United States

Background
The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) was created with the goal of quality improvement in bariatric surgery. Centers with MBSAQIP accreditation report outcomes to a national database. Staple line bleeds are a primary cause of postoperative hemorrhage in vertical sleeve gastrectomy (VSG). Review of our institution’s MBSAQIP semiannual report noted higher instances of reoperations following laparoscopic. This study sought to standardize practice across surgeons and reduce reoperation for bleeding following VSG.

Methods
Using the Plan, Do, Study, Act framework, two review periods were determined. Pre-intervention, surgeons used a hybrid robotic-laparoscopic approach to VSG in which the dissection was performed with the robot and a laparoscopic stapler was used to complete the sleeve. The intervention included standardizing an entirely robotic approach. A peer review and manufacturer recommendation from Covidien were used to develop our technique using 1-2 blue loads based on tissue thickness and feedback from the robot followed by white loads to complete the sleeve.

Results
Pre-intervention, 5/107 cases (4.67%) required reoperation with 80% due to staple line bleeds (3 hybrid technique and 1 robotic sleeve). Post-intervention, 1/56 VSG required reoperation for bleeding on a laparoscopic VSG. There were zero postoperative bleeding episodes for fully robotic sleeves. Sixty-nine percent of robotic cases used additional interventions (clips or oversewing staple lines at the index operation), and 31% did not require additional intervention. 

Conclusion
Standardizing robotic VSG decreased re-operations for bleeding. Reinforcement of robotic staple lines was performed in most cases and likely contributed to the reduction. Future work should consider standardizing reinforcement techniques or using reinforced stapler loads.

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Vertical Sleeve Gastrectomy Stapler Length – Quality Improvement Project

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Background: Vagus nerve stimulation (VNS) has been demonstrated to reduce stress-induced cortisol release. Several non-invasive techniques for VNS are currently available, including transcutaneous auricular and cervical VNS. Cervical VNS potentially activates efferent and afferent vagal nerve fibers, while auricular VNS activates the auricular branch of the vagus nerve, which is a purely afferent nerve. We hypothesized that VNS causes a state of mental tranquility, thereby reducing arterial blood pressure.
Methods: The study was approved by the Burrell College Institutional Review Board and included 16 healthy young participants (5 ♂) who provided written informed consent. Exclusion criteria included pregnancy, acute or chronic illnesses, and use of prescription medications, except contraceptives. Participants were randomly assigned to: time control (CTR, no intervention), transcutaneous cervical VNS (cVNS), transcutaneous auricular VNS applied to either the tragus (atVNS) or the cymba conchae (acVNS). A 30-minute baseline recording was followed by VNS or no intervention. VNS was applied three times for 5 min. Each 5-minute VNS was followed by 1 minute without stimulation. cVNS was delivered bilaterally using the Pulsetto device (25 Hz, 100 μs, < 40 mA). atVNS and acVNS (10 Hz, 300 μs, 2-3 mA). Heart rate (ECG), blood pressure (finger plethysmography), and a single-channel EEG (FP1 location) were recorded continuously. Statistics included one-way ANOVA for repeated measures with post-hoc t-tests for each experimental group. P < 0.05 was considered significant, 0.05 < P < 0.10 was considered a trend. 
Results: Systolic blood pressure only decreased during cVNS (133.6±5.0 mmHg at baseline vs. 124.2±4.8 mmHg, n=7, P<0.05) but not in the time control or both auricular VNS groups. No significant changes in heart rate were observed in any group. The amplitude of alpha waves in the EEG increased only in the cVNS group (0.654±0.070 arb. units at baseline vs. 0.827±0.076 arb. units, n=7, P=0.06) but not in the time control or both auricular VNS groups. No significant changes were observed for any other EEG waves.
Conclusion: Non-invasive transcutaneous VNS reduced systolic blood pressure and increased alpha waves in the EEG of the frontal lobe when the cervical vagus nerve was targeted bilaterally, but not when the auricular branch of the vagus nerve was stimulated unilaterally. Increased alpha waves are consistent with a more relaxed mental state, which may have caused the reduction in systolic blood pressure with cVNS, potentially through decreased stress hormone release.

NOTE: All listed authors contributed equally. 


Non-Invasive Cervical Vagus Nerve Stimulation Increases Brain Alpha Waves and Reduces Arterial Blood Pressure

Glioblastoma (GBM) is an aggressive malignancy of glial cells that has a median survival rate of 15-20 months even in the face of current models of treatment. Despite extensive research efforts long-term survival remains low. Thus, there is a high unmet need to develop novel therapies, however, the current treatment approach through resection, radiation, and chemotherapy have remained unchanged in the last few years. A major hurdle in developing novel therapies is the extreme immunosuppression of the tumor microenvironment seen in GBM patients. A key environmental factor in driving this characteristic malignancy is hypoxia. GBMs often have necrotic regions with limited perfusion and poor oxygen delivery. Additionally, delivery of corticosteroids for glioblastoma patients is common, yet their impact on cell signaling has been unexplored. The aim of this study is to elucidate the role of chronic hypoxia and dexamethasone and their effect on GBM gene expression and phenotype. GBM cell lines are typically immortalized and exposed to ambient air (normoxia, 21% oxygen) compared to physiologic oxygen levels (physoxia, 5% oxygen) within the brain. We hypothesize that patient-derived GBM cell lines under chronic normoxia tensions demonstrate differences in gene expression signatures that alters cell growth and treatment responsiveness. Previous work has shown ERK signaling, a regulator of tumor survival and therapy resistance, is modulated by oxygen levels. ERK is activated by receptor tyrosine kinases and the PI3K/AKT pathway. Here, we further investigated GBM gene expression and phenotype using 2 patient-derived cell lines (GB10 and GB43) that were maintained under physoxia conditions and continued dexamethasone treatment for at least two passages. We found that both cell proliferation and migration decreased, with significantly reduced doubling times in GB10 and GB43 cell lines. Additionally, we examined markers of EMT using RT-qPCR that showed increased Slug and decreased IGFBP1 transcripts in GB43 cells maintained in physoxia. Western blotting of ERK, PDGFRβ, and AKT showed increased phosphorylation. Further, hypoxic conditions showed increased chemoresistance to temozolomide in GB10 cell lines. Finally, we explored the influence of hypoxia on inflammatory cytokine expression through RT-qPCR. Thus, we show that chronic exposure to physoxia and dexamethasone alters cell proliferation, migration, therapeutic resistance, immunological environment, and cell signaling.

Elucidating the effects of a low oxygen environment and dexamethasone on cell signaling in glioblastomas

Background: Worse surgical outcomes are related to increasing patient age, particularly in the emergency setting. Appendicitis is one of the most common conditions requiring emergency general surgery (EGS) in the United States. We aimed to characterize and investigate the impact of comorbidities on outcomes in younger and older patients with acute appendicitis to inform post-operative care and follow-up. 

Methods: A retrospective chart review of the EGS registry was conducted for patients with acute appendicitis between 03/01/2023 and 08/31/2024 at three hospitals (one academic, two community) within our institution. Patients were stratified based on age: Younger (<65 years) and Older (≥65 years). The primary outcome was 90-day complication (e.g., SSI, C. difficile). Secondary outcomes included operative approach, readmission, mortality, and disposition. Multivariable logistic regression was performed to determine predictors of 90-day complication after adjusting for age, perforation, Charlson Comorbidity Index (CCI), and hospital. 

Results: 529 acute appendicitis patients were included, 81.3% (n=430) were <65 years, and 18.7% (n=99) were ≥65 years. Older adults experienced higher 90-day complication (19.2% vs 5.8%, p<0.001), readmission (28.3% vs 9.5%, p<0.001), mortality rates (5.1% vs 0.5%, p=0.002), and were significantly more likely to present with perforation (53.5% vs 18.4%, p<0.001). Older patients more frequently experienced systemic complications (e.g., C. difficile, sepsis), while younger patients more often had surgical-site complications. Older patients tended to be readmitted for cardiovascular or infectious reasons, whereas younger patients were readmitted for intraabdominal abscesses. On multivariable logistic regression, perforation independently predicted 90-day complication (aOR 4.85, 95% CI 2.41–9.74) and 90-day readmission (aOR 2.42, 95% CI 1.36–4.30). CCI was associated with increased odds of 90-day readmission (aOR 1.37, 95% CI 1.13–1.66) and 90-day ED visits (aOR 1.21, 95% CI 1.02–1.44). Age group was not associated with 90-day complication, or 90-day readmission to the hospital or ED. Outcomes were consistent across hospital sites.

Conclusion: Although older adults with acute appendicitis experience higher unadjusted rates of 90-day complication and 90-day readmission, age was not an independent predictor of these outcomes; rather, perforation and CCI were the primary predictors of adverse outcomes. This highlights the need for risk stratification and targeted postoperative management strategies, particularly among older EGS patients presenting with perforated appendicitis or significant medical comorbidities.

The Predominant Role of Perforation and Comorbidity Over Chronologic Age in Acute Appendicitis

Background
Cervical disc degeneration is a condition that significantly diminishes a patient’s quality of life. It is commonly treated with surgical interventions such as anterior cervical discectomy and fusion (ACDF) or cervical disc arthroplasty (CDA). Obesity, an ever-growing global public health concern, introduces unique challenges to spinal surgery due to its detrimental effects on biomechanical stress, wound healing, and recovery. Even with recent advancements in surgical techniques, the literature regarding how obesity affects the outcomes in ACDF vs CDA is limited. Therefore, the objective of this study is to compare clinical outcomes, functional recovery, and complication rates of CDA and ACDF in obese adults to provide evidence-based insights that can guide clinical decision-making for this high-risk population.

Methods
A retrospective database analysis was conducted using the multi-institutional database TriNetX, on the research network, wherein we looked at adult (>18 y/o) obese (>30 BMI) versus non-obese patients (18-29 BMI) undergoing ACDF vs CDA. Propensity score matching was done to ensure balanced demographic and clinical characteristics, which generated 26,272 patients for the 90-day analysis and 2,269 patients for the 2-year analysis in the obese ACDF group, and 2,270 patients for the 90-day analysis and 2,269 patients for the 2-year analysis in the obese CDA group. Our primary outcomes included functional improvement measured by the neck disability index (NDI), composite success, as well as readmission rates. Secondary outcomes included infections, deep vein thrombosis (DVT), cerebrospinal fluid (CSF) leak repairs, mechanical complications, adjacent segment disease, and cervical herniation. Risk ratios (RRs) and statistical significance (p < 0.05) were calculated to compare the two cohorts.

Results
Obese patients that underwent CDA were associated with significantly lower 90-day readmission rates (RR: 0.79; p < 0.001), fewer 2-year readmissions (RR: 0.58; p < 0.001), and improved functional outcomes, including composite success and Neck Disability Index scores (p < 0.001). CDA also demonstrated trends toward fewer infections, adjacent segment disease, and deep vein thrombosis, though these differences were not statistically significant. Mechanical complications and cervical herniation rates were comparable between the two groups. 

Conclusion
In obese patients, CDA demonstrated better functional recovery and lower readmission rates compared to ACDF, with comparable complication rates. Our findings support that CDA may be a more viable option for managing cervical disc degeneration in this vulnerable population.

Cervical Disc Arthroplasty vs. Anterior Cervical Discectomy and Fusion in Obese Patients: 90-Day and 2-Year Outcomes

ABSTRACT
Background: Femoral stem design is critical in cementless primary total hip arthroplasty (THA). Porous-coated and grit-blasted femoral stems are commonly utilized, but their relative performance in terms of revision rates and complications remains unclear. This systematic review aims to evaluate revision rates and reasons for failure between porous-coated and grit-blasted femoral stems to inform surgical decision-making.

Methods: A systematic search of peer-reviewed studies published through October 17, 2024, was conducted using PubMed, Embase, and Cochrane databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines focusing on porous-coated and grit-blasted femoral stems and primary cementless THA. Outcomes of interest included revision rates and reasons for revisions, such as periprosthetic fractures, stem loosening, dislocation, and infection.

Results: Twelve studies encompassing 1987 patients were included in this systematic review. The aggregated data indicates that porous-coated femoral stems exhibited revision rates as low as 1.5% (10/650 hips) compared to grit-blasted femoral stems with revision rates of approximately 9.2% (123/1,337 hips). In addition, studies focusing on porous-coated implants consistently reported significant improvements in functional outcomes, with Harris Hip Scores (HHS) improvements ranging from 16 to 47.6 points and postoperative HHS values reaching up to 96.1.

Conclusion: The findings of this systematic review support the clinical advantage of porous-coated femoral stems over grit-blasted stems in primary cementless THA. The lower revision and significant functional improvements seen through gains in the HHS suggest that anatomic design features of porous-coated stems enhance stress transfer, reduce stress shielding, and promote superior osseointegration.


Revision rates of porous-coated versus grit-blasted femoral stems in cementless Total Hip Arthroplasty: A Systematic Review

Effect of miR-29a-3p on PDGFA in Pulmonary Artery Smooth Muscle Cells

Background
In the United States, approximately 1 out of 10 infants are born prematurely. Bronchopulmonary dysplasia (BPD) affects many premature infants often due to being placed on mechanical ventilation at birth. The mechanisms of BPD are not well known and can also have a pulmonary hypertension effect (BPD-PH). In a preliminary study, we conducted a multi-omics analysis in tracheal aspirate of infants with BPD-PH and identified a panel of genes and miRNAs that were specifically highly expressed in BPD-PH. Of them, miR-29a-3p was the most highly expressed markers. The in-silico model of this biomarker panel identified angiogenic and inflammatory molecules as target pathways affected. In this study we investigated the effect of miR-29a-3p on the pulmonary artery smooth muscle cells (PASMC) which are dysregulated and hypertrophied in BPD-PH. 

Methods
PASMC were grown using Lonza smooth muscle growth medium and were transfected with 375nM of a FAM tagged miR-29a-3p mimic using the Mirus Transfection System at 300V. The control PASMC condition was transfected with a miRNA scramble. Cells were plated at a density of 3x106 cells/cm2 in a 6 well plate and 72 hours later, cells were imaged using the Cytation5 and harvested using the Lonza ReagentPack. Cells were RNA extracted, and RT-qPCR was performed for multiple mRNA transcripts (PDGFA, VEGF-A, IL-6, TGF-, ANGPTL4, TNF-).

Results
There was a significantly decreased expression of PDGFA in the miR-29a transfected PASMC when compared to control cells. We also noted slight trends in decreased expression of other angiogenic factors including VEGFA, ANGPTL4 and increased expression of inflammatory markers such as TNF- and TGF-. 

Conclusion
In our preliminary study miR-29a-3p has been overexpressed in premature neonates with BPD-PH. An increase in miR-29a-3p expression in PASMC decreased the level of PDGFA expression. Further research is needed to identify the specific mechanism through which the miR-29a modulates the angiogenic factors.

Impact of miR-29a-3p on Pulmonary Artery Smooth Muscle Cells

Title:
Evaluating Large Language Models for Pneumothorax Detection on Chest X-rays

Background:
The rapid advancement of large language models (LLMs), such as GPT-4o and Gemini 2.5 Pro, has prompted their exploration for medical image analysis tasks. Chest X-ray interpretation, particularly pneumothorax detection, remains a crucial diagnostic challenge. Accurate and timely detection significantly impacts patient outcomes. This study evaluates the diagnostic performance of two prominent LLMs, GPT-4o and Gemini, in detecting pneumothorax on frontal chest X-rays.

Methods:
Two thousand chest X-rays, evenly split into cases with and without pneumothorax, were evaluated using standardized prompts tailored for each LLM. The GPT-4o and Gemini 2.5 Pro models classified images based on predefined radiological criteria, including visible pleural lines, deep sulcus signs, lung translucency asymmetry, and signs of lung collapse. Confusion matrices were generated, and performance metrics such as accuracy, precision, recall, and F1-score were calculated to compare model efficacy.

Results:
The GPT model achieved an overall accuracy of 64%, with precision, recall, and F1-score for pneumothorax detection at 66%, 57%, and 61%, respectively. Conversely, the Gemini model exhibited a lower overall accuracy of 62% but demonstrated higher sensitivity (recall) at 88% for pneumothorax detection. However, its precision was notably lower at 55%, yielding an F1-score of 68%. GPT's balanced performance contrasts with Gemini's tendency toward high sensitivity at the expense of precision.

Conclusion:
Both GPT-4o and Gemini LLMs demonstrate potential in pneumothorax detection on chest X-rays but exhibit distinct strengths and weaknesses. GPT-4o provides balanced performance across metrics, suitable for general screening purposes. Gemini’s high sensitivity makes it advantageous for initial screening scenarios, despite a higher false-positive rate. These findings suggest tailored use-cases for each model depending on clinical priorities, highlighting the need for continued refinement of LLMs for medical imaging applications.

Evaluating Large Language Models for Pneumothorax Detection on Chest X-Rays

Background
Urinary tract infections (UTIs) are among the most common bacterial infections, causing pain and emotional distress for millions of patients each year. While Escherichia coli is the leading cause, Actinotignum schaalii is an emerging but underdiagnosed pathogen, especially in older adults and those with urologic conditions. This Gram-positive, facultatively anaerobic bacillus requires CO₂ and prolonged incubation to grow. These conditions are not met by routine urine cultures, leading to frequent underdetection, sterile pyuria, and progression to urosepsis. Molecular studies show a higher prevalence: one study detected A. schaalii in 16% of urine samples overall and up to 22% in patients over age 60. Despite its clinical relevance, taxonomy within the Actinotignum genus remains unclear. Notably, the distinction between A. schaalii and A. timonense has not been fully resolved. This study uses genomic and phenotypic tools to clarify species boundaries and enhance diagnostic accuracy.

Methods
Whole-genome sequence analysis was performed on 50 clinical isolates identified as A. schaalii, A. timonense, A. urinale, or A. sanguinis. Phylogenomic analysis was based on 560 conserved core genes, and average nucleotide identity (ANI) was calculated. Biochemical phenotyping was done using the Analytical Profile Index 50 Carbohydrate Fermentation (API 50 CH) assay. Comparative genomics was used to develop a multiplex PCR assay targeting specific rearrangements. The assay was benchmarked against matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-ToF MS).

Results
A. schaalii and A. timonense exhibited overlapping phylogenetic clades with ANI values exceeding the species-level threshold (>95%). PERMANOVA testing of API 50 CH profiles revealed significant metabolic differentiation (p < 0.001, R² = 0.32). A stable chromosomal rearrangement was identified, enabling the design of a multiplex PCR assay, which outperformed MALDI-ToF MS in classifying several misidentified isolates.

Conclusion
While the phylogenetics of A. timonense and A. schaalii are similar, differences exist in their metabolic profiles and chromosomal structures. Their metabolic profiles differ significantly, but species designation only explains a modest portion of the variation. Based on these findings, we demonstrate that A. timonense is closely related to A. schaalii, with potential for similar pathogenicity. Reclassifying A. timonense as a subspecies of A. schaalii and incorporating our new PCR assay enhances accurate identification, diagnosis, and targeted treatment of urinary tract infections, particularly in vulnerable populations.


Improving Identification of Actinotignum schaalii: An Overlooked Cause of Urinary Tract Infections

Abstract Title: Salvage irreversible electroporation (IRE) for radio-recurrent prostate cancer: perioperative and early postoperative outcomes 



Authors: William Connolly, BA, MSF1,2, Jarrett Noakes3, Katherine Wainwright1, Elias Hyams, MD1,2 

1Brown University, Providence, RI; 2Brown University Health; 3Florida Atlantic University 



Introduction: 

Local recurrence after radiation therapy (RT) for prostate cancer (PCa) creates a therapeutic dilemma based on risks of treatment in a previously radiated pelvis. Irreversible electroporation (IRE), a novel non-thermal focal therapy, has emerged as a potentially safe and effective local salvage therapy for these patients, however there are limited published data. 



Methods: 

We retrospectively analyzed 12 patients with radio-recurrent PCa who underwent salvage IRE (sIRE) between 12/23-1/25. These procedures were performed by one surgeon in a standardized transperineal approach. Pre-operative characteristics as well as post-operative outcomes were recorded. 



Results: 

Mean patient age was 75.4+/-5.38. All patients had undergone external beam radiation therapy +/- ADT for localized disease. Pretreatment Grade group was GG1, 2, 4, and 5 in 5(41.7%),4(33.3%),2(16.7%), and 1(8.3%) patient, respectively. Median pretreatment PSA was 5.3 (7.1). At sIRE, mean PSA was 5.15+/-2.30. All patients had local recurrence only by PSMA PET. All patients underwent saturation transperineal biopsy with cognitive targeting with confirmation of local recurrence. At 3 months postoperatively, mean PSA was 0.93+/-0.89. At 6 months, mean PSA was 1.78+/- 1.66. 5 patients had an MRI at 6 months showing treatment effect or artifact. One patient had a persistently elevated PSA and was found to have a new lung lesion on repeat PSMA PET. Urinary morbidity included two patients (16.7%) with bothersome storage LUTS treated medically; one patient had resolution within 3 months; one had persistent symptoms treated with PTNS. Three patients (25%) had post-operative UTI treated with oral antibiotics, and two patients (16.7%) with retention required limited TURP. 



Conclusions: 

Salvage IRE has encouraging early outcomes by PSA and radiographic response, though longer term follow-up is needed. Patient selection is critical to optimize success. While there was short term urinary morbidity, sequelae were rare. 







References: 

Smith CP, Xiang M, Armstrong WR, et al. Patterns of Failure in Men With Radiorecurrent Prostate Cancer: A Post Hoc Analysis of 3 Prospective Gallium 68 Prostate-Specific Membrane Antigen Positron Emission Tomography/Computed Tomography Imaging Trials. Int J Radiat Oncol Biol Phys. 2023;116(5):1079-1084. doi:10.1016/j.ijrobp.2023.02.039 

Valle LF, Lehrer EJ, Markovic D, et al. A Systematic Review and Meta-analysis of Local Salvage Therapies After Radiotherapy for Prostate Cancer (MASTER). Eur Urol. 2021;80(3):280-292. doi:10.1016/j.eururo.2020.11.010 

Frame G, Huang X, Haas R, et al. Accelerated growth and local progression of radiorecurrent prostate cancer in an orthotopic bioluminescent mouse model. Sci Rep. 2024;14(1):31205. Published 2024 Dec 28. doi:10.1038/s41598-024-82546-w

Salvage Irreversible Electroporation (IRE) for Radio-Recurrent
Prostate Cancer: Perioperative and Early Postoperative Outcomes

Objectives: 
Opioid use disorder (OUD) is a major public health concern. Integrated obstetric/addiction care models improve outcomes for pregnant and postpartum individuals with OUD. However, racial disparities in OUD treatment suggest potential inequities in service utilization. This study examines service utilization by race among pregnant individuals with OUD in an integrated obstetric/addiction clinic.

Methods: This secondary analysis used data from a retrospective medical record review study of pregnant patients with OUD receiving care at an urban outpatient integrated obstetric/addiction clinic. Participants included individuals who had a live birth between June 2019 and June 2021 and consented to participate in a research study. Demographic, obstetric, and substance use disorder treatment data were collected from electronic health records. Chi-square tests compared service utilization between non-Latine White and non-Latine Black/African American patients.

Results: The study included 41 participants: 68.3% White (68.3%) and 31.7% Black/African American (31.7%). Most participants (68.3%) attended four or more provider visits in the third trimester (White: 75.0%, Black: 53.8%). Third-trimester mental health counseling was utilized by 65.9% of participants (White: 67.0%, Black: 61.5%). No significant racial differences in service utilization were observed. Utilization of pediatric neonatal opioid withdrawal syndrome education (17.1%) and intimate partner violence screening (7.3%) were low.

Conclusions: Service utilization rates were similar across racial groups, suggesting equitable uptake within this sample. However, the study’s generalizability is limited by its sample size. Future research should incorporate diverse racial/ethnic groups and qualitative measures to assess patient experiences and barriers to care. 


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