General journals

Health Secretary Wes Streeting needs to stop trying to “politic” his way out of the dispute with resident doctors and focus on negotiating, the doctor tasked with leading talks with the government says.BMA Resident Doctors Committee (RDC) chair Jack Fletcher made the comments to The BMJ as resident doctors in England wrapped up their 15th strike since 2023.1Fletcher said that before the walkout negotiations with the Department of Health and Social Care (DHSC) had been going well.“We were moving in the right direction,” he said.The government’s latest offer included pay structure reform, reimbursement of royal college exam fees, contract reform for locally employed doctors, and up to 4500 more specialty training places over the next three years (including 1000 this April).Looking back on those conversations, Fletcher said that discussions about jobs and training numbers and trying to tackle the “gig economy”—which many doctors outside of training find themselves working in—were... [...]

MPs have urged the UK government to scrap a “dreadful” and “shameful” £330m NHS contract with the controversial US tech giant Palantir during a Westminster debate.1Palantir, which also provides services to US immigration enforcement and the Israeli military, is contracted to create a federated data platform (FDP) for NHS England to help streamline health service data.But the deal has proved controversial, with concerns raised by the BMA2 and others over risks to patient trust, data security, and Palantir’s background with military and surveillance contracts.Earlier this week—amid reports that ministers were mulling scrapping the contract3—The BMJ revealed how data from pilots of the FDP, run at Chelsea and Westminster Foundation Trust and promoted as a Palantir success story, were flawed.4Against this backdrop MPs debated the FDP on 16 April, with several Labour and Liberal Democrat MPs urging the government to remove Palantir as the contract supplier. The debate was led by... [...]

In recent weeks, the UK has seen masked students queueing for emergency meningitis jabs and the publication of the module 3 of the UK covid-19 inquiry,1 which criticised the government’s reliance on flawed advice that the virus did not spread through the air.2One aspect of our lack of readiness for the next pandemic is the current policy on protecting healthcare workers from airborne respiratory pathogens. Specifically, whether respirators should be used instead of ordinary medical masks. Current policy in the UK and many other countries,3456 based on non-inferiority randomised controlled trials,78 is that respirators are needed only for aerosol-generating medical procedures such as intubation. But such trials are inherently predisposed to produce null results and mislead policymakers and potentially cause harm.Randomisation reduces some forms of bias, but it does not abolish bias altogether. Post-randomisation biases can arise once a trial is underway, for example in how interventions are delivered, how... [...]

On the eve of the Easter bank holiday weekend, the UK government finally published the full text of its deal with the US government on the prices the NHS will pay for new branded drugs.1The central plank of the deal is to waive tariffs on UK pharmaceutical exports to the US in return for the NHS paying 25% more for new branded drugs. The initial mechanism for the latter is an equivalent increase in the National Institute for Health and Care Excellence’s (NICE) standard cost threshold from 1 April 2026, although further price increases may well be needed to meet the scale of extra drug spending the government has signed up to.2 This revised threshold means that a drug will be considered sufficiently cost effective if for every £35 000 extra it costs above the current standard NHS treatment for the condition, it improves health by at least one quality... [...]

The Pakistan Medical Association (PMA) has raised alarm over 329 children who have tested positive for HIV in the southeastern province of Sindh in the first quarter of 2026, calling it a sign of major failures in infection control and regulation.A separate BBC investigation reported 331 HIV positive children in Punjab province in 2024 and 2025 in an outbreak linked to unsafe injection practices.Sindh health department data, reported by local media, showed 329 children among 894 HIV cases recorded from January to March 2026.1 The PMA blames the rise on contamination resulting from lax health practices such as reuse of needles in unauthorised clinics, and it warned in a 14 April statement that the reported figure was “merely the tip of the iceberg.”It estimated that the actual number of infected children could be fourfold higher than currently documented, because of the critical unavailability of mass screening facilities across the province.The... [...]

In July 2025 I took part in a protest against the proscription of Palestine Action.1 I am now among more than 2000 people who have been arrested for peacefully holding a sign reading “I oppose Genocide. I support Palestine Action,” and who now await prosecution for an action designed to highlight both the human cost of the genocide in Gaza, and the inappropriate use of antiterrorism legislation against the direct-action group Palestine Action. After my arrest, the GMC (General Medical Council) opened an investigation into my conduct and referred me to an interim orders tribunal to decide if my practice should be restricted while it “completes its investigation.”By contrast, the GMC took no immediate action when I was charged in 2022 for criminal damage after a protest undertaken to highlight JP Morgan’s role in driving the climate crisis, a case which has since resulted in my acquittal.2In the UK over... [...]

Anxiety disorders are the largest class of mental health disorders and highly prevalent,1 yet substantial treatment gaps exist. Despite there being well established first-line treatments, only 25% of affected people globally receive treatment,2 ranging from about a third in high income countries34 to less in low and middle income countries.5 Of those receiving treatment, systematic reviews show overall response rates of about 50% for cognitive behavioural therapy (CBT)6 and medication.7 This stagnation in new effective treatments and response rates is exacerbated by a historic innovation drought in psychopharmacology: while the global burden of anxiety is projected to intensify—driven by evolving socioeconomic instabilities and the long-tail effects of the covid-19 pandemic—the development of novel psychotropic medications has remained disproportionately scarce. A new review in The BMJ provides a timely analysis of the emerging therapeutic landscape.8 However, while innovation is important, we must also target the barriers inhibiting equitable access to existing... [...]

The UK health secretary has promised to end “outdated and misogynistic practices” in healthcare that leave many women feeling “gaslit” and in pain.The government’s relaunched women’s health strategy, published on 15 April, will tackle problems such as a lack of adequate pain relief during invasive gynaecology procedures, said Wes Streeting.1“The NHS has a problem with everyday sexism and an appalling culture of medical misogyny,” Streeting said at the strategy’s launch. “Being ignored, gaslit, humiliated, and disrespected are all too common experiences for far too many women.” He pledged to put women’s voices centre stage and “ensure no woman is left fighting to be heard.”The strategy sets out plans to tackle a crisis in gynaecology waiting lists, which in January stood at 565 000.2 Some conditions, such as endometriosis, can take nearly a decade to diagnose.3The strategy also pledges to redesign clinical pathways for heavy periods, urogynaecology, and menopause to speed... [...]

Humanitarian aid and healthcare share a commitment to treat all lives equally. That promise is strained in war but should not be conditional. Since 2023, a record number of attacks have been recorded against healthcare infrastructure, health workers, and, more recently, medical research and pharmaceutical manufacturing capacity in Lebanon and Iran.1 Healthcare infrastructure, hospitals, and emergency services are no longer protected in conflict settings, in violation of international law.2 Healthcare services and humanitarian aid are increasingly treated by governments and armed groups as leverage to manage, pressure, and punish civilian populations.3In January 2026, Israeli authorities moved to deregister and suspend dozens of international non-governmental organisations in Gaza and the West Bank unless they complied with new registration requirements. The demands included disclosing identifying information about Palestinian staff and members of their families. This threatens humanitarian assistance at scale: international organisations run about 60% of field hospitals and deliver much of... [...]

Wales will increase its minimum unit pricing (MUP) of alcohol from £0.50 a unit to £0.65 from October, following in Scotland’s footsteps to help ensure its effectiveness is not eroded by inflation.1MUP is a targeted policy focusing on cheap, high strength, store bought alcohol.2 The largest falls in alcohol consumption and related harms with MUP have occurred in heavier drinkers—although there is limited evidence of benefit for those with alcohol dependence, where wider support is recommended.23 MUP disproportionately benefits people who are more deprived.23 Most stakeholders in the UK, including the alcohol industry, support MUP.4England has been left behind on effective alcohol policy and needs to act. Policymakers should learn lessons from MUP delivery and evaluation in Scotland, Wales, and other forward thinking regions. A future proofed mechanism to set the level of MUP, such as an inflation linked floor price, is important.5 Policymakers should also consider a minimum unit... [...]

Kickbusch’s call to reframe artificial intelligence (AI) governance through a planetary health lens is timely and compelling.1 As AI systems—particularly large language model (LLM) applications—move rapidly into use, we must ask how governance can be operationalised in healthcare practice.One of the most practical and underused levers for responsible AI is robust evaluation. In healthcare, evaluation standards have long aligned innovation with patient safety, quality, and equity. Encouragingly, this is a growing area of AI research, with emerging frameworks for assessing clinical performance,23 extensions to trial reporting such as CONSORT-AI,4 and examples of structured safety testing in real world tools.5A critical gap remains, however. Current evaluation frameworks rarely consider the computational and environmental costs of LLM powered systems, with environmental impact absent from criteria even in otherwise comprehensive approaches.6 Although recent frameworks such as FUTURE-AI7 have broadened evaluation, environmental and computational impact remain largely neglected. Each LLM query carries an energy... [...]

Six months after the Gaza ceasefire was announced Palestinians are still experiencing “extreme deprivation, hunger, injury, and death” as Israeli attacks and aid restrictions continue, charities have warned.1Five major humanitarian organisations—the Danish Refugee Council, the Norwegian Refugee Council, Oxfam, Refugees International, and Save the Children—have assessed the progress made against the ceasefire plan and produced a scorecard. They conclude that the ceasefire announced in October 2025, with the promise of an end to attacks and an increase in aid, is failing.At least 738 Palestinians have been killed since the ceasefire came into effect, said the UN.2 At least 70 000 Gazans have been killed in Israeli attacks since 7 October 2023, although experts say that the true number is probably much higher.3The UN’s human rights chief, Volker Türk, said that Palestinians were still unsafe amid routine Israeli attacks. “The unrelenting pattern of killings reflects continuing disregard for Palestinian lives, enabled... [...]

Questionable authorship practices have long been a concern for scientific integrity because they create a climate of mistrust in researchers and their findings. Deliberately hiding the contributions of some and naming undeserving individuals as authors both threaten research integrity. [...]

             In the vacuum           lungs filched, folded                 excoriated [...]

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

This Viewpoint discusses a new Centers for Medicare & Medicaid Services (CMS) model to expand access to novel obesity medications and lifestyle interventions for Medicare and Medicaid beneficiaries. [...]

This Viewpoint discusses the masking effect of dense breast tissue regarding early detection of advanced-stage breast cancer. [...]

To the Editor A recent study demonstrated that coffee consumption may reduce the recurrence of AF after electrical cardioversion. A notable feature of this trial was its interventional design: rather than introducing coffee to noncoffee drinkers, the investigators interrupted coffee intake among individuals who were already habitual consumers. This approach raises an important methodological question—whether the observed benefit reflects a true antiarrhythmic effect of caffeinated coffee or whether caffeine withdrawal in the abstinence group may have contributed to AF recurrence. [...]

To the Editor The DECAF trial provides reassurance regarding caffeinated coffee consumption and AF recurrence. Yet, for electrophysiologists, reconciling these findings with physiological data raises a mechanistic paradox involving both arrhythmic substrate and withdrawal physiology. [...]

To the Editor A recent trial involving 200 patients with persistent atrial fibrillation (AF) or atrial flutter after successful electrical cardioversion examined the effects of continuing caffeinated coffee intake for 6 months compared with abstinence. The study challenges long-held concerns that caffeine is inherently proarrhythmogenic. However, importantly, the investigators did not report the timing of coffee intake, a variable that may meaningfully influence caffeine’s physiologic effects and the interpretation of the trial’s findings. [...]

To the Editor A recent trial showed that caffeinated coffee consumption reduced AF/atrial flutter burden over 6 months compared with caffeine abstinence. However, extrapolating these benefits to “other caffeinated products” warrants caution and may pose a public health risk. In this study, energy drinks accounted for 5% or less of caffeine sources. [...]

In Reply We thank the Letter authors for their thoughtful suggestions and questions about our recent DECAF trial. [...]

This US longitudinal cohort study assesses the association of artificial intelligence scribe adoption with changes in electronic health record time expenditure and visit volume and how associations vary by clinician characteristics. [...]

“Asthmanaut” evokes the experience of an asthma exacerbation through the metaphor of an astronaut navigating the thin air between Earth and outer space. The speaker, struggling to “[t]ake strangled sips,” describes feeling as though he were “[i]n [a] vacuum,” “pull[ed]” by the gravity of stars as he attempts to return to Earth. Through vivid images and descriptive phrases, the poem conveys the substantial morbidity of this disease. Nevertheless, the speaker does not merely describe the almost surreal experience of an asthma exacerbation but also reproduces the sensation of dyspnea through the poem itself. Form and content reflect one another in numerous ways: the lines are short, invoking shallow breaths, and the poem’s visual outline resembles an alveolus or branching airway. Additionally, the frequent use of alliteration, onomatopoeia, harsh consonants, and multisyllabic words (eg, “lungs filched, folded/excoriated”) induces labored breaths while reading the poem aloud, which are accentuated by the lack of punctuation, aside from commas. Fortunately, the sounds and images at the end of the poem become more euphonic as the speaker describes “[coming] down/…to stoop and kiss the earth//And savor one sweet gulp/of atmosphere.” The poem subsequently invites us to complete the journey of the asthmanaut by simulating the breath of relief that the speaker imagines. Returning to Earth along with the speaker, who invokes weightlessness by omitting a concluding period, we float (if only temporarily) “unhounded.” [...]

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. [...]

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

  Abstract Background Adherence to subsequent lung cancer screening (LCS) is essential but not well characterized in biennial national programs. Objectives To assess whether baseline LCS results and their management are associated with subsequent screening adherence and clinical outcomes. Methods We analyzed participants in the Korean national LCS program who underwent baseline low-dose computed tomography (CT) between 2019 and 2021 and remained lung cancer-free for 2 years. Baseline results were classified as true negative or false positive (FP); FPs were grouped by management (invasive diagnostic procedures, chest CT surveillance, or no further evaluation). Adherence to the next biennial screening was modeled using multivariable logistic regression. Lung cancer incidence and all-cause mortality were assessed using Cox models with a 2-year landmark design. Results Among 235,753 participants, 54.4% returned for subsequent screening. Compared with true-negative results, adherence was lower among those with FP results who underwent invasive procedures (adjusted odds ratio [aOR], 0.64; 95% confidence interval [CI], 0.56–0.72) or CT surveillance (aOR, 0.77; 95% CI, 0.74–0.80) but was similar among those with FP results without further evaluation (aOR, 1.00; 95% CI, 0.95–1.04). In the landmark analysis, FPs were associated with higher risks of lung cancer incidence (adjusted hazard ratios [aHRs], 2.95–2.49 across management groups) and higher all-cause mortality among those who underwent invasive procedures (aHR, 1.57; 95% CI, 1.10–2.24) or CT surveillance (aHR, 1.23; 95% CI, 1.07–1.41). Conclusion Downstream management after baseline FP findings, rather than FP status alone, was associated with subsequent LCS adherence, highlighting the need to support return screening in higher risk FP groups. [...]

Abstract Background We aimed to examine the relationship between acute events and frailty trajectories of community-dwelling adults aged 60 and older. Methods We included 3146 participants, aged 60+, from the Swedish National Study on Aging and Care in Kungsholmen (SNAC-K). We considered all myocardial infarctions (MIs), lower respiratory tract infections (LRTIs) and falls that resulted in a hospitalization 5 years before to 12 years after SNAC-K baseline (2001–2004). Frailty was operationalized using a data-driven frailty index (FI), scored from 0 to 1. Linear quantile mixed models were used to examine the relationship between number and type of acute events and FI trajectories over a median follow-up of 11 years. Results Falls (n = 690) were most common, followed by LRTIs (n = 353) and MIs (n = 205). Those with more acute events showed significantly higher frailty levels over time from age 75 to 95. The greatest differences in frailty trajectories by event count were observed at age 80, with increases between zero to one, one to two and two to three or more events of 0.04 (95% confidence interval [CI] = 0.03–0.05), 0.08 (95% CI = 0.05–0.11) and 0.09 (95% CI = 0.05–0.13) FI units, respectively. Falls emerged as most deleterious, but there were also clear differences by MI and LRTI count after imputing frailty at death. Conclusion Older adults who experience falls, LRTIs and MIs are more likely to sustain unfavourable frailty trajectories, with increasingly higher frailty levels with each additional acute event. Prevention, before age 75, should be optimized to avoid a vicious cycle of acute events and frailty progression as well as reduced lifespan. [...]

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

Abstract Retrospective, propensity-score-adjusted (PSA) studies have indicated to practitioners in the field that contrast-induced acute kidney injury (AKI) after contrast-enhanced CT (CECT) is of minor importance or even non-existent. This has led to controversies between clinicians demanding CECT not to miss any diagnoses and radiologists reluctant or even refusing CECT in risky patients. A critical review of AKI/dialysis risk post-CECT in PSA studies was performed based on a Cochrane Library/Embase/PubMed search up to December 2024 with stratification for various populations. Among unselected emergency-/inpatients with chronic kidney disease, CECT was associated with significantly higher AKI incidence than in controls in 8/10 cohorts (weighted absolute risk increase 4.0 percentage points (pp), cohort range −4 to 16.9 pp at glomerular filtration rate (GFR) [...]

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

Abstract Alzheimer's disease (AD) is neuropathologically defined by amyloid-beta (Aβ) plaques and tau neurofibrillary tangles. However, co-pathologies and other pathobiological processes are involved in the pathogenesis of AD, contributing to neurodegeneration and clinical symptoms. The most common co-pathologies in people with AD are alpha-synucleinopathy, vascular brain injury and transactive response DNA-binding protein of 43 kDa-related pathology. Neuroinflammation, iron accumulation, cholinergic dysfunction and cellular senescence are recognized pathobiological processes beyond Aβ- and tau-related pathology. However, the exact mechanisms by which these co-pathologies and pathobiological processes contribute to the neurodegeneration and clinical symptoms in people with AD remain unclear. The individual combination of these co-pathologies and pathobiological processes increases phenotypical heterogeneity in people with AD. This highlights the unmet need to advance their current understanding, and the field strives to develop accurate biomarkers for personalized assessment and investigation. Elucidating this biologic-clinical complexity and heterogeneity is crucial for increasing our current understanding of AD, with implications for diagnosis, prognosis and therapeutics. [...]

Abstract Background Effectively identifying individuals exposed to drug underuse, overuse and potentially inappropriate medication (PIM) in older adults is essential for minimizing preventable drug-related harms. Methods We analysed data from 54,296 individuals aged 60–74 years from the German National Cohort (NAKO). We assessed the frequency of PIM, untreated conditions (medication and vaccination underuse) and medications without indication (overuse) utilizing the Fit fOR The Aged (FORTA) list. Factors associated with PIM, medication overuse and underuse were identified by multivariable logistic regression models. Results The frequency of PIM, underuse and overuse of medications was 26.1%, 19.1% and 23.6%, respectively. In participants with available vaccination information, 90.6% and 62.7% did not have the recommended pneumococcal and annual influenza virus vaccinations, respectively. Parkinson's disease, arterial hypertension, epilepsy and depression were strongly associated with PIM use, with 16.2-, 4.5-, 4.3- and 2.1-fold increased odds, respectively. Osteoporosis, atrial fibrillation, Parkinson's disease and chronic obstructive pulmonary disease were identified as particularly strongly associated with underuse, with 9.5-, 6.1-, 2.6- and 2.0-fold increased odds, respectively. Depression and epilepsy were the most prominent factors associated with overuse (1.6- and 1.5-fold increased odds). Conclusion PIM and medication overuse, as well as drug and vaccine underuse, are very common among older German individuals. Comprehensive medication reviews are needed to improve medication quality. This work identifies people with specific characteristics who would benefit the most and could be prioritized for medication reviews. [...]

Journal of Internal Medicine, Volume 299, Issue 5, Page 537-537, May 2026. [...]

Abstract Objectives To investigate, in early rheumatoid arthritis, whether bridging with glucocorticoids (GCs) is associated with an increased risk of flare following GC tapering and withdrawal. Methods A total of 810 NOrdic Rheumatic Diseases Strategy Trials And Registries (NORD-STAR) patients were included in this post hoc analysis: all received methotrexate (MTX), in addition to which 135 patients received oral GC bridging therapy (‘oral GC group’); 80 received intra-articular (IA) GC bridging therapy, sulfasalazine and hydroxychloroquine (‘injection GC group’); and 595 received one of three (certolizumab pegol, abatacept and tocilizumab) biologic disease-modifying antirheumatic drugs (bDMARDs), hereafter the (‘bDMARD group’). Clinical disease activity index (CDAI) flares (≥4.5 increase in CDAI score) were assessed longitudinally. Results Up to 48 weeks, flare occurred at least once in 43% of oral GC, 24% of injection GC and 28% of bDMARD patients. Over-time relative risk (RR) was higher with oral GC bridging (adjusted RR, 1.54; 95% CI, 1.16–2.03) but similar with injection GC bridging (adjusted RR 0.93; 95% CI, 0.54–1.55) versus bDMARD. Flare rates were numerically higher in the oral GC versus bDMARD group at all time points (12, 24, 32, 40 and 48 weeks), with a significant difference at w.40, the visit after protocol-defined GC discontinuation; at this visit 27% of patients who discontinued GC experienced flare; 29% among those in remission; 33% remained on low-dose prednisolone at 48 weeks. Conclusion Discontinuation of oral GC bridging therapy on background MTX is associated with increased flare risk, even among patients in remission. Flare rates with IA GC bridging plus triple therapy did not differ from the bDMARD group. Trial registration number EudraCT 2011-004720-35; ClinicalTrials.gov NCT01491815. [...]

Abstract Primary hyperparathyroidism (PHPT) is a common endocrine disease that typically presents in peri- and postmenopausal women. PHPT is due to a single parathyroid adenoma in most cases, which leads to stable hypercalcemia over years. Nowadays, the diagnosis is often coincidental, reached by chance in subjects without specific symptoms—asymptomatic PHPT. However, the patients might have subtle disease-related manifestations. Management standards have been reviewed through international workshops over more than three decades, leading to absolute and relative indications for parathyroidectomy (PTX), the only curative treatment. The alternative to PTX is observation without intervention in asymptomatic patients without organ manifestations and only mildly elevated calcium levels (mild PHPT). On the basis of recent literature, our aim is to challenge current recommendations for managing PHPT with focus on mild asymptomatic disease, integrating informed patient preferences. Considering the changing patient demography with increasing life expectancy, more sensitive visualization procedures, improved surgical techniques, and new data on PHPT-related morbidity, we test some of the established indications for PTX, particularly age as an isolated criterion, and the validity of a circulating calcium “threshold” for considering PTX. Additionally, bone mineral density (BMD) decreases for at least a decade with observation in contrast to PTX, where BMD normalizes after surgery and remains stable in the axial compartments for years. Therefore, skeletal-related thresholds for PTX also deserve review. In conclusion, we suggest integrating more clinical outcomes and wider perspectives in decision-making for the management of mild PHPT, taking patient preferences into consideration, and focusing on informed and shared decision-making. [...]

Abstract Tuberculosis (TB) remains a major global health challenge, with multi-drug antibiotic regimens as the current standard of care. While effective at killing Mycobacterium tuberculosis, these treatments do not resolve persistent inflammation, prevent lung damage, or reverse immune dysregulation that contribute to poor outcomes and disease recurrence. Precision medicine offers a promising alternative but requires deeper insight into disease mechanisms to enable tailored interventions. This comprehensive review introduces the concept of immune endotyping to define the underlying disease mechanisms as tools to decode clinical and immunological heterogeneity in TB. TB displays a wide spectrum of clinical phenotypes, from latent or asymptomatic infection to mild or severe disease with characteristic non-cavitary or cavitary lung pathology. Instead, distinct immune endotypes capture the diverse biological pathways that shape disease progression and treatment response. Similar clinical presentations may arise from different immune dysfunctions, underscoring the need to move beyond broad phenotypic classifications. Advances in multi-omics and computational analyses uncover immune signatures that enable stratification for host-directed therapies (HDTs) targeting hyperinflammation, immunosuppression, coagulopathy or metabolic exhaustion. Integrating clinical, radiological, and immunological data through multimodal profiling is essential for developing personalized interventions. We also explore how endotyping has transformed treatment in other diseases, offering valuable insights for TB. Additionally, we present examples of how putative immune endotypes may be targeted with appropriate HDTs. In summary, this review underscores the potential of immune endotypes to advance precision medicine in TB, moving beyond one-size-fits-all treatment to improve outcomes, especially in severe and drug-resistant cases. [...]

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

ANZ Journal of Surgery, Volume 96, Issue 4, Page 697-700, April 2026. [...]

ANZ Journal of Surgery, Volume 96, Issue 4, Page 1032-1033, April 2026. [...]

ABSTRACT Introduction The presence of colonic adenomatous polyps is a risk factor for colorectal cancer. Australian Guidelines changed in 2019 so that the surveillance colonoscopy intervals and polyp risk stratification were changed to reflect evidence available. The purpose of this research was to understand compliance with the Guidelines and implications for the health system. Methods Using routine hospital administrative datasets, all polyp surveillance colonoscopies performed from January 2018 to September 2020 in three government-funded hospitals in Central Queensland, Australia, were analysed. Colonoscopy intervals were calculated and compared with national recommendations. ‘Early surveillance’ was defined as greater than 6 months earlier than recommended. Logistic regression analyses were used to assess early surveillance or not, adjusted for potential confounding. Interval cancer and adenoma detection rates were also examined. Results Surveillance colonoscopies were performed for 294 patients with low-risk polyps, 20 with intermediate-risk polyps, 321 with high-risk polyps and 12 with very high-risk polyps during the study period (total n = 647). Early surveillance occurred in 566 (87.5%). The overall interval cancer rate was 0.9% (6/647), and adenoma detection rates were 62.2% (357/574) before the change of guidelines and 79.1% (53/67) after the change. No examined demographic or clinical factors were associated with early surveillance. Conclusion Despite outstanding and high-quality colonoscopy services being provided, higher than recommended colonoscopy surveillance was identified in the regional public hospitals in Central Queensland. Hospital processes should be improved to ensure appropriate intervals between procedures to avoid using scarce healthcare resources. [...]

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

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

ABSTRACT The American College of Surgeons' Minimum Hospital Standardization (MHS) Programme was central to its foundation and subsequent growth over the next 40 years. Its significance was second only to the election of its Fellows. The development of the MHS exactly overlapped the years preceding the foundation of the College of Australasian Surgeons in 1927 and its reputation was well known to Australasian surgeons and governments—yet it was never developed in Australasia. The current interest in Australian Clinical Quality Registries and the upcoming College's Centenary is an opportunity to reappraise a missed opportunity. [...]

ABSTRACT The American College of Surgeons' Minimum Hospital Standardization (MHS) Programme was central to its foundation and subsequent growth over the next 40 years. Its significance was second only to the election of its Fellows. The development of the MHS exactly overlapped the years preceding the foundation of the College of Australasian Surgeons in 1927 and its reputation was well known to Australasian surgeons and governments—yet it was never developed in Australasia. The current interest in Australian Clinical Quality Registries and the upcoming College's Centenary is an opportunity to reappraise a missed opportunity. [...]

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

ABSTRACT Background There is increasing evidence that the addition of preoperative antibiotics (OAB) reduces infectious complications after colorectal surgery. To understand practice patterns in Australia, Australian hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) collecting targeted colectomy and proctectomy data were collated. Methods Adult patients who had elective restorative colectomy or proctectomy between January 2015 and November 2023. Results Eight hundred thirty-nine patients were included. Mechanical bowel preparation (MBP) alone was the most common strategy for segmental colectomy (42.46%) and proctectomy (75%). The rate of MBP and oral antibiotics (OAB) remained low (11.7% to 25.3% between 2019 and 2023). This was associated with a decline in superficial SSI (11.7% to 4%) over this time. When the cohort was divided into three groups: MBP+/OAB+ (n = 143), MBP+/OAB− (n = 458) and MBP−/OAB− (n = 238), there were no statistical differences in infectious complications between the groups. However, the MBP+/OAB+ group had the lowest superficial surgical site infection (SSI) rate in the laparoscopic (5.3%) and open surgery (9.2%) subgroups. This was associated with a significant reduction in the odds ratio (OR) 0.52 (95% CI 0.27–1.01) of developing any SSI and a reduced length of stay in the open subgroup. Conclusions Despite recommendations by several international guidelines, level 1 evidence from meta-analyses and network meta-analyses as well as a Cochrane review that MBP and OAB reduce infectious complications, there remains a low uptake of MBP and OAB in major colorectal surgery at major NSQIP hospitals in Australia, with even lower uptake in smaller non-NSQIP hospitals. [...]

ABSTRACT Background Anastomotic leakage (AL) is the most feared complication after colorectal surgery, with high morbidity and mortality. Early detection remains challenging, as clinical and radiological signs are often delayed. This study aimed to evaluate the diagnostic value of procalcitonin (PCT) kinetics between postoperative days (POD) 1 and 3 in predicting AL after colorectal surgery. Methods A prospective analytical study was conducted from January 2021 to January 2024 at the Department of General Surgery, Trauma and Burns Center, Ben Arous, Tunisia. Patients undergoing colorectal resection with immediate anastomosis were included. Serum levels of white blood cells (WBC), C-reactive protein (CRP), and PCT were measured on POD1 and POD3. The diagnostic performance of each marker and their kinetics was assessed using receiver operating characteristic (ROC) analysis. Results Among 114 included patients, 11 (9.6%) developed an AL. Significant associations were found with older age (p = 0.038), absence of bowel preparation (p = 0.048), and manual anastomosis (p = 0.013). PCT and CRP levels at POD3 were significantly higher in patients with AL (p  0.51 ng/mL showed the best performance (AUC = 0.94). The combined variable (CRP + PCT at POD3) achieved an AUC = 0.95 and a negative predictive value of 98.9%. Conclusions PCT kinetics between POD1 and POD3 are a reliable early predictor of AL after colorectal surgery. Combined monitoring of PCT and CRP improves diagnostic accuracy and may optimize postoperative management. [...]

ABSTRACT Background Wide-awake local anaesthesia no tourniquet (WALANT) is increasingly used globally for hand surgery, offering clinical and operational benefits. However, its adoption in Australia remains understudied. This study assessed current WALANT usage among Australian hand surgeons to identify key factors influencing its implementation. Methods A national cross-sectional survey of all Australian Hand Surgery Society (AHSS) active members (n = 164) was conducted in 2024. The survey examined current WALANT use, perceived benefits and drawbacks, as well as facilitators and barriers of incorporation into practice. Quantitative data were analysed using descriptive and inferential statistics and qualitative data were analysed thematically. Results Sixty-eight surgeons responded (41% response rate). Seventy percent had performed WALANT at least once, and 50% incorporated it in practice. Current WALANT use was associated with hand surgery fellowship (OR = 8.7), prior WALANT exposure during training (OR = 6.1) and practice in university/teaching hospital (OR = 3.2). Respondents highlighted avoidance of general anaesthesia, shorter recovery, improved patient satisfaction and lower costs as benefits. Conversely, workflow inefficiencies, limited outpatient infrastructure, concerns over anaesthetist scheduling and remuneration and the absence of dedicated billing codes were the dominant barriers. Non-users viewed WALANT as more complex and remained wary of adrenaline safety, whereas users perceived more benefits and reported few technical concerns. Conclusion WALANT is used by a substantial proportion of Australian hand surgeons, but broader adoption is limited by systemic and institutional barriers contributing to a perception gap. Training, infrastructure, policy reform, appropriate funding mechanisms and interprofessional collaboration may support wider integration of WALANT in Australia. [...]

ABSTRACT Purpose Ileocolic intussusception is a paediatric emergency requiring rapid reduction of the telescoped bowel. Often initial attempts at reduction are conservative, using gas or liquid enema. Our aim is to examine the success of pneumatic reduction over the past 17 years at our centre, compare our rates of success and complication to the published literature, and evaluate the use of delayed repeat reduction attempts (DRRAs). Methods A retrospective single centre review of all patients with attempted pneumatic reduction of ileocolic intussusception, between January 2006 and December 2023. Patient demographics, clinical history, number of initial and delayed reduction attempts, and surgical outcomes were reviewed. Results Three hundred fourteen patients had successful reduction out of a total 375 attempted (success rate 84%). In general, the further the distal extent of the intussusceptum, the decreasing likelihood of successful pneumatic reduction (95% ascending colon; 86% hepatic flexure; 85% transverse colon; 40% splenic flexure; 50% descending colon; 35% sigmoid colon). The success also decreased with each repeat attempt in a single session, but DRRAs showed relatively increased success. Rates of bowel resection in patients transferred to theatre after initial attempts compared with DRRAs were similar (23% vs. 22%). Bowel perforation occurred in 0.8% (all during the first reduction attempt). Conclusions This study supports the use of multiple attempts at the pneumatic reduction of ileocolic intussusception, with evidence that subsequent delayed repeat attempts after 4–6 h are effective at reducing operative intervention rates without increasing the risk of bowel perforation or resection. [...]

ABSTRACT Background Photon-counting detector CT (PCD-CT) is a technology that directly counts individual photons and their energy, compared to conventional energy-integrating detector CT (EID-CT) which measures the total deposited X-ray energy without distinguishing photon energies. PCD-CT promises to provide higher quality images at equal or reduced radiation doses. We aimed to compare the objective and subjective image quality of PCD-CT to EID-CT for low-dose chest CT. Methods Asbestos-exposed participants from the Western Australian Asbestos Review Program underwent paired EID-CT (2023–2024) and PCD-CT (2024–2025) at a reduced radiation dose. Three independent chest radiologists rated relative image quality on a 5-point Likert scale, with higher scores indicating better quality on the right-hand image. Quantitative image noise was measured in the descending thoracic aorta. Interobserver agreement was assessed using κ statistics, intraclass correlation coefficients (ICC), and near-agreement (±1 category). Results Fifty subjects (median age 77 IQR 10.25 years; 40 men) were included. Across 150 ratings, 88% fell in categories ‘somewhat higher’ (4) or ‘much higher’ (5), favouring PCD-CT. The pooled mean score was 4.2. Individual reader mean scores ranged from 3.6 to 4.7. Interobserver agreement was modest by exact κ statistics, but near-agreement (±1 category) was high (80%–98%) and intraclass correlation coefficients demonstrated strong reader consistency. Quantitative analysis showed similar image quality despite approximately 40% reduced radiation dose for PCD-CT. Conclusions PCD-CT provides superior subjective image quality to EID-CT for low-dose chest CT, at a substantially reduced radiation dose. Trial Registration Clinical trial number: ACTRN12621001627842; https://www.anzctr.org.au/ [...]

ABSTRACT Introduction Endovascular thrombectomy (EVT) is the gold standard treatment for managing emergent large vessel occlusion (LVO) ischaemic stroke. The role of perfusion CT imaging in selecting appropriate candidates for EVT is well established. New understanding of the benefits of EVT in later stages of infarct have raised questions about the requirement of perfusion CT. This study assessed the accuracy of non-perfusion imaging for making appropriate EVT referrals. Methods We reviewed 50 consecutive acute stroke presentations with-contrast CT, CTA and perfusion imaging. Observers included two neuroradiologists and two senior radiology registrars. Cases were anonymised, and perfusion data removed. Diagnostic accuracy metrics (sensitivity, specificity, PPV, NPV) for evaluating hyperdense vessel (HV), acute infarct (AI) and LVO were calculated. Interobserver agreement was measured. Sensitivity for recommending IR discussion was compared against clinical outcomes. Results High interobserver agreement was observed for LVO detection (κ = 0.92) and IR referral (κ = 0.96). Consultants demonstrated higher sensitivity for HV (92%) and AI (76%), while registrars exhibited higher specificity (HV: 94%; AI: 96%). Both groups achieved > 90% accuracy in LVO detection. Sensitivity for IR recommendations was 91.5% for consultants and 96.0% for registrars (p = 0.5). All cases that proceeded for EVT in this cohort were identified by all four reviewers and the same clinical recommendation was made. Conclusion Non-perfusion imaging offers robust diagnostic accuracy for detecting LVO, making it a reliable tool for EVT decision-making in resource-constrained centres. Perfusion imaging enhances diagnostic confidence and clinical planning, particularly in complex cases. Its integration into workflows should remain a priority where feasible. [...]

ABSTRACT Introduction Percutaneous transhepatic cholangioscopy has emerged as a viable alternative to endoscopic retrograde cholangiopancreatography for the management of biliary duct calculi. This study aimed to evaluate the outcomes of treating biliary duct calculi using SpyGlass-assisted percutaneous transhepatic cholangioscopy. Methods A retrospective review was conducted of all patients who underwent SpyGlass-assisted percutaneous transhepatic cholangioscopy at a single-centre between May 2021 and December 2024. Demographic, clinical, imaging, procedural, and adverse event data were collected from electronic medical records. The primary outcome was clinical success, defined as complete resolution of presenting symptoms with associated improvement in biochemical markers. The secondary outcome was technical success, defined as complete clearance of biliary duct calculi on direct visualisation using SpyGlass cholangioscopy and fluoroscopic imaging. Adverse events were recorded and classified according to severity using the Clavien-Dindo classification. Results Between May 2021 and December 2024, 27 patients underwent 42 SpyGlass-assisted percutaneous transhepatic cholangioscopy procedures for 32 distinct clinical presentations. Clinical success was achieved in all presentations, and technical success was recorded at 83% of procedures. Adverse events occurred in 36% of procedures, the majority of which were minor (Clavien-Dindo classification Grade 1 or 2). There was a single case of procedure-related mortality. Conclusion SpyGlass-assisted percutaneous transhepatic cholangioscopy appears to be a safe and effective alternative for the management of biliary duct calculi, particularly in cases where endoscopic retrograde cholangiopancreatography is unsuccessful or contraindicated. [...]

ABSTRACT Introduction Financial toxicity refers to the objective financial burden and subjective financial distress caused by medical treatment. Cervical cancer patients experience high financial toxicity internationally, and local evidence suggests similar challenges in New Zealand. This study aimed to measure the prevalence and severity of financial toxicity in patients undergoing radiation treatment for cervical cancer at Wellington Blood and Cancer Centre (WBCC). Methods Twelve patients undergoing cervical cancer treatment and 29 patients receiving curative radiation therapy completed surveys including demographics, COST-FACIT measure of financial toxicity and quality of life (EORTC QLQ-C30) at treatment commencement and again at treatment completion. Group comparisons were analysed using repeated measures ANOVA. Results Cervical cancer patients (n = 10) reported significantly greater financial toxicity than comparison patients (n = 27), with lower COST-FACIT Scores (20.6 vs. 29.7), p = 2. Younger age, greater distance from WBCC and cervical cancer treatment group were independently associated with increased financial toxicity. Global Health Scores, Financial Difficulty Score, Social Functioning Score and symptoms were significantly worse in the cervical cancer group. Eight out of ten participants (80%) From the cervical cancer group met criteria for financial toxicity based on COST-FACIT Score. Median out of pocket costs and income-related loss were $1814NZD (IQR $1041–$2182) for cervical cancer patients, compared to $264NZD (IQR $71–$558 p = 0.006, Mann–Whitney U Test) for others. Conclusion Patients receiving radiation for cervical cancer experience significantly higher financial toxicity than other WBCC patients. Addressing the financial burden of treatment should be a priority in support for this vulnerable group. [...]

ABSTRACT Purpose Tumour oxygenation influences the radiobiological effect of yttrium-90 (Y90); thus, baseline hemoglobin (HGB) may affect treatment response. This study evaluated whether baseline HGB is associated with outcomes in patients with unresectable intrahepatic cholangiocarcinoma (ICC) treated with Y90 transarterial radioembolisation (TARE). Methods We retrospectively analysed 136 ICC patients treated with glass microsphere Y90 from 2004 to 2020, stratified by baseline HGB: ≥ 12 g/dL, 10–11.9 g/dL, and  [...]

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

ABSTRACT Introduction Accurate preoperative physiological assessment is critical for high-risk patients undergoing lung resection to predict postoperative lung function. This study compared quantitative dual-energy CT (DECT) perfusion with SPECT/CT for lobar perfusion mapping in an at-risk oncological cohort. Method In a prospective, single-centre study, 20 high-risk candidates for lung resection (FEV1 or DLCO [...]

ABSTRACT Purpose To evaluate whether embolic agent selection influences outcomes following selective arterial embolisation (SAE) of renal angiomyolipomas (r-AMLs) and to assess procedural safety and effects on renal function. Materials and Methods A retrospective observational study was performed of all r-AML SAEs undertaken at a tertiary institution between 2015 and 2024. Change in tumour size on pre- and 3–6-month post-procedural imaging was the primary outcome. Secondary outcomes included technical success, re-intervention rates, complications (Clavien–Dindo), renal function change and length of hospital stay. Outcomes were compared across embolic agents including microparticles, liquid embolic agents, coils and combined approaches. Results Forty-nine patients (51 lesions) underwent angiography, with SAE attempted in 54 procedures. Technical success was achieved in 91%. Tumour size reduction occurred in 91% of lesions with follow-up imaging, with a mean reduction of 1.75 cm (p  [...]

ABSTRACT Background Natural language processing (NLP) was used to extract structured information from large numbers of radiology reports with the aim of showing the feasibility of this approach for system monitoring, conducting clinical research and improving practice. Methods In total, 220,000 consecutive radiology reports were processed using an NLP pipeline (Radiology Text Analysis, or RATA). The indications, modality, technique, anatomy and findings were mapped to SNOMED CT codes. A subset of 941 reports identified as CT-KUB was analysed to examine the pipeline's performance in detecting renal tract stones (RTS), compared with a manual reference standard. The Fisher exact and Cohen kappa tests were applied. Results Compared with the reference standard, RATA had accuracy 95%, sensitivity 94%, specificity 97%, positive predictive value 98% and negative predictive value 91%, with kappa statistic 0.9. Sub analysis showed that, of 366 females, 50% had negative RTS diagnoses, while only 32% of 566 males had negative RTS diagnoses (two-tailed p  [...]

ABSTRACT Background In breast malignancy, localisation of axillary nodes is crucial for guiding targeted axillary dissection (TAD), particularly following neoadjuvant chemotherapy (NACT). While many localisation techniques exist, many have limitations with flexibility in scheduling, patient discomfort or issues with implantables (e.g., radioactive seeds, radar reflectors or magnetic markers). Ultrasound-guided Radioguided Occult Lesion Localisation (ROLL) was originally used for non-palpable breast lesions and relatively new in localisation of axillary lymph nodes. The authors aim to share the experience of ROLL in this single tertiary centre. Material and Methods From March 2020 to December 2024, 41 suspicious axillary nodes from 30 patients who underwent ultrasound guided ROLL were included in this study. Results The technical success rate was 95.1% (39/41 nodes) as confirmed by the appreciation of radioisotope in post-injection scintigraphy and subsequent intra-operative localisation. Among 21 patients (26 nodes) who underwent NACT, the mean size of lymph node pre- and post-NACT was 2.1 cm (1.0–4.3 cm) and 1.2 cm (0.7–3.2 cm), respectively. The distance from lymph node to skin was 1.5 cm (0.8–2.5 cm). The primary pathology was breast cancer in 26 patients (33 nodes). A tissue marker clip was inserted into 27 (65.9%) lymph nodes. Main technical challenges include small or deep lymph nodes and those that are either unclipped or marked with clips demonstrating limited sonographic visibility. Conclusion Ultrasound-guided ROLL is an effective method for localising axillary lymph nodes, including small, deep or clipped/unclipped nodes that are challenging to identify. This technique offers improved patient comfort and logistical flexibility, and its high accuracy provides a strong argument for its role in TAD. [...]

ABSTRACT Introduction Teleradiology services are increasingly being used to cover growing after-hours computed tomography (CT) demand. It is unclear if this is associated with increased CT utilisation due to reduced radiologist oversight of imaging requests. Method 7, 120 consecutive evening and weekend CT examinations performed over a 17-month period at a single 350-bed New Zealand hospital were used to calculate both the mean number of CT examinations per hour and the mean study attributable time (SAT) per hour for both teleradiology and on-site radiology coverage. The teleradiology service provided reporting services but did not vet or protocol requests (this was determined by the requesting clinician). Results Teleradiology coverage was associated with an increased number of after-hours CT examinations per hour compared with on-site radiology coverage (2.00 vs. 1.85 examinations, p = 0.02). A higher study attributable time for the teleradiology group was also found (23.6 vs. 21.6 min, p = 0.02). No statistically significant difference was identified for radiation-sensitive subgroups, although the number of examinations was small. Conclusion Teleradiology services were associated with greater emergency CT utilisation, hypothesised to be due to the lack of radiologist involvement in scan vetting and protocolling. These findings emphasise the role of the radiologist as a clinical advisor and collaborator in addition to the task of image interpretation. Further data from other centres and in radiation-sensitive populations would be useful to confirm if these findings generalise. [...]

ABSTRACT Objective To co-design, deliver and evaluate a suicide prevention workshop aimed at improving the knowledge, skills and confidence of general practice and community staff in rural South Australia. Setting A 2.5-h in-person workshop was delivered across three rural communities on the Eyre Peninsula, Australia. Participants Sixty-seven individuals attended the workshop. Of these, 61 completed a pre- and post-workshop survey (91% response rate). Participants who completed the survey included practice staff (n = 27), mental health or psychosocial support workers (n = 18), community volunteers (n = 6), suicide prevention network representative (n = 4) and other (n = 6). Method The design of the workshop was guided by Participatory Action Research principles and underpinned by the Double Diamond model. The workshop was co-designed by a multidisciplinary advisory group, including two individuals with lived experience. The objectives of the workshop were to help attendees to: (1) recognise verbal and non-verbal warning signs of suicidal ideation, (2) respond effectively to provide immediate support and (3) connect individuals with appropriate referral services. A mixed-methods pre–post survey assessed changes in participants' confidence, knowledge and skills aligned with these objectives, along with their perceptions of the workshop. Pre- and post-workshop responses were compared using the Wilcoxon Signed-Rank Test, with statistical significance set at p  [...]

ABSTRACT Objectives Older adults in rural communities often have difficulty accessing mental healthcare. Community paramedicine may offer a novel opportunity to address this need. This study aimed to explore whether a feasibility trial of a community paramedicine programme, CP@clinic, can influence mental health outcomes in rural adults. Setting This study was conducted in a regional town in Victoria, Australia, across six clinic sites, offering a free, 3-h drop-in service with community paramedics for individuals seeking health assessments or advice. Participants 205 clients (mean age 70 years) attended a community paramedic clinic. Design The mixed-methods feasibility trial ran from 2022 to 2024. Data was recorded on chronic disease, quality of life, loneliness and mental health. Fourteen participants were interviewed to explore experiences and perceived benefits. Results 47% of clients attending CP@clinic reported anxiety or depression. These participants experienced higher rates of social isolation, poverty, and health lifestyle risks. Participants reported that CP@clinic helped to improve their mental health both directly, through onward referrals to healthcare providers, and indirectly through improvements in mental health determinants across physical and social domains. Conclusion This study found a clear overlap between mental, physical, and social health needs of CP@clinic consumers. There is a need for accessible community-based services that address the mental health needs of older rural adults. CP@clinic may provide an opportunity to improve mental wellbeing in this population and should be further evaluated for this purpose. [...]

ABSTRACT Background Persistent health workforce shortages in regional, rural and remote Australia compromise access to equitable, high-quality care. Despite multiple initiatives, recruitment and retention challenges remain. Evidence-informed, context-specific solutions are needed to address local workforce needs. Aim To identify and prioritise locally responsive health workforce models in Central Queensland and assess their feasibility, acceptability and effectiveness from the perspective of local stakeholders. Methods A modified Delphi method was used, comprising two rounds of online surveys with health practitioners and administrative staff. In Round One, participants rated 11 workforce models, developed from prior qualitative interviews and expert roundtable discussions, on feasibility and effectiveness using a five-point Likert scale. Open-text responses were collected to provide qualitative insights. Models meeting predefined consensus thresholds (≥ 70% feasibility or ≥ 60% effectiveness) progressed to Round Two, where participants, stratified by profession (nursing, medical, allied health, other), re-evaluated the shortlisted models. Quantitative data were analysed using descriptive statistics, and qualitative responses were analysed using deductive thematic analysis (Braun & Clarke, 2006). Results Seven models met consensus thresholds in Round One: Placement, Career Broker, Transport Partner, Telehealth Blended, Advertisement/Pop Culture, Expatriate and FIFO. In Round Two, the Placement model was consistently rated highly across all professional groups, with strong support also for the Career Broker and Transport Partner models, particularly among allied health and nursing participants. Models requiring significant system reform, such as Expatriate and FIFO, received more variable ratings. Conclusion Locally grounded, system-supported strategies, especially Placement, Career Broker and Transport Partner models, were favoured over approaches relying on external incentives or structural overhaul. Implementation of these models, supported by pilot testing and collaborative evaluation, offers a promising pathway to strengthening rural and regional workforce sustainability. [...]

ABSTRACT Background Persistent health workforce shortages in regional, rural and remote Australia compromise access to equitable, high-quality care. Despite multiple initiatives, recruitment and retention challenges remain. Evidence-informed, context-specific solutions are needed to address local workforce needs. Aim To identify and prioritise locally responsive health workforce models in Central Queensland and assess their feasibility, acceptability and effectiveness from the perspective of local stakeholders. Methods A modified Delphi method was used, comprising two rounds of online surveys with health practitioners and administrative staff. In Round One, participants rated 11 workforce models, developed from prior qualitative interviews and expert roundtable discussions, on feasibility and effectiveness using a five-point Likert scale. Open-text responses were collected to provide qualitative insights. Models meeting predefined consensus thresholds (≥ 70% feasibility or ≥ 60% effectiveness) progressed to Round Two, where participants, stratified by profession (nursing, medical, allied health, other), re-evaluated the shortlisted models. Quantitative data were analysed using descriptive statistics, and qualitative responses were analysed using deductive thematic analysis (Braun & Clarke, 2006). Results Seven models met consensus thresholds in Round One: Placement, Career Broker, Transport Partner, Telehealth Blended, Advertisement/Pop Culture, Expatriate and FIFO. In Round Two, the Placement model was consistently rated highly across all professional groups, with strong support also for the Career Broker and Transport Partner models, particularly among allied health and nursing participants. Models requiring significant system reform, such as Expatriate and FIFO, received more variable ratings. Conclusion Locally grounded, system-supported strategies, especially Placement, Career Broker and Transport Partner models, were favoured over approaches relying on external incentives or structural overhaul. Implementation of these models, supported by pilot testing and collaborative evaluation, offers a promising pathway to strengthening rural and regional workforce sustainability. [...]

Australian Journal of Rural Health, Volume 34, Issue 3, June 2026. [...]

Australian Journal of Rural Health, Volume 34, Issue 3, June 2026. [...]

ABSTRACT Objective To present key discussion points from a workshop where attendees reflected on personal and professional development achievements gained through their involvement in Pain Revolution's ‘Local Pain Collectives’ program. Design Reflexive thematic analysis of notes written by workshop attendees and key points discussed during workshop activities. Setting An in-person workshop was held in Melbourne, Victoria. Participants A cohort of Pain Revolution Local Pain Collective facilitators, their mentors and Pain Revolution's executive team. Results Twenty-eight meeting attendees (19 facilitators, six mentors and three executive team members). Facilitators reported gaining increased knowledge of contemporary pain science, greater confidence communicating with other healthcare providers and improved interactions with their patients. Further, they related that their local collective members reported similar improvements in their understanding of pain and their patient interactions. They described that their collectives enabled new professional connections, enhanced a sense of belonging to a community of like-minded healthcare providers and increased collaborative pain care in their communities. Conclusions The increased connection, sense of belonging to a community of like-minded healthcare providers, and formation of collaborative care networks are all important program impacts given the lack of existing literature regarding interventions targeting professional isolation. [...]

ABSTRACT Objective This study investigated the diagnostic accuracy of point of care ultrasound (PoCUS) by rural family physicians (FPs), using consensus ‘imaging expert’ interpretation as the reference standard. Design Cross-sectional. Setting British Columbia, Canada. Participants Five rural FPs and seven specialist physicians (imaging experts). Methods Rural FPs saved images from their PoCUS scans over 2–10 weeks. For each scan, two expert reviewers, who were unaware of the identity of FP study participants and their interpretation of scans, independently interpreted images. Main Outcome Measures Image interpretation agreement between FPs and imaging experts: percentage agreement, sensitivity, and specificity. Inter-rater reliability between expert reviewers when interpreting images, as measured by percentage agreement. Results Seven imaging experts reviewed images from 55 scans performed by five rural FPs. Among the 20 scans with expert pair agreement (that was not ‘unable to assess’), expert interpretation was the same as an FP's for all but one scan (95%). For the other 35 scans, experts in a pair (a) both could not make an assessment based on images provided (‘unable to assess’) (n = 4) or (b) had differing interpretations (n = 31). Conclusion We found interpretation agreement among imaging experts for a minority of scans, resulting in inadequate power to assess the diagnostic accuracy of PoCUS by rural FPs. When using secondary image review to assess rural PoCUS quality, we recommend limiting the number of PoCUS working diagnoses being investigated, developing image sharing guidelines for FP participants, and using consensus agreement by multiple experts as the reference standard. [...]

ABSTRACT Background One comprehensive stroke centre (CSC), in North Queensland, Australia, supports almost 700 000 people across 750 000 km2. Access to urgent ischaemic stroke treatment is challenging for remote and regional residents, who are more likely to carry stroke risk factors and have a 17% higher stroke incidence than those in major cities. Aims To review and report on patient demographics, stroke characteristics, interventions, and outcomes of ischaemic stroke in this regional population. Methods Retrospective review of admissions to a North Queensland CSC (March 2022—September 2023) with acute ischaemic stroke (ICD-10-AM: 163). Results Among 305 patients, the median age was 72 years, 57% were male, and 10.5% identified as First Nations. Common stroke risk factors included hypertension (83%), smoking background (58%) and hypercholesterolaemia (57%). Stroke aetiology was unknown in 42%, followed by cardioembolic (31%). Median onset-to-emergency department time was 90 min, and to the CSC was 343 min. Thrombolysis was administered to 6% at the referring facility, and 7% on arrival to the CSC (median door-to-needle time, 73 min). Endovascular clot retrieval occurred in 11.7% of the primary presenters, with an overall successful recanalisation rate of 89%. The 6-month mortality rate was 22%. Conclusions High rates of modifiable risk factors require improved community management. Delayed presentation highlights potential gaps in stroke awareness and access to healthcare in this region. Reaching timely reperfusion targets should become a priority, which requires support from multiple stakeholders. The high proportion of unknown aetiologies may reflect incomplete stroke work-up, documentation, or loss to follow-up. Targeted stroke education for regional and remote communities and healthcare providers is recommended. [...]

ABSTRACT Aims This commentary explores the evidence and experience of the Remote Vocational Training Scheme (RVTS) to reflect on the long-term training of general practitioners (GPs) and rural generalists (RGs) within rural Aboriginal Medical Services (AMS). Context Aboriginal Community Controlled Health Organisations (ACCHOs) and their AMSs provide culturally informed, holistic health services that directly and indirectly address a breadth of primary and preventative healthcare for First Nations communities. However, commonly only short-term and specialised GP/RG training posts are available in these settings, which contrasts with the continuity of care and stable workforce often required in First Nations communities. The Remote Vocational Training Scheme (RVTS) has over 10 years of evidence and experience in implementing a rural AMS training stream, providing 3–4 years of continuous training for GPs/RGs based in the same AMS. Approach This paper reflects on the lessons learnt by the RVTS leadership team and the evidence from an independent evaluation to inform longer-term training of GP/RGs in rural AMSs across the sector. At the time of the evaluation in November 2023, the AMS stream had enrolled 71 doctors, 36 of whom had completed training in the same AMS, with 14 participants still in training. The commentary offers valuable insights into the design, delivery and outcomes of the program, providing guidance for broader implementation of longer-term training. Conclusion Longer-term rural AMS training provides valuable learning to trainees whilst ensuring continuity of care and medical workforce stability for First Nations communities. It could be enhanced by incorporating selection and training conditions that prioritise holistic, retention-focused support for trainees. [...]

ABSTRACT Objective The Escape Room in a Briefcase (ERiB) is a highly portable activity for students to observe and practice interprofessional practice competencies. The ERiB was incorporated into a University Department of Rural Health's Student Workshop in Interprofessional Education (SWIPE) to facilitate delivery of effective interprofessional education (IPE) to students on placement in rural and regional locations. The evaluation aimed to understand the students' gaming experience and improvement in understanding of interprofessional competencies and to gain feedback about the ERiB activity. Setting Health facility-based education rooms across six different locations in the Darling Downs and Southwest Queensland. Participants Eighty-seven university students who were undertaking a clinical placement for a health degree in the Darling Downs or Southwest Queensland participated in one of 13 SWIPE sessions over a 2-year period. Design The research utilised an interpretivist approach to qualitative design, with data collected via semi-structured focus groups with students after the ERiB activity. Results Analysis revealed four key themes: frustration during teamwork, collaborative capability, situational humility and intrinsic motivation, which were interpreted as core capabilities underpinning interprofessional practice. Conclusion The ERiB activity is an exciting and innovative method that provides IPE opportunities for students on placement in any location. This interactive activity appears to succeed as an effective IPE tool, facilitating skills in communication, teamwork and collaboration. [...]

ABSTRACT Objective To investigate the trends in the perceived social isolation and improved wellbeing of Australian medical students over a 6-year period (2017–2022) during their rural clinical school (RCS) placements. Methods Data were analysed using descriptive statistics and multinomial logistic regressions to identify the trends and factors contributing to perceived social isolation and improved wellbeing during RCS placements. Design This is a retrospective, cross-sectional study of the 2017–2022 FRAME (Federation of Rural Australian Medical Educators) dataset. Participants Data were collected from 2915 Australian medical students who completed RCS placements. Setting Respondents were located at RCS placements across 19 Australian universities. Main Outcome Measures The main outcomes were self-reported social isolation and improvement in wellbeing. Results Over 30% of respondents reported experiencing social isolation. Factors contributing to social isolation were preference to practice in a capital city and lack of financial or overall support from the RCS, while lack of academic isolation was protective. More than 80% of respondents perceived the RCS placement had a positive impact on their wellbeing. Positive influences on wellbeing were associated with active role-modelling of self-care, support services and mentorship by a rural-based clinician. The COVID-19 years did not significantly impact perceived social isolation or improved wellbeing. Conclusions Most medical students on RCS placements reported positive impacts on their wellbeing, while over 30% experienced social isolation. Targeted support strategies that reduce social isolation and enhance student wellbeing on rural placements may help improve rural workforce retention and address healthcare shortages. [...]

Despite widespread recognition that mental and emotional concerns in childhood have risen to an unprecedented high, there continues to be a sense of hesitancy in approaching mental and emotional development in pediatrics. This hesitancy is related to pervasive barriers including lack of comfort, time, and perhaps most importantly, lack of resources to offer families. However, research supports that families benefit from interventions that foster healthy relationships and whole health throughout development, which are fundamental to pediatric practice. Pediatricians are skilled in addressing whole health as they support the physical, mental, emotional, developmental, and social well-being of families from the birth of a child to their transition into adulthood. They are also accustomed to assessing health on a spectrum that includes prevention, early identification, treatment, and support as they work through concerns and diagnoses with families in an iterative manner and over the long-term. This type of practice that focuses less on expeditiously arriving at diagnoses and narrow treatments for concerns is important for mental and emotional development. This report presents a reframe of mental and emotional development as part of whole health as opposed to a condition that should only be diagnosed and treated when something is “wrong.” The report also provides a stepped approach that may be helpful for addressing mental and emotional health concerns in pediatrics and acknowledges the advocacy that is needed to expand mental and emotional resources widely. [...]

10.1542/6389985742112Video AbstractPEDS-VA_2025-0731966389985742112OBJECTIVESWe hypothesized that the incidence, clinical presentation, isolate serotypes, and isolate antibiotic susceptibility of Streptococcus pneumoniae causing pneumonia in children varied before and through the course of the COVID-19 pandemic.METHODSPatients aged 18 years or younger at 8 children’s hospitals in the United States admitted with culture-positive pneumonia were identified. Serotyping of pneumococcal isolates was performed at a central research laboratory. Clinical and laboratory data were collected retrospectively with a standardized case report form.RESULTSWe identified 190 patients with pneumococcal pneumonia from 2017 to 2023. Cases decreased significantly in 2020 (P  [...]

In this issue of Pediatrics, Engstrom et al1 use data from a unique resource, the US Pediatric Multicenter Pneumococcal Surveillance Study Group (PMPSSG), to provide insight into the contemporary epidemiology of pneumococcal pneumonia in children. Given marked changes in respiratory pathogen epidemiology during and after the COVID-19 pandemic, as well as the availability of new multivalent pneumococcal conjugate vaccines (PCVs), this work is both timely and clinically relevant. [...]

In March 2022, the US Food and Drug Administration issued a drug safety communication (DSC) recommending monitoring of thyroid function in children up to 3 years of age who receive intravascular injection of iodinated contrast media (IV ICM) for medical imaging. In response, a group of pediatric and imaging experts convened to review the current scientific evidence on thyroid dysfunction after IV ICM and to provide recommendations on thyroid testing and management after IV ICM administration in infants and children. There are considerable gaps in knowledge related to the risk of thyroid dysfunction in young children exposed to IV ICM, and we strongly recommend that high-quality prospective studies be proposed and funded to clarify the incidence, risk modifiers, natural history, and outcomes of thyroid dysfunction after IV ICM exposure in this population. [...]

Kaufman DA, Lucke AM, Cummings JJ; American Academy of Pediatrics, Committee on Fetus and Newborn. Postnatal Cord Blood Sampling: Clinical Report. Pediatrics. 2025;155(6):e2025071811 [...]

BACKGROUND AND OBJECTIVESAlthough emergency department (ED) prescribing is targeted as a potential contributor to opioid-related harms, the impact of efforts to curb prescribing and subsequent harms are poorly understood. We examined how rates of ED opioid prescribing and subsequent opioid-related harms have changed over time among adolescents.METHODSWe conducted a cohort study using linked administrative data sets of patients aged 12 to 17 years who were discharged from any ED in Alberta, Canada, from April 1, 2010, to June 30, 2020. Opioid prescription fills in the 3 days after an ED visit were included. Our primary outcome was the development of opioid-related harms: a 1-year composite of opioid-related ED visit, opioid-related hospitalization, and opioid agonist therapy prescription. Joinpoint regression was used to identify changes in rates.RESULTSAmong 1 197 829 ED visits, ED opioid prescribing decreased from 3.3% of visits in 2010 to 1.2% in 2020; specifically, codeine and oxycodone prescribing decreased while tramadol and other opioid prescribing increased. General EDs prescribed more opioids than pediatric EDs (2.5% vs 1.5%) and saw slower decreases over time. The development of opioid-related harms increased from 0.15% in 2010 to 0.28% in 2020.CONCLUSIONSDuring a decade when ED opioid prescribing to adolescents decreased substantially, subsequent opioid-related harms nearly doubled in Alberta. Broad deprescribing measures in the ED may not effectively combat the opioid epidemic in this province. However, caution should remain for patients with longer prescription durations, frequent ED use, and mental health or substance use comorbidity and further studies are needed to better delineate patient-level risk. [...]

10.1542/6388486816112Video AbstractPEDS-VA_2025-0721916388486816112BACKGROUND AND OBJECTIVEAn increase in type 1 diabetes (T1D) incidence and severity was reported worldwide during the COVID-19 pandemic. The objective is to analyze whether this also occurred in the Chilean population aged less than 20 years.METHODSA population-based analysis was performed with people aged less than 20 years with T1D from a nationwide registry (2007–2023). Annual and quarterly incidence rates were calculated. Incidence rate ratios were used to compare averages by sex, age groups, and season. A seasonal autoregressive integrated moving average (SARIMA) model was used to predict incidence rates from 2020, comparing them with actual rates. An individual pre-post analysis was also performed with patients aged less than 18 years with T1D from 3 tertiary centers (2016–2023). Diabetic ketoacidosis (DKA) proportions were compared with Fisher’s exact test between 2016–2019 and 2020–2023.RESULTSThis study included 9583 individuals. T1D incidence increased from 7.4 cases in 2007 to 13.9 cases in a population of 100 000 aged less than 20 years in 2023. Average incidence rates were significantly higher in the 10- to 14-year age group and in winter. Actual quarterly rates were significantly higher than those SARIMA predicted from 2020 to 2021 and not significantly different from 2022 to 2023. Of 334 patients, 71% had DKA. A significant increase in DKA from 64.3% to 75.9% was found in 2020–2023 (P = .03).CONCLUSIONSThis study includes relevant data after 2021 and regarding severity. A significant increase in T1D incidence was found during the COVID-19 pandemic, paired with a higher severity at onset, returning to the prepandemic trend afterward. A causal relationship may be argued. [...]

In this issue of Pediatrics, Kutz et al report the incidence of type 1 diabetes (T1D) in youth younger than 20 years in Chile from 2007 to 2023.1 They identified a wave-like pattern in the incidence of T1D following the onset of the pandemic. This began with an increase in 2020 and 2021 that exceeded previous predictions, before declining to predicted rates in 2022 and 2023. This finding is consistent with large registry data from several European countries, including Germany and Scotland, that report a significant but temporary increase in new T1D cases, that was followed by a return to pre-pandemic rates or even a decline below predicted levels, indicating a wave-like pattern.2,3 Data from the Southern hemisphere provided by Kutz et al therefore confirm that this is a global phenomenon. This leads to the crucial question of whether this temporary peak is directly attributable to SARS-CoV-2 infections or whether other factors played a role. [...]

10.1542/6388766477112Video AbstractPEDS-VA_2025-0730006388766477112BACKGROUNDSARS-CoV-2 vaccination during pregnancy reduces COVID-19 risk in infancy. Whether maternal vaccination before pregnancy similarly protects infants against COVID-19 is unknown.METHODSWe examined the effectiveness of maternal messenger RNA SARS-CoV-2 vaccination before and during pregnancy in preventing COVID-19 in infants aged 0–6 months born between July 1, 2021, and June 30, 2023, at Kaiser Permanente Northern California. Maternal vaccination status was categorized as vaccinated during pregnancy, during a prepregnancy interval (0– [...]

Primary adrenal insufficiency, or Addison disease, can be caused by an autoimmune process and presents with poor growth, poor weight gain, nausea, vomiting, fatigue, and skin hyperpigmentation. During times of stress or illness, patients with untreated or insufficiently treated adrenal insufficiency are at risk for adrenal crisis progressing to hypotensive shock, lethargy, confusion, coma, and death. While primary adrenal insufficiency is reported as a rare cause of encephalopathy, and more rarely encephalitis in adults, it is not known to be associated with encephalitis in children. Here, we present a unique case of a female 17-year-old who presented with significant encephalopathy and magnetic resonance imaging findings consistent with acute leukoencephalopathy with restricted diffusion and who was ultimately found to be in adrenal crisis secondary to influenza-related encephalitis. Due to rapidly declining neurologic function and concern for infectious encephalitis, the new diagnosis of adrenal insufficiency was not initially identified. Less common electrolyte derangements, including hypercalcemia and hyperphosphatemia, also contributed to difficulties in diagnosis. After initiation of steroid replacement, the patient progressed to make remarkable functional progress. This case underscores the importance of navigating diagnostic uncertainty in complex pediatric care to improve patient outcomes. In addition, this case contributes to the growing literature of primary adrenal insufficiency in the pediatric patient and demonstrates the important role of glucocorticoids on neurologic function and calcium/phosphate metabolism. [...]

10.1542/6389887024112Video AbstractPEDS-VA_2025-0725596389887024112INTRODUCTIONIn 2015, the Indian Health Service reported an obesity prevalence rate of 29.7% for American Indian/Alaska Native children aged 2 to 19 years. The purpose of these annual evaluations is to describe the prevalence of obesity, prediabetes, and diabetes for American Indian children living on one reservation in the Northern Great Plains.METHODSFrom 2019–2020 through 2022–2023, American Indian students in grades kindergarten through 11, with parental consent, were screened for height, weight, body mass index (BMI) percentiles, and hemoglobin A1c (HbA1c) levels. χ2 tests were used to determine differences in BMI percentiles, HbA1c levels, sexes, and changes over time.RESULTSIn school years 2019–2020 through 2022–2023, students with overweight or class I, II or III obesity ranged from 60.9% to 68.6%. The percentage of students with any class of obesity ranged from 41.8% to 50.3%. Students in every grade (kindergarten-11) and every age (6–17 years) had overweight and classes I, II, and III obesity; every age from 5 to 17 years had prediabetes. The percentage of students with a hemoglobin A1c level from 5.7% to 6.4% significantly increased from 4.7% to 9.9% (P = .001) in 2019–2020 through 2022–2023. Of students with a hemoglobin A1c level of at least 6.5%, 70% were male, 18.8% were diagnosed type 1 diabetes, and 81.2% were diagnosed with type 2 diabetes.CONCLUSIONSPrevalence of obesity among these American Indian students is higher than 2015 rates. Prediabetes rates suggest an increase in the incidence and prevalence of diabetes is possible for these children. Interventions are needed to decrease the disease burden. [...]

At 4:04 am on August 9, 1963, President John F. Kennedy waited silently in a dim basement corridor outside the hyperbaric oxygen chamber at Boston Children’s Hospital. He was exhausted, hollowed out by two sleepless nights and a mounting sense of foreboding. Earlier in the week, his administration had announced the signing of the Limited Nuclear Test Ban Treaty, a notable milestone in Cold War arms control.1 But on that dark morning, geopolitics felt impossibly distant. Just beyond the chamber’s steel walls, the President’s newborn son was dying. [...]