General journals

William Blake, George Russell, and Aldous HuxleyAldous Huxley (1894‒1963) is best known as a novelist, particularly for his futuristic science fiction novel Brave New World (1932), although most of his other well known novels were social satires.However, Huxley was also a poet and essayist, his best known essays being two that are often published together: The Doors of Perception (1954) and Heaven and Hell (1956). In the former, Huxley described his disappointing experience with mescaline:“I swallowed four-tenths of a gram of mescalin dissolved in half a glass of water and sat down to wait for the results. … From what I had read of the mescalin experience I was convinced in advance that the drug would admit me, at least for a few hours, into the kind of inner world described by Blake and AE. But what I had expected did not happen. I had expected to lie with my... [...]

NHS watchdogs will re-evaluate their decision not to fund two new Alzheimer’s treatments on the health service after appeals from the drugs’ manufacturers.The National Institute for Health and Care Excellence (NICE) has also confirmed that the reassessment will take place under new, and controversial, cost effectiveness thresholds that were agreed as part of a trade deal with the US.1NICE previously concluded in June234 that lecanemab and donanemab should not be provided on the NHS for treating mild cognitive impairment or mild dementia caused by Alzheimer’s disease.Despite substantial interest in the drugs from patient representative groups NICE determined that neither was a cost effective use of NHS resources.The treatments were estimated to cost five to six times more than the threshold NICE can normally recommend, with high rollout costs including both regular infusions and monitoring of side effects such as swelling and brain bleeds.But NICE has now said it will review... [...]

What has led to such a large spike in cases when compared with previous outbreaks?“This is the most fascinating question that has arisen from this outbreak,” says Emma Wall, clinical professor of infectious diseases at Queen Mary University of London. She tells The BMJ, “Meningitis A outbreaks in the Sahel [semi-arid region extending from Senegal in West Africa to Sudan and Eritrea in East Africa] can comprise thousands of cases, but MenB has never caused an outbreak of this size before.”While the UK has previously seen meningitis outbreaks caused by the bacterial strain B of meningitis (MenB), case numbers have been small—as with the two cases seen in nursery in 20231—or have occurred over many years, as happened in Gloucestershire in the 1980s.2“It’s speculation, but whether this strain has acquired the ability to spread more rapidly is something under investigation,” Wall explains. “Otherwise, I suspect this is due more to... [...]

At the time of writing, the outbreak of invasive meningococcal disease in Kent includes 18 confirmed cases, 13 of which have been identified as type B (MenB), plus 11 suspected cases.1 Sadly, this has included two fatal infections. This outbreak is notable for its large number of cases in a short period, described as “unprecedented” by the UK Health Security Agency (UKHSA),2 and for the response, with extensive media coverage and widespread public anxiety about the perceived risk nationwide.The acquisition of Neisseria meningitidis requires close contact, with transmission occurring through saliva or respiratory droplets from a person carrying the organism.3 Most transmission events result in carriage, and around 10% of the population carry N meningitidis at any time.4 In the pre-vaccination era this rate was as high as 33% in adolescents with additional risk factors, which included attendance at pubs or clubs and cigarette smoking—echoing the discussion about the current... [...]

Rules regarding ways doctors must keep their personal beliefs in check when treating patients are being updated by the General Medical Council.The regulator has launched a consultation1 on proposed changes to its personal beliefs and medical practice guidance,2 which was last fully updated in 2013.The GMC said it was updating the guidance to reflect legal, social, and cultural changes. Examples include the government’s recently published guidance on defining “anti-Muslim hostility”3 and debates over assisted dying legislation.The regulator said it wanted to allow doctors to practise in line with their beliefs and values, while respecting patients’ own beliefs and “maintaining good and safe care.”It follows cases such as that of Kent GP Richard Scott, who was given a formal warning by a medical practitioners tribunal in 2023 after telling a vulnerable young patient seeking mental health treatment that he needed to reconnect with God.4The GMC clarified that the guidance does not... [...]

bmj;392/mar20_2/s520/FAF1faRalph Ross Russell—or R3, as he was affectionately known—became a neurologist at a time when strokes were not deemed worthy of academic attention. He was one of the first to make study of the condition into a research and clinical specialty, paving the way for better understanding and care, and playing a pivotal role in turning the treatment of stroke into the medical success story that it often is today.From the outset of his career Ross Russell was at the forefront of academic research in neurology. His first senior position was as a research scholar and lecturer in medicine in Oxford under George Pickering, regius professor of medicine, at the time of much debate on the nature of hypertension and when vasospasm as the cause of transient ischaemic attacks (TIAs) was being challenged. Ross Russell’s research focused on the mechanism of hypertension and its role in cerebrovascular disease, research he... [...]

A plastic surgeon who is serving a life sentence for attempting to murder a colleague and burn down his home has been struck off the UK medical register.Jonathan Peter Brooks was convicted of attempted murder and arson with intent to endanger life last April.Leicester Crown Court, sitting at Loughborough, heard that Brooks hated Graeme Perks, who had recently retired as head of plastic surgery at Nottingham University Hospitals NHS Trust and was a witness against Brooks in disciplinary proceedings.Brooks went to Perks’ house in the early hours of the morning of 14 January 2021, a few days into the disciplinary hearing.Brooks, dressed in camouflage and equipped with petrol cans, a knife, and a crowbar, broke in through the conservatory and doused the foot of the staircase in petrol.Perks was woken by the sound of smashing glass and came downstairs and interrupted Brooks before he could start the fire, but was... [...]

AbstractObjectivesTo provide evidence on the longitudinal accuracy of glomerular filtration rate (GFR) estimating equations that include creatinine and cystatin C to monitor patients with moderate chronic kidney disease.DesignProspective, longitudinal, cohort study.SettingPrimary, secondary, and tertiary care across six centres in England, 1 April 2014 to 31 December 2017.Participants1229 adults (≥18 years) with moderate chronic kidney disease (creatinine estimated GFR of 30-59 mL/min/1.73 m2 for at least three successive months before recruitment).Main outcome measuresAbility of estimating equations to monitor GFR over three years, with slope deviations from reference measured GFR (iohexol clearance) within ±3 mL/min/1.73 m2/year indicating agreement. Ability of GFR estimating equations to detect disease progression (ie, a reduction in measured GFR of ≥25% with a reduction in disease category).ResultsAfter three years, 875 participants had measured and estimated GFR data recorded at the start and end of the study and comprised the study cohort. Median measured GFR decreased from 48.1 mL/min/1.73 m2 at baseline to 43.6 mL/min/1.73 m2 at three years. GFR was estimated with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and European Kidney Function Consortium (EKFC) estimating equations. Median change in measured GFR exceeded median change in estimated GFR for all equations. All equations achieved agreement with change in measured GFR in >72.5% of participants. Dual biomarker equations showed better agreement with change in measured GFR (CKD-EPIcreatinine-cystatin 78.6% of individuals, 95% confidence interval 75.8% to 81.3%; CKD-EPI(2021)creatinine-cystatin 78.1%, 75.2% to 80.8%; and EKFCcreatinine-cystatin 80.2%, 77.4% to 82.8%) than CKD-EPIcreatinine (73.1%, 70.1% to 76.1%) (all P [...]

Heritability of human life spanEstimates of the genetic contribution to human life span have been surprisingly low, often around 20% or less. A reanalysis of Scandinavian twin cohorts suggests that these figures are distorted by mortality from extrinsic causes, including infection, violence, and unintentional harms (Science doi:10.1126/science.adz1187). When such deaths are excluded, heritability of intrinsic life span rises to about 50%, similar to that of other complex traits such as body mass index, blood pressure, or general cognitive ability.Maternal diabetes and epilepsy in offspringMaternal diabetes was linked to an increased risk of epilepsy in offspring in a Canadian birth cohort of more than two million children (Pediatrics doi:10.1542/peds.2025-071138). After adjustment for socioeconomic and clinical factors, the risk of epilepsy was 30-40% higher among children of mothers with type 1 or type 2 diabetes and about 15% higher among those exposed to gestational diabetes, compared with children of mothers without diabetes.... [...]

The US Centers for Disease Control and Prevention (CDC) recently agreed to fund a $1.6m(£1.2m) study on the hepatitis B vaccine that has glaring similarities to unethical biomedical research of the past.1 The study is on hold while the African CDC assesses its ethics and necessity, but even the fact that this potentially harmful study was proposed reveals the extent of backsliding in science, ethics, and research funding. We are regressing to the days when research on Black subjects was detrimental to their health rather than beneficial. The healthcare community must act to defend decades of progress and protect the health of Black people globally.The proposed study was planned to take place in the West African country of Guinea-Bissau where hepatitis B affects 18% to 19% of the population.2 The research team has already conducted 25 years of research there, with results from 10 studies never becoming publicly available.3This new... [...]

A woman in her 70s presented with an eight month history of transverse nail changes affecting all fingernails and toenails. She had a history of breast cancer treated with mastectomy, followed by six cycles of docetaxel based chemotherapy with concurrent radiotherapy, and she remained in remission. Transverse nail changes were first noted two months after starting chemotherapy. The final cycle was completed four months before presentation.Physical examination showed six transverse grooves on all nail plates (fig 1). Fungal cultures and potassium hydroxide tests found no evidence of fungal infection. Nor was there evidence of bacterial infection on microscopic examination of a nail sample.bmj;392/mar19_6/e086978/F1F1f1Fig 1A diagnosis of Beau’s lines was made. Beau’s lines present as palpable transverse depressions caused by transient arrest of nail matrix proliferation, affecting the full thickness of the nail plate.1 In this patient, the six transverse grooves corresponded sequentially to the six chemotherapy cycles.Changes involving all or... [...]

Obsessive-compulsive disorder (OCD) remains one of psychiatry’s most disabling conditions, affecting about 1-2% of the population.1 People with OCD have an 82% increase in all cause mortality compared with unnafected matched people from the general population,2 with suicide being a major contributor.3 The disorder is also associated with academic underachievement and labour market marginalisation, even after adjustment for psychiatric comorbidity,45 as well as reduced quality of life.67 The review by Abramowitz and colleagues (doi:10.1136/bmj-2024-083443)8 summarises the current treatment evidence for OCD, identifying cognitive behavioural therapy (CBT) with exposure and response prevention (ERP) and serotonin reuptake inhibitors (SRIs) as first line treatments. People with OCD face a dual challenge: many never get these treatments—particularly CBT—because of structural, financial, and geographical barriers9 and, among those who do, only about a third have a robust response (defined as 50% or higher symptom improvement from baseline).10 Most will experience persistent symptoms, and few proved... [...]

This Perspective examines aluminum exposure from vaccines and diet, including how the body processes aluminum, possible health effects, and safety considerations. [...]

Although more women may prefer clinic-based testing for cervical cancer screening overall, home-based self-sampling may be more popular among certain populations. [...]

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

This study examines patterns of Medicare’s G2211 billing code to understand its uptake and how often these payments went to primary care. [...]

This Medical News article discusses new findings that males have higher mortality than females even after accounting for behavioral, clinical, and sociodemographic factors. [...]

In the context of an ongoing public health emergency related to drug toxicity deaths, emergency department (ED) visits are undeniably important opportunities to identify individuals with high-risk opioid use and to engage them in care. Emergency departments are available every hour of the day, every day of the year in many communities and provide low-barrier touchpoints for individuals with high-risk opioid use, many of whom have concurrent social vulnerabilities. Increasing access to evidence-based harm reduction and treatment options for people with opioid use disorder in EDs is a crucial aspect of the response to the ongoing drug toxicity crisis. In this issue of JAMA, D’Onofrio and colleagues report a study conducted across 29 sites (with both federal funding and in-kind pharmaceutical support) that importantly pushes existing boundaries of ED-based care. D’Onofrio and colleagues tested a novel approach to initiate an extended-release formulation of buprenorphine for patients with opioid use disorder. The authors found no difference in treatment engagement at 7 days or 30 days among patients who received 7-day extended-release injectable buprenorphine compared with those who received sublingual buprenorphine. Additionally, they reported low rates of precipitated withdrawal in both groups. [...]

With me shirtless, pantless, in boxers Sitting on the examination table In the sanitary brightness of the operatory The Dermatologist knocked and entered soon Fluttering around like over pollen, Checking spots on forehead, shoulders, and back, Before bending down to examine my legs, hairless Overall some spots to murmur about, a couple requiring A quick blade for biopsy or nitrogen freeze— We soundtracked his flight around me talking about Our recent holidays in the sun, his in the Bahamas Mine in Cancún, agreeing they were needed to restore Living as we did in a Winterland without wonder And our favorite activity, morning walks on the beach Surf washing up promises of seashells Sun rising methodically on cue Back to my skin, of course I applied sunscreen Much as I enjoy this undivided, clinical attention. [...]

Cardiovascular disease (CVD) risk increases for men years before it does for women, a prospective study published in the Journal of the American Heart Association found. The study aimed to investigate whether the well-established earlier onset of coronary heart disease in men persists in contemporary populations and whether age at onset differs between the sexes for other types of cardiovascular disease. [...]

New research suggests that cataract surgery does not aid in the progression of nonneovascular age-related macular degeneration (AMD) to neovascular age-related macular degeneration (nAMD). [...]

This prospective cohort study investigates whether coffee and tea intake are associated with dementia risk and cognitive function in female participants from the Nurses’ Health Study and male participants from the Health Professionals Follow-up Study. [...]

This randomized clinical trial assesses the effect of emergency department (ED)–initiated 7-day extended-release injectable buprenorphine vs sublingual buprenorphine on treatment engagement at 7 days among patients with opioid use disorder. [...]

This trial examined whether 7-day extended-release injectable buprenorphine given in the emergency department (ED) improved treatment engagement at 7 days vs sublingual buprenorphine among adults with untreated opioid use disorder. [...]

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 Background North Korean defectors in South Korea offer a rare natural model to trace cancer risk evolution after rapid environmental transition, given shared genetics but markedly contrasting early life exposures with South Korean residents. Methods Using the Korean National Health Insurance database, we constructed a nationwide matched cohort of 25,798 North Korean defectors and 1,276,601 South Korean residents (1:50 frequency matching by sex, age, and index year). We compared overall and site-specific cancer risks and examined time-varying hazard ratios (HRs) since resettlement. Results Overall cancer risk was higher among defectors (HR 1.13; 95% confidence interval, 1.07–1.18), particularly in men (HR 1.31). Liver (HR 2.53), uterine cervical (HR 2.10), and lung cancer (HR 1.69) were markedly elevated, reflecting infection- and deprivation-related legacies. In contrast, cancers more prevalent in developed countries, notably breast (HR 0.48) and colorectal (HR 0.71), were initially lower. However, HRs began to rise over time, especially for breast cancer, indicating a trend toward convergence with host-population patterns. Conclusion The cancer profile of North Korean defectors demonstrates a dual burden: persistent risks from infection-related cancers rooted in pre-defection exposures and growing vulnerability to lifestyle-related cancers after resettlement. These findings highlight the importance of dual-track prevention strategies that address both legacy and emerging cancer risks in rapidly transitioning populations. [...]

Background Current guidelines recommend at least 10 years of follow-up for all pheochromocytoma and paraganglioma (PPGL) patients and lifelong monitoring for high-risk individuals. Nonetheless, data identifying patients who may not require routine lifelong follow-up are scarce. Methods Among 999 patients with PPGL, 703 who were non-metastatic, non-hereditary, and had undergone complete resection were included. Variables that significantly differed between the recurrence (n = 50) and non-recurrence groups over 10 years (n = 83) were identified, and cutoff values were determined using receiver-operating characteristic curve analysis. These very low-risk criteria were validated in an internal cohort and an external dataset from the National Institutes of Health. Results The non-recurrence group was older and had smaller pheochromocytomas (PCCs) than the recurrence group, with cutoffs of 37 years and 5.7 cm, respectively. The non-recurrence group had a higher percentage of patients with pheochromocytoma of the adrenal gland scaled score (PASS) [...]

Journal of Internal Medicine, Volume 299, Issue 4, Page 421-421, April 2026. [...]

Abstract Objective To compare the efficacy and safety of extended interval (Q3–4W) enzyme replacement therapy (ERT) versus standard biweekly (Q2W) ERT in clinically stable type 1 Gaucher disease (GD) patients. Methods We emulated a target trial with a sequential trial design, using data from the French Gaucher Disease Registry. Eligible patients were treated for ≥2 years biweekly without clinical events. Every 3 months, switchers to Q3–4W were matched to Q2W patients by age, sex, referral center follow-up, disease history (bone events, anemia, thrombocytopenia, splenectomy, and hepatosplenomegaly), and dose of ERT. The primary outcome was a composite of GD-related events (bone events, anemia, and thrombocytopenia). A 10% non-inferiority margin was prespecified. Secondary outcomes were biomarker changes and economic analyses. Results Among 280 eligible GD patients, 63 switched to Q3–4W and were matched to a total of 215 Q2W patients, followed for an average of 6.3 years. No significant difference in the risk of clinical events was observed between groups (hazard ratio: 0.98 [95% confidence intervals (CI): 0.54–1.51]). During follow-up, absolute risk difference remained below the 10% non-inferiority threshold at all timepoints. Biomarkers remained stable or slightly decreased in the Q3–4W group. The dosing interval extension led to an average reduction of 55 infusions per patient, corresponding to approximately €450,000 saved per patient over 6 years. Conclusion In stable GD1 patients, extending ERT administration to every 3–4 weeks was non-inferior to the standard biweekly regimen, supporting personalized spacing strategies that may improve quality of life and reduce healthcare costs. [...]

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

Abstract Background Chronic intestinal pseudo-obstruction (CIPO) is a severe gastrointestinal motility disorder that may be idiopathic or associated with systemic disease. In idiopathic cases, the pathophysiological mechanisms remain poorly defined. Although mutations in angiogenic factors have been reported in mitochondrial forms of CIPO, their role in non-mitochondrial cases is still unclear. Objective To investigate genetic and molecular contributors to CIPO, with a specific focus on intestinal microvasculature. Methods Jejunal samples from patients with CIPO were analysed by whole exome sequencing (WES) and mitochondrial DNA (mtDNA) profiling. Morphometric and immunohistochemical studies assessed collagen remodelling, vascular architecture, neuromuscular integrity and hypoxia. Expression of angiogenic factors, including thymidine phosphorylase (TP) and vascular endothelial growth factor (VEGF), was evaluated. Results WES did not identify known CIPO-causing variants, but rare mutations in collagen-related genes were detected in a subset of patients. Tissue analysis revealed higher fibrosis, vascular remodelling with a predominance of very small vessels, thinning of the longitudinal muscle and neuronal loss. TP and VEGF expression were significantly reduced, whereas hypoxia-inducible factor-1α (HIF-1α) was markedly upregulated. mtDNA integrity and copy number were preserved, whereas haplogroup J was overrepresented. Multivariate analysis linked these alterations to a higher frequency of sub-occlusive episodes. Conclusions Vascular dysfunction and collagen abnormalities emerge as key contributors to neuromuscular degeneration in CIPO. These findings provide novel mechanistic insights into disease pathophysiology and support further exploration of vascular-targeted therapeutic strategies. [...]

Abstract Background and objective The development of Type 1 diabetes (T1D) is shaped by genetic predisposition and epigenetic regulation. Human leukocyte antigen (HLA) risk alleles are major genetic determinants, but the epigenetic landscape in relation to disease onset remains unclear. Early-life epigenetic modifications may reveal how environmental and epigenetic factors interact in T1D pathogenesis. Methods We investigated epigenetic differences in cord blood DNA from individuals with different HLA risk alleles who later developed T1D using epigenome-wide association studies. Result High-risk HLA carriers showed differentially methylated genes (DMGs) mainly involved in immune and autoimmune processes, resembling patterns in other autoimmune diseases. In contrast, low-to-neutral risk carriers exhibited DMGs linked to signaling cascades, metabolic pathways, and Type 2 diabetes–related mechanisms such as beta cell function and insulin signaling. Conclusion These findings indicate that heterogeneity in T1D pathogenetic mechanisms based on HLA background may influence disease development. [...]

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

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

Abstract The integration of immune checkpoint inhibitors into perioperative management marks a major evolution in curative-intent oncology. This review examines the current evidence for perioperative immunotherapy encompassing neoadjuvant, adjuvant, and combined strategies in melanoma and non-melanoma skin cancers, non-small cell lung cancer (NSCLC), triple-negative breast cancer (TNBC), esophageal and gastroesophageal junction cancer, renal cell carcinoma, urothelial carcinoma, head and neck squamous cell carcinoma, colorectal cancer, gynecological malignancies, and hepatocellular carcinoma. Neoadjuvant immunotherapy demonstrates biological advantages by exposing the immune system to intact tumor antigens, consistently improving event-free survival and pathological response rates across tumor types. Notable successes include CheckMate 816 in NSCLC, KEYNOTE-522 in TNBC, and emerging trials in melanoma that show superior outcomes compared to adjuvant-only approaches. Pathological complete response and major pathological response have emerged as robust surrogate endpoints correlating with long-term survival. In contrast, adjuvant immunotherapy shows more variable results, with demonstrated recurrence-free survival benefits but inconsistent overall survival (OS) advantages—particularly concerning given the risk of overtreatment in patients potentially cured by surgery alone. Critical challenges include the absence of predictive biomarkers in most cancer types, immune-related adverse events occurring in up to 30% of patients, substantial healthcare costs, and insufficient OS follow-up duration in many approved indications. Future priorities include biomarker development, adaptive trial designs incorporating response-guided therapy, and long-term toxicity assessment. Although perioperative immunotherapy is reshaping curative-intent cancer treatment, optimal patient selection, treatment sequencing, and safety optimization remain essential for widespread implementation. [...]

Abstract Background Large-scale studies on the association between celiac disease (CeD) and acute pancreatitis (AP) are scarce. Objectives To investigate the long-term risks of incident and recurrent AP in patients with CeD. Methods Through the Swedish nationwide histopathology cohort Epidemiology Strengthened by Histopathology Reports in Sweden, we collected data on biopsy-confirmed CeD diagnosed between 1969 and 2023 (n = 57,221) and matched them with general population reference individuals (n = 279,126) by birth year, sex, calendar year, and county. Cox regression estimated average adjusted hazard ratios (aHRs) for incident and recurrent AP over time, whereas flexible parametric survival models assessed time-varying incident risks. Results During a median follow-up of 15.5 years, incident AP occurred in 549 patients with CeD (incidence rate [IR]: 58.7/100,000 person-years), and 1732 reference individuals (IR: 37.8). The multivariable-adjusted hazard for incident AP was consistently increased in patients with CeD compared with reference individuals (aHR = 1.42 [95% confidence intervals {CI}: 1.28–1.58]), resulting in one extra incident AP event per 185 CeD patients during the first 25 years after diagnosis. Increased incident risks were observed for gallstone- and non-gallstone-related AP, and severe AP, but not alcohol-related AP. Conversely, in study participants who had survived a first AP episode, CeD was not associated with an increased risk for recurrent AP (aHR = 0.85 [0.67–1.08]). Sensitivity analyses, including a sibling comparison, confirmed the main findings. Conclusion CeD is linked to a moderately increased long-term risk of incident AP, but not to recurrent AP after the first episode. Clinicians should be aware of this increased risk and counsel patients with CeD on AP risk factors. [...]

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

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

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

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

ABSTRACT Restoration of tactile sensation in fingertip reconstruction is essential for hand function. This systematic review aimed to evaluate differences in the outcomes of innervated (IF) and noninnervated local flap (NIF) reconstruction for digital soft tissue defects. PubMed, MEDLINE, Cochrane, and EMBASE databases were systematically searched. English-language articles reporting sensibility outcomes were included. Eleven studies, published between 1983 and 2023, with a total of 591 flaps were included in the analysis. The sensibility outcome of the reconstructed fingers in IF is significantly better than that of NIF. Neurorrhaphy should be performed in local flap fingertip reconstruction to improve the sensory outcome. [...]

ABSTRACT Background Obesity is a major risk factor for perioperative complications following total joint arthroplasty (TJA). Bariatric surgery has been proposed to reduce these risks, but previous studies report inconsistent findings. The effect of bariatric surgery before arthroplasty remains uncertain. We sought to determine whether prior bariatric surgery, compared with no bariatric surgery, is associated with reduced perioperative medical complications, reduced surgical complications and differences in revision rates. Methods A systematic literature search was conducted in the major databases since their inception up to June 2025 to identify studies comparing postoperative outcomes in patients undergoing total hip or knee arthroplasty with or without prior bariatric surgery. Random effects meta-analysis was used to pool risk ratios across studies. Results Thirty studies comprising over 6.2 million patients met inclusion criteria. Bariatric surgery prior to arthroplasty was associated with lower risk of several systemic complications, including venous thromboembolism (hip RR 0.72, 95% CI 0.54–0.94; knee RR 0.70, 95% CI 0.51–0.94), sepsis (knee RR 0.51, 95% CI 0.39–0.65) and stroke (knee RR 0.58, 95% CI 0.41–0.81). These benefits were most pronounced in hip arthroplasty, where lower rates of periprosthetic joint infection (RR 0.71, 95% CI 0.55–0.91) and mechanical loosening (RR 0.72, 95% CI 0.57–0.91) were also observed. Conversely, knee arthroplasty demonstrated higher risks of revision (RR 1.28, 95% CI 1.04–1.57) and dislocation (RR 1.55, 95% CI 1.03–2.31), without significant differences in wound complications or mechanical failure. Conclusions Bariatric surgery prior to total joint arthroplasty is associated with meaningful reductions in medical complications, but these benefits do not consistently extend to surgical endpoints. An increased revision risk in knee arthroplasty highlights the need for individualised preoperative optimisation, nutritional assessment and timing considerations to balance systemic and mechanical risks. Trial Registration: PROSPERO: CRD420251105136. [...]

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

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

ABSTRACT Background Colorectal cancer remains a leading cause of mortality worldwide. We investigated whether adding socioeconomic information to machine learning models can improve the prediction of colorectal cancer-specific mortality. Methods Using data from the Fundação Oncocentro de São Paulo (FOSP), we analyzed individuals diagnosed with colorectal cancer between 2000 and 2023; however, predictive models were developed using patients diagnosed from 2000 to 2021, ensuring a minimum follow-up of 24 months for the 2-year mortality outcome. Thirty predictor variables were included, including clinical factors associated with the disease and socioeconomic factors such as income, educational attainment, HDI components, as well as distance and travel time to healthcare facilities. We tested seven machine learning algorithms using a 70/30 training/testing split. Discrimination was measured by the area under the receiver operating characteristic curve (AUC-ROC), comparing versions with and without socioeconomic factors. Results The Random Forest algorithm provided the best discrimination for predicting the risk of death due to colorectal cancer within 2 years after diagnosis (AUC-ROC = 0.92). The addition of socioeconomic and access-related predictors (Human Development Index [HDI] components, education, distance/travel time to healthcare facilities, and type of coverage) improved the AUROC by 0.13 (0.79–0.92) compared with the clinical-only model. Conclusion The inclusion of socioeconomic variables in conjunction with clinical data in machine learning models has the potential to enhance the ability to predict colorectal cancer-specific mortality in patients with colorectal cancer. [...]

ABSTRACT Introduction Choledocholithiasis detected during laparoscopic cholecystectomy is common. There is no consensus for the best management in this context. Trans-cystic biliary stent insertion is a well described but less commonly used method for managing choledocholithiasis with the gallbladder in situ. Methods Retrospective study including all patients undergoing trans-cystic biliary stenting followed by ERCP at Box Hill Hospital, from 2021 to 2024. Outcomes compared to control cohort of native ERCP for choledocholithiasis at the same institution. The primary outcome was post-ERCP pancreatitis. Results Trans-cystic stenting was attempted in 49 patients. 45 (92%) were successful. The median age was 52 years, 73.4% were female, and 67% admitted emergently. No episodes of post-ERCP pancreatitis occurred when the trans-cystic stent was in position at ERCP, compared with 5% in the control cohort. Biliary cannulation rate was 97% if a stent was present, compared with 91% in the control cohort. 20% of stents had migrated by the time of ERCP. One patient developed pancreatitis post failed trans-cystic stent attempt. No other complications were recorded. The median length of stay (LOS) was 5.0 days. A 40% of patients were discharged prior to ERCP, resulting in a shorter median LOS: 4.0 versus 6.0 days (p = 0.014). No statistical differences were detected between variables for unsuccessful stenting, stent mis-deployment, or stent migration. Conclusion Trans-cystic stenting resulted in a low rate of post-ERCP pancreatitis and a high rate of biliary cannulation. It can be safely implemented by general surgeons and may result in a reduced length of stay. [...]

During robotic right-sided colectomy, although changing body position is required to change the surgical view, it can be a complicated and troublesome procedure in robotic surgery, especially without an integrated table motion. We describe an efficient, simple surgical method to smoothly change the surgical view during robotic right-sided colectomy without changing the body position, called the scope port hopping method (SCOP) method. [...]

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

ABSTRACT Background Undertriage of women with trauma is associated with preventable deaths. This project was developed to determine whether older women with trauma were less likely to be admitted to a specialist trauma unit. Methods The study was undertaken at a specialist, level one trauma service and included all people aged 65 and older admitted following trauma over a twelve-month period. Patients were included if they were admitted to general medicine, trauma or orthopaedics. The primary outcome was admission to general medicine versus trauma. Baseline data included age, sex, Charlson Comorbidity Index (CCI), mechanism of injury (low fall vs. other) and baseline function. Injury Severity Score (ISS) was calculated by trained assessors. Results A total of 648 (50.3%) were admitted to trauma, 286 (22.2%) to orthopaedics and 352 (27.4%) to General medicine (GM). 686 (53%) of patients were women. Low fall was the most common mechanism of injury (75.6% of women, 51.3% of men). In a multivariate model to look at admission to GM versus trauma, including age, sex, language other than English, CCI and ISS, women were more likely to be admitted to GM (1.67 (1.14, 2.44)). Low fall was the biggest predictor of general medical admission versus trauma (11.4 (6.7, 18.9)) Low fall was associated with mortality (2.0 (1.11, 3.67)). Conclusions Accounting for age and frailty women and people with low falls were more likely to be admitted to a general medical unit than a trauma unit compared to men. This supports the need for standard admission guidelines for trauma. [...]

ABSTRACT Objective To systematically review and compare reduced-dose and standard-dose computed tomography (CT) protocols for craniocerebral and craniofacial trauma, focusing on image quality and radiation dose optimisation strategies. Methods A systematic review was conducted following the PRISMA 2020 guidelines. Searches were performed across PubMed, EMBASE, Scopus, Web of Science, Cochrane Library, LILACS, and TripDatabase for studies published between November 2024 and January 2025. Observational studies comparing reduced-dose with standard-dose CT protocols were eligible. Two reviewers independently screened titles, abstracts and full texts, with discrepancies resolved by consensus. Data were extracted regarding scanner type, acquisition parameters, dose metrics (CTDIvol, DLP) and image quality assessments. Results Of 641 records screened, 7 studies met the inclusion criteria. None reported diagnostic accuracy metrics; therefore, a quantitative descriptive synthesis was performed. Across studies, reduced-dose CT protocols achieved 21%–89% dose reduction while maintaining comparable subjective and objective image quality. Iterative reconstruction, spectral shaping and current modulation were the most effective techniques for optimising image quality with lower radiation. Limitations Evidence was limited to observational studies without diagnostic reference standards, and heterogeneity in protocol reporting restricted data comparability. Conclusion Reduced-dose CT protocols demonstrate comparable subjective and objective image quality to standard-dose acquisitions while achieving substantial radiation dose reductions. Techniques such as iterative reconstruction, tube-voltage modulation, spectral shaping and automated exposure control were consistently associated with meaningful dose optimisation. These findings support the clinical feasibility and safety of implementing dose-optimised CT protocols in trauma imaging. Implications for Practice Findings support the clinical feasibility and safety of implementing dose-optimised CT protocols for trauma imaging. [...]

ABSTRACT Introduction Higher BMI is associated with reduced breast screening participation but it is unclear if BMI is a proxy for other potential barriers to screening. This study describes the correlations between BMI and body image, perceptions of risk, and pain in a large sample of breast screening participants to help identify targets for improving screening participation within people with obesity. Methods A survey collected information on body image, perceived risk of breast cancer, and pain experienced during mammography from 10,751 participants attending BreastScreen Western Australia between June and December, 2023. Latent variable analysis was used to generate single unobserved index variables for perceived risk, body surveillance, and body shame. Spearman's rho correlations were estimated between BMI, four body shame variables, six body surveillance variables, overall perceived risk index, and a pain score. Results BMI was significantly positively correlated with responses indicating increased body shame and increased body surveillance, except for one question where participants with increased BMI indicated that they think it is more important that their clothes are comfortable than look good. BMI was also positively correlated with overall perceived risk index (r s  = 0.08, p  [...]

ABSTRACT Introduction This study aims to analyse the practice patterns of radiotherapy (RT) for pancreatic cancer (PC) in Korea. Methods A questionnaire comprising 17 questions on RT for PC was sent to board-certified radiation oncologists participating in the Division for Pancreaticobiliary Cancer of the Korean Radiation Oncology Group. Results Twenty-three hospitals participated in the survey. In 2022, 11 hospitals reported adjuvant RT cases after resection (66 patients), 4 hospitals reported neoadjuvant RT cases before surgery (80 patients), and 16 hospitals reported definitive RT cases for locally advanced PC (197 patients). Adjuvant RT dose and fractionation varied across institutions, either conventional (45–54 Gy in 25–30 fractions) or hypofractionated (37.5–45 Gy in 15 fractions) regimen. Definitive RT indications included progressive disease or an increase in tumour markers during systemic therapy (12 responses), incomplete systemic therapy due to treatment-related adverse event (10 responses), ineligibility for multiagent chemotherapy due to patient performance including old age or comorbidities (9 responses), planned RT after completion of chemotherapy according to the institutional protocol (3 responses), and ineligible for conversion surgery despite the completion of chemotherapy (3 responses). The application of RT techniques and dose-fractionation schedules also varied depending on the available equipped machine, tumour location, and relationship with neighbouring organs at risk. Conclusions Current analysis showed significant heterogeneity in the practice patterns of RT for PC in Korea, particularly in dose fractionation schedules and RT indications. These findings highlight the need for further research and standardisation of RT practices to optimise treatment outcomes. [...]

ABSTRACT Background Beta Thalassaemia Major is a hereditary disorder characterised by defective protein synthesis in the beta-globin chain, leading to chronic anaemia. As a consequence of repeated blood transfusions used to manage anaemia, excessive iron accumulation occurs, primarily in the liver and other vital organs, leading to organ damage. Purpose To determine the correlation between liver iron concentration and iron accumulation in the liver due to blood transfusions in paediatric patients diagnosed with Beta Thalassaemia Major, using shear wave elastography and liver magnetic resonance imaging apparent diffusion coefficient measurements. Materials and Methods A prospective study was conducted from January 2025 to April 2025 on 77 paediatric patients diagnosed with Beta Thalassaemia Major, utilising liver shear wave elastography, liver apparent diffusion coefficient, T2* values and serum ferritin levels. Results Descriptive statistics for the continuous variables of the patients: elasticity median (10.39 ± 4.39 kPa), velocity median (1.81 ± 0.36 m/s), liver ADC (0.52 ± 0.42), liver T2* (4.93 ± 5.15), LIC (9.45 ± 5.7). The median elasticity values differed significantly across the iron overload severity groups (p = 0.006). A post hoc analysis was performed to identify the groups responsible for this difference. The analysis revealed that the differences originated from comparisons between the mild (9.58 ± 3.62) and severe (14.44 ± 5.91) groups, the moderate (9.47 ± 3.24) and severe (14.44 ± 5.91) groups and the severe (14.44 ± 5.91) and normal (8.16 ± 2.44) groups (p ac [...]

ABSTRACT Purpose This study aims to estimate the carbon footprint associated with external beam radiotherapy in a low- and middle-income country (LMIC) context, specifically at the Uganda Cancer Institute (UCI), and to evaluate whether sustainability should be a priority alongside treatment access in such radiation therapy settings. Methodology A carbon footprint analysis was conducted for patients treated for locally advanced cervical cancer at UCI between 2023 and 2024. The assessment included emissions from three key components: (1) patient travel to and from the facility, (2) pre-treatment imaging using CT and 2D simulation and (3) energy consumption by three Varian TrueBeam linear accelerators during treatment and idle times. Emission estimates were calculated using activity data and standard global warming potential (GWP) conversion factors. Results Patient travel emerged as a major contributor to carbon emissions due to the centralisation of services in Kampala and the lack of regional treatment centres. Energy use from LINACs and imaging contributed less significantly, owing in part to Uganda's low-carbon electricity grid powered largely by hydropower. CT scans generated approximately 0.105 kg CO2 per scan, and LINAC operations added modest emissions depending on usage patterns and machine idle time. Conclusion While radiotherapy-related emissions in LMICs like Uganda are relatively modest compared to high-income countries, they are non-negligible and expected to rise with growing access to cancer care. Incorporating sustainability considerations into the future planning of radiotherapy infrastructure and service expansion is both feasible and necessary. Carbon-conscious planning should be integrated into decisions around siting and radiotherapy expansion to promote environmentally responsible cancer care in LMICs. [...]

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

ABSTRACT Introduction The reality of rising greenhouse gas emissions and global temperatures underscores the urgency of transitioning to a net-zero energy system. Modern radiotherapy contributes to the total healthcare domain emissions. As the global incidence of cancer rises, expanding treatment capabilities is critical. However, sustainability in high-emission healthcare disciplines is equally paramount. This paper explores the academic knowledge base and practical strategies for understanding and managing emission contributions to align with sustainability goals. The European Union's Corporate Sustainability Reporting Directive and climate disclosure frameworks in Australia and New Zealand require certain organisations, including large hospitals and radiotherapy networks, to report their direct and indirect emissions. Methods Climate disclosure frameworks emphasise transparency and resilience to climate risks, supported by methodologies such as the Greenhouse Gas Protocol and ISO 14064. The study narratively examines existing literature and practical solutions through engaged scholarship and provides insights into modelling radiotherapy emissions guided by the principles of the Corporate Sustainability Reporting Directive. Results Radiotherapy emissions are a small but significant share of healthcare emissions, with indirect emissions dominating. They are estimated at 6.75 Mt. CO2e, accounting for approximately 0.3% of global healthcare emissions. While sustainable construction and innovative technologies reduce upstream impacts, downstream greenhouse gas reductions remain limited despite travel minimisation efforts. Conclusions By advancing sustainability in radiotherapy, this work contributes to the broader healthcare sector's efforts to mitigate climate impacts and aligns with international climate commitments. [...]

ABSTRACT Introduction 68Ga prostate-specific membrane antigen (PSMA) has been shown to have prognostic value in detecting PSMA expressing metastasis from prostate cancer, but inevitably, there are cases in which suspected metastases demonstrate equivocal uptake. This study aims to assess whether there is a direct relationship between SUVmax of the primary prostate lesion and the presence of nodal and distant metastasis. Methods Retrospective review of 265 primary staging 68Ga-PSMA PET/CT studies performed at a single centre on a single PET/CT was performed for the SUVmax of the primary lesion, and the presence of PSMA-avid nodal/distant metastases. Results Analysis shows that a single unit increase in SUVmax of the primary prostatic lesion corresponds with a 1.6% increased odds of nodal metastases, 1.7% increased odds of distant metastases and a 2% increased odds of having either. A single unit increase in the log of the SUVmax corresponds with odds ratios of 2.061, 2.038 and 2.294 respectively. Conclusion There is a weak but statistically significant correlation between the SUVmax of the primary prostate lesion and the presence of metastases on primary staging 68Ga-PSMA PET/CT for biopsy-proven prostate cancer. However, because the relationship is so weak and the significant overlap in SUVmax in local versus advanced disease, using SUVmax as the sole predictor of advanced disease is unreliable. [...]

ABSTRACT Background Evaluating therapeutic efficacy in colorectal malignancies presents significant challenges when relying solely on conventional anatomical imaging approaches. The primary aim of this prospective study was to compare the diagnostic effectiveness of integrated positron emission tomography–computed tomography (PET-CT) and diffusion-weighted magnetic resonance imaging (DWI-MRI) for monitoring chemotherapy response in patients with colorectal cancer. Methods This prospective comparative analysis included 132 histologically confirmed patients with colorectal cancer planned for first-line chemotherapy (FOLFOX, FOLFIRI, or CAPOX). Twelve of 132 patients left the study during follow-up. Patients underwent baseline PET-CT and DWI-MRI exams, with repeat scans at 3, 6, and 12 weeks post-treatment. Response assessment used RECIST v1.1 for morphology, PERCIST v1.0 for metabolism, and quantitative apparent diffusion coefficient (ADC) analysis for DWI-MRI. Survival outcomes, correlation studies, and receiver operating characteristic curve analysis were used. Results Patients had a mean age of 62.7 ± 9.6 years, with 51.7% men. PET-CT indicated a 36.0% ± 25.3% SUVmax reduction, and DWI-MRI showed a 51.4% ± 42.1% ADC rise at 12 weeks (p  [...]

Journal of Medical Imaging and Radiation Oncology, Volume 70, Issue 2, Page 141-145, March 2026. [...]

ABSTRACT In July 2022, the Australian Medical Services Advisory Committee (MSAC) recommended the establishment of an Australian NLCSP (National Lung Cancer Screening Program), using low-dose computed tomography (LDCT) for the early detection of lung cancer in asymptomatic high-risk individuals. MSAC's recommendations for the NLCSP included core requirements as follows: (i) routine biennial screening, (ii) use of the PanCan risk prediction model for reporting baseline LDCT, and (iii) the use of the most recent version of Lung-RADS for reporting follow-up LDCT. Necessary adaptations were made to incorporate these requirements, resulting in a bespoke protocol for the Australian context. This article summarises the rationale and development of the NLCSP Nodule Management Protocol. [...]

ABSTRACT Introduction Ground level falls are common in the geriatric population, often culminating in Emergency Department attendance and a CT ‘pan scan’. These scans are routinely performed with intravenous iodinated contrast media (ICM). The types of injuries identified in this cohort can often be adequately characterised without ICM. Safety issues exist with ICM use, with contrast-induced acute kidney injury (CI-AKI) particularly relevant to the geriatric population. This study assessed the diagnostic utility and safety of ICM administration in this cohort. Methods A retrospective case control study of geriatric patients undergoing CT pan scan over a 6-month period was performed. Patients were included if they had suffered a ground level fall. The radiology report for each patient was reviewed to assess injury types. The creatinine of each patient who received ICM was assessed to determine the presence of CI-AKI. Results A total of 549 patients were included in the final analysis. Two hundred four patients suffered at least one traumatic injury. The majority of injuries were musculoskeletal and spinal, with solid organ and vascular injuries only occurring in a small minority. Injuries were more frequently reported on non-contrast studies. 15.4% of patients suffered a CI-AKI. Conclusion Given the types of injuries identified in geriatric patients following low-energy blunt trauma, and when considering CI-AKI and other costs, routine use of ICM on CT pan scans in this population is not necessary. Reserving ICM studies only for patients deemed clinically high risk or with radiologically concerning findings on an initial non-contrast CT is a reasonable compromise. [...]

ABSTRACT Objective There is good evidence that a well-supported, positive rural clinical university placement experience contributes to rural origin students' intentions to practice rurally. However, not much is known about the support needs of rural origin students at university more generally. This research aims to identify and understand the support needs of rural origin health professions students entering and studying at university, using the lens of situational and experiential factors. Setting The research was conducted at a medium-sized Australian university with multiple metropolitan, regional and remote campuses. Participants Students enrolled in a health profession course who met criteria for rural origin were invited to participate. Design This research used a pragmatic mixed methods approach. Analysis examined the support needs identified by students for situational and experiential factors that influenced their experience of university study. Results The research revealed four rural origin health professions student profiles based on their enrolment patterns: Relocated students; Commuting students; Distance students; and Local students. Support needs were predominantly practical, but differed according to each profile type. Considerations for designing student support include adopting a ‘whole-of-course’, futures-oriented, situation-sensitive and reflexive view of the student's university experience, beyond the rural placement. Conclusion This research advances Australian Government education policy, which aims to increase participation and attainment rates for rural origin students at university. The findings suggest important first steps for university leaders responsible for designing appropriate supports for rural origin health professions students. [...]

ABSTRACT Aim To explore the role and impact of University Department of Rural Health (UDRH) targeted investment in embedded researchers and research–practice partnerships as mechanisms to increase research capacity in rural health and community services. Context Increasing rural research capacity and culture is crucial for improving rural health outcomes and a key deliverable for UDRHs. Rural health services often lack research capacity due to multiple factors including chronic workforce shortages, limited research infrastructure and resources, fewer academic partnerships and historical underinvestment in rural health research. Approach This commentary describes the development of an ecosystem of embedded researchers and research–practice partnerships in rural western Victoria. Three case studies provide examples of embedded researcher models that are supported by a UDRH, and the role of an Australian academic health science centre focusing on rural health outcomes, as an enabler of impact. These case studies are based on the perspectives of senior academics, leaders and embedded researchers, and their first-hand knowledge of Deakin Rural Health (a UDRH), rural health organisations and the rural research context. These case studies focus on the broader impacts of embedded researchers and their contribution to a research ecosystem. Conclusion UDRH academic leadership and targeted investment in embedded researchers, combined with support from rural health and community services, has created a research ecosystem. There has been synergistic growth in research capacity, output and research culture that exceeds what either UDRH or partner organisations could achieve independently. Despite this success, sustaining this ecosystem is challenging; there is a need to invest in embedded researchers and ensure an enabling environment for rural health services research through changes to policy and organisational culture. [...]

ABSTRACT Objective To evaluate the expansion of the Rural Health Multidisciplinary Training (RHMT) program into aged care services across rural Victoria. The program was designed to address workforce shortages and enhance allied health service delivery in Residential Aged Care Homes (RACHs). Setting The evaluation was set in aged care services in rural Victoria, Australia, specifically within RACHs partnered with four Victorian University Departments of Rural Health. Participants Participants were allied health students undertaking placements in a service-learning model, aged care providers and university staff involved in program implementation and evaluation. Design Through a collaboration between La Trobe University's John Richards Centre for Rural Ageing Research, the University of Melbourne's Department of Rural Health, Monash Rural Health, and two rural aged care providers, the evaluation employed a case study approach utilising the RE-AIM framework. Data sources included student focus groups and surveys, and stakeholder interviews and focus groups. The RE-AIM framework guided the data analysis. Results The program positively influenced student attitudes towards aged care, addressed resident needs through increased access to allied health services, and supported rural workforce development. Students reported meaningful engagement with older adults, which influenced perceptions and fostered interest in aged care careers. Despite challenges such as student financial burden and supervision limitations, the model demonstrated value for students and residents. Conclusion The evaluation highlighted how placements provided allied health students with meaningful connections with older people, influenced attitudes and prompted them to consider aged care careers—an outcome that has significant implications for future workforce planning. [...]

ABSTRACT Objective This study aimed to measure changes in staff perceptions of research capacity and culture in a small rural health service in Australia over time. Methods Staff completed the Research Capacity and Culture Tool, a valid and reliable survey that measures individuals' perceptions of their own research capacity and the research capacity and culture of their team and organisation. Data from 2015 was compared to 2023, following significant changes at the health service that focused on integrating research into the organisational structure. Design This was a repeated cross-sectional study in which data were collected from different individuals. Setting Data were collected from a rural health service in Victoria (Modified Monash Model 4–5). Participants All staff working in the health service were invited to complete the survey. Main Outcome Measures Research Capacity and Culture Tool. Results Results demonstrated improvements in eleven out of eighteen measures of research capacity and culture at the organisation level, six out of nineteen measures at the team level, but none at the individual level. Median improvements were modest, typically two points on the 10-point scale. Conclusions Integrating research into the health service organisation structure may be beneficial for its research capacity and culture. [...]

ABSTRACT Objective To explore how healthcare providers in rural aged care homes communicate about medications during transitions of care involving residents. Setting Two residential aged care homes in rural Australia. Participants Ten female healthcare providers including nurses, personal care assistants and pharmacists. Design Qualitative exploratory study using semi-structured interviews, analysed thematically, with engagement mapped via the Patient and Family Engagement Framework. Consolidated Criteria for Reporting Qualitative Research guidelines were followed. Results Two themes emerged from the interview data: (1) Providers' perceptions of medication communication roles and responsibilities, and (2) Providers' perceptions of challenges to engaging in medication communication. Nurses played a central but often reactive role, with resident and family engagement varying by capacity, proximity and interest. Personal care assistants and visiting pharmacists and personal care assistants contributed valuable safety and observational insights. Communication with other providers was fragmented and influenced by systemic and contextual inefficiencies. Conclusion Healthcare providers in rural aged care homes, particularly nurses, face challenges in medication communication during care transitions. Structured, collaborative strategies are needed to ensure consistent information sharing and proactive resident and family engagement, with opportunities to strengthen contributions from pharmacists and personal care assistants in supporting person-centred care. [...]

ABSTRACT Objective To explore the perceptions of rural residential aged care home (RACH) residents and family carers about the integration of allied health students in service delivery, and its impact on residents' health and wellbeing. Setting Two rural RACHs in Northern NSW, where allied health students (Physiotherapy, Occupational Therapy, Speech Pathology, Nutrition and Dietetics and Social Work) attended rural clinical placements and were integrated in service delivery for residents. Participants Twelve residents who received student-integrated services from the RACHs and five family carers. Design This was a qualitative evaluation. Residents and family carers were approached to participate in a semi-structured interview. Interviews were recorded, and audio interviews were transcribed verbatim. The transcripts were analysed using reflexive thematic analysis to generate themes and sub-themes. Results Three themes, each with several sub-themes, emerged from the interview data. The first theme was facilitators of effective care, and sub-themes were: modes of services, team-based approach and continuity of care. Continuity of care between successive groups of students was identified as an aspect of placement that requires improvement. The second theme presented how residents' functional abilities and emotional wellbeing improved after participating in student-led assessments and interventions. The third theme was participants' satisfaction with the students' competency and professionalism in delivering services. Conclusion From the perspectives of residents and family carers, allied health student placements can enhance service provision in rural RACHs in Northern NSW. These placements offer potential to grow the rural allied health workforce and assist in meeting the health service needs of older rural adults within the region. [...]

ABSTRACT Problem Programs that identify people with a low-risk allergy who can be safely delabeled by a direct oral challenge have emerged but are mostly reported in tertiary centres. There is limited information in the rural setting where resources are more constrained. Setting A medium-sized rural health service in Victoria (Australia). Key Measures for Improvement The outcome measure was the number of patients with a low-risk penicillin allergy who completed a penicillin oral challenge. Strategies for Change The penicillin oral challenge program developed considered four critical workflows: choice of allergy assessment tool, identifying those with a low-risk penicillin allergy who were interested in an oral challenge, oral challenge supervision and communication of the outcome. These were tested through Plan, Do, Study, Act (PDSA) cycles. Effects of Change Of 23 allergy assessment tools completed, fifteen revealed a low-risk allergy (PEN-FAST score 0, 1 or 2). Six people were not interested in the oral challenge and three did not have their interest recorded. Of the remaining six, four had an oral challenge (27%). Lessons Learnt Utilizing teamwork and the broad skill set of generalist rural staff, this rural health service was able to complete a penicillin oral challenge for over 25% of inpatients with a low-risk penicillin allergy. [...]

ABSTRACT Objective Australians living in rural areas have a higher prevalence of dental caries and higher potentially preventable hospital admissions for oral health conditions compared to metropolitan-dwelling Australians. Despite high burdens of dental disease and a lack of systems supporting oral health, including water fluoridation and access to dental services, rural Australians have been given limited opportunities to participate in oral health research, resulting in gaps in our understanding. The objective of this study was to explore rural health consumer experiences of using and accessing oral health care services. Design Cross-sectional online survey. Setting Rural and remote Australia (MM2–MM7). Participants Members of the Rural Health Consumer Panel aged over 18 years. Results One hundred and thirty-nine Rural Health Consumer Panel members responded to the survey. Key sociodemographic characteristics included a median age of 61 years, predominantly female (74.5%) and highly educated (73% holding tertiary qualifications). The majority of those visiting an oral health professional in the past 12 months reported visiting a dentist (47.5%). Over a third (38%) of respondents did not visit any oral health professional in the past 12 months. Private health insurance coverage was associated with more regular dental and oral health check-ups. Key challenges in accessing oral health care included cost, wait times for an appointment, and distance travelled to receive care. Conclusion Rural people in this study face barriers in accessing oral health care, contributing to low rates of preventative dental and oral health visits. The difficulty in accessing oral health services and lower rates of private health insurance in rural areas further exacerbate these inequities. Further research is required to gain a deeper understanding of the experiences of rural people in relation to accessing oral health services and involving rural people in developing place-based solutions across communities. [...]

ABSTRACT Objective Despite significant literature on access to, and utilisation of, health care, less attention has been given to the agency of rural service users to use, or not use, health services. This paper aims to understand the decisions of residents from two rural communities to use, or not use, health services. Setting Participants were recruited from Neighbourhood Houses in two rural communities in northern Victoria, Australia, located relatively close to a regional centre. Participants Twenty participants with significant socioeconomic needs were included. Design The study used a qualitative design and constructivist paradigm to undertake semi-structured interviews which were analysed thematically. Results Three types of decisions to access health services were identified. First, regular users prioritised their health, valued health care, and usually had a trusted healthcare navigator. Second, sometimes users identified barriers to accessing services, primarily not having a trusted GP and cost. Third, avoiders of health services suggested they did not prioritise their own health, it was easier to not attend, they did not believe health services led to better health outcomes, and poverty or other social issues prevented use. Some respondents moved between the three types, being regular users for children and when they had a trusted GP, and sometimes users for themselves or when barriers arose. Conclusion This study identified the strong role of GPs and the relational aspects of accessing and utilising health care. It calls for stronger engagement with disadvantaged rural residents to build trust in health care among those avoiding health services. [...]

Australian Journal of Rural Health, Volume 34, Issue 2, April 2026. [...]

ABSTRACT Objective To explore allied health students' perspectives on rural immersion placements facilitated by the University of Newcastle Department of Rural Health (UONDRH), and how these experiences influence learning quality and rural career intent. Setting Four rural UONDRH sites across New South Wales, Australia, where students undertook extended placements ranging from 12 weeks to a full academic year. Participants Sixty final-year allied health students from nutrition and dietetics, occupational therapy, medical radiation sciences, physiotherapy, and speech pathology programs. Design A qualitative study using semi-structured interviews was conducted post-placement. Data were analysed using qualitative content analysis, supported by field notes and student co-analysis to enhance rigour and authenticity. Results Four themes emerged: (1) Focusing inwards—students initially prioritised their own needs; (2) Focusing nearby—support networks and interprofessional learning enriched the experience; (3) Focusing outward—community engagement fostered critical reflection and cultural awareness; (4) Focusing forward—considered their career intent, but now with a knowledge of rural health care context. The extended duration of placements enabled deeper immersion, reflective practice, and a broadened understanding of rural health contexts. Conclusion Rural immersion placements offer transformative learning experiences that foster clinical competence, interprofessional collaboration, and rural career interest. Addressing structural barriers and enhancing rural job opportunities are essential to harnessing this intent and strengthening the rural allied health workforce. [...]

ABSTRACT Objective To explore the experiences of breastfeeding complications in women and the perspectives of the clinicians who care for them in rural and regional areas. Design This qualitative study recruited and interviewed mothers with recent breastfeeding experience, and clinicians regularly managing breastfeeding complications. The interviews explored experiences about breastfeeding including seeking healthcare support for breastfeeding (mothers) and experiences in caring for women with breastfeeding complications (clinicians). Audio recordings were transcribed, and a thematic analysis was undertaken. Setting This study took place in rural and regional Victoria (Modified Monash Model [MMM] classified 3–6 areas), Australia, in 2022. Participants A total of 20 mothers (MMM3-5 n = 12; MMM4-6 n = 8) and 18 clinicians including General Practitioners (n = 4), Maternal Child Health Nurses (n = 9), Lactation Consultants (n = 5) and Allied Health Practitioners (n = 2) participated. Results Mothers and clinicians reported a range of common breastfeeding complications, with mothers frequently experiencing multiple concurrent issues. Three themes were identified including expectations of breastfeeding, information and health literacy surrounding breastfeeding and barriers to accessing breastfeeding support services. Unrealistic expectations of breastfeeding, lack of clinician education about breastfeeding, the availability and knowledge related to local breastfeeding support services and geographic access were all elements that impacted the breastfeeding journey. Conclusion This study highlights the urgent need to improve healthcare for breastfeeding women in rural and regional areas. Broader policy issues must be addressed and resourced to ensure breastfeeding guidelines are universally accessible and equitable. This includes embedding evidence-based management within healthcare guidelines, effective monitoring to sustain progress towards breastfeeding targets, and further research to improve outcomes for rural and regional mothers and clinicians. Additionally, better promotion of existing breastfeeding support services is needed so mothers know when and how to access them. [...]

The editors of Pediatrics are issuing this Expression of Concern regarding the article “Defining the Reference Range for Oxygen Saturation for Infants After Birth” (doi.org/10.1542/peds.2009-1510), published on June 1, 2010. [...]

Citrobacter koseri, a facultative gram-negative bacillus, colonizes the intestine and environmental reservoirs. In neonates, especially preterm infants, it can cause severe central nervous system infections (eg, meningitis, encephalitis, abscesses), often with fatal outcomes. Pneumocephalus, an accumulation of intracranial gas, is a rare but deadly complication. We report a preterm female infant admitted to the neonatal intensive care unit (NICU) for respiratory distress who developed high fever and sepsis; blood culture results were positive for C. koseri. Rapid neurological deterioration with seizures occurred, and a cranial computed tomography scan showed extensive pneumocephalus. Despite intensive care, the infant died at 17 days. Autopsy and histology revealed widespread purulent meningitis and meningoencephalitis, pneumocephalus, cerebral hemorrhages, acute edema, and ventricular dilation. An environmental investigation traced the origin of the infection to the bathroom sinks, confirming the nosocomial nature of the pathogen. This case highlights the high virulence of C. koseri in neonates, the catastrophic potential of pneumocephalus, and the crucial importance of strict infection control in NICUs. [...]

10.1542/6386832750112Video AbstractPEDS-VA_2025-0748746386832750112Aluminum salts have been used as adjuvants in vaccines for nearly a century, enhancing the immune response to purified antigens and ensuring durable protection against serious infectious diseases. Despite their longstanding record of safety and effectiveness, aluminum adjuvants have become a focus of public concern, with claims linking them to developmental, neurologic, allergic, and autoimmune diseases. This review summarizes the immunologic rationale for aluminum adjuvants and evaluates the evidence for proposed safety risks. Aluminum salts have consistently been demonstrated over nearly a century of use to enhance the immune responses elicited by vaccines while also being well tolerated by nearly all who take them. Pharmacokinetic studies show that aluminum released from intramuscular vaccines is slowly absorbed and efficiently cleared by the kidneys, contributing minimally to systemic levels. Large-scale clinical and epidemiologic studies consistently demonstrate no association between aluminum-adjuvanted vaccines and autism spectrum disorder, neurotoxicity, allergic disease, or autoimmune disease. Clinically, vaccines adjuvanted solely with aluminum salts generally do not result in systemic reactogenicity, although local reactions are common. Collectively, the evidence strongly supports the safety of aluminum adjuvants and their necessity in certain vaccines. Clinicians can reassure caregivers that aluminum-containing vaccines provide clear benefits, with risks largely limited to transient local reactions and no systemic toxicity signal in large clinical and epidemiologic studies. [...]

10.1542/6386342693112Video AbstractPEDS-VA_2025-0718476386342693112BACKGROUND AND OBJECTIVESGaps exist in pediatric primary care office preparedness to care for medical emergencies, and providers often express discomfort in caring for these patients. Collaboration with local academic medical centers (AMCs) improved pediatric preparedness in community emergency departments. Our aims were to improve pediatric emergency preparedness and quality of care in a cohort of pediatric primary care offices using a model of in situ simulation and collaboration with local AMCs.METHODSThis was a multicenter, prospective study that measured emergency preparedness and quality of care in a cohort of pediatric primary care offices partnered with multiple AMCs. The study consisted of 3 phases: baseline assessment, an intervention phase, and follow-up assessment. Emergency preparedness was measured using a checklist derived from existing American Academy of Pediatrics guidelines, and quality of care was measured using in situ simulations of common pediatric outpatient emergencies. After baseline assessment, offices were shown their performance and worked with their local AMC on improvement strategies. Repeat assessment was conducted 6 to 10 months later to measure change.RESULTSTwenty-one offices were recruited, with 18 completing both preparedness assessments and 12 completing both in situ simulations. Median preparedness scores improved from 68% to 82% (P = .02). Median performance scores for the respiratory distress and seizure simulations improved from 50% to 82% (P  [...]

The American Academy of Pediatrics proposes guidance for the pediatric periprocedural anesthesia environment. Essential components are identified to optimize the periprocedural anesthesia environment for the anesthetic care of infants and children. Such an environment promotes the safety and well-being of infants and children by reducing the risk of adverse events. [...]

This technical report on Medicaid and the Children’s Health Insurance Program (CHIP), the cornerstones of the entire children’s health care delivery system, complements the 2023 American Academy of Pediatrics policy statement “Medicaid and the Children’s Health Insurance Program: Optimization to Promote Equity in Child and Young Adult Health.” The origin and intent of both the Medicaid and CHIP programs are outlined, and a current summary of issues related to enrollment, eligibility, funding, benefits, payments, quality assurance, and reporting in these programs that pertain to all children, including children with special health care needs (CYSHCN), is provided. Opportunities and drawbacks associated with states contracting with Medicaid managed care organizations are highlighted. This report also details mechanisms by which Medicaid can be modified through executive and legislative actions and summarizes past proposals (many recently resurrected) that would have degraded Medicaid’s ability to provide quality care for children. Special issues of interest for specific populations are explored, including children with special health care needs, adolescents, immigrant children, children in foster care, and adopted children, and the role of Medicaid and CHIP in addressing specific health care needs in the arenas of mental and behavioral health and dental care are discussed. Finally, the following 3 themes are emphasized: (1) the criticality of these programs to the current needs of children and the necessity to resolve operational factors that cause inequities; (2) the strategic importance of these programs to the well-being of the country’s future; and (3) the crisis with attracting, training, and retaining pediatric generalists and subspecialty physicians to lead the care of children in future generations. [...]

Confidentiality protection in health care fosters patient-physician trust and encourages the disclosure of sensitive health information. According to the American Academy of Pediatrics, respecting adolescent confidentiality for certain health information, when appropriate, is imperative for the well-being of adolescents. However, challenges to establishing confidentiality in health information technology include limited technological capabilities and varying state laws. There is a need for guidance on how to promote confidentiality for sensitive electronic health information while remaining compliant with federal rules on information sharing. This policy statement reviews the current challenges and provides guiding principles and recommendations for electronic health record developers, informaticists, clinicians, and policy makers on how to create an environment that promotes trust through the protection of confidentiality for adolescent patients. [...]

10.1542/6386833619112Video AbstractPEDS-VA_2025-0735446386833619112BACKGROUND AND OBJECTIVESIn 2019, the Consumer Product Safety Commission (CPSC) recalled inclined sleepers following reports of infant deaths. In 2023, recalls were reannounced after additional reports of infant deaths. This study used child death review (CDR) data to describe sudden unexpected infant deaths (SUIDs) that occurred in inclined sleepers.METHODSWe identified SUIDs that occurred in inclined sleepers from 2009 to 2023 from the Pediatric National Fatality Review-Case Reporting System (Pediatric NFR-CRS). Frequencies and proportions were calculated to describe demographic, incident, and supervisor characteristics.RESULTSFrom 2009 to 2023, 158 SUIDs occurred in inclined sleepers. One hundred and eight deaths (68%) occurred from 2009 to 2019; 50 deaths (32%) occurred after 2019. Most infants were younger than 4 months (67%). Most incidents occurred at the infant’s home (86%) under the supervision of a parent (83%). Nearly 30% were reported as placed supine to sleep and subsequently found unresponsive nonsupine. In 51 deaths (32%), the CDR team indicated the infant’s airway was obstructed when found: 55% by the inclined sleeper material and 35% by other soft bedding in the sleep environment (not mutually exclusive).CONCLUSIONSInfant deaths occurred in inclined sleepers even after the CPSC issued manufacturer recalls in 2019. Health care providers, home visitors, health insurers, and family-serving organizations should continue advising caregivers on the importance of a safe infant sleep environment, including use of a firm, noninclined surface, and avoidance of soft bedding. Improved dissemination of recalls of infant products that represent unsafe sleep environments may reduce the risk of sleep-related deaths. [...]

Hemoptysis secondary to diffuse alveolar hemorrhage (DAH) is uncommon in children. When it does occur, extensive investigations are often required to determine the underlying cause. We present a unique case of a 17-year-old previously healthy male adolescent with a history of allergic rhinitis, who initially presented with pneumonia in the setting of influenza A. He subsequently developed DAH, prompting further diagnostic evaluations that ultimately revealed a rare condition with long-term morbidity. [...]

OBJECTIVEIn 2023, the Advisory Committee on Immunization Practices (ACIP) recommended both nirsevimab for infants aged less than 8 months and RSVpreF vaccine for pregnant patients at 32 to 36 weeks’ gestation to prevent respiratory syncytial virus (RSV)–associated lower respiratory tract infections in infants. We compared the cost-effectiveness of the ACIP-recommended mixed nirsevimab and RSVpreF strategy vs a nirsevimab-only strategy for healthy, low-risk infants in the United States.METHODSA decision tree with nested Markov models compared 3 immunization strategies for healthy low-risk infants: no immunization, a mixed strategy of RSVpreF and nirsevimab per ACIP guidelines, and nirsevimab only for all infants. We estimated health and societal outcomes using quality-adjusted life years (QALYs) and costs from a health care sector perspective (ie, direct medical costs) and a societal perspective (ie, factors like caregiver productivity loss). We assessed cost-effectiveness using incremental cost-effectiveness ratios (ICERs) and a willingness-to-pay threshold of $150 000/QALY to benchmark cost-effectiveness and conducted sensitivity analyses.RESULTSFrom the health care sector perspective, neither the mixed strategy nor the nirsevimab-only strategy was cost-effective compared with no immunization, according to the $150 000/QALY threshold. From the societal perspective, the mixed strategy was cost-effective compared with no immunization ($117 848/QALY). Due to higher product costs, nirsevimab alone was not cost-effective compared with the mixed strategy ($347 821/QALY). However, if RSVpreF was not an option, the nirsevimab-only strategy would be cost-effective compared with no immunization ($134 391/QALY). Results were sensitive to assumptions about product costs and efficacy.CONCLUSIONPediatricians and obstetricians should jointly recommend RSV immunizations, as the ACIP-recommended mixed RSVpreF and nirsevimab strategy is a societally cost-effective method to protect infants. [...]

OBJECTIVETo test the hypothesis that community deprivation, race, and ethnicity lead to decreased likelihood of undergoing hepatoportoenterostomy, older age at surgery, decreased likelihood of achieving successful bile drainage, and lower rates of native liver survival for infants with biliary atresia.METHODSWe analyzed a prospectively enrolled cohort of infants with biliary atresia from the Childhood Liver Disease Research Network (ChiLDReN) that reflects the demographics of the US population. We tested the association between demographic, clinical, and anatomic variables and the probability of undergoing hepatoportoenterostomy, age at surgery, success of surgical intervention, and native liver survival using linear and logistic regression.RESULTSSeven hundred nineteen infants with biliary atresia from 15 centers met study inclusion criteria and 672 (93.5%) underwent hepatoportoenterostomy. After adjusting for potential confounders, Asian race (odds ratio [OR] = 0.21, 0.06–0.77), Hispanic ethnicity (OR = 0.33, 0.14–0.76), and community deprivation (0.71 per 0.1 increase, 0.52–0.97) were independently associated with decreased probability of undergoing hepatoportoenterostomy. Each 10% increase in community deprivation increased the age at hepatoportoenterostomy by approximately two-and-one-third days (estimate 2.31; P = .48). Black/African American infants were approximately 9 days older than white infants at the time of operation (estimate 9.19; P = .01), while age at hepatoportoenterostomy (OR = 0.90, P = .01) and successful bile drainage at 3 months (OR = 26.15, P  [...]