General journals

Hundreds of thousands of children are set to be lifted out of poverty, as the UK government has announced that it will end the limit restricting universal credit support to two children per family.The announcement—part of the autumn budget that was leaked by the Office for Budget Responsibility (OBR) ahead of a speech by the chancellor of the exchequer, Rachel Reeves—said that the two child benefit cap would be lifted from April 2026. Its removal would cost £2.3bn in 2026-27 and £3bn in 2029-30, said the OBR.This comes after a year and a half of political infighting within the Labour Party over the cap and other welfare decisions, such as previously proposed disability cuts.1 Some 4.5 million children—nearly one in three (31%)—are estimated to be living in poverty in the UK.In a speech at the King’s Fund yesterday the health secretary, Wes Streeting, called the two child limit “a terrible... [...]

As a final year medical student who is transitioning to a career in medicine after a 25 year career in professional services, I’m pleased that NHS England has mandated a 10 point plan to improve the working conditions of resident doctors, and particularly the senior level oversight and transparent reporting to ensure the changes are delivered.1I do, however, have three main concerns. Firstly, that doctors will view this as too little too late. There has been a real breakdown in trust between the Department of Health and Social Care and NHS England and the resident doctor community. This is not helped by recent non-pay changes agreed in the 2024-25 pay negotiations not being delivered—for example, exception reporting changes. The government really needs to focus on rebuilding trust with resident doctors so that we can move beyond the current stalemate.Secondly, the changes being requested are welcome but don’t cover many of... [...]

The case for a greater focus on medical “expert generalists” in the NHS has been in the health policy news recently. The NHS England diagnostic review of postgraduate medical training, which I discussed in my last BMJ column,1 was clear on the need for more doctors with good generalist skills, to reflect the reality that our ageing population has a growing number of people with multiple long term conditions. Chris Whitty, lead coauthor of that report and chief medical officer for England, made a similar case in his 2023 report Health in an Ageing Society,2 calling for doctors with the training, skills, and mindset to support a population with those changing needs.Doctors will increasingly be caring for patients with undifferentiated symptoms or several simultaneous conditions, often compounded by frailty or by age related cognitive or functional impairment. These patients need multiple medicines and have competing management priorities and trade-offs, use... [...]

Adding fluoride to drinking water has no negative effect on cognitive ability and may even confer a small cognitive benefit, research has found.1The finding comes as the public health practice of adding fluoride to drinking water faces increasing scrutiny in the US and the UK. Robert F Kennedy Jr, the US health secretary, has repeatedly criticised the adding of fluoride to water supplies, calling it “an industrial waste associated with arthritis, bone fractures, bone cancer, IQ loss, neurodevelopmental disorders, and thyroid disease.”Kennedy said this month that “the Trump White House will advise all US water systems to remove fluoride from public water.”2 In March this year Utah became the first US state to ban fluoride in public drinking water, despite opposition from the American Dental Association and the American Academy of Pediatrics.3Around 63% of the US population have fluoridated water. Most of western Europe does not add fluoride to its... [...]

Dairy drinks will be hit by the soft drinks levy and private funding will be used to help with the development of hundreds of new GP led health centres.These policies have been announced ahead of the 2025 budget, to be revealed in full tomorrow.In what has been dubbed the “milkshake tax” ministers announced the soft drinks levy would be extended to packaged milkshakes, sweetened yoghurt drinks, and ready-to-drink coffees to raise more revenue and tackle obesity.Health secretary Wes Streeting said, “The levy has already shown that when industry cuts sugar levels, children’s health improves. So we’re going further. A healthier nation will mean less pressure on our NHS, a healthier economy, and a happier society. It’s a simple change that is part of this government’s mission to give every child a healthy start to life.”The inclusion of some dairy products is part of a broader change to the soft drinks... [...]

A 10 day old baby died of sepsis following a biopsy after doctors gave her the wrong antibiotics, sent her home too early, and failed to get her parents’ informed consent, an inquest has heard.Willow Rose Courtney-Thompson, who was born prematurely on 12 October 2024, had problems feeding and underwent a suction rectal biopsy at the John Radcliffe Hospital in Oxford to rule out the rare bowel condition Hirschsprung’s disease.But an inquest heard the procedure was carried out without informed consent from her parents, Joseph and Lauren Courtney-Thompson, who were not made fully aware of its risks and benefits.Oxfordshire coroner’s court was told that Willow was sent home 10 hours after the procedure without adequate advice for her parents about signs of severe illness such as sepsis.Once home, Willow continued to feed poorly and was lethargic. After being found unresponsive on 22 October, she was taken to hospital with severe... [...]

We welcome Sheldon and Wright’s emphasis on social determinants of health rather than screening,1 but universal newborn whole genome sequencing (WGS) should be seen as an evolution of the heel prick programme, rather than a costly detour into genomics for its own sake. Biochemical screening already tests nine conditions; adding WGS widens that net to >200 treatable disorders and creates a secure genomic record for lifelong re-analysis. Early data from the UK Generation Study show that one actionable diagnosis is made for around every 200 babies, including spinal muscular atrophy detected before symptom onset, enabling curative therapy.2The authors warn of screening harms. Wilson-Jungner principles still apply: variant reporting must be limited to well validated, childhood onset conditions, with confirmatory assays and genetic counselling to curb false positives. With these safeguards in place, rapid WGS in a US neonatal intensive care unit cut one child’s diagnosis from weeks to days and... [...]

What happened after publicationAfter publication of this paper by Ma and colleagues (BMJ 2025;390:e085029, doi:10.1136/bmj-2025-085029, published 24 September 2025) and its linked editorial (BMJ 2025;390:r1893, doi:10.1136/bmj.r1893),12 BMJ was alerted to concerns that messaging in key areas may not be sufficiently supported by the data presented in the work.Reason for expressing concernThe research paper1 shows an association between non-attendance at first breast screening and death from breast cancer. There is concern that a lack of data about all cause mortality, and/or lack of emphasis on those data, is a critical limitation. This may impact the implications of the work and BMJ is conducting additional statistical review.The main finding of the paper is an association between attendance at first breast screening appointment and breast cancer death. Both the authors of the research paper and the editorial conclude and/or call for interventions to improve adherence to screening. Their call not only implies a... [...]

The Autism Act 2009 is a landmark law that requires the government to produce an autism strategy for England, backed up by statutory guidance for the NHS and local authorities. Now, a House of Lords special inquiry committee—which I chaired—has published a new report examining the effectiveness of the act.1 We found that the act was a critical step forward in the recognition of autistic people, but successive governments have failed to deliver the change that autistic people need.Autistic people still face unacceptable inequalities in health outcomes and life expectancy. On average, autistic people with a learning disability die more than 10 years earlier than their peers.2 Meanwhile, our understanding of the population of autistic people has evolved. When the act was passed, about 1% of people were estimated to be autistic. Diagnosis rates are now much higher than this in younger people, but still much lower in older people.... [...]

What happened after publicationAfter publication of this paper by Ma and colleagues (BMJ 2025;390:e085029, doi:10.1136/bmj-2025-085029, published 24 September 2025) and its linked editorial (BMJ 2025;390:r1893, doi:10.1136/bmj.r1893),12 BMJ was alerted to concerns that messaging in key areas may not be sufficiently supported by the data presented in the work.Reason for expressing concernThe research paper1 shows an association between non-attendance at first breast screening and death from breast cancer. There is concern that a lack of data about all cause mortality, and/or lack of emphasis on those data, is a critical limitation. This may impact the implications of the work and BMJ is conducting additional statistical review.The main finding of the paper is an association between attendance at first breast screening appointment and breast cancer death. Both the authors of the research paper and the editorial conclude and/or call for interventions to improve adherence to screening. Their call not only implies a... [...]

Rates of whooping cough (pertussis) are rising in the US as fewer children are being vaccinated.Official data showed 35 493 cases of the disease in the US in 2024, a fivefold increase from 7063 in 2023. In the first three months of 2025 alone 6600 cases were recorded.1Outbreaks of the potentially deadly respiratory infection have been reported in Texas, Florida, California, Oregon, and other states. State data showed that Texas reported 1928 cases of pertussis in 2024, but by October 2025 it had more than 3500.The increase in prevalence has come hand in hand with falling uptake of the whooping cough vaccine, in a trend experts warn is being driven by antivaccination misinformation and laws that make it easier for parents to get exemptions from school vaccine requirements.Kristina Bryant, professor of paediatrics at the University of Louisville School of Medicine in Kentucky, told The BMJ on 21 November, “We’re definitely... [...]

Nearly one in three women worldwide—some 840 million—have experienced sexual violence in their lifetime, a report by the World Health Organization (WHO) and the UN suggests.The organisations also condemned the fact that rates of such violence had barely dropped in more than two decades.The data presented showed changes over time in the estimated global prevalence of physical or sexual intimate partner violence against women aged 15-49 from 2000 to 2023. In 2023, 25.8% of women aged 15-49 (uncertainty interval 23.7% to 28.8%) had experienced physical or sexual intimate partner violence at some point in their life, which compared with 30.8% (27.9% to 34.4%) in 2000.For the first time the report includes national and regional estimates of sexual violence by someone other than a partner. Findings suggest that some 263 million women have experienced non-partner sexual violence since age 15. Shockingly, in just the previous 12 months as of 2023, 316... [...]

To the Editor A recent study that applied artificial intelligence (AI) to automate echocardiography reporting demonstrated high accuracy across diverse cohorts, offering a strong foundation for future AI-integrated workflows. However, several issues require further clarification. [...]

To the Editor A recent article presented information about PanEcho, an AI system for automated multitask interpretation of echocardiograms. While it demonstrated high diagnostic accuracy for comprehensive echocardiographic analysis and potential utility in point-of-care screening, several methodological concerns require careful consideration. [...]

In Reply We appreciate the thoughtful comments from Ms Wu and colleagues and Dr Zhang and colleagues about our article. Both Letters comment on the representativeness of patient cohorts and whether demographic bias could emerge in model predictions. We agree that bias is a key consideration for the responsible deployment of AI algorithms, which we addressed with multisite validation across diverse cohorts and statistical analyses on group fairness. Of note, our cohorts spanned a large US-based health system representative of the local demographic census (19.1% non-White, 7.9% Hispanic), including an emergency department cohort with point-of-care imaging (34.2% non-White, 11.4% Hispanic), as well as geographically distinct cohorts from Europe and California (11.1% Hispanic). More importantly, the model’s robust performance across cohorts with variable demographic composition suggests that PanEcho, the AI system, learns key phenotypes through direct associations rather than confounders. Supplemental analysis also demonstrated that the model performed equitably across sex for 13 of 15 diagnostic tasks and across race for 25 of 26 groupwise comparisons. We therefore observed no evidence of demographic bias in the applications of the AI system, although continued evaluation is essential. [...]

Groping out of my sedation, halfway conscious, halfway not, hallucinatory and maybe not, [...]

This Viewpoint discusses the effect of changes in vaccine policies on public health and strategies for reversing the policies’ direction. [...]

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

Intraoperative hypotension is very common, affecting 30% to 80% of surgical patients. Results of observational studies suggest that even brief episodes of intraoperative hypotension are associated with an increased risk of postoperative complications, but the definition of hypotension varies across studies. Prior observational studies suggest that exposure to a mean arterial pressure (MAP) lower than 60 mm Hg to 65 mm Hg increases the risk of postoperative myocardial and kidney injury. Based on these data, current guidelines recommend maintaining MAP at 60 mm Hg or higher during surgery. However, several questions remain unsettled: Is intraoperative hypotension is a marker of underlying illness or a modifiable contributor to harm? Does the optimal MAP target vary across individuals, suggesting that a more personalized approach is warranted? [...]

This Medical News article discusses updated blood pressure recommendations from the American Heart Association and the American College of Cardiology. [...]

Recently, few questions in adolescent health have sparked more controversy than “is social media good or bad for youth?” This simple yet unresolved question is entrenched in a polarizing debate. For every study linking social media to harm, a counterclaim is made of no measurable impact. This controversy has arguably slowed progress toward policies that could provide clear guidance or protections for children and families. Yet, from a public health perspective, the most urgent question may not be whether social media is universally good or bad, but rather, what kind of evidence would be good enough to motivate policy action? [...]

This meta-analysis evaluates the prevalence and characteristics of discordance between creatinine- and cystatin C–based estimated glomerular filtration rate as well as the association of discordance with adverse outcomes. [...]

Chronic kidney disease (CKD) affects more than 800 million people worldwide, significantly increasing the risk for kidney failure, cardiovascular disease, and all-cause mortality. Accurate assessment of glomerular filtration rate (GFR) is essential for identifying and managing CKD. Although GFR is most accurately measured by analyzing the rate of kidney excretion of infused exogenous substances, such as inulin or iohexol, this is not practical in most cases. Therefore, estimated glomerular filtration rates (eGFRs) have become important for CKD diagnosis and management. [...]

The JAMA Insights titled “Microplastics and Human Health,” published on October 15, 2025, was corrected to fix the spelling of a coauthor’s surname. This article was corrected online. [...]

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 Studies suggest an increase in autoimmune diseases following SARS-CoV-2 infection and/or COVID-19-vaccination. We aimed to describe possible associations in Norway. Methods We used information from the emergency preparedness register for COVID-19, BeredtC19, for all residents aged 18–64 (N = 3,450,080). BeredtC19 includes data from mandatory nationwide registers on demographics, SARS-CoV-2 tests, deaths, vaccinations, and hospitalizations. Cox regression was used to estimate adjusted hazard ratios (aHRs) for 30-day and 30–180 day risk windows. Findings SARS-CoV-2 infection was associated with an increased risk of purpura, thrombocytopenia, and agranulocytosis within 30 days and 30–180 days. In the first 30 days, Bell's palsy and inflammatory arthritis were associated with infection, whereas 30–180 days postinfection showed an association with polyneuropathy. Vaccination was associated with an increased risk of inflammatory bowel disease (IBD) and celiac disease, both in the first 30 days and 30–180 days postvaccination. Additionally, in the first 30 days postvaccination, we found associations with inflammatory arthritis and erythema nodosum, and between 30 and 180 days with arthralgia, agranulocytosis, and acute disseminated encephalomyelitis (ADEM). There was also a reduced risk of dermatopolymyositis 30–180 days postvaccination. Interpretation Most autoimmune disorders showed no significant association with SARS-CoV-2 infection or COVID-19 vaccination. Associations between vaccination and IBD and ADEM warrant further investigations, as these observations reflect associations and do not establish causality. [...]

Abstract Background Individuals with psoriasis have a high prevalence of metabolic dysfunction–associated steatotic liver disease (MASLD), yet the association between MASLD as a cardiometabolic risk factor and cardiac manifestations in this population remains unclear. Objectives We aimed to evaluate associations between MASLD, cardiometabolic risk factors, and cardiac structure and function in adults with psoriasis. Methods We performed a cross-sectional analysis of 255 adults with psoriasis prospectively enrolled. Participants underwent transthoracic echocardiography and transient elastography. MASLD was defined by hepatic steatosis with a controlled attenuation parameter of ≥250 dB/m and the presence of ≥1 cardiometabolic risk factor(s), excluding other liver disease causes. Cardiac structure and function were compared between individuals with psoriasis and MASLD and those without MASLD. Associations between MASLD and myocardial dysfunction were assessed in uni- and multivariable regression models. Results MASLD was present in 92 participants (36.1%), of whom 5 (5.4%) had evidence of increased liver stiffness. Those with MASLD exhibited higher blood pressure, body mass index (BMI), and more adverse cardiometabolic profiles. MASLD was associated with cardiac structural changes and worse diastolic and systolic function. After adjusting for age, sex, and BMI, most associations were attenuated. In fully adjusted models, higher BMI and diabetes, but not MASLD, were independently associated with myocardial dysfunction. Conclusions In adults with psoriasis, the association between MASLD and cardiac structural and functional changes was attenuated after adjusting for BMI and cardiometabolic risk factors, underscoring the importance of cardiometabolic risk factor control, in particular of obesity and diabetes, in psoriasis with concomitant MASLD. [...]

Abstract Background The long-term risk across severity strata of people infected with SARS-CoV-2 has not yet been comprehensively described. Methods Using nationwide registries, all COVID-19 cases in Sweden with [...]

Abstract Background and objective Post-infectious sequelae can increase burden on healthcare systems. We aimed to assess the long-term effect of COVID-19 on healthcare utilization across all levels of care. Methods In this register-based cohort study, we included all adult (≥18 years) residents in Sweden's two largest counties with a registered COVID-19 index date between 31 January 2020 and 9 February 2022. Each exposed individual was matched 1:1 to a control without registered COVID-19 on index date based on gender, birth year, vaccination status and the change in number of healthcare contacts between 2018 and 2019. We counted the number of healthcare contacts across all levels of care during the pre-index (13–1 months) and post-index (4–15 months) full-year periods. A difference-in-difference (DID) analysis was used to assess changes in the number of healthcare contacts and specific diagnoses, between each individual's pre- and post-periods, as well as comparing individuals with and without COVID-19. Results The study included 753,905 matched pairs, comprising 1,415,432 unique individuals. Trends in healthcare contacts were parallel between the matched groups prior to the index date. The DID analysis revealed a mean increase of 0.33 (95%CI 0.30–0.36) healthcare contacts following COVID-19, mainly observed from a smaller proportion of the population (5%) and by contacts with primary healthcare. The largest diagnosis-specific difference was observed for reactions to severe stress (0.02, 0.01–0.03). The estimate varied across gender, acute COVID-19 severity, virus variant period and vaccination status. Conclusion This study demonstrates increased healthcare utilization after COVID-19 in a smaller proportion of the population. [...]

Abstract Cryoglobulinemia (CG) is defined by the presence of serum immunoglobulins that precipitate below 37°C and redissolve upon rewarming. It is classified into three types based on immunoglobulin composition. Type I, a rare form, involves monoclonal IgM or IgG and is linked to lymphoproliferative disorders. Types II and III are known as mixed CG (MC): Type II consists of polyclonal IgG and monoclonal IgM with rheumatoid factor (RF) activity, whereas Type III includes polyclonal IgG and polyclonal IgM with RF activity. MC is predominantly associated with hepatitis C virus (HCV) infection and involves B-cell lymphoproliferation and autoantibody production. CG may lead to systemic vasculopathy, ranging from mild symptoms (purpura, asthenia, and arthralgia) to severe complications such as skin ulcers, peripheral neuropathy, renal involvement, and non-Hodgkin lymphoma. Compared to MC, Type I is more often marked by severe cutaneous involvement (ulcers, gangrene), hyperviscosity, and a higher risk of morbidity due to the underlying hematologic malignancy. Management of Type I requires control of vasculopathy and treatment of the hematologic neoplasm, whereas MC demands antiviral therapy in all HCV-associated or hepatitis B virus–associated cases. Severe vasculopathy in both types may benefit from corticosteroids, immunomodulators, anti-CD20 monoclonal antibodies, and plasma exchange. A multidisciplinary approach is essential for addressing both etiology and complications, thereby improving outcomes. This review summarizes the pathophysiology, clinical features, recent etiopathogenetic insights, and therapeutic advances related to the various forms of CG. [...]

Abstract Background The microbiota–gut–brain axis has been implicated in dementia. Yet whether dementia is associated with microscopic colitis (MC), an age-related inflammatory colonic disease involving gut dysbiosis, remains unknown. Methods Using the nationwide ESPRESSO cohort in Sweden, we compared MC patients histologically diagnosed 1990–2017 and aged ≥30 years to their population-based comparators and siblings, separately. MC association with incident and prevalent dementia diagnosis, respectively, was investigated in a matched cohort and a matched case-control design. Findings Following 13,037 MC patients and 61,710 population comparators for a median of ∼10 years, we observed 4674 incident dementia cases (46% were Alzheimer's disease [AD]). During the first 5 years since biopsy, MC was associated with a 19% higher dementia risk (adjusted hazard ratio [aHR]: 1.19; 95% confidence interval [CI]: 1.07–1.32). This short-term association applied to both AD and vascular dementia and appeared stronger as compared to siblings (aHR: 1.55; 95% CI: 1.22–1.97). After 5 years, it attenuated to null in both comparisons, regardless of dementia subtype. Prior dementia was less prevalent in MC (adjusted odds ratio [aOR]: 0.73; 95% CI: 0.65–0.82). This inverse association was independent from medications commonly prescribed in MC but was not supported by sibling findings (aOR: 1.11; 95% CI: 0.81–1.51). Conclusions MC patients may be more vulnerable to dementia diagnosis in early disease course. The intriguing inverse association between MC and preexisting dementia implies a possible underdiagnosis of MC in demented population and warrants further investigation. [...]

Abstract Objectives Anti-MDA5 dermatomyositis (anti-MDA5 DM) is the most severe subtype of dermatomyositis, due to its pulmonary involvement. Current treatment involves corticosteroids and immunosuppressants, but variability in responses exists. This study aims to evaluate the efficacy and safety of Janus kinase (JAK)– and calcineurin–inhibitor combination (JAK–CNI) in anti-MDA5 DM patients. Methods A nested case–control study was conducted within a retrospective cohort of 234 anti-MDA5 DM patients. Patients receiving JAK–CNI were matched 1:2 with comparators. All-cause mortality or transplant within a year was compared using Cox proportional hazards models. Infectious and noninfectious side effects were also assessed. Results Twenty-seven patients receiving JAK–CNI were compared to 52 matched controls. Almost all these patients had pulmonary involvement. Thirty-nine (49%) died or were transplanted during follow-up. No significant improvement in survival or transplant-free survival was observed with JAK–CNI compared with comparators (hazard ratios 1.02, 95% confidence intervals [0.48–2.16]). Results were consistent regardless of intensive care unit (ICU) admission status and when analyses were restricted to patients with rapidly progressive interstitial lung disease. A trend toward a beneficial effect of the JAK–CNI combination was observed in non-ICU patients. Infectious complications were frequent (n = 49, 62%), with no excess risk in patients receiving JAK–CNI. Conclusion JAK–CNI showed a similar outcome to other immunosuppressive combinations. However, as the study included the most severe cases, the potential benefit of early JAK–CNI introduction in less severe forms cannot be dismissed, as suggested by the nonsignificant trend in non-ICU patients. Future studies are needed to clarify the optimal timing and patient selection for JAK–CNI therapy in anti-MDA5 DM. [...]

Abstract Background Obesity and poor physical fitness in youth are established risk factors for future cardiovascular disease and cancer. However, their potential impact on the risk of severe bacterial infections later in life remains unclear. Methods This register-based cohort study followed almost 1 million Swedish conscripts (mean age 18.3 years) over a period of three decades. Measured body mass index (BMI) and cardiorespiratory fitness (CRF) at conscription to military service served as exposure variables, whereas outcomes included morbidity and mortality attributed to bacterial pneumonia, sepsis, and infective endocarditis. Results High BMI and low CRF in late adolescence were strongly associated with an increased risk of bacterial pneumonia, sepsis, and infective endocarditis in adulthood. The highest risk was seen among the obese for sepsis (hazard ratio [HR] 3.1 (2.7–3.5)), with elevated hazards observed already at high-normal BMI levels (22.5–25 kg/m2), compared with BMI 18.5–19.9. The risk of dying due to bacterial infections increased gradually with higher BMI. High, compared with low CRF, was associated with lower risk of contracting bacterial infections (0.78, 0.76–0.80), and dying from them (0.58, 0.51–0.65). Conclusion High BMI and low CRF in adolescence are associated with an increased risk of contracting and dying of severe bacterial infections later in life. Hence, addressing these preventable risk factors in youths may serve as an effective measure to improve their long-term health. [...]

Abstract Tuberculosis (TB) remains a leading infectious cause of morbidity and mortality, and the development of a new, highly effective vaccine would have a tremendous beneficial impact on global health. Although conventional memory CD4 and CD8 T cells will likely be key mediators of long-lived, vaccine-elicited protection, a potent T cell–inducing vaccine against TB has been elusive. Protection by Mycobacterium tuberculosis (Mtb)-specific T cells is mediated primarily through their communication with Mtb-infected macrophages. Here, we discuss emerging evidence of multiple structural and immunoregulatory factors that limit effective T cell–macrophage interactions in TB granulomas, posing a unique challenge to vaccine-induced protection. Developing new TB vaccination strategies will require a better understanding of the crosstalk between T cells and infected pulmonary macrophages and strategies to enhance these interactions. [...]

Abstract Background Renal dysfunction increases cardiovascular (CV) risk. We compared cystatin C-based estimated glomerular filtration rate (eGFRcys), creatinine-based eGFR (eGFRcr), and their ratio (eGFRcys/eGFRcr) in relation to major adverse cardiovascular events (MACE) and all-cause mortality in chronic coronary syndrome, assessing the added prognostic value of the eGFRratio. Methods In this post hoc analysis of 14,513 Stabilization of Atherosclerotic Plaque by Initiation of Darapladib Therapy trial patients, we investigated associations between baseline eGFRcys, eGFRcr, their ratio, and MACE and all-cause death using Cox regression models, unadjusted and adjusted for eGFRcys, eGFRcr, and their combination. Discrimination was assessed using Harrell's C-index; added value by the fraction of new information (FNI). Results Median age was 65 years; 82% were male. Median eGFRcys was 77 (interquartile range [IQR]: 61–94) and eGFRcr 79 (IQR: 65–91) mL/min/1.73 m2. Over 3.7 years, 1449 MACE and 1063 deaths occurred. Lower eGFR values and eGFRratio were associated with increased MACE risk, primarily driven by CV death. For eGFRcys 60 versus 90, the hazard ratio (HR) for MACE adjusted for eGFRcr was 1.77 (95% CI: 1.49–2.09, FNI 54%). In contrast, eGFRcr adjusted for eGFRcys showed no positive association (HR 0.82, 95% CI: 0.68–0.97, FNI 3%). A lower eGFRratio was linked to higher MACE risk (HR 1.99, 95% CI: 1.80–2.21), which remained after eGFRcr adjustment (HR 1.89, 95% CI: 1.70–2.10, FNI 54%) but was attenuated after eGFRcys adjustment (HR 1.29, 95% CI: 1.13–1.46, FNI 5%). Conclusion In chronic coronary syndrome, lower eGFRcys, eGFRcr, and eGFRratio were associated with higher MACE and mortality risk. eGFRcys had the strongest association; eGFRcr and eGFRratio added limited incremental value. [...]

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

Abstract Background Dysfunction of δ-aminolevulinic acid dehydratase (ALAD), the second enzyme involved in heme biosynthesis, leads to two pathologies: genetic and acquired. The genetic form is an ultrarare, severe childhood-onset disease inherited in an autosomal recessive manner, whereas the acquired form usually affects adults due to enzyme inhibition by specific chemicals. Aims and patient cohort This study reports the molecular characterization of three pediatric patients with genetic ALAD deficiency porphyria (ADP), including two siblings, and five adults who exhibited features suggestive of heavy metal poisoning. Furthermore, using an innovative mouse liver model, we performed in vivo functional analysis of the pathogenic variants and lead susceptibility alleles identified in the ALAD gene. Results Siblings (one female) were found to carry the c440_441delinsTT (p.Arg147Leu) variant in homozygosis. However, the vector expression system confirmed a pathogenic role only for the c.440C > T substitution. The third patient exhibited compound heterozygosity, with a c.839G > A (p.Gly280Glu) dominant variant and a hypomorphic c.724G > A (p.Val242Ile) allele. The rs1805313 and rs8177800 common intron variants were most prevalent in patients with acquired ADP. However, increased ALAD activity for the rs1139488 synonymous variant and a hexameric ALAD conformation for the rs1800435 missense variant have been established. Conclusion These findings underscore the molecular heterogeneity of the ALAD gene and present the first reported case of ADP in a female patient. [...]

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

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

ABSTRACT Background Colorectal cancer liver metastasis (CRCLM) profoundly impacts the overall survival rates of affected individuals. Although chemotherapy remains a cornerstone of treatment, the variability in tumour response presents a considerable challenge to effective clinical management. Radiomics-based artificial intelligence (AI) modelling, utilising pre-treatment imaging, has been proposed as a tool to predict treatment response and inform therapeutic decision-making. Methods A systematic search using Clarivate (Web of Science) and Ovid (Embase and MEDLINE) from inception to April 8, 2025, was performed in accordance with Preferred Reporting Items for Reviews and Meta-Analysis (PRISMA) guidelines. Studies evaluating the use of AI radiomics models to predict CRCLM response to chemotherapy treatment, alone or in combination with targeted therapies were identified. Full-text review and data extraction were performed independently by two reviewers. Risk of bias was assessed using the Checklist for Diagnostic Test Accuracy Studies. Results Thirteen studies met inclusion criteria. All studies described the development and validation of AI models with no implementation studies. The AI models developed demonstrated a varied ability to predict CRCLM response to chemotherapy. Predictive performance was classified as good in six studies and excellent in three. Model development used differing combinations of imaging modalities (CT or MRI), lesion inclusion criteria, dimensionality (2D vs. 3D), and use of clinical features. Most studies did not validate model performance in an external dataset. Conclusion Radiomics-based AI models show potential in predicting chemotherapy response in CRCLM. However, limited external validation and methodological variability currently restrict clinical applicability. Standardisation and prospective validation are required for clinical translation. [...]

ABSTRACT Background While studies have explored the gender gap in scientific literature, there is a scarcity of information on the impact within surgical publications. We examine the gender gap in Plastic and Reconstructive Surgery papers across two prominent Australasian journals. Methods All original clinical science articles published in AJOPS and ANZ Journal of Surgery were reviewed from 2018 to 2024. The gender of the first and last authors, as well as the subspecialty category, type of paper, journal volume, year and issue were entered in a database for further analysis. In addition, we examined whether first author gender was correlated to the gender of the senior faculty with whom they were co-authored. Results A total of 344 papers met the inclusion criteria for the study. Male authorship was more prevalent accounting for 65% in comparison to female authorship at 35%. When selecting for editorials only, male first authors accounted for 83% (43) versus female first authors at 17% (10). Excluding editorials, male first authorship reached 62% (183) while females made up the remaining 38% (108). In terms of senior authorship, males accounted for 80% (234) versus 20% (59). Conclusion Despite some fluctuation, our findings demonstrate a persistent disequilibrium in gender representation in the chosen journals which likely reflects the current disparity in the profession. Whether the increased recruitment and retention of female trainees and surgeons, is gradually translating to publication output, is not entirely understood. Further research is needed to identify and address the barriers to publication experienced by women in plastic surgery. [...]

ABSTRACT Background Renal vein and caval tumour extension occurs in 10%–25% of patients with renal cell carcinoma. This study aims to examine perioperative morbidity and survival outcomes after radical nephrectomy with inferior vena cava tumour thrombectomy at a quaternary institution in Australia. Methods This was a retrospective review of nephrectomy with tumour thrombectomy cases between June 2012 and 2022 at a single centre, followed up until September 2024. Overall survival (OS) was visualised by Kaplan–Meier plots and comparisons between survival by presence of metastases, margin status, and thrombus level (I-III vs. IV) were explored with the log-rank test. Recurrence-free survival (RFS) in patients without initial metastases was also examined. Results We identified 39 patients, 25 (64%) were male and the median (IQR) age was 64 years (55–69). Metastatic disease was present in 14 patients (36%). Nineteen (49%) had level IV (supradiaphragmatic) tumour thrombus involvement. Six patients (15%) died in hospital, including two intraoperative deaths. A further 14 (36%) experienced Clavien-Dindo grade III or IV complications during their hospital stay. The median OS was 57 months (95% CI: 17–not reached). Excluding those who died in hospital, the median OS was 60 months (95% CI: 33–not reached). There was a significant difference in OS observed by the presence of metastatic disease (p = 0.003), but not with margin status (p = 0.35) or thrombus level (p = 0.22). The median RFS for M0 patients was 60 months (95% CI: 8–not reached). Conclusion While associated with high morbidity and mortality, nephrectomy and caval thrombectomy remain an effective treatment option for otherwise fatal advanced RCC. [...]

ABSTRACT Background Large defects of the posterior trunk after soft tissue sarcoma resection represent a challenge in reconstructive surgery. Coverage with musculocutaneous flaps or free flaps is often associated with donor site morbidity and functional deficits. With increasing popularity, the clinical indications of locoregional perforator flaps have been expanded to defects of the back. In the present study, the use of various perforator propeller flaps for oncologic reconstruction of large soft tissue defects of the posterior trunk is evaluated. Methods Between 2014 and 2023, perforator propeller flaps were performed in 23 patients for reconstruction of large soft tissue defects after sarcoma resection in different regions of the posterior trunk. Results Soft tissue defects after wide resection of soft tissue sarcoma of the back comprised the cervical, thoracic, lumbar, and sacral regions. Donor sites included perforator propeller flaps of the posterior intercostal artery, lumbar artery, and superior gluteal artery vascular territories. The dimensions of the soft tissue defects of the flaps were 166.6 ± 17.3 cm2. All perforator propeller flaps survived. Revision surgery was required in two patients (partial necrosis of flap tip due to hematoma, n = 1; infected seroma with impaired wound healing, n = 1). During the follow-up (range 6 months–8 8 years) no donor site morbidities or functional deficits were noted. Furthermore, aesthetic results showed excellent contour reconstruction and all patients were satisfied with the surgical outcome. Conclusion In our experience, perforator flaps represent a safe, versatile and reliable option to resurface large posterior trunk defects following oncological resection. [...]

Tumors of the central mandible requiring marginal mandibulectomy and floor of mouth resection require reconstruction for cosmetic and functional purposes. The split mentalis muscle flap is a simple, quick and low morbidity option for central mandibular defects and has been demonstrated effectively with the use of a split skin graft. We submit a modification of the split mentalis muscle flap demonstrating mucosilization without the morbidity associated with the split skin graft. ABSTRACT Tumors of the central mandible requiring marginal mandibulectomy and floor of mouth resection require reconstruction for cosmetic and functional purposes. Numerous reconstructive techniques have been described for small–moderate sized defects of the central mandible/anterior floor of mouth. Robust local flaps have been well described; however second stage procedures are required for pedicle division. The split mentalis muscle flap is a simple, quick and low morbidity option for central mandibular defects and has been demonstrated effectively with the use of a split skin graft. We provide a modification of the split mentalis muscle flap without the morbidity associated with a split skin graft and its utility to support a prosthesis following surgery and radiotherapy. [...]

ABSTRACT Objective This pilot study aimed to assess the interrater reliability of quantitative measures derived from video-based evaluation of laparoscopic cholecystectomy performance, with the future aim of developing an objective assessment tool and the use of artificial intelligence for this procedure. Methods This study was conducted at a single metropolitan training hospital in Australia. Quantitative metrics based on 30 randomly selected videos were evaluated by three surgeon assessors. Interrater reliability was measured using percent agreement (PA) for categorical items and intraclass correlation coefficient (ICC) models for numerical items. Results Interrater agreement varied. For numerical items, moderate agreement was found for Hartmann's pouch grasping, gallbladder rotation, and incorrect clipping; good for perforation; and excellent for time to critical view of safety. Key categorical procedure-specific items (e.g., 360° cystic duct dissection, two-window view) achieved at least moderate agreement. Case difficulty assessment showed good to excellent agreement. Registrars demonstrated prolonged time to critical view of safety, more frequent Hartmann's pouch grasping, more gallbladder rotations, and increased instrument insertions. Competency ratings showed 45.8% of registrars as ‘developing’, while consultants were rated predominantly ‘good’ (40%) or ‘excellent’ (20%). Conclusions There is potential to develop an objective video-based evaluation tool for laparoscopic cholecystectomy based on more quantitative assessment items, as evidenced by the interrater reliability results in this pilot study. Further research on artificial intelligence and computer vision will be beneficial in establishing a reliable and valid scoring tool. [...]

ABSTRACT Background Despite the decreasing risk over time, lymphoedema remains a significant concern for patients undergoing breast cancer surgery. Most advice aimed at minimising the risk of lymphoedema is largely unsubstantiated by evidence, often leading to unnecessary limitations on the affected limb that may adversely affect quality of life and survivorship. There is a paucity of data regarding patient perceptions of lymphoedema risk and the strategies they adopt to mitigate this perceived risk. Methods This study invited New Zealand patients who had undergone breast cancer surgery to complete an online questionnaire regarding their treatment history, perceived risk of lymphoedema, and whether they believed certain historical risk factors contributed to lymphoedema. Additionally, patients were asked whether they avoided any activities to reduce this perceived risk. Results A total of 683 valid responses were received. 77% of those who underwent sentinel node biopsy (SNB) and 72% of those who had axillary node dissection (AND) overestimated their risk of lymphoedema development. Risk-reducing strategies (RRS) were adopted by 85.9% of individuals without a diagnosis of lymphoedema, with an average of 4.1 strategies per participant. Those who had undergone AND were more likely to adopt such strategies. Conclusion The majority of respondents overestimated their risk of lymphoedema and adopted RRS to mitigate this perceived risk, despite the absence of substantial evidence supporting these strategies. [...]

ABSTRACT Background Patients with complex defects secondary to traumatic injuries, severe infection or locally advanced malignancies present a therapeutic challenge. Surgical techniques continue to evolve that focus on reducing flap associated morbidity. The gracilis free flap is a workhorse in reconstructive microsurgery, and its design can be adjusted to optimise donor site form and function. This study's objective was to determine treatment outcomes following reconstruction using a modified gracilis muscle free flap termed ‘the gracilette’. Methods Adult patients received treatment at the Princess Alexandra Hospital and the data were prospectively recorded. Statistical analyses were performed to examine the relationships between patient demographics, clinical characteristics, reconstructive features and treatment outcomes. The primary outcome was free flap failure. Secondary outcomes included acute microvascular compromise, return to theatre and donor site complication. Results Eleven patients were treated between June 2019 and December 2023. Harvested flap dimensions varied between 7 × 4 cm and 10 × 6 cm ( [...]

ABSTRACT Background Total mesorectal excision (TsE) for rectal cancer is associated with significant morbidity. The ‘Watch and Wait’ approach, following a complete clinical response (cCR) to total neoadjuvant therapy (TNT), is increasingly considered as an alternative to surgery. The Internet offers extensive resources but the quality of these resources relating to ‘Watch and Wait’ is unknown. This study evaluates the availability and quality of online resources on ‘Watch and Wait’ as an option for patients with rectal cancer. Methods Using Google, search phrases: ‘patient information watch and wait rectal cancer’ and ‘patient information non-operative management rectal cancer’ were employed. The first 50 results of each search were assessed. Relevant sites meeting inclusion criteria were assessed using the DISCERN instrument, which evaluates the quality of published health information on treatment choices. Results Of 100 sites reviewed, three were duplicates. Fourteen sites provided dedicated patient-oriented information. Among non-dedicated sites, there were 63 scientific articles, 7 blogs, 6 resources for surgeons, 3 medical news articles, 2 videos, and 2 blocked sites. Of these 14 websites, 5 (35.7%) were updated within the last 2 years; 8 (57.1%) were associated with hospitals and clinics, and 6 (42.9%) with government or non-profit organizations. Most sites detailed the benefits of non-operative management, but 10 (71.4%) omitted uncertainties or risks. Only two (14.3%) were deemed ‘high-quality’ by DISCERN criteria. Conclusion Online patient resources on ‘Watch and Wait’ for rectal cancer are limited and often of poor quality. High-quality websites should be identified and recommended to patients wishing to seek further information on this topic. [...]

ABSTRACT Introduction Melioidosis (organism: Burkholderia pseudomallei) is an uncommon but serious cause of mycotic aortic aneurysms in endemic areas of North Queensland and Southeast Asia. This study describes the presentation, management, and outcomes of melioidosis-associated aortic aneurysms at a regional tertiary centre. Methods A retrospective review of all open and endovascular aortic aneurysm repairs recorded in the Australasian Vascular Audit and in the institutional electronic database between 1 January 2019 and 15 May 2025 was performed. Patient demographics, comorbidities (including ischaemic heart disease, type 2 diabetes, hypertension, end-stage renal failure, and smoking status), aneurysm characteristics (location and maximum diameter), procedural details (repair type, American Society of Anesthesiologists (ASA) score and device selection) and outcomes at 30 days, 90 days and 12 months were collected. Results Among 217 AAA repairs (17 open, 200 EVAR), six (2.8%) were mycotic and, of these, five (2.3%) yielded B. pseudomallei on culture. Four patients presented as emergency ruptures, while one with an ectatic aorta was referred electively by the infectious diseases team. Aneurysm diameters ranged from 30 mm to 60 mm, all involving the infrarenal aorta or aortoiliac segment. Two patients (40%) died—one from gastrointestinal complications within 30 days and another from an unrelated cardiac event at 12 months. The other three recovered without further aneurysm-related issues. Conclusion Although rare, melioidosis aortic aneurysms in endemic regions almost invariably present as surgical emergencies and carry a high risk of both early and late mortality. These findings highlight the necessity of prompt imaging, targeted microbiological diagnosis, and rapid initiation of either endovascular or open repair together with appropriate antimicrobial therapy. Multicentre studies are needed to refine long-term management strategies and antibiotic protocols for this life-threatening infection. [...]

Journal of Medical Imaging and Radiation Oncology, Volume 69, Issue 8, Page 852-853, December 2025. [...]

Journal of Medical Imaging and Radiation Oncology, Volume 69, Issue 8, Page 771-775, December 2025. [...]

ABSTRACT Despite the extensive body of literature on post-contrast acute kidney injury and prophylaxis, there is ongoing disagreement on the appropriateness of intravenous contrast administration and prophylactic measures in patients with poor renal function. Existing reviews indiscriminately include data from both historical high-osmolar (HOCM) as well as modern low- (LOCM) and iso-osmolar contrast media (IOCM). This systematic review assesses existing literature on contrast-associated kidney injury in adults (defined as individuals over 15 years of age) from intravenous (IV) iodinated LOCM/IOCM for computed tomography (CT) and prophylactic hydration with saline. Studies were searched on PubMed, Medline/Ovid, Cochrane and the University of Auckland Library. Papers were separated into trials and non-trials, with the references of non-trial articles followed until the original trial was identified, and duplicate patient groups were removed. The quality of studies were assessed using the GRADE system. Of 1253 potentially relevant studies, no high quality studies were identified. There were 13 moderate to low quality studies relating to contrast-associated acute kidney injury (CA-AKI), with the remaining assessed as very low quality. Inferences based on the moderate to low quality studies suggest that although contrast-induced acute kidney (CI-AKI) is a real phenomenon, the effect is not of a magnitude that is clinically significant for stable patients irrespective of baseline renal function. There was only a single low quality study for prophylactic IV hydration with saline, with the remaining studies being of very low quality. [...]

ABSTRACT It is widely accepted that treatment and care for patients with cancer must and should happen, as it is what everyone would want for themselves and their loved ones. Everyone wants the best possible care, but climate change and the extreme weather that it causes are increasingly affecting everyone including patients in negative ways. To continue giving the best possible cancer care without harming our environment and therefore patients, there is a need to optimise care. Through improving efficiency, reducing travel, using renewable energy and other measures it is possible to limit our environmental impact whilst still giving the best care available. In many cases this creates a win-win-win scenario for patients and the environment and, in many cases, significant cost savings. [...]

ABSTRACT Objectives The CT scan plays a vital role in diagnosing and managing urolithiasis. However, variability in CT windowing techniques may alter the measurement of stone dimensions, thus affecting decision-making. This study aims to analyse the diagnostic accuracy and variability of urinary stone measurements with different CT window settings. Methods An electronic search was performed in PubMed, Scopus, Web of Science, and the Cochrane Library until July 2025 for studies comparing stone size measurements between standard soft-tissue and bone window settings. Meta-analysis was conducted using a random-effects model. Results The findings suggest that stone measurement through bone window settings is more accurate and shows less inter-observer variability than soft-tissue window settings. Smaller slice thickness and multi-planar reformatting further improved accuracy. Bone window settings also showed better consistency in diagnostic judgement, especially for smaller stones relevant to treatment planning such as ureteroscopy or conservative management. Conclusion Bone window imaging should be applied when assessing urinary stones using CT as it improves measurement accuracy and reduces variability. However, standardisation of imaging protocols is still required. This review highlights the need for consensus guidelines on CT windowing in urinary stone evaluation to support accurate diagnosis and improved patient management. [...]

ABSTRACT Objectives To assess what motivates medical imaging utilisation and to understand what referring clinicians, and those who operationalise these referrals, consider important when making decisions to refer to medical imaging in the South Australia Public Health System. Design, Setting Two cross-sectional surveys were purpose-built for online delivery. One was conducted from March–August 2023 for SA Health referring clinicians, and another was conducted from February–July 2023 for South Australia Medical Imaging (SAMI) clinical staff. Participants Two cohorts were surveyed: referring clinicians within SA Health (n = 138) and SAMI clinical staff (n = 251), from both metropolitan and regional locations. Main Outcome Measures Two customised survey instruments. Results A range of factors was reported to influence how clinicians' decisions to request medical imaging, including patient-related, staff-related and system-related factors. Both clinicians and SAMI staff agreed that ‘improving overall patient health’ and ‘reassurance or confirmation of disease absence’ were key motivators for requesting medical imaging. However, notable differences emerged in how other motivations were rated, as well as factors clinicians consider important when referring patients for medical imaging. While a small number of clinicians acknowledged over-requesting, a much larger proportion of SAMI staff perceived over-requesting as a common issue among referring clinicians. Conclusions This study is the first to explore the perspectives of South Australian clinicians on the factors that motivate medical imaging requests. It highlights a complex array of drivers influencing referral practices and differing perceptions of overuse between those who refer and those who operationalise those referrals. The findings can inform the development of targeted, evidence-based strategies to optimise medical imaging referrals, improve resource use and enhance healthcare delivery for the South Australian community. [...]

ABSTRACT Introduction Accessing radiation therapy is a challenge for rural cancer patients. This study explored the rates of receiving radiation therapy for rural Māori and non-Māori New Zealanders with breast, prostate or lung cancer compared with their most urban counterparts. Method Rates of receipt of radiation therapy per 100,000 population were calculated using radiation treatment data from 2014 to 2020, obtained from the Radiation Oncology Collection and resident population estimates from StatsNZ. Rurality was assigned by the Geographical Classification for Health (GCH). Results For females with breast cancer, receipt of radiotherapy was lower for those over 75 living in smaller cities (U2) and for non-Māori aged 45–64 living rurally. For prostate cancer, there was higher receipt of radiotherapy by rurality in those under 65. For lung cancer, radiotherapy rates were higher in rural patients under 65, particularly females and non-Māori, but lower receipt of curative radiotherapy was observed for the most rural (R2/R3) Māori females and males over 75. Irrespective of rurality, Māori receipt of radiotherapy was lower than non-Māori in the youngest age groups for breast and prostate cancer, while Māori aged 45–74 with breast cancer, and Māori females and males with lung cancer in almost all age groups and GCH categories, had higher rates of radiotherapy than their non-Māori counterparts. Conclusion This study observed some rural–urban differences in receipt of radiation therapy for the three cancers studied, though with evidence of variability by age group and cancer type, and significant differences between Māori and non-Māori. [...]

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

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

ABSTRACT Glucagon-like peptide 1 receptor (GLP-1) agonists have been traditionally used in the treatment of type II diabetes. However, in recent times they have become a cornerstone in the pharmacological management of weight loss, and their use is increasing rapidly. Interventional Radiologists (IRs) need to understand GLP-1 agonists as they will increasingly encounter patients taking these medications in their daily practice, with implications for quality of care. These drugs have the potential to impact fasting glucose levels and gastric emptying, with implications for peri-procedural management when giving conscious sedation for an IR procedure. There is a need for IRs to adapt to the modern landscape. This review discusses the pharmacological effects, peri-procedural implications, and the need for IR-specific guidance in managing patients taking GLP-1 agonists. [...]

ABSTRACT Introduction This study evaluated local control and overall survival following hypofractionated stereotactic radiosurgery (HF-SRS) using the CyberKnife system for brain metastases ≥ 10 cm3, addressing the challenges of balancing efficacy and toxicity in larger lesions. Methods We enrolled patients with 1–4 newly diagnosed brain metastases from lung or breast cancer. The primary endpoint was local control of the treated metastases. The secondary endpoints were overall survival and incidence of radiation necrosis. Survival endpoints were evaluated using the Kaplan–Meier method. A Cox proportional hazards regression model was used to test for significant associations between clinical factors and outcomes. Results Between December 2016 and December 2018, 63 patients with 65 large brain metastases were included in this study. Of all the 63 cases, 55 cases were initially treated with HF-SRS; eight had tumour recurrence after gamma knife treatment. The radiosurgical margin dose (median, 30 Gy; range, 25–34 Gy) was prescribed at an isodose curve of 60%–75% (median, 67%) with multiple fractions (median, three fractions; range, 2–4), targeting a median tumour volume of 18.1 cm3 (range, 10.1–39.6 cm3). The median follow-up was 19 months. The local tumour control rates were 100%, 100%, and 92.58% at 6, 12, and 18 months, respectively. The 6-, 12-, and 18-month survival rates were 95.24%, 82.51%, and 68.61%, respectively. The cumulative incidence of radiation necrosis in patients who underwent primary HF-SRS was 7.02% and 14.04% at 1 year and 18 months, respectively. Conclusion We report our experience treating large brain metastases with HF-SRS. HF-SRS showed favourable local control with low incidence of complications. [...]

ABSTRACT Introduction This study examines the results of vacuum-assisted biopsy (VAB) for suspicious microcalcification as the only significant mammographic finding, with particular reference to women under age 40 years. Methods The study cohort comprised symptomatic or asymptomatic women who had full-field digital mammography at the Wesley Breast Clinic over a 9-year period (2013– 2021). Suspicious microcalcification was subjected to vacuum-assisted biopsy (VAB). The histological results were classified as: (a) invasive cancer, (b) ductal carcinoma-in situ (DCIS), (c) atypia, (d) papillary lesions or (e) benign tissue. Results Of the 139,911 women examined by mammography, 5967 were under 40 and had mammography because of symptoms or significant risk factors for breast cancer. Overall, 1748 (1.2% of mammograms) revealed a suspicious cluster of microcalcification as the only abnormality. 68 of these were in women under 40 (1.1% of mammograms in these women). A positive result for malignancy, (DCIS or invasive cancer) was obtained in 20.8% of VABs overall, including 16.1% of women under 40 (2 invasive, 9 DCIS). Women under 50 had about half the risk of a malignant result on VAB compared with women aged 50 and over. B3 lesions (of uncertain malignant potential) were uncommon in women under 40. Conclusions The small number of women under 40 who had suspicious microcalcification requiring VAB, and of cancers thus found, suggests that, unless significant risk factors are present, it is difficult to justify mammography in women prior to age 35 with the sole aim of detecting microcalcification which could be, for example, DCIS. [...]

Australian Journal of Rural Health, Volume 33, Issue 6, December 2025. [...]

ABSTRACT Objective To explore how mobile interviewing can be utilised to better inform rural health promotion efforts, as well as the type and breadth of data generated. Mobile methods are defined by the researcher and participant being in motion in a specific setting, collaborating in the data collection process. Setting A rural health service catchment in Victoria, Australia. Participants Members of local Progress Associations, Town Advisory Committee and service clubs within the catchment. Design The study employed an exploratory qualitative design. Mobile interviewing was used in the form of unstructured guided tours, led by participants. The theme provided was ‘What in your town helps or hinders community health?’. Content and thematic qualitative analysis were applied, and a socioecological model was adopted to structure the findings. Results Six guided tours involving seven participants were conducted. Local drivers of health were identified across all five levels of the applied model (intrapersonal, interpersonal, institutional, community, public policy). Institutional-level factors figured most prominently during the guided tour discussions (e.g., relating to the agricultural sector or not-for-profit community organisations). Community factors (e.g., intentional support between local organisations) were also highlighted. Public policy factors were the least discussed out of the five levels of the socioecological model. The study found that perceptions of community health drivers varied substantially, even among geographically close and demographically similar towns. Conclusion The study highlights how mobile interviewing can generate rich, contextual data. The findings suggest that guided tours can serve as a valuable tool for rural health promotion practitioners, providing a holistic understanding of local drivers of health and informing more tailored interventions. [...]

ABSTRACT Objective This pilot study evaluated the feasibility and acceptability of a student-led group falls prevention exercise program delivered to a fixed hub via telehealth to older adults in a remote community. Design A convergent parallel mixed-methods design involving pre- and post-participation outcome measures, semi-structured focus groups and interviews explored the experiences and perspectives of participants completing the program and health professional students conducting the sessions. Setting Telehealth delivery to a very remote town (Modified Monash Model 7) in southwestern Queensland from a regional city in southeast Queensland. Participants Over 2022 and 2023, 17 community participants completed the program. Seven final year students, six studying exercise physiology and one studying physiotherapy, completed a clinical placement in a regional health and wellness clinic and implemented the telehealth program during their placement. Results Community participants demonstrated significant improvements in mobility and function following program participation, with higher BOOMER scores (M = 13.12, 95% CI 11.94–14.29) and faster 10-m walk times (M = 8.56 s, 95% CI 7.31–9.81) compared to baseline (M = 10.94, 95% CI 9.04–12.84; and M = 10.31 s, 95% CI 8.32–12.31, respectively). Clinically meaningful gains on the 10-m walk test were achieved by 64.7% of participants. Beyond physical outcomes, the program fostered valuable social connections. Health professional students reported increased awareness of effective telehealth strategies and growth in clinical skills as additional benefits. Conclusions Telehealth delivery of a group-based exercise program to a fixed hub appears to be a feasible and well-accepted model of rural health service delivery for both older adults and health students. Wider implementation of this approach to a broader range of health services could improve access to high-value care for rural and remote communities. [...]

ABSTRACT Objective To explore the place of origin and placement locations as predictors of non-metropolitan practice among domestic pharmacy graduates from the University of Tasmania (UTAS). Methods The 2023 principal place of practice (PPP) for all domestic UTAS pharmacy graduates between 2011 and 2022 was identified using the Australian Health Practitioners Regulation Agency (Ahpra) online registration database. The graduates' place of origin (home address at the time of course application), locations where they undertook placements, and their 2023 PPP were described using the Modified Monash Model (MM) classification system of remoteness. A multivariable logistic regression model was used to identify independent predictors of regional (MM2), or rural or remote (MM3–7) PPP. Results 329 domestic UTAS pharmacy graduates were practicing in Australia in 2023; 58.7% were working regionally and 13.1% in a rural or remote area. Predictors of a regional PPP included regional (aRR 36.32, 95% CI 7.88, 167.33, p  [...]

ABSTRACT Objective To explore the perceptions of rural Australian clinicians towards antenatal point-of-care ultrasound (APoCUS) training and accreditation, investigating barriers and enablers to continuing professional development (CPD). Methods A prospective cross-sectional online survey of rural Australian clinicians (doctors, nurses, midwives) was undertaken in 2023, using non-probability sampling with self-selection/voluntary response. The survey targeted rural clinicians caring for pregnant patients. Thematic and descriptive analyses were performed with response frequencies grouped by role, work sector, APoCUS use and previous training experience. Fisher's exact test was used for association. Results Fifty-seven responses were analysed (41 midwives/nurses, 16 physicians/doctors). Two-thirds were performing APoCUS, half reported formal or on-the-job training, and none were accredited. Midwives/nurses had a poorer understanding of their scope of practice (eligibility to learn/perform APoCUS) and accreditation requirements. Interest in accreditation was high, particularly for the midwife/nurse cohort. The perceived benefits of accreditation surrounded improved patient care and services, scanning capability and professional satisfaction. The main barriers to pursuing accreditation were supervision for scanning and assessments, cost, time commitment and workforce shortages. Half of the respondents had access to employer-provided CPD funds, and most reported having to self-fund to meet professional registration requirements. Conclusion Australian rural clinicians are driven to upskill and provide high-quality care to patients but face significant barriers to CPD and attaining accreditation, evidenced by low accreditation rates. Future efforts should focus on simplifying accreditation processes, improving access to qualified supervisors/mentors and raising awareness of training and accreditation opportunities while providing support and incentives for rural clinicians to facilitate access. [...]

ABSTRACT Objective Evaluate the impact on spirometry quality of a culturally responsive Indigenous Health Worker Spirometry Training and Mentoring programme (IHWS). Methods Participation in two-day face-to-face IHWS including post-training telehealth mentoring Design Submission of spirometry reports before training (T1), after training (T2) and after telehealth mentoring (T3). Setting Urban, rural and remote primary healthcare services in Queensland Australia. Participants Primarily Australian First-Nations Health Workers. Main Outcome Measures Two raters used nine-point quality criteria to score spirometry at T1, T2 and T3. Inter-rater reliability was assessed using Cohen's original kappa. Reports submitted at a minimum of two time-points were included in the analysis. A linear mixed model analysis and post hoc analysis assessed differences in total scores across different timepoints. Results Between 2011 and 2018, 360 participants (75.5% Indigenous) attended 43 workshops. Of the 284 participants attending workshops #1–#34, 56.7% (161/284) hadn't performed spirometry before IHWS and were excluded from comparative analysis because spirometry reports could be submitted at only one timepoint (T2). Introduction of telehealth mentoring sessions from workshop #35, increased spirometry submission for assessment at T2 from 9.9% (28/284) to 68.4% (52/76). Thirty-six participants submitted reports at two timepoints or more. Spirometry quality improved across all timepoints (p  [...]

ABSTRACT Objective Quality indicators (QIs) specific to older adults receiving health care in rural and remote settings can be used to monitor healthcare quality, inform service improvements, and outcomes for these populations. This scoping review aimed to identify population-based QIs used to evaluate healthcare quality received by older people in rural and remote settings. Methods Two academic databases and grey literature sources were searched to identify population-based rural QI monitoring programs or rural QIs, routinely used and reported since 2012. QI program and specific characteristics, including country of origin, dimension of care quality captured, domain represented, QI type, data sources used, reporting strategies, and care settings were summarised. Findings Nine QI programs from seven countries with 52 QIs were identified. The QIs measured quality-of-service delivery (n = 28, 54%), accessibility (n = 11, 21%), resources (n = 9, 17%), and hospital readmissions (n = 4, 8%). Most QIs were outcome (n = 25, 48%) or process (n = 19, 37%) indicators, considering the dimension of safe healthcare. Three QIs (6%) measured rural hospital readmission in older people residing in rural areas. Conclusions Three QIs measuring the proportion of older adults with unplanned rural hospital readmission were identified that could facilitate consistent reporting and benchmarking of care provided to older adults residing in rural and remote communities. Given the known disparities in equitable access and quality of healthcare for older people residing in rural and remote areas, these findings highlight the need for QIs across all quality dimensions to monitor healthcare quality and drive improvements in access and quality of healthcare. [...]

ABSTRACT Objective Primary: To evaluate adherence to statewide guidelines for managing fever in infants [...]

Australian Journal of Rural Health, Volume 33, Issue 6, December 2025. [...]

ABSTRACT Objective To analyse the changes in psychiatric inpatient admissions following the 2022 Lismore floods, focusing on admission frequency, length and reason. Methods We separated our dataset into two groups of equal time frame, representing the 12 months directly preceding (N = 407) and directly following (N = 500) the floods, and analysed the differences between them. Design A retrospective cohort study. Setting The adult inpatient mental health service of Lismore Base Hospital. Participants 907 patients admitted to the Lismore Base Hospital adult inpatient mental health unit between 1 March 2021 and 28 February 2023. Main Outcome Measures Patient characteristics, number of admissions, admission length and admission reason were compared between the pre-flood and post-flood groups. Results We found a 22.9% (p = 0.002) increase in the number of admissions and an 18.2% (p = 0.001) reduction in the median admission length following the floods, culminating in no change in the total time spent in hospital when summed across all admissions. Additionally, there was a reduction in the length of Suicidality, Homicidality or Deliberate Self-Harm (DSH) admissions (p  [...]

Australian Journal of Rural Health, Volume 33, Issue 6, December 2025. [...]

Australian Journal of Rural Health, Volume 33, Issue 6, December 2025. [...]

BACKGROUND AND OBJECTIVESChildren with prenatal substance exposure are at high risk of child protection involvement during infancy. We quantified the risk and timing of child protection system involvement until age 12 years among children with and without prenatal substance exposure.METHODSA whole-population birth cohort (2007–2018) was assembled from data linked for the New South Wales Child E-Cohort, Australia. The prenatal substance exposure population included children with records indicating prenatal substance exposure in hospital, emergency, mental health outpatient, opioid treatment, and/or child protection reports data. We estimated the risk of child protection responses (screened-in reports, investigations, substantiations, and out-of-home care [OOHC]), and child maltreatment types.RESULTS1 161 876 children (17 976 with prenatal substance exposure) and 717 063 mothers were included. By age 1 year, 75% of the prenatal substance exposure population born in 2018 had ≥1 screened-in report, 34% ≥1 substantiation, and 20% ≥1 OOHC placement, compared with 4%, 0.8%, and 0.2% of all other children, respectively. By age 12, 90% of the prenatal substance exposure population born in 2007 had ≥1 screened-in report, 61% ≥1 substantiation, and 39% ≥1 OOHC placement, compared with 18%, 5%, and 1% of all other children, respectively. One-half of the prenatal substance exposure population had neglect recorded by age 12. Health and socioeconomic disadvantage were more common among the prenatal substance exposure population.CONCLUSIONChildren with prenatal substance exposure experienced high child protection involvement early in life. Child protection reports represent an opportunity to mobilize nonstigmatizing substance use in pregnancy and antenatal care to prevent escalating child protection interventions. [...]

Infants and children with prenatal substance exposure (PSE) experience high rates of child protection system (CPS) involvement.1 Reporting to CPS is often initiated around the time of birth due to concerns about future risk of abuse and neglect, but reporting mandates vary by jurisdiction, state, and/or country and interpretation of these mandates can further vary by hospital and provider.2–5 Few studies have been able to look at cumulative risk of CPS reports, investigations, and substantiated abuse and neglect following PSE throughout childhood because data systems involving administrative claims, CPS data, and substance use records are rarely linked or tracked longitudinally. In this issue of Pediatrics, Powell and colleagues were able to link population-level health, substance use, and CPS data spanning a 12-year period to compare childhood CPS involvement among children with PSE compared with those without in New South Wales (NSW), Australia.6 They found, unsurprisingly, that by age 12 years, when compared with children without documented exposure, children with documented PSE had significantly higher rates of CPS reports that were screened in for investigation (90% vs 18%), CPS cases that were substantiated (61% vs 5%) and out-of-home placement episodes (39% vs 1%). [...]

An international panel of 27 experts (pediatric and movement disorder neurologists, psychiatrists, and parent representatives) from all continents participated in a Delphi process to establish international consensus guidelines for the evaluation, diagnosis, and management of children with Sydenham chorea (SC) based on best evidence and expert opinion. In total, 88 recommendations reached consensus. Practitioners should identify key signs of SC (chorea and hypotonia), screen for behavioral, mobility, swallowing, speech, and cognitive impairments, and acute rheumatic fever (ARF) features including carditis. Etiological evaluation will differ according to population ARF risk. At all times, patients, families, and educators should receive support, information, and guidance to minimize the impact of SC on academic and social functioning. Antibiotic treatment is recommended at first presentation. Long-term secondary antibiotic prophylaxis should follow international or local guidelines, and measures to reduce pain and distress associated with intramuscular antibiotics will aid in adherence. Immunotherapy (corticosteroids) is recommended in moderate to severe SC. In those with inadequate recovery, intravenous immunoglobulin or plasma exchange should be given. In SC relapse, repeat clinical assessments, etiological investigation, and antibiotics plus corticosteroid therapy should be considered. This consensus guideline will standardize the evaluation and management of patients with SC and direct future research to improve the lived experience and outcomes of patients and families. [...]

We have read with great interest the recent article, Recommendations for pneumonia in hospitalized children with neurologic impairment, by Thomson et al1 and deeply appreciate their efforts in establishing an evidence-based management framework for this special population. The recommendations provided in the article are of significant guiding value. As clinicians in the field of rehabilitation, we wish to build upon the valuable insights of this paper by offering a few supplementary recommendations, specifically focusing on children with mild neurological impairment—a group often overlooked in clinical practice—from the perspectives of functional assessment, rehabilitation intervention, and continuity of care. Our aim is to enhance treatment efficacy and promote antimicrobial stewardship without significantly increasing resource expenditure. [...]

On behalf of the authorship team, I sincerely thank Dr He and colleagues for their thoughtful engagement with our article, Recommendations for pneumonia in hospitalized children with neurologic impairment.1 We deeply appreciate their efforts to extend the conversation on children with neurological impairment—a population that is indeed underrepresented in both research and clinical protocols. [...]

10.1542/6380058992112Video AbstractPEDS-VA_2025-0710516380058992112OBJECTIVEEarly childhood advanced primary care models are promising ways of addressing child and family needs, but there is limited evidence to support short-term sustainability within current Medicaid payment structures. We evaluate claims-based outcomes associated with 3-2-1 IMPACT (IMPACT), an early childhood advanced primary care model, compared with the standard of care.METHODSUsing New York State Medicaid claims, we identified and matched children aged 1 to 35 months receiving care at 3 IMPACT sites and 3 comparison sites within a large public hospital system. Regression models were used to analyze use, expenditure, enrollment, and quality outcomes between groups.RESULTSThere were 6045 children at the treatment sites and 4832 matched children from the comparison sites. IMPACT was associated with a significant increase in 6 or more well-child visits and a decrease in emergency department visit rates. There was also a significant increase in 6 more well-child visits specifically for Black and Hispanic children seeking care at IMPACT sites compared with comparison sites. There were no significant differences in expenditures, other use types, or Medicaid enrollment across groups.CONCLUSIONAn early childhood advanced primary care model that incorporates multiple evidence-based programs can show short-term, positive effects on preventative and acute care use and quality within Medicaid. These results highlight short-term strategies for sustainability while awaiting the long-term, cross-sector benefits expected from models like IMPACT. Future studies addressing additive model component effects and longer-term outcomes across mother-child dyadic and social-emotional outcomes are warranted. [...]

In this issue of Pediatrics, Boolchandani et al describe HIV screening rates in 40 US pediatric emergency departments (EDs) and identify patient and hospital factors associated with HIV screening.1 In their analysis of 2 134 563 adolescents without a known HIV infection who were discharged from an ED visit between 2019 and 2023, only 1.3% (n = 28 052) received HIV screening during the visit. Despite International Classification of Diseases, Tenth Revision (ICD-10) codes suggesting elevated HIV risk (eg, signs or symptoms of HIV infection, concurrent symptoms, or diagnosis of another sexually transmitted infection [STI]) and/or a current pregnancy among most of the adolescents tested for HIV (n = 20 972, 75%), more than 90% of adolescents with those symptoms, findings, and/or diagnoses were not tested. Importantly, only 7080 adolescents without readily identifiable symptoms of STI or pregnancy underwent screening. This is a notable gap given that early HIV infection, as with bacterial STIs, is most often asymptomatic. [...]

10.1542/6378936297112Video AbstractPEDS-VA_2025-0721086378936297112BACKGROUND AND OBJECTIVESAdolescents account for one-fifth of new HIV infections in the United States. Despite Centers for Disease Control and Prevention (CDC) recommendations for universal opt-out HIV screening for individuals aged 13 years or older in all health care settings, many adolescents remain undiagnosed due to limited access to testing. This study aimed to describe HIV testing rates in US pediatric emergency departments (EDs) and identify patient and hospital factors associated with testing.METHODSWe conducted a cross-sectional study of pediatric ED encounters for patients aged 13 to 18 years at 40 US children’s hospitals (January 2019-December 2023). Patient and hospital characteristics were analyzed using multivariable logistic regression analysis to assess associations with HIV testing.RESULTSOf 2 134 464 ED encounters, 28 052 (1.3%) included HIV testing. Of these, 75% (n = 20 972) were targeted tests based on ED diagnoses, whereas 25% (n = 7080) were screening tests. Factors associated with HIV testing were female sex (adjusted odds ratio [aOR], 1.46; 95% CI, 1.42–1.51), Black/African American race (aOR, 1.71; 95% CI, 1.65–1.77), 2 or more races documented (aOR, 1.52; 95% CI, 1.38–1.66), public insurance (aOR, 1.69; 95% CI, 1.63–1.75), and living in very low Childhood Opportunity Index neighborhoods (aOR, 1.67; 95% CI, 1.59–1.75). Hispanic/Latino (aOR, 0.84; 95% CI, 0.80–0.87), Asian (aOR, 0.73; 95% CI, 0.64–0.83), and adolescents with complex chronic conditions (aOR, 0.53; 95% CI, 0.49–0.57) were less likely to have HIV testing.CONCLUSIONSHIV testing during pediatric ED encounters was rare, demonstrating an opportunity to enhance pediatric HIV screening practices in accordance with recommendations from the CDC. [...]

10.1542/6378837665112Video AbstractPEDS-VA_2025-0711476378837665112OBJECTIVESIt is unclear how long youth with opioid use disorder (OUD) should continue taking buprenorphine, and what adherence they should achieve. We identified patterns of duration/adherence and assessed associations with subsequent overdose, emergency department (ED) use, and hospitalization.METHODSThis retrospective cohort analysis used 2014–2022 data from the Massachusetts Public Health Data Warehouse. We identified youth aged 13 to 26 years initiating buprenorphine and used group-based trajectory modeling to categorize youth into duration/adherence trajectories over 12 months. Using multivariable Cox regression, we examined associations between trajectories and time to fatal/nonfatal opioid overdose, all-cause ED use, and all-cause hospitalization during the subsequent 12-month period.RESULTSAmong 11 649 Massachusetts youth initiating buprenorphine, most were aged 21 years or older (89.0%), male (60.3%), white non-Hispanic (85.9%), and enrolled in Medicaid (55.4%). We identified 4 patterns of medication use: (1) high adherence for 12 months (23.7%); (2) low adherence for 12 months (27.5%); (3) discontinuation in 3 to 9 months (16.4%); and (4) discontinuation in less than 3 months (32.5%). Trajectories included 580 (5.0%) and 774 (6.6%) youth switching to methadone and naltrexone, respectively. Compared with high adherence for 12 months, overdose risk was higher with low adherence for 12 months (adjusted hazard ratio [aHR], 1.46; 95% CI, 1.24–1.73), discontinuation in 3 to 9 months (aHR, 1.82; 95% CI, 1.52–2.17), and discontinuation in less than 3 months (aHR, 1.76; 95% CI 1.50–2.06). Compared with high adherence, low adherence and discontinuation in less than 3 months had higher risk of ED use, and all other trajectories had higher risk of hospitalization.CONCLUSIONSMedication adherence may prevent overdose, ED use, and hospitalization. Strategies to increase treatment duration/adherence likely avert harm. [...]

Streptococcus pyogenes (GAS) is responsible for many pediatric infections. Although outcomes are generally favorable with prompt diagnosis and treatment, it is necessary for pediatricians to remain vigilant for complications. We discuss a rare GAS complication: post-streptococcal myositis. An 8-year-old female patient recently hospitalized for cervical lymphadenitis presented with extremity pain and difficulty walking. Initial work-up revealed marked nonspecific inflammation, normal creatine kinase (CK), and superficial thrombophlebitis. Her symptoms progressed rapidly to high fevers, erythematous nodules, severe pain and edema, and superficial thrombophlebitis extension despite antibiotics and nonsteroidal anti-inflammatory pharmacotherapy. This was associated with rising inflammatory markers, extensive myositis of the extremities and mild fasciitis of the calves on imaging, and a muscle biopsy with normal architecture and no evidence of vasculitis or necrosis. A markedly elevated anti-streptolysin O (ASO) and anti-DNase B led to the diagnosis of post-streptococcal myositis. Symptoms responded rapidly to systemic steroids, with complete recovery within 5 months. Limited case reports of post-streptococcal myositis exist, which similarly describe severe myalgia and fevers, inflammation, elevated ASO, and typically normal CK. Most describe a self-limited disease course. This case describes a unique manifestation and sequelae of streptococcal infection in a child with an impressive degree of systemic inflammation and thrombotic complications. This report also describes pediatric muscle biopsy results in association with this diagnosis. Post-streptococcal myositis should be considered for patients with severe unexplained inflammation and myalgia. [...]

10.1542/6380058313112Video AbstractPEDS-VA_2025-0730236380058313112OBJECTIVEDyadic care of the mother and infant simultaneously may improve postpartum morbidity and mortality. The aim of this scoping review was to synthesize the spectrum of dyadic care models that have been implemented globally, summarize the outcomes measured, and identify research and practice opportunities of maternal-infant dyadic care.METHODSWe conducted a comprehensive literature search through December 24, 2024, in 8 databases. The inclusion criteria were original research on interventions that provided care for both the mother and infant within 1 year of delivery, with outcomes reported for at least 1 member of the dyad. Studies were excluded if the evaluated practices are now considered standard of care or were educational only.RESULTSA total of 117 studies from 28 countries met the inclusion criteria. Ten dyadic care models were identified: shared medical visits, provision of maternal care at pediatric appointments, group dyadic care, mother-baby psychiatric units, care for mothers in the neonatal intensive care unit, couplet care, home visits by medical professionals, home visits by community health workers, mobile device interventions, and nutritional supplementation during pregnancy. Home visits by medically trained personnel were most frequently studied. Common outcomes assessed were maternal mental health, infant rehospitalization, breastfeeding rates, and implementation outcomes of acceptability and feasibility. Efficacy varied, with some interventions showing positive impacts, particularly those involving trained health professionals over longer periods.CONCLUSIONDyadic care interventions offer a compelling opportunity to streamline services, build trust between families and providers, and improve outcomes across the life course. [...]