setting: Single tertiary academic referral center. Methods: We retrospectively reviewed surgical cases from January 2001 to January 2025. Inclusion criteria: patients ≥18 years with biopsy-proven scalp squamous cell carcinoma involving the periosteum without cortical invasion on imaging. Management of the deep margin included either burring of the outer table or periosteal excision alone. Demographic, surgical, and oncologic outcomes were collected and analyzed descriptively. Results: Twenty patients met inclusion criteria. Median age was 70 (range 56-92), and 18 (86%) were male. Thirteen (65%) patients underwent calvarial burring, 7 (35%) underwent periosteal excision. Local recurrence occurred in 31% and 29% of the burring group and non-burring group. Disease-free survival at 2 years was 46% and 57% in the burring and non-burring group, respectively. Overall survival at 2 years was 77% and 86% in the burring and non-burring group. Three patients in the burring group had local recurrences with intracranial extension, 1 died of disease, 1 died with disease and concurrent meningitis, 1 is alive with disease recurrence currently on palliative treatment. There were 7 disease-related deaths. Conclusion: Burring did not confer a significant oncologic advantage compared to periosteal excision alone when there was no gross cortical invasion. Local recurrence in patients undergoing calvarial burring was associated with intracranial extension of disease.

Abstract Endoscopic sleeve gastroplasty (ESG) facilitates 13.6%–16.2% total body weight loss (TBWL) at 12 months, but falls short of that seen with surgical vertical sleeve gastrectomy, in part owing to the retention of the gastric fundus. In adults with obesity, gastric fundal mucosal ablation (GFMA) reduces fasting plasma ghrelin (FPG), hunger, cravings, and accommodation. Combined GFMA-ESG could improve TBWL. This study aimed to evaluate the effectiveness and safety of sequential GFMA followed by ESG in adults with obesity, building on previously published 6-month results of GFMA alone. This was a prospective, first-in-human, two-phase clinical trial. Ten participants underwent GFMA, followed by ESG at month 6, and were followed for 12 months post-ESG (18 months total). GFMA was performed using hybrid argon plasma coagulation to lift and ablate the entire gastric fundal mucosa. ESG was performed using standard full-thickness endoscopic suturing of the gastric body. The primary end point was TBWL; secondary end points were safety and changes in FPG, maximum tolerated volume (MTV), and validated appetite questionnaires. Mean TBWL was 22.5% (SD 8.3%) at month 18. Hunger-related behaviors and eating self-efficacy showed sustained improvements. FPG was decreased at month 6 and returned toward baseline by month 18, while MTV remained suppressed. No serious adverse events occurred. Sequential GFMA-ESG is safe and induces substantial weight loss, reduced MTV of ingested nutrients, and improved behavioral measures. This combination approach builds on prior traditional ESG and GFMA-only results and may represent a promising advancement of endoscopic therapeutic options for weight loss.