Point of care ultrasound (POCUS) has become an invaluable tool in healthcare across multiple disciplines. For the past 30 years, obstetricians and gynecologists in many hospitals have had access to ultrasound equipment and commonly utilize it in labor and delivery suites and emergency rooms for a broad range of conditions. POCUS can be divided into gynecologic and obstetric applications-the latter can be further categorized into fetal POCUS and maternal POCUS. While fetal POCUS primarily assesses the fetus, maternal POCUS is crucial for evaluating conditions that impact a mother's health during pregnancy, intrapartum, and postpartum, such as cardiopulmonary status. The COVID-19 pandemic highlighted the importance of maternal POCUS for timely diagnosis and management, which can ultimately reduce maternal morbidity and mortality. This study aimed to characterize the current use of maternal POCUS, identify barriers to its adoption, and explore opportunities for greater integration into clinical practice nationally among Women's Health (WH) departments within the Veterans Affairs (VA) healthcare system. A prospective observational study was conducted from June 2019 to March 2020 through a web-based survey distributed to all VA medical centers. The survey was first distributed to all chiefs of staff about facility-level POCUS use, training, competency, and policies. A follow-up survey was sent to all WH chiefs to obtain service-level data on diagnostic and procedural POCUS use, training needs, workflows, and equipment availability. Statistical analysis utilized the Chi-squared test to uncover associations between POCUS use and various group characteristics, with a significance threshold of p<0.05. Response rates were 100% among chiefs of staff (n = 130) for the facility-level survey and 77% among WH chiefs (n = 61) for the service-level survey. Diagnostic or procedural POCUS was used by only 30% of all WH groups. The most frequently reported diagnostic applications included assessment of the uterus (23%), ovaries (23%), and intrauterine pregnancy (16%). The most frequently identified procedural application identified was intrauterine device insertion, reported by 23% of the groups. Key barriers to POCUS use included a lack of equipment (56%), lack of trained clinicians (49%), insufficient funding for training (28%), and lack of support staff (26%). While 69% of WH chiefs expressed support for POCUS training, only 23% of chiefs reported having a structured process for obtaining POCUS training for their clinicians. This discrepancy underscores the need for enhanced education and awareness initiatives to align clinician perspectives with the growing benefits of POCUS in clinical practice. This national survey highlighted the low utilization of maternal POCUS among WH clinicians in the VA healthcare system and pointed to critical barriers, including equipment shortages and training gaps. Addressing these barriers through enhanced training, resource allocation, and leadership support is essential to fully leverage the potential benefits of POCUS use in maternal care. Future efforts should focus on evaluating the impact of improved POCUS training and investment in POCUS infrastructure on maternal health outcomes.
Emergency physicians spend hours on the electronic health record (EHR) per shift but only minutes per encounter. Empiric evidence regarding the relationship between EHR time and safety outcomes is scant. To evaluate whether emergency physicians' EHR use was associated with of high-risk unscheduled returns, defined as an emergency department (ED) visit resulting in hospital admission within 72 h of a preceding ED discharge (index visit). Retrospective case-control study of adult patients at 3 EDs in a single health system from March-August 2022 with any of the 10 most common chief complaints. Index ED visits (cases) preceding high-risk unscheduled returns were matched 1:1 to controls without subsequent high-risk unscheduled returns matching on age, sex, acuity score, chief complaint, site, night arrival, and Charlson comorbidity index. Attending physicians' EHR use time was compared between cases and controls using logistic regression adjusted for chief complaint and clustered by physician. Of 13,747 ED visits meeting inclusion criteria, 300 (2.2%) met our case definition; these were matched to 300 controls with similar baseline characteristics. Physicians spent a mean (SD) of 7.16 (5.70) EHR minutes on cases, compared to 8.00 (6.23) min on controls (p = 0.08). Index visit EHR time (in minutes) was not associated with high-risk unscheduled return visits (OR 0.98; 95% CI 0.95-1.00) in adjusted analyzes. Attending physicians' EHR time on index ED visits was not associated with odds of unscheduled return. Future research should further examine the association between EHR use patterns and ED quality and safety, including in high-risk groups.
Is time-lapse monitoring (TLM) with or without a machine learning selection algorithm for embryo selection cost-effective when compared with conventional culture and selection? Neither TLM with or without the use of machine learning for embryo selection is likely to be cost-effective when compared with the conventional approach. TLM adds cost to IVF treatments without improving clinical results. Recent randomized controlled trials (RCTs) provide evidence that TLM is unlikely to increase pregnancy or live birth rates (LBRs) relative to conventional embryo culture and selection. To date no cost-effectiveness analysis of TLM has been published. A cost-effectiveness analysis (CEA) from a healthcare perspective was performed based on data from our multicentre RCT on TLM, which was conducted from 2017 to 2020. Women scheduled for Day 3 single embryo transfer during their first, second, or third oocyte retrieval were included. The trial included three strategies: (i) TLE: embryo selection based on a machine learning algorithm and uninterrupted culture; (ii) TLR: routine morphological embryo selection and uninterrupted culture; and (iii) CON (Control): routine morphological embryo selection and interrupted culture. In total, 1731 couples were included. The difference in mean costs between treatment groups was calculated with the following cost items: laboratory procedures, laboratory facilities (incubator, disposables, service), embryo transfers, pregnancies, miscarriages, and deliveries. We did not consider costs of stimulation, oocyte retrieval, and IVF/ICSI procedures as these were identical in each group. The effectiveness measure for the CEA was the cumulative LBR. Incremental cost-effectiveness ratios were calculated for direct comparisons between strategies. The 12-month cumulative LBR rate was similar in the three treatment groups: TLE 48.7%, TLR 48.4%, CON 48.2%. The mean difference in costs was €237 (95% CI: -35 to 508) between TLE and CON, and €55 (95% CI: -203 to 313) between TLR and CON. The incremental cost-effectiveness ratio between TLE and CON for one additional live born was €45 950; for TLR versus CON, it was €26 905. The probability that TLE or TLR are cost-effective was low for all willingness-to-pay level, with several scenarios resulting in comparable findings. This study reports the cost-effectiveness for one time-lapse incubator; however, more systems are currently available. While our cost-effectiveness analysis provides evidence that TLM is unlikely to be cost-effective, its use is not inferior to conventional methods in terms of clinical results and can offer certain advantages for IVF laboratories. The authors received a grant from the Netherlands Organization for Health Research and Development (ZonMw) for the execution of the SelecTIMO study (Health Care Efficiency Research programme grant 843001602). Merck (Germany and the Netherlands) supplied the six time-lapse incubators, funded the laboratory adjustments, and provided technical support and training to laboratory personnel before and during the study. The following declarations of competing interests are outside the submitted work: J.M.J.S. reports research grants from Ferring BV and Merck BV, speakers' fees from Merck BV and travel support for attending meetings from Merck BV and Goodlife BV. C.B.L. reports speaker's honoraria from Merck and Organon (The Netherlands), travel support from Merck and Organon, and was Editor-in-Chief of Human Reproduction. M.v.W. is Editor-in-Chief of Human Reproduction Update. The remaining authors have no conflicts of interest to declare. NTR5423: ICTRP Search Portal (who.int).
Acute limping in preschool-age children is a common chief complaint in the outpatient orthopaedic clinic. This can be a manifestation of a serious condition (eg, osteomyelitis, septic arthritis) or a benign self-resolving process. The objectives of the study are to describe the epidemiology of limping and determine predictors of children with nonbenign limp etiologies. This is a retrospective electronic health record (EHR) study of children younger than 6 years old presenting to an outpatient orthopaedic clinic with a chief complaint of limp from January 1, 2017 to December 31, 2021. Study subjects were identified from the EHR using natural language processing (NLP) with the term "limp" or its variations. Etiologies of limp were categorized into 3 groups: "benign/self-resolving," receiving "advanced treatment," and "inconclusive." We calculated and compared demographic and clinical characteristics of the subjects. We conducted multivariable logistic regression for the outcome of nonbenign etiologies of limping in preschool-age children, adjusting for demographic and clinical factors, and reported adjusted odds ratios (OR) and 95% CIs. We created 2 models, 1 with and 1 without the inclusion of laboratory results. During the study period, 458 patients presenting with a limp met inclusion criteria. Males comprised 34%; the mean age was 2.9 (SD: 1.3) years. Limp etiologies were categorized as benign 57% (95% CI: 52, 61), advanced treatment 13% (95% CI: 10, 17), and inconclusive 30% (95% CI: 26, 34). In the multivariable model without laboratory results, increased odds of nonbenign diagnosis were associated with each additional day of limping (aOR: 1.09, 95% CI: 1.04, 1.15) and joint edema (aOR: 12.37, 95% CI: 6.24, 24.52). In the model including laboratory results, increased odds of nonbenign diagnosis were associated with joint edema (OR: 10.63, 95% CI: 3.27, 34.51) and a C-reactive protein (CRP) value >0.24 mg/dL (OR: 7.38, 95% CI: 2.37, 22.97). Preschool children commonly present with benign etiologies of limp to the orthopaedic clinic. A nonbenign diagnosis is more likely to be associated with persistent symptoms, joint edema, and elevated CRP. Level II.
R. Xu, F. Feng, X. Yu, Z. Liu, and L. Lao, "LncRNA SNHG4 Promotes Tumour Growth by Sponging miR-224-3p and Predicts Poor Survival and Recurrence in Human Osteosarcoma," Cell Proliferation 51, no. 6 (2018): e12515, https://doi.org/10.1111/cpr.12515. The above article, published online on 28 August 2018 in Wiley Online Library (http://onlinelibrary.wiley.com/), has been retracted by agreement between the journal Editor-in-Chief, Qi Zhou; and John Wiley & Sons Ltd. Concerns were raised by a third party regarding duplicated images in multiple figures. An investigation by the publisher found apparent duplications within Figures 3C and 5B, as well as images reused in or taken from other articles by different authors: 2E in Li et al. 2016 (https://doi.org/10.2147/JPR.S118581) and Guo et al. 2019 (https://doi.org/10.1155/2019/4390839); 5F in Zhang et al. 2018 (https://doi.org/10.1590/1414-431X20187439) and Zhu et al. 2019 (https://doi.org/10.18632/aging.102600); and 5B in Chen et al. 2019 (https://doi.org/10.1177/205873841882074) and Zhang et al. 2019 (https://doi.org/10.1007/s10120-019-01018-7). Due to the extent of these apparent duplications, the editor has lost confidence in the results reported, and therefore the article must be retracted. Corresponding author Lifeng Lao agrees with this decision. The other authors did not respond to the publisher's notice of retraction.
Colonel (Ret.) Richard C. Niemtzow, M.D., Ph.D., M.P.H., transformed the modern perception of acupuncture through his development of Battlefield Acupuncture (BFA) and his visionary leadership as founding Editor-in-Chief of Medical Acupuncture. His work embodied a "logic of simplicity" that joined clinical efficacy, operational practicality, and human compassion. This article reflects on Niemtzow's translational vision-how he bridged Eastern and Western epistemologies, military medicine, and humanitarian service-and offers a personal remembrance of his editorial mentorship and correspondence. His enduring legacy lies not only in a protocol of five auricular points but in a model of clarity, humility, and disciplined compassion that continues to guide acupuncture's integration into contemporary medicine. While mixed randomized evidence invites continued scientific scrutiny, the underlying philosophy of concise, teachable, and field-ready pain relief remains a durable contribution to modern integrative care.
Clinical decision algorithms used by clinicians guide evidence-based decisions and actions. Automated tools can help with the adoption and sustainability of these algorithms, and automation is especially needed in the emergency setting which requires quick decision making in a chaotic environment. This preimplementation study evaluated whether a large language model (LLM) can apply the Pediatric Emergency Care Applied Research Network (PECARN) Head Injury Algorithm safely and accurately on emergency department notes, a preliminary step in the development of a clinical decision support tool for treating pediatric head injuries. We studied the safety and capability of an LLM, Generative Pretrained Transformer (GPT), to apply the PECARN Head Injury Algorithm using notes of patient encounters aged 3 months - 18 years who presented to a pediatric emergency department (ED) with chief complaint of "head injury". A dataset of 24 patients was curated to include a diverse range of symptoms for developing models and a dataset of 122 was randomly selected for testing. We developed and compared four LLM models to extract clinical features from clinical notes. Primary outcomes were safety, measured as negative predictive value (NPV), and accuracy of the LLM models compared to gold standard pediatric emergency medicine (PEM) physicians. Secondary outcomes were the accuracies for the nine features used in the PECARN algorithm. All models demonstrated high NPV comparable to PEM physicians. The GPT model with the highest combination of NPV and accuracy was the prompt-engineered "Optimized Features Model" (NPV = 0.98, accuracy = 0.89), which performed similarly to that of the ED clinicians in both NPV (0.99) and accuracy (0.92). Our LLM-based tool for a clinical decision algorithm demonstrated high accuracy and NPV. While promising, further studies on scalability and feasibility are needed to ensure LLM-based digital health tools encourage safe, effective care for pediatric patients in the ED.
Recently, orthodontic treatment using temporary anchorage devices (TADs) has advanced and developed to correct more severe occlusal and dentofacial discrepancies. The aim of this article is to use an innovative method using TADs for total mandibular arch distalization to establish the functional occlusion after relapse of orthognathic surgery. The patient was a 22-year-old man with a chief complaint of mandibular protrusion at the first visit. The diagnosis was skeletal and dental Class III malocclusion accompanied by retrusive maxilla and protrusive mandible. The crossbite and concave facial profile could be improved with the appropriate amount of mandibular set-back by mean of Le Fort I osteotomy and bilateral sagittal split ramus osteotomy (BSSO). However, occlusal relapse showing negative overjet was found 3 months after surgery. After TADs placed in the ramus, total mandibular arch distalization has started using them. Six months later, appropriate overjet and functional occlusion could be established and gained. Their course has been uneventful for 3 years since then. This retreatment could achieve the efficient results with maintained adjacent teeth positioning with less patient compliance. As a result, the mandibular anterior teeth were retracted about 3.0 mm with lingual inclinations. This technique for relapse in orthognathic surgery is rare in the literatures. Orthodontic treatment using TADs is easy to access and effective approach for the patients with for relapse in orthognathic surgery.
Pain is one of the most common clinical symptoms in pediatric patients with acute lymphoblastic leukemia (ALL). Analgesics may cause side effects that can impact the child's health. Laser acupuncture is a nonpharmacological therapy that can help manage cancer-related pain in pediatric patients. A case study was conducted on a 14-year-old male patient who presented with a chief complaint of pain in both soles of the feet, which had persisted for 3 months prior to hospital admission. The patient had been diagnosed with and was being treated for ALL. The patient developed pain in the soles of his feet after receiving three courses of vincristine-based chemotherapy. Physical examination revealed bilateral pitting edema. Laboratory tests revealed leukocytosis and elevated levels of serum serum glutamate pyruvate transaminase (SGPT). Electromyography with nerve conduction studies revealed signs of lower extremity motor axonal polyneuropathy. The patient underwent daily routine therapy using laser acupuncture with the RJ-laser pen, Nogier frequency E (36.50 Hz), power output of 50 mW, and an energy density of 0.5 Joules/cm2 applied for 20 s at auricular points according to bilateral battlefield acupuncture (BFA), and 2 Joules/cm2 applied for 80 s at LI4, ST36, GB34, SP6, and LR3 points bilaterally. The patient's pain level was assessed using the Numerical Rating Scale (NRS). The patient experienced a reduction in pain after six therapy sessions, as indicated by a decrease in NRS from an initial score of 5 to 1. This case report suggests that laser acupuncture therapy might help reduce some of the neuropathic pain experienced by pediatric patients who are being treated for ALL. Furthermore, research should be done in determining whether laser acupuncture can be more widely recommended as an adjunctive or complementary therapy in these settings.
Pourfour du Petit syndrome (PdPS) is a rare oculosympathetic hyperactivity syndrome characterized by ipsilateral mydriasis, eyelid retraction, and hyperhidrosis. We report a case of a 36-year-old female who presented to the emergency department with a chief complaint of a dilated pupil with photosensitivity and blurred vision in the left eye (OS). On examination, the best corrected visual acuity was 20/20 in both eyes (OU). Anisocoria was observed with the right pupil measuring 4 mm in the dark and 2 mm in the light and the larger left pupil measuring 6 mm in the dark with minimal constriction in the light. There was no relative afferent pupillary defect (RAPD). Magnetic resonance angiography (MRA) and digital subtraction angiogram (DSA) of the head showed a 7 mm left paraclinoid ICA aneurysm. Neurovascular neurosurgery placed a flow diverting stent into the left ICA. Repeat DSA demonstrated near-complete resolution of the left ICA ophthalmic segment aneurysm status post-flow diversion. At the last follow-up one year later, the patient was stable clinically and radiographically with no further recurrences. Clinicians should be aware that anisocoria can be a potentially life-threatening presentation of intracranial vascular lesions.
This article is the 10th of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series. In most cases, these will be research articles that are targeted at the perioperative echocardiographic diagnosis and treatment of patients after cardiothoracic surgery, but in some cases, these articles will target the use of perioperative echocardiography in general.
One hundred and sixty-eight years lie between the first description of mitochondria as "pale roundish granules" and their eventual recognition as the "chief executive organelle" of the cell. Booming mitochondrial research during the last three decades has revealed that being the "powerhouse of the cell" is just one of many fundamental roles mitochondria play for cellular life. Mitochondria are at the crossroads of complex metabolic pathways; they regulate cellular signaling and innate immunity, and they determine whether a cell should divide, differentiate, or die. Human disorders caused by malfunctioning mitochondria have been described starting at the beginning of the 1960s, nowadays, it seems widely accepted that there are hardly any human diseases anymore that are not associated with dysfunctioning mitochondria. Even the process of aging seems to be controlled by this powerful organelle. This review is written for Pharmacologists, Physicians, and Healthcare Providers who are not familiar with mitochondrial biology and with the tremendous insights gained during the last three decades into the vital roles this cell organelle plays for life and death. It is aimed at raising awareness of still underappreciated mitochondrial diseases, which represent the largest group of inborn errors of metabolism.
Hypertension is a major modifiable risk factor for cardiovascular disease. Asymptomatic hypertension is a common presenting chief concern and incidentally noted vital sign abnormality in the emergency department. Elevated blood pressure readings in the ED may be inappropriately attributed to pain, or other factors. Although there are clear dangers of rapidly lowering blood pressure in patients with asymptomatic hypertension, recent literature demonstrates the potential benefits associated with prescriptions for antihypertensive medications at the time of emergency department discharge. This article reviews relevant literature and clinical policy statements regarding diagnosis and treatment of asymptomatic hypertension in the ED and highlights clinically useful information for emergency physicians from recently published guidelines regarding best practices in the care of patients with hypertensive disorders.
Generative artificial intelligence (AI) use has been suggested to have adverse mental health consequences but a causal relationship has not been examined. To simulate a randomised controlled trial of AI use in a work, school or personal context by applying target trial emulation to multiple waves of data from a nationally representative survey. We conducted a target trial emulation using non-probability survey data from three waves of a nationally representative survey conducted between 18 June 2024 and 8 January 2025. Participants aged ≥18 years reported generative AI use frequency at baseline. High-frequency use was defined as multiple times per week or more. The primary outcome was depressive symptom severity measured using the Patient Health Questionnaire 9-item (PHQ-9) at follow-up. Generalised causal forests assessed heterogeneity of treatment effects. Among 19 099 participants assessed at baseline, 2862 (15.0%) reported AI use at least multiple times per week. A subset of 3109 (16.3%) returned for follow-up. In the primary weighted analysis, high-frequency use was not significantly associated with change in PHQ-9 score at follow-up (mean difference -0.18, 95% CI -0.94 to 0.59; p=0.65). Multiple sensitivity analyses using alternate outcome definitions also did not identify significant causal effects. Generalised causal forests yielded no significant evidence of heterogeneity of effect (p=0.81). In an emulated randomised trial among US adults, generative AI use was not associated with subsequent depressive symptoms. This result does not support the premise that AI use causes greater depressive symptoms, although adverse outcomes among vulnerable individuals cannot be excluded. AI use is unlikely to cause increased depressive symptoms among most US adults. Continued monitoring should clarify potential risks among vulnerable populations.
Over 50% of persons with unresectable stage III non-small cell lung cancer (NSCLC) treated with standard-of-care concurrent chemoradiotherapy (CCRT) and durvalumab consolidation progress or die within 18 months. Here adults with untreated, unresectable stage III NSCLC were randomized to nivolumab plus CCRT followed by consolidation with nivolumab plus ipilimumab (arm A) or nivolumab alone (arm B) or CCRT followed by consolidation with durvalumab (arm C). The primary endpoint was progression-free survival (PFS) in arm A versus arm C and secondary endpoints included overall survival (OS), PFS in arm B versus arm C, response rates and safety. At a median follow-up of 30.5 months, there was no statistically significant difference in the primary endpoint of PFS in the nivolumab plus ipilimumab arm versus durvalumab arm (hazard ratio (HR): 0.95, 96% confidence interval (CI): 0.77-1.19; P = 0.65). Descriptive OS analysis showed no improvement (HR: 1.12, 95% CI: 0.87-1.43). Nivolumab alone did not improve PFS or OS versus durvalumab (PFS, HR: 0.84, 95% CI: 0.69-1.04; OS, HR: 0.97, 95% CI: 0.76-1.24). Nivolumab plus ipilimumab and nivolumab alone plus CCRT resulted in increased pneumonitis. These results emphasize the need for novel efficacious treatments for these individuals. (ClinicalTrials.gov: NCT04026412 ).
Aging is accompanied by a progressive decline in skeletal muscle mass and function, culminating in sarcopenia, a major contributor to frailty, disability, and mortality in older adults. While skeletal muscle aging has traditionally been attributed to cell-autonomous and local tissue mechanisms, increasing evidence suggests that systemic, cell non-autonomous processes play a central role in coordinating aging across organs. The brain, particularly the hypothalamus, has emerged as a key regulator of organismal aging, yet its contribution to skeletal muscle aging remains poorly defined. Here, we tested the hypothesis that senescence confined to the brain is sufficient to induce aging-like molecular remodeling in skeletal muscle via systemic mechanisms. To model brain senescence, young mice were subjected to fractionated whole-brain irradiation (WBI), a well-established approach that induces widespread cellular senescence and neuroinflammation in the brain while sparing peripheral tissues. Two months after WBI, transcriptomic profiling of quadriceps muscle was performed and compared with that of naturally aged mice. WBI-induced robust gene expression changes in skeletal muscle that closely mirrored those observed during chronological aging. Pathway-level analyses revealed marked downregulation of mitochondrial organization, respiratory chain assembly, and metabolic processes, alongside enrichment of remodeling- and stress-associated pathways. Upstream regulator analysis identified FOXO1, FOXO3, KLF15, and STAT3, which are key drivers of muscle catabolism and atrophy, as central mediators of the observed transcriptional program. Semantic similarity analysis further demonstrated a high concordance between WBI-induced and aging-associated biological processes. Collectively, these findings demonstrate that brain senescence is sufficient to drive sarcopenia-like transcriptomic remodeling in skeletal muscle, implicating central nervous system aging as an upstream regulator of peripheral muscle decline. This brain-muscle aging axis may contribute to frailty in individuals with accelerated brain aging and in cancer survivors exposed to cranial irradiation, highlighting brain senescence as a potential therapeutic target to mitigate systemic aging and skeletal muscle dysfunction.