General journals

At least 10 doctors and five other healthcare workers have been arrested and detained in Iran, with one facing a potential death sentence, human rights groups and doctor organisations warn.It comes as the nation continues to be rocked by anti-regime protests which started in late December.Norway based rights group Hengaw said in a statement1 on 27 January that Alireza Golchini, a surgeon from Qazvin in northwestern Iran, was arrested on 10 January for providing medical care to injured protesters.He is reportedly facing charges of waging war against God, which carries a risk of execution. Golchini was severely beaten during the arrest and several of his teeth were broken, Hengaw said.In the days before his arrest, Golchini posted on social media offering to provide medical help to people injured in the protests. He had previously provided treatment to people injured during the “Woman, Life, Freedom” (Jin, Jiyan, Azadi) protests in 2022.2The... [...]

Stokel-Walker correctly highlights that, despite its prevalence and serious consequences, delirium remains under-recognised and poorly managed.1 One reason we continue to “do little” is our persistent diagnostic tunnel vision—particularly the tendency to treat delirium as solely secondary to infection.As a foundation year 2 doctor, I frequently encounter acutely confused patients on night shifts. The default assumption is infection, prompting comprehensive septic screens. But sometimes infection is not present, and other factors emerge, such as recent medication changes, environmental disruption, sleep deprivation, or inadequately managed pain—showing the multifactorial nature of delirium.These contributors are well supported in the literature. Polypharmacy and psychoactive drug use are major contributors, as are environmental factors such as sensory deprivation, noise, and ward transfers.2 When the medication is stopped and routine stabilised, cognition can improve within days—without antibiotics. Another major problem is sleep disturbance, which is associated with an increased risk of delirium.3 Pain is also independently... [...]

Robert F Kennedy Jr’s “cherrypicked” appointees to a federal autism committee have sparked alarm among autism advocates and experts.On 28 January 2026, the US health secretary named 21 new members to the Interagency Autism Coordinating Committee (IACC).1But critics have noted that at least eight of Kennedy’s new appointees have publicly questioned vaccine safety or are linked to groups that promote vaccine-autism theories.Alison Singer, head of the Autism Science Foundation, who served on the committee from 2007 to 2019, said, “The newly constituted IACC represents a complete and unprecedented overhaul, with no continuity from prior committees and a striking absence of scientific expertise.”2Critics have noted that the new committee’s membership tilts towards parent advocates and includes few established autism researchers, compared with previous committees.Among the new members is John Gilmore, founder and executive director of the Autism Action Network. The Washington Post reported that Gilmore had described his son as “vaccine... [...]

Resident doctors in England have voted overwhelmingly to extend their mandate for strike action over pay and jobs for another six months.Some 93% of resident doctors who voted in a ballot voted in favour of further action (26 696 of 28 598). Turnout for the ballot was 53%, with 54 432 resident doctors in total eligible to vote.After the result the BMA’s Resident Doctors Committee (RDC) urged the government to act immediately to prevent further strikes taking place in the coming months.RDC chair Jack Fletcher said, “This is not a problem the government can wait out. Ministers cannot be shocked that 93% of doctors have voted to strike after being recommended a pay cut this year by the same health secretary who promised a journey to fair pay.“And without thousands more training posts the bottlenecks in medical training are going to continue to rob brilliant young doctors of their careers.... [...]

Médecins Sans Frontières is to be banned from operating in the Gaza Strip and West Bank after reversing its decision to share details of its Palestinian staff with Israel.The reversal followed a fierce backlash against MSF’s initial decision to comply with Israel’s new regulations to keep operating in the region—with some critics accusing the charity of “moral bankruptcy” over the issue.1MSF announced the change in its position in a statement on Friday 30 January, saying it would no longer share a list of its Palestinian and international workers with Israeli authorities as it had not secured “assurances to ensure the safety of our staff.”In response, Israel said it was “moving to terminate the activities” of MSF in Gaza and the West Bank,2 as the charity had breached its new regulations for organisations wanting to provide humanitarian aid in the region.Israel’s Ministry of Diaspora Affairs and Combating Antisemitism said MSF must... [...]

An analysis of 15 commercially available tattoo inks in Australia has found levels of metals and carcinogens, including arsenic, cadmium, chromium, lead, and toluidine, far above European limits.The study concluded that not one of the tattoo inks met EU safety standards, yet Australia currently lacks binding limits on the composition of tattoo inks.Analytical chemist W Alexander Donald from the University of New South Wales Sydney said that the study highlighted a potentially dangerous regulatory blind spot.“The most concerning thing was definitely those heavy metals like lead, arsenic, cadmium,” Donald said. “People should be informed about what’s in here, if they’re injecting it into themselves.”Researchers used liquid chromatography-tandem mass spectrometry to analyse the 15 ink samples—eight black and seven coloured inks.They found that antimony, arsenic, cadmium, chromium, copper, lead, selenium, and tin were all present at levels above those set by EU regulations.1One ink had more than four times the EU... [...]

The US government will withhold funding to Gavi, the global vaccine alliance, until it stops using vaccines containing thiomersal (known as thimerosal in the US), a preservative containing mercury, officials have said.The move threatens $300m included in a house approved FY2026 funding bill, which still needs Senate passage and final enactment.“Until a plan for removal of thimerosal containing vaccines is developed and the plan initiated, the United States will withhold future new funding,” an official at the US Department of Health and Human Services told Reuters last week.1The US is one of Gavi’s original donor countries and has historically been among its largest funders, often cited at roughly 13%.Thiomersal was phased out of childhood vaccines in the US in 2001. It has been used in some multi-dose influenza vaccine vials, but current US guidance for the 2025-26 season recommends only thimerosal-free, single dose flu vaccines.The preservative is mainly used in... [...]

What was the Leng review?In autumn 2024 health and social care secretary Wes Streeting asked Gillian Leng, president of the Royal Society of Medicine and a former chief executive of the National Institute for Health and Care Excellence, to carry out a rapid independent review into the safety and scope of the roles of physician associate (PA) and anaesthesia associate (AA).1The review was an attempt to “reset the hostility” after the long and bitter debate in the NHS over the safety and effectiveness of the roles.Leng was tasked with assessing how effectively PA and AA roles were currently deployed in the NHS and how any new roles should work in the future.What did Leng recommend?Leng’s report, published in July 2025, made 18 recommendations, all of which were accepted by the government (box 1).234Box 1Leng’s key recommendationsPAs should be renamed physician assistants, and AAs renamed physician assistants in anaesthesia, to avoid... [...]

Types of dose-related adverse drug reactionsThe Law of Mass action predicts that all adverse drug reactions are related to the concentration of the drug at the site of action, and therefore to the administered dose.1 In other words, there is no such thing as a non-dose-related adverse drug reaction.According to the DoTS (dose, time, susceptibility) classification of adverse drug reactions (ADRs), there are three types of adverse drug reactions in relation to the dose or concentration of the drug with which the reaction is associated2:• hypersusceptibility reactions: these are reactions that occur at doses or concentrations that are lower than those usually associated with therapeutic benefit; all allergic reactions come under this heading, plus a few reactions that are not allergic but occur at low concentrations, such as angioedema associated with ACE inhibitors;• collateral reactions: these are associated with doses or concentrations that are within the same range as those... [...]

A new safety warning to doctors and patients around a rare but potentially fatal side effect of glucagon-like peptide-1 (GLP-1) receptor agonists has been issued by UK regulators.Sold under brands like Ozempic, Wegovy, and Mounjaro, GLP-1 injections are for weight loss and to treat type 2 diabetes.But their use has been linked to a rare risk of developing pancreatitis, a dangerous inflammation of the pancreas that can prove fatal in extreme cases.Data published by the Medicines and Healthcare Products Regulatory Agency (MHRA) on 29 January show that, between 2007 and October 2025, the agency had received 1296 reports of pancreatitis—including 19 reports of deaths—in people who had been taking GLP-1 agonists or dual GLP-1/glucose-dependent insulinotropic polypeptide (GIP) receptor agonists.1That tally of 19 deaths is nearly double the number of pancreatitis related deaths (10) reported in GLP-1 agonist users by last June.2 At the time, the MHRA announced a study into... [...]

Navigating the prostate specific antigen (PSA) screening quagmire is challenging without falling into prostate cancer’s “heterogeneity black hole.” I read the 23 year follow-up of the European Randomized Study of Screening for Prostate Cancer (ERSPC), presented as confirming a “sustained reduction in deaths,” as exacerbating this dilemma by amplifying modest gains (13% relative risk reduction; rate ratio 0.87, 95% confidence interval 0.80 to 0.95) while downplaying substantial harms.1 With an absolute risk reduction of 0.22% (0.10 to 0.34; number needed to invite 456, 306 to 943), the update reinforces why no country mandates routine PSA screening: the overdiagnosis burden rarely justifies the benefit.2The ERSPC’s limitations remain substantial. It omits quality-of-life outcomes, overlooking the “labelling effect” of indolent diagnoses. Lead time bias inflates survival from diagnosis without extending life; overall mortality has remained similar between screened and control groups in previous analyses (rate ratio around 0.99). Overtreatment harms—biopsies, incontinence, and impotence—are... [...]

Which ideological approach is best to govern a health system? A widely read BMJ feature by Luke Taylor examines the fortunes of Colombia’s health system after attempted reforms introduced by its current government. Taylor, who has lived in Colombia—the setting for the latest series of The Night Manager, whose main character, played by Tom Hiddleston, finds himself at a fork in the road—paints a picture of a once functioning health system now in crisis.Colombia delivered some of the highest healthcare coverage in Latin America, with the lowest out-of-pocket spending, while being one of the lowest funded. You might put this success down to its model of “mandated competition” (doi:10.1136/bmj.s76).1 One of the features of this insurance based model is partnership with the private sector, which is tightly regulated and managed to control corporate profits. Care for poor people is fully subsidised. The Netherlands has a similar model.Now for the politics.... [...]

This Medical News article discusses key learnings from new World Health Organization guidance on the use of glucagon-like peptide-1 (GLP-1) medications for the treatment of obesity in adults. [...]

The World War served to focus attention in a popular way on the problems of human nutrition to an extent never observed before. The appeal of the United States Food Administration to the nation asserted that all our questions centered in food: its production, its distribution, its use, its conservation. “The more you know about these things,” Mr. Hoover exhorted, “the more valuable you will be and the greater will be your service to humanity.” During our first year as a belligerent (April 1, 1917, to April 1, 1918) we exported fifteen billion pounds of food—an increase of more than 200 per cent over the prewar average. The food shipped was enough to ration completely more than 21,000,000 men, and to supply a considerable surplus of protein-rich foods and fats besides. Much of this surplus was the result of the saving of the American people. This was done in spite of the fact that the estimated total production of the country for the fiscal year, in terms of nutritional units, was from 7 to 10 per cent below the average of the previous years. [...]

To the Editor I appreciated the recent Review of geroscience, which is timely and has multiple strengths, including its description of the status of promising interventions that may alter the aging process. However, it seems puzzling that an important class of interventions was not mentioned: exercise. There is substantial evidence that some forms of exercise can influence aging-related biological pathways, not just single conditions such as sarcopenia. Exercise affects multiple aging-related pathways listed in the article as targets for altering the biological aging process, including increasing autophagy, decreasing systemic inflammation, increasing DNA repair and decreasing telomere shortening, and preserving mitochondrial function in multiple tissues, not just muscle. This omission seems particularly striking because unlike the other interventions listed, it is not experimental but has been extensively tested, is proven to be of benefit for a variety of conditions, and is included in current lifestyle recommendations. Noting the potential effects of exercise would provide clinicians and patients with a possible way of affecting aging-related pathways that can be recommended based on existing evidence of benefits and implemented without waiting for future research. [...]

In Reply We thank Dr Hecht for his perspective and agree that exercise affects age-related cellular physiology and is beneficial for the prevention of disability and improvement in quality of life. In contrast, translational geroscience targets pathways identified through interventions shown to extend lifespan in model organisms such as mice, nematodes, and fruit flies. Studies in mice have shown that exercise benefits many indicators of health, but it does not appear to increase lifespan. Exercise induces many molecular changes, which makes it difficult to isolate which are responsible for its potential health benefits and complicates the selection of particular pathways to target for therapeutic translation. A major National Institutes of Health initiative, the Molecular Transducers of Physical Activity Consortium, is coming to completion. The initiative is intensively studying molecular changes induced by exercise in both humans and mice. It promises to provide molecular targets for interventions that may mimic or enhance the effect of exercise. This effort notwithstanding, increasing physical activity is a pillar of health promotion and disability prevention and should be vigorously encouraged. [...]

To the Editor We have several comments about the recent Review by Drs Chaker and Papaleontiou on hypothyroidism. [...]

In Reply We thank Ms Xiao and colleagues for recognizing the value of our Review on hypothyroidism and for highlighting several topics, including thyroid function monitoring for patients receiving thyroid hormone treatment who achieve euthyroidism, nonthyroidal illness syndrome, and subclinical hypothyroidism. With regard to monitoring strategies for achieving thyrotropin targets, we agree that thyroid function assessments should be performed regularly before transitioning to annual monitoring. [...]

To the Editor A recent Review on prostatitis correctly noted that important chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) clinical trials were powered using at least a 4-point decrease in the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) total score. A meta-analysis estimated the placebo response in CP/CPPS at −4.2 (95% CI, −6.31 to −2.09). This information should be communicated to patients and clinicians because it might be useful in the shared decision-making process about potential treatments. A systematic review and meta-analysis that included 35 randomized clinical trials of patients with CP/CPPS demonstrated that for every additional week of any given treatment for CP/CPPS, the total NIH-CPSI score decreased by a mean of 0.19 points. These findings imply that 32 weeks of treatment would be required to achieve an NIH-CPSI score reduction of 6 points, which constitutes the conventionally accepted minimum clinically important difference. Although the exact magnitude and duration of the placebo response in CP/CPPS are unknown, the placebo effect does not appear to change over time. [...]

To the Editor A recent Review on prostatitis provided a comprehensive summary but presented computed tomography (CT) as the sole advanced imaging technique for suspected prostatic abscess. In our view, magnetic resonance imaging (MRI) offers distinct advantages over CT in this clinical context. [...]

In Reply We agree with Dr Di Bella and colleagues that TRUS and MRI are alternative imaging modalities to CT for diagnosing prostatic abscess. Although TRUS has historically been first-line imaging to evaluate for prostatic abscess, CT is now more commonly performed because of greater accessibility and less patient discomfort than with TRUS. Magnetic resonance imaging provides better soft tissue characterization than CT and higher sensitivity for abscess detection. However, we respectfully disagree that MRI should be consistently prioritized over CT for subacute or chronic abscess presentations. Our perspectives are shaped by limitations of the US health care system, which may differ from systems in other countries. [...]

This Viewpoint examines adversarial collaboration—bringing investigators with opposing views to design, analyze, and publish studies together, often with a neutral arbiter—as a strategy for credible biomedical science. [...]

This prospective management outcome study conducted at multiple centers in Belgium, Canada, France, and Switzerland assesses whether using an age-adjusted D-dimer cutoff allows clinicians to safely rule out deep vein thrombosis (DVT) in adult patients presenting with suspected DVT. [...]

In youth we learn; in age we understand.Marie von Ebner-Eschenbach, Aphorisms [...]

The treatment landscape for first-line oncogene driver-negative metastatic non-small-cell lung cancer (NSCLC) has remained largely unchanged in recent years. Since the 2016 approval of the anti-PD-1 immune checkpoint inhibitor (ICI) pembrolizumab for front-line treatment of patients with metastatic NSCLC with PD-L1 expression of 50% or greater,1 numerous ICI monotherapies and combination regimens have followed. With an abundance of treatment options already available in the first-line setting, the HARMONi-2 trial—the results of which are presented by Anwen Xiong and colleagues in The Lancet2—raises critical questions: does ivonescimab, a novel bispecific antibody targeting VEGF and PD-L1, offer meaningful clinical advantages over existing PD-1 or PD-L1 inhibitors? And is there a compelling need for another therapeutic option in this space? [...]

In the Chief Medical Officer for England's 2018 independent annual report, we called for the creation of a Composite Health Index (CHI)1,2 to track and inform efforts to improve the nation's health. The UK Office for National Statistics (ONS) responded by developing a beta Health Index3 followed by three updates, the latest covering 2015–21, which was published in June, 2023.4 We commend the ONS for their work, although funding constraints have since halted updates. With the new Secretary of State prioritising health-driven economic growth, we believe a renewed CHI should play a key part in tracking and informing these efforts over the coming years. [...]

Tuberculosis is a leading cause of death globally. Given the airborne transmission of tuberculosis, anybody can be infected, but people in high-incidence settings are more exposed. Risk of progression to disease is higher in the first years after infection, and in people with undernourishment, immunosuppression, or who smoke, drink alcohol, or have diabetes. Although cough, fever, and weight loss are hallmark symptoms, people with tuberculosis can be asymptomatic, so a high index of suspicion is required. [...]

Our findings indicate that young children with AIPL1-related retinal dystrophy benefited substantially from subretinal administration of rAAV8.hRKp.AIPL1, with improved visual acuity and functional vision and evidence of some protection against progressive retinal degeneration, without serious adverse effects. [...]

Inherited retinal dystrophies are a genetically heterogeneous group of disorders that cause vision loss through degeneration or dysfunction of retinal photoreceptors. Gene-based therapies aim to correct the underlying molecular defect to arrest further degeneration or to ameliorate the dysfunction. Large improvements in vision have been reported in early phase clinical trials of gene-based therapies for some inherited retinal dystrophies characterised by functional defects with preservation of cellular architecture,1–4 and one gene therapy, voretigene neparvovec, has received regulatory approval. [...]

We are writing to respond to comments from Joshua W Miller and colleagues1 regarding our 2024 report of the Lancet standing Commission on dementia prevention, intervention, and care.2 Miller and colleagues propose adding homocysteine to the list of potentially modifiable dementia risk factors, citing a 2013 post hoc analysis of data from the VITACOG trial.3 This analysis suggested that lowering homocysteine concentrations through vitamin B supplementation reduced atrophy in a subgroup of people with mild cognitive impairment. [...]

Street vendors, who make up a substantial portion of the informal workforce in many low-income and middle-income countries, remain largely excluded from formal health insurance coverage, which poses a major risk to their health and financial wellbeing. Despite their key economic role, street vendors often do not have the legal recognition, stable income, and collective bargaining power required to access public or private health insurance schemes.1 [...]

Gill Livingston and colleagues report an updated combined population attributable fraction (PAF) of 45% for modifiable dementia risk.1 This statistic provides important direction for risk reduction and will receive much attention. [...]

I read with interest the Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission by Gill Livingston and colleagues.1 The authors present an updated meta-analysis on the association between hearing loss and dementia, reporting a pooled hazard ratio (HR) of 1·37 (95% CI 1·00–1·87), which is lower than previous estimates (1·9; 1·4–2·7).2 [...]

In the Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission, Gill Livingston and colleagues identify a final set of 14 modifiable risk factors for delaying or preventing dementia.1 However, although sleep was discussed, it was not included in this final set. [...]

We read with great interest the Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission.1 Although the report offers valuable insights, we believe it overlooks the substantial role of oral health in dementia risk. [...]

We are pleased that our 2024 Lancet Commission's1 discussion of dementia risk has prompted international interest. Within it, we have been transparent about the assumptions behind our new population attributable fraction (PAF) calculations and present the best current estimates. These estimates will continue to change with new research and adjustments in the way people live. We discuss other risk factors that might be included in the future as stronger evidence emerges, but which have not yet reached the consistent, high-quality evidence threshold for inclusion. [...]

Abstract Objectives To describe the rationale, design and data collection procedures of the Swedish CArdioPulmonary bioImage Study (SCAPIS) re-examination, which, in its further scope, aims to quantify and explain the development of atherosclerosis, pathological cardiovascular ageing, longitudinal decline in lung function and the malignant transformation of pulmonary nodules among middle-aged Swedes in the longitudinal SCAPIS. Methods SCAPIS re-examination is a prospective observational study reassessing approximately 15,000 participants (50% of the original SCAPIS cohort) from six university hospitals. Participants were aged 55–75 years at follow-up, occurring a median of 8.1 years after the baseline investigation. Standardized protocols replicated baseline imaging and functional assessments, including questionnaires, clinical assessments and extensive computer tomography imaging. Results Interim analyses of the first 5000 participants (50% women; median age 65.5 [61.8–69.1] years) indicated an expected age-related increase in the prevalence and treatment of hypertension (from 22% to 37%) and diabetes (from 4% to 8%), together with a modest rise in central adiposity. Body mass index (median 26.6 kg/m2) and the proportion of obesity (22%) remained largely stable, whereas current smoking decreased from 7.5% to 3.4%. The observed patterns were consistent in men and women. Conclusion Here we present the rationale, design, methods and management of incidental findings in the SCAPIS re-examination. By integrating serial imaging, functional testing and biomarker profiling, the re-examination will furnish unprecedented insight into cardiopulmonary disease dynamics in an ageing population. These data will underpin personalized risk prediction and inform preventive strategies, while serving as a benchmark for future population-based imaging cohorts. [...]

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

Journal of Internal Medicine, Volume 299, Issue 2, Page 177-177, February 2026. [...]

Abstract Background Liver disease is on the increase worldwide, with cirrhosis and liver cancer accounting for around 3.5% of all deaths. Objectives Investigate the prognostic utility of three non-invasive liver fibrosis markers in the Welsh primary care population for identification of those at risk of cirrhosis or hepatocellular carcinoma (HCC). Methods Using the Secure Anonymised Information Linkage (SAIL) Databank at Swansea University (2000–2017), we identified people with liver blood tests allowing calculation of three commonly used liver fibrosis markers: aspartate transaminase to alanine transaminase (AST/ALT) ratio, AST to platelet ratio index (APRI) and fibrosis-4 index (FIB-4). We modelled 10-year risk of cirrhosis/HCC across a range of thresholds using competing risk survival analysis and compared their prognostic value using decision curve analysis (DCA). Results Blood tests enabling calculation of FIB-4, APRI and AST/ALT were available for 203,005 people. At commonly utilized cut-points to detect advanced fibrosis/cirrhosis of 3.25, 1.5 and 1.0 for FIB-4, APRI and AST/ALT, respectively, the 10-year risks of cirrhosis/HCC were 4.7%, 16% and [...]

Abstract Excess aldosterone is a key driver of cardiovascular, renal, and metabolic injury, promoting hypertension, myocardial fibrosis, proteinuria, and progressive chronic kidney disease (CKD). Conventional therapies, renin–angiotensin–aldosterone system (RAAS) inhibitors, and mineralocorticoid receptor antagonists attenuate downstream receptor signaling but do not suppress aldosterone biosynthesis, allowing residual hormonal activity that perpetuates tissue damage. The long-term efficacy, endocrine selectivity, and clinical significance of directly inhibiting aldosterone synthesis, however, remain only partly defined, particularly with respect to sustained aldosterone suppression, preservation of cortisol production, and applicability across diverse cardiorenal disorders. This review provides a comprehensive and mechanistically focused synthesis of preclinical and clinical evidence on aldosterone synthase inhibitors (ASIs), examining their pharmacologic specificity, hormonal effects, and emerging therapeutic potential in primary aldosteronism (PA), resistant hypertension, and CKD. Next-generation ASIs—including baxdrostat, lorundrostat, dexfadrostat phosphate, and vicadrostat—demonstrate >100-fold selectivity for CYP11B2 over CYP11B1, enabling potent and reversible aldosterone suppression while maintaining cortisol biosynthesis. Across early-phase trials, these agents consistently reduce aldosterone concentrations, lower systolic and diastolic blood pressure, decrease albuminuria, and normalize potassium balance in PA, with favorable safety and minimal hypothalamic–pituitary–adrenal axis disturbance. Collectively, these findings position ASIs as a selective and mechanistically coherent therapeutic strategy that addresses residual aldosterone activity beyond conventional RAAS blockade. Although current evidence relies largely on surrogate endpoints, ongoing phase III outcome trials will determine whether ASIs can translate mechanistic promise into durable cardiovascular and renal protection, potentially redefining the therapeutic landscape of aldosterone-mediated diseases. [...]

Abstract Background Previous observational studies have reported an increased risk of venous thromboembolism (VTE) among non-steroidal anti-inflammatory drug (NSAID) users compared with non-users. However, these studies may have been subject to bias due to unmeasured confounders related to patient conditions requiring NSAIDs. We employed an active comparator new user cohort design, using acetaminophen as the active comparator. Methods New users of either NSAIDs or acetaminophen aged 18–65 years were identified from a Japanese health insurance claims database. The adjusted hazard ratio (aHR) of VTE among new NSAID and acetaminophen users within 60 days of prescription was calculated using propensity score overlap weighting and Cox regression. To examine how a naïve comparison between users and non-users of NSAIDs might affect the results, we repeated the analysis using non-users of NSAIDs as the comparator group instead of acetaminophen users. Results Among 4,282,421 new NSAID users and 2,728,202 new acetaminophen users, 1504 (0.022%) developed VTE during follow-up. New NSAID users had a significantly lower incidence of VTE compared with new acetaminophen users (aHR, 0.70; 95% confidence interval [CI], 0.62–0.80). When compared with non-users, NSAID users had a significantly higher incidence of VTE (aHR, 3.18; 95% CI, 2.85–3.55). Conclusion Although new NSAID users had a lower incidence of VTE than new acetaminophen users, they had a higher incidence compared with non-users. Assuming that acetaminophen does not increase VTE risk, these findings suggest that NSAIDs themselves may not increase VTE risk. [...]

Abstract Primary aldosteronism (PA) is a common cause of hypertension. Compared to patients with essential hypertension, untreated PA is associated with a two- to fourfold greater risk of cardiovascular disease, renal failure, and death. PA is caused by increased secretion of aldosterone from one adrenal gland in 30% of the patients and both adrenal glands in 70%. Patients with unilateral PA can be cured by adrenalectomy, whereas patients with bilateral PA should be treated with mineralocorticoid receptor antagonists. With these disease-specific treatments, the long-term prognosis is generally favorable. A major challenge in the management of patients with PA is, however, subtype differentiation, that is, to determine whether the disease is unilateral or bilateral. Adrenal imaging using CT or MRI misclassifies more than one third of patients, and clinical variables—including blood pressure, aldosterone, and renin concentrations—provide limited guidance, underscoring the need for more accurate diagnostic approaches. Adrenal vein sampling is currently considered the gold standard for this purpose, but it is a technically challenging procedure performed only in specialized centers. After adrenalectomy for unilateral PA, histopathological assessment and subtyping are crucial for determining postoperative prognosis. This process is complex and relies on detailed functional analyses that are not always straightforward to interpret. Therefore, new approaches for subtyping PA are required. In this review, we summarize recent advances in the management of patients with PA, with particular focus on the limitations of current approaches to subtype differentiation and the emerging roles of novel techniques, including positron emission tomography, steroidomics, proteomics, and transcriptomics. [...]

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

Abstract The etiology of Alzheimer's disease (AD) remains under active debate. In this perspective, we explore the hypothesis that a primarily infection-caused chronic dysregulation and weakening of human innate immunity via the underexpression, degradation, and inactivation of innate immune proteins necessary for direct antimicrobial effects and regulation of host defense and autophagy could lead to AD. Key evidence relates to the fact that important innate immune proteins such as LL-37—which can bind Aβ and block amyloid formation—as well as Apolipoprotein E, antiviral interferons, and TNF-α can be degraded and deactivated by enzymes produced by the common oral anaerobic pathogen Porphyromonas gingivalis (Pg). Pg produces numerous virulence factors; of particular importance for AD are Pg’s gingipain cysteine proteases. Deleterious effects of chronic Pg infection and gingipains include a systemic downregulation and paralysis of the interferon response, particularly the antiviral interferon-lambda response, which enables replication of endemic herpesviruses. The result is a chronic, low-level viral infectious assault on gut, nerves, and brain causing the production of Aβ antimicrobial peptides, accumulation of Aβ plaques, phosphorylation of Tau, progressive neuroinflammation, and neurodegeneration. The resultant innate immune system dysregulation, as an AD etiology, ties together the well-known amyloid cascade hypothesis and the infectious theory of AD into a unified explanation of the pathology and cause of AD. If this theory holds true, it suggests preventative approaches: (1) test for and eradicate Pg from oral flora, and/or directly deactivate the gingipains; and (2) reduce Herpesvirus exacerbations by the use of antiviral drugs and/or vaccines (e.g., Bacillus Calmette–Guérin). [...]

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

Abstract Objectives To assess factors associated with rapidly progressive interstitial lung disease (ILD) (RP-ILD) at time of ILD diagnosis in a multicentric retrospective cohort study of antisynthetase syndrome (ASyS). We used a complementary unsupervised approach, hierarchical clustering, to delineate distinct phenotypes among ASyS patients with ILD. Methods A total of 132 patients with ASyS, defined according to the 2024 ACR/European Alliance of Associations for Rheumatology (EULAR) ASyS classification criteria, and ILD, diagnosed by CT scan, were included. RP-ILD was defined by the presence of respiratory failure at ILD diagnosis or rapid ILD progression during the first 3 months. Results In our study, 39% of patients had RP-ILD at ILD diagnosis. Multivariate logistic regression analysis with cluster-robust SE identified the factors associated with RP-ILD at ILD diagnosis as male sex (aOR = 9.7 [1.6–59.5], p = 0.006), fever (aOR = 128 [12.6–1300], p  [...]

Abstract Gene therapy is emerging as a groundbreaking strategy for treating epilepsy, offering new hope to patients who do not respond to conventional medications. Despite advancements in anti-seizure treatments, nearly 30%–40% of individuals with epilepsy continue to experience uncontrolled seizures, highlighting the urgent need for more effective and long-lasting solutions. By addressing the underlying causes of epilepsy at the genetic level, gene therapy represents a paradigm shift in treatment. Two key approaches are being explored: (1) activating or supplementing beneficial genes to suppress seizures and (2) silencing harmful genes or pathways that contribute to epilepsy. To achieve these objectives, viral vectors, such as adeno-associated viruses and lentiviruses, have shown promise in delivering targeted genetic interventions. In parallel, cutting-edge techniques such as optogenetics, chemogenetics, and clustered regularly interspaced short palindromic repeat-based gene editing are enhancing the precision of these therapies, enabling greater control over neuronal activity. However, significant challenges exist, including ensuring safe and efficient gene delivery, maintaining long-term therapeutic effects, and mitigating potential side effects. This review examines recent developments in gene therapy for epilepsy, assessing its potential to deliver targeted, long-lasting treatments for drug-resistant epilepsy. By examining current strategies, therapeutic targets, and emerging technologies, it provides insights into the promising future of gene therapy as a transformative tool in epilepsy treatment and summarizes current clinical trials utilizing gene and cell therapy technologies for epilepsy. [...]

ABSTRACT The sphincter of Oddi (SO), as the critical bidirectional regulatory valve structure of the pancreatobiliary system, still requires extensive research regarding its functional assessment and dysfunction repair. This systematic review examines SO regulatory mechanisms, diagnostic approaches for dysfunction, and repair strategies. Studies have demonstrated that SO myoelectrical activity is regulated by neural, humoral, and neurohumoral mechanisms, although the specific pathways involved remain incompletely understood. SO motility features both tonic and phasic contractions, with abnormalities closely linked to pancreatobiliary diseases. Pancreaticobiliary maljunction (PBM) or congenital SO anomalies may induce reciprocal reflux of pancreatobiliary secretions, thereby elevating the risk of biliary tract carcinogenesis, particularly cholangiocarcinoma and gallbladder carcinoma. While invasive SO manometry (SOM) remains the diagnostic gold standard for sphincter of Oddi dysfunction (SOD), noninvasive techniques such as quantitative hepatobiliary scintigraphy (QHBS) and secretin-stimulated magnetic resonance cholangiopancreatography (ss-MRCP) show promising clinical applicability. Current therapeutic options for SOD include endoscopic sphincterotomy (EST), endoscopic endoclip papilloplasty (EEPP), endoscopic papillary balloon dilation (EPBD), and transduodenal sphincteroplasty. In the precision medicine era, developing standardized noninvasive assessment tools and quantifiable, controllable, and visualizable methodologies for SO structure and function is imperative to achieve a precise understanding of its physiological and pathological states, ultimately maximizing patient outcomes in SO-related disorders. [...]

ABSTRACT Bowel anastomosis is a fundamental skill for gastrointestinal surgeons, who must be proficient in both stapled and hand-sewn methods. Various inverting suture techniques have been described, each aiming to optimize security and healing. We describe a hand-sewn, two-layer side-to-side anastomosis using a continuous inverting suture with counter-traction, accompanied by illustrative images and a video demonstration. [...]

ABSTRACT Background Cosmetic tourism has become increasingly popular, with patients seeking lower cost cosmetic surgery overseas. However, complications often necessitate management in local public hospitals upon their return, placing a burden on healthcare systems. This study examines the demographics, complications, interventions and resource utilisation of patients presenting to an Australian hospital with complications from overseas cosmetic surgery. Methods This study retrospectively reviewed patients who presented to Westmead Hospital, NSW, during two time periods—01/07/2022 to 01/01/2023 and 01/05/2024 to 30/12/2024—with complications following cosmetic surgery performed overseas. Hospital records were analysed to extract data on patient demographics, comorbidities, presenting complications, interventions, diagnostic tests and resource utilisation. Descriptive statistics were used to summarise the findings, and patterns in clinical management were evaluated. Results Twenty-four patients met the inclusion criteria, with a mean age of 38.4 ± 12.5 years; 87.5% were female. Comorbidities included smoking (50%), mental health conditions such as anxiety, depression, or self-harm (20.8%) and hypothyroidism (12.5%). Abdominoplasty (54.2%), breast augmentation (20.8%) and liposuction (25%) were the most frequently performed procedures. The mean Charlson Comorbidity Index was 0.2 ± 0.4, and the mean LACE Index was 5.9 ± 1.5. Complications included wound dehiscence (45.8%), infection (41.7%) and seroma (20.8%). The median time from surgery to presentation was 3.8 weeks, with a mean hospital stay of 3.3 ± 2.9 days. Interventions included oral antibiotics (83.3%), IV antibiotics (58.3%), drainage or aspiration (33.3%) and surgery (54.2%). Conclusion Overseas cosmetic surgery is associated with high complication rates and significant utilisation of public hospital resources. These findings highlight the impact of cosmetic tourism on the Australian healthcare system. [...]

ABSTRACT Objective To assess the outcomes of a dual-surgeon approach to inflatable penile prosthesis (IPP) surgery, where two non-fellowship-trained urologists partnered to perform these procedures following intensive proctoring by an international expert. Patients and Methods A retrospective analysis of patients who underwent ‘dual-surgeon’ IPP surgery over a 10-year period between August 2008 and July 2018 was performed. Data on patient demographics, peri-operative parameters, complications (Clavien-Dindo system), rate of prosthesis failure, and the necessity of revision surgery were extracted, analysed and compared to published outcomes from high volume institutions. Results A total of 175 patients underwent IPP surgery over a 10-year period. The mean age was 64 years (IQR 59–70), the mean operative time was 65.7 min (range 32–157 min), and the mean length of stay in hospital was 1.6 nights (range 1–6 nights). The majority of patients (90.9%) received a Coloplast Titan Implant. The overall complication rate was 22.2% (38/175). Notably, there were no complications > Clavein-dindo grade III. Six patients (3.4%) required revision surgery for mechanical failure. Conclusions Dual surgeons performing IPP after intensive training from visiting international experts can achieve comparable outcomes to high volume local and international centres. This strategy of dual-surgeon collaboration should be considered in low volume implanters with no prior fellowship training in prosthetic urology. [...]

ABSTRACT Background Upper gastrointestinal tract anastomotic leaks are associated with increased morbidity and mortality, especially in the 30-day post-operative period. Techniques to reduce tension at the anastomotic site have been postulated to reduce leak rates. Our study investigates if continuous nasojejunal suction (via Freka trelumina tube) compared with standard of care passive free drainage via nasogastric tube results in reduced anastomotic leaks. Methods A retrospective cohort study was performed on all patients undergoing upper gastrointestinal tract resections with primary high-risk anastomosis (proximal partial, total/extended total gastrectomies and oesophagectomies) over the period between 2012 and 2023 between two major tertiary centres for malignancy. Comparative analysis of outcomes was performed between patients who did or did not receive prophylactic continuous suction, with the primary outcome being the incidence of anastomotic leak. Secondary outcome was the association between patient baseline characteristics and past medical history with anastomotic leaks. Statistical analysis was performed using SPSS v25.0. Results Over the 10-year period there were 351 operative cases, with prophylactic suction applied to 62.3% (n = 219) of patients. Overall incidence of anastomotic leaks was 10.3%, with higher proportions from 2-stage oesophagectomies (12.2%), compared with 3-stage oesophagectomies (5.9%) and gastrectomies (6.8%). In the overall cohort, incidence of anastomotic leaks was lower in the suction group (8.7% vs. 12.9%); however, this was not statistically significant (p = 0.210). Further subgroup analyses of 2-stage oesophagectomies showed marginal significance (9.0% vs. 18.9%, p = 0.050). Statistically significant risk factors for anastomotic leaks include any smoking history, elevated BMI, history of ischaemic heart disease, and prolonged operation duration. Conclusions Continuous gastric conduit suction may reduce the incidence of anastomotic leaks in two-stage oesophagectomies; however, a randomized controlled trial is required to investigate this further. [...]

ABSTRACT Introduction The General Surgery Fellowship Examination is the final hurdle examination before being eligible for fellowship of the Royal Australasian College of Surgeons. The purpose of this study was to assess the consistency and reliability of this examination, specifically whether there was evidence of systemic gender bias. Methods This is a retrospective audit of marks awarded in the examination between 2018 and 2022. Examination components were marked separately by two examiners, who assigned a consensus mark after discussion. Candidates' marks were analysed according to their demographics. Inter-observer agreement between examining pairs was analysed, as were marks awarded by individual examiners. Results Overall, 811 candidates (548 [67%] men and 263 [33%] women) sat the examination, of whom 520 (64%) passed. The pass rate was consistent over the study period. A total of 5672 pairs of examiners' marks were analysed to determine inter-observer agreement. Inter-observer correlation was 0.89 (95% C.I. 0.88–0.89). There were 110 examiners (92 men and 18 women). No examiner's marks were outside the 95% control limit for strictness or leniency compared with their peers. Pass rates were similar for male and female candidates (343/548 [63%] male vs. 177/263 [67%], p = 0.20). There were 102 marking pairs with one female and one male examiner. Inter-rater agreement between these examiners was 0.86 (95% CI: 0.82–0.91) when examining men and 0.76 (95% CI: 0.76–0.85) for women. Conclusion We found the examination to be consistent, fair and reliable, with no evidence of systemic gender bias. [...]

ABSTRACT Background Surgical stabilisation of rib fractures in select patients is shown to significantly improve outcomes. However, there is considerable variation in surgical techniques necessitating a comprehensive analysis of current practices. Methods The MEDLINE, EMBASE, Cochrane Library Compendex, Proquest, Scopus, and IEEE databases were systematically searched for studies across four time periods P1(2000–2006), P2(2007–2011), P3(2012–2016), and P4(2017–2021). SSRF Techniques of fixation were assessed and classified by design principles. Variation in approach, indications, and postoperative complications of different systems were described. Results A total of 132 clinical studies with a pooled population of 6816 were described. A further 22 pre-clinical studies were included. Numerous emerging techniques were identified in the pre-clinical literature. Established techniques of fixation with clinical data include: plating with screw fixation (n = 87 of 132 studies), plating with clip fixation (19/132), intramedullary implants (2/132), bioresorbable devices (7/132), and others. Evidence mapping showed a growing pool of clinical data for plating with screw fixation and highlights the paucity of data available for other devices preventing formal statistical comparisons of postoperative outcomes between fixation systems. Conclusion There is a wide range of techniques described for surgical stabilisation of unstable rib fractures, with the number of clinical studies published increasing. There is a geographical variation in the techniques described, and a burgeoning interest in minimally invasive rib fixation. Comparative studies and pooled data are uncommon. As interest in this field grows, there is a need for multicentre collaborative studies and refinement of indications for SSRF. [...]

ABSTRACT Background The ward round is the main communication channel between doctors and hospitalised patients; however, it is often poorly received by patients. Patient perceptions are rarely considered when implementing interventions in inpatient environments. This study therefore aimed to thematically assess patients' perceptions of a ‘Standard care’ ward round versus a ‘Sterile Cockpit’ ward round. Methods There were 71 Standard Care and 70 ‘Sterile Cockpit’ ward rounds audio-visually recorded. The ‘Sterile Cockpit’ group received a modified ward structure consisting of a protected zone where aviation-safety rules (allocation of team roles, no interruptions, one person speaking at a time, repeating of plan) were applied. Following the encounter, patients completed a survey on their perceptions of the ward round. Statistical analysis using Generalised Estimating Equations was conducted for quantitative outcomes, and qualitative outcomes were analysed using the six-stage process for thematic analysis. Results Of the 141 recorded ward round encounters (51% male, mean age 61.6 [SD: 15.4]), there were 130/141 (92%) surveys completed. Overall, patients in the ‘Sterile Cockpit’ group had significantly higher satisfaction than the Standard Care group, even when adjusting for the patients' sex, age, emergency/elective admission, and clustering on the patient (IRR: 1.07, 95% CI: 1.00, 1.14, p = 0.036). Thematic analysis determined that patients' perceptions of surgical ward rounds revolved around three key themes (Structure, Understanding and Engagement) and two subthemes (Communication Quality and Time). Conclusion Implementing the Sterile Cockpit ward round model was associated with an improved patient experience by enhancing understanding, engagement and perception of team dynamics, without increasing ward round duration. These findings suggest the Sterile Cockpit is a pragmatic solution to improving patient care and optimising the short amount of time that is available for ward rounds. [...]

ABSTRACT Background Skin-reducing mastectomy (SRM) allows implant-based immediate breast reconstruction in women with large, ptotic breasts. This study aimed to evaluate the surgical and patient-reported outcomes (PRO) following SRM. Methods A retrospective analysis was conducted on patients who underwent SRM between January 2011 and December 2014. Surgical complications, oncological outcomes, and PRO (using BREAST-Q) were collected, with a median follow-up of 10 years. Results Fifty-five women (95 breasts) underwent SRM and completed the first round of the BREAST-Q questionnaire. 82.3% (n = 45) had SRM for cancer treatment, and the remaining had risk-reducing surgery. 83.6% (n = 46) had direct-to-implant reconstruction, and the remainder had a tissue expander inserted. The mean breast weight was 714 g, and the mean implant volume was 398 mL. The overall complication rate was 58.9%. The most common complication was skin loss due to flap/skin necrosis (24.2%), followed by capsular contracture (18.9%), seroma (7.4%), wound dehiscence (5.3%), implant infection (2.1%), and bleeding (1%). The early implant loss rate was 10.5%. At 10 years (n = 17), the local recurrence rate was 4.4%, the overall survival rate was 97.7%, and the disease-free survival rate was 88.9%. Breast-Q scores were comparable to previous studies (mean score of 65.33). 30.9% of patients (n = 17) completed the modified BREAST-Q questionnaire at 10 years of follow-up. Reconstructed breast satisfaction was high, and 76.5% of patients would choose to undergo SRM again if given the option. Conclusion In certain patients with larger breasts, SRM can facilitate implant-based immediate breast reconstruction without the need for mesh. Despite relatively high complication rates, patient satisfaction remains high. [...]

ABSTRACT Background Enhanced recovery after surgery (ERAS) pathways are increasingly utilised in autologous breast reconstruction (ABR) to improve patient outcomes. This Australian study evaluates the impact of our centre's newly standardised electronic ERAS pathway from 2023 to 2024 compared to a transitional ERAS cohort from 2017 to 2018. Methods A perioperative ERAS protocol was implemented for patients undergoing DIEP flap reconstruction for therapeutic or prophylactic mastectomies. Key components included comprehensive patient education, standardised perioperative surgical proformas, goal-directed fluid resuscitation, mitigation of opioid use, early mobilisation, and diet reintroduction. Outcomes from the 2023–2024 cohort were compared with the 2017–2018 cohort. The primary endpoint was length of stay (LoS), from admission to discharge. Secondary endpoints included daily and total oral morphine-equivalent daily dosage (oMEDD, mg), incidence and duration of patient-controlled analgesia (PCA, hours), Days 1–4 pain scores and rates of major and minor complications alongside standardised Clavien–Dindo classifications. Results A total of 102 patients were analysed (transitional ERAS, n = 48; standardised ERAS, n = 54). LoS for the whole cohort of unilateral and bilateral patients decreased from 5.8 days (5.0–6.6) to 4.5 days (4.1–5.0), p = 0.007. Total oMEDD reduced from 155.0 mg (134.3–175.5) to 111.6 mg (85.0–138.2), p = 0.011. PCA incidence remained unchanged at 16.7%, but duration decreased from 31.8 h (19.9–43.8) to 14.2 h (11.7–16.7), p = 0.010. These trends were consistent across subgroup analysis. No significant difference in major complication rate was observed. Minor complications showed a marginal decline. Conclusion Our standardised ERAS pathway for DIEP flap reconstruction significantly reduced LoS and PCA duration without increasing major or minor complication rates. These findings underscore the value of multidisciplinary perioperative collaboration and establish a framework for best practices in ABR within the Australian healthcare context. [...]

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

ABSTRACT Objectives To understand the adoption of reusable surgical and anaesthetic devices across public hospital operating suites and recovery areas in Victoria. Methods Snapshot audit of procurement data of common medical devices utilised in operating theatres that are available as either reusable or single-use devices. A list of 49 common medical devices was created, and the usage data were obtained through surveys conducted by remote interviews of procurement or theatre staff between August 2024 and January 2025. Descriptive statistics were used to summarise data. Nine public health networks (i.e., 14 hospitals) were surveyed, comprising 121 operating theatres and 21 endoscopy/procedure rooms. Results Eight out of nine (89%) metropolitan public health services in Victoria use mostly single-use surgical and anaesthetic devices in the operating theatre. Of the 49 surgical and anaesthetic devices surveyed, 46/49 (94%) had a reusable alternative available at a minimum of one of the nine health services surveyed. Five of 16 (31%) anaesthetic devices, 15/27 (56%) surgical devices, and 2/7 (29%) recovery room devices had a reusable alternative available. The average hospital adoption of surveyed reusable devices across all sites was 22/49 (45%). Conclusions Most (8/9) public health services in Melbourne surveyed utilise mostly single-use devices in perioperative settings. This audit provides a snapshot where reusable alternatives are available to influence future procurement. As the Victorian healthcare system rapidly transitions to renewable energy sources of electricity, there are considerable procurement opportunities to reduce scope three greenhouse gas emissions from healthcare. [...]

ABSTRACT Introduction While 2D mammography is the standard for breast cancer screening, its sensitivity is reduced in dense breasts, impacting early detection and extent assessment. This study, for the first time in New Zealand, evaluated the utility of supplementary multi-modality imaging (tomosynthesis, ultrasound and magnetic resonance imaging [MRI]) in a risk-stratified population. Methods A retrospective case study (May 2022–September 2023, New Zealand private clinic) analysed patients by Tyrer-Cuzick (TC) v8 lifetime risk and by Volpara density categories. All patients in the screening pathway (n = 2171) underwent 2D mammography and tomosynthesis. Those patients with high breast density received supplementary ultrasound, and those with TC8 Risk scores of ≥ 30% were offered abbreviated MRI. Symptomatic patients (n = 230) underwent standard diagnostic workup. Detection rates and extent of disease using multi-modality imaging were compared. Results Of the 2401 patients, 205 were high-risk criteria (≥ 30%) and 19 breast cancers (16 invasive, 3 DCIS only) were diagnosed. Tomosynthesis identified 38% (6/16) more invasive cancers than 2D mammography alone. Ultrasound and MRI detected an additional 27% (4/16) invasive cancers occult on other modalities, predominantly in those women with high density (Volpara ‘D’) breasts. Ultrasound and particularly MRI demonstrated superior accuracy in assessing disease extent, including identifying multi-focal and multi-centric disease that was not detected by 2D or tomosynthesis. Conclusion Supplementary imaging modalities, particularly MRI, significantly improve breast cancer detection and assessment of disease extent in high-risk women. These findings support a personalised screening approach integrating risk assessment and breast density to guide imaging modality selection. [...]

ABSTRACT Background Increased breast density is associated with increased breast cancer risk, particularly interval-detected cancers. This study describes interval cancer detection rates by breast density notification status and timing of diagnosis (0–12 months vs. 13–24 months). Methods 401,254 screening records for 235,333 clients attending a population-based screening program in 2016–2019 were extracted from the BreastScreen Western Australia database. Crude and age-standardised interval cancer rates (ASR), aggregated over three-year periods, were calculated per 10,000 client-years and reported by breast density notification status, screening round, and timing of diagnoses. Results Overall, interval cancer rates were 2–6 times higher in clients notified they had dense breasts compared to those who were not flagged as having dense breasts. The 2016–2018 ASRs were higher in the first year (vs second year) for clients notified they had dense breasts (ASRs: 28.2 (95% CI: 12.9–66.0) vs 20.6 (95% CI: 13.2–55.8) per 10,000 client-years, respectively), particularly notified clients screening for the first time (ASRs: 32.7 (95% CI: 6.9–111.2) vs 18.2 (95% CI: 5.9–92.0), respectively). The corresponding rates for 2017–2019 showed a similar trend but of lesser magnitude (ASRs: 17.6 (95% CI: 12.9–34.2) vs 15.7 (95% CI: 11.0–35.5) for 0–12 vs 13–24 months, respectively), regardless of screening round. Conclusion Interval cancer rates were at least similar or higher in the first 12 months compared to 13–24 months post screening for clients notified they had dense breasts, contrary to national reports of interval cancer detection rates. The clinical implications are two-fold: performance metrics for screening programs that notify women of their breast density may need refinement, namely interval cancer rate targets within 0–12 months, and breast density notification could lead to earlier diagnoses of interval-detected breast cancers. [...]

ABSTRACT Introduction Accurate staging is essential in anal cancer to guide therapy and prognostication. While MRI remains the modality of choice for local staging, its limitations in assessing nodal and distant metastases have prompted evaluation of FDG PET/CT as an adjunct. The American College of Radiology recommends FDG-PET/CT as a complementary modality for initial staging, particularly for nodal assessment. Methods A systematic search of PubMed, EMBASE, Web of Science and Scopus was conducted up to August 2025 following PRISMA guidelines (PROSPERO ID: CRD1149778). Studies included reported adult patients with biopsy-proven anal squamous cell carcinoma who underwent both MRI and FDG-PET/CT for initial staging. Primary outcomes included per-patient sensitivity/specificity for metastasis, changes in TNM staging and therapeutic outcomes, including management modification. Results Six studies (n = 246) met the inclusion criteria. Five studies reported on staging changes, where FDG-PET/CT altered staging in 22.5% (95% CI: 12.3–34.7) of patients, more commonly through upstaging than downstaging (16.2% [95% CI: 10.7–22.5] vs. 6.3% [95% CI: 1.5–14.2]). Upstaged patients were predominantly nodal (74.6% [95% CI: 63.2–83.1]). Previously occult metastases were identified with FDG PET/CT in 3% (95% CI: 1.1–6.9) of patients. Management changes occurred in 20.7% (95% CI: 14.9–27.4), predominantly through radiotherapy field expansion or dose modifications. Conclusion FDG-PET/CT following MRI provides incremental diagnostic and therapeutic value in anal cancer staging, through refining nodal and metastatic staging and influencing radiotherapy planning, supporting its routine integration to optimise staging accuracy and management decisions. Trial Registration PROSPERO: CRD42023446290 [...]

ABSTRACT The uptake of stereotactic radiosurgery (SRS) for the treatment of brain metastases (BM) has been rapid. SRS differs from other forms of radiation therapy in that large radiation doses are typically delivered with small margins for error and high dose heterogeneity. Geometric accuracy relies on the integrity of the entire treatment chain including patient immobilisation, imaging, treatment equipment and verification. Given this requirement for high fidelity geometric and dosimetric accuracy, credentialing for SRS within clinical trials requires special considerations. This process is further complicated by the range of treatment equipment that may be used to deliver SRS. The Trans-Tasman Radiation Oncology Group (TROG) SRS Technical Working Group was established to develop technical guidelines for SRS to BM in clinical trials in Australia, New Zealand and any other countries contributing to TROG recruitment. The panel comprised experts from Radiation Oncology, Medical Physics, Radiation Therapy and the TROG Quality Assurance (QA) team. These guidelines were developed collaboratively to assist trial management committees to formulate SRS credentialing and QA requirements appropriate for the clinical questions addressed by their trial. [...]

ABSTRACT Introduction CT guided microwave ablation (MWA) provides a suitable nonsurgical alternative for the treatment of hepatocellular carcinomas (HCC) in order to improve overall survival and local tumour progression. The purpose of this retrospective audit was to evaluate the overall efficacy of MWA and provide local data into the treatment's success, recurrence rates and overall survival. Methods A retrospective single centre audit of MWA for Hepatocellular Carcinomas (HCC) undertaken by interventional radiology at a large tertiary centre identified 90 eligible participants between January 2019 and 31st August 2024. Analysis among participants evaluated the overall technical success, procedural morbidity and mortality, and oncological outcomes including overall survival and local tumour progression through descriptive statistics. Results Of the 89 included participants (90 ablated HCCs), there was no reported immediate post-procedure residual disease with a peri-procedure morbidity of 5.6%, with all reported procedural complications minor. Median recurrence-free survival was 26.5 months (IQR 8.25–39.75 months) with a median time to local tumour progression of 12 months (IQR 8.5–48.1 months). The overall local tumour progression rate was 13.3%. The overall survival at one year was 88.89% (n = 63) and two years of 72.92% (n = 48). The median survival time was 35 months (95% CI 30–42 months). Conclusion MWA provides an effective and feasible nonsurgical treatment option for solitary HCCs with reported local tumour progression, overall survival, and technical success consistent with internationally published literature. [...]

ABSTRACT Lung cancer is a major disease that seriously threatens human life and health. As one of the main treatment methods for lung cancer, radiotherapy (RT), while combating cancer cells, inevitably causes damage to the surrounding normal lung tissues. Radiation-induced lung injury (RILI) is a common and serious complication of RT that can seriously affect the treatment process of patients, reducing their quality of life (QOL) and survival time. Conventional RT aims to reduce the incidence of RILI in patients by limiting the radiation dose to normal lung tissue. This approach assumes that lung function is uniformly distributed. However, there is heterogeneity in human lung function. To address this challenge, functional lung imaging (FLI) has emerged and become a research focus. In the field of medical imaging technology, Single-Photon Emission Computed Tomography (SPECT), Positron Emission Tomography (PET), Magnetic Resonance Imaging (MRI), CT, and other technologies can all obtain FLI. Whatever imaging modality is used, lung perfusion (Q) on imaging serves as a surrogate for RILI. Furthermore, the combination of FLI and RT has given rise to functional lung avoidance RT (FLART), which can precisely reduce radiation exposure to functional lung (FL) regions by adjusting the radiation dose distribution, thereby effectively reducing the incidence of RILI. This narrative review comprehensively explores several key aspects, including FLI modalities, the definition of FL, the clinical applications of FLART, the impact of FLART on QOL, and the limitations of FLART. These discussions provide a good basis and guidance for the follow-up clinical work. [...]

ABSTRACT Introduction The purpose of this study was to understand the clinical indications and utility of a barium swallow study in patients who have already been investigated with an upper gastrointestinal (UGI) endoscopy. It would be useful to determine the additional diagnostic information provided by a barium swallow study given endoscopy is considered the gold standard for examining the UGI tract. Methods This retrospective study examined all barium swallow studies performed at a single tertiary hospital and identified patients who had been investigated with an UGI endoscopy in the preceding 6 months. The radiology request forms, barium swallow reports, UGI endoscopy reports and clinic letters were reviewed to determine the most frequent clinical indications, quantify and characterise new findings on barium swallow and determine the proportion of patients with alteration in management. Results Between 1 January 2023 and 30 September 2023, 105 of 318 patients investigated with barium swallow studies had received a recent UGI endoscopy. Over half of the study requests were non-specific, aimed at identifying the cause of dysphagia. A total of 59 studies (56.2%) demonstrated findings that were not apparent on UGI endoscopy. The most common new finding was dysmotility (n = 53, 89.8%). Of the patients with new findings, 24 (40.7%) experienced no change in management, nine (15.2%) were offered lifestyle advice, seven (11.9%) were referred to speech and language therapy and seven (11.9%) were started on medication. Conclusion A barium swallow study is a helpful adjunct to UGI endoscopy, especially in the diagnosis of dysmotility. [...]

ABSTRACT Acute lymphoblastic leukaemia (ALL) is the most common paediatric malignancy and remains one of the most common causes of cancer-related death in children and adolescents. It is characterised by the proliferation of immature lymphoid cells capable of infiltrating bone marrow, blood and extramedullary sites. Five-year overall survival rates exceed 90% with current multidrug chemotherapeutic regimens. This manuscript reviews the abdominal imaging features of leukaemic infiltration in children with ALL at the time of initial diagnosis and following relapse. [...]

ABSTRACT Introduction This retrospective single-institution study evaluated the safety, efficacy and durability of stereotactic radiosurgery (SRS) for trigeminal neuralgia (TN) and related facial pain syndromes—including TN1, TN2, multiple sclerosis (MS) associated-TN and atypical facial pain (AFP). Methods We included 192 patients treated with Gamma Knife SRS between 2015 and 2022 at Australia's only publicly funded GK centre. Outcomes included Barrow Neurological Institute (BNI) pain scores, time to response and relapse. Kaplan–Meier and Cox regression analyses were performed. Results Median follow-up was 5 years. Treatment response occurred in 88.5%, with a relapse rate of 30%. Faster response was seen with 85 Gy (p = 0.004) and prior SRS (p = 0.02). MS-related TN relapsed earlier than vascular, tumour, idiopathic or stroke-related causes (p = 0.027) and TN1/TN2/AFP (p  [...]

ABSTRACT Aim To evaluate the incidence of pseudoprogression on 18F-FDG PET/CT scans in metastatic melanoma patients commencing immune checkpoint inhibitor therapy and to determine the average time to confirmed 18F-FDG PET/CT response in the pseudoprogression cohort identified. Methods Patients with metastatic melanoma who underwent baseline and follow-up 18F-FDG PET/CT scans after commencing immune checkpoint inhibitor therapy at Alfred Hospital (2012–2023) were retrospectively reviewed. Cases of pseudoprogression were identified by a keyword search of reports and confirmed on image review by a nuclear medicine physician. Data on timing of confirmed response, immune-related adverse events, and autoimmune history were also collected. Results 10/401 (2.49%) metastatic melanoma patients were confirmed as having pseudoprogression on PET/CT. 8/10 (80%) had new FDG-avid lesions and 2/10 (20%) had an increase in size and SUVmax of original disease. 8/10 (80%) of patients achieved complete metabolic remission on subsequent PET/CT scans with an average time to confirmed reduction of disease on PET/CT of 28.4 weeks. 4/10 (40%) received dual agent immunotherapy. 8/10 (80%) developed irAEs of varying types and severity. 2/10 (20%) had a history of pre-existing autoimmune disease. 9/10 (90%) of pseudoprogression patients are alive at last review. Conclusion Pseudoprogression on 18F-FDG PET/CT occurred in approximately 2.5% of metastatic melanoma patients commencing immunotherapy with an average time to subsequent confirmed response of ~6 months. This highlights the importance of not ceasing immunotherapy prematurely based on early 18F-FDG PET/CT findings. [...]

ABSTRACT Introduction Cancer is the current leading cause of death in Australia, with a mortality and morbidity burden that is expected to rise with the aging population. Despite radiotherapy being indicated in 52% of cancer cases and contributing to 40% of cancer survival, radiation oncology (RO) research has not been prioritised by domestic or international research funding groups. Methods This study reviewed the past 5 years of publicly available oncology grant funding data from Australia's largest funding organisations, including commonwealth, individual state and territory governments, and philanthropic organisations. Data were retrieved from individual organisations' websites and GrantConnect. Grants for potential RO projects were identified using search terms. Additional descriptive information was retrieved using search engines. The combined data were assessed to determine inclusion/exclusion from the final RO grant pool. Descriptive statistics were generated using Microsoft Excel. Results Our analysis identified 1660 oncology grants, of which 74 (4.5%) were deemed to be RO grants. The total value of oncology grants was AUD$1.89 B, and RO grants was $60 M (3.2%). Of the RO grants, 39% were provided by philanthropic organisations, 39% by the Commonwealth Government and 22% by state and territory governments. Only 9% of RO grants were awarded to radiation oncologists. Conclusions This study demonstrates the low proportion of Australian oncology research funding awarded to RO projects. The gap between the clinical importance of RO and the funding it receives risks delays in more effective and less toxic radiation therapy reaching Australian cancer patients. [...]

ABSTRACT Introduction Diagnostic radiologist reporting productivity can be measured via Relative Value Units (RVU). The volume of other operational or clinical activities during a radiologist's workday is burdensome but has thus far escaped quantitation and is often not recognised by referrers or administrators. The purpose of this study was to quantify and classify non-RVU-generating activities and measure their impact on productivity. Methods A prospective, observational study was performed at a large public hospital. Radiologists' activities were observed for a whole day over a total of 62 days. Radiologists' RVUs straddling 5 days before and after the observation day were reviewed to account for potential Hawthorne Effect bias. Results Across all radiologists, a median of 31% (IQR: 22%–36%) of their workday was occupied by non-RVU-generating activities. Despite that, in their remaining workday, in aggregate, the radiologists' median productivity—as measured by RVU-equivalent minutes—was 62% (IQR: 26%–114%) higher than their expected EFT equivalent. 46% of radiologists' non-RVU activities were devoted to trainees. Another 34% is devoted to interactions with referring colleagues, whilst 12% is spent on administration and operations. Conclusions Almost one third of a radiologist's daily responsibilities encompass non-RVU-generating activities crucial for the effective operation of an academic radiology department. Implementing tools to capture and quantify such activities is essential for garnering recognition within the organisation and with hospital administrators. At our hospital, each radiologist produces nearly two-thirds of an additional radiologist's workload during the remaining reporting time; a critical warning indicator for burnout risk and quality deterioration. [...]

ABSTRACT Objective To determine if the establishment of a multidisciplinary allied health training demonstration site, as one part of the expanded Rural Health Multidisciplinary Training (RHMT) programme in the Lachlan region, had a positive social return on investment (SROI). Methods This SROI only reflects the incremental impact of the expanded RHMT programme delivered by one University Department of Rural Health (UDRH), to one additional training demonstration site in the Lachlan region. Scope does not include the well-established ongoing RHMT programme, nor the complete body of work being delivered by the UDRH. This SROI investment referred to the grant to fund the incremental expansion of the RHMT programme to training demonstration sites in more remote settings, in addition to the in-kind and/or cash resources provided by the UDRH. The SROI was based largely on actual data (evaluative) and some future data (forecast). Operational and qualitative data were collected to determine the investment and return of the programme. Design The SROI was conducted over a 3-year time horizon, took a societal perspective, and included consumer feedback in both the design and interpretation of results. A 25% discount to the value of future rural employment was applied for attribution. There was no comparative group. Setting Rural New South Wales, Australia. Participants Multidisciplinary health students who completed a placement at the training demonstration site and their supervisors, host organisations and members of the rural community, including First Nations peoples. Main Outcome Measures Value of the ‘investment’ required to implement the expanded RHMT programme. Value of the ‘social return’ generated from the expanded RHMT programme, including the value of the students' intended future rural allied health employment. Results The expanded RHMT programme included 99 students across 422 weeks of placement. For every $1 spent on the expanded RHMT programme, the SROI was $1.60. The intended future rural health employment attributed 65% of the SROI value. Conclusion This study supports ongoing federal government funding into quality rural health student placements, with benefits of value observed for students and their supervisors, host organisations and members of the rural community. [...]

ABSTRACT Objective To understand how rurality and socioeconomic deprivation intersect to influence health outcomes for Māori (Indigenous population) and non-Māori in Aotearoa New Zealand (NZ). Methods Firstly, Census 2018 was used to describe population-level distributions of NZ's 4.7 million residents by rurality [measured using the Geographic Classification for Health (GCH)], socioeconomic deprivation [using NZ's Deprivation Index (NZDep)], and ethnicity (Māori and non-Māori). Secondly, using the national Mortality Collection as the numerator and Census-based population estimates as the denominator, rural: urban mortality rate ratios (MRRs) for Māori and non-Māori, adjusted for NZDep, were estimated from multivariate Poisson regression models. Results For the NZ population, rurality and socioeconomic deprivation were found to intersect differently for Māori and non-Māori. Of the 160 170 all-cause deaths in 2014–2018, 64% were 75 years or older. Almost half (46%) of the deaths in those under 75 years were considered amenable. For Māori and non-Māori aged 45–59 years, higher rates of mortality (all-cause and amenable) for rural residents, compared to urban, were attenuated when adjusted for socioeconomic deprivation. In those under 45 years, rural: urban disparities in mortality (all-cause and amenable) remained; for example, for Māori the crude amenable MRR was 1.31 (95% CI 1.17, 1.47) and the adjusted, 1.26 (95% CI 1.13, 1.41); for non-Māori, the respective estimates were 1.45 (95% CI 1.33, 1.58) and 1.46 (95% CI 1.33, 1.59). Conclusions Māori ethnicity, living in rural areas and socioeconomic deprivation frequently co-exist. Rural–urban disparities in all-cause and amenable mortality evident in younger age groups, particularly those under 45 years of age, cannot be explained by ethnicity or socioeconomic deprivation. [...]

ABSTRACT Objective Management of psychiatric disorders in the perinatal period is a common presentation in primary care. There is a need to understand how general practitioners (GPs) use guidelines and resources and incorporate the knowledge within clinical practice. This study aims to explore Australian GPs' knowledge and confidence in psychotropic prescribing in all stages of pregnancy in accordance with current guideline recommendations. Design Cross-sectional anonymous online survey. Setting National GP survey was undertaken. Participants 132 GPs responded, 84% female, with 41% rural and 59% in metropolitan practice. Main Outcome Measure: exploring knowledge and confidence in psychotropic prescribing, vignettes of a range of clinical scenarios following recommended guidelines, and resource use and screening practices. Exploratory analysis using nonparametric tests occurred between sub-groups within the data, including zones of practice and GP experience. Results Overall, 83% were confident in psychotropic prescribing, a percentage that decreases with more complex and specialised psychotropic medication usage. Rural GPs had higher levels of prescribing knowledge and confidence across scenarios; however, they ranked accessing support from perinatal and general psychiatry lower in treatment choices. Years of experience were not significant. All GPs were aware of clinical prescribing guidelines, with up to 95% having used them. This was less so, with only 37% aware of Australian national perinatal mental health guidelines. Discussion GPs have considerable knowledge and confidence and follow best practice recommendations in prescribing common psychotropic medications. The more complex the mental health requirements, the reduced level of confidence and need for greater specialist support. Differences in rural practice locations were observed and could be better served with streamlined support and referral pathways to specialist perinatal mental health advice. Clinical pharmacological practice guidelines were used; however, lack of awareness and usefulness of national guidelines on perinatal mental health could be improved by more specific guidance targeted to a GP population. [...]

ABSTRACT Objective This qualitative research study investigated the lived experiences of postnatal support received by mothers in rural North Queensland and how health service delivery is affected. Setting and Participants Postnatal mothers, aged over 18, who live in rural or remote areas based on the Modified Monash Model (MMM) 4–7 in North Queensland were eligible for the study. Design This study was grounded in a constructivist paradigm and employed a qualitative research design utilizing semi-structured interviews. Data was analyzed using reflexive thematic analysis informed by a feminist theoretical framework. Participant interviews were conducted via Microsoft Teams videoconferencing software. Findings Three themes were generated from the data that provide insight into the postnatal social support available to participants and how this could inform woman-centred rural health service delivery: (1) marry the farmer, marry the farm (2) connection, continuity and clinical handover and (3) rebuilding the village. Discussion Women experienced many challenges ranging from social isolation to broader health system and workforce issues that undermined access to healthcare during their transition to motherhood. Continuity of care and health professionals having ‘rural cognisance’ is highly valued among mothers. Health professionals working with rural mothers should be informed about local and online opportunities for social connection. Rural mothers are resilient, building their own support network, despite health system failings. The narratives of rural mothers highlight significant deficiencies in the existing service models and underscore the necessity for systemic reforms that prioritise woman-centred care. Conclusion Rural mothers' postpartum experiences are shaped by isolation, limited healthcare access and structural challenges. While rural mothers demonstrate resilience, the ongoing emphasis on self-reliance obscures urgent systemic failings and highlights the pressing need for inclusive, woman-centred rural maternal health policy and service reform. [...]

ABSTRACT Introduction Community Health Workers (CHWs) play an important role in delivering primary health care (PHC) services in rural and remote areas. Community perceptions regarding CHWs impact the acceptance, satisfaction and utilisation of health care services. This subsequently affects overall health outcomes and equity within the system. However, the various factors influencing these perceptions are still dispersed across different studies. Objective To identify and synthesise the factors influencing community members' perceptions of PHC services delivered by community health workers in rural areas. Design Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 guidelines, a Systematic Review was conducted. Method A thorough search across seven databases for English-language peer-reviewed publications from 1990 to 2024 yielded 4996 records. Following screening of titles and abstracts, we reviewed 231 full texts and ultimately included 30 articles for in-depth appraisal. Results Articles from 15 countries identified three interconnected thematic clusters affecting community perception: (1) structural and service delivery cluster, including CHW accessibility, service availability and healthcare quality; (2) trust cluster, such as trust, competency and confidentiality and (3) identity and sociocultural cluster, including CHWs' gender and CHWs from the same community. Conclusion Incorporating identified factors into the training curriculum for CHWs, their capacity to meet community expectations and build trust can be enhanced. These insights can be used to align services with community needs. This systematic review identified important factors for improving CHWs' delivery of PHC services in rural areas that ensure these services are sustainable and responsive to community needs. [...]

Australian Journal of Rural Health, Volume 34, Issue 1, February 2026. [...]

ABSTRACT Objective To describe the clinical and demographic profile of Australian children first diagnosed with acute rheumatic fever (ARF) or rheumatic heart disease (RHD) before the age of 5 years, with comparison to children aged 5–14 years. Methods Linked emergency department, hospitalisation, RHD register and death records from the End RHD in Australia: Study of Epidemiology were used to identify first ARF/RHD diagnosis occurring in [...]

ABSTRACT Introduction Understanding the unique affordances of place-based medical education (PBME) is essential to train highly skilled physicians for a particular place. Clinical reasoning (CR)—a context-specific core physician competency—is well suited to achieve this goal. Objective To map existing evidence and conceptualise how ‘place’ impacts CR development in medical students and trainees. Design Using PRISMA ScR guidelines, empirical, peer-reviewed, full-text, English-language journal articles on PBME in Medline, CINAHL, Scopus, and ERIC databases published between 1975 and 2024 were reviewed. Place and CR development were defined as participants' sense of authentic clinical training environment and learning of relevant to cognitive and sociocultural processes of patient diagnosis and management, respectively. A theory informed constructivist content analysis of data was undertaken. Results Of 2874 records, 27 met the inclusion criteria. CR development was an indirect finding in 26/27 reports. Evidence was available only for rural medically underserved places which afforded ‘HARD’, detailed as follows: longitudinal integrated clerkships, routine parallel consultations, closely knit teams, and workforce constraints enabled Hands-on patient engagements (H), Abundant patient exposures (A), and supported taking responsibility in patient care (R). Exposure to diverse practice niches and resource constraints sensitised students to Diversity in clinical practices (D). Discussion ‘HARD’ characterises place dependence and place attachment in CR development and fosters an identity aligning with expert clinicians situating reasoning in context. These underpin dynamic patterns of context signifying the distinctiveness of place. Conclusions Exploring distinctiveness of place using ‘HARD’ framework can transform PBME scholarship to prepare more physicians ready to serve intended places, including the medically underserved. [...]

ABSTRACT Objective To understand student and supervisor perceptions of the benefits and challenges of undertaking longer-term rural placements. Participants and Setting Nursing, midwifery and allied health students who completed a clinical placement of at least 8-week duration in the Darling Downs and South West Queensland regions in 2022 and placement supervisors. Design Qualitative inductive design using semi-structured interviews. Results Nineteen student and 14 supervisor interviews were conducted. Four key themes were identified—(1) Rural community connection and engagement, (2) Students developing confidence and integrating into healthcare teams, (3) Investing in student supervision and (4) Social, practical and logistical considerations. Conclusion Results suggest that longer-term placements facilitate valuable rural community connections and foster trust between students and supervisors, leading to increased independent practice and, in some cases, reduced supervision workload. Both community connections and integration into healthcare teams are likely to foster place-based connections over the longer duration of placements, thereby positively contributing to rural workforce outcomes. Social, practical and financial challenges were noted, and as such, adequate supports are critical to positive longer-term placement experiences. Rural workforce policy should continue to promote longer-term health placement opportunities, including sufficient support for placement provider organisations and supervisors, to support rural workforce recruitment and retention. [...]

ABSTRACT Objective To identify the barriers and facilitators for timely detection and optimal management of otitis media (OM) in Aboriginal children in a primary care setting from the perspective of Health Care Providers (HCPs). Setting A large regional town in the Kimberley region of Western Australia. Participants Thirty HCPs to Aboriginal children. Design A qualitative, aboriginal co-designed, participatory action research study with semi-structured interviews and focus groups. Results Barriers were identified throughout the child's presentation and management and included challenges with paediatric ear examinations, earwax obstructing the view of the tympanic membrane, unfamiliarity with diagnostic tools, multiple guidelines with varying recommendations, and confusion with accessing ENT specialists. Multiple facilitators were identified and included training HCPs in paediatric examination techniques and wax removal, a single best practice guideline, and system changes to facilitate access to ENT specialist support if required. Importantly, an expanded clinical role of Aboriginal Health Practitioners (AHPs) was identified to augment efficient and effective clinical OM assessment and management in children presenting to clinic. Conclusions All barriers could potentially be overcome through a programme that enhances theoretical knowledge and practical skills in paediatric ear examination, otoscopy, and safe, timely removal of earwax, improved communication with ENT specialists, and an expanded clinical role for AHPs. Our findings carry important implications for managing OM in primary care services across Australia. [...]

ABSTRACT Objective This case study describes the contributions made by the Broken Hill University Department of Rural Health (BHUDRH) to improving child health care access and health outcomes over almost three decades. Background Compared to their metropolitan counterparts, rural and remote children experience persistent inequities in health, development, and education, exacerbated by environmental and service access challenges. Methods A retrospective synthesis of program documentation, evaluation reports, and peer-reviewed literature relating to four major BHUDRH-supported initiatives: lead management programs, the Allied Health in Outback Schools Program, School Health Hubs, and the School-Based Primary Health Care Registered Nurse initiative was undertaken. Findings The BHUDRH contributed to the development and delivery of child health services through investments in program development; research and evaluation; workforce development; and service delivery. The BHUDRH used its intellectual capital to help guide these developments through leadership and cross sector collaboration; governance and oversight; and securing funding for infrastructure development. Outcomes included a 75% reduction in average blood lead levels; access to allied health services for approximately 150 school children annually; establishment of $4.7M School Health Hub infrastructure across seven primary schools; and creation of a new workforce of school-embedded primary health care nurses. Conclusion This case study demonstrates how UDRHs act as catalysts for sustained, system-level change in response to community-identified health priorities. Lessons from Broken Hill highlight the value of university-community partnerships, research translation, and cross-sector governance in addressing complex rural health inequities. These contributions highlight the significant contributions made by UDRHs in rural contexts beyond health workforce parameters. [...]

Australian Journal of Rural Health, Volume 34, Issue 1, February 2026. [...]

10.1542/6384470372112Video AbstractPEDS-VA_2025-0738056384470372112BACKGROUND AND OBJECTIVESHumans use storytelling to create meaning from suffering, including after the death of a child. The elicitation of and response to stories remains underused in medicine, and in particular, within parental bereavement. Thus, we sought to explore how bereaved parents choose to share the story of their child.METHODSThis is a secondary analysis of a dual site, survey-based study of parents’ experiences following their child’s death from cancer 6 to 24 months earlier. Our qualitative inquiry focuses on inductive, iterative analysis of free-text responses to the following question: “If you would be willing to share, please tell us about your child. What would you like us to know about him/her?”RESULTSA total of 128 parents completed the survey; 101 parents (79%) representing 81 children shared stories about their child. Responses took the form of narratives that varied in terms of structure (eg, verb tense, subject, narrative arc) and content (eg, character development, narration/voice). Parents highlighted their child’s appearance, traits, and passions. Most did not detail cancer history or death. Parent narratives progressed through themes of medicalization, humanization, and supernaturalization in the “character development” of their child, who was frequently characterized as “otherworldly.”CONCLUSIONSBereaved parents whose child died of cancer have a desire to tell their child’s story. When given the opportunity, nearly 80% of parents in this study chose to share. Thematic progression may be a framework for narrative repair. Parental narratives of their deceased child provide new insights into their bereavement experience and may help to develop novel supportive interventions. [...]

CONTEXTCystic fibrosis–related diabetes significantly impacts health outcomes of people with cystic fibrosis (CF). Understanding the effects of CF transmembrane conductance regulator modulator (CFTRm) therapy on glycemic control is crucial for improving overall health in CF.OBJECTIVETo evaluate the impact of CFTRm therapy on glycemic control in people with CF.DATA SOURCESA comprehensive literature search was conducted from January 1, 2011, to September 19, 2024, in PubMed, Embase, and Cochrane Central Register of Controlled Trials.STUDY SELECTIONEligible studies included interventional trials comparing CFTRm therapy to no treatment or placebo and observational studies reporting glycemic outcomes—assessed by oral glucose tolerance test or continuous glucose monitoring—pretherapy and on therapy or between treated individuals and controls.DATA EXTRACTIONTwo authors independently extracted data with full adherence to the Cochrane Handbook.RESULTSElexacaftor/tezacaftor/ivacaftor therapy (ETI) significantly improved 120-minute glucose levels (mean difference, −24.30 mg/dL; 95% CI, −44.82 to −3.96) and lowered hemoglobin A1c (HbA1c) levels (mean difference, −0.44%; 95% CI, −0.75 to −0.13). Regression analyses showed that earlier ETI therapy initiation was associated with lower HbA1c values (P = .03). In contrast, lumacaftor/ivacaftor, tezacaftor/ivacaftor, and ivacaftor monotherapy were not associated with significant changes in any assessed outcomes.LIMITATIONSOur analyses may underestimate the endocrine effects of CFTRm therapies, as most included papers assessed pre- and on-therapy outcomes in the same patients, potentially overlooking the gradual deterioration of glycemic control.CONCLUSIONSETI therapy significantly improves glycemic control in CF, particularly when initiated at a young age. Further research is needed to confirm and detail these findings. [...]

This month’s Ethics Rounds presents a case of an adolescent and her parent who object to the presence of a transgender adolescent in an established sexual trauma support group. To what extent do clinicians have a duty to consider the most beneficial therapeutic setting for all attendees? To what extent should the religious beliefs of a cisgender adolescent or the identity of a transgender attendee impact the group attendance of others? The case raised an opportunity for ethicists, therapists, an adolescent medicine physician, a social worker, a chaplain, an attorney and conflict mediator, and a palliative physician to consider gender identity and religious nondiscrimination as an ethics stance while also noting respect for persons, dignity, religious freedom, and therapeutic benefit ratios. It is important to foster ethically aligned and equitable care models in a nation increasingly polarized by different “bedrock beliefs.” [...]

10.1542/6385005849112Video AbstractPEDS-VA_2025-0728856385005849112OBJECTIVESConcussion is common in early childhood, yet the rate of persisting symptoms after concussion (PSaC) is unknown. We sought to determine the frequency of PSaC after early childhood concussion and identify potential predictors of PSaC.METHODSWe conducted a cohort study enrolling children aged 6 months to younger than 6 years presenting to Canadian and US emergency departments (EDs) with concussion or orthopedic injury (OI) and uninjured children from the community (community controls [CCs]). The primary outcome was PSaC at 1 month after injury determined by reliable change analysis. PSaC were also tracked through 12 months after injury. Potential predictors of PSaC were analyzed using multivariable logistic regression.RESULTSWe enrolled 418 children: 235 with concussion, 108 with OI, and 75 CCs. Median age was 2.8 years, and 50.7% were male. At 1 month, PSaC were documented in 28% of children with concussion, higher than in the OI group (10%, P = .006) and the CC group (2%, P  [...]

This clinical report provides an updated evidence-based set of recommendations for the long-term follow-up of patients with congenital diaphragmatic hernia (CDH) after discharge from initial hospitalization. Since the last American Academy of Pediatrics report was published over 15 years ago, there have been significant advances in our understanding of the manifestations, diagnostic and surveillance approaches, and therapies for the cardiopulmonary, neurodevelopmental, gastrointestinal/nutritional, and surgical adverse outcomes that are commonly encountered in patients with CDH. Consideration is also given to patient and caregiver quality of life, which has been a relatively overlooked component of this disease in previous CDH guidance. Because CDH severity and the prevalence of adverse outcomes are not only variable but also change with patient age, differential guidance is provided based on low-risk and high-risk status and are presented in a timeline format. Providers may use the guidance in this clinical report to develop an individualized long-term plan that balances care with available resources to support quality of life through the lifespan. [...]

Pediatricians may be asked or choose to provide care for parents during a child’s visit. This care may include treatment of infectious diseases; immunization; screening, referral, or treatment for mental health issues; and assessment and management of breastfeeding problems. By providing medical care to parents, pediatricians can reduce barriers to care and improve the timeliness of needed interventions. This policy statement describes some practical and medical-legal issues associated with caring for parents and provides guidance about when and how pediatricians can provide care in a way that minimizes liability risk, even when a physician-patient relationship may be established. Common situations when pediatricians may consider providing care for parents are reviewed, and recommendations considering the pediatrician’s personal preferences, training, and medical-legal considerations are provided. [...]

In this issue of Pediatrics, Rose et al1 present the incidence of persisting symptoms after concussion (PSaC) in young children, a population historically underrepresented in concussion research. Their multicenter cohort study evaluated children aged 6 months to less than 6 years old presenting to emergency departments (EDs) in Canada and the United States for head injury compared with children who had isolated orthopedic injuries or were healthy community controls. Although nearly all had a Glasgow Coma Scale score of 15, inclusion required at least 1 concerning feature—palpable skull fracture, loss of consciousness, headache, or altered mental status—placing most in the intermediate-to-high risk categories of the PECARN head injury rule.2 Using caregiver reports on the Report of Early Childhood Traumatic Injury Observations and Symptoms (REACTIONS) and reliable change index (RCI) analysis, they found that 28% of children with concussion experienced PSaC at 1 month, 24% at 3 months, and 16% at 12 months, as compared with 10% of orthopedic controls and 2% of community controls. The only independent predictor of PSaC was total symptom burden at the initial ED visit. [...]

Therapeutic hypothermia to a temperature of 33.5 to 34.5 °C initiated within 6 hours of birth and continued for 72 hours reduces the risk of death or moderate-to-severe neurodevelopmental impairments in neonates with moderate-to-severe hypoxic-ischemic encephalopathy (HIE) born at ≥36 0/7 weeks of gestation. This specialized therapy requires neuromonitoring, neuroimaging, and plans for follow-up of neurodevelopmental outcomes. Any center or practitioner involved in newborn deliveries should have action plans for prompt recognition and initiation of therapeutic hypothermia or transfer of infants with possible HIE to a center providing therapeutic hypothermia. Because many neonates with HIE are born at places that do not provide therapeutic hypothermia, therapeutic hypothermia centers should work with their referring hospitals, birthing centers and practitioners to implement educational programs that focus on the identification, initial clinical management of affected neonates, and prompt transfer of neonates with moderate-to-severe HIE. [...]

10.1542/6384471752112Video AbstractPEDS-VA_2025-0733066384471752112Neural tube defects (NTDs), such as myelomeningocele, are serious birth defects preventable with adequate maternal folate intake. In the United States, Hispanic populations have disproportionately high NTD rates. Mandatory fortification of enriched cereal grains in the 1990s significantly reduced NTDs but excluded corn masa flour (CMF), a staple in many Hispanic diets. This shortcoming may contribute to persistent disparities in NTD rates. We pursued a state legislative mandate for folic acid fortification of CMF to reduce NTDs. We also developed a legislative model that can be replicated nationwide to encourage broader fortification of CMF. A task force engaged the Hispanic community through bilingual outreach to understand dietary habits and the role of CMF to optimize the impact and cultural utility of resulting legislation. Based on these conversations, legislation was drafted with consultation from fortification experts ensuring scientific and policy viability. A legislative sponsor was secured through targeted engagement and lobbying. In June 2025, HB384 was signed into law by the governor of Alabama, mandating folic acid fortification of CMF and tortilla products. Opposition cited concerns about genetic variation in folic acid metabolism, prenatal care access, and governmental overreach. Alabama’s legislative success demonstrates a model for addressing sources of disparity in health care access and outcomes. Additional states replicating this approach may promote national CMF fortification policy or incentivize industry adoption of CMF fortification, potentially preventing up to 120 NTD cases per year in the Hispanic community, saving up to $100 million in annual health care spending. [...]

BACKGROUND AND OBJECTIVEThe use of telehealth to bring a family member virtually to the bedside for family-centered rounds (FCR) is a promising strategy to increase family members’ access. We aimed to evaluate the impact of offering families the option to use virtual FCR in the neonatal intensive care unit (NICU) on parental and neonatal outcomes.METHODSThis 2-arm cluster randomized controlled trial assigned families of hospitalized infants to the option of using virtual FCR (intervention) or to usual care (control). Intervention families could also attend FCR in person (usual care). All eligible families of infants who were admitted to this single-site neonatal intensive care unit during the study period were included. Outcomes included FCR attendance, parent experience, family-centered care, parent activation, parent health-related quality of life, length of stay, breastmilk feeding, and neonatal growth.RESULTSFrom March 2023 to 2024, 486 families were randomized (325 intervention, 161 control). Infants in the intervention arm were estimated to have 4.81 (95% CI 3.65–6.32) times the parent attendance rate of infants in the control arm (unadjusted incidence rate ratio: 4.62 [95% CI 3.40–6.28]). The intervention arm had 0.37 (95% CI 0.18–0.75) times the adjusted odds of a 30-day emergency department revisit compared with the control arm (unadjusted odds ratio: 0.48 [95% CI 0.25–0.91]). No statistically significant positive intervention effects were observed for other secondary outcomes.CONCLUSIONSOffering virtual FCR increased parent attendance and reduced 30-day emergency department revisits among NICU infants. [...]

10.1542/6385526909112Video AbstractPEDS-VA_2025-0734586385526909112BACKGROUND & OBJECTIVESleep-disordered breathing (SDB) may be a remediable contributor to abnormal cognitive outcomes for children with myelomeningocele. We investigated the frequency of SDB among neonates with fetal vs postnatal myelomeningocele repair.METHODSIn this nine-center, prospective, observational study, neonates with myelomeningocele born at more than 30 weeks gestational age underwent a 10-hour bedside polysomnogram at at least 35 weeks postmenstrual age, before hospital discharge. The primary outcome was SDB severity, reflected by the apnea-hypopnea index (AHI; number of respiratory events per hour of sleep). Decisions regarding surgical timing (fetal vs postnatal), technique (open fetal vs fetoscopic approach), and SDB treatment were made by the clinical teams.RESULTSAmong 173 infants, 92/173 (53%) had SDB (median AHI 22.5, IQR 12.2–44.2). In unadjusted analysis, AHI was higher among the 90 neonates with fetal repair vs 83 with postnatal surgery (median 29, IQR 14–49, vs 19, IQR 10–36, P = .008). In propensity-adjusted multivariable models, prematurity was independently associated with AHI, whereas surgical timing (fetal vs postnatal) was not. Hindbrain herniation, myelomeningocele level, and clinical need for ventriculoperitoneal shunt did not predict AHI in adjusted models. Supplemental oxygen was commonly prescribed, for 44% of fetal vs 39% of postnatal myelomeningocele repair infants (P = .5).CONCLUSIONSSDB affects more than half of neonates with myelomeningocele. The higher AHI after fetal surgery could stem from the elevated incidence of prematurity in this group. As SDB is treatable and has a potential impact on neurodevelopment, routine screening could become an integral part of a strategy to optimize long-term medical and neurodevelopmental outcomes. [...]

Highly pathogenic avian influenza A (H5N1) (H5N1 hereafter) is an emerging pathogen in mammals. The recent recognition of H5N1 in dairy cattle increases opportunities for human exposure and infection and may accelerate a trajectory toward sustained human-to-human transmission. Furthermore, the presence of virus at high concentration in unpasteurized milk raises new risks for humans, especially infants and children. Milk has been identified as a vehicle for viral transmission in and between mammalian species, including humans. Sialic acids (SAs) found on cell surfaces are important mediators of species susceptibility to specific influenza strains and play an important role in viral tropism. New data demonstrate that SA receptors with α2,3 linkages capable of binding avian influenza strains are present in human mammary tissue. The presence of SA receptors that can bind avian influenza and a comparative analysis of viral transmission risk of raw and pasteurized milk in several mammalian species have implications for human milk feeding. During this period of sporadic human infections with H5N1, further research and collaboration is warranted to address the potential risk of human milk contamination. Infants and children are particularly vulnerable to emerging infections during pandemics and have unique needs that may be overlooked. Pandemic preparedness must address the needs of all populations at all life stages, including pregnancy and infancy, and must include support for the safety of human milk. [...]