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Observational studies consistently link intraoperative hypotension to adverse postoperative outcomes, leading guidelines to recommend maintaining mean arterial pressure (MAP) ≥60-65 mmHg during noncardiac surgery. Whether targeting higher intraoperative blood pressure values improves clinical outcomes remains uncertain. We conducted a PRISMA-guided search on PubMed, Cochrane CENTRAL, Scopus, and Embase from inception to April 2026. Randomized trials comparing higher intraoperative blood pressure targets, either as fixed absolute thresholds or personalized to preoperative baseline, versus routine blood pressure management in adults undergoing elective noncardiac surgery with general anesthesia were included. Outcomes included in-hospital or 30-day mortality, postoperative delirium, acute kidney injury (AKI), 30-day major cardiovascular events (MACE), acute myocardial injury, stroke, length of stay, and intraoperative hypotension. Fifteen trials (15,603 patients) were included. Higher targets did not reduce AKI (RR = 0.95; 95% CI = 0.85 to 1.06; p = 0.36; I² = 16%) or acute myocardial injury (RR = 1.02; 95% CI = 0.94 to 1.12; p = 0.59; I² = 0%) compared with routine targets, with firm evidence from trial sequential analysis (TSA). Higher targets were associated with a significant reduction in postoperative delirium (RR = 0.73; 95% CI = 0.54 to 0.98; p = 0.04; I² = 26%), although TSA indicated the cumulative evidence remained insufficient to draw firm conclusions. No significant effect was observed on in-hospital or 30-day mortality (RR = 1.00; 95% CI = 0.75 to 1.34; p = 1.00; I² = 0%); evidence on 30-day MACE, stroke, and length of stay was similarly insufficient to draw firm conclusions. In adults undergoing elective noncardiac surgery, targeting higher intraoperative blood pressure values does not improve major postoperative outcomes compared with routine management. A potential reduction in postoperative delirium warrants confirmation in adequately powered trials.

Synovial sarcoma is a rare malignant mesenchymal tumor, accounting for 5-10% of soft tissue sarcomas, mainly affecting adolescents and young adults near large joints. Thoracic involvement, particularly in the chest wall, is extremely rare. Diagnosis is difficult due to histologic overlap with other tumors, requiring immunohistochemistry and molecular detection for confirmation. Treatment involves complete surgical excision with adjuvant therapy, guided by a multidisciplinary approach. A 15-year-old Arab male presented with right upper limb numbness, pain, and progressive dyspnea. Physical examination revealed a firm, non-tender supraclavicular mass above the right clavicle, with mild edema of the right upper extremity. Chest radiography showed a right apical opacity with mediastinal shift to the left. Contrast-enhanced computed tomography (CT) demonstrated a large, heterogeneous mass originating from the right upper chest wall, extending into the lower cervical region, displacing the trachea, encasing the subclavian vein, and infiltrating adjacent neural and muscular structures. CT-guided biopsy confirmed a diagnosis of monophasic synovial sarcoma. The patient underwent complete surgical excision with vascular reconstruction, followed by referral for adjuvant oncologic therapy. Primary chest wall synovial sarcoma is a rare and diagnostically challenging tumor. Early recognition, accurate histopathological confirmation, and multidisciplinary management with complete surgical resection are essential to optimize outcomes and reduce the risk of recurrence or metastasis.

Private equity (PE) involvement in healthcare has risen steeply, with a growing investment in healthcare from $5 billion to over $100 billion from 2000 to 2018. The impact of graduate medical education (GME) with PE ownership is unknown. We aimed to characterize the national burden of medical training program closures associated with PE-owned institutions and quantify the scale of trainee displacement across the United States. The Private Equity Hospital Tracker created by the Private Equity Stakeholder Project was utilized to review all PE owned hospitals in the United States. These hospitals were then cross-referenced with the Accreditation Council for Graduate Medical Education (ACGME) records to account for currently functioning residency programs. The Federation of State Medical Boards list of closed residency programs was reviewed to assess for PE ownership. A wide internet search was utilized to review news articles, and hospital websites to assess the number of displaced trainees from hospital closures. Predictive scenario modeling was utilized to estimate physician work force loss. National GME programs. Trainees in GME programs. Of the 6120 hospitals in the US, currently there are 460 (7.5%) hospitals which are owned by a PE firm. Of those, 169 institutions were acute care and critical access hospitals. Sixteen (9.4%) of these institutions were found to have active GME programs. Review of the FSMB Closed Program Registry identified 52 residency or fellowship program closures, of which 19 (36.5%) occurred at hospitals owned or financially managed by PE firms. These accredited programs which were closed due to multitude of reasons, have displaced many trainees from various residency programs. Records on displaced trainees from these closures are unavailable and unknown. Based on available trainee complement data, an estimated 1756 residents and fellows were displaced across these programs. Predictive scenario modeling demonstrates physician work force loss of 0.02-0.21 physicians per 100,000 population. The impact of PE ownership on GME is unknown. Based on our review, there is a need for increased scrutiny and accountability of PE firms impact on GME with the rising predominance of PE owned hospitals and bankruptcies. Further studies are required to assess impact of trainees in PE owned institutions and closures.

In the dual context of global climate governance and supply chain reconfiguration, carbon risk has emerged as a critical element influencing company competitiveness. However, existing research has predominantly focused on the internal economic consequences of carbon risk (e.g., investment, financing, and financial performance) while neglecting its impacts on inter-firm supply chain relationships. Furthermore, empirical evidence on this topic in emerging economies under stringent carbon regulations remains particularly scarce, and the relative importance of different transmission mechanisms has not been quantified. This research empirically investigates the impact and mechanism of carbon risk on corporate supply chain resilience. Using Chinese A-share listed companies between 2012 and 2022, the study finds that carbon risk significantly reduces supply chain resilience.The mechanism analysis shows that the carbon risk undermines the supply chain resilience by raising the environmental uncertainty, degrading the internal controls, and increasing the financial risk. The Karlson-Holm-Breen (KHB) method shows that environmental uncertainty is the main mediating path. The results of the moderation analysis show that information asymmetry and financing constraints exacerbate the negative effect of carbon risk on supply chain resilience, while green innovation effectively mitigates this negative effect.The results of the moderated mediation study suggest that green innovation negatively moderates the positive effect of carbon risk on environmental uncertainty. The moderating effect diminishes nonlinearly as green innovation escalates. Specifically, when green innovation is low, the indirect effect of carbon risk on supply chain resilience through environmental uncertainty is significantly negative; however, when green innovation is high, this indirect effect becomes insignificant. Heterogeneity tests reveal that the negative effects of carbon risk on supply chain resilience are more significant for firms that are non-state-owned, smaller, belong to heavily polluting industries, or have high supply chain concentration.The findings deepen the knowledge of the economic consequences of carbon risk while providing valuable insights for firms optimizing supply chain resource allocation in low-carbon transitions.

We report a case of a 64-year-old woman who had a subcutaneous schwannoma accompanied by hemorrhagic cystic degeneration in the left lower extremity. The patient presented with a progressively enlarging subcutaneous mass over an 8-year course, accompanied by activity-induced dull pain. Physical examination revealed a firm, well-defined nodule measuring 5.0 × 3.5 × 0.5 cm, with a negative Tinel's sign. Ultrasonography initially led to misdiagnosis of the lesion as a hemangioma; histopathological examination following complete surgical excision confirmed schwannoma. Microscopic analysis demonstrated characteristic Antoni A areas (featuring palisading spindle cells and Verocay bodies) and Antoni B (showing myxoid degeneration, cystic changes, and hyalinized vasculature). Subcutaneous schwannomas are prone to misdiagnosis because of the absence of typical imaging features. This imaging limitation necessitates a multidimensional analysis that integrates imaging with clinical manifestationsand histopathological features for accurate identification and differential diagnosis. Complete surgical excision achieved local disease control, and no recurrence was observed during the 4-year follow-up.This case highlights the importance of considering schwannoma in the differential diagnosis of chronic subcutaneous lower extremity masses. Establishing a "clinical-imaging-pathology" tripartite diagnostic framework is critical for early and precise management.Although photodynamic therapy or photodiagnosis was not performed in the present case, accurate recognition of rare superficial tumors with atypical manifestations may support appropriate lesion characterization before selecting diagnostic or therapeutic strategies, including photo-based approaches when clinically applicable.

Masson tumor, also known as intravascular papillary endothelial hyperplasia (IPEH), is a benign reactive proliferation of endothelial cells that may present in various places in the body, most commonly in the head-and-neck region. It is more common in adolescents and adults and rarely presents as a lytic skull lesion in the pediatric population. A 10-year-old right-handed previously healthy male presented with a painless, firm, gradually enlarging swelling over the right frontal scalp for 2 months but was otherwise neurologically intact. Computed tomography scan of the brain showed a lytic lesion in the right frontal bone with an enhancing soft-tissue component and a small dural/extradural extension and with no intracranial abnormality. Differential diagnoses included Langerhans cell histiocytosis (LCH) and, less likely, sarcoma. The patient underwent right frontal craniectomy with complete excision of the lytic lesion and cranioplasty reconstruction. Histopathology revealed papillary endothelial proliferation within a vascular lumen with positive reticulin staining, consistent with IPEH (Masson's tumor), without malignant features. IPEH is a rare benign vascular lesion that may present as an osteolytic skull lesion, even in pediatric patients, and may be radiologically mistaken for more common or aggressive lesions such as osteosarcoma, Ewing's sarcoma, or LCH, requiring histological analysis for confirmation. It should be considered in the differential diagnosis of pediatric lytic skull lesions, and complete gross total resection is typically curative.

Radiomic models for meningioma consistency prediction typically optimise discrimination while remaining opaque: They rarely clarify which features drive predictions, where discriminative patterns arise, or what they correspond to on MRI, limiting clinical interpretability and hindering clinical adoption. We developed an interpretable radiomic framework from preoperative T1-Gd MRI in 42 resected meningiomas (soft n = 16, intermediate n = 13, firm n = 13). Tumours were segmented using a semi-automated workflow, validated against independent neuroradiologist segmentations in 19 cases (Dice 0.84 ± 0.12). From 1409 radiomic features, ICC-stable features (ICC ≥ 0.75) were retained and redundancy removed (|r|> 0.95). Patient-level cross-validation with LASSO-based feature selection and CatBoost was applied. Interpretability was addressed through three components: stable-feature identification (WHICH), SHAP attribution, and voxel-wise local radiomic mapping using an 11 × 11 × 11 sliding window (WHERE), supplemented by a radiomics-to-radiology feature dictionary (WHAT). Three features formed a compact signature: Textural Entropy (wavelet-LLH_glrlm_RunEntropy), Calcification Index (exponential_gldm_LargeDependenceHighGrayLevelEmphasis), and Local Homogeneity (wavelet-LHH_glcm_InverseVariance). CatBoost achieved macro-averaged one-vs-rest AUC 0.87 and accuracy 66.7%; errors were mainly between adjacent classes (fold-averaged off-by-one accuracy 90.3%; aggregate 38/42, 90.5%). Local maps showed spatially heterogeneous texture and focal high-grey-level dependence hotspots in firm tumours, although group-level Calcification Index differences did not survive Bonferroni correction. We present a proof-of-concept interpretable radiomic framework that integrates established explainability techniques-LASSO-based feature stability analysis, SHAP attribution, voxel-wise spatial mapping, and a radiomics-to-radiology dictionary-to link stable radiomic signatures to spatial tumour patterns and recognisable MRI characteristics, offering a potentially extensible approach for other imaging tasks where tissue composition influences clinical decision-making.

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths globally, and cases are predicted to rise dramatically over the next few years. Overcoming the immune microenvironment in HCC remains a challenge, and innate immune populations such as tumour-associated neutrophils can potentially impair the success of immunotherapy. Elucidating the mechanisms of neutrophil recruitment across liver endothelium could lead to new approaches to boost the efficacy of immunotherapy. CLEC14A is an endothelium-specific receptor regulating sprouting angiogenesis, upregulated in low shear environments. We found CLEC14A to be highly expressed in both HCC vessels and on vasculature during acute liver injury, leading us to hypothesise that CLEC14A may regulate neutrophil recruitment to the liver and HCC. We found that CLEC14A positively correlated with a neutrophil signature and infiltration in public datasets and surgically resected tissue from HCC. Spatial transcriptomics (ST) of CLEC14Ahigh- and CLEC14Alow-expressing tumours confirmed upregulation of myeloperoxidase in CLEC14Ahigh tumours and correlation with other shear-dependent markers but a negative correlation with vascular endothelial growth factor A. To build on our correlation studies, we explored the role of CLEC14A in neutrophil recruitment across liver endothelium. We undertook in vitro recruitment studies with flow-based human liver endothelial assays and in vivo models of neutrophil recruitment. Using siRNA knockdown of CLEC14A and specific blocking antibodies to CLEC14A, we found that CLEC14A knockdown blocked the firm adhesion of neutrophils to liver endothelium, but this was independent of its interaction with its known ligand MMRN2. Finally, we confirmed that Clec14a deficiency led to a significant reduction in neutrophil recruitment across the sinusoids in an ischaemia-reperfusion liver injury model. We unveil a link between the angiogenic receptor CLEC14A and neutrophil recruitment. Targeting of CLEC14A on tumour endothelium is potentially a new approach to regulating neutrophil infiltration in HCC. © 2026 The Author(s). The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Against the backdrop of global climate change and China's "Dual Carbon" strategy, the energy sector faces unprecedented pressure to simultaneously pursue digital and green transformation. However, existing literature predominantly examines the impacts of these two transformations on corporate ESG performance in isolation, neglecting their synergistic effects and the underlying transmission mechanisms. This study aims to examine the impact of the coupling coordination between digitalization and greening on the ESG performance of energy enterprises, and to investigate the mediating roles of absorptive capacity, human capital, and investor attention. Using panel data from 1543 firm-year observations of Chinese A-share listed energy companies from 2011 to 2022, we employ a fixed-effects model, mediation analysis framework, and dynamic panel system GMM method. The results indicate that the coupling coordination between digitalization and greening significantly enhances corporate ESG performance, with a one-standard-deviation increase in coordination degree leading to a 0.153 standard deviation improvement in ESG scores. Furthermore, we find that absorptive capacity, human capital upgrading, and investor attention serve as significant parallel mediating mechanisms, accounting for 27.3%, 38.5%, and 16.7% of the total effect respectively. Heterogeneity analysis reveals that the promoting effect is more pronounced in enterprises located in western China and traditional energy firms. Additionally, we demonstrate that improved ESG performance further facilitates total factor productivity, explaining approximately 30.8% of the total effect of coupling coordination on economic efficiency. This study constructs a comprehensive "technology-organization-market" analytical framework, provides theoretical insights and empirical evidence for energy enterprises to achieve synergistic development of digitalization and greening, and offers policy implications for supporting the low-carbon and intelligent transformation of the energy industry.

Salivary gland tumors represent less than 4% of all head and neck tumors, with pleomorphic adenoma (PA) being the most common among them. The palate represents the most frequent site of occurrence. Although typically presenting as a firm and sessile mass, PA may occasionally exhibit unusual clinical or histological features that complicate diagnosis. We describe an unusual case of a 46-year-old woman presenting with a pedunculated PA of the hard palate, exhibiting superficial ulceration and mild pressure induced bone erosion detected radiographically. The lesion was completely excised under local anesthesia. Histopathological examination confirmed the diagnosis of PA with adipocytic metaplasia, an uncommon finding that may mimic malignant transformation. Healing occurred uneventfully and no recurrence was observed after a 12 month follow up. This case highlights the importance of recognizing atypical clinical and histological variants of pleomorphic adenoma and establishing an appropriate differential diagnosis. Accurate diagnosis and optimal management require careful correlation of clinical, radiological, and histopathological findings. Long term follow up remains essential to ensure early detection of potential recurrence or malignant transformation.

Surgery serves as a crucial therapeutic modality for gynecological malignancies, occupying a central role in the multimodal treatment framework for common gynecological cancers including cervical cancer, ovarian cancer, endometrial cancer, and vulvar cancer. Its clinical value extends across the early, middle, and advanced stages of tumors, encompassing multiple therapeutic objectives such as radical resection, cytoreductive therapy, and palliative relief. This video showcases the laparoscopic en bloc excision of enlarged obturator lymph nodes, focusing on key technical strategies for safe and effective dissection in the complex pelvic anatomical region-where close proximity to critical structures like the obturator nerve and iliac blood vessels poses inherent risks. The patient was initially planned for laparoscopic total hysterectomy due to cervical intraepithelial neoplasia grade III (CIN III), with no preoperative imaging or clinical indicators suggesting the need for lymphadenectomy. During the procedure, the surgical team unexpectedly identified enlarged, firm obturator lymph nodes, which postoperative pathological analysis confirmed as metastases from urethral squamous cell carcinoma-a known primary tumor prone to pelvic lymph node spread. The surgical approach prioritized meticulous anatomical landmark identification (including the obturator nerve and vascular bundles), strict adherence to fascial plane boundaries, and combined use of blunt dissection and precise suturing. These techniques minimized the risk of vascular injury and nerve palsy, common complications in pelvic lymphadenectomy. This case underscores the feasibility and safety of laparoscopic management for complex pelvic lymphadenopathy when guided by refined surgical skills, leveraging the technology's high-definition visualization advantage. As a medical educational resource, the video aims to equip surgeons with practical insights to enhance their technical proficiency in dissecting lymph nodes within high-risk anatomical areas, supporting improved intraoperative decision-making and patient outcomes.

BACKGROUND Solitary neurofibromas of the colon are extremely rare and are most often reported in patients with neurofibromatosis type 1 (NF1). Although usually benign, these lesions can rarely undergo malignant transformation, particularly when associated with NF1. Therefore, isolated cases merit careful evaluation and follow-up. CASE REPORT A man in his 70s with a history of benign prostatic hyperplasia presented with recurrent abdominal pain, constipation, and unintentional weight loss of 5 kg over 1 month. Physical examination revealed a firm, non-mobile mass in the right lower quadrant, with no other systemic findings or features suggestive of NF1. Laboratory investigations were within normal limits except for mildly elevated lactate dehydrogenase, while carcinoembryonic antigen was normal. Computed tomography and magnetic resonance imaging demonstrated a cystic lesion arising at the base of the appendix and protruding into the cecum. Colonoscopy revealed a large, smooth polypoid mass, and biopsy showed a spindle-cell lesion of neurogenic origin. The patient underwent an open right hemicolectomy with primary ileocolic anastomosis, due to persistent symptoms and concern for potential complications. Final histopathology confirmed a benign isolated colonic neurofibroma with negative resection margins and a reactive mesocolic lymph node, with no evidence of malignancy. The postoperative course was uneventful. The patient remained asymptomatic, with no recurrence during more than 3 years of follow-up. CONCLUSIONS This case highlights that isolated colonic neurofibroma should be included in the differential diagnosis of nonspecific or submucosal colonic masses. Long-term follow-up is important to monitor for local recurrence, possible malignant transformation, and the later appearance of NF1 features.

Glomus tumors are rare mesenchymal tumors that typically occur in the extremities, particularly the intravascular subtype. We present a case report of a 28-year-old male with a painless firm nodule on the left cheek. High-frequency ultrasound (HFUS) revealed a mass within a superficial vein of the left cheek, characterized by well-defined margins, a regular shape, heterogeneous echogenicity, and relatively rich internal vascularity. These ultrasound features were highly similar to the typical imaging of intravascular papillary endothelial hyperplasia, leading to initial misdiagnosis. Following clinical evaluation and per the patient's request for definitive treatment, surgical resection was performed. Histopathological and immunohistochemical analysis confirmed the diagnosis of a glomus tumor originating from a facial superficial vein. In conclusion, this rare superficial venous glomus tumor presented with atypical clinical and imaging features, notably the absence of typical pain and distinct differences from the imaging characteristics of extremity glomus tumors. This case report aims to improve the recognition of such lesions and prevent misdiagnosis between intravascular papillary endothelial hyperplasia and facial superficial venous glomus tumors.

By exploiting the panel data of 100 countries over the period 2006 to 2022, I show how climate change policies and green growth within a circular economy affect entrepreneurship. Higher energy intensity predicts a lower rate of new firm creation. In contrast, higher green growth correlates with a higher number of new businesses. The interaction between energy intensity and green growth indicates that environmental support can partially offset the adverse effects of energy-intensive economic structures. Using genetic distance to the United Kingdom as an instrumental variable, I establish a causal relationship. In particular, the findings suggest that well-designed environmental policies can act as a catalyst for new firm formation, especially in circular economies facing structural and developmental constraints.

Congenital hepatoblastoma (CHB) is a rare liver malignancy in infants that is diagnosed either in utero or during the first month of life. This tumor typically demonstrates rapid progression in its early stages. Early detection and prompt intervention are critical for optimal outcomes. We describe a 10-day-old Arab female neonate who presented with a firm, well-defined abdominal mass in the right upper quadrant, extending slightly across the midline to the left iliac fossa. Laboratory evaluation revealed a markedly elevated alpha-fetoprotein (AFP) level of 663,600 ng/mL, along with leukocytosis, thrombocytosis, and mild anemia. Imaging studies demonstrated a 7 × 7 cm liver tumor involving segments VI and VII, with arterial enhancement, necrotic areas, and intrahepatic biliary duct dilatation, but without evidence of metastasis. Fine needle aspiration confirmed fetal/embryonal-type hepatoblastoma. PRETEXT staging classified the lesion as PRETEXT I, indicating very low risk. The infant received nine cycles of neoadjuvant cisplatin-based chemotherapy, which resulted in significant tumor reduction and facilitated complete surgical resection. Postoperative recovery was uncomplicated. This case illustrates the importance of prompt diagnosis and multidisciplinary management of CHB using combined chemotherapy and surgery. Notably, even in the absence of classic risk factors or syndromic associations in neonates, an abdominal mass warrants thorough investigation. At 18 months of follow-up, the patient demonstrates normal growth and development with no evidence of tumor recurrence and AFP levels within normal range, indicating sustained remission.

Fibromatosis-like metaplastic carcinoma (FLMC) of breast is a rare neoplasm that exhibits distinct low-grade cytomorphology, a tendency for local recurrence and a favorable prognosis. This retrospective study aimed to evaluate the clinicopathological and immunohistochemical features of FLMC and assess its clinical behavior. Six female patients with histologically confirmed FLMC were included. Hematoxylin and eosin-stained slides were reviewed, and immunohistochemistry for keratin AE1/AE3, keratin CAM5.2, keratin 5/6, p63, EMA, ACTA1, desmin, and CD34 was performed. The mean age was 57.3 years, and all patients presented with a painless breast mass. Tumors were firm, unencapsulated, and averaged 4.9 cm in size on gross examination. Microscopically, they showed bland spindle cells in fascicular and storiform patterns with infiltrative borders. All tumors were positive for keratin AE1/AE3, keratin CAM5.2, and p63. EMA was positive in 1/3 tumors, keratin 5/6 in 3/3, ACTA1 in 2/3. All tumors were negative for desmin and CD34. No nodal metastasis was identified. On follow-up, one patient developed bone metastasis after 2 years, while the others remained disease-free 3 years post-surgery. FLMC is a rare low-grade epithelial malignancy that can mimic benign spindle cell lesions, making immunohistochemistry essential for diagnosis. Complete surgical excision with clear margins is curative in most patients.