General journals

Doctors’ leaders have reacted strongly to the government’s proposed 2.5% pay rise for clinicians next year, suggesting it’s “neglect dressed up as restraint.”The Department of Health and Social Care (DHSC) submitted its annual evidence1 to the pay review body, the Doctors’ and Dentists’ Remuneration Body (DDRB), calling for a 2.5% uplift in 2026-27. It warned that anything higher would hamper the NHS’s ability to deliver services and could mean cuts to staffing levels.The BMA has condemned the proposal, however, calling it “indefensible” and one which is likely to worsen already strained relations between the union and government.The union is already in dispute with the government over the online GP consultation rules introduced from 1 October, and its resident doctor members are set to hold a five day strike from 14 November.23In its 103 page submission to the DDRB, the DHSC said it has only planned for a 2.5% pay uplift... [...]

Mention China to a medical journal editor, and their mind will leap to studies on irrelevant research questions drawn from the UK Biobank. It might also jump to numerous analyses of Global Burden of Disease study data. It will inevitably dwell on risks of research misconduct and ethical breaches. The overriding sentiment, however, might be: how do we get through an avalanche of substandard submissions seeking an international journal with an impact factor?On a recent trip to China I championed the advice of Doug Altman, The BMJ’s former chief statistician who not only led the field of medical statistics but helped establish it. In a landmark editorial in The BMJ in 1994 describing the “scandal of poor medical research,” Altman wrote, “We need less research, better research, and research done for the right reasons” (doi:10.1136/bmj.308.6924.283).1 Good advice travels slowly, in time and place. Urging China’s researchers to abide by Altman’s... [...]

Doctors have urged Florida policymakers to reject plans to end childhood vaccine mandates, with others claiming they are being silenced on the matter by their institutions.On 3 September, Florida Surgeon General Joseph Ladapo announced that “the Florida health department is going to be working to end all vaccine mandates in Florida law.” He said, “Who am I, as a government or anyone else, to tell you what you should put in your body?”The announcement builds on the decision by Florida Governor Ron DeSantis during the covid-19 pandemic to reject vaccine and mask mandates for schools and workplaces.Florida is scheduled to end mandates for the hepatitis B, chickenpox, haemophilus influenza type b, and pneumococcal conjugate vaccines in December. The state’s health department said this will go into effect 90 days after the 3 September announcement.But before mandates can be removed for other vaccines, including those for measles, the change must be... [...]

A long criticised study on antidepressant use in adolescents has been flagged with an “expression of concern” by a leading academic journal after the launch of legal action.12George Murgatroyd III, a lawyer, is suing the publishing giant Elsevier, as well as the American Academy of Child and Adolescent Psychiatry, demanding the retraction of the 24 year old randomised trial.3Concerns about the widely cited article—including numerous demands for retraction456—have been circulating for almost as long as the paper itself, and the trial, known as Study 329, is regularly referred to as one of the best examples of spin, misreporting, and ghostwriting in industry funded medical research.In 2012 paroxetine’s manufacturer, GlaxoSmithKline (GSK), was fined a record $3bn (£2.27bn; €2.58bn), in part for illegally promoting paroxetine using the journal article.7 Published by the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP) in 2001, the article declared paroxetine “generally well tolerated... [...]

Older people are systematically excluded from research, particularly clinical trials, despite having the highest health and care needs.1 The joint statement from research funders calls for a renewed commitment to ensuring better inclusion of older adults, particularly those with multiple long term health conditions.2But the statement doesn’t mention the growing number of older people with cognitive impairment who are often excluded altogether.3 This is primarily owing to the ethical, legal, and methodological complexities around involving participants who lack capacity to consent. A researcher we interviewed described this as “an insurmountable black box of horrendousness that I dare not go into” fearing that, if they get it wrong, they will be “illegal . . . and the ethics police will come for you.”4 This urgently needs to be tackled if we are to ensure better inclusion.Hope comes in the form of trials methodology research, which provides evidence based strategies to improve... [...]

McNally raises the very important point of reversing silent osteoporosis.1 As a gynaecologist with a special interest in menopause care, I want to highlight the importance of hormone replacement therapy (HRT) for the prevention of osteoporosis in women.As McNally quotes, the prevalence of osteoporosis in women increases significantly from 2% at age 50 to 50% at 80. The average age of menopause in the UK is 51.2 Oestrogen has a profound effect on bone, and replacement of oestrogen in women has been seen to improve bone health in numerous studies—so much so that the British Menopause Society states that it should be considered a first line therapeutic intervention for the prevention of osteoporosis.34 This is especially true for women with premature ovarian insufficiency (whether iatrogenic or non-iatrogenic).5 Alongside discussions about balanced diet, vitamin D and calcium supplementation, reducing smoking, and improving exercise, HRT should be part of the consultation for... [...]

Osteoarthritis affects more than 595 million people worldwide, and it is a leading cause of musculoskeletal pain and disability. Driven by ageing populations and an increase in obesity, the prevalence of knee osteoarthritis is rising exponentially, and it is projected to increase by 75% by 2050.1 Osteoarthritis has become a global health crisis that threatens quality of life, sustainability of healthcare systems, and workforce participation.2In a linked study, Yan and colleagues (doi:10.1136/bmj-2025-085242) report the results of a systematic review and network meta-analysis evaluating the comparative effectiveness of five different modalities of exercise in the management of knee osteoarthritis.3 The findings reaffirm the benefits of exercise, with aerobic training showing the most consistent improvements in pain, physical function, and gait across follow-up time points. Strengthening and mixed exercise interventions statistically significantly improved physical function at 12 weeks, although effect sizes were smaller, whereas neuromotor training benefited gait performance, yet only in... [...]

Sertraline may start working on key depression symptoms such as suicidal thoughts and feelings of sadness within two weeks, much earlier than previously thought, new research shows.Published in Nature Mental Health,1 the study reanalysed data from 571 patients included in the Panda trial, a randomised controlled trial comparing the selective serotonin reuptake inhibitor (SSRI) sertraline with a placebo.The research team reported that the SSRI had “beneficial effects on core depression and anxiety symptoms as early as after two weeks of treatment” but that these may be masked by side effects of the drug and other symptoms of depression early on.The researchers said that the findings could help doctors to have more nuanced discussions with patients about expectations when starting the drug. But critics said that while the study showed “small effects on some selected individual symptoms,” it was not clear “whether these effects have any clinical relevance.”An estimated 8.9 million... [...]

Hundreds of thousands of ChatGPT users exhibit signs of psychosis, mania, or suicidal intent every week, a company audit indicates.1The finding, released as part of an update to the AI technology to better detect these types of conversations, comes amid a wider debate on how chatbots could exacerbate mental health problems.OpenAI, ChatGP’s developer, estimated that around 0.07% of users in a given week show possible signs of mental health emergencies related to psychosis or mania. Additionally, 0.15% of users had conversations with explicit indicators of potential suicidal planning or intent.Although the overall percentages are small, ChatGPT has recorded as many as 800 million active users in a week, meaning the figures represent a huge number of individuals. Scaled up, they mean that each week around 1.2 million users are considering suicide and 560 000 are showing signs of psychosis or mania per week.OpenAI recently updated ChatGPT after consultation with 170... [...]

Prostate specific antigen screening reduces the risk of death from prostate cancer by 13%, one of the largest randomised studies of its kind concludes.1This overall reduction in mortality was similar to that seen with breast or bowel cancer screening, experts said.The results of the study, published in the New England Journal of Medicine and with a median follow-up of 23 years, come amid ongoing debate about the value of a PSA based screening programme, owing to the substantial risk of overdiagnosis and overtreatment.2 Experts say further research is needed to investigate a more targeted approach to screening and how to incorporate MRI scans of the prostate before biopsy.Prostate cancer is the most common cancer in men in the UK, with an estimated 63 000 diagnoses every year and more than 12 000 deaths.The European Randomized Study of Screening for Prostate Cancer (ERSPC), conducted across eight European countries from 1993 to... [...]

Thousands of patients with undiagnosed hepatitis B, hepatitis C, or HIV have been identified through a testing programme for bloodborne viruses run in hospital emergency departments.The programme was launched in April 2022 and now covers 34 emergency departments in areas in England with the highest HIV prevalence.1 Blood tests taken during emergency care are automatically tested for HIV, hepatitis B, and hepatitis C unless patients choose to opt out.A new evaluation report2 commissioned by NHS England shows that over 33 months more than 7 million tests for bloodborne viruses were conducted at the 34 sites, with a test uptake rate of 70%. At 24 sites with complete surveillance data there were 3667 new hepatitis B diagnoses, 831 new hepatitis C diagnoses, and 719 new HIV diagnoses over the three year evaluation period.Among the HIV diagnoses were 291 people previously diagnosed with HIV who had stopped attending treatment but who were... [...]

When I started medical school, the NHS felt like a constant. The idea that resident doctors might strike for months on end seemed unimaginable. Yet for those of us training now, strikes have become routine. Each time a picket line forms outside our hospitals, we’re reminded that we’ll soon be among them—with our shifts and the conditions we work under on the line.Resident doctors have taken industrial action before, in the 1970s and again in 2015-16, but what sets this period apart is the scale and persistence of the walkouts.1 For medical students, the strikes are not abstract disputes between unions and the government; they form part of the backdrop to our training and are reshaping how we see our futures. This prolonged period of industrial action fosters solidarity, but it also risks fuelling disillusionment. Unless policy makers respond, the NHS risks losing the next generation of doctors.For many of... [...]

Exposure to fine particulate matter air pollution was associated with greater dementia severity and Alzheimer disease neuropathic change, found a study published in JAMA Neurology. [...]

Women who’ve had cervical cancer face an elevated risk of anal cancer, a hazard that may increase with both time and age, according to findings published in JAMA Network Open. [...]

At the last annual session of the American Medical Association, held in Atlantic City in May, a resolution was introduced into the House of Delegates by the delegate for the Section on Pathology and Physiology, urging the establishment by the Board of Trustees of a periodical which would be representative of pathology and allied sciences in this field. At the meeting of the Board of Trustees held in Chicago in September, such a journal was definitely constituted, to be published by the press of the American Medical Association, along the same plan as the other special periodicals now issued, including the Archives of Internal Medicine, the American Journal of Diseases of Children, the Archives of Neurology and Psychiatry, the Archives of Dermatology and Syphilology, the Archives of Surgery and the Archives of Otolaryngology. It may safely be said that these journals have earned high repute in their fields not only as the leading periodicals in the specialties they represent but also for the manner in which they have advanced the progress of medical knowledge through affording investigators suitable mediums for the expression and interchange of opinion. Since the first of these periodicals, the Archives of Internal Medicine, was established, in 1908, the Board of Trustees has been constantly besieged by representatives of various departments of medicine to add to the list. It was these considerations, no doubt, that moved the Board of Trustees to give favorable consideration to the newest member of the group—the Archives of Pathology and Laboratory Medicine. [...]

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

This prespecified secondary outcome analysis of a randomized clinical trial assesses the effect of a bivalent respiratory syncytial virus (RSV) prefusion F protein–based vaccine on incidence of hospitalization for cardiorespiratory disease among adults aged 60 years or older. [...]

Cannabis use may negatively influence a woman’s ability to get pregnant, new research suggests. [...]

The emotional capacity of poetry can be an apt partner with methodical science. Although algorithms, efficiency tools, and guidelines are essential for the safety of patients (and indemnify the conscientious investigators who use them), best medical practice demands sensitivity to patients’ perspectives, especially the challenges faced when seeking care. These can include complex feelings around diagnoses and treatments that are not always readily elicited or expressed. Poetry can convey such aspects of the patient experience that may be missed or go unspoken. “Phase I, Arms Crossed” first nods to this nuanced intricacy with the title’s entendre. For researchers, a crossover trial indicates an abstruse study design. However, cloaked in “quiet prayers” with protectively crossed arms, through poetry the speaker creates spiritual similes that express a yearning for healing of cancer during participation in a research study. This wish for redemption, “You hope the trial doesn’t know/how much you want to be chosen,” arises amid intersecting undertones of confessed guilt, depersonalizing laboratory draws, and superstition; that the speaker imagines the research study itself has agency and can somehow choose the eventual outcome ironically heightens a sense of powerlessness. The poetic melding of biological and supernatural infuses us all with a searing reminder that a new chemotherapy trial may mean something far more than data to participants vs researchers. For in poetry, lines of treatment chairs can seem like a church’s pews, “odorless” drugs become “almost holy,” and ID wristbands are talismans—while ultimately, statistically significant outcomes can become answered prayers. [...]

This Viewpoint discusses a report from the National Academies of Sciences, Engineering, and Medicine on aligning therapeutic investment with unmet need to better serve the health of the US public. [...]

This study uses US national data to examine Epstein-Barr virus–seronegative donor kidney use among Epstein-Barr virus–seronegative children. [...]

This Viewpoint explores how training in both the medical and health humanities complements biomedical research, expanding clinician-scholars’ understanding of human health. [...]

This randomized clinical trial conducted at centers of the United States Neonatal Research Network assesses whether early intratracheal administration of a combination of budesonide mixed with surfactant, compared with surfactant alone, reduces physiologic bronchopulmonary dysplasia or death by 36 weeks’ postmenstrual age in extremely preterm infants. [...]

After opening a manuscript rejection email, many researchers are left asking themselves, “Why was my work really rejected?” Early-career investigators who can correctly answer this question will improve future manuscripts and are more likely to publish in high-impact journals. Yet learning these lessons typically occurs by trial and error. [...]

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 The exponential rise in plastic production has driven widespread contamination by micro- and nanoplastics (MNPs) in the environment. These plastic particles and their chemical additives have been detected in water sources, human bodily fluids, and reproductive tissues. With global fertility rates declining, their role as potential contributors is under investigation. This scoping review compares findings from in vitro experiments, in vivo studies across animal models, and epidemiological data to assess potential reproductive hazards associated with MNP exposure. Forty original studies published within the last decade were identified. MNPs have been detected in human breast milk, placenta, endometrium, ovaries, testis, semen, follicular fluid, blood, and urine samples. Humans are estimated to absorb 74,000–121,000 particles annually through inhalation, ingestion, skin contact, and use of plastic materials, including medical devices. Experimental evidence demonstrates that MNPs can cross biological barriers, interact with cells, and disrupt cellular pathways, including steroidogenesis, energy metabolism, inflammatory pathways, and oxidative stress. Thirty in vivo animal studies have associated MNPs with altered reproductive endpoints in both males (i.e., altered semen quality and spermatogenesis) and females (i.e., altered folliculogenesis, depleted ovarian reserve, and reduced litter sizes), with possible transgenerational effects. In conclusion, current evidence suggests MNPs may represent a reproductive health hazard to humans and animals. The relative contributions of particle toxicity and their chemical additives remain difficult to disentangle. Overall, plastics and their associated chemicals represent a serious health and environmental concern, which continues to grow in the absence of restrictions and international agreements. [...]

Abstract Objectives Inflammatory bowel disease (IBD) is a chronic disorder linked to cardiovascular disease (CVD). However, the impact of histologic and clinical activity on this association remains unclear. Methods We conducted a nationwide cohort study in Sweden involving 59,168 IBD patients diagnosed in 1969–2017 with histologic evaluation and 91,800 patients diagnosed in 1969–2020 with assessment of clinical activity in 2006–2021. The primary outcome was incident major adverse cardiovascular events (MACE), a composite outcome encompassing ischemic heart disease, stroke, and heart failure. Cox proportional hazards model estimated adjusted hazard ratios (aHRs) of MACE and its subcomponents. Results We found an increased MACE risk following histologic inflammation (n = 868, incidence rate [IR]: 86.3/10,000 person-years) compared to remission (n = 558, IR = 71.3) (aHR = 1.16 [1.04–1.30]). This excess risk was evident in Crohn's disease (aHR = 1.30 [1.03–1.64]) and ulcerative colitis (aHR = 1.13 [1.01–1.27]). Histologic inflammation was associated with an increased risk of ischemic heart disease, myocardial infarction, ischemic stroke, and heart failure, but not with hemorrhagic stroke. Compared to clinically quiescent IBD, active IBD was associated with an increased MACE risk (IR: 131.4 vs. 93.7; aHR = 1.54 [1.46–1.63]) and all MACE subcomponents. In patients with clinically quiescent IBD, histologic inflammation remained linked to myocardial infarction (aHR = 1.29 [1.06–1.58]) and heart failure (aHR = 1.19 [1.00–1.43]). Conclusion Both histologic and clinical activities of IBD were associated with an increased MACE risk, suggesting that improved disease control may reduce MACE risk in IBD. [...]

Abstract Background and objectives Beyond genetics, environmental factors may contribute to the rising incidence of inflammatory bowel disease (IBD). Statins, widely used for cardiovascular risk reduction, also have anti-inflammatory properties and have been hypothesized to reduce IBD risk, though data are limited. We prospectively assessed the association between statin use and risk of developing IBD among individuals eligible for statin therapy for primary prevention of cardiovascular disease. Methods Using a prospective new user design within the Danish National Registries, we identified a nationwide cohort of individuals aged ≥40 years from 2008 to 2022 eligible for statin therapy for primary cardiovascular prevention. Statin users were matched 1:5 to nonusers on age, sex, calendar year, and cardiovascular risk factors. Cox proportional hazards models were used to estimate adjusted hazard ratios (aHRs) for incident IBD. Results We identified 110,961 statin users and 554,805 matched nonusers. Statin use was associated with a reduced risk of IBD (aHR 0.84, 95% CI 0.72–0.97), with subgroup analyses showing similar reductions for Crohn's disease (aHR 0.84, 95% CI 0.65–1.09) and ulcerative colitis (aHR 0.83, 95% CI 0.69–1.00). This corresponds to a number needed to treat of 2881 to prevent one additional IBD case over 5 years of statin treatment. Findings remained consistent when censoring individuals at statin discontinuation. Conclusion In this nationwide prospective study, statin use among individuals eligible for primary cardiovascular prevention was associated with a lower risk of developing IBD. These findings suggest a potential additional benefit of statins and support further research into their role in IBD prevention. [...]

Abstract Background Little is known about the initiation of alcohol use disorder (AUD) treatments among cancer survivors, despite the unique harms that unhealthy alcohol use may have on this population. We assessed patterns, timing, and predictors of AUD treatment among cancer survivors. Methods We used commercial claims data on US adult cancer survivors from 2011 to 2021 in this retrospective cohort study. We included individuals with a new AUD diagnosis and continuous insurance enrollment. We measured initiation and timing of Food and Drug Administration (FDA)-approved (naltrexone, acamprosate, and disulfiram), non-FDA-approved (gabapentin, topiramate, and baclofen), and investigational (ondansetron and varenicline) medications for AUD (MAUDs), psychosocial therapies, and rehabilitation for AUD. We employed survival analysis to identify sociodemographic and clinical predictors of time to AUD treatment initiation. Results Among 6,682,292 cancer survivors, 44,081 individuals newly diagnosed with AUD met the inclusion criteria. Of these, 14.7% initiated FDA-approved MAUDs (3.0%), psychosocial therapy (13.0%), or both (1.3%). The median time to initiate FDA-approved MAUD or psychosocial therapy was 28 days. Overall, 6.3% and 10.4% of cancer survivors, respectively, initiated non-FDA-approved and investigational MAUDs. Age, use of antineoplastic agents, mental disorders, and comorbidity severity are potential determinants with varying effects on AUD treatment initiation. Conclusion Less than 15% of cancer survivors initiated recommended MAUDs or psychosocial therapy in the year following their new AUD diagnoses, and those who did initiate treatment did so nearly a month after receiving AUD diagnoses. Interventions are warranted to enhance treatment initiation among cancer survivors with AUD to reduce alcohol-related harms. [...]

Abstract Although research on ageing has largely concentrated on understanding the fundamental biology of the ageing process and devising pharmaceutical interventions in order to slow it down, increasing evidence has underscored the crucial role of environmental inputs across the life course and across generations, in shaping both individual and intergenerational trajectories of age-related health. These include nutrition, air pollution, social deprivation, lifestyle factors, climate change and exposure to environmental toxins, including microplastics and nanoplastics. The development of the concept of the exposome of ageing and the emergence of the new field of ‘exposomics’ have identified a blind spot, in particular, for geroscience. The impact of the exposome affecting human ‘healthspan’ (i.e., years lived in good health), extending across generations, is significant and yet under-explored in research. As such, it is under-appreciated that the declining health of the planet will have intergenerational ripple effects, epigenetically priming adverse health in future generations. We discuss the capacity to manipulate our exposome to mitigate against such effects, by addressing root causes, rather than symptoms, of both physiological and planetary dysregulation, dysfunction and decay. We propose a systems-based framework that reconnects research on ageing with exposomics and planetary ecology, creating a new field of ‘ecological or exposome pharmacology’, harnessing the activity of Nrf2 as a senotherapeutic intervention to improve trans- and intergenerational physiology in the face of declining planetary health. [...]

Abstract Background Elevated low-density lipoprotein (LDL) cholesterol causes atherosclerotic cardiovascular diseases. Variables of whole-body cholesterol metabolism, for example, high cholesterol absorption efficiency, might also be atherogenic, whereas the role of bile acids is controversial. Objectives This post hoc study concerns the impact of cholesterol absorption on bile acid metabolism. The hypothesis was that cholesterol absorption efficiency interferes with bile acid metabolism. Methods Cholesterol metabolism was studied using absolute and relative methods. Elimination of cholesterol from the body as bile acids and neutral sterols was assessed from 24-h faecal collections and analysed by gas–liquid chromatography. Cholesterol absorption efficiency was evaluated by a peroral continuous dual-isotope feeding method, and cholesterol synthesis by a sterol-balance technique. The relative methods included analyses of serum biomarkers of cholesterol absorption efficiency and cholesterol synthesis by gas–liquid chromatography. Results Faecal bile acids, neutral sterols and cholesterol synthesis were lower in high- versus low-cholesterol absorbers. Elimination of cholesterol from the body as bile acids and neutral sterols was reduced in high- versus low-cholesterol absorbers. Serum and LDL cholesterol levels did not differ in low- versus high-cholesterol absorbers. Absolute and relative methods of cholesterol metabolism correlated with each other, suggesting that the results can be considered valid. Conclusion In high-cholesterol absorbers, poor elimination of cholesterol from the body as bile acids and neutral sterols may indicate an increased risk of atherosclerosis. It can be prevented by decreasing cholesterol absorption and increasing reverse cholesterol transport by dietary means combined with ezetimibe and statin treatment, when needed. [...]

Journal of Internal Medicine, Volume 298, Issue 5, Page 367-367, November 2025. [...]

Abstract Background Neutrophil activation plays a crucial role in the pathogenesis of rheumatoid arthritis (RA), but its involvement in RA-associated interstitial lung disease (RA-ILD) remains unclear. This study investigated the involvement of N-formyl methionine (fMET) and its receptor formyl peptide receptor-1 (FPR1) in neutrophil-mediated inflammation in RA-ILD. Methods Plasma and sputum levels of fMET and neutrophil activation markers were measured by ELISA in two cohorts (n = 269 and 314) spanning multiple disease subgroups. Neutrophil activation was assessed by flow cytometry following plasma stimulation, with or without FPR1 inhibitors. Results Calprotectin levels were significantly elevated in both plasma and sputum of RA-ILD patients compared to controls and RA-noILD patients (p  [...]

Abstract Background Primary sclerosing cholangitis (PSC) is often intertwined with inflammatory bowel disease (IBD), presenting a complex clinical scenario. The coexistence of IBD–PSC complicates disease management and progression, potentially exacerbating outcomes. Objectives This study aims to evaluate the specific impact of IBD in patients with PSC, focusing on both liver-related and IBD-specific clinical outcomes. Methods This retrospective study, utilizing the TriNetX database, performed propensity score matching to compare clinical outcomes between IBD–PSC and PSC-only patients, as well as IBD–PSC and IBD-only patients. Diagnoses were identified based on International Classification of Diseases-10 coding. Results The study analyzed 1941 patients with IBD–PSC, 234,081 with IBD alone, and 628 with PSC alone. Patients with IBD–PSC had significantly higher mortality compared to IBD alone (16.0% vs. 7.5%; hazard ratio [HR]: 2.256, 95% confidence interval [CI]: 1.853–2.747, p  [...]

Abstract In this article, we present the state-of-the-art on socioeconomic health inequalities with a focus on the Nordic countries. Health inequalities have increased over time and can be observed for both mortality and morbidity. We show that cross-national comparisons reveal surprisingly high inequalities in the Nordic countries. It is now well established that health and mortality inequalities prevail also at older ages. We show, with data from Sweden, that the interpretation of how mortality inequalities evolve over the life course is markedly different depending on whether we focus on absolute or relative inequalities. Although there is a consensus on basic descriptive facts, disagreements on how these facts are best explained and why they persist and even increase remain. We present a general discussion on how to explain health inequalities, as well as a discussion on why patterns may differ between European regions and across the life course. We introduce a framework for understanding health inequalities, fundamental cause theory and discuss to what extent the evidence aligns with the theory. We review contemporary discussions on health inequalities in light of recent evidence based on novel methods for causal inference. We argue that health inequalities have important ramifications for population health regardless of whether they are primarily shaped by social causation or social selection and end by noting that as modern societies aspire to become more meritocratic, it is possible that socioeconomic position becomes increasingly important for health. [...]

Abstract Background Systemic lupus erythematosus (SLE) mainly affects women of reproductive age. Late-onset SLE patients (lo-SLE, ≥50 years) are generally indolent and have less severe manifestations. Objective The present study aims to decode molecular differences underlying the distinct clinical presentations between lo-SLE and early onset SLE patients. Methods In a cohort of 243 treatment-naïve Chinese SLE female patients, we carried out clinical analysis and experimental validation studies. RNA-seq was used to identify differentially expressed genes (DEGs) of lo-SLE patients. Reverse transcription quantitative polymerase chain reaction and flow cytometry were utilized to validate DEGs and enriched cell types. The discovery was further compared to findings in a European cohort. The immunosuppressive function of CD71+CD235a+ erythroid cells (CECs) was evaluated by coculturing peripheral blood mononuclear cells (PBMCs) with CECs. Results Differential expression analysis identified a group of hub upregulated genes in lo-SLE patients. These genes, overrepresented in erythrocyte differentiation, are highly enriched in CECs. In our Chinese cohort, CECs abundance in peripheral blood was inversely correlated with disease activity. Increased CECs in treatment-naïve lo-SLE patients may play an immunosuppressive role by inhibiting CD8⁺ T cell function and IFN-γ production. This immunosuppressive role was evidenced by the significant suppression of IL-6, IFN-γ, and IL-17A production by healthy donor's PBMCs cocultured with SLE bone marrow-derived CECs. Conclusions This pioneering study has revealed a panel of CECs genes as potential molecular markers for lo-SLE, supporting a novel erythroid modulation theory. These novel findings provide valuable insights into previously unrecognized molecular mechanisms underlying the latent disease activity of lo-SLE. [...]

Abstract Background Due to the expanding screening of coeliac disease (CeD), low positive and borderline negative serum transglutaminase 2 antibody (TGA) values are causing increasing confusion in clinical practice. Objectives To investigate the significance of these findings in a well-defined patient cohort. Methods Altogether 311 IgA-competent adults, with clinical suspicion or family history of CeD, underwent duodenal sampling and testing for TGA (ImmunoCAP EliA, cut-off 7.0 U/mL) and endomysial antibodies (EmA). TGA values 7.0–14.0 U/mL were defined as low positive and 3.0–6.9 U/mL as borderline negative. Besides conventional histology, small bowel mucosal TGA-targeted IgA deposits and γδ+ intraepithelial lymphocytes (IELs) were determined as CeD-specific markers. Results Twenty-eight (9%) individuals had low positive TGA, and 22 (79%) were also positive for EmA. Among those with low positive TGA, all EmA positive and 50% of the EmA negative subjects were diagnosed with CeD. Thirty-nine individuals (13%) had borderline negative TGA, and 36% were positive for EmA. Of these, 79% of EmA positive and 12% of EmA negative subjects were diagnosed with CeD. Additionally, 29% of the subjects with borderline negative TGA and no diagnosis exhibited signs of incipient CeD, including positive IgA deposits, increased density of γδ+ IELs and presence of human leukocyte antigen DQ2/DQ8. All subjects with TGA ≥ 3.2× upper limit of normal (22.4 U/mL) received a CeD diagnosis. Conclusion Low positive and borderline negative TGA frequently implies a CeD diagnosis, particularly in EmA positive individuals, or at least may be an indicator of an early stage of the disease. [...]

ANZ Journal of Surgery, Volume 95, Issue 10, Page 1973-1976, October 2025. [...]

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

ABSTRACT Internal hernia due to large mesenteric defects following laparoscopic colorectal surgery is an uncommon but increasingly recognized complication with significant morbidity. The prophylactic closure of these defects remains debated due to potential associated complications. This article presents a novel method that is both simple and effective in preventing such hernias following left hemicolectomy by securing the neo-descending colon to the lateral abdominal wall using a laparoscopic tacking device. [...]

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

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

ABSTRACT Background Appendiceal neoplasms are rare but clinically significant findings in appendicectomy specimens. An international meta-analysis reports a malignancy rate of 1.98%. This study aimed to determine the local incidence of appendiceal neoplasms at Hawke's Bay Hospital, New Zealand, over a 10-year period and compare it with international data. Methods A retrospective review was conducted of all appendicectomies performed at Hawke's Bay Hospital between January 2014 and December 2023. Demographic and histopathological data were extracted from electronic medical records. Neoplasms were classified as carcinoid tumours, mucinous neoplasms, or adenocarcinomas. Patients were categorised by ethnicity and rurality. Results Of 2333 appendicectomy specimens with complete histology, 67 (2.87%) were neoplastic. These included 27 neuroendocrine tumours (40.3%), 25 mucinous neoplasms (37.3%), and 15 adenocarcinomas (22.4%). Patients of New Zealand European ethnicity accounted for 71.6% of cases, while Māori represented 22.4%. The majority of neoplastic cases (91%) were from urban areas. Nearly half of patients with appendiceal neoplasm have their surgery at [...]

ABSTRACT Objective Acute appendicitis is a common presentation in most emergency departments, and the presence of appendiceal fecolith on CT is indicative of earlier progression to complicated disease. This study aimed to assess the association between appendiceal fecoliths identified on preoperative computed tomography (CT) and the severity of appendicitis, using integrated clinical, radiological, surgical, and histopathological data. Methods We conducted a retrospective observational study of 529 adult appendicectomy patients diagnosed with acute appendicitis via CT between 2010 and 2020 at two tertiary hospitals in Sydney, Australia. Patients were stratified into two groups based on the presence or absence of an appendiceal fecolith on CT. Demographics, inflammatory markers, imaging features, operative findings, and histopathological outcomes were compared. Results An appendiceal fecolith was identified on CT in 18.1% (n = 96) of patients. Baseline demographics and symptom duration were similar between groups. However, the fecolith group had significantly elevated inflammatory markers (CRP: 66.8 ± 9.0 vs. 45.5 ± 3.0 mg/L, p = 0.014; WBC count: 14.4 ± 0.4 vs. 12.4 ± 0.2 × 109/L p  [...]

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

ABSTRACT Background Emergency laparotomy is associated with high morbidity and mortality rates. Various risk stratification tools, including the National Emergency Laparotomy Audit (NELA) score, Portsmouth-POSSUM (P-POSSUM), American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) risk calculator, and the Hajibandeh Index, have been developed to predict postoperative outcomes. This study aims to compare the predictive accuracy of these scoring systems in assessing morbidity and mortality in patients undergoing emergency laparotomy. Method A prospective observational study was performed at PGIMER, Chandigarh, from January 2023 to June 2024. A total of 510 individuals who underwent emergency laparotomy were included. Preoperative risk evaluation was conducted utilizing NELA, P-POSSUM, ACS-NSQIP, and Hajibandeh Index. Primary outcomes included 30-day mortality, while secondary outcomes assessed surgical site infection (SSI), anastomotic leak, and re-exploration. Diagnostic accuracy, sensitivity, specificity, and the area under the receiver operating characteristic (ROC) curve were evaluated. Outcome The NELA score had the greatest predictive accuracy for 30-day mortality (C-statistic: 0.979). The Hajibandeh Index was the most sensitive predictor of surgical site infection and anastomotic leakage, with C-statistics of 0.760 and 0.741, respectively. P-POSSUM demonstrated the greatest specificity in predicting re-exploration. Conclusion NELA is the most dependable predictor of mortality, although the Hajibandeh Index excels in predicting postoperative morbidities. P-POSSUM provides better specificity for re-exploration risk. Integrating these tools into clinical practice can optimize patient risk assessment and improve outcomes. [...]

ABSTRACT General surgeons may encounter complex gallbladder cases throughout their careers, particularly in the context of acute or complicated gallbladder disease. The risk of bile duct injury is significantly elevated during non-elective procedures due to factors such as inflammation and anatomical variations. Over the past decade, robotic surgery has seen increasing adoption in hepatopancreatobiliary (HPB) procedures, offering enhanced visualization, improved instrument dexterity, and greater surgical precision. These advantages are especially valuable in the minimally invasive management of complex biliary injuries. Several authors have demonstrated the feasibility of robotic surgery for both acute and delayed bile duct repair. The video provides an educational demonstration of this minimally invasive procedure, serving as a practical guide for surgeons and trainees managing such complications. It illustrates the feasibility of the robotic technique and its association with favorable patient outcomes, underscoring the potential value of this approach in complex cases. [...]

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

ABSTRACT Background Sarcopenia describes a loss of muscle mass and function, which progresses with age. Sarcopenia predicts peri-operative morbidity and long-term survival. The most effective method to quantify sarcopenia is unclear, although measuring psoas muscle density (PMD) by circumscribing both psoas muscles and taking an average density appears promising. This research investigated whether the mean density of a representative ellipse from the psoas muscles (PMDe) provides a simpler approach to obtain the same prognostic information as PMD. Methods This single-centre retrospective cohort study included 432 patients undergoing elective colorectal surgical resection at University Hospital Geelong (Victoria, Australia), 2007–2014. PMD and PMDe were measured from pre-operative CT scans. Pearson correlations investigated the relationship between PMD and PMDe. Logistic regression models described how these measures correlated with peri-operative morbidity. Kaplan–Meier curves described correlations with long-term survival. Results PMDe correlated well with PMD (R2 = 0.818). Both PMDe and PMD correlated with major complications (OR = 0.962 (95% CI: 0.935–0.990) and OR = 0.963 (95% CI: 0.938–0.989), respectively) and peri-operative mortality (OR = 0.928 (95% CI: 0.873–0.988) and OR = 0.903 (95% CI: 0.847–0.962), respectively). Receiver Operating Curves (ROC) demonstrated PMDe (AUC = 0.770 (95% CI: 0.619–0.921)) was a slightly less sensitive marker of peri-operative mortality than PMD (AUC = 0.829 (95% CI: 0.731–0.928)). PMD correlated with long-term survival (p = 0.02); PMDe did not (p = 0.20). Conclusion PMDe correlated closely with PMD and both were effective prognostic markers of perioperative outcomes in patients undergoing major elective colorectal surgery. Further studies of these measures as proxies for sarcopenia from other centres, and examining outcomes from a range of patient cohorts are warranted. These may inform shared decision making around the risks of major surgery. [...]

Journal of Medical Imaging and Radiation Oncology, Volume 69, Issue S2, Page S4-S5, October 2025. [...]

Journal of Medical Imaging and Radiation Oncology, Volume 69, Issue S2, Page S146-S176, October 2025. [...]

Journal of Medical Imaging and Radiation Oncology, Volume 69, Issue S2, Page S275-S284, October 2025. [...]

Journal of Medical Imaging and Radiation Oncology, Volume 69, Issue S2, Page S1-S3, October 2025. [...]

Journal of Medical Imaging and Radiation Oncology, Volume 69, Issue S2, Page S177-S216, October 2025. [...]

Journal of Medical Imaging and Radiation Oncology, Volume 69, Issue S2, Page S6-S30, October 2025. [...]

Journal of Medical Imaging and Radiation Oncology, Volume 69, Issue S2, Page S217-S274, October 2025. [...]

Journal of Medical Imaging and Radiation Oncology, Volume 69, Issue S2, Page S31-S145, October 2025. [...]

ABSTRACT Introduction Medical imaging in acute settings is increasing. This study aimed to quantify the utilisation of medical imaging in inpatient (IP) and emergency department (ED) settings, indexed against ED presentation/inpatient separation numbers. Methods Data of IP and ED studies (XR, CT, US) performed at Western Health (Melbourne, Victoria, Australia) over 6 years from 2017 to 2023 were collated. Linear regression analyses were used to assess trends in acute workload, amount of imaging performed and rate of imaging per 1000 ED presentations/IP separations. Data from three hospital campuses were analysed. CT and US studies were allocated to body region/study type sub-categories to assess relative numbers. Results Statistically significant trends of increasing study numbers and studies per 1000 acute encounters for most modalities and campuses were observed. A minor trend of falling ED presentation and IP separation per 1000 population was observed. COVID-19 pandemic events temporarily reduced acute hospital workload, but changes were transient and did not affect imaging rates. Conclusions Growth in acute medical imaging is multifactorial, driven by increased acute hospital workload and compounded by increased rates of imaging per 1000 acute presentations. Healthcare services will need to rationalise the use of imaging, become more efficient and expand to meet growing demand. [...]

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

Journal of Medical Imaging and Radiation Oncology, Volume 69, Issue 7, Page 699-703, October 2025. [...]

Journal of Medical Imaging and Radiation Oncology, Volume 69, Issue S1, Page S4-S6, October 2025. [...]

ABSTRACT Objective To determine the effect of cultural security training (CST) for health professionals and access to an Aboriginal Brain Injury Coordinator (ABIC) for Aboriginal Australians with stroke or traumatic brain injury (TBI). Design A stepped wedge cluster randomised controlled trial; the intervention package consisted of CST for hospital professionals and 6-month access to ABICs providing education, support, liaison and advocacy; the commencement order of the intervention phase was randomised. Setting Four urban and four rural hospitals in Western Australia, 2018–2022. Participants Aboriginal adults ≥ 18 years hospitalised with stroke or TBI. Main Outcome Measures Primary outcome was quality of life (Euro QOL–5D-3L Visual Analogue Scale (EQ-VAS)) score at 26 weeks post-injury. Secondary outcomes were modified Rankin Scale, Functional Independence Measure, Hospital Anxiety and Depression Scale, Modified Caregiver Strain Index at 12 and 26 weeks, rehabilitation occasions of service, hospital compliance with minimum processes of care (MPC), acceptability of interventions, feasibility of ABIC role and costs. Results In total, 108 participants recruited (target 312), 75% rural residents; 26-week outcomes assessment completed for 78% of participants. The adjusted mean QoL showed no significant difference (p = 0.83). The MPC outcome favored the intervention group, adjusted difference in means 6.8% at 26 weeks, 95% CI (0.40%, 13.26%). There were no significant differences between control and intervention groups for other secondary outcomes. Conclusions CST and implementation of an ABIC were feasible, acceptable and improved care processes for a predominantly rural population. Health outcomes did not differ. The effects of the COVID-19 context are discussed. Trial Registration ACTRN12618000139279 [...]

ABSTRACT Background & Aim Rural hospitals in Aotearoa New Zealand (NZ) struggle to recruit and retain their senior medical workforce. This study focuses on one rural hospital (Dunstan) with a stable senior medical workforce to explore factors influencing its success. Methods NZ Rural Hospital Medicine Fellows participated in virtual semi-structured interviews exploring their experiences and perceptions of why the hospital under study has a stable senior medical workforce. Thematic analysis using a positive deviance approach was undertaken. Results Seventeen participants were recruited. Four themes were identified: (1) ‘A great place to live’ relates to Dunstan's rural hospital location and regional amenities; (2) ‘A scope of clinical practice that Fellows enjoy’ reflects on the model of care at Dunstan Hospital; (3) ‘Strong collaborative relationships’ describe successful internal (within the rural hospital) and external (professional and academic) relationships; (4) ‘Purposeful investment’ conveys the time and leadership required to build relationships, establish the professional environment, and continue to look forward. Discussion Successfully building and maintaining a stable senior medical workforce in NZ rural hospitals requires investment. Findings show what can be achieved through sustained longstanding partnerships, both locally and nationally, and the critical role of supportive management. Building and maintaining a desirable professional environment for the senior medical workforce and other clinicians could enhance recruitment and retention, as does a robust connection with professional training and academia. [...]

ABSTRACT Introduction This study assessed the Virtual Wound Consultancy Service (VWCS) in reducing travel burden and lowering travel costs for rural patients requiring wound care. With one-third of Australians in regional or remote areas facing limited healthcare access, this study examined how virtual care could overcome geographical barriers, focusing on travel time and cost. Methods A retrospective analysis compared service utilisation and travel savings between patients using the VWCS and those receiving traditional in-person care. Data from chronic wound patients across inpatient, outpatient and residential aged-care settings in a large rural health district (July 2018 to March 2024) were reviewed. Key outcomes included travel time, travel costs and travel distance. Results The VWCS significantly reduced travel burdens. Patients living more than 201 km from specialist centres saved an average of 444 min per round trip. Financially, patients saved up to AU$507.49 per trip, with the highest savings for those farthest away. The VWCS also provided timely access to wound care, with an average wait time of 3.7 days from referral to consultation. Most services involved audio/visual assessments (40%), case management (27.5%) and email consultations (18%). Over the study period, the VWCS serviced 384 patients, averaging 2.6 consultations per patient. Conclusion The VWCS significantly improves access to wound care for rural populations by reducing the time burden. These results support expanding virtual care models in rural areas. Future research should assess long-term clinical outcomes and refine virtual care delivery for greater quality and cost-effectiveness. [...]

ABSTRACT Aims To exponentially amplify the impact of health research in regional, rural, remote, and very remote (RRRvR) communities for improved health outcomes and reduced health inequities. Context RRRvR health inequities are severe, enduring, and largely impervious to our best efforts to address them. It is unjust that, simply because of where they live, some people do not have the health they need to live the life they want. Although research has been one of our greatest inventions for solving problems, it has had little impact on the problems with which RRRvR communities grapple. Improving the beneficial impact of RRRvR research was the focus of a recent Research Australia University Roundtable. Approach As someone with an abiding interest in research methodologies and the research process more generally, I read widely on research matters, am research active, review research funding applications, and train others in research processes. This commentary is a synthesis of my insights from the Roundtable as well as the published literature, including my own published work. Conclusion For people in RRRvR communities to reap the benefits that research has the potential to offer, far more substantive changes are required than adjusting assessment criteria or funding streams. It is the context within which research is conceived and conducted that must be reimagined. Without changing the context, other alterations are likely to be ineffective. When research becomes a genuine partnership between researchers and RRRvR communities to answer locally prioritised problems, we might finally achieve the impact that is required. [...]

Australian Journal of Rural Health, Volume 33, Issue 5, October 2025. [...]

Australian Journal of Rural Health, Volume 33, Issue 5, October 2025. [...]

ABSTRACT Objective Describe Australian occupational therapy (OT) workforce distribution trends by total numbers, demographics, work type, and job roles across remoteness levels. Design Exploratory spatial analysis of workforce distribution compared to total populations between 2013 and 2021. Setting Australia. Participants OTs participating in registration surveys (2013–2021) and Australians from the 2011, 2016, and 2021 National censuses. Main Outcome Measures Proportion of occupational therapists, hours worked, First Nations inclusion, leadership roles, and practice areas across Modified Monash Model (MMM) levels of remoteness compared to populations. Results Despite a 72% national workforce increase (over 10 000 OTs) over nine-years, metropolitan areas consistently retained a disproportionate share of workforce, hours worked, specialised practice areas, leadership roles, and First Nations identifying therapists. Regional centres showed the highest growth but would require similar growth for 4–15 years to equal metropolitan ratios, while workforce gaps will likely widen for other remoteness levels. Private sector hours increased substantially by 100-h/10 000 population, while public sector hours increased by just 1-h. However, private sector growth did not extend equitably to rural and remote places. Metropolitan, regional, and large rural towns outpaced all other remoteness levels in leadership growth suggesting a centralising tendency. At current rates, representative First Nations proportions will not be achieved. Equity against 2021 numbers requires redistribution of at least 1717 therapists, 278 formalised leadership positions, and increased specialised services to rural and remote places. At least 598 additional First Nations identifying therapists are needed nationally, of which 406 (68%) are needed in regional, rural, and remote places. Conclusion Persistent maldistribution of the OT workforce across remoteness levels reflects structural inequities unlikely to resolve through organic growth. Current rural workforce strategies appear insufficient to address geographic and cultural disparities. Targeted investment in rural workforce development, including incentives and pipeline models are likely required to support equitable availability of OT services. [...]

ABSTRACT Objective This study aimed to explore healthcare experiences of transgender and gender diverse (TGD) individuals, their whānau (family), and primary care clinicians in rural Aotearoa New Zealand. It explored the enablers of gender-affirming care (GAC) and the challenges that remain, using these insights to build a culturally responsive, strengths-based model of care. Design Qualitative study using semi-structured interviews, analyzed via reflexive thematic analysis. Setting Whanganui, a regional district in Aotearoa New Zealand. Participants Participants included 12 TGD individuals, two whānau members, and five clinicians providing GAC within primary care. Main Outcome Measures Experiences of accessing and delivering healthcare, with a focus on GAC pathways, mental health support, and culturally appropriate service models. Results TGD participants described fragmented systems requiring self-navigation, with delays, gatekeeping, and limited access to affirming mental health services. Clinicians reported gaps in training, a lack of clear pathways, and few referral options. Both groups emphasized the value of peer support, whānau-centered models, and culturally safe approaches. There was shared support for a local, centralized GAC service in Whanganui, building on existing resources and grounded in cross-sector collaboration, clinician education, and local leadership. Conclusion This study demonstrates both the challenges and potential of rural TGD healthcare. Findings support a regionally tailored model of GAC involving services and community, sustained through partnership and grounded in cultural safety. In Whanganui, strong foundations already exist to support such a model. With local adaptation, it could guide equitable service development in other rural regions of Aotearoa. [...]

ABSTRACT Objective To explore the use of flipped classroom (FC) design for occupational therapy and speech pathology students studying in regional Australia. Setting Occupational therapy and speech pathology students in a regional Australian university in Central Queensland. Participants 33 occupational therapy and speech pathology students provided survey data; 5 students supplied in-depth data from focus groups; three educators completed teaching reflections. Design A multiple case study methodology was implemented based on Yin's definition1. Case study one involved occupational therapy students and case study two involved speech pathology students. A sequential exploratory mixed methods design was embedded within each case study. After participation in a unit using FC design, students completed a quantitative survey followed by a focus group for each case. Document analysis of teacher reflections and unit evaluations was also completed. Results Quantitative results show that student confidence, knowledge, and satisfaction are strongly supported by the FC approach. Rich qualitative data from the cases yielded four themes: individual attributes of the educator; purposeful and flexible design features; the role of the student as an active learner; facilities and resources for flipped classrooms. Conclusion This case study data supports the benefits of FC design for health professions students, has enabled the development of a conceptual framework which could be applied to health professions and beyond to other disciplines, and has also provided the foundations for guidelines to support educators to implement FC methodology. [...]

ABSTRACT Objective To examine the demographic differences between individuals with Type 2 Diabetes (T2D) enrolled in rural and urban clinics and evaluate the quality of care they receive. Design Cross-sectional observational study. Setting Primary care data from four large Primary Healthcare Organisations across the Auckland and Waikato regions of New Zealand. Participants Patients aged 18–75 years with T2D from February 2021 to August 2022. Main Outcomes Measures Associations between rurality and sociodemographic variables, clinical measures, and prescribing rates. Results A total of 56 937 patients with T2D were included, with 85.3% enrolled in urban practices and 14.7% in rural. Rural clinics had a significantly higher proportion of Māori individuals than urban clinics (31.4% vs. 17.4%). Patients in rural clinics had lower but not clinically significant reductions in mean HbA1c, LDL-c, blood pressure, and eGFR than those in urban clinics; however, the number of laboratory tests completed during the study period was lower in rural clinics. Māori were less likely to receive HbA1c and uACR tests than non-Māori. Clinically indicated prescribing for metformin (79.1% vs. 72.5%), ACE inhibitors (80.5% vs. 75.2%), and statins (61.2% vs. 54.4%) was higher in patients enrolled in urban than rural clinics (all p  [...]

ABSTRACT Objective To examine differences and changes in workplace and demographic factors between metropolitan and rural surgeons in Australia over 10 years. Methods A retrospective study which analysed data from the Health Workforce Dataset Online Data Tool, based on annual registration data from the Australian Health Practitioner Regulation Agency (AHPRA) spanning 2013–2022. The dataset includes information on all surgeons who have completed their training and are registered as fellows with the Royal Australasian College of Surgeons, and who were working in Australia during the study period. The factors analysed included mean hours worked per week, gender, age, and origin of qualification. Regions of work were defined using the Modified Monash Model (MM) model. Results During the study period, the number of surgical fellows in Australia increased from 4568 to 5724, with a notable increase in the proportion working in metropolitan regions. On average, these surgeons worked 45 h per week across most regions. The percentage of female surgeons rose from 9.6% to 15.4% in metropolitan regions and from 6.9% to 12.4% in rural regions. Surgeons working in rural regions tended to be older. However, there has been an increase in the number of surgeons aged 35–44 working in these areas. Additionally, sub-specialties other than general surgery were rarely found in rural areas. Conclusion While the number of surgeons in Australia has increased, there is a disproportionate shortfall of surgeons practising in rural areas. [...]

ABSTRACT Aim To propose the novel role of Aboriginal and/or Torres Strait Islander Allied Health Co-Worker to address an urgent unmet need in rural and remote Australia that focuses on disability, rehabilitation and preventative health needs in a unique cultural context. Context Allied health and therapy assistants represent a rapidly expanding workforce with considerable potential to relieve workforce shortages and address urgent and unmet healthcare needs in rural and remote Australia. However, the current recognised roles of “Allied Health Assistant” or “Therapy Assistant” are incompatible with the needs of the Aboriginal and Torres Strait Islander communities. Approach This commentary prosecutes the case that for Aboriginal and Torres Strait Islander families and communities, the allied health assistant role should be adapted to an Aboriginal and/or Torres Strait Islander Allied Health Co-Worker (AHCW). The AHCW would provide allied health clinical care within the scope of an allied health assistant, as well as cultural brokerage and leadership to support the cultural needs of the people and communities with which the services are interacting. Recommendations are proposed for sustainable implementation of this role. Conclusion It is proposed that Aboriginal and/or Torres Strait Islander Allied Health Co-Workers' roles and appropriate recognition of their cultural leadership roles be introduced and embedded in health and disability employment policies. [...]

10.1542/6376238924112Video AbstractPEDS-VA_2024-0681336376238924112BACKGROUND AND OBJECTIVESex chromosome trisomies (SCT), including XXY, XYY, and XXX syndromes, have been historically underdiagnosed. Noninvasive prenatal cell-free DNA screening has significantly increased identification, leading to a need for pediatric care for a growing population of newborns with SCT. Our goal was to analyze and compare perinatal, medical, and physical features in infants with prenatal identification of SCT through 12 months of age.METHODSThe eXtraordinarY Babies Study is a prospective natural history study of prenatally identified children with SCT. Participants enroll prior to 12 months of age and have medical histories and examinations at 2-, 6-, and 12-month visits. Descriptive statistics were followed by comparisons between SCT groups (t tests, analysis of variance, Fisher exact tests). Relative risks were calculated compared to general population rates.RESULTSA total of 309 infants are included (XXY = 182; XXX = 76; XYY = 51). Relative risk (RR) compared to general population is elevated for breastfeeding difficulties (51.1%; RR 2.7 [CI 2.1–3.4]), positional torticollis (29.4%; RR 7.5 [5.3–10.7]), eczema (47.6%; RR 3.5 [3.1–3.9]), food allergies (19.4%; RR 2.4 [1.9–3.1]), small cardiac septal defects (7.8%; RR 17.3 [11.8–25.3]), and structural renal abnormalities (4.5%; RR 10.1 [6.0–16.8]), all P  [...]

We present a case of infectious endocarditis in the immediate post-transplant period in a 7-year-old child. On postoperative day 6, an elevation in inflammatory markers was detected, and the echocardiogram revealed a pedunculated mass on the mitral valve. The patient underwent surgical resection on postoperative day 14, followed by a 6-week course of antibiotics. The patient demonstrated complete resolution of endocarditis and, at 5-year follow-up, has excellent allograft function without recurrence of endocarditis. [...]

10.1542/6377236003112Video AbstractPEDS-VA_2025-0711346377236003112OBJECTIVETo examine the effects of acceptance and commitment therapy (ACT) on reducing psychological distress and promoting quality of life (QoL) in parents of children with cancer.METHODSA 2-arm paralleled randomized controlled trial was conducted with the intervention group receiving a 4-session weekly ACT-based intervention and the control group receiving the usual care. The primary outcomes were parental psychological distress and QoL. Secondary outcomes were parental experience of child’s illness, experiential avoidance, psychological flexibility, and child’s psychological adjustment to cancer. Data were collected at baseline (T0), after the intervention (T1), and 3 months after the intervention (T2).RESULTSA total of 142 children and their parents were recruited. Generalized estimating equation analyses showed that the intervention group reported significantly positive changes in parental psychological distress (β = −13.54, 95% CI: −20.04 to −7.03, P  [...]

“He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” William Osler [...]

OBJECTIVEThe American Academy of Pediatrics (AAP) publishes evidence-based infant sleep recommendations to prevent sudden unexpected infant death (SUID). We defined common patterns of infant sleep and care practices in Illinois and assessed variation in patterns across demographic characteristics.METHODSWe measured maternal report of AAP recommended practices in the 2016–2020 Illinois Pregnancy Risk Assessment Monitoring System, including breastfeeding greater than or equal to 8 weeks; no maternal smoking; and 4 aspects of the sleep environment for infant sleeping on back, on an approved surface, without items in sleep area, and without bed sharing. We applied nonhierarchical cluster analysis, coupled with knowledge of AAP recommendations, to define 6 mutually exclusive patterns of infant sleep and care practices. We produced weighted prevalence estimates for each individual practice and pattern and examined differences by maternal race and ethnicity, age, parity, education, and socioeconomic status using χ2 tests.RESULTSPrevalence estimates for individual practices ranged from 49.6% for infants sleeping without items in sleep area to 90.8% for not smoking. When examining patterns, only 19.3% of new mothers reported all 6 recommended practices; this pattern varied significantly across all demographics examined. The prevalence of the other 5 patterns were as follows: 8.1% following all 4 sleep environment practices, 28.1% bed sharing and breastfeeding, 11.7% bed sharing and no breastfeeding, 25.1% no bed sharing and back sleep positioning, and 7.8% no bed sharing and no back sleep positioning.CONCLUSIONExamining common patterns of infant sleep and care practices provides improved understanding of how infant sleep recommendations are followed and may inform intervention strategies. [...]

In this issue of Pediatrics, Holicky and colleagues describe findings from the 2016 to 2020 Illinois Pregnancy Risk Assessment Monitoring System (PRAMS), demonstrating important variations in maternal adherence to recommendations regarding infant sleep practices, breastfeeding, and smoking abstinence.1 Importantly, the report describes patterns of infant sleep and care practices instead of focusing on just 1 element. [...]

10.1542/6376239004112Video AbstractPEDS-VA_2024-0698086376239004112BACKGROUND AND OBJECTIVESHIV preexposure prophylaxis (PrEP) is a safe and effective way to reduce HIV acquisition and was approved for adolescents in 2018. We assessed whether states with minor consent laws (MCLs) allowing younger adolescents to receive PrEP without parental/guardian consent were associated with increased prescription fills.METHODSA legal review classified whether states had MCLs. A negative binomial regression model using national all-payer pharmacy claims compared PrEP fills between minors (13–17 years) and majority-age adolescents (18–19 years) between states with and without MCLs from 2015 to 2021, among 15 states with the highest minor PrEP fills. Key informant interviews (n = 25 experts from 7 states) elicited context for interpreting statistical results.RESULTSOn average, minors had lower PrEP fills than majority-age adolescents (incident rate ratio [IRR], 0.21; 95% CI, 0.17–0.24). However, the interaction term between MCL and age group was insignificant (IRR, 1.11; 95% CI, 0.91–1.36), indicating that age group differences were similar between MCL and non-MCL states. Experts described numerous barriers faced by adolescents in accessing PrEP, including confidentiality concerns, clinic access, stigma, providers’ hesitancy to discuss sexual health with and prescribe PrEP to minors, limited information on PrEP in school-based sexual education, and health care literacy.CONCLUSIONSWe did not find evidence that the gap in PrEP prescription fills between minor and majority-age adolescents was smaller among states with PrEP-inclusive MCLs. Strategies to address the numerous barriers in PrEP access experienced by adolescents may be needed. [...]

10.1542/6375930237112Video AbstractPEDS-VA_2025-0716056375930237112OBJECTIVESUnsafe sleep practices contribute to sleep-related infant mortality. Recent infant illness is a risk factor for sudden unexplained infant death. This study examined changes to safe sleep practices during and after infant illness.METHODSWe performed a prospective cohort survey study of caregivers of infants (aged 0–12 months) presenting to the pediatric emergency department (ED) for illness. Surveys assessed sleep practices before, during, and after illness (2-week and 1-month follow-ups). We assessed adherence to the American Academy of Pediatrics (AAP) safe sleep recommendations at each time point. Differences in adherence were evaluated using mixed-effects logistic regression, whereas Poisson regression was used to evaluate the change in number of safe sleep practices for selected participant characteristics.RESULTSOf 131 enrolled participants, 106 (81%) completed all follow-up surveys. Adherence to AAP recommendations was low ( [...]

OBJECTIVEThe objective of this study was to increase dental varnish application rates across a large pediatric primary care network for all children, regardless of insurance type or race and ethnicity, using a quality improvement (QI) intervention.METHODSFrom July 2023 to October 2024, we implemented a multifaceted, iterative QI intervention that included electronic health record (EHR) prompts, practice-level education, maintenance of certification credit with monthly audit-and-feedback, and financial incentives. The primary outcome was the proportion of eligible preventive care visits (children aged 6 months to 5.99 years) at which dental varnish was applied. Balancing measures included application rates by insurance type and race and ethnicity. We evaluated implementation using Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework measures as follows: “Reach” (number of visits with varnish applied), “Effectiveness” (proportion of children receiving ≥1 varnish annually), “Adoption” (proportion of practices administering varnish), “Implementation” (visit-level application rate), and “Maintenance” (annual reimbursement, comparing July 2022 to June 2023 with July 2023 to June 2024).RESULTSDuring the intervention, 92 056 eligible preventive care visits occurred. Varnish application increased from 3.7% preintervention to 30.5%, exceeding our 20% target. RE-AIM findings included the following: Reach, application at more than 4000 visits per month (up from ∼400); Effectiveness, more than 50% of children received varnish annually (vs 25% at baseline); Adoption, increased from 6 to all 33 practices; Implementation, 30.5% application rate; and Maintenance, reimbursement increased from $155 000 to $416 000. Improvements were consistent across child insurance and race and ethnicity.CONCLUSIONSA system-wide, EHR-enabled QI intervention significantly improved dental varnish application for all children, regardless of insurance type or race and ethnicity. This approach may serve as a scalable model for integrating dental varnish into pediatric primary care. [...]

10.1542/6376239505112Video AbstractPEDS-VA_2025-0718836376239505112OBJECTIVESTo assess the risk of concurrent emergency department use (Co-ED) among women with a preexisting disability and their infants.METHODSThis population-based cohort study was completed in Ontario, Canada. Included were all mother–infant pairs with a hospital delivery, 2008–2023. Those with a maternal physical (N = 152 171), sensory (N = 54 716), or intellectual/developmental (N = 2913) disability or multiple disabilities (N = 11 800) were compared with those with no disability (N = 1 548 178). Multinomial logistic regression–generated odds ratios (ORs) and 95% CI for Co-ED (ie, mother and infant both had emergency department (ED) visits within 90 days after hospital discharge), a maternal ED visit only, or an infant ED visit only were calculated, each vs no ED visit. Models were adjusted for maternal age, parity, income quintile, rurality, immigration status, and delivery year.RESULTSCo-ED was more likely among women with (5.4%) than without (3.4%) a disability (adjusted OR [aOR], 1.66; 95% CI, 1.62–1.71). The median number of days between the first maternal and first infant ED visit was 19 (IQR, 4–41) days, and 18.3% occurred within 24 hours of each other. The aOR for maternal ED visit alone was 1.38 (95% CI, 1.35–1.40) and 1.20 (95% CI, 1.19–1.22) for an infant ED visit alone.CONCLUSIONSCo-ED was an important outcome for all mother–infant pairs, particularly so for mothers with a disability, of whom about 1 in 20 experienced Co-ED. These dyads may benefit from careful postdischarge planning during the birth hospital stay and enhanced outpatient health care. [...]

In 1904, Abraham Jacobi envisioned a future where pediatricians used knowledge, privilege, and power for good, at the bedside and in society.1 His vision foreshadowed the Modern Hippocratic Oath, which acknowledges that we, as physicians, are members of a “society, with special obligations to [our] fellow human beings.”2–4 Every year, new physicians join our profession. New pediatricians conclude residencies, begin practice, or embark on further training. Our traditions ground and push us, new and seasoned, to act ethically and responsibly, to support children, and to advance and shape our field. Still, many of us are currently struggling to find our footing amid dizzying societal shifts affecting our patients, colleagues, science, and society. [...]