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Radical cystectomy (RC) is the standard therapy for muscle-invasive bladder cancer (MIBC) and refractory high-risk non-muscle-invasive bladder cancer (1-3). Single-port robot-assisted radical cystectomy (RARC) offers notable minimally invasive advantages (4-6), whereas conventional transperitoneal approaches are associated with intestinal and gastrointestinal complications (7). This study evaluated an optimized extraperitoneal single-port RARC with orthotopic neobladder reconstruction for improved surgical safety and clinical outcomes. A 57-year-old male presented with three months of intermittent painless gross hematuria. Pelvic CT revealed a bladder mass. Preoperative biopsy confirmed high-grade urothelial carcinoma with muscularis propria invasion, and the patient received gemcitabine-cisplatin neoadjuvant chemotherapy before radical surgery. Preoperative MRI identified a 3.2×2.9×2.6 cm bladder lesion without extravesical invasion or lymphadenopathy. During the procedure, the patient was placed in a supine position with buttocks elevated. A 5-cm infraumbilical single incision was made for da Vinci Xi-assisted extraperitoneal RARC, and a single-port multichannel device was deployed through the incision. Robotic instruments including a 30° endoscope, monopolar scissors, bipolar forceps, and a robotic stapler were arranged in a chopstick configuration. Via the extraperitoneal approach, we mobilized the bilateral ureters, bilateral vas deferens, and umbilical artery, dissected the bladder lateral ligaments with vascular ligation, and established a sufficient extraperitoneal working space. Bladder and prostate dissection was performed along the perivesical avascular plane, with careful protection and precise hemostasis of the dorsal venous complex. Standard pelvic lymphadenectomy was concurrently conducted during radical resection of the bladder and prostate (8). A segment of ileum was then harvested to construct an orthotopic neobladder (9), followed by anastomosis with the bilateral ureters and urethral stump. Operative time was 400 minutes with 200 mL blood loss and no transfusion. No perioperative complications occurred, and the patient was discharged on postoperative day 6. Pathological diagnosis was pT2aN0M0 with negative surgical margins and negative lymph nodes. The 12-month follow-up showed no tumor recurrence, normal renal function, complete daytime continence, and mild nocturnal incontinence requiring one nightly pad. Extraperitoneal single-port RARC with orthotopic neobladder reconstruction is a feasible minimally invasive procedure for MIBC. The optimized infraumbilical single-incision technique preserves peritoneal integrity and avoids intestinal mobilization, effectively reducing abdominal complications. It achieves reliable oncological results and improves patients' postoperative continence and quality of life.

To quantify 30-day all-cause mortality associated with pre-existing substance use disorders (SUDs) during acute SARS-CoV-2 infection, to compare mortality risk across major SUD subtypes (tobacco, alcohol, opioid, cannabis, cocaine, amphetamine, inhalant, and unspecified), and to evaluate the extent to which documented comorbidity burden accounts for observed SUD-associated mortality differences. Retrospective cohort study of adults aged 18-65 years or older with confirmed SARS-CoV-2 infection (March 2020-June 2023) from 63 US healthcare organizations contributing to the National COVID Cohort Collaborative (N3C). Confirmed infection required any 1 of an International Classification of Diseases, 10th Revision (ICD-10) diagnosis code of U07.1, a positive SARS-CoV-2 laboratory test (polymerase chain reaction or antigen), or a nirmatrelvir-ritonavir (Paxlovid) prescription. Multivariable logistic regression estimated adjusted odds ratios (aORs) for 30-day mortality associated with any SUD and with each SUD subtype, adjusting for age, sex, race and ethnicity, body mass index, and tobacco smoking status. Sensitivity analyses added the Elixhauser Comorbidity Index (ECI) and used an unrestricted cohort. Among 3,435,480 adults with confirmed SARS-CoV-2 infection, 406,064 (11.8%) had a pre-existing SUD documented before the index date, and 14,866 (0.43%) died within 30 days of the index date. Thirty-day mortality was higher among individuals with SUDs than those without (1.05% vs. 0.35%). SUDs were associated with more than doubled adjusted odds of mortality (aOR 2.38; 95% CI: 2.28-2.49). Additional adjustment for comorbidity burden attenuated but did not eliminate the association (aOR 1.53; 95% CI: 1.46-1.61). Alcohol use disorder (AUD) (aOR 2.63; 95% CI: 2.48-2.78) and opioid use disorder (OUD) (aOR 2.53; 95% CI: 2.35-2.74) conferred the highest risks. Mortality differentials between individuals with and without SUD persisted throughout the study period despite overall declines in COVID-19 mortality. Pre-existing SUDs, particularly alcohol (AUD) and opioid use disorders (OUD), identified a population at substantially increased 30-day all-cause mortality after COVID-19 diagnosis. Because unmeasured structural, behavioral, and treatment-related factors likely contribute to the residual excess risk beyond measured comorbidity, SUD is best interpreted as a clinically useful marker of heightened vulnerability rather than as an independent biological cause of mortality. SUD status, AUD, and OUD in particular, warrant explicit incorporation into short-term risk stratification for respiratory infections in both routine clinical care and pandemic preparedness planning.

Horseshoe kidney is an uncommon congenital fusion anomaly that can make renal tumor surgery especially challenging because of altered rotation, limited mobility, variable vascular supply, and an unpredictable collecting system (1-7). This video presents a robot-assisted partial nephrectomy for a high-complexity renal tumor in this setting. A 33-year-old man, with ECOG 0 and no relevant comorbidities, was diagnosed with a 7.5-cm solid renal mass in the central posterior portion of the left moiety of a horseshoe kidney. The lesion had a RENAL score of 10p. Contrast-enhanced computed tomography and three-dimensional reconstruction were used to understand the relationship between the tumor, aberrant vessels, renal hilum, and collecting system, supporting the decision to attempt nephron-sparing surgery (5, 8). Surgical technique and results: The procedure was performed through a transperitoneal robotic approach with the patient in right lateral decubitus using the Da Vinci Si platform. Port placement followed a standard renal robotic configuration, with a paramedian supraumbilical camera port, three robotic working ports along a craniocaudal lateral axis, a caudal fourth-arm port, and two medial assistant ports for suction, exposure, and support during renorrhaphy. After exposure of the horseshoe kidney and left hilar dissection, two arterial branches and one renal vein were identified. Tumor excision was performed under vascular control, with 20 minutes of warm ischemia and no collecting system opening, followed by two-layer absorbable renorrhaphy with adjunctive hemostatic agents. The operative time was 150 minutes. No transfusion, conversion, drain placement, or relevant immediate complication occurred. The urinary catheter was removed after 24 hours, and the patient was discharged 72 hours after surgery. Pathology showed clear cell renal cell carcinoma, Fuhrman grade 3, pT2N0M0, with negative surgical margins. During 12 months of oncologic follow-up, renal function remained stable and semiannual imaging showed no evidence of recurrence. Contemporary video reports have also emphasized the feasibility of advanced robotic renal surgery and complex partial nephrectomy strategies in selected patients (9, 10). In a carefully selected patient, robot-assisted partial nephrectomy supported by three-dimensional planning was feasible for a complex renal tumor in a horseshoe kidney, with negative surgical margins, preserved renal function, and no recurrence during 12 months of follow-up.

Retrospective analysis of a prospectively maintained multicenter pediatric spine registry. To characterize clinical presentation, revision strategies, bone graft utilization, and short-term outcomes in adolescent idiopathic scoliosis (AIS) patients undergoing revision for pseudoarthrosis. Pseudoarthrosis following posterior spinal fusion (PSF) for AIS is rare but clinically significant, often presenting with pain or implant failure. Contemporary, diagnosis-specific data describing revision strategies and outcomes remain limited. A multicenter registry was queried for AIS patients undergoing PSF with ≥2 years follow-up. Potential pseudoarthrosis cases were identified using complication codes and confirmed through review of radiographs, operative reports, and clinical documentation, defined as failed arthrodesis >6 months post-index fusion, excluding infection. Demographics, revision techniques, graft selection, and outcomes were analyzed descriptively. Among 3,532 eligible AIS patients, 22 had confirmed pseudoarthrosis requiring revision. Median time to revision was 2.5 years. Twelve patients (55%) presented with pain and 10 (45%) were identified radiographically. Implant failure most commonly involved the distal construct (17/22, 77%), with screw loosening in 9 (41%), rod fracture in 7 (32%), and screw breakage in 6 (27%). All revisions were posterior-only; 16 patients (73%) preserved index fusion levels and 5 (23%) required extension for junctional deformity. Revision was tailored to failure patterns, including focal screw revision and rod exchange, with partial rod revision used in 8 of 18 rod failures (44%). Graft use was heterogeneous, most commonly allograft (68%) and local autograft (46%). Post-revision complications occurred in 2 patients (9%), both surgical site infections, with one reoperation (5%). At median 1.2-year follow-up, no recurrent pseudoarthrosis was observed. Pseudoarthrosis after AIS PSF most commonly presents as distal mechanical failure. Posterior-only, failure-pattern-directed revision, typically preserving fusion levels with selective extension for junctional deformity, achieves favorable short-term outcomes. These findings provide multicenter, diagnosis-specific guidance for management of this rare complication. Level IV.

Gene-environment interactions between smoking and HLA genotypes have been reported in multiple sclerosis (MS) susceptibility, although their relevance beyond disease onset remains unclear. To examine whether the effect of smoking on disability progression differs according to HLA-A*02:01 and HLA-DRB1*15:01 status. Patients from two population-based case-control cohorts were classified by smoking status at diagnosis and by HLA-A*02:01 and HLA-DRB1*15:01 status and were followed for up to 15 years through the Swedish MS registry (n = 6807). Cox regression models were used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) for 24-week confirmed disability worsening (CDW) and time to Expanded Disability Status Scale (EDSS) 3, 4, and 6. Interaction was assessed on the additive scale. Compared with HLA-A*02:01-positive non-smokers, smoking at diagnosis was associated with a higher risk of disability progression primarily among individuals who lacked HLA-A*02:01, with consistently elevated risks of CDW (HR = 1.15, 95% CI = 1.06-1.26), EDSS 3 (HR = 1.26, 95% CI = 1.08-1.47), and EDSS 4 (HR = 1.50, 95% CI = 1.25-1.79). No clear effect of smoking was observed among HLA-A*02:01 carriers, and no evidence of interaction was detected between smoking and HLA-DRB1*15:01. These findings suggest that the impact of smoking on MS progression varies according to immunogenetic background.

Guillain-Barré Syndrome (GBS) is a rare autoimmune neurological disorder, mostly associated with preceding gastrointestinal or respiratory infections. Various bacterial and viral pathogens have been associated with GBS; Campylobacter jejuni being a well-established bacterial trigger. A few case reports and an outbreak of GBS wayback in 1976 also indicated an association of Shigella and GBS. Although Shigella primarily causes bacillary dysentery; however, it has been linked with neurological complications, including peripheral neuropathy. Shigella's substantial global burden, high endemicity in low- and middle-income countries (LMICs) with known neuroinvasive potential prompted us to explore its possible role in GBS outbreaks. This perspective discusses the recent GBS outbreak in India, the possible role of Shigella in GBS, and surveillance gaps for GBS in LMICs for rapid diagnosis and treatment.

Hereditary diffuse gastric cancer (HDGC) due to germline CDH1 pathogenic or likely pathogenic (P/LP) variants has traditionally been managed with prophylactic total gastrectomy (PTG), although contemporary data suggest a lower and more heterogeneous cancer risk. Real-world management patterns remain incompletely defined. We conducted a retrospective, single-center cohort study of adult patients with germline CDH1 P/LP variants managed between 2011 and 2024. Patients were categorized as undergoing PTG within 1 year of diagnosis or deferring surgery with endoscopic surveillance (ES). Primary outcomes included the detection of signet ring cell carcinoma (SRCC) and invasive gastric cancer. A total of 27 patients were identified (median age: 48 y; 81.5% female). Eight (29.6%) underwent early PTG, while 18 (66.7%) initially deferred surgery; 1 presented with de novo metastatic gastric cancer. Among PTG patients, 7 of 8 (87.5%) had Tis/T1a SRCC, and none had nodal involvement. Among those deferring PTG, surveillance was heterogeneous: 8 (44.4%) underwent structured ES, 6 (33.3%) had a single endoscopy, and 4 (22.2%) had no surveillance. Within structured ES, 1 patient (12.5%) developed invasive T2 disease, while the others had Tis/T1a SRCC or normal histology. Delayed gastrectomy (27.8%) revealed predominantly T1a SRCC without nodal involvement. Most detected lesions were early-stage and node-negative, and delayed gastrectomy did not appear to compromise pathologic outcomes in selected patients. However, invasive progression during surveillance underscores that ES is not without risk. These findings support a risk-adapted, patient-centered approach to CDH1 management with emphasis on structured surveillance and shared decision-making.

Lymphoedema assessment is central to diagnosis and management, but the optimal method remains uncertain. Tape measurement is widely used, although newer technologies may improve efficiency and patient experience. To compare five assessment methods for diagnostic accuracy, time-efficiency, cost and acceptability. Eighty-four adults with unilateral cancer-related lymphoedema underwent tape measurement, Perometer, L-Dex®, Bodystat Quadscan, and self-report. Analyses included reliability (Cronbach's alpha, Pearson's correlation), diagnostic accuracy and a health economic evaluation. Tape measurement at a 7.5% threshold achieved the highest accuracy (sensitivity 94%, specificity 95%). The Perometer was fastest and most favoured by participants, but was costly. Bio-impedance methods had moderate diagnostic value, particularly for early detection. The tape measure remains the most practical standard tool, while the Perometer offers efficiency and patient appeal where resources permit.

Mesonephric-like carcinosarcoma (MLCS) is an uncommon gynecologic malignancy comprising mesonephric-like adenocarcinomatous (MLA) and high-grade (HG) sarcomatous elements. We describe an endometrial MLCS in a 63-yr-old woman showing divergent p53 immunohistochemical expression, with abnormal expression in the MLA component and normal expression in the sarcomatous component. Dedifferentiated carcinoma and uterine mesenchymal tumors are primary differential diagnoses when sarcomatous elements predominate or exhibit round-cell morphology. A review of 25 endometrial MLCS cases, including ours, showed advanced-stage presentation in 48% (12/25), recurrence in 60% (15/25) and disease-related death in 28% (7/25) of cases, underscoring its aggressive behavior. Heterologous differentiation occurred in 16% of cases but was not essential for diagnosis when unequivocal HG sarcomatous cells were present. Component-specific next-generation sequencing of our case revealed identical KRAS, TP53, and RB1 mutations in both components, with additional PTPRT mutation and KLF5 amplification restricted to the MLA component, representing a novel molecular signature with potential therapeutic implications.

BACKGROUND Dermatomyositis is a rare autoimmune condition characterized primarily by proximal muscle weakness and cutaneous rashes, such as Gottron's papules and heliotrope rash, and is classified as a subtype of idiopathic inflammatory myopathies. While the clinical spectrum of dermatomyositis is broad, its initial onset as fulminant rhabdomyolysis (complicated by acute renal failure) is exceedingly rare. Such atypical presentations necessitate proactive clinical vigilance to ensure a prompt and accurate diagnosis. CASE REPORT Our patient was a 53-year-old woman who presented with progressive proximal muscle weakness, dysphagia, dysphonia, elevated creatinine kinase levels, hyperkalemia, and renal impairment. She was initially treated for rhabdomyolysis; however, due to increasing creatinine kinase levels and renal impairment, she required hemodialysis. During hospitalization she developed characteristic skin manifestations, including heliotrope rash and sleeve sign. Further investigation revealed pancreatic adenocarcinoma of the pancreatic head. CONCLUSIONS This report underscores the diagnostic difficulties in differentiating paraneoplastic-associated dermatomyositis from isolated primary rhabdomyolysis. It emphasizes the imperative of screening for occult malignancies in adult patients presenting with profound muscle necrosis and secondary kidney impairment. Identifying unusual clinical patterns of dermatomyositis early, combined with the rapid initiation of immunosuppressant and rigorous cancer surveillance, is essential for improving prognosis. This becomes paramount in scenarios in which the clinical presentation is suggestive of a paraneoplastic origin, notably pancreatic malignancy.

This study used a novel patient disability assessment, the Mississippi Qualitative Hand Pain Questionnaire (MQHPQ), to compare carpal tunnel syndrome (CTS) with other hand pain diagnoses (non-CTS) and then to the levels of impairment in the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment (ie, AMA Guides). One hundred prospective patients with a chief complaint of hand pain were administered the MQHPQ. Patients were grouped into CTS and non-CTS groups based on diagnosis at the time of their initial visit. Patient-reported disability was then compared with the percentage of total body impairment assigned by the AMA Guides. Patients with CTS (n=47) versus non-CTS (n=53) experienced increased severity (0.64 vs. 0.52, P=0.024) and greater levels of disability in all questioned activities of daily living. According to the AMA Guides, CTS can cause a range of 0% to 9% total body impairment (median 4.5%). Other participant hand pain diagnoses demonstrated total body disability ranging from 0% to 22% (average of medians 4.57%). Although the AMA Guides demonstrates similar percentages of impairment for the CTS group and the non-CTS group, patients with CTS who completed the MQHPQ experienced significantly increased disability in all tested activities of daily living and pain severity.

Catecholamine neurotransmitters and their metabolites are important biomarkers associated with neurodegenerative diseases, yet their accurate discrimination and quantification remain challenging due to structural similarity and complex biological environments. Herein, we report a tri-modal sensing platform based on metal-organic framework (MOF)-derived Co3O4 hollow nanocubes with in situ grown NiMn layered double hydroxide (Co3O4@NiMn-LDH) for the discrimination and quantification of catecholamine-related biomarkers. The oxidase-like performance of Co3O4@NiMn-LDH was significantly enhanced (1.98 U mg-1) through rationally regulation of the thickness of the NiMn-LDH shell. Using o-phenylenediamine (oPD) as the signal-responsive substrate and F-doped SiQDs as a blue-emissive fluorescent probe, the platform enabled colorimetric and ratiometric fluorescence sensing. Owing to their different reducing abilities, catecholamines and their metabolites inhibited oPD oxidation to varying extents, suppressing 2,3-diaminophenazine (DAP) formation and generating distinct absorbance signals. The decreased DAP production reduced fluorescence at 565 nm, while the emission of F-doped SiQDs at 469 nm was restored, yielding a reliable ratiometric fluorescence response. In the electrochemical channel, catecholamine-related compounds generated distinct current responses due to their different electrooxidation activities. Therefore, the tri-modal sensing platform was established for the quantification of epinephrine (EP), dopamine (DA), norepinephrine (NE), vanillylmandelic acid (VMA), and homovanillic acid (HVA) with satisfactory linear responses over a wide concentration range (1-100 μM). Moreover, machine learning-assisted linear discriminant analysis (LDA) enabled effective discrimination of these biomarkers. The tri-modal platform exhibited reliable performance in complex samples, indicating its potential for multimodal analysis of structurally similar neuroactive molecules and neurodegenerative disease diagnosis.

To evaluate the diagnostic accuracy of Luminetics Core, a Food and Drug Administration-cleared artificial intelligence-based screening system, in the detection of diabetic retinopathy (DR) in a predominately non-White population and identify potential shortcomings in clinical implementation that should be addressed to mitigate disparities in health care. Data were acquired via retrospective chart review and included 225 patients with a diagnosis of diabetes mellitus who were screened for DR using the LumineticsCore system (formerly IDx-DR) at the University Medical Center New Orleans (Louisiana). Metrics to assess DR detection efficacy included sensitivity, specificity, positive and negative predictive values, likelihood ratios, and indeterminate screening result rates. Stratified analyses regarding associated medical comorbidities also were performed. Clinic follow-up rates and time frames also were noted per screen result group. The study population had a diverse demographic profile, with 69.0% of subjects identifying as African American, 13.1% Hispanic, 10.7% White, 3.6% Asian, and 3.6% of subjects who either did not identify with the above racial/ethnic groups or declined to self-identify. The system yielded favorable performance measures in the study population regarding detection accuracy. It was found, however, that although most patients with a positive screen had ophthalmology referrals placed, 29.8% of patients with positive screen results did not attend their scheduled ophthalmology visit. The LumineticsCore system was found to be a reliable screening test for the detection of DR in the study population. The relatively high no-show rate for scheduled ophthalmology referrals in patients with positive screen results, however, sheds light on an implementation system issue in need of further evaluation.

The goal of this curriculum was to increase medical students' knowledge of obesity medicine as well as their comfort with and confidence in communication skills related to weight management by using a standardized patient (SP) encounter. We developed and evaluated a two-part weight management curriculum that used a synchronous interactive virtual didactic along with a formative SP session to teach communication skills related to obesity medicine. The didactic reviewed weight stigma and bias, diagnosis, and management of obesity along with foundational skills including how to take a complete weight history and counsel on SMART (specific, measurable, achievable, relevant, and time-bound) goal setting. The following week, each student participated in a 10-minute SP encounter to practice these skills, with 5 minutes of formative feedback. The curriculum was incorporated into the adult outpatient medicine clerkship at a large academic medical center. The historical control group included 32 clerkship students, and the intervention group included 61 clerkship students. We evaluated medical student comfort, confidence, and knowledge with weight management using pre/postsurveys. We evaluated medical student communication skills using an objective structured clinical examination. Comfort with, confidence in, and knowledge of weight management concepts increased after participation in this curriculum. Students who participated in the curriculum performed better on a weight management objective-structured clinical examination, particularly in the areas of obtaining a complete weight history and using shared decision making. This curriculum was effective at increasing medical student comfort with, confidence in, and knowledge of foundational weight management concepts in addition to their skills.

The diagnosis and monitoring of Alzheimer disease (AD) currently rely on clinician-administered, in-person, and cross-sectional pen-and-paper cognitive assessments. While clinically validated, these measures are time-intensive, infrequently administered, and limited in their ability to detect early, subtle, or short-term cognitive changes. Thus, more frequent, ecologically valid assessments are critical to improving sensitivity to early cognitive impairment and disease progression. This study aims to develop and pilot a smartphone-based assessment battery that combines active cognitive assessments with passive smartphone sensor data (eg, steps, sleep) and survey data to identify and longitudinally characterize cognitive impairment associated with AD. We developed a suite of digitized versions of standard cognitive tests alongside novel, game-based cognitive tests within the mindLAMP platform. Uniquely, these tests integrate into the platform's mobile survey and digital phenotyping capabilities to produce a comprehensive assessment tool capable of simultaneously tracking self-reported, behavioral, and cognitive symptoms in real time. These tools were unified within the Smartphone Monitoring Assessment in Real Time-Alzheimer's framework. Across a 6-month pilot study involving individuals with mild cognitive impairment or mild AD, we will examine the feasibility, acceptability, and longitudinal adherence to these assessments. We will compare digital cognitive and passive data streams against standard clinical assessments to evaluate their usefulness in detecting cognitive impairment and change over time. Recruitment began in April of 2025. As of February 2026, 13 participants with mild cognitive impairment or AD (mean age 72.8, SD 6.5 y, 8 male) and 12 controls (mean age 71.6, SD 7.8 y, 6 male) have been enrolled; recruitment is ongoing. Preliminary analyses on participant compliance, passive data, and variations in game scores are in progress. Data analysis is expected to be completed by mid-2026, and we anticipate results to be published in 2027. This study is funded by the a2 Pilot Awards, a subaward of funding given to the Trustees of the University of Pennsylvania under the a2 Collective, beginning in April 2024. Smartphone-based cognitive assessments, when combined with digital phenotyping, offer a scalable and ecologically valid approach to detecting and monitoring AD in real-world settings. This framework has the potential to enhance early detection, enable continuous monitoring, and support future machine learning-based automated identification of cognitive impairment, ultimately facilitating earlier and more personalized care.

Insertion of a compact motif into CARs enables activation-induced receptor shedding, thereby enhancing CAR T cell potency.