General journals

The UK’s statistics watchdog has warned NHS England and the Department of Health and Social Care over their claims about the benefits of Palantir’s federated data platform (FDP).1The Office for Statistical Regulation (OSR) examined how NHSE was using statistics to support claims about the success of the FDP, after several members of the public contacted the watchdog to express concern about how data were being presented.It identified that statistical teams at NHS England did not clear the FDP statistical data for public use before it was published. The watchdog recommended that these statistical teams should have a bigger role in overseeing claims made about the benefits of the platform.It also advised NHSE and ministers that all communications about Palantir’s software that include before-and-after data comparisons must be “clearly and appropriately labelled” and that any figures cited about its effectiveness “are communicated in a clear, accurate manner.”Members of the public expressed... [...]

Thick smoke from Canadian wildfires has blanketed Toronto, Detroit, Minneapolis, Chicago, New York, and Washington, DC, in July. At points, Detroit, Toronto, and other North American cities ranked among the worst in the world for air quality.1In several cities, monitors recorded fine particle pollution at or above levels the US Environmental Protection Agency (EPA) classifies as “hazardous” on its air quality index.2 EPA’s updated particulate matter of 2.5 μm diameter or smaller (PM2.5) breakpoints put the hazardous category at 225.5 µg/m3 and above. During July, Reuters reported hazardous readings in Minneapolis, Milwaukee, and Toronto, while state and local monitors recorded PM2.5 concentrations above 600 µg/m3 in parts of Minnesota and Wisconsin.3Some US politicians took to social media, blaming Canada as summer activities were curtailed and residents were warned to stay indoors. And in a reversal, wildfires in the US west are now sending smoke north across the border into British... [...]

NHS England’s announcement of an accelerated rollout of AI1 promises a beguiling future of shorter waiting times and better care for millions of patients. With a £10bn investment over three years, this is a major programme intended to deliver around half of the commitments in the 10 year plan and to generate £41bn in total benefits. Much of the gain is expected to be delivered through a new AI triage tool on the NHS app and through AI tools based on ambient voice technology.When taxpayers’ money is committed on this scale, decisions should be made transparently and based on evidence. For new medicines, we have machinery to do exactly that: regulatory approval, health technology assessment through the National Institute for Health and Care Excellence (NICE), the expectation of randomised trial evidence before widespread adoption, and a clear separation of private and public interests. For digital technology and AI, the evidential... [...]

An expensive and recently banned neck operation for Alzheimer’s disease spread rapidly through China and is now being tested in the US and other countries, despite a lack of randomised evidence to demonstrate its efficacy.Qingping Xie, a microsurgeon and president at Hangzhou Qiushi Hospital in the city of Hangzhou, China, performed the first ever deep cervical lymphatic-venous anastomosis (dcLVA) on a patient with Alzheimer’s disease six years ago after receiving ethical approval from his hospital for the highly experimental procedure. The procedure became popular1 in China and was featured in articles published in Science in 20252 and in Nature in 2026.3But the rapid expansion of the procedure ignited criticism about its lack of standardisation, high price, and potential complications,4 as well as the ethics5 of performing experimental surgery on such vulnerable patients. It was banned6 by Chinese authorities in July 2025 because of a lack of robust clinical evidence to... [...]

Medical students face official accusations of “unprofessionalism” to manage dissent or in retaliation for providing feedback about their education, a report warns.Students shared how they had been reported as being unprofessional for going home while sick, while others faced similar sanctions for legitimate complaints about their placement.These experiences were detailed in a report by the BMA, with the union warning that the practice left students afraid to raise concerns, including on patient safety, as doing so could harm their future careers.1This increasingly “punitive” and inconsistent enforcement of professionalism standards in UK medical schools is having a silencing effect across medical education and damaging trust in university leadership, the BMA warned.The report drew on survey data from 2573 UK medical students and data gathered from freedom of information (FoI) requests to medical schools.Nearly half (45%) of the students surveyed said they would feel uncomfortable raising concerns within their medical school, while... [...]

The Edinburgh Medical School, the first in the English-speaking world, was founded 300 years ago. Its prehistory included the establishment of several important institutions:a College of Surgeons in 1505;the University of Edinburgh in 1582;a physic garden in 1670;a College of Physicians in 1680;In the 1680s the Edinburgh physicians began work on the Pharmacopoeia Edinburgensis, which was finally published in 1699, and from 1685 onwards many university professorial appointments were made in subjects such as physic, anatomy, chemistry, and the institutes and practice of medicine. Although not associated with chairs in the first instance, materia medica and botany were also being taught. Then, in 1726, following a petition presented to the Edinburgh Town Council by four physicians, a Faculty of Medicine was established. This was followed three years later by the foundation of a teaching hospital, completing all the requirements for a fully functioning medical school. The school was successful in... [...]

We agree with Vogel that there is an abundance of unhealthy foods in many settings and that obesogenic environments are contributing to the obesity epidemic.1 The Institute of Health Promotion and Education and others have repeatedly called for a clear and consistent approach to food labelling to help increase awareness about the options on offer.234The UK has considerable variations in environment, and certain population groups are more at risk of becoming obese. There is strong evidence, for example, of increased incidence of obesity in families living in areas of deprivation.5 Even if we did have accurate and easy to read information on all foods, there are certain groups that may have limited choices.6Obesity is a complex issue that requires a range of coordinated actions, including providing healthy options in schools, hospitals, and other settings; limiting the clustering of fast food outlets; fiscal measures; tackling advertising and misinformation; provision of effective... [...]

A new report by the Health Foundation estimates that restoring population health to the level of 2014 would not only improve people’s health and wellbeing but also produce an economic benefit of £72bn (doi:10.1136/bmj-2026-100335).1 In summary, the calculation is built on one fact and one assumption. The fact is that population health has deteriorated since 2014: the UK now has 15.7 million working age adults with a long term health condition, up from 11.7 million in 2014. The assumption is that reducing the number of working age adults with long term conditions unlocks economic benefits through improved economic output, additional tax revenues, and reduced welfare spending. This is only the latest in a long line of credible reports to demonstrate the economic upside of investing in health. The UK’s new prime minister, Andy Burnham, should take note.There’s no reason to think that the level of long term health conditions in... [...]

AbstractObjectiveTo estimate the minimal detectable change (MDC) for the Patient Health Questionnaire-9 (PHQ-9) and its eight item (PHQ-8) and two item (PHQ-2) versions including differences by participant and study characteristics.DesignIndividual participant data meta-analysis.Data sourcesMedline, Medline In-Process and other non-indexed citations, PsycInfo, and Web of Science, 1 January 2000 to 9 May 2018.Eligibility criteria for selecting studiesDatasets from articles in any language if participants were aged ≥18 years, were recruited from any non-psychiatric setting, and were not recruited because they were seeking mental healthcare. Eligible datasets had a classification for major depressive disorder or major depressive episode based on a validated semi-structured or fully structured interview conducted within two weeks of administering the PHQ-9, PHQ-8, or PHQ-2.ResultsPooled MDCs across studies were estimated for the PHQ-9, PHQ-8, and PHQ-2 with random effects meta-analysis for 95% (MDC95), 90% (MDC90), and 67% (MDC67) confidence that change beyond measurement error occurred. PHQ-9, PHQ-8, and PHQ-2 analyses included 42 548 participants (94 studies), 42 592 participants (94 studies), and 44 085 participants (98 studies), respectively. Mean participant age was 49 years (standard deviation 17), and 60% of participants were women. Overall, 10% of participants had major depression (range 1-57% across studies). MDC95 was 5.72 points (95% confidence interval (CI) 5.54 to 5.90, 95% prediction interval (PI) 4.00 to 7.44) for the PHQ-9, 5.51 points (95% CI 5.33 to 5.68, 95% PI 3.87 to 7.15) for the PHQ-8, and 2.26 points (95% CI 2.15 to 2.37, 95% PI 1.20 to 3.32) for the PHQ-2. For the PHQ-9, MDC95 was highest in inpatient healthcare settings at 6.48 (95% CI 6.05 to 6.92) points. MDC95 for the PHQ-9 increased by 0.40 (95% CI 0.25 to 0.55) points for each 10% increase in the proportion of participants with major depression. Sex and age had minimal or no association. Subgroup and meta-regression findings were similar for the PHQ-8 and PHQ-2.ConclusionsBased on the pooled estimate, a six point difference on the PHQ-9, the PHQ version most used in clinical practice, could be an appropriate MDC threshold in general practice. A higher threshold may be preferred in specialty mental healthcare. MDC67 or MDC90 thresholds would provide less certainty that change has occurred. Alternative strategies, such as using the upper end of a prediction interval, would provide more certainty but a greater likelihood of not recognising change.Study registrationPROSPERO CRD42014010673. [...]

Growing awareness of online misogyny has converged with an explosion of AI driven digital violence against women. Over 11 days between December 2025 and January 2026, the AI tool Grok, developed by X, is estimated to have generated some three million sexualised images of women and girls, including more than 23 000 depicting children. At its peak, Grok was producing around one sexualised image of a child every 41 seconds.1 This marks a deeply worrying new phase of digital violence against women and children, in which abusive images can be generated by almost anyone and shared rapidly and widely. AI has expanded what was previously an episodic form of sexual abuse into mass, industrialised victimisation, with serious implications for public health.Image based sexual abuse is still widely described as “revenge porn,” but this term is misleading as it assumes a relationship, a retaliatory motive, and prior consensual participation in creating... [...]

Polypills and heart failureCritics argue that limited dosing options for polypills mean patients get suboptimal care, whereas polypill advocates counter that polypills are a more feasible option: most patients—especially those with socio-economic barriers to care—don’t get close to receiving guideline directed therapy. An open label trial compared a polypill containing metoprolol succinate (dosing options: 25/50/100/150 mg), spironolactone 12.5 mg and empagliflozin 10 mg with enhanced usual care in people with symptomatic heart failure with a left ventricular ejection fraction (LVEF) [...]

Two new pressurised metered dose inhalers (pMDIs) with lower carbon emissions have been approved by the UK’s drug regulator in a world first.1The inhalers aim to reduce the devices’ environmental impact without affecting the treatment.Such pMDIs are the most commonly used inhalers in the UK, accounting for around 70% of the 60 million devices prescribed each year. But they also account for around 3% of the NHS’ greenhouse gas emissions—the largest single contributor of all medications.The Medicines and Healthcare Products Regulatory Agency (MHRA) has approved new versions of drug company Chiesi’s Clenil Modulite 100 μg inhaler and Clenil Modulite 200 μg inhaler.The updated versions still include beclometasone dipropionate but use a new propellant, HFA-152a, to deliver the inhaled dose rather than the previously used HFC-134a.Chiesi said the new propellant could cut the carbon footprint of these beclometasone products “by up to 90% versus that of the current propellant.”The new inhalers... [...]

This Medical News article discusses a request from the US Department of Health and Human Services to update testosterone therapy product labels following evolving scientific evidence of their safety. [...]

This Medical News article discusses a new study that adds to existing evidence that acetaminophen use during pregnancy does not appear to cause autism or ADHD. [...]

This narrative review discusses the epidemiology, diagnosis, and treatment of alcohol-related liver disease. [...]

This Viewpoint discusses the expansion of blood-based biomarker testing for Alzheimer disease and outlines patient-physician communication strategies for end-of-life questions and physician-assisted death. [...]

The approval of additional respiratory biologics for asthma was associated with a significant decline in exacerbations, a study published in JAMA Network Open found. [...]

Listen to the JAMA Editor’s Summary for an overview and discussion of the important articles appearing in JAMA. [...]

To the Editor A recent randomized clinical trial reported that a web-based decision-support tool for antidepressant selection in patients with major depressive disorder was associated with lower all-cause discontinuation of antidepressants at 8 weeks compared with usual care. [...]

In Reply We thank Drs Parikh and Elwyn for their interest in our article that showed that using an evidence-based decision-support system (the PETRUSHKA tool), compared with usual care, may help more patients continue antidepressant treatment and reduce depressive and anxiety symptoms. Parikh and Elwyn raise interesting points that we believe deserve some contextualization. [...]

To the Editor We are writing in response to the Perspective article “A Call for Education Leadership in Accreditation Reform” to applaud some aspects of the article, provide relevant clarifications, and ensure awareness of work that is underway in graduate medical education (GME) following prior calls to action. [...]

To the Editor Dr Stern and colleagues argued persuasively for a transition toward outcomes-based accreditation and reaffirmed the importance of external validation in maintaining the profession’s social contract with society. Their call for reform is timely. However, several dimensions of the physician training and regulatory ecosystem warrant further consideration. [...]

In Reply We appreciate Drs Weinstein and Thibault’s and Dr Rajput’s thoughtful responses and agree that reform of accreditation focusing on outcomes and stewarded by physicians and educators must be part of the task of accrediting organizations at this time. The focus on GME raised by Weinstein and Thibault further articulates the ongoing silos and differences between GME and undergraduate medical education, particularly noting the various regulatory bodies, privacy, and data-definition challenges that impede meaningful data sharing. We strongly agree that these obstacles must be overcome in the current environment and should be prioritized. Rajput appropriately notes that accreditation (for institutions) and licensing and certification (for individuals) must be considered within the full complexity of the physician workforce and the current siloed approach to oversight. [...]

The US Food and Drug Administration (FDA) approved the first generic single-dose treatment for influenza. [...]

Richard Horton's Offline1 on the ten lessons for reproductive, maternal, newborn, child, and adolescent health is well judged, but misses the political economy trap that chronic resource scarcity itself creates and sustains. [...]

We commend the Lancet Editorial1 for highlighting the transformative potential of the UK Tobacco and Vapes Bill, which marks a historic moment in tobacco control. By introducing a generational prohibition on tobacco sales to individuals born after 2008, the UK has moved beyond incremental regulation towards a true tobacco endgame strategy focused on preventing smoking initiation. Once implemented, the strategy will likely become one of the most consequential tobacco control interventions of the modern era. [...]

Solja T Nyberg and colleagues1 report a consistent dose–response association between adult obesity and severe infections across Finnish cohorts and UK Biobank, and estimate that worldwide 8·6% (95% CI 6·6–11·1) of infection-related deaths in 2018, 15·0% (12·8–17·4) in 2021, and 10·8% (8·6–13·6) in 2023 might be attributable to obesity. These estimates are important for prevention policy; however, their interpretation depends on modelling choices and assumptions. [...]

Ayoub Boulares and Nicola Luigi Bragazzi raise four important methodological considerations regarding the association between adult obesity and severe infection risk reported in our study.1 Given the potential public health implications of our findings, we welcome the opportunity to clarify and provide additional context. [...]

We read with interest the Article1 by Alana C Desai and colleagues on the results of the well designed, large-scale Prevention of Urinary Stones with Hydration (PUSH) trial, which evaluated a multicomponent intervention to improve fluid intake and idiopathic urinary stone recurrence in adolescents and adults. Both the Article and the related Comment2 concluded that increasing daily urinary volume failed to reduce stone recurrence; therefore, alternative prevention strategies beyond solely increasing fluid intake should be sought. [...]

We read with interest the Correspondence from Alba Martina Renzullo and Simone Benvenuto regarding results of the Prevention of Urinary Stones with Hydration (PUSH) trial,1 and share their goal of avoiding potentially harmful interpretation of the results. Findings from the PUSH trial should not undermine the clinical aim of high fluid intake for stone prevention stipulated by current guidelines and supported by one prospective trial.2 Rather, the appropriate conclusion from PUSH is that individuals often struggle to reach the target urine output of 2·5 L per day, despite state-of-the-art adherence support (ie, an evidence-based multicomponent behavioural intervention). [...]

During clinical work and research, we ask about the intricacies of the lives of others, narratives which they have often not shared with friends, colleagues, and neighbours. We ask not out of curiosity but to work towards tangible benefits, whether for the patient directly or for others in future. I reflected on my working-class background in The Lancet's Wakley Prize Essay.1 I emphasised how my experiences shaped my work, through giving me an authentic understanding of patients from a similar socioeconomically disadvantaged background, clinically and in my research. [...]

The TORPEdO trial1 represents a landmark contribution to oropharyngeal cancer management, demonstrating similar late quality-of-life outcomes between intensity-modulated proton therapy (IMPT) and intensity-modulated radiotherapy (IMRT). However, as head and neck surgeons involved in the salvage of recurrent disease, we wish to draw attention to a signal deserving closer scrutiny. [...]

We thank Pietro De Luca and colleagues for their thoughtful letter and agree that surgical salvage after intensity-modulated proton therapy (IMPT) is an important and underexplored question. [...]

We read with interest the Article1 by Claudia Allemani and colleagues, which provides a landmark contribution to global cancer surveillance. Nevertheless, we have concerns regarding the representativeness of the Cancer Survival Index reported for Colombia: 72·7% for all cancers and 81·2% for the six WHO tracer cancers. [...]

We welcome the comments from Oscar Ramirez and colleagues, regarding the hospital-based surveillance system (VIGICANCER1) that includes 55–60% of Colombian children diagnosed with cancer. As VIGICANCER is not a population-based cancer registry (PBCR), it was not invited to contribute data to the CONCORD programme for the global surveillance of cancer survival. CONCORD-4 included data on 2725 children diagnosed with cancer during 2000–22 from four established PBCRs (Bucaramanga, Cali, Manizales, and Pasto), which covered about 8% of the national population of children in 2015. [...]

Improving outcomes for people with rare diseases is a major challenge, but it is possible. Amyloidosis is a heterogeneous group of rare disorders in which amyloid (misfolded protein deposits) accumulates in the tissues, causing progressive organ failure. Until recently, it was a rapidly fatal disease with few therapeutic options. However, as detailed in a Review in this issue, several new treatments have been approved since 2018, and for people with some subtypes estimated 10-year survival has increased from about 5% to 20%. [...]

Abstract Introduction Out-of-hospital cardiac arrest (OHCA) is a major health concern. Roughly 300,000 cases occur annually in Europe; overall survival is 11%. Given the disease burden and increasingly extreme temperatures due to climate change, we investigated the association between air temperature and risk of OHCA in Sweden. Methods This study employed a time-stratified case-crossover design to examine the relationship between daily mean air temperature and OHCA cases from the Swedish Registry for Cardiopulmonary Resuscitation between 2010 and 2019. Using a machine learning model, mean temperatures were estimated on a 1 × 1 km2 grid and converted into location-specific percentiles for Sweden's 290 municipalities. The relationship between temperature and OHCA was estimated using conditional logistic regression. Results 29,604 OHCA cases (32% women, median age 74 years) were included. The 1st percentile of temperature ranged from −32.7 to −5.98°C; the 99th percentile ranged from 16.6 to 22.8°C. The reference point, where OHCA risk was lowest, was the 86th percentile. The odds ratio (OR) of OHCA comparing 1st percentile of temperature with the 86th was 1.197 (95% confidence interval [CI] 1.066–1.344), and the OR of OHCA comparing the 99th versus 86th percentile was 1.156 (95% CI 1.058–1.263). Conclusions Location-specific extreme ambient air temperatures were associated with greater risk of OHCA in Sweden. This further adds to evidence suggesting that exposure to locally relative temperature extremes may increase risk of OHCA, even when temperatures do not represent extreme temperature events by absolute metrics. These results may be limited by potential discordance between ambient temperature and individual temperature exposure. [...]

Journal of Internal Medicine, Volume 300, Issue 3, Page 218-219, September 2026. [...]

Journal of Internal Medicine, Volume 300, Issue 3, Page 217-217, September 2026. [...]

  Abstract Background Postural orthostatic tachycardia syndrome (POTS) is a chronic form of orthostatic intolerance that primarily affects female patients. There are scarce data evaluating the long-term outcomes in POTS. Objectives This study sought to evaluate the long-term impacts of POTS over multiple decades in adult patients. Methods Past research participants at the VUMC Autonomic Dysfunction Center Research Unit (symptomatic ≥10 years) were recruited to participate in the study. A custom survey was administered at one time point. Participants were grouped as IMPROVED or NOT IMPROVED based on symptom course over time. Continuous data are reported as median (25th, 75th). Results Patients with POTS (n = 44; 98% female) were included in the analysis (62% response rate). Patient age at the time of survey was 48 (38, 54) years, with 23 (15, 27) years from POTS symptom onset, and 17 (12, 24) years from POTS diagnosis. Since diagnosis, symptoms completely resolved in 2%, improved in 46%, worsened in 25%, were unchanged in 11%, and demonstrated a variable symptom course in 16%. Patients who were NOT IMPROVED were more likely than those IMPROVED to have neuropathy, gastroparesis, and overactive bladder symptoms. Conclusions In a cohort of adult patients with POTS who received care at a national referral center for autonomic disorders, almost half reported their POTS symptoms as improved 10 or more years after symptom onset. Most patients with POTS experienced ongoing symptoms for many years after diagnosis. [...]

Journal of Internal Medicine, EarlyView. [...]

Abstract Background Although systemic lupus erythematosus (SLE) pregnancy frequently results in small for gestational age (SGA) infants, the understanding of underlying mechanisms is limited. We aimed to identify specific histological patterns of placental injury in SGA in SLE and to explore whether an altered balance of angiogenesis-related proteins precedes this outcome. Methods We prospectively followed 83 SLE and 67 control pregnancies. Placental histological patterns were determined according to the Amsterdam consensus in 63 women with SLE (76%), of whom 10 developed SGA. Soluble fms-like tyrosine kinase 1 (sFlt-1) and placental growth factor (PlGF) in plasma were quantified using LEGENDplex in the first, second and third trimesters. Results SLE patients remain at risk of having an SGA infant, and their placentas and infants had lower weight compared to controls. In placentas from women with SLE and SGA, maternal vascular malperfusion lesions were common (80% vs. 30% in controls; p = 0.010), but inflammatory lesions were not observed. Women with maternal vascular malperfusion gave birth to infants with lower birth weight compared to women without these lesions. The ratio of sFlt-1:PlGF in the third trimester was elevated in women with SLE with an SGA infant. Conclusion In a prospective cohort of well-controlled SLE patients with low disease activity delivering mostly at term, SGA and small placentas remain common. The increased prevalence of placental malperfusion lesions together with an altered balance of pro- and anti-angiogenic proteins suggests that the role of vascular and angiogenesis-related factors should be further explored in relation to SGA in SLE pregnancy. [...]

Abstract Objective Chronic insomnia disorder is common and burdensome, and current treatments remain limited. We conducted a multicenter, randomized, double-blind, placebo-controlled trial to determine whether a fecal microbiota transplantation (FMT)-based treatment protocol improves sleep outcomes in adults with chronic insomnia disorder. Methods Participants were randomly assigned 1:1 to receive short-course antibiotic pretreatment followed by donor microbiota capsules (n = 40) or placebo capsules without antibiotic pretreatment (n = 40). Within each group, participants were further randomized to receive synbiotic supplementation or matched placebo for prespecified exploratory subgroup analyses. The primary outcome was polysomnography-measured sleep efficiency (SE) at 1 month after treatment. Secondary outcomes included other polysomnographic parameters, patient-reported sleep outcomes, and safety; microbiota analyses were exploratory. Results Compared with placebo, the FMT-based treatment protocol improved SE (adjusted between-group difference, 13.9 percentage points; 95% CI 7.29–20.41; p = 0.003) and reduced wake after sleep onset. Synbiotic assignment did not suggest meaningful differences in SE. Insomnia Severity Index and Pittsburgh Sleep Quality Index scores showed sustained improvement from 2 to 6 months. Treatment was well tolerated, with mild, self-limited adverse events and no serious adverse events. The intervention increased microbial richness and diversity and altered community structure; responders and non-responders showed similar posttreatment β-diversity change but differed in baseline microbiota composition. Conclusion In adults with chronic insomnia disorder, an FMT-based treatment protocol incorporating antibiotic pretreatment improved objective sleep continuity and sustained subjective insomnia outcomes. Baseline microbial composition may contribute to treatment heterogeneity and merits further investigation. [...]

Journal of Internal Medicine, EarlyView. [...]

Abstract Multiple sclerosis has undergone a therapeutic revolution over the past three decades. Randomized clinical trials and real-world data demonstrate that modern disease-modifying therapies substantially reduce relapse rates and acute inflammatory activity detected by magnetic resonance imaging (MRI). However, disability accumulation increasingly occurs independent of relapse activity, highlighting progression biology as the principal unmet need. Converging epidemiological and molecular evidence supports a pivotal role for Epstein–Barr virus (EBV) infection in disease initiation, whereas later stages appear dominated by brain-intrinsic mechanisms, including compartmentalized inflammation, microglial activation, failure of remyelination and accelerated biological ageing. Population-based cohorts demonstrate that early high-efficacy therapy improves long-term outcomes, yet the risk of progression rises markedly after midlife despite effective relapse suppression. Emerging biomarkers, such as serum neurofilament light chain, glial fibrillary acidic protein, paramagnetic rim lesions and advanced quantitative MRI metrics, now enable more granular monitoring of progressive pathology. Integration of imaging, fluid biomarkers, genetics and machine learning offers opportunities for individualized benefit–risk stratification. Brain-penetrant Bruton's tyrosine kinase inhibitors, CD40 ligand-targeting biologics, refined B-cell-depleting strategies and emerging chimeric antigen receptor T-cell therapies represent promising approaches to target different aspects of compartmentalized inflammation and smoldering disease biology. Future management will require mechanism-informed treatment algorithms that align therapeutic choice with dominant disease drivers while incorporating comorbidity management, de-escalation strategies and potential EBV-targeted preventive approaches to optimize outcomes across the entire disease course. [...]

Journal of Internal Medicine, EarlyView. [...]

Abstract Aim Old age is associated with poor outcomes in patients with heart failure (HF). This study aimed to assess the impact of age on the effectiveness of a new integrated, transition-based nurse-led HF programme in a healthcare area with 209,255 inhabitants. Methods We conducted a population-based evaluation of all patients discharged from the hospital with International Classification of Diseases, ninth revision, Clinical Modification code for HF as the primary diagnosis in Catalonia between 2015 and 2019. We compared outcomes between patients exposed to the new HF programme with the rest of Catalonia, stratified by age. Results A total of 77,554 patients with HF were classified into three groups: 15–74, 75–84 and >84 years. In the Bellvitge University Hospital (HUB)-Delta area (3396 HF patients), comparison of the pre-implementation and consolidation periods of the programme showed a decrease in clinically related hospitalisation in the youngest group (hazard ratio [HR] 0.87; confidence interval [CI] 0.84–0.91, p  [...]

Abstract Since 1858, human atherosclerotic plaques have been shown to contain immune cells. But are these cells suitable therapeutic targets? Dozens of clinical trials of anti-inflammatory agents other than colchicine have been performed in patients with clinically evident atherosclerosis. None of these trials led any regulatory body in any jurisdiction to allow a cardiovascular indication for any of these agents. This discouraging work provides a background to evaluate new data on colchicine. In 2024–2025, new clinical trials of colchicine in patients with atherosclerosis showed benefit, no benefit, or harm. In 2025–2026, over a dozen meta-analyses so far have appeared, drawing on ∼34 trials, but do not agree with each other. One of these meta-analyses, Xie et al.’s in the Journal of Internal Medicine, provides a compelling graphical display of the pre-specified primary outcomes of six long-term clinical trials as they were published over time. The pattern of early positive trials, then newer negative (null) trials, suggests regression to the truth. Jeon and Cho et al.’s population-wide study in the Journal of Internal Medicine of patients with Type 2 diabetes and gout found no benefit from colchicine over nonsteroidal anti-inflammatory drugs on major adverse cardiovascular events. This information suggests several areas for reform of research on inflammation in atherosclerosis. Fully informed consent should require that clinical trials of anti-inflammatory agents in atherosclerotic arterial disease must disclose to trial participants the failures of this approach in over 50 clinical trials to date, spanning decades. Additionally, the field might reconsider its commitment to the Big Idea that inflammation must be a definitive therapeutic target in atherosclerosis. The track record so far for inflammation inhibition in atherosclerosis is extensive and disappointing—a fact that merits wider discussion. Therapeutic successes from targeting cholesterol-rich, apolipoprotein-B-containing lipoproteins—the proven causative agents of this disease—provide extraordinary evidence. Current data for colchicine and other anti-inflammatory therapies do not. [...]

ANZ Journal of Surgery, EarlyView. [...]

The Deadly Ears program presents outcomes for myringoplasty surgery provided for Aboringinal and Torres Strait Islander children on-Country in a culturally-specific service. ABSTRACT Background Australian Aboriginal and Torres Strait Islander children experience some of the highest rates of otitis media with tympanic membrane (TM) perforation in the world. Deadly Ears is a statewide, Indigenous-led outreach service providing on-Country ear health care across Queensland. We evaluated myringoplasty surgery outcomes delivered through this program. Methods A retrospective cohort study of Aboriginal and Torres Strait Islander children undergoing myringoplasty surgery by Deadly Ears between January 2015 and February 2025 was performed. Demographic, clinical, surgical, and audiological data were extracted from medical records. Primary outcomes were TM closure and improvement between pre- and post-operative audiological categories. Associations between primary outcomes and patient, ear, and surgical variables were analysed. Results One hundred and four children underwent 135 myringoplasties (median age 10 years, IQR 8–12) across nine communities. Surgical and audiological follow-up was complete for 123 (91%) cases (median follow-up 707 days, IQR 358–1156). Complete TM closure achieved in 60.2% of cases and perforation size improved in 74.8%. Hearing improved by at least one category in 64.2% of ears. The proportion of children with normal hearing increased from 3.7% to 44.7%. Cartilage-based grafts, consultant surgeon operating, and shorter time to initial follow-up were associated with improved TM closure rates. Hearing improvement was associated with age  [...]

ANZ Journal of Surgery, EarlyView. [...]

Institutional experience with robotic pancreatoduodenectomy was associated with significant improvements in perioperative outcomes after the first 50 cases. Low-risk patients subsequently achieved 10 of 11 international benchmark outcomes, supporting the safe implementation of robotic pancreatoduodenectomy within a structured high-volume programme. ABSTRACT Background Despite the growing adoption of robotic pancreatoduodenectomy (R-PD), there remains a paucity of literature examining the learning curve associated with R-PD and the comparison of outcomes between early and later phases of institutional experience in R-PD. Accordingly, this study analyses 100 consecutive R-PD cases at a tertiary centre in Singapore, comparing outcomes across the initial and subsequent 50 cases to assess the effect of the learning curve, and benchmarking low-risk patients against international open PD (O-PD) standards. Methods This study is a post hoc review of 210 consecutive patients who underwent minimally-invasive PD (MI-PD) between 2016 and 2025, of which 100 patients who underwent MI-PD with robotic assistance (R-PD) were included. Baseline characteristics and perioperative outcomes were identified, and univariate analyses were conducted to evaluate differences between the first 50 cases (Group 1) and subsequent 50 cases (Group 2). Benchmarking was also performed for low-risk cases against known O-PD cut-offs. Results Comparison between Groups 1 and 2 demonstrated a significant decrease in major postoperative complications (46% vs. 24%; p = 0.04), clinically significant post-operative pancreatic fistula (Grade B/C POPF) (39.1% vs. 18.2%; p = 0.05), POPF graded Clavien-Dindo Grade 3 and above (21.7% vs. 4.5%; p = 0.03) and delayed gastric emptying (46% vs. 14%; p = 0.00). Following risk stratification, Group 2 achieved ten of 11 benchmarks, compared with five of 11 in Group 1. Conclusion This study supports the safe and effective implementation of R-PD within a high-volume hepatopancreatobiliary programme. Outcomes improved substantially after 50 cases, with low-risk patients in Group 2 achieving nearly all international O-PD benchmarks. [...]

ANZ Journal of Surgery, EarlyView. [...]

Among 129 Hospital-in-the-Home patients undergoing warfarin re-initiation with therapeutic-dose LMWH bridging, 16% experienced bleeding, typically around Day 6, with no thromboembolic events or deaths. Postoperative patients had higher bleeding risk, while higher target INR and elevated anti-Xa were independently associated with bleeding, supporting risk-stratified re-initiation and early monitoring. ABSTRACT Backgrounds Warfarin remains the anticoagulant of choice for selected high-risk patients [1]. Its narrow therapeutic index and pharmacokinetics make perioperative management challenging. Bridging with low-molecular-weight heparin (LMWH) during warfarin re-initiation reduces thromboembolic risk but may increase bleeding risk. Methods We conducted a retrospective cohort study on patients managed through the Hospital-in-the-Home (HITH) service at a tertiary centre in Melbourne, Australia. All patients admitted between 1 January and 31 December 2024 undergoing warfarin re-initiation with therapeutic-dose LMWH bridging were included. The primary outcome was bleeding incidence and severity during dual anticoagulation, defined by International Society of Thrombosis and Haemostasis (ISTH) criteria. Secondary analyses evaluated clinical and surgical factors associated with bleeding. Results Of 2348 HITH admissions, 129 patients were included. Bleeding occurred in 21 patients (16%), including 3 major and 18 minor events; there were no thromboembolic events or deaths. Most bleeding was managed in the community with only two requiring procedural intervention. Postoperative patients had higher bleeding incidence than non-operative re-initiators (23.9% vs. 8.1%; RR 2.96, 95% CI 1.15–7.60; OR 3.58, 95% CI 1.22–10.46; Fisher's exact p = 0.0175). Bleeding occurred at a median of 6 days of dual therapy. Previous long-term warfarin use, renal impairment, higher target INR and elevated anti-Xa exposure were associated with bleeding; target INR and anti-Xa remained independently associated with bleeding on multivariable analysis. Conclusions Bleeding risk was more strongly associated with patient- and treatment-related risk factors than bridging duration alone. These findings support risk-stratified warfarin re-initiation and early monitoring during dual therapy. [...]

ANZ Journal of Surgery, EarlyView. [...]

ANZ Journal of Surgery, EarlyView. [...]

In this prospective study of 303 patients undergoing appendectomy for suspected acute appendicitis (AA), the Alvarado, RIPASA and AIR scores showed comparable diagnostic accuracy for AA (AUC 0.850, 0.878 and 0.871, respectively), with no significant difference among them. Among the four scoring systems evaluated, the AIR score demonstrated the best performance in predicting complicated appendicitis. It achieved the highest AUC for both perforated appendicitis (0.754) and plastron appendicitis (0.679). These findings indicate that the Alvarado, RIPASA and AIR scores can be used interchangeably for initial diagnostic risk stratification of AA in the emergency department. However, the AIR score may offer additional value in predicting the risk of complicated disease. ABSTRACT Background Acute appendicitis (AA) is one of the most common causes of acute abdominal pain requiring emergency surgery. This study compared the diagnostic accuracy of the Alvarado, Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA), Appendicitis Inflammatory Response (AIR) and Tzanakis scoring systems in patients undergoing appendectomy for suspected AA, with emphasis on predicting complicated appendicitis. Methods This prospective observational study was conducted at the University of Health Sciences Bursa Yüksek İhtisas Training and Research Hospital between June 2021 and February 2022. Patients consecutively undergoing appendectomy for suspected AA were enrolled. Clinical, laboratory and imaging data were prospectively collected and all four scores calculated at emergency department evaluation. Diagnostic performance was assessed by ROC curve analysis, with histopathological examination as the reference standard. Results A total of 303 patients were included; 193 (63.7%) were male, with a median age of 33 years (IQR: 24–43). AA was confirmed in 296 patients (97.7%), with perforated appendicitis in 53 (17.5%) and plastron appendicitis in 20 (6.6%). Alvarado, RIPASA and AIR scores were significantly higher in confirmed appendicitis (p  [...]

ABSTRACT Background Facial nerve dysfunction (FND) remains a key complication of parotidectomy. Intraoperative facial nerve monitoring (IOFNM) aims to assist facial nerve identification and preservation; however, its effect on postoperative FND remains unclear. This systematic review and meta-analysis evaluated the effect of IOFNM on facial nerve outcomes post-parotidectomy. Methods PubMed, Embase, MEDLINE (Ovid) and CINAHL were searched from inception to August 22nd, 2025. Primary outcomes were immediate and permanent FND, assessed using the House-Brackmann grading system. Retrospective and prospective double-arm studies were included. Screening, data extraction and risk of bias assessment (ROBINS-I/RoB-2) were performed independently. Random-effects meta-analyses were conducted using restricted maximum likelihood. Certainty of evidence was assessed using GRADE. Results Twelve studies (n = 2401) met inclusion criteria. Meta-analysis of ten studies (n = 2042) demonstrated significantly lower odds of immediate FND with IOFNM (OR 0.48; 95% CI: 0.31–0.72). This reduction occurred in superficial (OR 0.51; 95% CI: 0.30–0.87), but not total parotidectomy (OR 0.93; 95% CI: 0.42–2.08). Analysis of six studies (n = 981) found no significant difference in permanent FND (OR 0.84; 95% CI: 0.44–1.60). Four studies (n = 1369) reported operative time, with a non-significant reduction using IOFNM (MD –8.82 min; 95% CI: −18.78 to +1.13). Conclusion IOFNM is associated with lower odds of immediate postoperative FND, particularly in superficial parotidectomy, but its effect on permanent FND and total parotidectomy remains uncertain. IOFNM use should be tailored to surgical complexity and surgeon experience, with high-quality prospective studies needed to clarify its clinical utility. [...]

ANZ Journal of Surgery, EarlyView. [...]

ABSTRACT Background Microsurgical breast reconstruction is the gold standard for patients after a mastectomy. Despite the benefits associated with microsurgical reconstruction, there remain considerable challenges at the level of both patient and health service. This study aimed to uncover variables associated with post-surgical complications following microsurgical autologous reconstruction in a single centre Australian cohort with the aim of informing future strategies to reduce risk and cost. Methods We conducted a retrospective cohort analysis utilising data from the electronic medical records of a tertiary breast reconstruction service in Melbourne, Australia between August 2022 and February 2024. Data on post-surgical complications were collected, with a particular focus on respiratory and wound complications. Results A total of 204 women, with a mean age of 49.8 years, were included. Multivariate logistic analysis found that for every kg/m2 point increase in BMI, respiratory complications increased by 8%. Respiratory comorbidities and operative duration were also associated with respiratory complications. For every kg/m2 point increase in BMI, wound complications increased by 11%. Respiratory comorbidities and intra-operative fluid volume were also associated with wound complications. Conclusions We identified several pre- and intra-operative risk factors that may assist in informing changes to standard clinical practice, in the hopes of optimising the overall experience for a patient undergoing microsurgical breast reconstruction. These quantified risks may also enable better patient education or institutional decisions to offer alternative pathways to high-risk patients. [...]

ABSTRACT Background Differentiating transition zone (TZ) prostate cancer (PCa) from benign prostatic hyperplasia (BPH) on multiparametric MRI is challenging. The comparative performance of synthetic MRI (Sy-MRI) and apparent diffusion coefficient (ADC) for this task is unclear. Purpose To evaluate the utility of Sy-MRI parameters and ADC in distinguishing TZ PCa from BPH. Materials and Methods This retrospective study included 261 patients (89 PCa, 172 BPH) who underwent preoperative MRI (including DWI and Sy-MRI). Two independent radiologists, who did not have access to the histopathological diagnosis and clinical data, placed regions of interest (ROIs) by manually tracing the lesion margins at the largest cross-sectional area of the lesion on the ADC map to record the ADC values. On synthetic T1-mapping, T2-mapping and proton density (PD) maps, ROIs of comparable size were placed at the same level and in a corresponding location to record T1, T2 and PD values. Parameters were compared using the t-test or Mann–Whitney U test. Diagnostic performance was assessed with ROC analysis and the DeLong test. Results T1, T2 and ADC values were significantly lower in PCa than in BPH (all p ≤ 0.001), while PD showed no difference (p = 0.073). ADC yielded the highest diagnostic performance (AUC, 0.996 [95% CI: 0.992, 1]), which was significantly higher than that of T1 (AUC, 0.928 [95% CI: 0.893, 0.964]) and T2 (AUC, 0.907 [95% CI: 0.868, 0.947]) (both p  [...]

Journal of Medical Imaging and Radiation Oncology, EarlyView. [...]

ABSTRACT Background Acute aortic syndromes (AAS), including aortic dissection, intramural haematoma (IMH), and penetrating atherosclerotic ulcer (PAU), are uncommon but life-threatening causes of chest pain. Computed tomography angiography (CTA) is highly sensitive for AAS but is increasingly overutilised despite low diagnostic yield, exposing patients to radiation, contrast risk, and healthcare cost. The ADvISED rule-out algorithm, combining the Aortic Dissection Detection Risk Score (ADD-RS) with serum D-dimer, has demonstrated high negative predictive value (NPV) in prospective studies but has limited external validation. Methods We performed a retrospective cohort study of adult emergency department patients within a tertiary cardiothoracic referral network in southern New Zealand who underwent CTA for suspected AAS between January 2018 and January 2024. Clinical records were reviewed to retrospectively calculate ADD-RS and extract D-dimer results prior to imaging. CTA findings served as the reference standard. The primary outcome was the NPV and failure rate of the ADvISED rule-out algorithm (low ADD-RS [0–1] plus negative D-dimer [...]

ABSTRACT Neurointerventional procedures can deliver high localised skin doses and may cause radiation-induced cutaneous tissue reactions, yet the doses at which these occur have not been synthesised specifically for this setting. We systematically reviewed reported cutaneous reactions and associated radiation doses after fluoroscopy- or digital subtraction angiography-guided cranial or spinal neurointerventional procedures. Following PRISMA 2020, Ovid MEDLINE, Embase, Scopus and the Cochrane Library were searched in April 2026; case reports, case series and observational studies reporting a cutaneous reaction and/or a relevant skin dose were eligible. Screening and extraction were performed by two independent reviewers, and studies were appraised with the Joanna Briggs Institute checklists; findings were synthesised narratively, with cohort-derived incidence reported separately from case-level data. Twenty-five studies (approximately 686 patients; 11 countries) were included. Alopecia/epilation was the dominant reaction (21 studies); dermatitis/erythema (4) and ulceration/necrosis (2) were less frequent. Among cohorts, incidence ranged from approximately 5% to 56% and rose with skin dose and procedural complexity. Reported onset doses tracked established deterministic thresholds: temporary epilation clustered around the approximately 3 Gy threshold, whereas erythema and ulceration occurred at higher, usually cumulative, doses, and epilation below approximately 2 Gy was reported in radiosensitive patients. Alopecia appeared 2–5 weeks after the procedure and ulceration months to years later. Dose metrics were inconsistent, and 4 of 25 studies reported no dose. Standardised reporting of peak skin dose and dose-triggered, structured follow-up is needed. [...]

ABSTRACT Compared to other sites of skeletal metastases, skull base metastases are relatively rare with varying incidence reported in the literature. The most frequently implicated cancers are breast, prostate and lung carcinomas and lymphoma. While some lesions are asymptomatic, the clinical presentation may be with pain or cranial neuropathy. Adequate imaging techniques and knowledge of skull base anatomy are essential. Imaging features of metastases at various locations at the skull base will be described, highlighting important anatomical landmarks and clinical implications. [...]

ABSTRACT Background Osteoporosis and atherosclerosis are prevalent diseases that exert significant impacts on morbidity and mortality. Purpose To investigate the relationship between opportunistically measured thoracic vertebral bone mineral density (BMD) on coronary computed tomography angiography (CCTA) and coronary artery disease (CAD), coronary artery stenosis severity and coronary artery calcium score (CACS). Methods This retrospective study included 386 patients undergoing CCTA for suspected CAD. BMD was measured on non-contrast images using Hounsfield units (HU), and values [...]

ABSTRACT Image-guided thermal ablation (radiofrequency, cryo- and microwave ablation) is a safe and effective primary treatment for small renal mass and localised renal cell carcinoma ≤ 4 cm (T1a) with long-term cancer-specific survival rates equivalent to surgical resection (Level A). Image-guided thermal ablation can be considered as a treatment option for localised renal cell carcinoma > 4 cm (T1b) (Level B). Image-guided thermal ablation is a nephron-sparing treatment option, particularly for renal cell carcinoma in the solitary or syndromic kidney (Level B). Patients referred for consideration of image-guided thermal ablation of a small renal mass or RCC should be consulted pre-operatively by an Interventional Radiologist (IR) including comprehensive clinical evaluation and assessment of suitability (Level C). Pre-operative work-up should include medical history, physical examination, evaluation of functional status, comorbidities, assessment of coagulation status and renal function, and review of relevant imaging (Level B). Renal mass biopsy is recommended either prior to or at the time of image-guided thermal ablation (Level B). Tumour embolisation prior to thermal ablation is not routinely recommended (Level B). Renal tumour ablation should be performed with general anaesthetic or deep sedation, under cross-sectional imaging, and achieve an ablation zone margin of 5–10 mm. Adjunctive techniques should be used if the tumour is close to thermally sensitive structures (Level C). The treating interventional radiologist is a primary clinician responsible for care during a patient's admission for renal tumour ablation, including management of complications (Level C). Follow up after renal tumour ablation should include clinical consultation, renal function assessment, and cross-sectional imaging within 6 months, followed by regular cross-sectional imaging for 5 years (Level C). Renal tumour ablation is a cost-effective and preferred treatment for T1a renal cell carcinoma to maximise health benefits per dollar (Level B). Interventional Radiologists are the medical specialist group with suitable training and expertise to perform image-guided renal tumour ablation in Australia and New Zealand (Level C). [...]

ABSTRACT Introduction This narrative review examines endovascular treatments for acute pulmonary embolism (PE), focusing on percutaneous mechanical thrombectomy (MT). Methods PubMed (Medline) and Google Scholar were searched from January 1990 up to November 2024 (updated Feb 2026). Studies were included if they discussed PE and the use of thrombectomy devices. Full-text randomised controlled trial studies, observational studies, case series, and case reports were included. Opinion articles, letters to the editor, animal studies, and non-English studies were excluded. Results A total of 116 articles were reviewed. Current guidelines recommend systemic thrombolysis as first-line reperfusion for high-risk PE, whereas intermediate-high-risk PE is managed with anticoagulation and monitoring, with reperfusion reserved for deterioration. MT is currently an alternative, mainly when thrombolysis is contraindicated or has failed. However, the last two decades have seen a surge in thrombectomy devices including the FlowTriever, Indigo, and AngioVac. Numerous studies, most notably the PEERLESS trial, have reported rapid haemodynamic improvement with MT, including reduced pulmonary artery pressure, low major bleeding rates, and fewer intensive care admissions [1]. Conclusion MT has shown early promise in the management of PE. Much of the current evidence derives from single-arm trials, registries, and industry-sponsored observational studies, with randomised comparative data still limited. Nonetheless, randomised evidence suggests MT may reduce clinical deterioration, intensive care use, and hospital length of stay compared with catheter-directed thrombolysis, though without a demonstrated difference in mortality, intracranial haemorrhage, or major bleeding. Further trial evidence is required before MT is recommended as first-line in PE. [...]

ABSTRACT Background Vascular malformations (VMs) are congenital anomalies that often cause pain, swelling, disfigurement, and functional impairment. Conventional sclerotherapy, though widely used, typically requires multiple sessions and may yield incomplete resolution. Bleomycin–Electrosclerotherapy (BEST) and Bleomycin-Electroperfusiontherapy (BEPT) combine bleomycin with reversible electroporation to enhance endothelial uptake, potentially improving outcomes. Methods We conducted a retrospective cohort study (January 2024–August 2025) at Christchurch Hospital of 27 patients (40 procedures) with clinically and radiologically confirmed vascular malformations, where bleomycin had been administered percutaneously, intra-arterially or intravenously, followed by electroporation using the IGEA Cliniporator VITAE. Primary outcome was clinical improvement assessed by GAIS. Secondary outcomes included VAS pain scores, number of treatments, complication rates and subgroup analyses. This study is reported in accordance with the STROBE statement for observational studies. Results The cohort included venous (40.7%), lymphatic (18.5%), venolymphatic (7.4%) and glomovenous malformations (11.1%), intramuscular fast-flow vascular anomaly (3.7%), Klippel-Trenaunay spectrum (3.7%), FAVA (3.7%) and arteriovenous malformations (11.1%). Clinical improvement (GAIS 1–3) was observed in 24/27 patients (88.9%; 95% CI 71.9%–96.1%). Exceptional improvement or resolution (GAIS 1) was achieved in 37.0% and partial improvement (GAIS 2–3) in 51.9%, after a mean of 1.48 sessions. Mean VAS score improved from 6.3 to 2.4 (p  [...]

Journal of Medical Imaging and Radiation Oncology, EarlyView. [...]

ABSTRACT Introduction Breast density is a marker of risk both due to the increased burden of fibroglandular tissue, which may harbour malignancy, and to obscuration of lesions in mammography. This study aims to assess the reliability of Lunit INSIGHT MMG as a tool for estimating breast density compared to breast radiologists, evaluate density on a population level of > 600,000 clients, and compare the density in clients with/without implants. Methods 15,518 mammograms were abstracted to explore the intra- and inter-reader reliability between AI and breast radiologists. Variation in density was then evaluated by AI from 624,133 mammograms and stratified according to birth country and age. Finally, density was assessed in 4047 clients with implants and compared to 396,301 clients without implants. Results AI vs. breast radiologist inter-reader variability weighted kappa coefficient was 0.72 (95% CI 0.71–0.73). Clients with a North-East Asia background had the highest density, whilst clients of Aboriginal background had the lowest density. Density reduced with age across all backgrounds, though at different rates. Clients with implants had higher density than age-matched no-implant strata. Conclusion AI performed adequately in both intra- and inter-reader reliability. Notable gradients in breast density were observed with increased age but this effect was moderated by ancestry. This study population is significantly larger than any other in the published literature and has considerable diversity in age and ancestry. [...]

Journal of Medical Imaging and Radiation Oncology, EarlyView. [...]

ABSTRACT Objective Women in rural and remote Queensland face greater challenges in accessing fertility care than those residing in large regional or metropolitan centres of Australia. This study aims to explore the experiences of women accessing fertility care while living in a rural or remote area of Queensland and their perspectives on ways to improve fertility care. Setting Interviews were conducted either in-person (Townsville, Emerald, Cloncurry, Mount Isa), via telephone or Microsoft Teams. Participants Persons currently or previously accessing fertility care, while living rurally in Queensland, identifying as female at birth, being fluent in the English language, and aged 18 years or older participated. Design Qualitative semi-structured interviews, with data analysed via reflexive thematic analysis, were followed by a descriptive content analysis of participants' ideas for improving rural fertility care. Results Two main themes with 18 sub-themes emerged from the data. Theme 1: experiences of participants in accessing and receiving fertility care, whilst living in a rural or remote area, and Theme 2: participants' perspectives on how to improve the fertility care experience in rural and remote areas. Residence in a rural or remote location added to the complexity of fertility-related experiences. Rural living influenced fertility knowledge and information access, the accessibility of services, fertility care choice, privacy and social support. Participants articulated strategies from the availability of local information hubs to policy changes aimed at mitigating fertility care postcode-related disadvantage. Conclusion Rural and remote persons accessing fertility care have highlighted not only the challenges experienced but have proposed strategies to improve rural fertility care. [...]

Australian Journal of Rural Health, Volume 34, Issue 4, August 2026. [...]

ABSTRACT Objective To provide the first national analysis of the distribution and professional composition of PhD-qualified health professionals across metropolitan, regional, rural and remote Australia. Design Cross-sectional analysis of 2021 Australian Census data. Setting Australia, classified by Modified Monash Model (MM) remoteness categories. Participants Health professionals reporting a doctoral-level qualification (PhD). Main Outcome Measures Counts and proportions of PhD-qualified health professionals by MM category and occupation group; association between remoteness and PhD representation. Methods Occupations were grouped into medicine, allied health, and nursing. Residential locations were mapped to MM categories. Descriptive statistics and linear regression examined distribution patterns. Results Of 21 510 PhD-qualified health professionals, 85% lived in metropolitan areas (MM1), with 3027 (14%) in regional, rural and remote communities and only 12 ( [...]

Australian Journal of Rural Health, Volume 34, Issue 4, August 2026. [...]

ABSTRACT Objective To test the utility and acceptability of a novel VR training tool for community health practitioners in assessing diabetes-related foot disease in Aboriginal and Torres Strait Islander people. Methods The VR program featured five virtual patient models and a range of interactive assessments covering essential clinical and triage skills. Design Pragmatic quasi-experimental case series. Setting The VR training program was completed in collaboration with three Aboriginal Community-Controlled Health Organisations in regional South Australia, with recruitment directed internally at each organisation. Participants Forty-one primary healthcare staff participated, of which 34 were matched on pre- and post-VR surveys and 20 completed at least three training scenarios. Main Outcome Measures Evaluation consisted of pre-test self-efficacy scores immediately prior to participants undergoing training, submission of post-test self-efficacy scores, the System Usability Scale, and Training Evaluation Inventory scores after completing all training modules. Results Following completion of VR training, participants reported increased self-efficacy scores (n = 20) for performing key assessment and triage skills. User feedback (n = 39) demonstrated that participants generally agreed that the training user experience was engaging, acceptable, and of value for clinical education. Conclusion Community health practitioners generally found the VR training tool acceptable, useful, and increased their self-confidence in assessing and managing diabetes-related foot disease for Aboriginal and Torres Strait Islander people, highlighting the potential of VR to upskill community practitioners. [...]

ABSTRACT Objective To explore the risks and barriers to care of informal carers of farmers living on-farm with dementia and cognitive impairment. Methods Seven individual semi-structured telephone interviews were conducted between June and July 2025. Purposive sampling included carers to discuss their perceptions of caring for people with dementia living on farms. Design Qualitative study, grounded theory with iterative thematic analysis. Setting Rural Australia. Participants Informal carers. Main Outcomes Risks and barriers to care. Results Six themes were noted in the interviews: (1) Geographic isolation; (2) Physical hazards and farm responsibilities; (3) Interpersonal relationship conflict; (4) Inadequate government support; (5) Lack of local healthcare resourcing; and (6) Positive aspects of the farm environment. Participants discussed strategies for care, such as enlisting additional familial support. Some of these themes were unique to the farm context. Conclusion Carers of farmers with dementia highlighted a combination of risks and barriers to care that often interact synergistically with each other, leading to unmet needs for care. Carers highlighted a need for tailored solutions to care in the unique farm context. Integrating the farm environment with accessible assistance off farm appeared to be a strong desire among carers. [...]

ABSTRACT Objective To evaluate: (1) patient experiences and perceptions of Patient Watch; and (2) the effect on emergency department (ED) presentations, healthcare use, quality of life and chronic illness care. Design A prospective longitudinal cohort study using a convergent-parallel mixed methods study design combining: (1) qualitative semi-structured interviews analysed using reflexive thematic analysis and (2) quantitative assessment of Quality of Life-8D, Patient Assessment of Chronic Illness, routinely collected ED clinical data and Patient Watch programme data. Setting A large public health service delivering care across the home, community, aged care and hospital, serving a regional centre and small, medium and large rural towns in Western Victoria, Australia. Participants Forty-five participants were enrolled in the study. A subsample who completed all study requirements enabled baseline and 6-month follow-up analysis (n = 37). Intervention Patient Watch, a telehealth case management model of care adapted from a metropolitan to a rural context, to manage the care of frequent presenters to the emergency department. Results Before enrolment, patients reported health system, medical and situational complexity hindered effective care and contributed to high treatment burden, with acute exacerbations leading to increased healthcare use and negative care experiences. Patient Watch improved perceived care coordination, healthcare access and helped participants manage acute exacerbations. ED presentations (p  [...]

ABSTRACT Introduction Australia's ongoing healthcare workforce shortages have prompted exploration of alternative models of care. One such model is the Physician Assistant (PA), a role established and trialled internationally but inconsistently implemented in Australia. Objective Design To examine the role, function and professional positioning of PAs within the Australian healthcare system. Design Integrative review, guided by Whittemore and Knafl's (2005) framework. Findings Limited evidence of PA use in Australia was found. Of the identified literature, findings reveal that PAs have contributed across diverse clinical settings in Australia, including emergency departments, surgical units, and primary care, particularly in underserved and rural areas. Their scope of practice has spanned diagnostic, procedural, and care coordination roles, delivered under varying levels of medical supervision. Conclusion There is limited evidence on the use of PAs in Australia. Despite some positive outcomes, significant barriers, such as professional resistance and concerns about patient safety, role ambiguity, and lack of national regulation, have hindered broader adoption. [...]

Australian Journal of Rural Health, Volume 34, Issue 4, August 2026. [...]

ABSTRACT Objective To identify factors influencing implementation and integration of the paediatric ESCALATION system in country Western Australia. Setting and Participants Health professionals (nurses and doctors) working in country Western Australia. Design and Methods A multi-methods study using an interpretive descriptive approach guided by the Practical Robust Implementation and Sustainability Model (PRISM) and Normalisation Process Theory (NPT). Data collection across six sites included patient chart audit, health professional survey and focus groups/interviews. Data were analysed descriptively (audit and survey) and thematically (focus groups/interviews). Results An audit of 94 patient charts showed 61.7% met escalation of care criteria, while 69.0% of cases were escalated per policy. Among 114 survey responses, findings indicated system integration, with 95.6% reporting ESCALATION was part of their role, 93.5% agreeing it supported early detection of clinical deterioration and 93.8% reporting ease of use. Fewer identified local champions (66.7%), had confidence in others' use of the system (61.1%), reported sufficient training (69.0%), or were aware of reports demonstrating system effectiveness (55.0%). Seventy-eight health professionals participated in focus groups/interviews. Three themes were interpreted through the PRISM and NPT frameworks: (i) Enhanced patient safety (intervention characteristics and participants' perspectives; coherence; cognitive participation), (ii) Strengthening clinical decision-making (implementation and sustainability infrastructure; cognitive participation; collective action), (iii) Monitoring and fidelity (implementation and sustainability infrastructure, external; collective action; reflexive monitoring). Conclusion The paediatric ESCALATION system is embedded and valued, but sustaining fidelity through scale-up requires ongoing training, teamwork, confident communication and organisational support across regional, rural and remote WA health services. [...]

ABSTRACT Objective The prevalence of intracranial haemorrhage (ICH) and cerebral amyloid angiopathy (CAA) in the Northern Territory (NT) is unknown. This study aims to improve knowledge of haemorrhagic stroke in the NT, to evaluate the relevance of CAA and examine its association with chronic kidney disease (CKD). Methods Retrospective assessment of ICH cases admitted at Royal Darwin Hospital from 2015 to 2019. Epidural, traumatic, or aneurysmal subarachnoid haemorrhages were excluded. We assessed neuroimaging, demographics, kidney function, risk factors, and outcome. We examined differences in the Aboriginal and Torres Strait Islander population, the association of CKD with outcome, and CAA prevalence. Results We found 156 cases, mean age 63, 45% women and 34.0% Aboriginal and Torres Strait Islanders. MRI was performed in 39% of patients; 25% had possible/probable CAA. Mortality during admission was 37.2% and 32.7% were dependent. Mortality was independently associated with ICH volume and CKD. Aboriginal and Torres Strait Islander patients were younger, with higher smoking prevalence, diabetes, and CKD, and had lower independence at discharge. However, the prevalence of CAA was not different between groups, and CAA was not associated with CKD. Conclusions ICH in the NT has a poor outcome. The main predictors of mortality are CKD and ICH volume. There is no association between CKD and CAA, and CAA is not more prevalent in Aboriginal and Torres Strait Islander patients. CAA may be underestimated due to a lack of MRI, which was rarely performed in patients who died. Therefore, a prospective study is warranted to better characterise CAA in the NT. [...]

Australian Journal of Rural Health, Volume 34, Issue 4, August 2026. [...]

10.1542/6396774428112Video AbstractPEDS-VA_2026-076070A6396774428112 [...]

This supplement is a step forward in promoting health equity and a race-conscious approach in clinical practice and in tools, such as clinical practice guidelines (CPGs) and clinical reports (CRs). The series of important articles respond to the American Academy of Pediatrics’ call to eliminate race-based clinical guidance and calls for needed research to support the reevaluation of CPGs and CRs across key pediatric domains. Additionally, the authors not only highlight the complexities in making inferences but also delve into the pragmatic issues of implementation, highlighting consistent barriers to adopting a race-conscious approach in pediatric evidence-based medicine. It is not enough to describe disparities if there are not interventions to change outcomes. It is not enough to create race-conscious clinical guidelines if they are not used. Finally, in today’s world, implementation cannot be discussed without consideration of the impact of artificial intelligence (AI) now transforming evidence-based medicine. [...]

Pain is among the most common reasons children seek care in emergent settings, including emergency medical services and emergency departments. Despite well-established guidelines for pediatric pain management, racial and ethnic inequities persist. The drivers of these inequities are multifactorial. This review synthesizes the current literature on racial and ethnic inequities in pediatric pain management across the continuum of emergent care settings and highlights actionable strategies and research priorities to advance equitable pain care.Despite the known benefits of prehospital analgesia, children from minoritized racial and ethnic groups are less likely to receive analgesia, including opioids, and less likely to experience pain relief (also referred to as oligoanalgesia). Evidence regarding disparities in discharge prescribing is mixed.Although identifying disparities is an essential first step, meaningful progress requires understanding the root causes and implementing multifactorial, equity-centered interventions. Potential strategies include standardizing clinical processes to minimize variability, using equity-informed pain assessment tools and clinical guidelines, centering patient and family lived experiences, leveraging quality improvement methodologies, and re-examining clinician education to mitigate bias and improve pediatric pain care. Equity-focused research and interventions, coupled with advocacy, policy reform, and community partnerships, are essential to move the field beyond awareness toward sustainable and equitable delivery of pediatric pain care in emergent settings. [...]

Pediatric clinical guidelines and algorithms have frequently included race as a risk factor to be considered in clinical decision-making. This practice, commonly known as “race-based medicine” or “race correction,” substitutes race as a flawed proxy for socioeconomic status and genetic ancestry. The American Academy of Pediatrics has called for the elimination of race-based medicine and endorsed “race-conscious medicine” as a preferable alternative. Race-conscious medicine embraces race-neutral clinical tools and supports efforts to tackle the structural barriers to health that cause racial disparities. We aimed to assess recent progress and identify ongoing barriers in the implementation of race-conscious medicine in pediatrics. First, we review the role of medical societies and the research community in generating race-conscious alternatives to race correction, while noting that many pediatric tools continue to include race in ways that may negatively impact equity. Second, we discuss the role of health care organizations in implementing race-conscious guidance locally, drawing upon specific local and regional efforts to reveal organizational, cultural, technical, and financial factors that may facilitate or impede success. Third, we identify medical education governing bodies as essential in integrating the principles of race-conscious medicine into every stage of medical education. Fourth, we highlight the need for third-party clinical algorithm platforms and biomedical device manufacturers to provide access to race-conscious tools through their products. Finally, we address the role of the policy and regulatory landscape in accelerating or slowing the rate of progress, and the importance of patient engagement and redress of historical harms. [...]

A contextual understanding of how neonatal and infant health inequities have developed is crucial to dismantle the harmful effects of race-based medicine and transition to a race-conscious, trauma-informed approach. Past and present laws and policies influence not only the sociocultural context within which people live but also the accessibility and quality of health care delivered to birth people and infants. Race-based medicine operationalizes race as a proxy for presumed biology in medical risk and treatment algorithms. Many examples of this exist within Obstetrics and Neonatal-Perinatal Medicine and have contributed to health care–generated inequities. Transitioning to a race-conscious, trauma-informed approach requires acknowledging racism, not race, as a driver of outcome disparities and intentionally directing efforts toward mitigating and eliminating these inequities. This involves considering barriers that some families face outside of and within the neonatal intensive care unit, applying a culturally attuned and personalized approach, revising outdated policy and practice, diversifying the workforce, including key stakeholders in decision-making, and improving transparency in research design and evaluation. This supplement explores the inequities that become amplified or compounded across the perinatal life continuum from birth person to infant, relevant policies or interventions to mitigate and eliminate the inequities, and associated outcomes. The perinatal, neonatal, and pediatric community must continue to critically assess policy and research, recognizing the impact of racism on health inequities, medical education, and patient care. [...]

Respiratory health is the result of genetics and socioenvironmental factors that influence optimal lung development and function. Adverse socioenvironmental exposures are linked with pediatric respiratory diseases. Because pulmonary symptomatology is nonspecific, objective assessment of respiratory health is based on pulmonary function testing. Historically, pulmonary function testing was adjusted for race. With increased recognition of race being a social rather than a biological construct, the American Thoracic Society issued guidelines in 2023 recommending a “race-neutral” approach to the interpretation of lung function, as put forth by the Global Lung Function Initiative–Global equations. Using disease examples of asthma and pulmonary involvement in sickle cell disease, we describe effects of these guidelines on disease reclassification, including identification of worse airflow obstruction in Black children, that corresponded with disease burden. Despite the greater alignment of the race-neutral approach with disease burden, there is a possibility that reclassifying disease may widen the racial gaps. For these reasons, although we recommend clinicians to routinely incorporate spirometry for assessment of respiratory disease, we suggest that in the setting of an abnormal result, they not only address the underlying disease but also assess for, and address, adverse socioenvironmental factors that are known determinants of low lung function. This contextual analysis of pulmonary function is key in providing equitable respiratory health for all children. The recommendations also identify the need for additional research on its implications among healthy children and the role of biological variables such as genetic variation that are associated with ancestry and independently associated with lower lung function. [...]

Race as a modifying factor is widely used in clinical research, including when exploring the correlation between skin pigmentation (or tone) and bone mineral density (BMD), each representing a variable affected by vitamin D status. The underlying historical framework of BMD interpretation has been defined by socially constructed race definitions, rather than more objective factors such as genetics and environmental exposures. In this review, we provide evidence to support the importance of moving away from race-based standard definitions and toward more quantitative and empirical measures of skin tone. Current interpretations of BMD in both children and adults are dependent on race, which affects the interpretation of BMD in all individuals including those of mixed race. Vitamin D status is dictated in part by skin tone and can ultimately impact BMD. Therefore, exploring the relationship between skin tone and BMD must be considered in the context of vitamin D status. There are also regional differences in ultraviolet B exposure, influenced by latitude and the trend of migration to more urban areas, that impact melanin production within skin. Finally, genetics must also be considered as it plays a major role in the determination of both skin tone and BMD. In summary, there are multiple factors involved in considering the complex relationship between skin tone and BMD, which underscores the importance of a comprehensive examination of genetic underpinnings as well as environmental factors. [...]

Lisa M. Grisham, Jay P. Goldsmith, Ashley M. Lucke, Sheila M. Gephart; AAP Committee on Fetus and Newborn. Advanced practice nursing in neonatology: clinical report. Pediatrics. 2025;156(3):e2025073170. doi: 10.1542/peds.2025-073170 [...]

An error occurred in the article by Helm BM et al, titled “Standardized Criteria for Genomic Testing in the NICU,” published in the July 2025 issue of Pediatrics (2025;156[1]:e2024069591; doi: 10.1542/peds.2024-069591). [...]

OBJECTIVESThis ongoing phase 2/3 interventional, open-label study evaluated nirmatrelvir/ritonavir (NMV/r) in pediatric participants with mild-to-moderate COVID-19 at risk for severe disease (due to underlying medical conditions). Primary objectives were pharmacokinetics (PK) and safety. We report data from participants aged at least 6 years.METHODSTwice daily (BID) oral NMV/r was administered for 5 days to participants aged at least 6 years weighing at least 40 kg (Cohort 1) or 20 to [...]

10.1542/6392145091112Video AbstractPEDS-VA_2025-0752786392145091112BACKGROUNDDespite many hospitalized children missing recommended vaccines, vaccines are rarely administered during hospitalization. Our objective was to explore the key determinants for inpatient vaccine delivery in a sample of 11 US children’s hospitals.METHODSWe used the Pediatric Health Information System database to identify children’s hospitals in the Pediatric Research in Inpatient Setting network who were in the top tertile (n = 6) and the bottom tertile of inpatient vaccine administration (n = 5). We recruited pediatric nurses, pharmacists, and hospitalists to participate in semistructured interviews. Interview questions were based on the Consolidated Framework for Implementation Research and focused on current practices and barriers to inpatient vaccine delivery. Interviews were conducted via telephone or teleconferencing and were recorded and transcribed. Two reviewers independently coded transcripts using thematic analysis; a third reviewer resolved discrepancies, as needed.RESULTSWe conducted 36 interviews: 10 hospitalists, 14 nurses, and 12 pharmacists. Several themes emerged as key determinants for inpatient vaccine delivery, including the following: 1) timing: vaccine administration happened predominately at discharge, which at times jeopardized vaccine delivery; 2) access: vaccinating during hospitalization was particularly important when children had difficulty accessing primary care or when traditional health care services were disrupted, eg, during the COVID-19 pandemic; and 3) workflow: vaccine-related workflow is often not standardized and lacks ownership.CONCLUSIONSDespite variability in vaccine administration across children’s hospitals, there are many common barriers and determinants. Solutions that address these barriers and meet the needs of multidisciplinary clinicians are essential to improve inpatient vaccine delivery. [...]

BACKGROUND AND OBJECTIVESIn this study, we evaluated whether maternal COVID-19 and influenza vaccination status during pregnancy was associated with infant vaccine coverage.METHODSThis observational cohort study included infants 6 to 13 months old born at Kaiser Permanente Northern California between August 2021 and March 2024 and their mothers. We used the Kaplan-Meier approach to estimate the cumulative probability of infants receiving at least one dose of a vaccine and Cox models to estimate the hazard ratio of infant vaccination by maternal vaccination status adjusted for covariates. Mothers were considered vaccinated if they received a COVID-19 or influenza vaccine from 12 months before pregnancy onset date to 3 months postpartum; those who did not receive a vaccine in this window were considered unvaccinated.RESULTSThe study included 82 533 mother-infant pairs. Infants in the study had a 23.4% probability of receiving a COVID-19 vaccine and 66.2% probability of receiving an influenza vaccine in the first year of life. Infants whose mother received a COVID-19 vaccine during pregnancy were 9.65 (95% CI, 9.06–10.27) times more likely to be vaccinated against COVID-19 and those whose mother received an influenza vaccine during pregnancy were 3.67 (95% CI, 3.58–3.77) times more likely to be vaccinated against influenza than those whose mother was not vaccinated. Vaccination before pregnancy or during postpartum was also associated with infant vaccination compared with no maternal vaccination.CONCLUSIONSMaternal vaccination for respiratory vaccines was strongly associated with infant vaccination; increasing maternal vaccine coverage may improve infant coverage. [...]