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The use of robotic-assisted surgery has increased rapidly despite limited evidence of superior outcomes over more established surgical approaches such as laparoscopy. To evaluate whether and to what extent surgeons' financial relationships with industry are associated with the use of robotic-assisted surgery. In this cohort study, fee-for-service Medicare claims (January 1, 2011, to December 31, 2021) for patients undergoing 1 of 4 common surgical operations (bariatric surgery, cholecystectomy, colectomy, or ventral hernia repair) were linked to surgeon-level Open Payments data on receipt of industry payments from a large robotic surgical device company. Data were analyzed from April to August 2025. Receipt of a direct industry payment from a robotic-assisted surgical device company. Each surgeon's use of robotic-assisted surgery as a proportion of all surgeries performed by that surgeon. A staggered difference-in-differences (DID) approach was used to isolate the association of industry payments with the proportional use of robotic-assisted surgery among surgeons who received payment compared with control surgeons who never received a payment. Among 20 313 surgeons (mean [SD] age, 50.7 [10.2] years; 86.2% male) performing 886 385 surgeries, 5933 (29.2%) received at least 1 industry payment. Receipt of an industry payment was associated with a significant increase in the proportional use of robotic-assisted surgery, with a DID estimate of 9.9 percentage points (pp) (95% CI, 9.30-10.6 pp). Results were consistent across discrete procedures (eg, DID estimate of 11.7 pp [95% CI, 9.4-13.9 pp] for bariatric surgery and 10.3 pp [95% CI, 9.4-11.4 pp] for ventral hernia repair). There was a significant dose-dependent response. For example, surgeons receiving less than $500 increased use of robotic-assisted surgery after payment from a mean of 1.5% (95% CI, 1.4%-1.6%) to 3.7% (95% CI, 3.5%-3.9%), compared with 0.4% (95% CI, 0.4%-0.5%) to 17.0% (95% CI, 16.7%-17.3%) among surgeons receiving more than $10 000. In this cohort study, receipt of industry payments by surgeons was associated with increased use of robotic-assisted surgery compared with no receipt of payment, with a significant dose-dependent response. These results suggest that surgeon-industry financial relationships may be an important contributor to greater use of robotic-assisted surgery across the US.
We report an unusual case of a 34-year-old woman with liver and right heart failure caused by mass effect from a large hepatic adenoma compressing the bile duct, right atrium, and vena cava that was successfully managed with sequential radioembolization and orthotopic liver transplantation. This case highlights the potential complications of large adenomas and associated downsizing strategies needed to achieve a successful outcome. We believe that this is a topic of interest to the journal readership as hepatic adenomatosis is a rare indication for liver transplantation that many readers may not be familiar with.
Volumetric muscle loss (VML) injuries result in an irrecoverable loss of muscle mass and function. VML injury causes loss of both contractile tissue and associated neuromuscular junctions (NMJs). Biosponge (BSG) scaffolds, composed of gelatin, collagen, and laminin-111, have improved recovery following VML. However, improvements in NMJ quantity were not observed. Glial cell line-derived neurotrophic factor (GDNF) is known to promote motor unit survival and stimulate neurite outgrowth. In this work, BSG scaffolds were electrostatically coupled with GDNF via gelatin nanoparticles (GNPs) to support myofiber regeneration and preserve NMJs post-VML in a rodent model. In vitro determination of release kinetics revealed an initial burst release of surface-bound GDNF with almost an equivalent amount of electrostatically bound GDNF retained within the BSG post 1 week of incubation at 37°C in phosphate-buffered saline. To create the VML injury in male Lewis rats (10-12 weeks old), ∼20% of the muscle mass was removed from the tibialis anterior (TA) muscle of both hindlimbs. Relative to BSG + GNP alone, treatment with BSG + GNP + GDNF showed a significant increase (∼25%) in peak isometric torque at 6 weeks postinjury. Qualitative and quantitative histological analysis of NMJs revealed an enhanced overlap between pre and postsynaptic structures in the BSG + GNP + GDNF group. Additionally, the incorporation of GDNF slowed BSG remodeling and degradation. Overall, these results suggest that BSG-mediated GDNF delivery is an effective strategy for mitigating NMJ loss and enhancing muscle recovery following VML.
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To assess how medical students experience communication challenges in the operating room (OR), and how these barriers affect psychological safety. Cross-sectional, anonymous survey study. A single academic medical center in the United States. Eighty-three medical students who had completed a surgical clerkship and reported OR experience. The majority (73/83, 88.0%) reported difficulty hearing in the OR. Greater hearing difficulty was associated with lower psychological safety (ρ = -0.46, p < 0.001), especially with hierarchy (ρ = -0.44) and comfort seeking clarification (ρ = -0.42). Over two-thirds (68.7%) said hearing difficulty impaired their learning. Nearly 74% reported reduced confidence or sense of belonging. Thematic analysis of free-text responses revealed 7 themes, including fear of judgment, missed opportunities, and concern about career fit. Hearing-related communication barriers in the OR are common among medical students and are linked to reduced psychological safety, confidence, and learning. These findings suggest a need for structural and interpersonal changes to promote accessible, inclusive surgical education.
Percutaneous nephrolithotomy percutaneous nephrostomy (PCNL) is a minimally invasive procedure for kidney stone removal traditionally guided by fluoroscopy. This study aimed to evaluate the feasibility and outcomes of radiation-free PCNL using ultrasonography alone compared with standard fluoroscopy-guided PCNL. A total of 63 PCNL cases were eligible for radiation-free PCNL, but 27 were excluded (intraoperatively aborted, ureteroscopy performed instead, preoperative complex anatomy). Of the remaining 36 cases eligible for radiation-free PCNL, 11 were converted intraoperatively to fluoroscopic-based PCNL. Postoperative computed tomography (CT) imaging was available for only 16 of the 25 radiation-free PCNL cases and 4 of the 11 converted cases. We designated these 16 prospective radiation-free PCNL cases (2024-2025) as Group A. For comparison purposes, we identified a historical case-matched cohort of 150 PCNLs. Of these, 67 were excluded (similar reasons), leaving 83 retrospective fluoroscopy-guided PCNL cases (2022-2024) called Group B. A subset of Group A cases was converted from radiation-free intraoperatively to fluoroscopy and were designated as Group C. The primary outcome was stone-free rate (SFR), assessed postoperatively by noncontrast CT (2-3 mm slices). Secondary outcomes included estimated blood loss, complication rates (Clavien-Dindo), and postoperative stone events. The median preoperative stone burden was 35 mm in Group A and 27 mm in Groups B and C [p = 0.3]. SFR (Grade A) was comparable across Groups A, B, and C [38%, 30%, and 25%, respectively (p = 0.8)]. No differences were observed in complications or secondary outcomes. Radiation-free PCNL is feasible and yields comparable outcomes to standard fluoroscopy-guided PCNL, offering a promising method to reduce radiation exposure without compromising surgical success. However, we identified a consistent theme of poor visualization that prompted conversion to fluoroscopy for some of the cases. Innovation directed toward improving tool echogenicity is key to diffusing this technique.
We evaluated the impact of out-of-sequence (OOS) on organ utilization and also what factors impact the decision to employ OOS. Deceased donor liver allocation typically follows a ranked match-run of potential recipients. Organ procurement organizations (OPOs) may deviate from liver transplant standardized allocation using OOS matches. All eligible donors from the Scientific Registry of Transplant Recipients (SRTR) (January 1, 2013-August 31, 2023) were identified and merged with associated match runs in the Potential Transplant Recipient (PTR) data. OOS offers were defined as bypass codes (861-863; 760-765). Hierarchical mixed-effects models with eligible donors nested in OPOs assessed OOS practices versus organ utilization, controlling for liver graft risk with the Discard Risk Index (DSRI) by risk quintile, blood type, and year. OOS were more common each progressive year. Neither TC's ( R2 <0.01) nor OPO's ( R2 <0.01) OOS rate correlated with increased utilization. OOS was not associated with improved utilization (OR=1.11, 95% CI=0.90-1.38). Increasing graft risk in DBD&DCD grafts was associated with reduced utilization. Introducing OOS-allocation interaction terms improved utilization for DCDs of all risk levels, but only improved utilization for DSRI 5th-quintile DBDs. Thirty-eight percent of utilization was explained by graft factors versus 5% by TC-&OPO-variability (Conditional- R2 =0.431, Marginal- R2 =0.380). High-risk DCD grafts in DSRI 3rd to 5th quintiles were not more likely to be allocated through OOS despite these grafts demonstrating improved utilization with this approach. Only 15% of variation in OOS-allocation was explained by graft factors versus 23% by TC and OPO variability (Conditional R2 =0.388, Marginal R2 =0.154). OOS improves utilization in high-risk grafts, but graft risk is not correlated with their actual use. This highlights the utility of OOS, but also that this practice is currently incorrectly used.
Liver transplants for acute alcohol-associated hepatitis have risen rapidly over the past decade in concert with higher demand and satisfactory patient and graft survival, yet little is known about this population's long-term renal outcomes. Using the United Network for Organ Sharing registry, we identified patients undergoing isolated orthotopic liver transplant for acute alcohol-associated hepatitis in the safety net kidney after liver transplant era (August 2017 to December 2023). We used entropy balancing to identify a comparative control group using patient demographics and kidney disease risk factors. Recipients with acute alcohol-associated hepatitis had both a higher relative risk of being listed for (relative risk 2.1; 95% CI 1.7-2.8; 10.2% vs 4.8%) and receiving a safety net kidney after liver transplant (relative risk 2.0; 95% CI 1.6-2.8; 6.2% vs 3.2%) compared to controls. Among patients who were not listed for a kidney transplant, liver recipients with acute alcohol-associated hepatitis had lower posttransplant mean estimated glomerular filtration rates (69.0 vs 75.6 ml/min/1.73m2, P < .001) and were more likely to have stage 3 or 4 chronic kidney disease. It remains unclear whether these inferior renal outcomes are due to the underlying pathophysiology of acute alcohol-associated hepatitis, care practices (i.e., delays in transfer to the transplant center), or a combination of clinical factors.
To evaluate the association between enrollment in the Bundled Payments for Care Improvement -Advanced (BPCI-A) program and changes in utilization of minimally invasive surgery and 90-day episode spending for patients undergoing major gastrointestinal surgery. We compared hospitals that voluntarily enrolled in BPCI-A to control hospitals that did not participate. We used entropy balancing to reweight controls to match the BPCI-A cohort based on observable patient and hospital characteristics. We then used a difference-in-differences approach to estimate the association between surgical approach and 90-day episode payments. We used Medicare claims and American Hospital Association data between 2013 and 2021 to evaluate whether hospital enrollment in the BPCI-A program was associated with changes in 90-day episode spending and utilization of minimally invasive surgical approaches. Using entropy balancing, we reweighted the control group to achieve covariate balance with beneficiaries who obtained care at BPCI-A program hospitals. We performed a difference-in-differences analysis using multivariable linear and generalized linear models, adjusting for patient demographics, comorbidities, and hospital characteristics, with standard errors clustered at the hospital-year level to evaluate these outcomes. Changes in 90-day episode payments at BPCI-A program hospitals versus non-program hospitals were not significantly different (-$172, 95% CI: -$1104 to $760). In comparing trends at BPCI-A program and control hospitals, we identified no significant differences in utilization trends for minimally invasive surgical approaches (relative risk difference: -0.003, 95% CI: -0.10 to 0.04). The similarity in utilization trends between BPCI-A program and control hospitals was observed in the context of increasing overall utilization of MIS approaches from 40.3 to 38.4 to 43.9 to 42.9 during the study period, respectively. We found no evidence that hospitals participating in BPCI-A's major bowel surgery episodes led to differences in episode spending or utilization of minimally invasive surgical approaches.
There is a dearth of head-to-head studies comparing covalent Bruton tyrosine kinase (cBTK) inhibitors in adults with chronic lymphocytic leukemia (CLL). Real-world evidence may complement clinical trial data by assessing relative effectiveness in routine practice. This retrospective observational study used a de-identified Medicare Fee-For-Service database to compare real-world outcomes associated with first-line cBTKi monotherapies in older adults with CLL. Patients aged ≥ 65 years with CLL initiating first-line ibrutinib, acalabrutinib, or zanubrutinib monotherapy between January 1, 2020 and September 30, 2025 were included. Real-world time to treatment discontinuation (rwTTD), time to next treatment (rwTTNT), and overall survival (rwOS) were evaluated using Kaplan-Meier analyses and Cox proportional hazards models. Subgroup analyses were performed by age group. Among 10,523 patients included, 3006 (28.6%) received zanubrutinib (median follow-up 15.8 months), 4309 (40.9%) received acalabrutinib (20.7 months), and 3208 (30.5%) received ibrutinib (34.9 months). Median rwTTD was not reached (NR) for zanubrutinib, compared with 24 months for acalabrutinib and 14 months for ibrutinib. Median rwTTNT was NR for zanubrutinib, 40 months for acalabrutinib, and 20 months for ibrutinib. After adjustments for age, sex, race, CCI, and year of index, zanubrutinib had significantly longer rwTTD (hazard ratio [HR] 0.57 [95% CI 0.51-0.61]), rwTTNT (HR 0.63 [0.55-0.71]), and rwOS (HR 0.64 [0.54-0.77]) compared to ibrutinib. Zanubrutinib also had significantly improved rwTTD (HR 0.86 [0.78-0.94]), rwTTNT (HR 0.87 [0.78-0.96]), and rwOS (HR 0.77 [0.66-0.88]) compared to acalabrutinib. Similar patterns were observed when stratified by age group over 65. These findings demonstrate that zanubrutinib is associated with improved real-world outcomes compared with other cBTK inhibitors.
The use of robotic-assisted groin hernia repair is increasing rapidly across the US, but evidence regarding its comparative effectiveness to more established laparoscopic or open approaches is limited. To compare the incidence of long-term operative hernia recurrence between robotic-assisted, laparoscopic, and open groin hernia repairs. This retrospective cohort study analyzed groin hernia repairs among Medicare beneficiaries aged 65 years and older from January 2010 to December 2021, with 5-year follow-up, using a population-based analysis of US inpatient and outpatient administrative claims. Data were analyzed between August 2024 and April 2025. Surgical approach: robotic-assisted, laparoscopic, or open groin hernia repair. The main outcome was operative recurrence up to 5 years after initial groin hernia repair. Cox proportional hazards modeling was used to estimate the risk-adjusted cumulative incidence of operative recurrence up to 5 years after the initial procedure, controlling for patient demographics, comorbidities, hernia type (inguinal or femoral), and procedure type (unilateral or bilateral). A total of 199 163 Medicare beneficiaries (mean [SD] age, 72.6 [9.3] years; 29 307 female patients [14.7%]) were included in the study. From January 2010 to December 2021, the proportion of robotic-assisted procedures increased 8.6-fold, from 0.3% to 2.6%. The proportion of open procedures decreased 0.6-fold (84.4% to 51.9%), while laparoscopic procedures increased 3.0-fold (15.3% to 45.5%). Patients undergoing robotic-assisted hernia repair had the highest 5-year risk-adjusted cumulative incidence of operative recurrence (3.78%; 95% CI, 3.76%-3.79%), followed by open (3.37%; 95% CI, 3.36%-3.37%) and laparoscopic (3.21%; 95% CI, 3.21%-3.22%) approaches. Compared to open repairs, the laparoscopic approach was associated with a lower risk of operative recurrence (hazard ratio [HR], 0.75; 95% CI, 0.66-0.86), while there was no difference in risk of operative recurrence between the open and robotic cohorts (HR, 1.29; 95% CI, 0.48-2.10). In this cohort study among Medicare beneficiaries, robotic-assisted groin hernia repair was associated with a higher long-term cumulative incidence of operative recurrence compared to open and laparoscopic approaches. With low operative recurrence rates across all surgical techniques, these findings suggest that alternative measures of clinical value may be necessary to assess the benefits of minimally invasive approaches, particularly as robotic-assisted repair continues to expand.
To determine if spending is lower at high-volume esophagectomy centers. There is growing enthusiasm for centralization of care for operations with strong volume-outcome relationships, such as esophagectomy. While justifications for centralization of care have traditionally relied on clinical outcomes, little is known about whether spending also differs at hospitals with varying levels of experience performing esophagectomy. We queried Medicare claims data for fee-for-service Medicare beneficiaries undergoing esophagectomy from 2011 to 2021. Centers were categorized as high-volume (≥20 cases/year) or low-volume (<20 cases/year), a threshold backed by a large body of evidence and patient safety organizations. We used generalized linear models, adjusting for patient demographics and comorbidities, to estimate price-standardized episode payments for low- and high-volume centers. We identified 26,676 beneficiaries who underwent esophagectomy at 30 high-volume centers (7044 beneficiaries, 26.4%) and 1731 low-volume centers (19,632 beneficiaries, 73.6%) during the study period. Adjusted 90-day total episode spending was $62,305 [95% confidence interval: $61,239-$63,372] per beneficiary for high-volume centers; spending was 6.1% higher ($3781) at low-volume centers (total episode spending $66,087, 95% confidence interval: $65,362-$66,812), representing excess annual spending of $7.1 million. Index hospitalization, post-acute care, and readmission spending were also higher at low-volume centers. Low-volume centers had significantly higher rates of 90-day mortality and complications and longer length of stay. Compared to high-volume esophagectomy centers, Medicare spends more per episode at low-volume centers, possibly driven by readmissions and post-acute care utilization. Restricting esophagectomy to high-volume centers may both achieve safety and reduce spending.
As mitochondria have crucial roles in metabolism and signaling, their structure and function must be continuously monitored and rapidly adjusted to meet cellular demands. Critical to this regulation is a conserved stress response that detects and alleviates challenges to mitochondrial integrity. Recent work has shown that mitochondrial stress often elicits simultaneous protective reactions that act in a coordinated and tightly regulated fashion to preserve this essential organelle. Here we review components, coordination and control within this comprehensive stress response and discuss how increased understanding of mitochondrial stress signaling is beginning to inform therapeutic approaches directed against diseases of high unmet need.
Obesity is a chronic inflammatory disease associated with immune dysregulation. However, alterations in adaptive immune function remain unclear, particularly in the setting of childhood obesity and weight loss. We defined peripheral T cell dysregulation in a cross-sectional cohort of pediatric participants across weight categories and in a longitudinal cohort of adolescents with severe obesity undergoing bariatric surgery. We found increased expression of activation markers (including PD-1 and CD69) in non-naive CD8+ T cells whereas non-naive CD4+ T cells were skewed towards Tfh, Th17, and mixed Th2/Th17 populations. Consistent with a hyperactive state, T cells had enhanced capacity for inflammatory cytokine production (including IFN-γ and TNF-α), along with enrichment of gene sets associated with cytokine signaling, cell proliferation, and cell death. Notably, these phenotypic, functional, and transcriptional alterations were not fully resolved after bariatric surgery, despite clinically meaningful weight loss. Together, these findings demonstrate that pediatric obesity leads to dysregulation of adaptive immune function with incomplete normalization after weight loss.
This Viewpoint discusses the US Centers for Medicare & Medicaid Services’ Increasing Organ Transplant Access Model and outlines pathways to monitor the implementation of the model to ensure equitable access for all patients.
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To investigate whether a smaller tract size for percutaneous nephrolithotomy (PCNL) may result in fewer complications including blood loss, while retaining similar stone-free rates and operative time, utilizing a modern approach without postoperative nephrostomy tube. We performed a randomized controlled trial at five participating EDGE institutions in North America. Patients were randomized to receive 17.5Fr miniature tract vs 30Fr standard sized tract for PCNL without postoperative nephrostomy tubes. Demographic variables were similar. Mean decrease in hemoglobin was 1.84 g/dL for standard and 1.67 g/dL for mini (p = .654), with similar blood transfusion rates. Differences in stone-free rates (71% standard vs 77% mini) emergency room visits (13% vs 23%), additional procedural interventions (9% vs 3%), and intrarenal pressure measurements were not statistically significant. Mean pain scores in the post-anesthesia care unit were low in both groups (2.53 standard vs 1.88 mini, p = .440). Clavien-Dindo complication rates were 14% for standard and 15% for mini (p = .593). There were 11% and 5% of patients in standard and mini groups who experienced at least 2/4 systemic inflammatory response syndrome (SIRS) criteria (p = .370). Results from a multi-institutional randomized controlled trial evaluating mini versus standard PCNL without postoperative nephrostomy tubes indicate no statistically significant differences in intraoperative, postoperative, or stone-free outcomes. Surgeons should be empowered to utilize the PCNL tract size that best meets the needs of their patient, institution, and practice.
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